The drug addiction problem in Iran is more than a health care crisis. It is a broad societal one with staggering costs for communities and the government. Being neighbors with Afghanistan, the world's leading producer of poppies (the source of opium and heroin), doesn't help.
The Iranian government estimates there are at least two million people using drugs in a nation of 78 million. Of those, 200,000 are intravenous drug users and at least 50,000 are infected with HIV
Ali's wife left him five years ago because of his habit. Then after more than two decades as a human pin cushion, shooting up everywhere he could find a vein that hadn't dried up like straw, the needle took its toll.
"My whole body became infected," he says, pulling up a pant leg to show a weepy wound that he says still won't heal after two years.
After my wife left, I realized there was no one to take care of my kids," Ali says, "so I had to do it."
Ali says the change from drug addict to recovering addict happened quite quickly, thanks to an innovative Iranian clinic, The Persepolis Harm Reduction Center. Unique to the Middle East, the clinic provides both needle exchange and methadone treatment under the same roof.
"One of the friends I would shoot up with told me about this place," Ali says, "so we came here to the clinic to get new needles."
While he brought in used needles for new ones, Ali says he noticed other addicts that were coming for methadone. They were well-groomed; their clothes were clean; they seemed much healthier than those still shooting up. Within ten days of coming to the clinic, Ali switched to methadone.
The fact that there is a needle exchange and methadone program for drug addicts in an ultra-conservative Islamic country like Iran is primarily due to the efforts of Dr. Bijan Nassirimanesh.
He is a pogo stick of a man, bouncing with frenetic energy, as driven to helping drug addicts as they are to their drugs.
"The list of why people start drugs is similar all over the world," he says. "It starts with curiosity and ends with pain. It can be everything from a kidney stone, to, as one client told me, the day he accidentally backed over his child with his car. The mind can't afford to tolerate this kind of suffering."
Nassirimanesh now has three Persepolis Harm Reduction Clinics in Tehran, all treating about 500 addicts a day. He says the number of addicts and the spiraling HIV figures scared the Iranian Ministry of Health enough to let him start a needle exchange (controversial even in the U.S.) and methadone program to combat the problem. It's a remarkable accomplishment in a country where many women still wear full-coverage, black "chadors" in public and where even talking about drugs and sex is strictly taboo.
And when Nassirimanesh opened his clinics he did something most other centers, even in western countries, rarely do: he put the needle exchange and the methadone programs under the same roof. He believes doing so helps the addicts, like Ali, in their evolution toward recovery.
"The guy on the methadone program comes into the center," he says, "and sees the guy on the needle exchange program all hunched over and dirty, probably hasn't bathed in weeks. It reinforces the idea that he doesn't want to go back to that. While the guy on the needle exchange looks at the guy taking methadone who is clean, maybe even has a job and he thinks, 'Why don't I try that?'"
But Nassirimanesh says while his clinic is a good model, he needs at least ten more in Tehran alone to even begin to have a real impact on addiction and the spread of HIV.
"You have to cover 80 percent of the people to be effective," he says. He blames "cold-turkey" drug centers and abstinence-based HIV programs for allowing addiction and disease to spread unabated. "Those places a have a bloody 10 percent success rate," he says, throwing up his hands in frustration. "What do you do with the other 90 percent?"
He says that much of international health care spending has strings attached that don't allow funding for clinics like his -- a mistake that he says is a death sentence for many.
Nassirimanesh says his energy and enthusiasm for attacking this crisis have made some question whether he isn't on drugs himself. But he says it's the suffering of others that motivates him; indeed, he lost half of his regular practice as a young doctor when he decided to make his first medical office double as a drop-in center for addicts as well.
He describes how he became transformed by the issues of life and death at an anatomy class during his second year of medical school.
"I saw the cadaver for the first time and I got up on a chair to get a better view," he says, actually getting up on a chair to demonstrate. "The body was perfectly preserved and I just stared to speak with him because he seemed alive. What is the meaning of human life, what is the meaning of death -- and I suffered from a minor schizophrenic stage. I closed off all sources of life, and I put pictures on a wall that represented questions to me: skeletons, a married woman -- after awhile I felt a transformation, I had some answers. When you pass this red line you are no longer a normal guy. My fears turned into an engine driving me."
He gives me a tour around the clinic, a three story building, on loan from the city. Nassirimanesh says though there's a lot of support for the clinic there's been talk of a possible eviction, something he's desperately trying to head off in talks with municipal and Ministry of Health officials.
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