On this episode, Founder and CEO Lynn Madden speaks with Dr Arash Alaei.

In this episode, we sit down with Dr. Arash Alaei, a renowned physician and global health expert, to explore how public health and human rights intersect. From his pioneering work combatting HIV/AIDS in Iran to his efforts empowering underserved communities worldwide, Dr. Alaei shares powerful insights on resilience, equity, and the future of global health.

Join us for an inspiring conversation about courage, compassion, and creating change across borders.

Accolades:

2009: Heinz R. Pagels Human Rights of Scientists Award (New York Academy of Sciences) for his HIV/AIDS work.

2011: Jonathan Mann Award for Global Health and Human Rights (Global Health Council) together with his brother.

2011: Inaugural Award for Leadership in Health and Human Rights (Pan American Health Organization / World Health Organization)

2012: Inaugural Elizabeth Taylor Award in Recognition of Efforts to Advocate for Human Rights in the Field of HIV (sponsored by amfAR and International AIDS Society)

2017: Patroon Award (recognizing leaders making Albany, New York, a better place to live)

2018: Institute of International Education — SRF Outstanding Scholar Award (for exceptional academic work and commitment to students suffering under repression and conflict)

2021: National Medal of Excellence, awarded by the Minister of Health of Tajikistan

2021: “Physician of the Year of Tajikistan”, selected by the community and journalists

The APT Foundation has been committed to the promotion of health and recovery since 1970.

www.aptfoundation.org

Connect with Dr Lynn Madden: https://www.linkedin.com/in/lynn-madden-9b2aa18/

Connect with Dr Arash Alaei: https://www.linkedin.com/in/arash-alaei-md-68a00670/

This podcast is produced by Red Rock Branding: www.redrockbranding.com

Welcome along to the latest episode of Open Access Open Mic, a podcast brought to you by the APT Foundation. I am super excited to introduce today's guest who is an inspiring and innovative physician and educator with a wide scope of experience globally in HIV and substance use disorder care.

Arash Alaei holds a long list of awards and accolades, and I am super excited to learn more, not only about his story, but his unwavering passion for his work. So welcome along to Open Access Open Mic.

Thank you for having me. It's my pleasure to be with you and Dr. Madden.

Absolutely. We are also joined of course by Dr Lynn Madden as always. Thank you so much.

So without further ado, let's jump into some questions. Arash, please can you tell me a little bit about your background, especially about your groundbreaking work in Iran regarding both HIV care and opioid use disorder care? I'd love to know more.

I'm originally from western part of Iran, Kermanshah city. We have majority of people from Kurd community. Ethnicity, my ethnicity is Kurd. And it has long border with Iraq. So I grew up in that city and I was in a school. And later on I moved to Isfahan city to

plan and direction by new government and for Kurd community when they had, you know, plan to do music, dance and have fun, get together, it was part of the culture. One of the challenge with the new government was how they can continue their long culture activities. With that change, that was a little, you know, sad time and

oppression among individuals. Soon after that, you may know it was eight years war from Saddam Hussein when he was president in Iraq. He attacked Iran and my city and my province is one of the border prevailing with Iraq and we had big challenge in that time. I was grow up part-time in city.

and part-time as a disabled people in mountain and then we moved to the capital. So I wanted to give you know idea about what was the main challenges we had as a young generation in that time. So new approach by government, huge war and challenge with the situation we had as a disable. Because of that I saw numbers of

wonderful student around me who have been addicted. That was the beginning of history, how I learned about addiction and how I saw one of the best students we had in our class shifted to use drugs. And it was not only one person or two person. If you go to data, you can see in my city in that time,

we had the highest rate of addiction per capita in my city. That was the environment I grew up in. And that was, for me, passion when I joined medical school. How can I help those friends, not those people they have been stigmatized by community as an injecting drug user or as a drug user?

because they have been my friends. That was one of the passions I had. And at the same time, so my father is a professor of literature. And when I was a kid it was his routine to come to home with four or five newspapers and weekly journal and share it with us and say, okay, read those journals and newspapers.

not only focus in your books for, you know, receiving good grades. You should know about the challenges around the world. You should learn about innovation and other points. I have been familiar with the world of HIV AIDS when I was in K-12 school. That was during 80s. And that was, you know, how I learned from the other issue from

other side of the world later on I will give you how those backgrounds helped me to shift my career for lifetime to the HIV AIDS and substance use.

