Health impacts of US international economic sanctions: a scoping review

Abstract

Objectives

There is growing concern about potential deleterious health impacts from international economic sanctions imposed by the USA. We summarised the existing research on the health impacts of US-imposed international economic sanctions.

Design

Scoping review.

Data sources

PubMed, Embase, PsycINFO, EconLit and ProQuest Dissertations and Theses were searched through 30 November 2023 and Google Scholar through 22 December 2023, with an updated search of all databases through 26 January 2026.

Eligibility criteria

We included primary quantitative or qualitative English-language research documenting health impacts of economic sanctions in the domains of access to basic needs, access to medical services and supplies, and clinical outcomes.

Data extraction and synthesis

Two independent reviewers performed title, abstract and full-text reviews and extracted data from each paper using a standard data review form. We collected information on country/countries, domain(s), study design, population, data source(s), age, gender, sample size (n), results, including impact of sanctions on health-related measures and important emergent themes (for qualitative studies).

Results

We identified 2484 papers and included 43 in the review. Most studies (63%) were based in Iran. Access to drugs or medical equipment was evaluated in 25 studies (58%); 17 (40%) examined varied clinical outcomes and 8 (19%) focused on access to basic needs like clean water and food. The literature was of variable quality and some studies included incomplete methodological information. 42 of the 43 studies documented health-related harms associated with sanctions, including higher mortality rates, reduced access to essential medications, increased food insecurity and higher infectious disease rates.

Conclusions

This scoping review documents diverse health-related harms from international economic sanctions. The available literature consistently describes sanctions-associated health impacts. Uniformity of outcomes and methods would facilitate better quantification of health-related harms to inform physician involvement.

Trial registration number

OSF (https://doi.org/10.17605/OSF.IO/AKSDW).

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• We searched multiple databases to identify relevant articles, including outside the medical literature.

• Our review was limited to English-language articles, so we may have missed information published in other languages.

• In some studies, US and United Nations sanctions were not separable, so our findings may not purely reflect the specific impact of US sanctions.

Introduction

International economic sanctions are limits on international commerce, banking or trade imposed on a country by a government or other entity (eg, the United Nations (UN)).¹ Historically, the USA has implemented sanctions as a foreign policy tool designed to influence the behaviour of a target country in response to perceived inappropriate policy or actions. Interventions associated with sanctions may include arms embargoes, broad trade blockages or asset seizures; specific approaches can be complex and multi-modal, involving individuals, businesses or government entities. The US Office of Foreign Assets Control (OFAC) has outlined a list of countries on which the USA has imposed comprehensive economic sanctions.²

The frequency of economic sanction imposition has grown in recent decades³ with a nearly 10-fold rise in US-sanctioned entities since 2001.⁴ Currently, the USA is the most prominent sanctioning body in the world, sanctioning a third of all nations.⁵ In 2021, the Department of the Treasury stated that since the 2001 September 11th attacks, economic sanctions had become a ‘tool of first resort to address a range of threats to national security’.⁴ Along with this growth, research into the effects of sanctions on health has increased.^{6 7} Findings regarding the impact of sanctions are mixed, but the imposition of sanctions can affect a country’s economy, financial interactions, trade activity and the health of its private companies.⁶ Sanctions are not intended to directly harm the health of citizens of targeted countries and indeed may be specifically designed to avoid health impacts; for example, the US government created a carveout for humanitarian aid in sanction legislation in 2022.⁸ However, there is growing concern about the unintended consequences of sanctions that may undermine health in citizens of targeted states.

Physician activism has helped mitigate politically related harms to health in the past. Through the group Physicians Against Landmines, doctors successfully influenced world opinion about landmines, leading to treaties banning their use and resulting in a Nobel Peace Prize in 1997 for a consortium that included the physician group.⁹ Recognising the role physicians can play in advocating for population health, physician professional groups have been similarly motivated to action in the case of sanctions. The American Medical Association¹⁰ has formally recognised that economic sanctions threaten health in target countries and the American College of Physicians¹¹ has gone further, emphasising the role of physicians in optimising population health in the context of sanctions and the responsibility of doctors to evaluate and report on the health effects of sanctions.

To inform this work, multiple studies and reviews have evaluated health effects of economic sanctions, generally focusing on specific countries, populations and outcomes.^{12 13} Other more comprehensive reviews have used an economic prism that may be less relevant for physicians.¹⁴ To provide needed information and context for physicians, we performed a scoping review of the health impacts of US-based economic sanctions across the globe, considering the domains of access to health-related basic needs, access to medical services and clinical outcomes.

Methods

Protocol and registration

This scoping review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).¹⁵ Scoping reviews are not eligible for registration in PROSPERO; therefore, a protocol for this scoping review was registered with Open Science Framework (OSF; https://doi.org/10.17605/OSF.IO/AKSDW).

Eligibility criteria

We included original research studies (either quantitative or qualitative), published in English, that directly analysed the relationship between international economic sanctions imposed by the USA and health outcomes in one of 37 sanctioned countries or territories. We excluded articles that did not present new research findings (eg, systematic reviews). Sanctioned countries and territories were identified by the OFAC at the time of the initial database search.² We took an inclusive approach to the search, including all 12 countries within the Balkans and Yugoslavia, to capture all its constituent countries from 1990 to 1992. Alternate names and abbreviations were used for countries when relevant (eg, CAR for the Central African Republic, Hellenic Republic for Greece, etc). We included articles that mentioned or analysed countries beyond our list of 37 if the study analysed at least one country on the OFAC list. We excluded articles published before 1990 because this year marked a major expansion in the scope and frequency of US-imposed economic sanctions¹⁶ and because we sought to evaluate the more recent impact of sanctions. We also excluded articles that evaluated sanctions imposed solely by the UN, but we included articles that evaluated sanctions by both the USA and the UN (either differentiated or combined in the analysis).

Information sources and search strategy

We searched medical and other databases (PubMed, Embase, PsycINFO, EconLit and ProQuest Dissertations and Theses) on 30 November 2023 and Google Scholar on 22 December 2023. We conducted a second search of all databases on 26 January 2026. To identify search terms, we began with keywords from papers known to our team, then added terms from additional relevant references iteratively until searches yielded no new relevant papers. Search terms included “sanction*”, “embargo*” and “health” as well as the names of the 37 sanctioned countries and territories. The detailed search strategy can be found in online supplemental part 1. We performed reference tracking of all relevant systematic reviews identified in initial searches (n=50) to identify additional original research articles and added two additional articles later discovered by our team (SK and DK); these underwent each stage of review.

