Economic Sanctions Affecting Household Food and Nutrition Security and Policies to Cope With Them: A Systematic Review

Background: This review was conducted to identify the impact of economic sanctions on household food and nutrition security and policies to cope with them in countries exposed to sanctions. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020 were used to identify, select, appraise, and synthesize studies. Electronic databases in addition to Persian ones have been systematically searched for all related documents published until March 2022. Exclusion criteria were: lack of data related to food insecurity in countries subject to sanction and very low quality of the article. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal checklists. The results were presented as qualitative and quantitative syntheses. Results: Of 1428 identified studies, 36 publications remained in the review, which belong to Iran (n=8), Cuba (n=8), Russia (n=7), Iraq (n=7), and Haiti (n=6), respectively. Declining gross domestic product (GDP), devaluation of the national currency, and the quality of food, increase in inflation, unemployment, and consumer prices, infant and under 5 years mortality, energy, and protein deficiency, and the poverty rate were reported as sanction consequences. The most important strategies to improve food security were the humanitarian assistance provided by the international community (Haiti), equity and priority for vulnerable groups mainly by expanding the healthcare system (Cuba), adopting a food ration system in the oil-for-food program, and fixing the price of food baskets (Iraq), import substitution and self-sufficiency (Russia), support domestic production, direct and indirect support and compensation packages for vulnerable households (the approach of resistance economy in Iran). Conclusion: Due to the heterogeneity of studies, meta-analysis was not possible. Since inadequate physical and economic food access caused by sanctions affects especially disadvantaged and vulnerable groups, planning to improve food security and providing support packages for these groups seems necessary.


Background
Sanctions are interruptions of a country's communications, diplomatic, and/or economic relations and are considered to be a positive tool to facilitate the resolution of conflict in a less violent manner.However, economic sanctions that affect trade and finance can cause severe economic destabilization with grave impacts on the livelihoods and well-being of populations in affected countries. 1Economic sanctions are imposed by governments or the United Nations Security Council against individuals, companies, or countries.Iran and Iraq have experienced targeted economic sanctions (excluding food and medicines) by both the United Nations Security Council and the United States; whereas sanctions on Cuba by the United States (Unilateral) are comprehensive (including food, medicines, and medical equipment) and have extraterritorial components which effectively make it difficult for other countries to trade with Cuba.However, there is ample evidence of the adverse effects of any kind of economic sanctions on the welfare, health, and food security of civilians. 2It may appear as trade sanctions in the form of embargoes, seizures and/or boycotts, and interruption of financial and investment flows vis-à-vis a specific country.Recently, new forms of coercion have been emerging through asset freezing, asset control, and travel bans to influence persons who are perceived to have political influence. 3 Many of the sanctions imposed on countries around the world are aimed at weakening their economies, resulting in increased poverty, reduced food security, and public welfare.Although sanction objectives are rarely met, these sanctions nevertheless lead to a humanitarian disaster. 4,5Sanctions can influence all dimensions of food security: Availability would be limited by preventing civilians from acquiring related essentials such as farm implements, fertilizers, transportation equipment, spare parts, pharmaceuticals, or chemicals for sanitation.The Weakening of critical infrastructure including roads, ports, power plants, transformer stations, hospitals, factories, warehouses, and water and sanitation plants will disrupt the process, distribution, and access to food and may lead to the spread of diseases that make it difficult to absorb nutrients (utilization).A collapse in the education system, on the other hand, can worsen unemployment for years to come, in turn having an impact on access to adequate food. 5his systematic review was conducted to identify the impact of economic sanctions on household food and nutrition security and policies to cope with them in exposed countries in the framework of sustainable food and nutrition security system.The practical aim was to provide solutions to prevent food insecurity in vulnerable households in the face of new sanctions against Iran.

