IV. Findings: Human Rights and Drug Dependence TreatmentThe Right to HealthThe right to the highest attainable level of physical and mental health is guaranteed in various international human rights treaties to which Russia is a party, in particular the International Covenant on Economic, Social and Cultural Rights (ICESCR).123 An integral and directly enforceable element of that right is the right to non-discrimination in the enjoyment of the right to health.124 Respect for the right to health also incorporates respect for other rights, such as the right to privacy and the right to receive and impart information, which are also protected by treaties to which Russia is a party.125 Scope of the Right to HealthThe right to health under international law imposes an obligation on states to take the necessary steps for the prevention, treatment, and control of epidemics and other diseases. Because states have different levels of resources, international law does not mandate the kind of health care to be provided beyond a certain minimum level. The right to health is considered a right of “progressive realization.” By becoming party to the international agreements, a state agrees “to take steps… to the maximum of its available resources” to achieve the full realization of the right to health. The Committee on Economic, Social and Cultural Rights (CESCR), the body charged with monitoring compliance with the ICESCR, has identified four essential elements of the right to health:
That means that states must make available in sufficient quantity “functioning public health and health-care facilities, goods and services, as well as programmes.” As for the accessibility requirement, the Committee has defined four elements: accessibility without discrimination, physical accessibility, economic accessibility, and information accessibility (people have the opportunity to seek, receive, and impart information and ideas concerning health issues). Acceptability refers to the need for health facilities, goods, and services to be respectful of medical ethics and culturally appropriate. Finally, they must be scientifically and medically appropriate, and of good quality.126 While states should strive to offer the most effective and comprehensive treatment for drug dependence, the CESCR recognizes that the resources of a given state will be an important factor in the exact level of services the state can offer. In order to comply with the right to health, a resource-rich country will generally have to have a more developed treatment system in place than a poor country with a comparable drug dependence problem.127 Russia has made an explicit commitment to provide medical treatment to all its subjects. Its constitution states,
The 1998 Law on Narcotic and Psychotropic Substances stipulates that people affected by drug dependence disease shall be offered medical care for their condition. It specifies that this medical care includes “examination, consultation, diagnostics, [detoxification] treatment and medical-social rehabilitation.”129 Although Russia’s healthcare infrastructure suffered tremendously from the extended economic crisis that followed the collapse of the Soviet Union, since the late 1990s Russia’s economy has gone through a period of sustained and rapid growth with billions of dollars entering the economy in oil and gas revenues. Bolstered by this economic good fortune, Russia has recently been making considerable investments into the healthcare system. In September 2005 President Vladimir Putin announced the creation of four national priority projects aimed at developing social welfare in the country. One of these projects concerns public health. A total of 97.3 billion rubles (almost US$4 billion) was allocated to the national health project budget in 2006.130 In considering the issue of resources, it should be kept in mind that investment in effective drug dependence treatment can lead to savings in other spheres, as it reduces criminal behavior in patients who are effectively treated, enables patients to lead productive lives, and can prevent new health problems from emerging in patients. In the United States research has repeatedly shown that investments in effective drug dependence treatment are cost effective. For example, NIDA observes,
While cost effectiveness ratios will be different in different countries, it remains a factor in assessing available resources that investment in drug dependence treatment can lead to savings in other spheres. While available resources is a legitimate consideration for states and policy makers when developing and implementing health policy and services, respect for the right to health has other direct implications for how policy is developed that are not resource-related. It requires that policy decisions and choices about health policy are objective, rational, and evidence based. If they are made on criteria that are discriminatory or arbitrary they will be incompatible with respect for the right to health. Similarly, policy choices that have an unjustifiably restrictive or negative impact on the enjoyment of the right to health, in comparison to other available policy options, are also incompatible. The Availability Requirement
—Committee on Economic, Social, and Cultural Rights, General Comment 14 on the Right to Health132 Detoxification services are widely available throughout Russia although in some regions patients face waiting lists for admission to treatment. The availability of state rehabilitation services remains patchy despite increasing numbers of state and private rehabilitation centers being opened in recent years. Detoxification ServicesWith 192 substance abuse clinics that offer a total of more than 28,000 beds for detoxification for alcohol and drug dependence, these services are widely available throughout Russia. Additionally, drug users can also receive detoxification in certain other approved health facilities, such as psychiatric hospitals, should no substance abuse clinic be available in or near their place of residence. However, our research and that of others suggests that in some regions drug users who cannot pay for their treatment face waits before they can be admitted to clinics for treatment because of a lack of beds for free treatment. This raises concerns about the availability and accessibility of this form of treatment. In contrast, patients who had paid for treatment said that they were admitted immediately. These waiting lists potentially lead to the loss of patients. One drug user in Kazan was on the waiting list when Human Rights Watch interviewed him in late January 2007. He said that he had signed up on December 20, 2006, and had been told that he could start his treatment on January 25, 2007. While waiting, the drug user hung out at a drop-in center with active drug users and continued using drugs.133 A former drug user in Kazan said that when he wanted to check himself into the city detoxification clinic in Kazan several years ago, he was also told he should come back a month-and-a-half later. He told Human Rights Watch,
The interviewee said that he later learned that if he had paid a 500 ruble bribe he could have skipped the line. Another drug user said that although he was on the drug user registry he paid for detoxification treatment in January 2007 because “there were no beds for free treatment available.”135 Various drug users in Kazan said that they or their relatives had paid bribes to doctors at the detoxification clinic so that they could skip the waiting list. Inna Vyshemirskaya, the sociologist who conducted a policy assessment related to illicit drug use and health in Kaliningrad in 2006 and interviewed more than a dozen drug users and several dozen experts, told Human Rights Watch that drug users she interviewed who did not have money to pay for their treatment had often told her that they had to wait before they could be admitted.136 The chief narcologist for Kaliningrad, however, insisted in a meeting with Human Rights Watch that there were no waiting lists in early 2007, which interviewees confirmed. Fifteen percent of drug users surveyed for the Penza Anti-AIDS Foundation study said that they had been refused treatment by drug dependence treatment services on at least one occasion. A quarter of these people said the reason for this refusal was the lack of beds. A total of 22 percent of the people surveyed said that they had waited “a long time” for their hospitalization in the detoxification clinic. In Kaliningrad more than 40 percent of drug users surveyed reported long waits before admission. In Krasnoyarsk and St. Petersburg more than 30 percent did so. Conversely, only 6 percent of people surveyed in Penza and Orenburg said that they had had to wait a long time.137 The chief narcologist of Tatarstan defended the existence of waiting lists, saying that it helped motivate drug users for treatment.138 This assertion, however, is not supported by science.139 Some current regulations on detoxification services unnecessarily limit their availability. Private drug dependence treatment clinics are currently banned from offering medicated detoxification services, apparently due to fears of diversion of restricted substances.140 In most European and North American countries private clinics successfully provide detoxification treatment. Allowing private clinics to conduct detoxification treatment would increase the availability of these services and would give some drug users a choice of treatment. State clinics do not currently offer outpatient detoxification treatment, although in many regions narcologists do provide such services unofficially (and often for considerable charge). While a clinical setting will be needed during detoxification treatment for many drug-dependent persons, outpatient treatment would provide an important alternative for some patients and might help enrol people in treatment who cannot or do not want to make use of inpatient facilities.141 Methadone or Buprenorphine Maintenance TherapyMaintenance treatment for drug users is not available at all in Russia, as the use of methadone and buprenorphine for treating drug users is expressly prohibited by law (as already noted above).142 Despite overwhelming evidence of its effectiveness in treating drug-dependent persons, top health and law enforcement officials as well as policy makers in Russia continue to vehemently oppose maintenance therapy, often on the basis of selective and inaccurate interpretation of research findings. The policy decision not to make methadone and buprenorphine available for the treatment of drug-dependent persons, based on factors that ignore the best available medical evidence as to its effectiveness, can only be described as arbitrary and unreasonable, and as such is a violation of the right to health. The opponents of maintenance therapy in Russia, led by top officials, reject the vast body of solid scientific evidence compiled over decades through studies in numerous different countries that unequivocally confirms the effectiveness and cost-efficiency of maintenance treatment for drug users. They have dominated public discussion of the topic and managed to sideline scientific evidence in discussions of the issue in mainstream medical journals in Russia. They have variously maintained in these medical journals—in contradiction of the conclusions of the overwhelming majority of research studies—that maintenance therapy is dangerous for patients, ethically unacceptable, a ploy by drug companies to line their pockets, or has recently been shown to be ineffective as treatment. The most brazen publication of this sort was a memorandum that appeared in Meditsinskaia gazeta (Medical Newspaper) and Voprosy Narkologii (Issues in Narcology), both widely read among healthcare professionals, in 2005 under the signature of top healthcare officials, including Russia’s chief narcologist Nikolai Ivanets and the chair of the Russian Society of Psychiatrists. The memorandum selectively quotes a small number of research studies and articles by a few individual specialists that express concerns about maintenance treatment, while completely ignoring hundreds of studies that confirm its effectiveness and safety. On top of that, many of the citations and references in the memorandum were inaccurate or misleading. Some of the most outrageous assertions in the memorandum include:
