Parsa Erfani and Laila Fozouni / The British Journal of Medicine

 (April 24, 2020) — When we spoke with Maryam*, she recalled first noticing the lump in her neck in the summer of 2018. Sanctions on Iran had sharply increased, the Iranian currency had plummeted, and Maryam was facing increasing pressure at her job; she chalked it up to anxiety.

Five months later, a lymph node biopsy confirmed her diagnosis of lymphoma. Like most people facing a cancer diagnosis, she was scared and overwhelmed.

After completing her first two rounds of chemotherapy, Maryam was confronted by a dire reality. Vinblastine, one of her four chemotherapy drugs, was no longer in stock at her pharmacy in Tehran. Iran’s Vinblastine shortage threatened to turn her potentially curable disease into a terminal one.

Maryam is one of many patients in Iran who have lost access to life-saving medications since the imposition of “maximum pressure” sanctions in 2018. Unlike targeted sanctions that impact specific institutions and individuals, “maximum pressure” sanctions are much wider in scope and often include secondary sanctions that impose restrictions on international banks, which make interstate trade extremely difficult. 

While these sanctions include humanitarian exemptions to limit their impact on medical treatments and devices, the secondary sanctions on international banking systems severely limit the ability of sanctioned countries to finance humanitarian imports. Shortage of critical drugs ranging from anti-epileptics to chemotherapies have been reported in Iran and the International Court of Justice has ruled the humanitarian exemptions to be insufficient.

The ineffectiveness of these exemptions is being underscored as Iran faces one of the world’s largest covid-19 outbreaks, with roughly nine out of ten cases in the Middle East. There are many factors driving the magnitude of Iran’s outbreak, including a delayed response to initial cases. However, limited medical resources as a consequence of sanctions may have played a role in the surge of cases. 

For a healthcare system already struggling under the weight of sanctions, an increase in medical demand and failure in limited supply chains have precipitated a public health crisis. An insufficient stock of medications and medical equipment has proven to be devastating for patients and providers alike. Failure to contain the outbreak in Iran has affected patients across the globe, as early cases in many countries including Qatar, Iraq, Lebanon, Canada and the United States have been traced back to Iran.

The effects of sanctions on patients is not unique to Iran. Similar medical shortages and reports of patient harm have been documented in North Korea, Cuba, and Venezuela as a consequence of sanctions. However, current scientific research on sanction-related medical harm is limited in scope and breadth.

Who is responsible for these patients’ lives? Some may turn to governments of both sanctioned and sanctioning countries, others to human rights organizations. The voice of the international medical community, however, has been missing.

The silence of medical organizations may be driven by a lack of awareness. Deaths from war are visible, photographed, and well-documented; sanctions, on the other hand, are often viewed as a diplomatic, non-violent alternative. The harm caused by ineffective humanitarian exemptions is often slow, hidden, and much harder to quantify or comprehend.

The silence of medical organizations may also be due to their hesitancy to engage in politicized issues. Healthcare professionals have diverse political opinions, including on the use of economic sanctions as a geopolitical tool.

Separating one’s role as a professional from one’s role as a citizen remains a key challenge in an increasingly polarized political climate. But condemning sanction-related medical harm must not be conflated with supporting or denouncing governments that employ sanctions or experience them. 

As medical professionals who have taken an oath to “do no harm,” we have a responsibility to oppose patient harm, regardless of our individual politics. A patient’s right to medical care is not a political issue: it is a medical ethics concern. Two years ago, patients in Iran would have had access to their chemotherapy drugs; today, they do not. 

The medical community must play an active role in ensuring that patients in sanctioned countries are protected and have access to humanitarian necessities. Rigorous research and advocacy are necessary. Medical professionals must produce objective data regarding the medical repercussions of sanctions and the efficacy of existing humanitarian exemptions. They must also unite in advocacy to encourage policymakers and involved governments to pursue collaborative efforts that ensure channels remain open for the import of essential medicines and medical equipment.

When there is sufficient will, patients living under sanctions can be protected. It is time that medical professionals play a role in creating this will — even when we are not in the midst of a pandemic. 

Parsa Erfani (@ErfaniParsa) is a medical student at Harvard Medical School. 

Laila Fozouni is a medical student at the University of California San Francisco, and a recent graduate of the Harvard School of Public Health.

*Name has been changed to maintain patient confidentiality. Patient consent obtained.

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