| Thinking positive in Iran

If you have seen Elton John’s tribute to those lost to HIV/AIDS, “The Last Song,” the lyrics of that melody probably resonate whenever you come across a personal story involving AIDS. Dr. Kamiar Alaei’s public lecture at McGill University a few weeks ago was no exception to that rule.

If medicine and human rights could be merged into a genre of its own, Dr. Alaei’s story would fit into such a category. Kamiar and his brother Dr. Arash Alaei are not merely doctors; their passion for Iranian public health pushed them to establish an HIV/AIDS clinic, and persisted throughout their subsequent arrest and term of solitary imprisonment, allowing them to continue to strive in prison to create an integrated model of care in Iran.

The first case of HIV/AIDS in Iran was diagnosed in 1987 after the blood examination of a hemophilic patient. Policy makers at the time denied its existence and its link to drug use – it was not until 1995 that conservative policy makers took into account the various modes of transmission of HIV.  In 1996, a pilot study in three large prisons revealed a high rate of HIV-infected patients (5 to 8 per cent). The social stigma and the lack of HIV/AIDS knowledge at the time resulted in cases of loss of employment, denial of medical services, forced divorces, and the abandonment of family members.

In 1997, understanding the sensitive nature of the disease within Iranian culture, the brothers began running harm reduction and HIV/AIDS prevention care centres with a focus on intravenous drug users and prisoners. They established the first ‘triangular clinic’ in their hometown of Kermanshah in the west of Iran. These triangular clinics treated three different groups of patients: HIV-positive patients, drug users, and those who suffered from sexually transmitted infections (STIs), offering patients clean needles, condoms, antiretroviral therapy, and other medical services. The two brothers faced opposition from community and religious leaders, who implied that the citizens had failed morally in succumbing to these diseases.

Realizing that their approach needed to be multifaceted in order to create social change for those infected with and at high risk of HIV, they sought the support of NGOs, government organizations and religious leaders. This led to the establishment of unlabelled mobile clinics that tackled the barriers of stigma associated with patients visiting an HIV-specific clinic. Cultural sensitivity and education, together with the principle of societal inclusion and the prevention of isolation, combined to form a potent method of treating patients.

Eventually, their program grew to a network of clinics in 67 Iranian cities and 57 prisons. The brothers broadened their horizons by expanding the program to a regional level, including the neighbouring countries of Afghanistan and Tajikistan. They continued their efforts through international health advocacy and global information exchange. For example, Kamiar’s “Health Diplomacy” project, an exchange program for American medical students, brought U.S. medical students to Iran to work with their Iranian counterparts and continue post-visit collaboration via the Internet.

In 2008, their relationship with American institutions led these doctors to prison. The pair were suddenly arrested and kept in isolation from each other for eight months, and on December 31, 2008, the doctors were tried before Tehran’s Revolutionary Court. They were charged with “communications with an enemy government” and a number of secret charges, leading to an incarceration in Iran’s notorious Evin prison.

Dr. Alaei’s narrative of his experience in prison was reminiscent of the strife of great political prisoners, including Jawaharlal Nehru, Nelson Mandela, and more recently Aung Sang Suu Kyi; individuals whose dedication to their causes didn’t stop at the boundaries of their cells. As unfathomable as it sounds, these two brothers were delighted about one thing: they had landed in their exact target population – past drug users and sex workers. By expanding the prison library – thus expanding the knowledge of these prisoners – these two medical practitioners made the best of their situation.

Their story resonated beyond the walls of the prisons, and the world started to care. Before long, there was an outcry for their release via a collective coalition of scientists, human rights activists, and medical practitioners. Kamiar and Arash were released in December 2010 and August 2011, respectively.

Together, the doctors co-authored “Iran’s National and International Strategic Plans for the Control of HIV/IDU/TB,” and they helped develop Iran’s proposal to the Global Fund to Fight AIDS/TB/Malaria, which was awarded $16 million USD. The triangular clinic concept designed by the Alaeis was recognized by the World Health Organization (WHO) as the best-practice model for the Middle East and North Africa. The brothers have been celebrated on many  occasions for their outstanding contribution to the field of medicine in the presence of their dire circumstances, and were most recently awarded the WHO’s first Human Rights Award in 2011.

To quote Kamiar on the path of their journey he said, “We learn from nature. No river goes straight. The river changes its directions but not its goal.” They have proven that NGOs, government organizations, medical practitioners, and community and religious leaders have a collective responsibility to work together to create a social-cocktail of preventive care which will serve as the first lines of defence in the face of this health pandemic. It is only then that we even have a shot at facing the real enemy in the situation: the Human Immunodeficiency Virus (HIV).

These two brothers have paved the way of social medicine to impersonate the lyrics of that Elton John song, and have touched the lives of those both inside and outside prison, and with and without HIV. They have made these words come alive in people’s lives.

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