For a more detailed analysis of the inaccuracies in the memorandum, see a response to it from several dozen drug dependence treatment experts from Europe and North America that was published on the website of the International Center for the Advancement of Addiction Treatment.145 In another article, A.V. Nadezhdin of the National Research Institute for Substance Abuse wrote that “after a period of unjustified ‘high expectations,’ ‘hope’ and initial successes, countries that had introduced maintenance therapy programs had become disillusioned with them and have started to move away from the methadone programs.”146 However, as was described above, maintenance programs with methadone and buprenorphine, and sometimes also medically prescribed heroin, continue to be introduced in more and more countries and the number of patients has grown rapidly in recent years. While opponents of maintenance therapy have been able to publish the above memorandum and other writings, despite their gross inaccuracies, in medical journals in Russia, there has been very little space in these publications for articles that discuss the findings of the hundreds of scientific studies that have documented the merits (and challenges) of maintenance therapy. Vladimir Mendelevich, a psychiatrist and advocate of maintenance therapy, has observed that maintenance therapy
As if to affirm this assertion, when Mendelevich launched a website on maintenance treatment in February 2006 that was meant to encourage academic debate, the prosecutor’s office ordered him in for questioning as it had received a complaint from a member of parliament that the website promoted the use of illicit drug use. The prosecutor’s office closed down the website after an expert panel concluded that it contained propaganda for illicit drug use. Mendelevich himself, however, was not charged with any criminal offense.148 The willful publication of inaccurate information about maintenance treatment and the monopolization of the discussion on the topic violates the right to health, in particular the obligation to ensure access to accurate information about health issues.149 Access to appropriate information about health issues that enables individuals to make rational choices about their personal health is also an element of the right to private life protected by the European Convention on Human Rights (ECHR).150 The European Court of Human Rights has often held that a state has positive obligations that stem from an obligation to ensure effective respect for private life.151 An aspect of those positive obligations can be to make available and accessible accurate information on health risks.152 Failure to provide essential information could amount to a violation of the right to effectively protect a person’s private life. The ECHR also protects the right to receive information (paragraph 2 of Article 10) and accordingly a government may not arbitrarily restrict a person from receiving information that others wish or may be willing to impart to him.153 Rehabilitation ServicesRehabilitation treatment at state clinics is currently available in less than one-third of Russia’s regions, although the availability of rehabilitation treatment is gradually growing as regional governments are paying for the creation of centers. Despite the fact that Russian law contains an explicit guarantee that healthcare services, including rehabilitation treatment, must be available to drug users, the Russian federal government has failed to adopt a federal plan with a clear timeline for the creation of new rehabilitation centers and programs in the country’s regions and to make the appropriate funding available. Instead, the federal government has left the creation and operation of rehabilitation services to the regions and failed to take appropriate steps to ensure that regions were making rehabilitation services available, as required by law. In some regions, small private rehabilitation programs may be operational but these generally offer few beds, may be too expensive for drug users, or may not suit all potential patients because they are faith-based. The failure of the federal government to make adequate efforts to realize the law guaranteeing rehabilitation services to people affected by drug dependence is inconsistent with the right to health. The discrepancy between the availability of detoxification and rehabilitation treatment also makes no public health or economic sense, as patients in regions without sufficient rehabilitation programs can begin but not continue treatment of their drug dependence, thus severely compromising their chances of recovery. The limited availability of rehabilitation treatment was a problem in one of the three regions we visited to conduct research for this report. In Kaliningrad there is no state rehabilitation center although the city’s narcological clinic does offer a 45-day outpatient rehabilitation program after detoxification treatment. There are a number of private rehabilitation programs, including two that are offered by protestant churches and three nongovernmental centers with a total of about 60 beds. However, the faith-based programs require or expect that patients subscribe to the religious beliefs of the church offering the program. Treatment at the nongovernmental rehabilitation center costs about 7,000 rubles (approximately US$275) per month for six to twelve months of treatment for residents of Kaliningrad and more for people from other regions, putting it outside the budget for many drug users (although recently one of these centers has begun to offer some beds for free treatment). At the time of Human Rights Watch’s visit a substantial portion of these centers’ patients were from outside Kaliningrad region. Overall, rehabilitation services were unavailable to many drug-dependent persons in Kaliningrad. In an interview with a local newspaper, the chief narcologist for Kaliningrad decried the lack of a state rehabilitation center:
There have, however, been some important positive developments recently. The Ministry of Labor has awarded the Orekhovo rehabilitation center a grant that will allow it to admit some recovering drug users from Kaliningrad region free of charge. It also appears that in the next few years a rehabilitation center may in fact be established in Kaliningrad. In a regional program of measures to counter the circulation of illicit drugs and “anti-social behavior among youth” for 2007 to 2011, the government of Kaliningrad province has allocated about 1.5 million rubles (approximately US$600,000) to the construction of a regional rehabilitation center.155 At first glance, availability of rehabilitation treatments does not appear to be a problem in Tatarstan. The city of Kazan has several rehabilitation programs with a total capacity of about 70 beds. Both state narcological clinics in Kazan run short-term inpatient rehabilitation programs that have 12 and 28 beds, some of which are officially slated for free treatment. The region’s substance abuse service also has a three-month residential rehabilitation center in Bolshie Kliuchi, outside Kazan, which has about 30 beds and was opened in October 2006. A nongovernmental organization called Roza Vetrov runs a three-month outpatient rehabilitation program—with financial support of, among others, the local ministry of health and narcotic drug control police—with about 20 places. Yet, these rehabilitation programs are the only ones for all of Tatarstan, which has a population of 3.7 million people and an estimated 9,000 drug users in the city of Kazan alone.156 Furthermore, adjacent Volga regions, like the republics of Bashkortostan, Udmurtia, and Chuvashia, and Ulianovsk and Kirov provinces, do not have their own state rehabilitation centers, although some do have confession-based and commercial programs. The rehabilitation programs in Kazan thus end up serving these regions as well. Indeed, a number of people in Kazan said that there were waiting lists for non-paying patients who come out of detoxification and want to continue in rehabilitation. For example, Alexander Dmitriev, a psychologist at Roza Vetrov, told Human Rights Watch, “If you are a registered [non-paying] drug user, they can release you from the detoxification clinic and sign you up for ‘next week’ for rehabilitation. The question is, of course, how [the drug user] will make it through that week...”157 In Penza province a state rehabilitation center exists in Russky Ishim. However, the drug users we asked about this rehabilitation center dismissed any possibility of going there, saying it was a place where “homeless alcoholics live.” The rehabilitation center does not admit HIV-positive patients. Many other regions do not have state rehabilitation centers. For example, drug users in Tver province need to travel to Pskov province for rehabilitation, something that, according to a local narcologist, few do.158 A qualitative study conducted among drug users by Bobrova and others in the cities of Barnaul, Ekaterinburg, and Volgograd found that only Barnaul had a state-run rehabilitation center, with 25 beds. It observed that in the other cities
The Accessibility RequirementThe right to health requires that medical goods and services be accessible. As has been described above, this means that these goods and services must be physically accessible, provided without discrimination on any ground, affordable for patients (though not necessarily free of charge), and that information must be available about them. These various requirements are applicable to both detoxification and rehabilitation services. As the vast majority of drug users interviewed for this report had only made use of state detoxification services and had not received rehabilitation treatment, the discussion below focuses mostly on the accessibility of detoxification clinics. The accessibility requirement is of particular importance in the treatment of drug dependence because drug users are often marginalized, hidden from the public view for fear of criminal law sanctions or because of social stigma attached to drug use. In drug user circles, accurate information about drug dependence treatment options is often not readily available, while myths about it abound. These and other factors may make drug users ambivalent about ending their drug use, and their motivation for treatment may come and go. Ideally, therefore, drug dependence treatment should not just be readily accessible but clinics should also actively reach out to drug user communities to disseminate information and offer them treatment. In Russia, however, there are a number of barriers caused by state policy that keep drug users away from these services. An obvious and arbitrary barrier (mentioned above and discussed further below) is the fact that drug-dependent persons who voluntarily seek help—behavior that states should clearly encourage—are entered into a drug user registry (unless they pay for their treatment) which is used to impose restrictions on their rights. Other barriers to treatment-seeking behavior include the cost of treatment, and a requirement to collect paperwork on various health conditions prior to admission. These administrative and bureaucratic barriers are compounded by a widespread feeling of mistrust in state narcological clinics among drug users, who do not believe that the services they offer are effective, view the system as corrupt, and are concerned about breaches of confidentiality and poor conditions. State clinics have done little to reach out to potential patients to try to convince them otherwise, and rarely engage in proactive outreach to the drug user community. Physical AccessibilityIn the General Comment on the right to health, the Committee on Economic, Social and Cultural Rights defines the physical accessibility requirement in a literal sense. It states, for example, that “health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups.”160 However, there are also other barriers to access, such as excessively burdensome, and unnecessary, admission procedures that may deter people from seeking treatment and could thus violate the physical accessibility requirement. In Russia, a number of different factors keep people away from substance abuse clinics. Drug User RegistrationThe drug user registration system keeps users away from substance abuse clinics by penalizing rather than rewarding treatment-seeking behavior. In dozens of interviews, drug users who are not on the registry told Human Rights Watch that they were highly apprehensive about being registered as they feared that registration would lead to disclosure of their status to law enforcement agencies or others, as well as to restrictions on their rights, particularly their possibility to drive (see also below). Many drug users interviewed for this report said that they or their relatives had tried to collect money in order to pay for so-called “anonymous” services and avoid registration. Avoiding registration by paying for services is a formal practice, provided for by the law.161 For example, Andrei A. said,
