Iran: the force behind three conflicts

President Mahmoud Ahmadinejad's motorcade sped through the newly completed Resalat Tunnel for the ceremonial opening of a highway designed to alleviate Tehran's terrible traffic congestion. Building work began six years ago, when Ahmadinejad was still mayor of Tehran. Military leaders, clerics and diplomats sat in front of an elaborate stage at the entrance to the tunnel. While the Middle East is gripped by three of the most dangerous crises in years - in Iraq, Lebanon and Gaza - Iran displays a self-confidence that appears to the outside world to add fuel to the firestorms engulfing this region.

Ahmadinejad's speech was no different from others he has delivered. He virulently condemned Israel's bombardment of Lebanon and said that the "Zionist regime" had no future if it continued what he called its "vicious crimes against innocent Lebanese and Palestinians".

Such pronouncements cannot be explained away as the rantings of an unhinged leader. Iran does not conform to the stereotype presented by politicians in Washington and London, who describe it as a pariah, isolated by economic sanctions, and boxed in by US and British forces in neighbouring Iraq and Afghanistan.

For the theocracy in Tehran, nothing could be further from the truth. Never since the Islamic revolution in 1979 has Tehran enjoyed such influence and power in the theatres of the Middle East's current wars.

Of all the unforeseen consequences of the overthrow of Saddam Hussein, the most important is the clout that has accrued to Iran, which no longer has to worry about a dictator next door who cost it so dearly in blood and treasure in the first Gulf war.

The Iranians now have many levers of in fluence in Iraq, from long-standing ties to the most senior Shia Iraqi politicians and clerics who were exiled in Iran for decades, to close links with the Shia militias, an important enforcer of Iraq's violent politics. As a member of the Iraqi cabinet recently put it to me, only a few dozen exiles returned to Iraq from London, while hundreds of thousands came over the border from Iran in 2003.

Between the Anglo-American alliance and Iran, it is not difficult to guess whose political influence and culture carry more weight among Iraqi politicians, clerics and militia leaders.

Iran's power in Lebanon runs far deeper. People forget that Hezbollah is not a Lebanese invention. Its roots lie in Tehran, where it was established after 1979. In those first years the aim was to export the Islamic revolution. Its first destination was Lebanon. There it found fertile ground, thanks to Israel's invasion and occupation of the predominantly Shia south. It is hard to escape the conclusion that what is happening there now will only serve to strengthen Hezbollah, and that history will repeat itself.

But the most astounding spread of Iran's influence into the politics of the Middle East is to be found in the Palestinian territories, where previously it enjoyed little clout. Not any more. After the election victory of Hamas in January this year, the first place that the movement's leader, Khaled Meshaal, visited from his exile base in Syria was Tehran. He met both Ahmadinejad and Iran's supreme leader, Ayatollah Khamenei. As Asher Susser, director of Middle Eastern studies at Tel Aviv University, has observed: "A historic change in the balance of power has taken place [of an order] that has not happened since the 7th century."

Not since then has Persian influence been at the heart of Middle Eastern political affairs.

Western leaders are reluctant to discuss the shift of power in the region that Susser speaks about. Never has regime change in Tehran by British and US intervention been more of a strategic illusion, and the Iranian government knows that. If there is to be any change it will come from within.

Iran's restless population of 70 million - two-thirds of whom are under the age of 30 - knows that demographics will prevent any future government from turning the clock back. This is also a country where more than 60 per cent of university students are women. Moral and religious edicts cannot negate the incremental freedoms won by reformers over the past eight years.

Yet, as their emboldened government spreads its influence outwards, reformers inside the country wonder when the west will realise that all the talk of "regime change" merely weakens their progress towards real and lasting change.

This article first appeared in the 24 July 2006 issue of the New Statesman, War - Who can stop it now?

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Want to know how you really behave as a doctor? Watch yourself on video

There is nothing quite like watching oneself at work to spur development – and videos can help us understand patients, too.

One of the most useful tools I have as a GP trainer is my video camera. Periodically, and always with patients’ permission, I place it in the corner of my registrar’s room. We then look through their consultations together during a tutorial.

There is nothing quite like watching oneself at work to spur development. One of my trainees – a lovely guy called Nick – was appalled to find that he wheeled his chair closer and closer to the patient as he narrowed down the diagnosis with a series of questions. It was entirely unconscious, but somewhat intimidating, and he never repeated it once he’d seen the recording. Whether it’s spending half the consultation staring at the computer screen, or slipping into baffling technospeak, or parroting “OK” after every comment a patient makes, we all have unhelpful mannerisms of which we are blithely unaware.

Videos are a great way of understanding how patients communicate, too. Another registrar, Anthony, had spent several years as a rheumatologist before switching to general practice, so when consulted by Yvette he felt on familiar ground. She began by saying she thought she had carpal tunnel syndrome. Anthony confirmed the diagnosis with some clinical tests, then went on to establish the impact it was having on Yvette’s life. Her sleep was disturbed every night, and she was no longer able to pick up and carry her young children. Her desperation for a swift cure came across loud and clear.

The consultation then ran into difficulty. There are three things that can help CTS: wrist splints, steroid injections and surgery to release the nerve. Splints are usually the preferred first option because they carry no risk of complications, and are inexpensive to the NHS. We watched as Anthony tried to explain this. Yvette kept raising objections, and even though Anthony did his best to address her concerns, it was clear she remained unconvinced.

The problem for Anthony, as for many doctors, is that much medical training still reflects an era when patients relied heavily on professionals for health information. Today, most will have consulted with Dr Google before presenting to their GP. Sometimes this will have stoked unfounded fears – pretty much any symptom just might be an indication of cancer – and our task then is to put things in proper context. But frequently, as with Yvette, patients have not only worked out what is wrong, they also have firm ideas what to do about it.

We played the video through again, and I highlighted the numerous subtle cues that Yvette had offered. Like many patients, she was reticent about stating outright what she wanted, but the information was there in what she did and didn’t say, and in how she responded to Anthony’s suggestions. By the time we’d finished analysing their exchanges, Anthony could see that Yvette had already decided against splints as being too cumbersome and taking too long to work. For her, a steroid injection was the quickest and surest way to obtain relief.

Competing considerations must be weighed in any “shared” decision between a doctor and patient. Autonomy – the ability for a patient to determine their own care – is of prime importance, but it isn’t unrestricted. The balance between doing good and doing harm, of which doctors sometimes have a far clearer appreciation, has to be factored in. Then there are questions of equity and fairness: within a finite NHS budget, doctors have a duty to prioritise the most cost-effective treatments. For the NHS and for Yvette, going straight for surgery wouldn’t have been right – nor did she want it – but a steroid injection is both low-cost and low-risk, and Anthony could see he’d missed the chance to maximise her autonomy.

The lessons he learned from the video had a powerful impact on him, and from that day on he became much more adept at achieving truly shared decisions with his patients.

This article first appeared in the 01 October 2015 issue of the New Statesman, The Tory tide