Other

FAQs: Access to Health Care Supplies and “Dual Use” Items and Restrictions

July 9, 2025 Israel

What does international law say about access to medical supplies in conflict zones? What is the obligation of parties to a conflict to ensure access to health care supplies?

Medical supplies are never to be used strategically in warfare. In times of conflict, all parties to the conflict must both “allow and facilitate rapid and unimpeded passage of humanitarian relief for civilians in need.”[1] States under human rights law continue to have core obligations to maintain essential primary care, including through the provision of minimum essential food, and essential drugs.[2] In contexts where there is an ongoing occupation, the Fourth Geneva Convention of 1949 applies and requires that the Occupying Power, to the fullest extent of its available means, comply with its “duty of ensuring the food and medical supplies of the population; it should, in particular, bring in the necessary foodstuffs, medical stores and other articles if the resources of the occupied territory are inadequate.”[3]

Can a party prohibit access to certain medical supplies in conflict?

Typically, parties to the conflict cannot prohibit access to essential medical supplies. In situations where there is a serious risk that the medical supplies, included as part of humanitarian relief, may be diverted from their destination, a party to an international armed conflict does not need to allow free passage of consignments of medical aid.[4] However, in the context of an Occupation, if all or part of the population of the occupied territory does not have adequate supplies, the Occupying Power must ensure adequate relief schemes for that population and must “facilitate them by all means at its disposal.”[5] Thus, the Occupying Power cannot simply prohibit all access to medical supplies, although they can determine how such aid is provided. Further, under some circumstances, the denial of lifesaving health care in conflict may rise to the level of a war crime or crime against humanity under international criminal law.[6]

What is a “dual use” item?

A “dual use” item is an item that can be used for military and civilian purposes.[7] “Dual use” items are an important part of a country’s import and export control laws, which align with international treaty obligations to not transfer items or materials that could contribute to the proliferation of biological, nuclear, or chemical weapons.[8] “Dual use” items are also commonly considered within a country’s sanctions regimes.[9] In the context of armed conflict, the concept of “dual use” was not originally contemplated in the Geneva Conventions and their Additional Protocols, but has gradually increased over the past two decades, especially since the 9/11 attacks.[10]

How are “dual use” items regulated?

Each country decides what items and materials it considers to be “dual use” in their import and export control laws and policies. This prevents the transfer of these “dual use” items from one country to another and restricts “dual use” items from entering the country. The export and trade of “dual use” items may also be restricted through sanctions imposed by an individual country, regional authority, or the United Nations Security Council.

Are there international standards for “dual use” item regulation?

There is no international standard for the regulation of “dual use” items. This lack of an international standard applies to criteria for classifying items as “dual use,” restriction procedures for these items, and humanitarian exemptions for items.[11]

There are some international treaties concerning the non-proliferation of weapons of mass destruction, such as the 1972 Biological and Toxin Weapons Convention,[12] the 1993 Chemical Weapons Convention,[13] and the 1968 Treaty on the Non-Proliferation of Nuclear Weapons.[14] These treaties outline state obligations to not allow the transfer of items prohibited by these conventions.[15] However, these conventions do not have a specific list of “dual use” items subject to regulation. The one exception is the 1993 Chemical Weapons Convention, which includes a list of chemicals whose transfer is prohibited or intended use is regulated depending on their classification within three categories or “Schedules.”[16]

Outside of international treaties, the regulation of “dual use” items has been supplemented by non-treaty international export “regimes.” These multilateral regimes are not legally binding but are political agreements by participating states who agree to adhere to the export control lists and best practices of a given regime.[17] These regimes include the Australia Group,[18] the Missile Technology Control Regime,[19] the Nuclear Suppliers Group,[20] and the Wassenaar Arrangement on Export Controls for Conventional Arms and Dual-use Goods and Technologies.[21] While these regimes consist of informal groups of states and are politically binding control lists and best practices for those states, they can also serve as helpful examples of state practice and represent the accepted norms surrounding “dual use” item regulation.

Further examples of state practice regarding “dual use” item regulation can be found in individual country’s sanction regimes. In sanction regimes, the transfer of “dual use” items to a particular country is often restricted to curtail the military capacity of state and non-state forces and enforce compliance with international law. Individual countries, regional authorities (like the European Union), and the United Nations Security Council can also impose sanctions.

Are medical supplies considered “dual use” under international export regimes?

Under both international export and sanctions regimes, there is no precedent of medical supplies being restricted as “dual use.”

The Wassenaar Arrangement, Missile Technology Control Regime, and Nuclear Suppliers Group all include detailed language clarifying that items on their “dual use” lists that are intended for medical purposes are not subject to import and export control.[22] The Wassenaar Arrangement includes this specific agreement in its “dual use” item list: “Participating countries agree that equipment specially designed for medical end-use that incorporates an item controlled in the Dual-Use List is not controlled.”[23]

Like international export regimes, sanctions regimes imposed by individual countries, regional authorities, and the United Nations have included language outlining exemptions or exceptions for humanitarian actors, activities, or goods.[24] Exemptions permit humanitarian actors to apply for special approval to bring certain items, particularly those that could be considered “dual use,” into the country under sanctions.[25] Exceptions are provisions within sanction regimes that explicitly exclude the transfer of items intended for humanitarian or medical end-use from sanctions control.[26] A recent example[27] is the sanctions placed on the Russian occupied territories in Ukraine (Donetsk, Kherson, Luhansk, and Zaporizhzhia) by the European Union.[28] These sanctions include specific language noting that sanction controls on goods do not apply to humanitarian actors affiliated with or certified by the European Union who carry out activities in occupied territories.[29]

What items are classified as “dual use” and restricted from entering the Occupied Palestinian Territories (OPT) by Israel? Does Israel restrict medical supplies as “dual use” items?

It is difficult to determine what specific items Israel officially considers to be “dual use.”[30] The official list of items Israel considers to be “dual use,” which require special permission to enter the OPT, can be found in the 2008 Defense Export Control Order, amended in 2015.[31] This official list is composed of two parts: 56 items that require special approval to enter the OPT and 61 additional items that are regulated when entering the Gaza Strip specifically.

Controlled “dual use” items on this list include chemical compounds, metals and construction materials, machine parts, communications equipment, optic equipment and scanners, drilling equipment, and water pumps and sanitation materials. Some items on the list are specific, such as “Aluminum rods, circumference between 50 to 150mm,” while others are listed as broad categories, such as “Equipment and tools of physical and chemical analysis.”[32] Many items could be classified as being part of these broader categories, suggesting that the list may be much longer than it appears.

On March 28, 2022, Israel announced that 56 types of communication equipment will no longer require the special approval needed for items Israel considers “dual use.”[33] Israel made a similar announcement on January 2, 2023, stating that 50 medical items will no longer need special approval.[34] These items include surgical instruments, equipment, and devices as well as thermometers, sterilization equipment, and ventilators. The items listed as no longer requiring special approval in these announcements were not named explicitly in Israel’s original 2008 Defense Export Control Order. In November 2024, another updated list detailing “dual use” items that had been pre-approved for entry into Gaza (no longer requiring special approval) was released.[35] This list included several medical items such as X-ray machines; oxygen generators, concentrators, and flow meters; echo doppler ultrasounds; portable anesthesia machines; vital signs monitors; electrocardiographs; pre-pregnancy and postpartum supplies; and wheelchairs and crutches.[36] This implies that these items were treated as “dual use” items and regulated as such and indicates that the 2008 order does not reflect the comprehensive list of medical supplies that are considered “dual use” items by Israel. This also exemplifies the lack of transparency and clarity which has made determining which items Israel officially considers as “dual use” difficult for those seeking to provide humanitarian medical support in Gaza.

How do Israel’s “dual use” item restrictions compare to other export control regimes?

Israel is not a participating state in any of the multilateral export regimes (Australia Group, Missile Technology Control Regime, the Nuclear Suppliers Group, and the Wassenaar Arrangement), nor is Israel party to the 1993 Chemical Weapons Convention. While there is some overlap between chemical substances, materials, machinery, and communications equipment listed in the 2008 Defense Export Control Order and the multilateral regimes, Israel’s “dual use” regulations go beyond these international norms.

The same can be said when comparing Israel’s 2008 Defense Export Control Order and the list of items restricted from entering Russian-occupied territories in Ukraine through sanction controls imposed by the European Union.[37] This is due in part to the broad categories on Israel’s “dual use” list within the 2008 Defense Export Control Order, which could be interpreted as applying to many individual items that are not specifically listed.

