More than 13,500 asylum seekers remain trapped on the Greek islands in deplorable conditions as winter begins on December 21, 2017. Greece, with support from its European Union partners, should urgently transfer thousands of asylum seekers to the Greek mainland and provide them with adequate accommodation and access to fair and efficient asylum procedures.

Author: Human Rights Watch, Human Rights Watch
Posted: January 1, 1970, 12:00 am

(New York) – The latest revisions to China’s Criminal Law impose up to seven years in prison for “spreading rumors” about disasters, Human Rights Watch said today. The revised law, which took effect November 1, 2015, does not clarify what constitutes a “rumor,” heightening concerns that the provision will be used to curtail freedom of speech, particularly on the Internet.

“The revised Criminal Law adds a potent weapon to the Chinese government’s arsenal of punishments against netizens, including those who simply share information that departs from the official version of events,” said Sophie Richardson, China director at Human Rights Watch. “The authorities are once again criminalizing free speech on the Internet, which has been the Chinese people’s only relatively free avenue for expressing themselves.”

The National People’s Congress Standing Committee approved the addition of a provision to article 291(1) of the Criminal Law (Criminal Law Amendment Act (9)), which states that whoever “fabricates or deliberately spreads on media, including on the Internet, false information regarding dangerous situations, the spread of diseases, disasters and police information, and who seriously disturb social order” would face prison sentences – with a maximum of seven years for those whose rumors result in “serious consequences.” The vagueness of the provision means that individuals doing nothing more than asking questions or reposting information online about reported local disasters could be subject to prosecution.

In the past, the Chinese government has detained netizens who questioned official casualty figures or who had published alternative information about disasters ranging from SARS in 2003 to the Tianjin chemical blast in 2015, under the guise of preventing “rumors.”

The revision was made in the context of a wider effort to rein in online freedom since President Xi Jinping came to power in 2013:

  • In August 2013, the authorities waged a campaign against “online rumors” that included warning Internet users against breaching “seven bottom lines” in their Internet postings, taking into custody the well-known online commentator Charles Xue, and closing popular “public accounts” on the social media platform “WeChat” that report and comment on current affairs;
  • In September 2013, the Supreme People’s Court and the Supreme People’s Procuratorate (the state prosecution) issued a judicial interpretation making the crimes of defamation, creating disturbances, illegal business operations, and extortion applicable to expressions in cyberspace. The first netizen who was criminally prosecuted after this took effect was well-known blogger Qin Huohuo, who was sentenced to three years in prison in April 2014 for allegedly defaming the government and celebrities by questioning whether they were corrupt or engaged in other dishonest behavior;
  • In July and August 2014, authorities suspended popular foreign instant messaging services, including KakaoTalk, claiming the service was being used for “distributing terrorism-related information”;
  • In 2015, government agencies such as the State Internet Information Office issued multiple new directives, including tightening restrictions over the use of usernames and avatars, and requiring writers of online literature in particular to register with their real names;
  • In 2015, the government has also shut down or restricted access to Virtual Private Networks (VPNs), which many users depend on to access content blocked to users inside the country and also help shield user privacy;
  • In March 2015, authorities also deployed a new cyber weapon, the “Great Cannon,” to disrupt the services of GreatFire.org, an organization that works to document China’s censorship and facilitate access to information;
  • In July 2015, the government published a draft cybersecurity law that will requires domestic and foreign Internet companies to increase censorship on the government’s behalf, register users’ real names, localize data, and aid government surveillance; and
  • In August 2015, the government announced that it would station police in major Internet companies to more effectively prevent “spreading rumors” online.
     

Activists in China are regularly prosecuted for speech-related “crimes,” Human Rights Watch said. The best known of these crimes is “inciting subversion,” which carries a maximum of 15 years in prison. But authorities have also used other crimes such as “inciting ethnic hatred,” as in the case of human rights lawyer Pu Zhiqiang, who has been detained since May 2014 for a number of social media posts questioning the government’s policies towards Uighurs and Tibetans.

While providing the public with accurate information during disasters is important, the best way to counter inaccurate information would be to ensure that official information is reliable and transparent, Human Rights Watch said.

Above all, journalists should have unimpeded access to investigate and inform the public about these events, and the wider public should have the freedom to debate and discuss disaster response.

“The casualties of China’s new provision would not be limited to journalists, activists and netizens, but the right of ordinary people and the world to know about crucial developments in China,” Richardson said. “The best way to dispel false rumors would be to allow, not curtail, free expression.”

Posted: January 1, 1970, 12:00 am

In 2020 you should be watching for… more people going hungry and relying on aid to feed their families in the world’s wealthiest countries. 

The United Kingdom offers a stark example, as Human Rights Watch has documented. Since cuts in public spending on welfare for the poorest families began in 2010, use of the country’s largest network of food banks—making up an estimated two-thirds of the country’s food aid distribution—has skyrocketed 50-fold, to 1.6 million three-day emergency packages handed out last year. Smaller independent food banks have gone from a handful countrywide a decade ago, to around 820 today.

Schools, kindergartens, community centers, local charities, and faith groups have stepped in to fill gaps resulting from a decade of cuts; today, many provide food to vulnerable families, often with working parents, even making sure children get one warm meal a day during school holidays.

The UK is not alone. Germany’s Tafel network of around 940 food banks (or food tables), which opened in 1993 gave food to 1.65 million people last year; it has seen steady rises in demand over the past decade-and-a-half, with more and more women, children, and older people needing food aid.

In France, the Restos du Coeur (Restaurants of the Heart) network, gave out  around 130 million meals in 2017-18, the last year for which they have figures, through their emergency food aid program. One-third of such aid was directed to single parent families, and there is increasing concern about older people left to rely on their aid.

Analysts who have studied how food banks have become a feature of daily life over decades in the United States and Canada have warned that without a clear strategy to tackle hunger and improve social security, use of emergency food aid is likely to become normalized and permanent.

This hunger, so long a feature of poorer countries, risks becoming normalized in richer ones—  eroding people’s faith in their democratic institutions, and the relatively resource-rich societies in which they live.

Brexit could exacerbate hunger in the UK, especially if the UK were to leave without a deal. UK food aid providers are worried that an abrupt, unplanned departure could disrupt food supplies and cause price shocks for the country’s poorest consumers whose incomes would be most hit by the short term economic upheaval.

In France, amid widespread public protests about living standards and labor law changes, the government has begun restructuring unemployment benefits and is expected in 2020 to make changes to public pensions to address its deficits. This is likely to mean more people needing support from the Restos du Coeur so they have enough to eat.

In Germany, the coming year will see important arguments in court about whether scaling back welfare support for asylum-seekers—about 127,000 in the first nine months of 2019, which could leave many struggling to feed themselves—is lawful given Germany’s constitutionally guaranteed “dignified minimum existence.”

It can be hard to see a silver lining to the issue of hunger and food bank use in countries with more than enough resources to ensure everyone has food on the table.

Yet it is encouraging in the UK to see a broad coalition of civil society groups securing policy commitments from political parties to make the right to food enforceable in domestic law. More broadly, the discussion about the food as a human right offers a chance to change what is often a toxic conversation about human rights in the UK into one that resonates more widely with the public.

In France, the full effect of a 2016 law that requires large food retail stores to ensure food nearing its expiry date is given to those who need it rather than being wasted remains to be seen. But the early signs are promising—inspiring activists to demand other food producers (growers, processing plants, and restaurants) are also required to take similar measures. State efforts are needed at the same time to ensure that people have the means to feed their families.

Civil society organizations familiar with using the language of the 2030 UN Sustainable Development Goals in overseas aid efforts are having to articulate some of those same goals— ending poverty and achieving zero hunger—in human rights terms closer to home.

With better legal protections, better measurement, and stronger policy responses, this entirely avoidable hunger can be reduced drastically. Hunger in wealthy countries is not inevitable, and food banks are not a substitute for government action. As the UN’s former special rapporteur on the right to food and 57 other prominent academic and nongovernmental organization voices have warned, we should never get used to the idea of “leftover” food for “left behind people”.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Drone view of a quilombo (Afro-Brazilian) community in Minas Gerais State, southeast Brazil. Some of the houses are around 20 meters from the adjacent sugarcane plantation.

© 2018 Marizilda Cruppé for Human Rights Watch
Brazil’s National Health Monitoring Agency (Anvisa) released a report on December 11 with concerning findings about the food Brazilians buy every day in their local market.

Anvisa technicians gathered more than 4,600 food samples from supermarkets in nearly every Brazilian state between August 2017 and June 2018 (only Paraná State opted out of the study.) They tested 14 foods popular with Brazilians: pineapples, lettuce, rice, garlic, sweet potatoes, beets, carrots, chayote, guavas, oranges, mangoes, bell peppers, tomatoes, and grapes.

They found dangerous traces of pesticides, including some that are banned from sale in Brazil, in nearly one-quarter of the samples. 

Residues of the banned pesticide carbofuran, for instance, was found on many of the food samples. Health experts say carbofuran causes nausea, vomiting, diarrhea, and other acute poisoning symptoms. ANVISA prohibited carbofuran in 2017.

Another pesticide found in samples of lettuce is atrazine, which the European Union banned in 2003 because it interferes with reproduction and human development, and may cause cancer. It’s legal in Brazil, though.

Anvisa’s website spins the results, announcing that “plant foods are safe for the population to consume.” But the numbers and the science say otherwise.

Disturbingly, the study also shows that pesticide residue levels in these foods are rising rather than falling. This corresponds with a government-reported increase in pesticide use in recent years, as well as an increase in cases of acute poisonings from pesticide drift.

ANVISA’s study covers a period before President Jair Bolsonaro assumed office, but he has ushered in an era of deference to the powerful agribusiness lobby at the expense of the environment.

During his first year as president, he scaled back enforcement of environmental laws, weakened federal environmental agencies, and harshly criticized organizations and individuals working for environmental causes. As evidence of problems with pesticides mounts, the government is rushing to approve new pesticides or new brands of existing products.

New rules ANVISA passed within the last year designate the “risk of death” as the only criterion for classifying a pesticide as toxic. Members of Congress and supporters of Bolsonaro’s administration are pressing for policies that would weaken pesticide regulation even further. Congress this year considered a bill that would have crippled oversight, including by reducing the role of the environment and health ministries in approving pesticides. The bill didn’t pass, but you can bet that someone will reintroduce it.

Anvisa's report was published on Human Rights Day. One of the rights celebrated that day is the right to food, which includes the right to food safety. Another is the right to health, which depends on a decent, well-regulated food supply. Ensuring both these rights requires ensuring safe levels of toxins, bacteria, and other substances that can make food injurious to health.

 Brazil’s vast industrial farms depend on pesticides and herbicides. The pressure to deregulate is intense. But officials and lawmakers need to show courage and require safe farming standards to protect the rights to food and health of all Brazilians.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Secretary Alex Azar
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue SW., Room 445-G
Washington, DC 20201

RE: Proposed Rule on Health and Human Services Grants Regulation

Dear Secretary Azar,

Human Rights Watch opposes the Proposed Rule on Health and Human Services Grants Regulation (RIN 0991-AC16).[1] We also oppose the decision of the Department of Health and Human Services (HHS), effective immediately, that it will not enforce certain existing nondiscrimination protections in its grantmaking. The regulatory protections enacted in 2016 were designed to ensure that federal funding is not used to discriminate on the basis of sexual orientation and gender identity, among other grounds.[2] With the proposed rule, HHS would give grantees a license to discriminate that jeopardizes the rights of lesbian, gay, bisexual, and transgender (LGBT) people and compromises the effectiveness of federally funded health and welfare programs.

In recent years, Human Rights Watch has conducted firsthand research on the discrimination that LGBT people face in health and welfare programs. In February 2018, Human Rights Watch released a report entitled “All We Want is Equality”: Religious Exemptions and Discrimination Against LGBT People in the United States, which documented how state religious exemption laws jeopardize LGBT people’s access to physical and mental health care, adoption and foster care, and other goods and services.[3] In July 2018, Human Rights Watch released “You Don’t Want Second Best”: Anti-LGBT Discrimination in US Health Care, which specifically explored the barriers that LGBT people face in healthcare settings.[4] Finally, in November 2018, Human Rights Watch released Living at Risk: Transgender Women, HIV, and Human Rights in South Florida, which detailed in part how discrimination in healthcare programs and settings prevents transgender women from obtaining effective HIV prevention, treatment, and care.[5] Our opposition to the proposed rule is informed by the extensive research that formed the basis for these reports.

The proposed rule is a step in the wrong direction. It fails to recognize the significant discrimination and daunting barriers that many LGBT people encounter when seeking health and welfare services. It exacerbates these problems by sending a signal to providers and LGBT people alike that discrimination is permissible. It jeopardizes the rights of children, including LGBT children. And it promotes a dangerous approach to religious freedom that treats religious belief not as a shield, but as a sword used to deny other people their rights. To safeguard the rights of all people, Human Rights Watch urges HHS not to proceed with the proposed rule.

I. LGBT People Face Persistent Discrimination in Health and Welfare Programs

Under Executive Order 13563, HHS may only propose a rule where it has made a reasoned determination that a rule’s benefits outweigh its costs and it is tailored to impose “the least burden on society.”[6] However, the proposed rule fails to incorporate an understanding of the barriers that LGBT people continue to face in accessing health and welfare programs.

Data consistently show that LGBT people are at heightened risk for a variety of physical and mental health issues.[7] Yet LGBT people are less likely to have the means to seek medical care, and are twice as likely to be uninsured as their heterosexual, cisgender counterparts.[8] When they do seek care, they often face discrimination. In a nationally representative survey conducted by the Center for American Progress in 2017, 8 percent of lesbian, gay, and bisexual respondents and 29 percent of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity in the past year.[9]

Discrimination contributes to the physical and mental health issues that LGBT people experience. In a nationally representative survey from 2017, 68.5 percent of LGBT people who experienced discrimination in the past year said it negatively affected their psychological well-being, while 43.7 percent said it negatively affected their physical well-being.[10] Researchers have found that “in US regions where LGB people have better social and legal conditions, they also have better health and lesser health disparities compared with heterosexuals.”[11] Repealing protections for LGBT people may not only make it more difficult to curb discrimination, but may actually contribute to adverse health outcomes.

While healthcare settings offer particularly vivid examples, LGBT people interviewed by Human Rights Watch have also described discrimination in adoption and foster care, antiviolence programs and shelters, homeless shelters, programs for runaway and homeless youth, sexuality education, and other domains that will be affected by the proposed rule. Removing explicit nondiscrimination protections for sexual orientation and gender identity will put LGBT people at heightened risk in federally funded programs across these areas.

The proposed rule also sows confusion for grantees. Under Executive Order 13672, federal contractors are not permitted to discriminate in hiring and employment on the basis of sexual orientation or gender identity.[12] The proposed rule is likely to burden contractors and grantees by imposing inconsistent nondiscrimination requirements in different domains. The least burdensome option for society is to consistently prohibit discrimination based on sexual orientation and gender identity in both hiring and employment and in the provision of goods and services.

II. The Proposed Rule Jeopardizes LGBT Rights

Human Rights Watch has documented how discrimination on the basis of sexual orientation or gender identity prevents LGBT people from obtaining goods and services. The administration has announced or undertaken efforts to narrowly construe prohibitions on sex discrimination under federal law,[13] making explicit protections for sexual orientation and gender identity in HHS grantmaking particularly important.

Individuals interviewed by Human Rights Watch described three distinct difficulties that LGBT people face in obtaining health and welfare services. First, in our research, Human Rights Watch has documented multiple cases where LGBT people were refused services that were provided to heterosexual, cisgender people. At times, those refusals led individuals to delay or even forego the services they sought. In the domain of adoption and foster care, for example, one couple in Tennessee described being turned away from three different agencies and nearly giving up on becoming parents before finding an agency that would place children with a same-sex couple.[14] Similarly, same-sex couples in Michigan noted that being turned away from religiously affiliated adoption and foster care agencies significantly limited their ability to form a family, requiring lengthy travel and other barriers that heterosexual couples did not confront.[15] More than a dozen interviewees were unaware of local programs for people experiencing intimate partner violence and/or homelessness that were open to transgender individuals, leaving them unable to access vital programs available to others.[16]

While service refusals are a particularly glaring form of discrimination, they are not the only kind of discrimination LGBT people experience. Interviewees have described incidents of being mocked for their gender expression or repeatedly addressed by the wrong name or pronouns,[17] being chastised and prayed over during routine testing for HIV/AIDS,[18] and other forms of discrimination and disrespect. Allowing grantees to discriminate based on sexual orientation and gender identity increases the likelihood of this kind of mistreatment and humiliation in federally funded programs.

These various factors contribute to a third barrier that is exacerbated by discrimination: LGBT people’s hesitation to seek out goods and services in environments where they feel discrimination is likely. Practitioners who work with LGBT individuals noted that many of their clients had foregone care for years because of the discrimination they had faced in the past or felt they were likely to face from providers. Kelley Blair, who runs the Diversity Center in Oklahoma City, Oklahoma, noted from her practice that:

A lot of people have never been to therapy. And they may be 30 or 40 years old. They’ve waited a very long time to come in for services. They delay transitioning until they’re 40 or 50 years old. Some haven’t gone to a primary care health provider for basic things, basic healthcare issues. Our trans males haven’t gone in for pap smears until they’re 30 or 40 years old, some haven’t had basic HIV/AIDS screenings. And that’s because of the discomfort they feel with a general practitioner.[19]

LGBT individuals interviewed by Human Rights Watch expressed hesitation about trying to adopt or foster children from agencies they perceived to be hostile to LGBT individuals or seeking commercial services where they felt they might be turned away. On the heels of efforts to roll back nondiscrimination protections for transgender people under the Affordable Care Act, moving ahead with the proposed rule will only further the impression that discrimination against LGBT people is legally permissible and deter people from seeking the goods and services they need.

III. The Proposed Rule Jeopardizes Children’s Rights

In addition to the rights of LGBT people, permitting HHS grantees to discriminate in federally funded programs will jeopardize the rights of children. When child welfare programs are allowed to discriminate against LGBT parents, for example, children may face longer waiting periods or even age out of the system as a result. For LGBT children, these restrictions may prevent placements with families who are particularly well equipped to provide a loving, affirming home.

The proposed rule would also affect children’s rights outside of the child welfare context. Allowing providers of sexuality education to discriminate on the basis of sexual orientation or gender identity can, for example, prevent LGBT children from receiving information about sex and sexuality that is crucial to their sexual health and safety. And in interviews, LGBT young people experiencing homelessness have told Human Rights Watch that they feel uncomfortable and even unsafe in shelters that do not respect their gender identity and expression.[20] In these and other domains, the proposed rule would not only endanger LGBT rights, but the rights of children as well.

IV. The Proposed Rule Is Not Needed to Protect Religious Freedom

A portion of the proposed rule suggests that it is needed to safeguard religious freedom for recipients of federal funding.[21] As discussed more fully above, this argument misunderstands the freedom of religion, turning it from a shield for an individual’s beliefs into a sword used to deprive others of their rights.

The proposed rule would replicate some of the worrying features of recent religious exemptions in the United States. Unlike true religious exemptions, it would not attempt to strike a balance between equality and religious liberty, and instead would simply eliminate nondiscrimination protections wholesale in the name of religious objectors. It shows no regard for the harm that eliminating nondiscrimination protections would inflict on those who are at particular risk of losing access to goods and services. It instead would allow grantees to discriminate whether or not they harbor a religious objection, turning narrow exceptions for religious objectors into a universal rule. The result would not only fail to recognize the state’s legitimate interest in making federally funded services open to all, but also misunderstand the role of exemptions by turning narrow and particular exceptions into a sweeping license to discriminate. 

V.        Rights at Stake

The proposed rule will function in practice to limit a variety of rights under international law. Among these are the right to nondiscrimination, the right to health, and children’s rights.

