The demographic impact of the First World War on Iran, particularly during the famine years between 1917 and 1919, is the subject of controversy among researchers, laymen, and politicians. Historians have famously debated the root causes and precise number of casualties in this period, leading to bitter exchanges, “wild accusations,” conspiracy theories, and a high rate of historical revisionism—even by the standards of contemporary Iranian historiography.Footnote 1 Iran’s Supreme Leader Ayatollah Ali Khamenei weighed in by proxy on the matter through his website by subscribing to the claim that the famine was a genocide committed, and later covered up, by the British authorities. Scholars who disagree with Khamenei’s interpretation of this period, including one of the contributors to this issue of Iranian Studies, have been attacked on his website.Footnote 2 Other Iranian hardliners who have echoed this perspective have also, rather perversely, characterized recent documentary programming by the British Broadcasting Corporation on the period as a ploy by the United Kingdom to highlight Iran’s feebleness on the global stage.Footnote 3 The diverging assessments on the impact of the First World War on Iran has been fueled by the scholarship’s overreliance on Western diplomatic dispatches and memoirs, which were diminished and distorted by the conflict. The Allied powers had downsized their diplomatic presence in Iran at the outset of hostilities and the Central Powers only occupied a sliver of the country’s east after 1916. This resulted in a significant reduction of dispatches on issues that were not of an immediate military or strategic import. Similarly, the bulk of memoirs from the period, usually written by military staff, were either slanted by the writer’s ideological leanings or myopic due to their single-vantage perspective on larger national events with regional variability such as scarcity and disease.
Austrian psychologist Fritz Heider has postulated that finding causal explanations for events is a necessary component of building a stable and internally consistent understanding of one’s environment and the world.Footnote 4 At the heart of Iran’s epistemic polarization on the events of the First World War lies a deep human impulse to fill the historical void by creating causal explanations from limited data in a desperate effort to maintain one’s necessary individual and socio-psychological homeostasis.Footnote 5 In other words, the scarcity in both quantity and quality of data on the prevalence of death, deprivation, and disease in Iran during this period has been the principal driver of interpretive divergence, distortions, and conspiratorial constructs in the scholarship. This calls for a closer and more systematic examination of non-diplomatic medical and public health archival sources from 1914 to 1919, particularly the proceedings of the Iranian Sanitary Council, to reduce some of the prevailing attribution biases that dominate both the public and professional discourse on the morbidity and mortality in this period.
The Anglo-Persian Oil Company (APOC) Medical Records
The records and correspondences related to the medical activities of the Anglo-Persian Oil Company (APOC) are one of several underutilized sources of data on the impact of the First World War on the Iranian population.Footnote 6 The APOC’s medical services in Iran began in 1907 when Morris Youdelevitz Young, known as “the little doctor,” became the chief physician to the Concessions Syndicate, a forerunner to the APOC. He occupied this post through the First World War.Footnote 7 The APOC spent hundreds of thousands of pounds sterling from the pre-war years to the 1920s on the healthcare of Iranians “in order to fit Persian subjects for employment.”Footnote 8 The company founded an eighty-four-bed hospital in Masjed Soleyman and a larger medical facility in Abadan. By the 1920s, the hospitals were staffed by several doctors and were equipped with surgical suites and x-ray machines. They performed hundreds of operations every year as well as dental procedures. The APOC regularly inspected the water and food supply of its laborers, and the hygiene of the markets near its facilities, including the vegetable bazaar in Masjed Soleyman, which came to be known as the “cleanest bazaar east of Suez.”Footnote 9
The APOC’s Sanitary Section conducted plague prevention and eradication campaigns, including fumigation, rat-trapping, and necropsy of animals suspected of carrying the disease. Malaria, which was hyper-endemic in southwestern Iran where most of the APOC facilities were located, infected a significant portion of the company’s native workforce in this period. This prompted the APOC to engage in significant “conservancy work in order to keep within control the ubiquitous fly” that carried the disease.Footnote 10 It also regularly disinfected its buildings and the houses of its employees with sulfur to reduce the overall rates of infectious diseases. And it vaccinated its workers against smallpox, monitored the progress of epidemic outbreaks, and regulated burials in areas where its facilities were located.Footnote 11
