U.S. policymakers present sanctions as policies that are specifically aimed at the leaders of a regime. However, they can be devastating to the population of the targeted state. Often, it is difficult to meaningfully harm a government without causing collateral damage to its citizens, as a state can be both an oppressor of its people and at the same time provide them with food, medicine, and law and order—tasks that it cannot do as effectively if it is deprived of resources. Cutting off access to Western finan­cial markets and banking services and prohibiting investment in a country can likewise suffocate the private sector. Thus, aside from those narrowly targeted at the financial interests of individuals, economic sanctions practically always cause hardship to innocent third parties. Ironically, some of the people most victimized by these policies are those that the economic sanctions are designed to help.

Sanctions regimes that target the economy of a country usually have humanitarian exceptions. Despite this, other regulations usually serve to limit their effectiveness. For example, federal law prohibits the president from implementing sanctions on Iran that involve “the sale of agricultural commodities, food, medicine, or medical devices …”20 Still, sanctions related to the financial sector and other parts of the economy work to nullify these exemptions. To see why, imagine an American company that tried to trade in food or medicine but did not have access to banking services, such as the ability to take out loans or accept credit cards.21 Compounding the problem is the fact that Iran is a largely state‐​run economy, which makes it difficult to do business there while completely avoiding the government sector. Even when one can potentially operate within the letter of the law, the sanctions regime is of such complexity, and the potential consequences of running afoul of U.S. law so dire, that there is a chilling effect on many businesses.22

Some European banks have refused to process payments from Iranian firms that are exempt from sanctions on the chance that the banks may potentially face U.S. penalties as a result. In response to the Trump administration’s “maximum pressure” campaign, which was begun in 2018, an employee of an Iranian affiliate of the German pharmaceutical corporation Bayer said that her company was facing challenges in transferring money in order to pay for imported drugs. Since trade with major Iranian banks has been restricted by U.S. sanctions, companies have been forced to risk working with lesser known banks that could themselves one day be subject to sanctions, or else the companies stop operating in that country altogether.23 The American practice of applying secondary sanctions to those who have economic dealings with entities that violate Iranian sanctions also serves to scare off many businesses.24

In the case of the sanctions on Syria, the UN reports that the chilling effect “has even affected United Nations staff, who reported being refused bank accounts or mortgages from European banks when the word ‘Syria’ appeared in their job title.”25 Large human rights organizations based in that country have faced difficulties importing medicine, or even processing donations from abroad.26 Investigating one of the largest public hospitals in Damascus, the Los Angeles Times showed how the facility runs into trouble importing even the most basic medical necessities.27 If a piece of medical equipment breaks down, buying a replacement from a Western corporation becomes a bureaucratic nightmare, as “foreign suppliers often don’t dare send anything to Syria for fear of triggering unexpected vio­lations—a real possibility.” Getting access to software updates for hospital computers and other equipment can also be difficult. Banks from outside the United States have already paid billions of dollars in fines, most of it going to American regulatory agencies.28 According to one pharmaceutical supplier based in Aleppo, “I have money, I can’t transfer it, I can’t buy anything with it, I can’t even put it in the bank.” Sanctions affect every aspect of financing or running a modern economy. Apple even bans apps that have a Syrian origin, which led one bank in the country to create its app under a different name so that customers could download and use it.29

Moreover, even if the provisions regarding humanitarian exceptions worked as intended, most sanctions regimes would nevertheless harm the living standards of those in the targeted state, including hindering access to food or medicine. Policies that work to destroy an economy but carve out exceptions cannot be expected to have no effect on the exempted industries. Lowering economic output ensures that all sectors are harmed: the food and medical sectors depend on other industries such as construction, education, transportation, and, of course, banking. Countries that suffer from poor economic performance for whatever reason thus see worse health and nutritional outcomes. This means that humanitarian exemp­tions, even when they “work,” should not obscure the degree to which sanctions harm the population of the targeted country.

In order to estimate the economic effects of these kinds of policies, a 2015 study looked at 67 countries that were subject to American or UN sanctions between 1976 and 2012 and compared them to countries that did not face similar kinds of economic coercion.30 UN sanctions reduced GDP by an average of 2.2 percent a year, for an aggregate effect of more than 25 percent of GDP over a 10‐​year period. The effects of American sanctions were smaller but still significant, reducing GDP by about 1 percent a year, for a total effect of a 13.4 percent decline over seven years. The more stringent the sanctions regime, the greater the economic decline. As mentioned above, the GDP of Syria dropped by 75 percent between 2010 and 2015.31 Per capita income in Iraq likewise went from $3,510 in 1989 to $450 in 1996.32 The economy of Venezuela has been mismanaged for years, yet it did not completely collapse until after the election of Trump, when the United States began to place stringent sanctions on the Maduro government. From 2016 to 2019, GDP per capita income of that country dropped from $9,090 to a projected $2,550.33 While all of these countries have suffered due to bad economic choices made by their governments, rarely have modern countries seen declines of this magnitude without the imposition of Western restrictions on trade. Besides perhaps war, it is difficult to think of a tool of foreign policy that today causes more economic and humanitarian destruction than economic sanctions.

