When a tank is urgently needed to transport… methadone to hospitals

Author: Olya Belyaeva, Advocacy Manager, EHRA.

A tank is urgently needed! It doesn’t have to be a new one. The tank is needed to transport methadone to hospitals in Kazakhstan. Drug control authorities require paramilitary security for the transportation of drugs. However, the state is not going to allocate funds for security measures and this issue has not been resolved in 10 years.

Continue reading “When a tank is urgently needed to transport… methadone to hospitals”

The Magic Bracelet

Author: Olga Belyaeva, Advocacy Manager, EHRA

When I heard someone knocking on my hotel room’s door and shouting “She is dying!!!” I was in the bathroom. Just five minutes ago, I entered my room, took my coat and shoes off and… ran out straight away with Naloxone.

After that memorable meeting in Scotland, I carry it with me all the time.  

Glasgow. July 2018. My 45th birthday. “You know, we have a very serious problem with overdoses – those were almost the first words I heard from Stephen Malloy, part of the team of the European Network of People Who Use Drugs. I nodded and a routine though came across my mind: “Back at home, in Vilnius, up to 12 people are found dead in bad months. Under the guise of heroin, people are sold a mix of morphine and methadone together with fentanyl.”   

Looking at me attentively, Stephen went on: “My country has done very well with offering OST (methadone, buprenorphine) but everyone knows more MUST be done. People need easy access and doses that are suitable to them. There will be a small ‘Heroin Assisted Treatment’ program beginning in September 2019. and in time, if it is allowed to grow, it will change so many lives for the better; IT WILL SAVE LIVES.”

So here it is,” Stephen was holding an oblong narrow yellow box in his hand. “Are you ready to take it with you?”  I recognized it: once I saw such a box at a conference. It was convenient and stylish, with Naloxone inside. I said “Sure!” and took the box. “Then put this bracelet on. People will know that you have naloxone with you, if you overdose and they find you. They will be able to help you and you will be able to help others.”  Stephen watched me carefully, assessing my decision: was I really ready?

I put the bracelet on, found a place for the Naloxone box in my belt bag, where I already had my wallet, my phone and my beads. Then I continued my three-day work at the meetings on overdose response.

One of the meetings was dedicated to the topic of 48 hours after prison. There was a discussion with the experts in overdose theory on what should be done first: Naloxone injection and then artificial respiration or first artificial respiration and then Naloxone? My logic told me that first Naloxone is to be injected, which will help to ensure artificial respiration. “That’s a question of life, so it needs a correct answer. When I go to Ukraine, I will have to go and visit Vasiliy, he is an emergency doctor in the city of Dnepr. He saved my life more than once, so I believed him. He will tell what is to be done. He will also teach me how to do it,” I was thinking, packing my things to go to the EHRA headquarters in Vilnius.

Railway station. Stephen and Nicole’s birthday present – Scottish red and green check scarf – kept me warm. Standing at the platform, we gave each other goodbye hugs, listening to our heartbeats.  Making myself comfortable in my seat with a book, I realized that my eyes were constantly coming back to the yellow bracelet.  The sounds of the train, its rhythmic swing combined with polite and quiet travel companions – it all gave me a chance to think why it happened like this: I had 30 years of opoiod use behind me, but Naloxone became part of the things I always consciously carry with me only three days ago.

Why? With the daily use of opiates, which were cooked correctly using high-quality materials, overdoses were rare in our group. Usually they happened after the forced “treatments.” Since about 2005, if you hear someone had an overdose in Dnepr (Ukraine), the response would be: “He was lucky to survive.” Naloxone ampules were available in mobile clinics and from outreach workers since 2003. However, it was the first time in my life when I wore a bracelet saying “I have Naloxone.” We always tried to avoid carrying Naloxone ampules with us so that the police would not start working on us because of it: “Hey, Naloxone, so you’re a drug addict!” Then the standard scenario would follow: taking a bribe and letting us go for a while. Another scenario could be turning the life of the person and the family upside down, if they needed to show better “crime detection rate.” Quietly and invisibly, the bracelet started raising my level of consciousness about overdoses.  It became a part of me. I only take it off when I have my aikido practice. The rest of the time, I have the bracelet on my arm, which means I have Naloxone in my bag and my bag – on my belt.

The approach to have Naloxone “always at hand” helped me to save a person’s life at the hotel. I covered three floors – and 40 seconds after I heard someone knocking on my door, Naloxone was already doing its work in the body and helped us to keep our dear friend alive. We did artificial respiration, poured water, and our team of two people + naloxone helped to save our friend’s life. We prayed for Stephen and Nicole. I realized that I do not have practical reanimation skills, which work automatically. At the same time, wearing a bracelet saying “I have Naloxone” means that I have to be 100% sure about the things I am doing. So I still had the question: what should come first – Naloxone or artificial respiration? My trip to Dnepr was not coming soon, but the question was vital. So we invited a practitioner, an emergency care doctor to come to the EHRA office, share his experience and tell us what to do.

“After death, pinned pupils are seen only in people who died of opiate overdose. Sometimes it can also be an effect of cerebral hemorrhage, but in this case one pupil is constricted and the other is not,” told us an emergency care doctor from Vilnius. That is how easy it is to collect data and see how many people actually die of opiate overdose, who those people and their family members are and what can be done. Those are the things to be done:

First, 70% of people die as they are not able to breathe. When a person is unconscious, his tongue base goes down and closes the air passages.  What to do: put your hand on the person’s forehead, throw the head a little back and put the jaw down. Often you will hear a deep breath.  There are three ways to determine if the person is breathing: eye, ear next to the person’s mouth and watching the person’s chest. With your eye, you will always feel the air moving, with your ears you will hear it and the chest will help you to see it. A person makes 14-16 breaths per minute. So we wait for 10-15 seconds to see if we can hear or feel the person breathing or see the chest moving.

