In the framework of the 20th anniversary of EHRN we present a series of talks with people whose names and roles in harm reduction are well known. Throughout the year they will be sharing with us the most valuable things: their experiences, thoughts and memories.
Anya Sarang is the President of the Andrey Rylkov Foundation for Health and Social Justice. The Foundation was established in 2009 to promote and develop humane drug policy based on tolerance, protection of health, dignity and human rights. This interview was recorded during the First Regional Harm Reduction Conference for Central and Eastern Europe and Central Asia (CEECA), “Harm Reduction in the New Environment” (April 4-6, 2017, Vilnius).
How did you start your work in human rights defense?
In 1998 I started working with Medecins Sans Frontieres, in one of the first harm reduction programs in Moscow. We provided training to medical doctors, infectionists, drug treatment specialists and NGO representatives from all over Russia. These activities were supported by the Ministry of Health and the situation gave us a lot of hope. I remember us reading a newspaper which said, “50 HIV cases registered in Moscow”. And we thought that we'd train everyone and the epidemic would be stopped.
How many HIV cases are there now?
Over a million in all of Russia – these are just the registered cases. According to our research, only 25% of people know their status. So we may simply multiply by three-four, and the most conservative estimate is 2.5 million people.
And you thought you would solve this problem easily?
True, but we did have a chance! Nobody even knew anyone living with HIV. I had spent a year working there before one of our clients, a homeless guy, went to the AIDS Center to get tested. He turned out to be HIV positive and everyone was so surprised: “Can you believe it? Here's someone who really has HIV.” We talked and talked about it but we had never met such people. Today everyone knows someone who lives with HIV. The history of public health shows that if you start harm reduction programs early on you will avoid the epidemic. For instance, fewer than 2% of drug users in London have HIV. This isn't fantasy, it's a reality.
So what did you do?
By the end of the 90s there were dozens of organizations, AIDS Centers, drug clinics working on this – really conventional structures. Soros alone funded about 40 organizations. Gennady Onischenko (then chief physician) issued decrees on the need for harm reduction on an annual basis. Everyone was hoping this would become a mainstream healthcare activity.
Substitution therapy was the only problem. In 1998, they adopted a law on drugs which stated that drug dependent people could not be treated with narcotic drugs. Regardless of whether these were banned or controlled substances. This is a history of opposition to methadone programs. But everything related to needle exchange was not problematic at all. Only thing is, the government could never find money to fund it. It was like this, “If there are idiots willing to fund it, then let them fund it.”
It all changed in 2008. First, Tatiana Golikova (then Health Minister) spoke at an AIDS Conference and said that we didn't need the Global Fund's money anymore (The Global Fund to Fight AIDS, Tuberculosis and Malaria). We would invest our own money. A year later, she spoke at a Security Council meeting and said that harm reduction was a horrible idea.
Why did that happen?
I'm not a political scientist or Golikova's psychoanalyst, but there are two issues at play. First, it became clear that we're against the West. Second, this isn't ARV procurement when one can make enough money from a procurement tender to build a cottage or a winery. The ARV drugs still cost as much as they do in Western Europe although the generic drugs are so much cheaper in our region. Why bother with syringes or methadone which is really cheap? Nobody's motivated to do that. For this, we need dedicated, motivated people.
Are there any such people?
There are people at the Ministry of Health who support harm reduction, for example, Larisa Dementieva. Or Vladimir Yegorov, formerly chief drug treatment specialist, he's a great guy. They are still working somewhere but nobody has seen or heard from them. Since 2009, the government has been reluctant to manage healthcare efficiently; this approach became their ideology. The West is pushing us to do this, we don't need this, it's dangerous. They included in the national drug strategy points on harm reduction and substitution therapy being threats to Russia's national security.
How did they proceed after Golikova's statements?
The Global Fund funding has run out. At the end they wanted to give us money for Tuberculosis prevention but the Ministry of Health prohibited that. Since this is ideology, mainstream organizations won't be doing this. After all these statements and prohibitions we created the Andrey Rylkov Foundation in Moscow. Without any permits we have been giving out syringes and condoms, doing outreach work, street social work, giving out brochures – all on a voluntary basis.
What does the government propose as an alternative to substitution therapy and harm reduction?
For example, giving out naltrexone instead of methadone. It was created by the Americans but research has shown it to be ineffective. Neither the US nor Europe are using it, but we don't have substitution therapy anyway! Apparently they're helping us and we're interested in buying it because it's expensive. It blocks opioid receptors; it's a methadone antagonist.
Can this conservative trend be felt in Russian society?
Each spring, there is an outburst of civic activism in Moscow. They go out looking for drug users near drugstores. These activists catch drug users and bring them to the police. There are many such activists.
Do you try to work with them somehow?
We try to flee!
You're fleeing work!
People from the Anti-Dealer movement came to the MediaUdar festival and sent a complaint to the police. Or another example, the City Without Drugs movement opened an office in Moscow. Its head said, “If I catch someone from the harm reduction movement, I'll break their arms and legs.” So we were really worried that he'd do that. But he got hooked on methadone and they closed their office. The guy who created City Without Drugs, Yevgeny Roizman, became an MP and made sure single allowed doses were reduced. As if the government wanted to legalize drugs. Roizman reminds me of an early 20th century politician, a prohibitionist. Now he is the Mayor of Yekaterinburg, busy opening McDonalds restaurants; he is clearly on a winning streak.
Are your clients helping you?
Almost all activists used to be harm reduction program clients. Our coordinators Maxim Malyshev and Arseniy Pavlovsky participated in one of the first harm reduction programs in Tver. So it seems like those programs helped develop a generation of civic activists, people ready to fight for the health of their community.
What do you see in the future?
We changed the format of this work. Working with policymakers is actually a losing strategy in our situation. People from the Drug Control Service, Ministry of Health, Research Center on Drugs, MPs began asking, “So where are you going to take us?” So they go to Toronto, see a methadone program and say, “It's great”. Then they come back and nothing changes. Golikova once told the UN High Commissioner for Human Rights that there was no proof of the effectiveness of substitution therapy worldwide. We sent her two boxes full of articles in Russian.
So have you stopped communicating with civil servants altogether?
They keep talking about dialogue and we have decided that it would be done through the justice system. We have sued the Drug Control Service, the government and Putin. We have four cases related to substitution therapy at the European Human Rights Court. The activists have been persecuted for their complaints: one got fired, another was sent to jail, yet another was detained for alleged smuggling. They are real heroes.
Now it's important for us to join the global movement for drug policy reforms, to work on structural changes, to fight prohibition, to abolish many of the Conventions. Our region isn't very active in this, and the Russian government, on the contrary, is quite active. They used to travel to all kinds of international events and mumble something but now they're attacking.
While the global trend is actually going in an opposite direction.
True. Recently in Vienna we did a side event at the UN Commission on Narcotic Drugs. Our region is the only region in the world where the number of HIV cases is growing. Russia is responsible for 80% of the new HIV cases. Last year, 8 HIV service organizations were acknowledged as foreign agents. They do not do anything themselves and do not let others do anything.
We have told everyone about this, and at the end a woman stood up and said, “I'm also from Russia. We have done great work on prevention. And civil society is fully included. We have naltrexone instead of methadone.” It turns out, she was from the Ministry of Foreign Affairs and now she goes to all international conferences. Recently she shot down an international resolution on drug user health. Apparently, it wasn't part of the WHO mandate but rather, the mandate of the Commission on Narcotic Drugs. Everyone is shocked by Russia's behavior.