On the Scene III: Beyond Treatment and Prevention -- Harm Reduction in Afghanistan 9/30/05

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No one knows for certain how widespread drug use and addiction is in Afghanistan. A United Nations survey of drug use across the country has been completed, but its numbers are being crunched and have not yet been released. Afghan officials and experts cite a figure of 60,000 drug users in the capital city of Kabul (estimated population 3,000,000), but while the common conception is that that number reflects the number of opium or heroin addicts, reality is a bit more complicated.

Nejat Center, Kabul
When pressed on the issue at this week's Senlis Council symposium on the feasibility of licensed opium production, Dr. Mohammed Zafar, head of the Ministry of Counter Narcotics Drug Demand Reduction conceded that the 60,000 figure measured drug users, not drug addicts. The situation is further confused by the tendency here -- one of the ancestral homes of cannabis -- to consider it a "narcotic," a position that is neither medically nor scientifically defensible.

Dr. Jehanzeb Khan, international project coordinator for the UN Office on Drugs and Crime (UNODC) Drug Demand Reduction Afghanistan country office, broke those numbers down further during his presentation at the symposium. According to Khan, the rough figure of 60,000 includes 24,000 hashish smokers, 13,000 users of pharmaceuticals, 11,000 opium users, 7,000 heroin users, and 7,000 alcohol users. There are at least 500 injection drug users in the city, according to the UN numbers, said Khan.

That said, for Afghan anti-drug and treatment officials, international experts, and common Afghan citizens alike, the problem of drug abuse and addiction looms large. "Drug use has definitely increased here," said Dr. Mohammed Zafar, head of the Ministry of Counter Narcotics Demand Reduction Directorate. "In some districts in Badakshan (a remote, isolated province bordering Tajikistan and China), 40 to 60% of the population is addicted. In Gardez, they don't grow the poppy there, but we have 250 people addicted to heroin and they are injecting together, which is a threat for HIV."

rehabilitation group at Nejat for hi-res version
One of the world's poorest countries, decimated by a quarter-century of war and foreign invasion, and home to nearly 90% of the planet's illicit opium supply, Afghanistan is ill-prepared to deal with a rising tide of drug use. But despite all the obstacles it faces, including the weakness of the central government and limited support from the international community, the country is taking steps to confront drug use and help its citizens who fell into addiction and abuse.

According to Dr. Shairshah Bayan, coordinator of the Project for Integrated Drug Prevention, Treatment, and Rehabilitation in Afghanistan for the German non-governmental organization (NGO) GTZ, a major player in Afghan development issues, drug treatment and community awareness programs are ongoing in six of the country's 34 provinces to combat a tide of rising misuse linked both to the availability of opium and heroin and to terrible social displacement, unemployment, violence, trauma, and poverty arising from the country's sad and bloody history in the late 20th Century. Those programs include the standard repertoire of detoxification, group counseling, rehabilitation, outreach, and community awareness, he said.

Given the nature of Afghan society and the role of its women, GTZ and other drug treatment and prevention centers also include special programs for women and families who do not have access to in-patient treatment at the centers, Bayan added.

Still, Afghanistan's treatment and prevention efforts are in their infancy. Less than 100 treatment beds are available to serve a national population estimated at 25 million. (This fact prompted one Afghan woman audience member at the Senlis symposium to lash out at Afghan officials there. "We had more beds under the Taliban!" she exclaimed.)

anti drug posters at Nejat
But if the treatment and prevention effort is in its infancy, it is part of a National Drug Control Strategy elaborated by the ministries of Counter Narcotics and Public Health, both of which are working to expand the efforts as rapidly as possible given the lack of funding available. Those two entities earlier this year also signed a National Strategy for Harm Reduction for Injection Drug Users and the Prevention of HIV/AIDS, wrote Ministry of Counter Narcotics Demand Reduction Advisor David Macdonald in an e-mail to DRCNet taking us to task for a blog report this week in which we stated that a Kabul center was the only harm reduction project extant.

But by our definition of harm reduction, there is indeed currently only one such project. On the outskirts of Kabul, down a dusty side road, lies the Nejat Center, the only harm reduction center in the capital city, and indeed, the whole country. [A note on semantics: DRCNet differentiates between "harm reduction" and "treatment and prevention." The latter term refers to activities such as getting drug users off drugs or stopping them from starting in the first place, while "harm reduction" refers to programs that attempt to work with active drug users, such as needle exchange, condom distribution, and safe injection sites.]

