How Cholera Transformed Iran: Interview with Author Amir Afkhami




[aesop_content color=”#ffffff” background=”#333333″ columns=”1″ position=”none” imgrepeat=”no-repeat” disable_bgshading=”off” floaterposition=”left” floaterdirection=”up” revealfx=”inplaceslow” overlay_revealfx=”inplaceslow” aesop-generator-content=”Few diseases have killed so many and so randomly throughout history as has cholera. While mostly –though not entirely — dealt with throughout the world these days, the study of how and why it spread so easily in the past contributes a great deal to our understanding today of the medical and public health issues. In the recently published “A Modern Contagion, Imperialism and Public Health in Iran’s Age of Cholera,” Amir A. Afkhami, an associate professor of Psychiatry, Global Health, and History at George Washington University, takes readers back to the early 19th century, when cholera first hit Iran hard. Kayhan Life spoke to him about the book, its social, political, religious, and health lessons and why those are relevant nowadays.

“]Few diseases have killed so many and so randomly throughout history as has cholera. While mostly –though not entirely — dealt with throughout the world these days, the study of how and why it spread so easily in the past contributes a great deal to our understanding today of the medical and public health issues. In the recently published “A Modern Contagion, Imperialism and Public Health in Iran’s Age of Cholera,” Amir A. Afkhami, an associate professor of Psychiatry, Global Health, and History at George Washington University, takes readers back to the early 19th century, when cholera first hit Iran hard.

Kayhan Life spoke to him about the book, its social, political, religious, and health lessons and why those are relevant nowadays.


Q: Why did you write this book?

Amir Afkhami.

A: I wanted to rectify an important deficit in the historiography of medicine, public health, and Iran, with profound implications for the current sociopolitical and public health challenges faced by Iran, the broader the Middle East, and the Islamic world, by showing pandemic cholera’s seminal role in the emergence and development of modernity in Iran. And how cholera transformed the country’s institutions, governance, and perspectives on medicine, disease, and public health.

Q: Cholera is not a major concern in Iran, Asia or the Middle East anymore. The focus seems to have shifted to Africa. Why should an average person care about this? And are there lessons to be learned nowadays when much of Iran is suffering from flood waters?

A: Cholera continues to be an enormous problem in the Middle East, particularly in conflict zones. Currently, Yemen is in the midst of a cholera epidemic and two years ago suffered the world’s largest cholera outbreak, with more than 1 million cases. However, the story of Iran’s encounter with pandemic cholera has broader implications than just one disease. The book sheds light on the social and historical factors that have contributed to the vulnerabilities of Iranians and Middle Easterners as a whole to both communicable and non-communicable diseases alike.

“A Modern Contagion” challenges long-held historical assumptions on the universal role of safe water and sanitation in ending the recurrence and severity of cholera by showing how Iran brought an end to large scale outbreaks of the disease without fundamental improvements in its population’s access to underground piped drinking water and sewage systems.

Iran began to turn the tide against pandemic cholera in tandem with reforms in the country’s social and economic policies that began after the 1905 Constitutional Revolution and matured under Pahlavi rule after 1925, particularly with the institution of national vaccination programs.

Changes in the country’s institutional, religious, and social attitudes, driven by the Qajar elite, transformed broader societal perspectives on medicine, disease, and public health, which allowed Iranians to intervene effectively to stop the ingress of cholera and other infectious diseases after the First World War. Essentially, the book shows how an emerging scientific culture and good governance turned the tide against cholera in Iran. This has profound implications for Iran today, which continues to struggle with major deficits in governance ranging from financial mismanagement to poor environmental policies and the lack of rule of law.

Iran’s successful multifaceted struggle against Asiatic cholera holds the key to turning the tide in Yemen’s current cholera epidemic, where best practice approaches (i.e. sanitation versus vaccination) are still debated on the international stage. The same lessons apply to the current flood-related humanitarian emergency in Iran; namely that good governance ultimately holds the key to reducing the impact of both the disaster and potential secondary effects such as water-borne illnesses just as good governance ultimately turned the tide against pandemic cholera.

