Notes on a Foreign Country

by Suzy Hansen

  The South was also the epicenter of the HIV epidemic in the United States, and Mississippi had one of the highest HIV acquisition rates of all. African Americans in Mississippi were dying from AIDS at a rate 60 percent higher than the nation’s average. In the Delta, which stretches north and west of Jackson like a diamond, AIDS was a full-blown but silent crisis. Waiters got fired because restaurant owners didn’t want them handling food; dentists refused to serve patients with HIV. Half of HIV-positive Mississippians didn’t seek or receive treatment, because the vast majority of the people didn’t have health insurance. Forty percent of the people in the Delta were illiterate. Often, people didn’t even understand the words the doctors were using when they treated them.

  * * *

  ONE APRIL MORNING, I accompanied one of Dr. Shirley’s nurses, Claudia Cox, who was driving far from Jackson’s empty downtown to visit a patient named Vonda Wells. “The rural people are the worst,” she said. “‘Come to the oak tree.’ Well, hell, I’m from the city, I don’t know what no oak tree is. I know magnolia. I know pine trees.” Cox referred to her seven-year-old Ford Freestyle as her “office,” but it had the ambience of a video arcade: the petulant ding-ding-ding of her unused seat belt, the whir of a phone charger stuck in the cigarette lighter, a Galaxy S that rang with the opening of Cheryl Lynn’s disco hit “Got to Be Real.” Cox, a forty-five-year-old divorced mother of three, juggled phone calls and patients’ charts and cigarettes like some serene octopus, always catching the steering wheel just before the truck veered onto the grass. After twenty minutes, she pulled into a pebbly country driveway to suss out why Vonda Wells kept returning to the emergency room.

  Ms. Wells’s large figure filled the doorframe of the tiny old house. She was jovial despite the oxygen tubes running from her nose. “Is that yours?!” Cox exclaimed, pointing to the baby in Wells’s arms. “That’s my grandbaby!” Wells laughed and passed off the child to a teenager who disappeared behind a closed door. The two women sat down in a dark, damp living room crammed with couches.

  “All right, Ms. Wells, we come out and check on everybody,” Cox said in a tone that makes you want to put your head on her shoulder. “You had pneumonia, right?”

  Cox didn’t know oak trees, but she knew how to figure out the real causes of chronic health problems. For example: when to ask people whether they could not afford their insulin, or for some reason were not taking their insulin, or were not keeping their insulin cold, or couldn’t keep their insulin cold because they didn’t have a refrigerator, or couldn’t keep their insulin cold because they did have a refrigerator but didn’t have electricity to keep it running. Not having health insurance was a huge problem in Mississippi, but it wasn’t the only one.

  “So you good with doing your medicines?”

  Wells made a guilty face.

  “You oxygen dependent?” She was. “You know, you’re not typically overweight for us southern folk…”

  Laughter. “Oh, I’m overweight,” Vonda said softly.

  Wells had worked at a Jackson hospital as a certified nursing assistant for five years before she started getting sick with asthma-related illnesses. No one wanted a nurse carrying around an oxygen tank, she said, so now she was trying to work a handful of hours a week at the Four C’s, a Christian community center.

  “I stayed in Illinois for twenty-five years,” she said. “I didn’t really have asthma symptoms till I came down here…”

  “You been in this house?” Cox said. The house was obviously old, the rug thick, the air damp. “There’s something in the house that’s triggering it. I bet you need to get tested.” Cox made a note. “And I’m putting a little checkmark down here that you got the basic light, gas, and water … Your major problem is the asthma.”

  “And congestive heart failure.”

  “And congestive heart failure.” Cox paused and tilted her head. “Have you been taught how to manage your congestive heart failure? Because you should have a scale.” She looked around the house gamely as if she believed a scale might pop out from behind the TV.

  “I need a scale?”

