Iran International
A surge in counterfeit drugs has worsened Iran’s strained medicine market, forcing many with serious conditions to rely on the black market for scarce medication.
The shortage has deepened in recent months, driving prices ever higher. More than 100 essential medications, including treatments for cancer and rare diseases, are either scarce or entirely unavailable.
While Iran has long had an underground market for imported medicine, prices have soared since late summer, and reports of counterfeit drugs are rising.
Investigations by Iran International reveal that counterfeit medications are being sold at exorbitant prices—often reaching hundreds of dollars—right in the heart of Tehran. Cancer patients, in particular, face an increasingly dire situation.
“Not only have cancer and rare disease medications become shockingly expensive, but some have completely disappeared from pharmacies and even the underground market,” a pharmacist in Tehran said on condition of anonymity. “As original medicines grow scarce, counterfeit sales have increased.”
He noted that cancer drug prices range from 150 million rials ($180) to as much as four billion ($4800).
“A breast cancer patient had to pay 900 million rials ($1,100) for just 56 pills,” the pharmacist added. “She could have had a lower-quality Indian version a bit cheaper, but she was desperate to get the best on offer. We’ve had patients selling their property to get cancer treatment for themselves or loved ones.”
Buying drugs on the black market isn’t just costly—it’s dangerous. The pharmacist recalled a case where a patient needed Zavicefta, an antibiotic unavailable in pharmacies. Desperate, they turned to the underground market, paying 3 billion rials ($3600).
“The patient brought the drug to me and I could tell immediately it was fake. The real version comes in sealed packaging but theirs had been tampered with,” he said. “Imagine paying that much money and getting a counterfeit.”
A lawmaker on Iran’s parliamentary health committee had warned of the crisis a month earlier, reporting 116 scarce medications and predicting the number could increase tenfold within months without government intervention.
Iran International contacted several pharmacies in Tehran to inquire about various medications, and all confirmed the scarcity of imported drugs. Even major state-run pharmacies, such as 13-Aban and the Red Crescent, had limited or no stock.
Some Iran-made drugs are also becoming scarce due to shortages of raw materials and hoarding by suppliers who benefit from rising prices.
A young art student who lost her sister to leukemia shared her experience.
“My sister’s doctor prescribed German-made drugs, saying local alternatives wouldn’t be as effective and would make chemotherapy even harder. My father, two brothers, and I spent everything we had on her medication, but in the end, we lost her.”
She described the excruciating process of hunting for medication.
“For months, we visited 13 Aban and Red Crescent pharmacies every other day, only to be told they didn’t have it. We often had to buy from the black market. Some drugs, like Endoxan, we never found.”
For patients with rare conditions like hemophilia, MPS, and SMA, the situation is even worse. Patients and their families have staged several protests outside the Health Ministry and Iran’s Food and Drug Organization.
Such medication is not produced in Iran because it is not economically viable, Hamidreza Edraki, head of Iran’s Rare Diseases Foundation, told ILNA last month. Imports are stuck in customs for so long that they often expire before reaching patients, he added.
Those in charge are yet to address the situation despite warnings from all stakeholders.
On January 28, Iran’s Health Minister Mohammad Reza Zafarghandi announced that the price cap on several drugs would have to be raised because pharmaceutical companies could no longer afford production costs.
This policy may help increase supply gradually. The impact it had on prices, however, was immediate. For those Iranians in urgent need of treatment, things are looking to get a lot worse before getting any better.
"It's really a battle of generations," said Dagres, a senior fellow at think tank the Washington Institute's Iran program.
"Gen Z, Gen Alpha as well, as they come of age, are really pushing back against the Islamic Republic's norms and they're really trying to take back their country. Whether they succeed is another thing."
Dagres, who specializes in Iranian youth and curates the newsletter the Iranist, said the Iranian government realizes they may have already lost Gen Z so are staking their hopes for staying in power on their successors.
“They've been actually looking at the next generation, which is Gen Alpha."
"When they came up with the song Salam Farmandeh or Salute Commander. Mostly when you see kids it's Gen Alpha kids that are part of the regime choirs and also they're being forced to sing it at schools."
Gen Z, or those born between 1997 and 2012, make up less than 7 percent of the population but were at the forefront of the 2022 Woman, Life, Freedom uprisings demanding women's rights and the end of the Islamic Republic.
Though the protests were largely stamped out, the generation remains restive.
“(Tehran is) having to think ahead because really they're struggling and I think the prime example of how they struggled here was the Woman, Life, Freedom uprising itself. It was led by Gen Z girls and women,” said Darges.
The Islamic Republic is thinking outside the box, appealing to Persian nationalistic motifs to form the minds and win the battle of the new generation.
“They've made a play about the Shahnameh or the Book of Kings. They're really trying to tap more into Iranian nationalism, which is much more palatable to the average Iranian, regardless of age these days than more Islamic motifs," said Dagres.
A recent viral video showcases a reporter asking Gen Zs to identify the clerics in photos they presented. The girls could not tell the difference between Iran’s current Supreme leader Ali Khamanei and the founder of the Islamic Republic Ruhollah Khomeini.
The kids had no problem identifying K-pop bands and Billie Eilish, however. The moment illustrated how little interest the youth have in their rulers.
Iran’s Gen Z formed a counterculture, the opposite of what the government was trying to force onto them, consuming Western music, movies all in an underground way, Dagres said. But they are not afraid to showcase their color dyed pink hair and skateboards.
