In Iran, a brotherhood of doctors and patients
Few doctors anywhere in the world have done their country a greater service than the Iranian brothers Arash and Kamiar Alaei. Kamiar, who is 37, is currently living in Albany, N.Y., where he is working on a doctorate in public health. Arash, who is 42, is a resident of Tehran’s notorious Evin prison where until recently, Kamiar lived as well.
Kamiar was released from prison a few months ago, but out of concern for Arash, kept the news quiet. Now that Arash has completed half of his six-year sentence — it is customary in Iran for first offenders to be released at the halfway mark, although Kamiar stayed longer — Kamiar has started to speak out on his brother’s behalf. Last week, the brothers received a major award — the Global Health Council’s Jonathan Mann Award for Global Health and Human Rights.
The brothers’ story is a sobering reminder of the risks run even by sophisticated and well-connected advocates for social change. But their work has borne fruit: the changes that the Alaei brothers were instrumental in creating are still mostly in place in Iran today, and will likely last. In Fixes, we normally look at successful projects. But today I want to highlight the achievements of two people who did extraordinary things while working under hostile and ultimately dangerous circumstances.
Late last year, I wrote about Iran’s extraordinary programs to fight AIDS — a disease that in Iran, as in many other countries, is concentrated among injecting drug users. In the early years of the Iranian revolution, the ayatollahs decreed very harsh measures for drug users. All treatment was abolished; possessions of heroin could bring the death penalty. These policies led to astronomically high H.I.V. rates among drug users that threatened to unleash a wider AIDS epidemic. But during the government of Mohammad Khatami, Iran abandoned this approach and instituted a pragmatic, humane policy toward drug users, which includes the widespread use of needle exchange and the provision of methadone maintenance therapy — even in prisons. The policy has greatly reduced infection among drug users and kept H.I.V. from spreading into the general population. Among the biggest heroes of this story are the Alaei brothers.
When Kamiar was a medical student in Tehran in 1997, he saw a young hospital patient in isolation and asked his colleagues why. They said that the young man had AIDS. “Should we be scared of him?” Kamiar thought. “That can’t be right.” He began to learn about the disease and realized how misunderstood and stigmatized it was. He talked about it with his brother, who was then practicing general medicine. When Kamiar graduated, the two brothers began to treat people with AIDS.
Thus began a journey that had a consistent focus: the brothers’ identification with one of the most downtrodden and reviled groups in Iran. Their idea of medicine was much more than medicine. “I found I was more like a social worker,” Kamiar said. After the clinic was closed each day, he would go talk to his patients’ estranged families or the bosses who fired them to plead their case. He negotiated housing for H.I.V.-infected widows, and took groups of men on weekend trips to the mountains. The brothers even introduced their patients to potential mates — one case was charmingly documented in the BBC film “Mohammad and the Matchmaker.”
Patients needed clean needles, so the Alaeis began a needle exchange. Many patients wanted methadone, so they started with that. “We took a restaurant approach,” Kamiar said. “If you want tea in a restaurant, they give you tea. If you want a Coke, they give you a Coke.”
The stigma faced by the Alaeis’ patients was the same stigma H.I.V.-infected drug users faced in much of the world. But other problems were unique to Iran. The Alaeis had to negotiate the clerics. Prominent doctors and moderate religious leaders supported them and helped them make the Koranic case for their work: it was necessary to preserve health and help the vulnerable; it was the lesser evil. For example, the Alaeis decided that they needed to start work in prisons, as a prison stay was the single biggest risk factor for H.I.V.. They presented it to the authorities as a way to provide men condoms and counseling before their conjugal visits — to protect vulnerable women. The methadone and needle exchange were added later.
But Khatami would not be president forever. “The key point was sustainability,” Kamiar said. “We had a good administration. But what if the government changes?” They wrote a proposal to the Global Fund to Fight AIDS, Tuberculosis and Malaria and won $15.8 million for Iran — and made sure the money would be administered not by the government but by an independent United Nations organization. They began to reach outward, holding workshops for health and prison officials from Afghanistan and Tajikistan. They realized the advantage of the “even Iran” factor — conservative Iran’s use of harm reduction policies gave other Middle Eastern countries political cover to do the same. They did research on harm reduction and presented it at international conferences.
