Essay Journal of the Royal Society of Medicine; 2015, Vol. 108(2) 49–52 DOI: 10.1177/0141076814555938
Global health and security in the age of counterterrorism Leonard S Rubenstein Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA Corresponding author: Leonard S Rubenstein. Email: [email protected]
Fifteen years ago, the idea of advancing global health as an intrinsic good that demanded international attention and resources catapulted onto the global agenda. UN bodies gave new life to the long dormant concept of a right to health through clarifying interpretations of human rights law and the creation of a Special Rapporteur on the Right to the Highest Attainable Standard of Health. Broad social mobilisation on HIV/AIDS galvanised political action for donor funding commitments and inspired other health campaigns such as for safe motherhood and child survival, all based on the intrinsic value of health. Vastly increased development aid for global health followed, more than tripling from 1998 to 2013, reaching more than US$31.3 billion in 2013.1 Around the same time, and especially after the attacks of 11 September 2001, interest in the connection between health and national security grew. Concerns included prevention of bioterrorism and employing health interventions as a tool to wean populations away from allegiance to terrorist organisations.2 In policy circles, the two approaches to health – as an intrinsic good that warranted support and as an instrument of national security policy – seemed to dovetail. For example, national security became another rationale for greater commitments to global health spending by donors. Former U.S. Secretary of State Hillary Clinton frequently urged major increases in resources for global health both as a means to advance human dignity and as an element of what she called ‘smart power’ that would increase U.S. diplomatic leverage and national security.3 Many global health advocates welcomed this strengthened connection between global health and national security as a means of bolstering arguments for spending on global health, especially among policy-makers who otherwise were indifferent or hostile to development aid. For them, health as a national security intervention married the intrinsic value of health and its instrumental use, with benefits for both health and security. The connection between health and national security is of course not new. Cross-border spread of infectious diseases has been a concern of the
international community for decades, as has been demonstrated once again in the Ebola crisis. Research on tropical diseases was stimulated in part by needs to protect soldiers and colonial officers in affected regions of the world. Further, there has been a long history of states supplying health resources, from hospital ships to doctors and nurses, in the hope that their actions could advance their diplomatic objectives. In the 1990s, linkages between health and national security were also reflected in programmes such as health as a ‘bridge to peace’, which promoted health cooperation as a means of resolving or preventing conflict. A more nuanced facet of this approach was the inclusion of health programmes as part of initiatives to stabilise states with fragile governance or a recent history of armed conflict. State building and stabilisation most often focused on devoting resources to improve governance, reform the security sector, build a fair and effective justice system, reduce corruption, and provide jobs for people. Some of these initiatives, such as in the Democratic Republic of Congo, Liberia and Timor-Leste, also embraced the idea that a well developed and equitably run health programme could advance state legitimacy by building popular trust in government services that in turn could promote stability and contribute to the prevention of future conflict. The experience of such efforts in multiple countries has provided only modest support for the most limited of these objectives, such as increasing trust in government, and even less for preventing future conflict.4,5 These initiatives, however, mask tension between the concepts of health as an intrinsic good and health as an instrument used to achieve military or intelligence objectives. At root, health as a security intervention privileges security objectives over health outcomes and can distort or undermine the effectiveness of health programmes. Most worrying of all, security objectives can lead to interventions that affirmatively harm health. This tension became ever more pronounced after 9/11, as national security agencies sought to use health interventions to realise concrete military and intelligence goals.
