经济制裁对健康的危害

《柳叶刀全球健康》2025年8月刊

https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(25)00278-5/fulltext

全球卫生筹资是2025年的主要讨论议题，尤其是在本月初塞维利亚举行的第四届发展筹资问题国际会议之后。本期期刊收录了一系列关于此主题的证据，尤其关注各国目前使用的更具破坏性的经济手段。弗朗西斯科·罗德里格斯及其同事的面板分析再次证明，制裁确实会造成死亡：从1971年到2021年，美国或欧盟实施的经济制裁每年导致564,258人死亡（95%置信区间为367,838至760,677），高于每年与战争相关的伤亡人数（106,000人）。这一发现与《柳叶刀全球健康》此前发表的一篇文章相符，该文章指出援助制裁——特别是针对低收入或中等收入国家（LMICs）发展援助的经济制裁——造成了致命后果，导致1990年至2019年间，这些国家的婴儿死亡率每年上升3.1%，孕产妇死亡率每年上升6.4%。

制裁是一种限制性外交政策工具，通常应用于广泛的经济交易，其惩罚性目的是强制改变行为，例如制止侵犯人权或促进民主。根据全球制裁数据库，自1950年以来，制裁的频率和持续时间持续增长，但其实现既定目标的成功率仍然只有约30%。

所有经济制裁最终都会对健康产生制裁作用。制裁通过其对医疗产品获取、医疗保健服务提供和民众心理健康的直接影响，以及对粮食安全和社会经济发展等健康决定因素的间接影响，不可避免地甚至有意损害了人们的健康权。此外，制裁对健康的不利影响在儿童、妇女（相对于男性）和最边缘化群体中最为显著。由于经济制裁的有效性低，且对健康的影响显著且不均衡，因此，与军事侵略相比，经济制裁是否能有效减少死亡人数值得怀疑。

美国及其盟友撤回发展援助，从其影响来看，可以被视为事实上的制裁，尽管其意图可能有所不同。更糟糕的是，与大多数制裁不同，被制裁国的行为改变不太可能改变这种破坏性的行动路线。来自富裕强国的政治领导人应该反思并采取行动，解决实施经济制裁、削减发展援助与其促进公平和全球发展的道德义务之间的矛盾。

除了制裁和削减援助之外，中低收入国家必须转向更加自力更生、更具韧性的发展和卫生融资体系。一种方法是通过提高富人的边际税率以及加大对烟草、酒精和含糖饮料的征税力度等措施，拓宽卫生资金来源。债务仍然是中低收入国家发展的主要障碍；除了共同努力解决全球金融体系的缺陷外，利益攸关方还应部署更有效、更具创新性的债务减免工具，例如“债务换健康”和“债务换自然”，将债务偿还用于加强卫生系统和环境保护。

实现财务韧性的另一种方法是最大限度地减少效率低下。正如艾米·拉斯图卡及其同事所强调的，效率低下在医疗保健系统中普遍存在，并且与治理不善（特别是腐败）以及政府在医疗保健覆盖范围和基础设施方面的支出不足等因素相关。迪娜·巴拉巴诺娃及其同事将通过《柳叶刀》全球卫生反腐败委员会，研究根深蒂固的腐败制度和政治驱动因素，并通过打击医疗保健系统内外的腐败行为，指导政策制定者优化效率。

从2010年到2022年，全球四分之一的国家都遭受了某种形式的制裁，其中大部分位于非洲。这种制裁对象分布的不均衡引发了人们对制裁是否合理使用的质疑。如果经济制裁必须存在，那么实施制裁的国家必须监测并评估其所有后果，并建立明确的退出机制，以防止不必要的长期制裁。我们不应忽视制裁和削减援助带来的令人担忧的证据，那些拥有强大经济影响力的国家必须权衡由此造成的健康损失是否合理。

国际制裁对特定年龄段死亡率的影响：一项跨国面板数据分析

2025年8月

https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(25)00189-5/fulltext

摘要

背景

以往研究表明，制裁的实施与目标国家健康状况的恶化之间存在相关性。然而，这种因果关系的方向尚不明确。目前尚无研究使用旨在解决观察性数据因果识别问题的方法，在跨国面板数据中检验制裁对特定年龄死亡率的影响。

方法

在本项跨国面板数据分析中，我们利用1971年至2021年间152个国家的特定年龄死亡率和制裁事件面板数据集，分析了制裁对健康的影响。我们应用了一系列旨在利用观察性数据解决因果问题的方法，包括熵平衡、格兰杰因果检验、事件研究表示和工具变量法。

