Analysis: Iran war becomes a contest of who can take the most pain

DUBAI, United Arab Emirates (AP) — The war with Iran, for all its complexity and global effects, boils down to a single question: Who can take the pain the longest?

A surge in oil prices points to what may be Iran’s most effective weapon and the United States’ biggest vulnerability in continuing the campaign: damaging the world economy. A sharp rise in gas prices has rattled consumers and financial markets, and international travel and shipping have been severely disrupted.

U.S. President Donald Trump appears aware of the danger. As oil jumped to nearly $120 a barrel on Monday, the highest since 2022, he suggested the war would be “short-term.” That helped reassure markets and the price eased to around $90 — even as Trump, nearly in the same breath, vowed to keep up the war and the punishment on Iran.

On the other side, Iran has to endure a near-constant stream of American and Israeli airstrikes it can’t defend against. So far, the Islamic Republic is still in control, with leadership passing from the ayatollah slain in the war’s opening strikes to his son. Although its military has been hit extensively, it continues to launch missiles and drones across the region.

The Iranian public, which already rose up against its theocracy in nationwide protests in January, still boils in anger but have stayed home as they try to survive the heavy bombardment. Security forces have been on the street every day to ensure no anti-government demonstrations form.

The pressure is on U.S. allies as well. Gulf Arab states, while still not combatants in the war, face seemingly unending and occasionally fatal Iranian fire targeting oil fields, cities and critical water works. And Israel, while boasting of inflicting heavy damage on Iran’s missile program and other military targets, continues to be targeted by sophisticated Iranian missiles that send a buckshot-like spray of high explosives on its cities. Frequent air-raid sirens have disrupted daily life, closed schools and workplaces and created a tense atmosphere across the region.

There’s no immediate end to the war in sight — nor in the rhetoric coming from both America and Iran, whose bad blood extends back decades to the 1979 Islamic Revolution and the U.S. Embassy hostage crisis.

“We’ve already won in many ways, but we haven’t won enough,” Trump said in a speech Monday in Doral, Florida. “We go forward, more determined than ever to achieve ultimate victory that will end this long running danger once and for all.”

Iranian Foreign Ministry official Kazem Gharibabadi offered a mirror image comment from Tehran, boasting that the Islamic Republic had rejected contacts about a ceasefire that he said had come from China, France, Russia and others.

“At the moment, we hold the upper hand,” Gharibabadi told Iranian state television late Monday night. “Just look at the state of the global economy and energy markets — it has been very painful for them.”

He said it was Iran that “will determine the end of the war.”

For years before Israel and the U.S. launched the war on Feb. 28, Iran warned that, if attacked, it would retaliate on the entire Middle East, targeting the oil infrastructure that made its Gulf Arab neighbors fantastically wealthy. By contrast, Tehran's economy has been crippled by international sanctions.

Iran has now backed up its threat with barrages of missiles and drones. Qatar was forced to halt its production of natural gas, and Bahrain declared its oil operations couldn’t meet their contractual obligations. Other producers like Saudi Aramco are affected, disrupting a key source of energy for Asia — particularly China, which has sent a top envoy to the region.

Shipping broadly has stopped in the strategic Strait of Hormuz, the narrow mouth of the Persian Gulf through which 20% of all oil and natural gas traded passes, and up to 30% of world fertilizer exports. Iran didn’t need to mine the waterway — its attacks on several ships prompted companies to stop sending their vessels through the strait.

Trump has suggested U.S. warships providing escorts to tankers, but that has yet to materialize in a way to restart the traffic.

Early Tuesday morning, he threatened that if Iran stops the oil through the strait, “they will be hit by the United States of America TWENTY TIMES HARDER than they have been hit thus far.”

“Additionally, we will take out easily destroyable targets that will make it virtually impossible for Iran to ever be built back, as a Nation, again — Death, Fire, and Fury will reign upon them — But I hope, and pray, that it does not happen!” he wrote on his Truth Social platform.

Iran, however, only doubled down. The Revolutionary Guard warned on Tuesday that it won’t allow “a single liter of oil” to leave the Persian Gulf.

