On January 16, 1979, Shah Mohammed Reza Pahlavi, who had ruled Iran for nearly thirty-eight years, left the country in the face of a nationwide popular revolution—never to return. Shortly after his departure, it became known that the deposed monarch suffered from advanced cancer, and on July 27, 1980, he passed away in Cairo, at age sixty.
Did the shah's illness play a role in the advent of the Iranian revolution? A growing body of evidence indicates that it did. For one thing, his frantic drive "to transport a fourteenth century country into the twentieth century in a decade," widely considered the revolution's precipitating cause, was likely influenced by his foreboding sense of mortality. For another, the extent of Western governments' awareness of the shah's real state of health influenced their attitudes and behavior toward the beleaguered monarch, leading to the West's effective desertion at the most critical moments in his war for survival.
A Closely Guarded Secret
It is not clear when the shah developed cancer symptoms and when he was first diagnosed. One account traces this diagnosis to 1970 or 1971 when a biopsied gland in the shah's neck, noted by his eminent Viennese physician Karl Fellinger, revealed lymphoma; another account dates Fellinger's biopsy to late April 1974. What is clear, however, is that from at least May 1974, he was under regular observation by French and Iranian physicians, and that, in mid-September 1974, his situation was deemed sufficiently serious to justify the initiation of chemotherapy. By the time he left Iran in January 1979, the shah had been seen thirty-nine times by his main French physician, Georges Flandrin, thirty-five of them in Tehran.
The shah's illness was kept under wraps as Iran's most-guarded secret, becoming public knowledge only after the deposed monarch was moving from one country to another in search of a safe haven and medical treatment. It was only in the spring of 1977 that Empress Farah was informed of her husband's true state of health and his years-long battle against chronic lymphatic leukemia. Indeed, even the shah himself seems to have been kept in the dark regarding the true nature of his illness.
Anxious to spare the monarch the stress attending the term cancer, his personal physician convinced the two French doctors after their first examination of the shah in April 1974 to tell him that he had the less aggressive lymphoma known as Waldenstrom's disease. The shah accepted this diagnosis and only understood the full extent of his illness several years later.
In these circumstances, it was hardly surprising that Tehran's Western allies were largely unaware of the shah's cancer. While the French authorities might have been apprised by his French physicians of his cancer (though Flandrin told Farah that only seven persons knew about the illness), the U.S. foreign and intelligence services seemed oblivious to the issue. As late as January 1977, the Department of State informed the newly inaugurated President Jimmy Carter that at "age 57, in fine health, and protected by an absolute security apparatus, the Shah has an excellent chance to rule for a dozen or more years." This prognosis was echoed several months later by a CIA memorandum:
The Shah seems to have no health or political problems at present that will prevent him from being the dominant figure in Iran into and possibly throughout the 1980s.
Knowing the Secret
Despite these real-time manifestations of ignorance, the writing was clearly on the wall for Western leaders and security services to see. As early as October 1973, the shah delivered his political testament to the prime minister and army commanders, and the next year, as he was placed under regular monitoring by his physicians, he began talking about not being around for long, notably during his spring 1975 meeting with French president Valery Giscard d'Estaing. While the shah might not have been aware of the full extent of his illness, it seems he was sufficiently alarmed as to acknowledge his looming mortality. He accelerated his reforms, and the empress and the crown prince were increasingly involved in state affairs, laying the groundwork for succession.
There has also been growing evidence over the past decade that Western leaders, including President Carter, were better informed of the shah's illness than previously believed, not least since the CIA had reportedly been alerted by Israeli intelligence to the seriousness of the situation well before it spiraled out of control. In a 2009 interview, for example, Henry Precht, head of the Iran desk at the State Department (1978-80) and a political-military officer in the Tehran embassy (1972-76), argued that by the autumn of 1975 Tehran ambassador Richard Helms was already aware to some extent of the shah's health problems and his treatment by French physicians. The former head of the CIA's Near East and South Asia Division, Charles Cogan, similarly claimed that both the French and U.S. administrations knew about the shah's illness, the Americans from at least 1976. According to Iran scholar Marvin Zonis, it was not only the French intelligence services that knew about the shah's cancer through his physicians but also their British counterparts, which gained this information in the mid-1970s through their own sources.