  1. The Right to Freedom from Discrimination

The right to freedom from discrimination is a central principle of international human rights law.[22] As a party to the International Covenant on Civil and Political Rights (ICCPR), the United States is obligated to guarantee effective protection against discrimination, including discrimination based on sex, sexual orientation, and gender identity.[23] 

The UN Human Rights Committee, which provides authoritative guidance on the ICCPR, has clarified that the freedom of thought, conscience, and religion does not protect religiously motivated discrimination against women, or racial and religious minorities.[24] It has urged states considering restrictions on the manifestation of religion or belief to “proceed from the need to protect all rights guaranteed under the Covenant, including the right to equality and non-discrimination.”[25]

As Human Rights Watch has documented, religious exemptions at the state level have emboldened service providers to discriminate against LGBT people. Indeed, there is substantial evidence that permitting such discrimination is the primary motivation for some of these exemptions.[26] By granting virtually unfettered discretion to providers who refuse to meet the needs of LGBT people – and declining to provide any safeguards to mitigate the harm that such refusals inflict – the proposed rule likely fails to satisfy the US’s obligations under international law.

  1. Right to Health

Exemptions that deny or deter people from seeking healthcare services jeopardize the right to health. The International Covenant on Economic, Social and Cultural Rights (ICESCR) recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,”[27] without discrimination based on race, sex, religion, or “other status,” including sexual orientation and gender identity.[28] The United States has signed but not ratified the ICESCR, obligating it to refrain from actions that undermine the object and purpose of the treaty.[29] In addition, the ICESCR and the jurisprudence of the Committee on Economic, Social and Cultural Rights provide a useful and authoritative guide to the kind of state action necessary to advance and protect the right to health.

When states enact laws allowing healthcare providers to deny service because of an individual’s sexual orientation or gender identity, they undermine the right to health. Individuals may be denied services outright; have difficulty finding services of comparable quality, accessibility, or affordability; or avoid seeking services for fear of being turned away.

The Committee on Economic, Social and Cultural Rights has noted that the right to health is threatened both by direct discrimination and by indirect discrimination, in which laws appear neutral on their face but disproportionately harm a minority group in practice.[30] To promote the right to health, the Committee has thus urged states to “adopt measures, which should include legislation, to ensure that individuals and entities in the private sphere do not discriminate on prohibited grounds.”[31] 

  1. Children’s Rights

The United States is obligated to adopt special measures to protect children, as required by the ICCPR.[32] These protections include appropriate economic, social, and cultural measures.[33] Consistent with the right to equality before the law and to equal protection of the law,[34] measures of protection for children should be “aimed at removing all discrimination in every field.”[35]

The Convention on the Rights of the Child, signed but not ratified by the United States, provides an authoritative understanding of children’s rights globally and the measures needed to ensure they are respected and protected.[36]

The convention specifies that the best interests of the child should be a primary consideration in all actions concerning children, whether taken by public or private social welfare institutions, and should be the paramount consideration where adoption is concerned.[37] Permitting child welfare agencies to turn away qualified parents because of their sexual orientation or gender identity, however, limits the options available to children in need of placement and may delay or deny foster or adoptive placements for those children. Moreover, doing so may pose a particular threat for LGBT children who are in the care of agencies that harbor objections to LGBT people.

The convention additionally recognizes that children, including LGBT children, have the right to freedom from discrimination, the right to seek and receive information, and the right to the highest attainable standard of physical and mental health.[38]

Permitting discrimination in federally funded health and welfare programs undermines these rights and denies children the special measures of protection to which they are entitled.

VI. Conclusion

The proposed rule raises serious concerns about discrimination and access to substantive goods and services that are advanced by HHS grantmaking. It is virtually certain to limit LGBT people’s access to federally funded programs, license refusals of service and outright discrimination, and deter LGBT people from accessing the goods and services they need. It is also likely to jeopardize the rights of children, including LGBT children, who should be served by these programs. In these ways, it jeopardizes the right to nondiscrimination, the right to health, and children’s rights under international law. For all of these reasons, Human Rights Watch calls on HHS to reject the proposed rule.

Sincerely,

Ryan Thoreson
Researcher, LGBT Rights Program
Human Rights Watch

 

[1] Department of Health and Human Services, “HHS Issues Proposed Rule to Align Grants Regulation with New Legislation, Nondiscrimination Laws, and Supreme Court Decisions,” November 1, 2019, https://www.hhs.gov/about/news/2019/11/01/hhs-issues-proposed-rule-to-al... (accessed December 17, 2019).

[2] See Health and Human Services Grants Regulation, 81 FR 89393 (December 12, 2016).

[3] Human Rights Watch, “All We Want is Equality”: Religious Exemptions and Discrimination against LGBT People in the United States, February 19, 2018, https://www.hrw.org/report/2018/02/19/all-we-want-equality/religious-exe....

[4] Human Rights Watch, “You Don’t Want Second Best”: Anti-LGBT Discrimination in US Health Care, July 23, 2018, https://www.hrw.org/report/2018/07/23/you-dont-want-second-best/anti-lgb....

[5] Human Rights Watch, Living at Risk: Transgender Women, HIV, and Human Rights in South Florida, November 20, 2018, https://www.hrw.org/report/2018/11/20/living-risk/transgender-women-hiv-....

[6] Improving Regulation and Regulatory Review, Executive Order 13563 (January 18, 2011), https://obamawhitehouse.archives.gov/the-press-office/2011/01/18/executi... (accessed December 16, 2019).

[7] See Centers for Disease Control and Prevention, “About LGBT Health,” March 24, 2017, https://www.cdc.gov/lgbthealth/about.htm (accessed December 17, 2019).

[8] Kellan Baker and Laura E. Durso, “Why Repealing the Affordable Care Act is Bad Medicine for LGBT Communities,” Center for American Progress, March 22, 2017, https://www.americanprogress.org/issues/lgbt/news/2017/03/22/428970/repe... (accessed December 17, 2019).

[9] Shabab Ahmed Mirza and Caitlin Rooney, “Discrimination Prevents LGBTQ People from Accessing Health Care,” Center for American Progress, January 18, 2018, https://www.americanprogress.org/issues/lgbt/news/2018/01/18/445130/disc... (accessed December 17, 2019).

[10] Sejal Singh and Laura E. Durso, “Widespread Discrimination Continues to Shape LGBT People’s Lives in Both Subtle and Significant Ways,” Center for American Progress, May 2, 2017, https://www.americanprogress.org/issues/lgbt/news/2017/05/02/429529/wide... (accessed December 17, 2019).

[11] Brief of Ilan H. Meyer, Ph.D., and Other Social Scientists and Legal Scholars Who Study the LGB Population as Amici Curiae Supporting Respondents, Masterpiece Cakeshop v. Colorado Civil Rights Commission, No. 16-111 (U.S. 2017), p. 26.

[12] Jeremy W. Peters, “Obama’s Protections for L.G.B.T. Workers Will Remain Under Trump,” New York Times, January 30, 2017, https://www.nytimes.com/2017/01/30/us/politics/obama-trump-protections-l... (accessed December 17, 2019). The nondiscrimination protections were weakened when President Trump rescinded Executive Order 13673, which required contractors to provide documentation that they were in compliance, but the requirements themselves remain in place. See Mary Emily O’Hara, “LGBTQ Advocates Say Trump’s New Executive Order Makes them Vulnerable to Discrimination,” NBC News, March 29, 2017, https://www.nbcnews.com/feature/nbc-out/lgbtq-advocates-say-trump-s-news... (accessed December 17, 2019).

[13] See Ryan Thoreson, “Trump Administration Moves to Roll Back Health Care Rights,” Human Rights Watch dispatch, August 13, 2019, https://www.hrw.org/news/2019/08/13/trump-administration-moves-roll-back....

[14] Human Rights Watch interview with Chris and CJ P., Nashville, Tennessee, January 8, 2018.

[15] Human Rights Watch phone interview with Kristy and Dana Dumont, Dimondale, Michigan, January 29, 2018; Human Rights Watch interview with Erin Busk-Sutton, Detroit, Michigan, January 18, 2018.

[16] See, for example, Human Rights Watch interview with Judith N. (pseudonym), Johnson City, Tennessee, December 10, 2017; Human Rights Watch interview with Nadia Valdez, Howard Brown Health, Chicago, Illinois, March 26, 2018; Human Rights Watch interview with Andy Dugan, Equality Ohio, Columbus, Ohio, July 31, 2019.

[17] Human Rights Watch interview with Holly Calvasina, Choices, Memphis, Tennessee, January 10, 2018; Human Rights Watch interview with Renae T., Memphis, Tennessee, January 12, 2018.

[18] Human Rights Watch interview with Trevor L. (pseudonym), Memphis, Tennessee, January 10, 2018; Human Rights Watch interview with Kayla Gore, OutMemphis, Memphis, Tennessee, January 10, 2018.

[19] Human Rights Watch phone interview with Kelley Blair, Oklahoma City, Oklahoma, November 17, 2017.

[20] Human Rights Watch interview with Trace C. (pseudonym), New York City, New York, January 30, 2018; Human Rights Watch interview with Kyle P. (pseudonym), New York City, New York, January 30, 2018; see also Human Rights Watch interview with Elliott DeVore, Knoxville, Tennessee, December 8, 2017.

[21] Health and Human Services Grant Regulation, 84 FR 63831, 63832-63833 (November 19, 2019).

[22] International protections for the right to freedom from discrimination include the International Covenant on Civil and Political Rights (ICCPR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, ratified by the United States on June 8, 1992, arts. 2, 4, 26; International Covenant on Economic, Social and Cultural Rights (ICESCR), adopted December 16, 1966, G.A. Res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 2(2); Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), adopted December 18, 1979, G.A. res. 34/180, 34 U.N. GAOR Supp. (No. 46) at 193, U.N. Doc. A/34/46, entered into force September 3, 1981, art. 2; International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), adopted December 21, 1965, G.A. Res. 2106 (XX), annex, 20 U.N. GAOR Supp. (No. 14) at 47, U.N. Doc. A/6014 (1966), 660 U.N.T.S. 195, entered into force January 4, 1969, ratified by the United States on October 21, 1994, art. 5; International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families (Migrant Workers Convention), adopted December 18, 1990, G.A. Res. 45/158, annex, 45 U.N. GAOR Supp. (No. 49A) at 262, U.N. Doc. A/45/49 (1990), entered into force July 1, 2003, art. 1(1), art. 7.

[23] ICCPR, art. 26. The Human Rights Committee has clarified that article 26 of the ICCPR prohibits discrimination based on sexual orientation. See UN Human Rights Committee, Toonen v Australia, CCPR/C/50/D/488/1992 (March 31, 1994), http://hrlibrary.umn.edu/undocs/html/vws488.htm (accessed December 17, 2019). The Human Rights Committee frequently expresses concern about discrimination based on gender identity in its concluding observations on state compliance with the ICCPR. See UN Human Rights Committee, Concluding Observations: Azerbaijan, U.N. Doc CCPR/C/AZE/CO/4 (November 16, 2016), paras. 8-9; UN Human Rights Committee, Concluding Observations: Burkina Faso, U.N. Doc CCPR/C/BFA/CO/1 (October 17, 2016), paras. 13-14; UN Human Rights Committee, Concluding Observations: Colombia, U.N. Doc CCPR/C/COL/CO/7 (November 17, 2016), paras. 16-17; UN Human Rights Committee, Concluding Observations: Costa Rica, U.N. Doc CCPR/C/CRI/CO/6 (April 21, 2016), paras. 11-12; UN Human Rights Committee, Concluding Observations: Denmark, U.N. Doc CCPR/C/DNK/CO/6 (August 15, 2016), paras. 13-14; UN Human Rights Committee, Concluding Observations: Ecuador, U.N. Doc CCPR/C/ECU/CO/6 (August 11, 2016), paras. 11-12; UN Human Rights Committee, Concluding Observations: Ghana, U.N. Doc CCPR/C/GHA/CO/1 (August 9, 2016), paras. 43-44; UN Human Rights Committee, Concluding Observations: Jamaica, U.N. Doc CCPR/C/JAM/CO/4 (November 22, 2016), paras. 15-16; UN Human Rights Committee, Concluding Observations: Kazakhstan, U.N. Doc CCPR/C/KAZ/CO/2 (August 9, 2016), paras. 9-10; UN Human Rights Committee, Concluding Observations: Kuwait, U.N. Doc CCPR/C/KWT/CO/3 (August 11, 2016), paras. 12-13; UN Human Rights Committee, Concluding Observations: Morocco, U.N. Doc CCPR/C/MAR/CO/6 (December 1, 2016), paras. 11-12; UN Human Rights Committee, Concluding Observations: Slovakia, U.N. Doc CCPR/C/SVK/CO/4 (November 22, 2016), paras. 14-15; UN Human Rights Committee, Concluding Observations: South Africa, U.N. Doc CCPR/C/ZAF/CO/1 (April 27, 2016), paras. 20-21.

[24] See Human Rights Committee, General Comment 28: Article 3 (The Equality of Rights Between Men and Women), March 29, 2000, UN Doc. CCPR/C/21/Rev.1/Add.10, para. 21 (“Article 18 may not be relied upon to justify discrimination against women by reference to freedom of thought, conscience, and religion.”); Human Rights Committee, General Comment 22: Article 18 (1993), para. 2 (“The committee therefore views with concern any tendency to discriminate against any religion or belief for any reason, including the fact that they are newly established, or represent religious minorities that may be the subject of hostility on the part of a predominant religious community.”), in Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, UN Doc. HRI/GEN/1/Rev.1, at 35 (1994); ibid. at para. 7 (noting that “no manifestation of religion or belief may amount to … advocacy of national, racial, or religious hatred that constitutes incitement to discrimination” and that “States parties are under the obligation to enact laws to prohibit such acts.”).

[25] Human Rights Committee, General Comment 22, para. 8.

[26] Human Rights Watch, “All We Want is Equality.”

[27] ICESCR, art. 12.

[28] ICESCR, art. 2(2); UN Committee on Economic, Social and Cultural Rights, General Comment No. 20: Non-Discrimination in Economic, Social and Cultural Rights, U.N. Doc. E/C.12/GC/20 (July 2, 2009), para. 32.

[29] Vienna Convention on the Law of Treaties (1980), 1155 U.N.T.S. 331, art. 18.

[30] UN Committee on Economic, Social and Cultural Rights, General Comment No. 20, para. 10.

[31] Ibid., para. 11.

[32] ICCPR, art. 24; Human Rights Committee, General Comment No. 17: Article 24 (Rights of the Child) (April 7, 1989), para. 1, in Compilation of General Comments and General Recommendations Adopted by Human Rights Treaty Bodies, U.N. Doc. HRI/GEN/1/Rev.1, at 23 (1994).

[33] Human Rights Committee, General Comment No. 17, para. 3.

[34] ICCPR, art. 26.

[35] Human Rights Committee, General Comment No. 17, para. 5. As noted in section IV.a., above, the right to freedom from discrimination includes freedom from discrimination on the basis of sex, sexual orientation, or gender identity.

[36] Convention on the Rights of the Child, adopted November 20, 1989, G.A. Res. 44/25, annex, 44 U.N. GAOR Supp.

[37] Ibid., arts. 3(1), 21.

[38] Ibid., arts. 2, 13, 24.

Posted: January 1, 1970, 12:00 am

Aisha al-Shater, 39, has been detained for over a year in solitary confinement. Authorities have failed to provide her with sufficient medical care.
 

© Private / 2019

(Beirut) – Egyptian prison authorities should immediately provide jailed pro-Muslim Brotherhood activist Aisha al-Shater with critically needed medical care, allow her family visits, and release her if there is no evidence of criminal wrongdoing, Human Rights Watch said today.

Prison authorities have kept al-Shater, 39, in abusive detention conditions for more than a year, including months of solitary confinement and over a year without family visits. Authorities allowed her two short hospital visits in October 2019 but took her back to solitary confinement. Doctors believe she has aplastic anemia and bone marrow failure, serious medical conditions that can be life-threatening and require expert medical care. Of particular concern is a heightened risk of infection due to low white blood cell counts.

“As if arbitrary arrest was not enough, Aisha al-Shater has had to endure inhumane prison conditions and her family has been living in anguish knowing almost nothing about her health," said Joe Stork, deputy Middle East and North Africa director at Human Rights Watch. “Now, faced with a medical crisis, prison authorities should ensure she receives sufficient care by independent doctors.”

Police and National Security Agency officers in November 2018 arrested around 40 lawyers and humanitarian activists and volunteers, including al-Shater and her husband, lawyer Mohamed Abu Hourayra, who were active with the Egyptian Coordination for Rights and Freedoms. A relative told Human Rights Watch that one reason she was arrested is that her father, Khairat al-Shater, imprisoned since 2013, was the deputy chairman of the now-banned Muslim Brotherhood.

Sources close to al-Shater’s family said that in October 2019, prison authorities transferred her to Cairo University’s Qasr al-Aini hospital twice for medical treatment. On October 8, al-Shater was admitted for two days and then on October 31, she was readmitted for a week. Before being transferred to Qasr al-Aini, she apparently suffered acute episodes of fatigue and severe bleeding.

On November 25, after a public outcry, Prosecutor-General Hamada al-Sawy ordered the State Security Prosecution to open an investigation into al-Shater’s complaints about lack of appropriate medical care. The family said they learned through some inmates that al-Shater was transferred to the prison hospital a few days after that, but they were not able to get in touch with her.

Authorities should immediately transfer al-Shater to a fully-equipped medical facility, allow independent doctors to examine her, and make available to her family and lawyers detailed information about her medical condition, Human Rights Watch said. Human Rights Watch and other rights organizations have found that prison hospitals in Egypt often lack necessary medical equipment, medicines, and specialized doctors, and doctors who work in prisons or prison hospitals are subject to chain of command by Interior Ministry officers and often cannot make crucial clinical decisions independently. According to Egypt’s 1961 prison law, when a doctor determines that the prison hospital is not able to treat a case, only prison authorities can authorize a decision to transfer the prisoner to an outside hospital or call a specialist. Al-Shater’s mother, Azza Tawfik, said on Facebook that the family offered to pay for her treatment in a private hospital but prison authorities refused.

After having been “disappeared” for 20 days after her arrest, al-Shater appeared before a State Security prosecutor on November 21, 2018, who ordered her pretrial detention on charges of “joining a terrorist group.” Authorities held her in an undisclosed location, probably in a National Security Agency building in Cairo, until January 2019, when they moved her to al-Qanater women’s prison. A relative told Human Rights Watch that Aisha al-Shater has spent at least the last nine months in solitary confinement. The relative also said that prison authorities have prevented her lawyers and family from visiting, and no one has been able to see her since her arrest although the family obtained, at least once, a judge’s permission to visit her.

In June 2019, the Turkey-based opposition TV station Mekamleen broadcast a leaked sound clip of what the station said was a recording of al-Shater’s remarks before a judge reviewing her detention, and in which she said that she had been kept in solitary confinement in a cell that measured less than 2 meters by 2 meters without sanitary facilities. In the leaked clip, al-Shater said that she has been using a bucket as a bathroom and that she has been forbidden family visits or seeing her children since her arrest. 

The relative said that prison authorities have not allowed the family to officially obtain medical records for al-Shater or information on her condition. The relative said the little information they had was after she spoke with her lawyer briefly during a detention renewal hearing on November 7.

According to media reports, authorities had postponed al-Shater’s detention renewal hearing for two days because of her deteriorating health. She was then transferred in an ambulance on November 7 to a Cairo criminal court reviewing her detention. When the session ended, “they took her from a rear door” to prevent her from seeing or talking with her family, her sister told journalists. On December 17, the court renewed al-Shater’s detention for 45 more days. She was transferred to the court again in an ambulance.

According to a one-page medical report from early November which a source unofficially provided to Human Rights Watch, al-Shater was suspected of having pancytopenia (decrease in red and white blood cells and platelets) potentially due to aplastic anaemia from myelodysplastic syndrome, a serious bone marrow disorder. The report said that the onset of al-Shater's illness was “acute” and “progressing.” The report also said she experienced heavy menstrual bleeding and was given a bone marrow aspiration and administrated three blood transfusions and 36 units of platelets. She was also given Filgrastim, a medicine that stimulates white blood cell production.

A relative of al-Shater said that they showed the report to independent doctors who said she should be transferred to the Nasser Institute for Research and Treatment, a government hospital in Cairo, whose staff includes doctors specialized in bone marrow disorders.

