Questions around health and disease exceed the realm of medicine. They pertain to science, conceived as knowledge and mental structure through which humans interpret the experience of living and the embodiment of the natural world. In being essential frames of knowledge, health and disease—as much as life and death—they belong to a cultural and political sphere, maintaining an inescapable symbolic place in human affairs. Hence, to explore the history of health and disease means coming to terms with issues of life and politics, of governance and culture, of agency and structure. Consider the opioid epidemic causing hundreds of thousands of deaths in the United States: can a history of people’s relation to opioids do without considerations of politico-economics and cultural ideology? Does America’s form of government, embodied in the profiteering interest of the private pharmaceutical industry in tandem with the culture of never-ending consumerism, affect the unwrapping of the opioid epidemic? And does this health phenomenon bear upon institutional developments and historical trajectories in American society? Without being teleological, the response seems to lean towards the affirmative and future historians will have much food for thought on today’s health/political emergencies.

This nexus is not peculiar to the contemporary globalized world order. During Iran’s period of Constitutional Revolution (1906–11), many intellectuals had clearly identified how national emancipation, social justice and global politics intermingled with the imperatives of public health. In the journal Kāveh (1921), Sayyed Hasan Taqizadeh wrote that

Amir Arsalan Afkhami’s book, A Modern Contagion: Imperialism and Public Health in Iran’s Age of Cholera, is a fine example of how medical history helps us explore the nexus of global politics, life and disease in the making of the modern world. The book consists of an introduction, five main chapters, an epilogue and four appendixes. Its author is a scholar at ease with multiple disciplines: Afkhami is a psychiatrist who has researched global health and history, a position of strength from which he skillfully dissects how cholera transformed modern Iran.

Cholera is an infectious disease caused by a bacterium (vibrio cholerae) which spreads and multiplies in the small intestine. It often results in severe diarrhea, vomiting and life-threatening dehydration and systemic shock. The pandemic outbreaks, which originated in the Ganges delta, spread across continents following the movement of the British navy in the pursuit of trade and in protecting colonial interests.Footnote ² As Afkhami narrates, after a century of intermittent tribal conflict in the eighteenth century, the Qajar dynasty succeeded in enforcing a degree of territorial control, which in turn facilitated trade and pilgrimage routes along which the disease circulated, causing havoc across Iran.

From the early 1800s, cholera swept cyclically across the Iranian plateau every decade, meting out death indiscriminately, like no other historical force. In 1847, between 10 and 25 percent of Tehran’s population perished due to cholera infection, a catastrophe that also reached the shah’s immediate familial and governmental circles. Diseases must have had a deep impact on the psyche of Iranian rulers, who feared dying of poor health as much, if not more, than at the hands of royal contenders or invading armies. Hypochondria mingled with the specter of pandemics, an avenue where historians could dwell in future years.

Fear, as is often the case, is driven by ignorance. Indigenous medical knowledge relied upon either Galenic humoralism, as practiced by allopathic physicians trained according to Avicenna’s Canon, known also as tebb-e yunani (lit. Greek medicine), or embracing a fatalistic surrender in God’s hands whereby healing would occur by praying, through the mediation of people of special spiritual power or by simple miracle, all falling under the vague rubric of tebb al-nabi (prophetic medicine).

Political and intellectual elites captured the opportunity represented by the inefficacy of traditional healing practices in order to push a modernizing agenda in which public health policies were part and parcel of wider structural reforms in governance, cohabiting with the creation of new public educational institutions, such as the Dar al-Fonun. Contextual to this changing perception of humans in the world was the geopolitical challenge of governing Iran amidst the challenges of the Russian and British empires.

It is in this encounter that the book offers its most valuable contribution. By situating the Iranian narrative in a transnational perspective—after all, something inherent to the nature of cholera, a transhumant viral manifestation of bacterial disease—the book provides a compelling case of how health and geopolitics shape each other. The reader learns that the management of quarantine sites is not only a matter concerning public health; it is also—and rather—a question of strategic political value, which counterpoises British trading interests to Russian bids in Central and Western Asia.

The book also includes a number of maps where the reader can trace cholera’s journey across lands and seas from the Indian subcontinent and Mesopotamia, where borders are sites of strategic contention in anti-epidemic defense. (On a more trivial note, the first map, opposite the title page, is imprecise: the map locates Borujerd approximately to the south of Isfahan; instead it is at the heart of Iraq-e ʿAjam, which unfortunately is also misplaced on the map as south of Tehran, whereas it is in fact centered around the city of Arak, then called Sultanabad. The map on page 47, however, is correct and very informative about cholera’s movements in 1889.) In bringing to light this historical picture, Afkhami enriches the scholarship on the Great Game with fresh nuance. Others may be able to look into the Russian archives to expand further this line of inquiry.

