By Helen Redmond
Under the bridge downtown
Is where I drew some blood
Under the bridge
I could not get enough
Under the bridge
Forgot about my love
Under the bridge
I gave my life away
– Red Hot Chili Peppers
Drug users are drawn to bridges. They offer a modicum of privacy and camaraderie to go about the illegal business of staving off opiate withdrawal and tamping down painful feelings. On a recent trip to Kabul, Afghanistan, I stood among dozens of men injecting heroin and inhaling opium vapors huddled under scarves in small groups under the Pul-i-Sokhta bridge – the name means “burned bridge.”
Some corners were so dark I wondered how users found a vein to inject. The smog of combustible opium filled the air. The soggy mud under our feet was full of putrid human detritus. I saw caked blood on track-pocked arms, weeping sores, scars and necrotic tissue. All I could think of was this: It doesn’t have to be this way. The hell and human suffering under the Pul-i-Sokhta bridge is entirely man-made. Drug users in Kabul need a safe injection site (like this one), but instead, many will die from bloodborne infections and preventable diseases like HIV/AIDS and Hepatitis C.
Drug users at Pul-e-Sokhta bridge. (Photo: Helen Redmond)
I was at the bridge with a group of outreach workers from the Organization for Harm Reduction in Afghanistan (OHRA), who deliver “kites” filled with condoms, syringes and alcohol pads. Amidst feces, discarded syringes, cigarette butts and crushed plastic bottles, men surrounded me and Ziauddin, a former heroin user and a peer educator for OHRA. They shouted loudly and angrily about the police. Drug users are routinely assaulted and injured by officers driving them away from the bridge. Some are arrested. One man was beaten to death; Ziauddin showed me a picture of the dead man taken with his cell phone camera.
There is a mosque next to the bridge, and Ziauddin said the Mullah has given permission for Muslims to attack drug users with heavy wooden sticks. Hospitals openly refuse to treat the drug addicted. “We have no rights,” the men said over and over again. Then came a series of desperate pleas to the outreach staff, for basic items like food, clothing, housing and money. The men believe it’s the government’s responsibility to help them, although they’re cynical enough to understand that their criminal status makes any assistance unlikely.
Ziauddin explained many of the men have lost family support due to their opiate addiction. In Afghanistan, drug use brings tremendous shame to families. But to be without family is emotionally devastating in a country where there are few social support programs. Drug users depend on each other for survival, and meeting in public places to use drugs creates alternative families and community.
Scars of War
Afghans use drugs for many reasons, but in a country that’s suffered 30 years of uninterrupted war and foreign occupation, it’s no suprise that many men, women and even children use opiates. Opiates are well known for their calming effect, as well as their ability to mediate unpleasant emotions and suppress traumatic memories. Heroin and opium are fast-acting, powerful pain relievers with effects that last a long time, from seven to eight hours depending on the purity, which in Afghanistan, outreach workers told me, is about 80 percent.
The trauma of war creates the conditions for, and increases the risks of drug addiction. The prevalence of post-traumatic stress disorder (PTSD) in Afghanistan is among the highest in the world. Add that to the facts that more than 20 million Afghans live in poverty, the unemployment rate is 35 percent, and hundreds of thousands of internally displaced people live in squalid refugee camps. No one in Afghanistan talks about addiction as a brain disease; it seems obvious that addiction is a response to trauma and social and economic deprivation.
In Afghanistan during the civil war that ended with the Taliban taking power in 1996, Afghans took their revenge on symbols of Soviet rule. The Russian Cultural Center was bombed into a gigantic hulk of twisted metal and concrete catacombs. The ruins became home to thousands of traumatized Afghan men and boys who sought solace in the powerful derivatives of poppy. The center functioned as a no-frills opium den, an open-air drug market and a homeless shelter. In 2010, the drug users were evicted by force. A few were offered treatment, but the vast majority scattered to other parts of Kabul and created new open-air drug scenes, most famously, the Pul-i-Sokhta bridge.
The Soviet withdrawal from Afghanistan in 1989 didn’t end the relationship between the two countries. Afghan heroin has found its way across Russia’s borders and checkpoints and into the veins of over 1.8 million men and women between the ages of 18 and 39. A staggering 30,000 Russians die from overdose every year, a number far higher than all the Russian soldiers killed during the Afghan war. Is this Afghanistan’s way of avenging 10 years of war and occupation and death and the destruction of their country?
Russian officials blame the Afghans for their drug problem and routinely castigate the Karzai government and the NATO-led International Security Assistance Force (ISAF) for not eradicating more poppy fields, as well as for their failure to interdict more heroin shipments bound for Russia and other countries in Central Asia. But it is internal Russian drug policy that is killing thousands of heroin injectors, not only from overdose but also from HIV/AIDS.
The war on drug users in Russia is cruel in the extreme and consists of psychological torture and humiliation masquerading as drug treatment, incarceration and legally sanctioned discrimination. Proven harm-reduction interventions are rejected as “enabling” the drug-addicted to continue to get high. The government doesn’t fund syringe exchange and police have harassed, beaten and arrested those who hand out clean needles.
