Fifteen women and girls in headscarves and dark-colored manteaus—knee-length, long-sleeved overcoats mandated by Iranian law—sat in plastic chairs in a government-run health clinic, their eyes looking expectantly at me behind thick layers of eyeliner and mascara. It was my first time speaking to them alone and my Farsi skills and nerves were not up to the task. I held up a condom and tried to remember the word for “lubricant.” Passing out condoms to sex workers and sterile needles to drug users was not what I was expecting from a summer internship in 2007 at the National Youth Assembly, an NGO that coordinated a project on disease prevention within government clinics in Mashhad, the second-largest city in
Iran. The popular image of the country—even to me, raised with knowledge of Iranian politics and culture and having visited many times—is one where the government’s conservative, religious ideology reaches into every corner of life. Many would expect that the theology behind the government’s most well known laws—against alcohol, revealing clothing, and homosexuality—would naturally seep into its disease-prevention strategy as well.
And for years it did. For the first 20 years of the Islamic Republic, drug users were dealt with harshly. The government’s punitive approach dated from the 1979 Islamic Revolution, when newly empowered clerics decided to banish the corrupting ‘Western’ influence of drug use. Drug addicts were given six months to kick their habits, and those who could not were arrested and jailed.
Results were predictable: Iranian prisons overflowed with addicts, and HIV and hepatitis outbreaks among prisoners were common. A generation of Iranian youth coming back from the 1988 Iran-Iraq War was welcomed with a jobless economy hobbled by international sanctions. The veterans’ disillusionment and hopelessness threatened to swell the ranks of addicts, who could in turn spread disease to their wives and children. Forced to face reality, in the mid-1990s the Ministry of Health began to fund methadone-treatment programs for drug addicts and encourage the distribution of sterile needles to prevent the spread of disease. These prevention techniques are still used today. The changes, however, were not inevitable. In fact, it was only an active, sophisticated civil society that was able to convince politicians and the clergy to embrace a more pragmatic approach, according to Kaveh Khoshnood, a professor at the Yale School of Public Health who has done infectiousdisease research in Iran.
“They were able to begin to get heard and present alternatives, saying this addiction is a medical issue, a public-health issue,” Khoshnood said. “That’s the perspective that actually gained support and made it all the way to high-ranking government officials.”
Such a harm-reduction approach certainly seems out of place in a theocracy. It assumes that since “sinful” acts like drug use and prostitution will always exist, it’s better to reduce the dangers inherent in such risky behaviors instead of attempting to purge society through moralizing.
The juxtaposition, however unexpected, has worked. The harm-reduction approach has been applied inside the country by a constellation of homegrown Iranian groups, government agencies, and international aid workers. These agents distribute sterile needles and methadone and educate at-risk individuals in an attempt to cut down the country’s HIV infections. Government clinics in every province offer free testing, and if someone is diagnosed, he or she receives free antiretroviral drugs from the government. It would seem that the Islamic Republic has embraced a modern, pragmatic approach to disease prevention that could begin to limit the number of new infections and save the lives of those already infected.
In return for holding its nose and enacting progressive policies, the government has received extensive praise from the United Nations and other agencies and breathless, positive international news stories that counter coverage of oppression in the country or its nuclear ambitions.
“We have realized that an addict is a social reality,” Muhammad-Reza Jahani, vice president of the committee coordinating the government’s response to drug addiction and trafficking, told the New York Times in June. “We don’t want to fight addicts; we want to fight addiction.”
But a closer examination of Iran’s public health approach indicates an inconsistent set of policies that embrace care for one group—drug users—while insisting that the sexual behavior that could lead to HIV infection is a moral failing.
Midway through June 2007, I sat in a bare room in the house-turned-office that served as the NGO’s Mashhad headquarters, copy editing the English version of our program brochure. The doctor who ran our summer project, Vahid Nobahar, and his assistant strode in, returning from a meeting with government authorities. As they sat cooling off from the dusty Mashhad heat, they vented about the officials that had urged them to focus less on condom use and more on abstinence, especially in the printed materials that we distributed to young women and injecting drug users. They had managed to stave off the officials’ objections once more, but said the government’s protests had become more pronounced since Mahmoud Ahmadinejad succeeded the more liberal Mohammad Khatami as president in 2005.