! The Royal Society of Medicine 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
50
Journal of the Royal Society of Medicine 108(2)
One strategy used by the United States and its allies extended ideas about employing health programmes to advance stabilisation to military goals that included strengthening popular allegiance to governments. In conflicts in Iraq, Afghanistan and East Africa, health programmes for civilian populations became an element of counterinsurgency strategies designed to ‘win hearts and minds’, develop relationships with local leaders, and give people a stake in local governance. There is no evidence that they achieved their tactical objectives or advanced larger strategic goals. Their negative impacts on health systems, however, were palpable. They tended to skew distribution of health resources inequitably to areas of strategic importance rather than greatest need, to conflict with efforts to build or re-build sustainable health systems, and in some cases to undermine the security of healthcare facilities and personnel.4,5 These results should not be surprising, as the programmes were never designed to achieve sustainable long- (or even intermediate-) term benefits, but to advance short-term military objectives. This instrumentalisation of health for military objectives is troubling enough. The logic of the use of health programmes as a security intervention, however, led to interventions that were never intended to advance health, even as collateral benefit. Take, for example, the US Central Intelligence Agency (CIA) fake vaccination campaign as part of its effort to find Osama bin Laden. The CIA identified what it thought was the compound where bin Laden lived in Abbottabad, Pakistan, but had trouble confirming its intelligence. To try to establish his presence in the compound, the CIA enlisted a local doctor to start a purported hepatitis B vaccination campaign in the hope of drawing blood samples from children living in the compound. The campaign had no health purpose for the local population and the effort failed to obtain the children’s blood. The subsequent revelation of the existence of the fake vaccination campaign, however, exacerbated already severe local beliefs that UN-sponsored polio vaccination programmes, which are essential to the global initiative to eradicate polio, were a Western or antiIslam plot. Since the revelation of the CIA campaign, about 60 vaccinators have been murdered, most of them, according to reports, at the hands of the Pakistani Taliban. It is not possible to conclusively link their deaths to the fake vaccination campaign, but local observers in the best position to know believe that to be the case.6 The White House has since issued a memorandum stating that CIA will
not use fake vaccinations in the future, but it makes no commitment to refrain from use of health programmes that may have military or intelligence value but undermine faith in legitimate health providers.7 The logic of employing health instrumentally to advance security has also led to practices that deny healthcare as a counterterrorism strategy and punish those who offer it. The United States has enacted laws that deem the provision of healthcare services to be a form of ‘material support’ to terrorism. Under these laws, health providers can be criminally prosecuted for offering healthcare under the direction or control of a designated terrorist organisation or denied asylum for knowingly offering healthcare to a person affiliated with a terrorist organisation.8 Other policies can be directed at entire populations. In 2005, as part of its military and political strategy against Hamas, Israel issued a policy that limited food deliveries into the Gaza strip to the minimum amount needed to avoid malnutrition.9 There is dispute whether and how the policy was carried out, but the very existence of the plan, to manipulate health for advancing security objectives, is surely troubling. Finally, once health is understood as a means to advance security rather than an end in itself, regimes that commit atrocities against civilians invoke the very antiterrorism justifications outlined here to breach long-recognised legal protections of health facilities and medical personnel from interference or attack during armed conflicts or situations of political volatility. The most notable case is Syria, which has explicitly sought to deny healthcare to populations associated with the opposition on the grounds that it is denying healthcare to terrorists. According to the UN’s independent commission on Syria, government forces deny medical care to those from oppositioncontrolled and affiliated areas as a matter of policy and ‘instrumentalise medical care to further strategic and military aims’.10 The regime has bombed and shelled hospitals, arrested more than 500 doctors and other health workers, and killed well over 160 of them. Syria is rightly condemned for its conduct, which constitutes war crimes, and other governments reject the legitimacy of antiterrorism rationales as a justification for its attacks on healthcare. At the same time, Syria’s conduct is only the most extreme case of using health as a security intervention. Elsewhere, states have denied populations access to healthcare as an instrument of security policy. For example, in 2012, violent assaults on the Muslim Rohingyas by Buddhist groups in Burma’s Rakhine state, with apparent government
Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
Rubenstein
51
support, displaced thousands of people. In the aftermath, Doctors without Borders, which had been providing health services in the region for many years, continued to offer HIV, tuberculosis, malnutrition, malaria and mental health services, as well as antenatal and postnatal care to many of the tens of thousands of displaced Rohingyas. In response, Burma expelled Doctors without Borders from Rakhine state on the preposterous ground that it was providing preferential treatment to the Rohingyas, who of course were under attack and forced to flee. It is far more likely that Burma acted as a means of further marginalising and harming a population already suffering from exclusion and violence.11 This brief review shows that instrumental uses of health interventions to advance military, intelligence and other national security objectives vary from the relatively benign to the horrific. What they share is departure from an understanding that health is a central aspect of wellbeing and human dignity, and should never be manipulated to achieve non-health purposes. That understanding must be restored, affirmed not only by agencies with a health mandate, but by all organs of government and institutions of the international community. We are beginning to see some shifts away from the instrumentalisation of health for national security. The new stabilisation doctrine of the UK military is oriented towards viewing health as an element of human security rather than national security, which requires support for local health leadership and health priorities and an orientation towards sustainability.12 To make further headway, a number of steps are needed. States must take strong, uncompromising and principled steps to restore the sanctity of health as a form of respect for all humanity and demand protection and respect for those who provide it. They must affirm in every circumstance that health is an end and never a means, and that includes its place in fighting terrorism. Laws that criminalise the act of providing healthcare must be repealed. Global institutions designed to hold violators to account, historically very weak, must be strengthened. And we can no longer delude ourselves that use of health as a means to national security advances both.