Study selection

Titles identified through the search were reviewed for potential relevance by at least two reviewers—CS, EL or NP—in EndNote with disagreements resolved by consensus. Abstracts were reviewed for inclusion by CS, EL, HF and MM in EndNote in duplicate with disagreements resolved by consensus. Reference tracking of systematic reviews was tracked using Microsoft Excel. Potentially relevant abstracts underwent full-text review, which was performed in duplicate by two of the same four reviewers, with discrepancies resolved through additional assessment by two other reviewers and full-group discussion that included SK and DK in cases where consensus was not reached (see online supplemental part 2).

Data items and data collection process

We abstracted data from each study regarding the following characteristics: country or countries, domains (eg, access to medicine/pharmaceuticals/drugs, clinical outcomes, etc), population(s) (eg, general population, vulnerable populations, etc), age, gender, sample size, type of data collection method (ie, quantitative, qualitative, or mixed methods), data source(s) (eg, surveys, interviews, databases, etc), research study design (cross-sectional, longitudinal, interrupted time series, ecological, quasi-experimental or pretest-post-test), outcome/dependent/criterion variable(s), summary of results, sanctioning entity (USA solely or UN and USA) and research stakeholders (eg, government, non-profit, private, etc).

During full-text review, data were extracted from the included original research studies using the REDCap database. We created a novel data-abstraction form to identify key qualities of each study; the form was updated continuously to reflect patterns that arose in the data collection process not previously represented in the form. After any additions to the data abstraction form, we re-reviewed all previously abstracted studies to collect further information or clarify outstanding points. The REDCap abstraction form can be found in online supplemental part 2.

Methodological quality appraisal

In keeping with standard methods for scoping reviews,¹⁵ we did not formally evaluate risk of bias of included studies.

Synthesis of results

Tables 1–5 were used to organise the studies, summarise key aspects of each study and identify thematic trends in sanction outcomes outlined within the research. Quantitative studies were grouped by outcome domain; studies focused on clinical outcomes were further grouped according to ecological versus other study designs. Mixed-methods studies were included in the relevant quantitative tables and identified in footnotes. Given the diversity of the literature and consistent with scoping review methods, we did not set out to pool data or analyse trends.

Table 1. Summary of quantitative studies with ecological designs focused on clinical outcomes (n=8)^*.

Author (reference)	Region	Data source(s)	Sample	Population	Study summary
Gutmann et al17†	Multiple countries	US Census Bureau, sanctions datasets developed by Wood,54 Hufbauer et al55 and Neuenkirch and Neumeier56; Threat and Imposition of Sanctions (TIES) dataset; KOF Globalization Index; Polity IV Project data; United Nations (UN) data; World Bank data	98 countries 2483 country-year observations	General population	This longitudinal ecological study used country-level panel data from 98 countries (2483 country-year observations) over 1977–2012 with entropy balancing (a quasi-experimental matching approach) to estimate the causal effect of economic sanctions on life expectancy. US sanctions reduced life expectancy by approximately 0.4 years in men and 0.5 years in women
Ha and Nam18†	Multiple countries	World Development Indicator; Finnish social science data archive, varieties of democracy products; Global Sanctions Database; International Monetary Fund Financial Development Index Database	148 countries 25 245 country-year observations	General population	This longitudinal ecological study using panel data and a structural gravity model with two-way fixed effects across 148 countries from 1995 to 2018 and found a significant negative association (β=−0.30, p<0.01) between economic sanctions and life expectancy, implying a reduction of 0.30 years. This effect was driven primarily by developing countries (β=−0.43, p<0.01), with no significant effect observed in developed countries. Financial market development and institutional quality were found to significantly moderate this relationship
Ðurić and Peek-Asa52†	Serbia	Road traffic crashes from the Ministry of Internal Affairs of the Republic of Serbia; fatalities from The Republican Institute for Statistics; Census data; vehicle-based denominators from Ministry of the Interior registered vehicle data	155 000 road traffic crashes	General population	This ecological study in Vojvodina, Serbia (1996–2005) compared road traffic crash severity across three political periods. Compared with the period with neither sanctions nor military activity (2002–2005), severe injury crashes were 1.23 times more common during sanctions with military activity (1996–1999) and 1.21 times more common during sanctions without military activity (2000–2001). Fatal crash rates showed even stronger associations RR 1.38 and 1.25, respectively
Gibson et al19†	Multiple countries	HSE/HSEO Sanctions; Threat and Imposition of Economic Sanctions; Targeted Sanctions Consortium; EUSANCT; Global Sanctions; International Development Statistics; Global Health Financing; World Development Indicators; Polity5 Databases; Uppsala Conflict Data Programme; the IHME Global Burden of Disease Study	113 countries 3237 country-year observations	General population	This longitudinal ecological study used difference in difference analysis to examine the impact of aid sanctions on maternal and child mortality across 113 low- and middle-income countries from 1990 to 2019. During the study period, 67 countries were targeted by 88 unique aid sanction episodes, which was associated with significant increases in infant mortality of 3.1% (129.3 additional deaths per 100 000 livebirths; p=0.031), maternal mortality of 6.4% (10.9 additional deaths per 100 000 livebirths; p=0.015) and a trend toward higher under-5 mortality (increase 3.6%; 47.1 additional deaths per 100 000 livebirths; p=0.064),
Rodríguez et al20†	Multiple countries	Global Sanctions Data Base (GSDB); UN Inter-agency Group for Child Mortality Estimation; World Bank data from the UN Population Division and the Human Mortality Database; the Penn World Table; data from the UN Development Programme and UNESCO	152 countries 5321–5599 country-year observations	General population	This longitudinal ecological study using country level panel data examined the effect of international sanctions on age-specific mortality rates across 152 countries from 1971 to 2021 using entropy balancing, instrumental variables, event-study and Granger causality methods. Global sanctions were significantly associated with increased mortality across all seven age groups (six at p<0.01, one at p<0.05), with the strongest effects for under-5 mortality (8.4 log points; 95% CI 3.9 to 13.0) and the weakest for older adults aged 60–80 years (2.4 log points; 95% CI 0.9 to 4.0). Unilateral and US sanctions had adverse effects, while UN sanctions showed no statistically significant association with mortality. Unilateral sanctions were estimated to cause 564 258 annual deaths (95% CI 367 838 to 760 677) during 2010–2021, comparable to the global mortality burden of armed conflict
Peksen21†	Multiple countries	Child mortality data from WHO and UNICEF; data from Hufbauer et al55; Armed Conflict Dataset; Polity IV dataset; World Bank data	Number of countries not described 4055–4209 country-year observations	General population	The ecological study used time-series cross-national data for the 1970–2000 period to examine the effect of economic sanctions on under-five child mortality rates across countries, using both WHO and UNICEF mortality data as dependent variables and panel-corrected SEs to address heteroscedasticity. Higher economic costs of sanctions on the target economy were significantly associated with increased child mortality (p<0.05), while US involvement as a sender independently increased the predicted child mortality value by 35% (p<0.01)
Kim40†	Multiple countries	UNAIDS (Joint UN Programme on HIV/AIDS); TIES dataset; World Development Indicators (World Bank); Relative Political Capacity Dataset; AidData; CIRI Human Rights Databases	Ages >15 Women in 84 countries 584–660 country-year observations	Vulnerable population/chronic conditions	This longitudinal ecological population-level study with time-series cross-sectional data from 84 developing countries (1990–2012), demonstrated an increase in women’s HIV infection rate by 1.5% (p<0.05) during sanctions. The study also found that sanctions decreased female labour participation by 1.2% (p<0.1), and that increased female labour participation was associated with a reduction in women’s HIV infection rates (p<0.01), suggesting that reduced female labour participation is a key pathway through which sanctions increase women’s HIV rates
Mohamadi et al24 †‡	Iran	Ministry of Health and Medical Education (MoHME); Statistical Center of Iran; various disease registration systems; hospital and pharmaceutical resource registration systems; mortality registration systems; Interviews: 39 participants total—31 patients (with chronic or rare diseases from four provinces: Tehran, Sistan and Baluchistan, Hamedan, and Yazd) and eight healthcare policy makers/experts	Population level analysis/ecological component: age/sex N/A Iran national and 31-province indicator data Patients: ages 12–68; sex not described; 31 patients with chronic or rare diseases Policymakers/experts: ages 36–59; sex not described; eight healthcare policymakers and experts	General population, vulnerable populations/chronic conditions	This is a mixed-method study. This ecological panel data study examined 28 macroeconomic, healthcare resource and health outcome indicators across Iran (2000–2020) using Join Point Regression and mediation analysis (GAMM). 11 indicators (39.2%) showed significant trend changes after the 2009 change point; mediation analysis found significant increases during the sanctions period in OOP expenditure (+15%), household food expenditure (+6%) and mortality rates for COPD (+5%), thalassaemia (+2%) and hypertension (+1%). The qualitative component of the study used semi-structured interviews with 31 patients with chronic/rare diseases and eight health policy makers and found that patients identified diminished availability and reduced quality of medicines and healthcare services leading to delayed treatment, forced prioritisation of healthcare needs within families and financial distress. Policy makers highlighted sanctions’ negative effects on health system governance, workforce motivation and emigration, procurement of medicines and equipment and healthcare financing

