Police burn drugs, confiscated in Tehran: AIDS prevalence among drug injectors shocked Iran, which now offers addicts clean needles
Of Kamiar Alaei’s 63 days in solitary detention in Tehran’s notorious Evin prison, one of the worst was the day his cell was painted. Cell 74 of Unit 209 was tiny, six feet by four, and Kamiar, who is not tall, could flatten his palms on each wall when standing. But the ugly green walls provided companionship. They were covered with words, short poems, brief prayers—written with pens, scratched with broken plastic spoons, even written in blood.
“When you are in solitary you don’t know when it will be finished, so you have to keep your motivation to survive,” Kamiar said. The words on the walls provided his—he permitted himself to read one word a day. “I started from one side of the wall and read one word, and then I’d be done till the next day. It was like seeing an ad for a beautiful movie that you’ll watch tomorrow. I spent two or three weeks on one wall and then moved to another wall.”
Kamiar was new to prison. The interrogators were playing good cop/bad cop and he didn’t know if he could trust them. “People wrote ‘be strong’ and ‘don’t trust anybody,’” he said. “That helped me the most.”
Then one morning he woke up to the smell of paint. To his horror, the cells in his block were being repainted—a cheery yellow, but it was no consolation. The words of his predecessors were lost; now no one would understand what they had been through.
Kamiar was 34 when he was arrested, in his family’s apartment on 27th June, 2008. His brother Arash, five years older, had been arrested the day before. They were accused of conspiring with an enemy government to overthrow Iran’s regime. The evidence the eventually presented against them was laughable—one of Kamiar’s “secret meetings” cited by the authorities was actually a blind date.
What makes the Alaeis’ story unusual is not the how of their arrest and imprisonment, but the why. The official reason for their arrest was described by a spokesman for the Iranian judiciary: “They were linked to the CIA, backed by the United States government and state department,” said Ali-Reza Jamshidi. “They recruited and trained people to work with different espionage networks to launch a velvet overthrow of the Iranian government.”
But Kamiar and Arash—who got a three and a six year sentence, respectively—had not been breaking Iranian law, nor were they doing anything that could be considered dissent. They were AIDS doctors. They worked with Iran’s most marginalised populations—drug addicts, sex workers, prisoners—and invented new ways of helping those people that came to be adopted across the country as official policy. And they spoke about what Iran was doing in high-profile international meetings, bringing goodwill and credit to a government in desperate need of both.
These meetings were their undoing. The brothers were too public, too closely aligned with western scientists. “They were mixing it with Americans a bit too much,” said Ali Ansari, a professor of Iranian history at the University of St Andrews. “The government was trying to send a signal to people—don’t do things with the west on your own initiative.”
But few doctors had ever done more to help their country. AIDS in Iran is a problem of injecting drug users. Iran has one of the world’s highest proportions of young people and shares a 570-mile border with the world’s biggest opium producer, Afghanistan. These factors combined to give Iran the highest rate of opiate abuse in the world. “Addiction in Iran is ten times what is known in other countries,” said Antonio Mario Costa, who until recently was the head of the United Nations Office on Drugs and Crime.
After the Islamic revolution in 1979, drug addiction was pronounced counter-revolutionary, something forced on Iran by the west. All drug treatment centres were closed. For addicts, it was prison or labour camps. Possession of drugs in large quantities was a capital offence. Executions soared with an even harsher drug law that took effect in 1989; mass hangings began, mostly of people convicted after torture and summary trials by a revolutionary tribunal.
In the late 1990s, however, some government officials and influential academics began to recognise the consequences of this punitive policy. Even if they did not care about the health of drug addicts, they cared that the diseases of drug users would spread into the general population through sexual contact. They began to study HIV rates. Officials expected that rates would be high in prisons, which were full of drug addicts who were still injecting, sharing whatever needles they found or could improvise. But no one could imagine how high. At one prison surveyed in 2001 HIV rates were at a terrifying 63 per cent.
The AIDS prevalence rates among drug injectors shocked Iran into changing its approach to drugs. The policy today is inconsistent: the regime executes hundreds of people each year for drug trafficking after the most cursory of trials, and its paranoia and totalitarian tendencies have occasionally affected its policies towards drug abuse.
But the progressive attitude towards drugs that was begun during the Khatami government is, to an extent, being maintained. Drug abuse is treated mainly as a health problem, not as a crime (although drug dealers are treated very differently, often facing capital punishment). Instead of punishing drug users, Iran employs harm reduction, which seeks to prevent the spread of drug-related disease—including AIDS—by offering addicts clean needles, as well as the methadone and other drug substitution therapy that allows drug users to live normal lives.