For Iran's theocratic rulers, victory means surviving the campaign still in power, no matter the costs to the country and the region.

Trump has been vague and contradictory about his aims in the war. At times, he seems to push for overthrowing Iran's theocracy; other times, he seems to be willing to stop short of that, saying broadly that he wants to ensure Iran is no longer a threat to Israel, the region and the U.S.

That could give him flexibility in declaring that victory has been achieved, especially if real damage starts to show to the U.S. economy.

But if the war stopped right now, both the U.S and Israel would be left with major challenges.

One is Iran’s leadership. After an Israeli airstrike killed 86-year-old Supreme Leader Ayatollah Ali Khamenei at the start of the war, Iranian clerics named his 56-year-old son Mojtaba to the position, elevating him to the rank of an ayatollah.

Now Iran’s ultimate ruler, the younger Khamenei has long been viewed by analysts as being even more hard-line than his father, with close ties to the paramilitary Revolutionary Guard. Israel already described him as a target in its campaign, while Trump has said he wanted someone else in the role.

Also, Iran still has its stockpile of highly enriched uranium – one reason for the war that Israel and the U.S. have both pointed to. Iran had been enriching up to 60% purity, a short, technical step away from weapons-grade levels of 90%.

The U.S. bombed three Iranian nuclear sites in June during the 12-day war between Israel and Iran, likely burying much of the stockpile in the debris. Those sites to this day remain out of the reach of international inspectors.

Mojtaba Khamenei could issue a religious ruling, or fatwa, reversing his father’s earlier statements and ordering it to be used to make a weapon. That’s something both America and Israel, long believed to be the Mideast’s only nuclear-armed state, don’t want to see.

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EDITOR’S NOTE — Jon Gambrell, news director for the Gulf and Iran for The Associated Press, has reported from each of the Gulf Cooperation Council countries, Iran and other locations across the Mideast and the wider world since joining AP in 2006.

FILE - People gather in a rally to support Ayatollah Mojtaba Khamenei, the successor to his late father Ayatollah Ali Khamenei as supreme leader, in Tehran, Iran, March 9, 2026. (AP Photo/Vahid Salemi, File)

FILE - Plumes of smoke rise as strikes hit the city during the U.S.–Israeli military campaign in Tehran, Iran, March 5, 2026. (AP Photo/Vahid Salemi, File)

FILE - Drivers navigate a busy intersection past a sign displaying the current gas prices at a filling station in Plano, Texas, March 6, 2026. (AP Photo/Tony Gutierrez, File)

FILE - Policemen stand on top of their car with pictures of the late Iranian Supreme Leader Ayatollah Ali Khamenei, right and left, and his son Ayatollah Mojtaba Khamenei, the successor to him, center, during a rally to support him in Tehran, Iran, March 9, 2026. (AP Photo/Vahid Salemi, File)

FILE - A plume of smoke rises after a strike in Tehran, Iran, Monday, March 2, 2026. (AP Photo/Mohsen Ganji, File)

WASHINGTON (AP) — Dr. Nicole Saphier is President Donald Trump's latest pick for the vacant role of U.S. surgeon general, a nomination that ended the embattled campaign of his previous candidate, Dr. Casey Means, after it became clear she didn't have the votes to advance out of a Senate committee.

Saphier, a radiologist and former Fox News Channel contributor, has promoted several aspects of Health Secretary Robert F. Kennedy Jr.'s Make America Healthy Again agenda, including removing food additives, cutting ultraprocessed foods from diets and encouraging exercise.

But she has been a more vocal advocate for vaccination than Kennedy, and at times she has criticized the Trump administration's handling of health issues as “embarrassing.”

If confirmed as the nation's doctor, Saphier would be empowered to issue advisories that warn of public health threats. Surgeons general also have used the office to advocate on vaccination issues — though the office doesn't create vaccine policy.

