By Dr. Abbas Kebriaeezadeh, Foreign Policy: Last month, the U.S. Department of State released a video addressed to the people of Iran. In the video, Trump administration official Brian Hook claims that it is a “myth” that sanctions target Iran’s access to medicine. For more than a decade, my fellow Iranian medical professionals and I have been struggling to protect patients from the fallout of U.S. sanctions. We have studied sanctions impacts on Iran’s health care sector and advocated for better responses from our own government. Our findings make clear that the harms being inflicted on Iranian patients are not mythology.
Today’s integrated and interconnected world depends on banking systems and trade networks that are dominated by the United States. Consequently, the U.S. government is able to use economic sanctions to cause harm to economic, political, and even social relations in target countries with relative ease.
Although U.S. sanctions are engineered in a way that may appear not to target humanitarian access to food and medicine, in practice U.S. sanctions function as a tool of economic war.
Officials in Washington continue to insist that they maintain “exemptions” to their sanctions to protect humanitarian trade, even after the International Court of Justice has ruled that these exemptions are insufficient, leaving “little prospect of improvement” in the “serious detrimental impact on the health and lives” of Iranians individuals. At the end of the day, it is incumbent on the United States to heed this humanitarian warning.
Under U.S. President Donald Trump, the situation has gotten worse. Census Bureau data shows that the United States exported an average of $26 million of pharmaceutical products to Iran annually during the Barack Obama-era sanctions. Exports have averaged just $8.6 million a year in the last two years under the more draconian sanctions policies of Trump.
The Trump administration has also made it more difficult for European countries to export medicine to Iran. Swiss pharmaceutical exports to Iran fell 30 percent from 235 million Swiss francs ($240 million) in 2017 to 163 million francs ($167 million) last year, according to Swiss customs data. Even though sanctions were only fully reimposed in November 2018, Swiss exports that year fell below the 173 million francs ($178 million) annual average observed from 2008 to 2015.
Similarly, French pharmaceutical exports to Iran fell 25 percent from 194 million euros ($218 million) to 146 million euros ($164 million) last year, slipping below the 2008 to 2015 average of 150 million euros ($168 million), according to data from Eurostat.
In response to such pressures, and as part of its post-revolution policies of self-sufficiency, Iran has made important strides in safeguarding its people’s access to medication. Iran is a world leader in the production of generic drugs, helping significantly lower the cost of health care. According to Akbar Barandegi, director general of Iran’s Food and Drug Administration, almost 97 percent of the country’s needed pharmaceutical doses are provided by about 100 local pharmaceutical companies, most of which belong to the private sector. Just 3 percent of demand is met with imports, purchased from many of the world’s largest pharmaceutical companies.
These purchases may form only just a small proportion of total demand, but they relate to specific medications vital for the well-being of many patients, particularly those with advanced or chronic diseases.
Last year, several of my colleagues who work in the field of pediatric oncology published a note in the/ Lancet/ showing that chemotherapy drugs such as asparaginase, the leukemia treatment mercaptopurine, and even the basic pain killer paracetamol had run out of stock, threatening the treatment of thousands of children. Access to these medications is being significantly disrupted as a result of U.S. sanctions against Iran. This disruption takes three primary forms.
First, sanctions impact the availability of imports. While imports represent just 3 percent of Iran’s total demand by unit, they account for 39 percent of the country’s needs by value, reflecting the fact that imported medicines are typically five times more expensive than domestically-made equivalents and the fact that Iran tends to import specialized drugs, which are generally more expensive.
Just as with raw materials, banking restrictions have made it more difficult for Iranian importers to pay European and Asian suppliers for medicine. Shortages of imported medicines and skyrocketing costs are putting the most vulnerable patients—those with rare or advanced diseases—at the greatest risk.
There is particular concern over the risk to pediatric cancer patients. In this face of these import disruptions, opportunists have begun smuggling counterfeit and low-quality medicines into Iran through routes from Pakistan, Turkey, and the United Arab Emirates. Should disruptions grow worse, it could also lead to introduction of counterfeit or impure ingredients to domestically-manufactured medications, leading to not only low-quality drugs, but also new public health risks.
Second, sanctions interrupt domestic production by interrupting supply chains. Iran’s pharmaceutical manufacturers use over 10,000 different compounds in their production processes. The pressure of U.S. sanctions and the chilling effect on international banks have already made it impossible for many suppliers to reliably receive payment for raw materials sold to Iran. Some medications require 15 substances from different manufacturers in various countries in order to be produced. The absence of even one substance brings the production of that medicine to a halt.
Finally, the impact of sanctions on Iran’s economy hurts health care providers and consumers alike by reducing purchasing power. Lower government revenues and reduced access to foreign currency put a strain on health care spending, making imported drugs more difficult to afford for patients even when hospitals have them in stock. According to data released by the Central Bank of Iran, the cost of health care in Iran rose nearly 20 percent between November 2017 and November 2018.
Declining output will also create unemployment. The Iranian Pharmaceutical Industries Syndicate estimates that pharmaceutical manufacturers employ approximately 25,000 staff, while a further 100,000 workers are employed in distribution companies, pharmacies, and aftersales support. These workers are some of Iran’s best and brightest, and around 20 percent of those employed are university graduates. Their futures are at stake.
What may seem like sterile banking sanctions are truly much more dangerous. These sanctions disrupt the access of the Iranian public—especially the poor, the elderly, children, women, and patients suffering from chronic diseases—to the medications they require.
Medicines become more expensive and of worse quality. An unreliable supply chain leads to incomplete treatment of diseases and their becoming chronic. The crisis deepens when the slowdown in domestic production increases the country’s need to import drugs. All this is happening against the backdrop of the Iranian government’s strained resources as it is forced to import medicines at a higher price tag in those instances when a banking channel is available.
Responsible leaders in the United States recognize that there is little to gain by smothering humanitarian trade. European governments have sought clarity on humanitarian trade, only to be rebuffed. This forced France, Germany, and the United Kingdom to establish a special purpose vehicle, called INSTEX, to try to facilitate humanitarian trade. Iranians welcome this move, but the United States should not shirk its moral responsibilities. The Swiss government is negotiating directly with the Trump administration on a banking channel for humanitarian trade, but its efforts have so far been blocked by officials who are seeking the most extreme interpretation of “maximum pressure.” Iran’s European suppliers understand that this situation is dire, but the Trump administration remains unaccommodating.
During the Iran-Iraq War, the United States turned a blind eye to Saddam Hussein’s use of chemical and biological warfare against Iranian and Kurdish soldiers and civilians. Most damningly, the United States not only refused to place sanctions on Iraq to deter use of nerve agents, but it also refused to aid Iran’s access to the antidotes required to treat the victims of chemical attacks.
I happen to be one of those victims; Saddam’s chemical weapons burned my lungs and eyes, causing lifelong injuries for which I continue to take medication, and which have gotten progressively worse in my old age. Seared in my memory are the hundreds of victims I saw in warzone emergency facilities near the Iran-Iraq border who had little or no access to treatment equipment, especially antidotes.
Nearly 40 years on, the U.S. government continues to suffer from the same moral failures, and I continue to witness the results up close. Though I have survived this unconventional war, many of my countrymen and my patients have not—and their sanctions-induced deaths are not a myth.
First published in Foreign Policy.
Dr. Abbas Kebriaeezadeh, one of Iran's leading medical
professionals and a doyen of the country's pharmaceutical industry.