That's amazing. I love it when you hear about people's personal experiences and how their formative years have shaped where they are today. So you're studying one thing, but how wonderful that your father would encourage you to be so broad with your outlook. That's kind of great to hear. So thinking about right now, what positions do you currently hold, including sort of the current faculty appointments, etc?

Yeah, as I said, you know, I was in medical school in Isfahan University. I graduated and then I completed internship and, you know, internal medicine in Shaykh Bejdi Medical University. And then I moved, I worked in Iran for several years. I moved to United States. When I moved to United States, I started my career at university at Albany as an associate professor and doctor.

was the founder director of ⁓ Global Institute for Health and Human Rights. And later on, I moved from New York to California. Now I am faculty member at California State University Long Beach in Department of Health Science and Health Management. And last year, my proposal approved by the president and the committee to establish Center for Global Health. Now I am director of Center for Global Health.

Incredible, quite an incredible roll call there. I'm not going to embarrass you Arash, but what I am going to do in the show notes is I'm actually going to put a list of your accolades because they are quite phenomenal. I had a good look before we jumped on here. I won't embarrass you, but I will be putting them in the show notes. If you are interested, make sure you click that link below. So let's talk a little bit about the relationships between opioid use, injection drug use, and HIV and viral hepatitis.

So that's very important. When we look at the community, is diversity of people with different opinion, with different action. So that's, I think, beauty of each community when we see it as a big picture. When we go deeper, we see some of the people because of

something. That's something we have numbers of research to show. Sometimes it's because of depression, sometimes it's because of the personality, sometimes it's because of the environment, because of one thing or combination of some, you know, issues or personality or behavior. They will go to use one kind of drugs. But when they will be depend on

opioid drugs. So that will be big problem to be adapted and depend on the dosage of that kind of drug. We are talking about opioid use. So they will be depend and tolerance of the body. It's one of the big question we have. Step by step when they use same dosage of that drug such as opioids, such as heroin,

they cannot be in the situation they have been in the past. So because of that, step by step, they wanted to increase the dosage to go to be normal because that's, know, big argument we have sometime with the conservative community. Sometimes conservative community, they think they do it for euphoria. They did it for fun.

Maybe in the beginning they had some euphoria or for some fun, but later on they will be depend on that. That will be such as medication. They will be depend on that. But that dependency need to increase the dosage. So from sniffing, smoking, later on because of the money, because of the purity, because of the, you know, ⁓ adaptation of the body,

they will shift it to injection. Now we have additional harms around injection. Why? Because when they shift to injection, that will be one of the risks of blood burn diseases. blood burn diseases. Usually we see some people wanted to get together and share their needles. That will be the risk of

blood-borne diseases such as HIV, such as viral hepatitis. Sometimes they do that and they will go to have sex with the partner without any protection. So that will be additional risk for HIV. Because of that, there is correlation between drug use, injecting drug use, and people living with HIV AIDS. So that's,

step by step they will go to have those, you know, situation to be at risk to get those blood born diseases.

You explain it so well, you really do. And the progressive nature of it and the dependency and how it's not a choice. You know, it's often not a choice. And I'm gonna jump around my questions a little bit here because it's brought one to the top of my mind about the systemic barriers that are in place that hinder people getting access to care. I what systemic barriers do you believe most urgently need to be addressed?

in order to improve access to evidence-based treatment for opioid use disorder.

Yeah, so if I may, I wanted to go first to look at, you know, review some challenges and see how we can, you know, solve and find solution to remove those barriers. So number one, when we look at society, do we have empathy from society with those injecting drug users or there is taboo to say, okay, they wanted to inject drug, they...

Mm-hmm.

don't care about themselves, they don't care about community. That's one of the big issues, social barriers. When I was working in Iran, in our clinic, one of the big issues was family, stigma and discrimination from family of injecting drug users. They rejected them from family. They have been rejected from society.

