Impact of unilateral coercive measures on the right to health

The present report is submitted pursuant to Human Rights Council resolutions 27/21 and 45/5 and General Assembly resolution 74/154, in which the Special Rapporteur on the negative impact of unilateral coercive measures on the enjoyment of human rights was requested to, inter alia, gather all relevant information relating to the negative impact of unilateral coercive measures on the enjoyment of human rights; study relevant trends, developments and challenges; make guidelines and recommendations on ways and means to prevent, minimize and redress the adverse impact of unilateral coercive measures on human rights; and draw the attention of the Council to relevant situations and cases.

Through activities conducted under the mandate, including thematic research, official country visits, case analysis and management and capacity-building and outreach, the Special Rapporteur obtained information on the multifaceted impact of unilateral coercive measures, including economic and trade sanctions, asset freezes and travel restrictions, on the right to health and the catastrophic effects of such measures on the lives of people, in particular the most vulnerable, in countries targeted by sanctions.

In her 2020 thematic report to the General Assembly,¹ the Special Rapporteur highlighted the devastating effects of unilateral sanctions and overcompliance on the enjoyment of human rights in the context of the coronavirus disease (COVID-19) pandemic and addressed challenges in the application of humanitarian exemptions and in the delivery of humanitarian assistance for effective response and recovery.

1. A/75/209. ↩

The Special Rapporteur has issued a number of communications addressed to States and businesses about the sanctions-induced obstacles to the delivery of medicines, medical equipment, consumable and spare parts and pharmaceutical reagents to countries targeted by sanctions. The nexus of unilateral coercive measures and the right to health, in particular the impact of unilateral sanctions on access to adequate and appropriate health-care services, including the prevention, diagnosis, treatment and management of disease and other conditions, was an area of focus during country visits and meetings with governmental and non-governmental actors.

The present report contains a critical assessment of the impact of unilateral sanctions, secondary sanctions and overcompliance on the right to health, with a particular focus on the most vulnerable populations.

In the report, the right to the highest attainable standard of physical and mental health is discussed in relation to article 12 of the International Covenant on Economic, Social and Cultural Rights, including regarding the reduction in stillbirth and infant mortality rates; the healthy development of the child; the improvement of all aspects of environmental and industrial hygiene; the prevention, treatment and control of epidemic, endemic, occupational and other diseases; and the creation of conditions to ensure access to medical services.

The Special Rapporteur assesses the direct and indirect impacts of unilateral coercive measures on the right to health, in accordance with paragraph 3 of Committee on Economic, Social and Cultural Rights general comment No. 14 (2000), in which the Committee noted that the right to health was dependent upon the realization of other human rights, including the rights to food, housing, work, education, human dignity, life, non-discrimination, equality, the prohibition against torture, privacy, access to information and freedom of association, of assembly and of movement.

To inform the present report, the Special Rapporteur issued a call for submissions² addressed to States, United Nations entities and other international organizations, civil society organizations, academics, research institutions and others. Responses were received from the Governments of Armenia, Belarus, China, Cuba, Iran (Islamic Republic of), Iraq, the Russian Federation, the Syrian Arab Republic and Venezuela (Bolivarian Republic of). Responses were also received from the European Union, civil society organizations and 1 A/75/209. 2 See https://www.ohchr.org/en/calls-for-input/2023/call-input-2023-thematic-reports-un-human-rightscouncil-and-un-general. GE.23-14100 associations, lawyers and academics. The Special Rapporteur expresses her gratitude to all respondents.

2. See https://www.ohchr.org/en/calls-for-input/2023/call-input-2023-thematic-reports-un-human-rights-council-and-un-general. ↩

In the period 2022–2023, the Special Rapporteur frequently gave interviews to news organizations and other media outlets around the world to raise awareness about her mandate and the negative impact on human rights of unilateral sanctions and overcompliance in countries targeted by sanctions. She discussed findings from her country visits, including problems in the application of humanitarian exemptions.

From 31 October to 10 November 2022, she conducted an official visit to the Syrian Arab Republic. She met with government ministers and other officials, representatives of United Nations entities, other international organizations and civil society organizations, diplomats and academics in Damascus and conducted field visits outside Damascus.

From 3 to 6 May 2023, she participated in an academic conference in Cuba organized by the University of Havana, giving a keynote address and meeting with academics, students, representatives of civil society organizations and ministers and other governmental representatives.

In March 2023, she organized two expert consultations with civil society organizations and academics on a monitoring and impact assessment methodology that she was to develop and share with relevant stakeholders.

The Special Rapporteur seeks to strengthen awareness of the multifaceted adverse impacts of unilateral coercive measures and their serious implications for the right to development and the achievement of the Sustainable Development Goals. On 28 March 2023, during the fifty-second session of the Human Rights Council, she organized a high-level side event with the participation of Governments, civil society organizations, representatives of the United Nations human rights mechanisms and academics.

The Special Rapporteur participated in thematic conferences, webinars and online meetings organized by the European Parliament, civil society organizations and academic institutions and met with representatives of permanent missions to the United Nations in Geneva and New York and representatives of the Movement of Non-Aligned Countries and the Like-minded Developing Countries to raise awareness of overcompliance, extraterritoriality and the adverse effects of unilateral sanctions on the delivery of humanitarian assistance and on broader recovery efforts. She held meetings and consultations with academics, lawyers and representatives of business sectors affected by sanctions and consultations on the effects of unilateral sanctions on humanitarian assistance and on persons in vulnerable situations.

The Special Rapporteur is finalizing a sanctions research platform, which will serve as a comprehensive electronic repository of research relevant to the issue of unilateral coercive measures and their impact on human rights.

Over the past year, the Special Rapporteur has sent numerous communications to States and businesses referring, inter alia, to the extraterritorial implementation of or overcompliance with unilateral sanctions and their humanitarian impact. A complete list of activities is available on the website of the Special Rapporteur.³

3. See https://www.ohchr.org/en/special-procedures/sr-unilateral-coercive-measures/activities. ↩

Health-care systems are highly vulnerable to the impact of unilateral sanctions and the related zero-risk policies due to the resulting deterioration in standards of living, high inflation and difficulties in purchasing, paying for and delivering necessary medicines, medical equipment, spare parts, reagents and software. Overcompliance by the private sector prevents access to medicines, even in the absence of comprehensive or sectoral sanctions. In spite of declared humanitarian exemptions for medicine and food, businesses are often afraid to provide medical services or to sell medical goods, due to vague or overlapping sanctions regulations. Deliveries may be obstructed or delayed due to financial restrictions, including the exclusion of targeted banks or countries from the Society for Worldwide Interbank Financial Telecommunication (SWIFT), the freezing of the assets of central banks, sanctions imposed on transportation and insurance companies, threats of secondary sanctions, requests for multiple licences for procurement, transportation and insurance and even for the delivery of humanitarian assistance, the imposition of civil or criminal penalties for dealing with countries under sanctions and the zero-risk policies of third-country banks.

The Special Rapporteur notes with regret that the provision set out in paragraph 41 of Committee on Economic, Social and Cultural Rights general comment No. 14 (2000), that States parties should refrain at all times from imposing embargoes or similar measures restricting the supply of another State with adequate medicines and medical equipment, has not been respected. She is also alarmed about the ineffectiveness of humanitarian exemptions in unilateral sanctions regimes, which was recognized by the Committee in its general comment No. 8 (1997) in relation to sanctions regimes established by the Security Council.

The serious negative impact of unilateral sanctions and overcompliance on all aspects of the right to health, including access to health care, nutrition, clean water and sanitation, is widely recognized and was reflected in the majority of the submissions received by the Special Rapporteur. Even a report by a sanctioning actor acknowledged the “unintended” negative humanitarian impact of overcompliance and the need for mitigation.⁴

4. Submission by the European Union. ↩

The imposition of sanctions on States or economic sectors and the ensuing financial challenges, when exacerbated by the effects of overcompliance, prevent the purchase of, payment for and delivery of medicines, medical equipment, spare parts, raw materials and reagents in all countries under sanctions.

At the outbreak of the pandemic, the Special Rapporteur highlighted shortages of and the inability to purchase the medicines and medical equipment necessary for the diagnosis and treatment of COVID-19 and other diseases in many countries, including COVID-19 tests, oxygen and ventilation devices (Cuba, Iran (Islamic Republic of), Sudan and Venezuela (Bolivarian Republic of)); personal protective equipment (Cuba and Iran (Islamic Republic of)); spare parts and software, in particular for X-ray computed tomography, and ventilation devices (Cuba, Iran (Islamic Republic of), Sudan and Syrian Arab Republic); fuel, electricity, food, drinking water and water for hygiene purposes (Syrian Arab Republic and Venezuela (Bolivarian Republic of).⁵

5. A/75/209, paras. 37, 38 and 49–57. ↩

The Special Rapporteur notes with concern that the current situation remains challenging with regard to medicines, medical equipment, spare parts, vaccines, software, syringes, equipment installation and post-sale services.⁶ Difficulties with medical and diagnostic equipment deliveries were reported in all the submissions received. Due to unilateral sanctions and overcompliance, countries cannot use foreign currency to import humanitarian goods or to procure the following: respiratory, cardiac, endoscopic or pharmaceutical equipment or high-tech kits or drugs for certain forms of cancer,⁷ diabetes, haemophilia, leukaemia, ichthyosis, multiple sclerosis, autism,⁸ epidermolysis bullosa,⁹ thalassemia,¹⁰ kidney failure and disfunction, hypertension, anaemia, respiratory diseases,¹¹ chronic inflammatory demyelinating polyneuropathy, multifocal motor neuropathy and asthma; medicines for immunocompromised patients; prostheses and orthoses; factor VIII, hormones, anaesthetics, antibiotics, antidotes, immunoglobulin, immunosuppressors and blood derivatives;¹² blood-pressure, cardiac and antipyretic drugs; painkillers; and other essential drugs and equipment.¹³