Igor I., another drug user, said that he had never sought treatment at a drug clinic because of the registry: “I am a driver by profession. They would immediately put me on the registry and I would lose my job.”163 Igor I. said that he did not have the money to pay for “anonymous” treatment. A qualitative study of 86 drug users in two Russian cities in 2003 also concluded that drug user registration was an obstacle to treatment. It stated that
The study said that respondents felt that they were in a “vicious circle” and that registration was perceived as a “stamp on the forehead.” The study said that the negative attitude toward registration was also based on potential or experienced breaches of confidentiality toward parents, partners, colleagues, or neighbors. There was also fear that drug treatment services would share lists of registered drug users with the police and that this would lead to harassment by police.165 While several narcologists interviewed for this report defended the drug user registry as necessary to ensure public safety, there was also some recognition in the leadership of the drug dependence treatment service that the registry keeps drug users away from treatment services. Evgenia Koshkina, head of the epidemiological department at the Institute of Substance Addiction Research in Moscow, told Human Rights Watch that she and her colleagues were aware of the deterrent effect of the registry and that discussions were underway to change the system to limit categories of drug users who would be officially registered.166 However, it does not appear that these changes are imminent. Pre-admission PaperworkIn many regions drug users are required to obtain a variety of certificates regarding health conditions like HIV, hepatitis, TB, and syphilis before they can be admitted to inpatient detoxification treatment. In Irkutsk the narcological clinic even requires a cardiogram.167 This means that drug-dependent persons who want to get treatment must visit at least one and sometimes various medical institutions in order to undergo the relevant tests, potentially pay money for them, and then wait for test results. As a consequence, drug users who have decided to enter drug dependence treatment are more or less forced to continue their drug use, at least temporarily, to avoid the onset of withdrawal symptoms. From a public health perspective, it does not make sense to require these health certificates upon admission. The requirement creates an additional hurdle for drug users seeking treatment, delays the entry into treatment for people who may be very ill and in need of hospitalization, and may lead to the loss of potential patients. At the same time, there is no compelling public health need to have these tests done prior to admission.168 Human Rights Watch therefore considers these requirements to be arbitrary hurdles to the accessibility of drug dependence treatment that violate the right to health. As it is of obvious importance for staff at narcological clinics to know their patients’ HIV, hepatitis B and C, and tuberculosis status, the tests that are now required prior to entry into treatment should be conducted after admission as part of the intake medical examination. Where narcological clinics do not have the equipment to conduct these tests, arrangements should be made with other branches of the healthcare system, like AIDS centers and TB hospitals, to facilitate the tests. A drug user in Kazan told Human Rights Watch that he had paid someone at the narcological clinic a bribe so he would not have to present the certificates because he realized that he might reconsider his decision to enter into treatment if he was not admitted to the clinic right away. He said,
The arbitrariness of the requirement is underscored by the fact that not all health facilities offering detoxification treatment for drug users require new patients to present health certificates. In Penza, for example, Human Rights Watch was told that such a requirement does not exist and that the narcological clinic itself conducts HIV, hepatitis, and TB tests. In Irkutsk and St. Petersburg narcological clinics demand certificates for various health conditions upon admission into detoxification treatment, whereas psychiatric hospital #1 in Irkutsk and hospital #9 in St. Petersburg do not.170 Distrust of Drug Dependence Treatment ServicesOur research and that of others found a pervasive and profound lack of trust in state narcological services among drug users, which keeps many of them from seeking treatment. This distrust appears to be closely linked to the poor effectiveness and efficiency of the drug dependence treatment services offered in Russia. Many drug users also said that they did not trust the state clinics because they saw the clinics and their doctors as corrupt and not committed to their recovery. Although this distrust is not the consequence of a specific state policy that limits access to treatment in an arbitrary or discriminatory manner, Russia does have a positive obligation under the right to health to take steps to counter it. In particular, it needs to ensure that policies pursued by state clinics do not give objective grounds for distrust, which failure to offer effective evidence-based services could do. Furthermore, Russian authorities need to take steps to address the corrupt practices at the clinics that many drug users described. Human Rights Watch encountered considerable skepticism about the effectiveness of drug treatment provided at state clinics among drug users in each of the cities visited. In Penza this skepticism was particularly pronounced. Many of the drug users there completely dismissed the possibility of going to the narcological clinic for treatment. A worker at the harm reduction program in Penza said that she knows very few drug users who make use of the state clinics, as drug users generally see these services as ineffective.171 Yura Y., a drug user in his fifties who has used drugs for several decades, said that he had never been in the state clinic. He said,
Another drug user in Penza said that despite the fact that he had been using drugs for more than 15 years he had never gone to the local narcological clinic for detoxification because “they do nothing to help you there… I’d rather spend the money on drugs than pay 900 rubles [for ineffective treatment].”173 We encountered similar sentiments in Kazan and Kaliningrad as well. A 25-year-old female drug user from Kazan who last went through detoxification treatment in March 2006 told Human Rights Watch,
A sociologist in Kaliningrad who conducted research among drug users in 2006 and interviewed 14 drug users and more than two dozen officials and medical personnel who work on drug-use-related issues told Human Rights Watch, “There is a strong distrust of the narcological clinic [in this city] because of perceived ineffectiveness of treatment offered, the registry, and poor conditions.”175 Perceptions that doctors at state narcological clinics are overwhelmingly corrupt add to the distrust. Several drug users mentioned paying bribes in order to get into clinics without having to wait or to avoid having to bring in the paperwork on other health conditions that is normally required for hospitalization. A number of drug users and workers in harm reduction programs expressed the theory that state alcohol and drug dependence clinics are not interested in the recovery of drug users because they make good money off them as long as they are sick. As long as state clinics have a monopoly on medicated detoxification treatment, drug users have the option of the state clinic or unmedicated withdrawal at home. Echoing this common sentiment, one former drug user said,
Several studies by scientists have also found widespread distrust of the drug dependence treatment system. For example, a study conducted in three Russian cities in 2003 found that
The study also found that “treatment was perceived as stigmatized, thus discouraging drug users from using services and potentially leading to the continued use of drugs and/or risky behavior.”178 Another study by the same researchers, conducted in 2003 and 2004, corroborated these findings:
Some drug users also associated the drug treatment system with law enforcement. For example, Yura Z. from Penza, a drug user since 1994, expressed the view that “if you go to the clinic, the police will soon put you in jail for drugs.” He said that he preferred going through detoxification at home. He had found a narcologist who came to his house for a fee of 1,200 rubles per day, and gave him injections with the sedative relanium.180 Economic Accessibility and Non-discrimination
—Committee on Economic, Social, and Cultural Rights, General Comment 14181 The right to health does not require states to offer drug treatment services free of charge, but these services do have to be “affordable to all,” including socially disadvantaged groups—to which most drug-dependent people belong. However, as already noted, Russia’s constitution stipulates that “[m]edical aid in state and municipal health establishments shall be rendered to individuals gratis, at the expense of the corresponding budget, insurance contributions, and other proceeds.”182 It is, nevertheless, general practice in Russia that state and municipal clinics offer paid services along with those free of charge. Although in line with the constitutional requirement narcological clinics formally offer free treatment to patients, the treatment is often in fact not without costs. In many regions narcological clinics are underfunded and try to supplement their budgets by assessing out-of-pocket charges and encouraging patients to opt for paid services. Drug users in both Penza and Kaliningrad told us that they, or their parents, had paid doctors at the clinics for medications or had bought them at pharmacies on their instructions. (By contrast, drug users in Kazan did not complain of being assessed out-of-pocket charges and Albert Zaripov of Roza Vetrov said that in his experience free treatment in Kazan truly meant that treatment was free.183) Bobrova and others found in their 2003 study that these fees posed a significant obstacle to treatment for some drug users. Three-quarters of participants in the study mentioned financial difficulties as a barrier to accessing drug treatment. The study found that many drug users in need of treatment were unemployed and unable to pay for their treatment without assistance, and that most relied on their parents’ willingness and ability to pay for treatment. Its data also suggested that drug users
