Social worker in the flat of a drug addict in Donetsk doing outreach work. Drug addicts, like other marginalised groups, including Roma, are victims of the collapse of the health system in East Ukraine. Credit: Natalia Kravchuk/International HIV/AIDS Alliance Ukraine©

By Pavol Stracansky
KIEV, Jan 28 2015 (IPS)

With international organisations warning that East Ukraine is on the brink of a humanitarian catastrophe as its health system collapses, marginalised groups are among those facing the greatest struggle to access even basic health care in the war-torn region.

The conflict between pro-Russian separatists and Ukrainian forces has affected more than five million people, with 1.4 million classified by the World Health Organisation (WHO) and human rights bodies as “highly vulnerable” because of displacement, lack of income and a breakdown of essential services, including health care.

Fighting and accompanying measures imposed by both sides have led to medical supplies being severely interrupted or cut off entirely, hospitals destroyed or battling constant water and power cuts, and crippling staff shortages at health facilities as medical staff flee the fighting.

A complete lack of vaccines is threatening outbreaks of diseases such as polio and measles, while there are concerns for HIV/AIDS and TB sufferers as supplies of vital medicines dry up and disease monitoring becomes almost impossible.Fighting and accompanying measures imposed by both sides have led to medical supplies being severely interrupted or cut off entirely, hospitals destroyed or battling constant water and power cuts, and crippling staff shortages at health facilities as medical staff flee the fighting.

Massive internal displacement because of the conflict – latest U.N. estimates are of 700,000 internally displaced persons (IDPs) with the figure rising by as much as 100,000 per week – has also left hundreds of thousands living in sometimes desperate and unhygienic conditions, creating a further health risk and the chance that infectious diseases, such as TB, will spread.

But while there is a threat to healthcare provision from collapsing resources, some in the region are facing extra barriers to accessing health care.

Ukraine has one of the worst HIV/AIDS epidemics in the world and the spread of the disease has been fuelled mainly by injection drug use. But, unlike in many Eastern European states, the country has been running for more than a decade an internationally lauded range of harm reduction programmes which have been credited with checking the disease’s spread.

These have included opioid substitution therapy (OST) programmes available to drug users across the country. These are particularly important in East Ukraine because the majority of Ukraine’s injection drug users come from the Luhansk and Donetsk regions.

But local and international organisations working with drug users say that addicts’ access to life-saving treatment in those areas has come under increasing pressure since the start of the conflict and that it could be cut off entirely within weeks as supplies of methadone and buprenorphine used in the treatment run out and cannot be replaced.

The International HIV/AIDS Alliance Ukraine which runs many OST centres as well as other harm reduction programmes, has said that stocks of antiretroviral drugs, OST and other life-saving treatments will have run out by  February.  More than 300 OST patients in Donetsk and Luhansk have lost access to treatment since the conflict began, while a further 550 patients on methadone will run out of drugs soon if emergency supplies cannot be delivered.

U.N. officials in close contact with international organisations helping drug users as well as doctors in Donetsk have confirmed to IPS that clinics have only a few weeks’ worth of stocks of methadone left.

One doctor in Donetsk working on an OST programme, who asked not to be named, told IPS:  “There are serious problems with medicine supplies. The last shipments came in September last year and some patients have already had to finish their treatments. Many had been on it for a decade and in that time had forged new lives, put their, sometimes criminal, past behind them and had families. It was absolutely tragic for them when they stopped.”

It is unclear what will happen to all those no longer able to access OST treatment. Doctors say some have gone into detoxification, while others have moved to other cities in safer areas of Ukraine in the hope of continuing OST.

But with 60 percent of those receiving OST also being HIV positive, according to the Donetsk doctor, and reports that many are now turning to illicit drugs and needle-sharing again as access to OST is cut off, there are concerns that the disease, along with Hepatitis C which is rife among injection drug users, and tuberculosis, could be spread, and that the lives of many drug users will again be at risk.

OST patient Andriy Klinemko, who was forced to flee Donetsk with his wife when their house was destroyed in bombing last summer and who is now in Dnipropetrovsk in central Ukraine, told IPS: “OST patients in East Ukraine are being forced to move, but not all of them can and even those that make it to other regions may not be able to continue OST because there is no money left to run such programmes. It’s a bad situation and at the moment I really can’t see any way it’s going to get better.”

