Iran has been suffering from the spread of coronavirus for two months, during which the country has become one of the major global epicentres of the epidemic and an important stop for its regional spread. After 10 days of its spread, the virus became the main focus of the activity of the Iranian government and state institutions, particularly the health sector that, after the spread of the disease, has become the main centre of the work of the government and official institutions. The Iranian president underlined that combating the epidemic occupies all the government’s energy and constitutes the only focus of its meetings.
Iranian official institutions have sought to take several steps to counter the epidemic and prevent its spread based on the capacity of the health sector and crisis management strategies. These steps have witnessed several developments during the last few weeks, all of which demonstrate the attempt at finalizing the crisis management strategy and its maturation. They also demonstrate the existence of discrepancies between the various official institutions that have prevented the performance of a decisive role in controlling the disease and preventing its spread.
Development in the number of infections and contradicting stories
Government bodies have provided daily figures on the numbers of infections and deaths in an attempt to prove transparency and credibility after having been accused by several quarters of attempting to hide the reality of the disease spread. Within this framework, government sources have announced that the number of infections as of 25 March is 27,017, while deaths from the virus reached nearly 2,077. This means that the daily infection rate has stabilized at 795 cases while the daily death rate has stabilized at 61 cases.
Yet these official figures do not represent the reality according to different sources. While the Middle East Emergency Director at the World Health Organization (WHO) has confirmed that scientific estimates indicate that the weakest points in the Iranian programme for combatting coronavirus lie in the inadequate information on the infected people, indicating that the realistic figures of infected people and victims could be five times those published by government sources, parliamentary sources have supported this opinion. The deputy speaker of the Iranian parliament and the minister of health in the Khatami government Masoud Pezeshkian indicated that the government figures regarding infected people cannot be realistic and that hospitals are full of infected people, while the member of parliament for the city of Qom has indicated that the number of victims in the city of Qom itself is five times the number announced by the government. Afterwards, the member of parliament for the city of Rasht has described government figures of the number of infected people as a joke, underlining that the real figures may be four times the ones announced by the government.
These figures, confirmed by those announced by government sources from time to time, correspond to the ones mentioned in scientific and critical expectations and studies published by independent newspapers which confirm that the figures announced by the government are not proportional with the scientific logic for the spread of epidemics and that the total figures published by health sources confirm numbers of infected people that exceed those published daily by the government.
The difference in official figures could be attributable to a number of reasons, not limited to the official attempt to mislead public opinion. The main reasons were referred to in the remarks made by the WHO Middle East emergency director who announced that the main reason for this lies in the shortage of capabilities which makes the analyses to confirm the infection limited to those who suffer from advanced stages of the disease. This corresponds with what has been confirmed by sources that many people have died because of the disease without detecting their infection with the virus due to the shortage of capabilities.
The difference between the government and other institutions was not limited to the numbers of infections and deaths. It has also included the capacity of Iranian hospitals. Iranian president Hassan Rouhani had announced that Iran is not suffering from a hospital crisis, underlining that nearly 60 percent of hospital beds in the city of Mashhad are vacant and that many Iranian cities have a surplus of specialized and intensive care beds. On 26 March, Rouhani again announced that there is no shortage of hospital beds in Iran, underlining that there are 20 thousand beds ready to receive patients at Iranian hospitals, including 13 thousand beds in hospitals and 7 thousand stand-by beds to take care of recovered people in the convalescence period.
However, president Rouhani’s opinion contradicts those of members of parliament and members of his government. While the member of parliament for the city of Rasht announced that hospitals in the province of Gilan in northern Iran no longer have any beds to take care of patients, another member in the city of Langarud (in the same province) said that tens of infected people have died in Gilan province because of bed shortages in hospitals that have been full of infected people. The member of parliament for the city of Mashhad announced that city hospitals no longer have vacant beds as of end of March. The governor of Yazd in central Iran underlined that hospitals in the province no longer have any vacant beds due to the rise in the number of infected people. This was also confirmed by the deputy speaker of Iranian parliament who indicated that the number of infected people has exceeded the capacity of hospitals to take care of patients.
The infrastructure of the health sector
The health sector in Iran houses nearly 140,859 beds, distributed over 982 hospitals in different Iranian cities, including 860 public hospitals, 32 women’s hospitals, 38 psychiatric hospitals, 19 children’s hospitals, along with other specialized hospitals.