Second, we must fill the lungs with oxygen. “While an amputated limb or finger can be stitched back to the body even after three hours, a brain cell left without oxygen for four minutes, dies and this process is irreversible.” We breathe in 21% of oxygen, breathe out – 17%. So that’s what we need to do straight away: hold the nose and carefully breathe the air into the person’s lungs twice. This air will be enough to save the brain so that we have four minutes to inject Naloxone and ensure artificial respiration.

Third, make an intramuscular injection of Naloxone.

Fourth, artificial respiration: we press the chest 30 times and let go, going 4-6 centimeters deep, while breathing. You can watch the practical learning session by the emergency care doctor.

…Summer 2019. “Thank you, Stephen. Girls from the Narcofeminist movement and your Naloxone saved my friend’s life. As for the bracelet, it is a magic one. It helped me realize that I need to develop my skills to help people in different overdose scenarios.” When we met at the Harm Reduction International conference in Porto, we hugged each other tightly, not letting go for a while. 

Besides, I realized that consciousness means personal responsibility in action. People in our countries cannot carry Naloxone safely as they may have problems with police. Considering this, talented Sergey Bessonov and Dima Shvets came up with a way of how to make boxes and Naloxone packs, which are convenient to keep in a glove compartment in a car or at home. There is even an “excise label” to store the box until there is an emergency. They make those boxes for people, with love and understanding. They are stylish, nicely sized and pleasant to hold. Such boxes are made in the social dormitory of Ranar Charitable Foundation in Kyrgyzstan.

The yellow box, which came to me from Scotland, has already renewed its stock of Naloxone and now has other helpful things as well. The last thing I got from a friend of mine were tablets, which help in case of MDMA overdose.  In the center, there is a syringe with Naloxone. 

If someone needs help, I am ready.

“90% of successful reanimations are the ones when someone did something,” says the emergency care doctor.

 August 30-31, 2019

Kestutis Butkus: “The most important thing for me is not the decision of the Lithuanian court or the ECHR, but the fact that my case resulted in the passing of a law on the provision of OST in Lithuanian prisons. This is a real victory. Our common advocacy driving force.”

EHRA presents a series of conversations with people whose names and roles in harm reduction are well known in the region of Central and Eastern Europe and Central Asia, and beyond. They will share with us the most valuable – their experiences, thoughts, memories.

Kestutis Butkus is a well-known activist, one of the first from the community of people, who use drugs in Lithuania. 8 years ago, his right to health was violated by non-provision of opioid substitution treatment (OST) in prison (at that time, Lithuania remained one of the few EU countries where OST was inaccessible to people in prisons). Kestutis chose the path of struggle against the system and not because of, but rather in spite of, became one of the few (alas), who managed to influence the Law. Since 2018, opioid substitution therapy has been introduced in Lithuanian prisons, but we need to remember – this is only the beginning of a long way*

– What were the circumstances of your arrest in 2011?

– Eight years ago, police “apprehended” me by accident – they found a couple of grams of marijuana in the car. I had several outstanding fines at that time and the judge decided to sentence me to forty-five days in detention so that I would fully comprehend my crime. “Let him lie down and think,” she said. At the trial, I mentioned the methadone program, as I had been receiving substitution therapy for ten consecutive years, to which the judge’s reaction was: “This is outside our competence”.

– Wow. Did you agree with that ruling?

– I appealed, but my appeal was prepared by a person without a license (it used to be possible to do it that way) and then I was put on the wanted list. I didn’t know anything about it. Then one day I came to the migration services to collect my passport. First, they locked me in a room, then a convoy arrived and escorted me to prison. First to pre-trial detention, then to Lukiškės (a prison in Vilnius – comment by EHRA). During all that time no one really explained anything to me. I started writing letters – asking “what for”? There was no answer. Then I found out that those were the forty-five days of detention. It turned out nobody actually read my appeal, they didn’t even consider it. The court ruling came into force, which meant I had to be in prison.

On the first day of the detention, a doctor came to examine me, and I asked for methadone. The doctor, whose name was Mendelevich, said: “You’ll find it very hard – we don’t have a program here. I can only transfer you to the prison hospital, but everything is the same there, except that the ward is more spacious, and smoking is forbidden. You still won’t get methadone though, I can only prescribe “cockroaches”.

– What is it?

– We call light psychotropic substances “cockroaches”. They’re prescribed to everyone so that people can withstand imprisonment, but they have nothing to do with substitution therapy. I began to write appeals, requests, but there was no response.

– Do you remember the prison conditions well?

– Lukiškės is an old prison, it was built in the XIX century. At that time, it was considered one of the most modern in the Russian Empire (at that time most of Lithuania was under the Russian rule — comment by EHRA). These days however it falls short of the standards provided at similar institutions in the European Union. The cells are cramped, for four, there is a table, a washbasin and a toilet. Restriction of freedom is in itself a terrible thing, and those conditions make it simply indescribable. The first eight days were awful. I couldn’t sleep, I started suffering from claustrophobia, though I never had it before. I only managed to get through those moments because I could see a piece of the sky and some rooftops through the bars on the window. I was also lucky to have just one other inmate in my cell, not three (my neighbour was also from the community, by the way, but by that time he had gone through withdrawal).

– Did you spend your entire detention in Lukiškės?

– After eight days I was transferred to another prison – Provinishki (80 km from Vilnius – comment by EHRA). Once there I also immediately mentioned that I was on substitution therapy. The doctor’s answer was: “Don’t complain about your addiction. It’s dissoluteness, not illness.” I understood everything… I said: “I don’t need anything. Just prescribe me some aspirin to thin the blood” (I have a heart valve). They gave it to me, along with “cockroaches”. I was left in a one-person cell for fourteen days. All by myself, having bouts of insomnia…

– Did anyone know you were in prison without access to methadone? Were you allowed to have visitors?