Drug users and NGO workers said that narcological clinics pressured people indirectly to pay for treatment in several different ways. As mentioned above, in Kazan and Kaliningrad only limited numbers of beds are available for free treatment, sometimes resulting in patients having to wait weeks before they can start treatment, while those who pay are admitted immediately. The fee-for-anonymity system is another way in which drug users are pushed to pay for services. As has been discussed above, our research and that of Bobrova has shown that the vast majority of drug users who are not registered express a high degree of apprehension about being registered and many told Human Rights Watch that they and their relatives tried to find money to pay for treatment to avoid being registered.185 As noted above, the cost of treatment varies somewhat from region to region but averages between 750 and 1,000 rubles (US$30 and $40) per day. Ten days in detoxification treatment will thus cost a patient between 7,500 and 10,000 rubles (approximately US$300 and $400), payable at the start of treatment. The cost of rehabilitation services is even higher, as rehabilitation treatment lasts longer. For example, a standard paid treatment course of 28 days in the state-run rehabilitation program in Kazan costs 16,500 rubles (about US$625). Where no state rehabilitation centers are available, the cost may be even higher. Poor drug users face a starker choice than those with money: getting treatment but being registered as drug users or remaining off the registry but receiving no treatment. Igor I., a drug user in Kazan, is one of the people we interviewed who faced that choice. A driver by profession and the sole provider for a family of four, he told Human Rights Watch that he would lose his livelihood if he was entered onto the registry but did not have enough money to pay for treatment: “Paid treatment is really expensive. I don’t see how anyone could afford that.” Igor I. said that he had undertaken numerous attempts to stop using drugs, each time going through withdrawal at home, but was never able to stay abstinent for more than a month or two at a time.186 The fact that it is possible to pay for anonymity demonstrates that registration is not objectively necessary, but in fact creates an unnecessary burden only on poor drug users and therefore violates the principle that healthcare services should be accessible without discrimination. Information Accessibility
—Committee on Economic, Social, and Cultural Rights, General Comment 14187 States are obliged to ensure that patients can obtain and impart information about treatment services. In light of the considerable stigma attached to drug use and drug dependence treatment and the marginalization of drug users, UNODC and others recommend proactive steps by treatment centers to reach out to drug users with information about treatment through open access services, such as harm reduction programs, family support groups, drop-in centers, and telephone hotlines. In the regions Human Rights Watch visited, state narcological clinics did a poor job of making information about treatment available and encouraging drug users to seek treatment. In Kaliningrad, Penza, and Kuznetsk, for example, no adequate information was on display about effective drug dependence treatment modalities in the outpatient wards of state narcological clinics that are visited by many drug users and their families. In Kaliningrad Human Rights Watch researchers found no information about the nature of drug dependence or effective treatment modalities on the walls along a long corridor where drug users and their families wait to be seen by narcologists, let alone pamphlets or brochures with information that people could take home and digest at their leisure. Two pamphlets did invite people to come to individual or group consultations with psychologists and self-help groups, and briefly described the kinds of services that the psychologists offered. In Kuznetsk there were densely hand-written—and very difficult to read—posters about narcotic drugs and alcohol that provided little or no information about effective drug treatment modalities. In cities where open access services exist, like Kazan and Penza, narcological clinics often adopt a passive attitude: patients who show up at the clinic are seen and offered treatment, and the clinics do not seek to use open access services to reach out to the drug user community with information about treatment options and other relevant services. As a result, harm reduction programs and other open access services do not play the important bridging role they could perform between the drug user and the healthcare community. An HIV-positive peer counselor on antiretroviral treatment in Kazan told Human Rights Watch about his frustration with the lack of proactive outreach by the local narcological clinic toward drug users. He said that he felt that, as a peer counselor, he does work that the narcological clinics themselves should be doing but are not. He told Human Rights Watch that in the past year he had brought 50 drug users to narcological clinics, and motivated 30 of them to go through a rehabilitation program, seven of whom, he said, are now in a stable remission. Pondering his own situation, he said,
Cooperation between harm reduction programs and state narcological clinics is often limited to harm reduction programs bringing drug users who want to stop using drugs or need to reduce their dose to narcological clinics. In some cases, according to Anya Sarang of the Russian Harm Reduction Network, clinics will admit patients brought to them by harm reduction groups without a wait. Sarang was skeptical about the usefulness of proactive outreach by narcological clinics as long as these clinics offer poor quality services.189 Sergei Oleinik of the Foundation Anti-AIDS in Penza, which runs a needle exchange program, told Human Rights Watch that he would be happy to work with the drug treatment service, but only if it offered better treatment services. He said that his harm reduction program had agreed to circulate information about drug treatment services to drug users a number of years ago and had motivated some to enter into the treatment system. However, he said that these drug users came back with such poor assessments of the treatment they had received that he felt forced to abandon the effort out of fear of alienating his clients.190 In Kaliningrad street services hardly exist at all as the local authorities are strongly opposed to harm reduction programs that include needle exchange, which complicates accessibility of information about treatment services even more. A sociologist who conducted research among drug users and healthcare specialists told Human Rights Watch, “Because nongovernmental street services are completely non-existent, they [doctors at the narcological clinic] of course have trouble finding clients. There are no links to the [drug user] groups…”191 Svetlana Prosvirina, a peer counselor with the AIDS center in Kaliningrad who also leads a Narcotics Anonymous group, told Human Rights Watch that in 2006 she had had access to the inpatient facility of the narcological clinic where she provided patients with information about the group and encouraged them to attend it. But she said that “it ended in complete collapse” after a journalist sneaked into the facility and broadcast an unflattering piece about one of the narcologists. At the time that Human Rights Watch interviewed her, Prosvirina was no longer able to even visit the narcological clinic’s inpatient detoxification facility and outpatient rehabilitation program.192 In some regions narcological clinics run harm reduction programs or work closely together with them, and have thus established important links to the drug user community. Anya Sarang observed that in these regions drug dependence treatment services are generally more developed. For example, she said, in Toliatti in Samara province needle exchange is one of a series of services that the local narcological clinic has available to drug users. Among the other services offered, she named rehabilitation treatment and an aftercare program.193 The Acceptability Requirement
—Committee on Economic, Social, and Cultural Rights, General Comment 14194 Principles of medical ethics and cultural values are at the core of the acceptability requirement of the right to health. Healthcare goods or services that are inconsistent with these principles and values will also violate the right to health. A core aspect of the acceptability requirement is the right to respect for confidentiality of medical information. This right is also separately protected by the European Convention on Human Rights and Fundamental Freedoms and the International Covenant on Civil and Political Rights (ICCPR), to which Russia is also a party.195 The European Court of Human Rights has emphasized the importance of medical confidentiality by nothing that
While collection of statistical data about drug use, treatment uptake, and results serve an important and legitimate purpose, the evidence collected for this report suggests that in some regions local regulations require narcological clinics to disclose specific information on patients to law enforcement agencies, or that— whether such regulations exist or not—doctors at these clinics do so in practice. While the right to privacy does not establish an absolute rule of confidentiality of medical information, interference with this rule or breaches of it must be strictly justified. The European Convention on Human Rights stipulates that an interference with privacy is only legitimate if it is
Whether a restriction is “necessary” requires an assessment of whether a fair balance has been struck between the legitimate aim being pursued and the interests of the patient in maintaining the confidentiality of such data. The scope of this margin will depend on such factors as the nature and seriousness of the interests at stake and the gravity of the interference.198 Given that medical data may be highly intimate and sensitive in nature, the necessity for any State measure compelling communication or disclosure of such information without the consent of the patient must be carefully scrutinized and convincingly established.199 Provisions, like the 1998 Moscow order, that require the routine sharing of medical information on patients of drug dependence clinics violate Russian law, which holds that doctors may choose to breach confidentiality when a patient’s health condition may be due to an unlawful act. Furthermore, such routine sharing of medical information (other than statistical summaries) is unlikely to meet the requirement that it is “necessary in a democratic society.” Individual doctors must exercise careful judgment in making decisions regarding breaches of confidentiality in individual cases, even if Russian law formally allows for such breaches. In making such choices, doctors will need to carefully balance the importance of respecting confidentiality and the other relevant interests. Human Rights Watch believes that disclosure of a drug-dependent patient’s medical information because of the sole fact that he or she had voluntarily used an unlawful substance, thus causing harm to his or her body, would violate the right to privacy. The Quality and Scientific and Medical Appropriateness RequirementHealth services must “be scientifically and medically appropriate and of good quality,” which requires, among others, “skilled medical personnel, scientifically approved and unexpireddrugs and hospital equipment, safe and potable water, and adequate sanitation.”200 But it also means that states must, to the extent possible, employ treatment modalities that have been shown to be effective through sound scientific research, and to integrate evidence-based practices into existing modalities; a treatment modality that has been shown to be ineffective will fail the requirement of scientific appropriateness and quality. The progressive realization of the right to health means that states should periodically evaluate existing treatment modalities in order to identify shortcomings and enact improvements where necessary. Ideally, states should also conduct or fund sound scientific research into treatment modalities so that new, more effective treatments can be identified and introduced. The drug treatment system Russia inherited in 1992 from the Soviet Union was