Transcript Kaliningrad Policy - Temple University

Legal and Policy Barriers to Effective Health
Interventions among IDUs in Kaliningrad, Russia
Inna Vyshemirskaya (1), Alexander Koss (2), Victoria Osipenko (1), Olga
Burkhanova (3), Zita Lazzarini (4)(7), Scott Burris (5),(7), Patricia Case (6)
(1) Kaliningrad NGO Young Leaders Army, Russia (2) Immanuel Kant’s University of Russia, (3) Kaliningrad
NGO Help Now, Russia, (4) University of Connecticut Health Center, USA (5) Temple University Beasley School
of Law, USA (6) Fenway Community Health Center, USA (7) Center for Law and the Public’s Health at
Georgetown and Johns Hopkins Universities, USA
Issue: Kaliningrad region and city have one of the highest HIV prevalence rates in Russia. Despite the fact that the main
HIV transmission route in Kaliningrad is injection drug use, HIV prevention measures have not been targeted at IDUs.
The local health authorities have not supported health care interventions for IDUs. The NGO sector generally has been
too weak and unable to do so. Our research identified a set of interrelated legal, political, and social factors preventing
effective health interventions among IDUs in Kaliningrad.
Methods: Using a community-based action research method called Rapid Policy Assessment and Response (RPAR), a
research team guided by a Community Action Board collected written laws and policies, conducted 3 focus groups,
interviews with key informants including health care providers, lawyers, law enforcement representatives, NGO staff
(N=26) and injection drug users (N=14) to learn how the law, policies and their implementation influence health risks
among IDUs. The Kaliningrad RPAR was begun in March 2006; research was completed in December 2006.
RESULTS
Major routes of HIV transmission in Kaliningrad region in 1988-2005
0,9%
28,4%
70,2%
Injection drug use
Sexual contact
900
800
700
600
500
400
300
200
100
0
HIV prevalence per 100,000 inhabitants
684
548
482
322
281
60
20
1999
2000
1. Dominance of law enforcement authorities over other policy
actors
Russian law effectively gives the State Drug Control authorities
control over all activities dealing with IDUs. Russian law prohibits
“propaganda” (Criminal code, art.230) or “encouragement" (Federal
Law “On narcotic drugs and psychotropic substances”, art. 46) of
drug use. These laws could be interpreted to apply to public health
interventions aimed at IDUs. To avoid possible prosecution harm
reduction programs for drug users must be authorized by the health
authorities and the drug control authorities. In practice, the
Kaliningrad State Drug Control representatives will not approve
syringe exchange programs and take the position that any programs
conducted without their approval are illegal and prohibited. Health
authorities are unwilling to challenge the drug control agency. This
legal environment deters the willing and capable NGOs from doing
prevention work among IDUs.
832
615
374
121
2001
Kaliningrad Region
Mother-to-child transmission
770
738
418
187
2002
Kaliningrad
494
456
202
195
2003
540
231
2004
2005
Russia
“Harm reduction is impossible here as it’s
considered to be drug use encouragement
followed by criminal liability… there is a
specific article on that …for syringe
exchange. It can only be possible, if
approved by the drug control service and
local authorities” - Employee of the drug
control service
“The work with drug users should
definitely be done, but it mustn’t
encourage drug use. Syringe exchange
program isn’t needed. … Our attitude to
harm reduction programs is exclusively
negative. It’s the standpoint of our
service” - Employee of the drug control
service
“Best Practices” for HIV prevention among IDU and their availability in the Kaliningrad region
Counseling and testing programs targeted especially to high risk groups
None
Street outreach education programs
None
Harm reduction (NEP, etc.)
None
Detoxification programs
Available – 20 free places
Substitution therapy
None
Rehabilitation programs
Available – 4 centers with 100 chargeable places
“NA” or other 12-Step Groups
Available – attended by very few people
Number of IDUs in the Kaliningrad region (01.01.2006)
2,360 – officially registered IDUs
1,010 – IDUs, who have undergone anonymous treatment
23,000 – actual number of drug users including IDUs estimated by experts
2. Dominance of the abstinence model in health care and social welfare
State-sponsored drug treatment is based on detoxification and abstinence.
Methadone is illegal and harm minimization approaches are mistrusted or opposed
by health authorities and the narcological establishment in Kaliningrad. Few NGOs
work with IDUs and most of these focus on abstinence (targeted support to
particular IDU/CSW or rehabilitation work aimed at complete abstinence). Despite
the high level of HIV, neither state health authorities nor NGOs have any special HIV
prevention programs for IDUs in Kaliningrad. The staff of public health and social
welfare institutions serving IDUs (for drug treatment) are not entrusted with
responsibility for IDUs’ overall health. The majority of health, social welfare and
NGO specialists working with IDUs are not aware of, or ill-informed about, a harm
reduction approach. They neither realize the need for, nor are capable of, working
on health risk reduction. As a result, IDUs do not receive health risks reduction
assistance.
“In our country the treatment of many patients is not funded.
Do we have any special programs for people with diabetes,
cancer, etc.? First, normal people should be treated and
helped and only after that those other ones” – Doctor from the
emergency medical care
“Show me one recovered drug user, just one. Why should we
treat them? To spend money for them to resume drug use
afterwards? …I was always saying, and I am saying again:
there are no ex-drug users” – Junior doctor from the emergency
medical care
“…I am still pained when thinking: why I didn’t have this
knowledge before…I stopped believing that it’s possible to
get out of it. I thought that everything was lost. You know, you
make couple attempts and you see that it’s hopeless, so you
stop struggling and just go with the flow. … While using
drugs every user needs to know, that there are people who
managed to get out of it. They need to know positive
examples” – Former IDU, now an NGO member working with
IDUs and HIV+ people
”I work at the hospital for
quite some years, and this is
the first time for me to realize
that we should carry out work
on health risks. Until now we
are concentrating on turning
them to sobriety. These drug
users here in the hospital,
they come back here all the
time … and we continue
talking about sobriety to
them…” – Staff member of the
narcological facility
3. Stigma and scarce resources
We found that stigma exacerbates the lack of
services for IDUs in an environment in which public
health and social welfare programs of all kinds are
underfunded. Informants repeatedly opined that it
was wrong to spend money caring for IDUs or
preventing diseases among them, when other
“innocent” people do not receive the services they
needed. The widespread social stereotype that
drug use is incurable negatively impacts both the
quality of services for IDUs and IDUs’ attitudes
towards drug treatment. Staff of public health and
social welfare institutions serving IDUs do not
believe that drug users can recover and therefore
they are discouraged. This negative stereotype
and lack of positive role models of recovered IDUs
leads other IDUs to feelings of futility and
hopelessness and they stop trying to seek a way
out of drug use.
Conclusions: The complete absence of effective interventions for IDUs in Kaliningrad leaves IDUs in despair and
endangers public health. Prospects for improvement depend on:
• Developing actors able to challenge stigma and the abstinence model, and to advocate urgently for the drug control,
health authorities, and NGOs to take prevention measures targeted at IDUs;
• Nurturing the ability of those actors to raise funds and empower grass-root activities aimed at vulnerable populations;
• Building cooperative relationships with authorities and staff of public health and social welfare institutions serving IDUs.
Since a harm reduction approach (especially NEP) is rigorously opposed in Kaliningrad we strongly encourage donor
organizations to support projects that include not only NEP but also other activities aimed at health interventions.
This research was supported by NIDA/NIH Grant # 5 R01 DA17002-02 PI: LAZZARINI, ZITA . The findings and conclusions expressed are
those of the authors and not necessarily of NIH, NIDA, or the US Government.
NGO “YLA”,
Kaliningrad