Blog

When Innovation Meets Justice: How MediCapt is Transforming the Fight Against Sexual Violence in East and Central Africa 

As the 16 Days of Activism Against Gender-Based Violence unfolds around the world, conversations often center on the scale of the problem. We hear about alarming statistics, stories of harm, and the persistent barriers survivors face in their pursuit of justice, like how only 14 per cent of all women and girls worldwide (about 557 million) live in countries with robust legal protections guaranteeing women’s fundamental human rights. 

But in a meeting room in the heart of Nairobi this November, the focus shifted from what is broken to what is beginning to work. Not only the problems, but the solutions.  

As the 16 Days of Activism Against Gender-Based Violence reminds the world that violence thrives in silence, the work of PHR and its partners in Kenya and the DRC tells another story: one where innovation, collaboration, and courage are rewriting what is possible. 

On November 19th and 20th, Physicians for Human Rights (PHR) convened a roundtable on scaling MediCapt and strengthening forensic evidence documentation, bringing together innovators from Kenya and the Democratic Republic of Congo (DRC). MediCapt is a secure digital application that enables clinicians to document medical evidence of sexual violence, capture forensic photographs, and store information safely in the cloud. It replaces unreliable paper systems with structured, standardized, and secure digital documentation, preserving the chain of custody and improving the quality of evidence presented in court. PHR developed MediCapt in response to the very challenges that participants at the roundtable know all too well: lost or damaged files, insecure storage, inconsistent documentation, overworked staff, and broken links between the health, police, and justice sectors.  

Among the participants of this forum sat clinicians, heads of medical facilities, law enforcement officers, magistrates, government officials and digital health specialists, all of whom play a role in the documentation and prosecution of sexual and gender-based violence cases. Many in the room had never met before. But they shared one common reality: too often, people who survive sexual violence have their court cases collapse not because justice is impossible, but because critical evidence is missing, incomplete, or lost. 

One participant from a medical facility in Nakuru, Kenya shared that in a recent sexual violence case, the physical PRC (Post Rape Care) form, a crucial piece of medical evidence, had gone missing. Without the PRC form, there is simply nothing to corroborate the findings of the medical examination, effectively stripping the case of its evidentiary backbone, even when a survivor was ready to pursue justice. Instead, because the data collected with MediCapt was safely preserved in the cloud, the clinician simply reprinted the MediCapt-generated digital PRC form. The court accepted it. Justice did not stall. The court proceedings were able to proceed because critical medical evidence was preserved. Other clinicians shared similar stories. These accounts have enormous implications: in a system where paper is fragile and accountability depends on precision, a digital record protected a survivor’s chance at justice. 

MediCapt is also proving effective and adaptable in vastly different contexts; from the dense informal settlements of Mukuru in Nairobi to the fast-growing metropolitan landscape of Naivasha and at varying levels of health facilities. Despite differences in infrastructure, security, and population dynamics, MediCapt continues to respond to the realities on the ground. Participants also shared excitement about its next frontier: expansion to enable wider reach in Kenya and DRC, and potentially into new geographies such as Tanzania and Iraq. It is this flexibility, the ability to function across crisis and conflict, urban, and peri-urban spaces, that has positioned MediCapt as not just a regional solution, but potentially a global one. 

In her address, PHR’s Director of Programs, Karen Naimer, JD, LLM, reminded participants that technology alone cannot deliver justice. 

Each of your roles, when taken together, collectively supports survivors’ access to justice through proper documentation. Clinicians, police officers, magistrates, technologists, policymakers; none of these roles stand alone. It is your collaboration that gives survivors a real chance at justice. And that work must continue long after this roundtable ends.” 

Her message underscored a simple but powerful truth: innovation is only as strong as the people who carry it forward. 

By the close of the roundtable, participants had co-created a set of practical, context-specific recommendations aimed at improving MediCapt’s functionality, strengthening integration into national systems, and ensuring its long-term sustainability. Just as importantly, they left with renewed commitment; not only to a tool, but to a shared vision of justice for survivors. 

As the 16 Days of Activism Against Gender-Based Violence reminds the world that violence thrives in silence, the work of PHR and its partners in Kenya and the DRC tells another story: one where innovation, collaboration, and courage are rewriting what is possible. 

One case. One clinic. One country. One survivor at a time. 

And through MediCapt, their stories are no longer lost. 

Blog

The Power of the Clinician-Survivor Connection in Ukraine 

How PHR’s survivor-centered trauma-informed approaches are empowering Ukrainian health workers to document torture and sexual violence.

As part of Russia’s full-scale invasion of Ukraine, evidence is mounting of widespread torture and sexual violence perpetrated against Ukrainians. Survivors often face compounded harm from stigma, limited accountability pathways, and the challenges of navigating domestic justice systems.  

Against this backdrop, Physicians for Human Rights (PHR) is sharing our specialized experience using survivor-centered, trauma-informed methods to strengthen documentation of torture and sexual and gender-based violence in Ukraine. Our model goes beyond technical skill building for individual clinicians. In contexts around the world, we work to strengthen sustainable approaches to survivor medical care and treatment, forensic documentation, and access to justice by taking a systems-wide approach. In doing so, we co-design and develop standardized forms to support forensic documentation of torture and sexual and gender-based violence that can be integrated into national response frameworks. Through decades of partnerships in places like the Democratic Republic of the Congo, Kenya, and Iraq we’ve foster multisector networks to enhance collaboration among medical, law enforcement, and legal professionals, and ensure the comprehensive and compelling evidence collected can be preserved and stand up in court as part of supporting survivors’ healing.  

PHR is sharing our specialized experience using survivor-centered, trauma-informed methods to strengthen documentation of torture and sexual and gender-based violence in Ukraine.

Through our collaborations with the medical community and advocacy for institutional policy reforms, PHR is helping health care workers to more intentionally center survivors in their medical practice, with empathy and dignity, so survivors can be more supported when seeking pathways to justice and accountability.   

Dr. Michele Heisler, PHR Medical Director
Karen Naimer, PHR Director of Programs
Uliana Poltavets, International Advocacy and Ukraine Program Coordinator

The Challenge of Documentation 

High quality medico-legal documentation is crucial to achieve justice, provide holistic care, and seek necessary redress for survivors. As the numbers of survivors of torture grow, there are deficits in experts trained in medico-legal documentation, and regulatory restrictions limit the pool of such experts. Additionally, the absence of a nationally mandated standardized form to document forensic evidence in cases of torture, including sexual violence, is another barrier to achieving justice for survivors.  

PHR’s Ukraine program is addressing these challenges at both the policy and practice levels. One major focus has been supporting domestic legal reforms regulating medical documentation of domestic and gender-based violence (Ministry of Health’s Order 278). The planned amendments – currently pending adoption by the Ministry of Health – would introduce a standardized medico-legal certificate based on principles of the Istanbul Protocol, International Protocol on Documentation and Investigation of Sexual Violence in Conflict, and other international guidelines. The amendments would also incorporate a survivor-centered, trauma-informed approach to medical care and forensic documentation and allow non-forensic clinicians to contribute to documentation after appropriate training. In pursuing these policy reforms, PHR collaborated closely with health and legal professionals, and survivor representatives to cultivate national ownership of these reforms. We also worked together to introduce new innovations, such as obtaining informed consent from survivors before undergoing a medical evaluation and including conflict-related sexual violence in the scope of documentation.  

Training participants
Training participants
Training participants
Training participants

Dialogue Puts New Clinical Practices in Motion 

To address the need for clinicians who are trained in medico-legal documentation according to the Istanbul Protocol and other renowned standards, PHR, together with the World Health Organization (WHO), convened more than 25 Ukrainian forensic and non-forensic clinicians for a training on medico-legal documentation of torture and sexual violence in Lviv, Ukraine in July 2025. It followed an introductory overview of medico-legal documentation of torture and sexual violence delivered in June at the UNBROKEN Mental Health Center in Lviv which brought together more than 150 clinicians who work with survivors of captivity, torture and CRSV. 

A cornerstone of the July training was the integrated survivor-clinician dialogue, which PHR organized jointly with the Denis Mukwege Foundation, where representatives from more than 10 survivor organizations shared their lived experience and the barriers they face in addressing justice. Clinicians, in turn, spoke to the systemic constraints of their work. This mutual exchange deepened trust, clarified gaps, and inspired pathways for collaboration.  

Some survivors shared that the forensic evaluations they had undergone at national health facilities were traumatic experiences because the evaluations were held in rooms that reminded them of the prisons in which they were detained. For example, survivors shared that the bars on the windows of the hospital examination rooms triggered significant anxiety. Upon hearing survivors share this experience, one forensic psychiatric expert took immediate action and issued an order mandating the removal of bars on windows in all their national health institutions across the country.  

Over a four-day training, clinicians practiced survivor-centered, trauma-informed interviewing, evidence documentation, and medico-legal reporting using the Istanbul Protocol guidelines and Ukrainian standardized tools. They engaged in case-based discussions and hands-on exercises while also exploring self-care strategies to mitigate vicarious trauma (the cumulative effects of exposure to information about traumatic events and experiences). Post-training assessment showed significant knowledge gains – particularly among forensic experts – and participants praised the opportunity to connect across sectors. Participants showed the strongest gains in ethical principles and interview techniques and understanding the purpose of medico-legal documentation. 

As Ukraine continues to face the devastating consequences of Russia’s invasion, these collaborations show that health professionals and survivors working together can bring justice, accountability, and healing closer. 

Webinar: The Ripple Effects of Abortion Bans Across Medical Specialties

Webinar: The Ripple Effects of Abortion Bans Across Medical Specialties

Moderated by Alice Miranda Ollstein, senior health care reporter for POLITICO. Panelists:

  • Nicole Freehill, MD, MPH, Ob/Gyn in New Orleans, Louisiana
  • Katie Hauschildt, PhD, Assistant Professor in the Division of Pulmonary, Allergy, and Critical Care Medicine at the Oregon Health & Science University
  • Michele Heisler, MD, MPA, Medical Director at Physicians for Human Rights and Kutsche Memorial Research Professor of Internal Medicine and Public Health at the University of Michigan
  • Payal Shah, JD, Director of Research, Legal, and Advocacy, Physicians for Human Rights

Recorded on September 30, 2025.

Explore PHR’s new research documenting how abortion bans are limiting clinicians’ ability to provide care across a wide range of specialties in the United States.

Brief

Cascading Harms: How Abortion Bans Lead to Discriminatory Care Across Medical Specialties

Executive Summary

Since the U.S. Supreme Court ruled to overturn the federal constitutional right to abortion in Dobbs v. Jackson in June 2022, 28 states have introduced legislation banning or curtailing access to abortion care.1 Most of this legislation includes criminal or civil penalties on health care providers who provide abortion care. Physicians for Human Rights (PHR) and partners have conducted research with health care providers in Oklahoma, Idaho, Louisiana, and Florida to document the multiple ways that state abortion bans have harmed the health of pregnant patients.2 In this research, providers repeatedly emphasized the cascading impact of abortion bans on other forms of care and the need for peer clinicians from multiple specialties to work together to address restrictions that impede quality of health care.

To further investigate the impact of abortion bans on health care beyond reproductive health care, PHR conducted 33 semi-structured interviews with physicians from reproductive and non-reproductive health specialties across 20 states in three different policy environments: states with abortion bans before 12 weeks, states with abortion bans after 12 weeks, and states with abortion protections. PHR’s research team spoke with physicians providing reproductive health care (specialties included obstetrics-gynecology, family medicine, and emergency medicine) to understand the continued and changing impacts of abortion bans on reproductive health care beyond abortion provision three years post-Dobbs. Our research team also interviewed physicians from non-reproductive health specialties – such as rheumatology, dermatology, pulmonology/critical care medicine, oncology, hematology, neurology, and cardiology – who regularly prescribe teratogenic medications, treat patients with health complications that are contraindicated for continuing pregnancy, or treat patients who develop medical conditions (e.g., cancer) for which immediate treatment would necessitate abortion care.

These shared and widespread impacts of abortion restrictions highlighted in this research reinforce the need for physicians and other clinicians across specialties to engage in joint advocacy to ensure that additional rollbacks, such as restrictions on mifepristone and misoprostol, do not go into effect.

Our research highlights how abortion bans and restrictions create cascading effects that extend far beyond reproductive health care, compromising the quality and effectiveness of medical care across reproductive and non-reproductive specialties. As one participant in a state with abortion protections stated:

“It’s really, really, really hard to document all of the ways that these laws are harming and frankly killing women. And so when we get the report that these are the number of women who died because of  restricted access to [abortion] care, that number is 100 percent going to be an underestimate. We are not going to include in that number the women who had pulmonary hypertension and their doctor didn’t talk to them about abortion as an option. We’re not even going to know about the women who wanted abortion but couldn’t put together the resources to get out of state to get that abortion. There are so many women that it is going to be impossible for us to consistently count how many are going to be harmed, that are women who are going to have a complication that isn’t going to be addressed until it’s too late and they   lose their ovary or they lose their uterus and they lose their ability to have children forever. That’s another thing that’s going to be so hard for us to count and say, ‘This is the impact of this law’.”Participant 25

People in Florida hold up signs during a reproductive rights rally on the second anniversary of the Supreme Court ruling to overturn Roe v. Wade. Photo by Marco Bello / AFP via Getty Images

These restrictions have hindered the ability of providers in diverse medical fields to follow evidence-based practices and standards of care, creating a pervasive chilling effect that results in substandard care and discriminatory treatment for reproductive-age women and pregnant patients.

Physicians highlighted:

  • Delays in care for patients who experienced complications from acute or chronic medical conditions during pregnancy.
  • Delays and denials of abortion care in cases of worsening acute and chronic medical conditions during pregnancy.
  • Changes in prescribing teratogenic medications to reproductive-age patients due to a fear that patients might become pregnant and be unable to access abortion care, with particular impacts on individuals from marginalized communities and lower socioeconomic statuses.
  • Physician concerns about including abortion care as a possible option when counseling patients in the face of severe comorbid medical conditions in pregnancy.
  • Difficulty with pharmacies dispensing medications associated with pregnancy termination, such as mifepristone and misoprostol.
  • Continued fear of providing abortion care under confusing exceptions and severe criminal and civil penalties in state-level abortion bans.

The striking similarity of these impacts across both reproductive and non-reproductive specialties highlights the urgent need for joint action across medical specialties to prevent further restrictions, including on medications used for abortion. The findings add to a strong and growing body of evidence of the chilling effect of abortion bans on the provision of high-quality, evidence-based health care and their adverse impact on pregnant and reproductive-age patients.3 As an obstetrician-gynecologist in a state with an abortion ban before 12 weeks shared:

“I had a patient the other day who came to me at 15 weeks and had chronic kidney disease. And at the start of her pregnancy her creatinine was 4 [normal range is generally up to about 1.1 mg/dL for women depending on lab and muscle mass], which is not a good predictor of a healthy and uneventful pregnancy. And by the time she had gotten to us at 15 weeks, her creatinine was [at a dangerously high level]…. But if you just were to look at her and talk to her, you would say, ‘Oh, you’re stable, you look healthy.’ The problem here is that many people are construing threat to maternal life as actually seeing a sick person in front of them, a physically ill-appearing sick person, and kind of just disregarding all of our training and evidence-based education to know that a rising creatinine, although someone might not physically look ill, is an extremely concerning sign in early pregnancy. And one that without a doubt will become worse as the pregnancy progresses .… And what we are doing is sitting and waiting almost for irreversible damage to occur before we do something and offer them [abortion care].”Participant 3

At their core, these restrictions – both current abortion bans and proposed measures to further restrict mifepristone and misoprostol access by the U.S. Food and Drug Administration and state governments – are attacks on science, health care, and medical and individual autonomy. As physicians described, the failure to provide patients with the full range of options for treatment, including the option for abortion care, harms treatment practices for a wide variety of conditions and results in discriminatory care for patients.

These shared and widespread impacts of abortion restrictions highlighted in this research reinforce the need for physicians and other clinicians across specialties to engage in joint advocacy to ensure that additional rollbacks, such as restrictions on mifepristone and misoprostol, do not go into effect. These restrictions do not just harm reproductive health; they undermine the fundamental principles of medicine by restricting clinical autonomy, limiting physicians’ ability to counsel patients effectively, and preventing them from offering the most effective treatments. Health care professionals have an obligation to stand against policies that interfere with their duty of care and deny patients the right to comprehensive medical care to help ensure that patients can make the best decisions for their health and lives.

