Oleg Aizberg, PhD is a psychiatrist. He is an Assistant Professor at the Psychiatry and Narcology Department of the Belarusian Medical Academy of Post-Graduate Education (BelMAPO) in Minsk. He graduated from the Minsk Medical University, specializing in medical care. He then spent three years working at the Minsk Municipal Drug Treatment Clinic. Later he interned at the BelMAPO Psychiatry and Narcology Department where he is currently an Assistant Professor. In 2002, he interned at the Higher Medical School’s Psychiatry and Psychotherapy Department in Hannover. Oleg conducted training sessions on drug treatment for doctors in Kyrgyzstan in the framework of the European Union’s CADAP project, then he participated in the Assistance Project at Columbia University, New York, assessing the effectiveness of opioid substitution therapy in Tajikistan, Kazakhstan and Kyrgyzstan. Expert of treatment protocols in the countries of the Project "Harm Reduction Works - Fund it!".
Oleg, how did you encounter harm reduction?
The first time I heard about harm reduction was in 1994 when I was studying at the Medical University. I was in my fourth year when we all gathered for a lecture by two members of the Psychiatry Department, Professor Roman Yevsegneev and Assistant Professor Vladimir Poznyak. They had just visited Amsterdam to learn about its services for drug users. Of course, what we heard from them in 1994 was exotic: methadone buses, needle exchange, working with sex workers… The way they presented it was that we should also start implementing such services. That lecture influenced my mindset greatly. By the way, Professor Yevsegneev is still my chief. And Professor Poznyak is now in charge of the Drug Treatment Unit at the WHO (World Health Organisation – EHRN) in Geneva.
Were their views supported by other healthcare representatives?
Other doctors weren’t of the same opinion. In 1997, I graduated and went to work in drug treatment (at the Minsk Drug Treatment Clinic). So I ended up at a unit which was responsible for registration and treatment of drug users in the whole city. It took me a short while to realize that the treatment that was being offered was rather ineffective. At that time, we had no rehabilitation centers or substitution therapy. Even in Russia or Ukraine there were very few such programs. A year later I went for a working visit to Svetlogorsk where we had opened a needle exchange program (NEP). I saw how that worked and that such assistance was possible (and needed). Afterwards a NEP opened in Minsk and I became a consultant there.
Was the program supported by the state or by international organizations?
It was supported by both. The initial funding came from donors and then the state also supported it, although not always. Later, because of that program I went first to St. Petersburg to see how needle exchange services operated there. Then I visited Ukraine many times. At some point I met Dr. Emilis Subata (one of the founders of the Eurasian Harm Reduction Network, Director of the Vilnius Center for Addiction Disorders – EHRN) when he came to conduct a workshop in Minsk. He invited me to visit Lithuania in order to organize a joint workshop on assessing an index of addiction severity. It was in Vilnius that I saw substitution therapy programs for the first time.
Were you aware of EHRN’s work at that time?
There is an NGO in Vilnius which I think still exists, the Geneva Initiative (currently the Global Initiative on Psychiatry, it exists in Lithuania since 2001 – EHRN). It organized study tours for young narcologists and psychiatrists. That was in 1998 or 1999. One of the study tours was to the Czech Republic, where our colleagues from Holland shared information about substitution therapy. That’s when I heard about the Network for the first time. The Internet wasn’t ubiquitous then, so for many of us such study tours were one of the few ways to learn about European harm reduction programs.
Which means that more and more information was becoming available… Were you able to implement that knowledge?
It call came together really well. I left the drug treatment center and I lost interest in that topic for a while because nothing was being done in Belarus. Nothing at all. I started writing my dissertation on alcohol dependency. And then, after I lost interest in the topic of drugs, it caught up with me. Two things served as catalysts: in 2002 I went to Hannover for a six-month internship. And there I saw astonishing things such as an experimental medical heroin distribution program (they had just started a big research project in Germany). I ended up at a center specializing in studying the effectiveness of substitution therapy. That influenced me so much that after my return I started thinking about how that information could be used in Belarus.
Indeed, I and my colleagues tried to start a substitution therapy initiative in Minsk, Svetlogorsk and Gomel, but we couldn’t move it beyond a certain point. People would submit their projects and those projects would just end up on someone’s desk. Second, in 2004 a colleague from St. Petersburg suggested that I participate in writing a book on drug treatment (that was about drug treatment in Russia, not Belarus). And that it was desirable that I wrote something on substitution therapy because at the time, very few reviews were available in Russian. In fact, there was one but it was outdated - it was from 1994. So there we were 10 years later stuck with that review. I wrote a big review which resonated with a lot of people. I didn’t think it would, really. I think that happened because it was the only source of information at that time. They started citing it; my colleagues would write me asking for additional materials, although it was just a result of literature reviews and my internship in Germany. Clearly we didn’t have any more experience in the region, myself included, because we didn’t have anything in Minsk. I did have some experience as a result of my internships, having seen what it was like “over there”, but the frameworks were really different. And so gradually we started doing something in Minsk. They started involving me in some expert assessments and that was how I returned to the field.
