Islam and Social Policy

5. Islam and Health Policy: A Study of the Islamic Republic of Iran

181 5 Islam and Health Policy: A Study of the Islamic Republic of Iran1 Carol Underwood The Iranian revolution of 1979, inspired by Islamic precepts and presided over by Muslim religious figures, brought Islam to the forefront of social, political, and economic discussions. Subsequent events around the world, in which tragedies have far outweighed triumphs, have kept discussions and debate about Islam and development very much on the global agenda. Political pundits were forced to reformulate some of their conjectures about the Muslim world, while scholarly social critics were compelled to reassess their assumption that Islam as a sociopolitical force had outlived its potential.These events have also had practicalconsequences :Muslimleadersanddevelopmentspecialistsbegan to reevaluate the influence—whether manifest or latent—of religious understandings, practices, and institutions on policy formation and implementation. While this reorientation has been far from complete, it provides a clear contrast to the middle decades of the twentieth century,when regimes throughout most of the Muslim world turned to nationalist or socialist rhetoric to garner(ormaintain)legitimacyandsoughttodistancethemselves from tradition and religion. The wide-ranging effect of this shift is too broad to explore in one study, but our understanding of how the explicit incorporation of religious principles has altered IslamFinalPages.indd 181 5/26/04 4:19:34 PM 182 Islam and Social Policy policy formation and implementation can be furthered through the analysis of postrevolutionary Iran. The purpose of this chapter is to examine the impact of religious doctrine,as refracted through political discourse,on health policy in Iran. To provide a backdrop for this discussion, a brief profile of health policies prior to the revolution follows. Prerevolutionary Health Policy Social policy in developing nations is guided, though not necessarily determined, by the state’s interpretation of the causes and prerequisites for development. Modernization theory was the dominant paradigm in development thought in the 1950s and 1960s. The central contention of modernization theory, which conceptualizes societies within a bipolar framework,is that development is a unidirectional evolutionary process as exemplified in the development of the modern West.Through the introduction of certain concepts and technological interventions,it was argued, development would take off—but this development should be controlled and incremental. This same approach was used in the fields of medicine and public health—health improvement was sought through technology and curative care rather than through broad changes in social and economic structures. The guiding principle was that traditional ways inhibited development : tradition was juxtaposed to “modernization.” The Shah and his supporters were loyal proponents of the modernization perspective and often found themselves at odds with traditional leaders, including the Muslim‘ulama. Cosmopolitan medicine was relatively well established among theurbanelitebythe1960s.Medicalschoolshadbeenestablished not only in Tehran, but also in many of the provincial capitals. As Iran became more thoroughly integrated into the world economy, foreign suppliers of medical technology, together with transnational pharmaceutical companies,increasingly influenced IslamFinalPages.indd 182 5/26/04 4:19:34 PM Islam and Health Policy 183 the practice of medicine in Iran. The inevitable struggle between public health specialists and private enterprise medicine saw the latter predominate, but the public health sector continued to act as a countervailing force. BaseduponlessonslearnedfromChina’sexperienceswithprimary health care (PHC),several pilot projects were undertaken in Iran in the 1970s.With the wholehearted support of Iran’s major public health schools, health planners set out to test the capacity of ruralhealthhousestoprovidebasicpreventiveandcurativecare for the rural population. One major and very successful program was established inWestAzerbaijan,where—significantly—there was no medical school to serve as the basis for opposition to the emphasis on primary care delivered by paraprofessionals.2 Other effective projects were located in Shiraz, the provincial capital of Fars province, and among the Qashqa’i nomads. Rural health houses were linked to an urban hospital;there were no intermediary referral centers. Despite these experiments with PHC, there was tenuous evidence ,at best,that these services would be instituted nationwide (Andreano 1984).Indeed,the pilot projects faced stiff opposition fromthemedicalestablishment,includingprofessorsanddeansof the leading medical schools,as well as from influential physicians, who argued that the“quality of care”would suffer.Geographically and temporally limited, the pilot projects had little effect on the population at large. As Andreano notes, “Provision of, and access to, health care in rural areas in 1978 was still where it was in 1973. One is left with the conclusion that the disparities that...