^*Includes one mixed-methods study.

^†Both US and UN sanctions.

^‡Additional domain: access to medical services and supplies.

CIRI, Cingranelli-Richards Human Rights Data Project; COPD, chronic obstructive pulmonary disease; EUSANCT, sanctions dataset covering the European Union, United Nations and USA; GAMM, generalised additive mixed model; GSDB, Global Sanctions Data Base; HSE, Hufbauer-Schott-Elliott sanctions database; HSEO, Hufbauer-Schott-Elliott-Oegg sanctions database; IHME, Institute for Health Metrics and Evaluation; KOF, Swiss Economic Institute; MoHME, Ministry of Health and Medical Education; OOP, out-of-pocket; RR, relative risk; TIES, Threat and Imposition of Economic Sanctions; UN, United Nations; UNAIDS, Joint United Nations Programme on HIV/AIDS.

Table 5. Summary of qualitative studies, grouped by domain (n=15).

Study	Country	Sample interviewed	Population	Study methods summary	Important emergent themes
Domain 1: clinical outcomes
Toorang et al59*	Iran	Ages 40–90; 17 women/13 men; 30 stakeholders	General population	Interviews with 30 professors (n=10), administrators (n=9), experts (n=4), managers (n=3), clerks (n=2), researchers (n=1) and health workers (n=1) regarding determinants of childhood obesity in Iran, using inductive thematic content analysis	Higher rates of childhood obesity
Haghjou et al60†	Iran	Age not reported; 28 women/25 men; 53 healthcare experts.	Vulnerable populations/chronic conditions	Semi-structured interviews with experienced healthcare professionals in specialties including haematology-oncology (n=9), surgery (n=10), radiation oncology (n=8), internal- medicine subspecialties (n=6), pathology (n=5), radiology (n=4), cancer/basic sciences (n=4), nuclear medicine (n=3), clinical pharmacology (n=2), community medicine (n=1) and family medicine (n=1) analysed using inductive qualitative content analysis regarding the impact of sanctions on cancer care	Reduced access to medications, devices and high-quality care. Increased adverse events
Domain 2: access to basic needs
Amerzadeh et al37*	Iran	Ages 35–78; 9 women/21 men; 30 stakeholders	General population	Qualitative semi-structured interviews analysed using inductive-deductive thematic content analysis, with stakeholders (academics, experts, key informants) regarding economic barriers and unhealthy food consumption	Higher intake of unhealthy foods among families
Wang et al38†	Sudan	Age/sex not reported; 41 professionals/civilians	General population	Semi-structured interviews with Sudanese professionals and civilians (37 living in Khartoum and White Nile, 4 living abroad) regarding humanitarian impacts of US sanctions on Sudanese civilians, including access to food, clean water, medicine, utilities, public health deterioration, healthcare affordability and food insecurity, to build a theoretical model	Reduced access to medications and basic commodities
Domain 3: access to medical services and supplies
Deilamizade et al44	Tehran, Iran	Ages 25–58; 48 men; 48 clients (23 drop-in, 25 residential)	Vulnerable populations/chronic conditions	Qualitative multi-method study using interviews, questionnaires, neighbourhood observations and treatment centre statistics with recreational drug users, including 23 male clients of drop-in centres serving primarily homeless drug users, and 25 clients of residential treatment centres, regarding drug availability and their use habits during sanctions. Analysis used grounded theory coding	Utilisation of more harmful alternatives by recreational drug users and higher prices for drugs
Mehtarpour et al61	Iran	Age not reported; 11 women/13 men; experts/researchers	General population	Semi-structured interviews with experts and researchers including managers from the Ministry of Health (n=14), Iran veterinary organisation (n=4), the national professional associations (n=3) and researchers (n=3) regarding provision of medical supplies to combat anti-microbial resistance. Thematic analysis was performed	Less availability of needed supplies to combat anti-microbial resistance
Shahabi et al62*	Iran	Age/sex not described; 38 rehabilitation-sector stakeholders	General population	Qualitative semi-structured interview study using framework analysis with experts including health policymakers (n=11), faculty members (n=8), rehabilitation experts (n=7), physiotherapists (n=5), orthotists/prosthetists (n=4) and occupational therapists (n=3) regarding sanctions’ impact on physical rehabilitation services	Inability to fund and educate regarding physical rehabilitation services, and lack of necessary equipment and supplies
Azami et al63	Iran	Age/sex not described; 32 medical-equipment stakeholders	General population	Semi-structured interviews with key-informants in the Iranian healthcare system including policymakers from the Ministry of Health and Food and Drug Administration (n=9), Members of the Currency Board of Trustees (n=3), heads of medical-equipment departments at medical universities (n=2), public and private hospital managers (n=5), heads of medical-equipment departments at selected hospitals (n=7) and board members from private medical-equipment companies (n=6) regarding medical equipment procurement. Thematic content analysis was performed	Inability to obtain medical equipment through multiple financial and economic mechanisms
Shahabi et al, 64	Iran	Age/sex not reported; 39 rehabilitation-financing stakeholders	Vulnerable populations/chronic conditions	Semi-structured interviews with 39 experts (policy-makers, academics, practitioners and civil society) regarding problems with physical rehabilitation financing (PRF) policies, with thematic analysis using Kingdon’s multiple streams framework	Lower budget in health and welfare sectors for physical rehabilitation financing
Bastani et al 65*	Iran	Age/sex not reported; 18 pharmaceutical policymakers/managers	General population	Semi-structured interviews with 18 national- and university-level pharmaceutical policymakers and managers, using framework analysis regarding pharmaceutical procurement after imposition of sanctions	Difficulties in pharmaceutical financing, purchasing, importation, production, storage and distribution
Naghdi et al66 *	Iran	Mean age 51±6; 4 women/10 men; stakeholders	Vulnerable populations/chronic conditions	Semi-structured interviews conducted with 14 Iranian stakeholders regarding challenges related to services for rare diseases, using qualitative content analysis	Inability to provide services or purchase drugs for rare diseases
Kiani et al67 *	Four provinces, Iran	Ages 20–68; 18 women/13 men; 31 patients.	Vulnerable populations/chronic conditions	Qualitative semi-structured telephone interviews using inductive content analysis with patients diagnosed with chronic and rare diseases, including kidney transplants (n=9), diabetes (n=7), thalassaemia (n=7), haemophilia (n=4) and cancer (n=4) regarding impact of sanctions on disease management	Reduced access to healthcare, medications and high-quality services
Karami Matin et al68	Kermanshah Province, Iran	Age not reported; reportedly 9 women/11 men; 20 hospital staff/managers	General population	Qualitative public hospital staff semi-structured interviews with management (n=7), nursing (n=4), pharmacy (n=4), medical equipment (n=3) and laboratory (n=2) departments, using inductive thematic analysis regarding health system performance in Iranian hospitals as a result of US sanctions	Reduced access to medications and devices
Mohammadshahi et al69	Iran	Age/sex not reported; 10 experts	General population	Scoping review supplemented by surveys conducted with 10 health policymakers, managers and researchers regarding the relationship between sanctions and public health (medical services and supplies). Methods included a scoping review and qualitative analysis of interviews	Reduced access to medications and devices
Nazari et al70 *	Tehran, Iran	Ages 43–86 (mean~56); 9 women/12 men; patients, family and NGOs	General population, vulnerable populations/chronic conditions	Semi-structured interviews with cancer patients (n=10), family members (n=6) and NGO representatives (n=5) regarding sanctions’ effects on cancer care in Iran, using inductive qualitative content analysis	Reduced access to medications, devices and specialty care

^*Both US and UN sanctions.

^†Additional domain: access to medical services and supplies.

NGO, non-governmental organisation; PRF, physical rehabilitation financing; UN, United Nations.

Table 2. Summary of quantitative studies with other designs focused on clinical outcomes (n=7).