They have been rejected from health care workers because health care workers, they look at them as someone who did crime, not as a people who has been depend on some medication. ⁓ Opioid is one kind of medication. Sometimes when we go to the cardiovascular disease, look at emergency room. So majority of emergency room, they need to have morphine, one kind of opiate.

So, but for those people, they are depend on that. but overall, when we look at society, when we look at providers, so they had negative opinion about this group of community. That's from social. Structural, as I said, service. Let's go to legal. So in many countries, using drug is illegal and then

The result will be push those people to go to prison, to go to court, to go to jail, or to be in the closed setting. Depend on country can be days to years. So huge legal barrier. So now we have legal barrier, we have social barrier, and we have a structural barriers as a service providers. Now, let's say person A wanted to receive

alternative receive treatment and therapy to come out with those barriers is never ever happened to see good outcome. So with that let's go back. Which approach should we have? Our approach is human right based approach. When we look at human right based approach we have triple A cube.

availability of service, easy access and affordability, acceptability, and quality. Now, is service available in some countries because of legal barrier? They don't like to have any service and they said this is abstinent oriented, you must go to prison, there is no alternative. Unfortunately, this is the big issue we see. And in Iran, in the beginning we had that problem. They said no way.

prison or quit. No alternative treatment. availability. Number two is access. When we talk about access, let's say maybe treatment is available, but access to treatment has numbers of challenges. This is the project I have pleasure to work with Dr. Madden and Professor Rick Altice in Tajikistan. This is big project.

supported by Yale University, funded by NIH, and I am country PI under the supervision of Dr. Madden and know, Professor Altice to see in Central Asia what are those barriers and how we can solve it. So now in Tajikistan, I wanted to switch with your permission to the country that we are working. Methadone as one of the medication for people who inject drugs or people who use

opioid disorders is available. For affordability, it's free of charge. So then there is no need to pay. But to receive it, you can see a series of challenges and barriers. Number one, they have to have a full document and register all of those documents. And when they register those documents, it will show to the government and the stakeholder

This person used drugs and because of that they cannot find any job. Look at this. In one hand they have to submit all of the ID card and ⁓ identify themselves to the treatment system. But from the other side, when they say, I used drugs and I wanted to come out, that will be big background check issue and they cannot find job.

Number two, they have to go to the health facility every day. So with that, they cannot find any time to go to the normal life, to make money, to find a job, long distance to go there. Number three, from service providers, there is a guideline with very low flexibility. I can say there is no flexibility.

If you look at that guideline, it means they wanted to go to army as a soldier. It's not about flexibility. You wanted to have patient as a center of the idea. So patient must follow doctor's direction without any flexibility for dosage of treatment. There is very limitation. And then patient must follow doctor's not from doctor to see what's the need of patient. If patients say, I need more,

to increase the dosage. No, you have to follow me. I know better than you. This is, you know, the tradition they have here. And the project is trying to show them how they can get together, see the issue they have, and together find solution with some support from outside, not as a showing direction to them. To share.

experience of other countries, experience of experts, but how they can solve the issue by local people. That's the point. when I wanted to go back to your question, when we look at the access, those are the challenges we see in Tajikistan. In Iran, when I was working, the barriers and issues were different. So we had huge legal barriers. We had

huge problem with the police, how we can work in the clinic and not to receive any negative message or they wanted to arrest our patient. That was big challenge we had. But step by step, this is the point. How we can solve the barriers, that's the point. Number one, to be flexible, to put patient as a center and

get together around that person to solve that person's issues, to help to find solutions for that patient's need not to follow doctors and regulation.

Lynn I mean, I'm hearing the solution, but it's never happening. It's never forthcoming, know, patient centered and flexibility. It brings us back into like sort of the...