And as recently as 2002, the Iranian Center for Disease Control’s pamphlet on disease prevention stated, without any mention of condoms, “The best way to avoid AIDS is to be faithful to moral and family obligations and to avoid loose sexual relations. Trust in God in order to resist satanic temptations.”
The pamphlet and Nobahar’s experience are indicative of the government’s unwillingness to acknowledge sexual realities that affect the country’s health profoundly. This delusion gained international notoriety during President Ahmadinejad’s visit to Columbia University last year, where he made the claim that Iran has no homosexuals.
Khoshnood believes the government’s more tolerant stance is limited to drug users because drug use—and especially opium use—is a more acceptable and ingrained vice, dating back hundreds of years in the Iranian social landscape. Opium, of course, is widely available from nearby Afghanistan, and despite the Iranian government’s efforts, which include a 13-foot-high wall along the two countries’ border, tons of the drug still get in each year. Premarital sex, on the other hand, is a much more resilient taboo. Women regularly have hymen-repair surgeries to present a virginal front for husbands, and Nobahar told me that many Iranian youth prefer anal sex to preserve their “virginity.” Knowing they cannot get pregnant this way, many women do not bother with condoms, leaving them especially vulnerable to infection.
Laila, a very pretty girl listening to my presentation on condoms, was a seventeen year-old sex worker engaged to be married. She, like the other girls, came to the clinic for basic health services. Laila raised an arm laden with stacks of gold bangles and asked me how old I was.
“Nineteen,” I answered.
“Do you have a fiancé?”
“No.”
“Be careful! You’ll get too old,” she advised.
I held out the condom for Laila and the other girls to pass around and feel its texture, and started explaining how they could convince their partners to use them, techniques particularly important in a society where men often have the upper hand. The girls blushed and turned down the condom. Even sex workers in Iran want to avoid confronting the sticky issue of sexual health at all costs.
These are the kinds of challenges and cultural roadblocks ingrained in Iranian civil society that make it extremely difficult—albeit by no means impossible—to have a robust, realistic public health policy.
Government and the media can defeat cultural taboos if enough political will exists to make it happen. Millions of Iranians have illegal satellite dishes that stream in American and Middle Eastern channels and provide Iranian youth—70 percent of the population—their cue for popular culture and fashion trends. The government could harness that power through public service announcements or ever-popular soap operas, an approach that has affected health behavior for the better in dozens of countries for decades. For example, after a Kenyan soap opera discussed family planning in 1987, contraceptive use in the country increased by 58 percent. That approach, of course, will only be taken if the government first recognizes the appeal of Western culture and legalizes the popular satellite dishes.
It’s unfair, however, to place all the blame on the government.
Culture and tradition, independent of politics, play a huge role in propagating a society’s schizophrenic view of sex. Though public policy can encourage safe sex, an open attitude toward sexual health can never be achieved without the efforts of millions of Iranian parents. Members of this older generation, who bore the abuses of the Shah and led and lived through a revolution only to fight a bloody war with a neighboring country for the next eight years, can be forgiven if they didn’t prioritize the ‘sex talk’ when raising their kids, today’s teenagers and twenty-somethings. Iranian culture, with its obsession with family reputation and status, leaves no room to acknowledge that youth will inevitably go astray of strict religious edicts, and better be able to do so with the tools that will keep them safe. So while Iranian parents worry about what the neighbors will think, on the streets of Iran’s cities and towns their teenaged sons and daughters are confronting the opportunities, risks, and realities of sex on a daily basis.
Some say the Iranian government could only bear to face the reality of premarital and homosexual relations if there develops a transmission crisis analogous to that of drug users and HIV in the mid-1990s.
“It’s much more difficult for the Iranian government to put out a report saying ‘We have tens of thousands of women selling themselves on the street,’” Khoshnood said. “That is so against what the Islamic Republic is supposed to be.”