But drug users are not the only marginalised community struggling to access health care.

Historically, the estimated 400,000-strong Roma community in Ukraine has, like Roma in many other Eastern European states, faced widespread discrimination in society, including in employment and education.

They have also always had limited access to healthcare because many Roma lack official ID documentation which makes it difficult for many to obtain official health care, while widespread poverty also means services and medicines which require any payment are also inaccessible to most. Meanwhile, many Roma settlements are in remote locations, far away from the nearest health centres.

Dr Dorit Nitzan, head of the WHO’s Ukraine Office, told IPS: “Even before the conflict, Roma in Ukraine had limited access to curative and preventive health service. As a result, Roma children have extremely low vaccination coverage. Moreover, rates of tuberculosis and other communicable and non-communicable diseases are higher among Roma than in the general population.”

Discrimination is also a problem. Zola Kondur of the Chiricli Roma rights group in Ukraine, told IPS: “In terms of healthcare, Roma are among the most vulnerable in the country. They are treated badly because of their ethnicity.”

However, the problems for Roma have dramatically worsened since the conflict began. Some human rights groups have said that since the separatist regimes took power in the region, Roma have faced systematic violent and sometimes fatal repression.

According to a report this month of an international mission to monitor human rights

by the Kharkiv Human Rights Protection Group, Roma living in separatist-controlled areas have been “subjected to open aggression from militants ….[who] have carried out real ethnic cleansing” against them. Many have fled and become IDPs, subsequently facing health struggles.

Dr Nitzan said: “As in every crisis, if not given special attention, marginalised and vulnerable groups are at higher risk. In Ukraine, many Roma lack civil documentation, and thus cannot be registered as internally displaced persons and are not included in the provision of any health services.

“Moreover, their inability to pay ‘out-of-pocket’ limits their ability to procure medication and/or services. Compounding this is that many Roma IDPs are residing at the margins of society, in remote geographical locations, where no services are available. All of these factors make health services inaccessible to Roma.”

Local rights groups say that Roma who have managed to flee to safe areas have often ended up homeless and starving after facing problems accessing aid because of a dismissive attitude from volunteers and staff at social institutions, while their lack of identification documents also prevented them from accessing any official help.

However, even those who have managed to find treatment have sometimes faced further problems.

Kondur told IPS: “In one case a Roma family moved from Kramatorsk to Kharkiv. A little boy had a heart problem brought on by the stress of the fighting and he was taken to hospital. One night, a group of young people broke the window of the boy’s hospital room, shouting ‘Gypsies get out’. The boy had a heart attack.”

Edited by Phil Harris

Irina was 21 when she first started using drugs. More than 30 years later, having lost her husband, her home and her business to drugs, she is still battling her addiction.

But, like almost all female drug addicts in this former Soviet state, she has faced a desperate struggle not only with her drug problem, but with accessing help in the face of institutionalised and systematic discrimination because of her gender.

“Georgia’s society is very male-dominated,” she told IPS. “And this is reflected in the attitudes to drugs. It’s as if it’s OK for men to use drugs but not women. For women, the stigma of drug use is massive. There are many women who do not join programmes helping them as they would rather not be seen there.”

Women make up 10 per cent of the estimated 40,000 drug users in Georgia, according to research by local NGOs working with drug users.“Georgia’s society is very male-dominated and this is reflected in the attitudes to drugs. It’s as if it’s OK for men to use drugs but not women. For women, the stigma of drug use is massive. There are many women who do not join programmes helping them as they would rather not be seen there” – Irina, now in her 50s, who has been taking drugs for 30 years

However, because of very strong gender stereotyping, women users have very low access to harm reduction services – only 4 percent of needle exchange programme clients are women and the figure is even less for methadone treatment.

Local activists say this startling discrepancy is down to the massive social stigma faced by women drug users.

Dasha Ocheret, Deputy Director for Advocacy at the Eurasian Harm Reduction Network (EHRN) told IPS: “In traditional societies, like Georgia’s, there is a much stronger negative attitude to women who use drugs than to men who use drugs. Women are supposed to be wives and mothers, not drug users.”