If you had the power, it's a question for both of you, okay? If you had the power to implement one major policy change tomorrow to reduce opioid related harm, what would it be and why?

think that's a really hard question. And Dr. Alaei and myself, may not have exactly the same answer culturally or from a particular country. From my perspective, I think that it would be really important to reduce stigma and increase the use of these medications as standard operating procedure by health care professionals so that you could receive them in any setting. So in the United States,

Similar to what you just heard Dr. Alaei describe in Tajikistan, there are a lot of limitations on the use of methadone as a medication for the treatment of opioid use disorder. And one of those limitations is you have to receive it in a specialty care program. So you have to go to that place and they're not widely available in many parts of the country, right? So it's much more affordable than some of the other medicines, but much less available. And there are many healthcare professionals

who don't um prescribe these medicines or don't work in the specialty care settings in order to prescribe them. And I think that one thing we could do in the United States is think differently about the touch points. If people show up in an emergency department, how do we identify their opioid use problem? What do we do? If they show up in a primary care practice, let's treat them right there in real time.

if they show up in a skilled nursing facility? Are we screening for opioid use disorder in jails, in prisons? So we have about 7 and 1 million people in the US who are living with opioid use disorder. And around 12 % of them are receiving medicines for opioid use. That's not good enough in terms of really improving the overall public health picture of each of those persons, but all of us ⁓ as well.

So I wonder Dr. Alaei what your thought is there?

From my side, know, I wanted to go back to that right-based approach. know, if the power that you said, may I have, if that will go to change the opinion of people, I try to change opinion of people to see injecting drug users and drug users same as others. That's the big issue that Dr. Madden mentioned. So don't...

stigmatize or discriminate people who use drug. When we look at other services, how we take care of people with diabetes, numbers of innovation, billions of dollars for research, go to the facility, go to the community, everywhere. How we take care of people with blood pressure, they have blood pressure. You can find it in any location. Fantastic program. When we go to the drug addiction, so

numbers of limitations. So that's the opinion. But if I don't have that power to change the opinion and I have power to change policy, same. Please look at this right approach, right-based approach. Availability, easy access, affordable, acceptable. Why we have numbers of regulation, law, policy to provide service and see

patient satisfaction, that means acceptable by patient, but when we go to drug addiction, we don't care about patient satisfaction. So because of that, there are numbers of policy and barriers because we wanted to have them to follow us, not us to help them to solve their issue. So those are, you know, the main fundamental challenges we have. If we can

Solve that because the model of service, there are numbers of research, Dr. Madden, Professor Altice and other experts, they have numbers of solutions, evidence-based solutions. We don't want to talk about some dreams. It's not dream. It's evidence-based research, you know, and implementation. But the issue is how we can change the opinion of people.

how we can change those policies and limitation to see everybody equal.

That's fabulous answer. That's the mission. That's the mission Arash. We're doing it. We're doing our best. ⁓ Back onto some more of the correct format of questions that I was working through. But what case would you make for a scale up of medications for opioid use disorder, especially in Central Asia around the access as well?

Yeah, in Central Asia, you know, that's the point, you know, how again, you know, it will go to that policy and opinion of people. For example, so we have some of the key stakeholders, they are working with us and they know the barrier and challenge, but they don't want it to change. So how we can find a way to change the opinion of people, change the approach. That's, you know, as I said, you know, it's my pleasure to be member of this.

project, the main goal of this project is change. How we can change not to do same work we had without any result. Is there any possibility to change and see the outcome? Maybe sometime we have better outcome, maybe not, but again it will help us to change again and again and again. So for Central Asia, that's one of the points. How

we can change those policy and limitation that is in the guideline for the clients. So for example, every day, every morning they have to go from eight to 10. If they go later than 10, there is no medication. Think about it. Those people are receiving high dose of methadone. But if they go 10 minutes later, there is no way to receive it.

that will be huge problem and they will go to inject because they need it. ⁓

flexibility to increase dosage because of the need of the patient. Those are two important points we see. And how we can advocate to say friends, they are our friends. Here is free of charge facility. Put it in the mass media. Put it in the advertisement. We are here to help you. We are. How many advertisements we have? I can say zero.

zero advocacy about coming using this free of charge services. those are, know, ideas that we are working on that and hope to step by step. It's in the progress. I'm so optimistic and I can give you some example in some areas where we are going well. I cannot say in

all of the locations that we are working because this project is nationwide. So this project is supporting all of the facilities they provide opioid substitution therapy. But because of difference, so in some facilities we see progress, in some of the facilities they are in the middle, but in some of the facilities we have challenges. Overall,

I think you know how we can have easy access to the service is the key. But the point again is that can we force them? That doesn't work. That means you know those providers. This is the beauty of project. How providers can find solution by support. That's the point. That's because of that we need a little longer term.

support, step-by-step motivation and finding direction will be available for

You're always very positive, Arash, and I'm thinking, I was just sat here thinking, okay, so we know that we have the evidence to support open access, right? Everything that you said, we know is a fantastic way of helping so many individuals. We've also got the research to back it up. Are things moving quick enough for you?

