MINIMISATION OF HIV RISKS AMONG YOUNG DRUG USERS IN ST. PETERSBURG, HELSINKI AND STOCKHOLM PROJECT

Transcription

1 PÄIVI PURO & TANJA TUORI MINIMISATION OF HIV RISKS AMONG YOUNG DRUG USERS IN ST. PETERSBURG, HELSINKI AND STOCKHOLM PROJECT A-Clinic Foundation, Helsinki Convictus-organisation, Stockholm Vozvratscheniye Foundation, St. Petersburg A-Clinic Foundation Duplicate Series no 53 A-Clinic Foundation 2006 ISSN (print) ISSN (online) ISBN (print) ISBN X (pdf)

2 CONTENTS Summary 1. Introduction 6 2. Background and Reasons for the Project 7 3. Project in the Context of a Wider Society and Changing Drug Use and Infectious Diseases Situation Situation in St Petersburg Situation in Helsinki Situation in Stockholm Project Organisation and Management Project Management and Project Finance Network Finance Communication Evaluation Working Methods and Implementation Results and Impact of the Project Snowball Operations in Helsinki and St. Petersburg Service Provider Network and Snowball Operations Russian Snowball Operation in Helsinki Snowball Operation in St. Petersburg Training Co-operation Networking Partners in Training Co-operation Multi-professional Team and Network Training in St. Petersburg Information Production Partner Network in Information Production Information Production in St. Petersburg Information Production in Helsinki Information Production in Stockholm Experience Exchange The Service Provider Network in Experience Exchange The Practical Dimensions of the Experience Exchange Promotion of Service User Rights Co-Operation Network for Promoting the Service User Rights Promotion of Service User Rights as Part of the Working Methods of the Project 49 2

3 6.6. Evaluation of the Project as a Model for a Pilot Project on Substance Abuse Work in Neighbouring Areas Evaluation Information Network of the Project Project s Evaluation Information as an Evaluation Model Conclusions of the Results and Evaluation of the Project Suggestions for Developing Substance Abuse Work in Nearby Areas 53 Sources 58 Appendices Appendix 1: Members of the Project Group Appendix 2: Press Release on the Final Seminar Appendix 3: Program of the Final Seminar 3

4 Summary In the final report on Minimisation of HIV risks among young drug users in St. Petersburg, Helsinki and Stockholm project ( ) are described the results and outputs of the project and the whole project is evaluated on basis of the needs and demands to develop further co-operation in neighbouring areas. The project was funded by the Nordic Council of Ministers. The project was realised as co-operation between Vozvratscheniye Foundation from St. Petersburg, Finnish A-Clinic Foundation and Deaconess Institution of Helsinki, and Convictus organisation from Stockholm during The starting point of the project was to identify development aims and focus points in the Nordic dimension and for co-operation in nearby areas where reduction of the risks of infectious diseases relating to drug use was given priority. The project s working methods were (1) building co-operation networks, (2) training professionals and developing their work, (3) developing local service systems, (4) accumulating information, and (5) promoting of human, civil and service user rights for drug users in substance abuse treatment service field. In the project local and international substance abuse treatment workers were brought together in order to arrange mutual exchange in information, experiences and learning. The training co-operation of the project was based on surveys made on current working methods employed in substance abuse services and the need for their development in St. Petersburg, and taking advantage of experiences and skills of Finnish substance abuse treatment services in realisation of the training. The main themes in the training were how to meet drug users, how to motivate substance abuse treatment work, working in a multi-professional team environment, coping with the work and networking. In St. Petersburg and in Helsinki a so-called Snowball operation was implemented which is based on peer collaboration or work. In these operations substance abuse treatment employees educate users of intravenous drugs on the risks of infectious diseases associated with the use of drugs, and train them to tell about these risks to other drug users. Through this education or training and employing this ground-breaking method also drug user and service user rights were promoted by giving support and treatment drug users or customers actually need. In Finland the Snowball operation had been implemented once before among Finnish speaking drug users. Now this method was employed for the first time among the largest group of immigrants and account was taken especially of linguistic and cultural differences. In St. Petersburg the Snowball operation was implemented for the first time in Autumn This trial run was used to assess and determine the potential success of the working method. It proved that there is a great need for peer collaboration or work also in Russia, however, this work needs to take into account local conditions and boundary values. 4