Q: The sub-headline of the book is “Imperialism and the Public Health in Iran’s age of Cholera.” You refer in the book to the role of commercial interests of the British empire and shipping good from India through the Persian Gulf. But are you accusing the British empire (and Russia) of having deliberately turned a blind eye to the disease in favor of commerce and strategic gains in the region?

A: Russian and British rivalry for dominance in Asia at the cusp of the 20th century, known as the “Great Game,” often extended to using their respective authority over quarantine stations and mandated sanitary interventions in Iran to advance their own political, military, and economic goals in the region at the expense of Iranian public health.

It is not that Russia and Britain “turned a blind eye” to the disease as much as that their own strategic interests took precedence over stopping the disease from reaching Iran. This included British antipathy towards any restriction over its maritime commerce from India, where pandemic cholera often originated, and the Russian use of overland quarantines to divert trade, collect intelligence, and enhance its political prestige.

These activities hindered efforts to stop the ingress of cholera and other pandemic diseases despite advances in the science of bacteriology at the time. Iran’s failure to shape an independent sanitary course prolonged its susceptibility to pandemic outbreaks that continued to decimate its population and its economy, despite Tehran’s growing sanitary knowhow and medical manpower.

Q: You make reference in the book to the Shiite culture of Iran, and its associated traditions and behavioral patterns, as a factor – even to this day –  contributing to the spread of cholera. Could you explain that briefly?

A: Religious-cultural norms of water purity such as the Islamic belief that running water or stagnant water of a religiously-sanctioned volume (ab-i kur) could not be defiled magnified the impact of cholera in Iran. Because of this, Iranians sometimes performed religiously mandated washing of cadavers in the same rivers and streams that they used to obtain drinking water and then buried their dead near the same potable sources. These enduring behaviors in the Qajar period were extraordinary multipliers of a water-borne disease like cholera.

Traditions linked to Shi‘ite sectarian identity, such as devotional visits to shrine cities and the practice of seeking to be buried at the holy sites by the predominantly Shi‘ite Iranian Muslims also increased cholera’s dissemination and virulence. Iranians often hired caravans to carry both the living and the dead to these venerated locations, which included Najaf, Karbala, Baghdad, and Samarra in the Ottoman Empire and Mashhad in Iran. The poorly wrapped cadavers ofcholera victims often continued to disseminate the disease, prolonging and expanding the reach of pandemic cholera waves in the country during the Qajar period.

Finally, the disease often entered Iran by way of Shi‘ite pilgrims from the Indian subcontinent or Iranians returning from shrines in the Ottoman Empire. Similarly, a significant number of cholera cases in Iran today come from neighboring Iraq, Pakistan, and Afghanistan across the same pilgrimage routes.

Q: Also related to the Shiite culture of the country, you make repeated references to how the clerical leadership played politics with the ruling regimes and how that impacted the (lack of) effectiveness in dealing with cholera. Could you summarize your conclusions?

A: The almost complete absence of civic leadership during the cholera outbreaks permitted local forces to subvert the central government’s authority, revealing the country’s deteriorating state of governance, particularly in the last decade of the nineteenth century and the years leading up to the 1906 Constitutional Revolution.

Shi‘ite clerical leaders were particularly effective in mobilizing popular discontent in the wake of the epidemics and cementing their role as leaders against Western encroachment and government exploitation at that time. They exploited tensions along Iran’s religious and economic divides and mobilized widespread discontent against the government’s ineptitude and Western commercial interests to achieve their own economic and political goals. The disturbances that followed the epidemics of 1889-1892, including the clerically-led Tobacco Protest, harmed Iran’s economy, political stability, and hindered necessary investments in the country’s sanitary infrastructure. Similar challenges against the government’s public health policies by high ranking clerics, such as the public condemnation of quarantines and other restrictive interventions during the 1904 outbreak, not only helped spread the outbreak but also magnified casualties in Iran.