Based on these findings, Physicians for Human Rights recommends the following:

To the U.S. Government and Congress:

  • Enact and implement national laws and policies that ensure rights and remove barriers to abortion care and maternal health care.
  • Ensure that all people can access comprehensive reproductive health care with dignity, free from discrimination and criminalization, regardless of where they live.
  • The U.S. Food and Drug Administration (FDA) must refrain from further restrictions on the medications mifepristone and misoprostol given rigorous evidence of their safety.
  • Continue and reaffirm the longstanding interpretation that the Comstock Act does not apply to the mailing of medication or supplies for legal abortion.
  • Monitor the impact of abortion bans on the provision of reproductive and other health care and on health inequities, including by employing U.S. Congressional authority to investigate discrimination in programs and services funded by the U.S. Department of Health and Human Services.
  • Support legislation that prohibits clinicians’ civil or criminal liability, disbarment, loss of license, or other retribution or reprimanding measures where clinicians provide life- or health-preserving abortion care in line with medical standards.

To State Governments and Legislatures:

  • Repeal state-level abortion bans as well as all other restrictive laws and regulations that effectively obstruct access to abortion. This includes enacting legislation that:
    • Decriminalizes abortion and removes professional, civil, and criminal penalties for health care workers who provide abortion care to patients.
    • Repeals laws that could be used to prosecute or penalize people for having an abortion, including a self- managed abortion, assisting another person to access abortion care, or for pregnancy outcomes.
    • Removes all medically unnecessary requirements for provision of abortion care.
    • Establishes shield laws to protect patient access to abortion and protect health care providers.

To Health Care Providers and Institutions:

  • Speak out against laws criminalizing abortion or otherwise restricting access to abortion, including by raising awareness of the harms caused to patients and health care systems and ensuring clinicians are not prohibited by their medical institutions from speaking out against such laws.
  • Assist clinicians in navigating abortion bans and restrictions and providing patients with the proper standard of care, including by providing them with accurate and up-to-date legal guidance as well as guaranteed and timely legal support for abortion-related investigations or legal proceedings.
  • Continue to support clinicians and medical students of all specialties to attend trainings on abortion and other reproductive health care, including clinical training and ethical guidance.

To State and National Medical Associations:

  • Vigorously advocate for the repeal of abortion bans and restrictions and continue to speak out against the range of injuries – criminal, civil, and moral – caused by abortion bans and restrictions.

Endnotes

  1. Talia Curhan. State Bans on Abortion Throughout Pregnancy | Guttmacher Institute. Guttmacher Institute, 2024. https://www.guttmacher.org/state-policy/explore/state-policies-abortion-bans.
  2. Christian De Vos, Michele Heisler, William Jaffe, Payal Shah, Tamya Cox-Touré, Priya Desai, Nimra J. Chowdhry, Risa Kaufman, and Rabia Muqaddam. No One Could Say: Accessing Emergency Obstetrics Information as a Prospective Prenatal Patient in Post-Roe Oklahoma 5. Physicians for Human Rights, OCRJ, and CRR, 2023. Accessed March 22, 2025. https://phr.org/our-work/resources/oklahoma-abortion-rights/. Lift Louisiana, Physicians for Human Rights, Reproductive Health Impact, and Center for Reproductive Rights. Criminalized Care: How Louisiana’s Abortion Bans Endanger Patients and Clinicians. Accessed August 12, 2025. https://phr.org/our-work/resources/louisiana-abortion-bans/. Whitney Arey, Michele Heisler, Payal Shah, and Danielle Whisnant. Delayed and Denied: How Florida’s Six- Week Abortion Ban Criminalizes Medical Care. Physicians for Human Rights. Accessed August 12, 2025. https://phr.org/our-work/resources/delayed-and-denied-floridas-six-week-abortion-ban/.
  3. Daniel Grossman, Carole Joffe, Shelly Kaller, Katrina Kimport, Elizabeth Kinsey, Klaira Lerma, Natalie Morris, and Kari White. Care Post-Roe: Documenting Cases of Poor-Quality Care since the Dobbs Decision. Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, 2023. Whitney Arey, Klaira Lerma, Anitra Beasely, Laurie Harper, Ghazaleh Moyayedi, and Kari White. “A Preview of the Dangerous Future of Abortion Bans — Texas Senate Bill 8 | New England Journal of Medicine.” New England Journal of Medicine 38, no. 5 (2022). https://doi.org/10.1056/NEJMp2207423.
Report

Cruelty Campaign: Solitary Confinement in U.S. Immigration Detention

Executive Summary

The Crisis

The United States maintains the world’s largest immigration detention system, detaining an average daily population of nearly 60,000 people in immigration detention.¹ U.S. Immigration and Customs Enforcement (ICE) detains people in a network of facilities across the country where they often endure inhuman conditions, including solitary confinement.² Solitary confinement is the practice of isolating people in small cells without meaningful human contact for 22 hours or more per day.³

Over the past decade, the use of solitary confinement in immigration detention has risen at an alarming rate, with unprecedented numbers of immigrants held in isolation. Congress recently authorized a significant increase in funding to expand immigration detention, which will likely exacerbate this widespread, prolonged use of solitary confinement as detention capacity increases.

The effects of prolonged solitary confinement can be lethal, as in the case of Charles Leo Daniel, who died after spending more than 13 years of his life in solitary confinement in various detention settings, including almost four years in solitary confinement in ICE detention. The adverse health effects of solitary confinement are well-established, extensively researched, and thoroughly documented across decades of literature, including post-traumatic stress disorder, self-harm, elevated suicide risks, lasting brain damage, and hallucinations. These effects often persist beyond the confinement period, resulting in enduring physical and psychological disabilities, especially among people with preexisting medical and mental health conditions.Vulnerable populations, including those with medical and mental health conditions, are often subjected to solitary confinement at high rates despite ICE’s own directives mandating its use as a last resort.¹⁰

Key Findings

This report, “Cruelty Campaign: Solitary Confinement in U.S. Immigration Detention,” authored by faculty and students from Harvard Law School’s Empirical Research Services and the Harvard Immigration and Refugee Clinical Program (HIRCP), the Peeler Immigration Lab, and Physicians for Human Rights (PHR), provides an updated analysis of solitary confinement in U.S. immigration detention with an additional regional focus on facilities in New England. It builds on the February 2024 report, “‘Endless Nightmare’: Torture and Inhuman Treatment in Solitary Confinement in U.S. Immigration Detention,” by the same authors.¹¹

Based on publicly available ICE data and records obtained through Freedom of Information Act (FOIA) requests, “Cruelty Campaign” reveals alarming trends in the use of solitary confinement:

  • Over a span of just 14 months, from April 2024 to May 2025, more than 10,500 people were placed in solitary confinement in immigration detention centers across the United States.
  • In the first four months of the second Trump presidency, the monthly increase in the use of solitary confinement was twice the rate observed between 2018 and 2023, and more than six times higher than during the end of the previous administration.¹²
  • On average, during the first three months of 2025, solitary confinement placements involving people with vulnerabilities lasted more than twice as long as they did in the first fiscal quarter of 2022, when ICE began reporting statistics on the solitary confinement of vulnerable populations.¹³ This increase is evident in both the average consecutive days per placement (38 days in early 2025 compared to 14 days in late 2021) and the average cumulative days per person (44 days in early 2025 compared to 20 days in late 2021).¹⁴
  • Detailed analysis of facilities in New England shows that between 2018 and 2023, nearly three out of four solitary confinement placements lasted 15 days or longer, the threshold that UN human rights experts consider to be torture.¹⁵ On average, people spent about a month in solitary confinement, and some were isolated for more than a year.¹⁶
  • Where mental health status was reported, almost half of the solitary confinement placements in immigration detention in New England involved individuals with reported mental health conditions,¹⁷ contrary to ICE directives requiring its use only as a last resort for vulnerable populations.¹⁸
  • Notably, the average number of vulnerable individuals subjected to solitary confinement nationally increased by approximately 56 percent per quarter in fiscal year 2025 compared to 2022, with increasing numbers of individuals experiencing multiple placements.¹⁹
  • Individual case analysis in New England reveals systemic use of solitary confinement for arbitrary and retaliatory purposes, including punishing people for filing grievances; requesting basic needs like showers; sharing food; or reporting sexual assault, practices that violate international prohibitions on arbitrary detention independent of duration.²⁰
A detained person looks out from his ‘segregation cell’ – a common euphemism for solitary confinement – at the Adelanto Detention Facility in Adelanto, California. (Photo by John Moore/Getty Images)

Data Shortcomings

This analysis is constrained by fundamental flaws in ICE’s data collection and reporting systems.²¹ Recent independent analysis has found significant mathematical discrepancies in ICE detention data, and unexplained facility count changes.²² These systematic reporting failures mean that the findings in this report, while based on the best available data, may still underestimate the true scope of solitary confinement abuses, adding another layer to the transparency and accountability failures that advocates have documented for over a decade.

Sounding the Alarm for Years

This report adds to over a decade of persistent advocacy and research by PHR,²³ the National Immigrant Justice Center,² Solitary Watch,²⁵ whistleblowers,²⁶ and others; investigations, inquiries, and reports by government oversight bodies,²⁷ independent journalists,²⁸ and members of Congress;²⁹ briefings to high-level government officials;³⁰ and multiple congressional hearings focused on solitary confinement.³¹ The 2024 findings presented in “‘Endless Nightmare’: Torture and Inhuman Treatment in Solitary Confinement in U.S. Immigration Detention” revived congressional inquiries, media investigations, and urgency about ICE’s use of solitary confinement.³²

Leaders at the U.S. Department of Homeland Security (DHS) and ICE faced pressure to end solitary confinement altogether or, at the very least, make major changes to reduce its use, particularly among the most vulnerable people in ICE detention.³³ In December 2024, ICE introduced new reporting requirements,³⁴ representing a modest transparency improvement.

Trump Administration Escalation

Rather than implementing recommendations to protect vulnerable people and end solitary confinement, the Trump administration has doubled down on the use of detention. The “One Big Beautiful Bill Act,” signed on July 4, 2025, more than quadruples ICE’s detention budget, which amounts to $45 billion through 2029.³⁵ This massive expansion of resources for a system already characterized by torturous conditions,³⁶ combined with little to no oversight, creates the conditions for catastrophic human rights violations on an unprecedented scale.

ICE’s continued lack of transparency hinders a comprehensive assessment of solitary confinement practices in immigration detention because granular data specific to each placement is not publicly reported.³⁷ While the new reporting requirements shed additional light on the use of solitary confinement in immigration detention, publicly released national data from April 2024 to May 2025 still omit key details, including circumstances and duration of each solitary placement.³⁸

Abuse in New England Facilities

Furthermore, the analysis of New England facilities demonstrates that county and state-run facilities are critical sites for intervention by state policymakers and advocates.³⁹

This regional focus exposes harmful practices and equips policymakers and advocates with actionable insights to dismantle systems of abuse.

Immediate Action Required

ICE’s use of detention has only increased under the current administration.⁴⁰ Given ICE’s planned continued expansion of detention and escalating use of solitary confinement, immediate action is required at all levels of government.

This report presents comprehensive recommendations across multiple levels of government to end solitary confinement in immigration detention. Given significant obstacles to federal reform, state and local action has become essential. The authors make the following recommendations:

State and local governments should renegotiate contracts with ICE to assert stronger control over detention standards and accountability measures.

Federal Government:

  • ICE must publicly commit to ending solitary confinement entirely through a binding directive that includes presumptive release for vulnerable populations.
  • The president should immediately halt immigration detention expansion at a minimum and eliminate solitary confinement in all immigration facilities.
  • Sign the UN Optional Protocol Against Torture to enable international oversight.
  • Congress must defend its constitutional oversight authority against ICE’s unprecedented obstruction by passing emergency legislation to restore unannounced inspection rights, strengthen civil rights oversight mechanisms, and ratify international monitoring protocols.

State and Local Government:

  • States should pass legislation eliminating or reducing solitary confinement in facilities within their borders.
  • States should increase procedural protections for those placed in isolation.
  • State Attorneys General should conduct regular unannounced inspections.
A person lights candles during a vigil for people in custody at a nearby U.S. Immigration and Customs Enforcement detention center in Portland, Oregon. (Photo by Nathan Howard/Getty Images)

Cover image: In an aerial view, detained people form an “S.O.S.” while displaying a banner saying “Help we want to be deported we are not terrorists, S.O.S.,” in the courtyard at the Bluebonnet Detention Center in May 2025 in Anson, Texas. (Photo by Brandon Bell/Getty Images)

Endnotes

1 “ICE Detention Statistics,” U.S. Immigration and Customs Enforcement, https://www.ice.gov/detain/detention-management (last accessed August 15, 2025) [hereinafter “ICE Detention Statistics”]. According to ICE there were 59,380 people in immigration detention as of August 10, 2025. ICE Detention data excludes Office of Refugee Resettlement transfers/facilities, as well as U.S. Marshals Service prisoners.

2 See generally Harvard Immigration and Refugee Clinical Program, Peeler Immigration Lab, Physicians for Human Rights,“‘Endless Nightmare’: Torture and Inhuman Treatment in Solitary Confinement in U.S. Immigration Detention” (2024)[hereinafter “Endless Nightmare”]; National Immigrant Justice Center, Physicians for Human Rights, “Invisible in Isolation”(2012) [hereinafter “Invisible in Isolation”].

3 The United Nations Standard Minimum Rules for the Treatment of Prisoners, Rule 44 (2015), https://www.unodc.org/documents/justice-and-prison-reform/Nelson_Mandela_Rules-E-ebook.pdf [hereinafter “Mandela Rules”]. ICE maintains that they do not use solitary confinement but rather “segregation.” However, ICE “segregation” allows for people to be detained alone in a small cell for at least 22 hours a day, meeting the generally accepted definition of solitary confinement. See, e.g., “ICE Needs to Improve its Oversight of Segregation Use in Detention Facilities,” Dept. Homeland Sec. Office of Inspector General (2021) (https://www.oig.dhs.gov/sites/default/files/assets/2021-10/OIG-22-01-Oct21.pdf) [hereinafter “2021 DHS OIG Report”].

4 “The Solitary Confinement Crisis in Immigration Detention,” 25 Nev. L.J. 617 (2025) at 619 (https://scholars.law.unlv.edu/cgi/viewcontent.cgi?article=1968&context=nlj#page=26&zoom=auto,-47,750) (documenting over 7,000 immigrants placed in solitary from April 2024 to February 2025, surpassing the total of 3,775 placements recorded during the entire year of 2023).

5 See, e.g., “Immigration Challenges and Concerns in Implementing the ‘One Big Beautiful Bill,’” American Immigration Council, https://www.americanimmigrationcouncil.org/blog/immigration-challenges-implementing-the-one-big-beautiful-bill/ (July 15, 2025).

6 “Charles Leo Daniel’s Death in NWDC in Context,” University of Washington Center for Human Rights, https://jsis.washington.edu/humanrights/2024/03/15/nwdc-conditions-research-update-daniel-death-in-context/ (March 15, 2024); seealso Nina Shapiro, “Immigrant who died in ICE custody spent 13 years in solitary — many in WA prisons,” The Seattle Times (April 4, 2024), https://www.seattletimes.com/seattle-news/immigrant-who-died-in-ice-custody-spent-13-years-in-solitarymany-in-wa-prisons/.

7 Peter Scharff Smith, “The Effects of Solitary Confinement on Prison Inmates: A Brief History and Review of the Literature,” 2006, 34(1) Crime and Justice 441, https://doi.org/10.1086/50062; Louis Favril, Rongqin Yu, Keith Hawton, and Seena Fazel, “Risk factors for self-harm in prison: a systematic review and meta-analysis,” (August 2020). The Lancet Psychiatry 7 (8): 682-691. doi: 10.1016/S2215-0366(20)30190-5

8 Christopher Wildeman and Lars H. Andersen, “Solitary confinement placement and post-release mortality risk among formerly incarcerated individuals: a population-based study,” The Lancet no. 5, (February 2020): e107 to e113, https://doi.org/10.1016/S2468-2667(19)30271-3.

