For the sick, it doesn’t matter whether sanctions or government mismanagement is more to blame for the dire state of Iran’s health service. A doctor-in-training gives us an inside look

I left Iran at a young age and have always enjoyed going back to visit family, relive childhood memories and learn about the challenges of life there. Growing up abroad, I decided to become a doctor, and between my studies and applying for a job, I decided to take up an opportunity in late 2015 to shadow one of Iran’s most renowned neurosurgeons.



I had opted for neurosurgery even before I started medical school, partly because someone close to me had suffered from a brain tumour. The uncertain outcomes, the fear, the emotional and physical pain that both the patient and those around them must endure are hard to describe.

Neurosurgery is a speciality where the surgeon cannot just focus on treating the disease. The surgeon has also to attempt to preserve the patient’s identity, the most important characteristic of our existence.

One of the difficult aspects of the job is to prepare the family for what is to come and to discuss what kind of life is worth living. This is not just a matter of sickness and health, life or death. Are we, for example, willing to a sacrifice a young girl’s speech and language to gain a few years of life?

Neurosurgery not only calls for excellence in emotional and physical capabilities, but for a deep sense of moral values. This is what attracted me to the specialty years ago, long before I ever thought it would help take me back to Iran.

By the time Iran’s nuclear agreement with world powers was reached in July 2015, supposedly clearing the way for the easing of sanctions, there had been years of reports of Iranian patients dying from curable diseases for want of life-saving medical supplies. Although trade in medicine was not formally blocked by international sanctions, it was near impossible for importers to pay for the required supplies as western banks shunned any contact with Iran.

On my first visit to a hospital in Tehran in December, I was struck by an emotional intensity. In the UK, trainees spend hours practising “breaking bad news” while expressions of emotion are reserved for special side rooms. In Iran, news is openly shared and discussed whenever and wherever possible, by doctors and families alike.

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As I made my way through the hospital, there was a relieved, ecstatic father wandering around offering pastries to one and all, praising God as he informed everyone his young boy had been cured. On the opposite side of the corridor, an elderly woman sat on the floor with her hands raised, praying. Judging by her pillow, one could only guess how long she had been there.

The relieved father knelt by her side: “It will be okay. God is great, He is looking after all of us. They had told me to give up on my son but they were wrong. Here, have something sweet. It will bring you good fortune.”

“If it were only that simple,” I thought to myself.

When I found the surgical theatres and introduced myself, I was ushered into the surgeons’ lounge and told to have breakfast as I awaited the arrival of my consultant, Dr A.

While I was served fresh Iranian bread and tea, I eavesdropped on a conversation across the table between two surgeons. The younger one was complaining that insurance companies were refusing to pay him for plastic reconstructive surgeries, which most patients could not afford privately.

“I can’t leave them to die,” he lamented. “I perform the operations as I have a duty to save my patients, but I haven’t been paid properly for months. I don’t know what to do anymore.”

At this point, Dr A arrived. The lounge went quiet and everyone rose from their seats to greet him. He was in his early 70s and wearing a tie, a piece of clothing frowned upon by the government as western. I could almost see and sense the decades of experience and wealth of knowledge in his eyes and demeanour. He asked me to get changed into scrubs and meet him downstairs in the operating theatre.

The first case was a 27-year old woman who had come in for a minimally invasive procedure. This involved sending a camera-like device through her nasal passage to repair a leak from the space above her nose, known as the sphenoid sinus. She was suffering from a malignant, incurable tumour of the sphenoidal sinus and had undergone a previous surgery to remove part of the tumour in her brain. But it had not taken long for the tumour to spread.

This new surgery was not meant to cure her, but only improve her quality of life during the limited time she had left. Part of the procedure to repair the leak would involve sealing the area with a ‘dural patch’, which is made to resemble the thick covering that envelopes the brain.

When, during the operation, Dr A located the leak, he asked one of the nurses to get him a specific kind of patch, one I knew provided a better seal than others available. The nurse reminded him that they had only three of these patches left and that the patient would have to pay for it herself; she suggested a cheaper alternative might be more suitable as the patient was not going to live much longer.

“Never mind that,” Dr A replied. “She is only 27 and deserves the best care we can give her. I don’t want her to live the next few months with brain fluid dripping from her nose.” He then turned to me and whispered that if the patient could not afford it, the cost would be deducted from his own salary.