Q: You point out in the book how the society’s attitude changes from “acts of Gods” to microbiology helped combat cholera in Iran. Was that shift in attitudes unique to Iran, or even Asia, or was it a universal phenomenon, just part of world evolution, if you’d like?

A: The acceptance of the germ theory of disease was neither universal nor a smooth one. In the Western context, for example, the germ theory supplanted the predominantly secular miasmatic theory of disease transmission which posited that diseases were the product of environmental factors such as contaminated water, foul air, and poor hygienic conditions.

Local cultural and political contexts played an important role in how germs were characterized and how rapidly this view of disease causation was accepted. However, with few exceptions, the germ theory of diseases became ascendant around the world in the 20th century and became the theoretical underpinning of infectious disease epidemiology, the development and use of anti-microbial drugs, and furthered the use of vaccines and public sanitation for infection control.

Q: Just as with the Shah himself, the Iranian leadership going back to the 1800s seemed to have had more trust in the French medical establishment than in any other country’s – say, British, Russian, Belgian, or German. Was that purely for colonial reasons or was there a good medical reason behind it?

A: For most of the Qajar period, it was customary for the shah’s principal non-Iranian physician to be a Frenchman; at least since the time of Drs. Labat and Louis André Ernest Cloquet, who were physicians to Muhammad Shah Qajar in the 1840s. The French felt that these appointments reflected their prestige and political influence in Iran. In the 1900s President Emil Loubet of France personally intervened to have Muzaffar al-Din Shah issue an edict appointing the French Jean-Etienne Justin Schneider as his chief physician in place of his English doctor, Hugh Adcock. So the preponderance of French physicians in Royal Qajar service was principally driven by politics. The French government saw these physicians as an important arm of their diplomacy in Iran. They subsidized their salaries,pensions, and would often award them with the Légion d’Honneur for their political service.

Mohammad Reza Shah’s preference for French doctors to treat his cancer is another matter. In the earlier part of his reign, he had sought treatment from physicians at New York Hospital-Weill Cornell and his appendectomy surgery was performed, in Tehran, by the chief of surgery at New York Hospital. In a recent article in the Washington Post, I argue that the Shah’s break with the American medical establishment was driven more by worries about confidentiality.


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Q: You end the book by shifting the focus to drug addictions, narcotics, and HIV/AIDS. Is there a medical correlation with cholera or are you trying to just use societal and political reaction to cholera as a red flag against what you refer to as “religious barriers to prevention” and “illiberal approach to the current social, economic, and political” crises of the country?

A: Both epidemics are fueled by similar geographic, social, political determinants: Iran’s common border with Afghanistan, the world’s largest opium producer, has made the drug and its derivatives readily and cheaply available to consumers just as Iran’s shared border with India, the endemic home of cholera, made it vulnerable to regular invasions by the pandemic over a century ago. Iran’s counternarcotic efforts are paralyzed by the same type of corruption, rigid

ideologies, and turf wars in the government and security apparatus that hindered Tehran’s ability to stop the spread of cholera. An on-again, off-again draconian and religiously inspired punitive and unscientific approach using imprisonments and executions have only doubled the population of addicts in the last 7-8 years much as religious beliefs in water purity worsened the cholera epidemics. Just as Iran’s diplomatic missteps with European imperial powers worsened its vulnerability to cholera, its current decades-old hostility towards the United States and its interventionist policies in the region has deprived Tehran of critical intelligence and coordinated cross-border police action that could reduce the flow of narcotics across its frontiers. Ultimately, I believe that good governance and a scientific approach to the problem of narcotics will turn the tide against this most recent epidemic, much as it did in turning the tide against cholera as described in my book.


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