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Abstract
Existing histories of public health in Iran often center on elite or urban narratives. This paper shifts the focus to Iran’s villages by examining the twentieth century public health history of rural northern Khuzestan. It argues that Khuzestani villagers desired, rather than resisted, modern medical services. However, vertical decision-making and the prioritization given by public health planners to economic concerns over social well-being led to the uneven distribution of services and failure to fulfill the expectations of Khuzestan’s villagers. This paper uses memoirs, official reports, correspondence, and other records from the Development & Resources Corporation, along with reports from Iran’s Ministry of Education and Ministry of Health, to bring a richer picture of Iranian villagers’ twentieth century history into focus.
ORCID
Bryan Sitzes http://orcid.org/0000-0003-4906-4892
Notes
1 Regarding the title of this article, Afkhami also examines “sanitized modernity” in his book A Modern Contagion. For other histories written on public health in modern Iran, see Good, “Health Care in Modern Iranian History”; Schayegh, “Sport, Health, and the Iranian Middle Class”; Seyf, “Iran and Cholera”; Ebrahimnejad, Medicine, Public Health and the Qajar State; Floor, Public Health in Qajar Iran; Azizi and Azizi, “Iranian Medical Students Abroad”; Harris, A Social Revolution.
2 Hakim generally indicates a philosopher or Islamo-Galenic physician. Ebrahimnejad, Medicine, Public Health, and the Qajar State, 252.
3 Scott noted decades ago that peasants tended to appear in histories as either rebellious movements or as “anonymous contributors to statistics on conscription, crop production, taxes, and so forth.” Weapons of the Weak, xv.
4 On the establishment of medical infrastructure in early twentieth century southern Khuzestan, see Floor, History of Medicine in Iran, 107‒29.
5 See Hooglund, Land and Revolution; Kazemi and Abrahamian, “Nonrevolutionary Peasantry”; Kazemi, “Peasant Uprisings”
6 David Rahimi, “Remembering Revolution.” Arunima Datta (‘Immorality,'” 587) noted that “Indian coolie women often consciously acted upon fleeting opportunities to forward their own interest, not necessarily to challenge or change the societal order.”
7 For case studies of other twentieth century development plans and their unintended social and ecological consequences, see White, The Organic Machine, and Carse, Beyond the Big Ditch.
8 “A Rural Development Project for Dasht-i-Mishan,” 1959, DRC Records (885:1); John Oliver to Russell E. McClure, “Rural Development Project for Dasht-i-Mishan,” 25 January 1959, DRC Records (885:1); George M. McClure to Russell E. McClure, “Public Health Survey,” 20 October 1959, DRC Records (884:8).
9 See Salmanzadeh, Agricultural Change; Hooglund, Land and Revolution; Najmabadi, Land Reform.
10 Latifpur, Khuzestan, vol. 1, 249‒63; Seyf, “Iran and Cholera,” 176. According to Shahnavaz (Opening Up, 118‒19): “Up to and even after 1898 ... there was hardly an epidemic-free year. In 1893, due to outbreaks of cholera, small-pox, and remittent fever [a type of malaria], there was a ‘considerable mortality’ in Muhammareh and upper Karun ... Two years later it was influenza, and in 1901 small-pox. The next year a combination of cholera and small-pox caused distress. During the summer of 1904 the whole region in the south was visited by plague and cholera ... Another epidemic of cholera ... hit Muhammareh and Khuzestan in 1911.”
11 Kasravi, Pansad saleh, 178‒80. Austen Layard traveled regularly through Shushtar less than two decades after the epidemic and reported nearly 20,000 casualties of the plague. Layard, Early Adventures, vol. 2, 42.
