Healthcare systems are complex assemblages designed to control equally complex individual and population health problems. The relative containment of infectious diseases (contagious illnesses like HIV, tuberculosis, cholera, or the measles) is a key indicator of how well healthcare systems are functioning. Infectious disease epidemics are driven by social interactions; sexual practices, patterns of drug use, and even hand and food washing behaviors enable infectious diseases to spread and shape the course they will take through the population. Effective healthcare systems are able to intervene on these epidemiological processes and reduce the prevalence of these diseases through effective prevention and evidence-based treatment strategies.
By each of these measures, the Ukrainian health care system is not working. Though rates of drug use and condom use are similar in the US and Ukraine, the population prevalence of HIV in Ukraine nearly 4.5 times higher,1 and the HIV prevalence among Ukrainian drug users is on par with the highest HIV prevalence in sub-Saharan Africa. The rate of tuberculosis infection is more than 30 times higher in Ukraine than the US, and the Ukrainian healthcare system’s cure rate for hospital-treated multi-drug resistant tuberculosis is no better than if the patients had received no treatment at all.2 These are not recent failures that can be attributed to regime change, revolution, or war; these are long-standing realities that have defined Ukrainian healthcare for decades.
Ukraine is quickly becoming a world leader in technology and software development. For every 100 Ukrainian citizens, 144 cell phones are in use.3 Ukraine is home to the fourth largest number of certified IT professionals in the world, right behind the US, India, and Russia. Why is it that the same nation which Forbes recently called “the next silicon valley”4 can’t cure tuberculosis, can’t control HIV, and has permitted the re-emergence of polio, a vaccine preventable disease previously eradicated from the European continent for more than a decade? Why has the medical imagination of disease in Ukraine failed to evolve as new knowledge and technologies have emerged? Why is distrust in the healthcare system so high? Why do the same Ukrainians who have developed discriminating tastes and high expectations on the consumer market feel powerless in the face of a centralized healthcare system that is, in principle, designed to serve them?
In the essays that follow, public health scholars who have worked extensively in Ukraine examine four key topics in infectious disease control—public vaccination, pediatric tuberculosis, injection drug use, and the healthcare needs of men who have sex with men—to answer to this question.
Recent geo-political events have thrust Ukraine onto the world stage in unprecedented ways. The increased attention to Ukraine’s political and economic situation is long overdue, yet nevertheless tends to overlook one feature that has attracted international attention to Ukraine for more than a decade: its unusual HIV epidemic. Injection drug use and HIV are synergistic public health problems that remain poorly controlled in the region. In 2014, estimated HIV prevalence among adults aged 15-49 was 1.2% and more than 300,000 individuals in the country are currently living with HIV.1 Injection drug use was the primary driver of HIV transmission in Ukraine from the earliest recorded infections in the mid 1990s until the year 2008, when drug use was finally overtaken by heterosexual transmission as the most common route of infection.2 Overall, between 2005 and 2012, 44.9% of all newly reported HIV cases occurred in injection drug users.3
The WHO recommends a wide variety of services and policies for the control of HIV among people who inject drugs. These include regular HIV testing and counseling, appropriate linkage to and retention in HIV care, and the prevention of incident HIV infection through evidence-based substance dependence treatment programs (like medication-assisted therapy with methadone or buprenorphine), and harm reduction strategies including the distribution of syringes and other injection equipment. Ukraine offers all of these services. Though the economic and political troubles that have affected all aspects of life in Ukraine have also occasionally hampered HIV-related care (Ukraine has experienced stock-outs of primary HIV medications, for example), the Ministry of Health has not done a terribly bad job, all told, of putting these health care mechanisms in place.
Why, then, are these efforts failing? Why is HIV still spreading at its current rate, affecting nearly 1 in 5 drug users in Ukraine?4 The problem is not the policy environment for promoting better health care for drug users, but the social and political will to see those policies through to their full potential. Here, I argue that three related but distinct factors hinder the advancement of health care and HIV prevention among people who use drugs in Ukraine: (1) the fundamental incompatibility between social stereotypes about addiction and the ideal social self in contemporary Ukraine; (2) the perceived responsibility of the government to perpetuate the oppression of drug using individuals; and (3) significant financial interests of people and organizations that continue to profit from the disenfranchisement of drug users and, therefore, resist changes to the status quo.
Today’s popular views on drug use in Ukraine can be traced back to two different legacies of Soviet medicine. The oldest of these conforms to the Marxist view that all forms of illness or disease (which drug addiction was, at least partially, considered to be) were products of the larger socio-economic environment. The Bolshevik Revolution, according to this logic, “eliminated the basic antagonistic contradictions between the socioeconomic structure and the health of the people, and thus did away with the basic source of illness for the workers.”5 Those who remained caught up in illegal drug use following the socialist liberation of the working classes, therefore, had to be willful, wanton drug users who carried the blame for their own behavior.