Additionally, Israel specifically lists items that are not included in the multilateral export regimes like fertilizers, pesticides, and water skis. Israel’s list does not include language outlining any possible exemptions for medical end-use, unlike the specific exceptions made in export and sanctions regimes. Israel’s announcement of medical items that will no longer require special approval indicates that Israel has been treating at least some medical items as “dual use” items. As previously mentioned, there is no precedent for the restriction of medical supplies as “dual use” under international export regimes and sanctions regimes. This is a significant difference between Israel’s restrictions and international norms, including sanctions imposed on areas experiencing armed conflict like Russian-occupied territories in Ukraine.

How has the war in Gaza impacted Israel’s practices in terms of restrictions on medical supplies? Were additional items restricted from entering Gaza beyond what was included in the list of “dual use” items? What items were restricted?

Organizations providing humanitarian aid reported items that were restricted from entering Gaza beyond those indicated in the 2008 Defense Export Control Order. These include anesthesia, oxygen cylinders, cancer medications, maternity kits, water filtration systems, water purification tabs, insulin, batteries, ultrasound machines, scissors, generators, crutches, wheelchairs, ventilators, X-ray machines, and sanitary pads and menstrual health kits.[38] Other than restrictions on specific items used in water filtration systems,[39] the rest of the aforementioned items were not explicitly listed in Israel’s 2008 Defense Export Control Order. In interviews analyzed by Physicians for Human Rights, health care workers deployed to Gaza reported restrictions on anesthesia, pain killers, sanitation supplies, scalpels and their handles, insulin, orthopedic materials (drills, screws, plates, etc.), suture supplies, dressings and gauze, ultrasound machines, airway and intubation supplies, AI Stat machines for blood monitoring, water purification materials, hormone medications for reproductive health, dialysis supplies, batteries, oxygen cylinders, tourniquets, clamps and staplers for wound closure, and pulse oximeters. Like the restricted items reported by organizations, other than restrictions on water filtration supplies, the rest of the items are not explicitly mentioned in Israel’s 2008 Defense Export Control Order.

Several of the items reported as restricted fall within the list of medical items that since January 2023 no longer require special approval for entry into Gaza. Per Israel’s own policy, surgical equipment, instruments, and devices; sinks; electric wheelchairs; fetal dopplers; machines for sterilizing medical equipment; UV sterilizers; ventilators; sterile sealing machines; oxygen regulators; pulse oximeters; and tourniquets should not be restricted. However, based on reports from health workers and organizations providing aid to Gaza, this list of unrestricted items has not been applied following October 7, 2023. Many of the medical items reported as restricted, such as X-ray machines, ultrasound machines, pre-pregnancy and postpartum supplies, wheelchairs, and crutches, are included in the November 2024 updated list as “dual use” items pre-approved for entry into Gaza.[40] Israeli officials have claimed that they are abiding by the 2008 Defense Export Control Order,[41] however, as previously outlined, the items reported as restricted are not explicitly stated on this list. Our research shows that there is not a publicly available official, definitive, and updated list of items that are restricted from entering Gaza that is being enforced by Israel.[42]

Based on the evidence collected here, it is clear that these restrictions on medical supplies entering Gaza imposed by Israel extend well beyond legitimate security concerns about “dual use” items that could serve military purposes. The breadth and scope of “dual use” restrictions and additional ad hoc limitations imposed after October 7, 2023 fail to align with international standards and do not include established humanitarian exemptions under “dual use” regimes, suggesting objectives that reach far beyond preventing military advantage.

[1] The International Committee of the Red Cross, “Customary International Humanitarian Law Study, Rule 55,” 55, accessed June 26, 2025, https://ihl-databases.icrc.org/en/customary-ihl/v1/rule55. (establishing this as a norm of customary international law applicable in both international and non-international armed conflicts).

[2] Office of the High Commissioner for Human Rights, “Committee on Economic, Social, and Cultural Rights, General Comment 14: The Right to the Highest Attainable Standard of Health (Art. 12), E/C.12/2000/4,” August 11, 2000, https://www.ohchr.org/sites/default/files/Documents/Issues/Women/WRGS/Health/GC14.pdf.

[3] The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Article 55 – Food and Medical Supplies for the Population,” accessed June 27, 2025, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-55; See also, The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Article 56 – Hygiene and Public Health,” accessed June 27, 2025, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-56.

[4] The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Article 55 – Food and Medical Supplies for the Population,” 55; The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Article 56 – Hygiene and Public Health,” 56.

[5] The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Article 59 – Relief I. Collective Relief,” accessed June 27, 2025, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-59; The International Committee of the Red Cross, “Convention (IV) Relative to the Protection of Civilian Persons in Time of War. Geneva, 12 August 1949. Article 60 – Relief II. Responsibilities of the Occupying Power,” accessed June 27, 2025, https://ihl-databases.icrc.org/en/ihl-treaties/gciv-1949/article-60. It should be noted further that “the Occupying Power shall in no way divert relief supplies from the purpose for which they are intended” except for in cases of urgent necessity which are in the interest of the population of the occupied territory.

[6] See generally, Dustin A. Lewis, Naz K. Modirzadeh, and Gabriella Blum, “Medical Care in Armed Conflict: International Humanitarian Law and State Responses to Terrorism” (Harvard Law School Program on International Law and Armed Conflict, September 2015), https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2657036.

[7] See e.g. “Nato Standard | AJP-3.9 | Allied Joint Doctrine for Joint Targeting, Edition B, Version 1” (NATO Standardization Office (NSO), November 9, 2021), https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1033306/AJP-3.9_EDB_V1_E.pdf.

[8] Machiko Kanetake, “Dual-Use Export Control: Security and Human Rights Challenges to Multilateralism,” in European Yearbook of International Economic Law 2020, ed. Marc Bungenberg et al. (Cham: Springer International Publishing, 2022), 265–90, doi:10.1007/8165_2021_67.

[9] Alice Debarre, “Safeguarding Humanitarian Action in Sanctions Regimes” (International Peace Institute, June 24, 2019), https://www.ipinst.org/wp-content/uploads/2019/06/1906_Sanctions-and-Humanitarian-Action.pdf.

[10] Oona A. Hathaway, Azmat Khan, and Mara Redlich Revkin, “The Dangerous Rise of Dual-Use Objects in War,” SSRN Scholarly Paper (Rochester, NY: Social Science Research Network, August 27, 2024), doi:10.2139/ssrn.4938707.

[11] Kolja Brockmann, “Challenges to Multilateral Export Controls: The Case for Inter-Regime Dialogue and Coordination” (SIPRI, December 2019), https://www.sipri.org/publications/2019/policy-reports/challenges-multilateral-export-controls-case-inter-regime-dialogue-and-coordination.

[12] United Nations, Office for Disarmament Affairs, “Convention on the Prohibition of the Development, Production and Stockpiling of Bacteriological (Biological) and Toxin Weapons and on Their Destruction,” Office for Disarmament Affairs Treaties Database, April 10, 1972, https://treaties.unoda.org/t/bwc.

[13] The Organisation for the Prohibition of Chemical Weapons (OPCW), “Chemical Weapons Convention | OPCW,” accessed June 27, 2025, https://www.opcw.org/chemical-weapons-convention.

[14] United Nations, Office for Disarmament Affairs, “Treaty on the Non-Proliferation of Nuclear Weapons,” July 1, 1968, https://treaties.unoda.org/t/npt.

[15] Kanetake, “Dual-Use Export Control.”

[16] The Organisation for the Prohibition of Chemical Weapons (OPCW), “Annex on Chemicals,” OPCW, accessed June 27, 2025, https://www.opcw.org/chemical-weapons-convention/annexes/annex-chemicals/annex-chemicals.

[17] Brockmann, “Challenges to Multilateral Export Controls.”

[18] “History,” The Australia Group, accessed June 27, 2025, https://www.dfat.gov.au/publications/minisite/theaustraliagroupnet/site/en/origins.html.

[19] Missile Technology Control Regime (MTCR), “Frequently Asked Questions (FAQ),” accessed June 27, 2025, https://www.mtcr.info/en/faq.

[20] Nuclear Suppliers Group, “About the NSG,” accessed June 27, 2025, https://www.nuclearsuppliersgroup.org/index.php/en/about/about-the-nsg.

[21] The Wassenaar Arrangement, “About Us,” accessed June 27, 2025, https://www.wassenaar.org/about-us/.