based more on ideology than on scientific evidence of effective treatment practices. Although Russia abandoned a number of problematic Soviet-era treatment practices, it neither clearly embraced an evidence-based treatment philosophy nor conducted a thorough review of the treatment system to introduce new practices based on scientific evidence. To this day, many elements of the drug dependence treatment system are clearly not consistent with well established principles of effective treatment of drug dependence. Russia’s rejection of maintenance treatment on essentially ideological grounds and its attempts to manipulate opinion about this treatment in the medical community seem to signify a continued willingness to attach greater importance to ideological considerations than to scientific evidence of effective treatment approaches. Treatment Policy Ignores Nature of Drug Dependence Disease As was mentioned above, scientific research has clearly established that drug dependence is a chronic and relapsing disease. The requirement of the right to health that health services must be scientifically and medically appropriate means that states should employ treatment modalities that take account of this fact if they are to be consistent with the right to health. Russia’s drug dependence treatment system, however, does not take this into account and insists that patients abstain from drug use immediately, completely, and permanently. When patients relapse treatment is considered to have failed. This policy is not consistent with the chronic and relapsing nature of drug dependence disease. The reality of this health condition is that many drug-dependent people have great difficulty achieving long-term abstinence (especially without maintenance therapy), that recovery from drug dependence rarely follows a linear path, and that relapses are a natural part of the recovery process for most people. Failing to recognize this and integrate it into treatment policy undermines the provision of scientifically and medically appropriate treatment programs. A treatment policy that insists on a linear path to recovery is not only inconsistent with contemporary scientific evidence but also complicates the treatment process itself. Most importantly, it complicates the treatment system’s ability to retain patients in treatment for an adequate amount of time. As has been explained above, patient retention is one of the key factors in treatment success. By placing on patients expectations that evidence has demonstrated only very few drug-dependent people can meet, and by failing to convey to patients that relapses are a normal part of the recovery process for most people—in fact, it equates relapse with failure—this treatment policy almost inevitably leads to disheartening assessments of treatment success for most patients, and thus undermines patient motivation to stay in treatment. It is also likely to have contributed to the abovementioned sense among many drug users that treatment offered at narcological clinics in Russia is not effective. The policy furthermore makes it impossible for doctors and their patients to draw up realistic individual treatment plans—another key aspect of evidence-based treatment—as these should anticipate the possibility of relapses, and prepare patients for such an eventuality. None of the people interviewed for this report had received counseling in detoxification treatment on the likelihood of relapses or on tactics they could employ to overcome one should it happen. Finally, the right to health requires—and best practice standards recommend—that patients in drug dependence treatment are provided with information on prevention of HIV and other blood-borne diseases as well as on the risk of drug overdose (which is particularly high after detoxification treatment) so that they are better able to protect themselves from harm should they return to drug use. As discussed above, such counseling does not currently take place in state narcological clinics in Russia, due, no doubt in part at least, to the system’s exclusive focus on abstinence. Treatment policy focused on patients’ complete abstinence from drug use also compromises the ability to evaluate the successes and failures of the treatment system in a meaningful way. Proper evaluation mechanisms are an important element in ensuring the scientific and medical appropriateness and the quality of medical services on offer, as they facilitate progressive improvement of these services. Yet, using abstinence as the only formal criterion does not make public health sense, as, for reasons explained below, it does not provide a meaningful picture of the effectiveness of treatment and yields little useful information that would allow the introduction of improvements into the treatment system. While sustained abstinence from drug use is the ultimate goal of drug dependence treatment systems in most countries, in recognition of the chronic and relapse-prone nature of drug dependence most treatment systems have developed diversified treatment goals and indicators for treatment success that go beyond just abstinence. These goals and indicators may include, along with abstinence: continued commitment to treatment, continued stay in treatment, the frequency and length of a patient’s relapses, the patient’s physical and mental well-being, his or her family and employment situation, and changes in the patient’s risk behavior during relapses.201 Russia’s current treatment philosophy does not take into account any of these important indicators, and can thus assess treatment success only in a very limited way. There appears to be increasing recognition in the healthcare community in Russia that the lack of differentiated treatment goals and assessment criteria is problematic. For example, the 2003 treatment protocol for rehabilitation of persons dependent on drugs of the Russian Ministry of Health recognizes that this is the case by stating that the “syndrome of dependence persists during all stages of rehabilitation, and is not reduced completely even in cases of long remissions.”202 Human Rights Watch found that some drug treatment doctors do apply broader criteria in their work with individual patients, even if they are not part of the formal assessment system. For example, Olga Komarova of the narcological clinic in Kuznetsk told Human Rights Watch,
In an article that appeared in the substance abuse journal Narkologia as well as on a website dedicated to illicit drug use in Russia, Mikhail Zobin, the head doctor of a private substance abuse treatment clinic in Moscow, and E. Egorov, a professor of psychiatry at the State University of St. Petersburg, point out that the rigid assessment of the success of treatment for drug dependence is at odds with general practices in Russian psychiatry, where a classification of treatment progress is used that differentiates between full remission and other degrees of progress in the treatment of patients. They state, “The possibility of a spontaneous relapse with schizophrenia, affective disorder, or epilepsy, even when correctly treated, does not raise any question among specialists. If [drug] dependence is a psychiatric disorder then why should its treatment be assessed only according to the first criteria of remission [full remission]?”204 The authors also note that some drug treatment experts recently have begun to write about incomplete or partial remissions in patients with opioid dependence as showing a positive dynamic.205 Failure to Facilitate Patient RetentionAs was mentioned above in Chapter III, it is a well established fact that detoxification on its own is unlikely to help drug dependence patients achieve lasting recovery, and that staying an adequate period of time in treatment is crucial to its success. Detoxification should be used not just to withdraw a patient from physical dependence on drugs but also to begin psychosocial interventions aimed at motivating the patient to stay in treatment. The US Substance Abuse and Mental Health Services Administration/Center for Substance Abuse Treatment (SAMHSA/CSAT) observes, “detoxification presents a unique opportunity to intervene during a period of crisis and move a client to make changes in the direction of health and recovery.”206 Indeed, research indicates that “addressing psychosocial issues during detoxification significantly increases the likelihood that the patient will experience a safe detoxification and go on to participate in substance abuse treatment.”207 Russian drug dependence treatment experts recognize the importance of retaining patients in treatment. For example, the 2003 Ministry of Health treatment protocol for rehabilitation of persons dependent on drugs notes specifically that effectiveness of detoxification treatment alone is very low and stresses motivational counseling to retain patients who are in rehabilitation programs.208 Russian drug treatment doctors complained to Human Rights Watch about the fact that only a small percentage of drug users proceed with rehabilitation treatment after detoxification. As was mentioned above, Nikolai Ivanets, Russia’s chief narcologist, suggested to Human Rights Watch that that is the case because many drug users “simply don’t want to be treated.”209 Our research shows, however, that detoxification treatment in Russian state clinics does little to work with drug users on their recovery and motivate them to stay in treatment. It appears that in many detoxification clinics the detoxification process barely goes beyond the narrow process of withdrawing the person from physical dependence and managing symptoms. Drug users and some drug dependence treatment experts identified two principle reasons why state narcological clinics have not been able to motivate more patients to remain in treatment: First, drug users said that they were kept in a heavily sedated state in detoxification treatment and often had trouble clearly recalling their experiences there, which complicates any motivational or other forms of counseling. Secondly, drug users in all three regions told us that, in fact, very little motivational counseling takes place during detoxification, that clinic staff do not involve patients in the development of individualized treatment plans, and that little is done to build a therapeutic alliance between patients and medical staff. The positive experience of some patients we interviewed who had continued into the rehabilitation phase highlights how regrettable it is that many patients are not being retained and that rehabilitation treatment uptake is low. Andrei A. from Kazan, whose very negative assessment of a detoxification clinic is given below, contrasted that with his experience of a state-run rehabilitation center:
Heavy sedationDetoxification treatment in Russia is heavily medicated, with patients routinely receiving a cocktail of medications that includes strong sedatives, antipsychotics, pain killers, and antidepressants. Almost all drug users who had been through detoxification treatment told Human Rights Watch that they had been heavily sedated during the first four or five days of their treatment and had been in a semi-comatose condition. They said that sedation in subsequent days was reduced so that they regained consciousness but many said that they remained heavily sedated even then. A drug user in Kazan, Ilya I., said,
Igor Y., another drug user from Kazan, described his January 2007 stay in a local narcological clinic:
Dima D., a drug user from Penza, told Human Rights Watch that he was in the local detoxification clinic for two weeks in January 2007 but that he remembers little from those weeks: “I was under tranquillizers the whole time.”213 The practice of heavy sedation of patients interferes with the ability to engage patients, work on building a therapeutic alliance with them, develop individualized treatment plans that address their various needs, and motivate them to stay in treatment. For example, one former drug user said when asked whether he had received counseling on psychological dependence while in the detoxification clinic,