In 2008, according to UNAIDS, the United Nations programme on HIV/AIDS, Iran gave out more clean needles than Canada. It currently has nearly twice as many prisoners on methadone maintenance therapy as Britain does. It has thousands of methadone clinics.
With harm reduction, Iran has kept an AIDS epidemic among drug users from spreading through society, saving countless lives. The evidence is overwhelming that harm reduction reduces disease and crime, while not increasing addiction. But the idea that the state should pass out needles to drug addicts is, at first glance—possibly second as well—scandalous. Social conservatives have blocked its use in many of the places that need it most. Yet the ultraconservative near-theocracy of Tehran is treating drug use much as if it were Amsterdam. It happened in no small part because of Arash and Kamiar Alaei.
*** I met the Alaeis in New York in October last year just days after Arash got out of prison. The occasion was a small gathering organised by Physicians for Human Rights, which had mounted an international campaign for their release. As the brothers told their story—Kamiar in confident English, Arash more halting—it was clear they had the serenity, certitude and stubbornness required of the most dedicated dissidents.
The brothers grew up in Kermanshah, a city of about a million in Iran’s west. The city is thousands of years old and has an ancient tradition of tolerance, which the Alaei family celebrated. They were upper-middle class and not particularly religious. Their father, Shaban Alaei, was a professor of Persian literature at the University of Kermanshah, and in the afternoons opened his house to high school students, whom he taught for free. Shaban knew thousands of poems. Every weekend he would open a book at random—“it was very exciting,” said Kamiar—and read a poem, then explained to his children what lessons it carried. Later, when he was in solitary confinement, Kamiar drew sustenance from the many poems he had memorised, reciting them to himself.
When the brothers were boys, the family travelled to Tehran to celebrate the New Year with an uncle and aunt. At dinner, their uncle suffered a heart attack. But he could not go to the hospital, as he had been drinking wine; the punishment for drinking alcohol was lashing or whipping. Their uncle waited until his body showed no signs of drink, and in the early morning, he went to the hospital. It was too late—he died two days later. It was the beginning of the brothers’ interest in helping those marginalised because they had violated society’s rules.
In 1998, Kamiar was interning at the Department of Lung Disease in Tehran when he saw a tall young man who was being kept in isolation, attended not by a nurse but by his mother. “He has AIDS,” a nurse told him. He began to learn about the disease, and the more he studied the more he was struck by how much it was misunderstood. Fear of AIDS patients was widespread. A prominent politician and physician in Kermanshah had raised money to set up an AIDS reference hospital there, but it had been cancelled after large protests, which turned violent. Local residents worried the whole city would be stigmatised.
Kamiar and Arash (who was practising general medicine) decided to do their post-doctoral internship in Kermanshah studying AIDS. They knew they would have no income and would be living with their parents. Fariba Mansouri, the head of Kermanshah’s health commission, gave them a room on the second floor of a big clinic at the medical university—a “clinic” with room enough for only two chairs. She told them “We’ll give you the opportunity, but if something happens, you’re on your own,” Kamiar said.
The brothers knew local citizens would not embrace a second attempt to treat AIDS patients, but the clinic would be tiny and discreet—the only people who knew about it were their clients. And although drug use—and working with drug users—was illegal, the Alaeis had the unofficial support of local authorities and the medical university. “The government was very worried about AIDS, but didn’t have the authority to control all officials and religious leaders,” said Arash. “So it supported some pilot programmes.”
Initially, two chairs were enough—they only had a few patients a week. They found themselves doing as much social work as medicine. People with AIDS were fired from jobs, shunned by friends and family, abandoned by spouses. “Their isolation was terrible,” said Kamiar. They found that half of the AIDS patients who died within a year of their diagnosis died by suicide. The Alaeis went to see their patients’ employers to plead for their jobs. They arranged weekend trips, negotiated housing for HIV-positive widows and even looked for partners for their patients. (The BBC short film, Mohammad and the Matchmaker, follows one such marriage.) After a year, the clinic was seeing dozens of people a day.
The Alaeis’ patients had multiple problems. The brothers realised that they couldn’t treat AIDS in isolation, so they expanded the clinic into what they called a “triangular” clinic, treating drug addiction and sexually-transmitted infections, as well as AIDS. Their goal was to help their patients with all their problems—medical or otherwise—or refer them to people who could.