Church Mission Society (CMS)
The records and correspondences related to the medical activities of the Anglican Church Mission Society (CMS) from this period have also been underutilized.Footnote 12 The CMS’s involvement in Iran’s healthcare began with the establishment of a hospital in Isfahan’s New Julfa district by Dr. Robert Bruce in 1879. Fifteen years later, Dr. Donald W. Carr and Mary Bird established two more dispensaries in other quarters of the city.Footnote 13 In 1897, Dr. Emmeline Stuart created a gynecological unit attached to the second English Hospital in Isfahan.Footnote 14 The CMS also founded hospitals in Yazd (1898) and Kerman (1901).Footnote 15 By the 1920s, its medical facilities in Isfahan had a total of 200 hospital beds (120 beds for men and 80 for women); including private wards for upper-class patients, isolation beds for patients with tuberculosis, and surgical wards with well-equipped operating theaters (Figure 1). The CMS hospitals also had laboratories which allowed its physicians to conduct paraffin tissue embedding and histological investigations, blood culture analysis, blood typing, and bacteriological diagnosis.Footnote 16 These hospitals played a crucial role during the First World War years as epidemics and sick refugees, both internally displaced and from Ottoman territories, overwhelmed the country’s limited healthcare infrastructure. The CMS also played a key role in implementing the British government’s famine relief activities. London saw the famine as a strategic threat to its interests in Iran. The diplomatic correspondence between the British ambassador in Tehran and his superiors clearly show that they sought to address the unremitting food insecurity in Iran, lest it play into the hands of “extremists” such as the secessionist Jungle Movement (Jangali), which had proclaimed the Caspian province of Gilan an independent Soviet Socialist Republic.Footnote 17 The British spent considerable sums of money on importing flour to reduce the price of bread in Shiraz and spent thousands of tumans on a monthly basis for relief work in Tehran, Mashhad, and Hamadan.Footnote 18 Even the British ambassador’s wife, Lucia Marling, began her own independent relief work in Tehran (with her husband’s consent) feeding over seven hundred and fifty people daily at the height of the famine in the capital in 1918.Footnote 19
Surgical theater at the CMS hospital in Yazd (postcard).
Source: Author's collection.
The Iranian Sanitary Council
The printed transcripts of the meetings of the Iranian Sanitary Council (majles-e hefz-e sehhat) are probably the most important systematic record of population health in Iran during the First World War. It is also surprisingly underutilized in the historiography of the period. The Iranian Sanitary Council, made up of prominent Iranian and European physicians in Tehran, was first convened by Nasir al-Din Shah’s trusted French physician-in-chief, Joseph Desiré Tholozan, in response to a growing threat of pandemic cholera in the winter of 1867. The Council met sporadically in the ensuing decades, mainly during major epidemics such as the bubonic plague outbreak of 1876 and the cholera epidemics of 1889 and 1892.Footnote 20 Its proceedings, standardized in 1877 by the shah’s minister of public instruction, Aliqoli Mirza Eʿtezād al-Saltaneh, began with a detailed report on mortality and morbidity in the capital, followed by a listing of death rates and prevailing diseases in the provinces based on information supplied by corpse washers and physicians.Footnote 21 By 1904, the Sanitary Council began meeting on a more regular basis, and not just during periods of national emergency, under the presidency of Mozaffar al-Din Shah’s French military physician, Jean-Etienne Justin Schneider. Two years later, the newly convened Iranian National Assembly furnished the Sanitary Council with a modest budget that allowed it to meet on a monthly basis, gather epidemiological data from the country’s major districts, and publish its proceedings. The printed transcript of each meeting was distributed within the government and among all major embassies in Tehran.Footnote 22 However, the Sanitary Council remained largely advisory, focused on gathering and reporting on regional morbidity and mortality figures and formulating sanitary and disease prevention policy for the government. Its inability to take on operational responsibilities was largely due to its limited financial resources and the political machinations of European imperial powers.
