December 8th, 2016
At a busy restaurant in central Kabul this past July, Abdur Raheem Rejaey, a former injecting heroin user, met with colleagues to discuss launching a peer educator training program to protect the health of drug users. It was the culmination of an extraordinary personal journey, as well as evidence of new hope for everyone who uses drugs in Afghanistan.
The program would launch in fall 2016, he said. It would be delivered by Bridge Hope and Health Organization, an Afghan-led harm reduction initiative that Rejaey founded in 2015, with support from the National AIDS Control Program (NACP) of Afghanistan’s Ministry of Public Health. It relied on just $15,000 seed money provided by Madawa, another Afghan harm reduction organization, and funded by the Czech Republic.
As we left the restaurant, Rejaey, a tall and thoughtful man in his 50s, observed the staff busily serving an Iftar dinner crowd during Ramadan.
“They are all young,” he said. “What jobs will they have when older?”
Unemployment and under-employment is a major problem in Afghanistan, with 81 percent of workers employed in “vulnerable work,” such as low-paying service industry jobs. Those who can typically migrate to other countries in search of better-paid work to support relatives.
Rejaey was once one of them. In 1978, at the age of 16, he migrated to Tehran, Iran to work in carpentry. But catastrophic misfortune led him to prison, homelessness and what he describes as his addiction to opiates.
According to a 2012 national survey of 2,000 urban households in Afghanistan, where the poppy crop accounts for over 90 percent of the world’s heroin, 5.6 percent of households had at least one person using opiates. (Of course, such figures are notoriously unreliable in any country, and the true number may be higher.)
On Death Row in Iran
Rejaey’s nightmare began in 1981 after he learned of his father’s death and tried to return to Afghanistan for his funeral.
Rejaey had paid an agent to obtain work in Iran, as most Afghans without visas did at this time. This man, who was making money from him, did not want him to leave the country and pulled a knife on him. Rejaey carried a small knife in those days for self-defense, which he also pulled out.
When the man saw it, Rejaey relates, he laughed and said, “Now I will kill you.”
The agent moved towards Rejaey with the larger knife to stab him in his stomach, but Rejaey stepped aside and tripped the man. His attacker fell onto his own knife and was fatally wounded.
There were Afghan witnesses present who could verify that Rejaey had acted in self-defense, but their testimony held little weight with the police. Instead, the police believed the version of events given by the dead man’s family, which hinged on the eye-witness testimony of a six-year-old girl named Mino.
Rejaey was put in prison. After 10 years, the court decided to place him on death row, waiting for Mino to turn 18, when she could testify as an adult. Two years later Rejaey was brought to the gallows to be hung—but Mino stopped the execution.
The young woman withdrew her statement, saying she disagreed with the sentence. To placate the dead man’s family, Rejaey’s former accuser asked him to pay a fee of 1.6 million Iranian Rial, then worth approximately $23,500. Rejaey managed to do this using money pooled from fellow prisoners, his brother and his own savings.
Once freed, Rejaey, who had few opportunities or resources, says without hesitation that he worked as a drug dealer because it paid more than carpentry. He had used opioids only twice in prison, for pain relief. But after learning that his mother had also died while he was in prison, he began using heroin.
He spent the next seven years in Iran injecting heroin, before returning to Afghanistan in 2001 to try to break from his addiction.
Treatments in Afghanistan
In Afghanistan, treatment programs generally prescribe “cold turkey”—a miserable and sometimes dangerous experience—for anyone seeking to kick opiates. Government data suggests 70 percent of those treated relapse.
I detoxed seven times this way,” says Rejaey. “I would go back and use.” His brother offered him a place to live, but that only lasted six months. “My brother tried to help me but seeing this failure kicked me out. Then I became homeless.”
From 2002 to 2008, he squatted at the Russian Cultural Center in Kabul, which had become an encampment for homeless people.
[Abdur Raheem Rejaey (right) with other homeless drug users in Kabul in 2008. Credit: MdM /Farhad Habib.]
Then in 2008, Oliver Maguet of Médecins du Monde (MdM) visited the encampment. He saw Rejay, who had a swollen leg from an abscess on his groin, and offered him treatment. MdM brought methadone into Afghanistan, as part of a pilot study, and Rejay became first participant in the trial of just 71 Afghans. It worked for him.
[Abdur Raheem Rejaey in 2008, when he was receiving treatment for his abscess and before he began methadone treatment. Credit: MdM / Farhad Habib.]
“MdM got me healthy, so I wanted to use my life to help others,” explains Rejaey. He worked as a peer educator for MdM from 2008 until 2013. Since 2010, Rejaey has received steady support in his work from Mat Southwell of CoAct, a UK-based group that provides technical support to grassroots organizations like Bridge.
A Successful Methadone Program: Threats and Expansion
These days, since the Russian Cultural Center has been renovated, most homeless opiate users in Kabul live at the Pul-e Sukhta bridge.
Idris, who is 34, was working in Iran as a truck driver when he began injecting heroin. “When I started using drugs, I didn’t know what it was,” he says. He shared needles with a friend because “we didn’t have enough between us and injecting was the economical solution. We didn’t know that sharing needles led to HIV.”
He had detoxed several times but returned to problematic drug use. Then he was able to try methadone thanks to MdM’s program. It “helped me a lot,” says Idris.