结果

我们的研究结果表明，制裁与死亡率上升之间存在显著的因果关系。我们发现单边制裁、经济制裁和美国制裁的影响最为显著，而联合国制裁则未显示出统计学意义上的影响。死亡率影响范围从5岁以下儿童的8.4个对数点（95% CI 3.9–13.0）到60-80岁人群的2.4个对数点（0.9–4.0）。我们估计，单边制裁每年造成564,258人死亡（95% CI 367,838–760,677），与武装冲突造成的全球死亡负担相似。

解读

制裁对公共卫生造成重大不利影响，其造成的死亡人数与战争相当。我们的研究结果强调了重新思考制裁作为外交政策工具的必要性，并强调了在使用制裁时保持克制以及认真考虑改革制裁机制的重要性。

引言

国际制裁是指各国政府为实现外交政策目标而对国际交易施加的限制。制裁是否会影响目标国家的健康状况，以及这些影响是否足以造成大量死亡，是当代经济治国理念中最具争议的问题之一。20世纪90年代关于制裁伊拉克对儿童死亡率影响的讨论，对政策辩论产生了深远影响，也是随后对萨达姆·侯赛因政府重新设计制裁措施的主要驱动力之一。

制裁可能导致公共卫生服务的数量和质量下降，其原因在于制裁造成的公共收入减少；³ 制裁导致外汇收入减少，从而限制了基本进口物资的供应，进而限制了医疗用品、食品和其他关键物资的获取；⁴ 制裁还会通过实际存在的或人们感知到的障碍，限制人道主义组织在目标国家有效开展工作的能力。⁵ 多年来，人们对传统跨领域制裁机制的人道主义影响的担忧促使了众多改革举措的出台。

尽管有这些举措，但近几十年来，经济制裁的使用却大幅增长。根据全球制裁数据库（GSDB）的计算，2010年至2022年期间，25%的国家受到美国、欧盟或联合国某种形式的制裁，而1960年代这一比例平均仅为8%。^8,9 这一增长主要源于旨在结束战争、保护人权或促进民主的制裁措施的增加。

我们旨在利用1971年至2021年间152个国家的年龄别死亡率和制裁事件的跨国面板数据集，研究制裁对目标国家死亡率的影响。

方法
数据来源

我们的制裁指标来自全球制裁数据库（GSDB），这是迄今为止最全面、最新的全球制裁数据集。我们重点关注三个国家或组织实施的制裁，因为预计这些制裁会产生重大影响：美国、欧盟和联合国。鉴于欧美经济规模庞大，且全球大部分贸易和金融交易均以美元或欧元结算，我们预计欧美制裁将产生显著影响。¹¹ 我们区分经济制裁和非经济制裁。经济制裁限制贸易或金融交易，而非经济制裁则涉及武器贸易、军事援助、旅行或其他问题。此外，我们还区分美国或欧盟单方面实施的制裁，以及与联合国针对同一目标实施的多边制裁机制同时实施的制裁。

研究背景

本研究之前的证据

2022年8月12日至10月18日期间，我们通过谷歌、谷歌学术和JSTOR检索到31项定量研究，这些研究运用计量经济学或校准技术评估制裁与社会经济发展指标之间的联系。检索词组合体现了定量研究方法（

计量经济学和校准）、感兴趣的解释变量（经济制裁）以及描述感兴趣的福祉指标的术语（例如，预期寿命、死亡率和健康状况）。四项研究直接探讨了制裁对死亡率的影响：一项研究了5岁以下儿童死亡率，一项研究了预期寿命，一项研究了儿童体重，一项研究了艾滋病毒感染率和死亡率。在我们检索到的所有研究中，没有一项研究使用旨在利用观察性数据解决因果问题的方法，系统地检验制裁对跨国数据中特定年龄死亡率的影响。

本研究的附加价值

本研究首次利用旨在解决观察性数据因果识别问题的方法，估算了经济制裁对特定年龄死亡率的影响。这些方法使我们能够解决以往研究中存在的内生性和混杂因素问题，并得出与全球制裁相关的死亡人数的定量估计。我们的研究结果表明，单边经济制裁，特别是美国实施的制裁，会导致死亡率大幅上升，对5岁以下儿童的影响尤为严重。