A recent book by Amir Aslan Afshar, former Iranian foreign minister and the shah's close confidant, argues that the Western governments knew about the monarch's illness and that this influenced their policies towards Iran, the shah, and the Islamists who challenged his rule. Afshar narrates discussions with the former director of the French domestic intelligence service, Yves Bonnet, who later served as the region prefect for the French island of Guadeloupe, which provide significant new insights into the shah's health and the extent to which the Carter administration, CIA, and the French government knew about the monarch's illness.
According to Afshar, Bonnet was present at the Guadeloupe summit of January 4-7, 1979, in which Carter, Giscard d'Estaing, British prime minister James Callaghan, and West German chancellor Helmut Schmidt discussed world affairs, including the Iranian crisis that was nearing its dramatic climax. In Bonnet's account, both Carter and d'Estaing considered the shah's illness an important reason why he could not continue and should be ousted. And while official U.S. documents about the Guadeloupe summit are not yet available, participants' recollections lend credence to Bonnet's claim regarding the Western leaders' decision to betray their long-standing ally and instead establish contacts with his arch enemy, Ayatollah Ruhollah Khomeini, who then lived in exile in a Paris suburb. President Carter, for example, admits in his memoirs that there was "little support for the shah" at the summit and that there was broad consensus among the Western leaders that the monarch "ought to leave [Iran] as soon as possible." For his part, President d'Estaing recalled that it was Carter who argued that the shah could no longer be in power and must leave the country.
The West and the Islamic Revolution
While Western awareness of his illness seems to have tilted the scales against the shah in his direst moment of need as narrated by Bonnett, Afshar goes further to accuse the West of enabling, if not facilitating, the overthrow of the shah, partly because of its awareness of his real health condition. This charge was echoed by the shah himself in his memoirs, by some former Iranian officials (e.g., Minister of Education Manouchehr Ganji; Parviz Sabeti, head of the Third Bureau of SAVAK, the domestic security and intelligence service), and by a growing number of Western scholars, commentators, and former officials.
Thus, for example, Alexandre de Marenches, former head of the French External Documentation and Counter-Espionage Service, claims to have warned the shah that President Carter was determined to overthrow him. He recalled having "mentioned to the shah the names of those in the United States who had been given responsibility of seeing to his departure and replacement" and having also informed the monarch of his participation "in a meeting where one of the questions for consideration was, 'How is the shah's departure to be managed, and by whom shall he be replaced?'"
Gen. Wesley Clark, former NATO supreme allied commander Europe, revealed in an interview that Carter had sent Gen. Robert Huyser to Tehran in early January 1979 to persuade the Iranian military not to intervene in support of the shah. According to Clark:
The [Iranian] generals tried to warn the Americans; they said be careful, you're playing with fire, and you're going to let Ayatollah Khomeini come back in. We sent in an American general, over to tell the Iranian generals to back off. So, for about 60 days we kept the military from intervening in Iran.
Carter himself supports this, stating: "He [Huyser] had dissuaded some of its [the Iranian military] leaders from attempting a coup."
Another perspective was offered by Vladimir Kuzichkin, a Russian KGB security officer, stationed in Iran during the reign of the shah and the revolutionary regime's early years, who defected to Britain in 1982. In his memoirs, he accused the Carter administration of facilitating the Islamic revolution and claimed that KGB analysts believed that the CIA supported Khomeini, including through Iranians living in the United States. One of these was Ibrahim Yazdi, a U.S. citizen with whom the Carter administration had secret contacts at least since earlier in the 1970s. One of Khomeini's closest aides, Yazdi went on to become the first foreign minister of the Islamic Republic.
Another Khomeini confidant (and would-be foreign minister) who interacted with the Carter administration was Sadegh Ghotbzadeh. During the Guadeloupe summit, Bonnet read a personal fax from Ghotbzadeh to the four participating leaders, in which he thanked them for their support for the anti-shah opposition. In a secret meeting with President Carter's chief of staff Hamilton Jordan following the shah's overthrow, Ghotbzadeh inquired whether the CIA could assassinate the monarch in his Panama exile. (Ironically, Ghotbzadeh himself would be executed by Khomeini in September 1982 on charges of espionage for the United States.)