9 Lauren Brinkley-Rubinstein, et al. “Association of Restrictive Housing During Incarceration with Mortality After Release,” 2(10) JAMA Network Open (2019), doi:10.1001/jamanetworkopen.2019.12516.

10 Caitlin Patler, Altaf Saadi, and Paola Langer, “The health-related experiences of detained immigrants with and without mental illness,” Journal of Migration and Health 11 (2025): 100302, https://doi.org/10.1016/j.jmh.2025.100302; Endless Nightmare; U.S. Immigration and Customs Enforcement, 11065.1, “Review of the Use of Segregation for ICE detainees,” 2013 (https://www.dhs.gov/sites/default/files/publications/segregation_directive.pdf) [hereinafter “2013 ICE Segregation Directive”].

11 Endless Nightmare.

12 ICE Detention Statistics; Harvard Law School FOIA: Updated Spreadsheet Showing Solitary Confinement Stays Between September 4, 2018, and September 13, 2023, released by ICE on December 30, 2024 [hereinafter HLS FOIA: Spreadsheet]. On average, from April to November 2024 (before ICE changed its policy on reporting), the number of individuals reported in solitary confinement increased by one percent each month. From February to May 2025 (following the presidential inauguration), this rate increased sixfold, reaching 6.5 percent. By comparison, between September 2018 and September 2023, the number of solitary confinement placements increased by an average of 3.4 percent per month. Replication data and analysis for “Cruelty Campaign: Solitary Confinement in U.S. Immigration Detention” is available on Harvard Dataverse, https://doi.org/10.7910/DVN/45K4PC.

13 ICE Detention Statistics.

14 Id. ICE operates on a fiscal year, which runs from October 1 to September 30. The first calendar quarter of 2025 corresponds to the second fiscal quarter of 2025, and the last calendar quarter of 2021 corresponds to the first fiscal quarter of 2022. The number of consecutive days refers to the duration of each individual placement in solitary confinement, while the number of cumulative days represents the total duration of all solitary placements experienced by each individual with an identified vulnerability.

15 HLS FOIA: Spreadsheet; Mandela Rules.

16 IHLS FOIA: Spreadsheet.

17 Id. Over 44 percent of solitary confinement placements in New England facilities between 2018 and 2023, for which mental health status of the detained individual was documented, reported a mental illness.

18 See, e.g., 2013 ICE Segregation Directive.

19 ICE Detention Statistics. On average, 265 individuals with vulnerabilities were reported in solitary confinement each quarter in fiscal year 2022, compared to 413 each quarter in fiscal year 2025.

20 The Mandela Rules; United Nations, International Covenant on Civil and Political Rights, Articles 9 and 10, Office of the High Commissioner for Human Rights (last accessed August 13, 2025), https://www.ohchr.org/en/instruments-mechanisms/ instruments/international-covenant-civil-and-political-rights; Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, arts. 1 and 16; Inter-American Commission on Human Rights, Principles and Best Practices on the Protection of Persons Deprived of Liberty in the Americas (2008).

21 See, e.g., 2021 DHS OIG Report, Endless Nightmare

22 See “ICE Can’t Add: Recent Data on Detention Facilities Hogwash,” TRAC Reports, Inc. (July 18, 2025), https://tracreports.org/whatsnew/email.250718.html. For example, ICE reported 56,816 detained individuals nationally in July 2025, yet the sum of facility-level average daily population (ADP) figures amounted to 42,221, a discrepancy of nearly 14,000.

23 Endless Nightmare.

24 Invisible in Isolation.

25 “New Fact Sheet on Solitary Confinement in Immigration Detention Warns of Growth Under Trump,” Solitary Watch (February 6, 2025), https://solitarywatch.org/2025/02/06/new-fact-sheet-on-solitary-confinement-in-immigrant-detentionwarns-of-growth-under-trump/.

26 “Immigrants, Doctors & Whistleblowers report to Congress failed mental health care and abuse in ICE detention,” National Immigrant Justice Center (September 23, 2022), https://immigrantjustice.org/press-release/immigrants-doctors-whistleblowerreport-to-congress-failed-mental-health-care-and-abuse-in-ice-detention/.

27 2021 DHS OIG Report.

28 Spencer Woodman, “ICE’s use of solitary confinement ‘only increasing’ under Biden, new report reveals,” International Consortium of Investigative Journalists (February 6, 2024), https://www.icij.org/investigations/solitary-voices/ices-use-ofsolitary-confinement-only-increasing-under-biden-new-report-reveals/.

29 “Warren Questions ICE About Reports of Misuse of Solitary Confinement at Immigration Detention Facilities,” U.S. Senator Elizabeth Warren (June 2, 2019), https://www.warren.senate.gov/oversight/letters/warren-questions-ice-about-reports-ofmisuse-of-solitary-confinement-at-immigration-detention-facilities.

30 “Immigration Detention: Actions Needed to Collect Consistent Information for Segregated Housing Oversight,” U.S. Government Accountability Office (October 2022), https://www.gao.gov/assets/gao-23-105366.pdf. [hereinafter “2022 GAO Report”].

31 See, e.g., “Ahead of U.S. Senate Hearing on Solitary Confinement, Survivors of Solitary Confinement & Allies Rallied to Urge President Biden and Congress to Enact the End Solitary Confinement Act, American Civil Liberties Union” (April 16, 2024), https://www.aclu.org/press-releases/ahead-of-u-s-senate-hearing-on-solitary-confinement-survivors-of-solitary-confinementallies-rallied-to-urge-president-biden-and-congress-to-enact-the-end-solitary-confinement-act; “Legacy of Harm: Eliminating the Abuse of Solitary Confinement: Hearing before the Comm. on the Judiciary,” 188 Cong. (2024), https://www.congress.gov/event/118th-congress/senate-event/LC74471/text; see also “Reassessing Solitary Confinement: The Human Rights, Fiscal, and Public Safety Consequences: Hearing before the Subcomm. on the Constitution, Civil Rights, and Human Rights,” 112 Cong. (2012), https://www.judiciary.senate.gov/imo/media/doc/CHRG-112shrg87630.pdf.

32 See Endless Nightmare. See also, e.g. Letter from Senator Edward J. Markey and others to Secretary Alejandro Mayorkas and Deputy Director Patrick J. Lechleitner (March 29, 2024), https://www.warren.senate.gov/imo/media/doc/letter_solitary_confinement_in_immigration_detention_32924.pdf; “Arrests, Removals, and Detentions Varied Over Time and ICE Should Strengthen Data Reporting,” U.S. Government Accountability Office (July 2024), https://www.gao.gov/assets/gao-24-106233.pdf; “[VIDEO] ‘Last Week Tonight with John Oliver’ Features PHR’s Investigations into Abuses in ICE Detention,” Physicians for Human Rights (March 9, 2025), https://phr.org/our-work/resources/video-last-week-tonight-with-john-oliverfeatures-phrs-investigations-into-abuses-in-ice-detention/.

33 Id.

34 Immigration and Customs Enforcement, Policy Number 24002, “Review of the Use of Special Management Units for ICE Detainees” (December 6, 2024), https://assets.aclu.org/live/uploads/2025/04/ICE-Special-Management-Units-for-ICEDetainees-Policy_Final.pdf, [hereinafter “2024 ICE SMU Directive”].

35 U.S. Congress. One Big Beautiful Bill Act, H.R. 1, 119th Cong., 1st sess., Public Law 119 21, enacted July 4, 2025, https://www.congress.gov/bill/119th-congress/house-bill/1/text.

36 See FN29.

37 ICE Detention Statistics.

38 Id.

39 This is reflected in evidence from a multitude of FOIA productions on file with the author that will be discussed throughout this report.

40 ICE Detention Statistics.

Brief

On the Brink of Catastrophe: U.S. Foreign Aid Disruption to HIV Services in Tanzania and Uganda

Executive Summary

On January 20, 2025, the U.S. government issued a freeze on all new foreign aid funding and a 90-day review of existing foreign aid.1 A few days later, the administration issued stop work orders on all existing foreign aid awards 2 and began dismantling the United States Agency for International Development (USAID).3 A limited humanitarian waiver for lifesaving assistance programs was issued,4 but excluded programs related to abortion; family planning; gender or diversity, equity, and inclusion (DEI) ideology programs; and other non-life saving assistance.

The United States President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. government’s flagship program to combat HIV in low-income countries, received a limited waiver 5 that halted all HIV prevention funding except for prevention for pregnant and lactating women. This excluded all key populations who are disproportionally burdened by incident HIV infections, such as men who have sex with men and sex workers.

As PEPFAR accounted for almost 90 percent 6 of pre-exposure prophylaxis (PrEP) initiations globally7 – a method where antiretroviral medicine is taken as a daily pill or long-acting injection to prevent new HIV infections – many people at risk for HIV have lost access to HIV prevention through PrEP.8

There is a narrow window within which sufficient resources can be used to stabilize and strengthen remaining services to prevent backsliding on decades of progress in HIV care, treatment, and prevention.

The abrupt freeze on U.S. foreign assistance made antiretroviral therapy (ART) clinics unable to dispense medication purchased with U.S. resources for several days. In May 2025, the White House proposed a 66 percent cut to global HIV funding, threatening a program that has saved an estimated 26 million lives. While PEPFAR’s unique structure, a Centers for Disease Control and Prevention (CDC)-specific court order,9 and partial waivers10 prevented a total collapse of PEPFAR, the U.S. foreign assistance ecosystem is tightly connected and the dismantling of USAID severely damaged service delivery around the world. While USAID received roughly 60 percent of PEPFAR funding, CDC supported the majority of people initiated on ART. This structure, along with the waiver, meant that disruptions varied between and within countries.

To understand the impact of the disruption to PEPFAR, Physicians for Human Rights (PHR) collaborated with partners to document the impacts of the sudden foreign aid disruption to HIV programs in Tanzania and Uganda. In these two countries, PEPFAR has historically provided over half of HIV response funding, making them especially vulnerable to aid interruptions. Both countries face severe and lasting HIV epidemics, have laws that criminalize key populations,11 12 and rely heavily on U.S. support for HIV treatment and prevention services.

A woman sits at the waiting area outside The AIDS Support Organization (TASO) office in February 2025 in Kampala, Uganda. TASO is an NGO in Uganda that offers an array of HIV and AIDS services, with 50 per cent of its funding coming from USAID. Photo: Getty Images

Listen: Community Health Workers Reflect on Impacts of Aid Cuts

Uganda:

Differentiated service delivery for HIV is a proven strategy for improving health and prolonging life. Many people living with HIV receive six months of drug at a time. With supply and funding uncertain, programs are scaling back and community fears are mounting.

Speaker: HIV positive peer counselor.

This research brief draws on 29 oral history interviews, including five focus groups, with doctors, nurses, peer counselors, people living with HIV, key population members, and non-governmental organization (NGO) staff conducted in Tanzania and Uganda in April 2025. To document the impacts of the U.S. foreign aid freeze and HIV funding cuts, the multidisciplinary study team used purposive and snowball sampling in Moshi and Dar es Salaam, Tanzania and Fort Portal, Kampala, Kasese, and Tororo, Uganda. Participants had explicit control over how personal information was shared, with consent and demographic forms tailored to individual preferences. Interviews were recorded, transcribed, translated, and lightly edited for clarity, with thematic analysis combining inductive and deductive coding to identify key patterns.

This research brief finds:

• Harms to individual physical and mental health through curtailed access to lifesaving medications for prevention and treatment, as well as from stigma and discrimination.

• Damage to individuals’ outlook and public trust in domestic government, U.S. foreign aid, and antiretroviral medications.

• Reduced public health programming for HIV as core components of effective services were discontinued.

These harms were documented within the first 90 days of the foreign aid freeze and subsequent actions, including the stop work order that halted all activities including dispensing antiretroviral therapy for a week or more. By the time the oral histories were collected, some programs had resumed some level of activity under the waiver, albeit with employee terminations, stockouts, and limited clinic-based activities. Multiple interviewees expressed fear of a “dark future” marked by a catastrophic increase in rates of new HIV infections and AIDS deaths. When people interviewed for this project were contacted for updates prior to publication, some of the most profound disruptions in supplies and health workforce salaries had been temporarily remediated. This research brief concludes that there is a narrow window within which sufficient resources can be used to stabilize and strengthen remaining services to prevent backsliding on decades of progress in HIV care, treatment, and prevention.

Uganda: During a months-long stockout of HIV drugs at an Ugandan clinic, health workers searched in vain for supplies from other facilities to prevent new mother-to-child transmissions.. Now staff fear for the health of mothers and newborns living with HIV.

Harms to Effective Public Health Programming for HIV

Widespread Disruption to HIV Treatment and Prevention Services

The abrupt suspensions to U.S. foreign aid had profound impacts on HIV service delivery in Tanzania and Uganda. In the 100 days following these cuts, interviews with health care workers, peer educators, people living with HIV, and program managers in the field revealed the sudden disruption to key elements of HIV programs.13 14 One health care worker in Uganda described how a temporary disruption in services led to lasting damage to a program’s ability to follow up with clients:

“When that termination came in, the landlords for such premises [used for community drug distribution] were notified and they [rented] out these premises afterwards. So, by the time we came back [after the PEPFAR waiver], they were not there. So many people were accessing services from that spot. Some of them cannot even be traced. Just imagine you had clients who have been accessing services from a given point for over six years and…[suddenly]…you cannot trace them. It is really hard.”Clinical officer, Uganda

Sudden Disruption to Service Delivery

Ecosystems HIV programs are not modular. Rather, these programs are a complex, tightly connected ecosystem of services including clinical, community-based, pharmaceutical, and psychosocial aspects of different programs working together. When one element is removed, even temporarily, the whole ecosystem can fail. Simply stocking antiretrovirals on a pharmacy shelf is not sufficient to help people start and stay on lifelong treatment or prevention. Prior to the 2025 disruptions, HIV programs in Uganda, Tanzania, and across the region used evidence-based approaches to provide information, medication, and clinical care. After the U.S. foreign aid disruption, even in settings where drugs remain available, the evidence-based service delivery models have been dismantled. Key approaches, often called differentiated service delivery, such as multi-month dispensing, community-based drug distribution, outreach, and adherence and clinical support, have been discontinued with no notice or advanced planning. The restriction of PrEP to pregnant and breastfeeding women left patients belonging to key populations desperate to find alternative treatment and community health workers – including those who lost their jobs – inundated with calls asking for help.

At the time the narratives were collected, PHR and partners identified instances where services were partially restored under the PEPFAR waiver, such that antiretrovirals for people living with HIV (PLHIV) were still in stock at open clinics. In the absence of community-embedded health workers and drug distribution points, many PLHIV faced challenges in accessing this scaled-back offering. In other instances, medications were in dangerously short supply. Ugandan physicians described the impact of stockouts of antiretroviral medications that had, at the time of the narratives, lasted nearly three months:

“We have almost depleted our ARVs because we have new clients coming. So we have not received commodities since [the stop work order] because the warehouse that provides the commodities, their contract was terminated.”Physician and head of multiservice organization, Uganda

“In fact, I feel so bad […]. People were strong again and now their lives [are] start[ing] to decline. […] It is very hurt[ful]. The children who grew up in our hands, who were brought [to us close to] death and we have grown them up – now they are youth. Some are in the university […]. Now, if they go back to where we got them from – really, it has affected us so much. It’s like a mother seeing [her] children dying of hunger and yet [doesn’t] have anything to feed them. You see someone who [is] declining slowly…. Something should be done.”AIDS treatment center NGO executive director, Uganda

Tanzania: Human rights protections and public health programs go hand in hand for LGBT communities worldwide. In Tanzania, LGBT people living with HIV report surging stigma at the remaining facilities providing care.