Around the same time the Alaeis began their clinic, a doctor named Bijan Nassirimanesh in the town of Marvdasht, near the city of Shiraz, had decided to turn half his practice into a harm-reduction clinic. He didn’t even have any drug user patients, but he began to invite them in. He offered clean needles and buprenorphine therapy, buying the tablets on the black market. Nassirimanesh had no official backing. He was on his own, exposed, vulnerable to arrest. “It attracted me because it was scary,” said Nassirimanesh. “I was looking for adventure and rebellion.”
Nassirimanesh, like the Alaeis, eventually found official support, as Iranian health and prison officials saw that drug use needed to be treated as a health problem, not a crime. This was not a popular view in Iran, but its advocates had some advantages. In the late 1990s and early 2000s the government was led by President Mohammad Khatami, a reformer, and had an unusually high number of competent and dedicated officials.
The work of academics and doctors outside government, like the Alaeis and Nassirimanesh, was also important—the government could let them experiment with harm reduction while maintaining complete deniability. In 2002, Nassirimanesh moved to Tehran and won health ministry approval to set up a harm reduction clinic there, which he called Persepolis. He soon expanded to five clinics.
At the end of 2000, Parviz Afshar, the head of prison health, visited the Alaeis’ triangular clinic, and liked what he saw. Two years later, inspired by their example, he set up a triangular clinic in a Kermanshah prison. With money from the UN, Afshar brought prison and health officials from all over the country to train with doctors at the clinic, among them the Alaei brothers.
The hand of the reformers was strengthened by the encouragement coming from outside. It began in 1999, when Mo Mowlam was planning to visit Iran—the first state visit from a British government minister since the 1979 revolution. “The Blair administration and the Tehran administration were looking for subjects on which to have a first diplomatic rapprochement,” said Mike Trace, then the UK’s deputy drug czar. “We decided to do it on drugs because we had a shared interest there,” said Trace.
Iran’s first revolutionary governments were not interested in international opinion, but it mattered a lot to the Khatami government—it needed a counterweight to the conservatives. Trace wanted to make Iran’s leaders understand that its harm reduction advocates were making the country look good.
It helped that health is one of the most modern, science-based sectors in Iran—and one of the least susceptible to the influence of the mullahs. “When I look at Saudi Arabia, Tunisia or Malaysia, I see lots of interference from religion in public health,” said Nassirimanesh. “We’d have joint meetings between the health ministry and religious advisers. We’d laugh at them. It was none of their business.”
Nevertheless, they couldn’t ignore the religious leaders. The Alaeis recruited doctors from Kermanshah’s medical university and health department to find moderate clerics, and invited them to meetings and workshops to learn about the clinic’s philosophy and achievements. Nassirimanesh was doing something similar. They learned how to couch their points to meet Koranic standards.
Soon the Iranian Centre for Disease Management was using the triangular clinic model nationwide and taking it to international meetings. The Alaeis were invited to join a group writing the country’s national AIDS strategy. In 2004, the triangular clinic in Kermanshah won a prestigious international honour—the World Health Organization named it a “best practice,” praising the clinic’s “patient-centric” approach, one that tries to help people with all their complex problems. Interestingly, while the early version of the WHO’s report on the clinic credited the Alaeis, the final 53-page report doesn’t mention them once—“although they forgot to remove our pictures,” Kamiar said. He said that the health ministry asked the WHO to take the Alaeis out. The brothers took it as a sign of success—the government liked their work so much that it was time to take full credit for it.
By 2005, harm reduction was official policy in Iran. Ayatollah Sharoudi, the head of the judiciary, issued a letter instructing all judges, law enforcement and religious leaders to facilitate harm reduction programmes. “That was huge,” said Kaveh Khoshnood, an Iranian who is an associate professor at Yale’s School of Public Health. “People copied it and carried it around to show to the police if they were stopped.”
But that same year, Mahmoud Ahmadinejad won the presidency. He began to roll back many of Khatami’s political reforms. There were some attempts to do the same with harm reduction. Officials began to argue that harm reduction was immoral. The education ministry stopped plans to distribute a Red Crescent book for high school students about AIDS that the Alaeis had helped to write.
But harm reduction survived, kept alive by the support of doctors, medical universities, health officials, prison officials and international organizations.
Kamiar decamped for Harvard, joining the huge number of Iranian doctors who had studied abroad. He wasn’t fleeing, he said. Kamiar felt he could go abroad because harm reduction was so thoroughly entrenched. He didn’t see it as leaving Iran—he was back after four months, and returned every summer, bringing with him 15 to 25 American and Iranian-American students to work as interns with neglected communities in Iran on public health, and he intended to move back to Iran after graduation. Arash, always the more driven of the two, stayed in Tehran, expanding triangular clinics there, setting up training courses for doctors from Tajikistan, Afghanistan and Iraq, participating in and leading international collaborations.