The second and, arguably, more significant Soviet approach to understanding drug addiction was developed by psychologist Ivan Pavlov, who pioneered the concept of the conditional reflex. According to Pavlov, the term “conditional reflex” refers to the neural pathways that become hardwired in the brain through repeated exposure to the same stimulus.6 Pavlov’s famous laboratory canines who would salivate at the ring of a bell once they learned that this sound indicated feeding time often serve as the classic example of the conditional reflex in action. Applied to drug use, Pavlov’s ideas articulated a link between individual experiences and the seemingly compulsive behaviors of those labeled “addicts.” This logic was further applied by Soviet psychologist Mark Sereisky who argued that drug users were predisposed to addiction and simply needed a trigger, such as a first dose of morphine, to send them into uncontrollable patterns of neurologically enforced drug consumption.7
Both of these views are riddled with inaccuracies (as were the theories of addiction developed by the American scientific community at the same time, to be fair). Drug use is not necessarily an indicator of psychological or brain disease: non-addicted drug users vastly outnumber addicted drug users.8 For example, less than a quarter of heroin users in the US actually meet the diagnostic criteria for substance dependence, and that proportion has remained somewhat constant despite massive shifts in the total number of heroin users, addicted or otherwise, over the last 20 years.9 Moreover, the view that addiction is more akin to a learning disorder10 than a chronic relapsing brain disease11 is beginning to gain traction in the scientific community.
Nevertheless, popular myths of what drug addiction “really is” permeate contemporary medical and non-medical discourses about drug users throughout the world, including Ukraine. In my own research, I have spoken with countless patients, physicians, psychologists, and laypeople in Ukraine about what drug addiction “really is,” and the answer always sounds something like this: drug use severs the link between one’s will and one’s agency.12 A program consultant who has advised medication-assisted therapy programs for opioid dependent people across Ukraine articulated this idea as follows:
Drug users, they must have this desire to quit, because the behavior is bad. But the sin—the consequence—of this behavior is that it destroys your constitution—the thing inside of you that should be the strongest. So, when you are addicted, you understand. You know what is happening to you. But you can do nothing about it.13
Addiction, therefore, is defined not simply by compulsiveness or behavior but by the inability (or lack of self control) to act upon one’s inner desires.
This understanding of addiction—and the reason it is deemed socially problematic—overlaps with another stigmatized social category: the slave. The social imagination of ‘slavery’ in contemporary Ukraine is also an abstract judgment about one’s ability to act with free will. In her analysis of Ukrainian sociality in the early 2000s, Anna Fournier observed that “Slaves [are] not people,” and the term itself “denotes a lack of rights and the absence of agency.”14 During the Orange Revolution, Fournier interviewed a middle-aged political science professor who elaborated on what this phrase meant:
What are slaves? A silent, amorphous mass. Slaves carry out the tasks [vykonuiut zavdannia] given to them, otherwise they know their heads will be cut off. Slaves are mute, but now, now we can already talk. We have freedom [volia].15
She observed that protestors used language like “slaves” and “cattle” to describe those who opposed the protests and even those who chose not to get involved. These individuals, she was told, were either sell-outs who were paid to attend or had been “zombified [zombovani], brainwashed, or drugged.”16 These same epithets were repeated against Berkut officers and pro-government protestors during the EuroMaidan revolution in 2014 as well.
Slaves, drug users, zombies, and others who are believed to act without agency are assumed to pose a particularly dangerous threat to society on two levels. First, these individuals (and drug users especially) allegedly display an unwillingness to join in and support the social collective. For example, the perceived intentional refusal to work – and by extension a refusal to enter into the Ukrainian collective formed and defined by multiple overlapping relations of mutual dependence – is deeply ingrained into the popular stereotype of drug and alcohol use.17 I heard this sentiment repeated about drug users both in and out of formal treatment for their dependence during my fieldwork in 2013.
Second, the alleged mental weaknesses of slaves, zombies, and (especially) drug users renders them vulnerable to psychological exploitation. A cunning enemy could easily fill the crowd at a counter protest or staff a unit of government police officers or a brigade of separatist fighters, armed and unwieldy at a militia checkpoint, with such manipulable, zombie-like individuals. Ukrainian soldiers fighting in the Donbas have even made such claims, reporting that local separatists fighters were being drugged and “used as cannon fodder” by insurgent leaders. “Their blockposts are just littered with used syringes,” the report reads. “Drugs are brought to them in large quantities from across the Russian border…They feel nothing when they are killed.”18 These sentiments hardly encourage the compassion or patience for illicit drug users that programs in harm reduction and disease prevention require.
