1.7 Médecins Du Monde France - Street Children Project

Of all the medical/psycho-social programs for street children in St.Petersburg, the Médecins du Monde France project is the most comprehensive and wide ranging. Médecins du Monde Frances links with the health authorities and hospitals, their networks and agreements with epidemeological institutes; the social services coupled with their links with international and local NGOs provide a strong framework within which to conduct activities. The commitment of their social workers, psychologists and physicians both on the street and in the various medical centres is extremely high and their institutional knowledge unparalleled.

The focal point of Médecins du Monde Frances activities is carried out at Lakhtinskaya Street No.7. A team of doctors, assistants, nurses, psychologists and social workers offer a variety of services and material support to children from 16.00-21.00, 7 days a week.

Services

Primary health care

Access to free pharmaceutical products/PHC/essential medicines for epilepsy etc

Washing facilities

Clean clothes and underwear/disposal of old clothes

Psychological counselling

Blood testing intravenous and sexually transmitted diseases

Condom distribution/sex education

Information on Aids, drugs, alcohol

Facilitating a childs accomodation in a shelter or other unit

Arranging secondary health care treatment

Legal Advice

Networking between child/parents, arranging for a child's return to his/her home

In addition to this Medical Centre, "street interventions" are carried out 6 times per week in the Tousovkas : the metro and railway stations where the street children gather.

"Street interventions" are carried out by doctors, social workers and psychologists, providing social and medical services which build relationships built on trust and encourage the children to enter into less harmful environments.

Médecins du Monde France also operates a medical service at the state operated "Social Hotel" in the Petrogradskiy district and have developed a fixed point clinic at a lodging hotel for children run by a Christian organisation at Rasstayania Street No.19. The clinics provide primary health care as well as health education and awareness campaigns.

Médecins du Monde France are plan to construct a night centre with partial funding from UNICEF. This will provide a link for the children with 2/3 good shelters that operate in the city. The main problem with shelters is that they have quite rigid rules. Children who are taken straight off the streets often have behavioural problems which make it extremely difficult for them to abide by the rules of the shelter. This results in an extremely high "drop out" rate, with street children leaving the shelters less than 3 weeks after they have arrived.

The aim of the night centre is to provide a safe environment with certain conditions attached -- no drugs, no sex etc. but which is nevertheless not as rigid in nature as the shelters are perceived to be by the children. The night centre would be staffed by trusted Médecins du Monde France staff with whom the children have built trust from their work in the Medical Centre and on the street. UNICEF will provide a proportion of the funding for this night centre which will be built on municipal property in order to avoid paying rent with the intention of one day transitioning the structure to the municipal authorities via a local NGO.

A diagram on the following page illustrates how Médecins du Monde France structures, current and proposed are designed to encourage the flow of children off the streets and into more secure environments.

1.8 Médecins Du Monde France: Structures

1.9 Médecins du Monde Sweden Mission in St.Petersburg - Street Children

For reasons which will be elaborated on in the conclusions of this report, Läkare i Världen - Médecins du Monde Sweden should set up a long duration mission in St.Petersburg. Given the knowledge and experience of Médecins du Monde France, Médecins du Monde Sweden should implement a program which complements the projects of Médecins du Monde France and which can be carried out in collaboration with the existing Médecins du Monde France structures in the field and, crucially, their office in St.Petersburg. All activities should be conducted in close coordination with the Médecins du Monde France head of mission responsible and the Eastern European Desk in Paris. Agreements regarding areas of responsibility should be drawn up and signed once funding has been secured.

This assessment mission recommends the establishment of a concrete project to be implemented as soon as possible and for which an initial assessment has been carried out based on needs identified. It concerns the construction/rehabilitation of a public building space located in an area of social deprivation in the north of the city.