现有证据的启示

制裁对目标国家的健康状况造成了严重的负面影响，其影响程度与武装冲突相当。单边制裁、经济制裁以及美国制裁的影响尤为显著。鉴于此，政策制定者应重新思考将制裁作为外交政策工具的运用，并考虑采取措施大幅限制制裁的使用，以及改革制裁机制以减少其造成的人道主义后果。

我们的因变量包括新生儿（0-27天）、婴儿（0-1岁）、5岁以下儿童（以下简称5岁以下；0-5岁）、儿童（5-9岁）、青少年（10-14岁）、成人（15-60岁）和老年人（60-80岁）的死亡率。前三个年龄组的死亡率估计值由联合国儿童死亡率估计机构间小组利用生命登记系统数据以及基于抽样调查和人口普查的直接或间接估计值构建而成。世界银行利用联合国人口司（UNPD）和人类死亡率数据库的数据构建成人死亡率。我们直接根据联合国人口司公布的年龄别死亡率构建儿童、青少年和老年人群的死亡率。为了缩小成人死亡率的估计范围，我们将世界发展指标数据库中的男性和女性成人死亡率估计值与联合国人口司提供的按性别划分的人口比例相结合。

作为经济发展和现代化的衡量指标，我们使用了宾夕法尼亚世界表（Penn World Table）中经购买力平价调整后的人均收入对数、受抚养人口与劳动年龄人口的比率以及世界银行利用联合国人口司数据构建的农村人口比例。我们使用联合国开发计划署和联合国教科文组织的数据构建了女性预期受教育年限指标，该指标定义为在当前年龄别女性入学率下，普通女性一生中能够获得的受教育年限。我们还使用了来自 Polity5 项目的民主程度指标，以及来自乌普萨拉大学和平与冲突研究系和奥斯陆和平研究所内战研究中心的指标，该指标用于衡量该国是否卷入内战或国际战争。

面板固定效应回归

我们估计了面板固定效应回归模型，其中因变量为特定年龄死亡率指标，解释变量包括一个用于衡量该国是否受到国际制裁的指标，以及一组用于反映目标国家人口、经济和制度特征的控制变量。所有回归均包含国家效应和年份效应，分别用于衡量国家特有的、不随时间变化的因素（例如地理、文化和宗教）以及影响所有国家的、随时间变化的因素（例如医疗技术的变化）。因此，我们的基准模型设定如下：

The health toll of economic sanctions

The Lancet Global Health  August 2025
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(25)00278-5/fulltext

Financing for global health is the main topic of discussion in 2025, especially since the Fourth International Conference on Financing for Development in Seville earlier this month. This issue contains a range of evidence on this subject, but particularly on the more damaging economic levers wielded by states today. In their panel analysis, Francisco Rodríguez and colleagues once again demonstrate that sanctions do kill: economic sanctions imposed by the USA or the EU were associated with 564 258 deaths (95% CI 367 838–760 677) annually from 1971 to 2021, higher than the annual number of battle-related casualties (106 000 deaths). This finding aligns with a previous Article in The Lancet Global Health showing the lethal effects of aid sanctions—economic sanctions specifically targeting development assistance in low-income or middle-income countries (LMICs)—which resulted in a 3·1% increase in infant mortality and a 6·4% increase in maternal mortality annually between 1990 and 2019.

Sanctions are restrictive foreign policy tools that are commonly applied to broad economic transactions, with the punitive aim of coercing behaviour change, such as stopping human rights violations or promoting democracy. According to the Global Sanctions Database, the frequency and duration of sanctions have consistently grown since 1950, while their success rate of achieving the stated aim remains at about 30%.

All economic sanctions ultimately function as sanctions on health. Through their direct effects on access to medical products, provision of health-care services, and civilian mental health, as well as their indirect effects on determinants of health such as food security and socioeconomic development, sanctions inevitably or even intentionally undermine people's right to health. Moreover, the adverse effects of sanctions on health are most pronounced among children, women (versus men), and the most marginalised populations. With a low efficacy rate and a significant and uneven impact on health, it is questionable whether economic sanctions meaningfully reduce the number of deaths relative to military aggression.

The withdrawal of development assistance by the USA and its allies could be seen as de-facto sanctions in terms of their impact, although the intent may differ. Worse still, unlike in the case of most sanctions, changes in behaviour by the targeted states is unlikely to alter this devastating course of action. Political leaders from wealthy, powerful countries should reflect and act upon the inconsistency between imposing economic sanctions, reducing development assistance, and their moral obligations to promote equity and global development.