– I was allowed to see a lawyer for the first time in Proviniski – my ex-wife contacted Emilis Subata (Dr. Emilis Subata, Director of the Vilnius Center for Addictive Disorders). He in turn contacted the “I Can Live” Coalition (Vilnius, Lithuania), as I was their member. They managed to hire legal protection for me. Then we thought that this incident could set the wheels in motion for the introduction of OST in Lithuanian prisons. At that time, civil society had been trying unsuccessfully for more than ten years to discuss the matter with the prison department of the Ministry of Justice.

– What measures did the solicitor take?

– He prepared a petition to the prison authorities demanding that they provide me with methadone and requesting a written reply. As a result, a psychiatrist came to see me … (Interestingly, it was only then that I learned that such a specialist was available in prison). He began to reason with me. I said: “Don’t talk, give me a letter.” It was exactly that that acted as a “catalyst” for the whole process. When I was released forty-five days later, the Coalition’s human rights lawyers read the prison’s reply and confirmed that it could be used to refer the case to court, and that we had a chance to overhaul the system. As for my condition… I couldn’t return to the substitution program for a year after my release. I thought I had dealt with withdrawal and that I was able to pull through but I was wrong. I often left the city to see my friends or went to the forest — I didn’t want my daughter (she was still a teenager then) to see what was happening to her dad.

– When did you manage to become stable?

– It was only after a year that I was able to return to the program. That’s when my “marathon” started. First, we went to the local court – they ruled against me. Then we went to the district court, then to the Appeals court – with the same result. Six years later we reached the Supreme Court.

What was the ruling?

– Same as before. That’s why we wrote to Strasbourg, to the European Court of Human Rights (ECHR). The court looked into our case, registered it with a number and accepted it for consideration. The ECHR works according to the following procedure: there are two Chambers. The first one determines whether all opportunities have been exhausted at the national level (in our case it was a yes). And if so, transfers the case to the second Chamber. As soon as that happened, the Lithuanian State literally “woke up” – representatives of the Ministry of Justice, the management of the two prisons I had been in, and the Ministry of Health. Six years on, the Ministry of Health suddenly “remembered” that they had a damage recovery commission, which was to be contacted no later than two weeks after an incident. Of course, I had not contacted the commission. I filed an appeal to the Supreme Court of Lithuania for a retrial based on that fact. It stalled the whole process.

– What was the reaction in Strasburg?

– The ECHR wrote to my lawyers asking what was going on. Lawyers reported that the Ministry of Health had taken the case to court. Upon learning that Strasbourg suspended the case pending clarification.

– Circles of Hell all round…

– Another year went by. In 2018, the Supreme Court acknowledged that I was the injured party. The damage caused to me was estimated… at three hundred euros, plus a bit more for the lawyers and redress – the court admitted I had been right. We appealed those three hundred euros – the court added another thousand on top and just over a thousand for my defence. However, after talking to my lawyers, I decided not to stop there and filed an appeal to Strasbourg over other violations – conditions of detention, standards of hygiene and size of the cell. In the West, such conditions constitute torture.

Last summer, Strasbourg accepted my case. Based on international case law, the lawyers requested thirty-five thousand euros in compensation. And I want to add – that is not a huge amount. There were similar cases in Poland and the UK, where the compensation was about a hundred thousand or more.

– If ECHR rules in your favour, who’s going to be liable for compensation?

– The state. To be more precise – the Justice Ministry. The most important thing for me however is not the decision of the Lithuanian court or the ECHR, but the fact that my case resulted in the passing of a law on the provision of OST in Lithuanian prisons. This is a real victory. Our common advocacy driving force.

– That is, from now on, if someone in need of methadone is put in jail, they’re going to get it there?

– In prison, remand prison, temporary detention facility – everywhere. The law applies to anyone detained for two or more days. There is a catch though. Only those who are officially enrolled on the OST program can receive methadone. We won’t leave it as it is though – the community is putting pressure on the prison department writing letters asking to amend the law and I hope we will be heard.

– Why do you think it took the prison department years to resolve the issue of access to life-saving treatment in prisons? Ruining hundreds of lives along the way – of those who didn’t dare to stand up to the system. Was it money?

– The prison department have a healthcare department within it. And the healthcare department thought that introducing OST in prisons was a very complicated and costly process. They argued that they needed millions to do it. I remember another argument of theirs – where would they keep methadone in prison, it requires special storage conditions! Where else if not in prison! What could be easier than designating a room and installing a methadone dispenser! Implementing the program did not require any significant funds. Who knows though, maybe the prison department just wanted to get some extra money from the Justice Ministry? They are like a state within a state, aren’t they – they report to it but at the same time are independent. They even have their own special internal system, ranks and epaulets.

– It’s like an iceberg then – you can see the reasons that are at the top, that’s 10 per cent, but there are more issues underwater which account for the remaining 90 per cent of barriers.

– I’ll give you another example. They opened the so-called rehabilitation centre for drug users at a prison in Alytus (town in Lithuania – comment by EHRA.) They constructed a building for it especially, furnished it with everything new. Guess who’s moved in there? The entire bunch of the prison’s top dogs, inmates who have nothing to do with the rehabilitation program. Furthermore, they were selling drugs from there for a few years. You think the prison authorities didn’t know that? After all, it’s no secret that drugs are available in prisons at crazy prices. How could such amounts of drugs filter their way into institutions without some help on the inside, from the staff? –

The introduction of the methadone program has slashed the numbers of paying “clientele”. Therefore, my answer about the reason for such a disastrous delay in the implementation of OST in prisons sounds simple – “not profitable.” And I’m happy that my case managed to break the deadlock.