The rehabilitation of this space is to provide for a day centre for street children. This day centre will complement the planned night centre of Médecins du Monde France and will provide a focal point for street children in order to establish a warm, secure, day location as a substitute to the street. Educational and social activities would be conducted at this day care centre from 09.00 to 17.00 which would mirror the bridging mechanism of the night centre of Médecins du Monde France. Securely attached audio-visual equipment would provide street children with educational activities and entertainment to counteract the attractions of alcohol, solvents and heroin. Alternative forms of schooling could be introduced, including innovative methods of English teaching. A form of probation service could be set up to ensure that those children with criminal records to be encouraged to develop in other directions. As part of a wider knowledge transfer program, Médecins du Monde Sweden should bring probation service experts specialising in child crime, social welfare and reform to train their Russian counterparts in the social services and police force in liasion and supervision work.

It is envisiaged that the day centre would be operated by experienced staff who have built a working relationship with the children and earned their trust. It could be that Médecins du Monde France outreach social workers and others would be in a position to staff the centre once it is completed.

Médecins du Monde Sweden should also undertake to establish a full time medical presence in St Petersburg as quickly as funding allows. One possibility would be to recruit and finance the salaries of a doctor and nurse who are currently paid via Médecins du Monde USA (Doctors of the World), as DoW have intimated that there is only funding available for these positions for another two months. This doctor and nurse work under the superivision of the Médecins du Monde France Coordinators and it is envisaged that such a working relationship would continue.

The building which should be rehabilitated has already been provisionally assessed. While structurally sound, the creation of a second exit to comply with fire safety regulations will have to be created. The floor will have to be concreted. The space itself will have to be fumigated and cleaned. Rehabiliation work will include, plastering, painting, flooring, furnishing, the installation of toilets, bathroom, sprinkler system, some electrical fittings and complete furnishing. Initial costing of this 175 metre square building estimated at some 45,000 Euros.

Action: Médecins du Monde Sweden should begin to seek funding for a first stage of 50,000 Euros immediately.

2.0 Heroin Use in St Petersburg: Overview

As with the street children, the other marginalised grouping assessed in this report, accurate data regarding the total number of heroin users in St Peterburg is impossible to obtain at this time.

An official state gazette published a law on Prevention Matters Relating to Anti-AIDS infection cited a figure of 300,000 users in a city with a registered population of approximately 5 million persons. The Chairman of the Municipal Health Committee has stated that the number is around 200,000. Specialists working in the field of harm reduction for Médecins du Monde France and at the main hospital for infectious diseases (4) estimate a figure of between 150,000 to 200,000.

For the purposes of this report, the most conservative estimate of 100,000 is used in order not bring into doubt the profound magnitude of the situation. Figures based on this conservative estimate would suggest that heroin users constitute 2% of the population of St.Petersburg. Observations based on action and field research suggest that this relatively significant figure within the population is indeed, a conservative estimate.

There are a number of factors which could be considered significant in terms of explaining such massive intravenous drug consumption. As in the United States, heroin emerged for the as a significant factor for the first time following a war in a foreign country. Like the Vietnam veterans, Soviet soldiers in Afghanistan brought their habit discovered during a war without victory back to their home cities. Yet heroin use in Russia during the late 1980s was a relatively insignificant factor and did not forecast the epidemic of the last four years.

The first really significant factor was the massive economic decline and social dislocation in Russia which has occured over the last 10 years. The implosion of social order and institutions, of health services, youth groups and other social institutions, extended periods of hyper-inflation, political instability, attempted coups, the wars in Tajikistan, Chechnya, Ossetia, Abkhazia, Armenia and Azerbajian; the emergence of mass unemployment, the collapse of the Rouble and devaluation in the late 90's, the rise of the mafia, the absence of the enforcement of the rule of law, conflicting legal codes coupled with the unparalleled rate of privatisation. The political, economic and social disintegration that Russian citizens have witnessed over this period has undoubtedly played a role in creating the conditions for such an explosion of heroin use.