To be sure, Iran can boast that it is a model for other Middle Eastern countries in how to attack the HIV epidemic. It is one of only eight countries in the Middle East and North Africa that has signed on to a UN commitment to fight HIV/AIDS, and Iran’s uneven focus on drug users has at least abolished a great deal of stigma that still clouds prevention efforts throughout the Arab world. The fact that my group was even allowed to broach the subject of sexual health is a tribute to a legacy left by an active civil society and forward-thinking clerics who years ago put their stamp of approval on a harmreduction approach to AIDS prevention. But the country, and particularly the government, has a long way to go if it wants to prevent a major outbreak of HIV. The current HIV/AIDS rate is relatively low, but the 2008 UNAIDS report estimates there are about 86,000 people in the country living with the disease today, compared to 46,000 in 2001. Iran’s geographic position as a drug route between Afghanistan and Europe and its young population put it at special risk for an epidemic. Khoshnood believes that much of the progress made over the past decade in Iran’s public health policy is fragile and reversible, especially if proven methods of disease prevention are politicized and questioned. Recent events prove him right. This summer two of the architects of the country’s current harm-reduction policy toward drug users, brothers Arash and Kamiar Alaei, were arrested and charged by the Iranian government with “plotting to overthrow the government,” according to Iran’s E’temad newspaper. Human rights groups have called for the brothers’ release, claiming that their arrest is purely political and not grounded in their work, which was conducted openly.
“It’s basically dirty politics at its best,” Khoshnood said.
“The message is ‘Don’t work with NGOs in Iran.’ Unfortunately a lot of my American colleagues are freaked out.”
Such a chill effect could eliminate any chances for a diplomacy centered on public health. Though it may seem that public health is insignificant considering the other obstacles in the way of constructive Iranian-American relations—nuclear proliferation, human rights, and U.S. involvement in the Middle East come to mind—consider that in 2006, the Alaei brothers met with their American counterparts in Washington, D.C. at the first such State Department-approved meeting since the overthrow of the Shah. Kamiar Alaei recently graduated from the Harvard School of Public Health, and each summer took a cadre of students to Iran to research HIV/AIDS.
This kind of cultural and political exchange becomes incredibly unlikely if American foundations, previously willing to fund research and exchange with Iran, are afraid their grantees will be randomly arrested. Worse, Iranian activists could themselves decide that the risk of punishment is too great and decline to challenge cultural norms and stigma on a host of issues.
A few weeks after I arrived in Mashhad, I helped guide officials from UNAIDS on a tour of our prevention operations in the city, including the “Positive Club,” our peer-support program for HIV-positive drug users. Since my English was better than that of the doctors and other interns, I acted as a translator.
One man, in his mid-forties but prematurely aged, wanted me to tell his story to one of the officials. He was a manual laborer with a fifth-grade education who had managed to quit four addictions—heroin, cigarettes, hashish, and pills—after he learned he was HIV-positive, dulling the pain of withdrawal by banging his head against a wall. Now he travels around Iran, speaking to current drug users about his experience.
“Just tell her,” he urged, “that a positive diagnosis is not the end.”
And for years it did. For the first 20 years of the Islamic Republic, drug users were dealt with harshly. The government’s punitive approach dated from the 1979 Islamic Revolution, when newly empowered clerics decided to banish the corrupting ‘Western’ influence of drug use. Drug addicts were given six months to kick their habits, and those who could not were arrested and jailed.
Results were predictable: Iranian prisons overflowed with addicts, and HIV and hepatitis outbreaks among prisoners were common. A generation of Iranian youth coming back from the 1988 Iran-Iraq War was welcomed with a jobless economy hobbled by international sanctions. The veterans’ disillusionment and hopelessness threatened to swell the ranks of addicts, who could in turn spread disease to their wives and children. Forced to face reality, in the mid-1990s the Ministry of Health began to fund methadone-treatment programs for drug addicts and encourage the distribution of sterile needles to prevent the spread of disease. These prevention techniques are still used today. The changes, however, were not inevitable. In fact, it was only an active, sophisticated civil society that was able to convince politicians and the clergy to embrace a more pragmatic approach, according to Kaveh Khoshnood, a professor at the Yale School of Public Health who has done infectiousdisease research in Iran.
“They were able to begin to get heard and present alternatives, saying this addiction is a medical issue, a public-health issue,” Khoshnood said. “That’s the perspective that actually gained support and made it all the way to high-ranking government officials.”
Such a harm-reduction approach certainly seems out of place in a theocracy. It assumes that since “sinful” acts like drug use and prostitution will always exist, it’s better to reduce the dangers inherent in such risky behaviors instead of attempting to purge society through moralizing.