The fact that women and girls are increasingly not wearing the mandatory hijab, she said, showcases the subtle ways Iranians are resisting.
In a scene which went viral online, a group of Iranian schoolgirls raised their middle fingers at a portrait of Iran's leaders in a classroom, in another sign of sharp defiance.
Authorities used extreme force to quell their rebellion after the death in morality police custody of a young Gen Z'er, Mahsa Jina Amini, in 2022.
Sham trials, confessions forced through torture and a wave of executions in 2022-23 claimed the lives of many of their number, including 23-year-old Mohsen Shakari and Majidreza Rahnavard, both promising youths hanged for their activism.
Declining marriage and birth rates
Gen Z is also the generation that is coming of age and often holding off on getting married and have children.
So much of that is a result of their connection to less traditional Western culture, but also high unemployment, concerns over climate change, inflation in Iran and a rejection of Islam and tradition, Dagres said.
Islamic Republic officials say that by the year 2101 the population in Iran will halve even as neighboring countries experience rising birth rates.
Iran’s once-youthful population is aging fast. That has stirred concerns over a lopsided economy and a potential healthcare collapse in the future.
The United Nations (UN) projects that by 2050 one-third of Iranians will be 60 or older, representing a three-fold increase from 2021.
Iran’s Ministry of Science has called for the removal of educational content deemed to discourage people from having children to combat declining birth rates.
The average Iranian household went from 6 per family to three and now a growing number of youths are choosing to live with their partners.
It is a phenomenon in Iran called white marriage, where two unwed people live together, replacing the traditional marriage proposal where families would help set up relationships.
The latest findings from the state-run National Population Research Institute suggest the number of registered marriages in Iran has dropped dramatically since 2011 with almost half a million marriages registered - a fall from the peak of 891,627 marriages in 2010.
The Rejuvenation of the Population and Protection of the Family (RPPF) law, enacted by the Iranian Parliament in 2021 under a directive from Supreme Leader Ali Khamenei, imposes penalties for actions deemed to discourage marriage and childbearing.
Iranians struggling with depression
Depression is rife in Iran, Dagres said, with Iranians now turning to drugs like opium and alcohol which is haram or religiously banned to ease the pain. The economic hardships and day-to-day repression lead to their depressive state.
“Some of these Gen Z'ers are so desperate for a hit of alcohol because they become so addicted that they're purchasing ethanol from a pharmacy and drinking it," said Dagres.
With the demographics of Iran dramatically changing, Gen Z appears to have largely decided to seek change, and the Islamic Republic's influence over Gen Alpha has yet to be felt.
Only time will tell what sort of future the youth of Iran will achieve.
The ban enforced after the Islamic Revolution of 1979 was lifted in October 2019 under pressure from FIFA, the governing body for international football and its Asian counterpart the Asian Football Confederation (AFC).
FIFA had warned Iran’s football federation that it could face expulsion from global tournaments including the World Cup if women were not allowed to attend.
Despite the policy change, opposition festers.
In March 2022 women who had bought tickets for a FIFA World Cup qualifier between Iran and Lebanon in the religious city of Mashhad were pepper sprayed when they tried to enter the stadium.
Women are still not permitted to attend all matches. Local authorities frequently cite what they call insufficient preparation, such as the lack of designated seating areas for women as a reason for their exclusion.
When women are allowed, the number of tickets available to them is often limited, and female enforcement officers in black chadors are present to ensure compliance with mandatory hijab laws.
Nevertheless, footage and photos posted on social media show defiance of the hijab is widespread.
The hardline newspaper Kayhan, closely linked to the office of Iran’s Supreme Leader, criticized the decision to allow women into stadiums. On Thursday, the daily accused proponents of the change of “implanting the idea that women’s success and dignity lie in imitating men’s behavior and attire.”
Kayhan’s criticism followed the release of footage showing female fans at a match between Tractor FC and Persepolis FC on Wednesday in which both male and female fans were seen cheering and occasionally swearing.
Kayhan argued that women’s presence has not improved what it described as the “poisonous and unhealthy atmosphere” of stadiums. It said it has led to violations of what it called women’s dignity, a “fundamental principle in Iranian and Islamic culture," according to the hardline paper.
Iranian authorities have long justified the ban on women’s attendance as a measure to protect them from exposure to profanities often chanted by male fans, even if women were seated in separate sections of the stadium.
Over the years, some women have taken significant risks to watch matches. Disguised as men, they attempted to enter stadiums but were often caught, arrested, abused or even sentenced to prison terms.
The ultra-hardline outlet Mashregh News also criticized FIFA President Gianni Infantino, suggesting he should have attended the Wednesday game week to understand the authorities’ stance against women’s presence in stadiums.
Infantino has consistently pressured Iran on this issue, particularly after the tragic case of Sahar Khodayari.
In September 2019, Khodayari, nicknamed the Blue Girl after her favorite team Esteghlal FC (nicknamed the Blue Team), set herself on fire after being sentenced to jail for attempting to enter Tehran’s Azadi Stadium disguised as a man.
This issue has also been reflected in art and media. Jafar Panahi’s 2006 film Offside depicted the story of young women disguising themselves as boys to watch a World Cup qualifying match at Azadi Stadium. The film won the Silver Bear at the Berlin International Film Festival but was never approved for screening in Iran.