Means, a Stanford University-educated physician and MAHA influencer who didn’t finish her surgical residency in Oregon and has an inactive medical license, had faced a grilling from senators of both major political parties over her experience and stance on vaccination. She told The Associated Press her failed nomination was the result of a “yearlong smear campaign."

Trump's new surgeon general pick is director of breast imaging at Memorial Sloan Kettering Monmouth, according to her profile on the institution’s website. She has a medical degree from Ross University School of Medicine in Barbados along with fellowships at the Mayo Clinic, the profile said.

She has earned the approval of institutions including the American College of Radiology, whose president, Dr. Dana Smetherman, on Thursday called her a “tireless advocate for women's health.” Kennedy said in a social media post that her experience with breast cancer patients and early detection will help the Republican administration take on the chronic disease epidemic.

Saphier also was a longtime Fox News Channel contributor until this week — one of several of the channel's personalities Trump has brought into his administration. Trump's first surgeon general pick, Dr. Janette Nesheiwat, was also a contributor at the network, but her nomination fell apart last year after questions arose about her academic credentials.

An author and podcaster with her own show, “Wellness Unmasked with Dr. Nicole Saphier,” Saphier frequently comments on the Trump administration's approach to health, often positively. She also used the phrase “Make America Healthy Again” years before Kennedy popularized it. It was the title of a book she wrote in 2020 that criticized government handling of healthcare and the Affordable Care Act.

Saphier also has dipped into the wellness product industry, creating a line of herbal supplements called Drop Rx, according to her LinkedIn profile.

A mom of three boys, Saphier has often said she is thankful that she decided to keep her first son when she became unexpectedly pregnant at age 17. She has advocated for more resources for mothers who make the same choice.

Like Means, Saphier has questioned some aspects of the U.S. childhood vaccine schedule, including the universal birth dose of the hepatitis B vaccine, a longtime recommendation that the Trump administration has been trying to weaken.

She also has aligned with Kennedy's disdain toward COVID-19 vaccination requirements in schools, saying on her podcast in September that they were “a complete disaster" and one of the reasons for declining trust in vaccination.

Saphier says she supports immunization while arguing patients should be free to make their own medical decisions. In March, she praised acting U.S. Centers for Disease Control and Prevention Director Dr. Jay Bhattacharya for posting a message encouraging Americans to get vaccinated against measles.

“The more vaccine confusion we create, the more preventable disease we will see,” she said in September, urging the administration to get itself in order "because it’s really upsetting.”

While being supportive of the Trump administration at large, Saphier has publicly cringed at some of its health mishaps. Last summer, she decried its long-anticipated first attempt at a MAHA report, which cited some studies that didn't exist.

"There were a lot of flaws in this report," she said on her podcast. “In fact, it was pretty embarrassing."

She said Kennedy's firing of his first CDC director, Susan Monarez, after less than a month on the job was “a mess.”

"When we keep hearing radical transparency and we’re going to regain trust, I can tell you these shenanigans are taking us farther away from that mission,” Saphier said on her podcast.

In an email to the AP last year, Saphier said Trump's advice to pregnant women not to take Tylenol, which promoted unproven ties between the medication and autism, was overly simplistic. She said equally important, and missing from Trump's message, was the fact that untreated fever or severe pain can also pose serious risks to mothers and babies.

After Means' confirmation hearings earlier this year, Saphier said on her podcast that she expected Means would do a good job as surgeon general but wished she were “a little bit less involved with MAHA.”

“I’d really like to see a little bit more reaching across the aisle when it comes to public health,” Saphier said. “That doesn’t mean it has to be some Democratic nominee for surgeon general, maybe just someone a little less aligned with the MAHA movement who, I don’t know, finished their residency and has an active medical license.”

At least a few prominent MAHA influencers have suggested Saphier is no ally. Turning Point USA podcaster and anti-pesticide campaigner Alex Clark said in a post Friday that Saphier “gets an F when it comes to all things MAHA.”

President Donald Trump signs documents regarding the withdrawal of the current nomination and nomination of a new surgeon general in the Oval Office of the White House, Thursday, April 30, 2026, in Washington. (AP Photo/Alex Brandon)