6. Submission by the Islamic Republic of Iran. ↩
7. See https://www.hrw.org/report/2019/10/29/maximum-pressure/us-economic-sanctions-harm-iranians-right-health. ↩
8. A/HRC/51/33/Add.1, para. 28. ↩
9. See communications SWE 4/2022 and OTH 95/2022. All communications mentioned in the present report are available from https://spcommreports.ohchr.org/Tmsearch/TMDocuments. ↩
10. See https://www.ohchr.org/en/press-releases/2023/02/iran-over-compliance-unilateral-sanctions-affects-thalassemia-patients-say and submission by the Islamic Republic of Iran. ↩
11. A/HRC/54/23/Add.1, para. 43 ↩
12. Ibid. See also submission by the Syrian Arab Republic; and https://www.reuters.com/article/us-mideast-crisis-syria-sanctions-idUSKBN16M1UW. ↩
13. Submissions by Armenia, Iran (Islamic Republic of), Venezuela (Bolivarian Republic of), the Organization for Defending Victims of Violence, students at the University of Minnesota and the Palestinian Centre for Human Rights. ↩

More than 85 per cent of medicines commonly available globally do not reach the Bolivarian Republic of Venezuela, among them blood products, antibiotics, insulin, dialysis supplies, antiretroviral treatments, vaccines and drugs for malaria, tuberculosis, cancer, congenital heart disease and other chronic or communicable diseases, including through programmes authorized by the Pan American Health Organization. Even water systems can be affected, leading to difficulties in obtaining water.¹⁴ In Zimbabwe, even in the absence of sectoral sanctions, the Government is able to guarantee the availability in hospitals of only 50 basic medicines, mainly due to overcompliance by the private sector.¹⁵

14. A/HRC/48/59/Add.2, paras. 38, 39, 48 and 57. ↩
15. A/HRC/51/33/Add.2, para. 36. ↩

After sanctions were imposed on Belarus, many companies based in Finland, Germany, Poland, the United Kingdom of Great Britain and Northern Ireland and the United States of America stopped deliveries of life-saving medicines and diagnostic equipment, including for HIV/AIDS, tuberculosis, cancer, hepatitis B, hepatoses and cirrhosis, high-intensity painkillers, certain forms of antiepileptic medications, tranquillizers, sedatives, bone tissue calcium regulators, various types of sterilizing equipment and their spare parts, arthroscopes, raw materials and reagents.

Cuba faces many challenges to delivering life-saving paediatric medicines, painkillers and equipment, including: high-tech lung ventilators for newborns and children; nutritional supplements and foods for medical use and the dietary management of childhood disorders and diseases; arterial and venous lines; hydrophobic filters; temporary haemodialysis catheters for young children; paediatric dialysers, dialysis bags and catheters; devices for infants with acute renal failure; analgesics and anaesthetics;¹⁶ high-tech medical treatments and equipment for children with disabilities; pacemakers, supplies and medications for cardiovascular surgery; and stents, oxygenators, disposable electrodes, contrast media and radioisotopes.¹⁷

16. Submission by the Cuban Association of Paediatrics. ↩
17. Submissions by the Sociedad Cubana de Cardiología and PROSALUD. ↩

Serious procurement challenges were reportedly faced even by countries with developed health-care and pharmaceutical sectors (Cuba, Iran (Islamic Republic of) and Syrian Arab Republic),¹⁸ especially if they relied on deliveries from producers based in sanctioning countries. Even international cooperation in organ transplantation has been affected due to payment difficulties and the freezing of the assets of central banks and public 10 See https://www.ohchr.org/en/press-releases/2023/02/iran-over-compliance-unilateral-sanctionsaffects-thalassemia-patients-say and submission by the Islamic Republic of Iran. 11 A/HRC/54/23/Add.1, para. 43 12 Ibid. See also submission by the Syrian Arab Republic; and https://www.reuters.com/article/usmideast-crisis-syria-sanctions-idUSKBN16M1UW. 13 Submissions by Armenia, Iran (Islamic Republic of), Venezuela (Bolivarian Republic of), the Organization for Defending Victims of Violence, students at the University of Minnesota and the Palestinian Centre for Human Rights. 14 A/HRC/48/59/Add.2, paras. 38, 39, 48 and 57. 15 A/HRC/51/33/Add.2, para. 36. 16 Submission by the Cuban Association of Paediatrics. 17 Submissions by the Sociedad Cubana de Cardiología and PROSALUD. 18 A/HRC/54/23/Add.1, paras. 43 and 46. See also Kasturi Sen, Waleed al-Faisal and Yaser al-Saleh, “Syria: effects of conflict and sanctions on public health”, Journal of Public Health, vol. 35, No. 2 (2012); Richard Garfield, “The public health impact of sanctions: contrasting responses of Iraq and Cuba”, Middle East Report, No. 215 (2000); Zoë Pelter, Camila Teixeira and Erica Moret, “Sanctions and their impact on children: discussion paper” (United Nations Children’s Fund, 2022); and Oxfam International, Right to Live without a Blockade: The Impact of U.S. Sanctions on the Cuban Population and Women’s Lives (2021). GE.23-14100 companies.19 The inability to effect bank payments also affects cooperation between medical and research institutions in countries under sanctions.²⁰

18. A/HRC/54/23/Add.1, paras. 43 and 46. See also Kasturi Sen, Waleed al-Faisal and Yaser al-Saleh, “Syria: effects of conflict and sanctions on public health”, Journal of Public Health, vol. 35, No. 2 (2012); Richard Garfield, “The public health impact of sanctions: contrasting responses of Iraq and Cuba”, Middle East Report, No. 215 (2000); Zoë Pelter, Camila Teixeira and Erica Moret, “Sanctions and their impact on children: discussion paper” (United Nations Children’s Fund, 2022); and Oxfam International, Right to Live without a Blockade: The Impact of U.S. Sanctions on the Cuban Population and Women’s Lives (2021). ↩
20. Submission by the Islamic Republic of Iran. ↩

The result of shortages and the unavailability of medicines and medical equipment is an increase in suffering and mortality rates and reduced life expectancy for people with chronic and severe diseases. It is reported that every additional year of sanctions lowers life expectancy in sanctioned countries by as much as 0.3 years.²¹

21. Pelter, Teixeira and Moret, “Sanctions and their impact”. ↩

The Special Rapporteur is alarmed by the growing number of refusals by pharmaceutical companies to sell medicines, medical equipment, spare parts and high-tech equipment and to provide post-sale services, including under pre-existing contracts, to countries under sanctions; the challenges faced by banks in those countries to obtain letters of credit and ensure payments for medical items;²² and rejections by transport and insurance companies,²³ all of which force affected people, States and companies to seek alternative means of procurement, which are costlier. Such challenges also increase the risk of poor-quality products and the likelihood of corruption and other irregular practices.

22. Submissions by Belarus, China, Iran (Islamic Republic of) and Ahmed Zarzour. ↩
23. See https://www.reuters.com/article/us-mideast-crisis-syria-sanctions-idUSKBN16M1UW. ↩

In certain cases, doctors in the Syrian Arab Republic have been forced to import medicines and medical equipment through their networks abroad, at their own expense, so that they can treat their patients.²⁴

24. A/HRC/54/23/Add.1, para. 44. ↩

Due to the impossibility of procuring new and high-tech equipment, spare parts, reagents and software and the unavailability of post-sale and maintenance services, there is a severe shortage of equipment, including devices for basic blood and urine testing and kidney treatment, such as dialysis and haemodialysis; X-ray computed and positron emission tomography and magnetic resonance imagining devices; B-scan ultrasonography and X-ray machines; endoscopy devices; cardiac catheters, incubators; ventilators; and oxygen generators. The Syrian Arab Republic, for example, possesses a single linear accelerator²⁵ and the waiting period of six months for X-ray computed tomography is having a serious impact on timely diagnosis and treatment.²⁶ Even when specialized medical equipment has been successfully delivered, it often cannot be operated because of missing software or the lack of post-sale installation and maintenance services.²⁷ Similarly, the unavailability of spare parts and reagents has resulted in a twelvefold reduction in the number of child cardiac surgeries at a specialized paediatric cardiology hospital in the Bolivarian Republic of Venezuela.²⁸

25. Information from the Government of the Syrian Arab Republic. ↩
26. Information received during the visit of the Special Rapporteur to the Syrian Arab Republic in 2022. ↩
27. A/HRC/54/23/Add.1, para. 45. ↩
28. A/HRC/48/59/Add.2, para. 46. ↩

The Special Rapporteur sent communications to France, Sweden and Switzerland²⁹regarding the impossibility of procuring specialized medicines for 930 epidermolysis bullosa patients and 23,000 thalassemia patients in the Islamic Republic of Iran due to the reported reluctance of pharmaceutical companies based in those countries to sell medical goods to the Islamic Republic of Iran and challenges with payments or medical cargo insurance. A case filed by the Iranian Thalassemia Society in a United States court was dismissed³⁰ and the Government of the United States has not responded to letters sent by the Special Rapporteur on the matter.

29. See communications SWE 4/2022, OTH 95/2022, OTH 134/2022 and OTH 135/2022. See also https://www.ohchr.org/en/press-releases/2023/02/iran-over-compliance-unilateral-sanctions-affects-thalassemia-patients-say. ↩
30. See https://dockets.justia.com/docket/oregon/ordce/3:2022cv01195/168501. ↩

The situation has resulted in increased mortality rates and suffering among patients. Within a single year, 15 epidermolysis bullosa patients died due to a shortage of bandages. With only 10–15 per cent of the medicines needed available, deaths among thalassemia 19 See communication USA 23/2021. See also A/HRC/48/59/Add.2, para. 47. 20 Submission by the Islamic Republic of Iran. 21 Pelter, Teixeira and Moret, “Sanctions and their impact”. 22 Submissions by Belarus, China, Iran (Islamic Republic of) and Ahmed Zarzour. 23 See https://www.reuters.com/article/us-mideast-crisis-syria-sanctions-idUSKBN16M1UW. 24 A/HRC/54/23/Add.1, para. 44. 25 Information from the Government of the Syrian Arab Republic. 26 Information received during the visit of the Special Rapporteur to the Syrian Arab Republic in 2022. 27 A/HRC/54/23/Add.1, para. 45. 28 A/HRC/48/59/Add.2, para. 46. 29 See communications SWE 4/2022, OTH 95/2022, OTH 134/2022 and OTH 135/2022. See also https://www.ohchr.org/en/press-releases/2023/02/iran-over-compliance-unilateral-sanctions-affectsthalassemia-patients-say. 30 See https://dockets.justia.com/docket/oregon/ordce/3:2022cv01195/168501. GE.23-14100 patients increased, from 25–35 per year in the years prior to 2018 to 150–220 per year in the period 2018–2022, and life expectancy was reduced from 45–50 years to fewer than 20 years.

