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Economic Sanctions and Public Health: A View from the Department of State FREE

Madeleine K. Albright
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Department of State; Washington, DC 20520 (Albright)

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Ann Intern Med. 2000;132(2):155-157. doi:10.7326/0003-4819-132-2-200001180-00012
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I welcome the opportunity to comment on topics raised in this issue about the importance of minimizing the effect of economic sanctions on public health (12). The Clinton Administration fully supports this goal and seeks a partnership with the public health community in making further progress toward it.

Historically, sanctions have been used as a tool—short of war or other, more extreme measures of coercion—to induce a government violating international norms to improve its policies. Sanctions have also been used as a punishment for such violations. In recent years, especially, sanctions have often been supported or proposed by nongovernmental organizations concerned with such matters as religious freedom, respect for human rights, and the apprehension of war criminals. In the United States, this support is reflected in the flood of sanctions-related legislation annually considered by Congress.

Despite this, the overall record of sanctions as an instrument of policy has been mixed. In many cases, sanctions have been imposed for years, even decades, without achieving their objectives. However, most observers would agree that U.N. sanctions contributed significantly to the downfall of racist regimes in the former Rhodesia and South Africa. In this decade, sanctions caused Libya's government to make available for trial two men suspected of the terrorist sabotage of Pan American Flight 103. Currently, sanctions are an important source of pressure against the regime of indicted war criminal Slobodan Milosevic in Yugoslavia. In Burma, the democratic opposition, led by Nobel Prize-winner Aung San Suu Kyi, strongly supports sanctions as a way to prod that nation's repressive military toward a more open political system.

As a policymaker, I have long been concerned that sanctions—like force—can be a blunt instrument. When the United Nations or the United States imposes sanctions against a regime, whether in response to military aggression or egregious violations of human rights, it does not intend to create unnecessary hardships for innocent people, especially children and infants. Good intentions, however, do not automatically translate into good results.

In recent years, the United States has joined the United Nations and other concerned countries in exploring ways to preserve the effectiveness of sanctions while minimizing harm to innocent civilians. One method involves imposing only limited sanctions by, for example, restricting visas for government officials or prohibiting civil air transportation. A second method of limitation was articulated by President Clinton in July 1998 when he declared that “food and other human necessities should not be used as a tool of foreign policy except under extraordinary circumstances.”

The president's statement builds on a long-standing record. The United States has supported emergency food relief since at least the 1920s and has offered support for public health, infant nutrition, child survival, and anti-hunger projects around the globe for more than half a century. The U.S. Agency for International Development, in particular, has been a champion of public health in partnership with the United Nations Children's Fund (UNICEF), the World Health Organization, and a broad array of nongovernmental organizations.

These policies have been sustained even when the governments of the countries involved have been subject to sanctions. For example, over the past decade the United States has financed more than $1 billion in food and other humanitarian supplies that independent relief agencies have delivered to the people of war-torn Sudan. During the past several years, the United States has donated more than 400 000 metric tons of wheat and flour to the World Food Program for use in North Korea.

In the same vein, President Clinton announced in April 1999 that the United States would generally exclude food, medicines, and medical equipment from future sanctions and that we would extend that principle to existing sanctions where we have the discretion under U.S. law to do so. The change does not affect Iraq, Cuba, or North Korea, where food and medicine have always been exempt from sanctions, but it has enabled us to liberalize regulations that govern exports to Iran, Sudan, and Libya. To maximize the positive humanitarian effect of this policy adjustment, we are defining food broadly as anything that can be ingested by humans and animals, including feed and seeds. Since the adjustment has been made, U.S. companies have sold approximately 250 000 tons of corn to Iran.

In recent years, much controversy has surrounded the economic sanctions imposed by the United Nations Security Council against the government of Iraq. These sanctions stem from Saddam Hussein's brutal and unprovoked 1991 invasion of Kuwait and his subsequent failure to comply with weapons inspection and monitoring requirements. This failure cannot simply be shrugged off. United Nations Security Council resolutions are designed to ensure that Saddam Hussein does not again threaten his neighbors with aggression or the world with weapons of mass destruction. Saddam Hussein has used chemical weapons both in battle and against his own people. He has started two wars. He has lied repeatedly about Iraq's weapons programs. If sanctions were prematurely lifted and Saddam once again gained access to the money needed to build weapons of mass destruction, we could expect him to do so—without any moral compunction about their use.

From the humanitarian perspective as well as the diplomatic and security perspectives, the case for continued sanctions as a means of pressure against Saddam Hussein is overwhelming. There is no greater enemy to public health in Iraq than he. At the same time, we have an obligation, which we are meeting, to do all we can to minimize the harmful effects of sanctions on Iraqi civilians. Even under sanctions, Baghdad has always been free to import food and medicine. To make this easier, the United States took the lead more than 6 years ago in proposing an “oil-for-food” program, under which Iraq could use revenues from the sale of limited amounts of petroleum to purchase humanitarian supplies. Saddam long resisted this plan because he wanted to use his people's suffering to mobilize public opposition to sanctions. During the past few years, however, the program has been implemented and has grown steadily. The results are significant.

