[GSN] Part 2: Economic Sanctions - Annals of Internal Medicine

["Ramsey Kysia" <mbakery@DELETETHISerols.com>]

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Subject:                [GSN] Part 2: Economic Sanctions - Annals of Internal Medicine
        exposed as agent of State Dept!

"http://www.annals.org/issues/current/full/200008150-00018.html#top"
Annals of Internal Medicine, 15 August 2000 Volume 133 Number 4
LETTERS

Economic Sanctions and Embargoes

Letters on: Pages 308-312

TO THE EDITOR:
Physicians are compelled to relieve suffering. The Ethics and Human Rights
Committee's recommendations (1) to ameliorate the public health effects of
sanctions are a welcome first step toward helping vulnerable people in the
affected countries.
Although we should investigate and analyze the public health effects of
sanctions and embargoes, we should never forget that the biggest threats to
public health in the sanctioned nations are their leaders. In the Balkans,
Slobodan Milosevic has unleashed wars over the past decade that dramatically
affected the public health of nearly all the former Yugoslav republics,
while spilling over the borders of Yugoslavia into Macedonia and Albania.
Like Saddam Hussein, this indicted war criminal does not hesitate to cause
his people, and especially the vulnerable groups, to bear the enormous
public health consequences of his political self-preservation.
Yugoslavia and Iraq are only two examples of countries whose tyrannical
leaders cause real threats to public health. If physicians are to be
concerned about the public health of these nations, the issue becomes how
best to deal with the public health threat. The only alternative to
embargoes, other than war, is to rescind sanctions completely. To do this is
to unleash these despots on their own people and their neighbors,
precipitating even larger public health crises.

If the members of the American College of Physicians-American Society of
Internal Medicine are to wade into the public health controversy surrounding
sanctions and embargoes, we must do so with the sober realization that good
intentions toward the affected nations may have unintended consequences.
There will always be suffering in nations as long as irresponsible leaders
govern them. While we are obligated to do whatever possible to relieve that
suffering, we cannot be blind to the realities of complex humanitarian
emergencies. To do so puts the College at risk for becoming a cheap
propaganda tool for the real public health problems.
Michael Brumage, MD
Pearl City, HI 96782

References
1. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61.
=============
TO THE EDITOR:
Morin and Miles (1) do a great service to the medical community and the
general public by detailing the ethical issues involved in the imposition of
harsh economic sanctions that so clearly affect the health and well-being of
target populations, who are always the most vulnerable sectors bearing the
brunt.
Secretary of State Madeleine Albright's counterpoint editorial (2) claims
that Iraq is now importing as much food now as before the Gulf War. Because
she does not cite any source for this claim, I regard it as skeptically as I

do many other such "statistical" claims by the State Department that are
demonstrated to be meretricious and patently false on further examination.


Whether Albright's claim is true or not is beside the point. As Morin and
Miles point out, the humanitarian crisis engendered by sanctions such as
those currently used against Iraq does not cause one-dimensional damage. The
long-term effects of malnutrition are not overcome quickly; many are
permanent. Compounding the problem are the health effects of substandard
medical care, caused by de facto embargoes on so many items necessary for
even standard medical care. Finally, what good is adequate nutrition if
contaminated water is used to wash it down, thanks to the deliberate bombing
of the civilian infrastructure by the "allied" forces during the Gulf War?
Ken Freeland
Houstonians against U.S. Military Involvement
Houston, TX 77004

References
1. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61.

2. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
=====================
TO THE EDITOR:
I would like to congratulate Annals for publishing the papers on the ethics
of sanctions and the effects of sanctions on the health of nations,
particularly Cuba (1, 2).
As part of the wider international medical community, I take exception to
the offering of propaganda space to the U.S. Secretary of State, Madeleine
Albright (3). Because of the prestigious reputation of Annals, I fear that
Ms. Albright's comments might attain some validity. It seems obvious that
she must not have read the two articles she refers to in her editorial (3).
An even cursory glance at the Table in Dr. Barry's article (1) would suggest
that the "failed" system of government in Cuba has certainly not failed its
own people.
With regard to Albright's comment about "the challenge of responding to
regimes that ignore international law and run roughshod over the rights of
their own people," surely a case could be made for removing the plank from
one's own eye before the splinter from one's neighbor's. It is Albright's
own administration that violates international law, as explicitly pointed
out by Morin and Miles (2).
Finally, Albright's comments under the heading "Helping the People of Cuba"
prompt my earnest hope that the people of my country are spared any
consideration of Albright's condescending and dangerous "benevolence."
I congratulate Annals for highlighting the appalling situation caused and
perpetuated by what I perceive as an illegal blockade against a country
whose only crime is to seek an independent course for its own people. This
is a cause that Ireland has fought for (to international acclaim) for 700
years and that was cherished in the United States until recently.
David P. Hickey, FRCSI
Beaumont Hospital
Dublin, Ireland

References


1. Barry M. Effect of the U.S. embargo and economic decline on health in
Cuba. Ann Intern Med. 2000;132:151-4.

2. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights


Committee. Ann Intern Med. 2000;132:158-61.

3. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
===============
TO THE EDITOR:
Madeleine Albright (1) ignores recommendations from recent United Nations
agency reports (2-4) and simply restates State Department policy. Surely we
can expect initiatives from the U.S. government that go beyond the
demonization and denunciation of Iraq's political leadership. Iraq's
humanitarian budget comes from sale of its oil, the proceeds of which are
placed in a United Nations escrow account. Each contract submitted by the
Iraqi government must be approved by the United Nations Sanctions Committee,
which consists of representatives of Security Council member states. If a
single member questions a contract, it is placed on "hold." It is not
surprising that most holds are placed by the United States. As of 15
November 1999, the value of contracts on hold exceeded $1 billion (5). This
figure had not substantially changed as of 5 June 2000 according to the
United Nations Office of the Iraq Programme.
According to the Secretary-General's report of 12 November 1999 (2), nearly
18% of all applications for humanitarian supplies to Iraq have been placed
on hold. In the health sector, such items have included growth media,
diagnostic tests, diagnostic equipment using computers (such as computed
tomographic scanners and x-ray machines), ventilators, and intensive care
unit monitoring systems.
Health professionals can play an important role as advocates and mediators
in the sanctions debate. Iraq's 10 medical colleges are in desperate need of
continuing education materials and recent textbooks for their medical
libraries. Opportunities should be created for senior Iraqi physicians and
academicians to meet with their U.S. counterparts in conferences and
workshops to foster the kind of "people-to-people" ties that are now
possible in our relations with Cuba.
Leila Richards, MD, MPH
Brooklyn, NY 11201

References
1. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
2. United Nations Security Council. Report of the Secretary-General pursuant
to paragraph 6 of Security Council resolution 1242 (1999)S/1999/1162, 12
November 1999.
3. United Nations Security Council. Review and Assessment of the
Implementation of the Humanitarian Programme Established Pursuant to
Security Council Resolution 986. S/1999/356, 30 March 1999.
4. UNICEF. Situation analysis of children and women in Iraq. Baghdad:
UNICEF; 30 April 1998.
5. United Nations Office of the Iraq Programme.
"http://www.un.org/depts/oip"
==================
TO THE EDITOR:
Hans von Sponeck, the former United Nations Humanitarian Coordinator for
Iraq, predicted that in 20 years, universities in the United States will be
using the sanctions on Iraq as an example of how not to pursue foreign
policy. The publication of articles on the effects (1) and rationalization
(2) of embargoes on Cuba and Iraq holds promise of accelerating realization