5 Co-operation in nearby areas is currently mainly realised through fixed-term development projects. Also this project was this type of project, and the results can be benefited in planning future projects and developing of service systems. The project has some continuous aspects as well as the central project partners will continue their co-operation and new services will be available to the clients also in future. One of the aims for future is to establish these services as part of everyday work. Further economic and political support is needed though to aid the work of the civil organisations in nearby areas and among the Russian immigrants in the Nordic area and the EU from local, national and international levels. 5

6 1. Introduction This is the final report on the Minimization of HIV Risks among Young Drug Users in St. Petersburg, Helsinki and Stockholm ( ) Project. Here the results of the project are presented and evaluated as viewed by project partners, the organisations who were involved with the project. This project team consisted of NGOs working in the field, namely Vozvratscheniye Foundation from St. Petersburg, A-Clinic Foundation whose operation area is Finland and Helsinki Deaconess Institute, and Convictus organisation from Stockholm. These organisations have produced the documents presented in the final report and evaluation of the project from the local perspective as well as from the point of view of the inter-organisational networking and co-operation across the borders in neighbouring areas. The starting point for the project was to develop of methods of cross-border cooperation and networking in the Nordic dimension of the European Union and its neighbouring areas resulting in the reduction of infectious diseases relating to drug use. It was possible to make a contact with the target group, Russian speaking drug users, especially in St. Petersburg and Helsinki which meant that the in practice the project was realised in these areas. As the number of Russian speaking drug users was insignificant in Stockholm, the Swedish action was directed towards Baltic States, especially on Estonia and Lithuania. In the first sections of the report the background of the project and variations in the drug use and infectious diseases statistics in St. Petersburg, Helsinki and Stockholm are presented. Analysis and evaluation of the project organisation and working methods will be followed with the presentation of main outcomes and results of the project. The results are examined through describing different networks working in the project and how the work and the evaluation of the work was accomplished. The report will end with a summary where the main results of the project and evaluation model presented by the project are examined and assessed. Furthermore, the project provides observations and evaluation of the possible future models for cross-border substance abuse treatment work in neighbouring areas. The editors of the final report are Päivi Puro and Tanja Tuori. 6

7 2. Background and Reasons for the Project At the initiative of the Finnish-Russian Network of Social and Health NGOs which operates at the Health Promotion Centre (TEK as the Finnish acronym) the process was started in Spring 2001 which led to co-operation between A-Clinic Foundation, Helsinki Deaconess Institution, Swedish Convictus organisation and NGO Vozvratscheniye Foundation from St. Petersburg. The aim in this co-operation was to reduce the HIV risks resulting from drug use in St. Petersburg and among the Russian-speaking population both in Helsinki and in Stockholm. The working methods of the project in the field of substance abuse treatment work were (1) to build a network among the participants in the field; (2) education and development of working methods for the professionals in the substance abuse welfare field, especially relating to drug use; (3) to develop local service systems (with peer collaboration or work); (4) to gather information on the subject; and (5) to promote the human, civil and service-user rights for drug users. At a later stage the aim was also (6) to develop evaluation models for projects operating across borders in neighbouring areas. In the beginning the project partner from St. Petersburg and its essential needs for further development of services were already ascertainable in principle, however, this was not the case with the potential Finnish partners or working methods. Furthermore as funding was applied from the Nordic Council of Ministers, another project partner from another Nordic State not being Finland was needed. The Russia-network organised in early summer 2001 a meeting for service providers where A-Clinic and Helsinki Deaconesses Institution started drafting plans for the project and funding application. Through the co-operation network of Deaconesses Institution it was possible to find another Nordic partner for the project, Stockholm based Convictus organisation. Project plan and application were finalized in Finnish- Swedish-St. Petersburg co-operation and by August 2001 it was sent to the financier. The project was granted funding and it started in October 2001 with a collective meeting in Helsinki. The role of the project partners was divided to different areas of responsibility and the A-Clinic Foundation s central office was given the role of the central coordination of the project and a local branch, Vinkki, or more accurately its field work operation unit, Viitta, joined as substance abuse service provider and service developer for Russianspeaking drug users who are in HIV risk in Finland. Convictus organisation took the responsibility for both the Russian-speaking drug users in HIV risk in Stockholm and they were also to be responsible for the distribution of information and experiences gained from the project in Nordic area. Deaconess Institution in Helsinki would provide expertise, however, it did not become an official project partner. NGO Vozvratscheniye Foundation would develop its services in St. Petersburg and provide linguistic and cultural expertise on issues arising from substance abuse treatment work in Russian. As it is a Nordic project, one of the aims was to gain specific Nordic value. There is an increased need for Nordic co-operation as along with immigration, migration to return or tourism also drug users move from one country to another. Russian-speaking drug users have particular problems as in the one hand their language or culture is not 7

