A stocktake in ten sections. What strains do sanctions create for workers in the countries that impose them and in the countries they hit? What of this is shown, how strongly, and what has nobody studied? With tables of effects, levels of evidence and a list of gaps.
Contents
- Summary
- Question and method
- Five concepts
- Shown effects
- Sanctioning countries
- Countries under sanctions
- State of research by level of evidence
- Gaps
- What can be derived
- Limits of this study
1 Summary
2 Question and method
Questions. First: what strains do sanctions create for workers, in the countries that impose them and in the countries they hit? Second: what of this is shown, and how strongly? Third: where is knowledge lacking?
Method. On 3 November 2026 we searched the literature database Europe PMC through its open interface, with combinations of sanctions, embargo, mental health, burnout, moral distress, health workers and emigration, for Iran, Syria, Venezuela, Cuba and Afghanistan. Each reference was checked through Crossref (journal, volume, pages, year). Primary sources from official and international bodies were added: WHO, ILO, the UK National Crime Agency, the Bank for International Settlements, the ICRC, the Cuban Ministry of Education and the statistics office, the latter via newspaper reports. Not used were figures without a verifiable source and surveys by vendors in the compliance industry whose methods are not open. There is no survey of our own.
Levels of evidence. strong meta-analysis of prospective studies or several independent large studies with the same result. moderate a single peer-reviewed study or official data with open methods. weak survey without a random sample, interviews, statements by those involved, or a finding whose replication is disputed. missing no source found.
3 Five concepts
Occupational psychology offers a framework that covers both sides of a blockade: the job demands and resources model. Added to this are concepts that describe partial aspects. Table 1 summarises them and states how far they can be transferred to sanctions.
| Concept | Core statement | Evidence | Transferable to sanctions? |
|---|---|---|---|
| Demands and resources | Persistently high demands with dwindling resources lead to exhaustion; resources buffer. | Demerouti et al. 2001; Bakker and Demerouti 2017 | As a framework yes; a measurement under sanctions is lacking. |
| Job insecurity | Perceived insecurity is associated with poorer mental and physical health. | Sverke et al. 2002; Kim and von dem Knesebeck 2016; Virtanen et al. 2013 | Plausible for export staff and for workers in sanctioned countries; not measured. |
| Defensive decision-making | Those held liable for errors choose the option that protects them, not the best one. | Artinger et al. 2019: about one in four important decisions | Fits de-risking; not measured in sanctions screening. |
| Over-reporting under threat of penalty | Heavy fines for missed cases lead to reports when in doubt and dilute their value. | Takáts 2011, model with empirical test | Directly for anti-money-laundering and sanctions screening. |
| Moral distress | Suffering from not being able to act as one thinks right. | Nursing and medical research; Chebly et al. 2025 recommend programmes | Plausible where medicines are missing; not measured. |
| Scarcity in the mind | Persistent scarcity ties up mental capacity. | Mani et al. 2013; replications mixed (O’Donnell et al. 2021) | Disputed; no basis for statements about sanctions. |
Compiled by the editorial team; references in the sources.
4 Shown effects
Job insecurity has the best evidence. The 2002 meta-analysis by Sverke, Hellgren and Näswall found associations with lower satisfaction and poorer health; later reviews of prospective studies confirm this for depressive symptoms and heart disease. Table 2 and the chart show the values. What they do not show matters: the studies measure associations in observational data, and part of this is explained by poverty and living conditions. WHO estimates that at any point in time about 15 percent of working-age adults have a mental disorder, probably more among those with inadequate pay or job insecurity.