of von Sponeck's vision.
Morin and Miles (3) provide a welcome departure from ethical neutrality
toward moral responsibility in international health scholarship. Madeleine
Albright's editorial (2) is essentially an exercise in personalized blame
and elaboration of her 1996 judgment, as articulated in an interview on the
television show 60 Minutes. In that interview, she maintained that the death
of thousands of Iraqi children is "worth it." Illustrative of ahistorical
analytical reductionism, Albright's editorial circumvents the framework of
asymmetrical "new"-world-order global power and regional geopolitics, within
which sanctions are selectively imposed and human suffering is reproduced.
The humanitarian pretense, similar to the vocabulary of "collateral damage,"
is contradicted by credible evidence of deliberate destruction of Iraq's
public service infrastructure, notably electrical-power generation and
distribution facilities, so as to "degrade the will of the civilian
population" (4).
As a consultant to the United Nations Children's Fund (UNICEF), I reviewed
Iraq's health situation before and after 1990. This exercise brings into
focus the combined adverse effects of infrastructure destruction and the
imposition of sanctions. Particularly relevant in this regard is the
temporal specificity of serious compromise of the role of the welfare state.
As for the "oil-for-food" program mentioned by Albright in her editorial,
this is hardly a solution to the complex of adverse effects of sanctions (5).
Consideration of related factors, such as soaring inflation, declining
health services, and erosion of the skills of health professionals, is
imperative in any analysis that claims scientific validity.
Soheir A. Morsy, PhD
Washington, DC 20016

References
1. Barry M. Effect of the U.S. embargo and economic decline on health in
Cuba. Ann Intern Med. 2000;132:151-4.
2. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61.
3. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
4. Cruise Missiles: Proven Capability Should Affect Aircraft and Force
Structure Requirements. Document 95-116. Washington, DC: General Accounting
Office; 1995.
5. El-Bayoumi A. Sanctions, strikes and oil for food: humanitarianism of the
"new" world order. AAUG Monitor. 2000;15:10-4.
===================
TO THE EDITOR:
Madeleine Albright asserts that in Cuba, "food and medicine have always been
exempt from sanctions" (1). Yet Cuba's health system (operated by the Cuban

government) is absolutely banned by the U.S. embargo from purchasing basic
foodstuffs and is severely restricted from purchasing medicines and medical
equipment from U.S. companies worldwide. The State Department has knowingly
made false and misleading statements to Congress and the public about the
Cuban embargo to obfuscate the agency's role in violating the most basic of
universally recognized human rights.


By repeatedly carrying out such deception, the State Department has made a
significant contribution to blocking legislation to restore shipments of
food and medicine essential to the health of Cuba's civilian population. The
Table outlines other falsehoods promulgated on the Internet by the State
Department through its Fact Sheet, originally published on 5 August 1997
("http://www.state.gov/www/regions/ara/fs_cuba_healthcare_970805.html").
One can only assume that the misrepresentations are deliberate because they
were brought to the attention of the State Department by me (2-4) and other
people (5) over the past 2 years. On 24 July 1997, the State Department told
the Los Angeles Times that it would evaluate research data on the issue and
would correct any errors in its Fact Sheet. No correction has been
forthcoming, and the agency is now refusing to respond or otherwise discuss
the scientific data. The deception is being maintained by a "wall of silence."
While a difference of opinion over what is the best foreign policy is one
thing, deliberately misrepresenting the facts is quite another, especially
when the consequence of the deception contributes to the denial of food and
medicine to civilians.
Anthony F. Kirkpatrick, MD, PhD
University of South Florida
Tampa, FL 33612-4799

References

1. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
2. Kirkpatrick AF. The US attack on Cuba's health [Editorial]. CMAJ.
1997;157:281-4.
3. U.S. House Committee on Ways and Means, Subcommittee on Trade. The State
Department changes the record on Cuba: U.S. Agencies and World Health
Organization misrepresented. Testimony by Anthony Kirkpatrick and Harry
Vanden. Washington, DC: 7 May 1998.
4. Kirkpatrick AF. Role of the USA in shortage of food and medicine in Cuba.
Lancet. 1996;348:1489-91.
5. Impact of US Embargo on Health and Nutrition in Cuba. Washington, DC:
American Association for World Health; 1997.
=================
TO THE EDITOR:
The articles on economic sanctions (1-3) add importantly to the discussion
of humanitarian damage (4). Although Madeleine Albright states that the
Clinton Administration fully supports humanitarian goals, the accompanying
papers show that it has not. Nonetheless, her call for a partnership with
the public health community to make further progress is a commendable
challenge.