The Sanitary Council’s impact on Iran’s public health changed drastically after the first constitutional period in 1908, especially when the Second National Assembly (1909–11) agreed to expand the scope and power of the organization. The Council began reporting directly to the Ministry of Interior and received an independent budget derived from a tax levied by the Customs Department on cadavers bound for burial in Shiʿite shrines. This reduced the pressures exerted by both domestic and foreign interests, through discriminatory funding, that had hindered earlier sanitary interventions. Following the Lesser Tyranny (1908–9), a growing cadre of respected and patriotic young European-trained Iranian physicians gradually assumed a more proactive and vocal role on the Sanitary Council. They enhanced its executive capabilities, dividing its financial, staffing, and sanitary duties among three permanent commissions in addition to enacting a number of other organizational and fiscal improvements. These measures, and the backing of the progressive Second National Assembly, allowed the Sanitary Council to assume an increasingly operational role, taking proactive steps against epidemic outbreaks by improving urban hygiene and establishing sentinel disease detection on the country’s borders; including sanitary stations and lazarettos at Qasr-e Shirin and the Caspian Sea ports of Astara and Anzali.Footnote 23
The dissolution of the Second National Assembly did not stop the Sanitary Council’s momentum. It began an ambitious national vaccination program in 1911 with the purchase of smallpox sera from Paris and the appointment of public vaccinators throughout country. By 1912, the campaign had successfully immunized a significant number of school-aged children, despite shortfalls in the number of government vaccinators and prejudice against the procedure among the common population. The latter prompted the Sanitary Council to institute Iran’s first public health advertisement campaign to encourage vaccination, including posters and brochures written in colloquial language warning people of the dangers of smallpox and the lifesaving benefits of the procedure. These proactive disease detection and prevention measures reduced the impact and scope of epidemics in the year immediately preceding the First World War.Footnote 24
With the outbreak of the First World War in 1914, the Sanitary Council’s capabilities gradually declined. Financial shortfalls and political chaos in Tehran curtailed the Council’s ability to enforce hygienic regulations or carry out the necessary measures against epidemic and endemic diseases. Many European physicians who held key positions on the Council began leaving Iran to join their respective armies in the West. A number of temporary vice presidents, who lacked the consensus power of their predecessors, led the Sanitary Council until Amir Khan Amir Aʿlam (1876–1961) took over as ‘permanent’ president in January 1916.Footnote 25
Document: “The 150th Session of the Sanitary Council of the Persian Empire”Footnote 26
The 150th session of the Iranian Sanitary Council (Figure 2) was convened on the afternoon of 6 April 1915. Jacques Philippe Gachet, a French physician and professor at the French naval medical school (L’École de médecine navale de Rochefort), hired to teach at the Polytechnic College (Dar al-Fonun), was the titular president of the body since his arrival in Tehran in 1911. But like other European military physicians, he left Iran at the outbreak of the First World War to rejoin his unit in France. ʿAbd al-Ahad Sulayman Qazala Bey, a Chaldean physician from Baghdad and the Ottoman legation’s physician in chief in Tehran, led the meeting in his absence. Physicians to the legations of United States, Britain, and Russia who had remained in Tehran despite the outbreak of hostilities also attended the meeting along with representatives from the principal government ministries, Imperial Hospital, and the Indo-European Telegraph. A number of prominent Iranian physicians in Tehran, including Amir Khan Amir Aʿlam who would assume the Sanitary Council's mantel several months later, also attended the gathering.
Transcript of the 150th session of the Iranian Sanitary Council convened on April 6, 1915.
The hours-long meeting, which was conducted in French and translated into Persian, began with a presentation on the “sanitary situation” in the country, including the outbreak of typhoid fever in the province of Azerbaijan, and the cities of Mashhad and Tehran. After discussing the efficacy of vaccination against typhoid, the Council agreed to request a supply of a newer anti-typhoid serum created by the Pasteur Institute’s André Chantemesse.
Enteric diseases such as typhoid fever and amoebic dysentery were a regular feature of urban life during the Qajar period due to the exposed water, sewage, and waste disposal infrastructure in Iranian cities. This made food and drinking water vulnerable to fecal oral diseases as described in the transcripts of a Sanitary Council meeting several months earlier, which linked the ongoing typhoid fever epidemic in Tehran with its municipality’s practice of disposing of the city’s garbage next to the open water channels (jub) at the Dawlat and Yusefabad gates of the capital.Footnote 27
As its second and third items of business, the Sanitary Council reviewed the latest information on the progress of the plague epidemics in neighboring Baghdad and Bahrain and the threat of their extension to Iran’s frontiers. This was followed by a report on infectious disease-related morbidity rates in major Iranian cities during a nine-month period in 1914. Two statistics stand out in particular, the number of new cases of malaria in both the north and the south of the country and the high rates of syphilis, particularly in Isfahan and Kerman. The British legation’s physician, Anthony Neligan, who served on the Sanitary Council maintained that venereal diseases were “widespread among all classes” in Iran during this period.Footnote 28 Untreated (or under-treated) gonorrhea (suzāk), in particular, was credited as being the primary cause of sterility amongst Iranian men.Footnote 29 While Neligan agreed that syphilis was widespread, he maintained that the prevalent strains of the disease in Iran were milder in nature and did not attack the cardiovascular system, the nervous system, and the skin with the same frequency observed in Europe. As a result, cases of paralysis caused by neurosyphilis, aneurysms caused by cardiovascular infections, and non-cancerous cutaneous growths (gummas) were infrequent. In addition, Neligan claimed that hereditary syphilis, or the vertical transmission of the spirochete bacterium responsible for the disease, was extremely rare in Iran despite the number of infections.Footnote 30
As its fifth order of business, the Sanitary Council reviewed the latest reports on the country’s vaccination services, including the growing demand for diphtheria and typhoid vaccines in the provinces and the need for more vaccinators. The report on the vaccination services in the city of Mashhad described the poor quality of vaccine sera, which contributed to the dwindling number of people in the city that sought to be inoculated during the previous three months and induced the city’s government-appointed vaccinators to turn down their stipends since they felt unable to “render a service that deserves compensation.” Iran’s reliance on imported antigen and serum to meet its needs meant that the country’s vaccine stocks were not only limited but also often spoiled due to poor refrigeration in route. This was one of the greatest motivations for Iranian sanitarians to seek indigenous means for vaccine production in the ensuing years.Footnote 31 Despite the poor quality of the vaccines, however, a request by the governor of Tehran and the interior ministry for more vaccinators to be certified by the council showed that the overall demand for immunizations continued to trend upwards in tandem with the frequency of epidemic diseases during this period.