The Alaeis felt prepared. Their triangular model was now embedded in the fabric of health care in Iran. There was scientific evidence showing their success. The programmes were winning Iran international praise. They had no idea what was coming.
When we think of people jailed for noble work under a repressive government, courage is the word that comes to mind—we assume that they hear the threats and simply proceed. That is not what happened. The Alaeis do not consider themselves particularly courageous. They were, instead, three other much more mundane things. They were first of all, empathetic: they identified with their patients; abandoning them was unthinkable. They were also stubborn. Their third quality, perhaps, was naïveté. If the new government was threatening them, it was on a wavelength they couldn’t hear. “We thought at most, we would have to stop our work,” said Kamiar. “There were no signals. Never.” When he was arrested and thrown into solitary confinement in 2008, he said, “I thought there was some misunderstanding, that they wanted to arrest someone else.”
Nassirimanesh and others believe the Alaeis were singled out not because they worked on harm reduction, but because they had become an international face of Iran’s harm reduction policy—in part because of their energy and ambition, in part their good English. “They are among the few who were able to link what was going on inside Iran with those outside,” said Khoshnood. “In my own community at Yale, several researchers went to Iran because of them. They felt part of a larger community—a global community.”
There were people in Iran who felt that the Alaeis did not deserve as much of the spotlight as they were given. “They were outside [Iran] in almost every conference,” said Nassirimanesh. “But so many people put in a lot of effort—they haven’t been to any conferences at all. If you want to put yourself in history, you should say ‘I am part of a team.’”
“There was a large effort going on with harm reduction in Iran,” said Khoshnood. “They are part of that. Some things would have happened without them. Others not.”
In an email discussion group on harm reduction in Iran, the Alaeis’ arrest and imprisonment was endlessly analysed. Especially during the first year, some people were less than wholly sympathetic, complaining that the brothers had taken too much credit for the changes. The Alaeis argue that the rules for credit in academic work were constantly shifting: Ministry of Health officials at first objected to having their names on scientific papers—too risky—and later complained when they were left off. Kamiar said that after their arrest, the government tried to discredit them in the online discussion group, among other places.
The very suddenness and irrationality of the Alaeis’ arrest seemed designed to send a message to anyone who had contacts with the west: anyone could be next. There will be no warning. Better to stay at home.
Nassirimanesh was getting nervous. “I was getting messages that I was talking to too many people around the world, in English,” he said. “I felt so uncomfortable. There was never a clear threat, but I don’t think the Alaei brothers got a clear threat. I felt that maybe my time will come very soon.” He left for Vancouver, where he now does research on harm reduction.
The brothers’ only real clues about the reason for their arrest came from the questions their interrogators posed. They asked about their relationships with academics in the United States and about the international conferences they attended. They asked about their travels around Iran. “They said ‘why are you going to the northeast? Why are you going to the south?’” said Arash. “They said we wanted to have branches in different cities we can use to work against the government.”
When Kamiar was finally brought into a courtroom in early 2009, after eight months in prison, the judge addressed him as Kamran instead of Kamiar and asked him a series of bizarre questions: Why did the United States support a military coup in Iran in 1953 (answer: “But I was born in 1974!”); Why didn’t the US back the Palestinians in a dispute five days ago (“How should I know? I was in solitary”); Why did you have connections with Bill University? (The judge apparently meant Yale).
Absurd, but it was probably a true illustration of the government’s paranoia. “In the lead up to [the elections of] 2009, they were arresting a lot of people for ‘fomenting democracy,’” said Ansari, the St Andrews professor. “[The Alaeis’] medical activities were seen as a cover for US infiltration. It’s pure conspiracy.”
Apparently, Kamiar’s answers were satisfactory enough to get him out of solitary and into the general prison population. Although in the west Evin is infamous for the rape, torture and murder of political prisoners, it mainly houses common criminals. Kamiar and Arash, finally reunited, asked to work in the prison health centre. They were turned down, and given jobs in the cultural department.
“We didn’t like the atmosphere in prison,” said Arash. “Especially the way prisoners related to each other. So we decided to change it.” Despite some hostility from the common prisoners, who viewed political prisoners as elites, the Alaeis began educating the prisoners on AIDS, drug use, hand washing and other health issues. They taught English and encouraged other prisoners to teach Spanish (which Kamiar took up), German, Arabic, French and even Esperanto. They called publishers to collect material for the prison library. They organised sports leagues and circulated a prison newsletter. “Keeping busy from 6am to 10pm was how we survived,” said Kamiar.