[22] The Australia Group, “Control List of Dual-Use Chemical Manufacturing Facilities and Equipment and Related Technology and Software,” June 30, 2023, https://www.dfat.gov.au/publications/minisite/theaustraliagroupnet/site/en/dual_chemicals.html; Missile Technology Control Regime (MTCR), “MTCR Guidelines and the Equipment, Software and Technology Annex,” accessed June 27, 2025, https://www.mtcr.info/en/mtcr-guidelines; Nuclear Suppliers Group, “NSG – Guidelines,” accessed June 27, 2025, https://www.nuclearsuppliersgroup.org/index.php/en/guidelines/nsg-guidelines; “Control Lists,” The Wassenaar Arrangement, accessed June 27, 2025, https://www.wassenaar.org/control-lists/.

[23] “List of Dual-Use Goods and Technologies and Munitions List” (Wassenaar Arrangement on Export Controls for Conventional Arms and Dual-Use Goods and Technologies, 2024). https://www.wassenaar.org/control-lists/.

[24] Debarre, “Safeguarding Humanitarian Action in Sanctions Regimes.”

[25] Ibid.

[26] Ibid.

[27] For other examples of exemptions and exceptions for items with humanitarian and medical end-use, See

United Nations Security Council, “Security Council Resolution 661 – UNSCR,” accessed June 27, 2025, http://unscr.com/en/resolutions/661; United Nations Security Council, “S/RES/1737 (2006) | Security Council,” accessed June 27, 2025, https://main.un.org/securitycouncil/en/s/res/1737-%282006%29.

[28] Council Regulation (EU) 2022/263 of 23 February 2022 concerning restrictive measures in response to the illegal recognition, occupation or annexation by the Russian Federation of certain non-government controlled areas of Ukraine (2022). http://data.europa.eu/eli/reg/2022/263/2022-10-07/eng.

[29] Council Regulation (EU), “Consolidated Text: Council Regulation (EU) 2022/263 of 23 February 2022 Concerning Restrictive Measures in Response to the Illegal Recognition, Occupation or Annexation by the Russian Federation of Certain Non-Government Controlled Areas of Ukraine,” accessed June 27, 2025, https://eur-lex.europa.eu/eli/reg/2022/263/2022-10-07/eng.

[30] GISHA – Legal Center for Freedom of Movement, “Red Lines, Gray Lists,” November 1, 2022, https://features.gisha.org/red-lines-gray-lists/.

[31] Israel Ministry of Defense, “The 2008 Dual Export Control Order,” accessed June 27, 2025, https://exportctrl.mod.gov.il:443/Hakika/Pages/240618.aspx. The original version is in Hebrew.

[32] Ibid.

[33] Gisha provides a full English translation of the list of communication equipment. See, GISHA – Legal Center for Freedom of Movement, “Thermometers, Incubators, and ‘Selfie Sticks’: 100 Products That Israel Will No Longer Treat as ‘Dual-Use,’” February 9, 2023, https://gisha.org/en/thermometers-incubators-and-selfie-sticks-100-products-that-israel-will-no-longer-treat-as-dual-use-items/.

[34] Gisha provides a full English translation of the list of medical equipment. See, Ibid.

[35] Palestine – Logistics Cluster, “Palestine – Logistics Cluster Meeting Minutes, Jerusalem/Amman/Cairo, 13 February 2025 | Logistics Cluster Website,” accessed June 27, 2025, https://www.logcluster.org/en/document/palestine-logistics-cluster-meeting-minutes-jerusalemammancairo-13-february-2025.

[36] 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.

[37] Council Regulation (EU), “Consolidated Text: Council Regulation (EU) 2022/263 of 23 February 2022 Concerning Restrictive Measures in Response to the Illegal Recognition, Occupation or Annexation by the Russian Federation of Certain Non-Government Controlled Areas of Ukraine.”

[38] ActionAid, “Essential Aid Including Food and Medical Supplies Prevented from Entering Gaza, as 2.3 Million People Face Starvation and Disease | ActionAid International,” January 19, 2024, https://actionaid.org/news/2024/essential-aid-including-food-and-medical-supplies-prevented-entering-gaza-23-million; 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; 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/; Oxfam Policy & Practice, “Inflicting Unprecedented Suffering and Destruction: Seven Ways the Government of Israel Is Deliberately Blocking and/or Undermining the International Humanitarian Response in the Gaza Strip,” accessed June 27, 2025, https://policy-practice.oxfam.org/resources/inflicting-unprecedented-suffering-and-destruction-seven-ways-the-government-of-621591/; Ana Lucía González Paz et al., “‘Man-Made Starvation’: The Obstacles to Gaza Aid Deliveries – Visual Guide,” The Guardian, March 22, 2024, sec. World news, https://www.theguardian.com/world/2024/mar/22/obstacles-to-gaza-aid-deliveries-visual-guide; The Palestine Chronicle, “‘Long List of Banned Items’ – From Maternity Kits to Wheelchairs, Israel Blocks Gaza Aid – Palestine Chronicle,” accessed June 27, 2025, https://www.palestinechronicle.com/long-list-of-banned-items-from-maternity-kits-to-wheelchairs-israel-blocks-gaza-aid/; 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; United Nations Office for the Coordination of Humanitarian Affairs, “Gaza Humanitarian Response Update | 20-26 May 2024,” May 31, 2024, https://www.ochaopt.org/content/gaza-humanitarian-response-update-20-26-may-2024.

[39] Israel’s 2008 Dual Export Control Order does list “water disinfection materials – solutions with a concentration of over 11%, including hypo-chloride (HTH) and bleach with a disinfectant concentration of over 11% concentration, excluding sand glass for disinfection and filtering” and “dirty water pumps, with a pumping capacity of 10 liters per hour and above.” This could account for the restrictions of water purification materials; however, it is unclear if this includes water purification tabs which were reported by organizations as restricted.

[40] GISHA- Legal Center for Freedom of Movement, “Approval for the Entry of Dual Use Equipment – November 2024: Unofficial Translation.”

[41] Qiblawi et al., “Anesthetics, Crutches, Dates”; Human Rights Watch, “Gaza: Israel Flouts World Court Orders,” accessed June 27, 2025, https://www.hrw.org/news/2024/05/07/gaza-israel-flouts-world-court-orders.

[42] Paz et al., “‘Man-Made Starvation’”; Human Rights Watch, “Gaza: Israel Flouts World Court Orders”; Niku Jafarnia, “Extermination and Acts of Genocide,” Human Rights Watch, December 19, 2024, https://www.hrw.org/report/2024/12/19/extermination-and-acts-genocide/israel-deliberately-depriving-palestinians-gaza; Refugees International, “Siege and Starvation”; Oxfam Policy & Practice, “Inflicting Unprecedented Suffering and Destruction.”

Blog

A City Finds Its Voice: Mosul Establishes Survivor-Centered Justice

July 3, 2025 Mass Atrocities, Iraq

In May 2025, Physicians for Human Rights (PHR) sent a team of forensic experts to Mosul in northern Iraq to conduct a workshop on survivor-centered justice for judges from towns that experienced crimes firsthand committed by the self-declared Islamic State (IS or ISIL). Mosul, located in the Nineveh Governorate in northern Iraq, served as the capital for ISIL from 2014 to 2017 and was the site of horrific atrocities, including genocide and systematic sexual slavery, particularly against the Yazidi population.

Through collaboration with the Supreme Judicial Council and the Medical-Legal Directorate, PHR is helping to develop national guidelines that promote ethical, trauma-informed approaches to investigating and documenting sexual violence, including conflict-related sexual violence.

Today, Mosul is at the center of many of Iraq’s efforts to rebuild after ISIL’s occupation in the region ended. The city is the headquarters of the General Directorate for Survivors’ Affairs (GDSA), charged to oversee the implementation of the Yazidi Survivors’ Law and manage reparations for those survivors. Enacted in 2021, the landmark law for survivors of ISIL crimes provides reparations to women, and children who experienced abduction, sexual violence, and other related atrocities. Its passage marked a significant step toward justice and accountability as the law officially recognized that ISIL committed genocide and crimes against humanity.

Survivors applying for benefits – such as receiving a monthly stipend, medical care, rehabilitation, employment opportunities, and other material compensation, are required to file a criminal complaint and submit supporting investigative documentation. To date, more than 2,300 reparation applications have been approved. However, many survivors and eyewitnesses have described experiences of retraumatization and stigmatization when engaging with justice officials due to repeated interviews and the burdensome investigative process. In some cases, survivors are required to recount their experiences in non-confidential settings and without access to psychological support, resulting in serious psychological harm for survivors.

PHR has been deeply engaged with partners in Iraq for more than seven years, providing support to judges and health professionals to strengthen care and justice processes for survivors of sexual violence. Through collaboration with the Supreme Judicial Council and the Medical-Legal Directorate, PHR is helping to develop national guidelines that promote ethical, trauma-informed approaches to investigating and documenting sexual violence, including conflict-related sexual violence. Our ultimate goal with this initiative is to strengthen national justice processes and ensure meaningful support for survivors in their pursuit of redress.

