This paper is a critique of Vira Ameli’s essay titled “Sanctions and Sickness,” which was published in the March/April 2020 edition of the New Left Review. In her essay, Ameli employs selective evidence and makes inaccurate claims. Her piece is not only an unreserved defense of the Islamic Republic of Iran (IRI), but a deceitful portrayal of the IRI’s alleged achievements in building a model health care system and its allegedly successful fight against Covid-19.
In our view, the main problems with Ameli’s essay are as follows: 1) Iran’s health care system is not put into proper historical and comparative perspective; 2) Ameli idealizes the IRI and consequently exculpates it of some of Iran’s delayed and negligent measures for countering the coronavirus pandemic; 3) she includes significant misinformation on socio-economic, medical and political issues, as well as Western media coverage of Iran; 4) Ameli remains silent about the fact that she exclusively and uncritically relies on information and data coming directly from the institutions and media outlets of the IRI, as well as its ardent advocates; 5) she fails to allude to the repressive, hierocratic, anti-democratic, corrupt, inhumane and misogynist structure of the IRI.
Since early 2020 COVID-19 has grown to a global pandemic. Hundreds of thousands of people have already perished from the coronavirus. Although the situation in Iran is not as devastating as in the USA, Brazil, India and a few other places, it is nonetheless among the hardest hit countries in the world. While the official daily death toll in Iran started to decline by mid-April, numbers began to surge from June onwards once again.
The reaction of the IRI’s leaders to the deteriorating situation was no surprise to attentive observers of Iran. As usual, they were not to examine, investigate and assess their methods and policies to explicate the failure in the face of the calamity. It were the “great and small Satans”, led by Donald Trump and the policy of “maximum pressure” on the IRI that had to be portrayed as the main cause for failure and major obstacle in reducing the number of COVID-19 victims.
The sad thing is that the IRI’s approach to this life and death problem was adopted by an array of academics, intellectuals and Iran’s political analysts in the diaspora. Among studies of this sort, the essay by Vira Ameli, “Sanctions and Sickness”, that appeared in the prestigious New Left Review (March/April 2020 edition) stands tall. The deconstruction of her portrayal of the COVID-19 crisis in Iran and the way in which the authorities have confronted the problem, illustrates what did and did not actually occur during the pandemic in Iran. The arguments she puts forth and the information she overlooks are emblematic of a tendency to gloss over the IRI’s accountability in the face of the crisis. On the one hand her piece mirrors some dominant currents among adherents and advocates of the IRI. On the other hand it epitomizes the position of a considerable number of the self-anointed “anti-imperialist”. In effect, Ameli’s essay is among the most widely shared and sophisticated exponents of this thriving view and therefore serves as a foil to carefully analyze and methodically criticize this outlook through focusing on her omissions, misinformation and half-truths.
In our view, the main problems with Ameli’s essay are as follows: a) Iran’s health care system is not put into proper historical and comparative perspective; b) Ameli idealizes the IRI and consequently exculpates it of some of Iran’s delayed and negligent measures for countering the coronavirus pandemic; c) she includes significant misinformation on socio-economic, medical and political issues, as well as Western media coverage of Iran; d) Ameli remains silent about the fact that she exclusively and uncritically relies on information and data coming directly from the institutions and media outlets of the IRI, as well as its ardent advocates. Her sources hardly meet minimum standards of accountability and transparency; e) she fails to allude to the repressive, hierocratic, anti-democratic, corrupt, inhumane and misogynic structure of the IRI. In contrast, all objective observers of Iran are in consensus that the IRI is largely responsible for the poverty, tyranny, socio-economic crises and ethical degeneration which currently haunt the country; f) Ameli’s lavish depiction of the Iranian public health system may lead the reader to infer that there is perhaps some resemblance with the public health system instituted in Cuba after the 1959 Cuban Revolution. This is far from truth. The Cuban public health system with universal access to health care, its inroads to many scientific developments, and even helping other countries with medical care providers, is a novel progressive endeavor launched with egalitarian and socialist objectives.
On the contrary, the anachronistic regime that came to power after the 1979 Iranian Revolution with its archaic ideology, eclectic structure, as well as rentier and predatory institutions has largely been detrimental to the Iranian public health system. Prevalent medical and mental health issues among the Iranian populace, widespread drug addictions and the emigration of thousands upon thousands of medical and other professionals attest not to a burgeoning, but to a prostrating and distressed health care system. Most notably, women, ethnicities, non-Shi’ite populations as well as the working people, urban poor and impoverished classes have suffered most in this system.
But as we will see, none of the above factors is taken into consideration or even acknowledged by Ameli. To paraphrase Jacques Derrida, one of the greatest thinkers of the late 20th century, what is absent or has deliberately been left out in a text is as important as and sometimes even more telling than what is actually present and highlighted by the author.
The Iranian Health Care System in Disguise
Ameli’s statements about the IRI’s unique efforts in “building an effective health system“ (p. 49) reflect a failure to acknowledge long-term structural improvements in medicine and public health in modern Iran dating back to the mid-Qajar period especially under the premiership of Amir Kabir in 1848 and then during the Pahlavi dynasty (1925-1979). For example, she asserts that: “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.” (p. 50). She continues that the IRI’s “achievements have been remarkable: universal immunization; dramatic reductions in maternal and infant-mortality rates; effective family planning and population control.” (p. 50) However, Ameli does not allude to the fact that these developments were already taking shape prior to the 1979 Iranian Revolution. In fact, Iran’s social security system was established in the mid-1970s; the present system is based on the foundations laid by that one.