You know, this is, know, overall, when we look at the globe, you know, for many, you know, challenges, we have evidence-based solution, but we don't use it. You know, ⁓ this is the problem. You know, how research from library and journal will go to the field and see the outcome and how

our opinion or personality can accept those effective evidence-based approach because as you mentioned we knew about that we knew it from years it's not new you know for years the approach and evidence behind of that is clear but because of political sometimes because of personal

because of some opinion, so we see numbers of barriers to reach the goal. That's, I think that's the issue. But from my side, you mentioned it, I am positive and optimistic. We have to try. If we stay and say, if we give up, that's against any, you know, evidence and research and also against being, you know, human.

because we have to try to support those people who need this service. So part of my work is for substance use, part of my work is for HIV. Look at history of HIVs. In my, you know, career when I started to work in HIVs in my city, Kermanshah so we did rapid survey to find what is the main cause of deaths among

people living with HIV AIDS in my hometown. In that time, numbers of articles showed tuberculosis and opportunistic infections. What we found? Suicide. The majority of our patients before our clinic committed suicide because of cultural, social, legal stigma and discrimination.

So that's the point. So if we wanted to be quiet and say, okay, you have power, you think this is the direction, they think they know direction better than us. And then if we ignore evidence-based approach, that will be huge challenge and cost for those people who need us to be their voice. They are voiceless people.

and we have to be their voice and stay and continue, continue, continue. I learned this river never stop, maybe change the direction, but finally it will go to find sea or ocean. Definitely we will reach our goal.

I love that. I love that. I'm fairly sure I'm going to actually steal that and regurgitate that at another time for sure. ⁓ Let's talk about global health research. How does global health research benefit us all?

Nowadays when we see that's, know, one of my, you know, the discussion with my students. So this year we admitted numbers of doctorate of public health, new track, we developed it as a global health. And in, you know, in the first day of the orientation, I raised this idea, you know, and I asked them, so what do you think about global health?

Majority of them, they said, we worked in local and the priority for us is California. And I said, okay, friends, please count people around you. How many people from which origin and ethnicity and race you see every day. Nowadays, when we look at globe,

we don't have any isolated country or region. We see diversity in all regions, all countries. So with that, lesson learned from each other can help all countries. So sometimes we see, first us, but without them, we cannot think about us. That's the point. That's lesson learned.

Central Asia, maybe it's far from United States, but when we see this approach and barriers, we see it same issue and barriers in United States. Can we find some solution here and apply it in United States? Or from the other side, can we find some solution from United States and apply it in Central Asia? That's the beauty of global health. How we can lessen learn from each other and

because of diversity, maybe solution will be fine from the other countries, other community, other people, and can be applied in our community. That's we learned it during COVID-19. So for COVID-19, when we shared data, we found solution faster. If we wanted to say this is my country and I don't want it to share, I don't want it to communicate how many people died during that time. So that's I think.

for all, you know, subject in health, especially when we look at, you know, areas such as substance use, when we have cultural, social, legal barriers. So that lesson learned and collaboration between countries is needed. And it doesn't mean if we have very advanced, you know, ⁓ basic science research or very advanced hospital in one country,

and in other countries they don't have it, we can solve the issue. We have the same barrier because opinion, reaction and behavior of people are same. Those legal barriers and political opinion are same. So that is the beauty of global health, how we can lessen them from each other and apply it locally.

Beautifully put, collaboratively and collectively, we are much stronger together. Absolutely, beautifully put. Okay, last question from me, unless Dr. Madden has something for you. What do you consider the global priorities for substance use treatment and HIV care prevention? What do you consider to be the global priorities right now?

