Interview with Dr. Fereydoun Ala
Thank you very much for accepting this interview. Please let us know a little about your childhood.
I was born in Paris since, at the time, my father was the Iranian Minister Plenipotentiary in France. Instead of returning to Iran, once his four-year assignment ended, Hossein Ala was appointed Iranian Minister at the Court of St. James in London, where he served until 1935, before being recalled by Reza Shah.
However, my mother and I remained in Paris, which truly deserves its title of ‘The City of Light’, for a further few months, before traveling back to Iran by rail through Stalin’s Soviet Union at a time coinciding with “Yezhov’s Terror”. Although I was only five years old at the time, this wintry journey to Baku, and on by ship to what was then called Bandar Pahlavi (Anzali), has remained as an unforgettable memory.
Stalin so –called “second terror”?
Yes – Stalin’s so-called ‘second terror’, which involved even greater loss of life than the first. My mother and I were met at Anzali by my father, and we drove on by car to the newly completed Hotel Ramsar, set against the magnificent backdrop of the forested mountains, which to my eyes appeared a veritable paradise of comfort and progress. We drove on the next morning, through the dramatic Chalus pass and the Kandavan tunnel which had only recently been inaugurated, on to Tehran – a memorable journey indeed.
As for my primary education, apart from private tutors and personal lessons administered by my father in Latin, Greek and the piano, I was also sent to the Dabestane Nezami on Avenue Sepah, which drew many of its pupils from impoverished areas around Sangelaj, and this was a most salutary experience for me. In addition, I also attended the Lazariste St. Louis school, in order to obtain my French Certificat d’Etudes Primaires, as well as the American ‘Community School’ on Khiabane Qavam os-Saltaneh.
Although World War II had not yet ended, I was then sent off alone to continue my secondary education in England. My uncle Mohsen Qaragozlou saw me off at Port Said onto a troop-ship repatriating hundreds of British soldiers, and once we reached Gibraltar, we had to join a convoy of merchant ships escorted by British Naval Destroyers, for fear of German submarines still hunting the north Atlantic for easy prey. After twenty-five days at sea, we reached the port of Grenoch, near Glasgow in Scotland, which I recall as one of the blackest days of my life.
Everything appeared dirty and sooty, and the severe wartime food rationing – rationing especially of fresh fruit, sweets and meat, made life very austere. I reached London, to be warmly greeted by Mr. Hassan Taqizadeh, the Iranian Ambassador, who was a close friend of my father, and a most learned man, who had been a notable political fire-brand in the early days of the Constitutional Revolution. Mr. Taqizadeh undertook to be my guardian while I remained in Britain.
After only a few weeks in London, I entered Harrow, the ancient boarding-school where Winston Churchill had studied many decades before. From the windows of my small room, I could see the fires started by the last of the German V1 and the newer V2 rockets which fell at random in and around central London, causing much fear and insecurity.
In 1945, my father was appointed Iranian Ambassador to the United States of America, as well as the Iranian envoy to the new-found United Nations Security Council, where he was charged with defending Iran’s case against the Soviet Union, which had not only failed to evacuate its armed forces from northern Iran after the end of the war, as it was committed to do by the Tri-Partite Agreement signed at the Tehran Conference, but it covertly armed and supported Azarbaijani and Kurdish separatist movements which threatened the independence and territorial integrity of Iran. US President Roosevelt held “Uncle Joe” Stalin, the victor of Stalingrad, who had broken the back of the Wehrmacht, in affection and respect, and early after the war, it was not easy to interest the USA and the UNO in the protest of a small country against a super-power like the USSR, which was also one of the permanent members of the UN Security Council. Britain was even prepared to accept a compromise (reminiscent of the despised 1907 agreement between tsarist Russia and Britain, dividing Iran into ‘zones of influence’), whereby the Soviet Union might be allowed a free hand in northern Iran, provided that they did not interfere in Britain’s interests in the oil-bearing provinces of southern Iran.
To my father’s courageous, persistent and ultimately successful prosecution of Iran’s case, against all odds: the stubborn refusal of the Soviets to allow the inclusion of Iran’s case on the Security Council agenda; the efforts of the Soviet delegate and Mozaffar Firouz, Qavam os-Saltaneh’s Deputy, to discredit Ala at the Security Council, and Prime Minister Qavam os-Saltaneh’s prevarications and contradictory instructions to Ala, while under immense pressure from the Soviet Ambassador in Tehran…. must be given much of the credit, together with Taqizadeh and President Harry Truman, for retaining the independence and territorial integrity of Iran at this historic moment.
Despite my father’s grave preoccupations, he did not forget the importance of my education, and he arranged for me to join him in the USA in order to complete my secondary schooling at Milton Academy near Boston, following which I went to Harvard University, where I chose to study History as my major. However, instead of leaving after graduation, I stayed on for a further year of pre-medical studies, as I had decided to study medicine. This coincided with the premiership of Dr. Mosaddeq, the oil nationalization crisis, and a profound dearth of foreign exchange, so that meeting the costs of a US medical training was out of the question. Instead, I attended the Edinburgh University Medical School in Scotland, which was considered in America, to be the best medical school in Europe, particularly famous for its Department of Anatomy, where costs of tuition were incomparably lower than in the US.