PHR’s workshop in Mosul in May was conducted in close coordination with the Nineveh Court of Appeals and the GDSA. During the session, PHR emphasized the importance of using techniques to reduce retraumatization and ensure that survivors’ needs are prioritized throughout the judicial process. For example, since the GDSA announced that survivors residing abroad can apply for reparations and provide testimony via video conference at Iraqi embassies, PHR included a dedicated session on best practices for conducting remote interviews.

The workshop was held in the Mosul courthouse, a building in the center of the city that was once used by ISIL as a military training center and was severely damaged during the city’s liberation. Today, more than 10 years after ISIL seized control of the city, the reconstructed courthouse not only stands as a testament to resilience and recovery but also symbolizes the country’s efforts to strengthen justice for atrocities committed by ISIL.

The Role of Judges in Survivor-Centered Justice

For PHR, this workshop marked a significant milestone: it was the organization’s first time traveling to and working in Mosul, and the first time that our training was conducted inside a courthouse. Holding the workshop in the courthouse sent a powerful message that judicial authorities in Iraq are committed to delivering more effective and compassionate justice.

The judges’ active engagement reflected a shared commitment to restoring justice in a city that suffered unparalleled human rights violations and wartime destruction. Chief Judge of Ninevah and President of the Court of Appeal Raed al-Mosleh championed holding the training at the courthouse in Mosul. “Using the courthouse as a training venue for an international organization such as PHR sends an important message to the international community. A place that was once a source of violence and chaos has now become a platform for justice and humanity,” he said.

“Using the courthouse as a training venue for an international organization such as PHR sends an important message to the international community. A place that was once a source of violence and chaos has now become a platform for justice and humanity.”

PHR’s trainings have been especially timely as the judiciary in Mosul and throughout the country has shown increasing interest in handling complex cases related to sexual and gender-based violence, which often involve deeply traumatized survivors. This most recent consultation and training workshop focused on best practices for applying a survivor-centered approach to investigating cases presented to criminal courts under the Yazidi Survivors’ Law, with particular attention paid to crimes of sexual violence and slavery committed by ISIL. Among the key best practices we highlighted was to avoid retraumatizing survivors by reducing the number of interviews they are asked to participate in, ensuring safe, confidential, and supportive environments for survivors to share critical testimonies, and actively engaging survivors in the legal process by providing them with clear and comprehensive information at each step of the justice process.

The training was well received according to GSDA General Director Sarab Elyas, who shared the following: “Providing training to judicial professionals alongside representatives from the GDSA is a positive step toward advocating for a safe environment for survivors – one that respects their privacy and offers moral support.”

Through capacity development efforts such as these, PHR is helping our partners advance justice and accountability for survivors of ISIL atrocities. Central to this mission is the organization’s ongoing work to institutionalize survivor-centered policies that respect the dignity, agency, and rights of survivors of sexual violence.

This project is implemented with the support of the Peace & Stabilization Operations Program of the Government of Canada.

Other

Q&A: 4 July 2025 Hearing before the Cour de cassation (French Supreme Court)

July 3, 2025 Chemical Weapons, France

DOWNLOAD THE FULL Q&A

On the legality of the arrest warrant against Bashar al-Assad in the Syrian Chemical Weapons case (question of personal immunity)

This document shares detailed information about the upcoming hearing before the French Cour de cassation, during which a panel of judges will hear arguments about whether former President of Syria Bashar al-Assad should be legally immune from prosecution for his alleged role in the August 2013 chemical weapons attacks on Adra, Douma, and Ghouta in Syria.

In brief:

This hearing is an important moment for survivors and families of victims of chemical weapons in Syria, and possibly a milestone in accountability for the crimes committed by former President Bashar al-Assad against the Syrian people.

The hearing will be held before the Plenary Assembly of the Cour de Cassation (‘Court of Cassation/French Supreme Court’), representing the highest level of judicial review on immunity for international crimes, an issue of critical global importance.

The hearing can be followed in person and will be available online (after the hearing).

DOWNLOAD THE FULL Q&A

Multimedia

Dr. Salim Abdool Karim on Impact of U.S. Aid Funding Cuts

June 26, 2025 U.S. Global Health Funding Cuts, Global

Salim S. Abdool Karim, MD, PhD, FRS, director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA) and PHR Advisory Council member, reflects on the wide-ranging consequences of cuts to U.S. aid by the Trump administration. As an expert in clinical diseases epidemiology, Dr. Abdool Karim warns of both the unmistakable immediate outcomes and incalculable future impacts of the U.S. funding cancellations.

Blog

Health Workers at the Frontlines of Justice: Confronting the Intergenerational Impact of Sexual Violence in Conflict

June 18, 2025

On June 19, the international community marks the International Day for the Elimination of Sexual Violence in Conflict – a day to honor the strength of survivors and recommit to the pursuit of justice and healing. This year’s theme, “The Intergenerational Impact of Sexual Violence” calls global attention to the profound and enduring harm inflicted not only on survivors, but on families, communities, and future generations.

For over 35 years, Physicians for Human Rights (PHR) has partnered with health workers around the world to confront conflict-related sexual violence. Our work is guided by the understanding that the impacts of violence reverberate across generations, and that justice and healing can begin, often, with a health professional.

A Holistic Model Rooted in Health and Human Rights

PHR’s work addresses the wide range of impacts of conflict-related sexual violence through a unique model that combines:

Rigorous, science-based forensic documentation and research to expose patterns of perpetration of support accountability;

Capacity strengthening for medical, legal, law enforcement, and psycho-social professionals to equip them with the tools and skills to response effectively and ethically;

Trauma-informed, survivor-centered care that prioritize survivor safety, agency, and healing;

Multisectoral networks of professionals who coordinate to support survivors on the pathway to care and justice; and

Strategic advocacy rooted in evidence to advance policy change, promote accountability, uphold legal standards, and improve care for survivors.

In countries including the Democratic Republic of the Congo (DRC), Ethiopia, Iraq, Kenya, Syria, and Ukraine, PHR works hand-in-hand with frontline health workers who play a critical role in identifying, documenting, and responding to conflict-related sexual violence – often under conditions of instability and extreme resource scarcity. These providers are not only caregivers. They are witnesses, advocates, and essential agents in the fight for accountability.

Documenting Abuse – and Its Long-Term Impact

Health workers are often the first to see and identify the physical and psychological consequences of sexual violence, including among children. In conflict settings, those consequences can span a lifetime – shaping survivors’ access to education, health care, livelihood, and social inclusion.

PHR partners with medical professionals to equip them with the tools to document injuries, collect forensic evidence, and translate clinical observations into court-admissible records. In the DRC, our work with clinicians helped expose the staggering scale of conflict-related sexual violence, including cases involving children – and contributed to landmark convictions, such as the 2017 Kavumu judgment, where children were the targets of brutal sexual violence and the forensic evidence gathered by health professionals in the community played a pivotal role in securing justice for the young survivors and their families.

Through our award-winning MediCapt app, PHR supports clinicians to securely record and transmit medical evidence of sexual violence to the justice sector to support accountability. More effective than traditional paper forms, MediCapt enables clinicians to capture comprehensive forensic medical evidence to inform investigations, strengthen prosecutions, and improve the likelihood that perpetrators will be held accountable.

Building Bridges Between Medicine and Justice

PHR’s capacity development programs foster collaboration among health professionals, law enforcement, lawyers, and judges. In Kenya, DRC, Iraq, Ukraine, and beyond, we’ve helped establish multisectoral networks that ensure survivors receive coordinated, respectful care and support.

We train providers not only in forensic documentation, but in trauma-informed approaches that recognize the specific needs of young survivors and mitigate the risks of re-traumatization. These trainings are co-developed with local professionals and are continually updated to reflect global best practices in the collection, documentation, preservation, use, and transfer of forensic evidence of sexual violence.

We set standards for how professionals can support child survivors. PHR developed, in partnership with a global community of practice, foundational principles to provide key considerations for professionals to use when developing and implementing consent and assent processes for child survivors of sexual violence that respect children’s right to be heard and evolving capacity within trauma-informed justice and reparation processes.

By empowering health workers to advocate for survivors and interface effectively with the justice system, PHR helps ensure that healing and accountability can happen in tandem.

Meeting the Moment: Rising Need, Shrinking Support

The intergenerational impact of sexual violence underscores the urgency of long-term, systemic solutions. Yet even as needs rise, funding for survivor-centered, evidence-based programs is diminishing.