The Special Rapporteur welcomed the assistance of the Government of Sweden, in cooperation with the United Nations Children’s Fund (UNICEF), in the delivery of bandages for epidermolysis bullosa patients in August and September 2022³¹ but notes with regret that, due to the inaccessibility of direct bank transfers and other challenges for delivery, a sustainable solution has not yet been found, with a high likelihood that the stock of bandages will be depleted by the third quarter of 2023. Similarly, a one- to two-month supply of bandages remained as of July 2023 for the 124 epidermolysis bullosa patients in Belarus, following a Swedish company’s refusal to sell bandages to the country.

31. See https://spcommreports.ohchr.org/TMResultsBase/DownLoadFile?gId=37281. ↩

The Special Rapporteur notes the existing challenges for the delivery of medicines for thalassemia patients in the Islamic Republic of Iran. Responses to the communications received from Switzerland³² and the Swiss pharmaceutical company concerned³³ provide contradictory information, and do not ensure the availability of life-saving medicines for patients. No response has been received from France, the France-based pharmaceutical company concerned or the United States. It is illustrative, however, that the Swiss producer of thalassemia medicines was subjected to a fine of $17 million for deliveries to the Islamic Republic of Iran during the period 2008–2011.³⁴

32. See https://spcommreports.ohchr.org/TMResultsBase/DownLoadFile?gId=37445. ↩
33. See https://spcommreports.ohchr.org/TMResultsBase/DownLoadFile?gId=37440. ↩
34. See https://home.treasury.gov/system/files/126/20160705_alcon.pdf. ↩

The Special Rapporteur is concerned about the detrimental effects of unilateral sanctions and overcompliance by the private sector on disease prevention and control. Many countries report being unable to deliver vaccinations recommended by the World Health Organization (WHO), including for measles (Bolivarian Republic of Venezuela),³⁵ polio (Iran (Islamic Republic of),³⁶ Syrian Arab Republic,³⁷ Venezuela (Bolivarian Republic of) and Zimbabwe), yellow fever (Bolivarian Republic of Venezuela), rotavirus, diphtheria and tuberculosis (Somalia, Venezuela (Bolivarian Republic of) and Yemen).³⁸ In the period 2016–2018, about 2.6 million children in the Bolivarian Republic of Venezuela were deprived of vaccines.³⁹ To date, vaccination coverage through COVAX in that country is about 20 per cent. The child vaccination rate in the Syrian Arab Republic dropped from 95 per cent to about 60 per cent between 2006 and 2022.⁴⁰

35. A/HRC/48/59/Add.2, paras. 41–43. ↩
36. Pelter, Teixeira and Moret, “Sanctions and their impact”. ↩
37. Sen, Al-Faisal and Al-Saleh, “Syria: effects of conflict and sanctions”, pp. 197 and 198. See also submission by the Syrian Arab Republic. ↩
38. Submission by Maat for Peace, Development and Human Rights Association. ↩
39. A/HRC/48/59/Add.2, paras. 41–43. ↩
40. Richard Hanania, “Ineffective, immoral, politically convenient: America’s overreliance on economic sanctions and what to do about it”, CATO Institute, 18 February 2020. ↩

Similar challenges have been reported in the delivery of laboratory kits and tests (Cuba, Iran (Islamic Republic of) and Venezuela (Bolivarian Republic of)).⁴¹ The Islamic Republic of Iran has reported a failure to deliver HIV drug resistance sequence analysis tools to improve the care and treatment of patients living with HIV and tests for asthma and chronic obstructive pulmonary disease, despite joint efforts by the Ministry of Health and the United Nations country office. Belarus has been unable to procure testing systems for treatment-resistant tuberculosis and HIV, even through the Global Fund to Fight AIDS, Tuberculosis and Malaria. The absence of tests and medicines has resulted in outbreaks of typhoid (Syrian Arab Republic),⁴² HIV/AIDS (Venezuela (Bolivarian Republic of)⁴³ and Zimbabwe),44 opportunistic infections (Bolivarian Republic of Venezuela),⁴⁵ tuberculosis 31 See https://spcommreports.ohchr.org/TMResultsBase/DownLoadFile?gId=37281. 32 See https://spcommreports.ohchr.org/TMResultsBase/DownLoadFile?gId=37445. 33 See https://spcommreports.ohchr.org/TMResultsBase/DownLoadFile?gId=37440. 34 See https://home.treasury.gov/system/files/126/20160705_alcon.pdf. 35 A/HRC/48/59/Add.2, paras. 41–43. 36 Pelter, Teixeira and Moret, “Sanctions and their impact”. 37 Sen, Al-Faisal and Al-Saleh, “Syria: effects of conflict and sanctions”, pp. 197 and 198. See also submission by the Syrian Arab Republic. 38 Submission by Maat for Peace, Development and Human Rights Association. 39 A/HRC/48/59/Add.2, paras. 41–43. 40 Richard Hanania, “Ineffective, immoral, politically convenient: America’s overreliance on economic sanctions and what to do about it”, CATO Institute, 18 February 2020. 41 A/HRC/48/59/Add.2, paras. 37, 49 and 50. 42 Hanania, “Ineffective, immoral, politically convenient”. 43 A/HRC/48/59/Add.2, para. 51. 44 Submission by the Sexual Rights Initiative. 45 A/HRC/48/59/Add.2, paras. 48 and 98. GE.23-14100 (Democratic People’s Republic of Korea⁴⁶ and Venezuela (Bolivarian Republic of))⁴⁷ and dengue (Cuba).

41. A/HRC/48/59/Add.2, paras. 37, 49 and 50. ↩
42. Hanania, “Ineffective, immoral, politically convenient”. ↩
43. A/HRC/48/59/Add.2, para. 51. ↩
45. A/HRC/48/59/Add.2, paras. 48 and 98. ↩
46. See https://koreapeacenow.org/wp-content/uploads/2019/10/human-costs-and-gendered-impact-of-sanctions-on-north-korea.pdf. ↩
47. A/HRC/48/59/Add.2, para. 42. ↩

The Special Rapporteur is concerned about reports of the psychological effects, especially on young people, of the dramatic economic situation and the unavailability of jobs, food and medicines, which have resulted in a loss of hope (Cuba⁴⁸ and Syrian Arab Republic).⁴⁹ Disillusionment and psychological suffering are compounded by the unavailability of specialized medicines for mental health conditions, including postnatal and other types of depression, anxiety-depressive disorders, self-harm and suicidal behaviour and ideation.⁵⁰

48. Submission by Samer Awad. See also A/HRC/54/23/Add.1. ↩
49. Submissions by Sociedad Cubana Multidisciplinaria para el Estudio de la Sexualidad and the Centro Oscar Arnulfo Romero. ↩
50. Joint submission by Coming Out, Center-T and the Sphere Foundation. ↩

In its general comment No. 14 (2000), the Committee on Economic, Social and Cultural Rights referred to the obligation of States to guarantee the availability of health care, including a sufficient quantity of safely accessible health facilities, goods and services provided by skilled medical personnel, scientifically approved and unexpired drugs and hospital equipment and the underlying determinants of health, such as safe and potable drinking water and adequate sanitation facilities.⁵¹ In its general comment No. 22 (2016), the Committee noted the importance of the provision of sexual and reproductive health care, including contraceptives and medicines for the prevention and treatment of sexually transmitted infections and HIV/AIDS.⁵²

51. See also submission by the Sexual Rights Initiative. ↩
52. See also A/HRC/48/59/Add.2, para. 43. ↩

All these elements are negatively affected by the cumulative impact of unilateral sanctions, overcompliance and the deteriorating economic situation in the countries under sanctions. Due to the rapid reduction in country revenue and impediments to the delivery of necessary goods and equipment, the construction, reconstruction and maintenance of hospitals and primary health-care centres has stopped in Venezuela (Bolivarian Republic of)⁵³ and Zimbabwe.⁵⁴ In the Syrian Arab Republic, since the adoption in the United States of the Caesar Syrian Civilian Protection Act and despite the widespread destruction as a result of the 12-year-long conflict, all reconstruction efforts, including of hospitals, water supply systems and electrical grids, have stopped due to the refusal of donors, foreign businesses and financial institutions to provide for the delivery of construction materials, spare parts and software or to process payments for such goods and services.⁵⁵

53. A/HRC/48/59/Add.2, para. 37. ↩
54. A/HRC/51/33/Add.2, para. 36. ↩
55. A/HRC/54/23/Add.1, paras. 15, 27 and 53. ↩

Countries under sanctions have reported a decreased capacity of Governments to guarantee free or affordable treatment for all types of diseases due to hyperinflation, the growing cost of insurance, delivery and bank transactions,⁵⁶ physical impediments to the delivery of medical goods and the need to source tests, laboratory equipment, reagents, anti-viral medications and high-tech equipment in distant markets and to find alternative delivery routes.

56. Submissions by Iran (Islamic Republic of) and Venezuela (Bolivarian Republic of). ↩

In some countries, numerous private medical services have been discontinued due to their inability to deliver medicines and equipment as a result of sanctions and overcompliance⁵⁷ or the inability of patients to afford the high cost of private health care.58 46 See https://koreapeacenow.org/wp-content/uploads/2019/10/human-costs-and-gendered-impact-ofsanctions-on-north-korea.pdf. 47 A/HRC/48/59/Add.2, para. 42. 48 Submission by Samer Awad. See also A/HRC/54/23/Add.1. 49 Submissions by Sociedad Cubana Multidisciplinaria para el Estudio de la Sexualidad and the Centro Oscar Arnulfo Romero. 50 Joint submission by Coming Out, Center-T and the Sphere Foundation. 51 See also submission by the Sexual Rights Initiative. 52 See also A/HRC/48/59/Add.2, para. 43. 53 A/HRC/48/59/Add.2, para. 37. 54 A/HRC/51/33/Add.2, para. 36. 55 A/HRC/54/23/Add.1, paras. 15, 27 and 53. 56 Submissions by Iran (Islamic Republic of) and Venezuela (Bolivarian Republic of). 57 Submissions by Belarus and Venezuela (Bolivarian Republic of). 58 A/HRC/51/33/Add.1. GE.23-14100