Author (reference)	Region	Data source(s)	Sample	Population	Study summary
Chen et al39*	Multiple countries	Our World in Data; Global Sanctions Data Base; Oxford COVID-19 Government Response Tracker	181 countries 174,174–192,724 country-day observations	Vulnerable populations/chronic conditions	This quasi-experimental, retrospective panel data study used a difference-in-differences (DID) estimator across 181 countries over the period 1 January 2020–31 December 2022 and found that economic sanctions were associated with significantly higher daily confirmed COVID-19 cases and deaths per million in target countries; the longer the sanction period, the more severe this effect (p<0.01). These negative effects were significant in Asian countries but not in non-Asian countries. Additionally, stronger government responses, including containment and closure measures, economic support and health system actions weakened the adverse impact of economic sanctions on pandemic outcomes
Kim23	Multiple countries	UNAIDS; TIES dataset; World Development Indicators (World Bank); Relative Political Capacity Dataset; AidData	Ages <15, sex not described 71 countries 740–878 country-year observations	Vulnerable populations/chronic conditions	This longitudinal panel study using pooled time-series cross-sectional data examined the impact of economic sanctions on children’s (<15 years) new HIV infection and AIDS-related death rates across 71 developing countries from 1990 to 2012. Using fixed-effects regression with Driscoll-Kraay SEs and controlling for GDP growth, democracy, political capacity, health spending, literacy, urbanisation, health aid, exports and HIV prevalence, the study found that economic sanctions significantly increased children’s new HIV infection rate by approximately 2.5% (p<0.05) and AIDS-related death rate by approximately 1% (p<0.1)
van der Werff et al43	Cuba	Surveys administered to primary school children aged 4–14 years in two Cuban municipalities	Ages 4–14, sex not described 1321 primary school children	Vulnerable populations/chronic conditions	This cross-sectional study examined the relationship between early childhood exposure to the Cuban economic crisis of the 1990s (‘Special Period’) and the occurrence of atopic diseases later in childhood among 1321 primary schoolchildren aged 4–14 years. Children were classified into three exposure groups based on birth date relative to the economic crisis period (January 1990–January 1996): unexposed (born ≥1996), exposed during infancy only (born 1994–1995) and exposed during both infancy and early childhood (born before 1994). Atopic diseases were assessed using the ISAAC questionnaire. After adjustment for age and municipality, exposure during infancy was significantly inversely associated with asthma (adjusted OR 0.56, 95% CI 0.33 to 0.94) and allergic rhinoconjunctivitis (adjusted OR 0.46, 95% CI 0.25 to 0.85)
Petrescu22	Multiple countries	Demographic and Health Surveys; Hufbauer et al55; World Development Indicators; EMDAT; OFDA/CRED International Disaster Database; dataset developed by Lacina et al57	Ages<3, sex not described 228 273 children 69 countries	General population	This pooled repeated cross-sectional study examined children under age 3 from 69 developing countries (children born before 2006) to estimate the impact of in utero exposure to economic sanctions on infant weight z-scores, child height z-scores and under-3 mortality. The study found that in utero exposure to sanctions led to significantly lower infant weight (each additional month of exposure decreased weight by 0.008 SD; p<0.05), and that exposure to the first 2 years of sanctions increased the probability of death before age 3 (0.9 percentage points increase for 9 months of exposure on a baseline probability of 5.19%)
Karimi et al26 *†	Iran	Clinical data from medical records and patient interview from the Hematology Research Center; Namazee Hospital in southern Iran	109 patients and 20 specialists Patients: Thalassaemia: age not described, 33 male and 36 female Haemophilia: age not described, 38 male and 2 female, 40 patients Clinicians: 20 treating specialists	Vulnerable populations/chronic conditions	This longitudinal retrospective chart review study compared treatment availability in 2009 versus 2012 and clinical outcomes in 2006, 2009 and 2012 found that during sanctions, access to deferoxamine declined by ~70% and deferasirox by ~50% for thalassaemia patients, with a significant increase in serum ferritin (p=0.036). Access to lyophilised factor VIII concentrate for haemophilia A dropped from 96.7% to 3.3%, with significant deterioration of arthropathy and tripling of bleeding episodes (p<0.001). The survey component used structured disease-specific questionnaires administered to thalassaemia patients, haemophilia patients and 20 specialist physicians to assess perceived changes in medication availability, affordability and usage between 2009 and 2012. The overwhelming majority of both patients (92.8%–94.7%) and physicians (85%–89.5%) reported that sanctions had a considerable effect on access to medicines
Ali41 *†	Iraq	Databases; Blood bank registry of the Public Health Laboratory; Virology Center in Mosul, North Iraq; Parents were interviewed about their consultation at vaccine centres at the recommended time of vaccination	Ages 2–7, sex/gender not described 254 children screened for hepatitis B	Vulnerable populations/chronic conditions	This cross-sectional study examined the effect of international sanctions on hepatitis B vaccine availability and the occurrence of viral hepatitis B among Iraqi children born between 1994 and 1998 in Mosul, Iraq, during the period June 2000 to June 2001. Among 254 children screened for HBV at the Public Health Laboratory (Virology Centre) in Mosul, 74 (29.1%) were identified as HBsAg-positive carriers. Of the 62 cases with available documentation, 41 (55.4%) were not vaccinated and 21 (28.4%) had received only one vaccine dose. HBeAg was positive in 9 (14.5%) and anti-HBe in 50 (80.7%). The study documented severe vaccine shortages during the birth years of these children, with supply falling far below the estimated annual demand of 250 000 child doses. The number of HBsAg carrier children correlated with years of greatest vaccine shortage
Asadi-Pooya et al30 *†	Iran	Surveys; patients from the epilepsy centres in Shiraz, Tehran or Ahvaz; two questions about their experience with epilepsy and acquiring medication	Ages 1.5–69; 111 women/133 men 244 patients with epilepsy	Vulnerable populations/chronic conditions	This multi-centre cross-sectional survey of 244 patients with epilepsy during 2–6 February 2019, approximately 6 months after the reimposition of US economic sanctions on Iran (8 May 2018). The study assessed patients’ perceptions of hardship in obtaining antiepileptic drugs (AEDs) and changes in seizure control. 52.9% of patients reported significant hardship obtaining their AEDs, 37.7% reported drugs were scarcely accessible and 15.2% reported their AEDs were completely inaccessible, requiring a medication change. Patients on imported AEDs were disproportionately affected: 72% of those on imported AEDs versus 30% on domestically manufactured AEDs reported significant hardship (p=0.00001). 36% of patients reporting significant hardship perceived worsening of seizures, compared with 22% of those without hardship (p=0.017)

^*Both US and UN sanctions.

^†Additional domain: access to medical services and supplies.

AED, antiepileptic drug; anti-HBe, antibody to hepatitis B e antigen; DID, difference-in-differences; EMDAT, Emergency Events Database; GDP, gross domestic product; HBeAg, hepatitis B e antigen; HBsAg, hepatitis B surface antigen; HBV, hepatitis B virus; ISAAC, International Study of Asthma and Allergies in Childhood; OFDA/CRED, Office of US Foreign Disaster Assistance/Centre for Research on the Epidemiology of Disasters; UN, United Nations.

Table 3. Summary of quantitative studies focused on access to medical services and supplies (n=7)^*.

