Prof. Reza Madjzadeh: “Sanctions place the entire health system under pressure”

Mohsen Abdelmoumen:  Could you please introduce yourself to our readers and explain the reasons why you published a study on the impact of so-called ‘international’ sanctions on the Iranian healthcare system in the renowned journal The Lancet?

Prof. Reza Madjzadeh: I am Professor of Global Public Health at the University of Essex. A substantial part of my work sits at the intersection of geopolitical determinants of health, sanctions-related constraints, and health system resilience. Earlier in my career, I also served as President of Iran’s National Institute of Health Research, which monitored health-sector reform in pursuit of universal health coverage. That position gave me a close view of how political and economic pressures can reach health systems through channels that appear, at first sight, far removed from medicine itself.

My engagement with this subject was never merely academic, and certainly not narrowly national. In recent years, particularly in a world where sanctions have increasingly been presented as a supposedly “civilian” alternative to war, I became more concerned with a question that is too often evaded: What is the human cost of this instrument? What mattered to me was to make clear that sanctions cannot be understood only through the language of diplomacy, law, or foreign policy. They must also be examined through the lens of public health, equity, and the ability of health systems to preserve continuity of care under sustained pressure.

The central issue is simple. Humanitarian exemptions on paper do not necessarily protect patients in practice. Medicines, equipment, or other essential goods may be formally exempt. Yet, if banking channels are obstructed, payments are delayed, suppliers are deterred, or supply chains are disrupted, the patient experiences little difference between an exempted good and an unavailable one. That is why I regard this not simply as a political controversy, but as a foundational public health concern.

That was also the logic behind publishing in The Lancet. The purpose was not to speak only about one country. It was to bring a wider global health issue into sharper focus: if sanctions are to be treated as an alternative to war, then their human and health consequences must be scrutinised, measured, and monitored with equal seriousness. Ultimately, the question is how to protect health systems and the people who depend on them from avoidable harm caused by decisions in which they have played no part.

Can you describe the indirect impact of international sanctions on mortality and life expectancy in Iran?

If we want to be scientifically precise, we must begin by clearing away a common misunderstanding: one cannot establish the effect of sanctions on mortality or life expectancy by looking at a single country in isolation. Statistically, that gives us only one unit of analysis, while multiple other forces are operating simultaneously. For that reason, the more persuasive evidence comes from cross-national comparative studies that examine patterns across many countries over time.

Two studies are particularly important here. First, the 2025 Lancet Global Health paper by Francisco Rodríguez, Silvio Rendón, and Mark Weisbrot analysed 152 countries over the period 1971–2021. It is estimated that unilateral sanctions were associated with roughly 564,258 excess deaths per year. Second, Gutmann and colleagues, using data from 98 less developed and newly industrialised countries between 1977 and 2012, found that UN sanctions were associated with reductions in life expectancy of about 1.2 to 1.4 years, while US sanctions were associated with reductions of about 0.4 to 0.5 years.

These findings matter because they make it much harder to describe sanctions as a low-cost or merely administrative policy tool. Sanctions are often portrayed as a non-military alternative to war, yet the available evidence suggests that their human consequences can be severe. For that reason, sanctions should be taken seriously not only in foreign policy terms but also as a major public health concern.

Put differently, the issue is not only whether sanctions achieve their stated political objective. It is also the price exacted from ordinary people while that objective is pursued. Once cross-national evidence shows higher mortality and lower life expectancy, sanctions can no longer be treated as neutral instruments without profound human consequences.

Could you explain the direct and indirect mechanisms through which sanctions put the entire Health system under tremendous stress and affect the patients and the entire population, especially the weakest part of it, children, mothers and elders?

Sanctions do not affect health through a single, narrow pathway. They can place the entire health system under pressure in a cumulative and interconnected way. One of the recurring mistakes in public debate is to reduce the matter to a few medicines in short supply. In reality, sanctions operate across multiple levels of the system: procurement, financing, supply chains, service continuity, and the overall capacity to respond.

At the first level, sanctions make procurement more difficult. Even where essential medicines and medical equipment are formally exempt, that does not necessarily translate into timely or effective purchasing. Problems with financial transfers, blocked or delayed transactions, excessive risk aversion by banks and firms, and a broader climate of uncertainty that discourages commercial engagement can all obstruct the purchase and entry of essential goods. The issue, therefore, is not only whether something is legally prohibited, but whether it can move through the real operational chain on which care depends.

At the second level, these disruptions travel through the supply chain. Even when a product exists somewhere in the system, it may reach health facilities late, irregularly, or at much higher cost. This applies not only to medicines, but also to raw materials, diagnostic equipment, spare parts, consumables, and the continuity of laboratory and hospital services. The health system then enters a more fragile state, in which planning becomes more difficult, storage becomes less stable, and service provision becomes less predictable.