Other factors could be medical/cultural in nature. In Western Europe, most medications are now taken orally with only a relatively small number of vaccines and anaesthetics given intravenously. The dislike amongst western patients and consumers of the"unnatural" act of intravenous injection has been accentuated by the fact that comparitively few persons in the west, save diabetics and other minority groupings, are required to inject intravenously. This has not occured in Russia nor in many other parts of Eastern Europe, where injections play an prominent role in primary health care. Because of the onus on injections relating to medical matters it is possible to summarise that Russian youth does not view intravenous drug use as alien and with the same degree of trepidation as his counterpart in United Kingdom, where, according to some studies, up to 0.5 million pills of ecstasy were "popped" on bank holiday weekends during the summer of 1997.(5)

Another extremely important factor was and is the level of ignorance surrounding heroin use. In Sweden, a highly effective awareness campaign operated during the 1970s and 1980s and is often cited by Swedish young people as the primary reason for their relatively low consumption of illegal drugs. No such specifc, targeted, nation-wide campaign has operated in Russia. Ignorance as to the side-effects of heroin and the infectious diseases relating to usage remains extremely high.

Another crucial factor is market price and availability. Heroin is readily available in St.Petersburg and the costs are low. With a quarter to a gramme of heroin costing anything between 50 to 600 Roubles on the street, it is clear that a heroin habit, especially one supported through prostitution or criminal activities can be sustained for some time. The heroin route from Tajikistan is overland, simplifying a smuggling process made easier by the chaos and dissolution that marked the break up of the Soviet Union. These factors coupled with the low salaries of police, customs officials and the rise of transnational criminal organisations explain the ease with which small cells of drug smugglers or multi-million dollar operations import heroin to St.Petersburg. With the market price of 1 kg of heroin currently at 1000 US $ in Tajikistan, it is not difficult to surmise why so many are involved in this lucrative trade. Consumption has been stimulated by social, economic and poltical chaos, the same factors which have allowed such illegal trade to go unregulated for so long. The key variable which outside agencies may use to reduce the epidemic is through the reduction of ignorance through knowledge transfer.

4. The Bodkin Hospital, also known as Hospital no. 30.
5. Source: UK Drug Alert

2.1 Impressions from the Street

During the assessment mission, Médecins du Monde Sweden visited 4 locations on the Eastern, Western and Northern peripheries of St.Petersburg. The areas consisted of massive housing estates comprising of tower blocks built in the 1960's and 1970's - precisely the kind or areas believed by social scientists in the United Kingdom to be partially responsible for encouraging drug use through alienation, a lack of basic amenities and alternative entertainments etc.

Médecins du Monde Sweden accompanied the harm reduction bus operated by Médecins du Monde France and had the opportunity to observe hundreds of heroin users aged between 15 and 35 exchange dirty needles for clean ones, seek psychological assistance, medical attention, blood testing and other services.

The number of users was staggering, particularly when taking into account that it is only physically possible to cover a small area of St Petersburg and that only an estimated 25-30% of all users within the small areas covered avail themselves of the services provided on the bus.

Médecins du Monde Sweden also met with a significant number of heroin users who have been diagnosed as HIV-positive through voluntary blood testing.

The impression gained from the street is that only is there an epidemic in terms of heroin usage, but an HIV epidemic that is only now beginning to manifest itself due to the early stages of the process, psychological, legal and environmental factors.

Talking to heroin users it became clear that those interviewed attributed ignorance as a major factor relating to usage. Others stated that they lived in what are called "sleeping areas" -- there is no work in the housing estates, workers would travel to factories several miles away. Now a significant proportion of these factories are closed resulting in chronic, mass unemployment.

