The Silent, Deadly Remedy
BY RICHARD GARFIELD
Since the end of the Cold War, economic sanctions have become a common instrument of diplomacy.1 As tools of international pressure, sanctionsthe interruption of some or all economic relationsfall between diplomacy and armed force and usually aim to achieve political ends while avoiding the costs and destruction of war.2
In a two-superpower world, few states were not aligned with one of these powers; therefore, sanctions were ineffective since either the United States or the U.S.S.R. could build an alliance with any country cut off by the other. In the last decade of the 20th century, however, economic sanctions have become a more potent and frequent tool of hostile foreign policy. Growing reluctance to use U.S. ground troops to settle international disputes has made the search for alternative weapons of hostile foreign policy of paramount importance.
Additionally, consensus among nations on the appropriate use of military force in international diplomacy is increasingly rare. Generating such consensus requires shared values, international treaties, and international law, focused increasingly on human rights. War is usually justified only as a last resort in cases of grave domestic rights violations or territorial aggression by an offending state. Even in such cases, international wars are increasingly limited to expelling invading forces; there is little consensus that any one nations government should overthrow the government of another, demand unconditional surrender, or create occupied states. These limitations on engaging in full-scale, conventional warfare create pressure to find other means to negotiate hostilities between states.3 Thus, in the post-Cold War, one-superpower world, sanctions have become the weapon of choice prior to, instead of, or after limited wars.4
From 1993 to 1996, 35 new sanction regimes were initiated by the United States. U.S. sanctions now have been instituted or legislated against countries containing 68 percent of the worlds population.5 Most of those sanctions limit commercial relations or military cooperation; comprehensive sanctions that attempt to halt all commerce are far rarer.
The United Nations has also increased its use of sanctions in recent years. Prior to 1991, the United Nations instituted sanctions only twice, against Southern Rhodesia in 1966 and against South Africa in 1977. Since 1991, the UN and other regional organizations have instituted sanctions against Iraq, the Yugoslav federation of Serbia and Montenegro, Libya, Rwanda, Angola, Somalia, Liberia, Burundi, and Haiti. In 1998 and 1999, further U.S. sanctions were considered or legislated against Pakistan, India, China, Yugoslavia, and Nigeria.
Sanctions are popular because they quickly demonstrate determination and action on the part of leaders. Interest groups in developed countries can exert great pressure to take rapid action in this way with little opposition from the countries citizens. Often the only opposition against sanctions is voiced by the U.S. business community, whose major concern is lost sales and markets. Finally, sanctions appear cheapat least compared to expensive military interventions. For example, during the 1994 international military operation in Haiti to return exiled President Jean-Bertrand Aristide to power, the $8 billion cost of military intervention dwarfed the $250 million spent by all parties for humanitarian relief.6
It appears that the sanctioned country bears the full cost of sanctions. But many of those costs are borne solely by the civilian population. Most sanctions increase suffering among civilians, particularly among the most disadvantaged.7 The cases of Iraq, Haiti, and Cuba show how damaging sanctions can be, especially in terms of human suffering. Increasingly, reports of human suffering have made the subject of sanctions a volatile issue in the mind of the American public. In response, the State Department has criticized the methodology of the studies rather than their substance.
WAR AND PEACE . . . OR LIMBO
The UN Security Council is authorized to impose sanctions when a nation threatens peace and security or is guilty of aggression against another state. If sanctions are ineffective, they can be followed with military force, according to the UN charter. As Woodrow Wilson put it, sanctions were meant to be a "peaceful, silent, and deadly remedy" that no nation could resist.
But the decision in the early 1990s not to field a UN-based volunteer army took the teeth out of the UNs mandate for the use of force. Similarly, American troop losses during a joint U.S.-UN famine-relief operation in Somalia in 1992 eroded public support for U.S. military options. Sanctions, which are often criticized as a weapon of rich countries against the poor, have thus often been instituted not as the weapon of choice but as a tool of last resort among decision makers in the United States and the UN.8
It is ironic, however, that the UNs own charter charges it with promoting higher standards of living, social progress, solutions to health problems, educational cooperation, and respect for human rights. The Universal Declaration of Human Rights, the Convention on the Rights of Children, and other major human rights conventions also strongly condemn actions that hamper the provision of shelter, health services, and food, or that otherwise deny goods essential to survival. Basic rights to health, health care, education, and security are routinely violated when essential goods are withheld from the sanctioned country. Further, the UN and its member nations are obliged to uphold international principles of law concerning nonintervention and sovereignty; sanctions may violate both of these principles. The international order thus is turned on its head: the UN becomes the violator rather than the protector of human rights.
