INTERNATIONAL SANCTIONS, HEALTH IMPACT OF

To sanction a country is to interrupt communications, diplomacy, or economic relations. Sanctions have become especially common since the end of the Cold War. Sanctions appear to externalize all costs onto the sanctioned country. But a lot of those costs are borne by the civilian population.

War has become more destructive as weapons have become more powerful, more devastating, and more mobile. The 1977 Additional Protocols to the 1949 Geneva Convention prohibit any wartime measure that has the effect of depriving a civilian population of objects indispensable to survival. Article 70 of Protocol I mandates relief operations if civilian populations are not "adequately provided" with humanitarian goods. Article 18 of Protocol II calls for relief operations for a civilian population that suffers "undue hardship owing to a lack of supplies essential for its survival, such as foodstuffs and medical supplies." Article 14 of Protocol II guarantees the protection of goods indispensable to survival: "Starvation of civilians as a method of combat is prohibited. It is therefore prohibited to attack crops, livestock, drinking water installations and supplies and irrigation works." Ironically, most people would be better off materially in occupied territory during or after a war than in a country under comprehensive economic sanctions. Under sanctions, no such protections are assured.

This does not mean that sanctions are deadlier than war, as some have argued. The likelihood of injury or death is still greater from bombs or bullets than from a shortage of medicines or food. But even in the most aggressive of wars, most people are not exposed to bullets and bombs most of the time. By contrast, virtually the entire population of a country may be exposed to risks from a shortage of essential goods permanently under embargoes. This small increase in risk, when distributed among a large population for a long time, can result in more death and destruction than war.

COUNTRY BACKGROUNDS

Cuba was sanctioned by the United States in 1964. During détente in the 1980s sanctions were relaxed, permitting Cuba to purchase goods from United States companies through other countries. In 1992 the United States embargo was made more stringent with the passage of the Cuban Democracy Act. All United States subsidiary trade, including trade in food and medicines, was prohibited. Ships from other countries were not allowed to dock at United States ports for six months after visiting Cuba, even if their cargoes were humanitarian goods (see Table 1).

Haiti has been the poorest country in the western hemisphere for most of its two centuries of post-colonial history. When Jean-Bertrand Aristide became the country's first elected president in February 1991, half of the labor force was unemployed, half of all adults were illiterate, and a third of the people lacked access to modern health services. A military coup ousted Aristide in September, and sanctions were initiated by the United States and the Organization of American States (OAS), a regional body of the United Nations, in October 1991.

Sanctions began on all items exported to Iraq except medicines in August 1990. Following the Gulf War of January and February 1991, sanctions were reaffirmed by the United Nations. Starting April 1991, Iraq was again permitted to import food in addition to medicine. In fact, little of either

Table 1

commodity was imported. In 1995 the United Nations Security Council authorized sales of oil for the purchase of humanitarian goods. The government of Iraq approved the Oil for Food (OFF) plan only in 1996, and the first deliveries of humanitarian goods began in 1997.

Oil sales from the first five six-month rounds of the OFF program generated $7.7 billion for humanitarian goods. Goods purchased with these funds amounted to a little over half of this total, representing $394 per capita in the center and south of Iraq and $480 per capita in the north. Even though far more goods were being imported to Iraq under OFF than at any time since initiation of the embargo, the $3 to $4 worth of food and medicines distributed per capita per month under OFF represented only a fraction of the estimated $12 imported per capita per month during 1988–1989.

HEALTH EFFECTS

Total mortality per 1,000 inhabitants in Cuba rose from 6.4 in 1989 to 7.2 in 1994. The increase was almost entirely due to a 15 percent rise in mortality among those aged 65 years and older. From 1992 to 1993, the death rate for influenza and pneumonia, tuberculosis, diarrhea, suicide, unintentional injuries, asthma, and heart disease each rose by at least 10 percent among this older population, as some of those with chronic diseases requiring daily medication or laboratory support did not get needed goods. In all other age groups, mortality rates remained stable or declined.

Maternal mortality among Cubans rose sharply from formerly low levels in 1993–1994. Extraordinary efforts to provide extra food rations to pregnant women and revamp birthing procedures rapidly reversed the trend toward rising mortality. Infant mortality in Cuba, long among the lowest in Latin America, did not rise but failed to continue declining during those same years. Subsequent efforts to improve maternal nutrition and conditions for delivery led to continued declines in infant mortality starting in 1996.

In Haiti, the 1995 Demographic and Health Survey found that between 1987 and 1994 the mortality of children one through four years of age rose from 56 per thousand to 61 per thousand. This high a rate last occurred 17 years earlier. During the same period infant mortality declined 38 percent, from 101 to 74 per 1,000. Average life-expectancy for Haitians decreased by 2.4 years during the crisis and in 1994 stood at 54.4.

Much of the increased mortality among one-through-four-year-olds was due to a measles epidemic from June 1991 to November 1993. The Immunization Program Technical Committee had decided to delay a measles vaccination campaign until President Aristide returned.

In Iraq, a large-scale demographic survey carried out by UNICEF in the first half of 1999 showed that mortality levels after 1995 were double the rates in the late 1980s at about 131 per 1,000 live births and that mortality in the North was lower than the Center and South. The maternal mortality rate in all three countries rose during sanctions.

In Cuba, the number of laboratory exams provided in the country's 273 hospitals declined by 36 percent and the number of X-rays declined by 75 percent from 1990 to 1994. Most Cuban ambulances were in working order in the 1980s; fewer than half worked in June 1994. In Baghdad in 1996, since spare tires were not permitted due to their potential military use, only five of the 100 public ambulances were working; the parking lots looked like junk yards.

Almost all sanction legislation has provisions for exemptions for food and medicines. Nonetheless all sanctions led to limitations on the importation of foodstuffs and medicines due to disruption of commercial arrangements, complications in transportation, or lack of capital in the embargoed country with which to purchase the exempted goods.

METHODOLOGICAL CHALLENGES

The methodologic challenges to establishing a valid assessment of the impact of an embargo are daunting:

• Embargoes spread a small increase in risk of death, illness, or social stress among a large group of people. Small risks are difficult to measure with precision.
• This small change in risk may be obscured by concurrent events that independently contribute to the negative outcomes which result from an embargo, such as war, mass migration, or economic crisis.
• The impact of an economic sanction on health and well-being is mediated by a country's economic and social systems. Major impacts occur through the effect of sanctions on the production, importation, and distribution of essential goods. There are thus multiple pathways and steps by which influence is exerted on the health and well-being outcomes.
• Each sanction on economic trade is a type of natural experiment, where the intervention is national in scope and control groups with which to make comparisons are lacking. Baseline information available in sanctioned countries is usually limited in coverage or quality and, with the exception of Cuba, the quality of information on health and well-being has declined under sanctions.
• Changes in the distribution of essential goods within the family and the mobilization of underutilized resources due to political or social organization modify the impact of resource changes brought on by economic sanctions. These modifying influences are difficult to isolate and often go unrecognized or unmeasured. Even a dramatic decline in key resources does not always or immediately lead to increases in morbidity or mortality due to the resilience of such health assets as public education, healthy behaviors, trained health workers, and infrastructure, which deteriorate only gradually.
• Much available information comes from statistics from health or social service provider institutions. These organizations have information on services provided or people served (a numerator) but seldom have information on the underlying populations (the denominator) from which service users come. Such available information usually cannot be used to establish valid rates or to identify changing levels of demand, need, or severity.

FUTURE HUMANITARIAN ASSESSMENTS

Future assessments should focus more on the "well-being" aspects of "health and well-being." More needs to be learned about the impact of social deterioration on those who do not die or lie in hospitals for want of medicines during embargoes. Among children, this includes research on changes in mental capacity, educational achievement, and access to learning materials among those in school; and on employment and survival strategies among those not in school. Changes in learning and employment opportunities in higher education and in-service training should similarly be explored. Changing types and levels of delinquency and familial and governmental responses should be studied. Changing patterns and levels of family formation, family functioning, and family-related social pathologies should be identified. The loss of knowledge of professionals, cut off from routine international exchange, should also be evaluated. More needs to be known about the nutritional status of older children and adults along with that of young children, and research is needed to identify the pathways by which those changes occurred. Changing patterns of resource generation and utilization should be identified, including both formal (money) and informal (unpaid labor) resources. These measures of wellbeing will assist in identifying effective coping strategies, existing strengths in a society, and opportunities for relief and reconstruction.

Research should combine quantitative indicators of health and well-being with qualitative information to understand better how available inputs lead to the specific outcomes found. Such a combination will assist in clarifying the chain of events leading to damage, as well as those factors strengthening resilience or mitigating damage. This requires insights and measures not only from clinical medicine but also from demographics, sociology, anthropology, and psychology. Nongovernmental organizations have an important role to play in such assessments.

It has been shown that infant mortality has declined in some embargoed countries even during periods of severe resource shortages. This has occurred when scarce resources were distributed more efficiently, and health and national leaders mobilized child-health actions. When social and political emergency moves parents to special actions, much is possible. Cuba, for example, moved from about half to more than 90 percent breast-feeding of newborns during the first three months of the embargo, when leaders showed that breast-feeding would make up for lost formula imports. Similarly, a campaign to boil water before drinking gained support when it was broadcast that the embargo resulted in a lack of chlorine to treat water supplies. In other countries, campaigns promoting monitoring of child development and pregnant women; vaccinations; the use of herbal medicines; community participation in sanitation to reduce malaria and dengue transmission have been successful under the special conditions of externally imposed resources shortage caused by embargoes. In Iraq, the development of communitybased child nutrition and community development programs were stimulated. All of these basic health measures would have been beneficial prior to the embargo but were precipitated by a collective sense of emergency and the recognition of an opportunity to respond.

Improved monitoring, expanded humanitarian action, and the modification of national policies to protect the most vulnerable with simple low-cost public health actions will be needed to reduce humanitarian damage and speed recovery in countries affected by sanctions or other crises.

Richard Garfield

(see also: Famine; Genocide; Refugee Communities; War )

Bibliography

Ascherio, A.; Chase, R.; Cote, T. et al. (1992). "Effect of the Gulf War on Infant and Child Mortality in Iraq." New England Gamble of Medicine 327(13): 931–936.

Berggren, G.; Castle, S.; Chen, L.; Fitzgerald, W.; Michaud, C.; and Simunovic, M. (1993). "Sanctions in Haiti: Crisis in Humanitarian Action." Boston: Harvard School of Public Health, Program on Human Security, Working Paper Series, November 1993.

Doudi, M. A., and Dajant, M. S. (1991). Economic Sanctions: Ideas and Experiences. Boston: Routledge and Kegan.

Garfield, R., and Neugut, A. (1991). "Epidemiological Analysis of Warfare." Journal of the American Medical Association 266(5): 688–692.

International Federation of Red Cross and Red Crescent Societies. (1998) "Iraq Sanctions Create Their Own Disaster." In World Disaster Report 1998. Geneva: World Health Organization.

Rojas Ochoa, F., and Lopez Pardo, C. M. (1997). "Economy, Politics, and Health Status in Cuba." International Journal of Health Services 27(4): 791–807.

Weiss, T. G.; Cortright, D.; Lopez, G. A.; and Minear, L., eds. (1997). Political Gain and Civilian Pain: Humanitarian Impacts of Economic Sanctions. Lanham, MD: Rowman and Littlefield.