The impression gained from the street is that heroin users in Russia cannot be categorised in the manner of their counterparts in western Europe. People belonging to different ages, income groups and sub-cultures visited the bus. The nature of the epidemic seemed evident from the fact that it looked like most groups within Russian youth culture seemed to be involved. The cross-section of Russian society involved was staggering. There were those who had just learnt that they were HIV-positive, there were heroin users of many years, there were gangs of non-descript teenagers, young girls, sex workers and mothers. Toward the end of the night a user of 16 got on the bus in some distress. She was a 16 year old girl who had just discovered her flat mate dead from an overdose. She was distraught because she knew she would have to tell the police who generally do not view heroin users in anything approaching a sympathetic manner. The Médecins du Monde France staff calmed her down and counseled her on what to say to the police.

At all times the heroin users behaved in polite and often friendly manner while queuing for their syringes, dispelling some of the stereotypes held by the author. Heroin users constitute an extremely vulnerable group within Russian society. They should be afforded their human rights.

6. Variation in prices determined by the purity of the dosage (%cut with other substances), geographical area of purchase, quantity bought)

2.2 Heroin Use Data

As mentioned previously, there is no reliable data regarding the overall heroin use in St.Petersburg. Most figures are drawn from estimates from extrapolations the basis for which are often unreliable in themselves. This assessment therefore refers to small-scale field surveys carried out by Médecins du Monde France during the course of their harm reduction program and as such constitutes one of the most reliable sources regarding heroin use in St.Petersburg.

Médecins du Monde France exchanged approximately 146,000 syringes and registered 2075 new users during 2000. This represents an estimated 25% of the total number of users in the small areas that one harm reduction bus can cover during the course of a year. (7) A number of users agreed to be surveyed.

Age of User	Number of Users Registered
14 years old	3
14 - 15 years old	58
16 -17 years old	226
18 - 19 years old	403
20 - 24 years old	839
24 - 29 years old	387

7. The modus operandi of the project was to station the bus at a particular time and a particular place for a number of hours in order to establish a fixed routine which would encourage users to visit and exchange needles. Given the large open spaces covered by the vast housing estates, the time consuming nature of needle exchange, medical examination, blood testing, psychological support and thus the relatively long periods needed to be spent in 1 place, it is impossible for one bus to effectively cover a larger number of users without degrading its capacity to serve those already registered within walking distance. For more on harm reduction, please see section dedicated to the activities of Médecins du Monde France.

2.3 HIV-positive Data

The most potentially devastating statistics to emerge from the multi-location, Médecins du Monde France surveys concern their HIV-positive data collection program based on the testing carried out amongst the minority of users who volunteer for blood testing for HIV.

Month	Number tested	Number Tested HIV +	% HIV +
January	128	7	5.5
February	269	31	11.5
March	254	36	14.2
April	213	24	11.3
May	202	25	14.4
June	292	63	21.6
July	283	70	24.8
August	132	22	16.4
September	148	29	19.6
October	136	27	19.9
November	230	53	23
December	217	55	25.3

Of particular note are the figures showing an extreme acceleration in the rate of HIV infection. This survey was carried out in a number of St Petersburg suburbs in differing areas of the city. If they underline a general trend, and this trend continues into 2001, these statistics denote the onset of a particularly devastating AIDS epidemic with heroin use as the main source of transmission.

Other statistics released and recognised as reliable include the following:

There were 4494 cases of HIV infection registered in St Petersburg between 01.01.87 and 01.10.00. 3652 of these cases were registered in the first 10 months of 2000. During the month of October 805 new cases were registered against 440 cases for the whole of the year 1999. 95% of these cases are due to heroin use.

Hepatitis B and C are also common amongst heroin users. There is a serious problem because in Russia there is no state financial support available to any persons suffering from these diseases.

Vaccinations cost 10 US $. There are only 20 hospital beds available to those in the city suffering from multiple infectious diseases such as TB and Hepatitis B and C.