| Strain | Outcome | Measure | Value (95% CI) | Basis | Level |
|---|---|---|---|---|---|
| Perceived job insecurity | Depressive symptoms | OR | 1.29 (1.06 to 1.57) | 20 cohorts, meta-analysis | strong |
| Unemployment | Depressive symptoms | OR | 1.19 (1.11 to 1.28) | 20 cohorts, meta-analysis | strong |
| Perceived job insecurity | Coronary heart disease (age adjusted) | RR | 1.32 (1.09 to 1.59) | 17 studies, meta-analysis | strong |
| Perceived job insecurity | Coronary heart disease (fully adjusted) | RR | 1.19 (1.00 to 1.42) | 17 studies, meta-analysis | moderate |
| Mental disorder in general | Share of working-age adults | Share | 15% | WHO guidelines, per Malik et al. 2023; higher with inadequate pay or insecurity | moderate |
| Depression and anxiety | Working days lost | Estimate | 12 billion a year | WHO and ILO 2022; cost nearly 1 trillion US dollars | moderate |
OR: odds ratio; RR: relative risk; CI: confidence interval. None of these studies concerns sanctions. File daten/effekte_arbeit.csv.
By how many percent the odds (OR) or the risk (RR) are higher than without the strain. Meta-analyses of prospective studies; associations, not diagnoses.
| Strain and outcome | Higher by |
|---|---|
| Perceived job insecurity: Depressive symptoms (OR 1.29; 95% CI 1.06 to 1.57) | +29% |
| Unemployment: Depressive symptoms (OR 1.19; 95% CI 1.11 to 1.28) | +19% |
| Perceived job insecurity: Coronary heart disease (age adjusted) (RR 1.32; 95% CI 1.09 to 1.59) | +32% |
| Perceived job insecurity: Coronary heart disease (fully adjusted) (RR 1.19; 95% CI 1.00 to 1.42) | +19% |
Sources: Kim and von dem Knesebeck, International Archives of Occupational and Environmental Health 89(4), 2016, 20 cohorts; Virtanen et al., BMJ 347, 2013, f4746, 17 studies, up to 174,438 people. File daten/effekte_arbeit.csv.
5 Sanctioning countries
In the countries that impose sanctions, the burden lies with those who implement them. The mechanism is well described: a bank that misses a hit risks heavy fines; if it refuses a permitted payment, this costs it almost nothing. Takáts has shown that this calculation leads to reports when in doubt. The UK reporting office shows the volume: 872,048 suspicious activity reports and 57,081 requests for consent to a transaction in one year. For export departments it is shown that trade policy uncertainty lowers investment; in Germany, according to DIHK 2026, 69 percent of companies surveyed saw more trade barriers, 30 percent of them citing sanctions.
What is missing is the step from mechanism to person. How exhausted, anxious or satisfied analysts, export clerks and owners of small firms are under sanctions has not been measured by any independent study using recognised questionnaires. Table 3 therefore separates what rises from what is known about strain.
| Group | What rises | What is missing | Evidence | Level of evidence on strain |
|---|---|---|---|---|
| Sanctions and anti-money-laundering screening in banks | Volume, threat of penalty, time pressure | Room for manoeuvre: an error in the customer’s favour is punished, the reverse hardly | NCA 2024: 872,048 reports and 57,081 consent requests in one year; Takáts 2011 | missing |
| Export departments | Lists, licences, deadlines, tariffs | Predictability | Caldara et al. 2020: uncertainty lowers investment; DIHK 2026: 69 percent see more trade barriers, 30 percent of them cite sanctions | missing |
| Small firms and crafts | Refused or delayed payments, queries | Legal department, time, bargaining power | No official count of refused payments; individual cases | missing |
| Authorities that review exports | Number of applications, political attention | Staff | Artinger et al. 2019 on defensive decisions in administration, not on export control | weak |
The level refers to evidence on workers’ psychological strain, not on the mechanism. Mechanisms are partly well supported (see text).
6 Countries under sanctions
In the countries under sanctions it is mainly resources that dwindle: materials, money, colleagues. The BMJ Open review from October 2026 found harm to health in 42 of 43 studies; workers appear there in interviews with experts who mention effects on motivation and emigration. Where money stops altogether, wages are missing, as in Afghanistan in 2021. Where real wages fall, skilled workers leave, as the survey of young Venezuelan doctors and the figures of the Cuban Ministry of Education show.