Astonishingly, Ameli claims that Iran’s Islamic “government is committed to covering 90 per cent of medical expenses for every Covid-19 patient.” (p. 53) This somehow insinuates that Iran’s health care system is by and large well-functioning. But the fact of the matter is that in 2010, for example, only 39.3% of employed persons above the age of 15 were affiliated to pension health insurances and only 26.4% of those of retirement age were retirement pensioners with retirement coverage. Furthermore, many rural and nomadic populations have not even been registered. Significantly, the majority of the independent, self-employed segments of the labor market have to cover the lion’s share of health care expenses out of their own pocket. Consequently, they have to dispense 26% of their income to cover outstanding insurance costs whereas the government merely bears 3% of the charges. The upshot is that, as the majority of self-employed laborers live in precarious living conditions, many cannot afford to pay the medical fees. Indeed, there seem to have been 15-18 million uninsured people prior to the implementation of the Health Sector Evolution Plan. In 2014, this would have amounted to 20-24 percent, meaning about one fourth of the total population.
On a different note, Ameli writes that Iran “ranks 16th in the world in terms of research output in medicine” (p. 51), without any mention of the enormous brain drain of physicians, professors, students and more after the establishment of the IRI. In the early 2000s, more than 420,000 Iranians with higher education degrees resided in the United States, of whom 250,000 were doctors and engineers. According to the 2009 Annual Report of the IMF, Iran with the emigration of 150,000 to 180,000 educated and skilled individuals had the highest level of brain drain among ninety-one developing and developed nations, costing the country the equivalent of $50 billion. Moreover, in a recent study by Stanford University, Pooya Azadi et al. (2020) have shown that “the total number of Iranian-born emigrants increased from about half a million people prior to the 1979 revolution to 3.1 million in 2019, corresponding to 1.3% and 3.8% of the country’s population, respectively (…) As a proxy for the brain drain issue at large, the total number of active scholars among the Iranian diaspora has undergone a ten-fold increase since 2000.” Consequently, the number of medical scientists within the country is annually decreasing. Also, there is a lack of health personnel in the treatment of non-communicable diseases such as wounds and bone fractures.
Ameli’s treatment of the IRI’s handling of the drug abuse and HIV crises is even more problematic. She writes, “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 programs, and delivering care tailored to local cultural and community needs.” (p. 51), However, her statement obscures a number of important facts. For instance, in 2014, the UN drug office estimated that 2.2% of the population of Iran were drug addicts. Indeed, at least since the early 2000s, Iran seems to have harbored the highest per capita number of opiate addicts (especially opium and heroin) in the world. Thus, it would have been appropriate to concede that the IRI – in spite of all its preaching and propaganda about moving toward an exemplary, equitable, virtuous, decent, sacred and healthy society – not only suffers from a massive drug problem but is also carelessly incapable of coping with the HIV and drug epidemics.
Persecution and execution of dissidents, Communists, pro-democracy advocates, union activists, non-veiled and half-veiled women, non-Shi’ite religious societies (especially followers of the Baha’i faith), homosexuals, Kurds and various “ethnic minorities,” as well as other prisoners of conscience, has been no secret to the world public opinion. Intolerance, patriarchy, and violence have been characteristics and fundamental tenets of the Islamic Republic of Iran. But the regime’s persecution of the Alaei brothers in 2008 was another milestone in the state’s fundamental characteristic of demanding submission of its subjects. The arrest and imprisonment of these two committed medical doctors whose only crime was their perseverance in revealing the perils of HIV, is also quite enlightening as to the IRI’s disregard of vital public health matters. The Alaei brothers played a crucial role in persuading a few prominent members of the IRI’s medical establishment to discard the decades-old policy of denying the existence of key populations: people who inject drugs (PWID), “sex workers” (SWs), transgender persons, men who have sex with men (MSM) and people living with HIV (PLHIV). The medical advisors of President Mohammad Khatami (1997-2005) were the first to publicly acknowledge the problem. Albeit only implicitly, this paved the way for the treatment of the disease and for instituting harm-reduction programs.
In 1999 the internationally renowned medical doctors Arash and Kamiar Alaei initiated HIV prevention, care and treatment programs particularly focused on harm reduction for injecting drug users. With the brothers’ effective model, a nationwide needle-exchange program was instituted where condoms, clean needles and syringes were distributed free of charge at health clinics around the country. The Alaei brothers also shared their experiences with medical universities and health professionals to scale up HIV prevention and care programs, as well as methadone treatment centers in every province. They were successful in establishing clinics in 67 Iranian cities and 57 detention centers of the IRI. True, from 2000 to 2006 Iran became a “notable success” by “global standards” (p. 51). However, this success was on a regional level only and relative to the “Muslim world” which is generally intensely hostile to the aforementioned key populations at high risk of acquiring HIV, still ignoring the problem and refusing to provide care and public health facilities for people living with HIV. The Alaei brothers’ efforts came to an end when they were arrested in June 2008 and convicted of “cooperating with America”, “propaganda” and “membership in groups hostile to the system.” The conduct of their one-day trial did not meet the most basic standards of a fair trial and they spent three and a half years (Arash Alaei) and two and a half years (Kamiar Alaei) in prison. But the extent of “success” during those exceptional years should not be forgotten. In a private correspondence on 10 May 2020, Dr. Arash Alaei told Nasser Mohajer that: “From 2000-2006, only between 25% and 30% of all people living with HIV were aware of their HIV status. To date, and after 15 years, we have exactly the same percentages. This means we have made no progress with regard to this highly infectious disease.” In brief, Iranian doctors such as the Alaei brothers were able to successfully fight HIV despite the IRI’s impediments and not, as Ameli suggests, because of political or socio-economic measures taken by the state and its institutions.
