Forward to the Basics of Harm Reduction

Anna Dovbakh, EHRA

2 March 2020, Vilnius

It is not easy for me to stay optimistic in this endless dance “one step forward, two steps back”. Now when Kazakhstan, Ukraine and Russia simultaneously strengthening measures to combat drug-related advocacy (“propaganda”), particularly on the Internet, which make distribution of any information about safe drug use or saving your friend’s life in case of overdose risky, as well as protecting the health of people who use drugs, there is a persistent feeling of returning to the wild 90s (if not in the Middle Ages). We are facing the same challenges as before: lack of respect to human dignity and life, populistic screaming about the international conspiracy of ‘Soros minions’, decreasing resources for advocacy, threats to freedom of activists.

In July 2019, together with the Steering Committee we were thinking about the EHRA strategy for the coming five years and went twenty years back, remembering the journey that we made together, analyzing what inspired us throughout those years, what gave us the energy, what we were able to achieve, what difficult compromises we had to make, and what we are sorry about. It was a very useful reflection, giving us a chance to see the perspective of where we are going further and what past experiences we can use.

1997 (or even earlier) -2004 – “The Era of Harm Reduction Heroes”

What did we have when the harm reduction idea came to the region? A wide and visible spreading of opioid use as a response to social-economic crises, sudden poverty and feeling of hopelessness. Producing and using of substances were very risky, which led to HIV, viral hepatitis and social problems exploding among people who use drugs. What help was available in the countries: there are Soviet-time sobering-up stations and drug abuse clinics, AIDS centres are established, but no ART there. Social services based on the clients’ needs exist only in wonderful foreign handbooks. Human rights and humanity are very attractive but too “alien.”  That’s the time when the first Médecins Sans Frontières’ trainings and meetings with the consultants of the Open Society Institute gave rise to creative, brave people who saw no barriers and became the pioneers of harm reduction in the EECA region with high motivation, enthusiasm and commitment to succeed.  Back then, it seemed that everything was possible, though there were not so many resources and just a few projects per country of the region, but what projects – integrated, professionally open and exciting

2004-2011 – “Program Scale Up and the Golden Age of Global Fund”

It was a strong move to include harm reduction services into the programs of the Global Fund to Fight AIDS, Tuberculosis & Malaria. With such support, pilot programs for people who use drugs really got a chance to become accessible at the national level.  Behavioral studies were started, a lot of evidence-based data on harm reduction efficiency from our region appeared. We developed many publications, materials and trained thousands of social and health care workers.  Now there were new people – managers – as well as the notorious “coverage indicators” and loads of well-structured reports. In some of EECA countries there was opportunity to implement innovative program, to open community centers, offer psychological and legal support to help people, who use drugs. Unfortunately, this possibility lasted only for a short while.

The main compromise that we made back then was saying that harm reduction was equal to HIV prevention among people who use drugs. That was when standard projects made harm reduction services resemble a needle and syringe vending machine – distribution of syringes (no more than 7 to one person), information materials and condoms became enough for services coverage. However, some countries were able to open community centers.  From that time, we’ve had idea of minimal package of services, which has nothing in common with transforming of circumstances and quality of people’s lives. It couldn’t impact on behavior, social re-integration, as well as it does not provide security, without which it is impossible to think about health.

2011-2017 – “Sustainability and Transition”

The Global Fund and other international donors began to leave the middle-income countries, and it led to the fact that most of the current harm reduction services, as a community center or legal aid, in projects were reduced. In countries, the estimated cost of one client per year fell from $ 100 per person to $ 40, and then to $ 15, and thus the real consulting assistance from the social worker was reduced to zero. There were fewer protests, and more well-planned activism as a routine job. The key advocacy issue was transition to the domestic funding. At the regional level, the project “Harm Reduction Works – Fund It!” was initiated.  The regional network received the necessary resources for political influence, gained understanding of the government mechanisms (how budgets are formed, and laws are developed), with more active communication established with the wider world. My strong feeling in those years was that we are riders of the Apocalypse, telling about the end of funding from the Global Fund, but they do not want to believe us and turn away. There was a new wave of community development in a number of countries, with a new generation of activists and organizations and more active community engagement in the country coordination mechanisms.

2017-2019 – “Organizational Crisis and the Rise of Phoenix”

For many countries and members of the Association, harm reduction services were closed or were at risk of closing down. New alternative sources of financing, new partnerships and more stringent advocacy, even harsh competition for resources – that’s what we will remember from that times. For EHRA team it was an era full of adrenaline, which allowed us to hear and understand each other better and allowed members to feel their importance for the organization. The organization became a real network with real members and more transparent mechanisms. We are strong when we are in crisis – this is my lesson. When we are facing new challenges, we are defining our priorities as decriminalization and humane drug policy. Association has limited resources, that is why we need to focus on the actions which can help the survival of harm reduction services in the region, on their quality and accessibility.

What do we want to take into our future from that join path? Focus on values and freedoms, professionalism, leadership and team spirit. After all the compromises and having to follow the donor’s ideas, we are starting negotiations with local governments. Will we be able to show the real value of harm reduction for local community? Will we be able through our joint efforts to bring back the initial understanding of the quality of comprehensive social support services for people who use drugs? Young people use other, new substances and we need to build the trust relationships with clients once again. We need to bring professional help of medical experts (in this case, psychiatrists) and think what materials will be useful for maintaining health and life. Harm reduction 2.0. requires legislative changes that allow drug checking, for example.

Sadly, our experience of survival and providing help in crises/dangerous circumstances is becoming increasingly relevant.  I hope that we will become a little wiser, stronger and learn how to work together effectively.  So, we will break through. And finally, we will agree among ourselves what compromises we cannot make, how to protect quality of harm reduction services, and create a safe and supportive environment for people. After all, we do our work to make people feel like people. This is the basis of my weak optimism today.