The medical course in Britain was six years at that time, and after qualifying and completing my surgical and medical internships, I was able to obtain a one-year research grant from the Wellcome Trust to investigate anaemias associated with intestinal malabsorption, as a Senior House Officer.This was followed by successfully taking the dreaded examination for Membership of the Royal College of Physicians (MRCP) in internal medicine and haematology (probably equivalent to the Fellowship examinations in the USA), where only 20% of candidates passed at their first attempt. It may be that I was the first Iranian to become a Member (and later Fellow) of the Royal College of Physicians.
My father died in the summer months of 1964, and I definitively returned to Iran a few months later in order to begin my career after so many years spent abroad. I started by applying for a post at the Tehran University Medical Faculty. Dr. Jahanshah Saleh, who had been a member of my father’s second Cabinet at one time, was then Chancellor of the University, and Dr. Hafeezee was Dean of the Medical School, who dealt with the appointment of members of the Faculty. His was an enormously long room full of dozens of supplicants, waiting to see him and hoping for an appointment to the academic staff. It was said of him in jest, that if you went up to him claiming that you had come in to apply for the post of Chancellor of the University, he would hardly look up, but would merely say: “Indeed, indeed – do kindly write and let me have your application.”
In later years, I came to value his friendship, but at the time, the byzantine bureaucracy of the Tehran University Personnel Department was daunting indeed! Ultimately, after negotiating innumerable obstacles, I was finally appointed as Assistant Professor, with a princely salary of 600 Tomans per month! As I took up my clinical appointment at the premier teaching hospital in Iran – the Pahlavi Medical Centre (now called the Khomeini Medical Centre), I must confess to have been disturbed and shocked by the poor example set by the eminent Heads of Clinical Departments at the hospital, who came drifting in to their wards around 11:30 in the morning, after seeing to their private patients.
They would sit and drink a cup of tea with their junior staff, cheerily asking if there were any interesting cases in the ward, and having spent only a few minutes superficially examining a patient or two, they would be off again to their more remunerative private practice. This was not at all in keeping with the principles of medical practice I had learned to observe.
In my new appointment, I had the opportunity of establishing the first Clinical Haematology Department in the country. Until then, Haematology had merely been a branch of Clinical Pathology, dealt with by the Hospital Central Laboratory. Patients suffering from haematological disorders were therefore admitted to the general medical beds. Modern haematology of course requires its practitioners to be amphibious creatures, at home as a specialist both at the patient’s bedside, as well as in the diagnostic laboratory. What we therefore needed, was a specialized laboratory for our purposes. Fortunately, I was able to obtain a grant of 18,000 Pounds Sterling from the Sir Henry Wellcome Trust, which was to be matched by a similar sum from Tehran University, in order to provide for the creation of a modern haematology diagnostic laboratory. Needless to say, the University contribution never materialized! Nevertheless, the grant was generous enough to allow for the purchase of lab benches, glassware and all the equipment we needed. Indeed, it was even possible to recruit a technologist from abroad to help in the training of our staff for a few months, although I had to undertake the establishment of most of these laboratory procedures myself: Vitamin B12 absorption and Folic Acid assays; the application of radio-isotopes for measuring blood and plasma volume, red-cell and platelet survival; gel electrophoresis for abnormal haemoglobins; red cell enzyme allotypes like G6PD, etc, etc. I was fortunate in having clinical colleagues with outstanding skills in diagnostic microscopy – Dr. Zamanianpour and the late Dr. Akhavan, whose expertise in this aspect of haematology far surpassed my own.
Whilst awaiting the arrival of all our equipment and the creation of the appropriate spaces to set up our lab, I became interested in the diagnosis and treatment of the inherited bleeding disorders like Haemophilia A and B – the type carried by Queen Victoria, which she generously scattered about most of the royal families in Europe by marrying off her carrier daughters to: Alphonso XIII in Spain; Leopold of Belgium, and of course, Tsar Nicholas II of Russia, and the famous accompanying story of the monk Rasputin.
These inherited bleeding disorders were medical orphans in Iran, in that they had no advocate, and had not yet attracted the interest of anyone.
To make a definitive laboratory diagnosis of haemophilia A or B for the first time in Iran, with merely a few Pasteur pipettes and a cracked 37 degree centigrade water-bath was truly exciting. However, quite apart from diagnosis, we had to find a way of treating these wretched children, crippled by repeated joint haemorrhages, and often so disabled as to be entirely bed-ridden.
At the time, the only source of treatment for these patients was whole blood - we shall talk about the awful source and quality of this blood later on. However, the level of coagulation factors in whole blood is so tiny as to be ineffective, and some way must be found to concentrate these factors in order to carry out useful replacement therapy. I must emphasise that at that time in the mid-1960s, no industrial coagulation factor concentrates manufactured from human plasma were available anywhere in the world, other than Fraction I-O, initially produced by Birger and Margaretha Blomback at the Karolinska Institute in Stockholm, and later manufactured by Kabi. This fraction contained most of the fibrinogen and coagulation factor VIII from a unit of human plasma, in a concentrated form.