At the third level, sanctions exert pressure through financial channels and the broader economy. Reduced state revenue, macroeconomic instability, inflation, and the erosion of household purchasing power are not merely economic facts; they are translated directly into health risks. When public resources contract, the system’s capacity to purchase, maintain, replace, and support essential services diminishes. At the same time, families may no longer be able to afford transport, medicines, adequate nutrition, or regular follow-up. In this way, sanctions weaken both the supply of care and the population’s effective ability to use it.

Yet these pressures are not distributed evenly. This is where an intersectionality-informed perspective becomes essential. People are not vulnerable only because they are poor or ill. Multiple layers of inequality overlap, placing certain groups at greater risk than others. Those already living with structural disadvantage — through poverty, marginalisation, gender, age, chronic illness, or social exclusion — are more exposed under sanctions. They also tend to have less agency: fewer options to negotiate, relocate, compensate, or find alternatives.

That is why, across many sanctioned settings, the heaviest burden falls on children, mothers, older people, patients with chronic conditions, and marginalised communities. Children are especially sensitive to disruptions in nutrition, immunisation, and continuing care. Mothers depend on stable access to antenatal, delivery, and postnatal services. Older people and those with chronic illness depend more than most on uninterrupted medicines, follow-up, and ongoing support. When both the health system and household livelihoods are under strain at the same time, these are the groups that pay first, and most.

What are your main proposals to safeguard the healthcare system and the most vulnerable part of the population from the impact of international sanctions?

The best protection for a health system is not to use sanctions in the first place. Global experience has shown that sanctions cannot credibly be described as truly “smart” or harmless. Even when medicines, medical equipment, and other essential goods are said to be exempt, those exemptions frequently fail to secure timely and reliable access for patients in practice. From a public health perspective, the first principle should therefore be clear: the health of populations, and the continuity of essential services, should not be turned into an instrument of geopolitical pressure.

But international affairs do not always follow that principle. So the practical question becomes: if sanctions are imposed, how can harm to health systems and vulnerable populations be reduced? In my view, the first requirement is to move beyond mere declarations of exemptions towards their operationalisation. It is not enough for legal texts to state that humanitarian goods are exempt. Financial channels, payments, insurance, transport, procurement, and delivery all need to be protected so that the exemption actually works. If that chain fails, the humanitarian exemption becomes more a statement of intent than a mechanism of protection.

Second, the focus must shift from a few commodities to the health system as a whole. Protection does not mean ensuring that a small number of medicines somehow enter a country. It means preserving continuity of care, equipment functionality, emergency readiness, and the wider conditions that intensify health risk. The key question is not only what the outcome looks like, but whether early signs of weakening protection are being recognised in time: are services for chronic disease, cancer, maternal and child health, dialysis, or intensive care becoming less reliable? Are machines present but no longer maintainable? Is outbreak response capacity narrowing? Are household financial stress, food insecurity, or energy disruptions becoming health threats?

Third, protection is not possible without early, time-ordered, reviewable monitoring. If we wait until mortality or severe clinical deterioration is the first unmistakable signal, the opportunity for earlier correction is usually already lost. Monitoring needs to do more than document difficulty. It must show where strain is accumulating, for whom, through which channel, and what was done in response. A single shortage tells us very little; a recurring pattern tells us a great deal more.

Fourth, monitoring matters only if it serves decision-making. If it is not clear who needs to know, what they need to decide, and when they need to act, monitoring becomes documentation without protection. For national authorities, it should support decisions about which services are at risk of interruption and which functions must be protected first. For humanitarian actors and international agencies, it should reveal where humanitarian exemptions are failing in practice: in payments, procurement, delivery, maintenance, or service continuity. For legal, technical, academic, and policy partners, it should provide reviewable evidence that distinguishes clearly between what has been directly observed, what has been inferred, and what remains uncertain.

Fifth, protection must be organised proactively around vulnerable groups, not invoked rhetorically after harm has occurred. In sanctioned settings, burdens are not evenly shared. Children, mothers, older people, patients with chronic disease, and marginalised groups are usually hit first and hardest. Any serious response must therefore be built around them: protecting maternal and child health services, ensuring continuity of medicines for chronic illness, safeguarding care for older people, and supporting households whose economic distress is becoming a barrier to effective access.

Within this broader agenda, one genuinely important step has been the development of structured monitoring tools. The SHAMS tool was prepared for the WHO’s Regional Office for the Eastern Mediterranean and presented at the WHO Regional Committee’s October 2025 session. The related WHO/EMRO materials present SHAMS as a regionally owned monitoring approach and invite Member States to express their readiness to implement it, nominate focal points, validate indicators and data sources, and report back regularly to the Regional Committee. That matters because it moves the discussion from general concern towards systematic monitoring, earlier visibility, and more practical response.

My central point, then, is this: if we truly want to protect health systems and populations, exemptions must be judged not by their formal existence, but by their actual capacity to preserve real access, continuity of care, and timely response. If protection remains on paper alone, it offers little comfort to the patient whose medicine does not arrive or whose treatment pathway fails. The real test is what reaches the bedside, what is corrected in time, and whether responsibility can be translated from a general principle into a practical, reviewable process.

