Crown Center for Middle East Studies

Iran’s Response to the Coronavirus Crisis

A Conversation with Orkideh Behrouzan

Organized and edited by Naghmeh Sohrabi, Director for Research and the Charles (Corky) Goodman Professor of Middle East History, and David Siddhartha Patel, Associate Director for Research

April 11, 2020

Iran has been one of the worst hit countries by the current global outbreak of a coronavirus disease (officially known as COVID-19), with the World Health Organization (WHO) acknowledging over 4,200 deaths and 68,000 confirmed cases in the country as of April 11, 2020. A number of senior Iranian government officials have been infectedincluding a vice president, the deputy health minister, and over 20 members of parliament, including the speakerand the government’s response to the crisis has been criticized by both its supporters and critics. This public health crisis comes at a particularly fraught moment for the government and citizens of the Islamic Republic, amid renewed U.S. sanctions and merely months after a series of protests in late 2019.

In this Crown Conversation, we discuss the political and historical context of the crisis, including the Iranian government’s response to it, with Orkideh Behrouzan, faculty leave fellow at the Crown Center and associate professor in the Department of Anthropology at SOAS University of London. Professor Behrouzan is a medical anthropologist and physician and the author of Prozak Diaries: Psychiatry and Generational Memory in Iran (Stanford University Press, 2016).  

How has the Iranian government used the country’s medical infrastructure and other institutional tools to address the outbreak? And how has that response been similar to and different from its response to prior epidemics in Iran, such as the epidemic of HIV/AIDs about which you have written?

Let me start with pointing out that the epidemic in Iran had been underway for several weekssince Februarybefore the WHO declared the novel coronavirus outbreak a global pandemic on March 11. Therefore, in referring to the disease in relation to dates prior to March 11, I use the word epidemic for coronavirus disease, in order to reflect an accurate timeline and its clinical context.

The most significant defining feature of the coronavirus epidemic in Iran has been the politicization of the outbreak and the securitization of information about it. The first wave of the emergence of the infection in the holy city of Qom, in early February, was kept secret for weeks. These weeks were crucial in that they comprise the so-called “golden window” for preventing the spread of the virus and limiting fatalities. Later in February, when the outbreak was no longer a secret, none of the standard public health measures to contain the outbreak (including social distancing and limiting traffic to and from Qom) had been put in place. This resulted in the spread of the virus outside of Qom, the creation of several new epicenters within weeks, and high fatality rates in the provinces of Tehran, Gilan, Khorasan, Isfahan, and Mazandaran. This systematic cover-up of the outbreak by the establishment, despite several calls by clinical experts for action, had irreversible consequences for both Iranians and the wider region. As of April 11, there were officially due to coronavirus in Iran; however, the projected figures are orders of magnitude higher than official reports. Tens of health workers, doctors and nurses in particular, have lost their lives, most notably due to their unprotected exposure during the weeks when information about the epidemic was suppressed. Iran also became a key source of spread in the region, responsible for patient zeros and further spread of the virus in neighbouring countries, including war-torn Afghanistan.

Epidemics are medical and social constructions at once. They are both biological and political entities; their emergence, manifestation, and governance are intertwined with complex cultural and historical contexts and political agendas. Therefore, the history of public health efforts in post-revolution Iran is a significant context for understanding the social life of epidemics such as coronavirus and Iran’s response to it. In order to understand the response to this outbreak, we ought to situate it in the historical context of public health policymaking. This is not the first time that the Islamic Republic addresses an epidemic with a politicized approach and engages in denial or cover-up. There is a significant historical precedent in the history of HIV/AIDS in Iran, where the first case was detected in 1986. Yet, for over a decade, the official attitude toward the illness was that of denial, on the grounds of associations of the virus with homosexuality, a “foreign” infection, and what was deemed “deviant behavior.” I have elaborated on this history elsewhere and analyzed how and why Iranian policymaking with regards to HIV/AIDS changed in the late 1990s, leading the WHO to cite Iran’s National Plan for Fighting HIV/AIDS in 2004 as an exemplar of best practice. The story of how this shift occurred sheds light on the complexity of Iran’s fractured structures of power within and outside of public health arenas. 