Materials and Methods
The experiences of all exposed countries to economic sanctions and the experience of Iran with the previous round of sanctions, in particular from the escalation of sanctions in 2011 to the time of the Joint Comprehensive Plan of Action in 2015, were systematically reviewed.The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines 2020 were used to identify, select, appraise, synthesize, and report studies in the present systematic review to prepare a transparent, complete, and accurate account of why the review was conducted, how it was done and what the results were. 6The study was registered in PROSPERO with the Number CRD42020191028.
Literature Search Electronic databases (Embase, PubMed, Scopus, Science Direct, Web of Science, JSTOR, and Google Scholar) in addition to Persian ones (SID, Magiran, IranDoc, and Noor) have been searched for all related documents published until March 1, 2022.There was no time limit for the start date of the search.Keywords relevant to sanction (economic sanction, embargo, or monetary sanction) and food and nutrition (food*, nutrition, nutrient*, "food secur*, " and "food insecur*") were used.Moreover, some reference lists of identified studies, related projects, congresses abstract, dissertations, and relevant reviews were searched as gray literature to find more likely all eligible studies.According to the nature of the research topic, some sources eg, reports, preprints, working papers, and statements, produced by government departments and agencies, civil society or nongovernmental organizations especially organizations providing humanitarian aid, academic centers and departments, private companies, and consultants were searched, too.There was no limitation on the time of papers.The search strategy of the review is presented in Supplementary file 1.
Article Screening, Inclusion, and Exclusion Criteria Initial screening was performed using the title and abstract and then, full texts were downloaded if needed.After searching for related articles, they were selected and reviewed by the project executives to remove irrelevant items.All relevant results were extracted from cross-sectional, retrospective, surveys, cohort, before-after, interventional, and qualitative studies.There was no limitation for the target groups in terms of age and gender and language of published studies.Book chapters and available conference proceedings were also considered for more access to relevant data.Exclusion criteria were: lack of data related to food insecurity in countries subject to sanction and very low quality of the article.Duplicate citations and non-accessible old publications were excluded, too.
Data Extraction and Quality Assessment Two reviewers (FM-N and DG) conducted systematic processes of literature searches, quality assessment, and data extraction of eligible papers independently and potential conflicts were resolved through discussion.In cases of disagreement, help was sought from a third person (AH-R).Data extracted from the selected studies included author's name(s), year of publication, imposed countries, methodological characteristics (study design, sample size, and sampling method), sanction type and duration, the impact of sanctions on different dimensions of food security including availability, access, utilization, stability, policies, and programs to cope with them.Some related factors to the success of the programs and policies such as context and process were reviewed, too.
The quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal checklists for prevalence studies, quasi-experimental (non-randomized experimental) studies, and qualitative evidence.Each study can receive a high (H), medium (M), or low (L) quality rating. 7

Statistical Analysis
The main strategy in the analysis was data synthesis.The included studies found in each country were more than 4 studies; however, a meta-analysis of findings was not possible because of their heterogeneity in terms of the context of the society, studied dimensions of food security, policies to cope, and quality of the study.Therefore, the results were presented as a combination of qualitative and quantitative synthesis.In other words, the findings on the effects of the embargo on the food security of the countries and the strategies used to cope with them were reported from both quantitative and qualitative studies.

Results
A total of 1428 studies were identified through a search of databases and gray literature on the subject of food security in sanctions.After excluding 861 duplicate and unrelated papers, we found 240 studies that assessed the status of food security in countries exposed to sanctions.After the full-text review, 204 were completely excluded because of duplication of data, not having required data, and the very low quality of the article.Of the remaining 36 publications in the review, most papers (n = 36) belonged to Iran (n = 8), followed by Cuba (n = 8), Russia (n = 7), Iraq (n = 7), and Haiti (n = 6), respectively.Figure S1 (Supplementary file 2) shows the process of searching for and selecting appropriate articles in this systematic review.
Most of the studies were based on the existing routine data gathered in the imposed countries.Only three studies reported findings from interviews with experts and informants (1 in Iraq and 2 in Cuba) and another one in Iraq conducted document analysis.Review findings on the impact of economic sanctions on food and nutrition security and coping strategies against sanctions based on the imposed countries are presented as follows in Tables 1-5.