Unfortunately, the current trend is towards the complete marginalisation of international law and the United Nations framework in favour of the law of the jungle, which manifests itself through wars, embargoes and sanctions. In this context, does the WHO still play a relevant role in protecting public health, or should the Global South create new institutions to defend the principles for which you are fighting?

What we are witnessing globally is not merely the weakness of one institution. It is a deeper crisis of global governance, in which power increasingly overrides principle. In such a climate, those with greater political, financial, or geopolitical weight are often better able to impose their will. So the question is not simply whether WHO alone can protect public health. The more fundamental problem is that the multilateral order, which was supposed to rest on law, shared responsibility, and collective restraint, is repeatedly overshadowed by power asymmetries.

That said, I do not believe the answer is to discard WHO and imagine that an entirely new institution can readily take its place. WHO is the product of decades of collective action, international negotiation, institutional learning, and accumulated legitimacy. That standing was not built overnight. It remains the leading technical and normative authority in global health, and that kind of authority is not easily replaced.

At the same time, realism is essential. WHO operates in a profoundly political world. Tedros has repeatedly said that health is a political choice, and I take that not as a slogan, but as a statement of fact. Health is always shaped by power, budgets, priorities, law, and political decision-making. WHO, therefore, cannot function in a world like this as though health were purely technical. But that does not mean surrendering its ethical or scientific role. On the contrary, it means that its technical independence, moral clarity, and institutional strength become even more important.

In my view, then, the right course is not to move beyond WHO, but to strengthen it: its technical independence, its normative authority, and its capacity to connect evidence, monitoring, response, and accountability. Regional cooperation, South–South collaboration, and scientific and ethical coalitions are also important, but they should be complementary, not substitutes for an institution that has spent decades building global legitimacy.

It is also important to be fair. There are some encouraging signs from within the existing system itself. As I noted in my Lancet correspondence in October 2024, the WHO’s Eastern Mediterranean Regional Office has, in recent years, taken the issue of sanctions and health more seriously at the regional level. That process moved into a more practical phase in October 2025, when SHAMS was brought forward at the regional meeting and supported by Member States. The wider Regional Committee package also set out the next steps for implementation and reporting. This shows that movement is possible from within the institution: away from general principles alone and towards more structured, operational, decision-relevant work.

Of course, none of this means that enough has been done. It could have started earlier. It could be stronger. It still carries delays and limitations. But I do regard it as encouraging. Its significance lies in the fact that WHO, at least at this level, has begun to move beyond abstract concern towards practical tools that can make pressure visible earlier, generate reviewable evidence, and bring decision-making closer to real protection.

In the end, I do not see this as only a diplomatic question. It is also a cosmopolitan one. By that I mean that health should be understood not only through the interests of states, but through a shared human responsibility that extends across borders. Human suffering should not be worth less because of a passport, a government, or a geopolitical location. If we take that seriously, then the central question is no longer whether WHO should be abandoned, but how existing institutions can be strengthened so that they protect people more effectively in a world where political power is often becoming less restrained, not more.

My view is clear: WHO is not sufficient on its own, but it remains indispensable. We should have no illusions about its constraints, but neither should we walk away from it. It should be supported, reformed, and strengthened — while complementary networks are built around it — so that the claims of justice, evidence, and shared human responsibility can carry greater weight in global health.

Interview conducted by Mohsen Abdelmoumen

Reza Majdzadeh is a professor of Global Public Health at the School of Health and Social Care within the University of Essex. He boasts an impressive research portfolio of almost 350 peer-reviewed papers, some of which have been published in prestigious journals. With over two decades of professional experience, he has worked in diverse settings, spanning conflict-affected regions, resource-limited countries, and underserved areas in high-income nations. His primary focus centres on evidence-informed policymaking, with a specific emphasis on reducing health inequalities and promoting community engagement.

His expertise spans over 25 years, delving into teaching, research, and consulting in population health across diverse nations. His journey has taken him through both low- and lower-middle-income countries, as well as high-income ones. Notably, he held the position of Head of the National Institute of Health Research in Iran for four years. He undertook assignments in Sudan, Pakistan, and Jordan during his tenure with the World Health Organisation. His involvement with the work in Somalia and serving disadvantaged populations affected by multiple crises has excellent value in his career. His involvement in the health of First Nations communities in northeastern Ontario, Canada, highlights his commitment to addressing health inequalities.

In recent years, he has been dedicated to advancing the health of coastal communities in southeast England. His core focus in research and teaching centres on epidemiology and strengthening health systems. He is dedicated to measuring community health indicators and restructuring health systems to meet community needs. A central theme of his work is addressing health inequalities, exemplified through projects aimed at fortifying health observatories and devising essential health interventions tailored to community needs. He also brings substantial experience in conducting various workshops. These include workshops on measuring equity, diverse research methodologies, and crafting evidence-informed content for policymakers. His expertise spans multiple health domains, including the study of chronic diseases such as stroke, as well as advocacy for the welfare of vulnerable groups, including pregnant women and underserved populations.

Published in French in La Nouvelle République