MANILA — Iran is employing aggressive measures as it grapples to contain the spread of the novel coronavirus. The country has shut down schools, limited travel, and even called on its citizens to reduce the use of paper money.
“They are waking up [to the reality of the outbreak], but I wish they [did] it six weeks ago when we asked them several times,” said Dr. Kamiar Alaei, an Iranian doctor who has been awarded for his work on health and human rights.
Political considerations prevented the government from taking swift actions early in the outbreak, including informing and mobilizing frontline health workers early against the virus, Alaei said, who co-founded the Albany, New York-based Institute for International Health and Education with his brother Arash.
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He said the government initially referred to reports of the virus circulating in Iran as propaganda aimed at dissuading voter turnout at recent parliamentary elections. The government was also slow to stop flights to and from China, where the outbreak originated, and influential members of Iran’s Islamic Revolutionary Guard Corps dismissed early proposals to quarantine the city of Qom, two days after the first confirmed cases were reported there, Alaei said.
The government “unfortunately politicized this non-political health outbreak for several reasons,” he said.
But there’s another kind of politics in play that’s threatening Iran and other countries’ response to the COVID-19 outbreak — sanctions, which impact the countries’ ability to purchase test kits, medicines, equipment, and other necessary items for outbreak response.
Devex spoke to experts about the impact of sanctions in Iran, Syria, and North Korea.
“The North Korean state isn’t well-equipped to treat an epidemic, but it is efficient at monitoring and controlling its population.”— Esther Im, program officer, The National Committee on North Korea
Iran has faced a variety of international sanctions over the past four decades. Current sanctions include prohibiting U.S.-based entities from engaging in transactions with Iran, including the central bank. Foreign-based financial institutions that transact with sanctioned Iranian banks and entities could also lose access to the U.S. financial system.
While humanitarian goods such as food, medicine, and medical devices are generally exempt from sanctions, it is not always easy to make financial transactions with entities outside Iran in order to procure the items.
Past disease outbreaks have shown how challenging it can be for low-income countries to have access to new vaccines — and there is no global framework that guarantees equal access.
“There are lots of pharmaceutical companies or other organizations that … face a lot of challenges to … provide those medical devices and drugs,” Alaei said.
Drugs produced in the U.S. and Europe, in particular, are difficult to procure. While most of its needed drugs are produced in-country, Iran lacks medicines for cancer, cardiovascular disease, and multiple sclerosis, among others, Alaei said.
The World Health Organization was able to bring in COVID-19 test kits for an estimated 100,000 people in Iran, but Alaei said this won’t be enough to satisfy the needs of the population totaling over 80 million people. There’s also a need to procure medical equipment such as chest CT scans for lung testing. Not all 31 provinces of Iran have the necessary equipment to test for COVID-19, or their equipment is outdated or needs repair.
At the end of February, the U.S. government announced the lifting of some sanctions on Iran’s central bank, allowing it to engage in transactions for humanitarian purposes.
“I hope the U.S. government [will] facilitate and simplify the process to remove a lot of [the] bureaucracy. So by this way, the Iranian population … can get access to what they need in the early stage, rather than waiting for a while,” Alaei said.
The international community needs to provide aid and technical support to Iran, such as how to do crisis management for the COVID-19 outbreak, he said.
“Also I think they should be proactive, encouraging some of the pharmaceutical companies to provide those services, because [these companies] hesitate, as they may be targeted by other sanctions, or they may not get the money if they do their transactions,” Alaei said.
“If people are severely malnourished, they're much more, much more at risk.”— Kasturi Sen, independent scholar
Syria used to have one of the most advanced health systems, but this gradually collapsed due to the conflict — now in its ninth year — and international sanctions, said Kasturi Sen, an independent scholar.
Like in Iran, international sanctions on Syria have exemptions on humanitarian aid, such as food and medicine. But sanctions on oil supplies and banking have had an impact on the health system. There’s not enough oil for ambulances, and it’s been difficult to purchase some critical medical equipment.
“Ventilator machines [and] ambulances for emergency transport for those in hospital [are] affected since many have not been repaired for years,” Sen said.
But the oil embargo is most crippling both for the economy, people’s lives, and Syria’s response to a potential COVID-19 outbreak in the country, Sen said. For instance, surveillance work will require some capacity for electricity. But Syria hasn’t had access to fuel for the last year and a half, she said, noting that friends and colleagues in Damascus and rural areas tell her they feel lucky to have electricity for two hours a day.
There’s a massive shortage of medicine and food insecurity due to inflation, too. Prices of some essential household and food items such as gas, rice, and milk have significantly shot up. Sen said the prices of these goods had jumped hundreds and even thousands of percentage points since 2011.
“Nutrition [is important, but] no one talks about it. If people are severely malnourished, they're much more, much more at risk [of being infected with the virus],” she said.
But one of the most serious issues in Syria is the ban on dual-use goods such as chlorine which can be used to make bombs. Chlorine is often used in hospitals for cleaning and as a disinfectant, helping prevent infection.
Additionally, more than half of nurses and medics have left the country, Sen said. There’s also high anxiety, depression, and trauma among people there after years of conflict and sanctions, she added. In 2016, more than 100,000 mental health consultations were made in Syria, according to WHO.
Western countries need to reexamine long-running sanctions and the negative impacts on health, Sen said.
She also called on WHO to be more vocal in pointing out the impact of sanctions on accessing medicines and medical equipment in Syria.
“If they're trying to protect people and they can't protect them, they need to say it. You know, health is a political matter as well. It's not just an issue about having access to health services,” she said.
“The West gloats about exemptions to food and medicines,” Sen said. But the volume of documents that organizations need to complete can be a deterrent in applying for the exemptions and conditions attached to those exemptions can be very complicated, she said.
While no confirmed COVID-109 cases have been reported to date in Syria, that doesn’t mean the virus doesn’t exist there. “There are no borders for [this] virus,” Sen said, noting there is a large amount of travel between Syria, Iran, China, and Turkey. There have been reports of Syria exporting cases to neighboring countries such as Pakistan.
“The EU, US and UK among others (the Arab League) need to put the regime change agenda on the back burner. Driven by the regime change agenda the world has lost perspective on the rights of civilians to be guaranteed by international law and of their basic human rights to health care and food as particularly relevant to sanctions,” Sen said in an email.
Like Syria, North Korea has yet to report any confirmed cases of COVID-19. But the country has taken aggressive measures against the virus’ spread. In January, the North Korean government closed its borders to China, and suspended travel and tourism.
The government’s actions were similar to North Korea’s response to the Ebola outbreak in West Africa in 2014, although the measures taken in response to COVID-19 were faster and more comprehensive, according to a commentary on 38 North, a website dedicated to expert analysis on North Korea.
But the actions taken by the North Korean government may also be reflective of its understanding of the country’s health system. North Korea lacks the resources and equipment to deal with an outbreak such as COVID-19, said Esther Im, program officer at The National Committee on North Korea, an NGO comprised of persons with significant expertise in and diverse perspectives on North Korea.
“The North Korean state isn’t well-equipped to treat an epidemic, but it is efficient at monitoring and controlling its population,” Im told Devex.
Many of the country’s hospitals and clinics, particularly those outside Pyongyang, lack access to clean, running water and stable electricity. Even in some of the better-off hospitals, doctors have to reuse essential medical tools such as operating gowns, scalpels, and IV drips. Patients often bring in their own medication as not all hospitals have sufficient medicine supply, she said. Widespread malnutrition also makes the population vulnerable to infectious diseases like COVID-19.
International sanctions imposed on North Korea — mostly due to its nuclear program — add to the already challenged health system. As in Iran and Syria, humanitarian assistance is exempt from the sanctions, but sanctions on financial transactions make banks “highly risk averse” to transact with North Korea, making it difficult for NGOs.
In addition, even if the U.S. and the United Nations have indicated their willingness to expedite exemptions for humanitarian assistance to North Korea relating to the COVID-19 outbreak, the time it takes to complete exemption requests can be cumbersome.
Exemption requests to the U.N. sanctions committee often depend on the number of items and the details provided in the request. To apply for one, an organization usually takes a few days to 2 weeks. But license requests made by U.S. NGOs to the U.S. Office of Foreign Assets Control, can take several weeks, and the approval several months. These timeframes do not yet include the procurement period, which can take from a few days to nine months from order date to delivery. Getting TB drugs in the country can take 9-10 months, for example.
“The current situation reveals the tension between the imperative of immediate relief measures and the broader needs of North Korea's public health sector,” Im said.
While the North Korean government has the responsibility to allocate resources to address weaknesses in its health system — which Im said predates current sanctions — the international community must also “grapple with the unintended consequences of sanctions put on a population that is already made vulnerable by its government,” Im continued.
The aid community should make it clear to the government that it’s ready to provide assistance, and proactively think through response plans designed for multiple scenarios once the North Korean government allows international assistance, Im said.
At present, Im said what worries her is the North Korean government’s lack of transparency and unwillingness to allow assistance into the country to plan a response against an outbreak.
“My biggest concern is that North Korea will allow assistance and support too late and the window for containment will be lost, if it hasn't been lost already,” she said.
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