Haiti
The embargo on Haitian exports was instituted by the Organization of American States in 1991 and partially lifted by the United States in February 1992. 8Initial sanctions froze the Haiti government's assets in the United States and subsequent sanctions included more bans on imports and exports (excluding humanitarian goods).Sanctions were only lifted in 1994 after a re-establishment of the elected government. 1n Haiti, the price of basic foodstuffs rose fivefold from 1991 to 1993, unemployment increased quickly, and the export of mangoes decreased, on which many poor people depended.The national currency depreciated sharply and inflation hit hard.The estimated rate of low birth weight increased from 10% to 15% of infants.In addition, 7.8% of children under the age of five suffer from acute malnutrition compared to 3.4% in 1990.One of the important factors in increasing malnutrition was the absence of the mother at home due to economic activity.This has led to less attention being paid to breastfeeding, weaning foods for young children, and caring for sick children.During the sanctions, non-governmental organizations and governments performed key tasks outside government structures to prevent the legitimacy of the military regime.Many good employees left the government at that time and never returned.This has left Haiti with a weak infrastructure. 1 Iraq Sanctions on all items imported into Iraq except drugs began on August 6, 1990.Following the Gulf War in January and February 1991, sanctions were reaffirmed by the United Nations, and Iraq was allowed to import food in addition to medicine.Humanitarian organizations imported only 5% of the medicines and foodstuffs they deemed necessary for Iraq because their demands were not met by hostile governments.During these years, access to food to buy in the country has decreased and the power of poverty and reduced nutrition has increased and children under 2 years old are most affected.Due to the destruction of many infrastructures and the unemployment of a large number of people, despite the lifting of sanctions, many of them still depend on imports and rations produced by the government to make a living. 5ssia At the beginning of 2014, Russia was embargoed and had to retaliate and did not allow imports of meat and dairy products, vegetables, fruits, and fish from the United States, Canada, Australia, Norway, and the European Union states.
Despite the increase in the growth of domestic production of agricultural products, its effect on food availability was offset by a decrease in imports following the introduction of general and specific commodity sanctions.The price of red meat and milk for consumers increased due to reduced economic access, and consequently, food insecurity increased from 2013 to 2015.To counter the effects of sanctions on the nutritional status of the Russian people, the Russian Food Security Doctrine was established as a general framework for agricultural policy in which minimum targets for the domestic production of products such as potatoes, dairy products, cereals, and meat were established. 25The impact of Russian sanctions and stop trading on the economy, finance, and food availability of other countries has also been reported in some articles 44,45 which were not considered as the aim of the present review and so they were excluded.

Cuba
The tightening of the US economic embargo in 1992 may have an unintended but profound effect on the health and nutrition of vulnerable populations in Cuba. 46][49][50][51] Cuba's focus on high-quality training, universal access to care, heightened vigilance for breakdowns in the social safety net, and judicious use of scarce goods shows, once again, that remarkably good health outcomes are possible if the few medical resources are put to the best use. 28,52an Major sanctions against Iran were formed after the Islamic Revolution of 1957, after the occupation of the US Embassy in Tehran, and intensified following the challenge to Iran's nuclear program.Iran's nuclear program has faced various sanctions since 1996; but despite the diversity and multiplicity of sanctions, for reasons such as the gradual and permanent nature of sanctions, the existence of oil revenues, adoption of import substitution strategy, global competition, lack of full compliance of independent emerging economies with sanctions, and foreign banking, their effects have diminished.41 Few studies wad studied the impact of previous rounds of sanctions on the nutritional status of Iranians.A systematic review of Kokabisaghi showed that the sanctions on Iran have lowered the ability of Iranians to access the necessities of a standard life such as nutritious food and healthcare as a result of the devaluation of the national currency, increased inflation, and unemployment.These adverse effects are more severe in poor people, patients, women, and children.39 The main strategies in the agricultural sector to counter sanctions are to meet the country's food needs, support domestic production and reduce dependence, especially in the cereal, seed, livestock, and poultry industries using research and new technologies (Unpublished data).
Other Countries Sanctions, as a tool of coercive foreign policy, have been imposed on several other nations, such as North Korea, Libya, --The incidence of childhood mortality and severe malnutrition were higher during the period of the embargo than in the periods before and after the embargo.

--Medium
Abbreviations: GDP, gross domestic product; GNP, gross national product; OAS, Organization of American States.-Emphasis on disease prevention and primary healthcare.By educating their population about disease prevention and health promotion, the Cubans rely less on medical supplies to maintain a healthy population.A healthcare infrastructure to support primary-care medicine.

Medium
Abbreviations: GDP, gross domestic product; ANAP, National Association of Small Farmers; FAO, Food and Agriculture Organization; MINAGRI, Ministry of Agriculture; NR, not reported.

High Utilization Stability
Toghyani and Derakhshan, 2015 41 Economic sanctions/ 1978 to 2013 Time series data.
In long term, weak and strong sanctions had no significant impact on economic growth, but moderate sanctions with coefficient 0.024 have had a Negative impact on economic growth.
----Managing public opinion and insisting more on the principles and maintaining the independence of the country -Activating the domestic production capacity, strategic trade policy and seriously pursuing the approach of resistance economy -Active policy-making and diversification of the drawer exchange system -Identifying and planning to support the vulnerable groups.