Happily, by 1965, Judith Poole in the USA, discovered a home-made product called “Cryo-precipitate”, which completely revolutionized the treatment of haemophilia. Human plasma obtained by centrifuging whole blood, was rapidly frozen in a mixture of alcohol and dry ice, and then slowly thawed at 4 degrees centigrade. A dense precipitate left in the bottle after centrifugation, was found to contain most of the factor VIII and the fibrinogen from the original unit of plasma, which could be re-dissolved at 37 degrees centigrade. At a stroke, we were thus able to produce an artisanal concentrated factor VIII for the treatment of haemophilia A, rather like making ice-cream in a bucket, in the Haematology Department. This material was accumulated and stored in our freezers for use in covering corrective orthopaedic surgery for the rehabilitation of our crippled haemophilia A patients. Only a few brave, pioneering surgeons such as Drs. Sheikh ol-Eslami; Gorgi and Zahir, were prepared to hazard major surgery in severe haemophilia, using a home-made product. Those were exciting and anxious days indeed!
In 1971, the VIIth Congress of the World Federation of Haemophilia was held in Tehran – the first time this meeting had been held outside of Europe or Canada. However, the programme we devised was quite unusual: since the treatment of these bleeding disorders was so integrally linked with blood transfusion science, it seemed appropriate to include plasma fractionators and transfusionists for the first time, in order to complement the blood coagulation scientists and doctors attending the meeting. This was a first step towards the creation of modern, centralized, national blood transfusion services.
When all the equipment we had ordered to furnish our new clinical haematology laboratories arrived, we were able to establish entirely novel techniques and deploy all our skills. One of these novel techniques was the detection of what used to be called “Australian Antigen” discovered by Blumberg – the laboratory marker of hepatitis B, later called hepatitis B surface antigen (HBsAg), for the first time in Iran. The considerable significance of this exquisitely infectious virus was that it was widespread among professional blood sellers; that it could be transmitted through blood transfusion, and that it frequently caused chronic hepatitis culminating in cirrhosis and liver failure.
Witnessing the appalling standards of the hospital blood service at the Pahlavi (now Emam Khomeini) Hospital, as I came in to work every morning was truly painful: a herd of pale, sick-looking professional donors, drawn from the most vulnerable, impoverished sectors of society, were lined up by a tough, menacing ‘agent’. They were bled as they squatted on the floor, into re-usable glass bottles (supplied and re-sterilised by the Institut Pasteur), and most of them, especially those with rare blood groups, were so anaemic that only a small layer of red blood cells could be seen at the bottom of the bottles – the rest was plasma! They were then paid a pittance by the ‘agent’, before going off.
None of the donors were examined or tested. The blood was simply grouped, typed and used directly without further compatibility-testing, and these were the standards prevalent throughout Iran – in University Hospitals; Red Lion & Sun (now Red Crescent) Hospitals; private clinics; military hospitals – everywhere.
It means that there was no Blood Transfusion Organization at the time?
That is a good question. Essentially, every hospital had to fend for itself, and contract with one of these ‘blood shops’ to obtain blood to cover the needs of the day, with no thought for tomorrow. Naturally, we are only talking about whole blood – blood components were unknown at the time. The military also ‘paid’ for blood, but in a different way: the lowest ranks were ordered to ‘volunteer’ in exchange for 72 hours leave, thus confirming in the soldiers’ mind the baseless conviction that giving blood was harmful to the health
In the other words, each hospital had to fend for itself?
Yes - each hospital was supplied by an individual, commercial blood dealer. I got to know one of them, and he really was an excellent business-man. Naturally, I represented a threat to their business interests, and the steady progress of voluntary, non-remunerated blood donation by the ordinary urban population, fostered by the Iranian National Blood Transfusion Service (INBTS), began to seriously interfere with their market.
However, being pragmatic business-men, they saw that they would have to diversify into other forms of trade, such as fish-farming or raising mink. By some curious coincidence, though, all their workers happened to have rare blood groups, or to be O Rh D negative!
Well before the advent of the INBTS however, we had already started producing blood components on a small scale, in the Hospital Haematology Department, thanks to the gift of a large-capacity, refrigerated centrifuge: - platelet concentrates for those bleeding for lack of these tiny cells; plasma for our haemophiliacs or for burns patients, and red cell concentrates for use in surgery and anaemia – we had actually created our own little transfusion centre in the hospital ward!
However, producing blood components by using the Institut Pasteur glass bottles was difficult and messy, for we did not yet have access to the new multiple PVC blood bag assemblies which permitted one to separate cellular components of blood in a sterile, closed circuit.
It was clear that the time had come for a revolution in this important infrastructural sector of medicine and surgery, and that continued reliance upon buying and selling blood from the most wretched, vulnerable individuals in society, was gravely dangerous and morally indefensible.
