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  1. Guttz
    This is a story about a courageous policy in an unexpected place. In this place homeless shelters have vending machines selling clean syringes for injecting drugs. Drug users are not prosecuted as long as they are in treatment programs. Drug addicts are given clean needles and methadone maintenance therapy ─ available on a widespread basis even in prison. These tactics have worked to reduce crime, lower H.I.V. rates among drug users and keep AIDS from spreading out into the general population. The place is not Amsterdam. It is Tehran.

    In a week when the news about Iran is centered on nuclear facilities and desperate diplomacy, I’d like to focus instead on another serious problem, toward which this repressive, seemingly irrational theocracy has taken a pragmatic and enlightened approach.

    Sometimes there is no mystery about the best strategy to solve a problem, but for political reasons, that strategy is not used. Iran’s story offers useful lessons on how to build political support for effective solutions in tough circumstances.

    In Africa, AIDS is spread mostly by sexual contact. We know that people need to abstain from sex, be faithful to one partner, or use condoms. But there has been limited success on this front. We just aren’t very good at getting people to do these things.

    In many countries, however, the primary propeller of AIDS is not sex, but hypodermic needles shared by injecting drug users. This is the biggest driver of the H.I.V. epidemic in Eastern Europe, much of the Middle East and Asia and parts of the rest of the world. By recent measures, 62 percent of H.I.V. infections in Russia came directly from a shared needle. In Malaysia it is 76 percent, in Iran 68 percent. This is not just a problem for drug users. Unchecked H.I.V. epidemics among drug users move out into the general population by way of drug users’ sex partners. In a recent (and highly entertaining) book, “The Wisdom of Whores,” Elizabeth Pisani, an epidemiologist and advisor to Unaids, argued that Jakarta, Indonesia, has an H.I.V. epidemic 50 times larger than it would be if it had not allowed H.I.V. infection rates for drug users to climb from 0 to 47 percent in the late 1990s.

    America’s AIDS emergency among black women ─ who have an AIDS rate 23 times higher than that of white women ─ could have been prevented with timely programs to prevent needle sharing. Few of these women got H.I.V. from a needle ─ but the needle is how H.I.V. got into the black community to begin with.

    Preventing H.I.V. transmission among drug users, then, is a way to protect everyone.

    Unlike preventing sexual transmission of AIDS, this is something we can do. The strategy is needle exchange ─ giving drug abusers new needles, usually in return for their used ones. One reason it works is that drug users want it: every drug injector prefers using clean needles.

    Needle exchange is part of an overall approach to drugs called harm reduction, which seeks to make drug use less deadly to the addict and to diminish the crime and disease that drug addiction causes. In most countries that use harm reduction, possessing drugs is still illegal. But drug abuse is treated mainly as a disease, not a crime. An example of what harm reduction looks like can be seen in the Persepolis clinics, in Tehran’s south. Persepolis began as one drop-in center in a drug-ridden neighborhood, and later expanded to five centers. The clinics have outreach teams of former drug users who contact their peers on the street. The clinics offer needles, methadone, treatment for sexually transmitted diseases, AIDS tests and other medical care. They get people into drug treatment programs. Drug users can take showers, and sit all day and drink tea. When there is money, the clinics serve lunch and give out clothing. One clinic, with an all-female staff, is only for women. The clinics are an avenue for drug users to come into the health system, where they can get help.

    The evidence that harm reduction works is overwhelming. Critics of needle exchange have argued that it causes more drug use, but it has proven not to do so. Instead, it drastically reduces H.I.V. rates by preventing a small H.I.V. problem among drug users from becoming a large one in the general population. It saves money, especially compared with the usual alternative ─ prison. It fights crime. Drug users on methadone maintenance therapy commit far fewer crimes than other users, and are usually able to hold down jobs and have otherwise normal lives.

    But the overwhelming majority of drug injectors have no access to harm reduction. Widespread, effective needle exchange is mainly found in the expected places ─ Western Europe, Australia and New Zealand. In Russia, the country that most needs harm reduction, methadone is illegal and needle exchange is done only by tiny groups in a handful of cities. While some American cities use needle exchange (New York City is a much safer place because of its excellent needle exchange programs), it was illegal to use federal funds for needle exchange until last year. And under the Bush administration, Washington bullied international agencies to abandon their support for needle exchange.

    The problem is the politics. It seems wrong for the government to be muddying a “don’t-do-drugs” message by supplying the equipment for an illegal and dangerous activity. But to oppose harm reduction only provides the illusion of morality. Surely it is more moral to choose a strategy that does not increase drug use, but does save lives.

    Harm reduction is relatively new in Iran. After the Islamic Revolution in 1979, Iran cracked down hard on drug users, declaring addiction to be counter-revolutionary. All drug treatment was stopped. Hundreds of thousands of drug users were sent to labor camps. Possession of heroin was a capital offense.

