If upheld, Crimea's vote to split from Ukraine to join Russia could leave one clear winner: HIV.
While Ukraine and Russia both have large HIV epidemics driven by drug injection, Ukraine has moved successfully to slow the spread of HIV, including with the prescription of the daily medicines methadone and buprenorphine to help patients stop injecting street drugs and manage the struggle with addiction. Russia prohibits these medicines, a ban dating back to a reality-by-decree in the 1950s that claimed drug use was a product of unregulated and decadent Western individualism impossible in the worker-owned state of the USSR. President Putin -- as with his rejection of gay rights -- places grappling with the realities of drug use out-of-bounds in order to contrast the moral superiority of Russian culture with the decay of values in the West. Russian officials, psychiatrists known as "narcologists," define the terms of addiction treatment and dismiss or distort evidence from other countries, including Ukraine. They have gone so far as to close down websites and threaten Russian doctors who even mention methadone or buprenorphine.
Concern is building among Crimean doctors, patients and families. Some 800 people there now receive methadone or buprenorphine, and many have returned to work and health. There is only a few months' supply of medicine left in Crimea, and the authorities in Kiev say it may not be possible to send more in given the Russian troops massed on the peninsula. In the area of addiction treatment, Crimea has significant achievements to protect -- and should not undo progress in the name of allegiance to Russia, nor relinquish a model of drug treatment that has characteristics of international significance.
For over a decade, I have worked alongside and led practitioners and researchers in studies of addiction treatment in countries across the former Soviet Union. Crimea has created some of the most promising programs I have seen in the region. Rather than limiting addiction treatment to pseudo-scientific cures and blaming the nature of drug addicts for poor results, narcologists in Crimea challenged Soviet-era thinking and practices. In a dispensary in Simferopol, physicians and nurses trained in new approaches to treatment, openly exchange views about how to shape the provision of care for patients. This would be impossible in the Russian system where treatment is set by decrees from Moscow and where status in the hierarchy is substituted for evidence. Crimean nurses who once had been sent out to make drug users report for mandatory medical exams were retrained and paired with peer educators, turning home visits into occasions for overdose prevention and other help rather than state surveillance.
In Russia, individual narcologists in clinics will speak candidly about the failure of their approach, prolonged detoxification that use formularies of high-dose sedatives, anti-anxiety, and neuroleptic drugs to purportedly "remove the pathology of craving," and "restore normalcy." This is what might be called post-Sovietism, where professionals may no longer believe in the ideology, but they conform to it nevertheless. In contrast, one doctor responsible for managing the implementation of treatment in Crimea that included methadone and buprenorphine described the processes involved as having a "democratizing" character, with physicians experiencing themselves as participants in providing care that is responsive to patients' expectations for change.
Patients and families also see themselves as participants in, rather than objects of, treatment. In Simferopol, they helped renovate a building that served as an informal community center, offering a place to rest for those who had to commute long distances for their daily medicine. The center was also a space where doctors -- some without their white coats -- exchanged views with patients, parents and children gathered there. A small business enterprise producing construction materials helped patients move from a minimalist notion of treatment to something that stressed collective transformation. In 2009, a group of patients' mothers went to Sevastopol, the seat of Crimea's government, to challenge a proposal by pro-Russian politicians to restrict methadone treatment. Describing the benefits they had seen to their families, they demanded to know whether "the government is here to serve us, or we are here to serve the government?" An accompanying journalist reported the exchange. The restrictions were not imposed.
It is precisely this kind of citizen participation -- and the fact that methadone and buprenorphine treatment enables drug users to be among the citizenry who can take part -- that makes the medicines so threatening in Russia. Russian narcology's singular achievement is managing to sustain itself in multiple countries of the former Soviet Union despite any evidence of effectiveness. Russia rightly recognizes that independence from top-down narcological hierarchy, debate of treatment strategies, and the reframing of the physician's role to include obligations to patients rather than just state interests are a critique of the Russian model. The fact that Russian approaches do nothing to reduce drug use, or that associated HIV infections have continued to surge in Russia, is less important than the Putin party line that says morality is sufficient medicine.
Crimean officials are now conferring to assess what the referendum and transition to a Russian approach would mean for the local health system. In choosing affiliation with Russia, Crimea should not reject the needs of the socially vulnerable and some of the helpful responses emerging from within. HIV and drugs cross borders easily, affecting people of all ethnicities and political affiliations. State-run prevention and treatment services, though, are easily mired in politics. Crimea should choose a course that would sustain life-saving drug treatment programs, citizen participation and advances in the fight against drugs and HIV.