The impact of sanctions on civilians relates to the more general increasing
impact of wars on civilians. Globalization, inexpensive weapons, and
shrinking attention to the differentiation of military targets from civilian

victims leave civilians at increasing risk.
By any accounting, far more civilians have died after the 1990 Gulf War than
did troops during the war (5). The principle of balancing military necessity
with humanity, mentioned in the American College of Physicians-American
Society of Internal Medicine position paper (2), has been, and continues to
be, observed mainly in the breach. The paper highlights the importance of
monitoring humanitarian conditions when embargoes are instituted.


Remarkably, despite the provision of billions of dollars in Iraqi assets for
relief supplies and an unprecedented increase in child mortality, such
monitoring still does not exist in Iraq. The State Department's call to
avoid the "premature lifting of sanctions" ignores the College's position
that food and medicine should not be sanctioned to begin with. Reduced
official U.S. limitations on humanitarian goods in some sanctions ignore the
frequent observation that sometimes insurmountable impediments remain. For
example, the $100 million in licensed donations of medical goods for Cuba
actually resulted in less than $10 million in delivered value. This in no
way makes up for the United States-imposed prohibition against direct Cuban
purchases, which generates excess embargo-related costs to the health system
of an estimated $45 million each year.
The State Department, of course, responds mainly to perceived national
interests and legislative mandates rather than humanitarian concerns. Thus,
partnership with the public health community is essential to better separate
political from humanitarian issues in sanctions. The College's position
paper is a useful initiative toward this goal.
Richard Garfield, RN, DrPH
Columbia University
New York, NY 10032

References
1. Barry M. Effect of the U.S. embargo and economic decline on health in
Cuba. Ann Intern Med. 2000;132:151-4.
2. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61.
3. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
4. Garfield R. The impact of economic sanctions on health and well-being.
London: Overseas Development Institute; 1999. Relief and Rehabilitation
Network Paper 31.
5. Garfield R. Morbidity and mortality among Iraqi children from 1990-1998:
assessing the impact of economic sanctions. Goshen, IN: Fourth Freedom
Forum. 1999; Occasional Paper Series 16.
=======================
TO THE EDITOR:
The articles on economic sanctions (1-3) miss the most crucial point;
specifically, that they are illegal under international law. Madeleine
Albright (2), a staunch defender of "international norms" and human rights,
would have us believe that the United Nations or United States "does not
intend to create unnecessary hardships for innocent people, especially
children and infants." Morin and Miles (3) advocate the desire to "amend the
structure and application of economic sanctions ... to better protect the

health of all populations." Morin and Miles are deluding themselves, and Ms.
Albright is misleading the public.
Woodrow Wilson disclosed the absolute truth when speaking on economic
sanctions in Versailles in 1919: "A nation that is boycotted is a nation
that is in sight of surrender. Apply this economic, peaceful, silent, deadly
remedy and there will be no need for force. It is a terrible remedy. It does
not cost a life outside the nation boycotted, but it brings pressure upon
the nation which, in my judgement, no modern nation could resist" (4). Note


the word "deadly"[]sanctions are intended to kill civilians! As such, they
are illegal under international law (Protocol I, Part IV, Section I, Chapter
III, Article 54 of the Additional Protocols to the Geneva Conventions-1977;
International Conference on Nutrition, World Declaration on Nutrition, Food
and Agricultural Organization/World Health Organization, 1992; United
Nations General Assembly Resolution 44/215 [22 December 1989][]"Economic
measures as a means of political and economic coercion against developing
countries"; the Constitution of the World Health Organization, 1946; and the
Universal Declaration of Human Rights, 1948).
There is only one way to amend economic sanctions, and that is to abolish
them now and forever. The American College of Physicians-American Society of
Internal Medicine, the American Medical Association, and other U.S. public
health organizations would do well to join the chorus of international
voices advocating the total abolition of this "peaceful, silent, deadly
remedy."
Natalia Ganson-Myshkin, MD
Boston, MA 02124