There is no need for heavy sedation of patients during most of the detoxification process. SAMHSA/CSAT observes that while patients may require bed rest or reduced activity during the first 24 hours of detoxification, patients should generally “be ambulatory and able to participate in rehabilitative activities during detoxification.”215 Lack of counselingAlthough narcologists insisted that they conduct motivational counseling with detoxification patients, drug users described only very limited efforts to do so, often not by doctors or psychologists but by peer counselors from rehabilitation centers or self-help groups. The chief narcologists in both Tatarstan and in Kaliningrad said that they offer motivational services. Farit Fattakhov of Tatarstan, for example, told Human Rights Watch, “During detoxification, we motivate people for further therapy. We also conduct family therapy.”216 But asked whether they had received motivational counseling, most drug users said that they had not or that it was very limited. An outreach worker with the AIDS center in Kazan who had most recently been in a detoxification clinic in the summer of 2006 told Human Rights Watch that in his experience “there really is no contact with the doctors, they are not interested in the situation of the patient.”217 Igor Y., a drug user who had last been in a detoxification clinic in Kazan in January 2007, said,
Igor Y. said that that was the extent of the motivational counseling he had received. His previous experience in the detoxification clinic, in December 2005, had been similar. A drug user from Penza said that a psychologist had come to talk to him about his plans for the future when he was in the detoxification clinic in January 2007. He said that he had been asked whether he wanted to enter rehabilitation treatment but that he had said that he did not. That had, according to him, been the extent of the motivational counseling he received. A drug user from Kaliningrad told Human Rights Watch that she had repeatedly gone through detoxification at the local clinic, both free and paid, in 2006 but that she had received no psychological counseling and had never been invited to continue with rehabilitation treatment during any of her stays there.219 A number of drug users said that after coming out of the semi-comatose state of the first four or five days in detoxification treatment, they had had nothing to do and boredom set in, sometimes triggering a strong desire to use drugs. One drug user described his experience in the Kazan detoxification clinic:
He said that he got very bored in the clinic and started doubting his resolve to stop using drugs. For several days he drank alcohol to drive away the boredom. He said that alcohol-dependent patients, who in contrast to drug-dependent patients were allowed to leave the clinic, bought highly concentrated alcohol at pharmacies which they then diluted with water and consumed. Another drug user from Kazan, Ilya I., said that both times he received detoxification treatment, procedures were mostly limited to withdrawal from physical dependence. Describing his stay in a city detoxification clinic in Kazan in 2003 he said that, having slept the first four or five days,
The motivational counseling had been limited to occasional visits by peer counselors from the rehabilitation center:
After 10 days Ilya I. was so bored and felt such a strong urge to use drugs that he decided to go home. His doctor initially refused to release him but when Ilya I. threatened to break the rules so he would be forced out, he was indeed released. Ilya I. said that he began using again that same day. In their qualitative study of 121 drug users in three Russian cities, Bobrova and others found an important contrast between drug users who had received psychological counseling in detoxification clinics and those who had not:
One reason for poor motivational counseling in many clinics may be the fact that the 1998 treatment protocol for detoxification of persons dependent on drugs provides no guidance on the counseling efforts that should take place.224 In fact, the protocol’s silence on this issue leaves the strong impression that such counseling is not an integral and essential part of detoxification treatment. It appears that part of the problem may also be a lack of relevant staff in some clinics. Bobrova, for example, observes that some detoxification clinics do not have psychologists or psychotherapists on staff, even though such positions formally exist.225 Result: Failure to foster a therapeutic alliance and poor patient retentionWhile research suggests that a therapeutic alliance may be the single most important factor for treatment outcome, the abovementioned practices in Russian detoxification clinics are not conducive to the establishment of such alliances. As demonstrated by the enormous distrust among drug users toward narcologists, the staff at narcological clinics is often not succeeding in forging good relationships with their patients. The above testimony also suggests that staff at narcological clinics often make little investment in the development of relationships with patients. At the same time, the Bobrova study suggests that where such investments are made patients felt much more positive about their treatment experience. Counseling on HIV/AIDS and Other Health ConditionsDetoxification provides an important opportunity to counsel patients on HIV/AIDS and other diseases that are prevalent among drug users, as well as about drug overdose prevention. UNODC and NIDA recommend that drug dependence patients in detoxification and rehabilitation treatment are counseled on HIV and AIDS, TB, hepatitis B and C, and other health conditions that are prevalent among injecting drug users. Under the right to health, states have an obligation to take measures to prevent the spread of HIV and other health conditions. This requires that states ensure that people at risk of contracting these conditions should be provided with relevant information about prevention, care, and treatment whenever possible. For HIV, this means that patients must be told about the importance of needle exchange and be referred to needle exchange providers where available. It does not appear, however, that patients in narcological clinics are routinely provided with such information. For example, Dima D., a drug user from Penza, said that he had not received any counseling on HIV when he was in the narcological clinic in early 2007. As he said that he remembered little of his two weeks in the clinic due to sedation, it was not clear whether the counseling had not taken place at all or whether he did not remember it.226 A psychologist in Kuznetsk told Human Rights Watch that she does discuss HIV prevention in counseling sessions with drug users, although she admitted that it was at meetings of the self-help group she led a few years ago that HIV was extensively discussed.227 Andrei A., a drug user from Kazan, told Human Rights Watch that he was diagnosed with HIV in 2001. He said that he decided at the time to take his diagnosis with him to the grave. For years he did not discuss his HIV status with anyone. He said that it was not until he started treatment in an outpatient rehabilitation program at the NGO Roza Vetrov—having first been through detoxification and the rehabilitation program at the narcological clinic—that he learned that HIV is not a literal or metaphorical death sentence. During the rehabilitation program he heard other HIV-positive people speaking openly about their status, their lives with their status, and antiretroviral treatment. Andrei A. told Human Rights Watch, “I learned that people with HIV can have healthy children, even if both parents are HIV positive! It opened me up. I started talking to people here about my status, I went to the AIDS center for tests.”228 A female drug user told Human Rights Watch a similar story. She said that she had been diagnosed with HIV in 2005 but had not received any information about the disease at the time. Although she went through detoxification treatment at a clinic in Kazan in August 2006, she told Human Rights Watch that “I only started to learn about HIV here, in rehabilitation [at Roza Vetrov].”229 Albert Zaripov of Roza Vetrov told Human Rights Watch that very little counseling on HIV takes place during detoxification treatment for two reasons. First, he said, “It is hard to talk about this in detoxification because people are not of sound mind [due to the sedation]. How do you talk to people like that about avoiding risky behavior, or accepting an HIV diagnosis?”230 Secondly, he said, the narcological clinics do not have staff who really know the issue of HIV. In the past Roza Vetrov had employed some peer counselors to visit the detoxification clinic and rehabilitation center to counsel patients on HIV, but that initiative had been discontinued when funding ran out and no new funding could be found. Conditions at Narcological clinicsDrug users in all three regions also complained of poor conditions at narcological clinics. They spoke of poor material conditions, an often indifferent attitude of the clinic’s personnel, and objected to the practice of mixing alcohol- and drug-dependent people. Poor material conditions and indifference on the part of medical staff are by no means unique to the narcological system but are widespread across Russia’s healthcare system. A drug user from Kazan said that conditions in the detoxification clinic reminded him of a prison: “The toilet was horrible. You have to wash yourself with a hose. [As for the food,] I couldn’t make out most of the time whether it was porridge or water in the cup. The food was awful.”231 Several interviewees in Penza described the conditions inside the inpatient clinic there as particularly bad. Dima D., for example, said that although the outside of the building was recently renovated and looks new, on the inside the building is in very poor condition.232 He and other drug users said that the facility had only one bathroom for all patients, both men and women, and that this room is also used as a smoking room. A woman who had been in the facility in January 2007 told Human Rights Watch that she would go to the bathroom at the facility and would have to ask a group of smoking men to turn around and look the other way so she could use the toilet.233 In Kazan and Penza drug users also complained that they were mixed with alcohol patients at detoxification facilities. Many expressed an intense dislike of alcohol patients. For example, Dima D., a drug user from Penza, said, “The alcoholics shit and pee anywhere. They might smear poop on the walls when they are in delirium, they scream.”234 The head of the detoxification clinic in Kuznetsk identified the practice of mixing alcohol and drug patients as one of the key problems in her facility. She said that the two groups do not like each other but that her facility did not allow her to keep them separately.235 Andrei A. from Kazan characterized his associations with the local detoxification clinic as “abhorrence, disgust, grayness, dirt.” He described the attitude of the medical personnel as generally indifferent, although he said that he had received appropriate relief when he complained about stomach aches and other pains. He recounted an incident that had particularly outraged him:
