A female medical worker, wearing protective gear, is seen behind medicine bottles in a room at Rasoul Akram Hospital in Tehran, Iran, October 20, 2020. Photo: A Fatemeh Bahrami / Anadolu Agency

RASHT – Almost five million lives were on the line this week in Iran as the country’s ailing healthcare sector, crippled by US sanctions and troubled by reverse smuggling and price wars, appeared incapable of addressing a critical insulin shortage.

“There is no insulin,” reads a viral Persian hashtag seen in tens of thousands of tweets, and which has generated more than half a million impressions on Twitter in the past seven days.

With the country also in the grips of a new wave of coronavirus infections, with fatalities rising to levels unseen since the outbreak started in February, Iran’s minister of health has opted for silence in the face of the new crisis.

The shortage “is temporary,” said Mohammad Reza Shanehsaz, the head of Iran’s Food and Drug Administration, the highest-ranking authority to weigh in thus far. He stressed that the import of certain medicine types and equipment have been hampered by US sanctions.

He announced that the supply of insulin would be rationed and patients would be able to purchase the medication by producing their national ID cards. He also advised patients to shift their insulin usage from insulin pens to vials of human insulin, which are profusely available in the pharmaceutical market.

Kianush Jahanpur, the head of public relations at the Ministry of Health, who maintains an active Twitter presence with 28,000 followers, laconically responded to a desperate user who complained about failing to find insulin pens for his bedridden father at several drugstores, by writing “decrease the dosage of insulin.”

His reply prompted a spate of indignation among Iranians online, who accused him and other health ministry officials of mismanagement.

Niloofar Zolfaghari, a journalist in Tehran whose 60-year-old father is a type 2 diabetic patient, says these recommendations are “dangerous” and can entail irreparable consequences.

“The [human] insulin vials are widely available and sold by the drugstores. But a patient who previously consumed vials of human insulin and did not get a positive response and was instructed by the physician to switch to injections with insulin pens cannot relapse to vials on his or her own,” she told Asia Times.

“This is not a decision to be made by patients autonomously,” she warned.

Many drugs are in short supply in Iran, which is troubling for diabetics. Photo: AFP/A Fatemeh Bahrami/Anadolu Agency

Zolfaghari recounted that for her family, the quest to find insulin at government-owned pharmacies had been a daunting task for the past two years, and in recent months, it has become even more complicated.

“Up to two years ago, the pharmacies would supply as many insurance-covered insulin pens as prescribed by the physician. After a while, the insurance company stepped in to determine how many pens we were entitled to, which means, for instance, out of seven Apidra antidiabetic agents prescribed, the pharmacy would supply only two, and we had to buy the rest from private drugstores at higher prices,” she said.

“We had a stock of what he had saved until September, and then different drugstores told us this month that they had no insulin available to sell,” Zolfaghari added.

A disease characterized by elevated blood glucose and insulin resistance in the body, diabetes was the seventh cause of deaths in the world in 2016, and there are presently 463 million people living with diabetes globally.

In Iran, close to 11% of the population aged 25 and older suffers from diabetes, and 18% of the population is on the cusp of diabetes – that is, they are prone to develop type 2 diabetes if they don’t change their lifestyle and eating habits.

“Iran is accommodating the second largest diabetic population in the Middle East. By 2030, the number of diabetics in Iran would increase to nearly 9.5 million. So, there is an anticipation that shortage of insulin behaves like a returning wave every year,” said Homayoun Kheyri, an Iranian-Australian cell biologist and science journalist based in London.

US sanctions bite

The scarcity of insulin in Iran is primarily blamed on the sweeping US sanctions that have vaporized different sectors of Iran’s economy, ghettoizing the country by cutting it off from the international banking, finance, energy and transportation sectors and making it an uphill battle for it to even engage in the most basic humanitarian transactions for importing food and medicine.

“Sanctions are making health problems in Iran worse. We shall expect the consequences in the next decades,” Homayoun Kheyri told Asia Times.

“Health is a universal matter and we can understand it better after the Covid-19 pandemic. The United States has to ease the sanctions to the benefit of world health, not to the benefit of the Islamic Republic,” he argued.

The forlorn appeals of Iranians on social media, who clearly seem to be at the end of their tethers, pleading for insulin from Iranians traveling home from other countries, writing to international organizations and pharmaceutical firms for humanitarian assistance and urging the US government to show mercy at this fateful time, have had reverberations beyond Iran’s borders.