The wonderful film of Darioush Mehrjou’i, called “Dayereye Mina”, produced in the 1970s, brilliantly illustrates the moral and financial corruption involved in the blood trade, and the attitude of the urban middle and upper-classes towards what Professor Titmus at the London School of Economics called “The Gift Relationship” – “…we have plenty of money in Iran. Why don’t we just import blood like the Emirates, in compote tins?”
What was required was a widespread, continuous publicity programme, drawing the attention of every sector of the public to the dangers of current services, and the need for their participation in providing society, their friends and family, with safe blood from altruistic, healthy volunteers – in short, a social revolution!
At the time, Dr. Farmanfarma’ian, Head of the Plan Organisation for Development, and Dr. Sheikh ol-Eslamzadeh, Minister of Health, were enormously helpful in facilitating the realization of this ‘Grand Design’.
The first step was to obtain Parliamentary approval for the creation of a National Service as a legal entity, as well as an annual budget.
The former premises of the ‘Tehran Clinic’ on Avenue Villa (now Ostad Nejatollahi) were rented from the public-spirited Mrs. Firouzgar, for a modest fee. The building was gutted, and rebuilt specifically for our purposes as a clean, modern, welcoming centre, equipped with the latest automated laboratory equipment. We had to mark the contrast between our new centre, and the tawdry, filthy premises employed by the Pahlavi Hospital or the Red Lion & Sun on Khiabane Naser-e-Khosrow.
We did not want merely to create a ‘supermarket’ for blood products. We also wanted to establish an intellectual dimension associated with science and research. University doctors and scientists were consequently recruited to staff the various departments, hitherto unheard of in relation to blood transfusion in Iran, such as Clinical Immunology; Cryobiology; Blood Coagulation; Virology; Cancer Immunology; Histocompatibility for a future organ transplantation programme; Antenatal Serology; Plasma Fractionation…….
Of course our most pressing need was to launch a broad publicity, information and motivation campaign. Without voluntary blood donors, there could be no Blood Service, however advanced its scientific programme might be! The science and technology had to be learned and purloined from abroad, but the social mobilization and donor motivation programmes could only be forged and implemented in Iran.
Even though these programmes had to address every class and every sector of society, we decided to start at the top. It was my task to approach cabinet ministers, directors of organizations or business executives initially, in order to explain the horrors of the present blood services, and the virtues of obtaining the participation of the healthy population in providing safe blood for themselves and their fellow-citizens – an irresistible argument!
A date was then agreed for conducting a mobile blood collection session. A blood collection team composed of doctors, impeccably uniformed donor attendants and drivers would arrive at the appointed time, equipped with folding beds; clean white sheets and all the furniture required to take between 120 and 150 units of blood. I would usually start the proceedings by giving a promotional talk, followed by a film.
At the beginning, we had to use promotional films imported from the International Red Cross or the American Association of Blood Banks, but thanks to an excellent film made by Mehrju’i, we were thereafter able to show Iranian faces and Iranian scenes to very good effect.
To demonstrate our integrity, each volunteer was carefully examined and at least 10% or 12% were rejected as being ineligible for donation.
In a surprisingly short time, our persistence paid off, and we were gradually able to provide for all the needs of hospitals in Tehran. I must emphasise that all these services were entirely free-of-charge. Hospital laboratories were only permitted to charge patients for compatibility testing – the so-called cross-matching procedures. Our distinctive red and white cars, bearing the strong, simple INBTS emblem designed by the famous German artist Karl Schlamminger, were to be seen all over the city, delivering or picking up crates of blood units.
The windows of my car were smashed on a couple of occasions by the commercial blood agents, but this reaction was a measure of our success and their progressive bankruptcy.
The National Service started its activity in the capital, and this is essentially an urban activity, satisfying an urban need. One cannot turn up in some provincial village, asking people to part with their blood. They would think you to be mad, or else a crook, wanting to sell their blood in the cities. In those days forty years ago of course, some 70% of the population was rural, whereas today, the reverse is true.
After Tehran, the National Service had to justify its title, and establish regional centres in the major provincial cities. We had carefully calculated the probable requirements of these cities, including a contingency for a time when Plasma Fractionation in Tehran would provide for national self-sufficiency in Coagulant Factors; Albumin and Immunoglobulin. I had even dreamed that neighbouring countries might one day wish to send their crude plasma to us for fractionation, since establishing such a plant, like the establishment of oil refineries for fractionation of crude oil, is a complex and costly process. In any case, we had set up a ‘pilot plant’ for fractionating up to 10,000 Litres of fresh plasma per year in the basement of our building, and we were able to produce Albumin, polyvalent Immunoglobulin(Ig), and a specific anti-Rabies Ig, prepared in collaboration with the Pasteur Institute and the Tehran University Veterinary School, which provided its faculty and students as volunteers for immunization with the Iranian Rabies vaccine. When we reported our product at the International Society for Blood Transfusion Meeting in Paris in 1978, we were met with surprise, for only the Pasteur Institute in France, had manufactured such a product!