Author (reference)	Region	Data source(s)	Sample	Population	Study summary
Kheirandish et al25	Iran	Two pharmaceutical databases from the Iranian FDA	26 drugs	Vulnerable populations/chronic conditions	This interrupted time-series analysis demonstrated significant reduction in availability and use of 13 out of the 26 drugs over 68 months. Examples: reduction in interferon α2b use (0.014 daily doses/1000 inhabitants/day to 0.008 daily doses/1000 inhabitants/day), cytarabine use (1.4 mg/1000 population/day to 0.96 mg/1000 population/day) and selective β2-adenoreceptor agonist use (8.4 DID to 6.8 DID)
Asadi-Pooya et al27†	Iran	Clinical data from medical records from the outpatient epilepsy clinic at Shiraz University of Medical Sciences	Ages 0–47, mean 19 years, 101 women and 98 men with epilepsy	Vulnerable populations/chronic conditions	In this longitudinal retrospective chart review of 199 patients with epilepsy drug adherence was compared across two time periods: March 2010–2011 (before intensification of international economic sanctions) and September 2012–2013 (during intensified sanctions). Overall, approximately one-third of patients had poor drug adherence in both periods, with no significant difference in overall adherence rates between the two periods (69.8% vs 73.4% satisfactory adherence; p=0.4). However, there was a trend toward increased cost- and availability-related non-adherence during the sanctions period (1.5% vs 4%; p=0.07), with some antiepileptic drugs (eg, levetiracetam) increasing in price by up to 300% and others becoming unavailable (eg, zonisamide, nitrazepam)
Ghiasi et al28 †	Iran	Surveys developed following the standard methodology proposed by the WHO and Health Action International after obtaining the list of all the asthma medicines registered in the national formulary of Iran	40 community pharmacies in Tehran	Vulnerable populations/chronic conditions	This was a pre-post study conducted in 40 randomly selected community pharmacies in Tehran, Iran, comparing asthma medicine availability before (July 2012) and after (March 2013) the intensification of international banking sanctions against Iran. The study found that availability of imported asthma medicines declined by 67%–86% and locally manufactured medicines by 18%–62%, with the proportion of pharmacies stocking all essential asthma medicines (an inhaled corticosteroid plus a beta-agonist) dropping from 60% to 28% (p=0.003)
Marzieh et al29	Iran	Primary data collection using a combination of medical records and patient interviews from five treatment centres in Fars province	Age/sex not described; 249 patients with thalassaemia	Vulnerable populations/chronic conditions	This pre-post study compared data before and 1 year after the 2018 sanctions. This study found that all 249 major thalassaemia patients reported poor access to foreign oral iron chelation medication after sanctions. There was a significant shift in medication type from foreign and injectable drugs to domestically produced oral medication. Despite this medication change, serum ferritin levels did not change significantly (kappa=0.007, p=0.1)
Emami and Cheraghali53	Iran	Iran Food and Drug Administration Interviews were conducted with 13 experts in regulations, policy and production and importation of drugs	Quantitative portion: 31 medicines studied over time Qualitative portion: 13 pharmaceutical-sector experts	General population	This is a mixed-method study. Using a retrospective longitudinal descriptive trend analysis of numerical sales data for selected medicines over a 6-year period this study found a drop in medicine sales after partial (16.6%) and full (70%) sanctions including reductions in diabetes, respiratory, cardiovascular, anti-cancer and psychiatric medicine. Using semi-structured interviews with 13 experts the study found that interventions implemented to combat sanctions were insufficient to fully compensate for the negative effects of sanctions on medicine access
Gharibi et al58†	Iran	Validated questionnaires administered to patients, combined with medical record review; the patient registry was the Multiple Sclerosis Association (MSA) of East Azerbaijan province in Iran	Age/sex not described; 300 MS patients	Vulnerable populations/chronic conditions	This pre-post comparative study surveyed 300 multiple sclerosis (MS) patients registered with the MS Association of East Azerbaijan province, Iran, during April–May 2018 (pre-sanctions) and April–May 2019 (post-sanctions) to assess the impact of political-economic sanctions on health costs. The study found that sanctions increased catastrophic health expenditures by 15% (from 54% to 69%) and disease-related poverty by 14% (from 44% to 58%), with out-of-pocket payments rising by 14.3%
Ko et al42†	Multiple countries	German Institute of Global and Area Studies (GIGA) Sanction dataset by Von Soest and Portela (2012); GSDB; World Bank Open Data	76 countries 1174–1378 country-year observations	General population	This longitudinal panel data study examined the impact of international sanctions on child immunisation rates (DPT, hepatitis B, measles and polio) across 76 sanctioned developing countries from 2000 to 2019, using an unbalanced country-year panel with fixed-effects regression. The study found that US and EU sanctions, as well as economic and unilateral sanctions, significantly reduced vaccination rates for DPT, measles and polio, while UN and plurilateral sanctions generally did not show significant effects

