In the current global pandemic, Iran occupies a unique position. One of the first countries to experience the outbreak of covid-19, it is simultaneously the target of an economic blockade that goes back not years, but decades. How Iran has fared under this dual onslaught is determined by the interaction between its singular place in the geopolitical order and the distinctive character of its own institutions. The dominant power in international politics and its allies have put Iranian society under enormous pressure, yet among countries at a similar level of gdp, few—perhaps none—have more impressive records in building an effective health system. The course of the pandemic in Iran is the outcome of a collision between these two factors. To understand it, each needs careful examination. But first, a brief overview of its arrival and spread.
Rumours that the virus had reached Iran started to circulate in January, but it was not until 19 February that the first two cases of infection were confirmed in Qom. A key destination for pilgrimage and religious studies, the city annually attracts around 20 million visitors, including scholars and tourists from around 80 countries––including China, which is now Iran’s closest trading partner, with business connections and construction projects in Qom and other cities. Why the delay in announcing the arrival of covid-19? Although it would be attributed by the Western media to the government’s attempt to cover up the news, the fact was that testing kits had only arrived from China on 17 February. Another hold-up occurred when the who’s dispatch of testing kits to Iran was held up by shipment restrictions imposed by the American sanctions regime—the kits eventually arrived via a commercial flight from Baghdad, but the delay prevented the early-case detection crucial to controlling the pandemic. It soon became clear that the virus was more widespread than had been realised, spreading to Tehran, Arak and Gilan, and that health officials were behind in the case-detection race—a lag that was not peculiar to Iran, of course, but ubiquitous across countries that failed to deal with the contagion in a timely fashion.
By 21 February, seventeen cases were confirmed, with four people dying shortly after diagnosis. On the same day, the country held legislative elections despite the growing panic surrounding the pandemic. The timing was long-scheduled, but it raised subsequent questions about whether the elections should have been cancelled, and why Qom wasn’t promptly quarantined. The reality was that, by election day, the virus had already spread across the country: quarantining Qom would have done little to stop it reaching Tehran. Nevertheless, from a public-health perspective, Iran undoubtedly should have postponed the elections and intensified its case-finding and contact-tracing. Yet if the country’s response to the pandemic seems to have been blighted by incompetence and political inaction, this was not malign neglect, but rather the same mixture of bewilderment and complacency in the face of a colossal public-health threat that later paralysed other nations. France and the us also held elections and failed to implement social distancing several weeks after initial cases were detected. At the time, Iran was not flouting any who guidelines on containment of the spread. By 26 February it had closed schools and universities countrywide, while non-essential businesses were shut down just before the Nowruz, the Iranian New Year holiday.
The front line of defence against the pandemic is now the country’s health system. Following the 1979 Revolution, landmark reforms extended access to medical treatment across Iran through a vast network of community health workers and Primary Healthcare Centres. Instituted during the 1980–88 war with Iraq, the system was later described by the who as an ‘incredible masterpiece’.footnote1 Orchestrated in a pyramid structure with an efficient referral system, its achievements have been remarkable: universal immunization; dramatic reductions in maternal and infant-mortality rates; effective family planning and population control. Strategic advances in responsiveness, equity and universality were focused on continuously monitoring the population’s needs and modifying service-delivery systems to meet them. Among the public-health gains was ‘the most rapid decline in birth-rates in world history’, from an average of seven to two children per mother by the end of the century—‘a demographic transition of immense proportions’.footnote2
Currently, Iran’s health system comprises 150,000 physicians, 1,500 hospitals and 140,000 hospital beds for a population of 82 million––an average of 1.7 beds per 1,000 people. It also ranks 16th in the world in terms of research output in medicine. In the fight against hiv and drug use, two interconnected epidemics within the country, Iran has become a notable success both by regional and global standards, providing free and universal access to antiretroviral therapy and harm-reduction programmes, and delivering care tailored to local cultural and community needs. Moreover, a post-revolutionary policy of self-sufficiency has made great strides in the supply of affordable medicine and equipment, importing only raw materials. Before the Revolution, 80 per cent of medications in use were imported. Today, 97 per cent are produced internally, manufactured by around a hundred local pharmaceutical companies, most in the private sector. Yet while only 3 per cent of demand is covered by imports, these include vital medication for children and vulnerable patients with rare or advanced diseases, access to which has been disrupted by us sanctions.
For these gains have been made in the teeth of one of the longest and most vicious sanctions regimes in history. It is worth recalling that sanctions on Iran were first imposed by Carter, continued by Reagan, Bush Sr, Clinton and Bush Jr, greatly intensified by Obama, and then further escalated by Trump. Contrary to popular belief, the jcpoa which Obama extorted from Rouhani and Zarif did not lift sanctions on Iran; it merely suspended those which the White House had imposed via the un (with a clause allowing for their swift re-imposition), leaving intact those imposed by the us alone, which continued in force—and have since been ramped up under Trump’s ‘Maximum Pressure’ campaign, imposed in May 2019. The Trump Administration’s sanctions are openly designed to bring down the government of Iran through economic strangulation. The European powers that were also signatories to the jcpoa—France, Britain and Germany—though happy for thumbscrews to be further tightened on Iran to secure common Western objectives in the Middle East, did not support Washington’s decision to scrap the nuclear deal, and in 2019 set up a special-purpose vehicle, instex, to circumvent us sanctions against Iran. However, once it became clear that doing so would incur punishment from America, the project was quietly dropped: instex has only managed to handle one transaction since it was established.