During its first 45 years, the UN seldom had the dual role of hostile agent and humanitarian assistant. But in the past decade, in Iraq and Haiti, the people and their governments sometimes rejected UN organizations providing emergency aid because the UN helped create their misery in the first place.9 And while the UN Security Council imposes sanctions, UN humanitarian agencies must request special permission to import proscribed goods for their own use, such as gasoline in Haiti and pencils in Iraq.
NO RULES FOR SANCTIONS
Since the days of chivalry, there have been codes designed to protect civilian noncombatants in war. Notwithstanding such protections, the business of war has become more destructive as weapons became more powerful, more devastating, and more mobile. Prior to the U.S. Civil War, casualties in most conflicts were almost exclusively among combatants. Starting with the Napoleonic wars, accelerating with weapons of mass destruction in World War I and with the advent of the tank, submarine, and warplane in World War II, the world entered the era of total war, leading to rising death rates among combatants and noncombatants alike. To reassert rules of civilian protection and to make war more survivable following the horrors of the first World War, the international community codified and extended the Geneva conventions. These conventions specify the principles of legitimate military targets and protection of prisoners and noncombatants.
Through World War I, less than 20 percent of all deaths in wars occurred among civilians. This rose to 50 percent in World War II and the war in Vietnam, and has been higher than 90 percent in the intra-nation wars of the 1990s.10 Sanctions extend this remarkable trend: virtually all excess deaths under sanctions occur among disadvantaged groups of civilians.
Sanctions, if they were subject to the laws of warfare, would involve a careful process of selecting targets, taking precautions to avoid civilian deaths, and specifying the merits of a chosen approach relative to the probable civilian harm.11 Moreover, if sanctions were subject to the rules of war, sanctioning powers would have an enormous financial burden of providing the food and medicines necessary to meet their obligations to provide for captured enemies and their families. If sanctions came under the principle of distinction between military and civilian targets, many goods such as food and gasoline useful to the military but essential to civilians could not be sanctioned and the "silent, deadly" weapon Wilson evoked would lose much of its bite. Indeed, economic sanctions are, however viewed, a form of collective punishmentan approach rebuked by all the tenets of international conventions governing warfare.
Since most nations observe the rules of warfare by ensuring essential goods are available to captive populations, civilians are materially better off in an occupied territory during or after a war than in a country with comprehensive sanctions. This is the case, for example, in Iraq. Under sanctions, no such protections are assured. Sanctions impose major shortfalls in access to food and medicines, while only a small fraction of the lost goods are replaced by humanitarian groups.
Sanctions fall under international law, not the laws of warfare. Therefore, as with other human rights violations, a victim of sanctions normally must show damages in order to seek redress. And it can be difficult to prove direct adverse health effects of economic sanctions since they are a cumulative and collective phenomenon. Health problems such as higher infant mortality rates, malnutrition, or disease are the result of a chain of events, and the causative factors may not be readily apparent.
MEASURING THE COSTS
Sanctions cause major shifts in the production, importation, and distribution of essential goods. Therefore, the impact of sanctions on peoples health can be mediated by a countrys existing economic and social systems. When food, medicine, and other essential goods are scarce, these changes may also affect the distribution of essential goods within the family as parents make hard decisions about who receives the scarce resources. Economic sanctions also lead to political and social turmoil or damage to the environment. In Iraq, for example, lands not well suited for grain production are being farmed because of sanctions-related shortages, causing ecological changes and malaria transmission. Such effects are difficult to isolate or measure with precision.
Economic inefficiencies, inequitable distribution of goods, civil conflicts, and population movements also threaten a populations health and the ability of outside monitors to measure changes in health care and health status. One index of overall health is the infant mortality rate, since infants whose mothers lack food and medicine are more likely to die. However, infant mortality can decline even during periods of severe resource shortage if those scarce resources are distributed more efficiently.12 Even a dramatic decline in key resources does not always or immediately lead to increased illness or death since such health assets as public education, healthy behaviors, trained health workers, and infrastructure, may deteriorate only gradually.