Declarations Competing interest: None declared
Funding: Support for some of the research covered by this essay was provided by the Johns D. and Catherine T. MacArthur Foundation Ethical approval: No human or animal subjects were involved in the writing of this paper Guarantor: LR Contributorship: Sole author Acknowledgements: None Provenance: Not
commissioned;
peer-reviewed
by
Seye
Abimbola
References 1. Dieleman JL, Graves CS, Templin T, et al. Global health development assistance remained steady in 2013 but did not align with recipients’ disease burden. Health Aff 10.1377/hlthaff.2013.1432. 2. Feldbaum H, Lee K and Michaud J. Global health and foreign policy. Epidemiol Rev 2010; 32: 82–92. 3. Secretary of State Hillary Clinton, Initiative: The Next Phase of American Leadership. The Global Health Initiative: The Next Phase of American Leadership in Health Around The World. Remarks at Johns Hopkins School of International Studies, 16 August 2012. https:// blogs.state.gov/stories/2010/08/16/secretary-clintondelivers-remarks-global-health-initiative (last checked 8 October 2014). 4. Rubenstein LS. Post-conflict health reconstruction: search for a policy. Disasters J Disaster Stud Policy Manage 2011; 35: 680–700. 5. Gordon S. Health, stabilization and securitization: towards understanding the drivers of the military role in health interventions. Med Confl Surviv 2011; 27: 43–66. 6. Beaubien J. Taliban in Pakistan Derail World Polio Eradication, 28 July 2014. National Public Radio 2014. See http://www.npr.org/blogs/goatsandsoda/ 2014/07/28/330767266/taliban-in-pakistan-derailsworld-polio-eradicationby (last checked 8 October 2014). 7. Letter from Lisa Monaco, Assistant to the President for Homeland Security and Counterterrorism to Deans, 16 May 2014. http://apps.washingtonpost. com/g/page/national/letter-to-deans-of-public-healthinstitutions/1040/ (last checked 8 October 2014). 8. United States Code Title 18, §§2339A and 2339B, title 8 §1182(a)(3)(B)(iv)(VI). 9. State of Israel, Ministry of Defense, Coordination of Government Activities in the Territories. Gaza Strip Food Consumption in the Red Lines. 2005, http:// www.gisha.org/UserFiles/File/publications/redlines/redlines-presentation-eng.pdf (last checked 8 October 2014). 10. United Nations Human Rights Council, Assault on Medical Care in Syria; Report of the Independent International Commission on the Syrian Arab Republic, http://www.securitycouncilreport.org/atf/cf/ %7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9
Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
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Journal of the Royal Society of Medicine 108(2)
%7D/a_hrc_24_crp_2.pdf (last checked 8 October 2014). 11. Lipes S Medical Aid Group Seeks ‘Unfettered Access’ in Myanmar’s Rakhine State. Radio Free Asia, 25 July 2014. http://www.rfa.org/english/news/myanmar/aid07252014152613.html (last checked 8 October 2014).
12. Doctrine Note 11/22. Military Medical Contribution To Health Sector Development Within Security and Stabilisation Operations, no date. https://www.gov.uk/ government/uploads/system/uploads/attachment_data/ file/183467/MMCtoHSD_within_SandS_Ops.pdf (last checked 8 October 2014).
Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
Global health and security in the age of counterterrorism Leonard S Rubenstein Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA Corresponding author: Leonard S Rubenstein. Email: [email protected]
Fifteen years ago, the idea of advancing global health as an intrinsic good that demanded international attention and resources catapulted onto the global agenda. UN bodies gave new life to the long dormant concept of a right to health through clarifying interpretations of human rights law and the creation of a Special Rapporteur on the Right to the Highest Attainable Standard of Health. Broad social mobilisation on HIV/AIDS galvanised political action for donor funding commitments and inspired other health campaigns such as for safe motherhood and child survival, all based on the intrinsic value of health. Vastly increased development aid for global health followed, more than tripling from 1998 to 2013, reaching more than US$31.3 billion in 2013.1 Around the same time, and especially after the attacks of 11 September 2001, interest in the connection between health and national security grew. Concerns included prevention of bioterrorism and employing health interventions as a tool to wean populations away from allegiance to terrorist organisations.2 In policy circles, the two approaches to health – as an intrinsic good that warranted support and as an instrument of national security policy – seemed to dovetail. For example, national security became another rationale for greater commitments to global health spending by donors. Former U.S. Secretary of State Hillary Clinton frequently urged major increases in resources for global health both as a means to advance human dignity and as an element of what she called ‘smart power’ that would increase U.S. diplomatic leverage and national security.3 Many global health advocates welcomed this strengthened connection between global health and national security as a means of bolstering arguments for spending on global health, especially among policy-makers who otherwise were indifferent or hostile to development aid. For them, health as a national security intervention married the intrinsic value of health and its instrumental use, with benefits for both health and security. The connection between health and national security is of course not new. Cross-border spread of infectious diseases has been a concern of the
international community for decades, as has been demonstrated once again in the Ebola crisis. Research on tropical diseases was stimulated in part by needs to protect soldiers and colonial officers in affected regions of the world. Further, there has been a long history of states supplying health resources, from hospital ships to doctors and nurses, in the hope that their actions could advance their diplomatic objectives. In the 1990s, linkages between health and national security were also reflected in programmes such as health as a ‘bridge to peace’, which promoted health cooperation as a means of resolving or preventing conflict. A more nuanced facet of this approach was the inclusion of health programmes as part of initiatives to stabilise states with fragile governance or a recent history of armed conflict. State building and stabilisation most often focused on devoting resources to improve governance, reform the security sector, build a fair and effective justice system, reduce corruption, and provide jobs for people. Some of these initiatives, such as in the Democratic Republic of Congo, Liberia and Timor-Leste, also embraced the idea that a well developed and equitably run health programme could advance state legitimacy by building popular trust in government services that in turn could promote stability and contribute to the prevention of future conflict. The experience of such efforts in multiple countries has provided only modest support for the most limited of these objectives, such as increasing trust in government, and even less for preventing future conflict.4,5 These initiatives, however, mask tension between the concepts of health as an intrinsic good and health as an instrument used to achieve military or intelligence objectives. At root, health as a security intervention privileges security objectives over health outcomes and can distort or undermine the effectiveness of health programmes. Most worrying of all, security objectives can lead to interventions that affirmatively harm health. This tension became ever more pronounced after 9/11, as national security agencies sought to use health interventions to realise concrete military and intelligence goals.