Apart from that, Ameli paints a rosy picture of the country’s health care system when declaring that “a post-revolutionary policy of self-sufficiency has made great strides in the supply of affordable medicine and equipment, importing only raw materials (…) Today, 97 per cent are produced internally.” (p. 51) But in the next sentence she instantly contradicts herself:
Yet while only 3% 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 (…) 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 (p 51).
As a matter of fact, Iran is dependent not only on the import of essential raw materials such as active pharmaceutical ingredients (API), but also on semi-finished and finished products such as packages, protective wear and medicine. This is apart from the poor quality of many domestically produced pharmaceuticals and the lack of modern production technologies.
Deception and Contradictions
Astoundingly, Ameli argues that “among countries at a similar level of GDP, few—perhaps none—have more impressive records in building an effective health system.” (p. 49) However, a comparison between Iran and its neighbor Turkey reveals that her assertion is highly misleading. The system of public health and treatment in Iran has been one of the most successful in the Middle East and North Africa. This system was designed in 1973-1974 and became a pilot project in four years’ time. But it was only in 1986, during the devastating Iran-Iraq War (1980-1988), that it was implemented and put into practice throughout the country, in villages as well as large cities. With its execution, the number of health care workers and facilities increased and the mortality rate among mothers, infants, and children dropped massively, as did infectious diseases such as polio as a result of vaccination. This achievement met the international criteria for a successful health and treatment system for several years, until 2000.
From then on, however, we have witnessed the stagnation of this system and its effectiveness, so much so that neighboring Turkey, which was far behind Iran during the 1980’s, surpassed Iran in offering a much more efficient, comprehensive and effective public health system. Whereas Iran had 1.5 hospital beds per 1000 persons in 1978, this figure had risen to only 1.6 by 2018. By contrast, in Turkey – which in population density is similar to Iran – the average reached 2.8 hospital beds per person by 2018. Although Iran spends more money on health care, Turkey’s distribution of health care services is geographically more evenly spread out and life expectancy rates also surpass those of the IRI.
An important factor which has contributed to the rise of the Turkish public health system and the decline of Iran’s is the role that the state plays in providing the financial resources and essential investments to reduce the out-of-pocket payment by patients and to increase the availability of hospitals, medical equipment, pharmaceutical research, etc. In the Islamic Republic of Iran, it is the people and the private sector that provide a large percentage of the investment. In 2015, the state paid 50% of the total cost and the patients paid 43.7%. By contrast, 78% of the total budget for public health in Turkey was paid by the state, whereas private citizens’ expenditure in this vital domain did not exceed 17%. In 2015, both Iran’s per capita (prepaid private spending: $93; out-of-pocket spending: $539; government health spending: $600) and total per capita expenditure on health ($1232), exceeded Turkey’s per capita (prepaid private spending: $50; out-of-pocket spending: $176; government health spending: $820) and total per capita expenses on health ($1028). In other words, in comparison to Iran, citizens spend less than the state in Turkey. Thus, when adding up the total amount of expenditures, it becomes clear that the input/output in Turkey is much higher than what we see in the IRI. And this stands in striking contrast to the relative situation of the two countries some thirty-five years ago. The question that immediately follows this observation is what has happened to these expenses? Among the main factors with respect to this financial inefficiency are: mismanagement, corruption, and the lack of health personnel. And all this existed long before the Donald Trump presidency! What is more, a comparison with Cuba reveals that US sanctions are not the central factor behind Iran’s stagnant health care system. Whereas Cuba’s health care has been flourishing, possessing one of the most advanced systems in the world, Iran has hardly made any substantial progress.
The fact, Dr. Alaei argues, is that Iran’s public health system is more or less moving along the structure that was designed in 1973. No substantial change or innovation has occurred in the last 30 years. The only new initiative that had been proposed was the “development health care plan” introduced by the ex-Minister of Health, Hassan Ghazizadeh Hashemi in 2014, which was “the newest reform in the Iranian health system. Hospital-oriented transformation of the health service was launched in all governmental hospitals to help address the substantial increase in health-care costs in the past decade. The main objectives of this reform were to reduce health expenditure for patients, improve hospital organisation and quality of services, and provide equal access to inpatient care.” Hassan Ghazizadeh Hashemi was hoping to make the state pay for public health and save private citizens from this expenditure. The decision to reduce the medical budget in December 2018 was a watershed that made him resign his ministerial post. Indeed, the plan was altogether discarded too along with the minister himself in January 2019. It is important to note that prior to the Health Sector Evolution Plan approximately 15 million people, equivalent to 20% of the total population, had no health insurance of any sort. Presumably, they mostly live on the margins of urban centers. According to Tasnim news agency (6.3.2016), at the time of the implementation of the aforementioned plan, 16.7 percent of the Iranian population had no healthcare coverage. As to more recent official figures from 12.1.2020, 10% of the population still have no health insurance coverage. All these figures fly in the face of the claim that Iranians are enjoying universal healthcare coverage. Related to the Health Sector Evolution Plan are the increasing burden of healthcare costs as well as the issue of “privatization.” That said, the official figures on the uncovered population is all over the map and totally unreliable.
