The Role of Health Researchers in Documenting Health Suffering and Crimes against Humanity Resulting from 2018 US Sanctions against Iran

On November 20, 2018, the United States imposed unilateral sanctions on the Republic of Iran. The intention of these sanctions, which are being used in conjunction with other political pressures, is to impose financial hardship on Iran for its perceived support of Syrian president Bashar al-Assad and terrorism. The consequences of these sanctions for the Iranian population will be manifold, with health likely to be one of the first sectors to suffer. There is no designated international body responsible for monitoring population health in the wake of sanctions; thus, health researchers have a pivotal role to play in the international community. The timely collection of health data can supply bodies such as the United Nations Security Council with information about the justness of the US sanctions and can be used in making arguments to protect human rights, including health, and in preventing crimes against humanity. This article briefly explains the concept of crimes against humanity and how health data and health service researchers can play an important role in drawing attention to declining health indicators in a sanctioned country.

campaign to counter the Iranian regime's influence and destabilizing regional activities" and to impose a "financial toll on the Iranian regime" (U.S. Department of State, 2018). It is important for health service providers and researchers around the world to take note of these words. This paper highlights the role that health service research can play at the intersection of population health, politics, and international law.

Background
Sanctions have been prominent in the history of Iran-US political relations beginning with Iran's 1979 Islamic Revolution. The US response to the hostage crisis (1979)(1980)(1981) was to impose sanctions freezing all Iranian assets held in the US. The 1980s and 1990s were marked by US sanctions on Iranian oil resources and general trade. In 1996 the US passed the Iran and Libya Sanctions Act to penalize Iran for weapons of mass destruction as the rationale for these sanctions, despite a lack of proof that Iran was developing nuclear-related technology. These sanctions targeted the oil industry. In 2006 the US mounted a financial embargo against Iran, banning all business transactions between the two countries, citing Iran's support of terrorist organizations as the rationale for these measures. In 2010 the Comprehensive Iran Sanctions were implemented alongside various executive orders by former US president Barack Obama. In addition, the United Nations Security Council imposed multilateral sanctions in 2006 and 2011, referring to Iran's "undeclared nuclear activity" as the international security threat sparking these sanctions (Marossi & Bassett, 2015). Over the last four decades health service providers and researchers have continued to work in Iran despite sanctions causing challenging conditions, lack of medicine, and declining public health indicators (Gorgi, 2014;Velayati, Jamati, & Hashemian, 2015;Gorgi, 2013). At each of these time periods, health researchers have published articles calling for the end of sanctions and the exemption of health supplies and medicines from financial embargos. But little has changed. This article proposes an approach for health services researchers in mounting a response to sanctions: the use of health data, published as close to sanction implementation as possible when health indicators start to decline, to document the impacts of sanctions on local populations. This quantitative health research data can be used to effect change through international law.

