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BMJ No 7125 Volume 316
Education and debate Saturday 10 January 1998
Russia: sex, drugs, and AIDS and MSF
Hans Veeken
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"Russians like to use drugs intravenously; it is culturally accepted," says Vitalic without hesitation. I wonder if it is related to the preference of Russian doctors and patients for injectable drugs, but he goes on: "We do not like pills or smoking; we Russians go for the real thing." Vitalic is one of the outreach workers, trained by Médecins Sans Frontières to give preventive education on AIDS to intravenous drug misusers in the streets of Moscow. He seems the right person for the job. His hair is purple and with his tattoos and piercings he looks like a stereotypical drug misuser in the West. But I'm told that most injecting drug misusers in Russia are not easy to recognise: they are youngsters who shoot drugs before going home and they do so rather incognito.
| We sit in Vitalic's tiny office in the middle of Moscow, not far from the Kremlin. There is Russian pop music, and outreach workers walk in and out: it resembles a youth centre. "There are an estimated 100,000 injecting drug misusers in Moscow. But cities such as Leningrad, Kalinigrad, and Rostov will have similar numbers. Users are mostly between 15 and 25 years of age, but some are as young as 12. Drug misusers are not losers as in the West," Vitalic explains. "They lead a regular life, attend school, and socialise freely with non-users, which includes having sexual relationships." This makes the dynamics of the epidemic in the Russian context more frightenening, as the virus can spread rapidly to the rest of the society. |  |
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| People lying in the street are not rare in Moscow Photo: THE TIMES/FEATURES |
Ketamine is popular among schoolchildren, who use it intramuscularly. They buy the drug from babuschkas (the typical Russian grannies) in the street, one dollar per ml. "Some use up to twenty cc a day," Vitalic says. I wonder where the babuschkas get the drug from. I'm told there is a complete circuit functioning. Medical personnel are selling the drug in quantities to the mafia, who use babushkas to sell it on the street. These elderly women need the money desperately as their pensions are insufficient; bribes keep the circuit running.
"Other drugs that are sold are home made," says Vitalic. "Vint is very popular, it is based on ephedrine, extracted in a laborious process from cough syrup. The chemical ingredients for the process, such as sodium hydroxide, iodine, and phosphorus, are sold, prepacked in a kit, on the street. You can buy the cocktail ready made but that is expensive. Usually people share it with friends," Vitalic explains. "Why don't we go out and you see for yourself what it is like"?
We walk to Lubyanka, the main square opposite the former KGB building. Next to the metro entrance we watch drug misusers silently exchanging money with old ladies dressed in gowns. You need to know what is happening otherwise you would not notice. But then I see a girl injecting herself through her trousers. I'm curious to see what will happen. Five minutes later she jumps up, screams, gesticulates in all directions, and falls on the ground. Nobody seems to care. A policeman nearby looks the other way.
The babuschkas would sell her another shot if they were asked - they have no mercy, selling is their own survival. The girl's friends ignore her - they have enough problems. People lying knocked out on the street are not rare in Moscow. Most are homeless, the empty vodka bottle still clamped in their hands. I'm told jokingly: "If a Russian is seen drunk in public we will never say he is drunk. We say: "He did not eat enough."
142 million HIV tests
The first case of HIV in Russia was detected in 1987. But the government always denied that an epidemic could happen in Russia. However, in the same year an outbreak was reported from paediatric hospitals in the south of Russia: 300 children were infected through the use of unsterile needles. More cases were reported from other institutions; the government's response was mandatory testing and isolation of cases. AIDS centres were established where patients with HIV infection had to report and get their contacts traced. In total 142 million tests have been performed. One hundred and nintey six new cases of HIV were reported in 1995 and 1,535 in 1996.
Russia has 142 million inhabitants. The country is 2.5 times as large as the USA and stretches out across 11 time zones. Since the breakdown of the Soviet Union in 1991 the economy has collapsed and the healthcare system has broken down. Average life expectancy has dropped to 65 years.
The Ministry of Health was shaken by an epidemic among intravenous drug misusers in the neighbouring states of Ukraine and Belarus. The figures showed that 60% of the intravenous drug misusers in some towns were HIV positive - a scary figure as injecting drug misuse is increasing sharply in Russia. In the first half of 1997 a total of 1887 people were reported to be HIV positive and 1669 of them were intravenous drug misusers.
With health budgets depleted, the incidence of sexually transmitted diseases rose alarmingly (the incidence of syphilis rose from 34/100,000 in 1993 to 265/100,000 in 1996). Combined with an increase in intravenous drug misuse and a government that lacks insight and experience an HIV epidemic is inevitable. The Ministry of Health projects that there will be 800,000 HIV infected people in Russia by the year 2000. It needs to act now to prevent these cases. In one respect Russia is in a favourable position: the pandemic arrives 10 years later than in other countries and it can benefit from the experience of other countries.
"Safe sex" in the metro
In 1997 an AIDS prevention programme with three main components was started: a mass information campaign on safe sex; education of intravenous drug misusers; and training of healthcare workers. "This week the first public transport buses are driving through town with the posters: "Safe sex, my choice," says Oscar, the coordinator of the programme. "Next week there will be bill boards in the metro showing the same message. A video clip is broadcast several times a day on major television channels. The programme has been designed with the Ministry of Health; a Russian agency produced the clippings and the posters; the Dutch foundation for sexually transmitted diseases was consulted in the setup of the mass campaign." The message of the campaign, safe sex my choice, promotes the use of condoms; the approach is positive. In the past government posters have carried more negative, frightening images.
Health care on the bus
The next day I visit a mobile clinic run by Médecins Sans Frontières for homeless people. The clinic bus is parked strategically next to a train station where the homeless gather. It moves on to various locations in the city. The doctor is busy cleaning ulcers on people's legs. "Homeless people are mostly alcoholics," he explains. "They drink vodka until they fall on the ground and sleep. Many of them are ex-prisoners; they lost their apartment and papers. Others are divorced, ran away, or were kicked out." The ulcers smell but he stays friendly and continues his duties. "Health care is for free, but they have no papers to prove they are entitled to get the free treatment. Often they come from far away places or even different republics and have no means to go back home. Just giving them a ticket will do, to solve their problem. Before we refer them, they are washed, disinfected, deloused; their scabies treated; and if possible we hand out new clothes. We also provide social help." The social worker turns out to be a cardiologist. He laughs at my surprise on finding this out. "I was in genetic cardiological research before. I had to move back to clinical medicine because there was no money to continue the research. There was no material and I simply got no salary. But even as a doctor I could not survive to make a living for my family." He explains he earns 300 dollars a month in the hospital and Moscow is rated as the third most expensive city in the world.
Crisis
Russia faces a serious crisis. Walking in the streets one can not miss the vulnerable groups such as homeless people, alcohol misuers, and isolated elderly people. The drug scene, however, is more difficult to identify but is of particular importance from a public health point of view. In Russia an AIDS epidemic is looming. Action should be taken now as the number of people who are HIV positive increases rapidly.
Hans Veeken, public health consultant
email: hans_veeken@amsterdam.msj.org
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