The public sector hospitals account for 64 percent of the total hospitals with nearly 642 hospitals, while private sector hospitals account for 18 percent (174 hospitals), social security organization hospitals for 8 percent (75 hospitals), military hospitals for 6 percent (57 hospitals) and charity hospitals for 4 percent (38 hospitals).
As far as beds are concerned, public sector hospitals house 97,205 beds (71 percent of total beds), private sector hospitals 17,925 beds (13 percent), social security organization hospitals 11,570 beds (9 percent), armed forces hospitals 5,970 beds (4 percent) and charity hospitals 4,564 beds (3 percent).
In terms of intensive care, while the president of the Critical Care Society has confirmed that the number of intensive care beds in Iran is 7,200, the director-general of hospital administration at the Ministry of Health had announced in August 2019 that the number of beds in this sector is 5,820, including 3,535 beds in government hospitals, 1,100 beds in private sector hospitals and 405 beds in social security organization hospitals.
According to this data, the health system in Iran has one bed per 590 people, and one intensive care bed per 14,260 people (or one bed per 11,530 people based on the figures given by the president of the Critical Care Society).
In terms of human resources, Iran has nearly 130,616 doctors (one doctor per 636 citizens), of which 85,853 are general practitioners (one doctor per 967 citizens) and 44,763 are specialists (one doctor per 1,854 citizens). The health system in Iran employs nearly 160 thousand nurses, according to the secretary-general of the Nursing Syndicate (one nurse per 518 people).
The number of beds allocated by Iran’s health system to people infected with coronavirus is unclear. While figures issued by the government indicate that government hospitals have assigned 10 percent of their beds to people infected with the virus, the percentage is 60 percent as far as intensive care is concerned, according to health sources.
While official figures do not indicate yet an intensification of the crisis in Iranian hospitals so far, because as of 26 March 2020, there were nearly 29 thousand infections, 10 thousand of which have recovered from the disease, which means that the total number of infected people has not exceeded 19 thousand so far, i.e. up to 13.5 percent of the capacity of the disease, two cases are not promising:
a- Considering the worst-case scenario which confirms that the number of infections with the virus is five times the official figures, this means that the number of infections is nearly 95 thousand, or nearly 67 percent of the hospital capacity, which amounts to a real crisis for the health sector. It is not possible to verify whether the number of infections is close to this, yet the positions taken by officials of the health system indicate that the figures exceed the official level announced by the authorities. This is manifested in the hospital overcrowding in different Iranian cities and in the steps taken by the Ministry of Health such as calling retired staff and volunteers to counter the crisis.
b- Even if the official figures announced by the Ministry of Health regarding the number of infections are considered true, according to those figures, the number of infections is doubled every six days. This means that Iran will have nearly 60 thousand infections by mid-April, which in turn accounts for 42.8 percent of Iranian hospital capacity.
Despite official positions aiming at calming the situation and underlining that the Iranian health system and hospitals are not encountering a crisis yet, the overall steps taken by official institutions indicate that they have sensed the danger and are striving to counter it through various steps, as follows:
a- Official institutions have attempted to raise hospital capacity by building field hospitals and resorting to the capacity of military hospitals. While the Iranian army has confirmed placing 60 percent of the capacity of its hospitals in various Iranian cities at the disposal of the committee to combat coronavirus, underlining that 1,600 beds in army hospitals receive corona patients, the Revolutionary Guards have announced that they are working on placing 60 percent of the capacity of 24 hospitals along with 13 of their mobile hospitals at the disposal of the committee. The government has also started to build field hospitals in Qom (50 beds) and Rasht (74 beds) with the help of the armed forces.
b- Regime institutions have sought to build recovery hospitals to accommodate patients after they have received initial treatment in hospitals to ease the pressure. Within this framework, the Iranian army has built a recovery hospital in the capital with a capacity of 2 thousand patients. The commander of the Revolutionary Guards has expressed the Guards’ readiness to add 2-5 thousand beds in recovery hospitals. The Ministry of Health has also shown readiness to provide sports halls with beds to serve as recovery hospitals. That is why Rouhani spoke of the readiness of 4 thousand recovery beds, in addition to preparations for further 20 thousand beds. While some of those figures could be considered part of official propaganda rather than indicating actual readiness, they demonstrate a tendency by the authorities to develop a strategy of isolating treatment from recovery (in addition to underlining home isolation) to provide additional capacity to receive new waves of patients in hospitals.
