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The Quietest Casualties: Russian Public Health Policies Cause Patient Deaths in Crimea

2 Comments 🕔30.Sep 2014
A flier warning drug users not to use krokodil', a homemade injection drug derived from pharmaceutical opiates and various acidic solvents. The name derives from the soft tissue injuries that frequently accompany its use, causing skin to become discolored and scaly. Krokodil' use is very common in Crimea. Photo credit: Jennifer J. Carroll

A flier warning drug users not to use krokodil’, a homemade injection drug derived from pharmaceutical opiates and various acidic solvents. The name derives from the soft tissue injuries that frequently accompany its use, causing skin to become discolored and scaly. Krokodil’ use is very common in Crimea. Photo credit: Jennifer J. Carroll

 

by Jennifer J. Carroll

I have no way of knowing whether Dima is still alive. I have not seen him since October 2012, when we met in a clinic in Simferopol, Crimea. On that day, we sat for some time in his physician’s sunny office, eating chocolate-dipped marshmallows and discussing Ukraine’s public health policies.

Dima called himself a narkoman, a common Russian name for a drug user. For years, if not decades, he injected pharmaceutical opiates and locally available ‘street drugs’ like khimia and shirka. These drugs aren’t that uncommon where he’s from. The International HIV/AIDS Alliance estimates that nearly 15,000 of Crimea’s 1.9 million inhabitants inject drugs (International HIV/Aids Alliance in Ukraine 2012), and, in Crimea, homemade opiate solutions tend to be the drug of choice. For Dima, though, that all ended in 2008, when he enrolled in an opiate substitution therapy (OST) program, operated out of the clinic where we met.

From his slightly disheveled appearance, his grass-stained tracksuit, and the odd twitch that shakes his left knee when he tries to stand still, one might not immediately suspect that Dima is an expert in Ukraine’s national HIV control strategy, but he is. He knows more than almost anyone else, because his daily life is governed by the policies that criminalize his drug use, medicalize his addiction, and marginalize his social position. In October 2012, at the time of our last meeting, it had been four full years since he started receiving OST. When his clinic shut down in May 2014, it would have been nearly five and a half.

Every active OST program in Crimea, including Dima’s, was officially closed on May 1, 2014, under the authority of the Drug Control Service of the Russian Federation. More than 800 residents of Crimea were receiving OST when the shutdown occurred. The closure of these programs in Crimea has been nothing short of devastating. Since May, more than 20 of Crimea’s OST patients have reportedly died; at least three of those deaths were suicides (International HIV/Aids Alliance in Ukraine 2014b).

I would like to reach out to Dima, to see if he is doing well, but I have no way to contact him. Electrical and telecom services have been unreliable in Crimea, and Ukraine’s largest cellular provider recently suspended service in the region (Finley 2014). No way to call. No clinic to reach out to. I am left to wonder whether he is to be counted among the many casualties of Russia’s war in Ukraine.

The front entrance to a regional tuberculosis hospital, which houses an OST program serving approximately 60 patients. Photo credit: Jennifer J. Carroll

The front entrance to a regional tuberculosis hospital, which houses an OST program serving approximately 60 patients. Photo credit: Jennifer J. Carroll

 

Little white pills and little green men

In late February 2014, Russian soldiers invaded the Autonomous Republic of Crimea and facilitated a coup in the regional government. The invading troops came dressed in Russian military uniforms, but displayed no name, flag, rank, or insignia, prompting the locals to refer to them by the color of their uniform: “Little Green Men.”

On March 16, 2014, less than a month after this covert invasion, the Russian Federation staged a legally and procedurally flimsy annexation of Crimea. Anthropologists Elizabeth Dunn and Michael Bobick call this annexation a form of “theatre state” that “focuses on production of spectacle rather than economic development or the provision of social welfare” (Dunn and Bobick 2014). As they anticipated, the situation in Crimea quickly deteriorated following the invasion.

On April 2, the head of the Russian Federation’s Drug Control Service, Viktor Ivanov, publically announced his intention to close all OST programs in Crimea (Ivanov 2014). This announcement followed earlier promises that OST patients could continue receiving treatment through the end of 2014 (International HIV/Aids Alliance in Ukraine 2014a). Ivanov supported this decision by citing high levels of crime related to drug production and drug trafficking on the peninsula. He argued that the level of drug use in the local population was twice as high as in Russia – a claim contradicted by available evidence.[1] He characterized his desire to manage Crimea’s drug addicts in eugenic terms, saying “the ‘rejuvenation’ of drug addiction in recent years and the increasing number of female drug addicts [in Crimea] is causing a rise in the number of births of children with various disabilities, which is a threat to the gene pool.” He called Crimea’s 800 OST patients “legalized drug addicts” and “a serious problem that must be dealt with.”