References
1. Barry M. Effect of the U.S. embargo and economic decline on health in
Cuba. Ann Intern Med. 2000;132:151-4.
2. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61.
3. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
4. Carter BE. International Economic Sanctions: Improving the Haphazard U.S.
Legal Regime. Cambridge, United Kingdom: Cambridge Univ Pr; 1988:9.
===========
TO THE EDITOR:
I appreciate the courage of Annals in devoting attention to the morally
complex subject of embargoes and how they may affect health (1-3). I humbly
take issue with Secretary of State Madeleine Albright's position that the
U.S. embargo has permitted generous donations of medical sales and medical
equipment to Cuba.
Ms. Albright carefully uses the word "licensed" with regard to "$45 million
in medical sales in 1998 and the first half of 1999 and more than $100
million in humanitarian donations" (2). In actuality, licenses do not equate
to material sent to or received by Cuba. The complexity of the on-site
verification process required by the United States after a license is
obtained (verification that materials are not being sold for Cuban
government use) has made donations difficult to deliver. Indeed, Disarm, a

peace and social justice organization that has been granted licenses for
more than $191 million in humanitarian aid to Cuba over 5 years,
specifically noted that Cuba has been able to receive only a fraction of
Disarm licensed material ($47 million over 5 years [Schwartz R. Personal
communication]). Moreover, humanitarian aid does not necessarily reflect
actual Cuban needs. Indeed, in 1991, before the Cuban Democracy Act limited
trade in food and medicine, business with U.S. subsidiaries had reached $718
million; thus, $45 million in medical sales in 1998-1999 is a fraction of
Cuba's needs even if 100% of materials are received (4). At the recent


United States-Cuba trade conference, the president of the Cuban Chamber of
Commerce, Hector Perez, was quoted as saying that despite the U.S. State
Department's claim of $45 million in licensed medical sales, "zero" had
reached Cuba (5).
The Fourth Geneva Convention of 1949 and the Additional Protocols of 1977
mandated that food and medical supplies to civilians should be unhindered
even in war. United States-owned companies dominate the world market in
medicines and medical equipment, a domination that restricts the Cuban
people's access to such supplies. Ms. Albright's statement that food and
medicine are now exempt from U.S. sanctions against Cuba is misleading. Her
carefully worded editorial cannot disguise the fact that delays in
licensing, shipping, and on-site verification requirements make charity to
Cuba an unacceptable alternative to free trade in medicine and food.
Michèle Barry, MD
Yale School of Medicine
New Haven, CT 06520-8025

References
1. Morin K, Miles SH. The health effects of economic sanctions and
embargoes: the role of health professionals. Ethics and Human Rights
Committee. Ann Intern Med. 2000;132:158-61.
2. Albright MK. Economic sanctions and public health: a view from the
Department of State [Editorial]. Ann Intern Med. 2000;132:155-7.
3. Barry M. Effect of the U.S. embargo and economic decline on health in
Cuba. Ann Intern Med. 2000;132:151-4.
4. Denial of Food and Medicine. The Impact of the U.S. Embargo on Health and
Nutrition in Cuba. Washington, DC: American Association of World Health; 1997.
5. Fletcher P. US health care firms probe tricky Cuban market. 25 January
2000.
"http://www.cubanet.org/CNews/y00/jan00/26e11.htm" Last accessed 17
July 2000.


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