Harms to Individual Mental and Physical Health

Significant Changes in Health Care Decisions Among PLHIV Due to Fears About the Future

PHR and partners documented alarming changes in health-seeking behavior, including dose-skipping and rationing of medication due to uncertainty in future supply. When PLHIV discontinue and restart medications, the risk of developing a drug-resistant virus increases as each drug takes a different amount of time to be cleared from the body.15 When suboptimal levels of some or all drugs are present in the body, the virus can copy itself, allowing drug-resistant strains to emerge.16 In situations where PLHIV have interruptions in care, whether due to stockouts, difficulty accessing services, or other barriers, the risk of resistance increases. A young person living with HIV in Tanzania described dose skipping already occurring in their community:

“You’ll find that some people take their medicines but skip doses out of fear that when the medications are completely out of stock, they will not have medication to take. Their thinking is that, ‘I can take today, then skip tomorrow so that I can preserve them.’” -Young person living with HIV, part of counseling team for adolescents living with HIV, Tanzania

Fears of losing a steady supply of antiretrovirals are also influencing people’s decisions about having children, including one person who reported having an unwanted abortion due to fear of transmitting HIV to her baby because she might be unable to access her own ARV medication that prevents mother-to-child transmission.

“It was the first of March [when] someone [had an] abortion because of those rumors. They said, ‘I don’t want to get a baby with a HIV positive person, I’ll be blamed myself.’ She had an abortion, and I realized when she had already done it. And then [beginning in] March, we start[ed] hearing about the good news [of limited ART availability] …and she said, ‘No, I will not take any more pregnancy.’ She now lives alone and doesn’t want any partners.” -Young woman living with HIV and mental health project research coordinator, Tanzania

Collapse of Services for Community Members at Risk

The severe consequences of these funding disruptions, including interruptions to treatment, health services, and supplies, are falling hardest on some of the very communities PEPFAR was designed to support: people who are already criminalized, stigmatized, or otherwise pushed to the margins of society.17 18 LGBTQI+ communities, sex workers, and people living with HIV are bearing the brunt of the breakdown as community-led outreach, peer navigation, and mobile services – which are lifelines for many – have disappeared overnight. One clinical officer in Uganda described key populations being turned away from vital services:

“We… receive calls from the service users of how they can access their PrEP drugs. They reached [out] to facilities, [but those] facilities just send them away, [saying] ‘Please, you’re not supposed to come here unless you want us to call the police.’ Someone calls you [and says] ‘Please, how can I be supported?’ Things are really beyond.” -Clinical officer, Uganda

Harms to Future Outlook and Public Trust

This research brief also shows that people in Tanzania and Uganda remained fearful about the long-term future due to scaled-back HIV responses lacking differentiated service delivery, primary prevention, and last-mile strategies. People interviewed for this research brief reported that the funding has eroded trust in public health, amplified skepticism about donor motivations and donor-purchased commodities, increased loss to follow-up among people living with HIV, and diminished uptake of primary prevention. Multiple interviewees expressed fears of a “dark” future with increased costs to access care, a resurgence of unproven remedies, and exacerbated stigma. One clinician expressed fears about the future:

“What I see ahead is darkness… [W]e need to look into … [key and vulnerable populations (KVP)]i … with a keener eye and continue to offer support to them so that they are able to get the services they need. Because if we leave them behind, we will create a lethal bomb. We say that by 2030 we should have taken steps towards meeting the goals of the millennium…right? But if we ignore them [KVP] and leave them behind, we are creating a lethal bomb in the future…. Not just for them but also [for] organizations that are receiving funds to support KVP – they need to continue to be supported.” Doctor at a faith-based organization funded by PEPFAR, Tanzania

There are many harms already reported to date as a result of disruptions to PEPFAR, but the worst is yet to come if similar or long-term disruptions persist. The robust nature of HIV response, including decades of investment in community-based and -led responses, along with government support for human resources, clinical space, policy and guidance, and more, mean that avoidable deaths and new infections will not increase overnight, but rather inexorably over time. There is still a narrow window in which to act to stabilize PEPFAR programs so that the worst outcomes do not occur.

Several individuals who shared their experiences of abrupt terminations, stockouts, and working without pay for this research brief in March and April 2025 reported changes when contacted for updates as this brief was being finalized. When contacted for follow-up, people interviewed for this study said aid has resumed only in fragmented and precarious ways: in Tanzania, peer educators were rehired on reduced pay and short-term contracts to serve the general population rather than key populations, while in Uganda drug stockouts have eased but clinics report staff working under short-term salary agreements, leaving services fragile and under strain. In some instances, retrenched workers reported being rehired, clinics being restocked, and some community services having been restored through September 30, 2025, the end of the U.S. government fiscal year. These stop-gap measures come too late to forestall all harms, but they do underscore that countries and communities have, in some instances, found ways to maintain continuity amid the chaos. These countries and communities had been operating under the assumption that PEPFAR support would continue in a predictable pattern for the duration of the planning cycle and were in the process of making long-term plans for sustainable continuity, including in the context of reduced U.S. government support. Stabilization requires careful planning and sustained funding during the transition period.

This study underscores the urgency of restoring global health aid and renewing PEPFAR. Even a brief disruption to PEPFAR funding triggered widespread harm in Tanzania and Uganda, undermining essential services, eroding trust in health systems, and putting lives at risk. While the disruption to PEPFAR caused widespread challenges in the provision of HIV care and services in Tanzania and Uganda, not all is lost. The infrastructure to support implementation of HIV care and services through PEPFAR is largely intact. The findings make clear that PEPFAR is the critical backbone of public health responses and basic health services, including HIV response. PEPFAR’s renewal is vital to prevent further backsliding and to uphold the right to health for millions of people who rely on it.

Key Recommendations

To the U.S. Government:

  • Immediately restore, renew, preserve, and protect global health funding for essential HIV services, including full funding commensurate with need for global HIV programs in the FY 2026 budget, and subsequently reauthorize the PEPFAR program.
  • Reinstate support for HIV treatment; community-led outreach; PrEP access; differentiated service delivery models; peer-led health worker initiatives; community-led service delivery; and embedded health care workers providing HIV testing, counseling, and linkage to care for key populations.
  • Restore and preserve PEPFAR and other global health funding in a way that supports a planned, feasible, and transparent transition to country leadership and ownership of programs.

To the Governments of Uganda and Tanzania:

  • Uphold obligations under international human rights law to ensure the right to health. This includes ensuring that health services are available, accessible, acceptable, and of high quality, particularly for marginalized and key populations.
  • Develop national mitigation and transition plans in collaboration with civil society, donor governments, and regional partners to ensure continuity of lifesaving HIV care and address any gaps caused by the loss of U.S. funding.

To Donor Governments and International Global Health Partners:

  • Honor existing commitments, provide bridge funding, and support phased handover strategies that prevent catastrophic disruptions to core health services.
  • Invest in long-term system strengthening, including digital health systems, local procurement capacity, and health workforce development.
  • Foster greater South–South cooperation and provide flexible core support to national and regional civil society organizations, including those serving criminalized and marginalized populations.
  • Collaborate to monitor the impact of the U.S. aid cuts through public health and human rights mechanisms, ensuring that findings guide targeted responses.

To Regional Health and Accountability Mechanisms, including the African Union, the Africa Centres for Disease Control and Prevention, and the East African Community:

  • Support urgent regional dialogues with affected member states and donor governments to support coordinated responses and advance regional manufacturing and distribution of essential HIV and health commodities.
  • Explore voluntary coalitions for pooled procurement of essential HIV goods and commodities, including antiretrovirals, to support a shift from donor-led funding mechanisms.

To the United Nations, including the World Health Organization:

  • Formally acknowledge the public health and human rights consequences of the U.S. aid cuts and provide technical guidance to affected states on safeguarding access to HIV services and protecting the right to health.
  • Support global coordination and cooperation to close funding gaps, stabilize HIV service delivery, and uphold health-related rights across all affected countries.

Endnotes

  1. The White House. “Reevaluating and Realigning United States Foreign Aid.” Presidential Actions, January 20, 2025. Accessed August 5, 2025. https://www.whitehouse.gov/presidential-actions/2025/01/ reevaluating-and-realigning-united-states-foreign-aid/.
  2. Reuters. “Trump Pause Applies to All Foreign Aid; Israel, Egypt Get Waiver, Says State Dept Memo.” Reuters, January 24, 2025. Accessed August 5, 2025. https://www.reuters.com/world/us/trump-pause-applies-all[1]foreign-aid-israel-egypt-get-waiver-says-state-dept-memo-2025-01-24/.
  3. Nahal Toosi, Daniel Lippman, and Robbie Gramer, “Top USAID Career Staff Placed on Immediate Leave,” Politico, January 27, 2025, Politico, accessed August 5, 2025, http://www.politico.com/news/2025/01/27/ top-usaid-career-staff‑ordered‑leave‑00200854.
  4. US Department of State. “Emergency Humanitarian Waiver to Foreign Assistance Pause.” January 28, 2025. Accessed August 5, 2025. https://www.state.gov/emergency-humanitarian-waiver-to-foreign-assistance-pause.
  5. US Department of State. Information Memorandum: Implementation of Limited Waiver to Pause of US Foreign Assistance for Life-Saving HIV Service Provision. Sensitive but Unclassified memo to PEPFAR Implementing Agencies and PEPFAR Country Coordinators, February 1, 2025, pp. 1–3. Accessed August 19, 2025. PDF uploaded by Bhekisisa. https://bhekisisa.org/wp-content/uploads/2025/02/2025_02_01-Waiver[1]Notice-to-DPs-and-PCOs-FOR-DISTRIBUTION.pdf
  6. AVAC (PrEPWatch). Impact of PEPFAR Stop Work Orders on PrEP. Last updated July 2, 2025. Accessed August 19, 2025. https://www.prepwatch.org/pepfar-stop-work/
  7. U.S. Department of Health & Human Services. The US President’s Emergency Plan for AIDS Relief (PEPFAR). HIV.gov. December 23, 2024. Accessed August 19, 2025. https://www.hiv.gov/federal-response/pepfar[1]global-aids/pepfar.
  8. AVAC (PrEPWatch). Impact of PEPFAR Stop Work Orders on PrEP
  9. United States District Court for the District of Rhode Island, Motion to Enforce Temporary Restraining Order, Case No. 1:25cv00039 (JJMPAS), filed February 7, 2025, https://www.rid.uscourts.gov/sites/rid/files/ motiontoenforce.pdf
  10. U.S. Department of State. Info Memo: Implementation of Limited Waiver to Pause of US Foreign Assistance for Life-Saving HIV Service Provision. Washington, DC, February 1, 2025. PDF. https://bhekisisa.org/wp[1]content/uploads/2025/02/2025_02_01-Waiver-Notice-to-DPs-and-PCOs-FOR-DISTRIBUTION.pdf.
  11. Human Rights Watch. “They’re Putting Our Lives at Risk”: How Uganda’s Anti-LGBTQ+ Climate Unleashes Abuse. New York: Human Rights Watch, May 26, 2025. Accessed August 19, 2025. https://www.hrw.org/ report/2025/05/26/theyre-putting-our-lives-risk/how-ugandas-anti-lgbt-climate-unleashes-abuse
  12. UNAIDS. Country Progress Report – United Republic of Tanzania. Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS), 2020. Accessed August 19, 2025. https://www.unaids.org/sites/default/files/country/ documents/TZA_2020_countryreport.pdf
  13. Ehrenkranz, P., A. Grimsrud, C. B. Holmes, P. Preko, and M. Rabkin. “Expanding the Vision for Differentiated Service Delivery: A Call for More Inclusive and Truly PatientCentered Care for People Living with HIV.” Journal of Acquired Immune Deficiency Syndromes 86, no. 2 (February 1, 2021): 147–52. https://doi. org/10.1097/QAI.0000000000002549. Accessed via PubMed Central, PMCID: PMC7803437.
  14. UNAIDS. 2025. Recommended 2030 Targets for HIV. UNAIDS website. Accessed August 6, 2025. https:// www.unaids.org/en/recommended-2030-targets-for-hiv.
  15. Office of AIDS Research, National Institutes of Health, “HIV Drug Resistance,” Understanding HIV: Fact Sheets, last reviewed March 31, 2025, accessed August 6, 2025, https://hivinfo.nih.gov/understanding-hiv/ fact-sheets/drug-resistance
  16. Office of AIDS Research, National Institutes of Health, “HIV Drug Resistance.”
  17. Human Rights Watch. “Uganda: AntiLGBT Law Unleashed Abuse. Authorities Spread Misinformation; Perpetuate Violence, Discrimination.” Human Rights Watch News, May 26, 2025. https://www.hrw.org/ news/2025/05/26/uganda-anti-lgbt-law-unleashed-abuse-0.
  18. OutRight International. 2025. “Tanzania.” Our Work: SubSaharan Africa. Accessed August 6. https:// outrightinternational.org/our-work/sub-saharan-africa/tanzania.
Report

“You Will Never Be Able to Give Birth”: Conflict-Related Sexual and Reproductive Violence in Ethiopia

The conflict in Tigray, Ethiopia started in November 2020 between the government of Ethiopia and the Tigray People’s Liberation Front (TPLF), with involvement from Eritrean military forces who were called into to support Ethiopian armed forces, and numerous ethno-regional militia groups notably from the Amhara and Afar regions of Ethiopia. The conflict was marked by widespread and severe forms of conflict-related sexual and reproductive violence as well as other human rights violations by all parties, some of which amount to crimes under international law.1

Following the signature of the Cessation of Hostilities Agreement (CoHA) in November 2022 by the government of Ethiopia and the TPLF, violence continued, including widespread and severe sexual and reproductive violence along ethnic-political lines across regions by military actors.2 As the conflict unfolded, both the United Nations (U.N.) and the African Union (AU) established independent investigative mechanisms to document atrocities and preserve evidence for future justice and accountability processes.3 However, both mechanisms were prematurely shuttered, without investigators even being allowed into the country, after successful lobbying by the Ethiopian government to defer to national mechanisms, including the transitional justice process outlined in the CoHA.4 The decision to shut down these investigative bodies, and with their termination, the end of any impartial investigation into violation of international law, occurred despite the assessment by the U.N. and other actors. These assessments found that the consultative process undertaken in developing the transitional justice process, as well as the implementation, does not align with AU or international transitional justice standards.5 Notably, the process also lacks a survivor-centered approach, meaningful engagement with affected communities, or mechanisms to hold all perpetrator groups accountable, in violation of key international and regional standards on credible transitional justice processes.6 More recently the lack of openness of the transitional justice process to those seeking genuine accountability has been demonstrated by the Ethiopian government’s suspension of five human rights groups.7

The lack of timely and meaningful justice for crimes committed in Tigray raised the alarm that instability and further atrocities would be perpetrated in other regions of Ethiopia.

Many, including the U.N. International Commission of Human Rights Experts on Ethiopia (ICHREE), expressed concerns about how a lack of focus on timely justice and accountability for crimes committed in Tigray could fuel instability and the commission of further atrocities in other regions of Ethiopia in the near future.8 As conflict and instability spread to the neighboring Amhara and Afar regions in 2022 and 2023, reports of conflict-related sexual violence and other violations surfaced, and it became apparent that these warnings of further violence were being realized.

This report, prepared by a joint research team of medical, public health, and legal experts from the Organization for Justice and Accountability in the Horn of Africa (OJAH) and Physicians for Human Rights (PHR) finds that widespread, systematic, and deliberate conflict-related sexual and reproductive violence was committed in Tigray and has continued since the signing of the CoHA. Such acts constitute war crimes and crimes against humanity of sexual violence, forced pregnancy, sexual enslavement, and persecution on the intersection of ethnic, gender, age, and political grounds; further, they violate international human rights law (IHRL). While such violence has been perpetrated by all parties in a manner that indicates a desire to humiliate and harm, the data confirms that in Tigray, violence often was perpetrated with the expressed intention of, or in a manner consistent with the goal of causing grave and long-term harm, and destroying communities and the Tigrayan ethnicity. Furthermore, this report finds that a failure to meaningfully respond to the crimes committed in Tigray has led to a spread of atrocities, including crimes against humanity and war crimes, to the Amhara and Afar regions of Ethiopia.

OJAH and PHR used a mixed-methods approach, combining quantitative and qualitative data sources, including over 600 surveys of health care workers who had provided care to survivors of sexual and reproductive violence presenting at health facilities, a review of over 500 medical records, and 40 key-informant interviews and four focus group discussions with health care workers, humanitarian actors, and community leaders supporting survivors. Data were collected in Tigray, Amhara and Afar regions by a multidisciplinary research team looking at the period from the start of hostilities in Tigray in November 2020 through the end of data collection in October 2024. This mixed-methods approach allowed for triangulation of data around important themes related to sexual and reproductive violence perpetration experienced by survivors of sexual violence who reported these violations to health care workers and attacks against health care. This approach allowed OJAH and PHR to draw important conclusions about the perpetration of conflict-related sexual and reproductive violence and the impacts on survivors with important implications for further investigation and research, as well as justice and accountability.