^*Includes one mixed-methods study.

^†Both US and UN sanctions.

DID, defined daily doses per 1000 inhabitants per day; DPT, diphtheria, pertussis and tetanus; EU, European Union; FDA, Food and Drug Administration; GIGA, German Institute for Global and Area Studies; GSDB, Global Sanctions Data Base; MS, multiple sclerosis; MSA, Multiple Sclerosis Association; UN, United Nations.

Table 4. Summary of quantitative studies focused on access to basic needs (n=6).

Author (reference)	Region	Data source(s)	Sample	Population	Study summary
Hejazi et al33	Iran	Data on food imports, exports and costs, from the Statistical Center of Iran (SCI); economic news agencies for prices of staple foods not included in SCI reports; World Food Programme	Six food groups analysed over 27 time points	General population	Following the re-imposition of US sanctions in 2018, this interrupted time-series analysis demonstrated significant increases in food prices across all six food groups, with the steepest rises in vegetables, meat and fruit. Food insecurity rates increased from 2017 to 2019 in both urban (8.84%–11.2%) and rural (25.17%–29.2%) households. The estimated annual cost of a healthy diet was 3.6 times greater than what the average Iranian family spent on food
Afesorgbor31	Multiple countries	Global Hunger Index; Food and Agriculture Organization data; Hufbauer et al55	Age/sex N/A 66 countries 539–795 country year observations	General population	This longitudinal ecological panel study between 1990 and 2014 found sanctions increased the percentage of undernourished in the population by 2.92% and significantly increased the percentage of underweight children under 5 years. Financial sanctions and a combination of financial and trade sanctions significantly reduce food supply (decline of 73.24 kal/caput/day) and diet adequacy (decline of 2.08%)
Eskandarieh35*†‡§	Iran	Surveys; questionnaire designed by the MS research centre of Tehran University Medical Sciences to address stress and difficulties obtaining care and treatment services related to sanctions	1030 MS patients Age 18–50, 79% female	Vulnerable populations/chronic conditions	This cross-sectional study was conducted among multiple sclerosis (MS) patients recruited from the MS Society and Sina Hospital in Tehran, Iran, between January and August 2019, to assess the stress and challenges experienced by MS patients in accessing health services during the 2018–2019 period of political and economic sanctions against Iran. Key findings included that 83.4% of patients reported increased living expenses in 2019 compared with the prior year, the majority experienced very high or high stress related to increased costs of drugs, hospitalisation, rehabilitation and psychological counselling, and more than 50% reported reduced quality of nutrition and decreased physical, social and cultural activities due to the economic burden of sanctions
Pakravan-Charvadeh et al34	Iran	Surveys; the literature and expert comments served as the basis for the questionnaires design; food insecurity levels were measured using the Household Food Insecurity Access Scale; first-order structural equation modelling (SEM) was applied to determine factors that affect food insecurity	Age/sex not reported 392 households in Tehran	General population	This cross-sectional survey study examined 392 households in Tehran province, Iran, during the COVID-19 lockdown period from 1 April to 31 July 2020 to identify and rank determinants of household vulnerability to food insecurity. Data were collected via an online questionnaire, and first-order structural equation modelling was used to assess the relationship between seven dimensions of vulnerability and food insecurity. The study found that approximately 61% of households experienced food insecurity (25% marginal, 35.2% moderate and 34.9% severe). The SEM model explained 83.5% of the variance in food insecurity
Liu et al32*	Multiple countries	GSDB; Food and Agriculture Organization Statistics (FAOSTAT); UN Comtrade Database	More than 200 countries 1359–2330 observations	General population	This longitudinal ecological study examined the impact of international sanctions on food security across more than 200 countries, using three unbalanced panel datasets spanning 1950–2022 (sanctions data), 2000–2020 (SDG-2 indicators) and 1990–2019 (food security and trade data). Employing an instrumental variable 2SLS approach with country and year fixed effects to address endogeneity, the study found that sanctions were associated with increased prevalence of undernourishment, a significant rise in the population of children with moderate or severe stunting
Sahraian et al36†§	Iran	Structured questionnaire of patients in Tehran; Sampling at Sina Hospital (tertiary care referral centre), 16 Azar (neurology clinic) and the Iranian MS Society (IMSS)	Age not reported, 827 women and 212 men with MS	Vulnerable populations/chronic conditions	This cross-sectional survey of 1039 MS patients was conducted in 2018–2019, the period of increasing sanctions and found that 41.4% of MS patients could not pay to continue treatment and 68.82% experienced reduced nutrition quality during sanctions

