Our research indicates that in analyzing the impact of sanctions on long term and multi-faceted processes such as education, the perceptions and interpretations of individuals are as significant as tangible and measurable impacts. For example, alongside verifiable clinical or economic implications, rumors and hearsay become instrumental in shaping doctors’ and medical trainees’ informal and tacit forms of knowledge, which in turn continually shapes their mindsets and clinical decisions and/or teachings. These perceptual effects reflect conditions of possibility, opportunities or lack thereof and spaces of discrimination that are often masked in quantitative analyses of the impact of sanctions. 

Broadly speaking, sanctions’ impacts can be divided into direct and indirect categories: direct impacts include lack of access to certain diagnostic techniques, limited access to educational material (such as Coursera or Up-to-date or certain medical journals) or applications, and the challenge of monetary transactions to access or submit to certain journals that reject Iranian submissions outright based on the indication of “violating sanctions”. In many cases, a variety of methods are used to bypass restrictions and substitute access, such as piracy, VPN technology or alternative international resources. Direct impact is easier to identify in specialized areas of medical education, where cutting-edge diagnostic techniques, medical devices or access to academic exchange play more significant roles.

The main aspects of medical education that are clearly impacted by sanctions can broadly be categorized as: clinical decision-making, when lack of access to most up to date medical devices for diagnosis and treatment of patients during residency can limit the scope of experience and training; difficulties in academic exchanges and participation in research production due to risks and restrictions associated with traveling; increasingly prohibitive costs of membership in associations and of journals; as well as the perception of their identity as a doctor in connection to their own society and global community. Indirect effects, however, are manifest in more insidious, perceptual and reputational matters, such as a sense of isolation from the international scientific community and of losing exchange or learning opportunities; or even more tangible outcomes such as Western academics being reluctant to travel to Iran for conferences or academic exchanges out of concern for consequences in the U.S. This reputational and psychological deterrence is a by-product of both U.S. policies and more complex internal realities, such as the securitization of scholarly work by the Iranian regime over the past couple of decades, resulting in the detainment and harassment of several foreign and dual national scholars, with both pragmatic and psychological/ diplomatic implications.  

In sum, the impact of sanctions manifest in three experiential areas of decision-making: 

• clinical (treatment, distribution of resources, ethics of care, training); 

• research and the psychopolitics of knowledge production: what constitutes research, to what end (eg, CV, publishing with the goal of migration), dynamism and mobility (growth in plagiarism versus possibilities for international exchange); and 

• personal worldviews: intersection with broader life decisions, such as choice of specialty, whether to leave Iran, etc. 

a. Clinical decision making

Lack of access to the most modern techniques and medical devices for diagnostic and treatment procedures is the most tangible impact of sanctions on not only the quality of education, but also the perception of being “behind” the world. The quality of training, particularly in specialized areas, depends greatly on trainees’ access to techniques and medical devices they can experiment with during residency at public university hospitals. Imaging techniques such as computed tomography (CT) perfusion and radiotherapy techniques for specialized diagnosis in neurological issues and cancer, as well as disruption in availability of chemotherapy medications, are among the most common examples. 

Access to some commonly used educational material is also impacted, though scientific publications and textbooks are barely affected. Iran does not abide by copyright laws, so there has been unlimited access since the 1980s to offset copies of most original textbooks at a cheaper price. But online material is a different story. When access to online material is blocked, it is difficult to determine whether the cause is external sanctions (Coursera, Up To Date) or domestic censorship AKA “filtering” (Twitter, YouTube). The impact on first and second year medical students, who rely primarily on textbooks, is thus less significant than on clinical trainees. Access to some publishing resources has indeed fluctuated over time; some become available after a series of negotiations, including restricted access to PubMed that has now been sorted out, and instances such as the restricted access to Medline that was mysteriously lifted. 

The more tangible issues often have to do with restricted access to software and educational platforms. Apple’s strict adherence to sanctions resulting in blocked access to the Apple Store and applications, for example, is consequential, since many Iranians use its iPhones, iPads and laptops. Zoom and Coursera are complex examples of platforms that exclude Iranians from subscriptions. Coursera’s website states that it does not allow users in certain countries or regions including Iran to “access … certain parts of our site, including certain degree program content”.[15] Iranian users have shared screenshots of Coursera that block access of Iran IP addresses to the entire website.[16] Similarly, Zoom’s website states that, for regulatory reasons, Iranians cannot access its services.[17] However, there is little consensus among users on whether the real reason behind the blockage is sanctions or censorship and domestic agendas for monopolizing domestic platforms. In response to Zoom’s unavailability, a national alternative platform, NAMAD, was launched for Persian speakers, but educators and trainees frequently report its inefficiencies and question the academic versus ideological and political logic behind such “failed” attempts at promoting the discourse of “self-reliance”. Many educators are concerned that these domestic “equivalents” to global platforms or social media are both poorly received and often come with high cost and low quality. 