57. Submissions by Belarus and Venezuela (Bolivarian Republic of). ↩

Access to medical assistance abroad has been severely impeded by unilateral sanctions, including the freezing of the assets of central banks and other State resources previously used to cover medical expenses for citizens in need, and challenges in transferring funds. Sanctions have also resulted in travel restrictions, making it more difficult for people to travel abroad for medical treatment.⁵⁹ For example, the freezing of the assets of CITGO Petroleum, used to cover expenses for kidney and brain marrow transplants for Venezuelan children in Argentina⁶⁰ and Italy, reportedly resulted in the deaths of 14 children.⁶¹ In addition, the Islamic Republic of Iran has not been able to transfer money for ophthalmology treatment and trachea mesh insertion for people affected by mustard gas.⁶²

59. Submission by Samer Awad. ↩
60. See communication OTH 207/2021. ↩
61. See communication USA 23/2021. See also A/HRC/48/59/Add.2, para. 47. ↩
62. A/HRC/51/33/Add.1, para. 32. ↩

The physical blockade of certain territories is reported to have added challenges for access to health care, with broad regional implications.⁶³ Patients in the Gaza Strip and the West Bank, in the Occupied Palestinian Territory, are required to apply for approval to travel internationally for health reasons. Since 2017, the approval time for travel for non-urgent interventions has been extended to 23 days, sometimes longer, and the approval rate in 2022 was about 84 per cent.⁶⁴ It was reported that, in 2022, the parents of one third of children from Gaza and 15 per cent from the West Bank seeking to travel for medical treatment were refused permission to accompany them and that, of those requesting permission to accompany persons with disabilities on trips for medical treatment, three fifths from Gaza and one fifth from the West Bank were refused permission.⁶⁵ A total of 839 patients reportedly lost their lives while waiting for permission to travel for medical treatment in the period 2008–2021 and there is a growing number of severe, moderate and mild mental health disorders among adults and children.⁶⁶ The survival rate for cancer patients whose travel permission for chemotherapy or radiotherapy is delayed or denied is 1.5 times lower than for those whose requests are approved without delay.⁶⁷

63. Submissions by Armenia and the Armenian Bar Association. ↩
64. WHO, “Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan” (document A76/15), para. 23. ↩
65. Ibid., paras. 21 and 22. ↩
66. Submission by the Palestinian Centre for Human Rights. ↩
67. “Health conditions in the occupied Palestinian territory”, para. 24. ↩

The approval needed from Israel for the delivery of medicines and medical supplies to Gaza has created similar impediments, with the denial, in 2021, of 69 per cent of requests by private companies made through the Presidential Committee for Commodities Coordination of the Palestinian Authority for the delivery of oxygen, equipment and spare parts for diagnostic radiology, endoscopy and nuclear medicine technology and materials for limb prostheses, often on the basis that they are considered dual use.⁶⁸ Combined with a shortage of skilled health-care personnel, such challenges undermine the proper functioning of the health-care system.⁶⁹

68. WHO, Right to Health: Barriers to Health and Attacks on Health Care in the Occupied Palestinian Territory, 2019 to 2021 (2022). See also the submission by the Palestinian Centre for Human Rights; and WHO, “Health conditions in the occupied Palestinian Territory”, para. 20. ↩
69. Submission by the Palestinian Centre for Human Rights. ↩

The Special Rapporteur is alarmed by the multiple reports of a shortage of 30–50 per cent of medical personnel in countries under sanctions due to low salaries, hyperinflation and transportation costs (Venezuela (Bolivarian Republic of)⁷⁰ and Syrian Arab Republic).⁷¹ In Zimbabwe, the vacancy rate in the health sector is 89 per cent for midwives, 64 per cent for doctors and 49 per cent for nursing teachers. Most provinces have fewer than 10 health professionals per 10,000 people.⁷² Since 2021, Zimbabwe has been included in the list of 59 Submission by Samer Awad. 60 See communication OTH 207/2021. 61 See communication USA 23/2021. See also A/HRC/48/59/Add.2, para. 47. 62 A/HRC/51/33/Add.1, para. 32. 63 Submissions by Armenia and the Armenian Bar Association. 64 WHO, “Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan” (document A76/15), para. 23. 65 Ibid., paras. 21 and 22. 66 Submission by the Palestinian Centre for Human Rights. 67 “Health conditions in the occupied Palestinian territory”, para. 24. 68 WHO, Right to Health: Barriers to Health and Attacks on Health Care in the Occupied Palestinian Territory, 2019 to 2021 (2022). See also the submission by the Palestinian Centre for Human Rights; and WHO, “Health conditions in the occupied Palestinian Territory”, para. 20. 69 Submission by the Palestinian Centre for Human Rights. 70 A/HRC/48/59/Add.2, paras. 37 and 56. 71 A/HRC/54/23/Add.1, para. 49. 72 A/HRC/51/33/Add.2, para. 32 GE.23-14100 countries with the lowest number of health workers,⁷³ along with Somalia, the Sudan and Yemen.⁷⁴

70. A/HRC/48/59/Add.2, paras. 37 and 56. ↩
71. A/HRC/54/23/Add.1, para. 49. ↩
72. A/HRC/51/33/Add.2, para. 32 ↩
73. Submission by the Sexual Rights Initiative. ↩
74. WHO, “WHO health workforce support and safeguards list, 2023” (Geneva, 2023). ↩

Unilateral sanctions prevent health professionals from developing their qualifications and participating in international exchange and research programmes. Due to their nationality or Internet Protocol address, medical professionals from countries under sanctions face challenges in accessing online platforms (including PubMed); subscribing to and publishing in medical journals;⁷⁵ paying for membership of international academic and professional health associations⁷⁶ and participating in medical conferences and joint research; obtaining visas; and paying for travel.⁷⁷ Medical students are affected by the same limitations, in addition to being unable to access training in the absence of appropriate equipment, software and books.⁷⁸

75. See communications USA 9/2022, OTH 37/2022, OTH 38/2022, OTH 39/2022 and OTH 40/2022. See also submissions by Iran (Islamic Republic of) and Venezuela (Bolivarian Republic of). ↩
76. Submission by the Cuban Association of Paediatrics. ↩
77. Ibid.; A/HRC/51/33/Add.1, para. 58; A/HRC/51/33/Add.2, paras. 41, 81 and 86; and A/HRC/54/23/Add.1, paras. 57 and 58. See also submissions by the Islamic Republic of Iran, Samer Awad and the Palestinian Centre for Human Rights. ↩
78. Submissions by the Islamic Republic of Iran, Samer Awad, the Cuban Association of Paediatrics, the Sociedad Cubana Multidisciplinaria para el Estudio de la Sexualidad, the Centro Oscar Arnulfo Romero and the Sexual Rights Initiative. ↩

Domestic research is also reported to have been affected by impediments to the delivery of biological and raw materials, spare parts and laboratory equipment (Islamic Republic of Iran), including microscopes (Bolivarian Republic of Venezuela),⁷⁹ high-tech equipment (China) and the refusal to renew licences even if the equipment has been delivered.⁸⁰

79. See communication USA 13/2022. ↩
80. Submission by the Sexual Rights Initiative. ↩

Sanctions relating to energy, including diesel fuel and gasoline and their transportation, have had an enormous impact on access to hospitals, especially for vulnerable groups. In Venezuela (Bolivarian Republic of) and Zimbabwe, gasoline shortages⁸¹ impede people’s mobility, disproportionately affecting access to health-care facilities. In the Bolivarian Republic of Venezuela, more women now give birth outside health-care facilities, resulting in increasing rates of maternal and infant mortality.⁸²

81. A/HRC/48/59/Add.2, paras. 65, 66 and 99. ↩
82. See https://data.worldbank.org/indicator. ↩

Access to health-care facilities and the prevention and control of disease are impeded in many countries under sanctions by the inability to purchase and repair medically equipped vehicles⁸³ or to provide fuel (Syrian Arab Republic⁸⁴ and Venezuela (Bolivarian Republic of)).⁸⁵ Search-and-rescue helicopters, air ambulances and specialized vehicles used for transportation to health-care facilities are often qualified as dual-use goods and therefore not delivered,⁸⁶ raising mortality rates.

83. Submission by the Sexual Rights Initiative. ↩
84. See A/HRC/54/23/Add.1. ↩
85. A/HRC/48/59/Add.2, para. 65. ↩
86. See https://www.ohchr.org/en/statements/2023/02/genuine-solidarity-earthquake-survivors-calls-lifting-sanction-induced. ↩

Energy shortages in many countries under sanctions cause frequent power outages in hospitals and health-care centres. In the Syrian Arab Republic, the national grid provides electricity to health-care centres for only 10 or 11 hours per day in the principal cities and for only 1 or 2 hours per day in other parts of the country, with diesel power stations and generators providing electricity at other times. The irregularity of electricity provision, including due to system overload or deliberate power cuts, results in the interruption of 73 Submission by the Sexual Rights Initiative. 74 WHO, “WHO health workforce support and safeguards list, 2023” (Geneva, 2023). 75 See communications USA 9/2022, OTH 37/2022, OTH 38/2022, OTH 39/2022 and OTH 40/2022. See also submissions by Iran (Islamic Republic of) and Venezuela (Bolivarian Republic of). 76 Submission by the Cuban Association of Paediatrics. 77 Ibid.; A/HRC/51/33/Add.1, para. 58; A/HRC/51/33/Add.2, paras. 41, 81 and 86; and A/HRC/54/23/Add.1, paras. 57 and 58. See also submissions by the Islamic Republic of Iran, Samer Awad and the Palestinian Centre for Human Rights. 78 Submissions by the Islamic Republic of Iran, Samer Awad, the Cuban Association of Paediatrics, the Sociedad Cubana Multidisciplinaria para el Estudio de la Sexualidad, the Centro Oscar Arnulfo Romero and the Sexual Rights Initiative. 79 See communication USA 13/2022. 80 Submission by the Sexual Rights Initiative. 81 A/HRC/48/59/Add.2, paras. 65, 66 and 99. 82 See https://data.worldbank.org/indicator. 83 Submission by the Sexual Rights Initiative. 84 See A/HRC/54/23/Add.1. 85 A/HRC/48/59/Add.2, para. 65. 86 See https://www.ohchr.org/en/statements/2023/02/genuine-solidarity-earthquake-survivors-callslifting-sanction-induced. GE.23-14100 medical procedures and damage to medical equipment and sensitive medication, with no possibility of repair or replacement due to trade and financial restrictions.⁸⁷ IV. Indirect impact of unilateral coercive measures on the right to health