Condom distribution is met with similar violence. The Russians rejected millions of dollars from the Global Fund to Fight AIDS because a portion of the money must be used to distribute syringes. There is a full-blown AIDS epidemic in Russia as a result of needle sharing that the government refuses to address: 40,000 die every year.
Decades of studies have proven that methadone maintenance is the most successful and safe treatment for heroin addiction. But it is illegal in Russia despite methadone being on the World Health Organization’s list of essential medicines. Viktor Ivanov, former KGB agent and Russian drug czar, actually asserts that there is no medical data supporting the efficacy of methadone. The only support available for injection drug users are 12-step programs with notoriously low success rates, like Narcotics Anonymous, or so-called drug treatment centers like the infamous City Without Drugs, where clients endure harsh prison-like conditions during unsupervised, non-medical withdrawal from opiates. Drug users used to be handcuffed to their beds.
The Afghan government often blames Russia for its 10-year war and occupation for creating the conditions for opiate addiction to take root, and for the explosion of poppy cultivation in Helmand and Kandahar provinces in the south. Afghanistan is a poppy paradise, producing over 90 percent of the heroin that is exported to Central Asia and Europe.
A heroin or opium addiction can be maintained for as little as $4 day. The United Nations Office on Drugs and Crime (UNODC) estimates that nearly one million Afghans between 15 and 64 are recreational and/or problematic drug users. That number should be treated with caution, though, because of the reluctance to reveal drug addiction due to stigma, as well as the barriers to conducting research in rural areas where insurgency, language differences, and lack of roads or adresses make it unsafe or difficult for field researchers to visit. UNODC also has a vested interest in inflating the numbers of drug users to ensure that the drug war is maintained and its funding continued.
The Need for Peace
Back under the burned bridge in Kabul, Azim, his glassy pupils constricted to pinpoints, tells me he started using opium to cope with myriad losses when he was a 13-year-old. Now he injects heroin. A thick rubber band is wrapped tightly around Azim’s thigh and as I watch, he tries in vain to find a vein in his groin. The sharp needle hovers above his skin, but then he slowly places the syringe on the dusty ground and nods off. He does this over and over again.
Another regular at Pul-i-Sokhta bridge is a young man named Shams. He’s been using heroin for many years and says it helps him concentrate at work. He’s a translator for the U.S. military at Bagram prison, and his English is excellent. Other drug users explain that they moved illegally to Iran to find work to support their families. They found poorly paid employment and a lot of cheap heroin. Afghans are scapegoated for many social problems in Iran, and drug use was how they coped with both discrimination and the depression of being separated from loved ones.
Afghan women use opiates too. It is estimated that between 18,000 to 23,000 women are smoking opium or injecting heroin. Women are never seen getting high in public; they have drugs delivered to the privacy of their homes. Mothers, particularly in remote, rural areas, give opium to sick children (they blow the smoke into their mouths) because they lack access to healthcare and other non-opioid medications. Some of the children become addicted.
Many opiate users want drug treatment, so Nazir, another peer educator, scribbles their names on a waiting list to get into a methadone program. The problem is there are over 7,000 opiate addicts in Kabul and one methadone clinic in the city that serves only 77 people. Drug warriors in the Afghan government, like their counterparts in Russia, don’t like opiate substitution therapy (OST) and on two occasions blocked shipments of methadone from coming into the country. They prefer to fund abstinence-based treatment despite its high failure rate. Government drug prevention and education materials use the discredited slogan, “Just say no.”
It was left to the French doctors' organization, Médicins du Monde (MDM), to open the first methadone clinic in Afghanistan in partnership with OHRA. In 2012, the Afghan Ministry of Public Health accepted the necessity of OST and took over from MDM but capacity hasn’t increased to meet the need, and methadone maintenance is considered a “pilot” program, as if its efficacy needed to be studied.
The Afghan government refuses to adequately fund validated harm reduction interventions to treat opiate addiction, reduce the spread of HIV, lower the rate of overdose deaths and decrease the sharing of syringes. Treating drug addiction and stopping the spread of infectious diseases isn’t difficult. A report by the Global Commission on Drug Policy outlines how to do it: Mobile methadone vans, heroin or buprenorphine prescriptions, safe injection sites, condoms and naloxone distribution, and syringe exchange. These science-based, inexpensive, life-saving interventions are available right now.
It is the criminalization and demonization of drug users, funded and fueled by the U.S. war on drugs in Afghanistan that makes implementing these common sense and humane measures difficult. The Drug Enforcement Administration, the U.S. military and the U.S. Agency for International Development (USAID) have wasted billions of dollars on poppy eradication, alternative crop development and hunting down, prosecuting and incarcerating thousands of Afghans involved in the drug trade. The enforcement-led, punishment approach hasn’t made a dent in opium cultivation, the availability of heroin or the rate of addiction. That money needs to be channeled into a massive expansion of drug treatment that is available to anyone on demand.
The real crime is the relentless, brutal and deadly war on Afghan drug users, a vulnerable and traumatized segment of the population. The drawdown of American troops and the end of the war and occupation could help Afghanistan to develop a new drug policy based on human rights, respect and compassion.
*All names have been changed to protect privacy.
Originally published on Jul. 9, 2013