Hepatitis B & C statistics from multi-location survey

Disease	Number Tested	% Tested Positive
Hepatitis B	779	53%
Hepatitis C	920	66%

2.4 Médecins du Monde France Harm Reduction Program

The Médecins du Monde France Harm Reduction Program constitutes the most comprehensive project of its kind in St.Petersburg.(8)

A 45 seat touring passenger coach has been converted into a mobile clinic with a needle exchange system and hygene program combined with medical, psycho-social and blood testing services. A staff of doctors, nurses, psychologists, assistants and drivers man the bus in shifts, allowing it to operate 6 days a week at fixed points in St.Petersburgs many housing estates, located in the northern, eastern, western and southern peripheries.

Médecins du Monde France promote harm reduction through awareness campaigns conducted through leaflets and posters. These leaflets focus on aspects of health relating to heroin use, such as Hepatitis B and C awareness, emergency first aid in the event of an overdose, what to say to ambulance services, how the police should treat you (legal rights etc). Médecins du Monde France operate a response hotline to counter disinformation regarding heroin use and HIV. A recent example of which was the urban myth (apparently widely believed) that the bones of AIDS casualties was being ground up into the heroin: the heroin was thus infected with the virus making clean needles and the needle exchange irrelevant. Médecins du Monde France immediately issued a rebuttal of this false information. Médecins du Monde France also operate a harm reduction program for the many sex workers who use heroin and treat sexually transmitted diseases with a doctor and nurse specifically assigned to this task.

Médecins du Monde France are trying to facilitate the establishment of support groups for those living with HIV infection and those living with heroin use. Support groups are of particular value in the longer term and can serve as extremely important tools in the battle for awareness, public understanding, government funding and the lessening of prejudice and discrimination.

Another extremely important step is the creation of a network of doctors, public health workers, Non-governamental Organization (NGO) activists from various cities throughout Russia who are attempting to combat the heroin epidemic and the emerging HIV threat. Médecins du Monde established the group and organised the first meeting which was held in St Petersburg. The group is called "Doctors New Initiative" and seeks to share information and techniques regarding awareness, harm reduction and prevention programs operating in the various member cities. It also aims to act as a common front to lobby government for increased resources and funding to combat the epidemic. It could act as a facilitator in the knowledge transfer process.

8. Other harm reduction programs are operated by the Return Foundation and the City Hepatological Centre with support from the City of Malmö. There are reports that the Malmö supported project is running out of funds.

2.5 Médecins du Monde Sweden Mission in St.Petersburg -- Infectious Diseases Program

While the attitude of the Swedish government towards harm reduction programs is currently perceived as negative (9), and restricts the possibility for governmental funding within Sweden, there is considerable scope and need for a Infectious Diseases Program.

From the available data and even utilising the most conservative drug use estimates available, it appears as though St.Petersburg is at the entry point of an unprecedented HIV epidemic by Eastern or Western European standards. This situation must be closely monitored for it has the potential to pose one of the most serious environmental and human welfare risks in the Baltic region. If the multi-location micro-surveys conducted by Médecins du Monde France prove to be an indicator of a general trend, then the HIV epidemic represents a human catastrophe for Russia, but a national security threat to the Baltic states and Sweden itself.

This assessment report recommends that Médecins du Monde Sweden in collaboration with the leading infectious diseases research unit in Sweden, the Karolinska Institute (KI) establish a monitoring service to monitor and track the emergence of the possible HIV epidemic in St Petersburg. Given the close relationship between KI and Médecins du Monde Sweden, this report recommends the establishment of a working relationship between KI with field implementation and liasion by Médecins du Monde Sweden on the one hand, and Médecins du Monde France and the Doctors New Initiative on the other. This relationship would facilitate closer links between the research institutions and field NGOs in the countries concerned in order to facilitate the knowledge transfer process at a research and institutional level and awareness, prevention and harm reduction campaigns on the streets and in the media.