A woman survivor of sexual violence waits for transport with her baby by the roadside in the town of Mekele, Tigray. Photo: Arlette Bashizi/Getty Images

Ongoing Conflict-Related Violence in Tigray Constitute Crimes Against Humanity

In Tigray, survivors experienced brutal and deliberate forms of conflict-related sexual and reproductive violence which caused severe and permanent psychological and physical harm to survivors, their families, and communities.

“Gang rapes, including culturally prohibited practices, raping when they are bleeding, entering bad things like steel into their wombs, raping mothers in front of their families. Imagine how it is, it is very sad their children were killed and they were also raped. The damage to their bodies cannot be described.”

-A midwife in Tigray

In a previous analysis of medical records from a select number of facilities published in the August 2023 report Broken Promises: Conflict-Related Sexual Violence Before and After the Cessation of Hostilities Agreement in Tigray, Ethiopia, OJAH and PHR found that sexual violence in Tigray was a clear tactic during the active conflict period between November 2020 and November 2022 and has continued since the signing of the CoHA in November 2022.

Expanding on the findings in our prior report, this mixed-methods research confirms that crimes against humanity have been committed in Tigray related to the perpetration of sexual and reproductive violence, particularly targeting women and girls, including the crime of forced pregnancy in Tigray.9 This study shows that survivors who presented at health facilities often experienced:

  • multiple perpetrator rape;
  • vaginal, oral, and anal rape;
  • forced witnessing of sexual violence including against family members;
  • insertion of foreign objects into the vagina following sexual violence;
  • forced pregnancy and forcible transmission of HIV or other sexually transmitted infections (STIs);
  • sexual violence against children; and/or,
  • sexual violence committed alongside other forms of torture or killings.

These data also show that survivors continue to need complex and long-term health care to address the physical and mental health impact of conflict-related sexual and reproductive violence. Clinical data documented by health care workers and accounts shared with health care workers indicate that perpetrators intended to instill terror, humiliate survivors, and exert control over survivors. Furthermore, the data gathered related to the targeting of survivors specifically based on ethnicity and information gathered on intention to commit sexual violence to impair fertility, force pregnancy, and intentionally infect with STIs, including HIV. The deliberate and grave nature of the sexual violence committed along with reports by Tigrayan survivors to health care workers of perpetrators’ expressed intent to prevent future Tigrayan births require further investigation to determine if extermination as a crime against humanity and the crime of genocide has occurred.

“They inserted paper with written letters into the women’s vagina, causing damage and I still have a photo of those letters. We have seen this in more than one client. The letters found in their vagina stated a plan for revenge for 1990 [Ethio-Eritrean War; 1990 refers to the Ethiopian calendar which is the year 1998 when converted to the Gregorian calendar.], aiming to destroy the Tigrayan people. They threatened to eradicate the Tigrayan lineage, harm Tigrayan wives, and prevent Tigrayan mothers from giving birth. Many foreign objects, such as stones and more than 10 nails, were found in their uterus. [These objects stayed] inside the vagina for many days. They mentioned that all Eritrean military personnel were instructed to harm the vagina of Tigrayan women.”

A nurse in Tigray

In Tigray, our data from health care workers indicate survivors’ reporting that conflict-related sexual violence and reproductive violence were most often perpetrated by individuals who spoke languages or wore uniforms indicating affiliation with the Eritrean military who were fighting at the time in support of the Ethiopian government. Other perpetrators in Tigray included the Ethiopian National Defense Force (ENDF) as well as other groups working in support of the Ethiopian national government, including Amhara Special Forces and Fano militias.

“Those who came from western Tigray say they are Fano who were their neighbors before the war and those who came from the borders say Eritreans. The others also say ENDF and Prosperity Party. They were able to differentiate them using the language they were speaking. They weren’t able to differentiate the ethnicity of other Ethiopians. The perpetrators were committing those abuses in numbers and together at the same time.”

-A health officer in Tigray

“Let’s share [with] you the story of one girl, her arm was broken and became paralyzed when the perpetrators tried to remove Norplant contraceptive method inserted in upper arm, and this was aimed to force pregnancy from the perpetrator. This was done by Eritrean force (Shabia) since they were openly speaking about this, ‘You will give birth from us, then Tigray ethnic[ity] will be wiped out eventually.'”

-A psychologist in Tigray

The widespread and systematic perpetration of sexual and reproductive violence by Eritrean actors in Tigray was and continues to be committed with impunity. The government of Eritrea is not party to the CoHA and Eritrean perpetrators will not be held responsible through Ethiopia’s current transitional justice process. There is a need for justice and accountability for sexual and reproductive violence committed in Tigray for all actors. PHR and OJAH reached out to the governments of Ethiopia and Eritrea to request information on the status of proceedings for accountability and reparations for survivors but did not receive a response.

Maiani General Hospital in Shiraro on October 12, 2024. Photo: Michele Spatari/AFP/Getty Images

Conflict-Related Sexual and Reproductive Violence in Amhara and Afar Amount to War Crimes

In the Amhara and Afar regions, the patterns of perpetration of sexual and reproductive violence were indicative of violence that was driven both by the presence of ongoing, flaring conflict, and a lack of atrocity prevention stemming directly from the conflict in Tigray. Survivors identified perpetrators from military groups including the TPLF, who expressed intent when committing sexual and reproductive violence related to revenge for Amhara and Afar forces actions in the conflict in Tigray.

“They often said that during the war, it was frequently claimed that attacks were carried out by the TPLF, the government, and the Amhara Defense Force.”

-A nurse in Amhara

“For example, at the place where I was providing medical aid, there are people who have reported that they were raped and subjected to various sexual violence by TPLF members. There was a situation where different men took turns to rape sisters or women who were family members.”

-A physician in Amhara

The data indicates that the failure to meaningfully ensure accountability and justice for violations in Tigray through the transitional justice process and other national efforts has contributed to an enabling environment for sexual and reproductive violence in Amhara and Afar. This report, the first to comprehensively analyze patterns of perpetration of conflict-related sexual violence in the Tigray, Amhara and Afar regions, paints a clearer picture of ongoing widespread, systematic, and deliberate acts of sexual and reproductive violence and underscores the urgent need for justice, accountability, and care for survivors.

“The perpetrators must be punished, and the situation must be resolved, as the current lack of accountability is unacceptable. Victims have suffered economic, mental, and physical damage due to the actions of the perpetrators. True healing requires justice.”

-A health officer in Tigray

“Justice must be served impartially by legal experts, both Ethiopian and international. The involvement of neutral parties is crucial to ensure transparency and fairness.”

-A health officer in Afar

Furthermore, these data demonstrate failures by numerous actors – including international justice champions – to adequately fulfill their obligations under international humanitarian law (IHL), IHRL, and international criminal law (ICL) to respond to these violations, to prevent further atrocities, to provide justice, to ensure care for survivors, and to pursue accountability. To this end, OJAH and PHR make the following recommendations:

  • Ensure compliance with obligations under IHL and IHRL to prohibit sexual violence.
  • Facilitate access to physical and mental health services and other forms of rehabilitation for all survivors of conflict-related sexual and reproductive violence, without discrimination.
  • Ensure impartial, independent documentation and investigation of serious human rights violations and atrocity crimes that have occurred, including the preservation of evidence of serious crimes under international law, by re-establishing international and regional investigative mandates to monitor and document human rights violations and other violations of international law in Tigray, Amhara, and Afar.
  • Hold all parties responsible for conflict-related sexual and reproductive violence accountable and ensure reparations to survivors in Tigray, Amhara, and Afar through national, regional, and international justice mechanisms, including universal jurisdiction.
  • Ensure compliance with international and regional standards in the implementation of the transitional justice process mandated under the CoHA for violation in Tigray from November 2020 to November 2022, including allowing for involvement of independent international “experts with international experience in investigating and prosecuting significant human rights violations” as committed to in the CoHA.

Quantitative Data Snapshot

Tigray

  • Temporal analysis of medical records shows sexual violence incidents occurring from November 2020 through July 2024.
  • 91 percent of surveyed health care workers reported seeing patients who had experienced multiple perpetrator rape; medical records showed a median of 3 perpetrators per incident
  • 69 percent of surveyed health care workers reported survivors experiencing violence in groups
  • 74 percent of surveyed health care workers provided care to survivors who reported experiencing sexual and reproductive violence more than once
  • 90 percent of surveyed health care workers saw at least a few patients with unwanted pregnancy from CRSV (Likert scale: “All patients”, 3 percent; “Most patients”, 40 percent; “Some patients”, 21 percent; “Few patients”, 26 percent)
  • Within medical records reviewed 10 percent had reported unwanted pregnancies
  • 73 percent of surveyed health care workers treated survivors who reported that perpetrators used language expressing intent to destroy their ability to reproduce or have children, including by causing mental harm
  • 76 percent of health care workers surveyed reported observing higher rates of sexual violence among patients based on ethnic identity
  • Within the medical records reviewed 50 percent of patients tested were positive for STIs and 17 percent were positive for HIV. (The national HIV prevalence rate in Ethiopia is 0.09 percent.)10
  • 84 percent of health care workers surveyed indicated survivors identified members of the Eritrean military as perpetrators
  • 73 percent of health care workers surveyed indicated survivors identified members of the Ethiopian military as perpetrators
  • 51 percent of health care workers surveyed indicated survivors identified members of the Amhara militias and Fano as perpetrators
  • In 95 Percent of Cases in medical records, survivors identified perpetrators as being affiliated with armed groups

Amhara and Afar

  • Temporal analysis of medical records in Amhara and Afar show incidents occurring from February 2021 through July 2024.
  • 47 percent of health care workers surveyed in Amhara reported treating survivors who had experienced sexual violence committed by multiple perpetrators
  • 71 percent of health care workers surveyed in the Afar region had seen female patients who reported that they had experienced sexual humiliation. Within the medical records reviewed, 23 percent indicated cases of sexual humiliation and 11 percent indicated cases of forced nudity.
  • In Amhara, 79 percent of health care workers who were surveyed indicated survivors identified Tigray Forces as perpetrators; 35 percent indicated Ethiopian military and 24 percent indicated Amhara Special Forces.
  • In Afar, 33 percent of health care workers who were surveyed indicated survivors identified Tigray Forces as perpetrators; 9.5 percent indicated Eritrean militias.
  • 74 percent of surveyed health care workers in Amhara saw at least a few patients with unwanted pregnancy from CRSV (Likert scale: “All patients”, 3 percent; “Most patients”, 6 percent; “Some patients”, 41 percent; “Few patients”, 24 percent)
  • 91 percent of surveyed health care workers in Afar saw at least a few patients with unwanted pregnancy from CRSV (Likert scale: “All patients”, 0 percent; “Most patients”, 14 percent; “Some patients”, 29 percent; “Few patients”, 48 percent)

End Notes

1. ICHREE, “Report of the International Commission of Human Rights Experts on Ethiopia,” United Nations Human Rights Council, September 14, 2023, https://www.ohchr.org/en/hr-bodies/hrc/ichre-ethiopa/index.

2. Physicians for Human Rights and The Organization for Justice and Accountability in the Horn of Africa, “Broken Promises: Conflict-Related Sexual Violence Before and After the Cessation of Hostilities Agreement in Tigray, Ethiopia,” August 2023, https://phr.org/our-work/resources/medical-records-sexual-violence-tigray-ethiopia/.

3. African Union, “Press Statement on the Official Launch of the Commission of Inquiry on the Tigray Region in the Federal Democratic Republic of Ethiopia,” June 16, 2021, https://au.int/en/pressreleases/20210616/press-statement-official-launch-commission-inquiry-tigray-region-federal; UN OHCHR, “International Commission of Human Rights Experts on Ethiopia,” OHCHR, accessed January 16, 2025, https://www.ohchr.org/en/hr-bodies/hrc/ichre-ethiopa/index.

4. The African Commission on Human and Peoples’ Rights, “Resolution on the Termination of the Mandate of the Commission of Inquiry on the Situation in the Tigray Region of the Federal Democratic Republic of Ethiopia: ACHPR/Res.556 (LXXV) 2023,” June 13, 2023, https://achpr.au.int/en/adopted-resolutions/556-resolution-termination-mandate-commission-inquiry; “Concerns Regarding The Premature Termination of the Commission of Inquiry on the Situation in the Tigray Region of the Federal Republic of Ethiopia,” August 31, 2023, https://reliefweb.int/report/ethiopia/concerns-regarding-premature-termination-commission-inquiry-situation-tigray-region-federal-republic-ethiopia; UN News, “Ethiopia: Victims ‘Left in Limbo’ as Rights Probe Mandate Ends,” October 13, 2023, https://news.un.org/en/story/2023/10/1142297.

5. African Union, “African Union Transitional Justice Policy,” February 2019, https://au.int/sites/default/files/documents/36541-doc-au_tj_policy_eng_web.pdf; United Nations Secretary General, “The Rule of Law and Transitional Justice in Conflict and Post-Conflict Societies: Report of the Secretary-General,” August 23, 2004, https://digitallibrary.un.org/record/527647; “Guidance Note of the Secretary-General: Transitional Justice—A Strategic Tool for People, Prevention and Peace,” July 2023, https://www.ohchr.org/sites/default/files/documents/issues/transitionaljustice/sg-guidance-note/2023_07_guidance_note_transitional_justice_en.pdf.

6. Global Centre for the Responsibility to Protect, “Civil Society Concerns in Achieving Transitional Justice and Accountability for Atrocities in Ethiopia,” October 15, 2024, https://www.globalr2p.org/publications/civil-society-concerns-in-achieving-transitional-justice-and-accountability-for-atrocities-in-ethiopia/.

7. “Ethiopia: Key Rights Groups Suspended,” Human Rights Watch, January 29, 2025, https://www.hrw.org/news/2025/01/29/ethiopia-key-rights-groups-suspended.

8. International Commission of Human Rights Experts on Ethiopia, “Comprehensive Investigative Findings and Legal Determinations,” Fifty-Fourth Session, United Nations Human Rights Council, October 13, 2023, https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2023/10/report/comprehensive-investigative-findings-and-legal-determinations-international-commission-of-human-rights-experts-on-ethiopia/a-hrc-54-crp-3.pdf.

9. Physicians for Human Rights and The Organization for Justice and Accountability in the Horn of Africa, “Broken Promises.” 2023.


Cover image: A woman poses for a portrait in an undisclosed location in Shire, Ethiopia in October 2024. The survivor told the news agency AFP that she has been raped by three men in Eritrean army uniforms in 2022. Photo: Michele Spatari/AFP/Getty Images

Brief

Abandoned in Crisis: The Impact of U.S. Global Health Funding Cuts in the Democratic Republic of Congo

The United States has historically been the largest provider of humanitarian assistance and bilateral support to the health sector in the Democratic Republic of the Congo (DRC), contributing billions of dollars annually through mechanisms such as United States Agency for International Development (USAID), the President’s Emergency Plan for AIDS Relief (PEPFAR), the Global Health Security Program, and the President’s Malaria Initiative to improve health outcomes. In 2024, over 70 percent of humanitarian action in the DRC was funded by the U.S. The country, especially its eastern region, has endured decades of conflict that have profoundly weakened already fragile health facilities and overwhelmed hospitals, which have been tasked with caring for survivors of widespread conflict-related sexual violence, persistently high maternal and infant mortality rates, and emerging infectious diseases like mpox, a contagious virus causing fever, rash, and sores that spread through close contact. Humanitarian needs in the DRC have worsened sharply, especially since November 2021, when M23 reemerged engulfing eastern DRC in violence. The North Kivu and South Kivu provinces alone host 4.6 million displaced people, making the DRC one of the world’s largest centers of internal displacement.