Speaking at a press conference on June 19, Pavlo Skala, a senior program manager for the International HIV/AIDS Alliance in Ukraine, announced that a few dozen methadone patients were sent to rehabilitation facilities in Moscow, but most were left to fend for themselves, with little medical support for managing their withdrawal. The risk of death from overdose and other risky behaviors increases significantly in the first weeks following the cessation of OST (Davoli et al. 2007; Cornish et al. 2010; Degenhardt et al. 2009). Skala also reported that, as a result of the shutdown, many former methadone patients in Crimea had returned to illegal drug use and several dozen had died in only a matter of weeks. “This is a form of execution,” he said, “that constitutes inhumane treatment and torture according to international law…There will be [more] deaths. We expect increased rates of HIV and hepatitis infection. Russia will not record these statistics” (newsru.ua 2014).

An OST patient reveals a scar from an infected abscess on his upper arm and a button on his satchel that reads "Fight HIV and HCV [Hepatitis C virus] not people using drugs." Photo credit: Jennifer J. Carroll

An OST patient reveals a scar from an infected abscess on his upper arm and a button on his satchel that reads “Fight HIV and HCV [Hepatitis C virus] not people using drugs.” Photo credit: Jennifer J. Carroll

Successes unraveled

I once asked Dima why he entered the OST program in the first place. “I didn’t think much about the bigger picture then,” he told me. “I came here to figure out more immediate problems. I had just met my girlfriend. I was always lying to her, telling her that I had some kind of job to get to. At 8 in the evening, when we would be out for a walk, I would need to run off. I’d say I had some kind of job, as an excuse. But, she started to figure out what I was doing. And I thought, I need to get on this program, first of all to save the relationship. First, my family started to suspect, she started to suspect that I was on drugs. And secondly, things had started to really break down at my work. I would come in for a half a day, leave for my lunch break, and never come back. I realized that I needed something in my life to change somehow, that I needed to start on this program.” He did. Two years later, Dima and his girlfriend were married. They have a baby girl who is, today, approaching her fourth birthday.

Dima’s story is a single drop in a veritable ocean of evidence that OST is a tool that helps some people, a lot of people, improve their lives. OST is endorsed by the World Health Organization, Joint United Nations Programme on HIV/AIDS (UNAIDS), and United Nations Office on Drugs and Crime as “one of the most effective treatment options for opioid dependence” and “an important treatment option in communities…in which opioid injection places [injection drug users] at risk of transmission of HIV and other blood borne viruses” (World Health Organization 2004). In addition to HIV control, OST offers numerous other benefits: reduced risk of overdose and criminal activities, decreased financial stress on users and their families, improved adherence to anti-retroviral therapy and other medications, and improved mental and physical welfare of patients. Broader social impacts result from the implementation of OST programs, as well, including criminal activity and behaviors with a high risk of HIV transmission.

Ukraine first began offering OST in 2004 as part of a pilot program funded by the Global Fund to Fight AIDS, Tuberculosis, and Malaria. In the spring of 2007, I visited one of Ukraine’s few pilot OST clinics while on a research trip to Odessa. I spent a week shadowing an outreach worker who spent his days wandering the neighborhoods, distributing clean syringes to clients that he knew and collecting used needles for safe disposal. His name was Sasha, and he was participating in OST. He was so excited about the program. He insisted on taking me with him to the clinic every day and aggressively introducing me to the staff. Sasha also insisted on treating me each day to cup of heavily sugared, hot black tea, despite the outside temperature of nearly 90 degrees Fahrenheit, so that I could ‘relax’ while I sat waiting for him by the door. “It’s so great!” he told me. “I feel fine, I just come here and take my pills and that’s it. And you see a doctor every day, so you know you are healthy.”

By 2012, when I traveled to Simferopol for research, OST had been made available in each of Ukraine’s 25 administrative regions. In fact, substitution therapy had been available in Crimea since as far back 2005, meaning that public awareness of and the professional culture within these programs were already well developed when I first arrived. When Crimea was illegally annexed by the Russian Federation in March, a total of 806 patients were receiving this service in multiple cities, including Sevastopol, Simferopol, Yalta, Kerch, Evpatoria, and Feodosia. Thanks to these programs, the HIV rate in Crimea had begun to drop (UNAIDS 2013).