PHR is calling for renewed investment in health and justice systems that support survivors – especially children – and hold perpetrators to account. In the midst of a broader erosion of human rights and shrinking support for aid, PHR and our partners are advocating to ensure that the critical funding for survivors of conflict-related sexual violence is secured to enable healing, recovery, and redress.

Our partnerships on the ground demonstrate what is possible with sufficient support: real impact, scalable models, and a pathway to justice grounded in care.

A Call to Action: Justice Begins with Health Workers

This June 19, as we reflect on the enduring harm of sexual violence across generations, we recognize the immense courage and resilience of survivors of all ages and their families and communities who have endured this violence, and we appreciate the immense role of health workers who bear witness, collect evidence, and stand with survivors of all ages to support their justice process and healing journey. Together, we can build a future where no child inherits the trauma of unaddressed violence – and where every survivor’s path to healing begins with care, dignity, and justice.

Brief

Shuttered Clinics, Preventable Deaths: The Impact of U.S. Global Health Funding Cuts in Ethiopia

June 12, 2025 U.S. Global Health Funding Cuts, Ethiopia

This Physicians for Human Rights (PHR) research brief presents key insights from interviews with ten medical and public health experts who support projects across Ethiopia, including in Addis Ababa and Tigray, and data on the impact of the funding cuts across Ethiopia. This brief has a specific focus on Tigray where impacts of regional tensions have exacerbated by cuts to global health aid between February and May 2025. This brief can be used to inform U.S. policymakers, the government of Ethiopia, the international aid community, and global health and human rights leaders of the urgent need to act to restore funding to critical health services.

Read the Brief

Report

Document. Empower. Advocate.

2024 PHR Annual Report

It’s Time to Go Beyond the Clinic

A letter from Sam Zarifi, JD, PHR executive director

I write this letter shortly after a visit to Kenya, where I gathered with members of the Physicians for Human Rights (PHR) Board of Directors, our staff based in Africa, and some of our many local partners. I returned from this trip more alarmed than I have been in my 25 years of human rights investigations around the globe – and more convinced than ever about the importance of the work we are doing at PHR.

Global civil society – indeed the entire international human rights framework – is under strain like never before. In the United States, the early months of the Trump administration have seen a dizzying onslaught of attacks on rights, health, and the rule of law. The administration is brazenly undermining potential checks on its power, be it from Congress, courts, media, academia, scientific institutions, nonprofits, or protestors.

Expertise – including the expertise of health professionals – is not only met with skepticism, but with outright hostility. Critical scientific, medical, and public health institutions are being intimidated, muzzled, and defunded. The United States is not only withdrawing from but actively undercutting the organizations that form the foundations of the international human rights and global health architecture, from the World Health Organization to the Human Rights Council to the International Criminal Court (ICC).

“I returned from this trip more alarmed than I have been in my 25 years of human rights investigations around the globe – and more convinced than ever about the importance of the work we are doing at PHR.”

Read the PHR 2024 Annual Report

Seen from abroad, the U.S. government is signaling that rights can be trampled, that kindness is weakness, and that empathy is “suicidal.” As a result, human rights violators around the world are emboldened, from the Russian-occupied territories of Ukraine to the extractive mineral mines in the DRC to the besieged hospitals of Gaza. Combatants continue to use torture and rape as weapons of war in conflicts around the globe. Prohibited weapons as well as crowd-control weapons are deployed with abandon. The global dismantling of the U.S. aid system threatens to roll back the significant public health gains of the last century. And while brave health workers are on the frontlines responding to all these crises and more, they often find themselves in the crosshairs and targeted for fulfilling their oaths.

Against this grim backdrop, how do we keep fighting?

For me, the answer starts with Physicians for Human Rights and our incredible partners. For decades, PHR has confronted some of the most powerful perpetrators around the globe – and won. PHR has found ways to drive progress on some of the most difficult, seemingly intractable crises that humanity faces. And PHR has built a network of clinicians, scientists, lawyers, and advocacy experts that spans all U.S. states and scores of countries across all continents. PHR was built for times like these.

“For decades, PHR has confronted some of the most powerful perpetrators around the globe – and won. PHR has found ways to drive progress on some of the most difficult, seemingly intractable crises that humanity faces. And PHR has built a network of clinicians, scientists, lawyers, and advocacy experts that spans all U.S. states and scores of countries across all continents. PHR was built for times like these.”

Donate to PHR

Because when disinformation is rife, when society’s most marginalized are attacked, when universal values are called into question, the power of facts, evidence, and truth-telling becomes even more potent. Health professionals have unmatched tools, platforms, and skills to defend not only their patients, but their communities. In moments like these, medical professionals must go beyond the clinic. Now is the time to defend health and human rights inside and outside of health facilities, bringing the clinician’s toolkit to the fight for human rights across the United States and around the world.

I won’t sugar-coat it – everyone who cares about human rights and public health should brace for major tumult in the coming years. But as we set our strategy for the months ahead, it’s helpful to take stock of where we’ve been, the tools at our disposal, and the hard-fought wins we’ve achieved together.

And there were bright spots in the past year. After decades of tyrannical rule and 14 years of large-scale atrocities against civilians, Bashar al-Assad fled Syria and the Syrian people now have a rare opportunity to advance accountability and healing. A new international pandemic treaty was adopted. Despite facing immense attacks and sanctions, the ICC and International Court of Justice continued their independent investigations and prosecutions of some of the most egregious crimes of our time. In the 2024 election, United States voters supported reproductive rights at the state level. PHR played a role in all of these achievements – and many more that you will read about in the inspiring pages ahead. You’ll learn about how our network made a difference from Baton Rouge to Baghdad and from Kinshasa to Kyiv.

In times like these, there is strength in numbers. Autocrats feed on division, isolation, and helplessness. But mass mobilization has been and remains a mighty tool to prevent backsliding and safeguard human rights. And when talented professionals from the medical, scientific, and legal fields come together, there is so much we can do together to protect our communities.

So in this moment when so many are overwhelmed or searching for a way to make a difference, we invite you to join our movement. With your partnership, we can hold the line during these tumultuous times and ultimately drive toward a brighter world, where all rights are fulfilled for all.

Let’s get to work.

Sam Zarifi, JD

PHR executive director

Blog

Syria Should Review the Lessons from Iraq

May 29, 2025 Iraq

It took the rebels just 10 days to topple the Assad regime, whose father and son had ruled Syria brutally for more than five decades. However, rebuilding Syria and fostering national unity will take much longer than the rebels’ rapid takeover. Emerging from decades of dictatorship and a bloody civil conflict, Syria wrestles with multi-generational trauma and inherits a massive legacy of human rights violations, including killings, kidnappings, torture, and enforced disappearances by many perpetrators. United Nations (UN) reports highlight evidence of war crimes committed by all sides during the conflict.

Syria is deeply fractured along ethnic, sectarian, and geographical lines, reflecting divisions entrenched during the war, which has resulted in outbreaks of violence in recent months. Political and military interference by external players with conflicting agendas complicate Syria’s recovery. Widespread corruption, particularly within key institutions like the military, security forces, police, and the judiciary undermines trust in state institutions and the rule of law. Given these challenges, as Syrians are already saying, the country is a prime candidate for transitional justice (TJ) processes. Transitional justice is a set of processes and mechanisms that should not only focus on accountability, but also on addressing the legacy of violations to provide remedies and support the rebuilding of the country on the foundations of peace and justice.

On May 18, 2025, the Syrian government announced a new National Transitional Justice Commission, tasked with “exposing the truth about the grave violations committed by the former regime and holding those responsible accountable, in coordination with relevant authorities,” according to the Presidential l Decree No.20.

As international justice experts rush to offer Syrians their TJ expertise and services, the Syrians may do well to grasp the opportunity to draw relevant lessons from such experiences around the world—and more importantly from neighboring Iraq—while recognizing key differences between the two situations.

Parallels Between Iraq and Syria

What Iraq experienced after the 2003 fall of the Baath regime shares many similarities with Syria’s current situation. Both nations were ruled by the Baath Party for decades, with authoritarian families and their kin dominating power structures. In Iraq, the Sunni-dominated regime under Saddam Hussein mirrored the Alawite-led regime of the Assads in Syria. Both regimes created extensive paramilitary and security apparatuses to suppress dissent, relying on loyalists willing to use any means to maintain control. The nature and scale of the crimes and oppression committed by both regimes, particularly against dissenters, are similar.