Many female addicts are scared to access needle exchanges or other harm reduction services because they fear their addiction will become known to their families or the police. Many have found themselves the victims of violence as their own families try to exert control over them once their drug use has been revealed. Others fear their drug use will be reported to the authorities by health workers.

Registered women drug users can have their children taken away while they routinely face violence – over 80 percent of women who use drugs in Georgia experience violence, according to the Georgian Harm Reduction Network– and extortion at the hands of police helping to enforce some of the world’s harshest drug laws. Possession of cannabis, for example, can result in an 11-year jail sentence.

Irina, who admits that she arranges anonymous attendance at an opioid substitution therapy (OST) programme so that as few people as possible can see her there, told IPS that she had herself been assaulted by a police officer and that police automatically viewed all female drug users as “criminals”.

But those who do want to access such services face further barriers because of their gender.

Free methadone substitution programmes in the country are extremely limited and because levels of financial autonomy among women in Georgia are low, other similar programmes are too expensive for many female addicts.

Discrimination is not uncommon among health service workers. Although some say that they have been treated by very sympathetic doctors, other female drug users have complained of abuse and denigration by medical staff and in some cases being denied health care because of their drug use.

Pregnant women are discouraged from accessing OST, despite it being shown to be safe in pregnancy and resulting in better health outcomes for both mother and child.

Eka Iakobishvili, EHRN’s Human Rights Programme Manager, told IPS: “Pregnant women don’t have access to certain services – they are strongly advised by doctors and health care workers to abort a baby rather than get methadone substitution treatment because they are told the treatment will harm the baby.”

While some may then undergo abortions, others will not, instead continuing dangerous drug use and the potential risk of contracting HIV/AIDS which could then be passed on to their child.

Meanwhile, those harm reduction services accessible by women are not gender-sensitive, according to campaigners, who say that female drug users need access to centres and programmes run and attended only by women.

Irina told IPS: “On some [harm reduction] programmes, the male drug users there will abuse the women drug users for taking drugs. This puts a lot of women off attending these programmes.”

She said that she had asked for a women-only service to be set up at the OST centre she attends but that it had been rejected on the grounds that only a few women were enrolled in it.

Together, these factors mean that many women are unable to access health services and continue dangerous drug-taking behaviour, sharing needles and injecting home-made drug cocktails made up of anything, including disinfectants and petrol mixed with over the counter medicines.

But there is hope that the situation may be about to change, at least to some degree, as local and international groups press to have the problem addressed.

At the end of July, CEDAW (UN Commission on Elimination of Discrimination against Women) released a set of recommendations for the Georgian government to ensure that women obtain proper access to harm reduction services after local NGOs submitted reports on the levels of discrimination they face.

These include, among others, specific calls for the government to carry out nationwide studies to establish the exact number of women who use drugs, including while pregnant, to help draw up a strategic plan to tackle the problem, and to provide gender-sensitive and evidence-based harm reduction services for women who use drugs.

The government has yet to react publicly to the recommendations but local campaigners have said they are speaking to government departments about them and are preparing to follow up with them on the recommendations.

Tea Kordzadze, Project Manager at the Georgian Harm Reduction Network in Tibilisi, told IPS: “We are hoping that at least some of the recommendations will be implemented.”

The Georgian government has been keen to show the country is ready to embrace Western values and bring its legislation and standards into line with European nations in recent years as it looks to create closer ties to the European Union. Rights activists say that this could come into play when the government considers the recommendations.

Iakobishvili said: “These are of course just recommendations and the government is not obliged at all to accept or implement any of them. But, having said that, Georgia does care what other countries and big international rights organisations like Amnesty International and so on say about the country.”

Irina told IPS that only outside pressure would bring any real change. “The European Union, the Council of Europe and other international bodies need to put pressure on the Georgian government to make sure that the recommendations don’t remain on paper only.”

But, she added, “in any case, the recommendations alone won’t be enough. The whole attitude in society to women drug users is very negative. It has to be changed.”

(Edited by Phil Harris)