A rapid test that is commonly used by social workers in Ukraine to screen clients for infectious diseases. This test indicates that the patient who was tested is infected with HIV, hepatitis C, and syphilis. Photo credit: Jennifer J. Carroll

A rapid test that is commonly used by social workers in Ukraine to screen clients for infectious diseases. This test indicates that the patient who was tested is infected with HIV, hepatitis C, and syphilis. Photo credit: Jennifer J. Carroll

Russia’s regressive policies

In contrast, the Russian Federation is facing a massive HIV epidemic. Though surveillance mechanisms are poor, it is estimated that more than 1.2 million people are living with HIV in Russia. Furthermore, an estimated 9 out of every 10 of those HIV+ persons in Russia are not having their treatment needs met (UNAIDS 2013). The HIV epidemic throughout Eastern Europe has, for more than two decades, been primarily driven by injection drug use, and Russia has consistently adopted policies of criminalization rather than offering evidence-based treatment options (“Addicted to Crime: Russia Considers Jailing Drug-Users” 2014).

The HIV rate among drug users in Ukraine has fallen dramatically since 2005 but has, according to all available data, grown in Russia during that same time (UNAIDS 2013). Despite the demonstrable success of OST in Ukraine, and despite the presence of an estimated 8.5 million drug users in the country (“Experts Say Russia Not Ready to Fight HIV | News” 2014), methadone and buprenorphine, the two key drugs used in OST, are banned in Russia (“Rossiykaya Federatsiya Federal’nyy Zakon o Narkoticheskikh Sredstvakh i Psikhotropnykh Veshchestvakh” 1998), rendering these treatments entirely unavailable to the Russian population. Public health experts have estimated that implementing OST could decrease the rate of HIV infection in Russia by more than half (British Journal of Medicine 2014). It comes as no surprise, then, that Russia’s drug use and HIV prevention policies are widely considered complete disasters (Ralston 2013).

My training in public health and medical anthropology has taught me to appreciate a variety of measures for assessing the quality and efficacy of programs like this one: average medication adherence levels; rates of recidivism; the number of incident infections in the patient population. But my time on the ground in little, forgotten clinics, like the one in Simferopol where I met Dima, have taught me to take note of many more. I recall how shamelessly Dima and his friends stole marshmallows from the plate on their physician’s desk, revealing how comfortable and empowered the patients felt in this clinic. I recall laughter bubbling up from the courtyard, where nurses were chatting with young, opiate-addicted mothers, revealing meaningful relationships between patients and their caregivers. Most of all, I recall the things that individuals receiving OST told me about why they are in the program and how their lives have changed since they began.

Take Masha and Vova, for example. They were also patients in the Simferopol clinic, a happily married couple with a baby no older than three or four months when I met them. They had been receiving OST for nearly two years. Vova described the chaos that engulfed his life when their drug use spun out of control. “You wake up in the morning and what kind of problem do you have? You need to get healthy. And if everything is feeling good and normal, then great, but if you’re not feeling ok, then you have to go somewhere to get a fix, you have to get into some kind of trouble. And this place [the OST clinic], well, we just wanted life to come back to normal. With that garbage on the street, it wasn’t possible to operate normally. I was working, but I was missing a lot of days, so I had to find money through other means.”

For this family, and for many others, OST provided an opportunity for stability. Vova had no illusions about his prolonged chemical dependency, but, for him, the value of the program was visible in the calm that has returned to his family and his community. “It’s basically the same dependence,” he said, “but I don’t have to worry about getting into trouble, where I’m going to scrounge the money, how I’m going to pay the police, and so on….This program really cuts down on crime.”

As Vova spoke with me in the courtyard, Masha paced back and forth behind him, periodically correcting his word choices and rocking their baby boy to sleep. “Speak normally!” she griped. Vova turned to her and asked, “What? Am I not talking about normal things?” Shaking her head, still bouncing their baby on her chest, Masha gave a long sigh, annoyed that drug-related slang was slipping back into Vova’s words. That vernacular reminded her of a life they had left behind.

As with Dima, my communication with Masha and Vova has by now been completely severed. Back then, they appeared as two strong, determined individuals. I have hope that the instability and chaos they left behind has not re-entered their lives. But they live in a city that the Russian Federation now controls. Their support structure has been entirely dismantled. Statistics show that they are more likely to fall into harm’s way now than they were before they even began OST.