Conditions for drug users who pay for their treatment are often better than for those who do not pay. In some regions, detoxification clinics have separate wards for paying patients. Farit Fattakhov, the chief narcologist in Tatarstan, told Human Rights Watch that his clinic has private rooms and double rooms available for drug users, for example. An outreach worker in Kazan who said he had been in detoxification clinics eight or nine times over the last 18 years, most recently in the summer of 2006, told Human Rights Watch, “If you pay for treatment you get a room, if you don’t, you’re in the corridor.”237 Several drug users also said that the attitude of personnel and the medications offered were much better in the ward for paying patients than in the wards for free treatment. A female drug user from Kazan said, “Being in the free ward means a rude attitude of the medical personnel, insufficient medication, and insults. If you pay, you get servility… [The doctors] just gave me medication and then did not check in on me Not all drug users interviewed complained about treatment by doctors and medical personnel. Some said that they had had positive experiences. Principle of Non-discrimination and Restrictions on the Rights of Drug UsersAs has been discussed above, the drug user registry is a barrier that violates the rights of patients by discouraging access to drug treatment and fostering real and perceived breaches of confidentiality of medical information. Our research suggests that the current system of placing restrictions on the rights of registered drug users to obtain driver’s licenses and hold specific types of jobs also violates the principle of non-discrimination, as the restrictions are disproportionate in nature and applied selectively against certain groups of drug users.239 International law prohibits “any discrimination … on any ground such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status.”240 Policies that treat individuals differently based on a category or status may be lawful but only if the category is not one of the prohibited grounds, and the differential treatment is based on objective grounds and criteria, in pursuit of a legitimate goal, and is proportionate and necessary for achieving that goal. Narcologists and officials justify the restrictions on the rights of drug users as necessary for the public interest. In their opinion, restrictions on the right to obtain a driver’s license, for example, are necessary to prevent drug users from causing accidents. There is no doubt that public safety is a legitimate interest that may justify certain restrictions on the rights of specific categories of people. The question is whether these restrictions are necessary and proportional to the legitimate aim pursued. The proportionality of the restrictions imposed on drug users is questionable. As has been described above, a person on the drug user registry remains on it for at least five years (and longer in case of relapses). During this time the person cannot officially obtain a driver’s license or hold certain types of jobs. The restrictions are imposed on the sole basis of a doctor’s diagnosis of drug dependence without any attempt to determine whether the restrictions are actually necessary in the individual case. Human rights law generally frowns upon these kinds of blanket restrictions imposed on entire groups, as they almost inevitably lead to unnecessary restrictions on the rights of some members of the group. As with alcohol-dependent persons, many drug users can safely drive cars when they are sober. The question is not so much whether someone is dependent on drugs or alcohol but whether that person makes responsible choices on when to drive and when not. Indeed, most countries do not impose blanket restrictions on the rights of drug- or alcohol-dependent people. Instead, they make decisions on the appropriateness of a job candidate or applicant for a driver’s license in individual cases, with the help of reference checks, checks for citations for driving under influence, medical tests, and so on. Restrictions are imposed for the entire time the person remains on the registry. During this period, there is no periodic review process to determine whether the restrictions should still apply to the specific individual. This means that even people who have successfully stopped using drugs after treatment will not be able to hold certain jobs or obtain a driver’s license for a period of five years. That is excessively burdensome. Furthermore, the restrictions are imposed selectively. In most regions of Russia, patients who can pay for their treatment are not entered onto the registry and therefore do not face any restrictions on their rights. This policy discriminates against socially disadvantaged groups but it also undermines the rationale officials give for the existence of the restrictions system. Put in stark terms, the message of this system is that it is alright for rich drug users to cause car accidents but not for poor ones. Anton Blinov, a former drug user who currently works as a peer counselor at the AIDS center in Kazan, pointed out the absurdity of this system. Blinov was stripped of his driver’s license in 2005 because he was on the drug user registry. Trying to get his license reinstated, he said that he went to the chief narcologist of Kazan with a stack of letters of recommendations from, among others, doctors at the AIDS center that explained that he worked for the AIDS center, needed his car for his work, and did not use drugs anymore. He told Human Rights Watch about his conversation:
Blinov was not given his driver’s license back. Human Rights Watch pointed out this situation to the chief narcologist of Tatarstan. The narcologist shrugged and said, “Well, that’s our law…” Human Rights Watch therefore believes that the restrictions system as it currently exists violates the principle of non-discrimination. It should be abolished or reformed in a way that is nondiscriminatory and does not create a barrier to treatment-seeking behavior. In any case, our research findings suggest that in practice the functionality of the restrictions system is compromised by corrupt practices in both the traffic police and narcological clinics.A number of drug users who were on the registry told Human Rights Watch that being on the registry had not prevented them from obtaining drivers’ licenses. One drug user, who said he had been clean for six years but had not bothered to go to follow-up appointments at the narcological clinic (as required in order to be taken off the registry), said, “I did get my driver’s license, even though I’m on the registry. It’s corruption. Anything is for sale.”241 Another drug user said that he was not particularly worried about being on the registry: “After all, I can buy a certificate [at the narcological clinic] that I’m not on the registry even if I am. Also, you can buy a driver’s license [from the traffic police] without any certificates.”242 Research by the INDEM Foundation, a Russian NGO that has consistently monitored corruption in Russia since its establishment in 1997, shows that corruption is widespread both in healthcare settings and in the traffic police. In a 2005 report it estimated that 37.7 percent of people who had dealings with the healthcare system in 2005 had encountered corruption (up from 23.5 percent in 2001), as had almost 60 percent of people who had dealings with traffic police in that same year.243 123 International Covenant on Economic, Social and Cultural Rights (ICESCR), G.A. res. 2200A (XXI), 21 U.N.GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3, entered into force January 3, 1976, art. 11; also in the Convention on the Rights of the Child, G.A. res. 44/25, annex, 44 U.N. GAOR Supp. (No. 49) at 167, U.N. Doc. A/44/49 (1989), entered into force September 2 1990, ratified by Russia on August 16, 1990, art. 24. The right to health is also guaranteed in the European Social Charter (revised), Council of Europe, ETS 163, Strasbourg, 3.V. 1996, art. 11. Russia signed onto the European Social Charter on September 14, 2000, but has yet to ratify. 124 See ICESCR, art. 2 ; International Convention on the Elimination of All Forms of Racial Discrimination (ICERD), adopted December 21, 1965, G.A. Res. 2106 (XX), annex, 20 U.N. GAOR Supp. (No. 14) at 47, U.N. Doc. A/6014 (1966), 660 U.N.T.S. 195, entered into force January 4, 1969, art. 5; Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), adopted December 18, 1979, G.A. res. 34/180, 34 U.N. GAOR Supp. (No. 46) at 193, U.N. Doc. A/34/46, entered into force September 3, 1981, art. 12. 125 International Covenant on Civil and Political Rights (ICCPR), G.A. res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 52, U.N. Doc. A/6316 (1966), 999 U.N.T.S. 171, entered into force March 23, 1976, ratified by Russia on October 16, 1973; European Convention on Human Rights (ECHR), 213 U.N.T.S. 222, entered into force September 3, 1953, as amended by Protocol 11 which entered into force on November 1, 1998, ratified by Russia on May 5, 1998. 126 UN Committee on Economic, Social and Cultural Rights, General Comment No. 14: The right to the highest attainable standard of health, November 8, 2000, para. 12. The Committee on Economic, Social and Cultural Rights is the UN body responsible for monitoring compliance with the International Covenant on Economic, Social and Cultural Rights. 127 General Comment No. 14, para. 31. 128 Constitution of the Russian Federation, art. 41. 129 Ibid., art. 54(1). 130 Presentation by the deputy minister for health and social development, Ruslan Khalfin, at a meeting of healthcare officials on February 16, 2007. A powerpoint presentation can be found at http://www.mzsrrf.ru/userdata/Nacinl_Prjct.ppt (accessed July 27, 2007). 131 NIDA, “Understanding Drug Abuse and Addiction: What Science Says,” slideshow, undated, available at http://www.nida.nih.gov/pubs/teaching/Teaching3/Teaching5.html (accessed August 29, 2007). 132 CESCR, General Comment 14, art. 12(a). 133 Human Rights Watch interview with Sergei S., Kazan, January 23, 2007. 134 Human Rights Watch interview with Anton B., Kazan, January 24, 2007. 135 Human Rights Watch interview with Igor Y., Kazan, January 26, 2007. 136 Human Rights Watch interview withInna Vyshemirskaya and Viktoria Osipenko, Kaliningrad, January 30, 2007. 137 Draft report on the survey by the Penza Anti-AIDS Foundation, on file with Human Rights Watch. The questionnaire did not define the term “a long time.” As a result, it is impossible to determine how long these people waited before being able to enter into treatment. 138 Human Rights Watch interview with Farit Fattakhov, Kazan, January 25, 2007. 139 Elovich, “Drug Demand Reduction Program’s Treatment and Rehabilitation Improvement Protocol,” p. 16. 140 Article 55(2) of the 1998 Federal Act on Narcotic Drugs and Psychoactive Substances limits detoxification treatment to state institutions. Federal Act on Narcotic Drugs and Psychotropic Substances, art.55(2). 141 SAMHSA/CSAT notes, for example, that hospitalization or another form of 24-hour medical care “is often the preferred setting for detoxification” for patients with opioid withdrawal symptoms. SAMHSA/CSAT, TIP 45, p. xvi. 142 Federal Act on Narcotic and Psychotropic Substances, art. 55(2). 143 UNAIDS estimates that 940 000 people are HIV+ out of a population of 143 million, which is 0.656 percent, UNAIDS, “Russian Federation”, Country Page, 2006, http://www.unaids.org/en/Regions_Countries/Countries/russian_federation.asp (accessed October 1, 2007). 144 World Health Organization (WHO), United Nations Office on Drugs and Crime (UNODC), Joint United Nations Programme on HIV/AIDS (UNAIDS), Substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention (Geneva: 2004). 145 See http://www.opiateaddictionrx.info/pdfs/SayNo2MethadoneRealFacts.pdf and http://www.opiateaddictionrx.info/pdfs/SayNo2Methadone.pdf (accessed July 24, 2007). 146 A.V. Nadezhdin, undated, http://www.drugpolicy.ru/?page=publications/publ_hr61_methadon. 147 V.D.Mendelevich, “Drug dependence and narcology through the prism of public opinion and professional analysis” (“Narkozavisimost I narkologia cherez prizmu obshestvennogo mnenia I professionalnogo analiza”), Kazan 2006, p. 196. 148 Tom Parfitt, “Vladimir Mendelevich: fighting for drug substitution treatment,” The Lancet, Volume 368: 9532, pp. 279-279. 149 General Comment No. 14, para. 12. 150 Article 8 of the European Convention on Human Rights states that “1. Everyone has the right to respect for his private and family life, his home and correspondence. 2. There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.” European Convention for the Protection of Human Rights and Fundamental Freedoms, 213 U.N.T.S. 222, entered into force September 3, 1953, as amended by Protocols Nos 3, 5, 8, and 11 which entered into force on September 21, 1970, December 20, 1971, January 1, 1990, and November 1, 1998, respectively. 