Invisible frontlines: the overlooked health consequences of the war in Iran

Armed conflict in large urban settings rarely affects only the military. It disrupts health systems, displaces populations, and creates conditions for preventable health crises. When these risks are recognised early, many of their consequences can be mitigated. When humanitarian emergencies are ignored, they often follow. Reports from Tehran suggest that several warning signs of such crises may already be present. Communications from health professionals and international officials, many shared anonymously for security reasons, describe repeated attacks targeting military and governmental infrastructure, including nuclear and missile sites [1]. As in most modern conflicts, the boundary between military objectives and civilian consequences is rarely clear, with collateral damage, displacement, and mounting pressure on health systems. Health professionals working in such contexts are rarely able to speak openly about the risks they face [2]. The responsibility, therefore, falls on the international public health community to ensure that their situation is not ignored. Governments and all parties to the conflict, including external military actors, have an obligation to protect healthcare workers, medical facilities, and civilian lives. Accounts from professionals in Tehran describe a situation characterised by systemic vulnerabilities. To date, reports indicate that strikes have primarily targeted military or strategic infrastructure, but residential neighbourhoods have reportedly sustained damage where military compounds or security facilities are located within densely populated areas. Several hospitals have been damaged by nearby explosions, although there are currently no verified reports of deliberate attacks on healthcare facilities [3]. A school that sustained multiple hits, killing many children, appears to have been due to faulty intelligence [4]. More concerning is that Iran’s existing civil protection arrangements are severely inadequate. Iran has not maintained or modernised the protective infrastructure used during the Iran-Iraq War, and major cities lack functional public bomb shelters. There is no national civil defence plan and early warning systems and evacuation guidance are largely absent [5]. The situation is unfolding within a health system already under considerable strain as Iran’s national health insurance system has been degraded by years of sanctions [6]. Early indications suggest residents are leaving Tehran for smaller cities and for neighbouring countries [7]. Displacement from large urban centres rarely resolves humanitarian pressure but redistributes it. Smaller cities may suddenly face surges in demand for health services, medicines, food, and essential infrastructure, which local health systems may struggle to absorb. Evidence from many conflict settings shows that the indirect health effects of war often exceed deaths caused by direct violence [8]. Disruption of treatment for chronic diseases, interruptions in maternal and neonatal care, mental health crises, and outbreaks of communicable diseases frequently follow population displacement and disruptions to health services. Humanitarian crises rarely appear suddenly but develop under cumulative system stress: weakened health systems, displacement, disrupted supply chains, and delayed international responses. This is a war in which the three primary actors have, in different ways, rejected established humanitarian norms. The United States has left the World Health Organisation and challenged the international rules-based order. Israel has blocked humanitarian assistance to Gaza, and, by January 2025, its response to Hamas attacks and murder of Israeli citizens had reportedly killed over 70 000 of Gaza’s inhabitants, the majority non-combatants [9]. Iran has reportedly killed thousands of protesters in recent weeks [10]. None have acceded to the Rome Statute and thus the jurisdiction of the International Criminal Court. In such circumstances, it is more important than ever for the public health community to insist not just on a cessation of hostilities but also on long-established humanitarian norms. This urgency is heightened by the fear of what might come next, which may involve boots on the ground or guerrilla-style warfare, scenarios that typically amplify health system collapse, population displacement, and barriers to humanitarian access. First, all parties must commit to international humanitarian law, something that is increasingly being breached [11, 12]. This includes protecting medical personnel and health facilities, which must remain demilitarised and protected spaces. Second, the Iranian authorities must prioritise essential health services for all those who need them. This will obviously be challenging, given the effects of sanctions, the damage to physical and administrative infrastructure, and the ongoing attacks. However, an additional problem is the legacy of distrust because of the attacks by the authorities on health professionals treating those injured in the recent protests [13]. Third, demographic and disease surveillance systems must be sustained. Population displacement and overcrowding increase the risk of infectious disease outbreaks. Early warning surveillance systems are essential for rapidly detecting outbreaks and preventing secondary health crises. While not a substitute, journalists also play a crucial role in bearing witness to atrocities, as do the growing number of organisations, such as Bellingcat, analysing open-source intelligence (OSIN), who can challenge accounts by belligerents. Lessons can be learned from those who have worked hard to monitor the effects of conflict in Gaza under indescribably challenging conditions [14]. Finally, humanitarian coordination efforts must be mobilised. International organisations such as the World Health Organization and the Red Cross and Red Crescent play a critical role in conducting rapid health needs assessments and mobilising emergency medical support when national systems are overwhelmed. They must be given unfettered safe access. The situation in Iran is, sadly, not unique. The conflict has already spread to neighbouring states, while we in Europe have a conflict too: Russia’s full-scale invasion of Ukraine [15]. Russia is already engaged in hybrid warfare with EU member states [16], and many believe that there is a real threat to its neighbours in the coming years. This is at a time when the United States’ post-war security guarantee cannot be relied upon [17]. European countries must prepare. This will require increased defence spending, with consequences for sectors that promote health, alongside strengthened civil protection. This means learning from countries with long experience in this area, such as Finland, which has invested for decades in over 50 000 reinforced shelters covering nearly the entire population [18] and regularly tests its emergency plans. Public health experts have long called for stronger preparedness for the next pandemic. In a world where the post-war rules-based order is under threat, we must look at the full range of threats to health, including conflict. The immediate priority in Iran must be to protect healthcare facilities and personnel, maintain essential health services, and ensure the continuity of disease surveillance and humanitarian coordination. International organisations and humanitarian agencies must assess needs and mobilise support where national systems are overwhelmed, particularly for essential medicines. Public health institutions and communities also have a responsibility to amplify credible accounts from those working under dangerous conditions and to ensure that early warnings are not ignored. Protecting civilian health and preserving medical neutrality are not political positions. They are fundamental public health imperatives. Disinvestment in public health systems should be a global concern; preparation is preferable to crisis response. Conflict of interest: None declared. None declared. No new data were generated or analysed in support of this research.