Chapter one: mangoes change their skin
The night before my trip to India my colleagues shared their stories. Everyone was amazed at the country’s uniqueness and diversity of culture and religion. I listened to my friends and memorised everyday basics: I shouldn’t eat or drink anywhere and must buy anti-diarrheal and anti-mosquito medicines.
Day of arrival:
Nobody from our Tajik delegation has arrived yet. I went to a restaurant at the hotel and had breakfast. Waited for my body to have some sort of a reaction but nothing happened. Then I went outside into what felt like an incense-filled sauna. I went into a shop and bought a few big, yellow and expensive mangoes. The vendor, who looked about 25 and had a kind and trustworthy smile, talked to me about the relations between Russia and Ukraine, and offered me some home-made mango ice cream. I said I really wanted to try it but I was afraid, as I was told I shouldn’t eat anything anywhere. The guy laughed and explained that tourists shouldn’t buy anything from street stalls but shops and cafes mostly use clean drinking water, so it's safe. We agreed that I would come back for it in a couple of days, when I stop worrying about that safe trip advice that I had had. Back at the hotel, I washed the mango in boiling water. The fruit lost its initial good looks, went all wrinkly and grey, but remained delicious.
After satisfying the physical hunger, I went to a place of worship and meditation for people of all religions - the Lotus temple. Delhi’s underground is very clean and modern. The first train cars are for women. There are information leaflets everywhere about a special police line for women, staffed with female police officers. I took a ride in a general car and in the ladies’ car. I was equally comfortable. The only difference is that there’s more reason for smiles and joy in the ladies’ car: I watched little girls aged about two or three: dark curly hair, wearing three to five bracelets on each arm with golden-coloured skin, and large wide open eyes wearing black eyeliner. "It's to protect from the evil eye," the locals explained.
The road to the Lotus temple was a challenge. For many in Delhi, a rag stretched on four sticks dug into the ground is premium housing. It took about ten minutes to pass through a market selling incenses, toys and jewellery. I tread carefully trying not to step on a plate or someone’s clothes as people are sitting on the ground everywhere. Children, women with children and elderly people are begging for money. I remembered another warning – don’t give money to anybody because if you do they’ll follow you for your whole stay in India. And it will be more and more difficult to refuse.” So I tried not to look in the eyes of people who were sitting on the ground so as not to give them false hope.
Chapter two: Population 1,5 billion, speaking almost 500 different languages. How do people live, what do they consume?
I’m thinking “How can they manage harm reduction programs with so many people when there’s so many people in the country, where the language, people's habits, religion and food change every 100 kilometres. When I was in Ukraine I often heard that Georgia was able to reform its drug policy because the population is smaller. And here in India, there’s lots and lots of people. And they managed to set up harm reduction programs so that they are worth admiring and learning from.
On day one of the internship I immediately asked myself: how does the community work, what is the drug policy in this country? How do people live, what do they consume? The HIV Alliance staff know the answers and I will tell you what impressed me the most.
India’s drug policy
In India, a policeman can stop anyone on the street on suspicion. For example, the police can turn up at a party and pick whoever they "like" and run tests for psychoactive substances (PS). Th Regulatory Act of 1995 regulates this policing technique. The consumption and posession of PS results in punishment: if a drug is found in the blood, for example, and you smoked marijuana, then the penalty is the same as for posessing small doses: one year in prison or a fine equivalent to 150 euros. If the suspect still has PS in his pocket, he will be taken to court. Any person in court can request treatment and the court's duty is to establish whether that person is addicted and what treatment to prescribe. Treatment is an opioid substitution therapy program that is low-threshold and affordable or rehabilitation (I don‘t know more about the rehabilitation programs, I‘ll tell you more about OST).
This approach - treatment instead of punishment - works only if the quantity found on the suspect qualifies as a small dose (heroin - up to 5 grams, opium 25 grams, cocaine or amphetamine - 2 grams, charas (hashish) - 100 grams and ganja (cannabis in cones) - up to 1 kg).How is that small doses, you'll say? I thought so. There is not much good quality heroin available on the street, only the so-called brown sugar, which is expensive and has the minimum effect, so people mostly use Buprenorphine or prescription drugs. It’s still a mystery to me why don’t they just join the legal OST programs, I’ve never seen a lower threshold anywhere. All OST patients can drive to make a living in India, there no prohibitions or permission needed in this regard.