^*Both US and UN sanctions.

^†Additional domain: access to medical services and supplies.

^‡Total number of patients in the abstract appears to be in error; total calculated based on the reported subsets.

^§Possible sample overlap with Eskandarieh and Sahraian: both studies report 827 women, including overlapping authors and were conducted among patients with multiple sclerosis in Tehran during a similar time period. The extent of participant overlap was not reported.

FAOSTAT, Food and Agriculture Organization Corporate Statistical Database; GSDB, Global Sanctions Data Base; IMSS, Iranian Multiple Sclerosis Society; MS, multiple sclerosis; SCI, Statistical Center of Iran; SDG-2, Sustainable Development Goal 2; SEM, structural equation modelling; 2SLS, two-stage least squares; UN, United Nations.

Patient and public involvement

None.

Results

The literature search yielded 2484 citations; we ultimately identified 43 studies meeting inclusion criteria (figure 1). Tables 1–5 include details of all included studies.

Figure 1. Flow diagram of study eligibility assessment and inclusion.

Of the 43 included studies, 28 (65%) were quantitative (tables 1–4) and 15 (35%) were primarily qualitative (table 5). Given the topic, all quantitative studies were observational, using a variety of analytic approaches including difference-in-differences and various quasi-experimental methods (tables 1–4). More than half of studies (n=26, 60%) addressed the imposition of both UN and US sanctions. The majority of studies evaluated outcomes in Iran (n=27, 63%); the remainder evaluated outcomes in Iraq (n=1, 2%), Cuba (n=1, 2%), Serbia (n=1, 2%) and Sudan (n=1, 2%); 12 studies (28%) focused on multiple countries (online supplemental table 1). Most examined access to medical services and supplies (n=25, 58%), followed by clinical outcomes (n=17, 40%) and access to basic needs (n=8, 19%). Common data sources included interviews (n=19, 44%), databases (n=19, 44%) and surveys (n=9, 21%). A total of 24 studies (56%) focused on the general population, including 14 of 28 quantitative studies (50%) and 10 of 15 qualitative studies (67%). A total of 21 studies (49%) focused on specific vulnerable populations or those with chronic conditions, including 15 of 28 quantitative studies (54%) and 6 of 15 qualitative studies (40%). Specific measured outcomes varied widely (tables 1–5).

Findings regarding the impact of sanctions

42 of the 43 studies documented health-related harms from sanctions. Eight quantitative studies reported mortality or life expectancy outcomes, all of which found associations between sanctions and increased mortality or reduced life expectancy.^17–23 More specifically, studies found that sanctions were associated with higher rates of infant,^{19 20 22} child,^{19–21 24} adult²⁰ and maternal¹⁹ mortality. Other studies found associations between sanctions and lower life expectancy^{17 18} as well as higher rates of disease-related mortality.^{24 25} There were 12 quantitative or mixed-methods studies evaluating access to medical services and supplies, 10 of which focused on Iran. Notable findings included lower availability of medications for asthma, diabetes, cancer, benign haematological conditions (eg, thalassaemia and haemophilia) and seizure disorders.^26–31

Seven quantitative studies evaluated nutrition or food insecurity, all of which found decrements as measured by metrics such as per cent undernourished,^{32 33} per cent underweight (for children, specifically),³² child stunting rate,³³ infant weight and height,²² food insecurity^{34 35} and nutrition quality.^{36 37} Additional qualitative studies addressing nutrition in the context of sanctions noted poorer family nutrition and higher intake of unhealthy foods in Iran³⁸ and reduced access to basic commodities such as food and clean water in Sudan.³⁹

Five quantitative studies evaluated clinical outcomes related to infectious diseases. In the context of imposed international sanctions, these studies observed higher rates of COVID-19,⁴⁰ HIV,^{24 41} AIDS-related deaths in children²⁴ and child hepatitis B surface antigen carrier cases⁴²; one study found lower diphtheria/pertussis/tetanus, hepatitis-B and measles vaccination rates during sanctions.⁴³

Of note, the single study that did not document harm associated with sanctions was a cross-sectional study from Cuba that found an inverse relationship between rates of asthma and respiratory allergies in children with exposure to sanctions.⁴⁴ The authors hypothesised that unmeasured harms from sanctions, including higher rates of infectious diseases and poorer nutrition, resulted in lower susceptibility to allergies.

Qualitative studies generally discussed availability of medications, medical devices and other medical supplies, conducting interviews mostly with experts and policymakers (table 5), although one study interviewed recreational drug users in Iran regarding drug availability, noting a shift to more harmful alternatives during sanctions.⁴⁵

Discussion

In this scoping review, we identified 43 original research studies that evaluated health impacts of US-imposed international economic sanctions. While many studies (63%) focused on Iran and over half (58%) evaluated access to medical services and supplies, we found that the literature is diverse, addressing a broad range of specific outcomes across different vulnerable groups and the general population. Overall, 42 of the 43 studies documented health-related harms from sanctions including higher rates of child mortality, lower life expectancy, reduced access to medical services and supplies, and declines in nutrition and food security, particularly in Iran.