A single patient's daily dose of methadone in tablet form. Photo credit: Jennifer J. Carroll

A single patient’s daily dose of methadone in tablet form. Photo credit: Jennifer J. Carroll

Gains and losses

According to Michel Kazatchkine, the United Nations Secretary-General’s Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, the closure of Crimea’s OST programs constitutes “a blatant example of health policy being hijacked for political ends rather than being led by evidence” (Kazatchkine 2014). In this case, that evidence is predictive. At the time that the Russian Federation began its annexation of Crimea, the Ukrainian Ministry of Health reported that more than 8,000 residents of the peninsula, including Dima, Masha, and Vova, were living with HIV (Kazatchkine 2014). OST programs had been working successfully since 2005 to keep that number in check, but the unfortunate consensus among public health experts now is that rates of HIV, hepatitis C, and overdose will quickly rise in their absence (Grover et al. 2014).

Dunn and Bobick have argued that the annexation of Crimea fits into a larger pattern of Russian interference that has played out in other “breakaway” regions, including Transnistria, South Ossetia, and now in Donets’k and Luhans’k oblasts in eastern Ukraine. “Russia intervenes on behalf of its ‘compatriots’ in breakaway provinces,” they claim, “if and only if doing so serves its goal of reestablishing the sphere of influence it lost in the 1990s” (Dunn and Bobick 2014).

These alleged, geopolitical motivations, their scale and their character, stand in sharp contrast to the worries that have guided the actions of the people I met in Crimea’s OST clinics. Their reasons for joining the program varied. Some joined the program because they were tempted by the offer of free drugs. Others joined because their lives had reached a breaking point. Their reasons for staying, however, were almost all the same. Recovering addicts spoke of husbands, wives, parents, children, all of whom they longed to care for. “You know,” Dima told me, “my father is really ill and I want to help him. He needs treatment, and I want to help him buy those medicines…My daughter needs constant support. She’s growing. I have to help my daughter and my wife, plus I live with my mother, and I need to put bread on her table. Everywhere some kind of help is needed.”

Whatever Russia’s reasons for its multiple assaults on Ukraine, it is clear that the welfare of ordinary people is not at the heart of their intentions. Whether at the hands of a Grad rocket in Donets’k or of street drugs in Simferopol, countless lives have been lost in a military program that Russia has framed as social and political support for ethnic Russians living in Ukraine. Ukraine has been diligently counting its dead. These civilian and military death tolls have been held high by journalists, politicians, and ordinary citizens as a direct indictment of Putin’s aggression. For many Ukrainians, these statistics are a powerful signifier of what has been wrought and what has been lost.

The deaths of OST patients in Crimea, however, are not included among them. No one is there to count them. No one is there to hear them. They are quiet, predictable deaths of lovely people whom society easily forgets.

Watch the video below to hear the voices and concerns of Crimea’s former OST patients. (Video posted by Igor Kouzmenko, a member of the Association of OST Participants in Ukraine.) To turn on subtitles, click on the CC button in the bottom right corner of the video.

 

Jennifer J. Carroll is a doctoral candidate at the University of Washington, where she is finishing a PhD in social anthropology and an MPH in epidemiology. Her research investigates the epistemologies of international development and global health efforts in Eastern Europe. Her most recent project documented patient perspectives in Ukraine’s opiate substitution therapy programs, exploring what happens when standardized, evidence-based treatment protocols collide with a medical culture that equates the statistical with the political.

 


References

“Addicted to Crime: Russia Considers Jailing Drug-Users.” RT, 6 October 2011. Accessed September 12, 2014 from <http://rt.com/news/prime-time/drug-users-crime-law-235/>.

“Criminalization of Drugs and Drug Users Fuels HIV; Laws Should Be Reviewed, Say Experts.” BMJ-British Medical Journal, 13 July 2010. Accessed September 13, 2014 from <www.sciencedaily.com/releases/2010/07/100713191356.htm>.

Cornish, Rosie, et al. 2010. “Risk of Death during and after Opiate Substitution Treatment in Primary Care: Prospective Observational Study in UK General Practice Research Database.” BMJ- British Medical Journal 341. doi:10.1136/bmj.c5475.

Davoli, Marina, et al. 2007. “Risk of Fatal Overdose during and after Specialist Drug Treatment: The VEdeTTE Study, a National Multi-Site Prospective Cohort Study.” Addiction (Abingdon, England) 102(12): 1954–59. doi:10.1111/j.1360-0443.2007.02025.x.

Degenhardt, Louisa, et al. 2009. “Mortality among Clients of a State-Wide Opioid Pharmacotherapy Program over 20 Years: Risk Factors and Lives Saved.” Drug and Alcohol Dependence 105(1–2): 9–15. doi:10.1016/j.drugalcdep.2009.05.021.