12 Latifpur, Khuzestan, vol. 1, 249‒58.
13 Ibid., 251.
14 Ibid., 252, 262; Afkhami, “Age of Epidemics,” 50.
15 Mikhail, Nature and Empire, 214.
16 Khazeni, Tribes and Empire, 68.
17 Najm al-Mulk, Safarname-ye Khuzestan, 26.
18 Latifpur, Khuzestan, vol. 1, 262.
19 Shahnavaz, Opening Up, 35, 45.
20 Ibid., 51; Mikiya Koyagi, unpublished manuscript.
21 Afkhami, “Age of Epidemics,” 93, 328, 439.
22 Ibid., 204. The political battles between Britain and Iran over control of its quarantine regimes occupy a large part of Afkhami’s study. He also provides maps in his appendices for the progression of epidemics into Iran. They indicate paths through the Kurdish region, the ports on the Persian Gulf, and from Central Asia while Khuzestan does not appear as a major disease passage. Ibid., 467, 468, 484, 485,
23 Shahnavaz, Opening Up, 114.
24 Layard, Early Adventures, vol. 1, 147.
25 The khan’s son recovered. Ibid., 151‒2.
26 Bishop, Journeys in Persia and Kurdistan, 336‒7.
27 Durand, Autumn Tour, 125.
28 See Floor, Public Health in Qajar Iran.
29 Schayegh, “Sport, Health, and the Iranian Middle Class,” 342‒342. Kashani-Sabet (Conceiving Citizens, 137) also discusses the role of sport and exercise in early Pahlavi-era concerns for women’s health.
30 Schayegh, “Sport, Health, and the Iranian Middle Class,” 348‒9.
31 Kashani-Sabet, Conceiving Citizens, 66. The encouragement of large families ceased after the mid-1960s and family planning became the priority. Ibid., 192.
32 Ibid., 82‒3, 111, 134‒5.
33 Ibid., 112‒13.
34 Cronin, “Fall of Sardar Asad,” 211. At the same time, not all rural spaces endured equal neglect. Northern regions seem to have received more attention than southern regions. Naw’dust herself concentrated on rural women of Gilan. “While Azerbaijan had several foreign schools for girls, Khuzistan was reported as having none.” Kashani-Sabet, Conceiving Citizens, 135.
35 Williamson, Persian Oil Field, 145.
36 Ibid., 121‒2.
37 For a similar phenomenon in Ottoman Egypt, see Mikhail, Nature and Empire, 230‒41. For the Philippines, see Anderson, Colonial Pathologies. On “sanitary segregation” in Central America, see Sutter, “Nature’s Agents or Agents of Nature,” 733‒5.
38 Williamson, Persian Oil Field, 141.
39 Ehsani, “Khuzestan’s Company Towns,” 386.
40 Anderson, Colonial Pathologies, 116‒17.
41 Williamson, Persian Oil Field, 150‒1.
42 Ibid., 153.
43 Anderson, Colonial Pathologies, 202.
44 Williamson, Persian Oil Field, 133.
45 Ehsani (“Khuzestan’s Company Towns,” 362) lists the primary APOC towns in Khuzestan as Abadan, Masjed Soleyman, Omidiyeh, Aghajari, Haftkel, Naft-e Sefid, Gachsaran, and Lali.
46 Carl E. Taylor, “Report and Recommendations on a Health Program for the Khuzestan Region,” 1959, DRC Records (885:8), 14.
47 Curzon, Persian Question, vol. 2, 333.
48 It should be noted that two groups of Iranian businessmen actually initiated their own private projects to build smaller modern dams and irrigation systems on tens of thousands of hectares of land in Khuzestan in the late 1940s. These entrepreneurs were eventually forced to give up their lease or sell their land to the government for the DRC-controlled project. One group was the first to import a tractor into Khuzestan in 1947. Salmanzadeh, Agricultural Change, 191‒2. Ebtehaj had been considering plans for developing Khuzestan by 1945, when he was governor of Bank-e Melli (National Bank). Ebtehaj, Khaterat, 373.
49 Ekbladh, Great American Mission, 52, 71.
50 Ibid., 90.; On the transformation of health along the Nile after the construction of the Aswan Dam in 1902, see Derr, The Lived Nile.
51 Ebtehaj (Khaterat, 382) wrote that he was already aware of Lilienthal before meeting him because he was once the chairman of the TVA (1941‒46) and chairman of the United States Atomic Energy Commission (1946‒50).
52 Ekbladh, Great American Mission, 47‒8. Lilienthal regularly voiced anxiety about Soviet activities in his journals and viewed the Khuzestan project as an opportunity to counter Soviet influence in Iran. Lilienthal, Road to Change, 97.
53 Haines, Rivers Divided, 109‒10.
54 Ekbladh (Great American Mission, 159) noted that DRC drew much of its staff from the TVA headquarters in Knoxville, Tennessee.
55 Salmanzadeh, Agricultural Change, 191‒2.
56 According to Gilman (Mandarins of the Future, 38, 226), “the TVA became a prototype for how the state could act as a rational, benevolent enforcer of the national interest,” and David Lilienthal was a recognized member of the school of modernization theory. For the TVA’s influence on the Aswan High Dam project in Egypt, see Mitchell, Rule of Experts, 44‒5.
57 Lilienthal, Road to Change, 80.
58 Ibid., 81.
59 Ibid., 128.
60 Ibid., 130. Lilienthal (Anon. Activities, 8) later stated: “This is an unusual kind and quality of responsibility ... the breadth of the responsibility delegated by a sovereign nation to a private American company, a company having no official links nor financial dependence upon the U.S. Government, nor upon the United Nations. But neither we nor the contractors we employ acquire any ‘concession’ or proprietary or financial interest in the resources developed; compensation in all cases is limited to payment for the managerial or technical services rendered.”
61 Lilienthal, Road to Change, 131.
62 According to the invitation from the Chairman, J. W. Fulbright, the committee had “been interested in the operations of private American enterprises in countries receiving assistance from the United States.” Anon. Activities, 3.
63 Ibid., 4.
64 Ibid., 4.
65 Ibid., 8.
66 Ibid., 10.
67 For detailed discussion of the organization of and relationship between Iranian and DRC entities, how DRC selected contractors for Iranian projects, World Bank Iranian loan details, and other information, see ibid. According to Shahmirzadi (“Sazman va Modiriʿat,” 12), the Iranians who worked for KWPA came to be considered some of the most knowledgeable development experts in the country and officials in other provinces sought to hire them for their own projects.
68 Salmanzadeh, Agricultural Change, 38‒9.
69 “KDS Role in Public Health Activities in Khuzestan. Present: G. R. Clapp, Dr. J. Amouzegar, J. J. Goulden, T. A. Mead, 16 February 1958,” DRC Records (885:1).
70 T. A. Mead, “Medical and Health Problems in Khuzestan,” 1958, DRC Records (885:6), 10.
71 Jamshid Amouzegar, “A Report on Public Health Problems of Khuzestan (Ostan 6),” 1957, DRC Records (886:2), 10.
72 Williamson, Persian Oil Field, 124; Mead, “Health Problems,” 2. Dr. Mead notes on this page that the three hospitals at Ahvaz were operated by the Ministry of Health, the Railways Administration, and the Red Lion and Sun Society. Williamson described an impressive APOC hospital at Ahvaz in 1927, and it is unclear what happened to that institution. It is possible APOC/NIOC eventually considered it redundant as other hospitals opened in the city and consolidated operations at Abadan and Masjed Soleyman.
73 P. A. Satralker, “Diseases and other Health Hazards in Khuzestan Region—Iran,” 1957, DRC Records (885:2), Appendix: “Map of Khozisthan No. 2.”
74 Satralker, “Health Hazards.”
75 Afkhami, “Age of Epidemics,” 397.
76 The German doctor was not a new arrival to Khuzestan. He had spent the eight previous years working around Susangerd prior to joining the DRC and spoke Arabic. At least part of this time was spent working for the Imperial Foundation. J. C. Miller to Mr. Jandry, “Dr. Gremliza—Schistosomiasis,” 18 April 1958, DRC Records (885:1).
77 F. G. L. Gremliza, “Operation of a Mobile Medical Field Unit and Public Health Survey in Dez Irrigation Project Area for the Period September 1959 through June 1960,” 1960, DRC Records (885:7), 49.
78 F. G. L. Gremliza, “Report on the Operations of a Mobile Medical Field Unit and on a Public Health Survey in the Deshteh-Mishan Area of the Khuzestan Region: December, 1958, to June, 1959,” 1959, DRC Records (886:3), 30.
79 Taylor, “Report and Recommendations,” 6.
80 Schistosomiasis is sometimes referred to as “bilharzia” or “bilharziasis.” For an account of a similar campaign against hookworm in the United States, see Ettling, Germ of Laziness. DRC officials consulted some acquaintances from the Rockefeller Foundation on public health policy in Khuzestan and courted the organization for funding without success. For examples, see J. Clayton Miller to Jandrey, Oliver, and Clapp, “KDS Health Staff and Organization, 22 July 1958,” DRC Records (885:1); J. Clayton Miller to Crosby and Mead, “KDS Director of Health, 15 August 1958,” DRC Records (885:1).
81 Similarly, Schayegh (Who is Knowledgeable is Strong, 77) noted that “the principal concern was economic” in relation to malaria control in Iran in the first half of the twentieth century.
82 Public health officials both in Khuzestan and around the world eventually recognized the futility of completely eradicating a disease and shifted their goals toward its minimization. However, in 2016 researchers reported the elimination of schistosomiasis in Iran. Khademvatan et al., “Urogenital schistosomiasis,” 1390‒6.
83 Gremliza, “Survey in Dez Irrigation Project Area,” 1. A more extreme illustration of the internal contradiction between Gremliza’s affection for yet low opinion of Khuzestan’s villagers arises in the travel account of Carl Taylor: “[Gremliza] seems to have a great deal of energy and dedication to the work; he seems to be deeply interested in the village people and has an almost obsessive feeling that they have been neglected; he is appreciated by the village people of the Dasht-i-Mishan area and it is quite apparent that he has spent much time in the villages that we visited ... Now to turn to some of the difficult matters ... he has been training a corps of village lads as assistants for his mass village surveys ... When I commented on this efficiency Gremliza looked pleased and made the comment that he was training them ‘like dogs.’ The analogy, of course, may have different meaning in Germany.” Carl Taylor, “Diary of Trip to Iran: December 5th, 1958,” DRC Records (885:1), 4‒5.
84 Gryseels, “Schistosomiasis,” 388‒9. Gremliza believed in 1959 that schistosomiasis was not present in DIP canals, but Iranian public health professionals determined that not to be true by 1970. Arfaa et al., “Control of Bilharziasis,” 912. Anderson dedicates a chapter of Colonial Pathologies (104‒29) to the role of excrement disposal in colonial public health.
85 Iran’s Institute of Parasitology and Malariology began surveying the area for schistosomiasis nearly ten years before Gremliza began his surveys for the DRC, yet few results are evident. Arfaa, Bijan, and Farahmandian, “Present Status,” 358.
86 For examples in other regions, see Webel, “Infected Landscape” and O’Gorman, “Imagined Ecologies.”
87 J. Gaud and L. J. Olivier, “Report on Bilharziasis in Iran with Special Reference to Khouzistan Development Plans,” 1959, DRC Records (886:1), 9.
88 Gremliza, “Survey in Dez Irrigation Project Area,” 51; Amouzegar, “Health Problems,” 8; J. J. Goulden to New York Office, Attn: G. R. Clapp, “Bilharziasis Survey—Karkheh Irrigation Project by Dr. Gremliza,” 11 December 1957, DRC Records (885:1); John Oliver to J. J. Goulden, “KDS role in Khuzestan: Public Health Activities,” 7 January 1958, DRC Records (885:1).
89 Gremliza (“Survey in Dez Irrigation Project Area,” 1) wrote that “the history of mobile medical field units has been already described and explained in a previous KDS report on the operations of M.M.F.U.,” but it is unclear to which report he referred.
90 Ettling, Germ of Laziness, 125‒6, 158‒9.
91 Taylor, “Diary of Trip to Iran,” 2.
92 The institutional structure of Khuzestan’s public health services posed another challenge to thoughts of centralization. Various organizations existed as “private empires” with both discrete and overlapping activities. They operated in isolation from each other, communicating only with their superiors in Tehran. Taylor, “Diary of Trip to Iran,” 25‒7. Taylor met with many of the major national figures of public health (Chamseddine Mofidi, Jamshid Amouzegar, Torab Mehra, etc.). His short diary relays his conversations with each and their impressions of the state of Iran’s public health infrastructure at the time.
93 Gremliza, “Survey in Dez Irrigation Project Area,” 1‒2.
94 Gremliza, “Survey in the Deshteh-Mishan Area,” 34; Gremliza, “Survey in Dez Irrigation Project Area,” 4.; The MMFU did not survey in July or August of 1959, presumably because of the heat.
95 Gremliza, “Survey in Dez Irrigation Project Area,” 35.
96 By “view,” I refer to Scott’s Seeing like a State. By “return,” I refer to the countless references by both DRC and Iranian officials to their mission of “returning” Khuzestan to its “ancient glory days,” usually dated to pre-Islamic times. A quote from Lilienthal is representative: “This is the land of Cyrus, Darius, and Shapur the Great. Here many centuries ago, irrigated agriculture ... flourished, but with wars, natural catastrophes, neglect and time, much of the area reverted once more to desert.” Anon. Activities, 6. For further reading on the role of idealizations of a pre-Islamic past in Iranian nationalism, see Zia-Ebrahimi, Race and the Politics of Dislocation.
97 Gremliza, “Survey in Dez Irrigation Project Area,” 2.
98 Gremliza, “Survey in the Deshteh-Mishan Area,” 9, 12‒13.
99 Gremliza, “Survey in Dez Irrigation Project Area,” 2.
100 Gremliza, “Survey in the Deshteh-Mishan Area,” 13. Gremliza blamed the 80‒85 percent participation rate average of the six villages in the DIP on the absence of village leaders. His team surveyed twenty-five total villages in the Dezful area.
101 F. G. L. Gremliza, “Selected Ecological Facts on Health in the Dez Pilot Irrigation Area,” 1966, DRC Records (886:5), 86.
102 Gremliza, “Survey in the Deshteh-Mishan Area,” appendix; Gremliza, “Survey in Dez Irrigation Project Area,” appendix.
103 Satralker, “Health Hazards, 21; Gremliza, “Survey in Dez Irrigation Project Area,” 54. Amouzegar wrote in 1957: “Abadan is the only city in Khuzestan which could be said to have a piped water supply, but even at that incomplete. A municipal supply is now being installed for Khorramshahr. Plans are already underway by the Plan Organization for Ram-Hormoz, Dezful, Andimeshk, Khoram-Abad, and Behbahan.” Amouzegar, “Health Problems,” 5.
104 Gaud and Olivier, “Report on Bilharziasis in Iran with Special Reference to Khouzistan Development Plans,” 8.
105 Mead, “Health Problems,” 11.
106 Gremliza, “Survey in Dez Irrigation Project Area,” 51.
107 Communities around Iran had a variety of responses to parasitic worms. Around Isfahan, people would eat thyme or the seeds of bitter apple (Citrullus colocynthis; Persian: hanzal or hendevane-ye abujahl). Janeballahi, Pezeshki-ye Sonnati, 88.
108 On similar epistemologies in nineteenth century Egypt, see Mikhail, Nature and Empire, 202‒13. In the American context, see Valencius, The Health of the Country and Nash, Inescapable Ecologies.
109 KWPA, Quarterly Report 10 on Dez Multipurpose Project for Loan 247 IRN, 31 January 1963, DRC Records (527:4).; On 14 March 1963, an inspection of Shamoun by Mohammad Reza Shah represented yet another, more symbolic manner of state supervision. KWPA, Quarterly Report 11 on Dez Multipurpose Project for Loan 247 IRN, 30 April 1963, DRC Records (527:4).
110 KWPA, Quarterly Report 15 on Dez Multipurpose Project for Loan 247 IRN, 30 April 1964, DRC Records (527:6).
111 KWPA, Quarterly Report 15.
112 The report does not define these medical treatments. KWPA, Quarterly Report 14 on Dez Multipurpose Project for Loan 247 IRN, 31 January 1964, DRC Records (527:5).
113 Out of a total estimated DIP population of 115,430. In the rest of Khuzestan, 18,297 individuals were examined in areas deemed foci of schistosomiasis by Iranian public health officials. Research was supported by the Institute of Public Health Research at Tehran University’s School of Medicine and was funded by the Ministry of Health, the Near East Foundation, and the Plan Organization. Arfaa, Bijan, and Farahmandian, “Present Status,” 361.
114 A Bilharziasis Research Station affiliated with the Institute of Public Health Research was operating in Dezful by 1965, probably under the supervision of Dr. Chamseddine Mofidi. Arfaa, Sabbaghian, and Bijan, “Schistosoma Bovis,” 681.
115 Arfaa et al., “Control of Bilharziasis,” 913‒14.
116 Arfaa et al., “Effect of Hycanthone,” 372.
117 KWPA Mobile Medical Units continued to monitor, test, and treat villagers until at least February 1970, at which time they also completed a census of families living in areas soon to come under the management of international agribusinesses. Development & Resources Corporation, “Monthly Progress Report of Field and Project Advisory Services, January 21, 1970 to February 19, 1970, Bahman, 1348,” April 1970, DRC Records (558:2).
118 These are some of the primary issues addressed by Anderson in Colonial Pathologies.
119 Goodell, Elementary Structures of Political Life, 157.
120 KWPA, Quarterly Report 10; Gremliza, “Ecological Facts,” 79.
121 Goodell, Elementary Structures of Political Life, 148.
122 Qasemi, Barrasi, 38‒9.
123 Gremliza, “Ecological Facts,” 80.
124 When the agricultural growth rate during the Third Development Plan only reached 2.5 percent instead of the 4 percent target, state officials determined the fault lay with traditional cultivation organization rather than their own negligence or unrealistic expectations. Officials decided that international industrial agribusinesses were the solution for strong growth and the Ministry of Water and Power allotted 68,000 hectares of the Dez Pilot Irrigation Project for their use. This decision turned out to be a massive failure in both economic and human terms. The land they received was some of the best in Khuzestan, the Agricultural Development Bank of Iran (ADBI) paid half their start-up costs, their imports were allowed in duty-free, and they were given permission to operate for ten years without paying taxes. The Khuzestan Water and Power Authority “invited” landowners (former landlords and peasants who received property under land reform) to resell their property to the government. Residents of the 100 villages located within the agribusiness operations zones were relocated to shahraks within the zones. One group of three shahraks contained the inhabitants of twenty-five villages, of which twenty-two were bulldozed after the residents were evacuated. Four agribusinesses were operating in the region by 1974, and by 1976 they were massively in debt. The ADBI was forced to take charge of the operations and the entire affair became a scandal. Similar plans around the country were scrapped and new plans had no chance for implementation before the 1979 revolution. For more information, see Salmanzadeh, Agricultural Change, 236‒43; Khuzestan Water and Power Authority, “Farm Corporations for the Dez Irrigation Project, Part I,” 1970, DRC Records (804:3), 8; Najmabadi, Land Reform, 152; Goodell, Elementary Structures of Political Life, 161. Lilienthal (The Harvest Years, 267) had argued for the necessity of larger land plots for higher yields in a private meeting with the shah on 2 November 1961.
125 Goodell, Elementary Structures of Political Life, 172. Ansari (Khaterat, 204) also listed the absence of hospitals and clinics as one of the major complaints of Khuzestanis during his governorship in the mid-1960s.
126 Goodell, Elementary Structures of Political Life, 257.
127 Ibid., 175.
128 Shahrak residents also regularly attempted to keep animals despite regulations. Ibid., 179‒80.
129 Qasemi, Barrasi, 38.
130 Ibid., 39
131 Goodell, Elementary Structures of Political Life, 94, 241‒2.
132 Qasemi, Barrasi, 40.
133 Goodell, Elementary Structures of Political Life, 92, 260.
134 Harris, Social Revolution, 73.
135 For a brief history of this institution, see Nadim, “School of Public Health,” 868‒70.
136 Taylor, “Diary of Trip to Iran,” 21.
137 Carl Taylor, in “Diary of Trip to Iran,” 18, explicitly identifies an “intricate network of rivalries and competing personal interests [among the Iranian organizations] ... The Ministry of Health wants credit for whatever is done but does not want to take responsibility. The Institute of Malariology wants both credit and responsibility but it has neither money, personnel, nor resources to carry through the program that is needed. [Dr. Olivier, WHO representative] says that Dr. Mofidi ... is eager to use this Schistosomiasis lever in order to get appropriations from Plan Organization to build up the Institute laboratories into a National Institute of Health.”
138 Satralker, “Health Hazards,” 8.
139 For example, Lilienthal (Road to Change, 273) wrote in his diary, “Much as the Gremlizas apparently love the Arabs, they have no illusions about them vis-à-vis the Persians, in teachability, cultural background, etc.”
140 Arfaa et al., “Control of Bilharziasis,” 913.
141 Arfaa et al., “Effect of Hycanthone,” 369.