None of these sources separates the share of sanctions from other causes. For Cuba both halves belong in the calculation: the US embargo makes imports more expensive and foreign currency scarce; wage and price policy, the rules for private work and the persecution of critics, 1,351 political prisoners in September 2026 according to Prisoners Defenders, are in the hands of the Cuban leadership. The medical missions abroad are a separate dispute that is not caused by sanctions.
| Country and group | Strain | Evidence | Level | Other causes the source does not separate |
|---|---|---|---|---|
| Iran, health sector | Shortage of medicines and equipment; motivation and emigration | BMJ Open 2026 (63 percent of the 43 studies from Iran; interviews with experts); PLOS One 2026 (31 interviews: income, purchasing power, research funding) | weak | Inflation, economic policy |
| Venezuela, young doctors | Lack of resources in hospitals, emigration | Chebly et al. 2025: 312 responses, 40 percent emigrated, 97 percent see training impaired by lack of resources | weak | Economic collapse, disputed causes |
| Afghanistan, hospital staff | Loss of pay after donors stopped | ICRC 2022: took over salaries of nearly 10,500 staff in 33 hospitals | moderate | Taliban takeover in 2021 |
| Cuba, teachers | Low real wages, staff shortage | MINED via OnCuba: 17,278 teachers missing (October 2023); ONEI: average wage 5,839, education 5,451 pesos (2024); Douhan: 30 to 50 percent vacant posts, reportedly | weak | Government wage and price policy, emigration, repression (1,351 political prisoners) |
| Cuba, doctors on missions abroad | Withheld wages, pressure on those who quit | UN Special Rapporteurs 2019: indications of forced labour; Cuba’s foreign minister: the cooperation “saves lives”, more than 400,000 professionals in 164 countries | weak | Cuban state rules; not caused by sanctions |
| Self-employed in sanctioned countries | Foreign currency, payment routes, changing rules | No study on strain found | missing |
Levels as in section 2. Figures marked “reportedly” come from information presented to the body cited.
7 State of research by level of evidence
Table 5 summarises the state of research in ten statements. It is meant to prevent a well-supported general finding from being read as evidence for a statement about sanctions.
| Statement | Level | Why |
|---|---|---|
| Perceived job insecurity is associated with depressive symptoms. | strong | Meta-analysis of 20 prospective cohorts from 15 articles. |
| It is associated with coronary heart disease, partly via social circumstances. | moderate | 17 studies; after full adjustment just at the limit of significance. |
| Sanctions harm the health of the population in the target country. | moderate | 42 of 43 studies find harm, quality varies; the size is disputed (Lancet 2025 versus Gutmann et al. 2021). |
| Heavy fines lead banks to report when in doubt. | moderate | Theoretical model, consistent with empirical evidence; one paper. |
| Defensive decision-making is widespread in organisations. | moderate | Survey in public administration; not measured in banking. |
| Trade policy uncertainty dampens investment. | moderate | Peer-reviewed paper with firm-level and aggregate data (US). |
| Sanctions drive the emigration of health workers. | weak | Interviews and non-random surveys; causes not separated. |
| Compliance professionals are under greater psychological strain because of sanctions. | missing | No independent study found; industry surveys without open methods. |
| Scarcity lowers cognitive performance. | weak | Original study well known, replications mixed, authors in dispute. |
| Measures at the level of the organisation help against psychological strain. | weak | Recommended by WHO, which itself rates the evidence as of very low quality. |
Rating by the editorial team according to the rules in section 2.
8 Gaps
- Compliance staff. No independent study on strain from sanctions screening. What is needed is a survey with recognised instruments for strain and exhaustion, over several years, with a comparison group from other areas of banking.
- Events as natural experiments. New listings or packages hit departments at known times. Measuring before and after would show the association much more sharply than cross-sectional surveys.
- Small firms and the self-employed. Data are missing on both sides, although these are precisely the ones without a legal department. WHO itself calls workers in small firms, in informal work and in poorer countries unusually under-researched.
- Refused payments. Nobody counts them officially; without this figure neither the workload nor the damage can be estimated.
- Countries other than Iran. 63 percent of studies on US sanctions and health come from Iran. For Cuba, Syria, North Korea, Myanmar or Russia there is hardly any occupational research.
- Separating causes. Emigration and shortage have several causes. Comparisons with similar countries without sanctions are almost entirely missing for workers.