  Cox explained why people retain fluid. She then asked whether Wells had checked her blood pressure and told her that on her chart her blood pressure had been at 212 over 100, which is stroke level. Wells didn’t know that, and she looked briefly bashful, but Cox had a way of soothing embarrassment away. She asked Wells how many sodas she was drinking, and explained that juice has a lot of sodium in it, too. “Knowledge is power. Okay?” Cox said gently. “’Cause you’re forty and you’re oxygen dependent. We don’t want you goin’ on a date with an oxygen tank!” Wells laughed again.

  Cox said she would try to find a company who would come and test the house for toxins, and made an appointment for Wells to come back to a medical clinic. Wells got up to walk her to the door, the oxygen tube dragging the length of the house. Cox paused at one of the photographs on the wall.

  “You got a beautiful family!” Cox said. She zeroed in on a slim, healthy-looking, smiling woman. “Now, is that Mama?”

  “That’s Grandma,” said Ms. Wells. “She was ninety-five when she passed. I moved down here to help her out.”

  I saw something dark pass over Cox’s face, which might have been the same as what went through my mind: What had happened to America? Why had the previous generation lived to ninety-five, and the current one could barely breathe?

  All of the sick people I met shared a story of personal economic decline. There was Regina Huggins, a white woman in her forties who had been in the hospital twenty times in eight months, had no health insurance, and couldn’t afford a primary physician. She had worked for the Presto factory in Jackson for many years, until it closed, and after she was laid off, at the Piggly Wiggly. Neither the factory nor the grocery store offered health insurance, and after a lifetime of low-paying work she had nothing to show for it but three hundred thousand dollars in medical bills. There was Mamie Marshall, a licensed beautician who had worked for Packard Electric, a subsidiary of General Motors, and also as a bus driver for the Jackson public schools, and in her last working years as a nanny. She was dying of bone cancer. “I worked,” she said. But none of these employers—not one of America’s greatest companies, nor one of her country’s public school systems—had left her with the means to care for her health.

  * * *

  IT TOOK THE IRANIANS no less than a revolution and twenty difficult years to reform their own health care and economic disparities. Throughout the 1960s and 1970s, the Shah of Iran encouraged Iranians to become Westernized urban consumers, ignoring the concerns and plight of poor villagers living in the countryside. These policies, among many others, led to the Shah’s overthrow in 1979 and the rise of the Ayatollah Khomeini, who came to power in part because of his furious defense of the lives of the poor. Around that time, in the spirit of the revolution, a group of Iranian doctors proposed a new rural health care system. Such initiatives were what made the Islamist and Islamic movements from Hezbollah to the Muslim Brotherhood to Turkey’s AK Party so lasting; they provided basic human services.

  The Iranians built “health houses” in thousands of villages, to be used by fifteen hundred people within no more than one hour’s walking distance of the house, which was a thousand-square-foot building equipped with examination rooms and sleeping quarters. They staffed the houses with community health workers, or behvarzan, one man and one woman, and gave them basic medical training. The behvarzan were trained in nutrition, they could take blood pressure, they could keep tabs on who was pregnant and needed prenatal care, they could advise on family planning, provide immunization, and assess environmental conditions such as water quality and housing safety.

  It was these “health houses” that Dr. Shirley, and his Iranian partner, the academic Dr. Mohammad Shahbazi, wanted to imitate. The behvarzan came from the villages they would serve. Rural Iranians wouldn’t trust people they didn’t know, something that struck Dr. Shirley as similar to poor black
patients unlikely to trust white people from the city. The behvarzan got to know many of their patients from birth. Even during the most brutal years of the Iran-Iraq War, the Iranians implemented their plan, and today, seventeen thousand health houses have served twenty million Iranians. The idea of building seventeen thousand health houses seems daunting, but to Dr. Shirley, the system’s great appeal was its simplicity.

  When Dr. Shirley went on his tour of Iran in 2009, he noticed that some of the men did not look happy about the Americans’ arrival. While inside a teahouse, one Iranian man said to Dr. Shirley’s translator:

  “What are the Americans doing here? Did they come back to ruin our country again?”

