'Maximum Pressure' Sanctions Threaten Patients' Right to Health

Economic sanctions are commercial and financial penalties used by countries to restrict trade or transactions with specific entities of foreign nations. They can vary widely, from targeting specific individuals or institutions to targeting entire sectors of a nation’s economy. Governments often impose economic sanctions as a foreign policy tool to alter the behavior of states that threaten their interests, violate human rights, or are deemed to be a security threat. The United States has imposed more economic sanctions on other nations than any other country in the world, presently targeting Cuba, Iran, Sudan, North Korea, Syria, and Venezuela.

Economic Sanctions Hurt Ordinary People - Not Just Governments

A growing body of research shows that economic sanctions can have dire consequences for ordinary people, contributing to an increase in preventable disease and deaths. Although broad economic sanctions are typically presented as targeting governments, they often undermine a nation’s entire economy, and ordinary citizens pay the greatest price. Economic sanctions restrict the targeted nation’s ability to trade or access international markets, which causes a dramatic reduction in the nation’s income, thereby leaving public and private sectors with less capital to finance basic necessities. With a contracting economy, citizens face increased unemployment and decreased purchasing power, subsequently limiting their ability to buy essential foods and medicines.

To mitigate their impact on ordinary civilians, sanctions often include exemptions to allow for the trade of humanitarian necessities, such as life-saving medicines and medical equipment. However, these exemptions have proven to be ineffective in many countries due to the global dominance of the U.S. financial system and the threat of secondary sanctions. Because international banks and corporations are often tied to the U.S. financial system, U.S. sanctions often prevent other financial and commercial actors from trading with the targeted nation, even in the goods that are nominally exempted. Furthermore, international actors are discouraged from initiating trade with sanctioned countries due to the fear of having secondary sanctions placed on them by the U.S. The U.S.’s history of prosecuting companies that sell medical supplies to sanctioned countries only exacerbates this issue.

Patients Pay the Price - From Venezuela, to North Korea, to Iran

In Venezuela, broad economic sanctions that the Trump administration implemented in 2017 have inflicted serious harm to human life and health. They have exacerbated Venezuela’s economic crisis by causing the production of oil to fall by 60 percent, leading to a disruption in crucial social services. According to a report by the Center for Economic and Policy Research, these sanctions have contributed to reducing the Venezuelan public’s caloric intake, an estimated 40,000 deaths in 2017-2018, and the displacement of millions of Venezuelans.

Meanwhile, North Korea experienced sanction-related delays and funding shortfalls for specific UN humanitarian programs after U.S. economic sanctions were intensified in 2016. These delays affected programs that address severe acute malnutrition and vitamin A deficiency and are estimated to have led to nearly 4,000 deaths in 2018 alone, primarily in children under the age of five. A UN Panel of Experts expressed particular concern for an extensive list of humanitarian-sensitive items that are presently sanctioned in North Korea, including medical appliances such as an ultrasound, cardiograph, artificial respirator, X-ray machine, and orthopedic appliances for persons with disabilities.

In Iran, over two years of 'maximum pressure' sanctions have contributed to soaring unemployment, a plummeting currency, and immense inflation. The price of basic foods, such as bread and milk, have significantly increased in the wake of these sanctions. Due to both the threat of secondary sanctions limiting the import of specialized medicines and restrictions on raw materials needed to produce medical goods, access to medicine and medical supplies has sharply declined. In fact, U.S. pharmaceutical exports decreased from $26 million per year under Obama-era sanctions to only $8.6 million under the Trump administration. Doctors and patients have reported critical shortages of medications, ranging from antiepileptics to chemotherapies. A recent Human Rights Watch report has also underscored several cases in which crucial medicines listed on the humanitarian exemption list have been prevented from entering Iran due to sanctions. The International Court of Justice has ruled these humanitarian exemptions to be insufficient.

Economic Sanctions and Human Rights

Although economic sanctions are recognized by international law as a legal strategy to maintain international peace and security, current evidence shows that these recent 'maximum pressure’ sanctions have violated the human rights of citizens in multiple countries. Per General Comment Number 14 of the UN Committee on Economic, Social and Cultural Rights, "Parties should refrain at all times from imposing embargoes or similar measures restricting the supply of another state with adequate medicines and medical equipment, [and] . . . restrictions on such goods should never be used as an instrument of political and economic pressure." In reference to current U.S. unilateral sanctions on Cuba, Venezuela and Iran, the late UN special rapporteur Idriss Jazairy stated, "The resort by a major power of its dominant position in the international financial arena against its own allies to cause economic hardship to the economy of sovereign States is contrary to international law, and inevitably undermines the human rights of their citizens."

We entered medicine to treat patients, not to bear witness to their harm. At times, it may be challenging to tease out the extent to which patient harm inside sanctioned countries is caused by 'maximum pressure' sanctions versus other international and domestic factors at play. However, when sanctions fail to include reliable and accessible humanitarian channels that protect patients, they violate international law and threaten the core tenets of our profession - first, to do no harm. As physicians-in-training, we believe that opposing sanctions that infringe on patients’ right to health is our professional and moral obligation.

Laila Fozouni is a medical student at the University of California San Francisco, and a recent graduate of the Harvard School of Public Health. Parsa Erfani (@ErfaniParsa) is a medical student at Harvard Medical School.