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.

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