One of the greatest compliments we ever received at the INBTS, was from Boris Chain, joint winner of the Nobel Prize with Alexander Fleming and Florey, for the discovery of Penicillin. Chain was a consultant for the National Iranian Oil Company, which was exploring the possibility of using microbial cultures to produce fuel. Boris Chain came in to visit our centre one day, and before leaving, he confided in me saying that he felt “at home” with us for the first time since arriving in Iran, because “there was clearly something going on” – an intellectual ferment, in our laboratories, whereas all the other, beautifully appointed places he had visited were entirely stultified. Needless to say, we were all immensely flattered by these words of praise from such an eminent scientist.
Perhaps the most important and far-reaching policy decision of the INBTS was to propose the integration of the National Blood Service with the Armed Forces Blood Service. Our argument was that in most regional countries, the Armed Forces are kept entirely separate from civil society, with their own apartment blocks; their separate recreation facilities and clubs. This was also true of their own clinics, hospitals and (extremely backward and mediocre) blood transfusion facilities. While this arrangement might be adequate in peace time, in time of conflict or disaster, neither civil nor military services would be able to cope with acute demands on their own, particularly since the equipment and techniques of each were entirely dissimilar. In addition, in time of peace, it would be entirely appropriate for the healthy young men in the forces, to be seen to be contributing to the common good by volunteering their blood on a regular basis. Indeed, it would be essential to their role as leaders, that for the first time, officers should also be invited to make their contribution to Iranian society.
My proposal and my reasoning was fortunately accepted, and despite a good deal of opposition from certain vested interests in the Armed Forces, it came about that my good friend and colleague, Dr. Eftekhari who had been in charge of the Armed Forces BTS, became my neighbour in the room next to mine, and thenceforth, we gained access to the military garrisons, where we were able to conduct our usual blood donor sessions, which were met with considerable enthusiasm by officers and enlisted men alike.
It must be emphasized that this collaborative merger of civil and military blood services was almost unique in the African, Middle and Far Eastern countries, and I am only aware of a single exception.
This arrangement was enormously helpful to us as we started to establish Regional Centres in provincial chief cities. Our philosophy was to confine ourselves to few but first-class regional centres, associated wherever possible with the local university medical school, so that our energies would not be diluted, and so that we might succeed in maintaining the highest standards of quality.
We started with Shiraz, in a former restaurant near the Namazee Hospital. The establishment of this centre was followed by centres in Sari, Mashhad, Ahvaz and Hamadan, many of them being housed in pre-fabricated buildings, which allowed for flexibility and future expansion.
Quite apart from establishing safe, high-quality blood services in Tehran and several provincial cities, we had been intent upon establishing a parallel research and development programme, and by 1979, we had succeeded in publishing numerous scientific articles and reports in the international literature, much to our satisfaction.
Thus despite all the difficulties which had to be overcome, we had succeeded beyond our expectations in creating a veritable revolution in the nature and quality of the nation’s blood services, but above all, we had catalysed a social revolution, and a profound change in public attitudes towards voluntary blood donation, and the responsibilities we all bear towards our fellow citizens and co-religionists.
In 1981, I traveled to Britain, greatly in need of employment. After only a few idle months spent searching for a suitable appointment, I was fortunate enough to be designated as Director of the West Midlands Blood Transfusion Service in Birmingham, which at the time, was probably the largest blood centre in the United Kingdom. I also obtained a clinical appointment as Consultant and Senior Lecturer at the University Haematology Department.
Mine was an unusual appointment in the English Service, because apart from a class-mate Dr. Cash, who was Director of the Scottish National Service, all my colleagues in England, were Pathologists, rather than Clinicians, as he and I were. Indeed, the hospital clinicians and the transfusion service pathologists did not always enjoy the most cordial relations and mutual understanding at the time, for their priorities naturally differed.
Thus, in the 1980s, John Cash and I were probably the first practitioners of a newly- emerging specialty termed “Transfusion Medicine”, which went a long way towards bridging the gap between the two camps. As a clinician, I was well-placed to communicate easily with hospital practitioners, and it was rewarding to be involved in the establishment of new services such as liver transplantation or bone-marrow transplantation at the Queen Elizabeth Hospital. Overall, I remained in Britain for nearly twenty years.
And during the time, you had never came back to Iran?
No – I only returned to Iran for the first time in 1999. In the intervening years since my departure, I had been actively involved in consultancies for the World Health Organisation Eastern Mediterranean Regional Office (WHO EMRO), covering virtually all the countries of the Middle East as well as the newly independent Central Asian Republics. My main objective in the course of these assignments was to foster the development of centralized blood services and voluntary blood donation, just as in Iran during the 1970s. Among the countries of this region, the notable laggards were Egypt and Pakistan. Egypt, for instance, had been in close contact with Europe for centuries, and the Cairo opera-house had been inaugurated by Empress Eugenie. Yet, the blood services were backward, chaotic and highly commercial. The Ministry of Health had issued reams of regulations and directives relating to blood transfusion, yet in effect, nothing resulted from all this paperwork. The same was true of the stultified services in Pakistan, where I was frequently sent in an effort to remedy the situation.