Authorities cannot curtail the right to health as a punishment and prisoners should receive medical care without discrimination due to their legal status and that is at least equivalent to the standards available in the community. The United Nations “Mandela Rules,” which provide authoritative guidance on detention practices, state that prisoners have a right to medical care, including diagnostic and treatment, offered by sufficient, well-qualified medical personnel operating with clinical independence. Prisoners also have rights to sufficient living space, appropriate ventilation, lighting, heat, sanitation, clean water, and adequate and nutritious food. The Mandela Rules also set a 15-day maximum on confinement in isolation.

In 2017, President Abdel Fattah al-Sisi’s government introduced amendments to prison laws that provide for up to six months in solitary confinement. Such prolonged solitary confinement can amount to torture.  

In November 2019, two UN experts said that Egypt’s abusive detention conditions “may be placing the health and lives of thousands more prisoners at severe risk” and that such abuses including lack of sufficient medical care “may have directly led” to the death of former President Mohamed Morsy.

“The Prosecutor General’s order to investigate al-Shater’s complaints is meaningless without ensuring she is able to receive appropriate, sufficient medical care and communicate with her family and lawyers,” Stork said.

Posted: January 1, 1970, 12:00 am

This submission focuses on the impact of lead pollution on children’s rights, and the protection of students, teachers, and schools during armed conflict. It relates to article 24, 28 and, 31 of the Convention on the Rights of the Child.

Impact of Lead Pollution on Children’s Rights (article 24 and 31)

Lead exposure around the former lead and zinc mine in Kabwe, which operated from 1904 to 1994, is having disastrous effects on children’s health. More than one-third of the population of Kabwe, Zambia— over 76,000 people—live in lead-contaminated townships. Studies estimate that half of the children in these areas have elevated blood lead levels that warrant medical treatment.

At present, children living in nearby townships continue to be exposed to high levels of toxic lead in soil and dust in their homes, backyards, schools, play areas, and other public spaces. The Zambian government’s efforts to address the environmental and health consequences of the widespread lead contamination have not thus far been sufficient, and parents struggle to protect their children.

Children are especially at risk because they are more likely to ingest lead dust when playing in the soil, their brains and bodies are still developing, and they absorb four to five times as much lead as adults. The consequences for children who are exposed to high levels of lead and are not treated include reading and learning barriers or disabilities; behavioral problems; impaired growth; anemia; brain, liver, kidney, nerve, and stomach damage; coma and convulsions; and death. After prolonged exposure, the effects are irreversible. Lead also increases the risk of miscarriage and can be transmitted through both the placenta and breastmilk.

Human Rights Watch conducted three field research missions to Zambia between June 2018 and April 2019 and found that government efforts to address lead pollution have been far from adequate. Human Rights Watch also found that government-run health facilities in Kabwe currently have no chelation medicine for treating lead poisoning or lead test kits in stock, and no health database has been established to track cases of children who died or were hospitalized because of high lead levels.

In December 2016, the government began a five-year World Bank-funded project to clean up lead-contaminated neighborhoods and conduct new rounds of testing and treatment. Government officials and World Bank representatives told Human Rights Watch that the government intended to start the remediation and health components later in 2019. The project is intended to carry out remediation to reduce lead exposure in at least three townships and includes plans for testing and treating at least 10,000 children, pregnant women, mothers, and other individuals.

In recent months, several activities have started, such as health worker training, the procurement of chelation medicine, and greater information-sharing about the project with the community and the public. The government also recently announced it would also include 10 schools in the project.

Human Rights Watch welcomes this project, but is concerned about the serious delays in implementation: Three years after the launch, the project is just starting to get off the ground. Community leaders and groups in Kabwe have expressed frustration about the process and told Human Rights Watch that they had been left in the dark.

Furthermore, Human Rights Watch is concerned that that the project will not address the full scope of lead poisoning and contamination. In particular, the project does not address the source of the contamination, the mining waste. More than six million tons of mining waste are out in the open, and dust blows over nearby residential areas. If the source of the contamination is not addressed, the project risks not being sustainable.

Small-scale mining, that is mining with little or no machinery, is also a major issue and is now the main activity at the former Kabwe mine. Small-scale mining for lead is extremely hazardous, as residents risk getting exposed further to lead when adult family members work at the mine and return home with lead on their body, clothes, tools, or shoes. While the government has issued some licenses for mining, there are also unlicensed, illegal mining operations.

The government has also granted a large-scale mining license for much of the former mine area to the Berkeley Mineral Resources company. This company, together with its South African business partner Jubilee Metals, is planning to recover zinc, lead, copper, as well as the highly valuable metal vanadium. Jubilee Metals has bought a refinery right next to the former Kabwe mine for zinc processing, and has said it anticipates producing during 2020. Waste processing carries the risk of creating further problems by generating additional dust and polluting the water.[1]

Human Rights Watch recommends to the Committee that it call upon the government of Zambia to:

  • Develop a program for sustainable, comprehensive lead remediation, testing, and treatment in Kabwe. The program should be developed in conjunction with relevant ministries, affected communities, civil society groups, youth groups, and other relevant stakeholders. In particular:

Remediation

  • Develop a remediation plan that will allow for long-term containment or removal of lead waste.
  • Ensure that private operations for reprocessing minerals are part of this plan and carefully scrutinized and monitored by the government for human rights and environmental impacts, including through environmental and social impact assessments.
  • Ensure that small-scale mining operations are licensed and regularly monitored for compliance with national laws and regulations.
  • Invite all households in contaminated townships to participate in the voluntary remediation program to clean both yards and home interiors.
  • Remediate all contaminated schools, play areas, health centers, and other public areas.
  • Pave roads in contaminated townships to reduce dust.
  • Conduct regular monitoring of soil and air lead levels in Kabwe, and publish the results.

Health and Education

  • Ensure that all children in Kabwe are given access to free testing and, as appropriate, free treatment for lead poisoning. Make sure that the initial round of testing and treatment reaches all children under the age of 5 as well as pregnant and breastfeeding women; and that children previously tested and found to have elevated lead levels are given access to follow-up testing and treatment.
  • Track lead poisoning in the Health Management Information System (HMIS) or develop a separate database for Kabwe to track cases of lead poisoning, including lead-related hospitalization and mortality.
  • Ensure children with disabilities and learning barriers in affected areas are tested for lead.
  • Provide accommodations and individual learning support for children with learning barriers.

Protection of Education During Armed Conflict (article 28)

Zambia was among the first countries to endorse the Safe Schools Declaration, joining in May 2015.[2]

As of October 2019, Zambia is contributing 1007 troops to United Nations peacekeeping forces. Peacekeeping troops are required to comply with the UN Department of Peacekeeping Operations “UN Infantry Battalion Manual” (2012), which includes the provision that “schools shall not be used by the military in their operations.”  Moreover, the 2017 Child Protection Policy of the UN Department of Peacekeeping Operations, Department of Field Support, and Department of Political Affairs notes: “United Nations peace operations personnel shall at no time and for no amount of time use schools for military purposes.”

Human Rights Watch encourages the Committee to pose the following questions to the government:

  • Are protections for schools from military use included in any policies, rules, or trainings for Zambia’s armed forces?

Human Rights Watch recommends to the Committee that it call upon the government of Zambia to:

  • Congratulate the government of Zambia on endorsing the Safe Schools Declaration, thereby committing to use the Guidelines for Protecting Schools and Universities from Military Use in Armed Conflict.

[1] Human Rights Watch, We Have to Be Worried: The Impact of Lead Contamination on Children’s Rights in Kabwe, Zambia,(New York: Human Rights Watch, 2019) https://www.hrw.org/report/2019/08/23/we-have-be-worried/impact-lead-contamination-childrens-rights-kabwe-zambia

[2] The Safe Schools Declaration is an inter-governmental political commitment that provides countries the opportunity to express political support for the protection of students, teachers, and schools during times of armed conflict;  the importance of the continuation of education during armed conflict; and the implementation of the Guidelines for Protecting Schools and Universities from Military Use during Armed Conflict. See Global Coalition to Protect Education from Attack, Safe Schools Declaration, http://www.protectingeducation.org/sites/default/files/documents/safe_schools_declaration-final.pdf.

Posted: January 1, 1970, 12:00 am

Farmworkers harvest apples on a farm in New York.

© 2015 AP Photo/Mike Groll
 
(New York) – New York Governor Andrew Cuomo defended children, workers, and the environment by directing the state Department of Environmental Conservation on December 10, 2019 to ban the toxic pesticide chlorpyrifos, Human Rights Watch said today. The governor told the department to immediately prohibit all aerial spraying of chlorpyrifos and to enact regulations to ban all uses except for the spraying of apple tree trunks by December 2020. The governor mandated a ban of all uses, including for apple tree trunks, by July 2021.
 
A bill to ban the pesticide passed through the New York state legislature in April with strong bipartisan support. The governor vetoed the bill on December 10, choosing instead to mandate new regulations. Human Rights Watch urged the governor to sign the bill, warning that a regulatory approach could leave some chlorpyrifos in use and in other ways be less protective than legislation.
 
“Governor Cuomo stood up for public health and human rights by restricting the use of toxic chlorpyrifos,” said Margaret Wurth, senior children’s rights researcher at Human Rights Watch. “Human Rights Watch and other advocates are ready to hold him to his promise to ban the use of this pesticide entirely by July 2021.”
 
Earlier in 2019, the Trump administration announced that it would not ban chlorpyrifos, despite the evidence that it is a danger to human health. New York’s attorney general, Letitia James, is leading a coalition of state attorneys general in suing the federal government for its inaction on chlorpyrifos. Several members of Congress from New York are working to pass a national ban on chlorpyrifos.
 
Governor Cuomo’s directive makes New York the third state in the United States to restrict use of the chemical, which has been shown to harm brain development in children. Hawaii passed a law to ban the chemical by 2022, and California announced a ban to take effect in 2020.
 
The European Union announced on December 6 that it will ban chlorpyrifos beginning in 2020, after the European Food Safety Authority concluded that no amount of chlorpyrifos exposure was safe.
 
More than 80 other organizations supported the New York state bill to ban chlorpyrifos, including the New York state chapter of the American Academy of Pediatrics, representing more than 5,000 state pediatricians.
 
The Farm Bureau, a lobbying group that represents the agricultural industry, urged the governor to veto the bill and pursue regulations, the approach he ultimately adopted. A spokesperson for the New York Farm Bureau told Bloomberg Environment that the governor’s veto showed he “understands that there are new threats from invasive species to agriculture production and a permanent legislative ban would have ruled out all future use [of chlorpyrifos] should it be needed.”
 
Human Rights Watch opposes any use of chlorpyrifos, given the evidence of its dangers to human health.
 
Human Rights Watch has documented the exposure of children and workers to toxic substances in a range of countries, including Bangladesh, Brazil, China, Indonesia, Kenya, and Zimbabwe. In the US, Human Rights Watch found that children working in agriculture are often exposed to pesticides and reported acute health effects after exposure, including vomiting, nausea, dizziness, and headaches. Pesticide exposure is harmful for farmworkers of all ages, but children are uniquely vulnerable because their bodies and brains are still developing.
 
Research has shown chlorpyrifos to be particularly harmful to human health. Prenatal exposure has been linked to autism spectrum disorder, reduced IQ, and a range of disabilities in learning, memory, and attention in children. In adults, it has been linked to cancer and Parkinson’s disease.
 
Prior to the governor’s announcement, chlorpyrifos was approved for dozens of uses including on food crops such as apples, corn, brussels sprouts, broccoli, and cauliflower, and on golf courses.
 
“While the Trump administration disregards science and refuses to ban chlorpyrifos, Governor Cuomo and New York’s leaders are fighting to protect the public from a pesticide that can cause serious and irreparable harm,” Wurth said. “President Trump should follow suit and ban this toxic chemical.”
Posted: January 1, 1970, 12:00 am

Pressure is growing for New York Governor Andrew Cuomo to sign a bill that would ban the use of chlorpyrifos, a toxic pesticide.

The scientific evidence on the harms of chlorpyrifos is overwhelming and irrefutable. On Friday, the European Union acted to ban sales of chlorpyrifos beginning in 2020, after the European Food Safety Authority concluded that no amount of chlorpyrifos exposure was safe. The pesticide has been linked to reduced IQ and learning disabilities in children, as well as cancer, and Parkinson’s disease in adults.  

“Sara” (left) and “Susana,” 16-year-old twin sisters who worked together on tobacco farms in 2015, sit in their bedroom in the clothes they wear to try to protect themselves in tobacco fields. They described working near areas where pesticides were being applied. Susana said, “We are just working … and the worker is on the tractor spraying almost very close to us. But they don’t take us out of that area. They don’t even warn us that it is dangerous. Nothing. We are just working and we cover ourselves well because the smell is very strong, and we get sick with the smell of that spray.” Sara said, “I feel dizzy, very dizzy because the smell is unbearable. It’s very strong and my stomach begins to feel stirred. I feel as if I am going to faint right then and there from the smell.”

© 2015 Benedict Evans for Human Rights Watch

This week, the NYS American Academy of Pediatrics, representing over 5,000 pediatricians across the state, called on Cuomo to sign the chlorpyrifos bill citing “numerous studies showing that exposure to chlorpyrifos in the womb harms children’s brain development.” Human Rights Watch has joined with over 80 other organizations working to protect the environment, public health, workers and children to support the ban on chlorpyrifos.

In New York, the pesticide is used on apples, broccoli, cauliflower, Brussels sprouts, and other crops. It also seeps into the water supply, jeopardizing both public health and the environment.

Farmworkers are at particular risk. For two decades, Human Rights Watch has documented the dangers to children working in US agriculture, including pesticide exposure. Many children have told us that after encountering pesticides, they experienced vomiting, dizziness, headaches, burning of the eyes and nose, and other acute health effects.

The Trump administration has refused to ban chlorpyrifos, overruling recommendations from scientists at the Environmental Protection Agency. In the absence of federal leadership, it’s up to state leaders like Cuomo to protect the public from this dangerous chemical.

Governments are responsible for safeguarding health, especially for children, and ensuring workers are protected from exposure to harmful chemicals. That’s why banning chlorpyrifos is a human rights imperative. Cuomo still has time to do the right thing.

Author: Human Rights Watch
Posted: January 1, 1970, 12:00 am

Lebanese doctors chant slogans as they take part in anti-government demonstrations in central Beirut on November 12, 2019. 

© 2019 AFP/Getty

(Beirut) – Lebanon’s medical practitioners and public officials are warning that hospitals may soon not be able to provide patients with life-saving surgery and urgent medical care because of a financial crisis, Human Rights Watch said today.

The crisis stems from the government’s failure to reimburse private and public hospitals, including funds owed by the National Social Security Fund and military health funds, making it difficult to pay staff and purchase medical supplies. In addition, a dollar shortage has restricted the import of vital goods and led banks to curtail credit lines.

“The Lebanese government’s failure to pay its bills to medical facilities seriously endangers the health of the population,” said Joe Stork, deputy Middle East director at Human Rights Watch. “While politicians horse-trade over a new cabinet, the government is not responding to the desperate economic situation in the country and the clock is ticking on the ability of many doctors and hospitals to treat patients.”

Sleiman Haroun, the head of the Syndicate of Private Hospitals, told Human Rights Watch that the Finance Ministry has not paid private hospitals an estimated US$1.3 billion in dues since 2011, compromising their ability to buy vital medicines and medical supplies and to pay staff salaries. The ministry disbursed most of the funds owed up until 2017, Haroun said, but private hospitals received only half of what was owed them in 2018 and not a single payment in 2019.

Private hospitals account for 82 percent of Lebanon’s healthcare capacity. Public hospitals also have not been receiving payments from the government. Officials at the Rafik Hariri University Hospital in Beirut and the Hermel Public Hospital in the Bekaa Valley told Human Rights Watch that the government has not made any payments in 2019.

Medical suppliers who provide equipment for both public and private hospitals said that they have not been able to import medical equipment since September due to the shortage of dollars and the absence of government regulations that would prevent banks from arbitrarily restricting money transfers outside the country.

On November 16, private hospitals carried out an unprecedented “warning strike” to sound the alarm about the shortages they were facing and to urge government officials to pay their arrears. The head of the Order of Nurses, Mirna Doumit, told Human Rights Watch that nurses are threatening an open-ended strike if private and public hospitals continue to delay payment of salaries or cut salaries in half, as some hospitals had warned they would have to do. The Finance Ministry should urgently disburse the funds owed to hospitals, Human Rights Watch said.

Medical supply importers are reporting difficulties bringing medical equipment into the country due to the shortage of dollars that they say began in July but was exacerbated in November, as well as the resulting unofficial devaluation of the Lebanese pound.

“If [this crisis] isn’t resolved, people will go into the hospital and die inside,” Salma Assi, a spokesperson for medical equipment importers, told Human Rights Watch.

On November 26, the caretaker health minister, Jamil Jabak, warned of “a major lack of supplies and equipment, and if this continues, we could reach a very dangerous situation.” Haroun told Human Rights Watch that medical equipment shortages are “causing many problems in surgeries. If we need a certain size of stent and we don’t have it, we are having to use a different size, and this causes complications in the surgery.”

On November 26, the Central Bank issued a decision guaranteeing 50 percent of the dollars medical suppliers need for imports at the official rate, leaving them to obtain the remaining 50 percent at the market rate. Assi noted that the guarantee did not include new equipment or even spare parts: “Ok I understand excluding new equipment. No one is going to start new investments. But spare parts? If I have a ventilator or an MRI machine, and something breaks, what will the hospital do?” She said that medical importers categorically rejected this proposal.

Medical supply importers stated that even if they did have the remaining 50 percent of the dollars in their bank accounts, banks were refusing to allow them to transfer those dollars to manufacturers abroad.

The government should make every effort to use the resources at its disposal to meet its minimum obligations under international law and reverse the erosion of Lebanese peoples’ access to adequate health services, Human Rights Watch said.

The Central Bank should issue clear and transparent regulations on cash withdrawals and money transfers to protect depositors and ensure that those are being applied fairly by all banks. The Central Bank should also develop clear and cohesive regulations for businesses, especially importers of vital goods, to ensure that they are able to continue operations.

The next prime minister should establish a committee consisting of relevant stakeholders, including representatives from the Central Bank, Finance Ministry, Health Ministry, private and public hospitals, and medicine and medical equipment importers to develop responsible fiscal policies to meet the challenges that the economic crisis has posed to access to medical care, medicine, and medical equipment.

“Lebanon should ensure that the right to health and access to medicines, to surgical supplies, and care is protected,” Stork said. “People risk dying in hospitals unless the government ensures that hospitals have access to necessary medicines and medical supplies.”

The Dollar Shortage

Lebanon’s economy has long depended on a regular inflow of US dollars, and the Central Bank  has pegged the Lebanese pound to the US dollar at an official exchange rate of 1507.5 Lebanese pounds since 1997. Over the last 10 years, as economic growth slowed and remittances from the Lebanese diaspora have decreased, the quantity of dollars in circulation has declined. An increasing lack of confidence in the stability of the Lebanese pound in 2019 and concerns about the stability of the banking sector led depositors to withdraw from dollar accounts, making dollars increasingly scarce and causing the unofficial exchange rate to reach more than 2,200 Lebanese pounds to the dollar at the end of November.

A spokesperson for medical equipment importers, Salma Assi, told Human Rights Watch that Lebanon imports 100 percent of needed medical supplies. Suppliers must pay for imports in dollars, but receive hospital payments in Lebanese pounds. Around July, Assi said, medical importers started facing problems exchanging Lebanese pounds to dollars at banks due to the dollar shortage, and resorted to converting to dollars at private exchange brokers at rates higher than the official rate, losing significant sums in the process. However, they could not increase the price of the supplies, as those are priced in Lebanese pounds at rates set by the Health Ministry.

Assi said:

 

If [this crisis] isn’t resolved, people will go into the hospital and die inside. People on dialysis they get two sessions instead of three, do you know what this means? Their bodies are slowly getting poisoned. Do you know what it means not to have blood bags? … What will we do? Bring blood in a water bottle?

On November 24, medical equipment importers released a joint statement asking the Central Bank to guarantee 85 percent of the dollars the importers needed at the official exchange rate. The Central Bank in October had decided to do this for medicine, wheat, and fuel. The importers stated that they had started running out of some medical supplies, including bone screws, heart stents, dialysis filters, blood bags, medical gases, and spare parts, saying that remaining stocks would be depleted in a matter of weeks.