Medium
Ziaei et al, 2013 42,43 Economic sanction Cross-sectional 267 Rural households of Gorgan selected by stratified random sampling.
-Income, employment of household head, chronic illness of one of the household members, education level of household head and spouse, household size, and access to credit had a significant effect on the nonfood coping strategy.
The mean of the coping strategy index was 15.52.
-Most households use a coping strategy of "using less preferred and cheaper food."

Medium
Abbreviations: GDP, gross domestic product; PPP, purchasing power parity; ITS, Interrupted time series.Venezuela, Sudan, Sierra Leone, Burundi, and Malawi, the apartheid government of South Africa, and former Yugoslavia, over the past few decades.However, no study was found on the impact of sanctions on food and nutrition security that was eligible for inclusion in the current systematic review.
Effects of the economic sanctions on food and nutrition security and strategies to cope with them based on the review findings were summarized in Figure.

Discussion
The history of sanctions returns to the First World War, in which Germany was subject to a shipping embargo by the Allied forces.][55] So, sanctions have been interpreted as a weapon ever since.
The US government tried to prohibit the sale of grain to the Soviet Union before 1971 and to embargo all grain sales to the Soviets in 1999. 56,57More recently, the United Nations and the United States have, however, not planned for any economic sanctions on Ethiopia and Eritrea, which could compel both countries to de-escalate, because these sanctions would hurt the people of both countries which are highly dependent on food aides from international organizations. 58,59argeted regimes and their populations may experience multiple political consequences, such as weakening some regimes and strengthening others.Economic sanctions may also influence conflicts and security in targeted states.The intensity of such impacts varies even for targets, often depending on the internal dynamics of the targeted states and their relations with other countries.][62] A review by Gutmann et al found that UN sanctions reduce life expectancy by 1.2-1.4years and US sanctions by 0.4-0.5 years.Increased child mortality and deaths from cholera, along with declining public health expenditures, have been the main reason for the decline in life expectancy.Women are heavily affected by sanctions, too.There are concerns in the world about the undue effects of economic sanctions on human rights, especially children.Economic sanctions against countries are inconsistent with the United Nations Convention on the Rights of the Child, which deals with children's rights to access healthcare, social welfare, and education. 63Qualitative research based on two countries' case studies found that sanctions negatively affect the availability of food and clean water.These findings are corroborant with quantitative ones. 2,28Qualitative information is essential for developing useful causal models.Key informants from the social programs or data collection agencies already have a detailed understanding of which variables are related and the nature of their influence on each other. 64here is a growing policy consensus that economic sanctions are powerful tools to cope with major foreign policy crises.However, the real effectiveness of sanctions, particularly targeted sanctions and the circumstances in which policy change induce in sanctioned countries are in question. 65However, studies in different countries exposed to sanctions indicate deteriorating food security and nutritional status of the people particularly poor and vulnerable groups.These effects are mainly mediated by the increase in unemployment and food prices, decrease in food imports and purchasing power, and ultimately poverty increase. 39he impact of sanctions on poverty (a) increases with the severity of sanctions, (b) is larger for multilateral sanctions than for unilateral sanctions imposed by the United States, and (c) becomes longer lasting as the poverty gap widens 3.8 percentage points in sanctioned countries compared to the control group in the first 21 years of an embargo.A slowdown in exports and imports, as well as a reduction in foreign aid, are other pathways through which US sanctions negatively affect the target's poverty level. 66nalysis of household expenditure data showed thatdespite efforts of the agricultural sector -production, supply, and purchasing of milk and dairy products, red meats, and fish have decreased in both Iranian urban and rural households, especially after the cash transfer program, began the sanctions and inflation.However, the consumption of bread as the main staple food and oil remained almost unchanged. 67World Food Program 68 also reported the marked deterioration of the macroeconomic performance of Iran following the subsidy reform in 2010 and the intensification of sanctions in 2012.Real gross domestic product (GDP) fell by 5.8% in the year 2012/2013 and inflation increased by 41.2%.Soaring food prices and subsidy cuts have directly affected the food security situation among the poor and vulnerable population.Higher infant and under 5-year's mortality, energy, and protein deficiency, and poverty rate are also reported.
][71] Food aid can be considered as one of the strategies to reduce the effects of the embargo on the food security of embargoed countries.Despite the arguments made against the politicization of aid, mostly bilateral and multilateral aid remains tied to the political goals of rich countries.Such a link can be fragile (for example, aid is paid only if certain economic policies or political systems are adopted). 11,72On the other hand, the impact of sanctions on humanitarian action is closely related to the spread of counter-terrorism measures more broadly, which negatively affects the ability of humanitarian actors to operate.A restrictive environment for humanitarian actors, and their compounding effect leads to some challenges such as costs and delays caused by exemption procedures, restrictions on importing goods, restrictive clauses in donor agreements, fines, and prosecution. 73,74n Haiti, relying on international aid to maintain food security was not enough; In Iraq, the main strategy was to ration and deliver the minimum required food to all households based on the oil versus food program 1 ; In Cuba, reinforcement of the health services system and preventing mothers and children mortality led to the death of the elderly and men 28 ; In Russia, self-reliance was possible due to climatic conditions.Iran tried a combination of coping strategies aiming to maintain a minimum of food required for the lower deciles was applied.

