At a cancer treatment center in Iran's capital of Tehran, a doctor's fight to treat her cancer patients has become harder. As U.S. sanctions sink in, the flow of medicine and medical supplies in Iran appears to have slowed — and the reasons are difficult to pin down.
Dr. Mastaneh Sanei, an oncologist at the Roshana Cancer Center, says she's treating patients without the benefits of consistently functioning equipment and a reliable supply of drugs.
With the right treatment, she says, "you may not cure these patients, but they have the chance to prolong survival."
The shortages affecting Iran's hospitals and clinics are a particularly perilous example of an economic crisis that has worsened since the Trump administration reimposed economic sanctions on the country. The 2015 nuclear deal offered Iran economic relief in exchange for limiting its nuclear program, but the U.S. withdrew from the agreement last year and penalize doing business with Iran's oil, banking and other sectors and individuals.
U.S. officials insist that the sanctions explicitly do not apply to medicine or medical devices. But trade experts say heavy restrictions can have an impact on business decisions in sectors that may not have been targeted. Meanwhile, each nation's government blames the other for the squeeze on medicine.
Iranian Foreign Minister Javad Zarif has accused the U.S. of "economic terrorism" and of cutting off access to cancer drugs. The allegation is so explosive that Brian Hook, the U.S. special representative for Iran, addressed Iranians directly in a video, calling it a "myth."
In an interview with NPR, Hook blamed Iran's government, saying that "one of the challenges that medical supply firms have had is that when medical devices are imported, the devices that were supposed to help the Iranian people, the regime ends up selling them at a much higher price for profit."
In July, Iran's presidential chief of staff said that money for essential goods, including medicine, had disappeared, something U.S. officials cite as an example of how corruption has prevented drugs and medical supplies from reaching hospitals. Hook told NPR that in that case, more than 1 billion euros intended for medical supplies had disappeared.
Praying the radiation machine doesn't break
The Roshana Cancer Center is decorated with statues of angels — because "they save you," Sanei says.
Many specialists in Iran are worried about their ability to save patients.
Sanei says she likes her work. "Every day, new things happen. Every day, new discoveries," she says. But she is slowly being cut off from access to discoveries in the field.
She has been unable to access international research websites and medical journals. "Scientific sites have blocked us," she says, so she has trouble accessing "lots of research and union guidelines for cancer treatments in the world." And her colleagues desperately hope their technology doesn't break in ways they can no longer fix.
Through a door with a radiation sign, there's a huge radiation therapy machine from the U.S.-based company Varian Medical Systems.
On this day, it's working. But the doctors say it's hard to maintain the machines and obtain replacement parts when something breaks. "You don't have access to the main company, and you are not able to buy the spare parts we need," says Sanei.
Varian tells NPR that it does sell cancer care systems to Iran. It's an example of a disconnect between what U.S. companies and the government say they are doing and what medical care providers in Iran are experiencing.
A long-term problem
While the problem has intensified recently, Iran has experienced medicine shortages before.
In a 2012 report, then-United Nations Secretary-General Ban Ki-moon wrote that the "sanctions imposed on the Islamic Republic of Iran have had significant effects on the general population," among them "a shortage of necessary items, including medicine."
Part of the reason, he wrote, was concern about whether certain banking transactions would be allowed under the sanctions.
"Many foreign banks have stopped doing business with the Islamic Republic of Iran altogether, which has made it considerably difficult for Iranians to transfer funds and for private businesses to obtain lines of credit," the report said.
The unwillingness of companies and financial institutions to engage in business with Iran, even to sell goods such as medicine that are exempt from U.S. sanctions, is likely contributing to the current shortage.
"There are so many sanctions and they are so complex and they cover so many entities in Iran, especially in the financial sector, it's very difficult to find legal, viable, credible, efficient business counterparts in Iran for international businesses to do business with," says Elizabeth Rosenberg, a former Treasury Department sanctions official.
Even if Western companies do find Iranian business and banking counterparts, Rosenberg says, there's no telling what can happen along the supply chain. "Now most of the big [Iranian] banks are designated [for sanctions], and as you can imagine, any smaller bank doesn't have as much capital on hand, they may have less capacity to handle cross-border financial transactions, and they may also not have in place some of the appropriate controls for safety and soundness or anti-money-laundering controls."
Alan Enslen, an international trade lawyer at Baker Donelson in Washington, D.C., says it isn't just financial institutions that are reluctant to do business with Iran; it is also shipping and other companies along the chain. "Everybody feels like they're putting themselves at risk and so it has to be worth it," Enslen says. "I know it sounds like economics prevails over humanitarian concerns, but sometimes that's just the reality of how it plays out."
An article published in March by the Washington, D.C.-based think tank Atlantic Council said the Treasury has previously "prosecuted medical companies for selling small amounts of medical supplies to Iran, which in turn, has had a deterring effect on other companies doing business with Tehran."
The U.S. exported $12.5 million in pharmaceutical preparations to Iran last year, down by more than 80% from the annual total in 2009, according to the U.S. Census Bureau.
Europe has also reportedly reduced medical exports to the country. The European Union — which remains in the Iran deal and pressed the U.S. not to withdraw — set up a special office to finance food and medicine for Iran, but its work has begun slowly.
"People are poorer than they were before"
The economic toll of the sanctions isn't immediately visible in Tehran. Streets are bustling. Restaurants and cafes in many parts of the city are lively. In the more affluent areas, construction cranes dot the skyline.
Yet many Iranians are struggling. Amid high inflation, food prices went up by more than 70% between July 2018 and July 2019, according to Djavad Salehi-Isfahani, an Iran economy expert at the Brookings Institution, citing the country's official statistics. "The short of it is that people are poorer than they were before," he says.
Iranians have endured decades of sanctions, but this round is in some ways inflicting more pain.
"What's different is that the U.S. has reimposed the sanctions it lifted pursuant to the nuclear deal and it has layered on many more, including doing things like designating some Iranian financial institutions not previously designated and that were previously used to facilitate food, medicine and medical imports," says Rosenberg, who is now a senior fellow at the think tank Center for a New American Security.
"That's a particular affront to people who disagree with Trump's policy, and it certainly gives another talking point to those people who are laying the blame at the feet of sanctions. The reality around who is responsible may be somewhere in between the arguments offered on both sides."
"We are not guilty"
The economic troubles have triggered debate among Iranians about who's to blame.
In a country where people have long been hesitant to openly criticize the government, residents of Tehran recently interviewed by NPR were willing to fault Iran's ruling establishment.
That includes 32-year-old Mahsa Hadipour, who regularly visits the Roshana Cancer Center with her father, who has prostate cancer. She has struggled with rheumatoid arthritis for much of her life and can't find the prosthetic joints she needs in Iran. She can't afford treatment abroad, and she blames Iran's government for the strain on her family.
"It must be my own government," she says. "The government should be supporting us. Instead we're the ones who sacrifice at the hands of these political games."
Sanei, the oncologist, says she doesn't like Trump's politics but doesn't entirely blame the Trump administration, either. "They are right about the things they say about our country," she says. "But we are not guilty — people are not."
This story was reported in Iran and the U.S. NPR's Dalia Mortada contributed reporting in Washington, D.C. NPR's Bo Hamby produced the broadcast reports.