Although the Central Bank issued a decision on November 26 guaranteeing 50 percent of the dollars medical suppliers need for imports at the official rate, medical supply importers still reported trouble obtaining the remaining 50 percent.

Absent formal capital controls by the Central Bank, banks have set their own policies restricting depositors’ access to funds in their current dollar accounts and the transfer of money abroad, making it harder to import medical equipment and medicine. In a statement on December 3, medical supply importers stated that banks were refusing to allow them to transfer dollars already in their accounts to manufacturers abroad. Karim Gebera, the head Pharmaceutical Importers and Wholesalers Association, told Human Rights Watch that some banks were also not allowing medicine importers to transfer dollars already in their accounts to producers abroad.

Lebanese banks have also imposed severe restrictions on lines of credit, and foreign suppliers are now demanding full payment prior to delivery due to the refusal of insurance companies to cover shipments to Lebanon. Gebera said that Lebanon imports over 90 percent of the medicine it consumes. He said that medicine importers are facing a liquidity crisis as they are no longer able to take out lines of credit to cover their imports, and hospitals are unable to pay for medicine up-front. On December 3, medical importers warned that if hospitals cannot pay them in a timely manner, they will be forced to stop supplying them. Haroun, the head of the Syndicate of Private Hospitals, told local media that private hospitals are struggling to obtain necessary medicines, as “medicine importers are imposing conditions on hospitals regarding payments.”

International Obligations

Lebanon is a party to the International Covenant on Economic, Social and Cultural Rights (ICESCR), which requires it to take steps to achieve “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” Under the covenant, states parties must ensure “[t]he creation of conditions which would assure to all medical service and medical attention in the event of sickness.” According to the UN Committee on Economic, Social and Cultural Rights, the international expert body that monitors implementation of the ICESCR, this includes,

 

the provision of equal and timely access to basic preventive, curative, rehabilitative health services and health education; regular screening programmes; appropriate treatment of prevalent diseases, illnesses, injuries and disabilities, preferably at community level; the provision of essential drugs; and appropriate mental health treatment and care.

The right to health includes access to “timely and appropriate health care” and “(f)unctioning public health and health-care facilities, goods and services, as well as programmes, have to be available in sufficient quantity within the State party.” Any state “which is unwilling to use the maximum of its available resources for the realization of the right to health is in violation of its obligations” under Article 12 of the Covenant.

Although the Covenant recognizes that constraints due to the availability of resources and the right to health is subject to progressive realization, the committee has held that it also imposes on states obligations which are of immediate effect, including an obligation to take steps towards the full realization of the rights to health. Such steps must be deliberate, concrete, and targeted toward the full realization of the right. Under the Covenant, states are required to adopt appropriate “legislative, administrative, budgetary, judicial, promotional and other measures towards the full realization of the right to health.” States should also ensure that progress towards ensuring the right to health does not regress – e.g. that people are denied essential medicine that they previously had access to.

A state’s failure to take all necessary measures to safeguard persons within their jurisdiction from infringements of the right to health by third parties, and the failure to regulate the activities of individuals, groups, or corporations so as to prevent them from violating the right to health of others, also constitutes a violation.

Posted: January 1, 1970, 12:00 am

Under the patronage of Sheikh Mohamed bin Zayed Al Nahyan, Crown Prince of Abu Dhabi, the UAE is hosting a global health forum on November 19, 2019 on eradicating infectious diseases.

© 2019 Alexander Melnikov / Sputnik via AP
 
UPDATE:
 
On December 11, 2019, Treatment Action Group, hepCoalition, Human Rights Watch and over 50 other human rights and public health organizations, networks, and individuals sent a third letter to the United Nations Office on Drugs and Crimes (UNODC), whose mandate involves assisting countries in reforming their prison systems. The groups urged the UN agency to intervene publicly and privately to press the UAE to take appropriate action to end abusive practices against prisoners living with HIV.
 
(Beirut) – United Arab Emirates (UAE) authorities should ensure that all prisoners in their custody have access to appropriate HIV prevention, treatment, and care, Treatment Action Group, Action Against Aids Germany, Human Rights Watch, and 37 human rights and public health organizations and networks working on HIV and TB, said in a letter today to Sheikh Mohammad bin Zayed Al Nahyan, the Abu Dhabi crown prince. The groups also said that independent international monitors should be allowed regular access to prison and detention facilities.

Under Sheikh Mohammed’s patronage, the UAE is hosting a forum in Abu Dhabi on November 19, 2019, for global health leaders to share insights and best practices on eradicating infectious diseases.

“While the UAE hosts  a global forum on eradicating infectious diseases, vulnerable prisoners living with HIV in its own detention facilities are being denied critical and lifesaving treatment,” said Michael Page, deputy Middle East director at Human Rights Watch. “To show a genuine commitment to ending preventable diseases that affect the world’s most vulnerable communities, Sheikh Mohammed bin Zayed al Nahyan should first look to cleaning up his own backyard.”

On November 4, Human Rights Watch released research that revealed that Emirati prison authorities are denying non-national prisoners living with HIV in some UAE prisons regular and uninterrupted access to lifesaving antiretroviral treatment. Human Rights Watch also found that prison authorities in al-Awir central prison in Dubai and al-Wathba central prison in Abu Dhabi have segregated detainees living with HIV from other prisoners and systematically discriminated against them.

A second letter was sent to the UNAIDS executive director, Winnie Byanyima, and the United Nations Development Program administrator, Achim Steiner. The groups urged these UN agencies to intervene publicly and privately to press the UAE to take appropriate action to end the abusive practice against non-national prisoners living with HIV, including by allowing independent monitors private visits with prisoners.

On November 5, Saeed al-Hebsi, director of human rights at the UAE Ministry of Foreign Affairs and International Cooperation, told the Guardian “The UAE rejects the allegations put forward by Human Rights Watch. Every person has a right to proper health care and we guarantee medical services to all inmates in the UAE prison system.”

However, Human Rights Watch documentation, as well as that of other international human rights groups, demonstrates that the denial of adequate medical care in UAE prisons and detention facilities extends beyond prisoners living with HIV and other communicable diseases and is most common in state security facilities, where torture is systemic.

In May, Human Rights Watch reported the death of a cancer-stricken detainee, Alia Abdel Nour, following years of mistreatment and denial of adequate medical care by security forces and prison authorities. UAE authorities ignored repeated calls by European Parliament members, UN experts, and members of her family for her release on health grounds.

Over the past year, there have also been increased concerns for the deteriorating health of two unjustly detained rights activists, Ahmed Mansoor and Nasser bin Ghaith, who are reportedly being held in dismal prison conditions and denied access to health care in Al Sadr and Al Razeen prisons, respectively.

“Allowing independent and international monitors to conduct private and regular visits with prisoners in the UAE would be a step toward demonstrating that the UAE is meeting its international obligation to provide adequate medical care to all prisoners without discrimination,” Page said.

Posted: January 1, 1970, 12:00 am

“Angela,” 20, walks with her son near her home after returning from school in Migori county, western Kenya. She is a Form 4 student at a girls-only school. Angela became pregnant when her trainee teacher offered to pay some of her primary school fees in return for sex. Her father tried to marry her off to suitors after she gave birth, but Angela’s mother fought against this and supported her return to school. She wants to go to college and study nursing.

© 2018 Smita Sharma for Human Rights Watch

In late 2018, Sierra Leone's First Lady, Fatima Bio, opened a national campaign "Hands Off Our Girls."   Her campaign made big promises to reduce child marriages and teenage pregnancies in the country, in part to tackle the spike in teenage pregnancies following widespread rape during the Ebola crisis. Reflecting on this campaign, President Julius Maada Bio stated: "We have wasted a lot of time in restricting the potentials of women and girls."

In light of this important acknowledgment, his government senselessly adheres to a policy that intentionally wastes the potential of many thousands of girls who are expelled from school each year because they are pregnant - which also effects the number of girls who stay in secondary school in the country.

In Sierra Leone, like in Tanzania and many other African countries, one of the most often cited excuses for not letting pregnant girls stay in school is that they will "corrupt" other girls into pregnancy. But isolating and excluding pregnant girls from school will not stop teen pregnancies because "immorality" is not the cause.

Video

Giving Girls a Future: Allow Pregnant Girls, Young Mothers to Attend School

Tens of thousands of pregnant girls and adolescent mothers are banned or discouraged from attending school across Africa.

These punitive approaches, which in Tanzania and elsewhere have led to harassment and even arrest of pregnant girls, only serve to stigmatize and disempower girls, and to perpetuate gender discrimination. The fact is that many teenage girls are vulnerable to becoming pregnant because of factors such as poverty, violence, exploitation, and lack of knowledge about sexuality. Government officials might be quick to blame some of the most vulnerable girls, but authorities are incredibly slow when it comes to tackling these key factors through smart policies and programs.

The stories of hundreds of girls whom we have interviewed stand in sharp contrast to the dominant narrative by authorities and others in a position of power, such as teachers, education staff, or politicians who condemn them.

When we've asked girls - pregnant or not - what they think about their peers' pregnancies and drop-outs, most have told us that seeing other pregnant girls drop out of school is enough of a deterrent. Girls can often see that their peers have to deal with heavy stigma as a result of pregnancy. Their families reject or insult them. Most struggle to raise a child when they are children themselves.

In Tanzania, we interviewed Sawadee - she chose this pseudonym - who was in the third grade of secondary school when she got pregnant. Her neighbor - an adult man - followed her for a few years. He used to give her small gifts, which she felt she had to accept. At first, she refused to have sex with him, but her friends advised her to accept the money he was offering, as she would be better off. She got pregnant the first time they had sex, when she was only 16. Her parents kicked her out of their home, and she was expelled from school. For years, she dreamed of becoming a nurse - but getting back into education was nearly impossible: Sawadee and her daughter suffered hardship. She could only find very precarious jobs. "When I failed to get money, me and my baby didn't get a meal," she told us. Girls understand that pregnancy could mean the end of their hard-gained efforts to get a secondary or university education. Like Sawadee, they know pregnancy can destroy their ambitions.

But many girls also tell us about the challenges they face at school, and in their communities, which contribute to their vulnerability. Many girls we have spoken with became pregnant because they were raped, sexually exploited in exchange for food, money or grades or coerced into sex by adultsincluding their own teachers, and at a worryingly high rate, by boys their age.

But many also get pregnant following a sexual relationship they consented to with boys - often students or others they know in their communities. The lack of sexual education - or even how to protect themselves - plays a part in this.

Education ministries have a great tool available to act and respond in an empowering way. Age-appropriate comprehensive sexuality education can help students understand sexuality and reproduction and how to protect themselves from pregnancy or sexually transmitted infections. But importantly, this education can help them recognize that they can use their right of consent to decide when to have sexual relationships, and understand that sexual exploitation and abuse are crimes and that no one should subject them to sexual violence. Yet, many African governments refuse to provide comprehensive sexuality education in schools. Where it is provided it is often substandard. Most provide a half-baked and often unscientific version that focuses on the biology of reproduction or a stigmatized approach to adolescent sexuality that does little to protect students.

African governments have a legal obligation to promote girls' rights to education without discrimination. Sierra Leone should immediately lift the ban and not just allow all girls access to education, but support them fully to return to school. The African Union should call on Sierra Leone, Tanzania and all African governments to safeguard all girls' potential, and stop the exclusion of pregnant girls from schools.

Author: Human Rights Watch, Human Rights Watch
Posted: January 1, 1970, 12:00 am

Dubai's skyline, United Arab Emirates. 

© 2015 REUTERS/Karim Sahib/Pool

(Beirut) – United Arab Emirates (UAE) prison authorities are denying non-national HIV-positive detainees in at least one UAE prison regular and uninterrupted access to lifesaving antiretroviral treatment, Human Rights Watch said today. Detainees living with HIV are also segregated from the rest of the prison population in an isolated area and report facing stigma and systemic discrimination.

Multiple sources, including former non-national detainees in Al Awir Central Jail’s HIV units in Dubai, told Human Rights Watch that, while they are tested for HIV every three to six months, unlike the Emirati detainees held with them, HIV treatment is often delayed and interrupted, and sometimes denied altogether. Sources close to them reported that four prisoners said in September that they had not received any medication for between three and five months and that this is not the first time prison authorities have delayed critical medical treatment.

“The UAE has an obligation to provide health care, including antiretroviral medicines, to all prisoners in their custody without discrimination,” said Michael Page, deputy Middle East director at Human Rights Watch. “Denying, delaying, and interrupting treatment for HIV for non-national prisoners is a flagrant violation of the right to health and potentially the right to life.”

Continuity of care is crucial to effective treatment of HIV, resulting in decreased levels of circulating virus (or viral load), protecting an individual’s immune system, and reducing the possibility of transmission. Interruptions in treatment can increase the risk of developing viral resistance and lead to a much higher risk of fatal opportunistic infections.

One person with direct knowledge of the case told Human Rights Watch that a prisoner who recently fell seriously ill after being denied treatment for nearly four months said his test results showed an elevated viral load and a dangerously low count of infection-fighting CD4 cells, both of which can be warning signs of the possible onset of AIDS, which dramatically decreases life expectancy. Sources said that three other prisoners also expressed concern about their worsening health conditions and that prison officials were apparently indifferent to their repeated requests for appropriate care. Human Rights Watch is withholding details to protect people from retaliation.

Men and women who live with HIV are held in segregated units away from the rest of the prison population in Al Awir – the men in one area and the women in another. They include people serving sentences for nonviolent drug or financial crimes, others convicted of murder and other violent crimes, and others held in pre-trial detention who are sent to the central prison before facing trial or receiving a sentence only because they tested positive for HIV.

One former detainee said Emirati authorities held him in Al Awir Central Jail for five months without charge before transferring him to Al Sadr prison in Abu Dhabi. He said he was kept in solitary confinement for eight months in Al Sadr and received no treatment throughout his year-long detention in the UAE.

He also described the stigma and discrimination he and other prisoners living with HIV suffered in Al Awir: “The guards knew nothing about HIV, they were afraid even to enter our block, they wore special masks and gloves, and talked to us through glass. They treated us like wild and dangerous animals.”

The former detainee said that in al Sadr prison, when the conditions of prisoners living with HIV worsened, prison authorities would place them in isolation cells for several days. He said two prisoners living with HIV died during his stay at al Sadr.

Segregating detainees living with HIV from the rest of the prison population in Al Awir Central Jail also denies them access to the prison library and other amenities, sources said. “They put you there [in the segregated unit] and forget about you,” said another former detainee.

One former detainee in Al Wathba Central Prison in Abu Dhabi said that people living with HIV, hepatitis C, and other communicable disease in al Wathba were also segregated from the rest of the prison population. She is not HIV-positive.

International guidelines on human rights standards in prisons state that prisoners have a right to medical services, without discrimination, at least equivalent to services available to people in the community, including for HIV, tuberculosis, and other infectious diseases.

However, while the UAE provides HIV-positive citizens with free HIV treatment and care programs, and while it claims to do so for expatriates as well, according to local regulations, the government does not grant residency or work visas to persons with certain communicable diseases, including HIV. Moreover, non-nationals already in the country who test positive for these diseases are subjected to deportation proceedings. In 2012, a Gulf News article on the deportation of four female HIV-positive prisoners quoted a Dubai Central Jail prison official citing a decision by the public prosecutor to deport all HIV-positive prisoners, including those serving life sentences.

The denial of adequate medical care in UAE prisons and detention facilities extends beyond prisoners living with HIV and other communicable diseases and is most common in state security facilities, where torture is systemic. In May 2019, Human Rights Watch reported the death of a cancer-stricken detainee, Alia Abdel Nour, following years of mistreatment and denial of adequate medical care by security forces. UAE authorities ignored repeated calls by European Parliament members, United Nations experts, and members of her family for her release on health grounds.

Over the past year, there have also been increased concerns for the deteriorating health of two unjustly detained rights activists, Ahmed Mansoor and Nasser bin Ghaith, who are being held in dismal prison conditions and denied access to health care in Al Sadr and Al Razeen prisons, respectively.

As a UN member state, the UAE committed to joining worldwide efforts to end AIDS as a public health threat by 2030. To honor that commitment, UAE authorities should make sure that all prisoners living with HIV are receiving the critical care they require. The authorities should also allow independent international monitors to enter the country and regularly monitor prison and detention facilities, Human Rights Watch said.

On November 19, 2019, under the patronage of Sheikh Mohammad bin Zayed Al Nahyan, Crown Prince of Abu Dhabi, the UAE will host a forum for global health leaders to share insights and best practices to eradicate infectious diseases. 

“Public health institutions and HIV activist networks should pressure authorities to live up to their obligations and to their declarations of tolerance by ending this abusive practice and providing adequate medical care to all prisoners equally,” Page said.

 

Posted: January 1, 1970, 12:00 am

Video

Iran: Sanctions Threatening Health

The Trump administration’s broad sanctions on Iran have drastically constrained the ability of the country to finance humanitarian imports.

(Washington, DC) – The Trump administration’s broad sanctions on Iran have drastically constrained the ability of the country to finance humanitarian imports, including medicines, causing serious hardships for ordinary Iranians and threatening their right to health, Human Rights Watch said in a report released today. The administration in Washington should take immediate steps to ensure a viable channel exists for trade of humanitarian goods with Iran.

The 47-page report, “‘Maximum Pressure’: US Economic Sanctions Harm Iranians’ Right to Health,” documents how broad restrictions on financial transactions, coupled with aggressive rhetoric from United States officials, have drastically constrained the ability of Iranian entities to finance humanitarian imports, including vital medicines and medical equipment. While the US government has built exemptions for humanitarian imports into its sanctions regime, Human Rights Watch found that in practice these exemptions have failed to offset the strong reluctance of US and European companies and banks to risk incurring sanctions and legal action by exporting or financing exempted humanitarian goods. The result has been to deny Iranians access to essential medicines and to impair their right to health. Under international law, the US should monitor the impact of its sanctions on Iranians’ rights and address any violations sanctions cause. 

“Trump administration officials claim they stand with the Iranian people, but the overbroad and burdensome US sanctions regime is harming Iranians’ right to health, including access to life-saving medicines,” said Sarah Leah Whitson, Middle East director at Human Rights Watch. “The comprehensive web of US sanctions has led banks and companies to pull back from humanitarian trade with Iran, leaving Iranians who have rare or complicated diseases unable to get the medicine and treatment they require.”

Between November 2018 and October 2019, Human Rights Watch interviewed 21 people, including Iranian medical professionals, former or current employees of Iranian and international pharmaceutical importers of medicines, and lawyers and NGO workers with firsthand knowledge of the challenges of humanitarian operations in Iran. Some of the interviewees live in Iran, and many of those interviewed either previously lived in Iran and/or continue to travel to Iran but reside outside the country. Human Rights Watch interviewed US government policy experts with direct or indirect experience of working on Iran issues. A Human Rights Watch researcher also corresponded with several Iranians who had commented on social media about the inaccessibility of needed medicine for themselves or their family members. Human Rights Watch relied on available Iranian and US government official statements and analyzed economic and trade data produced by Iran’s Central Bank, Iran’s Food and Drug Administration (Sazman-e-Ghaza-va-Daroo), and Eurostat, the statistical office of the European Union based in Luxembourg.

Since the Trump administration formally withdrew the US from the international nuclear agreement with Iran in May 2018, it has re-imposed previously suspended nuclear related economic sanctions, including on oil exports, and added new sanctions. The US Treasury Department predicted the sanctions would lead to Iran’s “mounting financial isolation and economic stagnation.” Open-ended and comprehensive sanctions such as those that the Trump administration has imposed on Iran have negatively impacted the humanitarian needs and the enjoyment of the right to health for millions of Iranians, Human Rights Watch said.

On October 25, 2019, with the announcement of new sanctions on Iran, Treasury Secretary Steven T. Mnuchin said that “This administration remains committed to the unfettered flow of humanitarian aid to the Iranian people, who have suffered for forty years under the mismanagement of this corrupt regime.” However, US officials also have sent a contradictory message, saying that the strategy is in fact to cause enough distress for the Iranian people that they force the government to change its behavior – a recipe for infringing on Iranians’ economic rights. On February 14, 2019, US Secretary of State Mike Pompeo told CBS News: “Things are much worse for the Iranian people [with the US sanctions], and we are convinced that will lead the Iranian people to rise up and change the behavior of the regime.”