The attitude of the state as it is perceived in relation to its citizens is also complicit in the continued failure of healthcare for drug users in Ukraine. This can be said of both Russia and Ukraine (and arguably several other former Soviet states), despite the fact that they technically employ very different approaches to their respective drug use and HIV crises today. Opiate substitution therapy with a synthetic drug called buprenorphine was legalized in Ukraine in 2004.19 Methadone, another successful tool for substitution therapy, was legalized as a prescription drug by the Ukrainian Ministry of Health in 2008.20 Ukraine and Russia have different state polices about drug use and drug control. Russia, in contrast, has consistently adopted policies of criminalization rather than medicalization, rendering evidence based treatment options such as substitution therapy unavailable; methadone is not even legal for medical purposes in Russia.21 Despite these significant differences, however, Russian and Ukrainian responses to drug use have shared one highly visible characteristic: political theatrics that reference the scourge of drug use. In particular, Russian and Ukrainian politicians alike share a propensity for dramatically setting narcotics on fire.
During the summer of 2010, Viktor Yanukovych, then president of Ukraine, made headlines by presenting an array of illegal drugs at a cabinet meeting. Having affixed them to a folding display board like a science fair project, Yanukovych claimed to have bought all of these drugs, which included substances like marijuana to cocaine, online. His apparent goal was to embarrass the police force by accusing its leadership of turning its back on this type of drug trafficking. He then theatrically incinerated the drugs he had purchased, in full view of an emergency fire brigade and a cadre of news cameras, in a metal chute arranged in the courtyard outside of the Verkhovna Rada. More recently, this same type of display was put on by the Russian Drug Control Service in Russian-annexed Crimea. Viktor Ivanov, the head of this agency, ordered all of the methadone clinics on the peninsula closed on May 1, 2014, resulting in the eventual deaths of as many as one hundred patients.22 Ivanov defended this decision by citing high levels of crime related to drug production and drug trafficking in the region.23 The remaining stock of pharmaceutical methadone available in Crimea was incinerated by armed offers of the Drug Control Service. Cameras were present at this event as well.24
These otherwise silly theatrics make sense if we lend credence to the idea, discussed above, that drug users are naturally harmful to the social body of the nation. If the government’s role is to protect and support the nation, then flushing out drug users—imprisoning or oppressing them, rather than helping or treating them—is the purview of a ‘well-functioning’ state. This narrative is augmented further in Ukraine and the surrounding states through the paternalist legacy of the Soviet regime. Even soft authoritarian views render this sort of control over the body politic not simply the prerogative but the primary duty of the state. The inverse of this paternalist logic, of course, would state that the proliferation of drug use indicates the inability of a state government to maintain the integrity of it’s sovereign domain. Widespread drug use is then a marker of a failed or illegitimate state that cannot police its own citizenry. This is why Ukrainian newspapers have carried headlines like “Militants from the Luhansk People’s Republic Hooked on ‘Krokodil’”25 and “Militia in the LNR Get Carried away by Krokodil.”26 Krokodil is a home-made opioid that has gained popularity among injection drug users in Russia and Ukraine in the last 10 years or so. Thus, Ukrainian media outlets reference this narcotic derivative to characterize the Luhansk and Donetsk People’s Republics as failed states, non-functioning states, or even non-states through accusations of massive drug use and drug trade in these areas.
This view, of course, contradicts the medicalization of substance dependence, which, with tools like methadone and buprenorphine-assisted therapy, has become an international mainstay of HIV prevention among injection drug users. Russia has rejected medication-assisted therapy outright. Even basic harm reduction activities such as distributing condoms and clean injection equipment have been oppressed as inflammatory political activities.27 Ukraine has made medication-assisted therapy available, but the Ministry of Health has not shown enthusiasm for scaling up these programs (they currently serve less than 5% of Ukraine’s active injection drug users) or for taking over financial control from the Global Fund for the existing treatment slots.
Even if the tides were to shift and the political will to provide adequate healthcare to drug users were to blossom in Ukraine (which is unlikely under current circumstances of war), numerous financial interests would continue to stand in the way of this goal. At the 2015 Danyliw Seminar at the University of Ottawa, Margarita Balmaceda argued that the existence of market asymmetries, endemic corruption, and lack of transparency encourage elite groups to capture rents in areas over which these market irregularities grant them artificial control. Specifically, she suggested that the conflict in Donbas served such a purpose, arguing that “the manipulation of [state or geographic] boundaries and borders may create synergies not for the resolution of the [military] conflict, but for those energies accruing resources … in a way that supports the continuation of the conflict by making it a mutually profitable stalemate.”28 Similarly, the socio-political disenfranchisement of drug users in Ukraine, and Eastern Europe more broadly, is perpetuated not simply by groups of elites who have designed schemes whereby to profit from that disenfranchisement, but also by those who have haphazardly found this state of affairs to be profitable and would therefore offer resistance to any sort of change.