The diversity of the literature and challenges inherent to high-quality studies on this topic are notable. Qualitative studies involved interviews with diverse stakeholders, often experts, researchers and policymakers. The main insight from these studies, that access to supplies is reduced during sanctions, is not surprising but could inform future quantitative studies. Among quantitative studies, many were published outside the medical literature, with less complete descriptions of methods. The most meaningful outcomes studied were clinical, with eight studies evaluating life expectancy or mortality, often leveraging multiple data sources to conduct adjusted time-series analyses. While these methods are somewhat prone to biases, the datasets themselves are subject to inaccuracies, and the studies addressed different populations, their consistent findings are likely meaningful. Alignment on outcomes and methodological approaches across the research community would facilitate more complete understanding of these harms.

While sanctioning approaches may endeavour to avoid civilian harm, our findings highlight the collateral public health effects of this foreign policy tool. Sanctions are a blunt instrument. While the USA has exempted humanitarian items from sanctions, implementation is imperfect and harms to health can occur even when steps are taken to mitigate them, mediated through effects on social determinants of health, on healthcare providers or through other factors.⁴⁶ Sanctions are ultimately associated with the obstruction of access to humanitarian goods (eg, essential food, medicine, medical supplies, etc) and an increase in adverse clinical outcomes (eg, deaths, infections, etc). For example, studies described increased difficulties in disease management for chronic conditions such as haemophilia or epilepsy, poorer family nutrition, increased infant and child mortality, and higher rates of infectious diseases such as HIV and COVID-19. This growing body of research presents mounting evidence that economic sanctions do harm public health in target countries.

While the responsibility of governments to ensure global access to healthcare and uphold the right to health is codified in human rights declarations including the Universal Declaration of Human Rights and the Convention on the Rights of the Child, governments must balance multiple priorities, which may result in inattentiveness to unintended health consequences from sanctions. As apolitical health experts, physicians and physician organisations can play a critical role in focusing attention specifically on health effects and pushing to mitigate harms. Throughout modern history, physicians successfully worked for change personally and collectively, both in their home countries and internationally, advocating for issues like limiting environmental nuclear testing, fighting for global health equity and documenting atrocities in combat zones.^{47 48} In the past, this work has been enabled by a deep well of public trust in physicians.⁴⁹ Since the COVID-19 pandemic, fuelled in part by high levels of polarisation, trust in the healthcare system has declined in the USA.⁵⁰ However, trust in physicians remains higher than trust in other healthcare-related actors and institutions. Further, physicians remain the most trusted among the professions both in the USA and globally, with 84% of the US public expressing trust in doctors.^{51 52} As a result, physician advocacy around issues like the health effects of sanctions can still be meaningful and impactful.

Physicians and their member organisations have several tools for influence. First, they can conduct, advocate for, or fund research into health effects of sanctions; broad dissemination of the findings can keep the issue top of mind for the public and policymakers. Second, more physician organisations can issue position statements about the unintended consequences of broad economic sanctions. Physician groups are uniquely positioned to lobby policymakers across the political spectrum, as their professional standing and focus on maintaining health can avoid more polarising aspects of international politics and therefore may be better received. Physician groups can call for lifting sanctions that harm civilians while individual physicians can engage in research on the health effects of sanctions to document impacts. They can also increasingly move public opinion by engaging with modern media, through appearances on podcasts and through social media outlets, where they may themselves have large followings or can work with non-physician influencers.

Limitations

There are several important limitations to this review. First, we used an iterative process to identify search terms, but there is no reliable standard language across databases to identify relevant articles. We excluded non-English language articles, so we may have missed important observations. While we were able to include articles focused on many countries around the globe, articles published in other languages could have impacted our findings.

Second, in keeping with standard methodology for scoping reviews,¹⁵ we did not perform risk-of-bias assessments. Given the topic and the implicit observational nature of this body of work, included studies were subject to multiple potential biases, including confounding related to other local factors (eg, war) and reliance on self-report. In addition, mapping the mechanisms underpinning any documented harms, which may not be intuitive (eg, more severe injuries from vehicle crashes)⁵³, are beyond the scope of this review, though it is likely that shortages experienced under sanctions can have unpredictable ramifications. Further, the majority of studies focused on Iran, which may limit our ability to generalise findings to other regions impacted by sanctions, namely Latin America, East Asia, Eastern Europe and part of Africa. However, while there are clearly important cultural and systemic differences across diverse regions and countries, the broad impact of sanctions is likely similar.

Further, we included studies that did not differentiate between the impacts of US and UN sanctions and studies that included countries beyond the OFAC list. That inclusiveness may affect our ability to attribute health impacts to US-imposed sanctions vs other sanctions, although the distinction may not be critical when considering the problem overall. In contrast, we excluded countries that were not reported by the OFAC to have comprehensive sanctions on the ‘Sanctions Programmes and Countries List’ at the time of the initial search. While these countries may have experienced comprehensive US imposed sanctions at some point within the time period of interest (1990–2026), there is no detailed list of all historical major comprehensive sanctions programmes on the OFAC website. Thus, our reliance on OFAC’s updated list of sanction programmes may have led us to miss sanctions related health impacts to countries that were not sanctioned at all (eg, Haiti) or not comprehensively sanctioned at the time of the search (eg, China only subject to military company sanctions at the time of the search).

Finally, there are limitations to the literature itself that affect the strength and generalisability of our findings. Studies address diverse outcomes, which creates challenges for understanding the overall impact of sanctions. The many studies focusing on Iran may point to disproportionate impacts on that particular country but may simply reflect the duration of those sanctions and the existence of an Iranian infrastructure that is able to document health effects. In contrast, there are clear gaps in the literature evaluating harms to other sanctioned regions (eg, Venezuela, Syria, Sudan, etc). Future research should focus on broadening the geographic scope of research to capture more regions impacted by sanctions and on fostering more consistency by establishing optimal methods and the most meaningful outcomes.

Conclusions

This scoping review documents profound harms to the health of people living in sanctioned countries across a wide range of health-related domains and outcomes. Healthcare products and services should not be the target of sanctions, and indeed often are not. However, when actually implemented, sanctions programmes do not successfully preserve access to resources needed to maintain health. Inconsistencies in the evidence and methodological challenges limit our ability to quantify the impact, but it is clear that sanctions impact patient health and the ability of physicians to provide optimal care. As respected advocates for health, physicians could help by embracing their role in mitigating these important harms.

The views expressed in this article are exclusively those of the authors and do not represent the views of their employers.

Data availability statement

Data are available upon reasonable request.