During lunch I sat next to a young trainee surgeon, Amir, who proposed I meet him at the hospital the next day at five in the morning as he wanted to show me something. Like others mentioned in this article, his name has been changed to protect his identity. Amir was hoping to become an orthopaedic surgeon and had just taken the relevant exams. “To get into specialty training, you don’t just need the knowledge,” he said. “You need to also pass their background check, to make sure you are morally decent. Bet you don’t have to worry about these things in England.”

The following day Amir drove me to a nearby pharmacy. He explained that all the people queuing outside were seeking chemotherapy drugs, hoping they would get first option if they arrived today. He then took me to a booming medical bazaar where black-market prices had soared over recent years.

Many of the drugs had been smuggled, he said, and their authenticity was often questionable. Amir explained that Iran could make most generic medicines due to its decent domestic drug industry, but that it relied heavily on importing specialist medicines, such as chemotherapy drugs, and often could not offer a suitable alternative.

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On the way back to the hospital Amir told me more about the relationship between the government and the medical profession: “They have tried to target corruption in the healthcare system, which sounds like a good thing. But instead of acknowledging the way mismanagement and sanctions have pushed prices up, they have led the public to believe the doctors are the greedy ones trying to fill their pockets with money. That has damaged the doctor-patient relationship. Some patients don’t trust us and look at us with contempt. And this has led to a decrease in our income, as some patients and insurance companies refuse to pay the full amount for procedures or outpatient appointments. Sometimes they just don’t pay at all. I can barely afford to pay my rent anymore.”

Amir had great admiration for Dr A. “He has a sign in his clinic that reads ‘Pay whatever you can’ for people who don’t even have national insurance. He does a free clinic once a week for anyone from across the country. He was desperately wanted by world-renowned institutions, but he never left the country and wanted to serve his people. That’s also why he refuses to retire. Yet, people are still sceptical even about him. How is this all fair?”

He blew in the air as he parked the car.

As we walked into the hospital, I asked Amir what he thought of the nuclear agreement. “The sanctions have gone in the media,” he replied. “Nothing has changed for people, just take a look around.”

He then explained to me that sanctions were not a simple issue, since some Iranians had exploited them for their own benefit. A few years ago, a group of surgeons decided to boycott a medical device as the European company supplying it was exploiting a monopoly position in Iran to double the price. The surgeons were successful in forcing the company to bring down their prices to what they were charging in other countries.

But a few months later, a group from the department of health decided to take over the distribution and supply. Within weeks, the device doubled in price.

The final day of my time in Iran will live long in my memory. Roxanna was a ten-year-old girl referred to Dr A following the discovery of a malignant tumour near a part of the brain responsible for generating speech, known as Broca’s area. On the morning of the surgery, I accompanied Dr A as he went to check on Roxanna prior to the operation. She was wearing a pink Disney shirt and reading a book on her tablet as her mother sat by her bed, stroking her hair.

“How much longer do I have to wait, uncle?” she asked with a smile as we walked in.

“Not long, my dear,” Dr replied. “We are going to take you to theatre very soon.”

“Will it hurt, uncle?” she asked nervously.

“Not at all,” he smiled before signalling me to follow him for a private discussion.

“I cannot excise much of the tumour since we would risk affecting her speech,” Dr A told me. “So I will have to remove as much as I can and she will then have to have additional treatment, possibly radiotherapy.”

His tone changed as he pulled out a cigarette and continued. “I do not advertise my paediatric sub-speciality as I frankly cannot deal with it anymore. During clinics when I see children suffering from brain tumours, I run out to cry sometimes, as I’m almost certain these children will not be able to get the treatment they need. And this poor girl, her family, have no idea what awaits her. I smoke to calm myself down, it is all I can do now.”

For such a prominent figure and mentor to suddenly share such despair and hopelessness made me grasp the situation the Iranian medical system has reached. For children like Roxanna, it does not matter whether it is sanctions or government mismanagement that is more to blame.

When I think of the medical environment in Iran, I cannot help but draw parallels with junior doctors in Britain who have been considering a full-walkout for the first time in the history of the National Health Service as they face a stand-off over new contracts they believe endanger patient safety. In Iran, doctors not only struggle from the failure or inability of the government to provide support, but they also have to fight against the indifference – even callousness – of a world that has turned its back on the consequences of sanctions.

Yet these doctors have striven against all odds to protect the health of their patients. An excerpt from the Hippocratic Oath, which is recognised by medical institutions and doctors everywhere, best describes the commitment of those I had the honour of spending time with in Tehran.

“I will apply, for the benefit of the sick, all measures which are required. I will remember that I remain a member of society, with special obligations to all my fellow human beings.”

The Tehran Bureau is an independent media organisation, hosted by the Guardian. Contact us @tehranbureau