Now, still taking methadone, he has a family, a wife and a three-year-old son. He also worked for two years as a peer educator with MdM.
“To inject 0.5 grams is the same [effect] as 5 grams smoking, so it [injecting] lasts longer,” explains Farhad Habib, who previously worked as a psychologist with MdM. But injecting also increases the stigma of drug use, he adds. “People believe drug use is a one-way road, they believe they can’t come back from it. [But] methadone helps in this way.”
Of the 71 people involved in MdM’s original trial, 55 are still safely participating—a 77 percent success rate that easily outshines the 30 percent government figure for people going cold turkey.
But despite the success stories, methadone shipments to Afghanistan have periodically been blocked by the Afghan Ministry of Counter Narcotics. At times there have also been methadone shortages due to a plane not being able to land due to snow, or other logistical problems.
When shortages happened in 2010 and 2011, three patients died from from heroin overdoses during methadone withdrawals. Others withdrew from the program for different reasons. “We had three couples on the program, but they left,” says Rejaey.
In 2013, an Afghan group called the Organization of Technical Cooperation for Community Development (OTCD) took over the implementation of the methadone project. (After that, Rejaey continued working as a peer educator for another NGO, Solidarity for Afghan Families, for $80 a month, until he formed Bridge Hope and Health Organization in 2015, for which he receives a small stipend from supporters such as Southwell.)
Now, OTCD is working to scale up methadone treatment in the country, having overcome resistance from various Afghan government ministries.
The government’s National AIDS Control Program tells The Influence in an email: “It will require advocacy to convince the public to accept the fact that Methadone is drug which is on the national drug list too. Clarifying the fact that [it] is a lifelong treatment and medicine, the NACP is sure to win the support of the people.”
OTCD is expanding treatment with the help of a Global Fund grant of $130,000, while Bridge will help recruit, educate and strengthen the drug user peer-support network.
Drug User Peer Educators Fight to Bring Hope
Since September 2016, Bridge has been working with nine paid peer workers, trained by Madawa in advocacy.
[The peer educators and staff earlier this year. Credit: Michelle Tolson.]
Idris is one of those peer educators. He is also a member at the Global Fund Country Coordinating Mechanism and speaks on behalf of other HIV-positive Afghans. Antiretroviral treatment (ART) became available in Afghanistan in April 2009.
[Idris with his peer educator certificate. Credit: Michelle Tolson.]
Bridge’s peer educators, who at this point are all male, have been providing direct services, such as dressing wounds and abscesses, and also conducting community mapping exercises to assess the needs of their peers, analyze their problems and create awareness. Some of the educators are active drug users and some are on methadone; sometimes the methadone users use drugs recreationally.
[A peer educator collects information. Credit: Bridge peer educators.]
They are each paid about $100 a month for 20 outreach visits through the Madawa grant, which runs until January 2017. Rejaey and the Bridge peer educators are committed to continue their work voluntarily if necessary, until other grants come through. The minimum operating costs for Bridge to pay peer educators and Rejaey’s salary, continue to treat homeless drug users’ wounds and fund a simple office amount to $2,600 a month.
[A peer educator treats a wound. Credit: Bridge peer educators.]
Through their mapping exercises, they have identified around 2,700 drug users at 16 areas in Kabul, of whom 1,895 are homeless and 109 women. However, Bridge is careful to clarify that these figures are based only on their observations, and they do not dispute different drug-use figures collected through other surveys. For instance, Bridge did not count people who come to purchase drugs and take them to their homes. People who do this include university students and women, both housewives and sex workers buying for clients.
[Rejaey treating a drug user’s wound. Credit: Bridge peer educators.]
As well as collecting information and providing direct aid, Bridge is building allies who can influence Afghan society’s perception of drug users. Publicity is a part of this: Rejaey’s story was recently published in a book, Hope in Afghanistan, by Lida Akbarpoor Baran, about 11 Afghans creating change in their communities.
[Rejaey speaking at the book launch. Credit: Michelle Tolson.]
Bridge is partnered with Sustainable Alternative Economic Development for Afghans (SAEDA), which has a solid background implementing projects to train disabled people in in-demand work, such as mobile phone repair. Najibullah Niazi, who chairs Bridge’s board of directors, sees parallels in the issues addicted drug users face, as work is a key concern once they stabilize: “We are also working with the community for greater social inclusion of their Afghan brothers and sisters who use drugs to also take an active part of the development of Afghanistan.”
Razakhedri, who is another of Bridge’s peer educators and was the fifth Afghan enrolled in the methadone program that helped Rejaey, knows this. He says methadone healed the rift in his family.
[Razakhedri with his peer educator certificate. Credit: Michelle Tolson.]
The 51-year-old former tailor and father of two says that in 2008, before he received methadone treatment, his father-in-law had been advising his wife to divorce him. But not any more. Today, his 17-year-old son is taking courses in the information technology sector.
Razakhedri looks forward to bringing hope to other families through peer education. “Methadone changed my life 100 percent.”
Michelle Tolson has worked on media, research and communications projects in Afghanistan, Cambodia and Mongolia. Her work has appeared in publications such as Reuters Trust Law, Inter Press Service, The Diplomat and the GlobalPost. She has represented projects supported by the Asia Foundation Mongolia, Plan Cambodia, and UN Women, USAID and the US Embassy in Afghanistan.