The story of the last Shah began with his father, Reza Khan, a military commander who seized power in 1925 and established the Pahlavi dynasty. His son, Mohammad Reza Pahlavi, ascended to the throne in 1941 during World War II; the British and Soviets forced Reza Shah’s abdication because of his German sympathies.

The early years of the young Shah’s reign were marked by his attempts to consolidate his power in a world of competing interests. His vision for Iran centered on rapid modernization and Westernization, culminating in the 1963 White Revolution, an ambitious series of reforms that included land redistribution, women’s suffrage, literacy programs, and industrial development, funded by proceeds from the country’s massive oil deposits. Under his rule, Iran experienced unprecedented growth in education, industry, infrastructure, and military power. Tehran became a modern metropolis, and a new middle class emerged. The Shah, however, sought to achieve these advances through authoritarian control. His secret police, SAVAK, became notorious for suppressing dissent. The gap between rich and poor widened, and the conservative sectors of society became increasingly alienated by the rapid changes. By the mid-1970s, the opposition to the Shah’s rule had united intellectuals, leftists, and right-wing traditionalists. The Shah’s response to protests oscillated between concession and crackdown, ultimately satisfying neither reformers nor hardliners. On January 16, 1979, after a year of violent demonstrations and his refusal to use military force against the demonstrators, he decided to leave the country. His departure was followed by the establishment of the Islamic Republic.

The Shah had been under specialized medical care since April 1974, when he had noticed a swelling in the left upper part of his abdomen that turned out to be an enlarged spleen. Many of the details of how he was treated, who was involved, and who knew about his condition have remained controversial or unknown to this day.¹ It is clear, however, that his immediate care was managed by his primary physician in Tehran, acting on the direction of French consulting hematologists. They made a diagnosis of chronic lymphocytic leukemia but kept it secret at the request of Empress Farah, and the Shah was told he had Waldenstrom’s disease, a less severe condition. His primary physician maintained the deception, and when, in September 1974, the Shah again complained of abdominal discomfort, treatment with chlorambucil was initiated. It was given under the guise of “vitamin shots,” brought to the Shah disguised in containers of the harmless anti-malaria medication Quinercil.¹ In the following years, the Shah’s health ran a fluctuating course. At various times, treatment with chlorambucil was restarted, or the dose was increased. It is not clear, however, at what stage, if ever, the Shah was fully informed of the details of his condition, nor what the various interested foreign powers were able to find out about it.

When the royal couple left the country for Aswan, Egypt, on January 16, 1979, Egyptian President Anwar Sadat, a longstanding friend of the Shah, met them at the airport and escorted them to the Oberoi Hotel on the Nile. On January 22, 1979, the royal couple left for Morocco, first to Marrakesh and then to Rabat. Their stay in Morocco proved to be brief because of complaints from domestic Islamists, and on March 30 the royal couple left for the Bahamas. There a biopsy of a supraclavicular lymph node showed a large cell lymphoma and therapy with vincristine, procarbazine, nitrogen mustard, and prednisone was initiated.

In June the Bahamian government decided not to renew the couple’s visas, so they left for Cuernavaca, Mexico. There the Shah developed a fever and was eventually thought to have obstructive jaundice. He was already very emaciated, with hard, enlarged lymph nodes palpable in the neck, a large spleen, anemia, and a very low white cell blood count. President Jimmy Carter did not wish to admit him to the US but under strong pressure from Henry Kissinger reluctantly allowed him to enter the United States on October 22 under an assumed name. Computed tomography showed gallstones obstructing the bile duct, and these were removed. It also confirmed the presence of a greatly enlarged spleen and the histopathology of the removed cervical node showed a malignant lymphoma, for which radiation therapy was started at the Memorial Sloan Kettering Medical Centre (after being initially denied for “security reasons”). As convalescence from surgery required a stay in the United States of about six weeks, this proved unpopular with the new government in Iran and appears to have precipitated the storming of the US Embassy in Tehran and the kidnapping of US diplomats, military personnel, and intelligence officers.

 The Carter administration, in hope of freeing the American hostages, insisted the Shah leave and arranged on December 15, 1979, to send him to the Contadora Island in Panama. There the Panamanians rioted, objecting to the Shah being in their country. President General Torrijos kept the Shah isolated as a virtual prisoner in a hospital that provided poor care and charged exorbitant fees. He also appointed his own physician to manage the Shah’s medical care and did not allow other doctors access. In March Egyptian president Anwar El-Sadat renewed his offer of asylum and the Shah returned to Egypt. By this time his condition was almost terminal. Nevertheless, Dr. Michael DeBakey, a world-famous cardiologist, was called to take out the spleen. The operation went “beautifully,” but the head of the pancreas was injured and led to a subphrenic abscess that under normal would have to be drained. But the Shah died soon after the operation. on July 27, 1980. He is buried in the same mosque as his brother-in-law, Farouk, the former king of Egypt.

In more than one way, Mohammad Reza Pahlavi is a tragic figure. Young and initially inexperienced, he tried to bring about reforms to his country but eventually united all sectors of society against him. After the revolution, most countries refused to offer him even temporary asylum. At one time they had treated him as one of the world’s most powerful monarchs and maintained significant trade relations, bank accounts, and property. They were now concerned primarily about economic and energy interests, oil and export contracts, and the safety of their citizens. By the time the Shah arrived. in the United States, the Carter administration had already been secretly negotiating with the Iranian government about an extradition deal. Posterity has also questioned some later clinical decisions as unwise, particularly the surgical ones made in Egypt. Medically then, as well as politically, the Shah of Shahs qualifies as a tragic historical figure.

Further reading

• Khoshnood, A, and Khoshnood, A. The death of an emperor – Mohammad Reza Shah Pahlavi and his political cancer. Alexandria Journal of Medicine 2016;52(3):201-8.
• “Mohammad Reza Pahlavi.” Wikipedia. https://en.wikipedia.org/wiki/Mohammad_Reza_Pahlavi