Furthermore, Ameli states that, “Instituted during the 1980–88 war with Iraq, the [Iranian health care] system was later described by the WHO as an ‘incredible masterpiece’ ” (p. 50). The latter statement is an outright lie. As written, it implies that the WHO sent a team to assess the health care system in Iran and described it as such in its subsequent evaluation. The reference in the footnote of Ameli’s essay, however, is to a dubious correspondence published in the journal The Lancet Global Health. The sentence reads: “Despite successful implementation of PHC in Iran, which was described by WHO as an incredible masterpiece and a successful model, the family physician programme is yet to be implemented.” This is an invention by the authors of the letter to Lancet. These writers, Seyyed Meysam Mousavi and Jamil Sadeghifar, refer to a report published in the Bulletin of the WHO in 2006. The author of this report, Mojgan Tavassoli, writes: “Dr. Sirous Pileroudi, a retired former senior official with the Ministry of Health and one of the founders of the Iranian health-care system, describes the health houses as an ‘incredible masterpiece’.” Not surprisingly, we were unable to find any association between Dr. Pileroudi and the WHO, which suggests that he did not represent the WHO and was merely boasting about his self-proclaimed and unproved achievements. Contrary to these cacophonies, the reality of Iran’s health care system is explicated in an article published in one of the most credible medical magazines, The Lancet:
…the health service in Iran has no master plan and is in a state of chaos. The system is fragmented not only in financial resources, but also in leadership. A disparity between public and private service, separated health insurance, and an absence of universal protocols and guidelines is hampering this system. Moreover, an ineffective health information system prevents efficient assessment of health. Public health expenditure as a percentage of gross domestic product is still low and needs to be amplified.
Ameli puts forth another inaccurate statement, linking Iran’s population decrease to the IRI’s alleged advancements in health care and “effective” population control. Quoting Kevan Harris, who himself has published twice in the NLR (2010 and 2016), she writes: “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’,” (p. 51). But contrary to Ameli’s declaration, population control had already started prior to the Iranian Revolution. As Ervand Abrahamian points out: “The regime had dismantled the shah’s birth control clinics on the grounds that Islam and Iran needed a large population.” This happened after Ayatollah Khomeini’s momentous pronouncement in the city of Qom on May 20, 1979, when he proclaimed that: “Iran is so vast that some 150 to 200 million people can live in the country. In other words, if it has 200 million people, they can all live in comfort.” Furthermore, from 1981 until the 1986 census, “Iranian discourse shifted to pro-natalism, rapidly departing from international trends (…) The marriageable age was lowered to nine to promote early marriage and encourage early and prolonged fertility exposure.” In this context, “Sanctions and Sickness” further ignores and conceals a number of other important factors. These include the official promotion of polygamy after the establishment of the IRI, particularly after the ceasefire between Iran and Iraq in 1988 as well as the fact that “the cost of contraceptives rose significantly and prohibitively, from 100 to 1000 rials.”
While the annual population growth rate was on average 3% between 1956 and 1986, it started to decline rapidly after 1986, reaching an annual average rate of 1.9%. in 1996. The process of slowing down continued after 2006, achieving an annual average rate of 1.3% in 2016 (Statistical Center of Iran 2017). This positive outcome was particularly surprising since both Mahmoud Ahmadinejad in 2006 and the Supreme Leader, Ali Khamenei decided in 2012 to end family planning and replace it with a new demographic policy targeting population growth. On October 22, 2006, Ahmadinejad announced in parliament that, “Two children are insufficient; the Iranian population should reach 120 million people.” He went even further on April 10, 2010, and announced that the government would allocate one million Toman for each new born. Ameli also fails to mention the Supreme Leader Khamenei’s fatwa issued on July 25, 2012, decreeing an increase in Iran’s population, stating that “no measure should be taken to limit population growth before the population reaches 150 million.”
Iran undoubtedly experienced a demographic transition between 1986 and 2003: the fecundity rate decreased from 6.4 in 1986 to 2.3 in 2003. This was a spectacular decline of 70% within 17 years. However, as the Iranian demographer Marie Ladier-Fouladi points out:
…this demographic revolution was an outcome of societal evolution rather than state policies. Since 2009, the government and conservative forces adopted a population policy to attain 150 million inhabitants in short term. The analysis of demographic dynamics shows that this objective is utopian, and probably hides ideological and political drives to curb social opening and to support the Iranian geopolitical and demographic weight in the region, compensating the weak fecundity by a new immigration policy.
If we take a slightly longer view, the population of Iran in 1979 amounted to about 30-35 million and had increased approximately 2.5-fold to over 83 million, by 2020. With reference to UN data, World Population Review indicates that, “The population of Iran is increasing at an alarming rate (…) After increasing to 60 million in 1995, it grew straight up to 70 million in 2005. The population statistics graph shows how dramatically the population had been increasing from year to year”, and now the population of Iran amounts to almost 84 million.
As a matter of fact, about 38% of the population is under the age of 25 and the median age in Iran is ca. 32.0 years. In short, from the vantage point of the 40-year span since the establishment of the IRI, Ameli’s trust in the state’s “effective” population control (p. 50) looks much less impressive, casting a gloomy shadow over Ayatollah Khomeini’s inhumane demographic policy, as well as Supreme Leader Khamenei’s unrealistic and irresponsible order to almost double the population. The latter has fortunately not been heeded by the majority of the Iranian population thus far.
Another major problem with Ameli’s account and reasoning is her assertion that Iran’s inflation and high drug prices are a result of sanctions: “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,” (p. 52). First, without repudiating the importance of “Maximum Pressure” in reducing the Iranian government’s oil revenue as the main source of government income, this domineering policy cannot be considered as the major cause of inflation. The main drive behind the increase in inflation is internal, namely an increase of 28% in liquidity during the last two years . The increase in liquidity is generated by the Central Bank’s policy as well as the institutional role of a parallel banking system related to parastatal organizations. The government’s debt to banks and the bankrupt banking system feed on inflation and the devaluation of the national currency to reduce its debts and to benefit from the multiple rates of foreign currencies. Moreover, the deficit of the Social Security Investment Company is a result of the state’s default in reimbursing the amount due to this organization’s preference to sell 10% of its bankrupt enterprises (transferred to this organization as a way to pay its debts) in the Iranian stock exchange to absorb the liquidity. Finally, it is a well-known fact that 4.8 billion dollars devoted to the so-called importation of “vital goods”, including medication by President Hassan Rohani’s government, were “lost” or used to import cars and cell phones.
Last but not least, Ameli homogenizes Western media and amalgamates politico-economic interests by making unjustified accusations and distorting the sources she cites. She contends that: “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’ (…) 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.” (p. 55) All sides?! Is that really the case?! Irrespective of the general, journalistic quality of this or that media outlet, the way Ameli depicts the Guardian article is quite disingenuous. Contrary to what she is insinuating, the British newspaper is correct in writing that, “public trust in the authorities’ capacity to deal with the virus had been undermined by the government’s sluggish and complacent initial response to the outbreak, and by the state’s secrecy over the killing of hundreds of street protesters in November.” Interestingly enough, the Guardian’s “allegation” has been reiterated by Tehran and provincial newspapers, members of the Islamic Parliament and even the IRI’s leading intellectuals.
More significantly, in the very same article whose title is cited by Ameli, the Guardian noted that “Tedros Adhanom Ghebreyesus, the WHO’s director general, praised Iran for ‘switching on’ to the outbreak and for taking an ‘all-of-government approach’ (…) Tedros said the epidemic was continuing to spread, adding, ‘We are continuing to recommend that all countries make containment their highest priority’.” Again, the latter statement has remained unmentioned by Ameli as it would have undermined the validity of her presupposition. Indeed, if examples of anti-Iranian media coverage in the course of the coronavirus crisis “abound” (p. 55), she should at least have chosen a more adequate source to illustrate her allegations. This is not to mention the necessity of quoting an array of articles in European and American media outlets that singled out the IRI with the intention of denigrating and defaming the nation in the course of the corona crisis. Second, in contrast to the Iranian broadcast and print media which are mainly state-owned or state-controlled and subject to harsh censorship, Western media outlets – the majority of which are in private hands and represent different interest groups – are not necessarily antagonistic towards the IRI. As a matter of fact, a number of more or less influential newspapers and journals in Europe and the US (e.g. Junge Welt, Counterpunch) publish articles that target Western imperialism while typically remaining mute about the oppressive nature of the Iranian regime and its many crimes.
The Iranian Government’s Handling of the Covid-19 Crisis
Instead of acknowledging the slow reaction of most political establishments worldwide in coping with the pandemic, Ameli justifies Iran’s negligence as getting caught up in irresolvable contradictions. In her own words, the IRI’s response to the pandemic was not “malign neglect, but rather the same mixture of bewilderment and complacency in the face of a colossal public-health threat that later paralyzed other nations” (p. 50). On the one hand, she admits that first cases of Covid-19 were reported as early as January 2020 (p. 49), but vindicates the Iranian government’s inactivity by blaming it on others. Accordingly, she claims that “testing kits had only arrived from China on 17 February” and that “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” (pp. 49-50).
But Ameli’s selective amnesia towards the grave misconduct of the IRI in the face of this devastating pandemic is bewildering. Not only was the principle and practice of quarantine mocked and instantly rejected by the current government of the IRI as well as the bulk of the Shi’ite establishment, but Muslim sites and mosques were not immediately closed, and weekly flights to and from China continued undisturbed. Travelling across the country continued till late March, while “social distancing” and wearing masks were not the order of the day. Thus, it is not surprising that contact-tracing was not even taken into consideration by the Islamic regime in Iran. What is more, on March 5, Hossein Salami, the commander of Iran’s Islamic Revolutionary Guards Corps (IRGC), insinuated that the coronavirus could be an American biological weapon. On March 22, 2020, the Supreme Leader of the IRI unashamedly depicted the coronavirus as a supernatural creature, “demon, magical spirit, a ‘jinn,’ dispatched to undermine the Islamic Revolution.” In a speech in Tehran, broadcast live across the country marking Nouruz, the Persian New Year, he said that medicine from the US is possibly “a way to spread the virus more.” He also alleged without offering any evidence that the virus “is specifically built for Iran using the genetic data of Iranians which they have obtained through different means.” He further added that: “You might send people as doctors and therapists, maybe they would want to come here and see the effect of the poison they [the US] have produced in person.”
However, in a few weeks’ time, Iran’s Supreme Leader changed course and stopped talking about the enemy’s conspiracy to dispatch magical creatures to harm Iranians and destabilize the Islamic community. He instructed believers “to donate tithes and alms in money or in kind to the needy and all those ravaged by the coronavirus in the holy month of Ramadan.” Khamenei also opened a personal bank account for the victims of the coronavirus and pleaded to the devout to directly transfer their religious fees via his site.” Such acts, which are rooted in a centuries-old clerical tradition of charitable work among the populace (especially the poor, poverty stricken and laid off workers) is not deemed by Ameli as another instance of the IRI’s demagogy and irresponsibility vis-à-vis the population in times of calamity. On the contrary she depicts these “institutional mobilizations” along with “the strengths of the (…) health system to “curb coronavirus deaths” (p. 54). According to official data, widely contested by medical staff, as of Monday evening, May 18, 2020, Iran ranked 7th highest among 151 countries in deaths (7,057 deaths). In regards to confirmed cases, Iran ranks 10th highest among 151 with 122,492 cases, and in regards to case-fatality ratio (number of death/number of cases identified) it ranks lower, at 38th highest, or at 5.8% (100 × 7057/122492).
In spite of all this, it must be emphasized that the civil society in Iran, in contradistinction to its state and religious establishments, has played a key role in bringing awareness to the people on how to deal with the pandemic and with its philanthropic endeavors to save lives. It must be reiterated that this was partly the consequence of the IRI’s irresponsibility and institutional incapacity in the face of a precarious situation. Thus, more or less similar to countries with demagogic and right-wing populists in power, celebrities, humanists, philanthropists, ordinary people and, above all, medical experts and health care workers came to the fore, posting videos and online messages, asking people to stay home and not to contribute to the spread of the disease. Moreover, volunteers from all walks of life have sanitized public places, and distributed care packages that include disinfectants and masks for the poor.
Some Final Thoughts
The post-Cold War era has led to unprecedented new world disorder. It has paved the way for the powerful to bully their adversaries to pander to its whims and wishes. Economic pressures and military aggressions in Asia, Africa, Central and South America by US capitalism and European conglomerates have aggravated the divide between the rich and the poor; not only in the periphery, but in the center too. This has contributed to extreme polarization the world over and created an extraordinary chasm between the haves and the have-nots. The “America first” foreign policy pursued under Donald Trump has intensified a vast array of contradictions and conflicts. Obviously, this set of circumstances urgently calls for a strong democratic-socialist opposition as well as a robust peace movement across ideological lines.
In this “Age of Extremes”, authors who act as spokespersons of the IRI, or any other authoritarian state, criticizing the belligerent Realpolitik of US imperialism under Trump’s illiberal democracy and his right-wing populism, while ignoring the aggressive rule of their homegrown reactionary regimes who suppress dissidents, bolster corruption and predation are in effect weakening emancipatory endeavors for the cause of the working people in their quest for a just world. The political praxis of these academics, intellectuals and journalists stirs reactionary trends: worst kinds of nationalism, racism, white supremacist sentiments, anti-immigrant hatred, religious-fundamentalism, misogynistic attitudes and increasing animosity towards LGBT movements.
As for Iran, nothing should cast a shadow over the fact that the IRI is responsible for one of the most heinous crimes of the last quarter of the twentieth century. This theocratic regime is also notorious for having the highest per capita execution rate in the world. Its methodical suppression of freedom of thought, expression and assembly; its misogynistic characteristic enshrined in the constitution; and discrimination against religious and ethnic minorities has led millions of Iranians to go to the diaspora. The IRI’s foreign policy has also fed militarism and interventionist policies of super-powers in favor of anti-democratic governments in countries such as Saudi Arabia, Bahrain, Egypt and… IRI’s systematic support for Bashar al-Assad’s murderous regime, and its interference in the domestic affairs of Afghanistan, Iraq, Yemen and Lebanon in the hope of exporting the Islamic Revolution to these countries, has changed the balance of power against democratic forces in the region. In so doing, the IRI has enjoyed the tacit or explicit support of non-NATO super-powers such as China and Russia, who not only ignore the atrocities perpetrated by their regional ally, but find it easier to commit crimes that contravene emancipatory and humanist principles both within and without the country.
A multifactorial approach which captures both the internal and external causes of Iran’s (under)-development, as well as gross human rights violations on all sides of the geopolitical spectrum, is indispensable if a genuine new left is to emerge in Iran. A new left characterized by:
- Its commitment to seriously studying the past in order to not repeat previous mistakes.
- An embrace of a progressive anti-imperialist struggle through the democratization of society and the mobilization of all democratic forces. The struggle against imperialism cannot be successful without sidelining regressive and reactionary forces.
- Adherence to the Universal Declaration of Human Rights, social justice, separation of church and state, equal rights for women, and the principle of sovereignty, independence and self-determination of all nations.
- Agreement that in the lexicon of this new left, retrograde anti-imperialism where the ends justify the means, and the enemies of one’s enemies become one’s best friends, has no place.
It is important to note that these principles were previously partly propagated by the New Left Review and were adopted by most of the advanced sectors of radical intellectuals throughout the world, including the Iranian new left. However, this significant development of the 1980’s and 1990’s, mostly under the editorship of Robin Blackburn, gradually lost momentum at the NLR after 1999. Notably from 2003 the NLR steadily changed its approach towards anti-imperialist struggles and was no longer the formidable voice it used to be for democratic socialists and radicals of the “developing world” who were fighting repressive governments with belligerent attitudes towards US imperialism. Before this unfortunate shift, it would have been inconceivable to read in the New Left Review essays justifying regressive and reactionary “anti-imperialisms” that the late Fred Halliday called “the anti-imperialism of the fools” that is, nothing but brute anti-Americanism. Ameli’s essay, “Sanctions and Sickness”, in the March/April 2020 edition of the NLR had no place in this avant-garde journal.
 NLF has been one of the most important intellectual voices of the new left over the past 60 years. In the 1980s and 1990s, during the editorship of Robin Blackburn, several authors who strongly oppose(d) the Shah’s regime and the IRI wrote analytical papers on Iran based on sound facts and figures, most notably the late Fred Halliday (1982; 1987), Ervand Abrahamian (1991), Nikkie R. Keddie (1997) and Janet Afary (1997). However, since the early 2000s, especially after Susan Watkins took over – no such in-depth articles appeared in the NLR. Ameli’s essay is the first piece in the journal on Iran after a few years of relative silence.
 An earlier version of this paper was submitted to NLR. But after the editors ignored our repeated requests for an accelerated review, we retracted our submission.
 Cyril Elgood, A Medical History of Persia and the Eastern Caliphate (Cambridge: Cambridge University Press, 1951); Hormoz Ebrahimnejad, Medicine, Public Health, and the Qājār State: Patterns of Medical of Medical Modernization in Nineteenth-Century Iran (Brill: Leiden/Boston, 2004); Willem Floor, Public Health in Qajar Persia (Washington DC: MAGE, 2004); Amir A. Afkhami, A Modern Contagion: Imperialism and Public Health in Iran’s Age of Cholera (Baltimore: John Hopkins University Press, 2019).
 “Chronicle of the History of Social Security” (in Persian), Donya-ye Ekhtesad, Tehran, 18.05.2020, available at: https://donya-e-eqtesad.com/%D8%A8%D8%AE%D8%B4-%D8%AA%D8%A7%D8%B1%DB%8C%D8%AE-%D8%A7%D9%82%D8%AA%D8%B5%D8%A7%D8%AF-31/529147-%D8%AA%D8%A7%D8%B1%DB%8C%D8%AE%DA%86%D9%87-%D8%AA%D8%A7%D9%85%DB%8C%D9%86-%D8%A7%D8%AC%D8%AA%D9%85%D8%A7%D8%B9%DB%8C.
 Marie Ladier-Fouladi, “Les systèmes de retraite en Iran face au défi du vieillissement à venir“, in Valérie Golaz et Muriel Sajoux (eds), Les politiques publiques face aux réalités plurielles de la vieillesse dans les pays du Sud, pp.265-285 (2018), 276.
 Ibid., pp. 269, 275. This data is drawn from International Labour Office, World Social Protection Report 2014/15: Building economic recovery, inclusive development and social justice, Geneva 2014.
 Ibid., pp. 268-9, 276.
 Khane-ye Mellat (news agency of Iran’s Islamic Parliament), 12.1.2020.
 Mohammad Chaichian, “The New Phase of Globalization and Brain Drain: Migration of Educated and Skilled Iranians to the U.S.,” International Journal of Social Economics 39:1/2 (2012), pp. 18-38.
 Pooya Azadi, Matin Miramezani and Mohsen Mesgaran, “Migration and Brain Drain from Iran”, Stanford Iran 2040 Project, Working Paper 9 (April 2020), available at: https://iranian-studies.stanford.edu/sites/g/files/sbiybj6191/f/publications/migration_and_brain_drain_from_iran-stanford_iran_2040_project.pdf.
 Marie Ladier-Fouladi, Population et politique en Iran: de la monarchie à la République islamique (Paris: Institut National d’Études Démographiques, 2003), pp. 122-3.
 Lara Marlowe, “Hooked in Iran, where addiction rates are world’s highest”, The Irish Times, 17.06.2014. See also Karl Vick, “Opiates of the Iranian People”, The Washington Post, 23.09.2005; Sam Bagnall, “Tackling Iran’s heroin habit”, BBC, 16.06.2004.
 Nasser Mohajer’s personal correspondence with Dr. Arash Alaei, 10.-14.05.2020. See also David Ignatius, “In Iran, Searching for Common Ground”, The Washington Post, 06.09.2006.
 Amnesty International, “Iranian Aids doctors tried in closed hearing”, 08.01.2009; David Ignatius, “In Iran, Searching for Common Ground”, The Washington Post, 06.09.2006.
 Amir Havasi, “Hopes and Fears in Iran’s Pharma Market”, Financial Tribune, 13.09.2017; Farbod Ebadi et al., “Policy Analysis Of Iranian Pharmaceutical Sector; A Qualitative Study”, Dovepress 12 (2019), pp. 199-208.
 Nasser Mohajer’s personal correspondence with Dr. Arash Alaei, 10.-14.05.2020.
 For these figures, see Dr. Arash Alaei and Dr. Kamiar Alaei, “An Overview of the COVID-19 Situation: Lessons Learned from Iran”, Presentation for the Stanford Iranian Studies Program, 22.04.2020, available at https://www.youtube.com/watch?v=iIqgSSlH8qs&t=491s.
 Financial Global Health Database. The statistics/data are drawn from the 2015 census, before Donald Trump’s presidency and his maximum pressure policy on the IRI.
 Bahram Heshmati and Hassan Joulaei, “Iran’s health-care system in transition”, The Lancet 387: 10013 (2016), pp. 29-30, p. 30.
 Nasser Mohajer’s personal correspondence with Dr. Arash Alaei, 10.-14.05.2020.
 “Five challenges and 13 weak points of Health Sector Evolution Plan” (in Persian)_ Tasnim News Agency, 6.3.2016.
 “Deputy of health insurance of Iran: 10 Million Iranians do not have healthcare insurance” (in Persian), Tasnim News Agency, 12.1.2020.
 Kanoon-e Modafeane Hoghugh-e Kargar, “The deadly cancer of privatization of health care along with the education system” (in Persian), 23.6.2016.
 Khabar Online, “Ambiguity on the number of people who are deprived of insurance and the registration of only three and a half million people” [in Persian], 10.5.2014.
 Seyyed Meysam Mousavi and Jamil Sadeghifar, “Universal health coverage in Iran”, The Lancet Global Health 4:5 (May 2016), p. 305.
 Mojgan Tavassoli, “Iranian health houses open the door to primary care,” Bulletin of the World Health Organization, available at: https://www.who.int/bulletin/volumes/86/8/08-030808/en/. The authors Mousavi and Sadeghifar were respectively associated, in 2006, with the Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, and Department of Health Education, School of Public Health, Ilam University of Medical Sciences, Ilam.
 Bahram Heshmati and Hassan Joulaei, “Iran’s health-care system in transition”, The Lancet 387: 10013 (2016), pp. 29-30, p. 30
 Ervand Abrahamian, Khomeinism: Essays on the Islamic Republic (Berkeley: University of California Press, 1993), p. 140.
 Speech of Ayatollah Khomeini to “representatives of the people of Bahrain and Pakistan” (in Persian), 20.05.1979, Sahifeh-i Nur [Declarations, Messages, Interviews, Fatwas, Shari’a’s Permissions and Letters], Vol. 7, available at: http://www.imam-khomeini.ir/fa/C207_42377/.
 Katrina Riddell, Islam and the Securitisation of Population Policies (Burlington: Ashgate, 2009), p. 110.
 Marie Ladier-Fouladi, “La nouvelle politique de population de la République islamique: enjeux et défis” [The New Population Policy of the Islamic Republic: Issues and Challenges], Bulletin de l’association de géographes français 94:4 (2017), pp. 587-599, p. 589.
 Marie Ladier-Fouladi, La nouvelle politique de population de la République islamique : enjeux et défis (The new population policy of the Islamic Republic: issues and challenges), Bulletin de l’Association de Géographes Français (2017), https://doi.org/10.4000/bagf.2418, pp. 589-590.
 “Siasat-i Baray-e Afsayesh-e Jamiat Etekhas Nashode” (in Persian), BBC Persian, 23.10.2006.
 Ladier-Fouladi, “La nouvelle politique”, p. 587.
 UN: Department of Economic and Social Affairs, World Population Prospects 2019, Data Booklet, p. 17, available at: https://population.un.org/wpp/Publications/Files/WPP2019_DataBooklet.pdf. See also https://www.worldometers.info/world-population/iran-population/.
 “Iran’s population growth rate is about 1.1% (…) Iran’s fertility rate has been just over 2.1 births per woman consistently for the past few years, keeping the rate just above the population replacement rate of 2.1 births per woman.” See https://worldpopulationreview.com/countries/iran-population/.
 Central Bank of Iran reported by Islamic Azad University News Agency, 09.05.2020.
 For the Central Bank’s policy, see Farokh Ghobadi, “General grievance, what is the source of effective demand’s shortage?” (in Persian), Tejarat Farda 239, 1396 (2017), pp. 8-9. For the parallel banking system, see Bahman Ahmadi Amoui, Political Economy of Islamic Fraternity Funds and Credit Institutions – The Demise of an ideology (In Persian) (Tehran: Bongah Tarjomeh va Nashre ketab Parseh, 2018).
 See www.tabnak.ir, April 15, 2020. Hence, Ms. Ameli’s following attack on the New York Times cannot be viewed as anything other than a conspiracy theory that totally disregards the dynamics internal to the domestic economy such as the corruption of the political establishment: “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.” (pp. 54-5)
 “Coronavirus cases pass 100,000 globally as Iran threatens force to restrict travel”, Guardian, 06.03.2020.
 “The Trust of Society, the Capital that is Lost” (in Persian), Seday-e Eslahat 18.05.2020; “The Astonishing Corona Statistics by a Qom representative in the Majles” (in Persian), Hamshahri Online, 24.02.2020; “Recent Assertion on Statistics about the coronavirus in Gilan” (in Persian), Hamshahri Online, 29.03.2020; “What is more Dangerous, the Coronavirus or Distrust of the Authorities?” (in Persian) Bahar News, 25.02.2020.
 “Coronavirus cases pass 100,000 globally as Iran threatens force to restrict travel”, Guardian, 06.03.2020.
 The semiofficial ISNA news agency quoted Salami, saying that: “We will prevail in the fight against this virus, which might be the product of an American biological [attack].” Quoted in Jason Rezaian, “Iran’s response to the coronavirus is just making everything worse”, The Washington Post, March 7 2020.
 France24, 22.3.2020, available at: https://www.france24.com/en/20200322-iran-s-supreme-leader-khamanei-refuses-us-help-to-fight-coronavirus-citing-conspiracy-theory.
 “Ayatollah Khamenei’s Speech, Humanity never needed a Savior like Today” (in Persian), IRNA, 19.04.2020.
 “Financial Aid to the Victims of the Coronavirus was Activated on the Site of the Supreme Leader” (in Persian), Javan Online, 17.04.2020
 See, for example, https://www.yjc.ir/fa/news/7293477.
 In the summer of 1988, political prisoners throughout Iran’s detention centers who were serving their sentences were retried in inquisition-like tribunals. Some 5000 of them were tortured and executed in cold blood. See Nasser Mohajer (ed.), Voices of a Massacre: Untold Stories of Life and Death in Iran, 1988 (London One Word, 2020).
 Amnesty International Global Report: Death Sentences and Executions 2019, London 2020, pp. 5-13.