By Don Duncan
In the Pul-i-Sokhta neighborhood of Kabul, Afghanistan, hundreds of men gather under a bridge in the dark. They hunch over sheets of foil and breathe in the fumes from boiling heroin.
This is how Afghan drug addicts have traditionally taken heroin. They inhale it. But some of the other men here have needles. They seek out veins in their arms, legs, or groins and inject the drug.
This shift from inhaling heroin to injecting it has fueled the spread AIDS in Afghanistan.
Until recently, drug users in Afghanistan were at relatively low risk of HIV, but more than seven percent of intravenous drug users here are now estimated to be HIV-positive. Health workers fear that, unless strong action is taken now, the number infected will grow quickly and the virus will spread to the general population.
A worker for NGO Medicins Du Monde dispenses a dose of methadone for one of the clinic's 70 patients (photo: Don Duncan)Across town, the humanitarian aid organization Medicins du Monde, in conjunction with the Ministry of Public Health, is trying to address the problem. It has opened Afghanistan's first methadone clinic. Methadone is a drug that dulls an addict's craving for heroin, and because it is administered orally, there is no need for dangerous needles.
Mohammed Moussa has been on methadone — and off heroin — since the clinic opened last year. He comes daily to the clinic, where a worker carefully administers his methadone dose. Moussa knocks it back and washes it down with a cup of water.
"Methadone is completely different from detoxification, which is the usual treatment in Afghanistan," he said through an interpreter. "Methadone is very good for me. It helps me reintegrate into society and resume a normal life."
Methadone is widely used in the United States and Europe. It is also a key tool in fighting HIV in countries like Iran, Pakistan, and Russia, where needle sharing drives the epidemic. But in Afghanistan, as elsewhere, methadone remains controversial. Critics say it just replaces one addiction with another.
A More Manageable Addiction
Supporters of methadone argue, however, that it is a less destructive and more manageable addiction. Crucially, methadone does not carry the risk of spreading HIV.
Health workers who run the clinic say that traditional detoxification may help people who smoke heroin, but it is virtually useless for those who inject it — a practice that causes a much stronger addiction.
Olivier Vandecasteele of Medicins du Monde said that, given the growing risk from heroin and HIV in Afghanistan, methadone treatment is crucial.
"Being addicted to heroin is not a question of will," he said. "You need treatment, not just people telling you that you should stop it."
Vandecasteele says the clinic has proven its worth. In the past year, 80 percent of those who have gone on methadone have stayed off heroin. But aid workers like Vandecasteele do not make the decisions in Afghanistan. Religious leaders, politicians, and civil servants do.
Last month, the government decided against scaling up methadone. For now, Afghan officials are limiting methadone treatment to the one existing trial clinic and its 70 clients.
Injecting heroin in a drug den in Kabul (photo: Don Duncan)That is because, in Afghanistan, a much bigger concern than the war on HIV is the war on drugs. Afghanistan is the source of some 70 percent of the world's opium — the raw material for heroin — and the dominant attitude here regarding narcotics, including methadone, is zero tolerance.
"We need to be free from drugs," said Abdullah Warduck, head of the drug demand reduction section of the Ministry of Public Health, which works closely with the Ministry of Counter-Narcotics.
"The majority of drug users, they want to be free from drugs," he added. "They don't want to use the methadone."
Methadone as the Core Treatment
But those who advocate methadone treatment say they do not want to get rid of traditional detoxification centers; they just want to add methadone as another core treatment option.
Peter Graaff, Afghanistan director for the World Health Organization, said given how quickly Afghanistan's HIV epidemic is worsening, the country has no time to wait.
"This is our chance to get it right before it becomes the problem that is really going to overwhelm us and is going to be very costly and very painful and a very sad affair," he said.
Injecting heroin in a drug den in Kabul (photo: Don Duncan)In the meantime, many of the former heroin addicts who are now on methadone are employed by the clinic as outreach workers. They go into the drug dens of Kabul to give information on safe injecting practices.
They are also walking advertisements for methadone. As recently as a year ago, they too were taking heroin, and the transformation from strung-out addict to healthy outreach worker is obvious to those still shooting up.
"I hope to be included in methadone treatment," said Mohammad Jawad, an addict with needle marks in his arm.
But there is no room for him. For now, and for the near future, Kabul's only methadone clinic is full up.