When Sima, 35, entered a pharmacy in Tehran, her eyes darted around the shelves behind the counter, looking for a box to prevent kidney failure. Without it, she was running out of time.
She eventually found the drug at the seventh pharmacy she visited, in a wealthy part of Tehran. Her sense of relief evaporated when the pharmacist told her that prices had risen again, leaving her with no choice but to under-dosing her life-saving medicine.
As U.S. sanctions choke Iran’s economy, ordinary people with chronic and serious illnesses are struggling to find the medicines they rely on to survive. Severe shortages and daily price increases have forced many people like Shima to reduce their medication doses, postpone doctor visits, or self-medicate.
“The government has stopped the use of anti-cancer drugs for people who are considered terminal or very advanced,” said Shima, who did not want to give her real name to CNN so she could speak freely. “They only use it on people who are in the very early stages.”
A mother in Tehran who lost her only daughter was forced to switch from antidepressants to locally produced, less effective drugs. Seasonal influenza vaccinations were canceled this year because the government was unable to procure vaccines from Europe. Cancer patients are selling their televisions and refrigerators to buy expensive medicines.
A 55-year-old cancer patient, who asked to remain anonymous, said she too was running out of options.
“I asked people who were visiting or returning from abroad if they could take my medicines home with me, especially those that I can’t find or don’t have access to here,” a patient in Tehran told CNN. “Between the illness and the anxiety of war, I don’t know what to do.”
Iranian pharmacies interviewed by CNN found shortages and price hikes in several categories, including heart medicines offered as local generics rather than prescription brands, cholesterol-lowering drugs that are available but much more expensive, and migraine drugs that have disappeared from shelves entirely.
But Iranian media reports say the shortage is far more widespread, affecting everything from antidepressants to insulin to pregnancy drugs. Other drugs are completely unavailable, leaving sick people in Iran with either astronomically high prices or less effective generic versions.
Shahram Qalantari, president of the Iranian Pharmacists Association, said at a press conference last month that around 800 types of medicines have been affected by the shortage, and pharmacies are unable to procure substitutes due to rising costs.
“Everyone says we are brave,” the cancer patient added by phone. “But I don’t know if being brave in the face of death means anything.”
Mehdi Pir Salehi, head of the country’s Food and Drug Authority, said in February that Iran currently manufactures more than 97% of medicines by volume. The hardest hit will be imported specialty medicines that must be paid for in foreign currency. Shortages of these drugs are growing under US President Donald Trump’s maximum pressure campaign, which has tightened surveillance on Iranian banks and blocked oil exports, the Islamic republic’s main source of foreign currency.
“This high level of domestic production does not necessarily mean complete self-sufficiency,” said Peiband Bastani, a senior lecturer at Flinders University and co-author of a study examining the impact of sanctions on Iran’s pharmaceutical procurement. “Domestic manufacturing may still rely on imported materials, equipment and technology, but some specialized and expensive medicines will need to be imported.”
Iranian officials say pharmacies are unable to replenish stocks because insurance companies have stopped paying them. Millions of Iranians have insurance, so presenting an insured prescription at a pharmacy usually yields nothing, or patients have to pay out-of-pocket.
Rampant inflation, broken insurance payments, and the government’s inability to sell oil and obtain the foreign currency needed to repay pharmacies have disrupted supply chains.
Officials from the Iranian Pharmacists Association said at a press conference last month that more than 18,000 private pharmacies across the country are currently waiting for payments from insurance companies, and the insurance debt owed by pharmacies has reached about 800 trillion rials ($300 million).
“These pharmacies can no longer afford to continue investing their own funds and wait a year to receive the money owed,” the association’s president, Shahram Kalantari, said at the time.
Mohammad Hashemi, spokesman for Iran’s Food and Drug Administration, told Iranian state media in June that more than 40 pharmaceutical companies, equipment suppliers and distributors were affected by US and Israeli airstrikes on Iran earlier this year.
In late March, Israel attacked a factory belonging to Tofi Dar, a major Iranian pharmaceutical company that produced active ingredients for cancer drugs and anesthetics. The Israeli military alleged that the company supplied fentanyl to an Iranian company conducting “chemical weapons research and development,” a claim the company denies.
The airstrike also damaged the historic Pasteur Institute, founded more than a century ago. The Lancet medical journal reported that the attack devastated “key reference laboratories including genomic surveillance, rabies, HIV/AIDS, viral hepatitis, and vector-borne diseases.”
Last month, U.S. Treasury Secretary Scott Bessent announced that the United States would crack down on the complex network Iran has built over the years to allow Iranian entities to evade Washington’s wide-ranging sanctions. This is a move aimed at increasing pressure on Iran in the absence of a diplomatic solution.
The US government allows transactions related to “agricultural products, food, medicine, or medical equipment to Iran,” but adds several safeguards to ensure that such goods “are not diverted by the Iranian regime to fund its nefarious purposes.”
In 2019, the United States sanctioned the Central Bank of Iran and has since required foreign governments and institutions seeking payment protection to voluntarily send further information to the U.S. government, including details about shipments of medical supplies to Iran, details of who is purchasing the medicines, and written commitments not to resell to sanctioned individuals or entities.
The U.S. government last week tightened rules on other licenses, adopting a “presumptive refusal” position for certain licenses and saying applications would be reviewed on a case-by-case basis.
Experts say laborious bureaucratic procedures are preventing international companies from doing business with Iran.
“Sanctions could disrupt financing and international payments, reduce the willingness of foreign banks and suppliers to do business with Iranian buyers, and complicate the procurement and import of medicines, pharmaceutical ingredients and manufacturing technology,” Flinders University’s Bastani said.
Although Iran’s big pharmaceutical companies themselves are not sanctioned, some of the largest have ties to sanctioned charity conglomerates and sanctioned individuals. For example, Barkat Pharmaceutical Group, one of the country’s largest pharmaceutical companies that led the country’s production of COVID-19 vaccines, is involved in enforcing Imam Khomeini’s edicts, a licensing body that answers directly to the Supreme Leader.
“Over-compliance” is another problem, said Eric Ferrari, founder of a Washington, D.C., firm that specializes in sanctions and enforcement. Banks and counterparties may consider the transaction too risky.
“Even if you can identify a party or an intermediary that is not sanctioned, you still have to find a bank that is willing to process the transaction and will process the transaction and take the risk,” Ferrari told CNN. “Banks may say, ‘We have no idea who is who in Iran, how the money is going to flow, where the money is coming from, so let’s not trade.'”
Iran was negotiating with the United States to unfreeze some funds held in Qatar for humanitarian spending. Those negotiations have since stalled, with Iran focusing on negotiations over the future of the Strait of Hormuz and Washington returning to diplomacy.
“It’s getting more difficult every day,” Ferrari said. “I’m actually quite surprised that the Iranians were able to survive this long, given how onerous the sanctions regime is.”
