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.

Funding: The Center for Economic and Policy Research.

Declaration of interests FR is the owner of VenAnalytics, a for-profit consultancy, director of Oil for Venezuela, a non-profit organisation, and an expert witness in litigation involving Venezuela. SR and FR received financial support from the Center for Economic and Policy Research (CEPR) during the research phase.