As Coronavirus Spreads, Iranian Doctors Fear the Worst

Iran is often described as an isolated country, but the spread of the coronavirus has made clear that the Islamic Republic is less isolated than often assumed. Iran’s significant trade links with China, where COVID-19 originated, left the country vulnerable to the spread of the virus.

The outbreak in Iran is one of the world’s largest, with more than 2,300 confirmed cases and 77 declared deaths. Many of the first cases registered in other places—including Iraq, Lebanon, Georgia, Qatar, New Zealand, and even New York—are attributable to individuals who had traveled from Iran. Clearly, notwithstanding the attempts of U.S. President Donald Trump’s administration to isolate Iran politically and economically, Iran remains connected to the world. It follows that Iran’s success or failure to manage its coronavirus outbreak will directly impact the threat of a pandemic.

The combination of Iran’s physical interconnectivity and its relative political and economic isolation pose unprecedented challenges for international public health. The first two weeks of Iran’s coronavirus outbreak have been similar to those in other countries. Authorities were slow to take measures such as closing of schools and universities and canceling of public gatherings, including briefings and government meetings that contributed to the infection of numerous officials.

As the severity of the crisis became clearer, members of the public became anxious, adding to the strain on Iran’s health care system. People rushed to pharmacies and stores to purchase supplies. They rushed to hospital emergency rooms worried that a persistent cough could be COVID-19.

The combination of Iran’s physical interconnectivity and its relative political and economic isolation pose unprecedented challenges for international public health.

These are understandable reactions and are always preferable to indifference—any successful public-health campaign requires individual members of the public to take responsibility and proactive action. But as the number of confirmed cases mounted, so too did demand for respiratory masks and contamination suits, symptom relief medication, and immunity-boosting vitamins, as well as disinfectants, detergents, and related hygiene equipment.

Given its sophisticated manufacturing base, Iran produces many of these products domestically, limiting the initial impact of sanctions on the availability of medicine and equipment. However, inventories in pharmacies and shops are running low. Importers are struggling to get their hands on new inventory and factories are struggling to ramp up local production to keep up with the rising demand. U.S. sanctions are largely to blame for these disruptions.

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The Iranian companies producing medicine, disinfectants, and protective clothing also have a supply-chain problem; they are dependent on imported ingredients and materials. For example, even though antiviral drugs are manufactured in Iran, the raw materials are almost entirely supplied from China and India. Should Iranian manufacturers run out of these raw materials, it will be very difficult, if not impossible, to effectively contain and treat COVID-19 in Iran. U.S. sanctions are constraining the supply of raw materials and imported goods in two ways.

First, there is the issue of transport links. Even before the outbreak of the virus, the Trump administration’s reimposition of secondary sanctions on Iran in November 2018 saw many airlines and international shipping companies end their presence in the Iranian market. As a result, for a country of its size, Iran is unusually reliant on regional hubs for both air travel and freight forwarding.

As neighbors impose travel restrictions, Iran is facing difficulties in sustaining imports, particularly for time-sensitive deliveries by air. The World Health Organization recently faced delays in supplying Iran with coronavirus testing kits “due to flight restrictions” that prevented their dispatch from the United Arab Emirates.

The kits were eventually delivered via a commercial flight from Baghdad, but that route may also be closed as Iraq as now announced its first confirmed cases of the virus. A subsequent delivery of equipment did arrive in Tehran from Dubai—but only after the Emirati government arranged a military transport at the request of the World Health Organization.

Second, even if a viable means of delivery can be found, it has been well documented how U.S. secondary sanctions have restricted humanitarian trade with Iran by scaring off most banks from facilitating the necessary payments. The imports that do take place—from major suppliers such as Germany, Switzerland, and China—reflect long-standing business relationships in which the foreign exporter and Iranian importer have put the facilitating bank (usually a small merchant bank) at ease by preparing extensive compliance documentation.

The fact that humanitarian trade is currently conducted in this manner—a slow, inflexible process—makes it inherently difficult for Iranian entities, particularly governmental entities such as the Ministry of Health and Medical Education, to quickly identify new suppliers and purchase the required goods during a public health crisis. Moreover, sanctions have both weakened Iran’s currency and made it difficult for Iran to access its foreign exchange reserves, further adding to the time and cost of any emergency purchases.

Medical professionals in Iran are seeing the early signs of shortages. They are calling the Iranian vendors of respiratory masks, surgical gowns, and ventilators only to hear that the goods are out of stock. They are struggling to get antiviral medication even to those patients exhibiting the most acute symptoms.

While much of the global attention towards Iran’s response to coronavirus has focused on the question of whether or not the Iranian government has adequately managed the outbreak, there is a far more urgent concern among Iran’s doctors. If Iranian pharmaceutical companies and medical equipment manufacturers are unable to establish speedy and reliable means to import raw materials, the country could soon face a humanitarian catastrophe.

The Trump administration has made an offer of humanitarian assistance to Iran—but has provided no detail. To address the impact of sanctions on Iran’s ability to import and manufacture key items, it would be straightforward for the administration to provide greater legal clarity to exporters and the banks on which they rely—for example by expanding the definition of “humanitarian” goods so as to include items needed to fight COVID-19, such as respiratory masks and disinfection equipment, as well as raw materials, within the scope of existing general licenses.

Given that it is unlikely that the United States will take any such steps, it is commendable that the governments of France, Germany, and the United Kingdom have dispatched “equipment for laboratory tests as well as… protective body suits and gloves” to Iran. They will also be providing “urgent additional financial support close to €5 million to fight the COVID-19 epidemic affecting Iran, through the WHO or other UN agencies.” But these are stopgap measures.

To address the vulnerabilities of Iran’s domestic medical and medical equipment manufacturers, European governments could utilize the Instrument in Support of Trade Exchanges (Instex) trade mechanism, which was established to ease humanitarian trade between Europe and Iran by creating a standard compliance protocol and by eliminating the need for European banks to receive payments directly from Iranian banks.

The company, which boasts nine European states among its shareholders, has yet to make its first transaction. Nonetheless, policymakers are adamant that the company is nearly operational. Aiding Iran in its fight against coronavirus could provide Instex a renewed sense of purpose.

Of course, Western governments are increasingly preoccupied with their own coronavirus outbreaks, and further assistance may be difficult to coordinate. The Iranian health care system and the companies that supply the nation’s hospitals will continue to fight coronavirus without all the resources they need—a situation that has drawn parallels to the country’s experience during the Iran-Iraq War.

Nevertheless, Iran’s experience with COVID-19 offers a cautionary tale about the intersection of sanctions policy and international public health. The economic vulnerabilities that sanctioning countries seek to create in target countries never exist in true isolation. Just as a virus will attack the most vulnerable members of any given population, the coronavirus is now attacking the global health system at its most vulnerable points—before spreading everywhere else.