The Alaeis had rivals and adversaries, and there were the typical tussles over credit and money. But overall the Khatami government was pleased; Iran’s drug policies created international goodwill, and goodwill for Iran was scarce. The policies offered other governments an opening, an avenue for working with Tehran on something they could agree on.
But when Mahmoud Ahmadinejad replaced Khatami, the international contacts began to be viewed through a lens of suspicion. To the government, giving a paper at a conference began to look like sharing Iran’s internal information with other governments.
“They started to say ‘you cannot do this’ and began to restrict us,” said Kamiar. He decided it was a good time to get a master’s degree at Harvard. When his scholarship ran out, he went to the State University of New York at Albany, which has one of the largest AIDS institutes in the U.S., to study health policy and management. He was visiting Iran in the summer of 2008 when the brothers’ luck ran out.
On the night of June 25, 2008, police arrested Arash at a gas station. The next morning police came to take his papers and computers from their parents’ house where Arash lived — the brothers never had the money to move out. They also arrested Kamiar.
Some of the Alaeis’ colleagues felt there had been warnings. “I was getting messages that I was talking to too many people around the world in English,” said Bijan Nassirimanesh, another pioneer of harm reduction in Iran. “I felt so uncomfortable. It was not a clear threat, but I don’t think the Alaeis got a clear threat.” Nassirimanesh now lives in Vancouver, where he works on harm reduction.
Kamiar said there was no threat. “There were no signals. Never,” he said. When he was arrested, he said, “I thought there was some misunderstanding, that they wanted to arrest someone else.” But eight months passed. Kamiar was in solitary confinement in Evin prison — infamous worldwide for cruelty to political detainees — for 63 days, in a cell with nothing more than a mat on the floor. He had no reading material. He kept himself sane mainly by praying, meditating and reciting poetry his father had taught him as a child.
Outside of Iran, medical groups around the world were working for the brothers’ release. Physicians for Human Rights organized prominent AIDS experts in 80 countries to sign petitions, write letters and lobby for them. The brothers did not know about any of this. Arash didn’t even realize that Kamiar had been arrested until several months later, when they went to trial. The trial lasted a few hours. Kamiar was sentenced to three years and Arash six for “communicating with an enemy government.”
Evin houses political prisoners and ordinary criminals; it is not the prison for drug offenders. But the irony was not lost on the Alaeis — if the government wanted to stop their work, sending them to prison was a poor choice. They were not permitted to practice medicine, but no one could keep them from talking. “We started talking about H.I.V., but found that the prisoners needed more basic information — that you have to wash hands, for example.” Prisoners often came up to them to ask about their health problems. “We learned a lot — we started talking to them as focus groups,” he said.
The Alaeis started a smoking cessation program. They led exercises and organized soccer and volleyball tournaments. They taught English and recruited other prisoners to teach other languages. Kamiar studied Spanish. He might not ever be able to return to his AIDS work in Iran, he reasoned, but he could continue the work somewhere else that might need it. “Wherever you are, you do your job,” Kamiar said.
How do people become like the Alaeis — people who defy pressure from their government and society to do what they think is right? They did not think of themselves as particularly courageous. They had not planned on landing in jail — they didn’t even consider it a possibility. “We thought at the most, we would have to stop our work,” said Kamiar. They were pioneers in their struggle in Iran, but not lonely ones. Indeed, they were successful because they made partners, created allies.
What the Alaei brothers had was something else: empathy. They identify with their patients; abandoning them is inconceivable. “I was in prison for two and a half years — 870 days, 20,880 hours,” said Kamiar. “When you are in solitary it is like you die — you remember all you have done from when you are born until that moment. When I was in solitary, the things I did for patients helped me a lot. When I went through all their stories I felt happy.” Empathy is not courage, but it creates courage. It is what is shared by people like the Alaeis all over the world, people who have stood their ground, and made it shake.