Dunn, Elizabeth Cullen, and Michael S. Bobick. 2014. “The Empire Strikes Back: War without War and Occupation without Occupation in the Russian Sphere of Influence: The Empire Strikes Back.” American Ethnologist 41(3): 405–13. doi:10.1111/amet.12086.

Finley, JC, “Ukraine’s Largest Mobile Phone Provider Suspends Service in Crimea after Armed Invasion,” UPI, 11 August 2014.

Grover, Anand, et al. 2014. “Urgent Appeal: Health and Human Rights Crisis Imminent for Opiate Substitution Therapy Clients in the Crimea | Rylkov Foundation.” <http://en.rylkov-fond.org/blog/ost/rost/inpudostcrimea/>.

Heimer, Robert, and Edward White. 2010. “Estimation of the Number of Injection Drug Users in St. Petersburg Russia.” Drug and Alcohol Dependence 109(1–3): 79–83. doi:10.1016/j.drugalcdep.2009.12.010.

International HIV/Aids Alliance in Ukraine. 2012. “Estimation of the Size of Populations Most-at-Risk for HIV Infection in Ukraine as of 2012: Based on the Results of 2011 Survey.” <www.aidsalliance.org.ua/ru/library/our/2013/SE_2012_Eng.pdf>.

———. 2014a. “Press Release [in Russian].” <www.aidsalliance.org.ua/ru/news/pdf/05_2014/%D0%97%D0%A2%D0%9A%D1%80%D1%8B%D0%BC.pdf>.

———. 2014b. “Nakazano Vyzhyty: Poryatunok patsiientiv-bizhentsiv z Krymu ta Donbasu.” <www.aidsalliance.org.ua/ru/news/pdf/06-2014/19.06.2014/Release_19%2006%202014_UNIAN_OST.docx>.

Ivanov, Viktor. 2014. Vystuplenie predsedatelya Gosudarstvennogo antinarkoticheskogo komiteta, direktora FSKN Rosii V. P. Ivanova na Vyezdnom soveshchanii predsedatelya GAK “O perfoocherednykh sadachakh po realizatsii Strategii gosudarstvennoy antinarkoticheskoy politiki v subyektakh Rossiyskoy Federatsii Krymskogo federal’nogo okruga” (g. Simferopol’ 2 April 2014). Simferopol. <http://fskn.gov.ru/includes/periodics/speeches_fskn/2014/0402/104829810/detail.shtml>.

Joint United Nations Programme on HIV/AIDS. 2013. Global Report: UNAIDS Report on the Global AIDS Epidemic 2013. <www.unaids.org/en/media/unaids/contentassets/documents/epidemiology/2013/gr2013/UNAIDS_Global_Report_2013_en.pdf>.

Kazatchkine, M. 2014. “Russia’s Ban on Methadone for Drug Users in Crimea Will Worsen the HIV/AIDS Epidemic and Risk Public Health.” BMJ-British Medical Journal 348: g3118–g3118. doi:10.1136/bmj.g3118.

Quinn, Allison. “Experts Say Russia Not Ready to Fight HIV | News.” The Moscow Times, 17 August 2014. Accessed September 3 from. <www.themoscowtimes.com/news/article/experts-warn-of-forthcoming-hiv-epidemic-in-russia/505219.html>.

Ralston, Meghan. 2013. “Desperation Breeds Disaster: The Ugly Truth About Krokodil.” Drug Policy Alliance. <www.drugpolicy.org/blog/desperation-breeds-disaster-ugly-truth-about-krokodil>.

Rossiykaya Federatsiya Federal’nyy Zakon o Narkoticheskikh Sredstvakh i Psikhotropnykh Veshchestvakh.” 1998. <http://base.consultant.ru/cons/cgi/online.cgi?req=doc;base=LAW;n=154942>.

U Krymu cherez bvidsutnist’ likuvannia vzhe pomerlo blyzko 20 patsiientiv ZPT.” newsru.ua, 19 June 2014. <www.newsru.ua/ukraine/19jun2014/vich.html>.

World Health Organization. 2004. “WHO/UNODC/UNAIDS Position Paper: Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention.” <http://apps.who.int/iris/bitstream/10665/42848/1/9241591153_eng.pdf?ua=1>.


[1] For example, a 2010 study, which used statistics on HIV-seroprevalence among IDUs as a form of capture-recapture, estimated the presence of more than 80,000 drug users in the city of St. Petersburg alone, which is equals a per-capita rate of drug use nearly twice that of Simferopol (Heimer and White 2010).

 

2 Comments

  1. 🕔 13:03, 30.Sep 2014

    mika

    Jen, thanks a ton for exposing this important issue!

    reply comment

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