However, in Haiti and Iraq, the social disruptions that occurred when sanctions were imposed weakened the health system as well as the systems that report vital statistics. Further, information provided by the affected regimes cannot be considered reliable. In nearly all countries, basic information on births and deaths is available only from the government. The veracity of such reports is placed in doubt since outside, independent agencies often have limited ability to check on the completeness and accuracy of statistical information during a political crisis caused or exacerbated by sanctions.
Even where the ability to collect data is good, the data of greatest interest, infant mortality rates, can rarely be assessed in a timely manner. Few developing countries keep accurate and comprehensive records of births and deaths through data recorded in hospitals. Cuba is an exception. Therefore, to estimate the infant mortality rate, representative population surveys are needed to assess the mortality rate for infants or children under 5 years old. In most cases, other records of cause of death, nutritional status of children, and the quality of the public health infrastructure are the best real-time, albeit indirect, health indicators available.
In the past two decades, sanctions imposed on Haiti, Iraq, and Cuba have dealt severe blows to the economy and living conditions.
In Haiti, a military coup ousted elected President Jean-Bertrand Aristide from office in September 1991. The United States and the Organization of American States almost immediately initiated sanctions. Initially, the sanctions blocked access to U.S. financial assets of Haitian government leaders and prohibited payments to the de facto regime. Later sanctions prohibited most imports to and exports from Haiti (with the exception of humanitarian goods), restricted commercial flights, and imposed a freeze on arms and oil shipments. Sanctions were lifted in 1994 after a military contingent from the United States and the Organization of American States enforced the 1993 Governors Island Accord calling for General Raoul Cédras to step down. This led to a reestablishment of the elected government.
Sanctions in Iraq began in August 1990 following the invasion of Kuwait. After the Gulf War of January 1991, sanctions were reinstituted. The UN first sought to allow Iraq to sell oil to purchase humanitarian supplies in 1991; a resolution to that effect was passed in 1995, went into force in 1996, and finally resulted in an increased flow of food and medicine in 1997. Sanctions continue at present.
The United States has imposed economic sanctions on Cuba since 1964. During détente in the 1980s, sanctions were relaxed, allowing Cuba to purchase goods from U.S. companies based outside the United States. In 1992, following the dissolution of the Soviet Union, sanctions were tightened so that even U.S.-produced medicines were effectively prohibited. Despite criticism from most U.S. allies and Pope John Paul II in 1992, sanctions still continue.
Though data on the effect of sanctions on women are limited, Cuban records show a rapid rise in maternal mortality among Cubans in 1993 and 1994, when sanctions-related shortages in that countrys health system were most severe.13 Extraordinary efforts to provide extra food rations to pregnant women and revamp birthing procedures rapidly reversed the trend toward rising mortality.14
During Organization of American States sanctions on Haiti, food and income to buy it became scarce.15 A ban on fuel sales brought even humanitarian relief activities to a halt, making immunization campaigns and food distribution difficult. The decline in nutrition, immunizations, clean water, and availability of medical care were associated with an estimated 20 percent rise in the already high rates of mortality among children under five.16
By far the most serious modern case is Iraq. The chance of dying before reaching age five is estimated to have doubled from a low of 40 per 1,000 in 1990 to 87 per 1,000 in 1996.17 Over nine years, this accounts for a total of about 225,000 excess deaths among young children. Without taking into account increased mortality among other age groups, this represents at least four sanctions-related civilian deaths for each soldier who died in the Gulf War of 1991.18
Women and children dont need huge resources to maintain nutrition and essential medical care. Promoting breast feeding, guaranteeing access to food for women and children, preventing contamination of food and water supplies, ensuring immunization, and assuring stocks of a small number of emergency medicines could protect most women and children from the short-term threats posed by sanctions. Indeed, many families already respond to the perceived health threats of sanctions-related social disruptions by boiling water, seeking immunizations, and opting to breast feed. This mobilization of basic resources to protect the microenvironment of the child is likely responsible for the decreased infant mortality in Haiti, Nicaragua, and Cuba during sanctions. Nevertheless, mortality of children under 5 rose in Haiti, and mortality of the elderly over 65 rose in Cuba.19
Although almost all sanctions legislation in recent decades has provisions that exempt food and medicine, every country where sanctions have been imposed has experienced limitations on the importation of food and medicines. For the most part, sanctions have also been associated with economic hardship caused by capital shortages and limits on imports of consumer goods. In many countries, lack of foreign exchange resulting from economic sanctions had a greater impact than direct restrictions on importing medicine or food.
