Significance Public health structures were developed and expanded over four decades of war and isolation, allowing them to mobilise effectively against COVID-19 despite the negative impacts of US sanctions. However, economic constraints have prevented full lockdowns that might control case numbers, leaving exhausted medical workers without respite. Impacts There is no sign of an immediate threat to political stability, especially while Supreme Leader Ali Khamenei remains in good health. Foreign media narratives on poor health sector performance will have a short-term psychological impact but are likely to lose credibility. If Iran ever joins the WTO, its pharmaceutical sector will suffer significantly from the loss of protective tariffs.