* – According to the Report by the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment (CPT) from 2018: “…at Alytus, Marijampolė and Pravieniškės Prisons… Opioid substitution treatment was still not available in prisons visited. As in the past, methadone maintenance treatment was continued for persons in police custody but discontinued after their transfer to a prison. Further, there was still nothing on offer in terms of harm reduction, such as a syringe and needle exchange, distribution of condoms, etc.” //rm.coe.int/168095212f

 

The future is intersectional

Author: Maria Plotko, Program Officer, EHRA

Over the last few months, two important conferences on drug policy and harm reduction took place in Europe: activists were sharing best practices and tools at the International Harm Reduction Conference in Porto, whereas researchers were presenting their findings at the  annual conference of the International Society for the Study of Drug Policy in Paris. The two conferences shared the topic but crucially did not form joint advocacy efforts. What drug policy movement needs now is to connect these two worlds. Here are my highlights from both conferences.

  • Porto

The past Harm Reduction conference like probably always was the place where every person is not just tolerated but welcomed with a warm hug. Coming from Russia, where harm reduction is not really a mainstream,  it felt like a huge opposition gathering. The topics I followed were drug policy, human rights and providing funding for harm reduction. 

In accordance with the slogan of the conference — “people before politics” — quite a lot was said about human rights. We, as a society, tend to blame individuals and trust the system to fix them, but it is in fact more fair to blame the system and the state, and give individuals the tools and autonomy to change it. Changing the existing drug policies is a political process, as well as citizen discussion, so  we need to use the existing mechanisms to push the governments further. For example, professor Rodrigo Uprimny who is also one of the members of the UN Committee on Economic, Social and Cultural rights spoke about the “Berlin wall” between Geneva as the home of human rights and Vienna as the host of the Commission on Narcotic Drugs. “We should build the bridge and make drug policy a human rights issue,” he said. The first step was done by the Chief Executives Board of the 31 UN agencies which, right before CND, adopted a common position on drug policy that endorsed decriminalisation of possession and use of drugs.

As Nanna Gotfredsen from the Danish Street Lawyers said in her talk, by documenting the harm caused by repressive drug policies we can easily show what putting politics before people means. If only we could do the same with stigma and discrimination that these policies entail. People who use drugs are criminalized, stalked by the police, and at the same time have a hard time accessing legal aid almost everywhere in the world. There was a special session at the conference aimed at discussing the practices of paralawyers, or street lawyers, as a solution to this issue. Such programs of peer help to victims of human rights violations or violence  have been implemented in Denmark, Indonesia, and Russia, among others, and they were proven to be effective even in such severe circumstances as in the case of the Philippines.

For people coming from countries with draconian drug policies, like myself, the Portugese officials said a lot of groundbreaking things like ”criminal justice is never good for issues related to drug use” coming from the police representative or everyones favorite from a member of parliament Ricardo Baptista-Leite ”harm reduction and love have one thing in common they both should be unconditional”. To get to the world with a human-rights-based drug policy, we should encourage politicians to meet with people who use drugs, and, more generally, make people living at the margins of the community visible to the community and be helpful not only to people who use drugs but also to politicians and the police, ”allow them to take credit and praise them.”

  • Paris

A month later, another drug policy conference took place in Paris, this time bringing together scholars from all over the world. It was the 13th annual conference of the International Society for the Study of Drug Policy. For EHRA, this was the first time attending such a gathering.  Most of the speakers there were from the UK and the United States, some were representing Africa and Latin America. Our CEECA region was severely underrepresented at the conference, as I remember only two presentations covering Poland and the Baltic states (one of which was mine),  an done talk concerning a comparative analysis of drug policies in Germany and Azerbaijan.

Due to the growing number of countries which have legalized cannabis for medical and/or recreational use, the number of presentations on various issues related to this vast topic was enough to spend three whole days listening only about it. At the opening of this conference Anne Souyris, the Deputy Mayor of Paris for Health, said: ”We always wait for dramatic health events to implement harm reduction. In order to be effective, drug policy should be flexible and adaptable. We should do it on the go, start small and then structure if necessary.” But even if the government is pro-active, the role of civil society is to keep the topic on the agenda, to work with the government, and make the law better. In Uruguay, before the legalization of cannabis, over 60% of people were against it at the beginning. The president administration initiated the reforms in order to fight against drug trafficking, not necessarily for the benefit of the people or in the name of human rights, and the adopted legislation would have never been as we see it today if it wasn’t for the activists.

All the relevant arguments that we as advocates and harm reduction practitioners need were represented there: the efficiency of drug consumption rooms, the importance of decriminalization and depenalization, legalization of cannabis, and sensible policing. There was an interesting presentation which concerned an analysis of all publications on decriminalization which revealed that prevalence of use is taken to be the dominant indicator of drug policy success. As a result, it seems that countries pass the laws for one reason, and then evaluate a totally different thing.

Due to “insufficient methodological tools to conduct community-based research,” community involvement in the research was presented as a new trend. The reasons why researchers ‘should’ collaborate with peers listed on one of the slides were:

  • Utilitarian: increasingly, funders require it
  • Ethical: peers have the right to be involved in any publicly-funded research that may affect their health status or the services that they receive
  • Epistemological: peers have first-hand knowledge of the issues under consideration
  • Consequentialist: collaboration has the potential to improve the quality, relevance and impact of the research

Whereas HR2019 was filled with people from the community, harm reduction practitioners and advocates, this conference was almost pure science. At the end of each presentation, I was hoping to hear something about how that piece of research was used in policy making, and what was the reaction of the government, health professionals, or any other relevant stakeholders. However, strangely, most of the time presenters did not say a word about the next steps and policy implications that followed from their research, or how it was used in advocacy, or to what extent it was effective. Also, the presenters did not explain the reasons why they had decided to pursue this topic in the first place.