Were those internal or external expert assessments?
There were both. In 2008, I did a project for EHRN. The Network asked me to analyze the situation with opioid dependency treatment in Eastern Europe and Central Asia (EECA). I prepared and presented it at a meeting in Yalta, organized by Michel Kazatchkine (doctor, researcher, diplomat and human rights activist, UN Secretary-General's Special Envoy for AIDS in Eastern Europe and Central Asia – EHRN). That was an important moment when I realized I could participate in international assessments and analyze the situation alongside other experts).
In 2010, I and my colleagues from Central Asia, Alisher Latypov (researcher working in human rights advocacy related to people living with HIV – EHRN), Azizbek Boltayev (doctor, member of the International AIDS Society, Director of the Center for Studying Human Development in Bukhara, Uzbekistan – EHRN) and David Otiashvili (one of the founders of the Georgian Harm Reduction Network, Chair of the EHRN Steering Committee in 2009 – 2011 - EHRN) performed an analysis of OST in Kazakhstan, Tajikistan and Kyrgyzstan. That also was an EHRN project. In 2012, there was a large-scale project at New York’s Columbia University to assess substitution therapy in Central Asia, which took two years. It was not only about assessing programs but also about educating drug treatment specialists. Thanks to that project I learned how the US system works.
What domestic or international harm reduction projects are you involved in currently?
Currently I participate in an EHRN project to analyze treatment protocols in six countries, Harm Reduction Works - Fund It! I’m also involved in a European Union project which has several implementers: the University of Applied Sciences (Frankfurt, Germany) and the University of Prague (Czech Republic). This project is partially about research and partially about educating drug treatment specialists.
Can you speak about harm reduction in the region and specifically in Belarus?
A lot has changed in Belarus. First, it’s the regional projects such as those implemented by EHRN. Thanks to those projects one can see how assistance models work. I have examples when specialists that stopped working in drug treatment clinics went on to teach at research departments while continuing to work full-time in harm reduction programs, ensuring the link between harm reduction, medical facilities and the community of people who use drugs.
In Belarus, we have several systems for monitoring substitution therapy. They are not very well connected, however. There’s a monitoring center at the Republican Center for Mental Health. There are also periodic assessments and monitoring work being done by the community. By the way, that’s an EHRN project implemented through the NGO “Positive Movement”. It is coordinated by Lyudmila Trukhan (epidemiologist, coordinator of the work with injecting drug users, member of the EHRN Steering Committee – EHRN). She is basically the founder of harm reduction in Belarus. Lyudmila organized the first needle exchange sites and contributed a lot to the organization’s development.
Looking back, we must acknowledge Emilis Subata’s contributions. He did pioneering work on so many issues. What he did in 1994 to introduce harm reduction in Lithuania wasn’t even available in most Western European countries at the time.
My chief, Professor Roman Yevsegneev, once confessed to me: he didn’t believe that he’d see with his own eyes people receiving methadone. He thought that would never happen. I was a bit skeptical myself. But the situation has changed, including through EHRN’s efforts. Because the Network was a structure that helped catalyze this process in our region. We never had our own structures. We had a non-profit organization but what’s really important here is the regional role.
What has changed lately at the government level?
There is a Ministry of Health protocol on substitution therapy. There are similar documents for needle exchange programs, and some of them were also approved by the Ministry. However, the public opinion hasn’t really changed and presents an obstacle to expanding the services. Unfortunately, that’s a social phenomenon and it depends on how society is organized rather than on the specialists working in harm reduction. Unfortunately, not much can be done about it at this point.
In addition, many services depend upon (or are linked to) specific people. If those people leave and are replaced by others who don’t have similar capacities and attitudes, then we often see something that could be called “wrapping things up”. Formally, the services are operational but they aren’t what they should be. Everything is tied to that particular person. There’s no system that will operate like it did after that person leaves. It really depends on the human factor, on the human initiative. Maybe that’s the fate of any project, but in our field that can have fatal consequences because opioid-dependent patients don’t have many opportunities to ask for help. They’re really limited in that sense. And it often happens that there is just one place in their city or region where they can go. So, while there can be alternatives for other projects (say, there are many neurologists, gynecologists or psychotherapists), there is usually only one drug treatment specialist working in harm reduction. And a lot of things depend on that person. Too many things.