Finally, in a recent interview with the BBC, Ayatollah Hussein-Ali Montazeri, probably Khomeini's closest associate until their acrimonious falling out in 1989, revealed that he tried to convince the supreme leader to free the U.S. embassy hostages as a "goodwill" gesture to Carter since the Islamic Revolution's victory had been made possible thanks to the environment created by the U.S. president. This latest claim has been reaffirmed by new declassified U.S. diplomatic cables introduced by the BBC Persian Service that illuminate extensive contacts between Washington and the anti-shah opposition, Khomeini in particular, and how those exchanges paved the road for the ayatollah's triumphant return by pushing the Iranian military not to support the shah.
While their knowledge about the shah's cancer apparently drove the Western powers to give up on the beleaguered monarch by reinforcing their belief in his inability to weather the storm, there are still many unknowns concerning the role of the West, especially the United States, in the Islamic Revolution. Why, for example, did the West seek inroads to the Islamists instead of supporting the legal alternative to the shah: the reign of the empress together with the regency council until the U.S.-educated crown prince reached the legal age to become the new shah. This alternative was not only constitutional but also enjoyed the support of the military and the Iranian intelligence community, and offered the West continuity and stability in the region.
Nor is it clear why knowledge of the shah's illness did not result in close and critical monitoring of his health and, therefore, the events taking place in Iran. It was standard operating procedure for both the U.S. National Security Council and the CIA to initiate studies about how U.S. relations would be affected when foreign leaders became seriously ill, as happened, for example, when French president Georges Pompidou became ill with cancer. Iran was in a far more critical condition and had a greater strategic value for Western security due to its preeminent position in the region and the world oil market, yet this procedure was apparently not followed. And if such a study was conducted, how could the U.S. or French governments claim to have been taken by surprise?
Either way, the abandonment of the shah backfired in grand style. Not only has Tehran become a foremost catalyst of regional instability, but the fawning Western behavior vis-à-vis the shah's enemies failed to curry the desired favor with the Islamist regime. For if the Western chancelleries so readily betrayed a longstanding friend and ally, why should they treat an antagonist better?
Ardavan Khoshnood is a medical doctor and Ph.D. in emergency medicine at Skåne University Hospital at Lund, Lund University, Sweden. He also lectures in criminology at Malmö University, Sweden, and holds a bachelor of science in intelligence analysis from Lund University. Arvin Khoshnood holds a master of science in political science and human geography and a bachelor of science in intelligence analysis, each from Lund University. He has authored numerous articles on Iranian domestic and foreign policy.
 William J. Daugherty, "Behind the Intelligence Failure in Iran," International Journal of Intelligence and Counter Intelligence, 2001, no. 4, pp. 477-8.
 Savosh Khonsari, "The Shah's Spleen," Journal of the American College of Surgeons, Aug. 2011, p. 338.
 Ardavan Khoshnood and Arvin Khoshnood, "The death of an emperor: Mohammad Reza Shah Pahlavi and his political cancer," Alexandria Journal of Medicine, 2016, no. 3, p. 202.
 Ibid.; Leon Morgenstern, "The Shah's Spleen: Its Impact on History," Journal of the American College of Surgeons, Feb. 2011, p. 260.
 Farah Pahlavi, An Enduring Love: My Life with the Shah (New York: Miramax Books, 2004), p. 241.
 Abbas Safavian, interview by Bijan Farhoudi (in Persian), Lenziran, July 27, 2015; Morgenstern, "The Shah's Spleen," p. 260.
 Pahlavi, An Enduring Love, p. 252.
 Franklin P. Huddle, "The Future of Iran: Implications for the U.S.," Department of State, Bureau of Intelligence and Research, Digital National Security Archive (DNSA), George Washington University, Washington, D.C., Jan. 28, 1977
 "Iran in the 1980s," Central Intelligence Agency, DNSA, Aug. 1977, pp. 1-2; see, also, "Iran in the 1980s," DNSA, Oct. 5, 1977, p. 8.
 Khoshnood and Khoshnood, "The death of an emperor," p. 204.