    These punitive policies only added to a spiraling epidemic of drug use. Ten years ago, the United Nations Office on Drugs and Crime (UNODC) estimated that Iran’s drug problem was one of the most serious in the world (sharing a 570-mile border with opium-growing Afghanistan does not help.) The harsh policies only drove drug users further underground; fear of being caught with a needle meant users would use the community needle the dealer provided. Going to prison was particularly dangerous. Prisons are havens of needle sharing, and having been incarcerated is the single strongest predictor of H.I.V. infection in Iran. Good data is scarce, but at one prison surveyed in 2001, 63 percent of all injecting drug users were H.I.V. positive. Testing of drug users who visited the Persepolis clinic found that fully a quarter of them had the AIDS virus.

    Yet by 2005, harm reduction had become official policy in Iran. Ayatollah Mahmoud Shahroudi, the head of the judiciary, sent a letter to all courts and judicial authorities instructing them to support methadone and needle exchange. Even prisons in Iran now have widespread methadone, and there have been pilot projects in prisons for needle exchange ─ something not yet found in prisons in the United States, Canada or Australia. In 2007, 95 percent of drug injectors surveyed in Iran said they had used safe equipment when they last injected. (UNAIDS report, p. 94)

    The rate of new H.I.V. infections in Iran rose until 2005, and has dropped ever since. A top drug control official, Saeed Sefatian, said in 2008 that 18 percent of injecting drug users were H.I.V.-positive, but estimated that if it weren’t for harm reduction, that number would have been 40 percent. New infections among drug users have continued to drop. Surveys at sentinel sites in pre-natal clinics have not yet turned up not a single pregnant woman with H.I.V. (UNAIDS report, p. 97) ─ an excellent indication that the epidemic has been contained.

    By pointing out the success of this program, I do not mean to endorse Iran’s prisons, where political dissidents are being tortured. Nor does Iran’s modern approach to harm reduction redeem the government’s stone-age approach to just about everything else. The same ayatollah who told judges not to get in the way of harm reduction was the man who closed dozens of newspapers. The important point here is that even a theocracy as repressive and rigid as Iran ─ the anti-Amsterdam ─ managed to create policies that have likely saved the country from an AIDS and drug disaster. In Saturday’s column, I’ll tell the story of how the pragmatists in Iran managed to convince the clerics to adopt these policies ─ and what other countries can learn from their accomplishment.

    November 29, 2010, 8:35 pm


  1. Guttz
    How Iran Derailed a Health Crisis

    So how did Iran do it? How did a conservative theocracy decide to deal with its drug addicts as if it were Canada? In Tuesday’s column, I wrote that Iran is treating its massive epidemic of injecting drug use mainly as a health problem. With this strategy, it has effectively managed to lower H.I.V. rates among drug users and keep the disease from spreading. It has taken an approach to drugs known as harm reduction, which includes the provision of methadone maintenance therapy and clean needles to drug users.

    The science behind harm reduction is solid ─ but the politics are acutely dangerous. It is scorned in some countries that desperately need it, notably Russia. It is used only fitfully in the United States, as many readers commented. But advocates for harm reduction in Iran managed to build political support for changing very harsh drug policies to more rational and effective ones during the period of 2002 to 2005.

    Here’s what we can learn from them:

    Don’t waste a crisis. At the end of the 1990s, Iran’s health ministry commissioned a survey of drug use, which showed that drug injection was far more widespread than people had thought, and rising at explosive rates. There had already been three notorious outbreaks of H.I.V. in prisons. Iran was facing a genuine health crisis, one exacerbated by the punitive policies it had been using, since the strongest predictor of whether someone had H.I.V. was whether he had been in prison.

    This gave an opening to doctors in Iran who knew the evidence about harm reduction. They were able to cast it as a solution to a health problem and base the program in the health ministry, not the drug control officials ─ a much more congenial place. The AIDS crisis helped to depoliticize a normally controversial program.

    Recruit influential backers. In many countries, the lobby behind harm reduction is weak. In Russia, for example, the main advocates are the courageous nongovernmental organizations that work with drug users. The voices of drug users are crucial, of course, but is there anyone with less influence and public support? The government has crushed them.

    Iran’s advocates marshaled crucial support from doctors ─ at universities and in private practice. (Much methadone maintenance therapy is administered by private doctors on a for-profit basis.) Iran’s health sector is powerful and respected. It is also modern. No matter what the regime, Iran’s medical schools have emphasized real science. “When I look at other countries I see lots of power interference from religion in public health,” said Bijan Nassirimanesh, a harm-reduction pioneer in Iran and founder of Persepolis, a drop-in harm reduction center in Tehran. “You don’t see that in Iran except for sex education. The foundation (of science) was so strong that it became a shield.”

    Reform when you can. As several readers noted, harm reduction is not the only departure from religious orthodoxy in Iran – there are other ways Iran surprises, from its regulated market in kidneys to the prominence of its female film directors. (thank you to commenters A. Kamyar from Baton Rouge and Rohit from New York.) Many Iranians argue that their society is far more open and progressive than its rulers are, and Iran has had much better rulers than it has now. Harm reduction began under the relatively reformist government of Mohammad Khatami. It was still necessary to convince the clerics, but it became a far easier task when those in the bureaucracy who campaigned for harm reduction had the support of Khatami’s top officials. The government of Mahmoud Ahmedinejad would never have started harm reduction, but it continues the program because it has been successful.