The current impact of this blockade on the Iranian health system falls into three main areas. Firstly, sanctions block most financial transactions required by Iran for its general trading, including medical purchases; exemptions for ‘humanitarian’ items do not cover protective wear. Secondly, sanctions interrupt the supply chains of domestic production, as even locally produced medications and equipment often rely on inputs from multiple manufacturers in various countries. The absence of even one ingredient, such as vacuum packages for pills, can bring production to a halt.
Thirdly, by reducing purchasing power across the whole economy, sanctions hit healthcare providers and consumers alike. While the Trump Administration celebrates the 14 per cent contraction of the Iranian economy and rapid rise in inflation caused by ‘Maximum Pressure’, this downturn has slashed government revenues, straining the country’s universal health-insurance programme, and increased the cost of healthcare by nearly 20 per cent through rising inflation. To protect patients from market instability, the Ministry of Health regulates all drug prices. As a result, pharmaceutical companies are also under pressure, having little to no margin to overcome the burdens of inflation and price fluctuations. Bureaucratic price controls in conditions of scarcity typically lead to hoarding and black-market profiteering, and Iran is no exception. The result is further shortages for all Iranians, but especially working people who cannot afford exorbitant black-market prices.
On top of sanctions, Iran has been beset by crises over the past year, both natural and political, testing public trust in the government. March 2019 saw major floods starting in the northern cities and rapidly moving to the southern and western parts of the country, causing hundreds of deaths and displacements. In May, Trump’s ‘Maximum Pressure’ campaign intensified, tightening sanctions on oil sales. The Rouhani administration was forced to cut fuel subsidies, resulting in the threefold increase of gasoline prices in November that prompted widespread protests across the country. In early January 2020 the us assassinated General Qasem Soleimani, head of the irgc Quds forces. Iran retaliated with a missile attack on a us airbase in Iraq. Later its armed forces mistakenly brought down a Ukrainian passenger plane, killing 176 passengers and causing mass heartbreak and anger at home—an error that, in a chaotic year, fuelled society’s distrust in the state.
Against this backdrop, the task of balancing a public-health threat against an economic crisis on the eve of Nowruz was daunting. Iranians live highly interdependent lives, and it would probably have required a military deployment to confine the population during the annual festivities, risking hostile confrontations of the kind seen elsewhere. The Rouhani administration also had legitimate concerns about the risk of widespread hunger amongst the poor if the economy, already damaged by ‘Maximum Pressure’, was suddenly shut down. Instead, on 22 March it ordered the closure of all non-essential businesses that would have returned to work on 4 April, when the Nowruz holiday came to an end, and committed 18 per cent of the country’s budget, over $6 billion, to cover unemployment, health and social-insurance payments, with support extended to small businesses that do not lay off workers. An additional $1 billion from the country’s sovereign wealth fund is now being allocated to the battle against coronavirus. A new headquarters was established to coordinate a centralized response to the pandemic, under the auspices of the Health Minister.
Moreover, despite plummeting trust in the government, Iranian civil society has managed to mobilize and cooperate efficiently. Groups spanning distinct social classes and ideological positions coalesced around a campaign to pool human and capital resources in the fight against the virus. While the government is committed to covering 90 per cent of medical expenses for every covid-19 patient, these campaigners have raised money, sourced essential ventilators from private clinics and increased production of testing kits, masks, gowns and ventilators to support specially designated state hospitals. A fully equipped, 300-bed hospital was recently built through a ‘private sector for the public good’ campaign. Capital has also come in from the Iranian diaspora, despite the hurdles put in its way by financial sanctions. In addition to these civil-society efforts, the military have freed up a total of 4,000 sanatorium beds, with attached hospital beds for emergency care, and the Revolutionary Guards Corps has built small hospitals in remote parts of the country.
Health workers from Primary Healthcare Centres embarked on a campaign of case-finding and contact-tracing, through phone-calls, text-messaging and bespoke mobile applications. With the help of the Red Cross and Red Crescent Society of Iran, the Army also mobilized to check the temperatures of travellers and isolate symptomatic cases and their contacts. Finally, rapid investments in domestic production of ventilators aimed to ensure that no patient was left without the necessary support or equipment. At the time of writing, the country’s hospitals and icu beds are not fully occupied, demonstrating that Iran has so far been able to keep the pandemic within its healthcare capacity––the main rationale for ‘flattening the curve’. Thus, despite the initial shock of the crisis, which caught Iran with its guard down, the strengths of the health system, together with institutional mobilization, have combined to curb coronavirus deaths.footnote3
After the pandemic broke out, European countries piously called on the us to relent at least in medical relief, only to be told by Mike Pompeo that ‘humanitarian supplies and medicine are not sanctioned’. This is despite Washington’s obstruction of financial and transport channels—as international shipping companies and courier services either halted all dealings with Iran or bumped up prices for the Iranian market—which, as we’ve seen, prevented Iran from securing the timely delivery of testing kits and medical equipment. One consequence has been to make Iran unusually reliant on regional hubs for air and freight forwarding—a situation that aggravated difficulties when neighbouring countries imposed travel restrictions to combat the epidemic. Nonetheless, the us has redoubled its punitive measures, moving to block Iran’s request for an emergency $5 billion imf loan—the first such request made since the foundation of the Islamic Republic—to deal with coronavirus.