WHO EMRO regularly organized biennial specialist meetings bringing together the directors of regional blood transfusion services for seminars, workshops and up-dates with the participation of several distinguished European or American specialists. I was usually drafted in to set up these regular meetings, which were hosted by one of the regional transfusion services, in either Alexandria, Tunis, Amman, Damascus, Riyadh or elsewhere among regional countries. I constantly put it to the WHO authorities that, despite its recent isolation, Iran had a great deal to offer as an exemplary model for other neighbouring countries, and finally, in 1999, Tehran was selected as the venue for the transfusion meeting. Our host on behalf of the Ministry of Health, was the current INBTS (now called the Iranian Blood Transfusion Organisation – IBTO) Director, Dr. Taqikhani, who had also been sometime Director of the Pasteur Institute. We were all received with the utmost hospitality, and venues for our workshops and scientific sessions were well equipped. Among the tours organized by our host, was a visit to the IBTO Central Regional laboratories on Avenue Vesal e-Shirazi. As we all stepped off the bus, we were met by a most extraordinary uproar, as all the IBTO employees, young and old, greeted my return to Iran after an absence of nearly twenty years, with great emotion – a most moving event, which astonished the foreign guests from Europe and the Middle East.
Following the Islamic Revolution of 1979, a number of worthy institutions and departments had foundered, but although the blood transfusion service had suffered a succession of incompetent managers, and the loss of a number of specialists, it had nevertheless survived, with its skills, standards and moral principles intact. The organization had clearly been well-rooted at its inception, and its sheer utility during the conflicts which followed, ensured its survival and progress. Indeed, there can be no doubt that the Service is currently unrivalled in its quality and its reach and spectrum of activity, not only in this region, but far beyond.
When I returned to Iran after a prolonged absence, I recalled the interests I had had in bleeding disorders some 46 years before. I decided to become involved in the diagnosis and treatment of these inherited haemostatic disorders (to which thrombophilic disorders had recently been added) once again.
In most countries, there is a Haemophilia Society, usually organized by the affected patients or parents in order to act as advocates for these patients, and to deal with their social, employment or rehabilitation and re-training problems. On the other hand, in most cases, the haemophilia diagnosis and treatment centres, are conventionally located in teaching hospitals, in the hands of academic physicians.
However, in Iran, it was the Iranian Haemophilia Society itself which, in 2001, took the ambitious step of creating a Comprehensive Haemophilia Care Centre, comprising phenotypic, virological and genetic diagnostic laboratories; dental facilities; physiotherapy; specialist clinics for liver disease; orthopaedic problems; gynaecology, etc, etc. This is an exceptional model for haemophilia care, and the only other similar centre I am aware of, which is run by the national Haemophilia Society, is in Argentina.
The Iranian Comprehensive Haemophilia Care Centre (ICHCC) is a non-profit registered charity, which effectively acts as a reference centre for this country, and even on occasion, neighbouring countries, such as Afghanistan, Iraq, Armenia or Azarbaijan. I have established a small charity in London, which is dedicated to supplying laboratory reagents or equipment to the ICHCC, and it has been of great utility recently because of the severe international sanctions imposed upon Iran.
It is salutary now to look back some 46 years, when this group of patients were “orphans” without any advocate or recourse to medical diagnosis or treatment. Indeed, I can recall one of my colleagues berating me for wasting my time on these rare disorders in a country where children were still dying with measles or diarrhea. Today, it is a source of great satisfaction to see that there are specialized centres throughout the country, with an interest in inherited bleeding disorders and their treatment.
Iranian Blood Transfusion Organization belives that we have valuable blood productions which are not appreciated enough by users. There is no logical and acceptable relationship between blood transfusion organization and universities. Do you have any suggestion to help this situation?
Yes – as I mentioned earlier, I have always had an interest in the new ‘downstream’medical specialty now termed “Transfusion Medicine”. It is true that many doctors, most particularly surgeons, do misuse or over-use blood and blood products, and they do not care to be lectured about the correct indications for transfusion by anyone, much less by someone in the transfusion service or the hospital blood-bank. This has been a perennial problem throughout the world. Altering the habits and the professional ‘culture’ of medical practitioners is extremely difficult. Knowledge can be acquired or transferred; skills can be learned, but changing attitudes is much more problematic.
Spurred by the acute awareness that blood transfusion can transmit deadly diseases like HIV, HCV and HBV, my colleagues and I made efforts, in the late1980s, to develop and widely publicise guidelines for the rational use of red cells, platelet concentrates and plasma. In Iran, Dr. Jahangir Ahmadi was one of the pioneers of this movement at the IBTO. Yet it was only after Hospital Transfusion Committees (HTCs) began to be established, that these recommendations began to be put into practice. This was especially true when the government and professional societies made the regular meetings of these Committees mandatory. HTCs brought together the main hospital blood users – surgeons; anaesthetists; nursing sisters; haematologists; hospital blood-bank technicians, together with a representative of the Regional Blood Service: blood usage was critically examined and adverse or even fatal reactions to blood transfusion were scrutinized and analysed.
Blood transfusion system in Iran is based on donation not money motivated reasons. There are usually difficulties for volenteers during Ramazan month? Do you have any solution to offer?