In some sanctioned regimes, including Cuba and Yugoslavia, the United States and the United Nations respectively prohibited the purchase of medicines.20 Although affected countries routinely blame shortages of essential drugs, medical supplies, and surgical equipment almost entirely on the sanctions, this has been difficult to prove.
Those most affected include pregnant and lactating women, children under 5 years of age, the chronically ill in need of ongoing medical services, and the elderly. When food and medicine become scarce, women are at increased risk of being underweight at the start of pregnancy, failing to gain sufficient weight during pregnancy, and suffering from micronutrient deficiencies and infections. Needless to say, these conditions adversely affect the developing fetus.
In Cuba, the percentage of underweight infants rose 23 percent, from 7.3 percent in 1989 to 8.7 percent in 1993, wiping out 10 years of progress.21 The numbers of women who failed to gain sufficient weight during pregnancy or who were anemic also rose rapidly. A study of rural Haitians showed an increase in the proportion of malnourished children from 5 percent in 1991 to 23 percent in 1992.22 The number of malnourished children rose further still as sanctions weakened agriculture through 1994.
Sanctions are often associated with a dramatic increase in the price of staple goods. It is estimated that sanctions against Cuba create a virtual tax of 30 percent on all imports that must be purchased from smaller and more distant markets.23 The price of staple foods increased fivefold in Haiti from 1991 to 1993, unemployment rose rapidly, and a ban on the export of mangoswhich many poor people grow as a cash cropleft the poor with less money to buy other foods.24 Sanctions also can cause economic disruptions that make the countrys currency worthless. For example, in Iraq, the value of national currency plummeted and hyperinflation occurred, making a regular months salary worth no more than two dozen eggs.
Its not surprising, then, that countries with the greatest dependency on imported food have experienced the greatest declines in child nutrition. Prior to sanctions, about half of all proteins and calories intended for human consumption in Cuba and 70 percent in Iraq were imported.
Importation of foodstuffs declined by about 50 percent from 1989 to 1993 in Cuba.25 Reduced imports and a shift toward lower-quality protein products became significant health threats. Milk production in Cuba declined by 55 percent from 1989 to 1992 due to the loss of imported feed and fuel. The Cuban government used to provide a daily glass of milk to all children in schools and day care centers through age 13; now milk is provided only up to age 6.
Moreover, about half of all new pharmaceuticals in the last 20 years are produced only by U.S.-owned companies; since 1992, all of these medicines are off limits to Cuba.26 And in Iraq, rationed goods provide virtually no animal proteins or iron.
Young children, especially, suffer from poorer nutrition, increased transmission of infectious disease, and a medical system that cant respond to the increased needs under economic sanctions. Efforts in Cuba, where the medical system has aggressively tried to respond, and in Haiti, where up to a third of the population received medicine and food to minimize the effect of sanctions, have been only partially able to reverse these trends. The situation is most stark in Iraq, where diarrhea is now the major killer of children. In Iraq, in the 1980s, poor nutrition was almost exclusively related to overeating and obesity; by 1994 a third of all children under age five were malnourished from a lack of adequate nutrition.27
Weakened physical and medical infrastructures also strain the capacity of a health system to respond to emergencies during childbirth. More women may give birth without medical assistance or in a medical facility lacking electricity, transportation, or equipment and supplies for emergency interventions. The maternal mortality rate in all three countries has risen.
WHAT HAVE WE LEARNED
Even under the strictest sanctions, some goods manage to trickle through to civilians. Yet all these sanctions have increased costs and reduced economic activity. Sanctions with the greatest impact on the health of the general population are usually those that are multilateral and comprehensive and occur in countries heavily dependent on imported essential goods. Severe effects will also be felt when sanctions are implemented rapidly and are accompanied by other economic and social blows to a country. These characteristics apply to Iraq, whose plight is particularly poignant. Since 1990, about 205,000 excess deaths among children under 5 years old have been documented. These deaths occurred, in part, because of food shortages, inadequate breast feeding, early and inappropriate weaning in unsanitary conditions, failure to boil water, and failure to treat children early and aggressively when they had diarrhea and acute respiratory infections.