The prison authorities had enough, and moved them to the bakery and kitchen. There they campaigned for healthier food, started a hygiene campaign to keep the kitchen cleaner and took advantage of their jobs passing out bread to talk to prisoners about their cases. They were then made to sweep and rake leaves. In the spring of 2010 the authorities at Evin gave up and moved them to a prison for drug dealers and users. The staff there allowed them to work in the clinic. They started to educate prisoners about basic health care and doctors about epidemiology. They were reassigned to the kitchen.
At the end of 2010, after two and a half years—870 days, 20,880 hours, as he counts it—Kamiar was released. In Iran first-time prisoners are eligible for release after serving half their sentence; Kamiar had served a full year more than that. His release, moreover, was conditional for four years. His freedom depended on the government’s good will.
He decided to leave the country. Then began a high-speed Keystone Kops tour of Iran’s bureaucracy to collect the documentation he needed while not alerting the authorities.
Kamiar went back to Albany, where he had been studying at the State University of New York after his Harvard scholarship ran out. His sister Mahnaz was already there. She had lost her job as a computer engineer after the brothers’ arrest and moved to Armenia. A month before Kamiar’s release she went to Albany as well. Once in the US, Kamiar found a whole international network already at work for Arash, who was still serving his term. Kamiar had heard about it in prison: on one visit, each family member hugged him and Arash, and whisper one word in his ear—put together, the message was “Don’t worry, the world supports you.”
“All the international contacts made them high-profile,” said Khoshnood. “It got them in trouble, but it also protected them. ”
Because Arash was still in prison, Kamiar kept uncharacteristically quiet. He didn’t even tell many of his friends and family in Iran that he was free. After Arash passed the three-year mark—half his sentence—Kamiar began to speak out. When Arash had spent three years and two months in jail, he was freed. He quickly joined Kamiar in Albany.
Iran remains the only place in the Middle East taking its AIDS problem seriously. “They were and continue to be one of the few countries offering any services in the region,” said Claudia Stoicescu, public health analyst at the London-based Harm Reduction International. The number of places where addicts can get methadone maintenance therapy has soared—tripling in two years. “If I had stayed another year, I maybe would have ended up like the Alaei brothers,” Nassirimanesh said. But his Persepolis clinics continue—some under their own power, others absorbed into local health care facilities. Harm reduction continues to be state policy in Iran.
The evidence for its success can be found in the annual surveys of antenatal clinics that every country performs. As of 2011, only one woman tested in the survey sites has ever been found HIV positive. Harm reduction is containing the epidemic.
But Iran is driving with its foot on the accelerator and the brake at the same time. President Ahmadinejad announced in 2007 that there were no gay people in Iran, and cancelled the national commemoration of AIDS Day. The government shut down some research on addiction and cancelled a programme of collaboration on harm reduction between Yale and one of Iran’s most prestigious research organisations. Needle exchange programmes have been cut back—about 200 of the country’s 637 programmes closed in the last two years. Budget constraints are the main reason, but it shows how AIDS has ceased to be a priority. A new law allows judges to force addicts into detox programmes if they choose.
The most horrifying change is the rocketing number of executions for drug trafficking or smuggling since the middle of 2010. The Foreign and Commonwealth Office Human Rights Report counts 650 executions in Iran last year—of those, 85 to 90 per cent were for drug offences. Drug trafficking and drug use are very different, but these trials illustrate the government’s totalitarian tendencies. We know nothing about the vast majority of these trials, but in some of the cases that have come to light, the trials seemed no more serious than that of Kamiar. In at least one case, a political prisoner arrested for protest ended up being executed for drug trafficking.
Kamiar has just finished his comprehensive exams in Albany, and is starting his dissertation, on the impact of a new HIV testing policy in the United States. He put his prison-acquired Spanish to use running classes for teenagers on the Haiti-Dominican border, and spoke in El Salvador at a workshop on health and human rights in prison.
When Arash was released from prison, he applied to the authorities to resume his work. They told him that he could do no social activity—no doctoring, no teaching, no organising, no advocacy. So he, too, is in Albany, working with the university on its international collaborations and preparing a project to train harm reduction practitioners in Afghanistan, Tajikistan and Iraq. “We can’t go to our countries, so we should go to our border,” he said.
But if they could go home?
“We’d go tomorrow,” said Arash. “Tonight.” said Kamiar. “If we had the opportunity to work,” said Arash.
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