! The Royal Society of Medicine 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
50
Journal of the Royal Society of Medicine 108(2)
One strategy used by the United States and its allies extended ideas about employing health programmes to advance stabilisation to military goals that included strengthening popular allegiance to governments. In conflicts in Iraq, Afghanistan and East Africa, health programmes for civilian populations became an element of counterinsurgency strategies designed to ‘win hearts and minds’, develop relationships with local leaders, and give people a stake in local governance. There is no evidence that they achieved their tactical objectives or advanced larger strategic goals. Their negative impacts on health systems, however, were palpable. They tended to skew distribution of health resources inequitably to areas of strategic importance rather than greatest need, to conflict with efforts to build or re-build sustainable health systems, and in some cases to undermine the security of healthcare facilities and personnel.4,5 These results should not be surprising, as the programmes were never designed to achieve sustainable long- (or even intermediate-) term benefits, but to advance short-term military objectives. This instrumentalisation of health for military objectives is troubling enough. The logic of the use of health programmes as a security intervention, however, led to interventions that were never intended to advance health, even as collateral benefit. Take, for example, the US Central Intelligence Agency (CIA) fake vaccination campaign as part of its effort to find Osama bin Laden. The CIA identified what it thought was the compound where bin Laden lived in Abbottabad, Pakistan, but had trouble confirming its intelligence. To try to establish his presence in the compound, the CIA enlisted a local doctor to start a purported hepatitis B vaccination campaign in the hope of drawing blood samples from children living in the compound. The campaign had no health purpose for the local population and the effort failed to obtain the children’s blood. The subsequent revelation of the existence of the fake vaccination campaign, however, exacerbated already severe local beliefs that UN-sponsored polio vaccination programmes, which are essential to the global initiative to eradicate polio, were a Western or antiIslam plot. Since the revelation of the CIA campaign, about 60 vaccinators have been murdered, most of them, according to reports, at the hands of the Pakistani Taliban. It is not possible to conclusively link their deaths to the fake vaccination campaign, but local observers in the best position to know believe that to be the case.6 The White House has since issued a memorandum stating that CIA will
not use fake vaccinations in the future, but it makes no commitment to refrain from use of health programmes that may have military or intelligence value but undermine faith in legitimate health providers.7 The logic of employing health instrumentally to advance security has also led to practices that deny healthcare as a counterterrorism strategy and punish those who offer it. The United States has enacted laws that deem the provision of healthcare services to be a form of ‘material support’ to terrorism. Under these laws, health providers can be criminally prosecuted for offering healthcare under the direction or control of a designated terrorist organisation or denied asylum for knowingly offering healthcare to a person affiliated with a terrorist organisation.8 Other policies can be directed at entire populations. In 2005, as part of its military and political strategy against Hamas, Israel issued a policy that limited food deliveries into the Gaza strip to the minimum amount needed to avoid malnutrition.9 There is dispute whether and how the policy was carried out, but the very existence of the plan, to manipulate health for advancing security objectives, is surely troubling. Finally, once health is understood as a means to advance security rather than an end in itself, regimes that commit atrocities against civilians invoke the very antiterrorism justifications outlined here to breach long-recognised legal protections of health facilities and medical personnel from interference or attack during armed conflicts or situations of political volatility. The most notable case is Syria, which has explicitly sought to deny healthcare to populations associated with the opposition on the grounds that it is denying healthcare to terrorists. According to the UN’s independent commission on Syria, government forces deny medical care to those from oppositioncontrolled and affiliated areas as a matter of policy and ‘instrumentalise medical care to further strategic and military aims’.10 The regime has bombed and shelled hospitals, arrested more than 500 doctors and other health workers, and killed well over 160 of them. Syria is rightly condemned for its conduct, which constitutes war crimes, and other governments reject the legitimacy of antiterrorism rationales as a justification for its attacks on healthcare. At the same time, Syria’s conduct is only the most extreme case of using health as a security intervention. Elsewhere, states have denied populations access to healthcare as an instrument of security policy. For example, in 2012, violent assaults on the Muslim Rohingyas by Buddhist groups in Burma’s Rakhine state, with apparent government
Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
Rubenstein
51
support, displaced thousands of people. In the aftermath, Doctors without Borders, which had been providing health services in the region for many years, continued to offer HIV, tuberculosis, malnutrition, malaria and mental health services, as well as antenatal and postnatal care to many of the tens of thousands of displaced Rohingyas. In response, Burma expelled Doctors without Borders from Rakhine state on the preposterous ground that it was providing preferential treatment to the Rohingyas, who of course were under attack and forced to flee. It is far more likely that Burma acted as a means of further marginalising and harming a population already suffering from exclusion and violence.11 This brief review shows that instrumental uses of health interventions to advance military, intelligence and other national security objectives vary from the relatively benign to the horrific. What they share is departure from an understanding that health is a central aspect of wellbeing and human dignity, and should never be manipulated to achieve non-health purposes. That understanding must be restored, affirmed not only by agencies with a health mandate, but by all organs of government and institutions of the international community. We are beginning to see some shifts away from the instrumentalisation of health for national security. The new stabilisation doctrine of the UK military is oriented towards viewing health as an element of human security rather than national security, which requires support for local health leadership and health priorities and an orientation towards sustainability.12 To make further headway, a number of steps are needed. States must take strong, uncompromising and principled steps to restore the sanctity of health as a form of respect for all humanity and demand protection and respect for those who provide it. They must affirm in every circumstance that health is an end and never a means, and that includes its place in fighting terrorism. Laws that criminalise the act of providing healthcare must be repealed. Global institutions designed to hold violators to account, historically very weak, must be strengthened. And we can no longer delude ourselves that use of health as a means to national security advances both.