For internationally recognized and widely used resources such as Up To Date (UTD), the mechanism is more straightforward: the platform does not allow subscriptions from Iran. In the post-2015 climate of the nuclear deal, a loophole was briefly created for the Ministry of Health and Medical Education to obtain a legal subscription, but that was undone after 2018. At best, one now can access UTD via pirate Chinese websites, and one of our interlocutors, a veteran medical educator and clinician/researcher, pointed to dangerous consequences: first, normalizing illegal activity and breaking copyright laws changes a society’s sense of ethics over time; and secondly, going through too many loopholes and short cuts, some of which keep failing and have to be reinvented, creates mental fatigue and kills motivation, so one eventually thinks “why bother”. Significantly, several interlocutors expressed sentiments such as “how many times would one try to ‘break the filter’ on YouTube to watch a demo on a specific procedure before giving up?” This in part explains the over-reliance on textbooks in Iranian medical education, a trend that has become increasingly outdated globally and replaced by interactive platforms and manuals such as UTD. 

b. Research and knowledge production

During the brief period after the JCPOA, there was optimism that international exchanges would increase, but after the most recent round of U.S. sanctions and Trump’s maximum pressure policy, the number of foreign academics willing to risk traveling to Iran has dropped. It is also increasingly hard for Iranian medical students and faculty to overcome economic and political barriers (visa, travel ban, etc.) to attend international conferences. 

Our research indicates that the medical community is frustrated at the difficulties in establishing and sustaining connections to the international academic community, particularly after 2018. The contributing factors, however, go beyond the direct restrictions imposed by sanctions. Economic deterioration tied to the sanctions, restrictions on travel to Iran and the Iranian establishment’s suspicions and securitization of academic exchanges have further complicated navigation of the logistical barriers created by sanctions (such as transfer of money). 

The issue of mobility and access to global networks is intimately tied to visceral concerns about representation on the global scientific stage. Many medical doctors and scientists in official positions underscore the mutual nature of the damage at cultural and diplomatic levels but imply that sanctions have after all failed to diminish the academic quality of medical education, since restricted access to educational material has never stopped Iranians from finding alternative ways to access the latest scientific developments. The key issue, they maintain, is the entrenchment of cultural misconceptions and animosity between Iran and the U.S.: “if you are deprived of meeting people from other places, not to mention the experience of visa and border regimes, you end up with mutual resentment and misconceptions. That’s damaging for both sides”. 

Others with more hands-on experience are adamant that nuance is often missing from this often bipolar debate, especially among officials and the Diaspora who do not experience the day-to-day realities. Restricted mobility and international exchange via conferences, for example, is situated in a set of complex discursive processes, some sanctions related, some largely due to economic collapse, the rial’s devaluation, dwindling university budgets and decisions inherently related to domestic rather than international politics. The chicken and egg question is are international guests reluctant to visit Iran because of the renewed sanctions (with implications for U.S. travel since 2018), or because of misconceptions or geopolitical complexities? How to pinpoint which is more damaging to diplomacy and global community membership: sanctions’ brutal and inhumane reality? News headlines about detained foreign nationals? Issues related to scientific rigor? Or all the above?[18]

When a physician official and immunologist with extensive experience in research organized the first International Congress on Immunodeficiency in Iran in 2005, over 60 international guests were hosted in Tehran and treated to sightseeing in Isfahan and Shiraz. Fifteen years later, in the aftermath of renewed sanctions and heightened anxieties created by a punitive border regime that prohibits Europeans who have visited Iran to enter the U.S. without a visa, he laments, one should “forget about any such exchange”. A clinical immunologist by training, he uses the immunological metaphor of hypersensitivity to describe the damaging consequences of isolation from global economies of knowledge. Diminished international mobility due to sanctions, border regimes and, most recently, the significant currency devaluation that makes visas, travel and conference registrations increasingly unaffordable deprives all involved societies not only of academic exchanges (with the direct implication of missing mutual learning opportunities and certain clinical experiences), but also of exchanges that allow for cultural desensitization and immunity. The damage, he argues, is mutual. Isolation results in lack of familiarity and thus, in immunological terms, “hypersensitivity to foreign bodies”. 

But international exchanges are not limited to conferences and research trips. Over the past two decades, international student exchanges have gained new significance for medical education in Iran, a notion that was absent in the late 1990s. It is likely that sanctions contributed to a sense of urgency to seek opportunities elsewhere. European grants that involved funding individuals as opposed to institutions were not affected by sanctions. Iran has joined the International Federation of Medical Students’ Associations (IFMSA) and Erasmus Plus, a global health network for student exchange in each round of which four medical students are eligible to be hosted in Iran. A parallel memorandum of agreement with medical schools in Ukraine provides for one-month exchanges of medical students without fees. Established partnerships with U.S., German and UK medical schools for short-term clinical exchanges during internship and residency also existed but were all aborted after the reinstatement of sanctions in 2018. The 2015 Memorandum of Agreement with the Mayo Clinic, for example, had established a two-way route for three-month exchanges that the officials involved considered “a huge achievement and milestone”. But with the Trump administration and the subsequent travel bans, the plan was dropped. Similarly, the Tehran University of Medical Sciences (TUMS) neurology department agreed in 2017 with Leicester University for six to 12-month residencies for Iranians to receive part of their training in the UK. Since sanctions were renewed, however, it has become, financially and logistically, almost impossible to pursue that route. 

Other educators go further and raise concerns about long-term academic consequences. One involved in curriculum design for medical schools maintains: