Situational Analysis

The Islamic Republic of Iran, like many countries in demographic and socioeconomic transition, in recent years has experienced striking changes in the pattern of its serious health problems. While the death rate from infectious diseases (such as diarrhea and pneumonia) has declined, troublesome new maladies (including cardiovascular disease, diabetes, cancer, and myriad stress-related disorders) have escalated. In part, this disturbing new health profile appears to be the result of rapid urbanization and pervasive socioeconomic and gender-based inequities. Iran’s current situation is complex, influenced by oil, politics, and religion.

Oil—or “black gold”— in Iran, as elsewhere, has proved a two-edged sword. Thanks to its vast reserves, Iran in recent decades has developed into a middle income country, with a GDP (gross domestic product) per capita around $2,000. Yet for all its oil wealth and an extensive national Primary Health Care system, the country’s level of health remains far from optimal. The Under-5 Mortality Rate was 37 per 1000 in 1998.

Iran’s heavy dependency on oil export has serious implications for the long-term sustainability of health and development. The oil industry, owned by the federal government, is a major source of revenue, yielding 80% of export income and 16% of the GDP. Oil dependency has led to serious decline in agricultural production, with increasing reliance on imported food (including rice, a national staple). The vast import of grain (including recent huge shipments of surplus wheat from the United States) is bankrupting small farmers, thereby contributing to urban drift.

Furthermore, serious mismanagement of agricultural policies and technology has led to over-dependency on increasingly expensive chemical fertilizers and overuse of limited ground water. These factors contribute to the increasing cost of local food production. In the country’s relentless drive for economic growth, too little thought has gone into what may happen when the nation’s oil and water reserves run out.

 

Urbanization has been accelerated by the oil boom. Today 65% of Iran’s people live in cities. What were bucolic provincial towns, like Isfahan and Tabriz, when I bicycled through Iran 40 years ago, are now bustling cities. Tehran, the nation’s capital, has mushroomed. Although the city’s official population is 7 million, it is estimated to have 13 to 14 million people (nearly 1/4 of the nation’s population) when squatters, drifters, homeless people and refugees are included. Traffic and pollution have become horrendous. There has been a drastic increase in illnesses related to crowding, stress, road accidents, environmental pollution, junk food, drug use (from tobacco to cocaine), and breakdown of social cohesion.

Yet for all this trend toward urban “modernity,” the health profile in Iran remains mixed, with characteristics typical of both over- and under-development. In cities there has been an upsurge of the diseases of consumerism and industrialization in the new sedentary middle class, making heart disease, stroke, diabetes, and cancer the primary causes of death. Yet in outlying rural populations—as among the rapidly growing urban underclass—children still get sick and die from the ubiquitous “diseases of poverty” such as diarrhea and respiratory infection.

Persistent undernutrition . . . and obesity. Severe malnutrition in children has declined impressively in the last decade—in part due to a national program of food supplements . However, the rate of mild to moderate undernutrition in young children remains stubbornly high, in some areas from 20% to 40%. (Confusion in record keeping makes the data unclear.) Meanwhile obesity, both in children and adults, is becoming a growing health concern.

 

Increase in crime and violence. In training sessions I facilitated with senior health educators from different provinces, we practiced an active participatory approach to “community diagnosis” much used in Latin America. The groups listed and then prioritized the “most important health related problems” in their communities. At the top of the list of each group appeared problems they classified as indicators of collective psychosocial disfunction. These included violence (including high rates of domestic violence), mental depression, substance abuse, juvenile crime, and suicide (especially among women and adolescents). In exploring the “chain of causes” leading to these maladies, participants identified underlying causes such as low wages, social discrimination (by class and gender), hopelessness, and the widespread sense of powerlessness of ordinary people, who complain of a “lack of control over our lives.”

Growing income disparity and slave wages. In discussing the root causes of major health problems in Iran, participants pointed to the huge gap between rich and poor, which has been steadily widening. Today the richest 10% of the population earns 23 times as much as the poorest 10%.

While absolute poverty has declined in recent years, real wages of working people (including civil servants and professionals) are outrageously low: from US$100 to $180 per month. The (unofficial) poverty line is about US$120 per month. The international buying power of Iranian currency (the tuman) has been grossly devaluated. At current exchange rates, basics such as food, gasoline, and rent are about 1/10 the cost in USA. However, cost of imports—cars, machinery, medicines—is about double the dollar value in the U.S. (A small car in Iran may cost up to US$40,000).

