Economic sanctions and Iran's capacity to respond to COVID-19.

Iran was one of the first countries outside China to have a rapid increase in the number of cases of coronavirus disease 2019 (COVID-19). The country's capacity to respond to the virus is substantially impeded by unilateral economic sanctions re-imposed after the US Administration withdrew from the nuclear deal in May, 2018, and further US sanctions imposed as recently as March 18, 2020. As of March 31, 2020, the recorded number of people infected from COVID-19 in Iran was 41 495, with 2757 deaths, but these numbers are likely a substantial underestimation.

Even before COVID-19, Iran's health system was feeling the effect of the sanctions. Their impact is now severe because they restrict the government's ability to raise funds or to import essential goods. Of the ten countries with the highest number of recorded cases of COVID-19 to date, Iran is the poorest. In 2019, Iran had the lowest rate of economic growth (–9·5%) and highest rate of inflation (35·7%) recorded in the country for the past 20 years. This financial situation makes the funding of adequate prevention, diagnosis, and treatment of COVID-19 impossible, and the country cannot take the same measures adopted in other countries to strengthen responses, such as paying the full cost of obtaining treatment. Essential medicines and medical equipment are technically exempt from sanctions, but their availability is restricted by the effect of sanctions on the commercial sector, reducing manufacturing and trade capacity, and on foreign exchange. Consequently, although approximately 184 000 hospital and primary health-care staff are working to fight COVID-19, their efforts are thwarted by shortages of test kits, protective equipment, and ventilators. WHO has provided crucial supplies, sufficient equipment for 31 000 workers, but supplies are still substantially short of what is needed.

The COVID-19 pandemic has occurred at a time of economic crisis in Iran, in which steep increases in medicine price have affected approximately 6 million patients with complex and chronic illnesses; the situation is almost certainly worse now. This group of individuals is at particularly high risk of infection and disease progression.

As stated by the Director-General of WHO, “We're all in this together, and we can only save lives together.” He was clear that the pandemic caused by COVID-19, the spread of which is unaffected by national borders, can only be controlled by extraordinary co-operation between countries, putting political differences aside. Like elsewhere, delays in implementing strict physical distancing measures in Iran have likely made management of the increasing number of COVID-19 cases more difficult, but the impact of sanctions on the country's capacity to take these measures should not be ignored. Some countries (such as the UK) and some political leaders (including some in the USA), have recognised the urgent need to ease US sanctions on Iran. But the call to do so has achieved little global traction and time is running out.

The Organisation for Economic Co-operation and Development forecasts that global economic growth could decrease by 0·5–1·4% due to COVID-19. The harsh obstacles presented by US sanctions mean that Iran could bear a disproportionate share of this fiscal and health shock, leading to its probable economic collapse and inability to contain the virus that has implications for the entire world.