 

To conclude, the two conferences got me into thinking about why although they shared the messages and general conceptual frameworks, they did not share the audience. Stigma related to drugs is divisive even for people who use drugs, one can see the split between “bad drugs” and “good drugs”, for example,  socially acceptable upper-class party use contrasted with “those people in the street we have nothing to do with.” We see separate conferences for harm reduction, psychedelic, cannabis and ayahuasca users, cultivators, scientists and activists, doctors and police, palliative care and access to pain management.  Repressive drug policies affect the quality of life and safety of every person, and can be used as a way of controlling the population and implementing political repressions just the way we recently saw in Russia or like we see it happening every day in the Philippines. We have a common enemy — repressive drug policies. We need to join our forces and create an intersectional drug policy movement.

The impact of the Global Fund’s Eligibility Policy on the sustainability of the results of the last Global Fund HIV grant for Russia

Author: Ivan Varentsov, Sustainability and Transition Advisor, EHRA

The blog prepared on the basis of the presentation provided by the author on 29 April at the major session of the main program of the International Harm Reduction Conference, which was held in Porto from 28 April to 01 May, 2019

The situation with HIV in Russia is awful and here are some facts in support of this statement:

  • EECA is the only region in the world where the HIV epidemic continues to grow (UNAIDS, 2017)
  • Russia is home to 70% of people living with HIV in the region (UNAIDS, 2018)
  • The highest rates of newly diagnosed cases of HIV for 2017 were observed in the Russian Federation (71.1 per 100 000 population) (WHO 2018)
  • Russia and Ukraine contributed 75% of all cases in the WHO European Region and 92% of cases in the East (WHO 2018)
  • Results of the 2017 IBBS conducted in seven cities of Russia[1]:
    • 48,1 – 75,2% HIV prevalence among people who inject drugs (PWID),
    • 7,1 – 22,8% among men who have sex with men (MSM), and
    • 2,3-15.0% among sex workers (SW).
  • About 70% of all HIV cases in Russia are associated with the use of injecting drugs
  • More than 1 306 109HIV cases have been registered as of 1st November 2018 (Federal AIDS Center)
  • Coverage of PLWH by HIV treatment was about 42% in 2018[2]

To summarize: for many years there has been a concentrated epidemic among people who use drugs, sex workers and MSM in Russia with parenteral transmission being the predominant way of HIV spreading (42% of new cases in 2018). At the same time the government doesn’t support the implementation of prevention programs including harm reduction ones even at the minimum required scale.

Russia’s Global Fund eligibility context

Russia is an Upper-middle income country with high HIV disease burden, a member of G-20. It’s not on the Organization for Economic Co-operation and Development’s (OECD) Development Assistance Committee (DAC) List of Official Development Assistance (ODA) recipients. Normally this means that a country would not be eligible for any GF HIV funding. But there is a provision in the GF eligibility policy formerly known as “NGO rule”. According to this provision “Upper-middle income countries meeting the disease burden criteria but that are not on the OECD-DAC List of ODA recipients, may be eligible for an allocation for HIV/AIDS to directly finance non-governmental and civil society organizations, if there are demonstrated barriers to providing funding for interventions for key populations, as supported by the country’s epidemiology.  Eligibility for funding under this provision will be assessed by the Secretariat as part of the decision-making process for allocations”.

According to the 2019 Global Fund Eligibility List[3] Russia may get an allocation for HIV component for the next 3 years if the GF Secretariat decides that such barriers exist in country.

GF vs Russia Background

Since being established, the Global Fund has invested more than 250 million USD within Round 3, Round 4 and Round 5 to support HIV and TB response in Russia.  Actually, the only grant ever provided within the NGO rule was given to Russia in 2014 and it ended in summer 2018. What was important about that grant is that it was a $12 million project developed, coordinated and implemented by civil society and communities without any governmental involvement. It actually achieved very good results against set targets and was rated B1, with eight out of ten indicators rated A1.

The program consisted of three intertwined major components:

  • HIV prevention service delivery for PWID, SW and MSM (17 PWID programs, 5 MSM, 5 SW and 12 additional programs being co-financed)
  • Strengthening of community systems (establishment and support of 4 Community Forums to ensure the engagement of key populations in the meaningful dialogue with the government at all levels)
  • removing legal barriers (including 20 small grants)

Taking into account the relatively small funding available within this grant it’s, of course, impossible to say if this project had any impact on the HIV epidemic in Russia, and it would be really strange for someone to expect this. But it was of major importance for communities’ mobilization and strengthening of their systems. And of course, one should not forget about all those people who, thanks to the program, had access to HIV prevention services in more than 20 cities.

Eligibility crisis

The implementation of the last HIV program in Russia funded by GF ended in summer 2018. Everyone would probably agree that it would make sense for the donor to try and sustain the achieved results and level of services provided within the project until at least the end of 2019 when it becomes clear whether Russia is going to get a new allocation from GF or not.

Actually, there’s even a special provision in the GF eligibility policy allowing countries whose disease components within the existing grants become ineligible, to receive up to one allocation of Transition Funding to support priority transition needs following the change in eligibility. That’s unless the reason for the change in eligibility is due to the country obtaining High Income status or becoming an OECD-DAC member. But Russia was considered as ineligible to receive any transition funding from the Global Fund to sustain the achievements of the HIV project.