I have to confess that I am no longer entirely familiar with the current transfusion practices. I do know that after the Islamic Revolution, the ancient practice of venesection and cupping to “purify the blood” became a widespread ploy, used by charlatans and profiteers to take advantage of a the naïve public.
We ourselves at the INBTS, adapted ourselves to the increasing influence of Islam before the change of regime, and produced beautiful Islamic motivational posters, using quotations from Emam Ja’afar Sadeq, for instance in order to promote blood donation. Some of these elegant posters still decorate the walls of transfusion centres in Helsinki or Paris.
I am afraid I do not know much about the motivational publicity strategies employed by the IBTO at present, nor do I know how effective they are. What I do know is that the Service has hitherto been able to meet most of the needs of hospitals in Tehran and the provinces, with blood donated by volunteers.
Have you observed any difference between medical practitioners of last and current generations?
You must realize that I have been deeply affected by an era marked by the emergence of potentially mortal viruses transmitted by blood and blood products. We were already aware of the dangers of hepatitis B transmission in the 1970s. Then came another form of hepatitis which was called “non-A, non-B” (NANB) hepatitis, until it was identified as hepatitis C. Both of these virus infections can cause chronic inflammation of the liver, culminating in terminal liver failure. In the early 1980s, a frightening development was the appearance of the Human Immunodeficiency Virus, which was not identified in the laboratory until 1983, and which tragically affected so many children with haemophilia all over the world. At that time, practitioners of blood transfusion suddenly became criminals in the eyes of the patients and the media, and in France, Directors of the Service were put in jail.
I naturally also carried vivid memories of my years in Iran, when blood from professional donors frequently transmitted diseases such as hepatitis and malaria.
There can be no doubt that the safest blood for transfusion, is blood donated voluntarily by established, repeat donors. There is a great deal of evidence to demonstrate this truth. Money or any other form of reward encourages individuals at risk for infections to conceal their risk behaviour, and even the most sensitive laboratory screening tests cannot uncover all potentially infectious cases.
Quite apart from the risks of disease transmission however, this issue also has a human, moral and societal dimension: we are all in some way responsible for the health and welfare of each other. We should act upon this principle without expecting the government to do everything for us, and herein lies the germ of self-determination and democracy. Indeed, one can even venture to use the success of voluntary donation in a given society, is a sensitive index of its moral values and unity of purpose.
Unfortunately, one also sees the shocking trade in kidneys from living donors in this country, where impoverished individuals from rural areas come to the big city in the hope of improving their economic circumstances, and are taken advantage of by shady ‘agents’ who relieve them of one kidney in exchange for a sum of money. This grossly unethical trade is apparently overseen by the government.
In your opinion, which one cause the current powerful foundation; the personal perseverance of medical practitioners or the attitude of the system itself?
I cannot say that I find any very striking difference, although I must say that there has been a decline in the application of ethical principles in medicine and surgery.
While skills, capabilities and techniques have made enormous strides in the past 35 years, and advanced hospital care is now available in most of the major provincial capitals, so that one need no longer hasten to Tehran for complex surgical or medical treatment, yet one senses that medicine has increasingly become a big business. Young doctors are therefore brought up in this commercial, acquisitive environment, which becomes as natural to them as the aquarium is to the fish.
In addition, I cannot say that I am very impressed by the hasty, superficial way in which new patients are seen by most young practitioners: a proper history is rarely recorded, and a full physical examination, including neurological screening and retinal examination is almost never carried out. It is admittedly difficult for a busy practitioner to spare the time for applying these standards, but they are essential. I fear the fault lies with the senior faculty members of the medical schools.
Are you optimistic about the future of medical situation in Iran or not?
Of course it is true that medical practice has become progressively more commercialized virtually everywhere in the world, in comparison with the past. This is probably particularly true in the USA, where despite the expenditure of some 18% of the GDP upon medical care, yet this vast expenditure does not necessarily ensure better quality than elsewhere in the world. In addition, the practice of ‘defensive medicine’ is encouraged by the modern litigious society, where unnecessary investigations (such as expensive MRI or CT scans), or procedures (such as unneeded Caesarian Sections) are carried out for fear of being sued, and to increase profit. This unhealthy trend naturally multiplies the costs of care, without improving the quality of outcomes.
Any message to the young medical practitioners of Iran?
Yes – while it is true that in developing countries, including Iran, there are always individuals with vision and ‘fire in the belly’, who initiate and implement projects and programmes, institutionalizing and ensuring the persistence and continued development of these initiatives is exceedingly difficult in third world countries. I personally witnessed an example which illustrates this problem, some 40 years ago. A socially well-placed colleague in Sudan had succeeded in establishing the beginnings of a most progressive, modern blood transfusion network in his country. Unfortunately, the extreme political instability of the country caused this admirable service to be destroyed, to the point where even the window frames and electrical wires of the main central laboratories were looted, and no trace ultimately remained of all the efforts and good intentions of this exceptional individual.
As I mentioned earlier, establishing continuity in developing countries is difficult.