In Haiti, deep disruptions occurred among families both during and after sanctions. The U.S. aggressively tried to provide humanitarian assistance; in fact, no other sanctioned country has received as much help as Haiti, where humanitarian assistance replaced a third of the income lost due to sanctions. Yet Haiti has not recovered; indeed, in the four years since sanctions ended, economic, social, and political crises stimulated by sanctions continue to deepen.
Cuba has demonstrated by far the most effective responses in maintaining essential services and priority goods during sanctions. Cuba, with fewer calories available per person than Iraq and Haiti, has far less malnutrition, far fewer low- birth-weight infants, and rates of death from infectious conditions that nearly match those in the United States. Though the practice of curative medicine has deteriorated markedly in recent years, the Cuban experience since the tightening of U.S. sanctions is a model from a public health point of view.
In conventional warfare, most nations have accepted the key principles of just warfare. Since sanctions appear to be an increasingly common form of hostile foreign policy, the international community should apply these principles to the use of sanctions. The principle of differentiation directs those waging war to focus on military, rather than civilian, targets. The principle of proportionality directs them away from targets likely to cause unnecessary civilian harm relative to military benefit. The situations in Cuba, Iraq, and Haiti show that comprehensive sanctions violate these two essential provisions of just warfare. Therefore, comprehensive sanctions, when applied to achieve war-like goals, may violate more human rights than war itself, and these violations often cause long-term adverse effects.
For example, following a war, the winning powers may oversee the administration of the vanquished government. Under sanctions, the enemy power targeted by the country that imposed the sanctions remains in control. In such a situation, other countries or international organizations may be tempted to provide humanitarian goods to further intervene in the countrys politics. The UN, for example, insisted on establishing and supervising regulations for distributing humanitarian goods via the 1996 oil-for-food deal in Iraq. In Cuba, the United States insists on ground supervision of the distribution of humanitarian goods from private U.S. groups. Sanctioned governments rail against such interventions by hostile powers as violations of their national sovereignty.
In a decade of debate about the relative merits of economic sanctions, there has been a critical lack of a systematic approach to assessing and minimizing their humanitarian impact. After the debacle in Iraq, the world community can no longer assume that sanctions are necessarily less violent than warfare. The UN, the International Committee of the Red Cross, and nongovernmental organizations now recommend several actions to reduce sanctions-related damage:
nPrior to initiating sanctions, baseline data on health and well-being should be gathered. This, in fact, was done by the UN in Sudan and Burundi in 1998 in anticipation of imposing sanctions on those countries.
nLikely vulnerabilities of the target society must be anticipated and organizations must respond aggressively to provide necessary resources and deploy the agencies that can distribute them. Analysis of the effects of sanctions in the past is essential to determine the likely level of suffering and to decide if causing such damage to civilian populations is warranted.
nPublic health, economic status, population dynamics, and political conditions in sanctioned countries must be monitored to allow early detection of deteriorating conditions. The system should monitor short-term and long-term indicators of population status. For example, actual death rates of children under 1 year old and under 5 years old are good baseline indicators, but short-term changes in mortality and morbidity rates can also be estimated from data on the number of measles cases, the percent of all deaths due to diarrhea, and the prevalence of malnutrition among children.
nA streamlined approval process to speed the movement of essential humanitarian goods should be created. This could involve both a standard list of exempt items and blanket exemptions for a select group of international relief organizations.
nProcedures used in sanctioned countries for handling exemptions requests, distribution of goods, and on-site verification should be standardized.
Most importantly, the goals for sanctions should be reassessed in light of the extensive experience in the 1990s. Sanctions seldom achieve their stated goal: the overthrow of repressive regimes. Only military action can accomplish that. When a few individuals are responsible for inciting hostile action, desired policy changes may often be achieved by freezing the countrys assets, halting cultural exchanges, and imposing travel bans.
Sanctions are an important option; without them governments are left only with the options of business as usual or a rush to war. To play the intermediate role that sanctions can perform, they must be carried out in ways that eliminate the gross violations of human rights that have plagued them in the 1990s.n
Richard Garfield is a professor of clinical international nursing at Columbia University, in New York, New York.
1.D. Cortright and G.A. Lopez, eds., Economic Sanctions: Panacea or Peacebuilding in a Post-Cold War World (Boulder: Westview Press, 1995). See also L. Minear et al., "Toward More Humane and Effective Sanctions Management: Enhancing the Capacity of the U.N. System," Watson Institute for International Studies Occasional Paper No. 31 (Providence RI: 1998).