Those who strive to profit off of the disenfranchisement of drug users directly are more often than not official state actors. In the realm of conjecture, a number of elite leaders have been accused of complicity in international drug trafficking schemes. This includes not only the rightfully maligned leader of the LNR, Igor Plotnitsky, who has been accused of founding a “filial” drug cartel linked with a larger operation in South Ossetia,29 but also the head of the Russian Drug Control Service himself, Viktor Ivanov, who has been implicated in drug smuggling rings dating back to the 1980s and 1990s and accused of using his office to promote his own interests in the black market.30
The deeds of other profiteers who seek to extract resources from marginalized drug users are more clearly documented. The most egregious of these actors in Ukraine is the state police, whose harassment and extortion of street-level drug users and drug traders has been well evidenced.31 My own research among active opiate users in Ukraine has substantiated claims that the police effectively control the street-level drug trade across the country. Informants reported that police not only extort ordinary users and dealers but sell opiates of various forms out of their own pockets as well. As one of my informants described:
Those who bought drugs for themselves and were caught on their way home, they were thrown in jail. Those who sold drugs, they made a pay off and just kept selling. And the police, well, they get what they get, right? We have this walkway in the neighborhood, and they would grab guys there, addicts would be running, selling right by the apartments…. And every one of them is selling drugs.
Even directors of methadone clinics have reported being harassed by police officers who are angry at them for, as they see it, taking their customers away.
Actors who provide direct medical services—especially staff at hospitals and local pharmacies—are also able to profit from the failure of their own system to properly support people who use drugs in Ukraine. Pharmacies and pharmacy staff are able to profit directly from under-the-table sales of controlled narcotics to active users. Restrictions on the sale of narcotics and products with narcotic ingredients are in place in Ukraine, but there are an adequate number of less-scrupulous pharmacists willing to sell these drugs to anyone who can pay. Current regulations largely exist on paper, and pharmacies are rarely monitored or policed. Especially if they are willing to cut a deal with local police, pharmacists may find themselves in a position to sell drugs without a prescription to those who ask. As a result, most such pharmacies that I know of remain unmolested by law enforcement and run a rather steady business—so steady, in fact, that users and outreach workers I have worked with are able to mark these businesses on a map.
Hospitals, in contrast, benefit indirectly from the exclusion of drug users from basic health care services. The budget afforded to hospitals annually is determined by the number of beds the hospital is able to fill, which encourages over-admittance of patients, as well as the outcomes those patients are able to achieve.32 If the stigma against drug users, described above, is insufficient to deter a medical professional from providing care, the risk to the hospital’s annual budget that an ill, possibly HIV- or TB-infected injection drug user might pose may be enough to convince them otherwise. My own field notes are replete with drug users’ experiences of low quality or insufficient care in local polyclinics as well as several occasions when a drug user was literally turned away by staff at the hospital door. This sort of behavior is, of course, not practiced by all health care professionals, but a trend of such behaviors is observable, and the financial risks that hospitals face when treating drug users are, at least in their perception, very real.
Michel Kazatchkine, the UN Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, has lamented the unwillingness to promote the healthcare of those who use drugs in Eastern Europe. At a recent meeting of the UN General Assembly, he was quoted as saying:
The answer for me is that, first, health should be the priority, health of the individual, and public health. Even if you feel that you are somehow in contradiction with some of your internal laws and policies, you should revise those policies and laws because of public health emergencies, not the opposite.33
Such tactics would indeed bring Ukraine more in line with international public health approaches, but this is a hard sell when controlling drug users is seen as a basic responsibility, and allowing drug use to continue—even in the form of methadone treatment—is a violation of that social contract.
Russia has recently doubled-down and doubled-down hard on their rejection of the idea that the right of basic health care should be extended to people who use drugs. An NGO named “Society”, which carried out HIV prevention activities among drug users in the city of Saratov, has just recently been classified as a “foreign agent.” The local prosecutor has alleged that the activities undertaken by “Society,” including the distribution of condoms and clean syringes, is tantamount to the organization’s “participation in the West’s hybrid war against Russia.”34
Medication-assisted therapy programs continue to function in Ukraine, but their future is insecure. The Global Fund grant, which currently supports these programs in their entirety, is set to expire at the end of this calendar year. Following the financial restructuring of the Global Fund in 2012, it has been made rather clear that no further funding will be available. This will leave these essential yet relatively expensive programs in the hands of a Ministry of Health that can’t and perhaps won’t continue to support them. Despite the clear and undeniable success that OST has achieved in slowing the tide of HIV infection in Ukraine, negative stereotypes of drug users make these programs unpopular, and political will to pay for them out of national coffers is low. The course that Ukraine will ultimately remains to be seen.