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Delhi roma&drugs Delhi roma&drugs Presentation Transcript

  • Marel o Del, kas kamel, le Romes duvar (God hits whom he chooses; the Rom gets hit twice) An Exploration of Drug Use and HIV Risks among the Roma of Central and Eastern Europe Jean-Paul C. Grund, Hans Verbraeck, Paul Öfner Project Group Roma & Drugs, DV8 Research, Training & Development, Rotterdam/Amsterdam, The Netherlands, Frankfurt/M, Germany
  • Acknowledgements • Funder: International Harm Reduction program, Open Society Institute, New York. • Conducted by: DV8 Research, Training & Development. • We thank the board of DV8 for their intermediary efforts and general support, and Anita van der Hulst for managing the financial side of the project. • We thank all our interview respondents in the Czech and Slovak Republics, Hungary and Poland. • Likewise, our gratitude extends to the respondents of the Internet survey in cities across Central and Eastern Europe. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Acknowledgements • We also wish to thank our three interpreters, Ruben Pellar (CZ), Molnár Gábor (HU), Hanna Sokolowska, (PL) for their excellent services. • We thank Natalia Bobrova for her help with translating, managing and analyzing the Internet-based survey. • Josef Radimecky from the Czech Republic, Danica Klempova and Katarína Jiresová, both from the Slovak Republic, are thanked for providing additional data on access to treatment of Roma drug users. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Acknowledgements • During the writing process we benefited from the contributions of several people from all points of the compass, who deserve our gratitude. • These include the anonymous reviewers within the OSI network and Sue Simon who collected these reviews; • Dave Burrows (AU), Richard Braam (NL), Tomás Zábranski (CZ), Andor Ürmös (HU) and Natalia Bobrova (USA) for reviewing draft versions. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Background • Roma migrated from India in the late Middle Ages • They are probably the first, but certainly the largest “Ethnic Minority” in Europe. • Roma have a Long history of being subjected to Exploitation, Segregation and Persecution, not much unlike the history of the Jewish People. • After the social political changes in Central Eastern Europe and the Newly Independent States (CEE/NIS), Roma were hit hardest by the economic consequences of the newly evolving free market. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Background • Long history of problem use of alcohol and solvents. • Anecdotal Reports suggest rapid diffusion of Illicit drugs into Roma communities in all corners of Central Eastern Europe and the Newly Independent States. • Almost complete lack of research. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Research Questions • Main project goal: To describe the state-of-the-art information among experts and other key informers on the extent and nature of injection drug use and associated health risks among Roma in Eastern Europe. • Resulting research questions: – What is the extent and nature of (injecting) drug use in the Roma communities in Eastern Europe; – What is the extent and nature of HIV/AIDS risk behaviors among Roma drug injectors. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Research Questions • To inform the development of pragmatic communitybased HIV prevention and treatment activities for Roma drug users, the study also explored: – Existing initiatives and strategies in Roma communities that address drug use related health problems; – The level of awareness of the hazards to community health of an injecting drug use epidemic in Roma communities; – The interest among Roma organizations and activists to develop pragmatic community-based HIV prevention and drug treatment strategies. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Overview of Methodology Explorative Pilot Study • Literature Review • Internet-based Survey of Experts and Key Respondents (Treatment and HIV Prevention Providers) • In-depth Interview Study of Key Respondents in Czech Republic, Slovakia, Poland and Hungary • Key Respondents: National Policy Makers, Journalists, Representatives of Roma Self-Organizations, Treatment and Needle Exchange Providers, and (Peer) Outreach Workers 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Overview of Methodology • The Internet survey instrument was based on the original research questions and preliminary findings. • The survey aimed to generate a bird’s eye view of the total region—to get an impression of the extent of drug use; not to generate statistically analyzable data. • Survey data were entered into Excel and presented in table form. • Statistical analysis was not conducted, but data was cross-tabulated to compute approximations of addiction rates and participation in treatment and HIV prevention. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Overview of Methodology Table 1. Respondents of the Interview Study Phase Telephone Interviews In-Depth Interviews Hungary 13 15 (4) Country Czech Republic Slovakia 15 6 19 (11) 7 (2) Poland 6 3 (1) • Interviews were conducted in English, German, Romanes, Czech, Hungarian and Polish. • Interviews lasted from one hour to more than two and a half hours. • All interviews were recorded on mini disk. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Overview of Methodology • All telephone and in-depth interviews were transcribed verbatim into word processor files. • After cleaning, the data was subjected to a qualitative “Content Analysis,” guided by a formal analysis protocol and code book. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Results Extent & Nature of Drug Use 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use • Both the interview study and the Internet survey found that a comprehensive view of drug use in Roma communities is absent in all countries. • Illicit drug use was unknown of in Roma communities before the “Velvet Revolutions.” – “Roma in the Czech Republic were not hard drug users. Before the revolution there was pervitin in the Czech republic, but Roma only sniffed toluene. After the revolution Roma started to experiment with marihuana and later with heroin and pervitin.” (Baron of Ostrava Olah Roma) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use Start of Drug Use in Hungarian Roma Communities • Around 1990 drugs began to trickle into the Roma community of Budapest. So-called “party drugs” became available in discotheques and clubs, which were almost exclusively frequented by young Roma. • According to the Hungarian Vice-Minister of Sport and Youth Affairs, the appearance of the first Roma heroin users came as “a complete surprise” to Hungarian policy makers. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use Start of Drug Use in Czech and Slovak Roma Communities • In 1995 Czech policy makers first became aware of the use of illicit drugs in the Roma community. • Staff of the center for Treatment of Drug Dependencies in Bratislava described that heroin use started among Roma in 1989, 1990 in the Olah Roma and Hungarian Roma communities in Bratislava. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use Prevalence Estimations: Cautionary Notes • In most CEE countries there are no reliable data available on the overall number of drug users. • Estimates of the number of Roma (or other minority) drug users are particularly problematic, as ethnicity/cultural background is not registered in health care facilities, including drug treatment and syringe exchange programs. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use Prevalence Estimations: Data from the Internet Survey Table 2. Total Number of IDUs and Roma IDUs by City City Sofia Szeged Estonia Vilnius Kishineu Novorossiisk Pskov Rostov Na Donu Volgograd Odessa Poltava 04/03/01, 12TH IHRC, New Delhi, India Total IDUs % of Population 15-20000 1-1.5 2500 1 7000-8000 0.4-0.5 2000-3000 0.3-0.5 1416 0.2 9000 3.6 380-440 0.2 10000 1 18000 1.7 25000 2 up to 10000 3 Roma % of Total % of Roma IDUs No. IDUs Community 2000 10-13 2 3-400 12-16 5-7 100-200 1-3 3-10 50-60 2-3 6-10 564 40 4 No Information Available No Information Provided 100 1 2.5 2300 13 19 500 2 2 2 >1 3 J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use Prevalence Estimations: Proxy Indicators • 25% of Patients of the Bratislava Center for Treatment of Drug Dependencies are Roma. • 23% of contacts of the street-based needle exchange program in the same city are Roma. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature of Drug Use Prevalence Estimations: Key Respondents • “it is our impression that of the younger generation Roma [in the Czech Republic] 10% is somehow touched by the drug problem.” (Policy Maker, Czech National Drug Commission) • Some 25% of heroinists are Roma.” (Chief Clinician, Drug Treatment Center, Budapest) • In my generation and milieu, I mean, among my friends, 30% are on drugs. That includes all drugs. Personally, I know 20 to 30 people who use hard drugs.” (Rom respondent, working on the establishment of Drug treatment center for Roma addicts in Budapest) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature Drug Use Drug Choice • Inhalation of solvents and alcohol abuse remain important problems in Roma communities throughout the region. • Solvent users are described as very young, with starting ages even under 10. • These youngsters reportedly switch to alcohol during their teens, and, in many cases, end up as alcoholics. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature Drug Use Drug Choice • In Slovakia and the Czech Republic, Roma drug users reportedly mostly use heroin. • In Budapest, speed, XTC and cannabis products are regular features of certain nightlife spots, frequented by Roma. • But treatment providers contend that heroin is widely used among Budapest Roma. • Amphetamine is reportedly the drug of choice among the Roma participants of the needle exchange program in Szeged. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature Drug Use Mode of Administration - Czech Republic • Mode of drug administration seems to vary by area, context of use, drug of choice and availability. • In Prague, few Roma heroin users seem to inject. But outside the capital, the picture becomes less clear. • There may be a geographical difference: – In Northern Moravia chasing is reportedly the norm. – Northern Bohemian users may be more likely to inject. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature Drug Use Mode of Administration - Slovak Republic • Information from Bratislava is ambiguous. Most of the Roma sex workers reached by the local needle exchange program are injecting. • But the experience of the local (methadone) treatment program may be more significant: “Roma started smoking heroin cigarettes. … They only inject heroin when they are short of money. Right now when they have money they are chasing the dragon.” (Nurse, Center for the Treatment of Drug Dependencies, Bratislava) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Extent & Nature Drug Use Mode of Administration - Hungary • In Budapest and elsewhere in Hungary drugs such as amphetamines and heroin seem to be used in various ways, depending on the specific context of use. • Drug injecting is on the rise among Budapest Roma. – “… in the last four to five years the patterns of addiction among Roma are shifting from the classic substances, … to intravenous drug use.” (Hungarian vice-minister of Sport and Youth Affairs) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Results HIV Risk Factors for Roma Drug Users 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • HIV Risk Factors for Roma Drug Users Prevalence of Injecting Drug Use • The Internet Survey suggests that injecting is the norm in the wider CEENIS region, among Roma and nonRoma alike. • In Hungary, Slovakia and the Czech Republic prevalence of injecting drug use among Roma is reportedly lower than among Non-Roma. • In these three countries IDU prevalence among Roma may vary from region to region and, in metropolitan areas, perhaps from neighborhood to neighborhood. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • HIV Risk Factors for Roma Drug Users Needle Sharing “Between Gadjé and Roma drug users [in Budapest] there is a major difference, Gadjé injecting drug users use their own needles, but Roma injecting drug users only have one needle that goes around.” “Needle sharing is not so popular in Usti, because they know from us the risks of HIV and hepatitis.” “[Roma IDUs in Plzen] do not accept needles. They do not buy needles at pharmacies, but share the needles. They share needles, but they do not understand the risks.” (Outreach Workers, Budapest, Usti nad Labem, Plzen) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • HIV Risk Factors for Roma Drug Users Group Drug Use • Roma use drugs in friendship groups. • Drugs are used as a “social lubricant.” • Sharing drugs is a common demeanor. – “Pervitin is used in groups. Sometimes heroin too. I know a case of a Rom who earned a lot of money through a marriage. He shared his heroin with his friends. Heroin bought with prostitution money is most of the time also shared among Roma.” (Outreach Worker, Plzen) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • HIV Risk Factors for Roma Drug Users Sexual Risks • Involvement in prostitution. • Roma street prostitutes are at the bottom of the hierarchy in the sex business. • Taboo on condom use. • HIV prevention campaigns are not aimed at or attuned to Roma culture. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Results Access to Drug Treatment and HIV Prevention 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Access to Drug Treatment and HIV Prevention • Little has been undertaken to design appropriate drugs and AIDS policies for Roma communities in CEENIS, or for minority communities in general. • Treatment and HIV prevention designed for or aimed at Roma drug users are virtually non-existent. • The isolated position of Roma is a large barrier to utilization, and development of services for Roma IDUs. • Awareness among Roma self-organizations is extremely low. Denial is a common response. As a result, community-based initiatives are in its infancy. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Access to Drug Treatment and HIV Prevention • Roma IDUs have limited access to clean injection equipment (both @ pharmacies and NEPs). • Roma do not apply for HIV counseling and testing. • Overall, participation of Roma in existing drug treatment programs is negligible. • In particular in high threshold facilities, such as residential therapeutic communities, Roma do very poorly. • Notable exceptions are methadone maintenance programs in some CEE cities attract many Roma heroin users. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Access to Drug Treatment and HIV Prevention Table 1. Proportion of Roma patients among a random sample of “Toximans” in treatment between 1992 and 1999 at ‘CPLDZ’ Bratislava (N = 222) Ethnicity of Patients Roma (%) Treatment Modality All 25.2 Detoxification Unit: Start 15 Successful completion* 60 Middle Term Treatment: Start 15 Successful Completion** 17 Methadone Program 36.5 Needle Exchange Program 18 non-Roma (%) 74.8 85 63 85 24 63.5 82 *: Successfully completed 14-day detoxification **: Successfully completed 10 weeks In-Patient Treatment 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Results Drugs, Addiction and Disintegration 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Drugs, Addiction and Disintegration • Drug addiction puts pressure on traditionally strong norms of solidarity and mutual assistance. • Increasing numbers of Roma addicts end up on the street. • Overdose deaths of young Roma IDUs resulted in crises in a number of Roma communities • According to many respondents the larger social fabric of the Roma communities starts to show cracks. • Fear for drug-related community disintegration and a general feeling of insecurity are not uncommon. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Drugs, Addiction and Disintegration • Respondents associate drug addiction with the disenfranchised status of the Roma, pointing at discrimination, unemployment and segregation in particular. • From this perspective, use of drugs is said to alleviate the agony of day-to-day life. – “The drug is alleviating their deprivation.” – “Heroin is for them the best thing that happened in their life.” 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Drugs, Addiction and Disintegration • For an unspecified proportion of the Roma community, the drug trade provides a pathway to economic empowerment. • Participation of Roma in the drug economy changes the economical balance in their communities and threatens traditional power structures. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Results Consequences for Human Rights 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Consequences for Human Rights • Recent police actions suggest that repressive drug legislation introduced in the last years may stigmatize Roma drug users in particular. – “It is quite plausible that this new drug law is meant to, and will be used to attack Roma” (Representative Roma Rights Center) 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Consequences for Human Rights • The potential negative consequences of the increasing Roma involvement in drug use and dealing for the already questionable human rights situation of the Roma people are potentially immense. • Collective criminalization. • Labeling drugs as a Roma-specific problem. • Scapegoating Roma communities for the spread of drugs and HIV. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Conclusions • Drug Use among the Roma may well develop into Europe’s largest minority drug problem. • Roma drug users are at increased risk for HIV and other blood-borne infections. • Through secondary sexual transmission, the entire Roma community is at high risk as well. • Treatment and Prevention is absent or inappropriate. • Involvement in drug use and trafficking may seriously aggravate the already feeble human rights situation of the Roma. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Recommendations Education & Policy Advocacy • Roma Leadership: Break the Silence! – The potentially disastrous impact of the “Twin Epidemic” is grossly underestimated by the majority of Roma leadership. • UNAIDS: Support community-based interventions! – Drugs And HIV among the Roma People is positioned at the junction of many UN, sometimes conflicting interests. – Establish a special working group to promote HIV prevention among Roma and other minority drug users. • the European Union: Insist on Civil Rights! – Promote the wellbeing and civil rights of Roma communities in aspirant member states, including the development of pragmatic drug treatment and HIV prevention. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Recommendations Research • Establishment of a “Roma Community Research Working Group” (RCRWG) – Development of a Roma-guided research capacity could potentially overcome many anticipated barriers to researching drug use and the associated harms in Roma communities. – It would facilitate the investigation of drug use patterns and HIV risk behaviors from within the community. – Rapid assessment methodologies, as developed by the WHO, could be applied by trained “community field workers.” 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Recommendations Drug treatment and HIV prevention services for Roma users • Establishment of drug treatment and HIV prevention must be positioned within a wider context of community development. • Thus, Roma (users) must be involved in developing appropriate services for Roma drug users, such as: – Community-based low-threshold drug treatment (e.g. MMT) – Peer-based HIV prevention strategies: secondary exchange – Abstinence-only treatment is not in the interest of Roma • While some traditional Roma leaders advocated coercive approaches, these should be not be encouraged 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Epilogue "Everyone has the right to a standard of living adequate for the health and well being of himself and of his family, including medical care and the right to security in the event of sickness or disability." Universal Declaration of Human Rights (Article 25.1) “Since 1989 the Roma community is increasingly facing longterm unemployment. Since 1989 there has been a steady increase in drug use. The social problems among parts of the Roma community helped the spread of the drug epidemic.” JUDr. Vincent Danihel Slovak Government Office for Minorities 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • References • Presentation: Jean-Paul C. Grund, Paul J. Öfner, Hans T. Verbraeck: Marel o Del, kas kamel, le Romes duvar. (God hits whom he chooses; the Rom gets hit twice.): An Exploration of Drug Use and HIV Risks among the Roma of Central and Eastern Europe. Presented at the Twelfth International Conference on the Reduction of Drug Related Harm, Delhi, India, April 2001 • Full Report: Jean-Paul C. Grund, Paul J. Öfner, Hans T. Verbraeck: Marel o Del, kas kamel, le Romes duvar. (God hits whom he chooses; the Rom gets hit twice.): An Exploration of Drug Use and HIV Risks among the Roma of Central and Eastern Europe. Final Research Report to the International Harm Reduction Development Program, Open Society Institute, New York. AmsterdamRotterdam-Frankfurt/M: DV8Research, Training & Development, 2000. 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Contact Information • Jean-Paul C. Grund, Hans Verbraeck, Paul Öfner Project Group Roma & Drugs, DV8 Research, Training & Development, Elkenbachstrasse 8, 60316 Frankfurt/M, Germany • Address requests for copies or further information to: jpgrund@cs.com 04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD
  • Marel o Del, kas kamel, le Romes duvar (God hits whom he chooses; the Rom gets hit twice) An Exploration of Drug Use and HIV Risks among the Roma of Central and Eastern Europe Jean-Paul C. Grund, Hans Verbraeck, Paul Öfner Project Group Roma & Drugs, DV8 Research, Training & Development, Rotterdam/Amsterdam, The Netherlands, Frankfurt/M, Germany