Here’s the reason: after being ranked as high-income country by World Bank for a couple of years, Russia was downgraded to an upper-middle income country in 2016. But for the purposes of the Global Fund’s 2017 Eligibility it was still considered high-income and therefore not eligible. That happened because of another provision of the Global Fund’s Eligibility policy according to which a component which becomes newly eligible may receive an allocation only after being ruled eligible for two consecutive eligibility determinations.

Just to repeat – the country was not high-income, but it was considered as high-income retrospectively and just because of that was denied funding to sustain the achieved results of the latest HIV program.

Some implications of the Global Fund Eligibility Policy for sustainability of services provided by NGOs

Talking about the impact the above-mentioned Global Fund eligibility bureaucracy had on access of KAPs to prevention services in the cities covered by the project: in April 2019, out of the 23 NGOs implementing 27 HIV prevention projects within the last GF program, 20 were approached by the author with a short questionnaire and 12 responded. The organizations were asked about how the termination of the support available within the GF project has affected accessibility, coverage and financial sustainability of the services.

Accessibility of services:

  • 4 organizations managed to maintain the services but had to decrease the number of outreach workers, outreach visits and amount of hand-out materials purchased.
  • 3 organization mentioned that they stopped providing needles and syringes as they couldn’t afford to buy them with the governmental funding
  • 2 organizations mentioned that they continue providing outreach services but on a voluntary basis and will probably stop soon
  • 2 organizations stopped provision of outreach services at all
  • 1 NGO completely stopped its activities (in 2010 it received the Red Ribbon Award)

Coverage

  • All organizations mentioned the decrease in service coverage (between 0.2 and 18 times)

Funding

  • All organizations mentioned the decrease in funding available
  • Only 4 organizations managed to sustain the activities at a good level, all 4 due to the financial support from Elton John AIDS Foundation

Questions to GF and lessons to be learned

So, my big question to the Global Fund is – what was the point of abandoning everything that was achieved within the GF-funded 3-year project in 2018, when it’s highly likely that everything will have to be started from scratch in 2020? Isn’t it just a waste of money, time, efforts and lives of people affected by HIV?

I believe there is a lesson to be learned by the Global Fund: the Eligibility Policy’s requirement that a component meets eligibility criteria for two consecutive years should be changed if not abolished at all, as it’s inhumane and ineffective from an economic and epidemiological standpoint to wait for the second year to confirm if the country still has a ‘high’ disease burden or the same income status.

I do understand that now when Russia is considered a kind of global evil and that everyone is trying to impose sanctions on it, most donors have stopped the implementation of healthcare and other programs there. But donors should not mix up the country’s government and its people. People should come before politics and people who use drugs in Russia need your support as they don’t receive any from the government.

Taking into consideration all the factors about Russia such as its epidemiological situation with HIV, its geopolitical position, the migration flows in the region etc., – it should be clear that when planning a response to the HIV epidemic in EECA, the HIV situation in Russia must not be overlooked.

Failure to support the HIV response in Russia could jeopardize all efforts by donors and governments in neighboring countries to counteract the HIV epidemic there. One of the Global Fund’s major goals is to push for an end to the global HIV epidemic, and if it wants to achieve this goal in EECA it can’t neglect the HIV situation in Russia and avoid investing in it.

[1] //rylkov-fond.org/blog/health-care/hiv/ibbs/

[2] //medvestnik.ru/content/news/Ekspert-ohvat-lecheniem-VICh-inficirovannyh-sostavlyaet-ne-bolee-50.html?fbclid=IwAR3c_KOMBmojpQsde_75ZnPupZHrJr44EQ8uW_ECTuPanQJHGgN30grUvOw

[3] //eecaplatform.org/en/the-global-fund-eligibility-list-for-2019/

Special thanks to Jared Krauss/HRI and Steve Forrest/HRI for selected photos.

People Use Drugs. We Want To Know What Do We Use

Author: Eliza Kurcevic, Membership and Program Officer, EHRA

This year, during the International Harm Reduction Conference there was plenty discussions, workshops and exchanges of experiences about drug checking services. The more experienced organizations were speaking about the positive results of this harm reduction service, as well about the need to make it more accessible for people who use drugs, while organizations, which just started drug checking, were sharing the barriers and challenges they face while providing this service.

Continue reading “People Use Drugs. We Want To Know What Do We Use”

How are we doing? We’re summing up the first two years of “teal” self-government

Ganna Dovbakh, Executive Director of EHRA

It’s rare when you have a proper reason to tell how everything works inside the organization. You always praise the celebrant on their birthday and that is why today when it’s 2 years from the date of EHRA’s registration, I want to say a few words about us.

The first two years for us were the time of drafting new rules and looking for new approaches – both for our team and for me personally.

What is the added value of the regional network?

This question is usually the first to arise in all discussions, from discussing the development of a new project to information leaflets. Our members are doing national advocacy in their countries, while the regional organization becomes a source of new, unfamiliar, ways to achieve goals, learned from other countries or invented in a heated discussion of the team. We gathered together to invent and look at the world from a different perspective. That is why it is important to involve all members in the discussion. We strive to reach a consensus on the most important issues among 251 organizations and activists during our online meetings. I’m sure it would be perfect…

We come up with our ideas and then we think our common goals through and that is why the participants’ views are changing. For example, in 2018 we collectively developed the position of EHRA on drug policy, and even major experts in harm reduction discovered something new during the discussion. It has become clear to me that drug control is designed to fund law enforcement agencies and prisons. Money is the only indicator of national priorities. Drug policy does not exist separately from advocacy for sustainability of harm reduction services. We collected data to estimate criminalization costs and proved that those millions of dollars could have been spent on social services, which lack so much funding. How is it possible to convince decision-makers to spend these resources on the harm reduction services? We are still searching for the answer.

