Insulin Shortage Causes Havoc in Iran

By Soheila Tusi and Murad Zendegani, citizen journalists in Varamin. Their names have been changed to protect them.

Since October 18, Iran’s insulin shortage has been widely discussed, debated and railed against on social media. People suffering from diabetes have been giving their accounts of the stress they have endured after not being able to find insulin in pharmacies, while doctors have been going online to try to help some of these patients and express their frustration. We tell some of these stories here.

“There has been insulin available, but insulin pens have become scarce. Actually, it has become more expensive! There are two main reasons: first it is because it is foreign and imported, and the second is that the foreign currency rate of 4,200 tomans has been withdrawn, and no importer is willing to import it ... Our country produces insulin, but not insulin pens. Diabetics can use this insulin until the problem is solved."

These are the words of a doctor working in the treatment department of the Ministry of Health and Medical Education.

"Honestly, in this exceptional case, I do not blame the government too much," he said, speaking on condition of anonymity. "A government that can barely sell oil and hardly has any exports under sanctions, and considering that the country's foreign currency availability is low, and the government has no control over prices, and the value of the rial falls more and more every day, the way to survive is to first remove the cheap foreign currency for importing some commodities. I'm not saying it's right, but there is no other way."

In contrast, many people have pointed to government mismanagement and the phenomenon of drugs being smuggled abroad. On Monday, October 19, Mahmoud Najafi Arab, head of the Health Economics Committee of the Iranian Chamber of Commerce, said that one and a half times the amount of insulin the country needs were imported, but the shortage was due to "reverse smuggling" and "illegal insulin exports" out of Iran.

Najafi Arab said the reason for this was the allocation of 4,200 tomans in foreign currency and the import of cheap medicine, which is sold by people on the dollar open market to customers in other countries.

A man called Mojtaba has been preparing insulin for his father for the last few days. "It is a big lie to say that insulin pens are available with open market prices," he says. "I have gone all out to find insulin pens, but found nothing, neither at official prices or at open market prices.” Other forms of insulin, he says, cause his father to become hypoglycemic and makes his condition worse.

Insulin pens are easier for many patients to use because the dose can be easily adjusted, among other reasons. "It is very difficult for my father to adjust the dose of insulin in the vial and my father has to take it with a syringe,” Mojtaba says.

"Unfortunately, the authorities speak from a position of comfort," he said, referring to a tweet from Kianoush Jahanpour, who manages public relations for the Ministry of Health. Jahanpour responded on Twitter to a man who was worried about his father's hypoglycemia, advising him to use less insulin, or else use different sources of the drug. “We have been using a quota from 13 Aban Pharmacy, which we acquired with lots of difficulty,” tweeted Jahanpour, “or we bought it in the Nasser Khosrow open market at several times the official price."

An endocrinologist living in Tehran told us, "In the last few months, my patients have had problems with insulin. Many of them reduce the dose themselves due to insulin shortages, which causes the amount of insulin they take to be unresponsive and their blood sugar to not be regulated. Some of them skip meals for fear of insulin shortage, which in itself has disadvantages."

He says that as a doctor who has been dealing with diabetics in Iran for many years, he is ashamed by his patients' despair and helplessness. “These days, a lot of my patients are stressed about getting insulin, and this in turn raises their blood sugar," says the doctor.

Somayeh is a middle-aged woman responsible for providing insulin for her parents. "My parents have severe diabetes, and apart from me, who, thank God, am not currently affected, my other two sisters are also suffering from this disease. Because of my close association with diabetics, I know exactly how annoying it is. My parents inject about six packs of insulin pens each month. With the doctor's prescription in the booklet, I used to get each pack of six for 35,000 tomans [$1.16]. But the quotas were constantly being reduced, and instead of six, the pharmacies, such as the 13 Aban Pharmacy, gave two insulin pens for each prescription. No one knows what insulin pens means for elderly diabetics until they experience it. Insulin itself is a life-and-death issue, and the pen type, because of how easy it is to inject and the easier dose adjustment, really turns it into a saving grace.

"My parents do not really last more than a few hours without insulin injections, and I had to provide insulin for them in any way possible," Somayeh continued. "During the early days of the insulin shortage, I bought it from a pharmacy in the city center for 35,000 tomans [$1.10] each, equivalent to the official price of a six-pack of insulin. But now I have to search the whole city to find two of them and pay at least 150,000 tomans [$5].

"A few days before my parents run out of insulin, I get stressed; I contact a few people, and go to the pharmacies. I cannot rest until I find it and get it," she said.

Houman is a 38-year-old basketball player from Hamedan. He has had diabetes for years and so has to use insulin. "I have been exercising since I was a child and I have never been overweight or over-consumed sugar, sweets, or chocolate. My diabetes is genetic and by injecting a small dose of insulin a day, my problem is completely eliminated. Many of my friends and teammates did not even know about my illness.

Houman continued: ”Just a few months ago, the Deputy Minister of Food and Drug Administration of Hamadan Province announced that the foreign insulin quotas according to patients' monthly needs will be distributed, and it was at that time that, little by little, problems arose in finding insulin at the right price. It could be found at a more expensive price and after searching a few pharmacies. But for three days now, my insulin has run out and I have searched all over the city to find it. Now I have to use Iranian vial insulin, which is difficult for me to inject at my age, and I can never inject the right dose. I'm not really feeling well these days. Poor elderly men and women who try to use Iranian insulin if they have tremors in their hands, eyesight issues, and other physical problems." He also talked of his concern for children with diabetes.

Dr. Omid Rezaei, a specialist in internal medicine and a pediatric hematologist and oncologist, recently wrote on Instagram that children with diabetes are at risk of DKA, or diabetic ketoacidosis.

DKA occurs when the level of insulin in the blood is less than what the body needs, and manifests itself with symptoms such as exhaling ketones, a chemical the liver produces when it breaks down fat, which can be foul-smelling; nausea; vomiting; dehydration; abdominal pain; and eventually loss of consciousness. Treatment for the condition requires specialist care and emergency hospitalization in an intensive care unit.

In response to Jahanpour's tweet, Dr. Rezaei wrote: "Mr. Doctor who works in the ministry has tweeted to a boy who is worried about his father's hypoglycemia and reducing his insulin dose. This is the disease of our healthcare system: those who have not practiced medicine or have a medical degree in the Ministry of Health decide that they’ll practice medicine... Good for you who have never stayed up all night with a DKA patient until morning."

Rozita, an employee of a local pharmacy, says: "Government insulin pens and their allocated quotas are not [widely] available; a small quota is available in selected pharmacies such as 13 Aban and 29 Farvardin. The free market insulin – if found and sold  — is a crime.

"The Food and Drug Administration says a pharmacy that has a contract with the social security organization must sell insulin to the patient on insurance terms," ​​Rozita said. "If the patient goes to a pharmacy to get insulin with an insurance booklet and the pharmacy announces that it is selling the drug at a free market price, he has violated the regulations and people can report this violation to the 190 system to deal with the offending pharmacy. This is why pen insulin is scarce. Otherwise, most pharmacies can offer pen insulin through the acquaintances they have and those who bring them rare and smuggled drugs. But each pen insulin on the free market is sold at 50,000 tomans [$1.70] at least. They cannot sell at the quota price because it is a loss. On the other hand, selling at a free market price also causes pharmacies to be sealed closed, fined, and a thousand other problems. For this reason, most pharmacists in the current situation prefer not to go near this product."