"The recent US Treasury and State Department announcement of a 'new humanitarian mechanism' for trade with Iran is a rare implicit acknowledgement that broad US sanctions on Iran have restricted the flow of humanitarian goods into the country,” Whitson said. “The US government should get serious about addressing the harm resulting from its cruel sanctions regime by creating a viable financial channel with reasonable requirements for companies, banks, and groups to provide humanitarian goods for people in Iran instead of requiring more burdensome hurdles.”

The October 25 designation of Iran as a “jurisdiction of primary money laundering concern under Section 311 of the USA PATRIOT Act,” constitutes an escalation of US financial sanctions against Iran. It includes a new mechanism to “increase transparency of permissible trade” with Iran. There is serious concern that complying with the burdensome requirements of the new mechanism will not be feasible for companies. It is also unclear whether compliance will supersede the prohibition on any trade, including humanitarian trade, with designated entities under terrorism provisions. As one former US official involved in Iran sanctions policy put it: “I suspect most will see this mechanism less as a humanitarian channel and more as an intelligence gathering function to enable additional US sanctions. For those of us seeking a real channel, this ain’t it.”

Human Rights Watch found that US economic sanctions on Iran, despite the humanitarian exemptions, are causing unnecessary suffering to Iranian citizens afflicted with a range of diseases and medical conditions. Some of the worst affected are Iranians who have rare diseases and/or conditions that require specialized treatment and are unable to acquire previously available medicines or supplies. This includes patients with leukemia, epidermolysis bullosa (EB, a type of disease that causes fragile, blistering skin), epilepsy, and chronic eye injuries from exposure to chemical weapons during the Iran-Iraq war.

People with severe forms of EB have been unable to get specialized bandages and are significantly more likely to get bacterial infections and develop sepsis. Children with epilepsy resistant to common treatments and unable to get imported medicines have frequent, uncontrolled seizures that risk injury and over time severe and permanent brain damage.

Over the past year, the US Treasury Department has added a large number of institutions, including Iranian government and private banks, to the Specially Designated Nationals and Blocked Persons List for the sanctions. US and non-US companies and financial institutions that engage in transactions with these entities can be prosecuted in the US. The serious regulatory and due diligence requirements placed on international firms trading with Iran have left only a small number of companies and banks with the capacity to finance trade with Iran and a willingness to accept the increased financial and legal risks.

Excessive caution or “overcompliance” by banks and pharmaceutical companies is a significant factor for this, Human Rights Watch said. Human Rights Watch found, for instance, that a European company refused to sell the special bandages needed by patients with EB despite the humanitarian exemption. Human Rights Watch reviewed correspondence with two other banks in which they refused to authorize humanitarian transactions with Iran.

The Trump administration’s broad use of “terrorist” designations further threatens humanitarian trade with Iran. The April designation of the Islamic Revolutionary Guard Corps, part of Iran’s military force, as a Foreign Terrorist Organization, could affect up to 11 million Iranians, the New York Times reported. While these designations do not apply to medicines, they increase the potential risks for companies if they end up in transactions with designated entities. Moreover, the September 20 decision to impose further sanctions on Iran’s Central Bank severely restricts the last remaining Iranian financial institution able to engage in foreign exchange transactions involving humanitarian imports, rendering the “humanitarian exemption” nearly meaningless.

“We have now, for a full year, tried to find banks that are able and willing to transfer money from donors [for our humanitarian operations],” Jan Egeland, secretary general of the Norwegian Refugee Council, which supports thousands of Afghan refugees in Iran, said in August. “But we are hitting a brick wall on every side. Norwegian and other international banks are afraid of US sanctions to transfer the money that governments have given for our vital aid work.”

Under international law, a country or coalition of states enforcing economic sanctions should consider the impact on the human rights of the affected population, especially their access to goods essential to life, including medicines and food. Human Rights Watch opposes sanctions that have a disproportionately negative impact on the human rights of the affected population, or that create unnecessary suffering, in particular for vulnerable populations.

The US government should work to establish viable financial channels for humanitarian trade with Iran and take immediate steps to ensure that humanitarian exemptions are effective in facilitating Iranians’ access to medicine and medical equipment, Human Rights Watch said.

“Ordinary Iranians are bearing the brunt of America’s sanctions policy, and their hearts and minds will be keeping tabs on the parties that are causing them harm,” Whitson said.

While sanctions diminish Iran’s capacity to meet the needs of residents, they do not take away Iran’s human rights obligations. The Iranian government should ensure that citizens and residents can enjoy their right to health without discrimination and should take all possible measures to reduce the negative impact of sanctions on vulnerable groups. This includes the government’s obligation to prevent corruption and misuse of resources.

Posted: January 1, 1970, 12:00 am

Summary

In May 2018, the Trump administration formally withdrew from the international nuclear agreement with Iran, known as the Joint Comprehensive Plan of Action (JCPOA), agreed upon by the Obama administration in July 2015. Over the next 120 days, until November 5, 2018, the US government re-imposed all economic sanctions related to Iran’s nuclear program that had been previously lifted, including “secondary sanctions” on non-US entities that conduct financial or commercial transactions with Iran.

Though the US government has built exemptions for humanitarian imports into its sanction regime, broad US sanctions against Iranian banks, coupled with aggressive rhetoric from US officials, have drastically constrained Iran’s ability to finance such humanitarian imports. The consequences of redoubled US sanctions, whether intentional or not, pose a serious threat to Iranians’ right to health and access to essential medicines—and has almost certainly contributed to documented shortages—ranging from a lack of critical drugs for epilepsy patients to limited chemotherapy medications for Iranians with cancer.

At the core of the harmful knock-on effects of renewed US sanctions on Iran is that in practice, these sanctions have largely deterred international banks and firms from participating in commercial or financial transactions with Iran, including for exempted humanitarian transactions, due to the fear of triggering US secondary sanctions on themselves. As a result, Iranians’ access to essential medicine and their right to health is being negatively impacted, and may well worsen if the situation remains unchanged, thereby threatening the health of millions of Iranians.

On several occasions, US officials have indicated that the pain US sanctions are causing for ordinary Iranians is intentional, part of a strategy to compel Iranian citizens to demand their autocratic government to “change behavior” – a recipe for collective punishment that infringes on Iranians’ economic rights. For instance, on February 14, 2019, US Secretary of State Mike Pompeo told CBS News, "Things are much worse for the Iranian people [with the US sanctions], and we are convinced that will lead the Iranian people to rise up and change the behavior of the regime.” The US Treasury Department itself predicted that US policies would lead to Iran’s “mounting financial isolation and economic stagnation.”  

The Trump administration, beyond re-imposing economic sanctions that had been suspended under the JCPOA, has repeatedly targeted Iranian financial institutions. On October 16, 2018, for example, the Office of Foreign Assets Control (OFAC) of the US Treasury Department further restricted Iran’s access to global financial markets by adding about 20 Iranian institutions to the list of Specially Designated Global Terrorists (SDGTs) for “supporting military force that recruits and trains child soldiers.”

Then, with the total re-imposition of sanctions suspended under the JCPOA, in November 2018, the US Treasury Department added at least 37 Iranian governmental and privately-owned banks, as well as Iran’s national oil company, to the Specially Designated Nationals and Blocked Persons List (SDN) of individuals subject to sanctions. Any company subject to US jurisdiction, US as well as non-US, that engages in transactions with SDNs can be subject to prosecution in the US, creating a significant risk for businesses, banks and global financial institutions essential for facilitating the import of essential medicines and medical equipment into Iran.

Previously, the US government had lifted sanctions on non-US entities as part of the JCPOA. The serious regulatory and due diligence requirements placed on international firms trading with Iran have left only a limited number of companies and banks with the capacity to finance trade with Iran and willing to accept the increased financial and legal risks of US secondary sanctions that come with those transactions.

These restrictions on financing, combined with the sharp depreciation of the Iranian currency, the rial, have resulted in severely limiting Iranian companies and hospitals from purchasing essential medicines and medical equipment from outside Iran that residents depend upon for critical medical care. Moreover, renewed US sanctions have directly impacted families’ purchasing power, contributing to inflation rates of around 30 percent in the past year. Iran’s nearly universal health care coverage currently absorbs a significant portion of health care costs. But the failure of this system, which is already under serious financial stress, will likely have devasting effects on millions of patients.

In July 2019, the UN Special Rapporteur on the situation of human rights in Iran said that he is “not only concerned that sanctions and banking restrictions will unduly affect food security and the availability and distribution of medicines, pharmaceutical equipment and supplies, but is also concerned at their potential negative impact on United Nations and other operations and programs in the country.”

Human Rights Watch found that current economic sanctions, despite the humanitarian exemptions, are causing unnecessary suffering to Iranian citizens afflicted with a range of diseases and medical conditions. Some of the worst-affected are Iranians with rare diseases and/or conditions that require specialized treatment who are unable to acquire previously available medicines or supplies. This includes people with leukemia, epidermolysis bullosa (EB, a type of disease that causes fragile, blistering skin), or epilepsy, and individuals with chronic eye injuries from exposure to chemical weapons during the Iran-Iraq war.

The consequences for these individuals can be catastrophic: people with severe forms of EB are now unable to access specialized bandages and are at significantly increased risk for bacterial infections, sepsis, fusion of fingers, and contractures of joints. Individuals with epilepsy who are resistant to common treatments and unable to access foreign-made medicines may suffer frequent, uncontrolled seizures that risk injury and result over time in severe, permanent brain damage. Shortages of essential medicines can affect a much broader range of patients as well. For example, an Iranian journalist has reported on severe complications after a Caesarean section believed to be related to the use of a “non-standard” anesthesia medicine because of lack of access to higher quality medication.

The abusive consequences of secondary sanctions, demonstrated by research conducted by Siamak Namazi, an Iranian-American analyst, on the sanctions regime during the Obama Administration prior to the JCPOA, have inevitably recurred with the re-imposition of sanctions by the Trump administration. But the difference now with the Trump Administration’s Iran sanctions is “that the US has re-imposed the sanctions it lifted pursuant to the nuclear deal and it has layered on many more, including doing things like designating some Iranian financial institutions not previously designated and that were previously used to facilitate food, medicine and medical imports,” Elizabeth Rosenberg, a former US Treasury Department sanctions official, told NPR. As Rosenberg pointed out, “most of the big Iranian banks are designated” – i.e., under sanction – and smaller banks “may have less capacity to handle cross-border financial transactions.” Iran is currently able to conduct business through a very limited number of banks and financial institutions closely affiliated with countries that had initially received waivers from the US to continue purchasing Iran’s oil, notably China, India and Turkey. These banks used Iran’s oil revenues, held in escrow accounts, to execute financial transactions for imports of medicine and other items prioritized by the Iranian government as essential goods.

Moreover, the tone of US government officials in public and private concerning economic transactions with Iranian institutions has contributed to companies and banks’ hesitation to engage in trade with Iran. For instance, Richard Grenell, the US Ambassador to Germany, told a German paper on May 6, 2019 that, “You can do as much business as you want in Iran, but we have a say with regards to your visa.” “Because if you do something, we’re not going to agree to let you enter our country,” he added.

Excessive caution or “overcompliance” by banks and pharmaceutical companies wary of falling afoul of US sanctions is a significant factor in limiting Iran’s access to funds for imports of medicines and medical equipment. As former French ambassador to Washington Gérard Araud told a Hudson Institute gathering in October 2018, “the fact is that banks are so terrified by the sanctions that they don’t want anything to do with Iran.” In the case of the specialized bandages needed for patients with epidermolysis bullosa, Human Rights Watch found evidence that a European company refused to sell the bandages as a result of sanctions despite the humanitarian exemption. In two other instances, Human Rights Watch reviewed correspondence from banks refusing to authorize humanitarian transactions with Iran after the imposition of sanctions.

This fear has even caused problems for humanitarian actors supporting thousands of Afghan refugees in Iran. The Norwegian Refugee Council (NRC) is the largest of five international NGOs working in Iran, where they have implemented programs in areas like education for over seven years. However, they are now facing similar hurdles financing their operations due to sanctions. “We have now, for a full year, tried to find banks that are able and willing to transfer money from donors [for our humanitarian operations],” said NRC head Jan Egeland in August 2019, “but we are hitting a brick wall on every side. Norwegian and other international banks are afraid of US sanctions to transfer the money that governments have given for our vital aid work.” 

According to individuals familiar with international humanitarian trade with Iran, the broad restrictions on financing of Iran-related trade have forced Iranian pharmaceutical companies to reroute even transactions that are fully authorized under US sanctions law through the hawala system, an informal remittance network that relies on existing family or other relationships of trust to make payments without transferring money. But, use of the hawala system often results in increased transaction costs and is difficult to use due to Iranian government health regulations, doctors and importers say. This has led importers to choose alternative pharmaceuticals and equipment of lower quality. In interviews with Human Rights Watch, as well as in posts on social media, patients reported suffering from serious side-effects when they had to choose medical alternatives after they either could not find or could not afford their usual medication in the market. Human Rights Watch is not able to independently verify the reported medical side effects resulting from the use of lower quality medicine or medical equipment.

The Trump administration’s broad use of “terrorist” designations further threatens humanitarian trade with Iran. The US has failed to clarify its April 15 designation of the Islamic Revolutionary Guard Corps (IRGC), a formal part of Iran’s military force, as a Foreign Terrorist Organization (FTO), which could impact up to 11 million Iranians. Even though medicines are exempted from sanctions, “they do become prohibited if they are found to be going to a designated actor or entity,” Richard Nephew, a former State Department office, told the BBC. Referring to such a designation, Jan Egeland from NRC told the audience in a conference on humanitarian aid that while governments in Washington, London, and Bern may not intend to sabotage his organization’s work with refugees, “no one is able to tell me that if you do [your operation] this way, [neither] you nor your staff will be in violations of our rules.”

The Trump administration’s September 20, 2019 decision to impose further sanctions on Iran’s Central Bank under its “counterterrorism authority” severely restricts the last remaining Iranian financial institution able to engage in foreign exchange transactions involving humanitarian imports, rendering the “humanitarian exemption” meaningless. According to Brian O’Toole, a former senior advisor to the director of OFAC, its impact “will be to further impair the delivery of food and medicine to the Iranian people.” On October 14, a representative of Iran’s drug importers association told Iranian media that after the US declared these sanctions, South Korean banks have suspended their relations with Iran.

On October 25, 2019, the US Departments of the Treasury and State announced a further escalation of US financial sanctions against Iran by the Financial Crimes Enforcement Network (FinCEN) bureau of the Treasury department, while at the same time announcing a new mechanism to “increase transparency of permissible trade” with Iran. The FinCEN action is aimed at depriving the Iranian government the ability to use “so-called humanitarian trade to evade sanctions and fund its malign activity” by designating Iran as a “jurisdiction of primary money laundering concern under Section 311 of the USA PATRIOT Act.” This designation is known colloquially as the “financial death penalty” because of the severe restrictions it places on a country’s financial institutions.

At the same time, the Treasury and State Departments also appeared to acknowledge the need to mitigate the consequences of the September 2019 US sanctions designation of the Central Bank of Iran (CBI) by jointly offering a humanitarian “mechanism” for humanitarian transactions in exchange for a commitment by companies and banks to conduct “enhanced due diligence.” The requirement for enhanced due diligence includes information about customers, including the identities of all consignees and intermediaries involved in the transactions, as well as monthly statement balances with the value, currency, and balance date of any account of an Iranian financial institution held at the participating host nation’s foreign financial institutions that is being used for humanitarian transactions. Moreover, the entity hoping to use the mechanism should provide a written commitment from any Iranian distributors involved in the transactions that they will not allow the goods to be sold or resold to Iranian designated individuals or entities and that the Iranian distributor will impose this obligation on downstream customers. It is, however, not clear from the guidance if complying with these burdensome requirements would be feasible for companies and whether it will supersede the prohibition on any trade, including humanitarian trade, with designated entities under terrorism provisions.

The impact of these parallel policy pronouncements remains to be seen. To many close observers of US sanctions policy, the humanitarian mechanism appeared unlikely to actually increase humanitarian exports to Iran. Instead, the combination of onerous requirements and a thinly veiled intelligence gathering function appeared aimed at garnering publicity rather than realistically confronting the humanitarian problems caused by US sanctions against Iran. 

For example, a sanction lawyer familiar with the issue told Human Rights Watch that the requirement for foreign banks to  provide far-reaching monthly reports to the US Treasury department with respect to any humanitarian transactions involving Iran in exchange for comfort letters from OFAC as to their sanctions exposure is a “new bureaucratic hurdle for humanitarian trade with Iran.”

Two former US and Treasury department officials with close knowledge of the US sanctions regime on Iran also reacted to this announcement by expressing skepticism about its effects. Brian O’Toole reacted to the announcement on Twitter by writing, “This does not help, and in fact probably makes the situation worse.” Richard Nephew also tweeted that “in the context of the 311 finding [USA Patriot Act money laundering provision] AND general atmosphere, I suspect most will see this mechanism less as a humanitarian channel and more as an intelligence gathering function to enable additional U.S. sanctions. For those of us seeking a real channel, this ain't it.”

A country or coalition of states enforcing economic sanctions should consider the impact on the human rights of the affected population, especially regarding their access to goods essential to life, including medicines and food. Open-ended and comprehensive sanctions such as those that the Trump administration has imposed on Iran have negatively impacted the humanitarian needs and the enjoyment of human rights of Iran’s general population. Human Rights Watch opposes sanctions that have a disproportionately negative impact on the enjoyment of human rights by civilian populations, or create unnecessary suffering, in particular for vulnerable populations.

The harmful effect of US sanctions on Iranians’ access to food and medicine should not be a surprise in light of similar effects observed in other sanctions regimes. The multilateral sanctions on Iraq in the 1990s, for example, notoriously decimated the Iraqi economy and “had a detrimental effect on the health of the population,” according to several health researchers.

The US government should take immediate steps to ensure humanitarian exemptions are effective in facilitating Iranians’ access to medicine and medical equipment. Most importantly, the US government should publicly clarify at the highest level that banks and companies face no legal or financial risks in exporting or financing exempted humanitarian goods to Iran. On August 6, 2019, OFAC issued “Guidance Related to the Provision of Humanitarian Assistance and Support to the Venezuelan People,” stating that OFAC “is committed to ensuring that humanitarian support can flow” to Venezuela and “encourag[ing] US persons to avail themselves to these authorizations,” including remittances. OFAC should issue an equivalent public “guidance” for Iran and adopt it as policy.

The imposition of sanctions does not diminish the human rights obligations of the targeted state. The Iranian government needs to take steps "to the maximum of its available resources" to provide the greatest possible protection for the rights of each individual within its jurisdiction. While sanctions inevitably diminish Iran’s capacity to meet the needs of its residents, the government is obligated to ensure that citizens and residents can enjoy their right to health without discrimination and should take all possible measures, including negotiations with other states, to reduce to a minimum the negative impact of sanctions on vulnerable groups. This includes the government’s obligation to prevent corruption and misuse of resources. In order to reduce obstacles to other states’ establishing humanitarian trade mechanisms with Iranian financial institutions, Iran should also ratify UN counterterrorism financial transparency initiatives.

Recommendations

To the US Government

  • Publicly clarify at the highest level that banks or companies face no legal or financial risks in exporting or financing exempted humanitarian goods to Iran.
  • Establish a mechanism to expedite financing of humanitarian exports to Iran.
  • Encourage other states to establish mechanisms for financing humanitarian imports to Iran, such as the INSTEX mechanism proposed by several European states.
  • The US should initiate diplomatic efforts, including direct talks with Iran, to ensure that humanitarian channels remain open for Iran to import essential medicine and medical equipment in order to safeguard Iranians’ right to health.