Activities regarding the founding of self-support groups to encourage sustainability and local capacity building should also be actively encouraged by Médecins du Monde Sweden in cooperation with local partners. While impetus and initiative for self-support groups must come from people living with HIV and trying to stop taking heroin themselves, there is no reason why Médecins du Monde Sweden cannot facilitate this local support process by providing space within which the activities of these extremely vital groupings can take place.

Action: Médecins du Monde Sweden in conjunction with KI should form a working group to assess possibilities and implement concrete measures in the aforementioned directions.

9. The Swedish government tends to prefer "Prevention" programs over harm reduction. While some label this policy as "repressive" it is clearly to late to effect a comprehensive prevention program given the prevalence of heroin use existing within the city and the lack of adequate law enforcement mechanisms and sea borders to halt the "market forces" which stimulate importation.

2.6 Human Rights, Legal Issues & Law Enforcement

One of the principle barriers standing in the way of street children accessing their right under the United Nations Convention of the Rights of the Child to medical care is the fact that many of them lack the correct documentation. The "Propiska" is the stamp in the internal Russian passport which notifies doctors, nurses, police and the health authorities that the holder of the stamp is registered in a certain city, town or village. If the person seeks state medical care in a region outside his or her "Propiska" area, then he or she will be denied it.

An ever increasing number of the children living on the streets of St Petersburg are not registered with the local authorities of that city. This makes state primary health and secondary care impossible for them.

Similarly, both street children and heroin users are subject to beatings and illegal detentions by certain police officers. Heroin users are often actively persecuted by police officers. Such persecution can be lawful when heroin users break Russian legal codes. However, drug users are subject to arbitrary arrest, police break new syringes and females are often exposed to sexual misconduct on the part of the police.

It is clear that there is the need for both knowledge transfer and field liasion when it comes to improving relationships between the police and the street children. This could be facilitated through a knowledge transfer and liasion process facilitated by a trained and experience probation officer who would train both social workers and police, drawing from his/her practical and theoretical experience. The probation officer would also educate the children on their rights under law and also suggest ways and means to lessen police hostility to them.

Based on the experiences of Médecins du Monde France, it is also necessary to provide the police with information on how to physically treat persons who may be infected with HIV, and on how to behave toward sex workers by drawing on anecdotes and role plays.

Finally, the establishment of a program which involves not only knowledge transfer, training and information flows, but of exchange would be of enormous benefit for doctors, nurses, social workers, public health officials and police in whose hands the task of improving the human rights both of the street children and the heroin users, lies.

2.7 Conclusions & Recommended Actions

This assessment report recommends that Médecins du Monde Sweden establish a mission of long duration in St.Petersburg. The assessment has focused on two vulnerable elements within the population, however, it is clear that there are needs to be met in a great many spheres and that Russian doctors would willingly cooperate in joint projects with their Swedish counterparts across the medical spectrum, ranging from reproductive health through to infectious diseases.

The geographic position in St. Petersburg generates an interest on the part of the Swedish people and state as to what goes on there. This is particularly true in matters relating to the potential HIV epidemic which knows no state boundaries and can be considered a matter of national security for Sweden.

Thus work should begin immediately on seeking funds for the initial Médecins du Monde Sweden Street Child Project. As described earlier in the report, this project will rehabilitate space for a day centre, provide for local medical staff, awareness literature for street children and the initiation of a permanent mission in collaboration with Médecins du Monde France and local partner NGOs. The project should complement the programs of Médecins du Monde France and as such should be carried out in close cooperation with the St Petersburg office, the head of mission and the desk officer in Paris.

A working group composed of KaroIinska Institute and Médecins du Monde Sweden members should be formed immediately to initiate an infectious diseases project based on HIV prevalence/incidence monitoring, knowledge transfer, network strengthening, training and exchange programs.

This updated version of the report is on the Médecins du Monde Sweden website along with maps and photographs in order to begin the process of heightening the awareness of the Swedish general public to the problems in St Petersburg. This awareness raising process will be accentuated through public speaking engagements and lectures as part of the preparatory stage.