Conspicuous wealth is plentiful in metro politan Iran: fancy cars, palatial homes, elegant restaurants, exclusive clubs, and all sorts of luxury goods. But these belong to the realm of an elite minority that has mysterious access to vast resources. By contrast, wages of working people, including most professionals, are so deplorably low that it is hard for families to make ends meet. Many people work double shifts; others “moonlight,” sometimes at illegal or ealth-threatening jobs.

Prostitution and drug use have exploded in the last few years, with an emerging epidemic of sexually-transmitted and needle-transmitted diseases. AIDS, which until recently had been denied and ignored by the state, is now spreading rapidly, especially among the prison population where drug use and anal sex are a normative rite. Among university students and even in primary schools, use of heroine and cocaine is a growing problem. According to some estimates, up to 1 in 20 people in Iran now use hard drugs. Drug dependency, in turn, contributes to the high rates of crime, violence, and prostitution.

Until recently, the strong Islamic taboo on prostitution has kept it minimal or at least well hidden. But recently, the direeconomic need of women, including college girls, has led to a new industry where women are picked up each evening in vans and transported to affluent clients. Unfortunately, few precautions are taken to prevent spread of infection and currently Teheran is experiencing an epidemic of sexually transmitted diseases. At last the Health Ministry is beginning to act on this time bomb for an AIDS epidemic. But it is hampered by religious taboos about discussing sex, which have made it difficult to promote condom use or relevant health education.

Domestic violence and family dysfunction are also growing concerns. There have been increasing reports of violence by men against their wives and children. Serious disturbances in young people are likewise prevalent. In girls as young as 11 years old, depression and suicidal tendencies are alarmingly common. Adolescent boys tend more toward anti-social behavior, and sometimes self-destructive acts.

Growing impoverished population. While insufficient wages contribute to the difficulties of millions of working people, in the cities there is also a growing underclass of unemployed and homeless persons. Every day I saw such persons, young and old, picking through garbage bins on the streets. I was told that many of these destitute people in Iran are refugees, including nearly 2 million from Afghanistan. This swollen underclass helps explain the alarming rise in tuberculosis.

Primary Health Care, Iran style

The Health Ministry has taken many innovative measures to confront both the old and new health problems in Iran. More than most countries, its has put into action certain principles of Primary Health Care proposed in the Alma Ata Declaration.

 

The frontline PHC unit in rural areas is the “Health House,” which is staffed by a male and female “behvarz” (community health promoters with 2-years training). The behvarz perform a wide range of preventive and educational activities, plus a few curative services such as Oral Rehydration Treatment for infant diarrhea, diagnosis and treatment of pneumonia.

Backing up the Health Houses in rural areas, and providing the first level of services in urban areas, are Urban or Rural Health Centers, staffed by 1 or 2 doctors, often a dentist, and several specialized health technicians (in Maternal Child Health, environmental health, etc.) This staff provides training and supervision of behvarz and an active network o community volunteers, mostly women.

Both Health Houses and Health Centers have outreach activities into the community, workplaces and schools. Good use is made of local volunteers (all women).

A number of interesting innovations in community health education, and in management and financing of comprehensive services are emerging from the provincial levels, often through the Medical Sciences Dept. of the Universities. Some of these experiments, such as the Participatory School Health Program in Isfahan and Cultural Houses and the Girls' Reproductive Health Course in Semnan are genuinely enabling advances. (These initiatives are described in the boxes.)

Other experimental programs are more questionable. For example, the Province of Tabriz has introduced a user-financed cost recovery scheme for frontline curative services, which resembles that promoted by the World Bank. This increase in cost for low wage earners is likely to lead many families to delay needed treatment, or to spend their limited food money on health care. This could well prove counterproductive, as it has in many countries where the World Bank has imposed its belt-tightening policies. If Iran chooses its priorities appropriately, it has ample resources to provide basic health services to all its citizens (and refugees) through a single payer national health plan.

The challenge faced by the Health Ministry is to design an approach to health education/promotion that can help mobilize people to confront these daunting health problems and work to correct their underlying causes. The Health Ministry has taken many important measures. However, the current political situation in Iran does not make attacking the root causes easy.

As described above, the most overwhelming health problems in Iran today stem, in large part, from the rigidly hierarchical and inequitable social order. This makes any comprehensive attempt to build a healthier society difficult if not dangerous. Those with wealth and power—divided as they are into conflicting camps—do not look kindly on reformers.