My late father closely supervised the first wave of Iranian students sent abroad, while he was Iranian Minister in Paris in the late 1920s. He always made himself available when these young men needed advice and support, and they virtually all worked hard and turned into useful members of an elite who returned to serve their country. An outstanding example of one of these students was Dr. Mojtahedi.
Yes – virtually all of the students who left Iran to study abroad in the 1920s and 1930s returned to benefit their country with what they had learned. Latterly however, many of these students, most particularly those who studied in the USA, remained to develop their lives and careers in America, taking advantage of the enormous opportunities which are available there.
While India, China, Ireland and Mexico sent their impoverished economic migrants to seek a new life in the US, Iran exported its elite, and we now see successful Iranians in virtually every walk of life: as members of University teaching staff; as engineers; surgeons; lawyers; business-men; as senior members of NASA – more so than almost any other nationality. This of course represents the irreparable loss of some of our most gifted individuals.
In your opinion, which one cause the current powerful foundation; the personal perseverance of medical practitioners or the attitude of the system itself?
This is a difficult question. I think preventive medicine and public health measures will continue to fulfill an increasingly important role, in contrast with curative medicine, which is costly and offers diminishing returns. Treatment is likely to become more specifically and more closely tailored to the nature and genetic make-up of the patient, rather than the current ‘one size fits all’ approach. Genetics will undoubtedly continue to occupy an increasingly significant role in the diagnosis of disease and in treatment. A good current example is the successful application of gene-therapy in severe Haemophilia B. So far, ten such patients have become self-sufficient, and have no longer required replacement therapy to treat or prevent bleeding for over three years. We have two eligible patients who will hopefully soon be treated with this ground-breaking form of treatment. One must remember that treating a severely affected patient with Haemophilia B may cost around $250,000 per year, or an approximate lifetime cost of at least $15,000,000. Gene-therapy on the other hand, may cost only $35,000 which, if successful, represents the cost of a definitive cure.
It is a source of considerable satisfaction that numbers of young doctors and scientists with an excellent training in genetics are now returning to their country, and once they start their work this will have the salutary effect of gradually breaking the current monopolistic hold exercised by a small cabal of specialists.
In medieval England, in the time of the poet Geoffrey Chaucer, a thirty-year old man was old, and young boys would gather around him to listen to his tales of battles and natural disasters. The situation today is utterly different, and morbidity and mortality due to infection, malnutrition or post-partum haemorrhage has given way to the degenerative disorders of more advanced countries, like arterial disease and myocardial or cerebral infarction, cancer, diabetes and dementia, even though mean survival now exceeds 80 years in the most favourable circumstances.
Any message to the young medical practitioners of Iran?
The most important spur is love – devotion to ones work, combined with integrity. Physicians still enjoy considerable respect and prestige in society, and they must behave in such a way as to deserve their status.
Are you satisfied in your life?
Very much so – I have experienced many ups and downs in the course of my life, but I am devoted to my country, and my wife Yekta and I spend nearly half the year in Iran. The small services I am able to render at our haemophilia centre continue to give me great pleasure.
You mentioned shakespear’ “Hamlet” in the interview which shows your passion to literature. What are you other occupations?
At Harvard College, I majored in History, and I still retain a deep interest in history and archeology, most particularly in connection with “Iranzamin” or Greater Iran, which also includes Central Asia. As for books that I am attached to – there are too many to enumerate, but I can mention Henri Masse, Jean Perrot, Christensen, and then English and French poetry and plays, such as the English Elizabethan poets, including Shakespeare, classical French theater like Corneille or Moliere, as well as more modern writers like Mallarme or Baudelaire, as well as Rilke and Goethe. I would also include American writers such as Hemingway, Dreiser, EE Cummings and Faulkner.
Since we have mentioned Shakespeare, I should mention that my grandfather Abolghassem Khan Qaragozlou Naser ol-Molk, who was the first Iranian (and one of the first Moslems) to study at Oxford University Balliol College. Later in life, he made superb translations of ‘Othello’ and ‘The Merchant of Venice’ into Persian, which remain as ‘belles lettres’ in their own right, and have been published by Niloufar.
What about sport?
I was always devoted to horse-riding from childhood, and as a school-boy, I ran the 100 metres in a very respectable time. At Harvard College, one of my greatest joys was to row pencil-thin single sculls on the Charles River.
You had special relationship with your father?
He was a very good father indeed, who despite his many heavy responsibilities and preoccupations, was always accessible and anxious to attend to my education. He himself was a learned man, who spoke impeccable French, English and a little German. He was an accomplished pianist and a gifted caricaturist whose cartoons and portraits of contemporaries who came to visit his father, will soon be published. His library was exceptionally in its time and comprised old Persian manuscripts and first editions of history and records of 17th and 18th Century European travelers to Iran.
Do you still own your father’s library?
No alas, I no longer have access to this outstanding collection of old and modern books. My father’s beloved library was housed in a separate octagonal pavilion reminiscent of the Safavid style, in the garden he inherited from his mother, located in Dezashib – a lovely garden which holds many evocative memories for me.