8 understood by Nordic substance abuse service providers or welfare systems and on the other hand Russian-speakers often have no tools to understand the Nordic society or way of life. This results in genuine difficulties to take advantages of the opportunities and services provided by the States and NGOs. One main aim of the project was to lower these thresholds and bring closer the different linguistic and cultural environments. Special attention was also given in the project for gender equality when assessing drug use situation and the need for treatment services. Especially the connections between drug use, HIV and prostitution were taken into consideration as they link closely with the subject matter of the project. In addition to strengthening Nordic co-operation in field, the aim was to conduct surveys of the local situations on the number and needs of Russian-speaking drug users (in Helsinki and Stockholm). Furthermore, the aim was to build permanent or long lasting co-operation networks and to draft new action strategies to minimize HIV risks among drug users. It is possible to identify many co-operation projects which have already taken place in North-West Russia and in Baltic States, however, resources have not been directed towards or they have been inadequate for the combined work on drug users and minimisation of HIV risks. Another aim in the project was to use the Nordic experiences which can be drawn from the project more widely also in Europe. The project has linked successfully for example with the Snowball operation developed by Belgian Modus Vivendi organisation and Dutch AMOC project which has been designed to help migrating drug users. Project observations have also been presented in European and other international seminars when possible. Funding from Nordic sources was applied as the project has Nordic character and partly because there do not exist adequate local or national funding sources or systems. 3. Project in the Context of the Wider Society and Changing Drug Use and Infectious Diseases Situation 3.1. Situation in St. Petersburg Even though alcohol is the most common used substance causing the most of the national health problems, the rapid increase in drug use during the 1990 s has increased the number of viral hepatitis and HIV infections especially among young population. Viral hepatitides and HIV have become very quickly common in Russia and other former Soviet Union area; first in Ukraine, Belarus and Kaliningrad areas and since 1999 especially in Russia. In Russia it is estimated that there are (in the halfway through 2001) around 3 5 million B- and C-hepatitis virus carriers. Last year there were registered around new HIV cases. The increased use of intravenous drugs has aided especially the spread of HIV virus. Mainly young adults have been infected, however, in certain areas also there are statistics of the increasing spread of the virus between years olds. Weakened immunity has made the population also more susceptible for tuberculosis and this epidemic is on the spread across the border in neighbouring areas. 8

