Harold Pollack is a public health policy researcher at the University of Chicago's School of Social Service Administration, where he is faculty chair of the Center for Health Administration Studies. He is a regular contributor to The Treatment.
I took the red-eye to Austria for a two-day conference at the International Society for the Study of Drug Policy. The deeply-cushioned comfy chairs in our windowless auditorium at the Vienna International Center didn’t help me fight the jetlag. Summoning my inner Michael Dukakis, I managed not to drool through “A critical review of the UNODC report, Sweden’s successful drug policy.”
Luckily, my jetlag abated in time for the plenary speech by Dr. Azarakhsh Mokri, a key official at the Iranian National Center for Addiction Studies. Iranians spend a lot of time in this building. The VIC houses the International Atomic Energy Agency and the UN Office of Drugs and Crime (UNODC). One VIC wing monitors Iran, The other monitors Iran’s immediate neighbor to the east, Afghanistan. I fear that both agencies work with equal futility.
Afghanistan accounts for about 93 percent of the world’s traded poppy, the base ingredient in opiates such as heroin. Thousands of tons are smuggled through Iran. For obvious reasons, Afghan drug smugglers have acquired impressive weaponry and training over decades of warfare. Surprising numbers of people die in firefights between smugglers and Iranian security forces along the long and lawless Afghan-Iran border. According to one news account, 3,300 Iranian soldiers and police have died in such clashes since 1979.
Like other countries that sit astride major smuggling routes, Iran faces severe drug problems. An estimated two million Iranians are substance users. Most users consume heroin or opium, often in highly pure form. HIV, crime, and other consequences predictably follow.
Also predictably, the Iranian regime has struggled to respond. Until the early 1990s, the regime followed an approach that would make William Bennett blush, arresting roughly 400,000 users per year. This approach did not succeed, though it filled Iranian prisons with drug offenders. From 1994 to 2002, the regime tried a massive detoxification effort. Not surprisingly, this was similarly unsuccessful. (Among treatment professionals, detox alone is not considered acceptable treatment for substance use disorders. The relapse rate among detoxed chronic users is essentially 100 percent when these programs are not accompanied by more powerful subsequent treatment interventions.)
Desperate to try something different, Iran then initiated a massive campaign of harm reduction and substance abuse treatment. With judicial and government support, syringe exchanges and condom distribution services are now provided at 300 centers throughout the country. Almost 20,000 prisoners receive these services. A pilot program is now in place that provides a small opium dose (“tincture”) as a maintenance treatment for users who have done poorly with other therapies. Possession of small amounts of heroin or opium for personal use has been implicitly decriminalized. More than 120,000 Iranians are now receiving methadone or other opiate substitute medications, with a goal of 400,000 by 2010. Iranian researchers have conducted clinical trials and have collected other data to document the public health gains achieved in this program.
Dr. Mokri and his colleagues deserve great credit for these developments. Starting essentially from scratch seven years ago, Iran has now enrolled roughly the same proportion of heroin users in evidence-based programs as the United States.
Describing this history, Mokri notes one hopeful lesson: “Do not overestimate the impact of ideology, tradition, and social norms.” These factors can’t be ignored, but they can be addressed. Mokri and his colleagues charted a political and administrative course that fit the realities and opportunities offered by an authoritarian religious government. As it happened, the Iranian regime allowed surprising space for effective public health policies to emerge.
Mokri and I chatted about mutual friends and about the role of Viennese doctors in the rise of modern pathology and public health. Urbane and educated in the ways of the west, he could comfortably belong at any American university or medical school. Anyone active in public health encounters many others of similar high caliber from Iran, and from many other countries with whom America doesn’t generally get along.
As the Obama administration makes its way in the world, it could do worse than to build bridges with public health leaders in many nations trying to address common challenges such as basic sanitation, maternal and child health, substance abuse and HIV prevention, and who struggle to husband scarce resources to provide basic services despite the demands of a rising middle-class that desires costly tertiary care. We have a great stake in seeing that these societies succeed in these efforts.
Here at home, as the administration contemplates a more humane start to our domestic drug policy efforts, we might draw inspiration from our Iranian counterparts. If they can accomplish what they have in a tough environment, we can do better.