c- The government and other relevant institutions have taken steps to avoid shortages in medical staff. While the government recalled retirees of the health system to work in hospitals for an additional salary to avoid the problem, the armed forces have sought to call up graduates of medicine and nursing for military service (although the call-up of new conscripts from other disciplines was suspended because of the spread of corona) to dispatch them to afflicted cities, in addition to underlining the role of the Basij forces in social monitoring and field disinfection programmes.
d- The government has allocated new amounts in the budget to counter the disease and support medical staff and the health sector. Within this framework, the government has allocated 530 billion tomans to support the committee to combat coronavirus, 980 billion tomans to support government hospitals, 200 billion tomans to pay for a rise in the salaries of medical staff, 300 billion tomans to contracting companies operating in the health system and paying their debts, and 1,600 billion tomans to social security institutions, bringing the total to 3,610 billion tomans, in addition to a significant portion of one billion dollars that Rouhani had requested from the National Reserve Fund to support the health sector in countering coronavirus.
Strategies of dealing with corona: chaos in managing the crisis and duplication of decision centres
Based on the follow-up of the most important decisions taken by official institutions in dealing with the crisis of the spread of coronavirus, the general framework of those decisions, the initial features of strategies to counter the virus and the shortcomings of those strategies can be viewed as follows:
1. From chaos to crisis: features of joining forces to manage the situation:
At the first stage of countering the disease, official efforts seemed dispersed. Disorganization could be observed in that period (which could be called the “period of chaos”) in the decisions that were taken without being implemented (such as the health monitoring decision with 300 thousand members of the Basij forces, and the decision of social isolation taken by the General Staff of the Armed Forces without being implemented). The number of centres for the provision of information has increased (contradictory figures were issued from local and central quarters). The performance of the government committee to combat the virus has generally been poor, which led to severe parliamentary criticism of the government. Efforts were made to change the composition of the committee to combat coronavirus so that it would be presided over by president Rouhani instead of the Minister of Health, or to change the body mandated with combating the virus, until Khamenei mandated the General Staff of the Armed Forces to supervise national efforts to combat the spread of the virus.
At a second stage, official institutions managed to overcome this chaos and put forward the features of a general strategy to combat the disease. This became possible through the handover of the tasks of the committee to combat the virus to the Iranian president himself, subjecting the efforts of the military committees to government supervision and unifying information channels, which enabled the shift from the stage of chaos to the stage of managing the crisis. Yet this organization remained administrative in nature so far, as it did not have a noticeable effect on the curves of the virus spread on the ground.
2. Duplication of management centres: the foremost challenge
Upon observing the official steps taken by the institutions concerned with combating the virus from the very first day of its spread in Qom city, a state of duplication has characterized the set of decisions taken in this respect, as follows:
a- Since the outbreak of the crisis in Qom city last February, different quarters, including members of parliament, have called for putting the city in quarantine to prevent the spread of the virus. Despite the different efforts, the government refused to impose the quarantine. It was later found out that the imposition of the quarantine was prevented by the Shiite clergy and commanders of the Revolutionary Guards. News leaked of the resignation of the Minister of Health in objection to the prevention of putting the city in quarantine.
b- During the spread of the virus in the northern provinces, parliamentary and press quarters demanded that quarantine be imposed on the two northern provinces, in addition to Qom city, to be followed by a demand that quarantine be imposed on all provinces. Although the government declined these demands owing to the negative effect of the quarantine on the Iranian economy, news reports have later shown that the decision centres which rejected the imposition of the quarantine were not from within the government, but rather the Supreme National Security Council which rejected the quarantine for security reasons, according to the deputy health minister.
c- While the government, through president Rouhani, was underlining the need to continue with everyday life, the governors of 13 provinces out of 31 Iranian provinces took local decisions to restrict public life and movement and imposed quarantine on their provinces. This demonstrates the duplication of decision within government vis-à-vis the quarantine issue.