To the US Treasury Department, Office of Foreign Assets Control

  • Establish a due diligence assistance program for companies wanting to export humanitarian goods to Iran
  • Authorize a financial channel for humanitarian trade, either directly or through governments that have expressed interest, such as the Swiss government.
  • Issue clear guidance regarding protection of humanitarian trade with Iran in light of the US designation of the Central Bank of Iran (CBI) as a Specially Designated National (SDN).
  • Publish the list of licenses granted for humanitarian trade and other steps taken to address the humanitarian need of Iranians since August 2018 and going forward publish monthly information on humanitarian trade licenses.
  • Dedicate resources for direct outreach to companies and financial institutions to clarify humanitarian exemptions.  
  • Publicly clarify that US and non-US banks and companies face no legal risks if transactions with Iran involve only exempted humanitarian goods.
  • Put in place and make public humanitarian exemption provisions for the Central Bank of Iran and other Iranian banks involved in financing imports of medicines and other humanitarian goods.

To the US State Department

  • Clarify and issue guidance regarding the implications for humanitarian trade of the State Department’s designation of Iran’s Islamic Revolutionary Guard Corps (IRGC) as a Foreign Terrorist Organization and issue clear guidance regarding the continued facilitation of humanitarian trade.
  • Appoint a designated staff with authority to ensure continuation of humanitarian trade with Iran.
     

To the US Congress

  • Request the Government Accountability Office to conduct a study on the impact of the United States government’s economic sanctions on the humanitarian situation in Iran.
  • Pass legislation obligating the US Treasury Department to establish a mechanism to finance humanitarian exports to Iran.
  • Pass legislation requiring the US Treasury Department to put in place humanitarian exemption provisions for the Central Bank of Iran and other Iranian banks involved in financing imports of medicines and other humanitarian goods.
  • Request OFAC to publish the list of licenses granted for humanitarian trade and other steps taken to address the humanitarian needs of Iranians since August 2018 and publish monthly information about licenses and exemptions issued for humanitarian trade and any other steps taken to mitigate the negative impact of sanctions on Iranians’ right to health.
  • Hold public hearings on the impact of US sanctions on the impact of sanctions on the health of Iranians and their access to medicines.

To the European Union and Member States

  • Operationalize a viable trade exchange mechanism to support humanitarian trade with Iran.
  • Press the US government to create or support the creation of a viable channel of financial transactions for humanitarian trade.

To the Iranian Government

  • Prioritize allocations of resources for imports of medicine, raw materials for production of medicine, and medical equipment.
  • Improve programs providing safety nets for Iran’s most marginalized populations, including people with disabilities.
  • Combat corruption and misuse of public funds in accordance with international human rights standards.
  • Take all possible measures, including negotiations with other states and ratification of counterterrorism financial transparency initiatives such as the Financial Action Task Force (FATF), to reduce obstacles to other states’ establishing humanitarian trade mechanisms.
  • Allow independent international organizations access to Iran to conduct research on key health and human rights concerns including thorough follow-up assessments of the impact of sanctions on the Iranian population.

Methodology

The Iranian government has rarely allowed international human rights organizations such as Human Rights Watch to enter the country to conduct independent investigations. Iranian citizens are often wary of carrying out extended conversations on human rights issues via telephone or email, fearing government surveillance that is widespread across social media platforms such as Facebook, Twitter, and the Telegram messaging application. Authorities often accuse critics inside Iran, including human rights activists, of being agents of foreign states or entities and prosecute them under vaguely-defined national security charges in the country’s penal code.

During several meetings with Iranian officials in New York as well as through an official letter on April 25, 2019, Human Rights Watch requested permission to travel to Iran to conduct this research. Iranian authorities did not respond to Human Rights Watch’s request to visit Iran or subsequent requests for information.

Between November 2018 and October 2019, Human Rights Watch interviewed six Iranian medical professionals, four former or current employees of Iranian and international pharmaceutical companies, two importers of medicines, two lawyers and four trade specialists familiar with humanitarian trade with Iran, three NGO workers with firsthand knowledge about the challenges of humanitarian operations in Iran, two experts on international sanctions law, and four other experts on US government policymaking on Iran and US sanctions policy. Some of the interviewees live in Iran, and many of those interviewed either previously lived in Iran and/or continue to travel to Iran but reside outside the country. Human Rights Watch interviewed US government policy experts with direct or indirect experience of working on Iran issues. A Human Rights Watch researcher also corresponded with several Iranians who had commented on social media about the inaccessibility of needed medicine for themselves or their family members.

Human Rights Watch reached out to 27 pharmaceutical and medical equipment companies that have sold products in the Iranian market, requesting information on the impact of re-imposed sanctions on their exports to the Iranian market. At the time of publication, three companies had declined to provide any information while the others failed to respond altogether. A copy of the letter sent to these companies is available in Appendix I.

All interviewees were informed of the purpose of the interview and the ways in which the information would be used, and when requested they were given assurances of anonymity. This report uses pseudonyms for all interviewees and withholds other identifying information for individuals and companies to protect their privacy and security. None of the interviewees received financial compensation or other incentives for speaking with Human Rights Watch.

Human Rights Watch relied on available Iranian and US government official statements and analyzed economic and trade data produced by Iran’s Central Bank, Iran’s Food and Drug Administration (Sazman-e-Ghaza-va-Daroo), and Eurostat, the statistical office of the European Union based in Luxembourg.

On May 30, 2019, Human Rights Watch wrote to the US Treasury Department’s Office of Foreign Assets Control (OFAC) requesting clarification on steps the US has taken to mitigate the harm of US sanctions to the Iranian people. The office acknowledged receipt of the letter, but as of time of publishing has not responded. A copy of the original correspondence is available in Appendix II. On October 16, 2019, Human Rights also wrote a similar letter to the Deputy Assistant Secretary for Counter Threat Finance and Sanctions at the Bureau of Economic and Business Affairs of the US State Department. A copy of this letter is available in Appendix III. Additionally, Human Rights Watch wrote to Iranian Foreign Minister Dr. Mohammad Javad Zarif; a copy of the letter is available in Appendix IV.

 

I. Timeline of US Economic Sanctions on Iran

US economic sanctions on Iran go back to the early years of US relations with the Islamic Republic, dating back to the embassy hostage crisis of 1979-81. Washington designated Iran a “state sponsor of terrorism” after the October 1983 bombing of the US Marine barracks in Beirut, banning US sales of weapons and dual-use items, as well as financial assistance, to countries that provide military goods to Iran. Various US laws and executive orders bar conventional arms transfers and transfers of technology that could have military applications, or ban transactions with Iranian entities alleged to support terrorist groups. These sanctions were not suspended by the JCPOA.[1] In addition, the United States has imposed sanctions on designated individuals and institutions for various purposes, including human rights abuses, that were not suspended under the JCPOA. Finally, entities seen as violating US sanctions by exporting to Iran or conducting financial transactions with Iran themselves risk being subject to so-called secondary sanctions.

In 1995, the Clinton administration banned US trade with and investments in Iran, and in 1997 prohibited US exports to other countries that would be incorporated into products imported by Iran. The 1996 Iran and Libya Sanctions Act authorized penalties against firms of other countries involved in Iran’s petroleum sector.[2] In 2012, the Iran Threat Reduction and Syria Human Rights Act, as well as Executive Order 13622, extended these restrictions to oil purchases from Iran, oil-export related insurance, and financial transactions involving the US financial system. Congress added provisions to the National Defense Authorization Act for the 2012 fiscal year that penalized foreign banks conducting a “significant financial transaction” with the Central Bank of Iran or any Iranian bank under US sanctions.[3] Since the US dollar is the prevailing international currency, these sanctions impaired Iran’s ability to repatriate hard currency. A 2013 executive order extended sanctions to Iran’s automotive sector.

Following the passage of UN Security Council Resolution 1929 (June 2010), dealing with Iranian nuclear activities, the European Union imposed sanctions “nearly as extensive” as those of the United States.[4] The EU suspended these sanctions as part of the JCPOA in 2016 and as of this writing they remain suspended.

The US Treasury Department’s Office of Foreign Assets Control (OFAC) has issued general licenses that permit the export to Iran of “certain food items, medicines, and basic medical supplies to Iran” without requiring further specific authorization.[5] These provisions also authorize financial transactions to support Iranian imports of these categories of goods from the United States or from a third country. General licenses, however, are capped at $500,000. According to the guidance OFAC issued on July 25, 2013, “the financing or facilitation of such sales by non-U.S. persons does not trigger sanctions, so long as the transaction does not involve certain U.S. designated persons (such as Iran’s Islamic Revolutionary Guard Corps (IRGC) or a designated Iranian bank) or proscribed conduct.”[6]

The definition of drugs under US export regulations includes prescription and over-the-counter medicines and medical devices, but certain vaccines, biological and chemical products, and medical devices (including medical supplies, instruments, equipment, equipped ambulances, institutional washing machines for sterilization, and vehicles carrying medical testing equipment) are not covered under the general license issued for humanitarian trade. Potential dual use of these substances and items in other industries such as manufacturing of weapons is the stated reason for this exclusion.

In July 2015, the UN Security Council endorsed the JCPOA and terminated the nuclear-related sanctions.[7] In January 2016, under the terms of the JCPOA, the EU lifted all nuclear-related economic and financial sanctions on Iran. The US loosened restrictions to allow US imports of luxury goods from Iran such as carpets, but the ban on general trade, including oil, remained in place. Most significantly, the JCPOA waivers allowed foreign subsidiaries of US firms to engage in non-military trade with Iran, and the US Treasury Department suspended its earlier efforts to convince foreign banks to refrain from financial transactions with Iranian banks. 

Iranian oil exports subsequently resumed nearly to 2011 levels, but international banks “were slow to reenter the Iran market” owing to uncertainty about restrictions under non-nuclear sanctions unaffected by the JCPOA suspensions. Those banks that did re-enter have largely scaled back their Iran transactions since the US withdrawal from the JCPOA.[8]

President Trump’s May 8, 2018 announcement of the US withdrawal from the JCPOA set in motion 90-day and 120-day “wind-down periods” for US sanctions that had been lifted.[9] On August 7, 2018, at the end of the 90-day “wind-down period,” the administration re-imposed sanctions on Iran’s automotive sector, trade in gold and precious metals, and US imports of Iranian luxury goods.[10]

On October 3, 2018, in a dispute concerning a 1955 treaty between Iran and the US on economic relations and consular rights, the International Court of Justice (ICJ), in response to an Iranian complaint, decided in an interim ruling that the United States should, as a provisional measure, “remove…any impediments arising from the measures announced on 8 May 2018” to exports to Iran of “medicines and medical devices, foodstuffs and agricultural commodities,” and spare parts and equipment necessary for the safety of civil aviation.[11] The ruling also determined that the United States should ensure that “payments and transfers of funds [for these goods and services] are not subject to any restriction.”[12]

The Court explained its ruling by saying “restrictions on the importation and purchase of goods required for humanitarian needs, such as foodstuffs and medicines, including life-saving medicines, treatment for chronic disease or preventive care, and medical equipment, may have a serious detrimental impact on the health and lives of individuals on the territory of Iran.”[13]

The US responded to the ICJ ruling the same day by pulling out of the treaty.[14]

Over the past year, the United States has imposed several other non-nuclear sanctions on Iran, designating a total of 1,000 persons and entities since the beginning of the Trump administration.[15] For example, on October 16, 2018, in a move ostensibly unrelated to the nuclear-related sanctions, the US Treasury Department designated the Basij Cooperative Foundation, a network of some 20 firms and financial institutions, as Specially Designated Global Terrorists (SDGTs) subject to sanctions for, “among other malign activities,” supporting a paramilitary force that recruits child soldiers.[16]

On November 5, 2018, at the end of the 120-day “wind-down period,” remaining US nuclear-related sanctions, including petroleum-related transactions as well as transactions by foreign financial institutions with the Central Bank of Iran or “re-listed” Iranian banks, went back into force. Media reports indicated that after November 2018, companies halted food, medical, or agricultural trade with Iran because banks would not facilitate even authorized transactions for Iranian clients.[17] The administration did issue six-month waivers allowing nine countries to continue purchasing Iranian oil – India, China, Turkey, Greece, Italy, Japan, South Korea, Taiwan and Iraq. With the exception of Iraq, those waivers were not renewed when they expired in May 2019.

On April 15, 2019 the US State Department designated the Islamic Revolutionary Guard Corps (IRGC), a formal part of Iran’s military force, as a Foreign Terrorist Organization (FTO).[18] As a consequence of this designation, “it is unlawful for a person in the United States or subject to the jurisdiction of the United States to knowingly provide material support or resources to a designated FTO.”[19] The administration provided no guidance on the scope of this broad designation, which potentially covers up to 11 million members of the IRGC and affiliate organizations.[20] Richard Nephew, who worked on implementing Iran sanctions under the Obama administration, told the BBC that while the sanctions do not apply to medicines, “they do become prohibited if they are found to be going to a designated actor or entity.”[21]

On May 8, 2019 the Trump administration announced sanctions against Iran’s industrial metals sector, representing an additional 10 percent of export revenues.[22] On May 23, India and Turkey announced separately that they had stopped purchasing Iranian oil as a result of the end of US waivers. Banks in both countries had played an important role in facilitating transactions for pharmaceuticals, experts told Human Rights Watch.[23]

Chinese officials have publicly opposed “unilateral” sanctions on Iran, and as of late July China was continuing to import Iranian crude oil and LPG.[24] On July 22 the United States imposed sanctions on a Chinese company and a top executive for transporting Iranian oil.[25]

After a Gibraltar court released a seized Iranian oil tanker in August 2019, Brian Hook, the US Secretary of State’s Special Representative for Iran, announced that “the US would offer rewards of up to $15 million for information that disrupts the financial operations of the IRGC and its foreign arm, the Quds Force, encouraging the maritime community to provide the US government with information on illicit Iranian oil transfers.”[26]

On September 20, 2019, in response to an attack on Saudi Arabian oil installations which the US government attributed to Iran, the US Treasury “under its counterterrorism authority” imposed further sanctions on the Central Bank of Iran (CBI).[27] “From here on out,” wrote former OFAC official Brian O’Toole, “any humanitarian trade with Iran cannot involve the CBI, which is a major impediment to such trade given the CBI’s role in the economy and in foreign exchange markets.”[28]

OFAC has not published the number of licenses issued for humanitarian trade with Iran after the re-imposition of sanctions in November 2018. Publicly available data shows that during the period between October 2014 and September 2016, out of 1,595 applications filed by US entities for a license for humanitarian trade with Iran, OFAC issued 556 specific licenses. Out of the 1,595 requests filed, 108 applications (28 granted) were for export of medicine and 1,246 (499 granted) were for medical equipment.[29] An October 2019 study conducted by the US Government Accountability Office (GAO) on the effectiveness of sanctions as a policy tool acknowledged that sanctions may also have unintended consequences for targeted countries, such as negative impacts on human rights or public health.[30]

II. Iran’s Medical Market and Responses to Facilitate Medical Imports

According to the head of Iran’s Drug and Food Organization (Sazman-e-Ghaza-va-Daroo), the country produces 97 percent of the medicines consumed in Iran.[31] However, this statistic obfuscates the serious risk external sanctions pose in restricting access essential medicine and medical treatment. A third of the medications produced in Iran are actually dependent on imported materials, and imported medicine, while only three percent of the total market, constituted roughly 30 percent of the value of Iran’s medical market in the period between March and November 2018.[32] Significantly, the majority of these imported medicines are those required for treating rare diseases, as well as multiple forms of cancer.

Several experts on Iran’s pharmaceutical market emphasized to Human Rights Watch the critical nature of ensuring Iran’s ability to acquire imported medicines, as Iranian patients suffering from complicated and rare diseases are dependent on them and have limited or no alternatives. Analyzing the list of imported medicines during the period between March and November 2018 published by Iran’s Food and Drug Administration, Human Rights Watch identified at least 240 imported drugs (of 433 total) on the World Health Organization’s (WHO) list of essential medicines.[33]

Iran’s market for medical equipment is even more dependent on imports. According to the head of the Medical Equipment office in the Ministry of Health, 70 percent of the country’s medical equipment is imported.[34] Imported equipment include electronic devices such Magnetic Resonance Imaging (MRI) and scanning devices as well as hospital beds.

After the Iranian rial began to depreciate significantly following President Trump’s initial statements that he intended to withdraw the US from the JCPOA, Iran’s Central Bank took several actions to facilitate domestic companies’ ability to purchase critical imported goods, including medications and medical equipment. In April 2018, the Central Bank designated a subsidized rate of 42,000 Iranian rials per US dollar available from the country’s foreign currency reserves for Iranian companies importing designated “essential goods.”[35]

On June 20, President Hassan Rouhani’s cabinet, in consultation with the Central Bank, published a three-tier list of priorities that are eligible to receive subsidized rates. According to government officials, medicine and medical equipment are on the list with the highest priority to receive a subsidized currency.[36] On August 6, 2018, a day before publishing the list of essential goods eligible for the 42,000 rial rate, Hassan Ghazizadeh Hashemi, the minister of health at the time, told media that the list included more than 5,000 items of medicine and 22,000 items of medical equipment.[37] On August 7, 2018, Iran’s cabinet released a list of 25 categories, mostly relating to agricultural products and medicines, eligible for the government-subsidized rate.[38] In September 2018, the Ministry of Industry announced an expanded list of 75 items, including vitamins, rennet and lactose enzymes, packaging material and equipment, and agricultural machinery.[39]

Other government officials’ statements implied, however, that some imported medical equipment might not be eligible for purchase using a subsidized currency. On August 12, the head of the Medical Equipment Office at Ministry of Health said only essential medical equipment would receive the subsidized rate.[40] On August 27, the vice chair of Iran’s parliamentary health commission said that out of the 2,000 imported dental products and dental equipment used in Iran, only 392 items would receive the government subsidized rate of 42,000 rials.[41] A doctor who owns a private specialized hospital in Tehran said that one of the biggest problems in importing medical equipment is increasing prices. “Much of our [imported medical] equipment is not eligible for the government subsidized currency [of 42,000 rials], and it is simply out of our price range to import new models of equipment to Iran.”[42]

For importers whom the government does not designate as beneficiaries of the subsidized 42,000 rial exchange rate (including some importers of health products), the Central Bank established an “integrated currency trading system (NIMA).” This network of registered money brokers is able to obtain a rate between the government subsidized rate (42,000 rials) and the market rate of around 116,000 rials.[43] To further mitigate the impact of sanctions, Iran has also used foreign currencies other than US dollars and has switched its official reporting currency from US dollars to euros.[44]

Iran’s policies to mitigate the effects of sanctions on its citizens have been accompanied by allegations of government corruption.[45] Iranian media outlets have reported alleged misallocation and misuse of government-subsidized dollars by Iranian corporate elites.[46] Thirteen petrochemical industry executives are currently on trial for allegedly embezzling revenues from shell companies they had set up to circumvent pre-JCPOA sanctions.[47]

 

III. US Sanctions Restricting Financing of Iranian Humanitarian Imports

Iranian trade analysts and pharmaceutical industry professionals interviewed for this report told Human Rights Watch that the main obstacle to Iran’s importing humanitarian materials officially exempted from US sanctions is that US sanctions themselves are restricting the means to finance these purchases.[48] Banks and financial institutions in other countries appear to be concerned about the risk of authorizing any business with Iran for fear of themselves incurring US sanctions, despite exemptions for humanitarian trade, a problem of excessive caution or “overcompliance” similar to the earlier period of US sanctions prior to the JCPOA.[49]

During that earlier period when the US and other states imposed extensive sanctions on Iran, researchers noted widespread disruption in distribution and lack of access to vital medicine for Iranian patients with different types of cancers and blood disorders, including hemophilia.[50]

Overcompliance is not limited to US banks and financial institutions. European banks have also refused to authorize transactions with Iranian companies since the Trump administration’s re-imposition of sanctions, several experts told Human Rights Watch.[51] “In the UK, for any transaction with Iranian companies, even the humanitarian ones that are exempted from sanction, I have to get involved in litigation on behalf of my clients who want to do business with Iran,” a sanctions lawyer who has represented European companies trading with Iran explained. “Often when we threaten the bank with a lawsuit, the transaction moves forward, but sometimes we have to start the pre-litigation process. This process is time consuming and sometimes leads to [foreign] companies deciding to not trade with Iran.”[52]

According to media reports, in the period between the US withdrawal from the JCPOA in May 2018 and the total re-imposition of sanctions in November 2018, at least two German, two Japanese, one Taiwanese, and one Austrian bank announced that they were ceasing their transactions with Iran.[53]

Foreign Minister Mohammad Javad Zarif in November 2018 published screenshots of four emails sent by pharmaceutical companies announcing their preemptive termination of their contracts with Iran because of the sanctions.[54] On May 18, 2018, Roquette, a French producer of starch for medical uses, informed its Iranian counterparts in a letter that it had decided to cease to all trade and sales with Iran, noting that “this decision is as a result of the recent announcement by the United States of America, which if ignored by us, is expected to adversely affect our US operations.” The German branch of JRS Pharma, in a June 27, 2018 message, stated that “due to political circumstances out of our control, our banks can no longer accept any payments linked to Iran business[es].” Gentige, a Swedish manufacturer of hospital equipment, wrote on August 28, 2018 that “due to extended sanctions against the Republic of Iran we have been informed by our compliance dep. that we are not allowed to engage in any kind of business with Iranian based customers.” The Italian pharmaceutical company Recordati wrote on June 11, 2018: “We are very sorry to inform you that as a result of recent and severe restrictions on the operations with your country we will be unable to continue the business of our products from 01.08.2018.”[55]

On August 5, 2019, Norwegian Refugee Council (NRC), a humanitarian NGO that carries out projects in Iran, including providing education and shelter to thousands of Afghan migrants and refugees in Iran, said the banks’ refusal to transfer money to aid agencies due to fear of sanctions has put their operation at risk.[56] “Humanitarian organizations are left hamstrung by politically motivated sanctions that now punish the poorest,” said NRC Secretary-General Jan Egeland, in a statement. Because no Norwegian banks have a direct relationship with banks in Iran, not only do they need to agree to authorize the transfer but they also need to find intermediary banks that are able and willing to transfer the funds to an Iranian bank. “We have now, for a full year, tried to find banks that are able and willing to transfer money from donors to support our work for Afghan refugees and disaster victims in Iran, but we are hitting brick walls on every side,” Egeland said.[57]

On September 19, 2019, Egeland told a group of humanitarian experts in a conference in Washington DC that, “We [NRC] have spent hundreds of thousands of Euros extra on legal studies and advice to make it clear to banks that is perfectly alright to transfer money [to Iran] and still no banks risk transferring because they are so afraid of US sanctions.”[58]

Human Rights Watch identified two main routes that Iranian companies have been using to import medical and other humanitarian goods. As the US expands sanctions, companies are finding it increasingly difficult to utilize either of these avenues to finance the import of critical medicines and medical equipment. 