Opioid substitution therapy (OST) in India began in the late 90s, but only with buprenorphine, as methadone was excluded from the list of essential medicines. In 2014, the government adopted an amendment to the Drugs and Psychoactive Substances Act of 1985, which made syringe exchange programs and OST legal. But even then there was a problem - police in the states weren’t informed about this amendment. Outreach workers are harassed throughout the country; police constantly tail them to find people who use drugs. Yes, there are advocacy and information programs targeting the authorities, but in practice everyone recognizes that the situation is far from ideal. Interestingly, the staff of India HIV/AIDS Alliance and their partners in the government don’t use the term "advocacy", they say "sensitization" instead.
The situation is quite difficult in prisons, too: there are HIV prevention programs, but substitution therapy with buprenorphine is only available in one prison. And even then, it’s still a pilot project (the evaluation of its effectiveness has been ongoing since 2008).
Hepatitis C. At the time of the internship neither the diagnosis nor treatment were introduced or implemented by the state. However, it is likely that the situation will change in the foreseeable future - at the International Conference on Harm Reduction in Montreal (May 14-17, 2017), the Manipur community of people who use drugs announced the success of its advocacy effort - 800 representatives of the community will receive both diagnostics and treatment with Sofosbuvir and Daclatasvir. Diagnosis will be paid for by donors, and treatment – by the state.
The head of the OST program in the state of Punjab, doctor Rana Ranbir Singh, said that previously there were more clients in his office. When elections are underway, police step up repression because they need figures and for people who use drugs are sentenced to prison terms. The program lost 160 people because of that.
Still, clients of harm reduction or HIV prevention programs are more protected from police repression in India. Anyone who is registered as an OST patient, and there are 177,000 of them in India, can be arrested, but the risk of going to prison is much lower, because doctors and NGO employees are helping out at the informal level. The situation is the same with MSM (sexual contact is a criminal offense), transgender people and sex workers. These groups are also subject to repression by the state and they can only be protected by the staff of prevention programs.
OST clients can be arrested for the use and possession of drugs. There are no strict rules against consumption in the programs. That’s an end goal, but they give people time to get used to their new life. How does it look in practice?
Here you can see the comprehensive report on the use of buprenorphine by a OST site in the city of Amritsar in Punjab. I was surprised by how open the data was for all those who came here, but also by lines such as "irregular clients", "regular clients", "very regular clients", "active clients".
"The majority of clients come on a regular basis, but even if they come once every three days, we still give them medication and at the same time we contact an NGO, so that outreach workers find that person and try to organize other services for them such as abscess threatment, naloxone, HIV or tuberculosis treatment, so that he would come for other services more often and then get OST more often.
It is a long process to make sure a person who uses drugs trusts health services and personnel. It‘s not the addiction that matters most to us but people and their life experience. Therefore, we have the opportunity to administer the medication every day or every three days," explains Dr. Rana Ranbir Singh calmly and amiably. "There‘s a first aid station near the OST site where they bring overdose victims. And it‘s there, where peer consultants explain that treatment is only three steps away (it‘s literally three steps, I counted - the author). There‘s buprenorphine treatment, and HIV and TB treatment, detox and many other services.“
The openness of information doesn’t just manifest itself in the statistics. There’s a checklist in a social worker's office, next to the desk on the right side of the client's chair. Social workers in our countries have to perform most of these tasks as well. However, I would still hang it on the wall to remember how important it is to greet a person, to make sure that he/she is comfortable, to take time to assure them about confidentiality.
"There is a minimum coverage that the center has to fulfill," continues Dr. Rana Ranbir Singh. "For example, instead of 100- people targeted in a plan, one center serves 255 people." Salaries are raised by 5-10% to all employees of the center each year. Also, if more people come to the centre, we employ more medical workers.The OST staff motivation is job satisfaction, 5-10% yearly pay rise and career opportunities "(I listed it in the order mentioned by the doctor).
"The impact of OST is also assessed by how low the number of people is who take syringes at the exchange points," says Mr. Manish Kumar, technical assistant for HIV programs from the National AIDS Control Organization (NACO) in the state of Punjab. At this point, I once again see how different their view of a low-threshold OST centre is from ours.
At the time of our conversation, 1,800 people have received assistance at Doctor Rana Ranbir Singh’s centre since 2010. There are five women registered but only two attend. As elsewhere, the problem is stigma. All OST, HIV prevention and treatment programs in India are 92% funded from the state budget.
Wiping tears of gratitude for such an understanding attitude towards people, with joy and recognition I presented Dr. Rana with the famous Lithuanian cheese.
I thought it was the coolest thing I saw during my internship. However, the next day we witnessed the work of a field OST clinic and drop-in centre. And they won me over completely.