- Gender. Gutmann and others found that sanctions lower women’s life expectancy more. Whether women are affected differently at work, for example in health and education, has not been studied.
- Effect of countermeasures. Whether general licences, guidance and contact points reduce the strain on screeners has never been measured.
9 What can be derived
What follows is derivation, not finding. The 2022 WHO guidelines recommend measures at the level of the organisation against psychosocial risks, training for managers and individual interventions as part of an overall programme; for training of workers themselves WHO found no effect on symptoms, and it made no recommendation for workplace screening. Transferred, this means:
- For banks and exporting firms: clear internal rules on when a permitted payment is executed, and backing for reasoned decisions in the customer’s favour; this reduces the incentive for defensive decisions.
- For supervisors and policy: exemptions and guidance that can be applied without lengthy legal review reduce uncertainty; details in “Humanitarian exemptions” and “Banks worldwide”.
- For aid organisations and donors in the health systems of sanctioned countries: securing wages and materials is the most effective resource; programmes against moral distress are recommended by experts, their effect under sanctions has not been tested.
10 Limits of this study
This study is a stocktake by the editorial team on a single day, not a systematic review following a fixed protocol. We searched one database, in English, German and Spanish; literature in Persian, Arabic or Russian is not covered. Figures from Cuba come from authorities via newspaper reports or from information given to the UN Special Rapporteur. The rating of evidence is the editorial team’s judgement and can be disputed; the reasons are given in each case.
This piece is information, not legal, investment or health advice. It makes no diagnoses. It reflects the view of the editorial team, relies on the sources listed and names opposing positions. “Helfen statt Blockieren” is non-partisan.
Sources
- Demerouti, Bakker, Nachreiner, Schaufeli, The job demands-resources model of burnout, Journal of Applied Psychology 86(3), 2001, 499 to 512, doi:10.1037/0021-9010.86.3.499, https://doi.org/10.1037/0021-9010.86.3.499
- Bakker, Demerouti, Job demands-resources theory: Taking stock and looking forward, Journal of Occupational Health Psychology 22(3), 2017, 273 to 285, https://doi.org/10.1037/ocp0000056
- Kim, von dem Knesebeck, Perceived job insecurity, unemployment and depressive symptoms: a systematic review and meta-analysis of prospective observational studies, International Archives of Occupational and Environmental Health 89(4), 2016, 561 to 573, https://doi.org/10.1007/s00420-015-1107-1
- Virtanen et al., Perceived job insecurity as a risk factor for incident coronary heart disease: systematic review and meta-analysis, BMJ 347, 2013, f4746, https://doi.org/10.1136/bmj.f4746
- Korenstein et al., Health impacts of US international economic sanctions: a scoping review, BMJ Open 16(10), 2026, e123343, published 9 Oct 2026, https://doi.org/10.1136/bmjopen-2026-123343
- Keyvani, Majdzadeh, Hanaee, Doshmangir, Determinants and policy approaches to healthcare professional retention in Iran, PLOS One 21(4), 2026, e0339855, https://doi.org/10.1371/journal.pone.0339855
- Chebly et al., Physician Shortages in Underserved Populations: Venezuelan Physician Perspectives on Emigration and Professional Development, Teaching and Learning in Medicine 38(1), 2025, 82 to 94, https://doi.org/10.1080/10401334.2025.2479146
- WHO Europe, WHO and ILO call for new measures to tackle mental health issues at work, 28 Sep 2022, https://www.who.int/europe/news/item/28-09-2022-who-and-ilo-call-for-new-measures-to-tackle-mental-health-issues-at-work
