Iran US

In this photo released by an official website of the office of the Iranian supreme leader, Supreme Leader Ayatollah Ali Khamenei speaks at a meeting in Tehran, Iran, Wednesday, Jan. 9, 2019. (Office of the Iranian Supreme Leader via AP)

On the eve of its 40th anniversary, the Islamic Republic of Iran faces an uncertain future. The nation is grappling with rising protests, strikes, acts of civil disobedience and an aging supreme leader, Ali Khamenei, who is rumored to have cancer. While the last of these might seem like the least significant, the illness of a previous Iranian leader had an oversized impact on the political direction of the country and its relationship with the United States.

Forty years ago, the U.S. made the mistake of not knowing about the deteriorating health of Mohammad Reza Shah Pahlavi. Failure to know that the shah was dying from cancer led to blunders in American policy, causing Washington to engage in a diplomatic course that did little to keep its staunch ally from being overthrown and replaced by a regime that has remained implacably hostile to the U.S. ever since.

On May 10, 1951, George C. McGhee, the assistant secretary of state for Near Eastern affairs, and Allen Dulles, the CIA’s deputy director of plans, met to discuss a deteriorating political situation in Iran. The country had descended into a protracted period of bitter partisan politics, large popular demonstrations and martial law after an attempted assassination of the shah by a communist sympathizer two years earlier.

Matters went from bad to worse following Mohammad Mossadegh’s appointment to lead the country. The prime minister came to power on a populist and anti-imperialist platform that centered on nationalizing Iran’s oil industry, a promise he unilaterally carried out 10 days before the Dulles-McGhee meeting.

The Americans saw Mossadegh as an unreliable demagogue, whose eccentricities, confrontational politics and obstinacy on the oil dispute would inevitably be exploited by the Kremlin to draw Iran into the Soviet orbit. The shah’s anti-communist and pro-American credentials, on the other hand, were never in doubt.

But to the chagrin of McGhee and Dulles, the American embassy in Tehran had sent word that the shah’s will to resist the rising radical elements in the Iranian government was faltering because of a mysterious illness that caused recurrent and debilitating bouts of abdominal pain.

Making matters worse, the shah was considering the advice of his physicians to leave the country and seek medical care in Europe, a move the Americans believed would bolster communists and other radicals in Iran.

To avert the shah’s departure, Dulles personally traveled to New York and recruited Dr. Claude E. Forkner to carry out a secret mission in Iran to diagnose, treat and reassure the hesitant monarch.

The move paid dividends for the United States: Following successful surgery and an uneventful recovery, the shah returned to the political fray as the Americans had hoped. But that relationship may have proved the intelligence community’s undoing.

A few months after the shah’s surgery, Forkner took on Mossadegh as a patient when the premier was visiting the U.S., potentially signaling that the doctor was an American intelligence asset. This may have left the shah unwilling to trust the American medical establishment, explaining why he ended his medical relationship with Forkner and largely forswore the services of American physicians for the remainder of his reign. This practice contributed to the U.S. intelligence shortfalls on his health decades later.

It is impossible to determine whether the outcome of the 1979 revolution would have changed had the Carter administration known that the shah was ill. But it is clear the health of Iran’s ruler played an oversized role in the country’s political trajectory, a fact that should not be overlooked by current policymakers as Iran’s potentially cancer-stricken supreme leader faces unprecedented levels of opposition and social unrest.

As commander in chief of Iran’s armed forces and vicar of the Shiite Messiah, Supreme Leader Khamenei is the ultimate arbiter over the Islamic Republic’s factionalized political system. His incapacity would escalate government infighting, unbridle the Islamic Revolutionary Guard Corps and degrade the ability of the regime to cohesively respond to internal disturbances. Washington’s readiness to respond to such an eventuality could turn a new leaf in the U.S.-Iran relationship for decades to come — and for that, the U.S. needs to be prepared with as much intelligence as possible.

Amir A. Afkhami is an associate professor of psychiatry, global health and history at George Washington University