What do we really have in common? EHRA brings together both organizations of people who use drugs and organizations that provide and develop harm reduction services. We unite very different, sometimes even warring states: the EU members, the countries that want to join the EU and the countries of the Eurasian Customs Union. Despite visible differences, politicians regard the needs of people who use drugs in a similar way in all these different counties, and therefore our overall objectives remain the same.

The elections to the Steering Committee of EHRA were held in different sub-regions and within a community of people who use drugs in 2018. Our new SC is very diverse but their members are united in their vision of priorities, which can be observed in decisions they make – from the choice of strategic partners to the selection of project performers.

My heart filled with great pride when a member of the Steering Committee justified the decision of the Association on partnership to one of our international partners. It was clear that this decision was balanced, wise and unanimous. There wasn’t even a single thought that the Secretariat could compromise. That’s exactly why we have the Steering Committee, its main purpose is to make decisions. Democracy is a painstaking and time-consuming process. Activism requires resources and, most significantly, it requires time.  And here I would like to thank EHRA members and especially our SC for the efforts they made and the time they spent on the development of our organization.

How do you make a horizontal management structure effective?

The Secretariat is an executive structure, it consists of project managers. I think it’s foolish to gather a team of great experts while being unable to give them the opportunity to come up with ideas and make decisions. It’s impossible to know, understand and feel everything that 13 people understand, feel and know.

The management systems where each employee can invent something and influence decisions have different names. They were once called partnership management structures, horizontal structure, or “empowering” management. All these approaches have been recently united into the concept of “turquoise/teal teams”. I can’t say that our Secretariat is already turquoise but we’re learning.

Frédéric Laloux describes such organizations of the future as living organisms. They are notable for self-organization, integrity and evolutionary goals. Staff of such organizations perceive their companies as a living creature with a soul rather than a lifeless mechanism or machine, they think that their organizations are able to develop themselves without managerial control or fixed strategic annual plans. Teal companies have moved from “pyramid structure” to “teals”: from rigid hierarchical structures with supervisory control to distributed leadership and project teams. Employees are perceived as individuals rather than tools. One of the “teal” indicators which is so important for me is that it’s comfortable to work here for people who use various substances, people with children or pets. You definitely could recognize “therapy dogs” in our office from our posts on social networks.

The experience of these two years of our “dream team” shows that we are the most effective in actions which are developed and experienced by people. Only when staff believe in action with all their hearts, success could come.

Access to information for all is the most important thing to ensure if you want to implement the principle of involving every team member in daily management. Our mailing list makes it possible to discuss events and plans and is very helpful for me. Anyone from the team can write there to alarm others of problem we have and almost immediately get various solutions to it.  All Secretariat team members discuss and develop goals, not just the management. With knowledge of accessible information about the region and the situation in the countries and rooting for the common cause, people come up with the simplest and most effective solutions. Thus, the movement of drug feminists, our assessments and new projects were born. When each employee and member is provided with opportunities to create and implement their crazy ideas, then we are able to act “out of the box”. The next challenge is to try and fit it into the overall organizational strategy and inspire the donors with these ideas.  If we believe in it, we could prove and justify, then we will be able to involve even the most bureaucratic donors with the most abstract priorities.

How do you become an effective Executive Director of the “teal” team?

When we gather together a team of high-level professionals who are always in the information flow and maintain constant contact with countries, it’s absolutely possible for them to make key decisions in their areas. The role of the executive director is to align all the activities with the overall strategy and use the wisdom of compromise.

I once found a short description of the leader’s tasks: identify the environment for your team (the context in which we operate, the players and all the challenges we might face on our way), set goals and then tirelessly thank people for their ideas and day-to-day work. My task is to inspire the team to reach ambitious goals and connect all the different ideas and people. I also should be an expert on experts, gather partners and like-minded people.

Someone asked me if it is possible for an anarchist to become a director. It seems possible to me, if we are aware that we are all equal in the team and recognize the importance of each other.

There are a few simple rules that help me avoid mistakes every day. They might be useful for you:

– Answer emails and read documents. Reading key documents, calls for proposals and position papers should be included in your work plan, the same as you do with meetings. An outside perspective for our documents make the message clearer and help us get rid of excessive emotions and too much passion.

– Don’t make quick decisions, give yourself time. Sometimes in order to make a decision you have to walk a few kilometers or get a night of quiet sleep. If you don’t have enough information to make a decision, specify it and consult others.

– Every director should be responsible for supervision and staff development.  Avoid petulance and hasty judgements, as hard feelings wrench a creative spirit. And trust is inspiring.

We are only setting off on our interesting journey. We are strong when we are together!

The direct speech of Oksana Ibragimova at the 65 session of the CESCR

The direct speech of Oksana Ibragimova, Kazakhstan Union of People Living with HIV and the member of EHRA’s Steering Committee at the 65 session of the UN Committee on Economic, Social and Cultural Rights (*CESCR) meeting:

My name is Oksana Ibragimova, I represent the Kazakhstan Union of People Living with HIV. We work with the Eurasian Harm Reduction Association and the Canadian HIV / AIDS Legal Network. In my four-minute speech, I want to focus the attention of the Committee on the main problem that hinders the prevention of HIV infection among people who use drugs, including opioid substitution therapy.

I am talking about criminalization of drug use, including the criminalization of drug possession for personal use. Due to criminalization, the main focus of drug policy in Kazakhatsan is on law enforcement, and not on health care.

It is precisely because of the resistance of the law enforcement agencies that the substitution treatment program in Kazakhstan is threatened with closure. The repression of law enforcement against people who use drugs is responsible for the increased vulnerability of people who use drugs to HIV. More than 50% of new HIV cases occur due to the use of non-sterile equipment for injecting drug use.