In this context, the New York Times’s assertion that ‘us sanctions are not responsible for the spread of coronavirus in Iran’ is an egregious misrepresentation. The us—whose strategy has been labelled ‘economic terrorism’ by Iranian officials—bears primary responsibility for hampering Iran’s ability to deal with a crisis that has crippled some of the most advanced healthcare systems in the world.footnote4 Yet the culpability of the Trump Administration, and the complicity of European powers that dissent from it in words but comply with it in deeds, are unlikely to be lost on ordinary Iranians. In a global pandemic, it is essential to question the actions of national governments––but the purpose of critical discussion should be public-health benefits, not political gains. The disparaging Western coverage of Iran’s response to the crisis has had the opposite effect: the media campaign to delegitimize the Islamic Republic has undermined global public-health efforts by impeding the flow of accurate information. The extent to which epidemiological analysis of Iran’s experience has been derailed by such orthogonal denunciations should be clear enough from the fact that the us, uk and France all failed to avoid similar public-health miscalculations. Rather than breaking the chain of viral transmission, Western governments and media broke the chain of knowledge transmission.
The asymmetrical pattern of condemnation adds a further dimension of chaos to an already complex and challenging humanitarian crisis. Examples abound. When Iran imposed a ban on travel to its northern cities, the Western media condemned it, the Guardian’s headline declaring ‘Iran threatens force to restrict travel’.footnote5 Yet the ban was a police measure, not a military lockdown, and was later criticized for not being implemented early enough. So restricting travel is savaged as an abuse of power, while not doing so is denounced as risking lives. Holding elections shows disregard for public health; cancelling them would be an excuse to avoid low voter turnout.footnote6 Virtually every decision taken by the Islamic Republic––whatever its merit or demerit—is subject to relentless media disparagement from all sides of the Western political spectrum. When Iran’s Deputy Health Minister and other government officials tested positive for covid-19, it was evidence of the dysfunctional Iranian response to the virus. When politicians in the us, uk and Canada contracted the illness, no such sensationalism was in order.
Campaigns of disinformation are also disseminated through Persian-language networks, funded by Iran’s geopolitical opponents—Saudi Arabia, the us and uk—and accessed within the country through satellite channels. One of these channels, Radio Farda, a branch of Radio Free Europe/Radio Liberty, recently announced that ‘the death toll from the coronavirus in Iran is five times higher than reported’. The us journal Foreign Policy followed suit, quoting Radio Farda as its source.footnote7 However, the claim is a distortion of a remark by a who representative that the number of infections—not deaths—could be up to five times higher than detected. Given the proportion of asymptomatic individuals and test-kit shortages in virtually all affected countries, it is obvious that the number of those detected will be lower than those infected. But truisms of this kind rarely sway liberal media in the West. Another example of the blunders and distortions of which they are capable is offered by the Washington Post, which reported on Iran’s ‘Coronavirus burial pits’—‘so vast they’re visible from space’—with the Guardian following suit uncritically.footnote8 In fact these were normal graves in a normal cemetery, enlarged by satellite imagery to remote ‘burial pits’ in which, it was implied, the authorities were secretly dumping hundreds of bodies—this at a time when the who was not disputing the statistics for fatalities in Iran. It thus appears that ideological rather than scientific factors have largely shaped the coverage of the country’s pandemic, with health experts side-lined in favour of political scientists and journalists.
The politicization of the coronavirus pandemic––and other crises––in the Islamic Republic is, of course, interwoven with campaigns for regime change. Lobbies like United Against Nuclear Iran, which have long pressed for ever tougher sanctions, have in recent months singled out pharmaceutical sales to the country, targeting the Western companies still trading with Iran. There was a chorus of indignation when Iran rejected the offer from Médecins sans frontières of a 50-bed field hospital, ignoring the fact that its co-founder, onetime French Foreign Minister Bernard Kouchner, has for the past three years addressed and endorsed the so-called ‘Free Iran’ gatherings of the mek—the ‘People’s Mujahedin of Iran’, a cult dedicated to violent regime change which, following the fall of its previous patron Saddam Hussein is currently stationed in Albania. In viewing the covid-19 pandemic through the prism of international power politics, Western governments, political observers and media pundits have not only failed to comprehend the facts on the ground; they have missed opportunities to learn from Iran’s experience—both what the country got right in responding to the pandemic, and what it got wrong—that could have benefited their own populations, in a world that today is interdependent not only economically and culturally, but perhaps above all in matters of public health.
Oxford, 1 April 2020