One route involves the limited number of banks based in or with branches in the countries that, until May 2019, had received waivers to continue purchasing Iran’s oil, particularly in South Korea, China, India, and Turkey. These banks held Iran’s oil revenues in escrow accounts to authorize financing imports of goods the Iranian government deemed essential. People who work in the pharmaceutical industry in Iran expressed fear that even these accounts will soon cease to operate. Even prior to the US decision in May 2019 to end most waivers, Human Rights Watch documented two instances where banks in these countries refused to authorize transactions for raw materials imports for pharmaceutical use.[59]

In another case, an employee at a leading international distributor of specialty chemicals told Human Rights Watch that in July 2018, a European company cancelled a contract for selling medical lactose to Iran because of “pressure” from European banks refusing to process the transactions.[60] “After we were not able to supply the Iranian companies with medical lactose, they had to purchase it from other countries at a lower quality,” this person added. Similarly, in March 2019, a bank located in one of the countries that have received exemptions to buy Iranian oil told clients in an email that “raw materials which are used for production of medicine, are not a medicine,” citing US OFAC guidance. “Therefore, we can consider mediating such goods only if they are of [our country’s] origin,” the email added.[61] This is contrary to OFAC guidance, which allows for the transfer of raw materials for humanitarian purposes regardless of country of origin.

On October 14, Amirhossein Moeeni Zand, the deputy head of Iran’s Drug Importer Association, told Shargh Daily  newspaper that “a few days after the most recent sanctions on the Central Bank, South Korean banks have stopped their relations with Iranians, and South Korean companies are one by one letting their Iranian counterparts know that because banks do not allow them to conduct financial transactions with Iran, they cannot sell their medicine to Iran.”[62] “Companies want to continue their collaboration, but financial restrictions in their country is preventing them,” Moeeni Zand added. On October 15, Gholamhossein Mehralian, the head of the drug and substance office at Iran’s Food and Drug Administration, told Fars News Agency that they can confirm that South Korea has stopped sales of drug and raw material to Iran.[63]

Iranian pharmaceutical industry workers told Human Rights Watch that the other route to finance the purchase of medical imports is the informal system of money brokers known as hawala, but this option adds transaction costs and involves significant delays that many businesses cannot afford.[64] Also, due to the Iranian government’s quality control and monetary policies, this route is not easily available for importing medicine.[65]

When transactions include a US entity with an OFAC license, use of the hawala system seems almost unavoidable because most US banks will not authorize any transactions with Iran, even humanitarian ones.[66] One person who worked for a US-based relief organization with an OFAC license explained that money raised for disaster relief after devastating floods in Iran in March 2019 had to be transferred through the hawala system via Canada.[67]

Iranian pharmaceutical and other health sector companies have the option of establishing an office outside Iran to access letters of credit from a limited number of banks outside Iran, but this adds costs that increase the price of medications.[68] Two people who worked on importing medicine to Iran said that the additional costs make this route is prohibitive for them.[69]

IV. Current Access to Medicines in Iran

Overview  

The Iranian Central Bank’s list of entities that receive a subsidized currency exchange rate shows that during the period between April 2018, when the government announced its new exchange rate policy, and April 2019, the government allocated over US$3 billion in foreign currencies to pharmaceutical and medical entities.[70] Most of this amount (US$1.7 billion) has been distributed in euros, while the other currencies that constitute a notable portion of the funds are Chinese yuan (US$560 million), Indian rupee (US$530 million) and Turkish lira (US$243 million).
 

currency

num_of_transactions

total_amount_per_currency

Amount in USD

Iraqi dinar

2

2122552053

1780014.60

Russian ruble

24

554982317.10

8291435.82

Indian rupee

205

36904627593

515834432.20

Omani rial

1

3444901.43

8947793.86

Swiss franc

3

9965406.83

10163180.29

Danish krone

1

835358.36

124293.39

Turkish lira

182

1403108246

247318875

South Korean won

101

81641374456

67416997.78

Japanese yen

26

719168349

6753709.97

Chinese yuan

523

3856109121

547517211.50

euro

747

1611764667

1788647780

Total

   

3202795725

One Iranian importer of medicine and a former employee of one of the biggest pharmaceutical importers in Iran told Human Rights Watch that while Iranian pharmaceutical companies used to purchase a majority of medicine for rare diseases from European companies and still try to do so, the increased caution of those European banks due to new sanctions, together with price increases, have pushed the Iranian companies to seek alternatives sourcing for raw material from Chinese and Indian companies, where material is cheaper and financing might be easier. Pharmaceutical experts who spoke to Human Rights Watch expressed concerns that this change in sourcing of raw material could affect the quality of medicine available in Iran for rare diseases.

According to Eurostat, the entity that publishes EU official economic and trade statistics, in 2018 EU countries exported to Iran about US$807 million worth of medicine and US$150 million worth of medical supplies.[71] This represents a decrease of US$40 million each for medicine and medical equipment in 2018, compared to 2016 and 2017, when JCPOA sanctions suspension was fully in force.

However, it is difficult to delineate a clear linkage between the time Iran distributes the currency and the time the trade is registered in the system. According to one expert, after receiving the currency, pharmaceutical companies have a period of six to nine months to import the medication.[72] Statistical analysis conducted by Esfandyar Batmanghelidj, founder of Bourse and Bazaar, a media company that supports business diplomacy between Iran and the EU, suggests that the cost of European medical exports to Iran is significantly higher than the cost of European exports to peer countries such as Pakistan, which is comparable in economic size but is not under unilateral sanctions.[73]

Impact on patients

Interviews with pharmaceutical experts and doctors in Iran indicate that while there is at present no acute nationwide lack of medications, patients with rare diseases that require imported medications for their treatment are facing increasing difficulty in accessing or completing their treatment.[74] A doctor and a researcher separately reported increasing difficulties in finding imported brands of eyedrops in the Iranian market, causing suffering for the large number of patients affected by chemical weapons during the Iran-Iraq war.[75] “Before the sanctions were imposed, companies were able to build up inventories, but the situation cannot continue for much longer,” said one pharmaceutical importer.[76] “If nothing changes in a year, Iranian patients will have significant challenges in accessing their most-needed treatments,” a doctor added.[77]

Quite apart from the limited ability to import medicines, there is the issue of affordability. The International Monetary Fund estimated that the inflation rate in Iran was 31 percent in 2018 and predicted that it could reach 37 percent in 2019 if oil revenues continue to plummet.[78] The plunging value of the rial has affected the affordability of locally-produced as well as imported goods. According to the Statistical Center of Iran, the cost of health care for families rose by 18.8 percent over the past 12 months across the country.[79] 

A Tehran-based doctor told Human Rights Watch that “basic medication is still available in the market, but foreign-produced vitamins and supplements have been omitted from the list of [government] insurance-subsidized medications. This can particularly affect patients with special diseases such as multiple sclerosis and cancer, who need medical supplements in their treatment plans.”[80]

A nurse who works at a government hospital in Tehran told Human Rights Watch that there are shortages, but so far, they have been temporary. “Recently we couldn’t find potassium, then medicine for nuclear scanning, and after that injections for Magnetic Resonance Imaging (MRI) scans,” she said, noting that “the latter two are imported.”[81]

Some patients have reported that the lower quality of imported raw materials or domestic alternatives may be causing serious side effects. In May 2018, Ehsan Bodaghi, a journalist with Iran Newspaper, the government’s official news outlet, tweeted that his wife had experienced severe complications after a Caesarean section and was told by a family member who is a doctor that “the complications were likely caused by non-standard anesthesia being used because of sanctions and a lack of adequate medication.”[82] Human Rights Watch has no way of determining how widespread such cases are.
 

Patients with Epidermolysis Bullosa (EB)  

Human Rights Watch documented a case in which a European company refused to sell Iran medication required for patients who suffer from epidermolysis bullosa (EB), a rare genetic condition that results in blistering of the skin and mucous membranes, and which afflicts more than 800 persons in Iran. Through an NGO called EB Home, the Iranian government provided these patients with dressings for blisters free of charge. After the re-imposition of sanctions, the company stopped selling to Iran a special kind of foam dressing that reduces and protects the blisters. In March 2019, the company wrote to the director of EB home that due to the US economic sanctions, it had “decided not to conduct any business with relation to Iran for the time being. This also applies to business conducted under any form of exemptions to the US economic sanctions.”[83] A lawyer who represents EB Home told Human Rights Watch that domestic alternatives for the dressing “often gets attached to the blisters, causing additional excruciating pain for the patients.”[84]
 

Cancer Patients

In November 2018, researchers affiliated with MAHAK Pediatric Cancer Treatment & Research Center, an NGO that treats children with cancer, published a list of drugs needed to treat leukemia.[85] Documents reviewed by Human Rights Watch showed that in May 2019, the NGO lacked pegaspargase, mercaptopurine, and vinblastine, three chemotherapy medications, all of which are on the WHO list of essential medicines.[86]

On July 30, Arasb Ahamdian, the head of MAHAK’s hospital told Euro News Persian service: “When it comes to cancer, the significant portion of medicine that children under our care use  fall under the 5 percent imported category that are very expensive and difficult to find.”[87] Several foreign media outlets have reported about patients, particularly children with cancer, suffering from lack of access to vital medications.[88]

“The ones who impose sanctions say that sanctions haven’t targeted medical and humanitarian issues in Iran,” Ahamdian said. “Its impact is visible in the lives of children with cancer.”

Epileptic Patients

On January 5, 2019, the official Islamic Republic of Iran News Network quoted Nesbi Tehrani, executive director of Iran’s Epilepsy Society, as saying that epilepsy patients face a shortage of medication as a result of sanctions.[89] “Some epilepsy patients are resistant to treatment and have to consume new foreign-made medicine that does not have a domestic alternative, but sanctions have caused a shortage in their medication,” he said. According to a study conducted by Iranian researchers on 242 epilepsy patients in Iran, 72 percent of patients who used imported anti-epilepsy drugs reported significant difficulty in accessing their medication during the period between August 2018 and February 2019. In comparison, 30 percent of patients who used domestically produced medicine reported significant difficulty in accessing their essential medication during the same period.[90]
 

Universal Health Coverage

As of 2015, around 90 percent of Iranian citizens were covered by some form of basic health insurance. Iran’s health insurance system offers subsidized medications for most diseases while covering most costs of treatment for patients with rare diseases.[91] In 2014, the Rouhani administration started implementing the Health Transformation Plan (HTP), aiming to achieve universal health coverage and reduce out of pocket expenditure.[92] Several Iranian experts and government officials have warned about the increased financial burden on Iran’s medical sector and dissatisfaction among the medical community as a result. Among doctors who spoke to Human Rights Watch, fears are growing that the decrease in government revenues as a result of sanctions will erode coverage. “One of the public hospitals located in the north of Tehran is already making patients buy necessary materials such as bandages and masks themselves from pharmacies outside the hospital,” a doctor told Human Rights Watch. “According to the hospitals’ regulations, the hospital should provide all the materials for the treatment.”[93]

Three people who work in the Iranian pharmaceutical industry, as well as a doctor who heads a private hospital in Tehran, told Human Rights Watch that since the re-imposition of sanctions, the list of medications that are covered by insurance has shrunk. In June, the Young Journalist Club news agency published a list of 79 medications that the Iran Food and Drug Administration recently labeled as “over the counter” and therefore no longer covered by insurance.[94]

Iran’s draft budget for the current Persian calendar year (March 2019 to March 2020) proposes a 12.6 percent increase in government’s expenditures over the previous year, with an 11 percent increase for health insurance and a 13 percent increase for public hospitals’ medical and research costs, all significantly lower than the projected inflation rate of 37 percent. Under the proposed draft, the health budget constitutes 19.6 percent of projected expenditures, compared with 23.6 percent in the previous year’s budget.[95]

Iranians’ access to medical equipment appears to be more restricted as a result of this severe currency depreciation and the government’s refusal to allow the use of the subsidized dollar rate for some of these purchases, a doctor who owns a private hospital told Human Rights Watch. These two factors have made it nearly impossible for health facilities to import up-to-date medical equipment. A hospital patient’s family member described to Human Rights Watch how the lack of a well-equipped intensive care unit in a hospital in western Iran in February 2019 had resulted in significant delays in admitting the patient to the medical care unit and contributed to the death of their relative.[96] A nurse who used to work a different hospital in western Iran told Human Rights Watch that after the re-imposition of sanctions, hospitals in her hometown were extending the expiration dates for serum kits, inhalator filters, and other medical equipment beyond what was allowed previously.[97] Another nurse who works at a hospital in Tehran said, “The situation for medical equipment is worse than medicine. My own colleague was not able to find a connecter he needed for a heart surgery.”

V. International Legal Obligations

Economic Sanctions and the Right to Health

The International Covenant on Economic, Social and Cultural Rights (ICESCR) – ratified by Iran and signed by the United States – obliges states to respect, protect, and fulfill the right to “the enjoyment of the highest attainable standard of physical and mental health,” as well as the right to an adequate “standard of living” that includes “adequate food.”[98] Parties to the convention are obliged to work toward the progressive realization of these rights over time “by all appropriate means” and “to the maximum of its available resources.”[99]

In 2013, the UN Special Rapporteur on the highest attainable standard of physical and mental health noted that, “[w]hile several aspects of the right to health are understood to be progressively realizable, certain core obligations cast immediate obligations on States, including the provision of essential medicines to all persons in a non-discriminatory manner.”[100] These essential medicines, defined by the World Health Organization, include painkillers, anti-infectives, anti-bacterials, anti-tuberculars, anti-retrovirals, blood products, cardiovascular medicines, vaccines, and vitamins.[101]

A country or coalition imposing economic sanctions needs to take into account the impact on the human rights of the affected population, including the right to health. Commenting on economic sanctions, the UN Committee on Economic, Social and Cultural Rights (CESCR), the authoritative body of independent experts that interprets the obligations of states parties to the convention, stated that “these rights must be taken fully into account when designing sanctions,” and that “the inhabitants of a given country do not forfeit their basic economic, social, and cultural rights by virtue of any determination that their leaders have violated norms relating to international peace and security.”[102]

In General Comment Number 14 about the right to health, the CESCR observed 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,” adding that “[r]estrictions on such goods should never be used as an instrument of political and economic pressure.”[103] Countries therefore have an obligation to ensure that any sanctions they impose do not violate Iranians’ right to health, including access to essential medication.

“When an external party takes upon itself even partial responsibility for the situation within a country,” the CESCR stated in its comment on economic sanctions, “it also unavoidably assumes a responsibility to do all within its powers to protect the economic, social and cultural rights of the affected population.”[104] The CESCR further stated that “the provisions of the Covenant… cannot be considered to be inoperative, or in any way inapplicable, solely because a decision has been taken that considerations of international peace and security warrant the imposition of sanctions.”[105]

In Comment Number 8, the CESCR noted the need for effective monitoring throughout the period that sanctions are in force. The imposing state or states have an obligation "to take steps, individually and through international assistance and cooperation, especially economic and technical" to respond to any “disproportionate suffering experienced by vulnerable groups within the targeted country.”[106]

Under the Maastricht Principles on Extraterritorial Obligations of States in the Area of Economic, Social and Cultural Rights, which constitute international expert opinion on this matter, “States must refrain from adopting measures, such as embargoes or other economic sanctions, which would result in nullifying or impairing the enjoyment of economic, social and cultural rights.”[107] Even “where sanctions are undertaken to fulfill other international legal obligations, States must ensure that human rights obligations are fully respected in the design, implementation and termination of any sanctions regime.”

The state that is the target of economic sanctions, in this case Iran, also has obligations as a party to the ICESCR, obligations that “assume greater practical importance in times of particular hardship.” Specifically, Iran remains obligated to take steps “to the maximum of its available resources” to “provide the greatest possible protection” of the right to health of individuals within its jurisdiction. “While sanctions will inevitably diminish the capacity of the affected State to fund or support some of the necessary measures, the State remains under an obligation to ensure the absence of discrimination in relation to the enjoyment of these rights ….”[108]

Acknowledgments

This report was researched and written by Tara Sepehri Far, Iran researcher at Human Rights Watch. Joe Stork and Michael Page, deputy directors in the Middle East and North Africa Division, Arvind Ganesan, director of the Business and Human Rights Division, Andrea Prasow, acting Washington director, Louis Charbonneau, United Nations Director, and Claudio Francavilla, European Union Officer, reviewed the report. Clive Baldwin, senior legal advisor, provided legal review. Tom Porteous, deputy Program director, provided program review. An associate in the Middle East and North Africa Division provided editorial and production assistance. The report was prepared for publication by Fitzroy Hopkins, production manager.

Professor Joe Amon, clinical professor at Drexel University Dornsife School of Public Health, also reviewed the report and provided expert opinion on potential health impacts. Beau Barnes of the law firm Kobre & Kim LLP reviewed the report's discussion of U.S. sanctions law and provided legal and practical suggestions.

We would like to thank all of the individuals and organizations that supported research and analysis for the report. We also wish to express our gratitude to all of those who spoke with us during this research.

 

 

[1] Unless otherwise noted, for details in this and following paragraphs see Congressional Research Service, “Iran Sanctions” [updated April 22, 2019] https://fas.org/sgp/crs/mideast/RS20871.pdf (accessed July 3, 2019). Another useful resource is International Crisis Group, “Spider Web: The Making and Unmaking of Iran Sanctions,” February 25, 2013, https://www.crisisgroup.org/middle-east-north-africa/gulf-and-arabian-pe... (accessed July 2, 2019).

[2] It became the Iran Sanctions Act after Libya was dropped in 2006.

[3] In November 2008, “the Department of the Treasury broadened restrictions on Iran’s access to the US financial system by barring US banks from handling any transactions with foreign banks” that are “on behalf of an Iranian bank.” (CRS p. 30)

[4] CRS p. 47.