87. A/HRC/54/23/Add.1, para. 48. See also the submission by the Palestinian Centre for Human Rights. ↩

The elimination of poverty and hunger; the promotion of inclusive and sustainable economic growth, agriculture, food security and improved nutrition; and full and productive employment and decent work for all are important aspects of the right to health. The complexity of unilateral sanctions, compounded by overcompliance, has resulted in economic crises, growing unemployment⁸⁸ and reduced incomes.⁸⁹ Countries under sanctions report high unemployment rates in the public sector, including among doctors, nurses, teachers, professors, public officers and judges,⁹⁰ and in the tourism and handicraft industries,⁹¹ resulting in the weakening of the formal economy and the expansion of the informal economy,⁹² with poverty rates above 90 per cent in the Syrian Arab Republic and Venezuela (Bolivarian Republic of).⁹³

88. A/HRC/51/33/Add.2, paras. 20 and 21. ↩
89. A/76/174/Rev.1, paras. 36–55. ↩
90. A/HRC/48/59/Add.2, para. 56. See also A/HRC/54/23/Add.1. ↩
91. A/HRC/48/59/Add.2, para. 67; and A/HRC/51/33/Add.1, paras. 24 and 63. ↩
92. A/HRC/48/59/Add.2, para. 32. ↩
93. A/HRC/54/23/Add.1, paras. 30 and 56. ↩

Due to the deteriorating economic situation and insufficient resources, sanctioned States are forced to discontinue or reduce the coverage of health care-related social support programmes, including free medical examinations and treatment and medicines. In the Islamic Republic of Iran, rising prices have made the cost of medicines and assistive equipment prohibitive. Some patients with rare diseases resell some of the specialized medications produced abroad that they receive for free or at reduced cost to pay for other basic needs, such as food, due to their dire economic situation.⁹⁴ Growing numbers of people sell their own organs as their only source of income.⁹⁵

94. A/HRC/51/33/Add.1, para. 30. ↩
95. Al Jazeera, “Desperate Afghans sell kidneys amid poverty, starvation”, 28 February 2023. ↩

Adequate nutrition constitutes a fundamental element of the right to health. Many countries under sanctions report high levels of food insecurity, including between 24 and 50 per cent in the Bolivarian Republic of Venezuela⁹⁶ and 60 per cent in Zimbabwe,⁹⁷ with a disproportionate impact on women and girls.⁹⁸ Agricultural unsustainability is exacerbated by sanctions and related impediments in access to irrigation, diesel fuel, agricultural equipment, spare parts, seeds and fertilizers.⁹⁹

96. A/HRC/48/59/Add.2, paras. 32 and 35. See also submission by Sures, Human Rights Study and Advocacy. ↩
97. A/HRC/51/33/Add.2, para. 24. ↩
98. Submission by the Sexual Rights Initiative. ↩
99. A/HRC/48/59/Add.2, paras. 56–66; A/HRC/51/33/Add.2, paras. 24 and 27; and A/HRC/51/33/Add.1, para. 41. See also Food and Agriculture Organization of the United Nations, Food Outlook: Biannual Report on Global Food Markets – June 2022 (Rome, 2022), pp. 72 and 77. ↩

It has been reported that 90 per cent of children in the Syrian Arab Republic depend on humanitarian assistance for survival and about 500,000 are severely food insecure.¹⁰⁰ In the Bolivarian Republic of Venezuela, the average number of meals has fallen to 1.5 per day, with minimal protein, and 50 per cent of children under the age of 5 are at risk of severe undernourishment.¹⁰¹ 101 Similar figures have been reported for other countries 102 and 87 A/HRC/54/23/Add.1, para. 48. See also the submission by the Palestinian Centre for Human Rights. 88 A/HRC/51/33/Add.2, paras. 20 and 21. 89 A/76/174/Rev.1, paras. 36–55. 90 A/HRC/48/59/Add.2, para. 56. See also A/HRC/54/23/Add.1. 91 A/HRC/48/59/Add.2, para. 67; and A/HRC/51/33/Add.1, paras. 24 and 63. 92 A/HRC/48/59/Add.2, para. 32. 93 A/HRC/54/23/Add.1, paras. 30 and 56. 94 A/HRC/51/33/Add.1, para. 30. 95 Al Jazeera, “Desperate Afghans sell kidneys amid poverty, starvation”, 28 February 2023. 96 A/HRC/48/59/Add.2, paras. 32 and 35. See also submission by Sures, Human Rights Study and Advocacy. 97 A/HRC/51/33/Add.2, para. 24. 98 Submission by the Sexual Rights Initiative. 99 A/HRC/48/59/Add.2, paras. 56–66; A/HRC/51/33/Add.2, paras. 24 and 27; and A/HRC/51/33/Add.1, para. 41. See also Food and Agriculture Organization of the United Nations, Food Outlook: Biannual Report on Global Food Markets – June 2022 (Rome, 2022), pp. 72 and 77. 100 Pelter, Teixeira and Moret, “Sanctions and their impact”. 101 A/HRC/48/59/Add.2, paras. 31–33 and 36. 102 Pelter, Teixeira and Moret, “Sanctions and their impact”. See also GE.23-14100 territories 103 under sanctions, with growing child mortality¹⁰⁴ 104 and prevalence of chronic diseases.¹⁰⁵

100. Pelter, Teixeira and Moret, “Sanctions and their impact”. ↩
101. A/HRC/48/59/Add.2, paras. 31–33 and 36. ↩
104. Jerg Gutmann, Matthias Neuenkirch and Florian Neumeier, “Sanctioned to death? The impact of economic sanctions on life expectancy and its gender gap”, CESifo Working Paper, No. 8033 (2019), p. 26; and Yiyeon Kim, “Economic sanctions and HIV/AIDS in women”, Journal of Public Health Policy, vol. 40, No. 3 (September 2019). ↩
105. Submission by the Sexual Rights Initiative. ↩

The Special Rapporteur on the right to food has stated that the continued imposition of crippling economic sanctions on Cuba, Iran (Islamic Republic of), the Syrian Arab Republic, Venezuela (Bolivarian Republic of) and, to a lesser degree, Zimbabwe severely undermines the fundamental right of ordinary citizens to sufficient and adequate food.¹⁰⁶ Other challenges include the interruption of supply chains and bank correspondence relations, SWIFT bans,¹⁰⁷ blockades of transport routes¹⁰⁸ and of the delivery of medicines and food provided by humanitarian organizations and the fear of secondary sanctions.

106. See https://www.ohchr.org/en/press-releases/2020/03/covid-19-economic-sanctions-should-be-lifted-prevent-hunger-crises-un-expert?LangID=E&NewsID=25761. ↩
107. Submission by China. ↩
108. Submissions by the Armenian Bar Association and the Palestinian Centre for Human Rights. ↩

The Special Rapporteur notes that the availability and sustainable management of water and sanitation are vital for the achievement of the right to health. She is concerned about the collapse of water and sanitation systems caused by the unavailability of electricity and fuel and the rising cost of water-quality control materials and equipment, such as cultivation media, chlorination tablets and other essential items.¹⁰⁹ Drinking water is distributed for only a few hours per week in the Bolivarian Republic of Venezuela¹¹⁰ or not at all (Syrian Arab Republic¹¹¹ and Zimbabwe,¹¹² as well as in Gaza),¹¹³ with serious adverse health effects from waterborne, bacterial and other diseases, such as cholera,¹¹⁴ malaria, dengue and lupus,¹¹⁵ while a shortage of water for irrigation, combined with climate change, has had serious consequences for domestic agricultural production in Iran (Islamic Republic of)¹¹⁶ and the Syrian Arab Republic.

109. Submission by the Islamic Republic of Iran. ↩
110. A/HRC/48/59/Add.2, paras. 62 and 63. ↩
111. A/HRC/54/23/Add.1, paras. 31–34. ↩
112. A/51/33/Add.2, paras. 28 and 29. ↩
113. Submission by the Palestinian Centre for Human Rights. ↩
114. Kim, “Economic sanctions and HIV/AIDS”; and Gutmann, Neuenkirch and Neumeier, “Sanctioned to death?”. ↩
115. A/HRC/48/59/Add.2, para. 48. See also submission by the Sexual Rights Initiative. ↩
116. A/HRC/51/33/Add.1, paras. 45–47. ↩

Challenges caused by unilateral sanctions and overcompliance force States under sanctions into survival mode, in which they prioritize food, health care and agriculture¹¹⁷ at the expense of other sectors, including transportation and the treatment of solid and medical waste and conflict-related pollution, including related to toxic munitions and explosive material.¹¹⁸ 118 States are also prevented from developing environmentally friendly technologies¹¹⁹ and procuring industrial filters and other up-to-date technologies, and instead https://koreapeacenow.org/resources/the-humanitarian-impact-of-sanctions-on-north-korea-2/. 103 Submission by the Palestinian Centre for Human Rights. 104 Jerg Gutmann, Matthias Neuenkirch and Florian Neumeier, “Sanctioned to death? The impact of economic sanctions on life expectancy and its gender gap”, CESifo Working Paper, No. 8033 (2019), p. 26; and Yiyeon Kim, “Economic sanctions and HIV/AIDS in women”, Journal of Public Health Policy, vol. 40, No. 3 (September 2019). 105 Submission by the Sexual Rights Initiative. 106 See https://www.ohchr.org/en/press-releases/2020/03/covid-19-economic-sanctions-should-be-liftedprevent-hunger-crises-un-expert?LangID=E&NewsID=25761. 107 Submission by China. 108 Submissions by the Armenian Bar Association and the Palestinian Centre for Human Rights. 109 Submission by the Islamic Republic of Iran. 110 A/HRC/48/59/Add.2, paras. 62 and 63. 111 A/HRC/54/23/Add.1, paras. 31–34. 112 A/51/33/Add.2, paras. 28 and 29. 113 Submission by the Palestinian Centre for Human Rights. 114 Kim, “Economic sanctions and HIV/AIDS”; and Gutmann, Neuenkirch and Neumeier, “Sanctioned to death?”. 115 A/HRC/48/59/Add.2, para. 48. See also submission by the Sexual Rights Initiative. 116 A/HRC/51/33/Add.1, paras. 45–47. 117 Kaveh Madani, “Have international sanctions impacted Iran’s environment?”, World, vol. 2, No. 2 (June 2021), pp. 231–52. 118 See https://www.ohchr.org/sites/default/files/documents/issues/ucm/statements/2022-1109/20221110-eom-syria-sr-ucm-en.docx. 119 Martin Heger and Maria Sarraf, “Air pollution in Tehran: health costs, sources, and policies” (Washington, D.C., World Bank, 2018), p. 9; Agence France-Presse, “Iran: le retrait de Peugeot et Renault mauvais pour l’environnement (responsable)”, Le Point, 2 October 2018; and Madani, “Have international sanctions impacted Iran’s environment?”. See also A/HRC/51/33/Add.1, para. 45; and communication USA 17/2022. GE.23-14100 are forced to rely on polluting and outdated sources of energy for both domestic and industrial use. All these affect the right to a favourable environment, with long-term health effects.¹²⁰