The sociopolitical landscapes of Iraq and Syria are also similarly diverse. Both countries are home to a mix of ethnic and religious groups, including Arabs, Kurds, Sunni and Shia Muslims, Christians, and minorities such as Yazidis, Turkmen, and Assyrians. In Syria, the Druze form an additional minority. Before 2003, Iraq’s Sunni Arabs, despite being less than 20 percent of the population, held power over a diverse society. Similarly, Syria’s Alawites, comprising around 10 percent of the population, had ruled since 1971. The military collapse of both regimes underscores the potential for Syria to face challenges akin to Iraq’s, but with the advantage of learning from its neighbor’s missteps.

There are also some key differences between the two situations. One significant distinction between post-2003 Iraq and present-day Syria lies in the nature of the transition of power. In Iraq, the United States-led invasion overthrew Saddam Hussein and transferred authority to opposition groups that had largely remained outside the conflict. In contrast, in Syria, opposition forces who assumed control following the fall of the Assad regime were themselves deeply involved in the decade-long civil war. Another important difference is the role of international involvement. After the fall of Saddam Hussein, Iraq was governed by the United States-led Coalition Provisional Authority (CPA) for over a year. The CPA acted as an occupation authority and made key decisions that shaped Iraq’s political framework and power-sharing arrangements. In Syria, by contrast, opposition groups seized control without the establishment of a formal transitional international authority, instead unilaterally asserting control over political and security institutions

Transitional Justice in Iraq: Lessons Learned

In Iraq, a significant lack of expertise in transitional justice, particularly among Iraqi and Arab-speaking experts, led to, among other things, the absence of a coherent strategy. The steps taken were ad hoc, influenced by exiled Iraqi politicians who failed to assess the perceptions of local Iraqis and by outside powers who accentuated divisions rather than worked to bridge differences. The transitional justice policies heavily relied on punitive measures and compensated specific victim groups without a long-term vision for reconciliation and rebuilding.

Iraq faced numerous issues after the fall of the regime. Apart from the lack of security and stability, the country lacked local capacity and expertise to respond to the massive crimes committed by the Saddam regime. This resulted in a situation where transitional justice was largely shaped by external actors. The outside powers failed to properly understand and assess the challenges that Iraq would face to build peace and reconciliation. By contrast, in Syria the new authorities have been very clear in wanting Syrians to maintain control and lead the process and this is further helped by Syrian actors, inside and outside, who have deep knowledge of the key TJ processes and institutions even while they may lack practical experience in implementing them.

As seen in Iraq, sectarian violence can have a devastating impact on peace and reconciliation efforts. Continued violence not only adds to the number of victims but also complicates any plan or process of transitional justice. The recent outbreaks of violence in Syria’s coastal areas and the south should serve as a warning: the country must act urgently to prevent a descent into chaos.

Iraq’s transitional justice efforts reveal a series of missteps that offer six critical lessons for Syria:

1. Vetting and De-Baathification

Shortly after the fall of Saddam’s regime, the CPA issued orders that disbanded the Iraqi military and removed high-ranking Baath Party members from public service. These measures, known as de-Baathification, were implemented without proper consideration of their long-term consequences. Tens of thousands lost their jobs, creating a massive security vacuum and fostering instability. The process targeted individuals based on rank rather than their actions, fueling resentment and marginalization. De-Baathification became politicized and was, in some instances, used as a tool to unfairly sideline political adversaries and remove them from the political arena.

2. Accountability Measures

The CPA established the Iraqi Special Tribunal to prosecute senior regime figures, including Saddam Hussein, for international crimes such as war crimes, genocide, and crimes against humanity committed by his regime. Iraqi law does not include international crimes. Although the tribunal was an Iraqi court, it was created by the United States. It heavily relied on the United States, the occupying superpower, which in many ways deterred other international support.

For many Iraqis seeing the former president in the dock answering to a judge was a psychological turning point—at last believing the reign of terror had finally ended. However, from the outset, the tribunal faced challenges, including a lack of security, poor public outreach, and allegations of illegitimacy due to U.S. influence.

Ultimately political expediency overtook the judicial process. Saddam Hussein was convicted and executed after only one trial and one case of criminal behavior. For Iraqis waiting to see him held accountable for many other crimes committed during his period in charge, this was a major disappointment.

3. Reparations

Iraq has established several reparation programs over the years, primarily focused on material compensation. These programs cover a broad range of survivors—not only those affected by the Saddam regime, but also those impacted by the violence that escalated after 2003. In 2006, the government began compensating victims of Saddam Hussein’s regime, including those who were killed, imprisoned, or had lost their jobs and properties. As the conflict evolved, the government expanded the scope of reparations in 2009 to include victims of military operations and terrorist attacks.

These programs have been costly, with at least USD 5 billion disbursed in cash to date. However, they have faced significant challenges, including widespread corruption, limited institutional capacity, and inadequate data collection mechanisms—all of which have contributed to flaws in implementation.

Critics have also pointed to political and sectarian manipulation of these compensation initiatives, with some victim groups being prioritized over others.

In 2021, a dedicated program was established to provide reparations for female survivors of ISIS atrocities—an important, though limited, step toward addressing gender-specific harms, stabilizing regions formally occupied by ISIS, and broadening the scope of transitional justice. It is important for Syria’s transitional justice process to also prioritize gender-specific crimes and the needs of sexual violence survivors, including reparations.

4. Truth-Seeking

Iraq failed to establish a comprehensive truth-seeking mechanism, as policymakers prioritized prosecutions over uncovering the truth. This approach has left victims without an official record of past atrocities nor a broader understanding of why this had been allowed to happen. To ensure non-repetition it is essential to understand the reasons and to put in place the necessary institutional and legal safeguards to prevent recurrence. After 2003, Iraq experienced numerous waves of conflict and upheaval, which led to a reliance on ad-hoc fact-finding committees to investigate specific events and crimes. However, these committees were often neither impartial nor transparent, serving the interests of those who created them rather than prioritizing the investigation, documentation, and dissemination of the truth.

Moreover, these sporadic fact-finding efforts were rarely made public, depriving society of a shared understanding of its history and undermining efforts to promote collective healing and reconciliation.

5. Addressing Missing Persons

Iraq faced significant challenges in dealing with mass graves and missing persons. Iraq has one of the highest rates of missing persons in the world. So far, approximately 221 mass grave sites have been discovered, with around 96 attributed to Saddam’s regime. Arbitrary exhumations by victims’ families and inadequate technical capacity have compromised evidence and hindered justice. Iraq has a law governing mass grave exhumations and in contrast with other measures, the Iraqi institutions dealing with missing persons have, over time, developed significant technical expertise. As such, they are potentially well-positioned to pass on that experience to their Syrian counterparts in building their capacity in this critical area.

6. Civil Society Engagement

The role of civil society is crucial in transitional justice—not only in advocacy and promoting accountability and justice, but also in gathering evidence and amplifying the voices of victims. However, this was not the case in Iraq after 2003, despite the massive number of victims and the widespread legacy of human rights violations. Decades of dictatorship and the absence of fundamental freedoms prevented Iraq from developing a robust civil society. This vacuum in the post-2003 period weakened the design and implementation of transitional justice measures.

Recommendations for Syria

To avoid the pitfalls experienced by Iraq, Syrian policymakers and international stakeholders should avoid the Iraqi ad-hoc approach and adopt a comprehensive and inclusive transitional justice strategy. This strategy should involve consultations within all sectors of Syria, and include short-, medium-, and long-term goals supported by data collection—such as public polls—to assess public perceptions and inform resource allocation. Transitional justice in Syria should be based on a victim-centered approach while avoiding retributive justice. The establishment of the National Transitional Justice Commission is a positive step in the transitional justice process. However, while the Commission is mandated to address violations committed by the Assad regime, it will find that it cannot ignore violations committed by all parties to the conflict. The justice component of the transitional justice process should not reflect a “victor’s justice” approach. Instead, the rights and needs of all victims must be addressed equitably and without discrimination.

Truth-Seeking and the Protection of Mass Grave Sites

A national truth-seeking initiative should involve all segments of Syrian society. Given Syria’s long history of violence and abuses, documenting and acknowledging the past is essential for designing effective reparations, promoting accountability, and fostering national unity. Such an initiative must be inclusive and transparent to ensure widespread societal buy-in. Moreover, the right to know the truth should be upheld as a fundamental human right.

As part of truth-seeking efforts, one of the most urgent issues is the protection of mass grave sites. Syrians will need to develop a legal framework to secure and protect mass grave sites. Exhumations should only begin after building national technical capacity and establishing a national entity to take the lead in this area. Nationalizing the process of identifying missing persons is essential to ensuring the collaboration of victims’ families, building trust, and addressing their needs.