International Law and Crimes against Humanity
Health data can be used by the international legal community to mount a case for crimes against humanity and violations of the principles of international law. There is currently a disconnect between international laws enacted to prevent human suffering that arises from attempts to maintain world order and the reality of suffering caused by international politics. International law imposes restrictions and rules on what nations can and cannot do. International politics is another matter, as we see with the 2018 US sanctions against Iran, and international law does not always dovetail with political decision-making.
The power of international law can be harnessed to protect human health in sanctioned countries.
International law applies in two discreet periods: wartime and peacetime. Laws of armed conflict derive from treaties such as the 1949 Geneva Convention and lay out explicit principles pertaining to matters such as the humane treatment of prisoners of war and the protection of civilians. International laws around peacetime interventions, such as sanctions, are not as clear. The United Nations was formed after World War II to prevent and restrict war, and the laws of armed conflict were solidified during this time.
Far less thought was given to laws around peacetime interventions. These can include anything from multilateral sanctions mandated by the UN Security Council to the withdrawal of economic aid and unilateral sanctions. The law of proportionality--that "the punishment should fit the crime"--does not apply to peacetime interventions as it does in armed conflict. Proportionality requires that harm to civilians be considered, rather than just military victory. The principle of proportionality is not applied to sanctions (a peacetime intervention), an oversight of international law that has already caused suffering for the Iranian people. This means that in imposing sanctions on Iran the US is not obligated to consider the numbers of Iranian civilians whose mental and physical health will suffer as a direct result of sanctions, nor the number of people who will die as a result of degraded health services or lack of medicine.
To reverse this lack of accountability on the part of nations that impose sanctions without regard for the impacts on the local population, an international convention on peacetime crimes against humanity is urgently needed. The international legal community and the UN General Assembly are considering such a convention (Murphy, 2015). In the interim, health researchers are empowered by population health data to build a case for cessation of inhumane political acts through the existing legal designation of crimes against humanity. This is the most effective way for health services research to affect change in politics and the human suffering caused by sanctions.
"Crimes against humanity" is a legal concept whereby nation-states and individual country leaders can be held accountable for their actions that cause harm to a population, in both wartime and peacetime (Murphy, 2015). The 2018 US sanctions against Iran would be classified as peacetime crimes. There are still legal steps to be taken by the UN General Assembly and the International Law Commission to create a convention on crimes against humanity. However, this legal concept is important for health researchers to understand. Article 7(k) of the Rome Statute of the International Criminal Court highlights the role of human health suffering, both mental and physical, as a result of international action. It defines crimes against humanity as follows: 1. For the purpose of this Statute, "crime against humanity" means any of the following acts when committed as part of a widespread or systematic attack directed against any civilian population, with knowledge of the attack:  (f) Torture; (g) Rape, sexual slavery, enforced prostitution, forced pregnancy, enforced sterilization, or any other form of sexual violence of comparable gravity; (h) Persecution against any identifiable group or collectivity on political, racial, national, ethnic, cultural, religious, gender as defined in paragraph 3, or other grounds that are universally recognized as impermissible under international law, in connection with any act referred to in this paragraph or any crime within the jurisdiction of the Court; (i) Enforced disappearance of persons; (j) The crime of apartheid; (k) Other inhumane acts of a similar character intentionally causing great suffering, or serious injury to body or to mental or physical health (UN General Assembly, 1998).

The Role of Health Research in Preventing Human Suffering Resulting from Sanctions
Article 7(k) points to the paramount importance of health research in the wake of sanctions. Sanctions are intended to cause suffering. Health research in the months and years following the 2018 sanctions against Iran will enable the tracking of changes to mental and physical health indicators in the population. Mental health indicators include depression, anxiety, and other psychiatric conditions while physical health metrics include child mortality and changes in morbidity and mortality related to economic hardship, such as lack of access to safe drinking water and adequate food.
Health researchers provide data that is not tracked elsewhere. Even in the case of comprehensive sanctions imposed by the UN Security Council, the health of the affected population is not monitored in a consistent or linear way. Historically, the world has seen reprehensible outcomes from this lack of health monitoring in the wake of sanctions. In Iraq it is estimated that half a million children died between 1990 and 1999 as a direct result of the sanctions--one of the most extreme instances of deaths resulting from a lack of health monitoring by the Security Council. When this quantitative health data was published by the US media, former secretary of state for the Clinton administration, Madeleine Albright was directly questioned about the number of children who died as a result of the sanctions. She responded, "I think this is a very hard choice, but … we think the price is worth it" (Albright, 1996).
Health researchers play a role in preventing injustice through the power of data. Data published in a timely way can be used to inform the public, which has the power to affect politics, and provides the international legal community with data to build arguments for stopping crimes against humanity. Health data shows that the situation in Iran has improved since 2013, when the five permanent members of the UN Security Council and Japan agreed on a Joint Plan of Action regarding acceptable terms for Iran's uranium enrichment and its nuclear program and lifting a three-decade period of multilateral sanctions. A

Conclusion
The history of US sanctions against Iran demonstrates the potentially severe consequences of unmonitored unilateral sanctions. At the same time, the recently available data on improved health metrics in Iran since 2013 shows that health research can play a major role in documenting changes in population health during and after sanctions. The positive developments in Iran may be rapidly reversed if the severity of the 2018 sanctions is not monitored closely. The relationship between health research and international politics is evident, offering health researchers an opportunity to expand the impact of their work to international law and relieve human suffering on a broader scale.

Funding
The author is funded by the Social Science and Humanities Research Council of Canada and by the Killam Trust of Canada in her role as a Killam Laureate.