- Takáts, A Theory of “Crying Wolf”: The Economics of Money Laundering Enforcement, Journal of Law, Economics, and Organization 27(1), 2011, 32 to 78, https://doi.org/10.1093/jleo/ewp018
- National Crime Agency, SARs Annual Report 2024 (April 2023 to March 2024): 872,048 reports, https://www.nationalcrimeagency.gov.uk/who-we-are/publications/747-sars-annual-report-2024/file
- Artinger, Artinger, Gigerenzer, C. Y. A.: frequency and causes of defensive decisions in public administration, Business Research 12(1), 2019, 9 to 25, https://doi.org/10.1007/s40685-018-0074-2
- Caldara, Iacoviello, Molligo, Prestipino, Raffo, The economic effects of trade policy uncertainty, Journal of Monetary Economics 109, 2020, 38 to 59, https://doi.org/10.1016/j.jmoneco.2019.11.002
- ICRC, Afghanistan: Health care system on life support, 30 Aug 2022, https://www.icrc.org/en/document/afghanistan-health-care-system-life-support
- OnCuba News, Aulas cubanas presentan un déficit superior a los 17 mil maestros (citing MINED), 24 Oct 2023, https://oncubanews.com/cuba/aulas-cubanas-presentan-un-deficit-superior-a-los-17-mil-maestros
- OnCuba News, De sueldo e inflación en Cuba (citing ONEI), 18 Apr 2025, https://oncubanews.com/cuba/de-sueldo-e-inflacion-en-cuba-salario-medio-estatal-aumento-un-25-en-2024-pero-sigue-sin-cubrir-necesidades-basicas
- OHCHR, Alena Douhan, end-of-mission statement on Cuba, 21 Nov 2025, https://www.ecoi.net/en/file/local/2133521/20251121-eom-stm-cuba-sr-negative-impact-unilateral-en.pdf
- Havana Times (from El Toque), UN Rapporteurs Request Information on Alleged Slavery of Cuban Doctors, 15 Jan 2020 (communication of November 2019), https://havanatimes.org/?p=165911
- OnCuba News, Cuba califica como mendaces las acusaciones de EE. UU. (Bruno Rodríguez), 26 Jan 2022, https://oncubanews.com/cuba/cuba-califica-como-mendaces-las-acusaciones-de-eeuu-sobre-presunta-trata-de-personas-en-sus-misiones-medicas
- Prisoners Defenders, Presos políticos en Cuba, septiembre 2026, 15.10.2026, https://www.prisonersdefenders.org/2026/10/15/presos-politicos-cuba-septiembre-2026/
- Helfen statt Blockieren, Voices: Bruno Rodríguez Parrilla, post on X, 28 Oct 2026, source given there
- Mani, Mullainathan, Shafir, Zhao, Poverty Impedes Cognitive Function, Science 341(6149), 2013, 976 to 980, https://doi.org/10.1126/science.1238041
- O'Donnell et al., Empirical audit and review and an assessment of evidentiary value in research on the psychological consequences of scarcity, PNAS 118(44), 2021, e2103313118; reply: Shah, Zhao, Mullainathan, Shafir, PNAS 120, 2023, e2206054120, https://doi.org/10.1073/pnas.2103313118
- Sverke, Hellgren, Näswall, No security: A meta-analysis and review of job insecurity and its consequences, Journal of Occupational Health Psychology 7(3), 2002, 242 to 264, https://doi.org/10.1037/1076-8998.7.3.242
- Malik et al., Mental health at work: WHO guidelines, World Psychiatry 22(2), 2023, 331 to 332, https://doi.org/10.1002/wps.21094
- DIHK, Rekord bei Handelshemmnissen, press release 24 Mar 2026 (Going International 2026), https://www.dihk.de/de/newsroom/rekord-bei-handelshemmnissen-usa-werden-zum-bremsklotz-chancen-in-indien-und-lateinamerika--175386
- Gutmann, Neuenkirch, Neumeier, Sanctioned to Death? The Impact of Economic Sanctions on Life Expectancy and its Gender Gap, Journal of Development Studies 57(1), 2021, 139 to 162, https://doi.org/10.1080/00220388.2020.1746277
- Rodríguez, Rendón, Weisbrot, Effects of international sanctions on age-specific mortality, The Lancet Global Health 13(8), 2025, e1358 to e1366, https://doi.org/10.1016/S2214-109X(25)00189-5
- Europe PMC, REST interface, search on 3 Nov 2026, https://www.ebi.ac.uk/europepmc/webservices/rest/search
All online sources accessed on 3 November 2026. Data files for checking: daten/ of this series.