  * * *

  THE HISTORIAN TONY JUDT once told me that when he was invited to speak at American high schools about world history, the question he often asked students first was “Who was Mossadegh?” None of the students had ever heard of him. For these Americans, the name Mossadegh meant nothing, while for the entire Middle East, Judt said, it meant everything—everything about America’s role in the Middle East, and in the world.

  In the 1950s, Mossadegh, the democratically elected leader of Iran, nationalized the Anglo-Persian Oil Company, which at the time was the British government’s largest single investment abroad. Mossadegh was able to unite his country’s monarchic, Communist, and Islamic communities under the banner of independence and a nationalist vision. Mossadegh wanted to modernize Iran’s legal and political systems without also Westernizing Iran. Most of the world cheered on Mossadegh’s challenge to the West, especially young nations with still-fresh memories of colonial excesses, such as India, Turkey, and Egypt. The West, unsurprisingly, had a different response. The editors of Time magazine named Mossadegh Man of the Year in 1951, out of anger; the article characterized Mossadegh as a child who threw temper tantrums. Still, Mossadegh believed that the United States would intervene on his behalf against the British.

  The United States worried they might lose the country to the Soviets. British diplomats didn’t believe that Iran’s communist party posed a threat, but happily manipulated the Americans’ fears, and convinced the Americans to join forces and wreak a special kind of havoc on Tehran. American intelligence officers used, according to the journalist Christopher de Bellaigue, “alarmist propaganda” to “instill panic that the country was sliding towards a communist takeover.” In August 1953, they bought off newspapers, employed thugs to pose as Communists, attacked mullahs and mosques, and spread rumors that Mossadegh was a Jew. In response to this phony violence, the real Communists soon rampaged through the city. A New York Times correspondent was nearly lynched.

  In the chaos, Mossadegh was overthrown and Iran’s political development was forever disrupted. In a sense, all the tensions that define the relations between the United States and Iran today are rooted in the fall of Mossadegh. An older Iranian once asked an American journalist, “Why did you Americans do that terrible thing?… To us, America was the great country, the perfect country, the country that helped us while other countries were exploiting us. But after that moment, no one in Iran ever trusted the United States again.”

  The coup preceded another historic event that would inspire young Muslims everywhere to rise up in defense of their country: the Algerian war for independence. In the academic Roy Mottahedeh’s The Mantle of the Prophet, his book about the political evolution of a young religious Iranian man before the Iranian revolution, a group of Iranian students learn about the plight of Algerian fighters battling against the French during the Algerian war of the 1950s and ’60s: hundreds had been burned alive in the Algerian desert. One student says, “The Iranians, as usual, confine themselves to weeping. If Mossadegh were still prime minister and we had freedom to act, Iran would do more than Egypt … We had a Rostam, a genuine lion.” It was the Iranians, these young Iranians said, who “let the English and Americans take Mossadegh away. The shame is ours as much as anybody else’s.”

  After Mossadegh, the Shah returned to power. The American ambassador recommended to the Shah to create an “undemocratic independent Iran.” The Shah soon became one of the United States’ closest allies. Iran was as much a modernizing ideal for the Americans as Turkey and Afghanistan had been. Modernization projects sprung up throughout the countryside, destroying local communities and draining the country of millions of dollars. As part of his “White Revolution,” a massive modernization program “framed by Western ideas, experts, and aid,” as the academic David Ekbladh writes, the Shah supported a development project in the Khuzestan region that would use five rivers for hydroelectric power and irrigation, with the goal of transforming indigenous agricultural practices. The regime predicted the area would become a “Garden of Eden,” and for the Americans, according to Ekbladh, “one of the great symbols of postwar liberal development.” Instead, the project was beset by technical problems, displaced thousands of people from their homes, and ultimately failed. Economic productivity in the region actually fell.