[5] See Specific Guidance on the Iran Sanctions, US Department of Treasury Resource Center, https://www.treasury.gov/resource-center/sanctions/programs/pages/iran.aspx.

[6] Guidance on the Sale of Food, Agricultural Commodities, Medicine, and Medical Devices by Non-U.S. Persons to Iran, Department of Treasury, July 25, 2015, https://www.treasury.gov/resource-center/sanctions/Programs/Documents/ir....

[7] UNSC Resolution 2231 (2015), https://undocs.org/S/RES/2231(2015).

[8] CRS p. 64.

[9] President Donald J. Trump is Ending United States Participation in an Unacceptable Iran Deal, White House, May 8, 2019, https://www.whitehouse.gov/briefings-statements/president-donald-j-trump... (accessed August 11, 2019).

[10] Executive Order 13846 of August 6, 2018 Reimposing Certain Sanctions with Respect to Iran, Federal Register Vol. 83, No. 152, August 7, 2018, https://www.treasury.gov/resource-center/sanctions/Programs/Documents/08...

[11] Alleged Violations of 1955 Treaty of Amenity, Economic Relations, and Consular Rights (Islamic Republic of Iran V. United States), Press Release, International Court of Justice, October 3, 2018, https://www.icj-cij.org/files/case-related/175/175-20181003-PRE-01-00-EN...

[12] Alleged Violations of 1955 Treaty of Amenity, Economic Relations, and Consular Rights (Islamic Republic of Iran V. United States), Order, October 3,2018, Conclusions and Measures to be Adopted, pp. 26-28. https://www.icj-cij.org/files/case-related/175/175-20181003-ORD-01-00-EN...

[13] Ibid.

[14] US Withdraws from 1955 Treaty Normalizing Relations with Iran, The New York Times, October 3, 2018, https://www.nytimes.com/2018/10/03/world/middleeast/us-withdraws-treaty-....

[15] Press Briefing with Brian Hook, U.S. Special Representative for Iran, and Victoria Coates, Senior Director for Middle Eastern Affairs, NSC, May 8, 2019. https://www.state.gov/press-briefing-with-brian-hook-u-s-special-represe....

[16] Treasury Sanctions Vast Financial Network Supporting Iranian Paramilitary Force That Recruits and Trains Child Soldiers, Press Release, US Department of Treasury, October 16, 2018, https://home.treasury.gov/news/press-releases/sm524. Specially Designated Global Terrorists (SDGTs) are entities designated under Executive Order 13224 (signed by President George W. Bush on 9/23/2001) and are a subset of SDNs (Specially Designated Nationals). OFAC takes the position that even humanitarian transactions are sanctionable if they “involve persons on the SDN List that have been designated in connection with Iran’s support for international terrorism or proliferation of weapons of mass destruction,”  see FAQ #637, persons designated as SDNs under EO 13224, Treasury Resource Center. https://www.treasury.gov/resource-center/faqs/Sanctions/Pages/faq_iran.a....

[17] Jonathan Saul, Parisa Hafezi, Exclusive: Global traders halt new Iran food deals as U.S. sanctions bite, Reuters, December 21, 2018, https://www.reuters.com/article/us-iran-nuclear-food-exclusive/exclusive....

[18] Statement from the President on the Designation of the Islamic Revolutionary Guard Corps as a Foreign Terrorist Organization, Press Release, April 8, 2019, https://www.whitehouse.gov/briefings-statements/statement-president-desi..., Designation of the Islamic Revolutionary Guard Corps, Office of the Spokesperson, Department of State, https://www.state.gov/designation-of-the-islamic-revolutionary-guard-corps/, April 8, 2019, https://www.state.gov/designation-of-the-islamic-revolutionary-guard-corps/.

[19] Foreign Terrorist Organization (FTO), Congressional Research Service, January 15, 2019. https://fas.org/sgp/crs/terror/IF10613.pdf.

[20] Edward Wong and Eric Schmitt, Trump Designates Iran’s Revolutionary Guards a Foreign Terrorist Group, The New York Times, April 8, 2019, https://www.nytimes.com/2019/04/08/world/middleeast/trump-iran-revolutio....

[21] Anahita Shams & Reality Check team, “Iran sanctions: What impact are they having on medicines?” BBC News, August 8, 2019, https://www.bbc.com/news/world-middle-east-49051782 (accessed September 27, 2019).

[22] Humeyra Pamuk, Jonathan Landay, Trump slaps new U.S. sanctions on Iran's metals industry, Reuters, https://www.reuters.com/article/us-usa-iran-sanctions/trump-slaps-new-us..., May 8, 2019.

[23] Human Rights Watch Interviews with 2 importers of medicine and a doctor who is the head of a medical hospital in Tehran May 2019.

[24] China continued Iran oil imports in July in teeth of U.S. sanctions, Reuters, August 9, 2019, https://www.reuters.com/article/us-china-iran-oil/china-continued-iran-o... (accessed August 11, 2019).

[25] U.S. Punishes Chinese Company Over Iranian Oil, New York Times, July 22, 2019, https://www.nytimes.com/2019/07/22/world/asia/sanctions-china-iran-oil.html (accessed August 11,2019).

[26] Special Briefing with Special Representative for Iran and Senior Advisor to the Secretary Brian Hook, September 4, 2019, https://www.state.gov/special-representative-for-iran-and-senior-advisor....

[27] “Treasury Sanctions Iran’s Central Bank and National Development Fund,” US Treasury press release, September 20, 2019, https://home.treasury.gov/news/press-releases/sm780, (accessed September 25, 2019).

[28] Brian O’Toole, “Iran central bank designation – what does it mean?” Atlantic Council, September 20, 2019 https://atlanticcouncil.org/blogs/new-atlanticist/iranian-central-bank-d..., (accessed September 25, 2019).

[29] Office of Foreign Assets Control Biennial Report of   Licensing Activities Pursuant to the Trade Sanction Reform and Export Enhancement Act of 2000, Department of Treasury, August 19, 2019, https://www.treasury.gov/resource-center/sanctions/Programs/Documents/8b... (accessed October 7, 2019).

[30] Agencies Assess Impacts on Targets, and Studies Suggest Several Factors Contribute to Sanctions’ Effectiveness, Report to Congressional Requesters, United States Government Accountability Office, October 2, 2019, https://www.gao.gov/assets/710/701891.pdf, (accessed October 10, 2019).

[31] “97% of Medicine Needed in the Country is Produced Domestically/ We Don’t Have Import of Radioactive Medicine,” Young Journalists Club, November 20, 2018 https://www.yjc.ir/00SGFz (accessed August 9, 2019).

[32] Import of Raw Material for Medicine Reduced to 33 Percent, Iranian Student News Agency (ISNA), November 7, 2018, https://www.isna.ir/news/97081607749/ (accessed August 9, 2019).

[33] For the WHO Model List of Essential Medicines see: World Health Organization, Model List of Essential Medicine, 21st list, 2019, https://apps.who.int/iris/bitstream/handle/10665/325771/WHO-MVP-EMP-IAU-... (accessed August, 9,2019).

[34] “ We Have about 1000 Producers of Medical Equipment in the Country,” National Medical Device Directorate, June 23, 2o19, http://www.imed.ir/Default.aspx?PageName=News&ID=2961&Language=1&title=%..., (accessed August 11, 2019).

[35] “The Rate of Dollar is set at 42,00 rial,” Islamic Republic News Agency, April 9,2018, https://www.irinn.ir/fa/news/581610/ (accessed August 15, 2019). The non-subsidized rate was 116,000 rialsto the dollar.

[36] The List of Goods Subjected to Subsidized Currency, Fars News Agency, June 20, 201548, https://www.farsnews.com/news/13970330001041/.

[37] “Announcing the Final List of Protected Goods in the Health Category,” Iranian Students News Agency (ISNA), August 6, 2018, https://www.isna.ir/news/97051508083/اعلام-لیست-نهایی-کالاهای-گروه-اول-سلامت-به-وزارت-صنعت-فردا (accessed October 18, 2019).

[38] “The List of Goods that Received 42000 rial Currency,” Eghtesad Online, August 7, 2018, https://www.eghtesadonline.com/بخش-بازرگانی-6/291193-فهرست-کالاهای-مشمول-ارز-تومانی-منتشر-شد-کالا-ارز-دولتی-می-گیرند  (accessed October 18, 2019).

[39] Table of goods that received the subsidized currency, Tasnim News, https://newsmedia.tasnimnews.com/Tasnim/Uploaded/Document/1397/06/12/139... (accessed October 18, 2019).

[40] “Only the Necessary Medical Equipment Will Receive the Subsidized Rate,” Eghtesad Online, August 12, 2019, https://www.eghtesadonline.com/بخش-طلا-ارز-7/292178-فقط-تجهیزات-پزشکی-ضروری-ارز-تومانی-می-گیرند (accessed October 18, 2019).

[41] “Why Dental Equipment Didn’t Receive Subsidized Currency?, “Islamic Consultative Assembly News Agency, August 27, 2018,https://www.icana.ir/Fa/News/400475/چرا-برای-واردات-تجهیزات-دندانپزشکی-ارز-دولتی-تعلق-نگرفت؟-شاید-این-تجهیزات-هم-در-آینده-ارز-دولتی-بگیرند (accessed October 18, 2019).

[42] Human Rights Watch phone interview with a doctor who is head of a private hospital, May 2019.

[43] As of August 13, 2019, the US Dollar was traded for 116,000 rials in the free market. The rate had increased to 180,000 in the early months of 2019.

[44] Iran switches from dollar to euro for official reporting currency, Reuters, April 18, 2018, https://www.reuters.com/article/us-iran-currency-euro/iran-switches-from... (accessed October 18, 2019).

[45] Lawmaker Says Sanction-Busting Corruption Is Part of Iran's Economic Structure, Radio Farda, May 11, 2019, https://en.radiofarda.com/a/lawmaker-says-sanction-busting-corruption-is... (accessed August 11,2019).

[46] Mohammad Mosaed, 3 Billion Euros for Two Famous Families, Shargh Daily Paper, May 7, 2019, http://www.sharghdaily.ir/fa/Main/Detail/220301 (accessed August 11, 2019).

[47] Golnar Motevalli, Iran Court Tries 13 in $7 Billion Petrochemical Fraud Case: Mehr, Bloomberg News, March 5,2019, https://www.bloomberg.com/news/articles/2019-03-09/iran-court-tries-13-i... (accessed August 13, 2019).

[48] For a good overview of humanitarian financing issues under sanctions, see Tayler Cullis and Amir Handjani, “The Anatomy of Humanitarian Trade with Iran,” Lawfare Blog, https://www.lawfareblog.com/anatomy-humanitarian-trade-iran (accessed July 25, 2019).

[49] Siamak Namazi, Sanctions and Medical Shortage in Iran, Woodrow Wilson Center, February 2013, https://www.wilsoncenter.org/sites/default/files/sanctions_medical_suppl...

[50] For a more comprehensive overview of the impact sanctions on health during prior to the 2015 nuclear agreement  see Setayesh and Mackey, “Addressing the Impact of Economic Sanctions on Iranian Drug Shortages in the Joint Comprehensive Plan of Action: Promoting Access to Medicines and Health Diplomacy.”, Globalization and Health (volume 12), Article number: 31 (2016), https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992..., (accessed August 22, 2019). Shahabi, et al. The impact of international economic sanctions on Iranian cancer healthcare, Health Policy, Volume 119, Issue 10, October 2015, Pages 1309-1318, https://doi.org/10.1016/j.healthpol.2015.08.012 (accessed August 22, 2019).

[51]A UK-based business analyst November 2018, Nina (pseudonym), a UK-based sanctions lawyer, June 2019, Sayeh (pseudonym), employee of a Lebanese food and medical raw material company in Tehran May 2019.

[52] Human Rights Watch phone interview with Nina (pseudonym), a UK-based sanction lawyer, June 2019.

[54] Javad Zarif, November 12, 2018, https://twitter.com/JZarif/status/1062066259154685952 (accessed October 18, 2019).

[56] Future of aid work at risk in Iran due to U.S. sanctions, NRC, August 5, 2019, https://www.nrc.no/news/2019/august2/aid-work-in-iran-at-risk-due-to-u.s.... There are an estimated 3 million Afghan refugees in Iran.

[57] Ibid.

[58] Jan Egeland, Secretary General, Norwegian Refugee Council, Future of Humanitarian Aid, Center for Strategic and International Studies, September 19, 2019. https://youtu.be/Mf5O8XTP7Nw.

[59] An Iranian employee of a foreign company subsidiary said that her company could not find a European bank to authorize the import of medical grade lactose used in making tablets. Human Rights Watch also reviewed an email from a foreign bank refusing to authorize transactions for raw material for pharmaceutical products from another country.

[60] Human Rights Watch interview with an employee of a French subsidiary based in Tehran, May 2019.

[61] Copy of email sent on May 1, 2019 available on file.

[62] “And Now Medical Sanctions by Koreans,” Shargh Daily, October 14, 2019, http://www.sharghdaily.ir/fa/Main/Detail/240970/%D9%88-%D8%AD%D8%A7%D9%8....

[63] South Korea Stopped Selling Drugs and Raw Material to Iran, Fars News Agency, October 15, 2019, https://www.farsnews.com/news/13980723000414/.

[64] Human Rights Watch interviews with an Iranian importer, April 2019, an employee of a Lebanese company specialized in distributing specialty chemicals April 2019, and an employee of the biggest pharmaceutical company in Iran that represents a US pharmaceutical company, May 2019.

[65] Importers are required to receive proper licensing from Iran’s Food and Drug Administration before importing medicine and have to use that permission to receive subsidized currency from domestic banks.

[66] The main problem is that the money first needs to be transferred out of the US by a US bank, and most US banks do not authorize such transactions when the destination is Iran.

[67] Human Rights Watch phone interview with a charity employer based in the US, May 2019.

[68] Tyler Cullis, Amir Handjani, The Anatomy of Humanitarian Trade with Iran, Lawfare, https://www.lawfareblog.com/anatomy-humanitarian-trade-iran, (accessed October 18, 2019).

[69] Human Rights Watch phone Interview with Mehrdad (pseudonym), a drug importer, May 2019. Interview with Maryam (pseudonym), a former employee of one of the biggest pharmaceutical companies in Iran, July 2019.

[70] Central Bank Statement, April 21, 2019, https://www.cbi.ir/showitem/19036.aspx.

[71] Data obtained from European Statistical Data Support in June 2019.

[72] Human Rights Watch phone interview with Maryam (pseudonym), former employee of one the biggest importer of medicine in Iran, July 2019.

[73] Esfandyar Batmanghelidj, “Why Iran Pays More for Each Kilogram of European Medicine”, Bourse & Bazar, October 3, 2019, https://www.bourseandbazaar.com/articles/2019/10/3/mysterious-price-dist...

[74] Human Rights Watch interview with Mehrdad (pseudonym), a drug importer, and Human Rights Watch interview with a member of emergency medicine board, April 2019; Human Rights Watch interview with a doctor who is head of a private hospital, May 2019.

[75] Correspondence with a researcher who worked with victims of Iran-Iraq war, April 2019. Interview with a doctor who owns a private hospital in Iran, May 2019.

[76] Human Rights Watch phone interview with Mehrad (pseudonym), a drug importer, April 2019.

[77] Human Rights Watch phone interview with a doctor who is the head a private hospital in Tehran, May 2019.

[78] Inflation rate, average consumer prices, World Economic Outlook, International Monetary Fund, https://www.imf.org/external/datamapper/PCPIPCH@WEO/OEMDC/ADVEC/WEOWORLD... (accessed October 19, 2019).

[79] Consumer Price Index in the Month of Farvardin of the Year 1398, https://www.amar.org.ir/Portals/1/1_Consumer%20Price%20Index%20in%20the%...

[81] Human Rights Watch interview with a nurse who worked at a public hospital in Tehran, June 2019.

[83] A letter sent by the company is available on file.

[84] Human Rights Watch interview with Hassan, a lawyer who represents the epidermolysis bullosa patients, April 2019.

[85] Mithra Ghalibafian, Shabnam Hemmati, Eric Bouffet, The silent victims of the US embargo against Iran, The Lancet, November 1, 2018, https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(18)30751-4/fulltext#%20 (accessed October 18, 2019).

[86] Copy of documents sent in April 2019, available on file.

[87] Impact of Sanctions on Cancer Patients in Iran, Euro News Persian Service and Associated Press, July 30,2019, https://fa.euronews.com/2019/07/30/iran-struggles-with-medicines-crisis (accessed August 12, 2019).

[88] Vital drugs for cancer patients in short supply in Iran because of U.S. sanctions, CBS news, August 19, 2019, https://www.youtube.com/watch?v=DxJMZTLf1xE.

[89] “Sanctions have Caused Shortage in Epilepsy Medication,” Islamic Republic News Agency, January 5, 2019, https://www.irinn.ir/fa/news/657223/ (accessed August 15, 2019).

[90] Ali A. Asadi-Pooya et al. Impacts of the international economic sanctions on Iranian patients with epilepsy, Epilepsy & Behavior, Volume 95, June 2019, Pages 166-168, https://www.epilepsybehavior.com/article/S1525-5050(19)30236-7/fulltext.

[91] Roshanak Ali Akbari Safa, Mohadese Safakish, “Benefiting from Health Service in the Country, 1393”, Statistics, Third Edition No.6, Pp 9-14, http://amar.srtc.ac.ir/article-۱-۱۵۲-fa.html (accessed August 15, 2019). For an overview of Iran’s health care system, especially in rural areas, see Kevan Harris, A Social Revolution: Politics and the Welfare State in Iran (University of California Press, 2017), Chapter 4. Despite making significant progress in expanding healthcare access, particularly for marginalized populations including refugees, the system suffers from mismanagement, inadequate funding, and a lack of accessibility for and discrimination against people with disabilities. See Human Rights Watch: https://www.hrw.org/report/2018/06/26/i-am-equally-human/discrimination-....

[92] Correspondent, “Rouhanicare.” Iranian president's unsung domestic success, The Guardian, September 4, 2017, https://www.theguardian.com/world/2017/sep/04/rouhanicare-iran-president... (accessed August 12, 2019).

[93] Human Rights Watch interview with a doctor who is the head of a private hospital in Tehran, May 2019.

[94] “Which Medicine was Excluded from Insurance?” Young Journalist Club, June 25, 2018, https://www.yjc.ir/fa/news/6576186/ (accessed August 12, 2o19.)

[95] Reza Moradi, Sanctions and Expansion of Poverty ; Reason for Reducing Unnecessary Expenditure, Tableau  Magazine, https://tableaumag.com/1397/11/تحریم%E2%80%8Cها-و-توسعه%E2%80%8C%E2%80%8Cی-فقر؛-دلیل-کاهش-ب/ ( Accessed October 18, 2019).

[96] Human Rights Watch interview with Masoud (pseudonym), an Iran analyst; his mother was hospitalized in in western Iran.

[97] Human Rights Watch interview with Setareh (pseudonym), a nurse who is now based in Turkey, June 26, 2019.

[98] Articles 11 and 12, International Covenant on Economic, Social and Cultural Rights (ICESCR), 1966.

[99] Article 2, International Covenant on Economic, Social and Cultural Rights, 1966.

[100] Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Anand Grover, on access to medicines, May 1, 2013, A/HRC/23/42, https://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Sessio....

[101]Ibid, para 40.

[103] See CESCR, General Comment No 14 (2000): Substantive Issues Arising in the Implementation of the International Convention on Economic Social and Cultural Rights, E/C.12/2000/4, para 41.

[104] CESCR, General Comment No. 8, para 13. 

[105] Ibid, para 7.

[106] See CESCR, General Comment No 8: The relationship between economic sanctions and respect for economic and social rights, 4 December 1997, E/C.12/1997/8; 5 IHRR 302 (1998), para 14.

[107] Maastricht Principles on Extraterritorial Obligations of States in the Area of Economic, Social and Cultural Rights (2011), Para 22., https://www.etoconsortium.org/en/main-navigation/library/maastricht-prin....

[108] See CESCR, General Comment No 8: The relationship between economic sanctions and respect for economic and social rights, 4 December 1997, E/C.12/1997/8; 5 IHRR 302 (1998), para 10.

Posted: January 1, 1970, 12:00 am