117. Kaveh Madani, “Have international sanctions impacted Iran’s environment?”, World, vol. 2, No. 2 (June 2021), pp. 231–52. ↩
118. See https://www.ohchr.org/sites/default/files/documents/issues/ucm/statements/2022-11-09/20221110-eom-syria-sr-ucm-en.docx. ↩
119. Martin Heger and Maria Sarraf, “Air pollution in Tehran: health costs, sources, and policies” (Washington, D.C., World Bank, 2018), p. 9; Agence France-Presse, “Iran: le retrait de Peugeot et Renault mauvais pour l’environnement (responsable)”, Le Point, 2 October 2018; and Madani, “Have international sanctions impacted Iran’s environment?”. See also A/HRC/51/33/Add.1, para. 45; and communication USA 17/2022. ↩
120. Submission by the Islamic Republic of Iran. See also A/HRC/54/23/Add.1, paras. 78 and 79; A/HRC/48/59/Add.2, para. 102; A/HRC/51/33/Add.2, paras. 32 and 88; and communication USA 17/2022. ↩

The Special Rapporteur notes with regret that the use of unilateral sanctions reduces the ability of States under sanctions to guarantee and promote occupational health and safety, including through social protection schemes. Countries reported deteriorating labour conditions and rising numbers of health-related and other incidents and referred to sanctions-related restrictions on the procurement of appropriate and up-to-date specialized equipment, including for pollutant measurements and the control and mitigation of occupational hazards.¹²¹

121. Submission by the Islamic Republic of Iran. ↩

Despite repeated calls by the Special Rapporteur for the lifting of all sanctions against any goods or materials needed for critical infrastructure and for the enjoyment of the right to health and its underlying determinants, and in consideration of the challenges set out above,¹²² she has received no meaningful response.

122. See https://www.ohchr.org/en/press-releases/2022/03/un-experts-urge-states-consider-humanitarian-impacts-when-imposing-or. ↩

The Special Rapporteur acknowledges that persons with disabilities and those suffering from rare or severe diseases in need of sustained medical attention are the most vulnerable in the face of unilateral sanctions and overcompliance.¹²³ The absence of adequate and sufficient medical assistance and treatment for persons with disabilities and for those with severe and rare diseases results in increased mortality rates, reduced life expectancy and the deterioration of overall health.

123. Submission by Sures, Human Rights Study and Advocacy. ↩

Unilateral sanctions and overcompliance create the conditions for the systematic violation of the rights of persons with disabilities and of provisions set out in the Convention on the Rights of Persons with Disabilities, including with regard to social support and access to health-care services in the country of residence and abroad¹²⁴ and to assistive technology and adaptive equipment. The Special Rapporteur notes with concern that much of this technology and equipment is subject to sanctions-related export controls because at least 10 per cent of their content and components is sourced from the United States. As a result, they are often procured through alternative routes, with serious cost implications.

124. A/HRC/48/59/Add.2, paras. 46 and 47; and A/HRC/51/33/Add.1, para. 28. See also communications SWE 4/2022 and OTH 95/2022; https://www.ohchr.org/en/press-releases/2023/02/iran-over-compliance-unilateral-sanctions-affects-thalassemia-patients-say; https://www.ohchr.org/sites/default/files/documents/issues/ucm/statements/2022-11-09/20221110-eom-syria-sr-ucm-en.docx; and submission by Unidad Nacional de Promoción de Salud y Prevención de Enfermedades. ↩

The general deterioration of transport systems and the unavailability of fuel in countries under sanctions add to the challenges faced by persons with disabilities and those suffering from rare or severe diseases in terms of access to health-care facilities, workplaces and community events, while electricity and water shortages constitute additional obstacles.

In the Convention on Elimination of All Forms of Discrimination against Women, States parties are requested to take all appropriate measures to ensure access to health-care services, including those related to family planning; appropriate services in connection with pregnancy, confinement and the postnatal period, granting free services where necessary, as well as adequate nutrition during pregnancy and lactation,¹²⁵ all of which are unfortunately affected by unilateral sanctions. The Convention on the Rights of the Child provides for measures to diminish infant and child mortality and to ensure appropriate pre- and postnatal health care for mothers, preventive health care for children and adequate nutrition and access to clean water.¹²⁶

125. See also Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 14. ↩
126. Ibid., para. 22. ↩

In Venezuela (Bolivarian Republic of) and Zimbabwe, in the light of the shortage of gasoline and the lack of medicine, tests, equipment and water in hospitals, the number of women giving birth without medical assistance has dramatically increased (up to 80 per cent, according to some reports) as have cases of extremely low haemoglobin¹²⁷ and underweight (for example, the rate of anaemia in pregnant women in Zimbabwe reached 33.2 per cent in 2019).¹²⁸ Such conditions, in the absence of haemostatic drugs, have led to an increase in infant and maternal mortality. In 2020, the maternal mortality rate was 680 per 100,000 births in Afghanistan,¹²⁹ 259 per 100,000 births in the Bolivarian Republic of Venezuela¹³⁰ and 357 per 100,000 births in Zimbabwe.¹³¹ In the Occupied Palestinian Territory, the insufficiency of health-care services results in the early discharge from health centres of mothers and their babies following birth, reducing opportunities for the detection of any medical complications and the provision of life-saving interventions¹³² and heightening the risk of preventable maternal and newborn mortality.¹³³

127. Submission by Sures, Human Rights Study and Advocacy. ↩
128. A/HRC/51/33/Add.2, para. 24. ↩
129. Submission by the Sexual Rights Initiative. ↩
130. Ibid. ↩
131. See https://data.worldbank.org/indicator/SH.STA.MMRT. ↩
132. See https://www.unicef.org/sop/what-we-do/health-and-nutrition. ↩
133. See https://palestine.unfpa.org/sites/default/files/pub-pdf/national_maternal_mortality_report_2020_0.pdf. ↩

The Special Rapporteur is alarmed about the growing impact of unilateral sanctions and overcompliance on children’s right to health, in particular growing rates of malnutrition, anaemia, underweight and undergrowth in newborns and older children and growing infant and under-5 mortality rates. In Zimbabwe, the infant mortality rate rose after unilateral sanctions were imposed in 2001; it stood at 36 per 1,000 live births in 2021. In the Bolivarian Republic of Venezuela, infant mortality increased from 15 per 1,000 live births in 2013 to 21 per 1,000 live births in 2021 and, in the Syrian Arab Republic, it increased from 16 per 1,000 live births in 2010 to 28 per 1,000 live births in 2014; the rate for 2021 was 18 per 1,000 live births.¹³⁴

134. See https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=ZW-VE-AF-SY. ↩

It has also been reported that, due to shortages of water and gas, people shift to unsafe water sources and open-fire cooking (Democratic People’s Republic of Korea,¹³⁵ Venezuela (Bolivarian Republic of)¹³⁶ and Zimbabwe),¹³⁷ with women and girls disproportionately exposed and affected.

135. See https://koreapeacenow.org/wp-content/uploads/2019/10/human-costs-and-gendered-impact-of-sanctions-on-north-korea.pdf. ↩
136. See A/HRC/48/59/Add.2. ↩
137. See A/HRC/51/33/Add.2. ↩

The economic crisis caused or exacerbated by unilateral sanctions has led to the increased emigration of men. As a result, women are left alone and forced to look for a source of financial support for themselves and their children. They are often the first to lose their jobs, however, especially in rural areas. They are vulnerable to trafficking in persons and sexual exploitation, including when migrating abroad.

In difficult economic circumstances, children and adolescents are vulnerable to violence, sexual and economic exploitation, drug use and involvement in criminal activities 125 See also Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 14. 126 Ibid., para. 22. 127 Submission by Sures, Human Rights Study and Advocacy. 128 A/HRC/51/33/Add.2, para. 24. 129 Submission by the Sexual Rights Initiative. 130 Ibid. 131 See https://data.worldbank.org/indicator/SH.STA.MMRT. 132 See https://www.unicef.org/sop/what-we-do/health-and-nutrition. 133 See https://palestine.unfpa.org/sites/default/files/pubpdf/national_maternal_mortality_report_2020_0.pdf. 134 See https://data.worldbank.org/indicator/SP.DYN.IMRT.IN?locations=ZW-VE-AF-SY. 135 See https://koreapeacenow.org/wp-content/uploads/2019/10/human-costs-and-gendered-impact-ofsanctions-on-north-korea.pdf. 136 See A/HRC/48/59/Add.2. 137 See A/HRC/51/33/Add.2. GE.23-14100 and armed conflicts (Cuba,¹³⁸ Syrian Arab Republic139 and Venezuela (Bolivarian Republic of),¹⁴⁰ with serious health and social consequences, including an increased prevalence of adolescent pregnancy, opportunistic infections and HIV/AIDS, particularly in the absence of adequate resources for the implementation of social protection, public health measures and family planning programmes. A recent example is the interruption in Cuba of the free distribution of contraceptives.¹⁴¹

138. Submissions by the Sociedad Cubana Multidisciplinaria para el Estudio de la Sexualidad and the Centro Oscar Arnulfo Romero. ↩
140. A/HRC/48/59/Add.2, para. 32. ↩
141. Submission by the Sociedad Científica Cubana para el Desarrollo de la Familia. ↩

The Special Rapporteur emphasizes that unilateral sanctions affect other populations in vulnerable situations. In particular, sanctions against the Islamic Republic of Iran hinder its ability to provide the 5.5 million Afghan refugees in the country with adequate food, health care, housing and other services.¹⁴² In addition, while in its general comment No. 6 (1995), the Committee on Economic, Social and Cultural Rights stipulated the need for preventive, curative and rehabilitative health treatment for older persons, multiple reports highlighted the health-care challenges affecting older persons due to sanctions-related economic and trade restrictions and overcompliance by businesses and the financial sector.

