Title : Is American hegemony a hazard to global health or can resilient nation states outlast economic sanctions: A synthetic-control analysis of Iran 1985-2023
Abstract:
Background: Economic sanctions are a widely used instrument of foreign policy but remain controversial due to their potential humanitarian consequences. Prior cross-national research has linked U.S, Imposed sanctions to substantial excess mortality globally, raising concern about their population-level health effects. However, such analyses may obscure country-specific dynamics, temporal heterogeneity, and the role of domestic health systems in shaping outcomes. Given recent geopolitical tensions and Iran’s history of repeated sanction escalations across distinct policy periods, Iran provides a useful and policy-relevant case to evaluate whether sanctions are associated with measurable deterioration in population health or whether underlying health-system resilience mitigates these effects.
Methods: We applied a synthetic-control design using World Bank indicator series to construct a counterfactual “synthetic Iran” from a donor pool of ten middle-income countries (Turkey, Thailand, Malaysia, Mexico, Indonesia, Brazil, Colombia, Peru, South Africa, Egypt). Separate models were estimated for infant mortality, under -5 mortality, life expectancy at birth, and GDP per capita. The pre-treatment period was 1985-2005, with matching based on full pre-intervention outcome trajectories and predictors including GDP per capita, fertility, urbanization, and health expenditure. We also incorporated benchmark year matching within the pre-treatment window to improve fit. Post-treatment effects were evaluated across key policy periods: 2006–2011 (UN sanctions), 2012-2014 (oil and financial tightening), 2015-2017 (JCPOA relief), and 2018-2023 (renewed sanctions following U.S. withdrawal from the JCPOA). Model fit and divergence were assessed using root mean square prediction error and placebo tests within the donor pool.
Results: Synthetic controls reproduced Iran’s pre-treatment trajectories with acceptable fit across all outcomes. After 2012, GDP per capita diverged substantially from the synthetic control, with relative declines of approximately 6.7% during 2012-2017 and 9.1% during 2018-2023, indicating sustained macroeconomic underperformance. In contrast, population-health indicators did not deteriorate. Infant mortality remained consistently lower than the synthetic comparison, with mean gaps ranging from -2.0 to -2.5 deaths per 1,000 live births across policy periods, and under -5 mortality showed similar reductions of -2.0 to -2.7 per 1,000. Life expectancy remained modestly higher than the synthetic control by approximately 0.7-1.0 years after 2006. Placebo diagnostics indicated that these divergences were detectable but not uniquely extreme within the donor pool, supporting cautious interpretation of effect size and specificity.
