Patients at Nazaraliev Medical Center
Muhammad had many good reasons for being pissed off. He was far from home, his arm was bleeding, and he'd recently come out of a coma. The stranger asking about his heroin addiction probably didn’t help. But he had already tried drug clinics in France, Spain, Italy, and Turkey, and none of them had worked. He’d come to Kyrgyzstan because he thought it was his last chance.
He’d traveled from Algiers based on the reputation of the Nazaraliev Medical Center, a private clinic near Bishkek. The center claims that 80 percent of its patients stay drug-free for at least a year after receiving treatment there. Many of those it treats come from Russia or the former Soviet Union, but there’s no shortage of domestic customers. Heroin use has drastically increased in Kyrgyzstan over the last decade. The last official estimate, in 2006, put the number of intravenous drug users in the country at 26,000. According to Dr. Alexander Zelichenko, director of the Central Asian Center on Drug Policy, there may now be around 100,000 users in a country with a population just below 5.6 million.
At the center’s gates I was met by Batma, my interpreter, a slim young woman wearing a long beige dress that made her look like Princess Leia. She led me into a room with eight hospital beds, two of which were occupied by middle-aged men with very pale faces. One was lying on his back, very still. The other breathed loudly through his mouth. Occasionally he jerked in spasms. They were undergoing "ultra-rapid opiate detoxification," which involves being injected with Naltrexone. The drug blocks the receptor sites where heroin acts on the nervous system and thus takes all the fun, euphoric parts out of opiate abuse. This process induces accelerated withdrawal, leading to intense pain, craving, and nausea. The center has a way to prevent the patient from experiencing any of this—namely, putting them in a coma for four hours.
The patients were being watched over by a doctor with a mustache. When I asked if it was hard to convince patients to agree to the procedure, he shook his head. "Most are happy to be in this state because when they come to us they are in a lot of pain. We do this to stabilize them. They used to do this in America, but there were some complications."
This was an understatement. The Guidelines of the US National Institute for Health and Clinical Excellence advise that "ultra-rapid detoxification under general anesthesia or heavy sedation... must not be offered. This is because of the risk of serious adverse events, including death." Doubts about the method are not confined to its risks. A recent US study compared detoxification with and without the use of anesthesia and found no differences in rates of completion of treatment programs.
Members of Nazaraliev staff
Yet, although the method is an integral part of treatment at the center, it isn’t mandatory. Sometimes a patient’s health precludes it. According to the doctor, "ten years ago patients were healthier—now their organs are like those of a 60-year-old." He attributes this at least partly to changes in drug use since the breakup of the Soviet Union. Fewer drugs were available, so people would often only use one drug, whereas now they can find whatever they want.
I asked if I could take a photo of the patients. "Of course," said Batma. "They won’t know. They are asleep." I took two photos before one of the nurses thought to disguise the men’s identities by looping a surgical mask over their eyes.
But rapid detox is only one part of the treatment. Of greater importance is what the center calls "mindcrafting," a blend of meditation, counseling, and Jungian psychoanalysis. Its aim is to rebuild the patient’s self-esteem and give them the "strength of mind to keep one step ahead of others in the context of globalization, with its rapid development of information technology and the rule of money and stress."
The corridors of the center are full of posters that seek to build these capacities. When we left the detox ward, I saw one that featured a cartoon of the human brain. The right hemisphere was colored red and had areas named "shame expander," "wimp centre," and "self-loathing reflex." On the left was "gun lust lobe," "invasion gland," and "oil shares layers." Beneath the brain, a pair of eyes stared up sorrowfully.
I asked Batma about the center’s high success rate. "There are no 100 percent guarantees, and of course it depends on their health. But if they have the motivation, it is possible. And treatment here is expensive compared to other places; a person thinks carefully before he agrees to it."
A month’s treatment for opiate addiction costs almost $8,000, with a "luxury" option that includes VIP meals and accommodation at a premier resort available for around $11,000. Even the regular treatment is beyond the means of most residents of Kyrgyzstan, where the average monthly wage is around $130.
For those who can’t afford this treatment, there are several state-run methadone clinics in Bishkek. The alternative, according to Batma, was that an addict's "parents just lock him in a room for a few weeks. Obviously," she said, then laughed, "it is not the best! What can also help is a problem stronger than addiction. For instance, Nick, if you have some stresses, if we throw you out of an airplane, you will forget about your problems."
On the way to the patients’ rooms we passed a gray-haired man wearing the dark glasses of the blind, but without a stick. He was moving slowly, and with care, but not touching the walls. “He has worked here for many years,” said Batma.
We went into a sparsely furnished room where a muscular man sat on a bed eating a Bounty bar. Andrey had come from Moscow, where he worked on subway tunnels. He had already finished the main part of his treatment and had come back as an outpatient. In a low, hoarse voice he told me he was originally from Magadan, in the northern subarctic of Russia. He’d started using opium in high school, then moved onto amphetamines and heroin. He joined the army after he left school and fought in the First Chechen War from 1994 to 1996, after which he gave up drugs. Several years later he was sent to prison (for what, he didn’t say), where he started using heroin again.
I asked Andrey if anything about the center’s methods had surprised him. There was a pause after Batma translated, long enough to make me wonder if I had asked the wrong question. Then he laughed in a slow, deep way that sounded wonderful.
"Everything!" he said. But what he found most challenging was the "mindcrafting." Patients are offered a narrative of struggle and redemption that draws on a blend of Jungian symbols and Kyrgyz folklore, what the center calls "lapidopsychotherapy." Patients are asked to choose a large stone and then hold it for 15–20 minutes every day while verbalizing their problems, either to another person or to themselves. The aim is for negative experiences to be imprinted on the "information memory of the stone." The treatment ends with the stone being carried up the Tashtar-Ata Mountain of Salvation and thrown onto a huge pile of other stones, thus freeing the patient of his or her troubles.