d- When quarters inside the government, represented by the governor of the central bank Abdolnaser Hemmati, and later on by foreign minister Mohammad Javad Zarif, asked the IMF for a loan of 5 billion dollars, this request was rejected by quarters from inside parliament and from inside the Expediency Discernment Council of the System, alongside quarters in the Revolutionary Guards, which underlined that borrowing from the IMF would constitute a humiliating act that cannot be accepted by the regime.
e- Differences continued between the government and revolutionary institutions on the issue of international assistance. While revolutionary institutions expelled the WHO medical team, and while the Supreme Leader of the revolution rejected western assistance for fear that it might be part of an international conspiracy, the Iranian president announced that the policy of the Iranian government adopts the acceptance of assistance from all quarters wishing to assist Iran.
Regardless of the details, all these developments could be held as manifestations of a deep duplication within the political structures in Iran between government and revolutionary institutions. While the decision by the Iranian Supreme Leader Ali Khamenei to place the committee to combat coronavirus under the supervision of the General Staff of the Armed Forces constitutes the most important decision within this duplication (it was interpreted as a step to marginalize the government and assign a central role to the armed forces which act under Khamenai’s supervision), it was not the only decision within this sequence.
1- Despite the attempts made by the Iranian official quarters to organize efforts to combat the spread of coronavirus, the regime is still quite far from what can be called a “general strategy”. Attempts to combat the epidemic remain dispersed and far from good performance. One of the main reasons that prevent reaching such a strategy is the clear fluctuation in the position of the government, represented by president Rouhani, among other reasons.
2- The government provides official figures regarding the numbers of infections and deaths on a daily basis. While these figures have increased steadily, they are quite far from being realistic. They contradict realistic data, scientific studies and the observations of international centres. Regardless of the reasons for the official blackout of real figures, the official lack of transparency on the size of the problem could be considered one of the main obstacles that hinder managing and containing the crisis, according to the WHO Middle East emergency director.
3- Upon studying the infrastructure, the number of beds and numbers of doctors in the Iranian health sector, it is clear that the official steps taken to restrict movement and developing schemes for partial quarantine can delay the crisis for several weeks or more if implemented strongly and continuously. They can also give the health sector time to deal with the situation. Yet this infrastructure will not be resilient in two cases:
a- If the number of infections far exceeds the one announced by the government and is close to the one stated by independent and international quarters (five times the official number). That would mean that Iran will reach 150 thousand infections within one to two weeks.
b- The health sector will not be able to hold in case the spread of the epidemic continues for several months even at the infection pace acknowledged officially. According to the official spread curve, the number of infections is supposed to range between 120 and 150 thousand within 45 days. This means that the number of infected people will be equal to the number of nurses.
4- The government can still manoeuvre by implementing the strategy of easing pressure on hospitals, reducing the treatment period by admitting patients to recovery hospitals, and continuing to implement isolation and quarantine programmes to slow down the spread pace and give the health sector a chance to show resilience in the face of the crisis.
5- The resilience of the health sector remains contingent on continuing to receive logistic support. While the quarters concerned with combating the crisis have managed to overcome the problem of shortage of the health capabilities of the medical staff by controlling the markets, monitoring the circulation of health goods and resorting to the assistance provided by some countries (including Japanese assistance worth 23 million dollars, European assistance worth 21 million dollars, Kuwaiti assistance worth 10 million dollars, in addition to non-monetary assistance from China, the UAE, Qatar and Russia), their continuity is contingent on the continuation of government support for the health sector and the arrival of additional international assistance, as follows:
a- Within the framework of the continuous government support, the government has so far provided 3,610 billion tomans to the health and insurance sector. It has also issued instructions for the payment of 3,833 billion tomans of additional support for the sector. This raises the government support for the sector to 7,443 billion tomans (nearly 500 million dollars). However, the sector needs more support to be able to show resilience in the face of the virus pressures, which is unlikely in light of the financial crisis witnessed by the government.
b- The crisis has prompted this government to request the Supreme Leader to provide a billion dollars from the savings of the National Reserve Fund. It has also prompted the government to request the IMF to provide a loan of 5 billion dollars within the framework of supporting the Iranian government in the face of the spreading virus.
