Political and economic determinants of health: the case of COVID-19 outcomes in Iran under sanctions


The world is living through an unprecedented evolutionary time that will affect how multilateralism and international relations work. More than ever, the direct effect of foreign policy on the health of citizens is highlighted, but perhaps no more so than in the case of Iran. While the Coronavirus disease 2019 (COVID-19) pandemic has affected and challenged all countries in the world, the case of Iran, under the unilateral economic sanctions imposed by the USA [1] is unique. Although it has been emphasized over and over on media that the sanctions do not target citizens or their health, it is impossible to ignore the deleterious effects of the political and economic determinants on the health outcomes of Iranians as the country transitions through the pandemic and adapts to life after COVID-19 cases peak. Iran has endured unilateral economic sanctions to various extents over the past four decades [2, 3], but some of the most stringent measures against the country have been put in place since May 2018 after the USA’s unilateral withdrawal from the Joint Comprehensive Plan of Action [1, 4]. Sanctions have already led to a stark depreciation of the national currency [5] (350% depreciation between April 1, 2018, and April 1, 2020 [6]), an overall decrease in national revenue, increased inflation, and unemployment [3]. This has also led to a decrease in Iran’s economic resilience and available disposable funds for contingency measures and welfare expenditure.

To date, officials report over 122,492 confirmed cases and 7,057 deaths due to COVID-19 out of a total population of 80.2 million people in Iran [7]. Lockdowns started in the final month of the Iranian calendar when most retail happens in anticipation of the new year. As a result,  small businesses were hit particularly hard, and many were pushed to bankruptcy. Those citizens without a steady source of income relying on day-to-day business are also hit severely due to the lockdown measures. Ten weeks later, people are restless to go back to “normal life” and resuming business-as-usual seems inevitable. More importantly, those in lower economic strata of the society need more substantial economic support than the governmental loan equivalent to 120 USD [8] to keep food on their plates and a roof over their heads.

Additionally, it is suggested that COVID-19 and enforcing national lockdowns have already caused despair, anxiety, and depression, and will lead to other mental health disorders such as Post-Traumatic Stress Disorder on a global scale in the long term [9]. Depressive disorders already rank third-highest among causes of Years Lived with Disability in Iran [10], but the post-COVID-19 wave of depressive disorders, as well as complications from other medical conditions that inevitably were neglected when most medical services focused on COVID-19, could lead to additional loss of economic productivity, further exacerbating conditions on a personal and societal level.

In recent years, Iran has achieved some level of Universal Health Coverage through its Health Transformation Plan [11]. However, 37.6% of health expenditures are still out-of-pocket payments [10]. Considering the existing burdensome non-communicable diseases causing 8 out of 10 top causes of death and disability in Iran [10], compounded by the yet-unknown long-term health sequelae of COVID-19, measures must be put in place to avoid catastrophic health expenditure on a large national scale for those seeking health services. The most readily available measure is to increase government health expenditure, which can also prove to be challenging due to the effects of the COVID-19 pandemic on the already weakened-by-sanctions economy.

The inevitable removal of lockdown measures is a matter of timing, but addressing the direct dire effects of sanctions on Iranians’ right to health [3] requires swift international attention. Amid the pandemic, it is the economic and political determinants of health that are dictating the outcomes. The pandemic has brought countries closer in that they are facing the same root cause for the various challenges they are facing, and it has created a spirit of solidarity among some politicians, scientists, and citizens. This solidarity should catalyze further conversation and action on protecting health as the top priority of any political decisions.

About the author:

Dr. Zahra Zeinali is an Iranian medical doctor currently conducting research on intersectionality with the Johns Hopkins Bloomberg School of Public Health and Global Health 50/50. She is a member of the Junior Doctors Network of the World Medical Association. She has prepared this blog entry in her capacity as an independent consultant reflecting her personal professional views.

Conflict of Interests

I declare no conflict of interests.

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