When we finished talking, I asked Andrey if I could take his photo; he nodded and stood. We went over to the window, and he stared calmly at me while I adjusted the camera. In the sunlight he looked tired, much older, as if he’d woken from the deepest sleep.
At lunchtime Batma and I ate rice and lamb with salad on a platform by the river. The water was so loud it all but drowned the birdsong. What with the setting, the food, and the warm sunshine, I was feeling very relaxed when Batma asked if I had ever used drugs. "Yes," I said. "But not heroin."
It was after lunch that I met Muhammad, the 25-year-old from Algiers who had been at the center for only four days. When I first saw him he was sitting on an unmade bed while a nurse tended to his arm. There wasn’t much blood, just a two- or three-inch trail. We shook hands, and I introduced myself in French, but when my French ran out we had to resort to a complicated system by which I addressed my questions to Batma, who spoke them in Russian to Muhammad’s friend Ahmed, who translated them into French.
Muhammad’s first coma had been difficult—his sight and memory were impaired for several hours. He was also disorientated and at first thought he was back in Algiers, and he couldn’t recognize Ahmed. It also made him hyperactive and unable to sleep. Yet he was optimistic about his chances of recovery. When the doctors offered him painkillers after he came out the coma, he threw them away. He said he was determined to get well and then go back to Algeria and marry his girlfriend.
This seemed like a good place to end things, but when I got up to leave, Muhammad protested. "Encore," he said repeatedly. I sat down, and he told me that if you were caught with drugs in Algeria you could go to prison for ten years. He claimed there was no treatment available for drug addiction inside, and that some people committed suicide rather than face the conditions.
Muhammad went on to accuse the Algerian government of being involved in the drug trade, both to make money and to ensure that there were enough drugs to keep people obedient. As he spoke his voice grew louder, his gestures more violent, as if he were arguing with someone who refused to be convinced. But when his mood shifted, the change was total. He lay back, looking exhausted.
From there, we went to a gymnasium and watched two men in shorts and T-shirts breathe at various speeds. First, they breathed slowly, bringing their arms up, then down. Then they were told to take deeper, faster breaths, while their arms went up and down so fast it was like they were trying to fly.
The last stop on our tour was an interview with Doctor Nazaraliev, after whom the center was named, a bald, thickset man in his 50s whose heavy tan made him look like a wrestler returned from a cruise. Doctor Nazaraliev told me of his quest to understand the causes of drug addiction. In the 1990s he had traveled around the world to meet drug dealers, addicts, police, and politicians. "I was in situations where I could have been murdered," he said, laughing.
His conclusion was that although social conditions, like poverty or unemployment, play a role in triggering drug abuse, individual psychology is of more importance. "It doesn’t matter if a person is poor or rich. If a person has an inferiority complex, is not a whole person, then there is a lack of spirituality. Their substitute for this is drugs, alcohol... some perversions.”
I asked if he thought it would be good to legalize some drugs: "Yes, but you must be very selective with this. Western people have gone through 500 years of personal development, and in those countries some drugs can be legalized—anything up to heroin. But in other countries, who reason on a collective basis, Latin America, Africa, post-Soviet countries, they don’t get the difference between light and hard drugs. Genetically, they are disorganized. If you legalize heroin, the country will be destroyed."
Such a deterministic view seemed to contradict the center’s emphasis on individual agency. My skepticism must have been apparent, because the doctor reached for a pen and piece of paper. "The human psyche," he said, then drew a circle, "is divided into three parts. The conscious, the unconscious, and an upper consciousness. As Westerners, you live in the conscious, you’re very smart, but have no intuition or insight—no enlightenment."
He drew another circle. "Humans consist of three parts: the mental, the emotional, and the body. We Kyrgyz are nomads; we are only 10 percent mental. This is why we like to fight. And have sex. If you give Kyrgyz people a billion dollars, they will try to steal it or hide it." The thought seemed to delight him.
Ascending the Mountain of Salvation is the climax of the mindcrafting program. In Kyrgyz, the mountain is called Tashtar-Ata, which means "father of the stone." According to Batma, Tashtar was a hero who had fought in a war against evil using special stones. After winning the war, Tashtar lay down to rest forever. In the place where his heart stopped beating, a mountain grew.
The view from Tashtar-Ata
The holiest place on it is a thorn tree on the lower slopes. People tie strips of cloth to its branches to petition Tashtar to grant them health and fortune. Patients are encouraged to do the same; for them the act is said to be a means of "recharging with strong directives, vitality, and confidence for a brighter, better future, trying to cut away a past filled with evil."
The center’s use of this narrative of struggle and redemption is an inspired piece of therapeutic opportunism, but for those whose belief systems can’t accommodate shamanic ritual, there are Christian, Islamic, Buddhist, and Jewish sites higher up the mountain.
We began to climb; after ten minutes we saw the three-barred cross of the Russian Orthodox Church. It was on top of a wooden hut supported by a concrete arch; gilt-framed portraits of Jesus, the Virgin Mary, and Patriarch Kirill looked down benignly. It took longer to reach the next shrine, a tree festooned with Tibetan prayer flags. On the ground, flanked by golden cups, a small Buddha was contemplating a twig and a pebble.
"Let’s rest," said Batma, and I gratefully obliged. For several minutes I thought about the blood on Muhammad’s arm, the twitch of the man in the coma. I wondered if I was too rational. It occurred to me that "shame expander" would be a great name for a band. When I heard the flick of a lighter, I didn’t turn around. Only when a familiar smell reached me did I look behind. "It’s a J," she said and handed me the joint. We passed it between us until the lines of Bishkek seemed small in the landscape of hills.