The juxtaposition, however unexpected, has worked. The harm-reduction approach has been applied inside the country by a constellation of homegrown Iranian groups, government agencies, and international aid workers. These agents distribute sterile needles and methadone and educate at-risk individuals in an attempt to cut down the country’s HIV infections. Government clinics in every province offer free testing, and if someone is diagnosed, he or she receives free antiretroviral drugs from the government. It would seem that the Islamic Republic has embraced a modern, pragmatic approach to disease prevention that could begin to limit the number of new infections and save the lives of those already infected.
In return for holding its nose and enacting progressive policies, the government has received extensive praise from the United Nations and other agencies and breathless, positive international news stories that counter coverage of oppression in the country or its nuclear ambitions.
“We have realized that an addict is a social reality,” Muhammad-Reza Jahani, vice president of the committee coordinating the government’s response to drug addiction and trafficking, told the New York Times in June. “We don’t want to fight addicts; we want to fight addiction.”
But a closer examination of Iran’s public health approach indicates an inconsistent set of policies that embrace care for one group—drug users—while insisting that the sexual behavior that could lead to HIV infection is a moral failing.
Midway through June 2007, I sat in a bare room in the house-turned-office that served as the NGO’s Mashhad headquarters, copy editing the English version of our program brochure. The doctor who ran our summer project, Vahid Nobahar, and his assistant strode in, returning from a meeting with government authorities. As they sat cooling off from the dusty Mashhad heat, they vented about the officials that had urged them to focus less on condom use and more on abstinence, especially in the printed materials that we distributed to young women and injecting drug users. They had managed to stave off the officials’ objections once more, but said the government’s protests had become more pronounced since Mahmoud Ahmadinejad succeeded the more liberal Mohammad Khatami as president in 2005.
And as recently as 2002, the Iranian Center for Disease Control’s pamphlet on disease prevention stated, without any mention of condoms, “The best way to avoid AIDS is to be faithful to moral and family obligations and to avoid loose sexual relations. Trust in God in order to resist satanic temptations.”
The pamphlet and Nobahar’s experience are indicative of the government’s unwillingness to acknowledge sexual realities that affect the country’s health profoundly. This delusion gained international notoriety during President Ahmadinejad’s visit to Columbia University last year, where he made the claim that Iran has no homosexuals.
Khoshnood believes the government’s more tolerant stance is limited to drug users because drug use—and especially opium use—is a more acceptable and ingrained vice, dating back hundreds of years in the Iranian social landscape. Opium, of course, is widely available from nearby Afghanistan, and despite the Iranian government’s efforts, which include a 13-foot-high wall along the two countries’ border, tons of the drug still get in each year. Premarital sex, on the other hand, is a much more resilient taboo. Women regularly have hymen-repair surgeries to present a virginal front for husbands, and Nobahar told me that many Iranian youth prefer anal sex to preserve their “virginity.” Knowing they cannot get pregnant this way, many women do not bother with condoms, leaving them especially vulnerable to infection.
Laila, a very pretty girl listening to my presentation on condoms, was a seventeen year-old sex worker engaged to be married. She, like the other girls, came to the clinic for basic health services. Laila raised an arm laden with stacks of gold bangles and asked me how old I was.
“Nineteen,” I answered.
“Do you have a fiancé?”
“No.”
“Be careful! You’ll get too old,” she advised.
I held out the condom for Laila and the other girls to pass around and feel its texture, and started explaining how they could convince their partners to use them, techniques particularly important in a society where men often have the upper hand. The girls blushed and turned down the condom. Even sex workers in Iran want to avoid confronting the sticky issue of sexual health at all costs.
These are the kinds of challenges and cultural roadblocks ingrained in Iranian civil society that make it extremely difficult—albeit by no means impossible—to have a robust, realistic public health policy.
Government and the media can defeat cultural taboos if enough political will exists to make it happen. Millions of Iranians have illegal satellite dishes that stream in American and Middle Eastern channels and provide Iranian youth—70 percent of the population—their cue for popular culture and fashion trends. The government could harness that power through public service announcements or ever-popular soap operas, an approach that has affected health behavior for the better in dozens of countries for decades. For example, after a Kenyan soap opera discussed family planning in 1987, contraceptive use in the country increased by 58 percent. That approach, of course, will only be taken if the government first recognizes the appeal of Western culture and legalizes the popular satellite dishes.
It’s unfair, however, to place all the blame on the government.