Even studies that focus on the costs of sanctions put most of their energy toward under­standing nutritional and health outcomes. This should not obscure the fact that, if even by some miracle nutrition and health outcomes did not decline in the face of comprehensive sanctions, the destruction of wealth would still represent a tragedy for millions of people. Economic growth is correlated with nearly everything that humans value, including time, convenience, comfort, and the ability of individuals to live their lives as they desire.34 While stories of vacations never taken, educational opportunities never pursued, and lifetimes of soul‐​crushing jobs that people cannot afford to leave do not make headlines, these costs are nonetheless real and significant for millions who suffer because of U.S. policy.

Of course, economic sanctions do influence nutritional and health outcomes, and several efforts have been made to quantify these effects in terms of lives lost and other metrics. Economic sanctions tend to kill through harming the most vulnerable: pregnant women, newborns, the sick, and the elderly. The economic sanctions on Iraq in the 1990s were said to have killed more than 500,000 children by increasing the infant mortality rate.35 Recently, researchers have argued that these numbers were manipulated by Saddam’s government, yet even the “corrected” numbers still imply a death toll that may reach into the six figures.36 A 1993 UN report indicated that sanctions on Haiti were killing 1,000 children a month.38 As the report says, that analysis does not take into account the effects of sanctions on hindering other international aid programs or preventing the North Korean government from addressing its own domestic needs. In Iran, sanctions are estimated to have contributed to the deaths of 1,600 people from the H1N1 virus in fall 2019 alone.39 Again, this number is based on one kind of death over a very limited period of time, during which much of the entire Iranian health care sector was—and remains—in crisis.

Finally, according to the Center for Economic and Policy Research, the Trump administration’s economic war on Venezuela led to more than 40,000 excess deaths between 2017 and 2018, calculated based on a nationwide survey that found an increase in mortality over that time period.40 This does not include any deaths that have resulted from the even more crushing sanctions regime inau­gurated by executive order in January 2019, which barred the United States from importing Venezuelan oil.41 The Maduro regime exported 35 percent of its oil to the United States in 2018, and the cumulative effect of sanctions is such that “oil export revenues in 2019 are projected to fall by a cataclysmic and unprecedented 67.2 percent from 2018.”42 Thus, the death toll in Venezuela as a result of sanctions likely continues to increase to this day.

In the case of Syria there are no estimates of the number of deaths from sanctions, likely because of issues with reporting and the fact that it is impossible to precisely differentiate between deaths that can be attributed to the economic embargo and those caused more directly by the war itself. Two things are worthy of note, however. First, the vast majority of the population lives in government‐​controlled areas, and second, key indicators of health and well‐​being have fallen across the board. This implies that a large portion of the health and nutritional effects of the war can be attributed to international sanctions, either by preventing aid or by suppressing economic activity. Between 2006 and 2016, the vaccination rate among Syrian children dropped from 95 percent to 60 percent, leading to the reemergence of diseases that were once practically eliminated, including typhoid, measles, and rubella.43 Between 2011 and 2016, Syrian production of wheat fell by 53 percent, lentils by 70 percent, and chickpeas by 30 percent, with an estimated 38 percent of the country being unable to meet basic food requirements as of 2018, which was after the worst of the fighting was over.44

These case studies represent only a small fraction of the total number of deaths that have resulted from international sanctions, as the studies involved usually cover only a short period of time in a single country, and often only look at a single metric, such as infant mortality. The Treasury Department website lists 22 countries with individuals or entities targeted by U.S. sanctions.45 If the harshest sanctions regimes can kill tens of thousands of people a year, then U.S. sanctions have likely led to the deaths of hundreds of thousands, and perhaps even millions, of people in the post–World War II era. While we will likely never have a precise estimate of how many people have lost their lives because of U.S. and international sanctions, the data that do exist imply that such restrictions on trade over the last two decades have, in the aggregate, been more deadly than all but a handful of wars across that same span of time.46