151 European Court of Human Rights, Airey v. Ireland, 1979, 2 E.H.R.R. 305, judgment of October 9, 1979, Series A, no. 32, p. 17, section 32. 152 European Court of Human Rights, Lόpez Ostra v. Spain, 1994, Application No. 16798/90, judgment of 9 December 1994, Series A, no. 303-C, and Guerra and others v. Italy, Application No. 14967/89 judgment of February 19, 1998, Reports 1998-I. 153 European Court of Human Rights, Leander v. Sweden, Application No. 9248/81, Judgement of 26 March 1987, Series A, no. 116, p. 29, section 74. 154 Marina Selivanova, “Drugs, like diabetes – an illness for life” (“Narkotiki, kak diabet, - bolezn na vsiu zhizn”), Argumenty i Fakty, September 6, 2006. 155 “Program of Kaliningrad province, ’Comprehensive measures to counter the unlawful circulation of narcotic drugs and prevention of anti-social behavior among youth for 2007-2011’” (“Tselevaia programma Kaliningradskoi oblasti ‘Kompleksnye mery protivodeistvia nezakonnomu oborotu narkotikov i profilaktiki asotsialnogo povedenia v detsko-molodezhnoi srede na 2007-2011 gody’”), p. 21. A copy of the program is on file with Human Rights Watch. 156 Interdepartmental commission on the fight against AIDS under the government of the Republic of Tatarstan, “Analysis of the situation of HIV-infection and injection drug use in the city of Kazan,” Kazan, 2006. 157 Human Rights Watch interview with Alexander Dmitriev, Kazan, January 26, 2007. 158 Human Rights Watch telephone interview with Yuri Ivanov,April 2, 2007. 159 Bobrova et al., “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities,” Drug and Alcohol Dependence. 160 CESCR, General Comment 14, para. 12(b). 161 Paradoxically, while Human Rights Watch found that drug users who are not registered were highly apprehensive about being put on the registry, most drug users who were on the registry told us that they had not come across any restrictions on their rights because of their registration. When asked about obtaining a driver’s license, one drug user laughed and said: ““I did get my driver’s license, even though I’m on the registry. It’s corruption. Anything is for sale.” Human Rights Watch interview with Roman R, Kaliningrad, January 31, 2007. But we also interviewed one former drug user whose driver’s license had been taken away from him because a traffic police computer had him listed as a registered drug user. The local narcological service had apparently shared his information—and possibly information on everybody on the registry in that town—with the traffic police. Human Rights Watch interview with Anton Blinov, Kazan, January 24, 2007. 162 Human Rights Watch interview with Andrei A., Kazan, January 24, 2007. 163 Human Rights Watch interview with Igor I., Kazan, January 23, 2007. 164 Bobrova et al., “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities,” Drug and Alcohol Dependence. 165 Ibid. 166 Human Rights Watch interview with Evgenia Koshina, Moscow, March 7, 2007. 167 Human Rights Watch email correspondence with Andrei Zlobin of the Community of People Living with HIV/AIDS, July 25, 2007. 168 Infectious diseases like HIV, hepatitis, or syphilis spread only through specific risk behaviors, and admitting patients with these diseases without prior knowledge of a patient’s status does not pose any additional risk to the health of the clinic’s staff or other patients. While active pulmonary TB is highly contagious and can spread through the air, a number of simple steps can be taken to minimize the risk of accidental infection of clinic staff and other patients and admit the person into treatment immediately. Medical doctors should conduct a basic screening of new patients upon admission for signs and symptoms of active TB—loss of appetite, rapid weight loss, night sweats, coughing—to identify high-risk patients. Patients without signs and symptoms of TB should be admitted immediately as the chance that they nonetheless have contagious TB is very small. High-risk patients should immediately be referred for a chest X-ray and, if positive for TB, be admitted to special TB wards at drug treatment clinics, where available, or to TB hospitals. These patients should under no circumstances be denied hospitalization as they pose a risk to the general public and are very sick. Human Rights Watch interviews with Dr. Douglas Bruce, a clinical instructor of medicine at the infectious diseases section of Yale Medical School and medical director of the SouthCentral Rehabilitation Center in New Haven; and Sharon Stancliff, medical director of the Harm Reduction Coalition in New York. 169 Human Rights Watch interview with Andrei A., Kazan, January 24, 2007. 170 Human Rights Watch email correspondence with Roman Muravev of FrontAIDS, Irkutsk, July 25, 2007. Human Rights Watch interviews with various drug users at hospital #9, St. Petersburg, July 2007. 171 Human Rights Watch interview with Irina I., Penza, April 11, 2007. 172 Human Rights Watch interview with Yura Y., Penza, April 16, 2007. 173 Human Rights Watch interview with Sergei S., Penza, April 16, 2007. 174 Human Rights Watch interview with Svetlana S., Kazan, January 25, 2007. 175 Human Rights Watch interview withInna Vyshemirskaya and Viktoria Osipenko, Kaliningrad, January 30, 2007. 176 Human Rights Watch interview with Arkadi A., Kazan, January 24, 2007. 177 Bobrova et al., “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities,” Drug and Alcohol Dependence. 178 Ibid. 179 Bobrova et al., “Injection drug users’ perceptions of drug treatment services and attitudes toward substitution therapy: A qualitative study in three Russian cities.” 180 Human Rights Watch interview with Yura Z., Penza, April 16, 2007. 181 CESCR, General Comment 14, para. 12(b). 182 Constitution of the Russian Federation, art. 41(1). 183 Human Rights Watch telephone interview with Albert Zaripov, June 29, 2007. 184 Bobrova et al., “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities,” Drug and Alcohol Dependence. 185 Ibid. 186 Human Rights Watch interview with Igor I., Kazan, January 23, 2007. 187 CESCR, General Comment 14, para. 12(b). 188 Human Rights Watch interview with Anton Blinov, Kazan, January 24, 2007. 189 Human Rights Watch telephone interview with Anya Sarang, Turkey, July 9, 2007. 190 Human Rights Watch telephone interview with Sergei Oleinik, Penza, June 29, 2007. 191 Human Rights Watch interview withInna Vyshemirskaya and Viktoria Osipenko, Kaliningrad, January 30, 2007. 192 Human Rights Watch interview with Svetlana Prosvirina, Kaliningrad, February 2, 2007. 193 Human Rights Watch interview with Anya Sarang,Turkey,July 9, 2007. 194 CESCR, General Comment 14, para. 12(c). 195 Article 8 of the ECHR and Article 17(1) of the ICCPR state, “No one shall be subjected to arbitrary or unlawful interference with his privacy, family, home or correspondence, nor to unlawful attacks on his honour and reputation.” According to Manfred Nowak in his treatise on the ICCPR, the right to privacy includes a right of intimacy, that is, “to secrecy from the public of private characteristics, actions or data.” This intimacy is ensured by institutional protections, but also includes generally recognized obligations of confidentiality, such as that of physicians or priests. Moreover, “protection of intimacy goes beyond publication. Every invasion or even mere exploration of the intimacy sphere against the will of the person concerned may constitute unjustified interference” [emphasis in the original]. Manfred Nowak, UN Covenant on Civil and Political Rights: CCPR Commentary (Kehl am Rein: N.P. Engel, 1993), p. 296. 196 European Court of Human Rights (ECtHR), Z. v. Finland, Application No. 22009/93, Judgment of 25 February 1997, Reports of Judgments and Decisions 1997-I, para 95. 197 European Convention on Human Rights and Fundamental Freedoms, art. 8(2). 198 See for example ECtHR, Leander v. Sweden, 1987, p. 25, para. 58; and, mutatis mutandisManoussakis et al. v. Greece, Application No. 18748/91 judgment of 26 September 1996, Reports 1996-IV, p. 1364, para. 44. 199 ECtHR, Z v. Finland, 1997, para. 96. 200 CESCR, General Comment 14, para. 12(d). 201 NIDA, “Principles of Drug Addiction Treatment: A Research-Based Guide,” p. 15. 202 Order No. 500 of the Ministry of Health of 22 October 2003, “Treatment Protocol: Rehabilitation of Persons with Drug Dependence Disease,” Chapter VI (on file with Human Rights Watch). 203 Human Rights Watch interview with Olga Komarova, Kuznetsk, April 12, 2007. 204 M. Zobin and A. Egorov, “Remissions with opiate dependence” (“Remissii pri opioidnykh narkomaniakh”), undated http://www.narcom.ru/cabinet/online/107.html (accessed August 29, 2007). 205 Ibid. 206 SAMHSA/CSAT, TIP 45, p. 23. 207 Ibid. 208 Order No. 500 of the Ministry of Health of 22 October 2003, “Treatment Protocol: Rehabilitation of Persons with Drug Dependence Disease,” Chapter VI (on file with Human Rights Watch). 209 Human Rights Watch interview with Nikolai Ivanets, Moscow, March 7, 2007. 210 Human Rights Watch interview with Andrei A., Kazan, January 24, 2007. 211 Human Rights Watch interview with Ilya I., Kazan, January 24, 2007. 212 Human Rights Watch interview with Igor Y., Kazan, January 26, 2007. 213 Human Rights Watch interview with Dima D., Penza, April 16, 2007. 214 Human Rights Watch interview with Anton Blinov, Kazan, January 24, 2007. 215 SAMHSA/CSAT, TIP 45, p. 74. 216 Human Rights Watch interview with Farit Fattakhov, Kazan, January 25, 2007. 217 Human Rights Watch interview with Slava Matiushkin, Kazan,January 23, 2007. 218 Human Rights Watch interview with Igor Y., Kazan, January 26, 2007. 219 Human Rights Watch interview with Tatiana T., Kaliningrad, February 1, 2007. 220 Human Rights Watch interview with Andrei A., Kazan, January 24, 2007. 221 Human Rights Watch interview with Ilya I., Kazan, January 24, 2007. 222 Ibid. 223 Bobrova et al., “Injection drug users’ perceptions of drug treatment services and attitudes toward substitution therapy: A qualitative study in three Russian cities,” Journal of Substance Abuse Treatment. 224 Order N. 140 of the Ministry of Health of the Russian Federation of 28 April 1998 “On the confirmation of standards (model protocols) for the diagnostic and treatment of the narcologically ill.” 225 Bobrova et al., “Barriers to accessing drug treatment in Russia: a qualitative study among injecting drug users in two cities,” Drug and Alcohol Dependence. 226 Human Rights Watch interview with Dima D., Penza, April 16, 2007. 227 Human Rights Watch interview with Olga Komarova, Kuznetsk (Penza province), April 12, 2007. 228 Human Rights Watch interview with Andrei A., Kazan, January 24, 2007. 229 Human Rights Watch interview with Alsu A., Kazan, January 24, 2007. 230 Human Rights Watch telephone interview with Albert Zaripov, Kazan, June 29, 2007. 231 Human Rights Watch interview with Rustem R., Kazan, January 26, 2007. 232 Human Rights Watch interview with Dima D., Penza, April 16, 2007. 233 Human Rights Watch interview with Maria M., Penza, April 11,2007. 234 Human Rights Watch interview with Dima D., Penza, April 16, 2007. 235 Human Rights Watch interview with Svetlana Maksimova, Kuznetsk (Penza province), April 12, 2007. 236 Human Rights Watch interview with Andrei A., Kazan, January 24, 2007. 237 Human Rights Watch interview with Slava Matiushkin, January 23, 2007. 239 The types of jobs that people registered as being dependent on drugs cannot perform include, among others, those that involve work at certain power stations, with any explosive substances or in industries that are high risk for explosions or fire, work as guards who carry arms, driving a car, or work linked to various aspects of the train system. 240 ICCPR, art. 26. 241 Human Rights Watch interview with Roman R., Kaliningrad, January 31, 2007. 242 Human Rights Watch interview with Zhenia Z., Kazan, January 25, 2007. 243 INDEM Foundation, “Corruption process in Russia: level, structure, trends. Corruption increase rate within four years' period as a result of the recent survey made by the INDEM Fund,” 2005, http://www.anti-corr.ru/indem/2005diagnost/2005diag_eng.htm (accessed August 31, 2007). |