The New England Journal of Medicine
Volume 336(17).Apr 24, 1997.pp 1248-1250.
Copyright 1997 by the Massachusetts Medical Society.
The Sleep of Reason Produces Monsters -- Human Costs of Economic Sanctions
Editorial by
Leon Eisenberg, M.D.
Harvard Medical School; Boston, MA 02115
(The following is an excerpt from the full-length editorial. See the full-length editorial with references.)
...
Iraq is an even more disastrous example of war against the public health. Two months after the end of the six-week war, which began on January 16, 1991, a study team from the Harvard School of Public Health visited Iraq to examine the medical consequences of sanctions imposed after the armed conflict. The destruction of the country's power plants had brought its entire system of water purification and distribution to a halt, leading to epidemics of cholera, typhoid fever, and gastroenteritis, particularly among children. Mortality rates doubled or tripled among children admitted to hospitals in Baghdad and Basra. Cases of marasmus appeared for the first time in decades. The team observed "suffering of tragic proportions.... [with children] dying of preventable diseases and starvation." Although the allied bombing had caused few civilian casualties, the destruction of the infrastructure resulted in devastating long-term effects on health.
An international group supported by the United Nations Children's Fund (UNICEF) carried out a more comprehensive study five months later by interviewing members of households selected to represent the Iraqi population. The age-adjusted relative mortality rate among children in the eight months after the war, as compared with the five years before the war, was 3.2. There were approximately 47,000 excess deaths among children under five years of age during the first eight months of 1991. The deaths resulted from infectious diseases, the decreased quality and availability of food and water, and an enfeebled medical care system hampered by the lack of drugs and supplies.
The Cuban and Iraqi instances make it abundantly clear that economic sanctions are, at their core, a war against public health. Our professional ethic demands the defense of public health. Thus, as physicians, we have a moral imperative to call for the end of sanctions. Having found the cause, we must act to remove it. Continuing to allow our reason to sleep will produce more monsters.
In mid-19th-century London, John Snow thought he discerned a pattern in the distribution of cases of cholera. He observed that in 10 days there were more than 500 fatal attacks of cholera within 250 yards of the spot where Cambridge Street joined Broad Street. What made that junction important was the fact that residents of the area obtained their water from the Broad Street pump. Because so many cases were aggregated in an area supplied by one water company, Snow petitioned the Board of Guardians of St. James parish to remove the handle of the pump. They did. The epidemic subsided.
Like John Snow, we have a responsibility to petition the authorities to remove the known causes of epidemics -- in this case, by ending U.S. restrictions on trade in nonmilitary supplies. Doing so will not make us popular in some circles. But neither the Hippocratic oath nor its contemporary versions contain clauses that make self-interest grounds for exempting physicians from "acting for the benefit of the sick... and keeping them from harm and injustice."