Declarations Competing interest: None declared
Funding: Support for some of the research covered by this essay was provided by the Johns D. and Catherine T. MacArthur Foundation Ethical approval: No human or animal subjects were involved in the writing of this paper Guarantor: LR Contributorship: Sole author Acknowledgements: None Provenance: Not
commissioned;
peer-reviewed
by
Seye
Abimbola
References 1. Dieleman JL, Graves CS, Templin T, et al. Global health development assistance remained steady in 2013 but did not align with recipients’ disease burden. Health Aff 10.1377/hlthaff.2013.1432. 2. Feldbaum H, Lee K and Michaud J. Global health and foreign policy. Epidemiol Rev 2010; 32: 82–92. 3. Secretary of State Hillary Clinton, Initiative: The Next Phase of American Leadership. The Global Health Initiative: The Next Phase of American Leadership in Health Around The World. Remarks at Johns Hopkins School of International Studies, 16 August 2012. https:// blogs.state.gov/stories/2010/08/16/secretary-clintondelivers-remarks-global-health-initiative (last checked 8 October 2014). 4. Rubenstein LS. Post-conflict health reconstruction: search for a policy. Disasters J Disaster Stud Policy Manage 2011; 35: 680–700. 5. Gordon S. Health, stabilization and securitization: towards understanding the drivers of the military role in health interventions. Med Confl Surviv 2011; 27: 43–66. 6. Beaubien J. Taliban in Pakistan Derail World Polio Eradication, 28 July 2014. National Public Radio 2014. See http://www.npr.org/blogs/goatsandsoda/ 2014/07/28/330767266/taliban-in-pakistan-derailsworld-polio-eradicationby (last checked 8 October 2014). 7. Letter from Lisa Monaco, Assistant to the President for Homeland Security and Counterterrorism to Deans, 16 May 2014. http://apps.washingtonpost. com/g/page/national/letter-to-deans-of-public-healthinstitutions/1040/ (last checked 8 October 2014). 8. United States Code Title 18, §§2339A and 2339B, title 8 §1182(a)(3)(B)(iv)(VI). 9. State of Israel, Ministry of Defense, Coordination of Government Activities in the Territories. Gaza Strip Food Consumption in the Red Lines. 2005, http:// www.gisha.org/UserFiles/File/publications/redlines/redlines-presentation-eng.pdf (last checked 8 October 2014). 10. United Nations Human Rights Council, Assault on Medical Care in Syria; Report of the Independent International Commission on the Syrian Arab Republic, http://www.securitycouncilreport.org/atf/cf/ %7B65BFCF9B-6D27-4E9C-8CD3-CF6E4FF96FF9
Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
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Journal of the Royal Society of Medicine 108(2)
%7D/a_hrc_24_crp_2.pdf (last checked 8 October 2014). 11. Lipes S Medical Aid Group Seeks ‘Unfettered Access’ in Myanmar’s Rakhine State. Radio Free Asia, 25 July 2014. http://www.rfa.org/english/news/myanmar/aid07252014152613.html (last checked 8 October 2014).
12. Doctrine Note 11/22. Military Medical Contribution To Health Sector Development Within Security and Stabilisation Operations, no date. https://www.gov.uk/ government/uploads/system/uploads/attachment_data/ file/183467/MMCtoHSD_within_SandS_Ops.pdf (last checked 8 October 2014).
Downloaded from jrs.sagepub.com at Univ of Connecticut / Health Center / Library on June 20, 2015