 Milo Jones and Philippe Silberzahn, Constructing Cassandra: Reframing Intelligence Failure at the CIA 1947-2001 (Stanford: Stanford University Press, 2013), pp. 95-6.
 Andrew Scott Cooper, The Oil Kings: How the US, Iran, and Saudi Arabia Changed the Balance of Power in the Middle East (New York: Simon and Schuster, 2011), p. 279.
 Charles Cogan, interview, DNSA, Aug. 1997; Babak Ganji, Politics of Confrontation: The Foreign Policy of the USA and Revolutionary Iran (London: IB Tauris, 2006), p.1
 Marvin Zonis, Majestic Failure: The Fall of the Shah (Chicago: University of Chicago Press, 1999), p. 160.
 Amir Aslan Afshar, Mémoires d'Iran: Complots et trahisons (Paris: Mareuil éditions, 2015)
 Amir Aslan Afshar, interview, Kayhan London, Dec. 14, 2015; Kristin L. Ahlberg and Adam M. Howard, eds., Foreign Relations of the United States, 1977-1980, vol. 1 (Washington, D.C.: Government Printing Office, 2014), doc. 106, p. 511.
 Andrew Scott Cooper, The Fall of Heaven: The Pahlavis and the Final Days of Imperial Iran (New York: Henry Holt and Company, 2016), p. 322; The Guardian (London), June 10, 2016; Ganji, Politics of Confrontation, p. 2.
 Jimmy Carter, Keeping Faith: Memoirs of a President (Fayetteville: University of Arkansas Press, 1995), p. 469.
 Valery Giscard d'Estaing, Le pouvoir et la vie, vol. 1 (Paris: Le Livre de Poche), p. 111.
 Afshar, Mémoires d'Iran, pp. 314-16; Armin Arefi, "Les derniers secrets du shah d'Iran," Le Point (Paris), Dec. 12, 2015.
 Mohammad Reza Pahlavi, Answer to History (New York: Stein and Day Publishers, 1980), p. 14.
 Erfan Qaneeei Fard, Dar Damgahe Hadese (Los Angeles: Ketab Corp, 2012), pp. 374-6, 531-2; Manouchehr Ganji, Defying the Iranian Revolution (London: Praeger, 2003), pp. 36-42
 Cooper, The Fall of Heaven; Cooper, The Oil Kings; Javier Gil Guerrero, The Carter Administration and the Fall of Iran's Pahlavi Dynasty: US-Iran Relations on the Brink of the 1979 Revolution (New York: Palgrave Macmillan, 2016); Javier Gil Guerrero, "Human Rights and Tear Gas: The Question of Carter Administration Officials Opposed to the Shah," British Journal of Middle Eastern Studies, 2015, no. 3, pp. 285-301; Gholam Reza Afkhami, The Life and Times of the Shah (Oakland: University of California Press, 2009); Michael Evans, Jimmy Carter: The Liberal Left and World Chaos (Phoenix: Time Worth Books, 2009); Houchang Nahavandi, The Last Shah of Iran (Berkshire: Aquilion, 2005
 Christine Ockrent, The Evil Empire: The Third World War Now (London: Sidgwick and Jackson, 1988), pp. 125-6.
 Wesley Clark, interview, Pierce Morgan Live, CNN, Aug. 15, 2013.
 Carter, Keeping Faith, p. 472.
 Vladimir Kuzichkin, Inside the KGB: My Life in Soviet Espionage (New York: Pantheon, 1991), pp. 233, 239-40
 Christian Emery, US Foreign Policy and the Iranian Revolution: The Cold War Dynamics of Engagement and Strategic Alliance (London: Palgrave Macmillan, 2013), p. 216.
 Afshar, Mémoires d'Iran, pp. 314-16.
 The New York Times, Sept. 20, 1982
 Grand-Ayatollah Hossein Ali Montazeri, interview, BBC, Dec. 17, 2014
 Kambiz Fattahi, "Two Weeks in January: America's secret engagement with Khomeini," BBC, June 3, 2016; The Guardian, June 10, 2016
 Jones and Silberzahn, Constructing Cassandra, pp. 95-6; Cooper, The Oil Kings, pp. 165, 280.