Sanctions and aid cuts aside, LMICs must shift to a more self-reliant and resilient financing system for development and health. One approach is to broaden health funding sources through measures such as increasing marginal tax rates on the wealthy and intensifying tax on tobacco, alcohol, and sugary drinks. Debt remains a major barrier to the development of LMICs; alongside collective efforts to address flaws in the global financial architecture, stakeholders should deploy more effective and innovative debt relief instruments such as debt-to-health and debt-for-nature, which redirect debt repayments towards health system strengthening and environmental preservation.

Another approach to achieving financial resilience is to minimise inefficiency. As highlighted by Amy Lastuka and colleagues, inefficiency is prevalent in health-care systems and associated with factors such as poor governance (particularly corruption) and inadequate government expenditure on health-care coverage and infrastructure. Dina Balabanova and colleagues, through the Lancet Global Health Commission on anti-corruption in health, will examine the deep-rooted institutional and political drivers of corruption and guide policymakers in optimising efficiency by targeting corrupt practices within and beyond health-care systems.

A quarter of all countries were subject to some type of sanctions from 2010 to 2022, with the majority located in Africa. This inequity in countries targeted raises valid questions about whether sanctions are being used appropriately. If economic sanctions must exist, countries imposing them must monitor and review all their consequences, with an explicit exit mechanism in place to prevent unnecessary prolongation. We should not ignore the alarming evidence on sanctions and aid cuts, and countries in the powerful position to wield these economic levers must weigh up whether the health toll is a justifiable trade-off.

Effects of international sanctions on age-specific mortality: a cross-national panel data analysis

August 2025
https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(25)00189-5/fulltext

Summary
Background
Previous research has shown a correlation between the imposition of sanctions and worsening health conditions in target countries. However, the direction of causality in this relationship remains unclear. No study has yet examined the effects of sanctions on age-specific mortality rates in cross-country panel data using methods designed to address causal identification in observational data.

Methods
In this cross-national panel data analysis, we analysed the effect on health of sanctions using a panel dataset of age-specific mortality rates and sanctions episodes for 152 countries between 1971 and 2021. We apply a range of methods designed to address causal questions using observational data, including entropy balancing, Granger causality, event-study representations, and instrumental variables.

Findings
Our findings showed a significant causal association between sanctions and increased mortality. We found the strongest effects for unilateral, economic, and US sanctions, whereas we found no statistical evidence of an effect for UN sanctions. Mortality effects ranged from 8·4 log points (95% CI 3·9–13·0) for children younger than 5 years to 2·4 log points (0·9–4·0) for individuals aged 60–80 years. We estimated that unilateral sanctions were associated with an annual toll of 564 258 deaths (95% CI 367 838–760 677), similar to the global mortality burden associated with armed conflict.

Interpretation
Sanctions have substantial adverse effects on public health, with a death toll similar to that of wars. Our findings underscore the need to rethink sanctions as a foreign-policy tool, highlighting the importance of exercising restraint in their use and seriously considering efforts to reform their design.

Introduction
International sanctions are restrictions on international transactions imposed by governments in pursuit of foreign policy objectives. Whether sanctions affect health conditions in target countries and whether these impacts are strong enough to cause a substantial number of deaths are among the most contentious issues in contemporary thinking on economic statecraft. Discussions in the 1990s on the effects on child mortality of sanctions on Iraq strongly influenced policy debates and were one of the main drivers of the subsequent redesign of sanctions on the Government of Saddam Hussein.

Sanctions can lead to reductions in the quantity and quality of public health provision driven by sanctions-induced declines in public revenues;3 decreased availability of essential imports, resulting from sanctions-induced reductions in foreign exchange earnings, which limit access to medical supplies, food, and other crucial goods;4 and constraints on humanitarian organisations, through real or perceived sanctions-induced barriers that hinder their ability to operate effectively in target countries.5 Concern with the humanitarian effect of conventional cross-cutting sanctions regimes has prompted numerous reform initiatives over the years.

Despite these initiatives, the use of economic sanctions has grown substantially in recent decades. According to calculations made using the Global Sanctions Database (GSDB), 25% of all countries were subject to some type of sanctions by either the USA, the EU, or the UN in the 2010–22 period, by contrast with an average of only 8% in the 1960s.8,9 This increase is driven by the growth of sanctions that have the claimed aim to end wars, protect human rights, or promote democracy.