Syrians have the advantage of a newly established international mechanism, the Independent Institution on Missing Persons in the Syrian Arab Republic. This institution will help bring expertise and capacity, coordination of international actors and a readiness to work inside Syria in partnership with an impartial and independent national body or bodies. Syrians should seek to benefit to the fullest from this new institution.

Conducting public surveys to understand public attitudes toward peace, justice, and reconciliation have been shown to be a useful way of gathering insights that reflect societal priorities and help shape transitional justice strategies.

Accountability

Syria should develop a comprehensive strategy for accountability for crimes committed over the past few decades. This strategy should reflect the following:

Defining the threshold for accountability, including which crimes and perpetrators should face prosecution and who may be eligible for other forms of accountability or even pardons, along with the conditions for such exemptions.
Ensuring the legitimacy of any justice process, it must address crimes committed by all parties to the conflict.
Assessing the capacity and limitations of the current judicial and law enforcement systems to determine the most effective accountability mechanisms.
Integrating accountability measures with other pillars of transitional justice, such as truth-seeking, reforms and reparations, to ensure a holistic and survivor-centered approach to justice and reconciliation.

To embark upon this strategy collecting data and mapping crimes and perpetrators to establish a clear record of violations will be an essential step and Syria can benefit from the data-gathering that has been done over many years by Syrian and international civil society organizations. It should also be able to call upon the Independent International Commission of Inquiry that has been gathering data on grave human rights and humanitarian law violations (including war crimes and crimes against humanity) since late 2011.

Syrian and international non-governmental organizations (NGOs) can also assist with data-sharing related to grave human rights violations. For example, Physicians for Human Rights (PHR) has meticulously documented the systematic targeting of Syria hospitals and health care workers during the civil war. This data and other credible sources can be used to inform Syria’s transitional justice efforts to hold perpetrators accountable for attacks on civilians and civilian objects committed during the war.

The prosecutor of the International Criminal Court has already visited Syria and the court may have a variety of useful roles in assisting Syria in its endeavors to deal with past international crimes, but even more importantly will be the strength of the partnership being established between Syria and the International, Impartial and Independent Mechanism that was established in December 2016 to assist “in the investigation and prosecution of crimes under International Law committed in the Syrian Arab Republic since March 2011.”

The national legal and judicial system in Syria should be strengthened to the point where it can effectively address atrocities. It is imperative that all relevant international entities and stakeholders support efforts to build the capacity of Syria’s national institutions.

Institutional Reform

With the dissolution of the Assad regime’s army, security agencies, and Baath Party by the new Syrian authorities, the following issues must be considered in the process of rebuilding the military and security forces and other institutions:

Vetting vs. Purging: Reforms should prioritize vetting individuals based on their actions and records rather than resorting to wholesale purges. This approach ensures fairness, minimizes disruptions, and preserves institutional functionality. A realistic objective and actionable plan must be established to guide this process. The institutional reform strategy should be forward-looking, emphasizing future resilience while safeguarding against potential abuses.
Security Sector Reform: Professionalize the military and security forces to eliminate corruption and ensure they protect citizens rather than suppress dissent. Oversight mechanisms are essential to building public trust.

Reparations

Unlike Iraq, Syria may lack the same level of financial resources to effectively address all the needs of survivors, especially after the destruction from the state’s policies during the lengthy internal armed conflict it has endured since early 2011. This will be felt most directly if discussions around compensation or reparations focus only on financial payments to victims. So, it will be important to manage survivors’ expectations to avoid false promises that could inadvertently deepen their suffering.

That said, while Iraq relied heavily on one form of reparations programs (financial compensation) successful reparations programs from around the world and in the Middle East North Africa (MENA) region (Morocco is an example) relied on several types of reparations including but not bound by financial compensations alone. Such programs have included communal programs, symbolic reparations and in some instances an official apology by the new head of state for the harm done to individuals or communities by the state. Programs have also been developed that extend the financial cost of reparations over several years as opposed to incurring the total cost in one year and for example have included subsidies in the health and education spheres for victims’ families and the survivors.

In many ways in a conflict such as the one in Syria, all of Syrian society has been victimized and programs recognizing this will likely help in the process of healing and restoring trust.

Strengthening Civil Society

Civil society organizations as well as survivors and families of victims should be empowered to participate in transitional justice efforts. Their involvement is essential and will enhance public engagement, ensure diverse perspectives, and build community trust. There will likely be differences in experience, knowledge, and perception between civil society activists abroad and also with those who remained inside Syria. That has been the case in many TJ processes around the world.

To ensure a broader involvement of civil society, particularly representatives of victims’ groups and different segments of Syria, the new Syrian authorities should establish inclusive consultation mechanisms that engage victims’ groups, women’s organizations, youth representatives, and minority communities in political and transitional processes. The authorities should also guarantee freedom of expression and assembly to allow civil society actors to operate without fear of reprisal.

The Role of Physicians for Human Rights (PHR)

Physicians for Human Rights (PHR) has played a significant role in documenting and collecting evidence of crimes committed in Iraq and Syria, in addition to capacity strengthening support for medical and legal partners in both countries. For example, in Iraq PHR confirmed that the Saddam Hussein regime used chemical weapons—including mustard gas and the sarin nerve agent—against the Kurdish population in the late 1980s. PHR scientists and investigators collected soil samples from the Kurdistan Region and assisted in the exhumation, identification, and determination of probable causes of death of victims found in mass graves. This evidence was later used by the Iraqi High Tribunal in the prosecution of Saddam Hussein and his aides for genocide against the Kurds, and in supporting compensation claims for Kurdish victims.

In Syria, since the start of the conflict in 2011, PHR has documented attacks on health care, including assaults on medical facilities and personnel. Based on this work, PHR has produced numerous reports and compiled substantial evidence of violations of medical neutrality. This documentation should serve as a key resource for any future accountability and reparations initiatives or programs in Syria.

Conclusion

The international community should provide technical and financial assistance to support Syria’s transitional justice process. Lessons from Iraq and other post-conflict settings can help guide these efforts. Syria’s situation remains fragile, and its political and social landscape risks collapsing or backsliding. Sustained international assistance is critical to help the country overcome these challenges.

Syria can benefit from existing international mechanisms and entities that can provide critical assistance, such as the International, Impartial, and Independent Mechanism (IIIM), established by the UN in 2016, and the Independent Institution on Missing Persons in the Syrian Arab Republic (IIMP), established in 2023. The data collected by the Commission of Inquiry (COI), established by the UN Human Rights Council in 2011 to investigate the human rights and humanitarian law violations during the conflict in Syria, is essential for any accountability, truth-seeking, reforms, or reparations programs. The ICC and other international institutions should stand ready to provide additional much needed technical support.

While Syria lacks financial resources after the destruction wrought by the lengthy civil conflict, it does not lack capable people who can develop and run these TJ programs. In many discussions and debates before and after the December fall of the previous regime, this expertise has been there for all to see. Their actions that lead to the establishment of the IIIM and the IIMP are a testament to these abilities and their resilience. What they may lack today, through no fault of their own, is the practical experience of developing and running such programs. They would do well to now link up with counterparts who have implemented such programs, in the MENA region and beyond, because they can provide crucial assistance in pointing out what worked well, what pitfalls to avoid, and more crucially with the benefit of hindsight to say what they might have done differently.

By learning from Iraq’s experience and implementing a well-thought-out transitional justice strategy, Syria can navigate its post-conflict period more effectively. Although the United States and other countries plan to remove or ease the international sanctions, the new Syrian government should take tangible steps to encourage their full removal. These steps should address the root causes of division and promote inclusive governance that respects the rights of all Syrian factions. Such efforts are essential not only for achieving lasting peace and stability within Syria but also for contributing to regional security.

Abdulrazzaq Al-Saiedi is an expert in transitional justice and rule of law initiatives in the Middle East and North Africa (MENA) region. He serves as Technical Expert for Physicians for Human Rights (PHR).

Originally published by New York University Center on International Cooperation (CIC).

Photo: Al Hajar al Aswad City, 4 kilometers south of the center of Damascus in the Darayya District of the Rif Dimashq Governorate, Syria. March 21, 2025. Courtesy of New York University.

Open Letter

Save Lives Globally and Safeguard Americans’ Health: PHR Urges Congress to Restore U.S. Global Health Leadership

May 16, 2025 U.S. Global Health Funding Cuts, United States

Download PDF

Dear Honorable Chairmen and Ranking Members:

Physicians for Human Rights writes with recommendations related to the proposed funding reduction for global health programming included in the White House’s FY26 budget request. While the full package and details on specific programs has yet to be released, the White House’s Fiscal Year 2026 (FY26) budget request includes billions of dollars of cuts to vital global health programs. This is a crucial moment to understand how the aid cuts imperil lives and health, and what the administration’s plans are to protect against global health threats that transcend borders.