    Speak the right language. The clerics needed to be sure harm reduction was Koranically acceptable, and that is what they were told. “There is a rule in Islam that between bad and worse, you have to accept bad,” said one Iranian drug expert, “Having needle and syringe programs is bad, but having H.I.V. is worse. There is no third option. University scholars, health professionals and N.G.O. activists talked to them in their own language.” Iran was also wary — as Russia is — of solutions that appear to be from the West. Although harm reduction in Iran developed after numerous conversations with experts from the United Nations, Britain and the United States, harm reduction’s advocates were able to argue to the clerics that it was an Iranian solution ─ one tailored to the particular problems that Iran was undergoing.

    Demonstrate that it works. Before needle exchange and methadone became national policy, politicians had to be convinced that they worked, and would not lead to increased drug use or other negative consequences. One of the first people to undertake harm reduction in Iran was Dr. Bijan Nassirimanesh, who practiced medicine in Marvdasht, a small city near Shiraz. Concerned about drug users, he decided in 1999 to turn half his clinic into a harm reduction site, working semi-clandestinely. In 2002 he moved to Tehran to try to work on a larger scale.

    At the same time, Arash and Kamiar Alaei, brothers who were doctors in Kermanshah, in Iran’s northwest, were running what has become known as a “triangular” clinic, because it treats addiction and sexually transmitted diseases as well as AIDS.

    The authorities took notice. Nassirimanesh went to the health ministry to try to get approval and funding for a drop-in center to do harm reduction in Tehran. “I was a very junior doctor but they took it seriously,” he said. “They didn’t want to implement these things themselves, so having a nongovernmental organization like Persepolis ready to do whatever was a perfect match. They didn’t say no to a single thing.”

    At the end of 2002, he established Persepolis. It was supported by the health ministry, but the money came from the United Nations Office on Drugs and Crime. In 2003, the Alaeis began to replicate their triangular clinic on a national scale with government help. Now these clinics exist in dozens of cities and prisons.

    Another way supporters of harm reduction helped their cause was to facilitate research about its effects, sometimes conducted by government ministries in collaboration with universities in Iran and abroad A study led by an Iranian studying in Japan in 2005 showed that needle exchange at the Persepolis clinic was associated with less needle-sharing.

    TODAY, harm reduction in Iran goes on but is precarious. There were 25,000 people on methadone maintenance in 2005, and between four and six times that number today. Needle exchange programs are also growing. Iran has just published an updated anti-drug strategy that does not change the policy significantly. Inside the bureaucracy, mid-level officials are still committed to harm reduction.

    But Ahmedinejad loyalists are replacing experts throughout the government, and many of the most important supporters of harm reduction in the government have been fired or have left. Academics and government officials are now in danger if they go to international meetings or have contacts with the West ─ even with universities. Even publishing scientific papers is suspect ─ the government has accused their authors of collecting information to be used by the West against Iran. Persepolis is down to two clinics from a high of five due to budget cuts, and Nassirimanesh left Tehran for Vancouver four years ago, where he works as a researcher on harm reduction. The Alaei brothers were arrested in 2008, subjected to a sham, one-day trial, convicted of plotting to overthrow the government and given three and six-year prison sentences.

    It is likely that the government’s paranoia and repression are driving drug users away from official clinics. “Trust is the cornerstone of harm reduction,” said Kaveh Khoshnood, an Iranian-American assistant professor at the Yale School of Public Health. “Drug users are watching the same footage as everyone else. They see thousands of people being beaten up. It has an impact on them, too – an erosion of trust.”

    Postscript: Reducing Harm in America

    Many readers commented that they hoped the United States would follow Iran’s example in endorsing harm reduction. I am aware that holding up Iran as a model is perhaps not the way to win friends for needle exchange here. There may be no people with less public support and influence on policy in Russia than drug users, but there are in America: Iranian officials.

    But a good idea is a good idea, even if Iran is employing it. And with the departure of the Bush administration, things have changed for American drug policy. As of July, 2010, American anti-AIDS programs overseas can finance needle exchange, and it is now legal to spend federal money on needle exchange at home. Needle exchange in the community is now largely a state and local issue, although a strong stand by the Obama administration would be important. Reader Zachary Berger of Baltimore suggested that perhaps Iran could begin controversial programs precisely because the mullahs didn’t have to worry about public opinion. In America, however, we do. The key, as Iran shows, is to emphasize that this is a health issue — not just for drug users, but for everyone.

    Another strategy Iran used that American advocates of harm reduction might want to put more effort into is to organize the medical establishment. Doctors could be particularly influential in opening up the last frontier for methadone and needle exchange in America: prisons. Prisons hold large numbers of drug users, at the peak of their motivation to change, who make up quite literally a captive audience. They are not just the place where harm reduction is most needed, they are also the ideal place to offer help. If only we could.

    December 3, 2010, 9:00 pm

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