9 Prior to 1999 there were estimated 100 HIV infections in St. Petersburg per year (total population 4,6 million). In 2001 (statistical high) there were registered new cases and during spring 2004 the number of HIV patients increased to over registered cases. In St. Petersburg every fifth of new HIV cases are reported between 15 and 18 years old and 76 % of new contagions fall within age group of 20 to 40 years old. Even though this official information and statistics available on the spread of the epidemic are alarming according to local expert sources the official figures are underestimated. HIV and other diseases transmitted by blood are a considerable risk for public health and therefore they form a risk also for the general population. According to different sources there are around drug users in St. Petersburg of whom there are 40,000 persons addicted to drug use and random users (in the greater area of Leningrad around 4,000 6,000, in the Republic of Karelia 5,000 7,000 and in the area of Murmanski around 6,000 25,000). The most commonly used drug is heroin. Lately also synthetic drugs have started to gain ground even though heroin is still available. Cocaine has become also increasingly available especially in St. Petersburg. (Pakkasvirta, 2004) During doctors have reported less drug use patients entering into treatment, however, it is believed that the number of users is not in decrease. There are too few treatment placements for the drug users and one of the main reasons why these persons do no seek the treatment is the belief and experience that it is very difficult or almost impossible to receive treatment. The main available treatment is based on withdrawal through medication. (Pakkasvirta 2004) Substance abuse treatment services in the former Soviet Union area have traditionally concentrated on medically treating alcoholism. The responsibility is given centrally for the health officials, especially for the doctors employed for the treatment of substance abuse. Prior to Perestroika drug problem was almost never officially discussed in public (Rusakova 2002). During the last decade drug related problems have been researched more and treatment systems have been developed. During this time drug use, as previously described, has increased, as well as drug related diseases, deaths and criminal activity linked with drugs has exploded. (Pakkasvirta 1999, 6 8; Minimisation of HIV risks among young drug users in St. Petersburg 2002, seminar materials; see also Rusakova 2002) According to Russian legislation the public drug use treatment work and arranging of treatment services is still the task of the health authorities. However, during last years services have increasingly been organized by private parties and by so-called halfway third sector, the representatives of which are different civil organisations, self-help groups (for example Anonymous Narcotics), religious groups, for example by the Russian orthodox church, and organisations by the bereaved (for example Azaria, Mothers Against Drugs organisation). Furthermore, quite a few international projects on drug use have operated in Russia (Pakkasvirta 2002). The third sector services are based often on psycho-social and non-medical or non-medicinal work. In private sector generally there are considerable variations on the use of drug use medication (Pakkasvirta 1999). For the customer it is a significant issue that Russian health care system still uses the traditional drug user registration model. In practice the registration ensures that those 9

10 persons who are on substance abuser observation list, also known as nursing home list, will receive public health treatment for free. Anonymous treatment in public service is possible but it will entail costs for the client. Russian drug legislation 1/4/1998 has granted for example for militia, procurator officials and customs officials with a wide powers to terminate drugs and other psychotropic substance use ( 41). The legislation provides for a shorter time period to answer for drug or other psychotropic substance use enquiries for the officials. Every official who receives a request for enquiry is required to act within three days ( 43). Law enforcement officials can also conduct an investigation on any person when there are grounds to suspect that a person is a drug addict, under the influence of drugs or has used drugs without a proper prescription by a doctor ( 43). In practice the information on the substance abuser observation list is also available for law enforcement officials if there are reasonable grounds for obtaining the information (Pakkasvirta 1999, 10 12; Minimisation of HIV risk among young drug users in St. Petersburg 11 14/6/2002). In Russia there has been discussion on the fact that legislation on the drug related crime and health care are not compatible with each other. These deficiencies are seen to create opportunities for misuse of power on behalf of the law enforcement organs and lead into weakening of situation of drug users. For example in St. Petersburg area local health care authorities estimate that the registration practice decreases the willingness to seek treatment for drug use problems. Another reason for disinclination for seeking treatment is also that the Russian criminal legislation has been tightened to the end that being under influence of drugs in a public place is now criminalised (Pakkasvirta 1999, 10 12; Minimisation of HIV risk among young drug users in St. Petersburg 11 14/6/2004, seminar materials; Puro 2002, 2004). As a conclusion it is possible to state regarding the situation in St. Petersburg that a radical societal change and explosive increase in drug use, problems related to it, and of infectious diseases (HIV, hepatitides, tuberculosis) and crime have lead into many different levels of problems both socially and from the point of view of health care in a situation where there is lack of proper economic resources for arranging help. In practice there are inadequate numbers of doctors and nurses working in the public sector and they do not have access to proper equipment and medicines. These ever increasingly complicated problems have created the need for multi-level professional aid structures through network building in different areas and fields, and induction and education of professionals working in the field. Creating a stronger role and status for social work is also an important challenge. There are radical developments happening in the service structures where public and civil organisations and private sector fields have developed mainly separately, even though increasingly there is networking and co-operation. In these sectors especially the need for co-operation between public and civil organisations is important. As to the development of services, this has been mainly reactive as the situation on drug use and infectious diseases has changed so radically and quickly in Russia. One important recent project could be mentioned here, namely the aim to unite the management of Russian health and social organisations. Remaining problematic areas for a drug user are the registration and the open questions relating to this practice. Further problems are created by the general attitude of the 10