Physicians for Human Rights urges members of Congress to exercise Congress’ power to determine the FY26 federal budget and to protect, restore, and fully fund global health aid to prevent further loss of life and grave risks to health arising from incapacitated global health response, globally as well as within our own borders.

Since January, the consequences of the U.S. government funding freeze have begun to ripple across the globe. This is especially clear in countries already strained by conflict, poverty, and weak health systems. From fears of a “superbug” in Zambia to Ebola containment breakdowns in Uganda, the stories emerging from health care workers reveal a worsening public health crisis that threatens not only vulnerable communities abroad, but also American global health security and strategic interests.

Physicians for Human Rights has spoken with health workers from conflict-devastated Tigray in northern Ethiopia, where an estimated 600,000 people died during the 2020 to 2022 conflict. They described how the U.S. funding freeze resulted in thousands of layoffs in the already deeply strained health sector, halted the reconstruction of three critical health facilities, and forced the closure of mobile clinics serving thousands of internally displaced people. The cuts are causing shortages of essential medical supplies and reproductive health services which clinicians report are leading to preventable deaths, including women dying in childbirth because the facility where they would seek care had closed. Our partners in Ethiopia also report that thousands of survivors of sexual violence, both children and adults, are no longer able to access facilities that provide a one-stop center for post-rape medical care.

The experience of Ethiopia is borne out across dozens of countries where lifesaving services, many funded for years by U.S. global health dollars, have suddenly disappeared, with no time for contingency planning, no bridge funding, and no alternative infrastructure. Projections published in The Lancet estimate that, “without continued PEPFAR programmes, models predict that by 2030, an additional 1 million children will become infected with HIV, 0.5 million additional children will die of AIDS, and 2.8 million children will additionally become orphaned by AIDS.” Partners have reported to Physicians for Human Rights that deaths have already occurred due to the disruption of programs addressing maternal and child health, tuberculosis, malaria, HIV, and other leading causes of death. These cuts have deadly consequences that will drastically increase over time.

The U.S. funding cuts are not only a manmade humanitarian catastrophe, but also undermine American global health leadership, global security, and strategic partnerships. The abrupt nature of the freeze and the absence of an organized response have sent a dangerous message: that lifesaving aid is now subject to abrupt cuts, rather than long-term planning grounded in public health and focused on health outcomes.

The funding cuts are destabilizing health systems while weakening preparedness for future pandemics. With global vaccination programs interrupted and monitoring tools like the Demographic and Health Surveys suspended, the United States’ ability to detect and contain emerging health threats is diminished. The longer this funding gap persists, the greater the risk of widespread disease outbreaks and instability – both of which ultimately impact the United States, through the emergence of drug-resistant infections that transcend political borders.

History has shown that when the United States leads on global health, the world is safer, and so are Americans. In the wake of the COVID-19 pandemic, there is no need to relearn this lesson. Global health investments are not charity, but a strategic, cost-effective investment in global stability and American prosperity.

For this reason, Physicians for Human Rights urges Congress to take the following actions immediately:

Protect, restore, and fully fund global health initiatives. This includes full multiyear appropriations for PEPFAR, global health support, and related programs that provide frontline health services, build resilient health systems, and improve infectious disease surveillance.
Insist on transparency, oversight, and reinstatement of monitoring programs such as the Demographic and Health Surveys, which provide essential data to assess health trends, track outcomes, and prepare for future threats.
Mobilize supplemental emergency funds or bridge resources, either through appropriations or bipartisan diplomacy, to mitigate the fallout from the January 2025 aid freeze and prevent further destabilization.
Encourage multilateral coordination, urging the United States and other donor governments and philanthropic partners to collaborate to help close critical funding gaps that jeopardize shared global health goals.

Millions of lives are at risk as long as these funding cuts remain in place. The United States must not abandon its long-standing role as a global health leader. Doing so not only endangers communities abroad, but it also increases the likelihood of future crises that will reach our borders. Now is the time to protect hard-won progress, save lives, and preserve the strategic advantages of American leadership in global health.

Physicians for Human Rights is also eager to connect you or your staffers to members of our networks who are experiencing the impacts of these policies on the ground around the world. Please contact us if you would like Physicians for Human Rights to arrange for a briefing with our experts and network members to understand the impact of these cuts.

Sincerely,

Payal Shah, JD

Physicians for Human Rights (PHR)

Director of Research, Legal, and Advocacy

Download PDF

Sent to:

Sen. James Risch
Chairman, Senate Foreign Relations Committee

Sen. Jeanne Shaheen
Ranking Member, Senate Foreign Relations Committee

Rep. Brian Mast
Chairman, House Foreign Affairs Committee

Rep. Gregory Meeks
Ranking Member, House Foreign Affairs Committee

Sen. Lindsey Graham
Chairman, Senate Appropriations Subcommittee on State and Foreign Operations

Sen. Brian Schatz
Ranking Member, Senate Appropriations Subcommittee on State and Foreign Operations

Rep. Mario Diaz-Balart
Chairman, House Appropriations Subcommittee on National Security and Department of State

Rep. Lois Frankel
Ranking Member, House Appropriations Subcommittee on National Security and Department of State

Report

Shadow Report for the Ethiopia State Party Report at the African Commission on Human and People’s Rights 83rd Session

May 6, 2025 Attacks on Health Care, Ethiopia

Executive Summary

Physicians for Human Rights (PHR) and the Organization for Justice and Accountability in the Horn of Africa (OJAH), have documented widespread, systematic and deliberate conflict related sexual violence (CRSV) in the Tigray region. Evidence gathered by PHR and OJAH, through a systematic review of medical records, shows that CRSV was used as a clear tactic during the active conflict period between November 2020 and November 2022 and has continued since the signing of the Cessation of Hostilities Agreement (COHA) in November 2022. In addition to ongoing CRSV, there have recently been reports of escalating tension along the Ethiopia-Eritrea boarder raising concern about a new war, and ongoing violence in Eastern Tigray, which is still reported to be occupied by Eritrean forces, and in areas in Western Tigray that are reported to continue to be occupied by Amhara forces. Since the signing of the COHA there has also been an escalation of conflict in other regions of Ethiopia. There have been reports of CRSV, attacks against health care, mass arbitrary detention, and mass killings among others in the Amhara, Afar, and Oromia regions.

It is critical that the Ethiopian Government conduct independent and impartial investigations into allegations CRSV and other atrocities and hold perpetrators to account. To the extent such efforts occur within a transitional justice framework, the Ethiopian Government’s Transitional Justice Policy has thus far failed to provide holistic, survivor and victim-centered pathways to peace and justice for all those impacted by the conflict in northern Ethiopia, as well as for victims and survivors of abuses across the country. Such shortcomings raise serious concerns regarding whether the Transitional Justice Policy complies with key regional standards, including the African Union’s Transitional Justice Policy. It is with concern for the escalation of violence across Ethiopia and the failure of efforts toward accountability and justice that PHR and OJAH proposes the following questions and recommendations be integrated into the Commission’s state review of Ethiopia at the forthcoming African Charter on Human and Peoples’ Rights session. This submission draws on public documents, including press reporting, research from PHR, OJAH and other human rights and civil society organizations, and United Nations documents and reports.

Download PDF

What does international law say about access to medical supplies in conflict zones? What is the obligation of parties to a conflict to ensure access to health care supplies?

Can a party prohibit access to certain medical supplies in conflict?

What is a “dual use” item?

How are “dual use” items regulated?

Are there international standards for “dual use” item regulation?

Are medical supplies considered “dual use” under international export regimes?

What items are classified as “dual use” and restricted from entering the Occupied Palestinian Territories (OPT) by Israel? Does Israel restrict medical supplies as “dual use” items?

How do Israel’s “dual use” item restrictions compare to other export control regimes?

How has the war in Gaza impacted Israel’s practices in terms of restrictions on medical supplies? Were additional items restricted from entering Gaza beyond what was included in the list of “dual use” items? What items were restricted?

The Role of Judges in Survivor-Centered Justice

A Holistic Model Rooted in Health and Human Rights

Documenting Abuse – and Its Long-Term Impact

Building Bridges Between Medicine and Justice

Meeting the Moment: Rising Need, Shrinking Support

A Call to Action: Justice Begins with Health Workers

It’s Time to Go Beyond the Clinic

A letter from Sam Zarifi, JD, PHR executive director

Sam Zarifi, JD

Parallels Between Iraq and Syria

Transitional Justice in Iraq: Lessons Learned

Recommendations for Syria

Conclusion

Executive Summary

Donate

Get Updates from PHR