142. A/HRC/51/33/Add.1, para. 68. ↩

Health-care challenges caused by sanctions also have serious adverse effects on the right of lesbian, gay, bisexual, transgender and other gender-diverse persons and intersex persons to the highest attainable standard of physical and mental health due to the unavailability or shortage of medications for gender-affirming hormone therapy and antiretroviral therapy or, when such medications are available, due to their low quality or doubled or tripled price, resulting in health complications and recourse to alternative means of procurement, including uncertified private supply chains.¹⁴³

143. Joint submission by Coming Out, Center-T and the Sphere Foundation. ↩

It is generally recognized that urgent medical care in cases of accidents, epidemics and similar health hazards and the provision of disaster relief and humanitarian assistance in emergency situations are integral to the right to health.¹⁴⁴ The Special Rapporteur regrets that the delivery of humanitarian assistance and the work of humanitarian actors have been substantially affected by the imposition of unilateral sanctions, due, in particular, to the overlapping, confusing and complicated sanctions regulations and the complexity of acquiring licences for humanitarian purposes through the existing system of humanitarian exceptions, exemptions and derogations.¹⁴⁵

144. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 16. ↩
145. See communications USA 21/2022 and OTH 106/2022. ↩

Countries that impose sanctions claim that such measures are not aimed at goods or processes that fulfil peoples’ basic needs and argue that the existing humanitarian exemptions are efficient.¹⁴⁶ They also point to their reported financial support for humanitarian assistance.¹⁴⁷ The Special Rapporteur notes that humanitarian exemptions are de facto ineffective, inefficient and unjustifiably narrow in scope.

146. See https://finance.ec.europa.eu/publications/sanctions-commission-guidance-note-provision-humanitarian-aid-compliance-eu-restrictive-measures_en; and https://finance.ec.europa.eu/eu-and-world/sanctions-restrictive-measures/humanitarian-assistance-environments-subject-eu-sanctions_en. ↩
147. Submission by the European Union. ↩

The Special Rapporteur has received information about complexities and inconsistencies in the application of humanitarian exceptions that make the work of humanitarian actors more challenging and undermine their ability to respond in a timely manner to emergencies. They also contribute to a sense of uncertainty over possible violations of the regulations. In particular, the Special Rapporteur has been informed of lengthy, expensive and complex licensing procedures;¹⁴⁸ serious delays in application processing, which can take up to a year and a half; high legal fees for regulatory interpretation and legal services; a heightened burden of proof for humanitarian operations; the requirement for safeguards against aid deviation;¹⁴⁹ the inability to deliver medical goods due to financial and transport restrictions; and overcompliance by businesses and banks in their imposition of embargoes on dual-use goods, including toothpaste, water-purifying reagents, laboratory equipment¹⁵⁰ and radioisotopes used for medical screening.¹⁵¹ Humanitarian actors, donors and financial institutions often do not have the expertise or the financial and human resources to navigate complex and interlinked sanctions regimes. Such challenges have reportedly shifted humanitarian work from a focus on needs assessment to risk assessment.¹⁵²

148. A/HRC/54/23/Add.1, para. 51. ↩
149. See communication USA 21/2022. See also https://finance.ec.europa.eu/system/files/2022-07/220630-humanitarian-aid-guidance-note_en.pdf. ↩
150. Submission by the Islamic Republic of Iran. ↩
151. Submission by Gujarat National Law University Student Research Development Council. See also https://www.iaea.org/newscenter/statements/iaea-director-generals-introductory-statement-to-the-board-of-governors-14-september-2020. ↩
152. See https://www.hrw.org/news/2023/06/22/questions-and-answers-how-sanctions-affect-humanitarian-response-syria. ↩

Although food and medicine are generally exempt from sanctions, other restrictions may apply, including prohibitions on receiving money from countries under sanctions, on entering their territorial waters or their airspace and on insuring cargo,¹⁵³ thus disrupting deliveries to countries under sanctions.¹⁵⁴

153. See A/HRC/51/33/Add.1 and A/HRC/48/59/Add.2. ↩
154. See communication SWE 4/2022. ↩

The response to the earthquake of February 2023 in the Syrian Arab Republic and Türkiye is a prime example of the above-mentioned challenges. Despite universal recognition of the catastrophic impact of the earthquake and the decisions by the United Kingdom,¹⁵⁵ the United States¹⁵⁶ and the European Union¹⁵⁷ to ease certain sanctions-related restrictions imposed on the Syrian Arab Republic by issuing special licences to enable earthquake relief efforts, the Special Rapporteur was concerned about the limited scope of these initiatives and their short term (180 days). She also questioned the capacity of the licences to resolve the persistent problem of overcompliance with sanctions, which has impeded the work of humanitarian actors, and whether they would dispel the fear of transgressing unilateral sanctions regimes through engagement with the Government of the Syrian Arab Republic to provide life-saving assistance and infrastructure rehabilitation. Information received for the preparation of the present report indicated that banks outside of the Syrian Arab Republic continued to block transactions relating to that country, even after the earthquake.¹⁵⁸ Cuba faces similar humanitarian challenges¹⁵⁹ under the embargo imposed by the United States, which has repeatedly been condemned by the international community, as shown in the voting patterns for General Assembly resolutions.

155. See https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1167660/INT-2023-2711256__Amended_17-02-2023__Syria_Humanitarian_GL.pdf.pdf. ↩
156. See https://ofac.treasury.gov/media/931106/download?inline. ↩
157. See Council Regulation (EU) 2023/407 of 23 February 2023 amending Regulation (EU) No. 36/2012 concerning restrictive measures in view of the situation in Syria. ↩
158. See https://www.hrw.org/news/2023/06/22/put-peoples-rights-first-syria-sanctions. ↩
159. Submission by the Unidad Nacional de Promoción de Salud y Prevención de Enfermedades. ↩

Existing challenges to the implementation of humanitarian exemptions and the delivery of humanitarian aid also affect the implementation of Security Council resolutions 2615 (2021) and 2664 (2022) and the upholding of the principles of humanity, neutrality, impartiality and independence. The Special Rapporteur notes with concern that sanctioning 148 A/HRC/54/23/Add.1, para. 51. 149 See communication USA 21/2022. See also https://finance.ec.europa.eu/system/files/202207/220630-humanitarian-aid-guidance-note_en.pdf. 150 Submission by the Islamic Republic of Iran. 151 Submission by Gujarat National Law University Student Research Development Council. See also https://www.iaea.org/newscenter/statements/iaea-director-generals-introductory-statement-to-theboard-of-governors-14-september-2020. 152 See https://www.hrw.org/news/2023/06/22/questions-and-answers-how-sanctions-affecthumanitarian-response-syria. 153 See A/HRC/51/33/Add.1 and A/HRC/48/59/Add.2. 154 See communication SWE 4/2022. 155 See https://assets.publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/1167660/INT-2023-2711256__Amended_17-022023__Syria_Humanitarian_GL.pdf.pdf. 156 See https://ofac.treasury.gov/media/931106/download?inline. 157 See Council Regulation (EU) 2023/407 of 23 February 2023 amending Regulation (EU) No. 36/2012 concerning restrictive measures in view of the situation in Syria. 158 See https://www.hrw.org/news/2023/06/22/put-peoples-rights-first-syria-sanctions. 159 Submission by the Unidad Nacional de Promoción de Salud y Prevención de Enfermedades. GE.23-14100 States and organizations may allow for the transfer of only limited funds by the United Nations and partner non-governmental organizations for humanitarian purposes.¹⁶⁰

160. See, for example, Council Regulation (EU) 2023/331 of 14 February 2023 amending certain Council regulations concerning restrictive measures in order to insert provisions on a humanitarian exemption. ↩

The obligation to promote and protect human rights, including the right to health, is usually understood as an obligation of the State of nationality or residence of the individual. The Special Rapporteur reiterates the responsibility of the State in this regard, as set out in article 2 (1) of the International Covenant on Economic, Social and Cultural Rights, to take steps towards the full realization of the rights recognized in the Covenant to the maximum of its available resources. She also emphasizes the universal and extraterritorial character of this obligation. The Charter of the United Nations provides for the obligation of States to respect and observe human rights universally, without any territorial limitation. A similar approach is reflected in the preambles of the Covenant and of the Convention on the Elimination of All Forms of Discrimination against Women and the preamble and article 1 of the Convention on the Rights of Persons with Disabilities.

In paragraph 39 of its general comment No. 14 (2000), the Committee on Economic, Social and Cultural Rights noted that States parties had to respect the enjoyment of the right to health in other countries, and to prevent third parties from violating the right in other countries, if they were able to influence those third parties by way of legal or political means, in accordance with the Charter of the United Nations and applicable international law.

Taking into account that many health-care and social support programmes depend on the availability of national resources, the Special Rapporteur believes that unilateral sanctions that diminish the revenue of States constitute a violation of the prohibition in international law against depriving a people of its own means of subsistence, including as set out in the preamble of the International Covenant on Economic, Social and Cultural Rights, and affects the fulfilment of the obligations set out in article 17 (2) of the Covenant and article 35 (5) of the Convention on the Rights of Persons with Disabilities.

Unilateral sanctions and overcompliance violate the obligation of States to cooperate in the achievement of the aims of the relevant human rights treaties, including regarding international development programmes, training programmes, the exchange of information, best practices and technologies, the facilitation of cooperation in research and access to scientific and technical knowledge.

In countries under sanctions, the prevention of the procurement of medicines and innovative medical and adaptive equipment for persons with disabilities, the inability of medical professionals and academics to acquire technical and medical knowledge due to limited access to online platforms, databases and conferences and the challenges faced by scientists in presenting and publishing their research all constitute violations of human rights, including under articles 4 (1) (i) and 32 of the Convention on the Rights of Persons with Disabilities, in addition to article 4 (1) (d), in which States parties are called upon to refrain from engaging in any act or practice that is inconsistent with the Convention.

