Professionals tend to conceive the general population as a mostly uneducated mass with tendency to self-destruction, illustrating it by historical and not very old examples of attacks on doctors during epidemics. On the other side, the population, especially when organized in groups possesses the enormous ability to self-protection, even when the mostly ‘professional’ state-owned mechanisms are broken. The amazing example of this society self-protection was brought by Russia’s modern life.
The problems with illicit drug use are growing in all post-Soviet space, including Russia. According to official and very approximate estimates, the number of only heroin users in Russia is about two millions. This is the largest heroin-using population in the world. In Russia, injection drug use is the major route of spreading of HIV epidemic, one of the fastest growing HIV/AIDS epidemics in the world. Of the 375 tons of heroin exported from Afghanistan, 1/5 goes to Russia. President Medvedev called the heroin illegal use as the national security threat. Moreover, Russian drug control agency says that locally produced synthetic drugs became even more important threat.
Unfortunately, Russia inherited from Soviet Union the punitive approach to users of illicit drugs. Drug users are criminalized and even medical care for them is a kind of punishment.1,2 In 2009, Russia rejected the cooperation with Global Fund and other international organizations; the Russian non-government organizations are closing one after another. The very patchy and unsustainable harm reduction network is disappearing all around Russia. The medical care provided by state to drug addicts consists of short detoxication, and the possibilities for continuous care are tragically limited. Russian Government refuses to fund any harm-reduction programs. The federal law prohibits the drug substitution therapy. Moscow government even blamed international organizations for Russia’s HIV epidemic, as an explanation of why their access to Russia is limited.
In the tragic situation when police invests more in oppressing the addicts than drug dealers, and treatment of addiction is not available, a few new organizations have appeared in a couple of Russian cities. The most famous is the Gorod Bez Narkotikov (City Without Drugs Fund) organization, created in Ural city Yekaterinburg in 1999. The organizations of this type usually provide care for addicts and provide information about dealers to police. The care consists of detoxification in the style pictured by Gene Hackman in ‘French Connection’—with chaining to the naked bed, fasting and subsequent rehabilitation in the closed community. The reportedly high efficacy of treatment in Yekaterinburg assured the almost total approval of Fund’s efforts by the population. Many addicts arrive to the ‘rehabilitation centre’ by themselves, but others are brought by parents or even hijacked by relatives with or without the support from the Fund to the centre.
In 2010, Yegor Bychkov and two other activists of the Fund from another Ural city Nizhni Tagil were accused of illegal imprisonment and torturing by drug addicts, who succeed to escape from the ‘rehabilitation centre’. State prosecutors supported the accusation literally saying that defendant induced the enormous suffering to people by depriving them from heroin. The court took into account the formal agreements signed by parents of these addicts with Mr Bychkov with intention to use the services of the ‘rehabilitation centre’. The first instance, court sentenced Mr Bychkov to prison for 3 years, but the appellation court changed the verdict to conditional term.
This change of the verdict was done under significant pressure from public opinion. Not only a number of manifestations around the country in defense of Mr Bychkov and others took place, but hundreds of newspapers published the articles of supportive nature. Sympathetic comments were provided by head of the national Drug Control Agency, leading specialist in narcology for the federal Ministry of health, and even by president Medvedev. The main point of the disagreement with Mr Bychkov was that only state can enforce treatment. Leading narcologist Dr Briun insisted on the wording ‘involuntary hospitalization’, classifying the actions by Mr Bychkov as illegal enforcement. Under current Russian law, psychiatric treatment (narcology is in the domain of psychiatry) may be involuntary only in severe cases when it is approved by the court. Actually, the state bodies want to have the legal possibility to send injection drug users beyond the fence for the isolation and enforced treatment. Of course, they want to have this possibility only in the hands of the state, and they do not want to discuss what they can offer as a compulsory care. At this time, the public understands the difference. On the one hand, state-owned clinics go by the law, but addicts get nothing except useless sedatives and beating; the support after the care is negligible—the relapse rate is almost 100% in couple of months. On the other, although ‘illegal’: City Without Drugs; harsh treatment, but the effect is reflected even in the city ambulance statistics. From 1999 to 2003, deaths from overdose in Yekaterinburg were reduced from 302 to 26.
As of Mr Bychkov, after the short-term imprisonment he is now free, and recently newspapers reported that he is going to reopen the ‘rehabilitation centre’. His work will be greatly appreciated by people of the Nizhni Tagil, because this is the only viable option comparing to short detoxication in state clinics and expensive and unscientific commercial services.
Yet, this is so far the only example of the self-organization of the Russian society for the health and well-being. There is a need for more because of the unprecedentedly high mortality and ineffective and unfair health-care system. In all countries, the care for drug addicts had been modelled under the strong pressure from the local communities and groups of interests. This is not an obstacle, but a normal reaction from the community responsible for its well-being and prosperity.