Culture and tradition, independent of politics, play a huge role in propagating a society’s schizophrenic view of sex. Though public policy can encourage safe sex, an open attitude toward sexual health can never be achieved without the efforts of millions of Iranian parents. Members of this older generation, who bore the abuses of the Shah and led and lived through a revolution only to fight a bloody war with a neighboring country for the next eight years, can be forgiven if they didn’t prioritize the ‘sex talk’ when raising their kids, today’s teenagers and twenty-somethings. Iranian culture, with its obsession with family reputation and status, leaves no room to acknowledge that youth will inevitably go astray of strict religious edicts, and better be able to do so with the tools that will keep them safe. So while Iranian parents worry about what the neighbors will think, on the streets of Iran’s cities and towns their teenaged sons and daughters are confronting the opportunities, risks, and realities of sex on a daily basis.
Some say the Iranian government could only bear to face the reality of premarital and homosexual relations if there develops a transmission crisis analogous to that of drug users and HIV in the mid-1990s.
“It’s much more difficult for the Iranian government to put out a report saying ‘We have tens of thousands of women selling themselves on the street,’” Khoshnood said. “That is so against what the Islamic Republic is supposed to be.”
To be sure, Iran can boast that it is a model for other Middle Eastern countries in how to attack the HIV epidemic. It is one of only eight countries in the Middle East and North Africa that has signed on to a UN commitment to fight HIV/AIDS, and Iran’s uneven focus on drug users has at least abolished a great deal of stigma that still clouds prevention efforts throughout the Arab world. The fact that my group was even allowed to broach the subject of sexual health is a tribute to a legacy left by an active civil society and forward-thinking clerics who years ago put their stamp of approval on a harmreduction approach to AIDS prevention. But the country, and particularly the government, has a long way to go if it wants to prevent a major outbreak of HIV. The current HIV/AIDS rate is relatively low, but the 2008 UNAIDS report estimates there are about 86,000 people in the country living with the disease today, compared to 46,000 in 2001. Iran’s geographic position as a drug route between Afghanistan and Europe and its young population put it at special risk for an epidemic. Khoshnood believes that much of the progress made over the past decade in Iran’s public health policy is fragile and reversible, especially if proven methods of disease prevention are politicized and questioned. Recent events prove him right. This summer two of the architects of the country’s current harm-reduction policy toward drug users, brothers Arash and Kamiar Alaei, were arrested and charged by the Iranian government with “plotting to overthrow the government,” according to Iran’s E’temad newspaper. Human rights groups have called for the brothers’ release, claiming that their arrest is purely political and not grounded in their work, which was conducted openly.
“It’s basically dirty politics at its best,” Khoshnood said.
“The message is ‘Don’t work with NGOs in Iran.’ Unfortunately a lot of my American colleagues are freaked out.”
Such a chill effect could eliminate any chances for a diplomacy centered on public health. Though it may seem that public health is insignificant considering the other obstacles in the way of constructive Iranian-American relations—nuclear proliferation, human rights, and U.S. involvement in the Middle East come to mind—consider that in 2006, the Alaei brothers met with their American counterparts in Washington, D.C. at the first such State Department-approved meeting since the overthrow of the Shah. Kamiar Alaei recently graduated from the Harvard School of Public Health, and each summer took a cadre of students to Iran to research HIV/AIDS.
This kind of cultural and political exchange becomes incredibly unlikely if American foundations, previously willing to fund research and exchange with Iran, are afraid their grantees will be randomly arrested. Worse, Iranian activists could themselves decide that the risk of punishment is too great and decline to challenge cultural norms and stigma on a host of issues.
A few weeks after I arrived in Mashhad, I helped guide officials from UNAIDS on a tour of our prevention operations in the city, including the “Positive Club,” our peer-support program for HIV-positive drug users. Since my English was better than that of the doctors and other interns, I acted as a translator.
One man, in his mid-forties but prematurely aged, wanted me to tell his story to one of the officials. He was a manual laborer with a fifth-grade education who had managed to quit four addictions—heroin, cigarettes, hashish, and pills—after he learned he was HIV-positive, dulling the pain of withdrawal by banging his head against a wall. Now he travels around Iran, speaking to current drug users about his experience.
“Just tell her,” he urged, “that a positive diagnosis is not the end.”
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