I think now when we look at HIV, we see more progress. So we see more progress, we see more investment, we see more innovation there. I think for HIV is much, ⁓ we see more more progress and better approach compared to substance use, opioid use. So for example,

but we see numbers of good news about vaccine, numbers of new medication we have, numbers of, you know, rapid tests with high, you know, sensitivity and specific. So those are progress we see in HIV is we don't see it in, you know, substance use and opioid use. That's one of the, you know, difference when we look at it. But overall, I think for future,

It's very important. Do we have any calculation to show the cost? Because, know, now I wanted to have, you know, policymakers as a target. So let's have policymakers as a target of this two, three sentences. Have you had any time to calculate how much money you lose

when people continue injecting drugs with new innovation and removing barrier and have easy access for alternative way to protect them in the safe, physical and mental situation. Or you ignore it. That's the point. We see this government found X tonnage

of you know, heroin or you know, amphetamine. Only they show that you know, demand not to look at you know, the solution they can find. So that is one of the big barrier we see and I think we should you know, work on that how we can find way to think about it if they wanted to look at it financially. There is numbers of you know, evidence we can show there is benefit.

for country to work on solving barriers? Because as I said, solution is here, but the issue is how we can remove those barriers. Can we have some investment to find better medicines, better ⁓ medication for them? Definitely with this technology, it's easy to find much better and easier low-cost action. But do we have any investment on that? No.

Unfortunately, nowadays we see step by step the budget for research decreasing. The priority is less for this global challenge for centuries. For centuries is not new. For centuries we see the challenges of people and you know some solution. But overall when we look at you know the action so it's

Unfortunately, nowadays is, you know, less priority for funding And from UN agencies, for example, when we look at UNODC, United Nations Office for Drugs and Crime, what are they doing? To be honest, what are they doing? Do we have any voice from them? Do we have any policy from them or nothing? If UN has one body for drugs,

What is the outcome of that? So we need to have reform in the body of the UN. We need to change the opinion of the policymakers to prioritize, you know, working in substance use. And we need to have some investment to help researcher to apply their finding in the new, you know, areas.

I was just going to say, think that is such a brilliant and thoughtful answer. It's one of the things that I really appreciate about the opportunity to work with Dr. Alaei know, is his perspective being so well informed by ⁓ not only his personal experience and expertise, but his, you know, work on the global stage and the opportunity to interact at different levels of

of the issue, if you will, or a set of problems that we're facing, I can say with some certainty that we do have some numbers that we've put in some countries. In the US, for example, that number is about $53 billion a year that is spent trying to, it's either lost wages, lost productivity, lost lives, crime that gets committed, $53 billion a year.

And one of the other measures that we have in this country, which is not measured widely in every country, are the number of people who die from drug overdoses. But there's so much between those two things. So that $53 billion a year, that represents people's lives and livelihoods and their families and communities. we really don't have a good metric, if you will, for looking across the globe in particular and agreeing.

that we're going to try and quantify what these harms really are, and we're going to therefore make these intelligent investments, ⁓ not only nationally, but at the local level. And I think that framework is still missing to a large degree. And I think so much of it is powered by stigma, all of the various kinds of stigma and the lack of appreciation.

of this human rights perspective that Dr. Alaei has brought to us this morning.

Absolutely. What a fascinating conversation. Bringing you guys together on Open Access Open Mic is an absolute win. there are so many things I want to go away and think about and draw upon. And there's facts I want to look up, you know, and hopefully the listeners feel the same as well. But the one thing that is overriding is that the work that you're both doing is incredible. And being that voice for the person who's invisible due to that lack of flexibility, that lack of understanding and

I got to agree with you, Lynn. I think for many countries it's hit them where it hurts and $53 billion a year. Surely even some of our more wealthy people, should we say, should be taking some notice of that figure. Thank you so much, Arash. I can't thank you enough for being a part of Open Access Open Mic. I'm sure we may rerun this again in the future and see what you're up to in a little while. But for now, Lynn.

Thank you.

Arash, thank you so much for being a part of Open Access Open Mic.

Thank you very much for having me.

Thank you, Claire and Arash.

Yeah, I appreciate you Arash and your work. It's my great pleasure to work with him.

My pleasure, my great pleasure to work with you and learn from your wonderful experiences. Definitely. And thank you very much for, you know, hosting us.