In January 2025, U.S. President Donald Trump signed an executive order to pause U.S. foreign assistance for a 90-day review. That order was followed by a stop work order that froze almost all US foreign assistance, except for limited waivers, that immediately and significantly reduced U.S. global health funding. In July 2025, the United States congress confirmed significant cuts to foreign assistance through a rescissions package. These actions severely impacted public health efforts in the DRC as the sudden cuts left no time to develop alternative plans to ensure continuity of services. This PHR research brief documents the effects of the cuts to U.S. global health aid in conflict-affected areas of the DRC.

Brief

“The System is Folding in on Itself”: The Impact of U.S. Global Health Funding Cuts in Kenya

The United States (U.S.) has historically been a major supporter of public health initiatives in Kenya. From 2020– 2025, the United States Agency for International Development (USAID) committed approximately $2.5 billion in foreign assistance to Kenya (approximately $470 million per year) with 80 percent allocated for health-related programs.

In January 2025, U.S. President Donald Trump signed an executive order to pause U.S. foreign assistance for a 90-day review, that order was followed by a stop work orders that froze almost all U.S. foreign assistance, except for limited waivers, that immediately and significantly reduced U.S. global health funding. In July 2025, the United States Congress confirmed significant cuts to foreign assistance through a rescissions package. These abrupt and sweeping cuts were not coupled with any preparations or alternative funding sources and so has left Kenya’s health system severely disrupted.

PHR’s research brief shows a health system that is struggling to adapt to the shock of the abrupt funding cuts, with devasting health consequences.

In Kenya, the effects of the funding cuts have been swift, for instance in the abrupt suspension of drop-in centers for community-based HIV monitoring and prevention funded through the United States’ flagship HIV program, the President’s Emergency Plan for AIDS Relief (PEPFAR). Approximately 41,500 health workers, 18 percent of he estimated total health care workforce, in Kenya are supported through U.S. funding, many of whom now face layoffs. Several antiretroviral therapy (ART) clinics were temporarily closed, some without proper referral systems. Key community-led initiatives, such as HIV prevention outreach and peer support services, have also been suspended. Prevention programs that provide diverse services such as pre-exposure prophylaxis, HIV counseling, and testing for adolescent girls and key populations, have been abruptly paused or reduced and threaten immense progress in ending the HIV epidemic. For example, there are reports that some of the girls participating in the U.S.-funded DREAMS program, which ensured that 66,000 girls remained HIV-free over three years, have started to engage in sex work for survival after this vital support ended. USAID cuts hit malaria net distribution, maternal and child health, immunizations, health data management systems and nutrition programs. Kenya, once a model for integrated community health programming, is now seeing signs of reversed progress, including reports indicating increased wait times, stockouts of essential medicines and vitamins, and clinic staffing shortfalls. The country also faces a serious risk of resurgence of malaria, HIV/AIDS, and vaccine-preventable diseases due to disruptions in treatment and prevention.

Kenya, once a model for integrated community health programming, is now seeing signs of reversed progress, including reports indicating increased wait times, stockouts of essential medicines and vitamins, and clinic staffing shortfalls.

Additionally, the withdrawal of U.S. funding for the Gavi, the Vaccine Alliance, a global public-private partnership that seeks to increase access to immunization in low-income countries poses a major threat to Kenya’s ability to immunize children against preventable diseases. The shortage of routine childhood vaccines compounds an existing crisis in Kenya where a recent measles outbreak affected over 2,900 children and killed least 18. The digital backbone of Kenya’s health system has also been significantly disrupted. The U.S. foreign aid freeze has halted the Demographic and Health Survey program which supported the collection of high-quality data to track health outcomes in over 90 countries, including Kenya, and disrupted critical health data systems, hampering routine monitoring, outbreak detection, and follow-up. As a result, disease and health outcome surveillance has deteriorated, impacting the work of community health responders and complicating efforts to easily understand the health impacts of the funding cuts.

Against this backdrop, this Physicians for Human Rights’ (PHR) research brief shows a health system that is struggling to adapt to the shock of the abrupt funding cuts, with devasting health consequences.

Multimedia

“We Could Have Saved So Many More”: Anguish and Death Caused by Israel’s Restrictions on Medical Supplies in Gaza​

"I was in the pre-op area when she was wheeled in, a tiny, 7-year old girl, screaming at the top of her lungs. That’s when I saw that she only had half her leg. She was grabbing in desperation at the physician who was standing next to her, and asking over and over again for anesthesia drugs. We rushed her into the operating room, despite knowing that the anesthesiologist does not have anesthesia drugs to give her, and he does not have sedation medicines to get her sedated or control her pain. As this little girl screams and writhes on the stretcher, the anesthesiologist just starts singing softly to her, like a lullaby. He knows that’s all the comfort he can offer her." 

– Dr. Mike Mallah, deployed to Gaza in March 2024. Watch his story.

Published July 9, 2025

Following the October 7, 2023 attack in Israel committed by Hamas and allied groups, the Israeli government launched a military campaign that has resulted in a humanitarian catastrophe for the 2.1 million Palestinians living in the Gaza Strip.[1] As injury and death tolls surged, health care professionals from across the world traveled to Gaza to address the dire medical needs and support local Palestinian health care workers, who had already been working under extraordinarily difficult conditions, facing constant threats, targeting, detention, and harassment, risking their lives to care for the wounded and sick.[2]

As these health care professionals returned from Gaza, Physicians for Human Rights (PHR) partnered with the Global Human Rights Clinic (GHRC) at the University of Chicago Law School and the Section of Trauma and Acute Care at the University of Chicago to analyze 47 interviews documenting what they saw while entering and providing care in Gaza.[3] At every point in their effort to provide care, volunteer health care professionals face systematic practices and policies that directly impact their ability to prevent suffering and loss in Gaza; specifically restrictions that prohibit them from bringing in basic supplies critical to providing lifesaving care. From morphine to scalpel handles, health care providers narrate how sweeping and unpredictable restrictions, imposed by Israeli authorities under the guise of “dual use” item limitations, resulted in foreseeable, severe, and often preventable pain and anguish to the women, men, and children who came to them seeking care. [4]

At every point in their effort to provide care, volunteer health care professionals face systematic practices and policies that directly impact their ability to prevent suffering and loss in Gaza; specifically restrictions that prohibit them from bringing in basic supplies critical to providing lifesaving care.

While the focus of this report is primarily on the period before Israel’s total blockade on aid to Gaza, which was imposed in early March 2025, it is important to highlight that the escalation of restrictions has only deepened the humanitarian crisis. These ongoing developments underscore the urgency of not only lifting the blockade but also ensuring independent monitoring to prevent the continuation of arbitrary restrictions on the delivery of lifesaving supplies.

Dr. Mike’s Story

Context

The Israeli military offensive in Gaza since October 7, 2023 has included attacks on civilian infrastructure,[5] including against medical facilities, transportation, and personnel.[6] As of July 2, 2025, the UN reports that military operations led by the Israeli Defense Forces (IDF) have resulted in 57,012 deaths and 134,592 injuries among Palestinians in Gaza.[7]

None of Gaza’s major hospitals have been spared, with the World Health Organization (WHO) finding that over 94 percent of all hospitals in the Gaza Strip have been damaged or destroyed.[8] According to WHO, 735 attacks on health care were reported in Gaza between October 7, 2023 and June 11, 2025,[9] resulting in the deaths of more than 1,057 health care providers,[10] and damage or destruction of 159 medical facilities.[11] The denial of health care has also occurred through the deprivation of access to medical supplies.[12] This violence and restrictions have occurred against a backdrop of mounting and acute medical needs arising from the armed conflict itself and the drastic deterioration of health outcomes across the entire population.[13]

Under the international law of occupation, Israel is considered the occupying power in the Occupied Palestinian Territories since 1967. Despite a formal withdrawal of Israeli military forces in Gaza in 2005, the International Court of Justice has affirmed that Israel asserts effective control over the territory’s “land, sea and air borders, restrictions on movement of people and goods, and collection of import and export taxes,”[14] and thus retains obligations to provide care for and protect the rights of people in Gaza under the law of occupation commensurate with its degree of effective control.[15]

The occupation and continued effective control have led to socioeconomic decline, restrictions on the entry of supplies,[16] and isolation that had strained the health system long before October 7, 2023.[17]  

Since October 7, 2023, restrictions on medical supplies in Gaza have taken multiple forms, including the outright prohibition of certain items, delays caused by protracted approval processes, denial of movement permits to aid convoys, and direct attacks on aid convoys, warehouses, and humanitarian personnel.[18] Several humanitarian and UN agencies we spoke to have described restrictions since October 2023 on virtually all supplies and equipment that have resulted in a near-total collapse of health services.

Since 2008, the Israeli government has had a list of “dual use” items that govern which supplies, including medical items, can enter Gaza.[19] Items on this list require special approval from Israeli authorities before being allowed to enter Gaza. The Israeli authorities claim that these restrictions are necessary because of these items’ perceived potential for diversion toward military use and argue that Hamas has been taking these supplies from their intended civilian use.[20] The claim that Hamas is diverting humanitarian aid from reaching Palestinians living in Gaza is widely refuted, including by the UN and the United States Envoy to Israel.[21] The list of restricted items is not transparently published or clearly communicated but appears broad in practice and regularly shifting.[22] Israel released updated lists in January 2023 and November 2024 identifying medical items that no longer require special approval, thus implicitly acknowledging their prior classification as “dual use.” [23]

The criteria for what items are restricted remain unclear. In addition to restrictions on “dual use” items, further limitations on medical supplies entering Gaza have been implemented since October 2023, even though the specific policy or policies, list of restricted items, and justification for these restrictions remain unclear and unpublicized.[24] Humanitarian organizations regularly submit requests to secure approval for bringing supplies into Gaza. However, even when clearance is granted by the Coordinator of Government Activities in the Territories (COGAT), items may still be blocked or denied entry at the border.

Further, while many medically necessary items are not explicitly designated as “dual use” by Israel, they have been restricted in practice, particularly since October 2023. These include items such as cold chain equipment, oxygen generators, insulin pens, and water purification tablets, which have been repeatedly delayed or denied entry into Gaza.[25]

In addition to supply restrictions, access to humanitarian services has also been severely hampered. Since the beginning of the armed conflict in Gaza on October 7, 2023, the routes of entry for medical aid and missions have been significantly limited and changed depending on the intensity of war, security situation, and access permissions.[26] These changes altered the inspection protocols and approval procedures for humanitarian convoys, including the movement of medical missions and the flow of medical supplies. The key events that impeded access are:[27]

Findings: Israel’s Medical Supply Restrictions Lead to Preventable Suffering and Death in Gaza

Before being deployed to Gaza, volunteer health care professionals were aware not only of the shortage of medical supplies but also of the overwhelming number of war-related trauma injuries affecting Palestinians living in Gaza. To manage the unprecedented scale and severity of injuries and alleviate enormous pressure on a collapsing and war-ravaged health system, health care providers participating in short-term medical missions sought to bring with them the essential medical supplies they anticipated would be needed for patient care for the duration of their mission. However, the majority of health care professionals traveling to Gaza who were interviewed shared that they were unable to bring in the supplies necessary to carry out even basic lifesaving medical procedures. In many cases, this was due to restrictions imposed by Israeli authorities, whose control over Gaza’s border crossings ultimately determines what humanitarian items are permitted entry. These limitations directly and negatively impacted their ability to provide care safely, effectively, and in accordance with professional standards to the patients they served in the weeks ahead in Gaza.

Blocked from Saving Lives: Restrictions on Medical Supplies

Within Gaza’s battered health system, Israel’s restrictions on medical equipment, supplies, and medications have posed a significant challenge for health care providers that prevented them from maintaining a minimum level of medical care for civilians. Our analysis shows that these restrictions were deliberate, excessive, unclear, unpredictable, and unjustified.

Opaque restrictions: “I felt that this was unnecessary withholding of things just to withhold it and to cause more destruction.”[37]

The health care providers we interviewed consistently described limitations on items they could bring to Gaza as extreme, inconsistent, and deliberately opaque. None of the interviewed health care professionals, nor any of the humanitarian organizations to which we spoke, were able to obtain a definitive list of banned items. The only publicly accessible list found by PHR and GHRC researchers was the “dual-use items” list from 2008, subsequently updated in 2015 and again in November 2024.[38] Critically, this list does not include most of the items reported by interviewed health care providers and humanitarian organizations as being restricted when they prepared to travel to Gaza or went through military checkpoints.

According to Israeli authorities, all restricted items have the potential for military use.[39] However, the prohibited supplies, such as medications including pain medication, wound care supplies, and surgical equipment, have no legitimate military purpose. All interviewed health care professionals reported that they did not witness any signs of militarization by Hamas or other armed groups within the medical facilities where they were working.

December 2023 to May 2024 – Limited instructions and frequent denials: “It’s hard to understand a pattern and to be able to prepare for that. It’s not consistent at all.”[40]

During the early phase of the war, from December 2023 to May 2024, health care providers were given limited instructions about what they could bring with them. At that time, medical missions were entering Gaza from the Rafah border. Israeli forces were not physically present at the border crossing and health care providers were able to bring as much luggage as they could manage into Gaza. Regardless, health care providers shared that despite being informed they could bring in supplies, they were required to submit a list of all items to Israeli authorities via the WHO and obtain approval before transferring them into Gaza. In many cases, items essential for performing basic medical procedures were denied entry on the basis of “dual use” restrictions. Humanitarian organizations have reported a consistent pattern of Israeli control over aid entering Gaza through the Rafah crossing, requiring all humanitarian shipments to undergo a lengthy scanning and approval process by Israeli authorities.[41]

“It was clear that anything that could be considered dual use would not be permitted to enter … like oxygen delivery systems … the [dual use] definition was expanded in such a vague way that as long as it could be used by some party that somehow would lead to a security threat then [it was not allowed] ….”

– A physician who worked in Gaza in January 2024.[42]


“Our organization has trucks that we try to bring in, and there’s some trucks that will have items that get approved to go in, and then another truck with the same items, they get rejected. And so it’s hard to understand a pattern and to be able to prepare for that. It’s not consistent at all.”

– A physician who worked in Gaza in January 2024.[43]

After May 2024 – More extreme and less workable: “We were told that we are not allowed more than one suitcase.”[44]

After Israeli forces seized control over the Rafah border crossing in May 2024, all medical missions were routed through Kerem Shalom/Kerem Abu Salem and restrictions on what health care providers could bring into Gaza became more extreme. Volunteer health care providers were only allowed to bring in one checked bag, a carry-on bag, and one backpack. After a period, this was reduced to simply one checked bag and one backpack.  Health care providers shared that only personal-use items were permitted in their bags; any items seen as going beyond what was needed for personal use could be confiscated. Health care workers reported that confiscation practices were arbitrary and varied depending on the Israeli officer at the border, making the rules highly subjective.

“The guidance that we received from COGAT [Israel’s Unit for Coordination of Government Activities in the Territories], was that we could only bring one bag, one large suitcase. That suitcase could not contain any medical supplies or equipment. If we were searched at the border, and found to have any medical supplies or equipment, then they would either be confiscated or the entire convoy could be turned back. And that was, in fact, the case for several convoys that went in before me. The things that we were not allowed to bring were basic things, tourniquets, large quantities of disinfectant. I couldn’t carry anything that would be perceived as a surgical instrument. I couldn’t carry anything that would be perceived as medical equipment.”

– A physician who worked in Gaza in July 2024.[45]

“You are only allowed one backpack, one hand carry [carry on], and one check baggage, and you are not allowed to take any medications, any money, any supplies. You’re not allowed to take even two phones or two laptops. You are allowed to just take what is personal stuff for you. And if they find anything like an extra phone, any kind of supplies, medications for that day, they will deny access to all the medical groups which are entering, which may be 20, 30, 40 people. They will all be denied access just because if one [worker] is taking something.”

– A physician who worked in Gaza in April 2024.[46]

Health care workers reported the following items as being restricted from entering Gaza: anesthesia, strong pain killers, sanitation materials, scalpels, scalpel handles, insulin, orthopedic tools (drills, screws, metal plates), suture materials, dressings and gauze, point of care testing, water purification materials, chest tubes, hormone medications for reproductive health, dialysis supplies, batteries, oxygen cylinders, airway and intubation supplies, tourniquets, clamps, skin staplers, and pulse oximeters. Notably, some of these items are included on the January 2023 and November 2024 Israeli lists of medical equipment that no longer requires special approval.