Afkhami’s contribution to global history does not undermine the specific benefits to Iranian studies. The book builds upon the momentum in medical history and, more generally, studies of health in modern Iran, as exemplified by several publications in the last decade.Footnote ³ It is true that the author has a multidisciplinary gaze, but his work is a historian’s work, archive-based with a rich collection of primary material from Persian, English and French sources. Its five chapters, organized in a chronological order encompassing the period from 1821 to 1926, capture how the disease shaped the major historical junctures of Qajar Iran. The acknowledgement of health as a historical factor is no minor element, as the book reveals the profound influence that cholera had on key events such as the Treaty of Erzurum (1823), the Tobacco protest (1890), the Constitutional Revolution and the aftermath of World War I. This is enough for future historians to rethink the conventional histories of a long century of state formation that paved the way for Iran’s public health system and political order in the twentieth century.

One of the ways in which the author could have discussed cholera as a multifaceted phenomenon—made of bacterial, cultural and political determinants—is the category of syndemics.Footnote ⁴ Syndemics are about contexts: they take into account the cluster of individual circumstances, community conditions, biomedical phenomena and structural power relations that determine health outcomes. First formulated in the nexus of substance abuse, violence and the HIV/AIDS epidemic, syndemics could be reframed to understand how Iranians experienced competing waves of disease, famine, opioid abuse and violent conflict in the long century discussed in the book.

Afkhami himself expresses clear interest in the subject of narcotics, opening and concluding the book with a broad-brush criticism of the Islamic Republic of Iran’s drugs policy. This is the only section of the book where the author relies on media reports, and this reliance weakens the scholarship of his argument in two key parts: the introduction and conclusion. He compares the cholera epidemic to the opioid epidemic of post-revolutionary Iran, arguing that both have been caused by governmental negligence, religious superstition and lack of a strong diplomatic strategy with neighboring countries. Afkhami places the burden of what he refers to as “the scourge of drugs,” using an early twentieth century terminology, on religion and on Iran’s illiberal state. They both impede an evidence-based approach to narcotics, just as clerical cadres had opposed anti-cholera measures in the nineteenth century. In taking this position, he is oblivious to the fact that draconian measures against drugs were not the product of Islamic religious activism—or exclusively the clergy—but rather of the modern secular state which sought to ally itself with western models of governance. Before the Islamic Republic, it was Mohammad Reza Shah who had first applied the death penalty for drug traffickers, concomitant with an avant-gardist opium distribution program which started in 1969, in an attempt to move beyond US-led drug prohibition and the rise of heroin “addiction” in the 1960s.Footnote ⁵

It may come as a surprise to read that the Islamic Republic’s former head of the judiciary, Ayatollah Shaikh Mohammad Yazdi, declared that ‘the death penalty for drug crimes is the product of states, not of religious law’.Footnote ⁶ The statement occurred ahead of Iran’s suspension of the death penalty for drug offences in 2017, a change in policy that reduced the number of death sentences by 80 percent. Overall, Iran’s drugs policy since the 2000s has demonstrated openness to policy experimentation and scientific research in the field of prevention and treatment, gaining the praise of international organizations, including the World Health Organization and the United Nations Office on Drugs and Crime. If one considers the skyrocketing levels of violence in countries with similar drug problems, such as Mexico, Colombia or Myanmar, levels of violence in Iran are significantly lower.

Instead, the country’s collaborations with regional partners have been systematically hampered by US administrations’ opposition in Afghanistan and Pakistan, rather than solely caused by the unwillingness or “diplomatic missteps” of Iranian governments. True, were Iran a US ally, the country would probably be the recipient of large-scale support of US funding to combat the flow of drugs (as it had been, with very poor results, in the Pahlavi era). It is true that much needs to be done on the Iranian side (and internationally: the US invasion of Afghanistan triggered a constant rise in the opiate economy and now meth production). As much as a world without disease is a pipe-dream, a world without drugs is an impossible thought, so a change in the interpretative paradigm is perhaps what is needed most. It may be that drug use in Iran is partly the pursuit of the mirage of “living life more fully,” partly a socializing practice in the absence of avenues of expressing desire in the public, and partly a mechanism for coping with epochal disruption caused by revolution, war and sanctions.

That aside, the book’s substantial chapters are a carefully researched, descriptively rich, highly readable and solidly global history of health and disease in the guise of cholera and policies to counter it. Undoubtedly, the book will be of great interest to scholars and students of modern Iranian history as much as historians of medicine and imperialism, in the global South and North.