  Between 1970 and 1979, the number of Americans in Iran jumped from eight thousand to fifty thousand. The scholar James A. Bill writes that “as time passed and the numbers grew, an increasingly high proportion of fortune hunters, financial scavengers, and the jobless and disillusioned recently returned from Southeast Asia found their way to Iran.” Conservative and rural Iranians who came to Tehran for work found themselves alienated and bewildered by the Western clothes, values, and behavior celebrated in their capital city, its magazines and miniskirts. “We found ourselves wondering,” one Iranian said, “is there any room for our own culture?”

  At the same time, Iran became one of the United States’ largest customers for weapons. The former CIA officer Kermit Roosevelt—a spy who played a large part in the overthrow of Mossadegh—now worked for the weapons dealer Northrop. Henry Kissinger promised Iran any non-nuclear weapon it wanted; the Shah once spent $10 billion on weapons in just one year. Many Iranians knew that SAVAK, the brutal secret police service, which employed as many as sixty thousand agents, as well as millions of informants, and was known for spectacular acts of torture and violence, had been trained by the CIA and Mossad. “Whoever fell into the grip of that organization,” wrote the Polish journalist Ryszard Kapuściński, “disappeared without a trace, sometimes forever.”

  Just before the revolution in 1979, Kapuściński noted that among the Iranians’ fiercest complaints were those directed at the thousands of foreign servicemen on their soil, all of them, especially Americans, operating with full diplomatic immunity. The Ayatollah Khomeini said, in one of his most famous speeches, “Our dignity has been trampled underfoot … If some American’s servant, some American’s cook, assassinates your marja in the middle of the bazaar, or runs over him, the Iranian police may not arrest him. Even if the Shah himself were to run over a dog belonging to an American, he would be prosecuted. But if an American’s cook runs over the Shah, the head of state, no one will have the right to interfere with him.” America and NATO had this diplomatic immunity arrangement in many countries, including Turkey, and it was deeply insulting to local people. The Shah’s “Great Civilization” was for many Iranians another grand humiliation.

  Living under such a dictatorship, with the secret police and an army of informants watching one’s every move, Iranians found in the mosque a kind of sanctuary. The forceful and accelerated push for modernization amplified the power of the mosque. West-loving Turks feared that Turkey would become Iran under Erdoğan, but whenever I asked if they knew about the horrors of the Shah’s era, they didn’t believe me: “But it was modern.” “It looked so much more Western.” “Women didn’t have to cover.” All they could see, somewhat understandably, was visual evidence that a country could regress on women’s rights. But Kapuściński saw this:

  The Iranian who has been harassed at work, who encounters only grumpy bureaucrats looking for bribes, who is everywhere spied on by the police, comes to the mosque to find balance and calm, to recover his dignity. He
re no one hurries him or calls him names. Hierarchies disappear, all are equal, all are brothers, and—because the mosque is also a place of conversation and dialogue—a man can speak his mind, grumble, and listen to what others have to say. What a relief it is, how much everyone needs it. This is why, as the dictatorship turns the screws and an ever more oppressive silence clouds the streets and workplaces, the mosque fills more and more with people and the hum of voices. Not all those who come here are fervent Muslims, not all are drawn by a sudden wave of devotion—they come because they want to breathe, because they want to feel like people.

  If the Shah represented modernity to the Americans, his downfall to them was, according to the Palestinian intellectual Edward Said, a “casualty to what was looked upon as medieval fanaticism and religiosity.” The Ayatollah Khomeini was just that medieval figure.

  But within this paradigm, what were the Americans? During the Iranian hostage crisis of 1979 and 1980, in which fifty-two Americans were held captive at the U.S. embassy for 444 days, President Jimmy Carter pleaded with a French lawyer working for the Iranians: “You understand that these are Americans. These are innocents.” The French lawyer recalled:

  I said to him, yes, Mr. President, I understand that you say they are innocent. But I believe you have to understand that for the Iranians they aren’t innocent. Even if personally none of them has committed an act, they are not innocent because they are diplomats who represent a country that has done a number of things in Iran …

  But to Carter, as Said explains, “Americans were by definition innocent and in a sense outside history.”