In the late 1980s and into the 1990s, Iranian officials vehemently denied the existence of HIV infections in Iran, despite alarming reports from medical professionals who were prevented from having public discussions of the illness. It took a decade of grassroots medical and cultural advocacy by multiple actors, including clinicians, to re-orient the cultural and linguistic association of HIV/AIDS from sexual activity to intravenous drug use, which was at the time the most common mode of transmission for the virus in Iran. It was a series of situated religious, medical, and cultural negotiations led by various groups of medical experts that played a key role in changing the policy narrative from the bottom up.

Unlike the ideologically-driven cover-up of HIV/AIDS, Iran’s response to coronaviruswhich has been one part incompetence and one part deceithas been motivated by contradictory political agendas. Those agendas include the clash between public health provisions and the protection of both the economic interests and religious status of the city of Qom, as well as obstructing the implementation of partial lockdowns and suppressing information about the outbreak in order to secure voter turnout and participation in the parliamentary election on February 21, 2020. By mid-March, Iran began to ramp up emergency efforts, designating coronavirus wards in specific hospitals; closing schools, universities, and some businesses in major cities; and promoting stay-at-home campaigns for self-isolation. The latter was met with varying degrees of compliance across different social strata, particularly in the lead up to the Persian New Year’s fortnight-long holiday period, and it did not include provisions to prevent holidaymakers from traveling between provinces. Many people had to return to work after the holidays, and on April 8, the government announced a phased lifting of lockdown on account of the urgency of sustaining major economic activities. Iran’s fragmented, opaque, and belated response to the outbreak of coronavirus was in part a reflection of an operational incompetence exacerbated by economic pressures, as well as a lack of consensus among different factions within the regime, laying bare a crisis of credibility and legitimacy with which the Islamic Republic increasingly struggles.

You noted that the holy city of Qom was the epicenter of the outbreak in Iran. Does that geography matter for both how the state handled the outbreak and how it has spread?

The early cases of coronavirus were hospitalized in Qom with the number of casualties rising by mid-February. Information about the outbreak initially spread through unofficial and individual accounts from Qom’s main hospitals while official accounts suppressed its news. Qom’s significance as the seat of the Shi’ite religious establishment has political, financial, and public health implications for the spread of the virus. Receiving some 22 million domestic and foreign pilgrims annually (2.5 million of those from abroad), hosting hundreds of foreign clerical students, including many from China, and being home to prominent Shi’ite clergy, religious leaders, and political and economic power players in the region (some with strong financial and theological ties with China), Qom was not an unlikely first epicenter for coronavirus in Iran. And yet health experts’ calls to close the shrine of Fatima Masumeh, to limit traffic to and from Qom, or to isolate the early cases of the illness were categorically dismissed by the government. Prominent infectious disease specialists, public health experts, and official bodiesincluding Iran’s Health Commissioncalled for the implementation of lockdown measures in Qom and other subsequently involved sites. They urged the government to intervene, isolate identified cases of the disease, stop flights to and from China, close the shrines (at this point, shrines in Karbala and Najaf in Iraq had already closed their doors), and mobilize reliable media to raise awareness about the risk of infection and preventive measures such as social distancing. These calls, some from within President Rouhani’s cabinet or the Ministry of Health, were rejected by “higher authorities.”

Qom is also significant in terms of its theological and financial relations with China. Of course, China has become one of Iran’s economic lifelines in the face of the U.S. sanctions; but it also has significant ties with Qom, ranging from the education of hundreds of Chinese clerical students in Shi’ite seminaries and cultural exchange programs during the Chinese New Year to large scale infrastructure projects, such as China’s construction of a solar power plant in Qom. Significantly, business interactions and commercial flights continued at a time when China was experiencing the peak of its coronavirus epidemic and despite demands by members of the Iranian Parliament and public health experts to stop such flights. Most notably, it was revealed that, even after the cabinet’s January 31 announcement to cancel all flights to and from China, at least 55 flights had continued to operate on that route between February 4 and 23 by Mahan Air, the carrier known for its strong commercial links with the Islamic Revolutionary Guard Corps (IRGC).