Restrictions on medical supplies and the entry of volunteer health care providers intensified significantly in 2025. Health care workers seeking to enter Gaza faced steadily increasing restrictions, including limits on the amount of medical equipment, electronics, and cash they could carry, as well as new caps on the number of providers allowed entry and the duration of their missions. While the Rafah crossing briefly reopened in February 2025 to allow health care workers entering Gaza and Palestinian patients seeking medical treatment to pass through, it was closed again by Israeli authorities in March 2025. Since then, restrictions have tightened even further, extending to the quantity of food volunteers are permitted to bring in, compounding the already severe operational challenges faced by medical missions and humanitarian actors on the ground.

Extreme restrictions equal extreme consequences: “We did have a surgeon who was capable of fixing that [the injury], but we didn’t have any tools to fix it.”[47]

Among the restricted items that health care providers highlighted were anesthetics and strong pain-relieving medications such as morphine and ketamine, which are essential in a wide range of medical procedures to reduce pain and ensure surgeries are performed without suffering. While some of these items may be permitted through formal humanitarian channels under specific conditions, health care professionals described a lack of access to any reliable, timely, and transparent supply chain. As a result, individuals and medical teams sought to carry in essential items themselves to ensure they could deliver care upon arrival. However, these efforts were frequently blocked by Israeli authorities. These individual restrictions, combined with systemic delays and denials in the official humanitarian aid process, contributed to severe shortages of lifesaving equipment and medicines on the ground.

“There were a lot of restrictions on what we could bring. We were told that certain classes of medications were off limits, so morphine, ketamine, any kind of opioids, powerful painkillers, I was able to bring things like paralytics and a small amount of sedatives and some local anesthetics, the restrictions have become a lot worse. I think my next deployment, that would not be possible.”

– A physician who worked in Gaza in March 2024.[48]

Health care providers also reported restrictions on tools and instruments needed to manage orthopedic injuries and perform surgeries. Screws, plates, drills, and scalpel handles were also prohibited with foreseeable and severe health consequences.

“We were doing trauma amputations without any anesthesia and we didn’t even have a full scalpel. The scalpel handles were not available. We can only use the tip of the blade, 11 blade or whatever blade that you’re getting because it’s banned as a dual use. So you just hold the tip off the blade and then splash some betadine on the patients and cut them and they are already in pain.”

– A surgeon who worked in Gaza in January 2024.[49]

Batteries needed to run essential medical devices, such as portable ultrasounds and blood testing devices used to assess and evaluate patients, were not allowed to be brought in.

“They don’t have the portable monitors. …People have shipped them in, but batteries are not allowed. This equipment cannot be used because they don’t have batteries, basically.”

– A physician who worked in Gaza in December 2024.[50]

Health care providers also reported a significant shortage of basic medical supplies, including antiseptics, antibiotics, gloves, gauze, intubation supplies, and basic medications.

Broad shortages and arbitrary restrictions highlighted above have crippled the health system’s ability to respond to the scale of injuries and illnesses in Gaza, and as will be outlined below, has led to preventable, severe pain and suffering, and loss of lives.

Agony and Amputations: Supply Restrictions Led to Deviations from Basic Standards of Care

Health care workers consistently highlighted that the available medical supplies in Gaza were far from sufficient to meet the health care needs due to the scale of war and nature of injuries. These shortages were attributed to the limited and delayed flow of humanitarian aid permitted by Israeli authorities. But health care workers also consistently noted that they were not able to bring in the medical supplies needed to supplement what they knew to be limited stocks. Their personal accounts offer insight into how severely restricted the larger humanitarian supply chains have been, with everything from items in individuals’ suitcases to aid convoys being prohibited.

“But the really upsetting scene that when we got close to Gaza on the highway, the many, many trucks of [aid] that come in from everywhere, from countries, from humanitarian organizations … stop[ped] on the highway, on both side[s] of the highway, in the middle of the highway.”

– A physician who worked in Gaza in January 2024.[51]

In its war in Gaza, the IDF is using a vast and complex array of weaponry that severely impacts civilians and devastates Gaza’s infrastructure.[52] These weapons cause large-scale damage and would place immense strain on any health system, let alone one that has been deliberately attacked.[53] The targeting of homes, schools, medical facilities, and camps for displaced people has resulted in an overwhelming number and variety of injuries. According to the Rehabilitation Task Force report, as of May 2025, around 30,000 Palestinians living in Gaza are in need of long-term rehabilitation services since October 2023.[54]

Health care providers working in Gaza described receiving patients of all ages with all types of war-related trauma injuries, including severe burns, complex fractures, vascular injuries, amputations, internal bleeding, and crush injuries caused by airstrikes and collapsing buildings.

“We saw a huge amount of traumatic amputations, predominantly in children. So thepredominant population we saw were women, children, much more so than men. Terrible, terrible burns. I mean, just the worst things you can imagine. Children who just literally burnt to death or such severe burns they were going to die.”

– A surgeon who worked in Gaza in December 2023.[55]

Many patients required effective pain management, surgical interventions, intensive care, and long-term rehabilitation, which have remained largely unavailable due to the lack of resources and supplies. These medical challenges unfolded in what was repeatedly described by humanitarian organizations and individual health care providers as the most dangerous and complex crisis they had ever encountered.

All these factors overwhelmed the health system, transforming treatable injuries into death sentences and rendering even basic care extraordinarily difficult, if not impossible.

Health care professionals described numerous cases where patients, including children, arrived at health facilities with injuries that under normal circumstances would have been survivable but proved excruciating or fatal due to delays in care or lack of essential resources such as anesthesia, blood products, or sterile surgical equipment. The result was a cruel paradox; doctors and nurses ready to save lives but unable to do so for lack of most basic supplies. This was not just a logistical problem, but a profound ethical burden experienced daily by health care providers, compounded by the harsh conditions under which they worked. 

Mike Mallah, MD, who worked in Gaza in March 2024, recounted how he was prohibited from bringing in anesthesia, IV fluids, antibiotics, and other essential medications. What he witnessed inside Gaza was even more devastating. He spoke of the unbearable helplessness among health care providers and the desperation of their patients. Dr. Mallah and other health care providers recounted treating major trauma injuries without appropriate pain management, leading to painful procedures and deaths.  

“I heard her screams before I saw her. I was in the pre-op area when she was wheeled in, a tiny, 7-year old girl, screaming at the top of her lungs. That’s when I saw that she only had half her leg. She was grabbing in desperation at the physician who was standing next to her, and asking over and over again for anesthesia drugs. We rushed her into the operating room, despite knowing that the anesthesiologist does not have anesthesia drugs to give her, and he does not have sedation medicines to get her sedated or control her pain. As this little girl screams and writhes on the stretcher, the anesthesiologist just starts singing softly to her, like a lullaby. He knows that’s all the comfort he can offer her.”

– Dr. Mike Mallah. Watch his story.

“One awful memory I have is of this eight-year-old girl coming in with the most appalling fatal burns. She was never going to have a chance…. She was never going to survive because the burns are too extensive and the facial burns were so bad you could see her facial bones through the burned flesh and she was going to die…. We couldn’t give her any pain relief. So she died in the most appalling agony.”

– A surgeon who worked in Gaza in December 2023.[56]

Health care providers performed limb amputations instead of standard vascular and orthopedic surgeries due to restrictions on surgical tools, screws, and plates, and shortages in essential supplies such as wide-spectrum antibiotics, sterilization equipment, and wound care materials. These choices represent a significant departure from internationally accepted standards of care, where surgeries to save limbs would typically be performed if the minimum necessary resources were available. Health care providers also described mass casualty events in which more challenging triage decisions had to be made under extreme pressure driven by limited resources, even beyond what they are accustomed to in other humanitarian settings.

“They have prohibited plates and screws and tool devices, which we use in the operating room to fix … bone fractures …. I remember when we landed in Cairo, they’re [Egyptian inspection officers] specifically looking for power tools. It didn’t make sense. Any screw plates, that didn’t make sense at that point. And a few days down when I saw this child, we did have a surgeon who was capable of fixing that [the injury], but we didn’t have any tools to fix it.”

– A surgeon who worked in Gaza in January 2024.[57]

The war in Gaza has also exacerbated a public health crisis that was already straining the health system long before October 2023. Chronic, non-communicable diseases, such as diabetes, hypertension, and renal failure, were highly prevalent in Gaza before the war.[58] With the health care system’s shift toward treating war-related trauma injuries, fewer resources were allocated to manage patients with chronic cases, and health care providers reported not seeing these patients as frequently as is required. Even when patients sought care, there were not enough supplies for health professionals to provide the needed care, including insulin for diabetic patients and hemodialysis, which requires purified water, for renal failure patients, resulting in preventable deterioration and more deaths among civilians.

“[T]hey were exacerbations of chronic medical conditions. We had one woman who would come in maybe every three or four days in diabetic ketoacidosis because she had type one diabetes and could not get insulin, so we would hospitalize her, release her. She had no way of getting any insulin anymore. So it was just a constant cycle, strokes, heart attacks, infections, sepsis, wound infections.”

– A physician who worked in Gaza in March 2024 and reported a restriction on bringing insulin injector pens into Gaza.[59]

Malnutrition is also a critical and compounding health crisis in Gaza, severely impacting patients with both war-related trauma injuries and chronic illnesses.[60] For individuals with traumatic injuries, malnutrition hinders the body’s ability to heal, weakens immune response, and increases the risk of infection and complications, often turning survivable injuries into life-threatening conditions. Health care providers reported a higher mortality rate in intensive care units due to infections and malnutrition.

In patients with chronic illnesses, health care providers saw that the lack of adequate nutrition undermined disease management, exacerbated existing conditions, and contributed to rapid clinical deterioration.

“So this was a very ugly, vicious pattern. If you don’t get killed from being bombed, you would get killed from lack of medical care and lack of wound care. If you don’t get killed from being bombed or lack of wound or medical care, you would die of lack of nutrition because in order for a wound to heal, you need good nutrition, good protein, good hydration, and they didn’t have that.”

– A nurse who worked in Gaza in January 2024.[61]

The severe shortage and restrictions on medical supplies have profoundly compromised the quality of care in Gaza, forcing health care providers to make life-or-death decisions under conditions that fall far below acceptable medical standards and contribute to unnecessary pain, suffering, complications, and loss of lives.

Conclusion

Since the beginning of the war in Gaza in October 2023, Israeli authorities have imposed strict, opaque, and arbitrary restrictions on medical supplies and created barriers to access for those seeking to manage acute trauma, war-related injuries, and chronic illnesses. These restrictions have included prohibiting essential medical items from getting into Gaza, delaying approval processes, and outright denying the entry of critical aid needed to sustain life.[62] As the war has progressed, these obstacles have compounded the collapse of Gaza’s health system, which is already immensely strained from the overwhelming scale of trauma injuries, the exacerbation of chronic conditions, and the profound deterioration of living conditions.

Health professionals are forced to operate in extremely challenging conditions while deprived of access to basic resources, making it impossible to deliver safe or effective care. Surgeries are performed without anesthesia, infections go untreated, and patients with survivable injuries or chronic illnesses die. The accounts presented here from 47 health workers who were in Gaza reveal a harrowing picture of human suffering marked by unnecessary pain, lasting disability, and preventable deaths. And these are merely a small snapshot.

These accounts are based on the experiences of health care providers who worked in Gaza on short-term medical missions. However, they demonstrate the scale of the health crisis and underscore the broader harm caused by Israel’s policies and practices obstructing medical care. These violations have only worsened between March and May 2025, with Israel’s complete blockade of humanitarian aid, including food, fuel, and medical supplies.[63]

Israel is bound by international humanitarian laws, otherwise known as the laws of war, in its conduct of hostilities in Gaza. This includes the Geneva Conventions of 1949, particularly Common Article 3 and the law of occupation, as well as customary international humanitarian law. Israel is also bound to ensure the rights of Palestinians in Gaza under international human rights law as it has effective control in the Occupied Palestinian Territories.

Under international humanitarian law, all parties to an armed conflict are obligated to ensure the protection and facilitation of medical care for the wounded and sick, without discrimination. Israel’s deliberate obstruction of aid and the denial of access to essential medical supplies and personnel represent a grave breach of these obligations.[64]

Under international humanitarian law, all parties to an armed conflict are obligated to ensure the protection and facilitation of medical care for the wounded and sick, without discrimination. Israel’s deliberate obstruction of aid and the denial of access to essential medical supplies and personnel represent a grave breach of these obligations.

The consequences of Israel’s obstruction of medical supplies and attacks on health will reverberate for years. The long-term impact on Gaza’s population, physically, psychologically, and socially, will not only be measured by lives lost, but also by lives permanently altered in the absence of timely medical care and adequate medical supplies. Where such policies and practices led to death and foreseeable and severe pain and suffering, they raise serious questions of violations of Palestinians’ rights to life, health, and freedom from torture and cruel, inhuman, and degrading treatment.

Amid unimaginable devastation and relentless violence, health care providers working in Gaza have demonstrated extraordinary courage and unwavering commitment to saving lives. Physicians for Human Rights and the Global Human Rights Clinic reiterate our appreciation, admiration, and respect for the lifesaving and health-preserving efforts of Palestinian and international medical professionals providing care in Gaza, who work with limited supplies, under threat of bombardment, and in overwhelmed facilities. Risking their own safety, they perform emergency surgeries, treat severely wounded civilians, and provide care to malnourished children and trauma victims. Their presence offers not only medical aid but also a lifeline of hope to a population enduring extreme hardship. Despite logistical hurdles, restricted access, and constant danger, these health care workers persist, driven by an unshakable sense of duty to protect human life and dignity in one of the world’s most challenging and dangerous humanitarian environments.

Recommendations

  • To All Parties to the Conflict:
    • Immediately cease all forms of violence against medical services, health care facilities, medical transport, health care workers, and humanitarian personnel in Gaza in compliance with international law, including international humanitarian law, international criminal law, and international human rights law.
    • Support all possible efforts to facilitate the work and access of humanitarian and medical agencies, including through UN coordination and local partnerships, in line with humanitarian principles.
  • To the Government of Israel
    • Respect and implement the orders of the International Court of Justice (ICJ) requiring that Palestinians in Gaza have access to lifesaving aid and essential services. This must include the evacuation of the sick and injured who cannot currently access care.
    • Immediately cease all unlawful attacks on health care, including the detention of health care workers, in compliance with international law, including international humanitarian law, international criminal law, and international human rights law.
    • Ensure medical and health care supplies can enter Gaza without delay, restrictions, or obstruction. Immediately lift the blockade on Gaza, establish safe humanitarian corridors, and allow the unrestricted and sustained flow of humanitarian aid, food, fuel, and medical supplies through all available means and delivered in line with humanitarian principles.
    • Ensure that items with medical end uses are not unduly restricted or delayed through inclusion in “dual use” lists or other policies or practices that prohibit their delivery into Gaza in line with internationally recognized standards and international law.  
    • Grant full and safe access to independent international investigative bodies to Gaza to assess the humanitarian situation, investigate allegations of Hamas’s misuse of humanitarian assistance, evaluate the impact of current Israeli policies and practices on basic human rights of civilians in Gaza.
  • To Hamas and Other Palestinian Armed Groups
    • Protect and facilitate access to and delivery of humanitarian aid at all times.
    • Ensure that humanitarian aid, including medical supplies, is not diverted from civilian use.
    • Cease using civilian areas or infrastructure for military purposes.
    • Respect and implement all applicable rules of international humanitarian law, particularly those aimed at the protection of the civilian population, including the principles of distinction, proportionality, and precautions in attack, and the obligation to take all feasible precautions against the effects of attacks, and the special protections guaranteed for health care facilities, transports, and health care workers.
    • Safely and unconditionally release all hostages held by armed groups in Gaza. Until they are released, ensure they are treated humanely.
  • To the Palestinian Authority
    • Support the opening of an independent international investigation to assess violations of international law, including international humanitarian law, international criminal law, and international human rights law in the armed conflict in Gaza.
  • To United Nations Member States
    • Urge all parties to the conflict to abide with international humanitarian law and Security Council Resolutions 2720, 2712, and 2728 on humanitarian aid and access, including by:
      • Ending indiscriminate and disproportionate attacks on civilians.Ensuring the unconditional release of all hostages.Supporting the safe delivery of humanitarian aid without delay or obstruction.
      • Working in close coordination with the United Nations and the Government of Egypt to facilitate the entry of the humanitarian convoy and to guarantee the immediate, safe, and unimpeded passage of humanitarian aid, medical personnel, and relief workers.
    • Apply diplomatic pressure to end the siege and facilitate unimpeded humanitarian access.
    • Establish clear guidance prohibiting the classification of essential medical supplies as “dual use” items, to prevent their restriction in humanitarian contexts.
  • To International Accountability Mechanisms, including the International Court of Justice, International Criminal Court, and United Nations Treaty Bodies
    • Investigate, pursue accountability, and secure reparations for attacks on health care in violation of international law, including the systematic denial and restriction of humanitarian access and medical supplies.