6- Perhaps international assistance will be Iran’s only resort in ensuring the resilience of the health sector in the face of the disease. However, the chances that the government will be able to obtain effective international assistance seem to be remote in light of the following points:
a- The sanctions regime prevents Iran from accessing such assistance unless a change takes place in the position of the US administration (which is unlikely in light of the current positions) or an international consensus is reached against the sanctions regime (also unlikely).
b- Insistence by revolutionary institutions and the revolution’s Supreme Leader on their strict positions towards receiving international assistance constitutes another obstacle in the way of this assistance. Manifestations of this strictness can be seen in their positions towards WHO assistance.
c- The lack of transparency in spending assistance money constitutes another reason that prevents accessing international assistance, especially in light of the hardline position towards the presence of international organizations on Iranian soil.
7- The duplication between government and revolutionary institutions (whose manifestations can clearly be seen in the decision to mandate the responsibility for combating the virus to a military committee and the rejection by the government of the decision, underlining that combating the epidemic has to pass through its channels) remains a major obstacle to achieving a remarkable result in combating the disease. Without overcoming this duplication (which is unlikely), it is quite difficult to expect a development in dealing with the crisis in an effective and fruitful manner.
8- The resilience of the Iranian health system against the virus is contingent on multiple factors, including: the extent of determination by the official quarters to provide economic and human support and enhance the capabilities of this sector, joining forces in managing the crisis, and implementing multiple options of quarantine to reduce the number of infections. However, what can be called the “resilience threshold” takes into account several factors, mainly the number of infected people who are admitted to hospitals which, according to the Iranian president, today house 20 thousand vacant beds only.
Premises of the scenarios: the three scenarios stem from the premise of accepting the figures issued by official institutions regarding the number of infections and the capacity of hospitals. If these two are treated with suspicion, this would mean that the Iranian health system will collapse more quickly. All scenarios are also based on the assumption that the pace of disease spread is also according to the official curve, and the assumption that the government will be able to allocate 50 percent of hospital capacity to countering the epidemic, taking into account the time factor (summer can be considered the point of getting rid of the disease burden), in addition to the assumption that the health sector will be economically resilient, especially in light of the government’s undertaking to cover all treatment costs of patients (which would add a burden it might not be able to withstand in light of the economic pressures it is under, unless it is assumed to access international assistance or resort to the savings of the National Reserve Fund).
First scenario: failure of the regime’s attempts to contain the virus and the continued pace of infections: this scenario is based on official data. The pace of infection is assumed to continue at the same level of increase (estimated by scientific sources at nearly 10 percent). According to this scenario, which assumes that the official quarters will fail to implement their quarantine programmes and slow down the pace of infections, the infection figures will double every week to reach nearly 81 thousand after two weeks, accounting for 57.5 percent of hospital capacity. The number of patients in need of health care beds will also reach 4,860 (if the views of specialists are taken into account regarding the need by 6 percent of patients for health care beds). This scenario means that the health system in Iran will collapse within less than a month.
Second scenario: relative success in reducing the pace of virus spread: this scenario is based on the same official data. It assumes that the schemes of official quarters will manage to prevent the continued increasing pace (10 percent). This means the possibility that daily infections will continue at that number (nearly 2 thousand infections daily). This means that the virus will take nearly 25 days to reach half the hospital capacity. This scenario, which is referred to by some directors at the Ministry of Health, does not perceive an end to the crisis, rather that reaching the resilience threshold will take longer (nearly two months) after which the health system would collapse if the government does not find a solution to the crisis.
Third scenario: success by the Iranian regime in containing the virus: this is the more optimistic scenario as it perceives that the government will manage to contain the crisis through reducing the number of infections as a result of the implementation of home isolation and quarantine schemes (which means the reduction of the number of infections to at least half where it presently stands) and the implementation of alternative programmes of recovery hospitals and home care to ease the pressure on the health system. If the government manages to take these two steps, the scenario perceives that the virus will only reach its peak in the summer as the rate of bed occupancy in hospitals will be decreased and the number of infections will be reduced because of the temperature. However, in addition to being overoptimistic of the success of official programmes in reducing infection with the virus, this scenario assumes also that the Iranian health system will show resilience in the face of economic pressures resulting from multiple reasons, including sanctions and economic recession as a result of the corona spread.
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