The outbreak in Iran is happening amid renewed U.S. sanctions and after popular protests, the targeted killing of a prominent Iranian military commander, and the mistaken shooting down of a Ukrainian passenger plane. How has this context affected how Iranians have responded?

The timing of the outbreak of coronavirus is significant in that the Islamic Republic’s crisis of credibility and Iranians mistrust of official accounts have reached an all-time high, especially in the aftermath of other recent tragedies in which the establishment engaged in deceit. These include the week-long shutdown of the internet across the country during November 2019 protests and covering up the number of people killed and arrested during the severe crackdown of the protestors, followed by the tragic downing by the IRGC in January of Ukraine International Airlines passenger flight 752 and the cover-up of the incident, which included attributing the crash to a mechanical problem until evidence emerged to the contrary. This was only a few days after heightened anxieties among Iranians about an imminent war with the United States in the aftermath of the targeted killing of Qasem Soleimani. Not only has the accumulation of these tragedies left Iranians overwhelmed with a sense of perpetual loss, there is also very little confidence left in top-down information coming from the establishment, which in turn results in high levels of public uncertainty and leaves room for misinformation and confusion.

The tragedy of coronavirus in Iran has also been compounded by the renewed U.S. sanctions that continue to cripple the economy and specifically damage the healthcare infrastructure and medical system despite the existence of advanced medical expertise in Iran. The recently added restrictions imposed by The Financial Action Task Force further stifle the economy and had already scarred Iranians’ collective spirit before the arrival of the epidemic. The U.S. government continues to claim that the sanctions include a humanitarian exemption for food and medicine, but unless U.S. sanctions on banking are lifted to restore Iran’s ability to purchase said goods from the West, such exemptions are meaningless. Specifically now, the United States’ refusal to lift sanctions as a matter of pandemic emergency exacerbates the burden of the pandemic on Iran and worsens an already uneven distribution of medicine, personal protective equipment (PPE), and testing kits inside the country.

Media coverage is another important element here. Many Iranians rely on information sourced from either social media or Persian-language media based outside of Iran. This coverage has at times included over-politicized analyses that can be influenced by pro- or anti-regime political agendas, while wrestling with an ongoing crisis of representation. However, these media have also created a much needed space for a discourse on transparency and the Iranian regime’s legitimacy, evoking heightened emotions not only in the aftermath of the above tragedies, but also in the context of a longer history of mistrust in official public health accounts. State-sanctioned domestic media, on the other hand, began their coverage of the outbreak belatedly and have primarily focused either on triumphant narratives of defeating coronavirus or on spreading clinical and practical information to raise awareness about preventive measures and offer clinical guidance, often from health practitioners. Both categories of media work ought to be understood in the context of a longer history of the public’s skepticism of official [public health] information, going back to the post-revolution securitization of biopolitical information, including statistics pertaining to drug use, suicide, and mental illnesses.

These sociopolitical and psychological contexts help us understand the impact of the outbreak, the response to it, the public anxiety around it, and the wounds underlying the burden of the pandemic on Iranians. The tragic death toll of the virus has left many families bereaved while the threat of its contagion has deprived them of the communal mourning practices that play a significant role in the psychological process of grieving and working through loss. What will remain after this pandemic crisis abates is collective and shared psychological ruptures that will not disappear once the virus does. The more unexpected legacy of this outbreak, however, would be the ways in which a post-rupture society’s relationship with power will change, how its sense of autonomy will be reconfigured, and how its trust in governance will be deeply wounded. What this means for the future of civil society, collective wellbeing, or the regime’s own sense of cohesion and stability remains to be seen and will depend on whether political will for transparency and confidence-building would or could transpire in the near future.  

The opinions and findings expressed in this Conversation belong to the author exclusively and do not reflect those of the Crown Center or Brandeis University.