A Woman injecting herself in the abdomen with insulin. Photo: AFP

Allie Marotta, a healthcare and insulin accessibility advocate in Brooklyn, who is also a member of the leadership team of the New York #insulin4all campaign, told Asia Times that Iran’s insulin shortage conundrum is a human rights crisis.

“People with diabetes are being forced to use antiquated and dangerous insulin which jeopardizes their right to adequate healthcare,” she said.

“Sanctions are an abusive tactic and a human rights violation. We’re seeing this clearly between the lack of personal protective equipment and now the insulin shortage in Iran. Sanctions cause mass loss of innocent lives and there is no political belief that can justify that,” she added.

According to Marotta, the best course of action at this time is to draw media attention to the simmering crisis and generate publicity to prod the US government into revising its sanctions policy and induce the Iranian government into acting in a more agile manner.

“If we make enough noise, we do have a chance of pressuring large international charity organizations and the insulin manufacturers to step in, which would be the most realistic goal,” she said.

The Brooklyn-based activist is now lobbying aid organizations and pharmaceutical companies to carve out legal workarounds and get insulin to people in Iran who need it immediately.

Problems at home

Even though the US sanctions are conceived as the main driving force behind the recent crisis, the Iranian government’s mismanagement and culture of corruption have also played a role.

The Rouhani administration, now in the final months of its mandate, has spectacularly failed to root out corruption in government agencies, regulate the markets and stave off the challenges associated with the depreciation of the rial, including an illegal drug trade.

Last week, reports that 19 truckloads of smuggled medicine entering Iraq from Iran were detected and confiscated by Iraq’s intelligence apparatus sent shockwaves across Iran. The report was doubly worrying against the backdrop of Iran’s own problems with drug shortages and the obstructions it faces in importing medicine.

It was initially suggested that the medical products, valued at hundreds of thousands of dollars, were made in Iran. Iranian authorities later denied the rumors and said the medicines were not manufactured in Iran and the cargo was not originating from Iran either, but merely transiting through the country on its way to Iraq.

Iran produces roughly 97% of its pharmaceutical needs domestically and expends €2.5 billion (US$2.9 billion) annually on the remaining 3% it imports from overseas. But patients usually denounce the quality of home-made medical products, which they say are either ineffective or involve significant side effects.

“Many valuable pharmaceutical materials that Iran uses to produce medications are dominated by major companies. It is not easy to buy them,” said Homayoun Kheyri.
As an alternative, Iran sources many of these materials from India, notes Kheyri.

“Iran buys many of these materials from Indian companies for cheaper prices. It is not a surprise if the quality is not great,” he said.

There are two insulin manufacturing lines in Iran, one of which was inaugurated in August. Novo Nordisk Pars is the spinoff of the Danish multinational firm Novo Nordisk, which had been active in Iran since 2005.

Mahdiar Saeedian, a physician and the editor-in-chief of the Danestaniha-ye Pezeshki medical journal in Tehran, narrated a different account of how this company contributed to the shortage of insulin in Iran.

“Novo Nordisk had set the price tag of $6 for each insulin pen. This year, several companies attempted to import insulin with similarly good quality from a number of European countries priced at $2-3 per each pen,” he said.

“With the arrival of these consignments, the Ministry of Health asked Novo Nordisk to moderate the prices, but the company, which had earned popularity among the patients and physicians, refused to mitigate the prices and slashed the supplies instead.”

Dr Saeedian said the Ministry of Health was not able to pull the strings on this company, and physicians across the country, rewarded with prodigal financial support by the manufacturing firm, refrained from prescribing other varieties of insulin. The result was an imbalance in the supply chain and the crisis that ensued.

He added that “it is the ‘reverse smuggling’ of medicine from Iran by the mafia syndicates which has largely contributed to the scarcity of insulin. The pharmaceutical mafia is an extensive and influential network in Iran and will continue operating regardless of which administration is in power.”

Should Democratic challenger Joe Biden win the US presidential election on November 3 and ease Washington’s pulverizing sanctions, authorities in Tehran will still need to immediately embark on full-fledged surgery to stamp out nepotism and corruption and address Iran’s healthcare sector cataclysm.