2. D. Losman, International Economic Sanctions (Albuquerque: University of New Mexico Press, 1979).
3. M. Walzer, Just and Unjust Wars (New York: Basic Books, 1977).
4. T. Buergenthal, International Human Rights (St. Paul, MN: West Publishing Co. 1995).
5. T. Weiss et al., Political Gain and Civilian Pain: Humanitarian Impacts of Economic Sanctions (Lanham, MD: Rowman and Littlefield, 1997).
6. E. Gibbons, Sanctions in Haiti: Human Rights and Democracy Under Assault (Westport, CT: Praeger Press, 1999).
7. R. Garfield, "The Impact of Economic Embargoes on the Health of Women and Children," Journal of the American Medical Womens Association 52 (4) (1997), pp. 181-4; R. Garfield, J. Devin, and J. Fausey, "The Health Impact of Economic Sanctions," Bulletin of the New York Academy of Medicine 72 (2) (1995), pp. 454-68.
8. Buergenthal, International Human Rights.
9. "Iraq Sanctions Create Their Own Disaster," International Federation of Red Cross and Red Crescent Societies, World Disaster Report 1998, Chapter 8 (Geneva: Red Cross, 1998); "UNICEF Analyse de la Situation de la Femme et des Enfants en Haiti (période 1980-1993)," (Port-au-Prince: UNICEF, 1994), p. 221, quoting a French cooperation study of 1992, which also showed a shortfall of 18 percent between the total minimum calories needed for the population, and the total available for consumption from production and imports.
10. R. Garfield, "The Human Consequences of War," in B.S. Levy and V.W. Sidel, eds., War and Public Health (New York: Oxford University Press, 1997).
11. Walzer, Just and Unjust Wars.
12. R. Garfield and S. Santana, "The Impact of the Economic Crisis and the US Embargo on Health in Cuba," American Journal of Public Health 87 (1) (1997), pp. 15-20.
14. Pan American Health Organization; Health Conditions in the Americas, Scientific Publication No. 549 (Washington, DC: PAHO, 1995).
15. PAHO/WHO, PAHOs Program of Humanitarian Assistance to Haiti 1991-1994: A Strategic Evaluation Report (Washington, DC: PAHO/WHO, March 1995), p. 8.
16. E. Gibbons, Sanctions in Haiti.
17. R. Garfield, "Morbidity and Mortality among Iraqi Children from 1990 through 1998: Assessing the Impact of the Gulf War and Economic Sanctions" (Goshen, IN: Fourth Freedom Forum Occasional Paper, 1999).
18. J. G. Heidenrich, "The Gulf War: How Many Iraqis Died?" Foreign Policy 70 (1993), pp. 108-125; B.O. Daponte, "A Case Study in Estimating Casualties from War and its Aftermath: The 1991 Persian Gulf War," PSR Quarterly 3 (1993), pp. 57-66.
19. G. Berggren et al., Sanctions in Haiti: Crisis in Humanitarian Action (Boston, MA: Program for Human Security, 1993); Garfield and Santana, "The Impact of the Economic Crisis and the US Embargo on Health in Cuba"; Haiti Survey on Mortality, Morbidity, and Utilization of Services 1994/1995 (Petion-Ville, Haiti: Institut Haitien de LEnfance, 1995).
20. J. Devin and Dashi-Gibson, "Sanctions in the Former Yugoslavia: Convoluted Goals and Complicated Consequences," in Cortright and Lopez, eds., Economic Sanctions, pp. 149-187.
21. Garfield and Santana, "The Impact of the Economic Crisis and the US Embargo on Health in Cuba."
22. Berggren et al., Sanctions in Haiti: Crisis in Humanitarian Action.
23. A.F. Kirkpatrick, "Role of the USA in Shortage of Food and Medicine in Cuba," The Lancet 348 (1996), pp. 1489-91.
24. Gibbons, Sanctions in Haiti.
25. Garfield and Santana, "The Impact of the Economic Crisis and the US Embargo on Health in Cuba"; E. Hoskins, " Public Health and the Persian Gulf War," in B. Levy and V. Sidel, War and Public Health (New York: Oxford University Press, 1997).
26. Kirkpatrick, "Role of the USA in Shortage of Food and Medicine in Cuba."
27. Garfield, "Morbidity and Mortality among Iraqi Children from 1990 through 1998."