During the 2.5 years that the oil-for-food program has operated, it has delivered $3.7 billion in food, $691 million in medicine, and more than $500 million in supplies for projects involving electricity, water and sanitation, agriculture, education, the oil industry, settlement rehabilitation, and demining. In addition, between December 1996 and July 1999, the U.S. State Department recommended the approval of licenses for the sale of more than $372 million in U.S. agricultural commodities for the program. The oil-for-food program has increased the daily caloric value of the Iraqi ration basket by 50% and has steadily improved health care. Iraq is now importing as much food and exporting almost as much oil as it did before the Gulf War.

Despite all this, the humanitarian crisis in Iraq persists. The question is why. A study issued last August by UNICEF provides strong evidence of the answer. In northern Iraq, where Saddam Hussein's government is not in control and the United Nations administers the oil-for-food program, child mortality rates are now lower than they were before the Gulf War. This point deserves emphasis: In northern Iraq, child mortality rates are lower now with sanctions than they were without sanctions before the war. By contrast, child mortality rates have more than doubled in southern and central Iraq, where Saddam Hussein remains in control and the Iraqi government rather than the United Nations administers the oil-for-food program.

The problem is that Saddam is not using the available resources for the intended purposes. According to the United Nations, the Iraqi government has spent only $9.5 million of the $25 million that has been set aside for nutrition supplies for vulnerable children, pregnant women, and nursing mothers. Until the United Nations called attention to the situation earlier this year, almost $300 million in medical supplies, or about half of the supplies shipped under the oil-for-food program, was sitting undistributed in Iraqi warehouses. In addition, while primary care needs go unmet, Baghdad has ordered expensive diagnostic tools, such as a high-resolution magnetic resonance imaging machine and a γ knife (which is used in complicated neurosurgery). There are also reports that the Iraqi regime is selling medicines received under the oil-for-food program to private hospitals at exorbitant prices. We also have evidence that the Iraqi military bulldozed 160 homes in the town of Almasha in June 1999 after local citizens protested Baghdad's failure to distribute food and medicine. Meanwhile, the regime is squandering its scarce resources on luxury cars, palaces, and resorts for the elite. Therefore, although the oil-for-food program is giving the people of Iraq, especially northern Iraq, access to essential food and medicine, it would be much more effective if the Iraqi regime began to do its part. It is Saddam Hussein's obstruction, not U.N. sanctions, that remains the primary cause of suffering in Iraq.

Cuba is another country whose government has sought to blame sanctions for its own failures. Unlike the sanctions against Iraq, the sanctions applied against Cuba are unilateral, not multilateral. This means that commercial opportunities are available to Cuba throughout the rest of the Americas, Europe, Asia, and elsewhere. Although U.S. sanctions are indeed a source of pressure, the fundamental problem is Havana's allegiance to economic and political doctrines that have failed everywhere they have been tried. The United States believes that the people of Cuba should have the same rights as their counterparts throughout the hemisphere, including the right to have a voice in choosing their own leaders. There would be no better route to greater prosperity and improved public health in Cuba than a government that was accountable to its people.

In the meantime, the Clinton Administration has taken steps to increase people-to-people ties between the United States and Cuba and to help the Cuban people prepare for a democratic future. These steps include licensing of food and agriculture sales to entities that are independent of the Cuban government and increasing the amount of remittances that persons in the United States can send to family members or independent organizations in Cuba. The sale of medicines, medical supplies, and medical equipment to Cuba is governed by the 1992 Cuban Democracy Act. Within the limits imposed by that statute, the Department of Commerce licensed approximately $45 million in medical sales in 1998 and the first half of 1999 and more than $100 million in humanitarian donations of medicine and medical equipment.

The United States cares deeply about the well-being of the Cuban people. That is why we support democratic change. To that end, we will continue to take steps to address humanitarian needs, aid the development of civil society, strengthen the role of nongovernmental organizations (including the church), and otherwise help lessen popular dependence on the Cuban state.

Our effort to improve the effectiveness of sanctions on behalf of peace and respect for human rights remains a work in progress. We cannot be satisfied as long as innocent populations suffer as a result of repressive or lawless leaders. The job of developing and revising effective sanctions is by nature multinational, but the United States should be a leader in that effort.

Accordingly, the Clinton Administration is committed to working with other nations and with international and nongovernmental organizations, including the public health community, to further explore the full range of issues related to sanctions. We are also working with Congress on legislation for sanctions reform that would provide the executive branch with greater flexibility in responding to changing circumstances and new information.

I congratulate Annals for devoting attention to a discussion of this politically, technically, and morally complex subject. Although I wish it were not the case, the challenge of responding to regimes that ignore international law and run roughshod over the rights of their own people is not likely to go away. We must continue to assess and reassess the tools we have available to respond and to ensure that sanctions, when used, are used in the best possible way for the best possible results.

Madeleine K. Albright, Secretary of State

Department of State; Washington, DC 20520

Barry M.  Effect of the U.S. embargo and economic decline on health in Cuba. Ann Intern Med. 2000; 132.151-4
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




Barry M.  Effect of the U.S. embargo and economic decline on health in Cuba. Ann Intern Med. 2000; 132.151-4
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


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