Limitations
Most of the studies were based on the existing routine data gathered in the imposed countries 16,17 and the use of both qualitative and quantitative literature is a positive attribute of this Review.The JBI Reviewer's Manual guides to authors for the conduct and preparation of many kinds of systematic reviews and evidence syntheses.Therefore, considering the diversity of the types of studies reviewed and that the JBI Reviewer's Manual included guidelines for almost all types of studies, we used JBI systematic reviews of mixed methods guidelines to quality assess the included studies.However, the JBI checklist is complex and detailed and its use for policy review is difficult which led to the assignment of low quality to many studies included in the review.The systematic review took longer than expected, because of the dispersion of studies and the COVID-19 pandemic made communication and sharing opinions difficult among the research team.Access to some scientific resources was limited, which makes it difficult to ensure access to all sources for a systematic review.
Since at the time of this review, much time has passed since the embargo in the countries and the studies carried out on its effects (10 years or more), likely the conditions described in most of the sanctioned countries, especially for vulnerable groups have gotten worse.Furthermore, a meta-analysis does not capture much of the gray literature that captures the social context or narratives of the affected population.It is a flaw in any meta-analysis that it does not fully capture what's going on.

Conclusion
Ample evidence was found about the adverse effects of any kind of economic sanctions on the welfare, health, and food security of civilians in embargoed countries, which are mainly mediated by the increase in unemployment and food prices, decrease in food imports and, purchasing power.Because the increasing rate of poverty caused by sanctions affects particularly the most disadvantaged and vulnerable groups, planning to improve food security and provide support packages for these groups (eg, women and children in lowincome households) seems essential.
The most important strategies to improve food security in countries under economic sanctions can be summarized in four categories: the humanitarian assistance provided by the international community (Haiti), equity, and priority for vulnerable groups mainly by expanding the healthcare system (Cuba), adopting food ration system in the oil-forfood program and fixing the price of food baskets (Iraq), and supporting production, processing, and distributing food to consumers (import substitution and self-sufficiency in Russia), support domestic production and reducing dependency especially in staple cereals, seeds, livestock and, poultry industry using new research and technologies, direct and indirect support and compensation packages for vulnerable households (the approach of resistance economy in Iran).
The effectiveness of sanctions is determined only by their political outcome, and the suffering of the people of these countries due to malnutrition in addition to their social and biological consequences is ignored.

Figure .
Figure.Effects of the Economic Sanctions on Food and Nutrition Security and Strategies to Cope With Them Based on the Review Findings.Abbreviation: GDP, gross domestic product.

Table 1 .
Impact of Economic Sanctions on Food and Nutrition Security and Policies to Cope With Them in Haiti Based on Included Studies in the Review

Table 2 .
Impact of Economic Sanctions on Food and Nutrition Security and Policies to Cope With Them in Iraq Based on Included Studies in the Review MediumAbbreviations: GDP, gross domestic product; UN, United Nations; NR, not reported.

Table 3 .
Impact of Economic Sanctions on Food and Nutrition Security and Policies to Cope With Them in Russia Based on Included Studies in the Review

Table 4 .
Impact of Economic Sanctions on Food and Nutrition Security and Policies to Cope With Them in Cuba Based on Included Studies in the Review

Table 5 .
Impact of Economic Sanctions on Food and Nutrition Security and Policies to Cope With Them in Iran Based on Included Studies in the Review