In its responses to the Committee’s List of Questions, Kazakhstan indicated that it is the Ministry of the Interior that is responsible for drug prevention. “Preventive registry of drug users” is indicated in the responses as preventive measures. This is a measure by which people who seek medical care are denied in their rights. This registry is not only not conducive to drug prevention. It impedes the realization of the right to health. This is just one of the examples showing that the police structure is not able to engage in adequate prevention among young people and among the most vulnerable and socially marginalized groups of the population. An excessive focus on law enforcement and repressive drug control measures hinders HIV prevention and other health measures among people who use drugs.

Drug policy issues need to be passed from the hands of law enforcement to the hands of public health, public education, and social support systems for the most marginalized groups.

In this regard, in addition to the recommendations on substitution treatment, we ask the Committee to recommend to the Republic of Kazakhstan to change the repressive focus of drug policies in regard to people who use drugs and, in particular, to decriminalize drug possession without sales goal.

 

* – Established in 1985, CESCR is a UN human rights body consisting of 18 independent experts that monitor implementation of the International Covenant on Economic, Social and Cultural Rights by its States parties, which are obliged to submit regular reports to the Committee on how the rights are being implemented in their countries. The Committee’s rules allow for international, regional, and national organizations and human rights institutions to submit parallel reports with questions for governments in advance of the dialogue with the states.

“There are normal people, and there is me, and there is a difference”: voices of the women, who use drugs from Estonia at the 65 session of the CESCR*

In 2017 EHRA together with Canadian HIV/AIDS Legal Network and LUNEST submitted shadow report and presented it at the 62  Pre-sessional working group of the UN Committee on Economic, Social and Cultural Rights (CESCR*) meeting in April, 2018. The report was made based on the study conducted in Estonia in 2017.

In the result the following question was included to the list of issues and on February 18-20, 2019 representatives from EHRA, LUNEST and the Human Rights Clinic from Miami University School of Law joined the 65 session of the CESCR to speak about the human rights violations faced by women who use drugs in Estonia.

We share a direct speech from the Committee meeting – a Statement by NN**, a woman, who uses drugs from Estonia.

Hello, my name is [NN]. I represent LUNEST. I live in Estonia. I have been using drugs since I was 12. Today I have two children.

I want to tell you that people who use drugs are exposed to severe stigma from medical staff. Not only in general hospitals, but also in places which work specifically with people who use drugs. Once I was told by an opioid substitution treatment center staff that there are normal people, and there is me, and there is a difference. That OST is useless, that I will take methadone until my old age, and if I leave, I will for sure come back, as it has happened to many others, as this is not a treatment at all. Many OST workers think that they are distributing drugs. Such rhetoric and behavior are not permissible. It shows a complete lack of awareness of harm reduction among healthcare workers. Such behavior keeps a person away from resocialization, and her self-confidence falls. This can lead to relapse. The rhetoric of hate kills people.

In addition, attitude to personal data is extremely negligent. When I was 13, the police came to our school. They searched children, and some were taken away for drug testing. I was among them. Results of the drug testing should have been known only to parents, but eventually the entire school, every teacher, knew the results. No one has helped me. I was transferred to home education, I was isolated from others. Today the disclosure of personal data leads to the fact that the results of tests that are taken during substitution treatment, are known by social services that can take children away, and blackmail mothers. In addition, staff of substitution treatment centers can call the employer and tell where they call from. People living in the region with the highest unemployment rate in Estonia are losing their jobs. For example, a woman with a small baby recently lost her job that she liked a lot.

Every woman who uses drugs has experienced violence. In my case, I cause small scale health damage to a man while trying to protect myself. I defended myself from a strong man. The police was not interested in my case, and I had to go to hospital on my own and pay for medical examination to certify my injury. I was a woman who used drugs, and the “victim” was a man, obviously stronger than me? No! He was my husband. The police said that I should not fight for our child, because I am an unemployed drug addict, without my own apartment. By that time, I was fired after the employer had learnt that I had used drugs a long time ago. I was told that our daughter would stay with my husband anyway, if he wanted, and I would only get things worse.

In 2012, I was caught by police for drug checking right in the street when I was walking around the city. I haven’t been using drugs by then for five years, and drug test showed methadone along. But a police officer loudly said in the corridor full of people: “I am so tired of you, addicts”. I haven’t used drugs for many years, so I cried.

I have known about the punitive juvenile system since I was 13, and I have never seen anything except deception. No help even when I asked for it. We have no centers where a woman could undergo rehabilitation without leaving the children, but to leave a child in that system even for a while often means to lose a child forever. For example, there was a condition for a woman to leave the methadone program in order to restore custody over her child. Women who use drugs love their children, but I saw how they gave up. When they face violence, they have no place to ask for help, and I have nowhere to go too. No one gives information.

Today I am not even trying to defend my right to see my daughter because she was taken by my ex-husband. Because I know that this can lead to restriction or loss of my parental rights.

Women are afraid to ask for help, I’m not the only one.

Thank you for your attention, I will be happy to answer your questions.

 

* – Established in 1985, CESCR is a UN human rights body consisting of 18 independent experts that monitor implementation of the International Covenant on Economic, Social and Cultural Rights by its States parties, which are obliged to submit regular reports to the Committee on how the rights are being implemented in their countries. The Committee’s rules allow for international, regional, and national organizations and human rights institutions to submit parallel reports with questions for governments in advance of the dialogue with the states.

** – NN asked not to disclose her name because of the fear of prosecution and further discrimination in healthcare and social services settings. NN is also concerned that OST program staff’s attitude to her may be worsened in case of her name disclosure.

 

p.s. We are pleased to report that the session ended in a high note: two Committee members pressed the Estonian delegation on all the issues we had presented, including the separation of children, Estonia’s harsh drug policy, the lack of OST and ART access, and the needed to end de facto criminalization of drugs, among other issues.