 

Therefore, the policy makers in the Health Ministry, with their mandate to “improve the health of the nation’s people” walk a political razor’s edge. They are trying to carefully build the political will and public consciousness to gradually reform the social order without being so conspicuous that they endanger their jobs, their freedom, or their lives.

Strategies for change. Given this tense situation, it did not take me long to figure out why I had been invited to Iran. Key persons within the Department of Health Education were long familiar with my work. They had translated my handbooks Where There Is No Doctor and Helping Health Workers Learn. They had studied our recent diatribe, Questioning the Solution: the Politics of Primary Health Care and Child Survival. Though we had friend" and said I had been their teacher. They are pragmatic idealists, eager to put the equity-building, community-based strategies of these books into practice. But, at the same time they are wisely aware of the risks. Strategically it was safer that I, as WHO-sponsored consultant, be the one to introduce this potentially revolutionary methodology. As an international consultant, I could make my “subversive” recommendations, which they could then implement with less risk.

The more I got to know the leaders of Iran’s Department of Health Education, the more I admired their insight, wisdom and courage.

The Competing Political Forces in Iran

A root cause of the health situation in Iran lies in the political standoff between competing centers of power. There are 3 political groups vying for leadership. In order of relative strength, these are:

1. The political arm of the fundamentalist Islamic sect, headed by the inner circle of ayatollahs (high priests), who maintain a rigid hierarchy of religious law and power;

2. the formal, elected government, headed by the President and National Parliment, which is trying to modernize the nation and adapt it to the global free-market economy; and

3. a motley, largely unorganized groundswell of elders, academics, students, and concerned citizens who share the vision of an equitable, compassionate and sustainable society.

In spite of the fact the official government is run by the elected President and Parliment, the clerical power structure under the Ayatollahs has the real power and final say over social and political decision-making. This is because under the peculiar constitution left in place by the Ayatollah Khomeini’s Islamic Revolution (which overthrew the US-supported Shah in 1979), decisive power lies with the unelected clerical establishment, now headed by the supreme leader Ayatollah Ali Khamenei. It controls the courts, the military, the religious police, and the heavy-handed intelligence services, as well as a good deal of the national wealth. It has used its arbitrary power to shut down pro-reform newspapers and imprison outspoken advocates of political change. There is little the formal government can do to mollify such tyranny.

Although the official, elected government has relatively strong popular support, it is in fact only a little more representative of the people than is the undemocratic clerical power base. The current president, Mohammad Khatami—though he won 77% of the vote in this June’s election—represents elite business interests that are courting transnational corporations. He and his Parliament are bent on following a model of development similar to that pushed by the World Bank, to make the rich richer in the hopes—however unrealistic—that “the rising tide will lift all boats.” (In most other countries that have pursued this model, more has trickled up than has trickled down.)

The third significant political group—which is of necessity a loose underground movement—is aligned neither to the fundamentalists nor the official government. Rather it consists of progressives and idealists, young and old, who are cautiously working to build a truly democratic society that is founded on respect for the rights, basic needs, and dignity of all people. Many involved in this movement are devotees of the Islamic faith. Yet they are critical of the oppressive hierarchy of the clergy. Some of them refer to their spiritually-based efforts for social change as the “Islamic Theology of Liberation.” Like the liberation theologians within the Catholic Church, they use passages from the holy scriptures (in this case, the Koran) to substantiate their commitment to building a fairer, more compassionate, and more equitable society.

It is in this “Islamic Theology of Liberation”—or call it a spiritual groundswell for social justice—that I place my hopes for a healthier social climate in Iran. In talking with a wide range of people, I got the feeling that many Iranians long for liberation from the self-aggrandizing power structures, whether clerical or profiteering, and whether internal or foreign. People want more voice in the decisions that shape their lives. They have a deep dedication to living in peace, in the spirit of respecting one another, of compassionately helping those in need (a basic thesis in the Koran), and of generously sharing the goodness that the earth provides.

 

The future health of Iran, I believe, will depend less on health services or economic growth than on health promotion in the largest sense. As elsewhere, it will depend on gradually building a fairer and more equitable society. Recognizing this under lying need, the Ministry of Health, which is to a large extent decentralized at the provincial level, has taken a number of innovative steps to encourage a cooperative participatory approach to problem-solving at the community level.