We aimed to investigate the impact of sanctions on mortality in target countries using a cross-national panel dataset of age-specific mortality rates and sanctions events for 152 countries between 1971 and 2021.

Methods
Data sources
Our sanctions indicators come from the GSDB, the most comprehensive and updated global dataset on sanctions compiled to date. We focus on sanctions imposed by three countries or organisations that can be expected to have substantial effects: the USA, the EU, and the UN. We expect European and US sanctions to have substantial effects given the size of their economies and the fact that most world trade and financial transactions are carried out using the US dollar or the euro.11 We distinguish between economic sanctions, which are those that restrict trade or financial transactions, and non-economic sanctions, which are those that deal with arms trade, military assistance, travel, or other issues. We also distinguish between sanctions that are imposed unilaterally by the USA or the EU, and those imposed concurrently with a multilateral UN sanctions regime on the same target.

Research in context
Evidence before this study
We identified 31 quantitative studies that use econometric or calibration techniques to assess the link between sanctions and indicators of social and economic development through searches on Google, Google Scholar, and JSTOR, carried out between Aug 12 and Oct 18, 2022. The searches combined terms characterising quantitative methodologies (econometrics and calibration), the explanatory variable of interest (economic sanctions), and terms describing the wellbeing indicator of interest (eg, life expectancy, mortality, and health). Four studies dealt directly with the effect of sanctions on mortality: one considered under-5 mortality, one considered life expectancy, one considered children's weight, and one considered HIV infection and death rates. None of the studies identified in our search had systematically examined the effects of sanctions on age-specific mortality in cross-country data using methods designed to address causal questions using observational data.

Added value of this study
This study provides the first estimates of the effect of economic sanctions on age-specific mortality derived from the use of methods designed to address causal identification on observational data. These methods allow us to address concerns over endogeneity and confounding that have limited previous research and to derive quantitative estimates of deaths associated with sanctions at a global level. Our findings reveal that unilateral and economic sanctions, particularly those imposed by the USA, lead to substantial increases in mortality, disproportionately affecting children younger than 5 years.

Implications of all the available evidence
Sanctions have substantial adverse effects on health conditions in target countries, effects similar in magnitude to those of armed conflict. These effects are particularly strong for unilateral, economic, and USA sanctions. In light of this evidence, policy makers should rethink the use of sanctions as a foreign policy tool and consider initiatives to substantially restrain their use and reform their design to reduce adverse humanitarian consequences.

Our dependent variables were mortality rates for newborns (0–27 days), infants (0–1 year), children younger than 5 years (hereafter referred to as under-5; 0–5 years), children (5–9 years), adolescents (10–14 years), adults (15–60 years), and older people (60–80 years). Estimates for the first three of these groups are constructed by the UN Inter-agency Group for Child Mortality Estimation using data on vital registration systems and direct or indirect estimates based on sample surveys and censuses. Adult mortality rates are constructed by the World Bank using data from the UN Population Division (UNPD) and the Human Mortality Database. We construct mortality rates for children, adolescents, and older groups directly from the age-specific mortality rates published by the UNPD. We combined male and female adult mortality rate estimates from the World Development Indicators database with population shares by sex from the UNPD to constrict our adult mortality rate estimate.

As measures of economic development and modernisation, we used the logarithm of per capita income adjusted for differences in purchasing power parity from the Penn World Table, the ratio of dependents to the working-age population, and the proportion of the population living in rural areas constructed by the World Bank using UNPD data. We used data from the UN Development Programme and UNESCO to construct an indicator of expected years of female schooling, defined as the years of schooling that an average female would attain in her life given the current age-specific female school enrolment rates. We also used a measure of democracy from the Polity5 Project and an indicator of whether the country was involved in either a civil or international war from the Department of Peace and Conflict Research at Uppsala University and the Centre for the Study of Civil War at the Peace Research Institute Oslo.

Panel fixed-effects regressions

We estimated panel fixed-effects regressions in which the dependent variables were measures of age-specific mortality rates and the explanatory variables consisted of an indicator for whether the country was subject to international sanctions and a set of controls capturing the target country's demographic, economic, and institutional characteristics. All regressions include country and year effects, which capture, respectively, the effect of country-specific time-invariant factors such as geography, culture, and religion, and of time-varying factors affecting all countries, such as changes in health technologies. Our baseline specification was thus: