A Letter from Catherine Thomasson, M.D.
Notes on Esfehan: Religious Freedom and the Health System
March 10, 2007
Dear friends:
We moved on to Esfehan — a beautiful city with eight beautiful bridges spanning the central river. At the heart of this city as in many cities there is a central mosque called Jameh Mosque. Begun as a structure in the 8th century, it may have been built onto a Zoroastrian temple (a monotheistic religion that predated the rise of Islam, brought by the Arabic invasion in the 7th to 9th centuries). Deep in the building, huge round pillars are covered with incredible brickwork design in the original structure. Over another archway in one of the openings is an example of intertwined branching stucco of the Mongol era. There is a maze of rooms with archways of different styles that we moved through, opening into a central courtyard — a feature of all mosques.
In the courtyard — on this 40th day of mourning for the death of the Imam Hussein, grandson of Mohammed — families have come to visit from the countryside and are having picnics. Children play as they do everywhere. The courtyard has four major entry ways that are decorated with beautiful tiles, along with the mosaics covering the interior of two huge domes.
We also visited Armenian churches, a Zorastrian temple, and a Jewish synagogue. The churches are located in the Jolfa region of Esfehan, along with 13 other Christian churches, mostly for the largely Armenian population. It appears there is freedom of religion for most religions: corroborated by Jewish families we met on the street! In fact, the largest religious library in the religious center of Qom has a very large number of handwritten Hebrew bibles displayed alongside ancient qur'ans. Conservative Islamic clerics advised us that both Christianity and Judaism are considered religions that also emanate from God and so are honored.
The center of Esfehan has one of the largest public squares in the world, a world heritage site. It is rimmed by a huge bazaar selling beautiful handcrafts and rugs as well as spices and other items. Interspersed within the square is the palace of the kings (shahs) of the 17th century as well as two mosques. The Imam Mosque has a double-layered dome that provides an incredible acoustic experience. Our guest host chanted the azzen, the call to prayer; it was amplified and beautiful. The mosaic work in the private king’s mosque called Sheikh Lutfollah Mosque was decorated with beautiful cream mosaic work. Across from it, the palace of Ali Qapu gave the Shah Abbas commanding views of the activities of the square.
The square and the bridges of the city are full of people willing and interested in talking. We spoke with high school students, professionals, and even those visiting from the country. They describe their daily life much like ours, with a healthy skepticism of television news.
We had no formal meetings in Esfehan, but many questions were answered throughout the trip about the medical system. The constitution of Iran basically sets access to medical care as a right of the people. The country has moved from one in which most upper-class children were educated outside of the country to a strong system of public universities and health education. The first university was built in Iran in 1935. In recent years, public university education is considered of higher quality than newer, private-pay universities in the country. Likewise, medical schools are felt to be producing an adequate number of all types of professionals, though most of the advanced medical care is found primarily in the cities. One-third of physicians are women. They work at a variety of locations — from public hospitals, which accept everyone and all forms of insurance, to private hospitals, which in some cases are better run if they’ve been set up by a business that has decided to open a facility for charity. Health care workers, like many workers in Iran, work long hours
The demand for more sophisticated care is rising, though the care is really quite advanced in urban settings. 96% of all pharmaceuticals are produced within the country as generics. The concept of insurance has been introduced relatively recently and limits care in some ways and has added the process of "co-pays." There are five medical conditions — which include diabetes and chronic kidney disease — for which all care is covered. There are separate insurances as well for veterans of the Iran-Iraq war and for families of those who’ve died or are disabled. Recently, a new insurance for the poor has been instituted. Most services are covered either by the public sector or through insurance. Some bureaucratic issues get in the way, such as: only men can register for their families, unless the woman has proof of a husband’s death or a recently-allowed divorce.
The rural areas are served as well by the Primary Care Network staffed by lay educated workers each responsible for 25 families. They are trained to provide public health education, vaccinations, and family planning, of which all types are available and free. HIV cases are rising (though still well below that of many other countries) and we saw two very well done public health posters at the airport in Tehran outlining the “A, B, C's” which stand for Abstinence, Being monogamous, and using Condoms. The largest population with HIV is heroin addicts, which has risen in recent years with the loosening of social laws and enforcement.
Public health statistics are markedly improved since the Islamic Revolution. Life expectancy has risen by a decade to 70 years, infant mortality is down to 33 per 1000 from 85 per 1000 in 1980. Population growth rates as well have plummeted faster than any developing nation, from a high in 1986 of 3.2% (when large families were still espoused by the clerical leadership) to 1.2% today. This trend is encouraged by limiting maternity leave benefits to three children and requiring family planning education for both men and women prior to receiving a marriage license. Of course, this change in religious policy is also backing the new family planning support.
Population control has also helped loosen the strain of absolute water shortages facing the country, though food imports are rising due to lack of irrigation water. Malnutrition rates, while improved, still have pockets of problems both in the rapidly increasing urban population and in rural areas. 92% of the population have good access to clean drinking water, one of the highest in the region, though many areas such as Tehran provide no waste water management. Small epidemics of cholera still occur as a result.
Now we are off to Qom.