As part of its sixth, seventh, and eighth order of business, the Sanitary Council delved into more administrative matters such as updates on the country’s sanitary establishments and finances. This included an inventory of medical and non-medical supplies at the sanitary station in the Caspian Sea port of Anzali, and a breakdown of the Sanitary Council’s outlays and funds raised to cover its expenses through taxes on burial-bound cadavers over the preceding year. Future expenditures, such as the expected costs of acquiring a permanent headquarters were also agreed upon. The Sanitary Council’s overall consensus, thoroughness, and systematic approach to plenary and budgetary matters during the meeting reflected the progress that Iranian sanitarians had achieved in the administrative aspects of public health after the first decade of the twentieth century.
For its ninth order of business, the Sanitary Council deliberated on general correspondences, including a letter by an important “religious authority” calling on the body to formulate effective measures against the spread of venereal diseases. The ensuing discussion on the subject included a recognition that Iran’s distinctive mores called for prevention measures that were different than those of Europe and the need for a comprehensive multi-tiered intervention to educate the population, particularly the youth, on the risks of sexually transmitted diseases. This was followed by a report by the Sanitary Council’s Hygienic Commission and the Commission on Personnel and Discipline on their activities, including producing better maps of caravan routes in the country’s southwestern frontier, manpower and jurisdictional issues at lazarettos and sanitary stations, and new vaccination posts and vaccinators. It should be noted that the archival section of the meeting recorded that the Sanitary Council had received the transcripts of the latest meeting of the Board of Health in the neighboring Ottoman Empire and the International Office of Public Health (Office Internationale d’Hygiène Publique), which Iran had joined in 1909. The office, located in Paris, was the first permanent global health organization created to oversee international rules on preventing epidemic outbreaks. It also collected and disseminated epidemiological data on infectious diseases, particularly plague, cholera, and yellow fever, and exchanged crucial information on the public health regulations of its member states.Footnote 32 This shows that the First World War did not significantly interrupt the flow of information on matters of public health and epidemiology between Iran and the West.
Parting Remarks: Famine or Disease, Does it Matter?
The Cambridge Dictionary defines famine as “a situation in which there is not enough food for a great number of people, causing illness and death.”Footnote 33 Yet scholars of the First World War in Iran often appear to justify their demographic opinions on the impact of the famine by differentiating between fatalities caused by scarcity versus epidemic diseases; thereby positioning the casualty figures within the very narrow confines of homeostatic hunger, and ignoring that hunger is a subjective experience of discomfort and not a biological process. As such, while hunger can be a symptom of inadequate dietary intake, it is not, strictly speaking, fatal or even, for that matter, a pathological process. This is reflected in both the embrace of ritualized hunger throughout history and a number of biomedical studies in recent years that have supported the health benefits of intermittent fasting. On the other hand, undernutrition, or the insufficient intake of calories, protein, and micronutrients to meet one’s functional needs can have a number of pathological consequences, resulting in observable physical effects. While prolonged starvation, or a total lack of nutrients needed for the maintenance of life, can cause permanent organ damage and eventual death, it is often not the primary driver of mortality during famines. Long before starvation becomes fatal, famine-struck populations usually succumb to infectious diseases or other illnesses. Famines that are triggered by periods of drought, such as the Iranian famine during the First World War, are closely linked with increased difficulty accessing clean drinking water, resulting in higher epidemic outbreaks of enteric diseases like cholera. Starvation also increases infection risk by lowering salivary and stomach acid levels that serve as the primary barriers against a number of ingested infections. The consumption of famine foods, such as opium in Iran, also contributes to lowering immunity against diseases ranging from cholera to influenza.Footnote 34 These examples illustrate that while numbers are important, splitting hair on the etiology of the period’s mortality between famine and diseases is at best myopic and at worst plain wrong. Rather, scholars of Iran during the First World War should view the prevailing famine and epidemics as part of an interconnected circle emerging from the larger, multifaceted, social vulnerabilities of the period.