Coming from a relatively young and culturally less-developed nation (the United States), what impressed me deeply about Iran is its long and vital history. I felt a kind of filial affinity towards its rugged yet lyrical people, seasoned in a culture charged with beauty, symbolism, spirituality and art, conserved and transformed through the ages. There is wealth of harmony and wisdom to draw on.

Also I was deeply moved by the warm and friendly welcome I received by Iranians everywhere I went. I especially appreciated their goodwill in view of the fact that the United States government has been hostile to Iran ever since the overthrow of the Shah in 1978. Washington has had no formal diplomatic relations with the Iranian government since the taking of hostages in the US Embassy. (To get into Iran I had to travel on a UN passport.) Although most Iranians are strongly critical of the US “might is right” foreign policy, they realize that many Americans are either opposed to those policies or unaware of their cruel impact. Therefore Iranians do not judge the visitor by his government, but welcome him as a fellow human being and potential friend.

I hope that we Americans can be equally gracious and understanding, in these troubled times.

‘Health Scouts’ in the Schools of Isfahan

Throughout Iran there are separate schools for boys and girls. Only at university level has an element of integration begun to be introduced. The Health Ministry recognizes the importance of reaching and mobilizing young people. During my visit to Isfahan Province, we visited a girl’s primary school to observe the Participatory Health Education Program. The key actors in this program are Health Scouts. The health scouts are children from 2nd through 5th grades who take responsibility for teaching and monitoring different health-related concerns with their fellow pupils. The 4 categories of health scouts are:

1. health educators,

7. nutritional health scouts,

8. environmental health scouts, and

9. classroom health scouts.

The health scouts are taught and monitored by a teacher specially trained in health education. This teacher is in charge of the school’s “Health Room,” which is equipped with a variety of health education materials as well as materials for recording children’s height and weight, and for keeping records on each child’s overall health and particular problems. Each health scout performs her duties for 4 months; then another child is trained and takes over the responsibility.

The school we visited had about 600 girls. We met with the four current Health Scouts. Over their school uniforms, the girls wore sashes of different colors, each according to her scout category. With confidence and clarity, each scout explained her distinct responsibilities.

The Health Education Scout explained how she advised her schoolmates on questions of cleanliness. This included, information about how germs and infections are spread, the importance of not using someone else’s toothbrush or towel, and danger signs for which the children should seek skilled medical help.

 

The Nutrition Scout gave her classmates advice about healthy foods. She warned them that eating a lot of sweets can damage the teeth. She recommended milk products because they strengthen the teeth and bones.

The Environmental Health Scout explained how she periodically checks the condition of the bathrooms and dining area. She advises her classmates about keeping their school grounds clean and instructs them to throw garbage in the trash containers. Holding up a poster saying “My city is my home!” she stressed the importance of cleanliness and sanitation in the home and neighborhood. She also encouraged protecting natural resources, concluding: “All things are gifts from God.”

 

The Classroom Health Scout explained how she teaches her classmates about health practices and habits. She showed us a simple first-aid kit she uses to attend minor injuries, and explained that she refers more serious problems to the Health Teacher. Every day the Classroom Health Scout checks the cleanliness of her classmates hands and teeth. Once a week, she helps the Health Teacher in an activity where all children brush their teeth with a fluoride liquid to prevent decay. She also teaches her classmates the importance of cutting—but not biting—their nails. (The health teacher explained to us that a great many of the girls chew their nails. She interpreted this as one of the many signs of anxiety common among school children.)

What impressed me most about the Health Scouts was the sensitivity, camaraderie, and spirit of equality with which most of them related to their classmates. For example, the Classroom Scout explained that when she found a child who chewed her nails or had dirty teeth, she made a point of speaking about this gently with the child, and never publicly. That the program had succeeded in awakening in the children such a spirit of thoughtfulness and caring was to me an important measure of its worth.

But what struck me as most wondrous of all was the big-hearted nature of the Nutrition Scout. A small dark girl with big questioning eyes, she had noticed that some of her classmates were overweight, while others were very thin. Often the overweight girls brought to school all kinds of tasty foods and snacks from their homes. Also they would bring money to buy goodies for the school shop. The thin girls brought nothing. So the Nutrition Scout began to encourage the well-fed girls to share some of their foods and snacks with the children who had very little. “By sharing,” she insisted, “everyone will be healthier.”

What a marvelous view! What a wonderful way to promote both individual and societal health! If the people and policy makers of Iran—and the world—could learn about health promotion and equity from this little girl, what a healthy nation and world we could achieve!