An outgrowth of a program begun across the border in Peshawar, Pakistan, in 1991 to deal with what would become millions of refugees fleeing factional violence in Afghanistan, Nejat opened its Kabul facility in 2003. It still deals primarily with refugees -- this time Afghans returning home who developed serious opium and/or heroin habits as they rotted in Pakistani refugee camps for years waiting for political violence to subside in their homeland.

At Nejat, Dr. Tariq Suliman leads a small team of doctors and social workers (many of them volunteers, some of the social workers graduates of his program) who bring addicts through a comprehensive rehabilitation program beginning with a one week detox followed by a second week of orientation and then a month-long rehabilitation program. During the program, clients are taught not only to resist the lure of opiates but also social and job skills, such as learning to weave carpets or make shoes, and some will even be able to get small loans to open small businesses. (Unsurprisingly, small businesses here often consist of a cardboard or wood shack, and whatever the product is, the overhead to open and operate a small business in Afghanistan is very small.)

It's not just drug treatment. Nejat also includes a harm reduction component, with an active needle exchange program, as well as condom distribution. With AIDS a rising problem, both are critical to the effort to get a grip on the epidemic. And while the inpatient treatment program is limited to men, the center's outreach programs also target women and children, a population typically neglected not only in drug treatment programs but by Afghan society as a whole. The silent, unseen part of the Afghan population, women are expected to be behind the walls of home and not out on the street.

"AIDS has been like the tsunami for us," said Dr. Suliman. "In addition to activities with injection drug users, we are also reaching out to sex workers in the Heribat district. We have a team there consisting of doctors, social workers, and volunteers that do outreach there. AIDS is a big shame, and it's getting worse every day," he told DRCNet.

The program is seriously underfunded, said Dr. Suliman. "While the Ministry of Counter Narcotics is trying to create programs, the government does not fund us; it says it's a local issue. The government is getting billions of dollars a year in assistance, and it needs to generate some funding for these programs. This is a very difficult situation, and we need long-term programs."

In the meantime, Dr. Suliman and the Nejat program do what they can with volunteers and a handful of ill-paid workers. Fortunately, Nejat is generating them with its treatment and rehabilitation program.

One group of brothers and sisters in their late teens and early twenties, the Yacubi family, is a sterling example. After the death of their mother in Iran, the family's father descended into heroin use, and the kids followed him. But as their money ran out, the Yacubi children realized they needed help and turned to Nejat. Now, three months later, the kids are not only clean, but helping at the center.

"We want the good life for our family," one of the Yacubi brothers told DRCNet. "Our big message is that we don't want to go the way of drug addiction again. That was a bad mistake. We are Afghans, and now we want to help the Afghan people."

That's the spirit. Despite the assistance of the international community -- and it is certainly deserved after the beating Afghanistan has taken from great power geopolitics -- the Afghan national will ultimately have to save itself. With drug treatment and prevention programs underway, with harm reduction programs gaining a toehold, and with the help of Afghan citizens like the Yacubis, the country is taking the first steps.

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Issue #405 -- 9/30/05

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Commentary: Direct from Kabul -- DRCNet on the Scene in Afghanistan This Week and Next | On the Scene I: European Think Tank Calls for Licensed Opium Cultivation at Afghanistan Conference -- Response Varied | On the Scene II: Afghanistan's Neighbors Look With Interest at Licensing Proposal | On the Scene III: Beyond Treatment and Prevention -- Harm Reduction in Afghanistan | Denied: Massachusetts Jury Slaps Down Overreaching District Attorney in "School Zone" Bust | Methamphetamine: House Democrats Challenge Harsher Penalties in Federal Methamphetamine Bill | Methamphetamine: SAMHSA Says Meth Use Steady, Problem Use Increasing -- Data Says Yes But Not as Much as SAMSHA Implies | Needle Exchange: LA Cops Hassle NEP Clients -- Complaint Filed | Harm Reduction: Canada Health Minister Says More Safe Injection Sites Should Open If Communities Approve | Web Scan: GAO Report, Cascade and AAPS Blast Meth Madness, New Orleans Jail in the Flood, MedMj Legal Brief Bank, Charles Shaw on Alternet, DEA's Microgram | Weekly: This Week in History | DRCNet T-Shirt Design Contest | OSI Offering Justice Fellowships in 2006 -- Deadline Next Month | Job Opportunity: National Field Director, Marijuana Policy Project | Weekly: The Reformer's Calendar

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