Unilateral sanctions and overcompliance by businesses, including banks and pharmaceutical, transportation and insurance companies, violate the due-diligence obligations of businesses and the States that own or control them or in whose territory or jurisdiction those businesses are domiciled. Businesses are obligated to take measures to prevent any violation of human rights, at a minimum those set forth in the International Bill of Human Rights. States are obligated to take all measures necessary to ensure that the activity of private businesses under their jurisdiction and control is exercised in full conformity with human rights standards.¹⁶¹

161. Guiding Principles on Business and Human Rights, principles 3–6. ↩

The Special Rapporteur concurs with the Committee on Economic, Social and Cultural Rights that the prioritization of business interests and activities over the obligation to respect human rights, the absence of appropriate measures to prevent such violations, including extraterritorially, and the failure to apply due diligence and to assess the impact on human rights of business activities all constitute violations of the International Covenant on Economic, Social and Cultural Rights.¹⁶²

162. Committee on Economic, Social and Cultural Rights, general comment No. 24 (2017). See also the Office of the United Nations High Commissioner for Human Rights (OHCHR) and WHO, “The right to health,” Fact Sheet No. 31 (Geneva, 2008), pp. 25 and 26. ↩

The Special Rapporteur believes that the use of the term “unintended”¹⁶³ with regard to the humanitarian consequences of unilateral sanctions is misleading and even dangerous, as it could imply the legitimacy of such measures. When unilateral sanctions are taken without the authorization of the Security Council, or exceed them, and do not meet the criteria for retortion and countermeasures, sanctioning States are responsible for the ensuing violations of international law and for any negative consequences, regardless of their intentions. States, as subject to international law, cannot act unconsciously. Therefore, the criteria of intention or guilt are not applicable.

163. Mehdi Majidpour, “The unintended consequences of US-led sanctions on Iranian industries”, Iranian Studies, vol. 46, No. 1 (January 2013). See also S/PV.8962; and Samir Aita, The Unintended Consequences of U.S. and European Unilateral Measures on Syria’s Economy and Its Small and Medium Enterprises (Atlanta, United States, The Carter Center, 2020). ↩

The Special Rapporteur reiterates that unilateral sanctions and overcompliance impede: the implementation of occupational safety and health standards, including measures to prevent occupational accidents and diseases; the requirement to ensure an adequate supply of safe and potable water and basic sanitation; the prevention of and reduction in the population’s exposure to harmful substances, such as radiation, harmful chemicals and other detrimental environmental conditions that have a direct or indirect impact upon human health; the minimizing, as much as reasonably practicable, of the causes of health and safety hazards inherent in the working environment; and the provision of adequate housing, safe and hygienic working conditions and an adequate supply of food and proper nutrition,¹⁶⁴ as set forth in the conventions and standards on occupational safety and health of the International Labour Organization (ILO), including the Medical Care Recommendation, 1944 (No. 69), the Promotional Framework for Occupational Safety and Health Convention, 2006 (No. 187), the Occupational Safety and Health Convention, 1981 (No. 155), and the Occupational Health Services Convention, 1985 (No. 161), and the recommendations of ILO, as set out in its publications entitled “Decent work and the 2030 Agenda for Sustainable Development” and Social Health Protection: An ILO Strategy towards Universal Access to Health Care.

164. Committee on Economic, Social and Cultural Rights, general comment No. 14 (2000), para. 15. ↩

The global community is currently facing the expansion and increasing complexity of various forms of unilateral sanctions regimes applied to governmental and non-governmental actors and economic sectors, in addition to threats of secondary sanctions, civil and criminal penalties for violations or the circumvention of sanctions and the growing use of zero-risk policies and overcompliance by banks, producers of goods, transport and insurance companies and other private actors.

Unilateral sanctions and overcompliance have a detrimental impact on the implementation of all aspects of the right to health of all people in the countries under sanctions, including access to adequate medicine, health-care facilities, medical equipment and qualified medical assistance; the prevention and control of disease; and an adequate number of health professionals with access to training and up-to-date scientific knowledge, technologies, research and exchange of good practices. Such sanctions also affect all relevant underlying rights, including the rights to adequate food, clean water, sanitation, electricity and fuel, to freedom of movement and to a favourable environment, economic and labour rights and the elimination of poverty. Women, girls, children, persons with disabilities, persons suffering from rare and severe diseases, older persons and socioeconomically marginalized groups are the most vulnerable in the face of unilateral sanctions.

Increasing mortality rates, reduced life expectancy, the rising prevalence of physical and mental health conditions and disabilities due to the lack of timely diagnosis and treatment and increasing physical and psychological suffering are only some of the serious tangible consequence. These constitute violations of human rights, such as the rights to life and to freedom from torture and inhuman treatment, and the principle of non-discrimination.

The imposition and implementation of unilateral sanctions and zero-risk policies violate numerous international treaty and customary obligations of States, including the obligation to promote universal respect for and observance of human rights and fundamental freedoms, in accordance with the Charter of the United Nations and the provisions of the International Covenant on Economic, Social and Cultural Rights, the Convention on the Elimination of All Forms of Discrimination against Women, the Convention on the Rights of Persons with Disabilities, the Convention on the Rights of the Child and many others, including ILO conventions and standards on labour and occupational safety and health. Such sanctions constitute unilateral coercive measures, which are inadmissible under international law and raise the issue of the international responsibility of the sanctioning States. Characterizing the effects on the right to health of unilateral sanctions and overcompliance as unintentional does not legitimize such conduct. The burden of proof of the legality of any unilateral means of pressure lies with the States and organizations that impose them.

The impediments resulting from unilateral sanctions and overcompliance prevent countries from fully exercising their obligation to guarantee the right to health within all available resources due to the scarcity of such resources and reduce their capacity to establish strong and reliable domestic health systems. They also constitute a violation by sanctioning States of the right to health. Similar responsibility for such a violation arises when States do not take all necessary measures to guarantee that businesses acting under their jurisdiction or control do not directly or indirectly affect the right to health.

Health-related humanitarian exemptions, exceptions and derogations are ineffective and inefficient due to complicated, confusing and overlapping sanctions legislation; complex and unclear licence application procedures; uncertainty about potential criminal and civil liability for the possible circumvention of sanctions regimes; uncertainty around the scope of humanitarian assistance; financial and other operational restrictions, including international payment interruptions and the freezing of the assets of designated financial institutions in sanctioned countries; and challenges in transporting and insuring humanitarian goods.

Sanctioning States and regional organizations should review measures taken without the authorization of the Security Council, or that exceed it, and lift those that do not meet the criteria for retortion or countermeasures, in full conformity with the standards and limitations of the law of international responsibility, as constituting unilateral coercive measures. Humanitarian concerns should always be taken into account by States when deciding on the imposition of any unilateral measures, including countermeasures (humanitarian precaution), and in the course of their application.

Unilateral sanctions should never affect the functioning of critical infrastructure relevant to health care, food, agriculture, electricity, water supply, irrigation, sanitation, seeds and fertilizers, all of which are necessary for the survival and well-being of populations.

States are obligated to take all possible legislative, institutional and administrative measures to avoid and minimize overcompliance and to ensure that the activities of private businesses under their jurisdiction and control do not violate the right to health and other human rights extraterritorially. Non-fulfilment of this obligation can be used as grounds for asserting the responsibility of the relevant States for violations of treaty obligations to protect the right to health.

Businesses should avoid zero-risk policies and overcompliance, which are incompatible with their obligations under the Guiding Principles on Business and Human Rights, especially regarding medicines, vaccines, medical equipment, spare parts and other goods necessary for the provision of health-related services and support to critical infrastructure.

The procurement and delivery of medicines, vaccines, medical equipment, food, spare parts, software, baby formula, equipment and goods necessary to guarantee adequate access to clean water and sanitation should not be dependent on a licensing procedure. Pharmaceutical, medical equipment, transportation, insurance and other types of companies, donors and humanitarian organizations should not be subjected to any type of punishment, restriction or reputational risk for their efforts to deliver goods vital to ensure the right to health.

States under unilateral sanctions should provide detailed information on all types of challenges arising from sanctions and overcompliance in their engagement with all relevant United Nations entities and mechanisms, including WHO, ILO, the United Nations Educational, Scientific and Cultural Organization (UNESCO), the universal periodic review, treaty body reports and special procedures of the Human Rights Council.

WHO should take the lead in monitoring the unhindered delivery of medicines, medical equipment, vaccines, consumables, spare parts and reagents and health-related goods that may be qualified as dual use.

WHO is invited to launch a special study on the impact of unilateral sanctions and overcompliance on the right to health in the countries under sanctions, with particular focus on persons in vulnerable situations, including women, children, older persons, persons with disabilities and those suffering from rare and severe diseases.

The United Nations treaty bodies should:
(a) Include in their engagement with States parties an assessment of the impact of unilateral sanctions on the right to health;
(b) Prepare an analysis of and provide their expert opinion on the impact of unilateral coercive measures on the relevant issues set out in their general comments;
(c) Assess the impact of unilateral sanctions on the ability of States under sanctions to effectively respond to their obligations under the provisions of the treaties.

ILO should:
(a) Monitor, in line with its mandate, the impact of unilateral sanctions on the ability of States under sanctions to fulfil their international obligations under the ILO conventions, recommendations and strategies on decent work, green jobs, social protection and occupational safety and health;
(b) Consider the possibility of launching an investigation into the impact of unilateral sanctions on the ability of States under sanctions to fulfil their obligations under the ILO conventions with regard to decent work standards, green jobs, social protection, occupational safety and health and assess the policies of sanctioning States and instances of overcompliance by businesses and the financial sector.

Humanitarian organizations and agencies should not be designated or subjected to civil or criminal penalties for doing their humanitarian work, especially in life-threatening situations, in accordance with the principles of humanity, neutrality, impartiality and independence, nor be obliged to bear the burden of proof and risks of sanctions regulations.

States are invited to engage in international adjudication, including through competent international quasi-judicial and human rights bodies, to settle disputes, protect human rights and determine responsibility and redress in sanctions cases.

Taking into account that unilateral sanctions affect the ability of States to effectively respond to contemporary threats and challenges and also affect all categories of human rights, the Special Rapporteur calls for the inclusion of an assessment, by all United Nations organs and specialized agencies, including OHCHR, WHO, UNICEF, the United Nations Population Fund, the World Food Programme, the Office for the Coordination of Humanitarian Affairs, the Office of the United Nations High Commissioner for Refugees, ILO, UNESCO and the International Civil Aviation Organization, of the legality and the humanitarian impact of unilateral sanctions.

Sanctions authorized by the Security Council should be implemented in full conformity with the limits of that authorization, with due consideration for humanitarian needs. The resolutions of the Council regarding humanitarian matters should be fully respected and implemented by all States. No reference to unilateral sanctions should be used to justify non-compliance with those resolutions.

The Special Rapporteur notes the important role of international and local civil society organizations in providing humanitarian assistance and life-saving services, especially to all those in vulnerable situations in countries under sanctions. Any discussions about the humanitarian situations in countries under sanctions should be inclusive and allow for the participation of all relevant stakeholders, including both international and local civil society actors.