Visuals created by 22 Degrees – Design and Innovation


[1] UNDP, “War in Gaza,” UNDP, May 28, 2025, https://www.undp.org/war-gaza; The Independent International Commission of Inquiry on the Occupied Palestinian Territory, “Report of the Independent International Commission of Inquiry on the Occupied Palestinian Territory, Including East Jerusalem, and Israel – Advance Unedited Version (A/HRC/56/26),” Question of Palestine, June 2, 2025, https://www.un.org/unispal/document/coi-report-a-hrc-56-26-27may24/.

[2] “oPt Emergency Situation Update: Issue 60 | 7 October 2023 – 17 June 2025” (World Health Organization, June 17, 2025), https://www.emro.who.int/images/stories/Sitrep_60_GS2.pdf?ua=1.

[3] Researchers at GHRC and the Section of Trauma & Acute Care Surgery at the University of Chicago have conducted 55 interviews to date and continue to collect data at the time of publication.

[4] The research team analyzed interviews with health care providers deployed to Gaza between December 2023 and December 2024. This analysis was supplemented by information gathered from conversations with humanitarian partners, insights shared by GHRC from additional interviews with providers deployed in 2025, and a comprehensive desk review of relevant materials.

[5] World Bank, European Union, United Nations, “Gaza Strip Interim Damage Assessment (Summary Note),” March 29, 2024, https://thedocs.worldbank.org/en/doc/14e309cd34e04e40b90eb19afa7b5d15-0280012024/original/Gaza-Interim-Damage-Assessment-032924-Final.pdf.

[6] The Independent International Commission of Inquiry on the Occupied Palestinian Territory, “Report of the Independent International Commission of Inquiry on the Occupied Palestinian Territory, Including East Jerusalem, and Israel – Advance Unedited Version (A/HRC/56/26)”; UN OHCHR, “Thematic Report: Attacks on Hospitals during the Escalation of Hostilities in Gaza (7 October 2023 – 30 June 2024),” December 31, 2024, https://www.ohchr.org/sites/default/files/documents/countries/opt/20241231-attacks-hospitals-gaza-en.pdf.

[7] UN OCHA, “Reported Impact Snapshot | Gaza Strip (25 June 2025),” United Nations Office for the Coordination of Humanitarian Affairs – Occupied Palestinian Territory, June 25, 2025, https://www.ochaopt.org/content/reported-impact-snapshot-gaza-strip-25-june-2025.

[8] World Health Organization, “Health System at Breaking Point as Hostilities Further Intensify in Gaza, WHO Warns,” accessed June 26, 2025, https://www.who.int/news/item/22-05-2025-health-system-at-breaking-point-as-hostilities-further-intensify–who-warns.

[9] “oPt Emergency Situation Update: Issue 60 | 7 October 2023 – 17 June 2025.”

[10] UN OHCHR, “UN Experts Horrified at Blatant Disregard for Health Rights in Gaza Following Deadly Raid on Kamal Adwan Hospital,” accessed June 26, 2025, https://www.ohchr.org/en/press-releases/2025/01/un-experts-horrified-blatant-disregard-health-rights-gaza-following-deadly.

[11] “oPt Emergency Situation Update: Issue 60 | 7 October 2023 – 17 June 2025.”

[12] UN OHCHR, “Thematic Report: Attacks on Hospitals during the Escalation of Hostilities in Gaza (7 October 2023 – 30 June 2024).”

[13] Ibid.

[14] “Legal Consequences Arising from the Policies and Practices of Israel in the Occupied Palestinian Territory, Including East Jerusalem” (International Court of Justice, July 19, 2024), https://www.icj-cij.org/sites/default/files/case-related/186/186-20240719-adv-01-00-en.pdf.

[15] Ibid.

[16] UN News, “New Import Restrictions Risk Triggering ‘Dramatic Deterioration’ in Gaza, Says UN Humanitarian Coordinator | UN News,” United Nations News, July 17, 2018, https://news.un.org/en/story/2018/07/1014952.

[17] United Nations Secretary General, “Report of the Independent International Commission of Inquiry on the Occupied Palestinian Territory, Including East Jerusalem, and Israel,” Pub. L. No. A/77/328 (2022), https://www.ohchr.org/sites/default/files/documents/hrbodies/hrcouncil/coiopt/2022-10-19/Report-COI-OPT-14Sept2022-EN.pdf.

[18] MSF, “In Gaza, Staff Are Risking Their Lives to Provide Care,” Medicins Sans Frontieres, May 29, 2025, https://www.doctorswithoutborders.org/latest/gaza-staff-are-risking-their-lives-do-their-jobs; The International Committee of the Red Cross, “Israel and the Occupied Territories: After Two Months of Aid Blockage, Humanitarian Response in Gaza on Verge of Total Collapse | International Committee of the Red Cross,” May 1, 2025, https://www.icrc.org/en/news-release/israel-and-occupied-territories-after-two-months-aid-blockage-humanitarian-response-verge-collapse.

[19] GISHA- Legal Center for Freedom of Movement, “Controlled Dual-Use Items – Unofficial Translation,” September 28, 2008, https://gisha.org/UserFiles/File/LegalDocuments/procedures/merchandise/170_2_EN.pdf.

[20] UN, “Cautious Response to Israel’s New List of Permitted Gaza Imports – IRIN News Article,” IRIN News, July 7, 2010, https://www.un.org/unispal/document/auto-insert-195032/; Israel Ministry of Foreign Affairs, “Hamas-Israel Conflict 2023: Frequently Asked Questions,” accessed June 26, 2025, https://www.gov.il/en/pages/swords-of-iron-faq-6-dec-2023#2.

[21] “UNRWA: Claims Versus Facts,” UNRWA, accessed June 6, 2025, https://www.unrwa.org/unrwa-claims-versus-facts-2025; -Samy Magdy, “U.S. Envoy Says Israel Has Not Shown Evidence That Hamas Is Diverting UN Aid in Gaza,” PBS News, February 17, 2024, https://www.pbs.org/newshour/world/u-s-envoy-says-israel-has-not-shown-evidence-that-hamas-is-diverting-un-aid-in-gaza.

[22] UN OCHA, “Gaza Humanitarian Response Update | 2-15 February 2025,” February 19, 2025, https://www.un.org/unispal/wp-content/uploads/2025/02/OPT.pdf; Tamara Qiblawi et al., “Anesthetics, Crutches, Dates: The Aid Israel Is Arbitrarily Keeping from Gaza,” CNN, March 2, 2024, https://www.cnn.com/2024/03/01/middleeast/gaza-aid-israel-restrictions-investigation-intl-cmd.

[23] GISHA- Legal Center for Freedom of Movement, “Medical Equipment No Longer on Dual Use: Unofficial Translation,” January 2, 2023, https://gisha.org/UserFiles/File/general/Medical_equipment_no_longer_on_dual_use.pdf.

[24] Refugees International, “Siege and Starvation: How Israel Obstructs Aid to Gaza,” Refugees International, Refugees International, (May 29, 2025), https://www.refugeesinternational.org/reports-briefs/siege-and-starvation-how-israel-obstructs-aid-to-gaza/. “Israeli authorities have also refused to provide clear criteria for the delivery of goods to Egyptian, Jordanian, or UN authorities, despite repeated requests. As humanitarian officials told Refugees International, In the absence of clear criteria, humanitarian actors have had to resort to informally crowdsourcing their own lists of approved and rejected items, accumulated based on the collective experiences of individual organizations.”

[25] Ibid.

[26] UN OCHA, “Humanitarian Access Snapshot – Gaza Strip | October 2024,” United Nations Office for the Coordination of Humanitarian Affairs – Occupied Palestinian Territory, November 11, 2024, https://www.ochaopt.org/content/humanitarian-access-snapshot-gaza-strip-october-2024.

[27] Aya Batrawy, “A Timeline of Events Leading up to Israel’s Rafah Offensive,” NPR, May 8, 2024, sec. Middle East crisis — explained, https://www.npr.org/2024/05/08/1249657561/rafah-timeline-gaza-israel-hamas-war.

[28] BBC, “What Is the Rafah Crossing and Why Is It Gaza’s Lifeline?,” November 1, 2023, https://www.bbc.com/news/world-middle-east-67121372.

[29] Tori Rodriguez, “Providing Care in Conflict Zones: A Neurosurgeon’s Mission to Gaza,” Neurology Advisor, May 29, 2025, https://www.neurologyadvisor.com/features/conflict-and-health/.

[30] Mari Carmen Viñoles, “What It Takes to Get Lifesaving Supplies into Gaza,” MSF, May 29, 2025, https://www.doctorswithoutborders.org/latest/impossible-task-getting-lifesaving-supplies-gaza.

[31] Nafisa Eltahir, “At Least 2,000 Medical Evacuations from Gaza Prevented by Rafah Crossing Closure, Says WHO | Reuters,” Reuters, May 29, 2025, online edition, https://www.reuters.com/world/middle-east/least-2000-medical-evacuations-gaza-prevented-by-rafah-crossing-closure-says-who-2024-06-25/.

[32] Associated Press, “Aid Trucks Begin Entering Gaza under Agreement with Egypt to Bypass Rafah,” NPR, May 26, 2024, sec. Middle East, https://www.npr.org/2024/05/26/g-s1-1069/aid-trucks-begin-entering-gaza-under-agreement-with-egypt-to-bypass-rafah.

[33] Reuters, “EU Ministers Agree to Revive Rafah Border Mission | Reuters,” Reuters, May 29, 2025, https://www.reuters.com/world/eu-ministers-agree-revive-rafah-border-mission-2025-01-27/.

[34] António Guterres, “Secretary-General’s Press Encounter on the Humanitarian Situation in Gaza,” May 29, 2025, https://www.un.org/unispal/document/sg-press-encounter-23may25/.

[35] “Emergency Medical Teams (EMTs) in the Gaza Strip | March – May 2025” (World Health Organization), accessed June 26, 2025, https://www.emro.who.int/images/stories/EMT_2025_-_Final.pdf.

[36] “The Secretary-General – Remarks to the Press on Gaza,” UN News, (April 8, 2025), https://www.ochaopt.org/content/secretary-general-remarks-press-gaza; Foreign Ministers of 23 Countries and EU Representatives, “Joint Donor Statement on Humanitarian Aid to Gaza (Non-UN Document),” Question of Palestine, May 29, 2025, https://www.un.org/unispal/document/joint-donor-statement-on-humanitarian-aid-to-gaza-non-un-document/.

[37] Interview UC_0027

[38] GISHA- Legal Center for Freedom of Movement, “Approval for the Entry of Dual Use Equipment – November 2024: Unofficial Translation,” accessed June 26, 2025, https://docs.google.com/document/u/0/d/e/2PACX-1vTomNNf8ZKonZht6yfWLF8d9L8gi5Ag7AN8V7be9ox40Sh74r3jKWuOzirHwhZuKA/pub?pli=1; GISHA- Legal Center for Freedom of Movement, “COGAT Officers’ Authorities Regarding ‘Dual-Use’ Permits Have Been Officially Regulated by Law, Following Gisha’s Legal Advocacy,” June 30, 2017, https://gisha.org/en/cogat-officers-authorities-regarding-dual-use-permits-have-been-officially-regulated-by-law-following-gishas-legal-advocacy/.

[39] Israel Ministry of Foreign Affairs, “Prime Minister’s Office Statement Following the Israeli Security Cabinet Meeting Ministry of Foreign Affairs,” June 20, 2010, https://www.gov.il/en/pages/prime_minister_office_statement_20-jun-2010; Israel Ministry of Foreign Affairs, “Hamas-Israel Conflict 2023.”

[40] Interview UC_0046

[41] Viñoles, “What It Takes to Get Lifesaving Supplies into Gaza.”

“On arrival at Egypt’s Al-Arish airport, humanitarian supplies are loaded onto trucks and taken to Egyptian Red Crescent warehouses, where they are inspected by Egyptian authorities. After inspection, they are reloaded onto trucks and driven to the Rafah border crossing. This first stage takes five to 10 days. 

At Rafah, all trucks are scanned, then driven to an Israeli checkpoint some 30 miles south at Nitzana, where the supplies are unpacked, loaded onto special pallets to fit into the scanner, and scanned again. The convoy then returns to Rafah, where supplies approved by Israeli authorities are unloaded from Egyptian trucks onto Palestinian trucks to enter Gaza. This stage can take weeks.”

[42] Interview UC_0046

[43] Interview UC_0046

[44] Interview UC_0011

[45] Interview UC_0001

[46] Interview UC_0022

[47] Interview UC_0008

[48] Interview UC_0045

[49] Interview UC_0008

[50] Interview UC_0030

[51] Interview UC_0021

[52] UN OHCHR, “UN Report: Israeli Use of Heavy Bombs in Gaza Raises Serious Concerns under the Laws of War,” OHCHR, June 19, 2024, https://www.ohchr.org/en/press-releases/2024/06/un-report-israeli-use-heavy-bombs-gaza-raises-serious-concerns-under-laws.

[53] UN OHCHR and Security Council, “Israel’s Attacks Have Devastating Impact on Gaza’s Hospitals, UN High Commissioner for Human Rights Tells Security Council – Statement,” Question of Palestine, May 29, 2025, https://www.un.org/unispal/document/israels-attacks-have-devastating-impact-on-gazas-hospitals-high-commissioner-for-hr-turk-tells-security-council-statement/; Amnesty International, “U.S.-Made Weapons Used by Government of Israel in Violation of International Law and U.S Law,” Amnesty International USA, April 29, 2024, https://www.amnestyusa.org/press-releases/u-s-made-weapons-used-by-government-of-israel-in-violation-of-international-law-and-u-s-law/; David Gritten, “Gaza War: Where Does Israel Get Its Weapons?,” BBC, April 5, 2024, https://www.bbc.com/news/world-middle-east-68737412.

[54] Rehabilitation Task Force, “Rehabilitation SitRep Q2 2025,” June 11, 2025, https://reliefweb.int/attachments/0ac8eeb2-a453-4e4b-bc2f-2acf64228f4c/Final%20Rehabilitation%20SitRep%20Q2%202025.pdf.

[55] Interview UC_0028

[56] Interview UC_0028

[57] Interview UC_0008

[58] Francesco Checchi, Zeina Jamaluddine, and Oona MR Campbell, “War in the Gaza Strip: Public Health Situation Analysis” (London School of Hygiene & Tropical Medicine, November 6, 2023), https://www.lshtm.ac.uk/media/75901.

[59] Interview UC_0045

[60] According to WHO, the entire population of 2.1 million in Gaza is experiencing extended food shortages due to the Israeli government’s blockade, with half a million at serious risk of hunger, acute malnutrition, starvation, illness, and death. (World Health Organization, “People in Gaza Starving, Sick and Dying as Aid Blockade Continues,” WHO, May 12, 2025, https://www.who.int/news/item/12-05-2025-people-in-gaza-starving–sick-and-dying-as-aid-blockade-continues.)

[61] Interview UC_0043

[62] UN News, “Recurring Denials Hamper Aid Delivery to North Gaza | UN News,” United Nations News, January 11, 2024, https://news.un.org/en/story/2024/01/1145422.

[63] David Gritten and Alice Cuddy, “Gaza Health System ‘Stretched beyond Breaking Point’, WHO Warns,” BBC, May 21, 2025, https://www.bbc.com/news/articles/cj933kj17n0o.

[64] The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949.,” accessed June 26, 2025, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949.

Get Updates from PHR