11 society and conflicting views on how to lessen drug related problems. Lately special attention has been given for HIV infected pregnant women and mothers of small children and their social and health conditions by civil organisations operating in St. Petersburg Situation in Helsinki Russian-speaking minority has existed already for several generations in Finland. The migration has increased since the 1960 s, and more and more Russians or Russian speakers have migrated into Finland first from the Soviet Union and then from Commonwealth of Independent States (CIS) and from early independent Republics. These have been called as new Russians. 1 Furthermore, in the 1980 s Finland had a booming economy with low unemployment which in its turn increased the migration. The fall of the Soviet Union (1991) and opening up the boarders accelerated migration into West, including Finland (Horn 1997, 209). In this section the aim is to draw together recent research and enquiries assessing the situation of immigrants from the former Soviet Union area, their living conditions and drug use (Puro 2001, 2002 and 2004). According to the Central Statistical Office of Finland 2 in 2003 migrated around 145,000 immigrants into Finland a bit less than third of whom were from the area of former Soviet Union. In 2001 around 9,000 of immigrants were originally born in Estonia and almost 35,000 in Russia or in other former Soviet Union areas. Of them around 30,000 were Russian native speakers and 11,000 Estonian speakers. According to the Central Statistical Office the immigration movement was at its peak between 1991 and 2001 and this mainly concentrated on the capitol area. 3 Across the border there were still waiting to migrate into Finland around 20,000 Ingrian (Karelian) persons in According to the Central Statistical Office research 4 the immigration is mainly return migration for persons being of Ingrian descend or marriage to person with Finnish nationality. Ingrian ethnicity was the reason for granting residence permit for 56 % of Russian immigrants and 63 % of Estonian immigrants. The average age for the immigrants was 33 years in Russian and 30 years in Estonian group (Mannila 2002a; 2002b; Centre of statistics 2003; see also Kyntäjä 2001, ). The height of immigration was in 1991 when altogether 6,500 persons moved from the former Soviet Union into Finland. Now-a-days around 2,000 persons a year migrate to Finland. Most of the immigrants have arrived from Russia and Estonia, then Ukraine. 1 The guiding Committee assisting the Council of Ministers has stated in 2000 on the reports dealing with the Russian minority in Finland that there are very little differences with the new and old Russians and the separation is merely theoretical (Suomen venäjänkielisen 2003, 10) 2 These statistics are based on census records. From these records can be found information on the Finnish foreign population for example through nationality, country of birth and language. Immigration record holds information on all immigrants since In this record there is also information on work and other census information. Immigrants will remain listed according to their nationality even after receiving Finnish nationality. 3 According to the European Union Drug Centre (EMCDDA, 2000) minorities in all around Europe live concentrated in city areas. 4 The research material for the Central Statistical Office report (2003) was gathered through using postal questionnaires from Russian and Estonian immigrants. Furthermore Vietnamese and Somali immigrants were interviewed. Altogether 1,361 immigrants participated in the questionnaire. The response percentage for the postal questionnaire from Russian immigrants was 60 % (542 immigrants) and from Estonian immigrants 63% (312) (Central Statistical Office, 2003). 11

12 There are only a few persons, individual cases, coming from other CIS and Baltic States each year. From Estonia there are coming less and less immigrants whereas from Russia after a short period of decrease now the migration has increased again. From Estonia there is more migration from Russian-speaking population than before. Presently the return migration mainly consists of young and middle-aged Russians whose Finnish roots are further down in the history (Kyntäjä 2001, 149, 153; Central Statistical Office of Finland 2003). Return migration based on Ingrian roots was popular in the 1990 s and made the immigrants from the former Soviet Union area the largest immigrant minority in Finland. The starting engine for this return migration was the New Year s speech by President Mauno Koivisto in 1990 and a statement given in the same year in April which gave the possibility for persons with Ingrian roots to move and live permanently in Finland. The return migration did start very rapidly during 1990 even though the country started turn into economic depression and mass unemployment (Jasinskaja- Lahti & Liebkind 2000, 124; see also Suomen venäjänkielisen 2003). According to international research return migration and marriage are exceptional reasons for migration internationally and in European area (Mannila 2002a; 2002b). Only in Germany, where the percentage on return migration is high, can be found an equally comparable situation to Finland. According to the report by the Central Statistical Office (2003) most of the immigrants from the former Soviet Union area live in the capitol area, less than 40 % of Russian migrants and more than 50 % of Estonian. The percentage of Russian women who were between 30 and 50 years old was considerably high. This probably has its reasons on the Russian- Finnish marriages where a Finnish man marries a Russian woman. However, in the capitol area lives a considerable number of the Russian young and older men and women. Estonian immigrants are mainly 20 to 50 years old. 75 % of Russian-speakers are of working age whereas the comparable figure for Estonians is 70 %. Still in the 1980 s only those Finnish persons who had moved abroad and afterwards returned to live in Finland would be understood as return immigrants. After the speech and statement by President Koivisto those persons living in the former Soviet Union area who have Finnish roots 5 are now considered to be return immigrants both in public discussion and in literature (Jasinskaja-Lahti & Liebkind 2000, 124). Originally a person was entitled to claim the status of a return immigrant if any of the four grandparents had had Finnish nationality. A new clause was inserted into the Immigration Act by the Parliament in 1996 (511/1996) whereby a more limited definition was adopted. According to this new clause a person is entitled to be classified as a return immigrant if two out of four grandparents or one parent had held Finnish nationality (Kyntäjä 2001, ). The second time the criteria was tightened was in January 2003 when the Parliament adopted a decision (HE 160/2002) whereby new language requirements, either Finnish or Swedish, need to be fulfilled if an Ingrian person is to claim return migrant status (Suomen venäjänkielisen 2003, 12). 5 Traditional Ingrian area has been the St. Petersburg and its nearby areas and the concept Ingrian refers to those immigrants and their descendants who moved from Finland into Ingria in 1600s. In the former Soviet Union area there has lived through times also other Finnish nationals and the right to return migration is granted for Ingrian as well as these other Finnish nationals (Kyntäjä 2001, 154). 12

13 According to the Central Statistical Office (2003) altogether 16,000 immigrants from the former Soviet Union are estimated to live in the capitol area, in the cities of Helsinki, Espoo and Vantaa. The majority of Russian or Estonian immigrants live in Helsinki, in eastern or north-eastern parts of the city (Jaakkola 1999, ). According to the experience of immigration units operating in the capitol area the immigration has decelerated during last couple of years due to difficulties of finding accommodation. Also the big cities in the capitol area have contributed to situation by demanding evidence of organized accommodation before the move and they have given up temporary housing (Helsinki being the last, from 1 April 2001). For the immigrant this means that they will have to try to find housing through private sector or set themselves into city housing queues and therefore it can take years to move into the area. It should also be noted that the Ingrians are not identified as their own group in the statistics and their nationalities vary widely because they come from different former Soviet Republics. Furthermore, family members, such as spouses, move usually with the immigrant and often they are not of Ingrian descend. Therefore it is difficult to draw a distinction in statistics between Ingrian and other immigrants from former Soviet Union (Kyntäjä 2001, , 153). A survey directed for the substance abuse service providers in the capitol area has been used to examine the circumstances of Russian-speaking drug users (Puro 2001). Widely published estimations on the increase of drug use problems among immigrants from former Soviet Union area and especially escalation of drug use among young immigrants who have been moving into the capitol area since 1994 formed the basis or starting point for the survey. According to the assessment made young drug users most often use heroin. From the discussions it could be drawn out that drug use has different implications for immigrants than the local population. These are linked with on the one hand to the status of being an immigrant and awareness of living between two cultures, loss of own cultural identity, and on the other hand linked to the moral standards of the world and the sub-culture where young immigrants live. The continuing increase in drug related crime and organized crime has brought out questions whether these young immigrants belong to a special risk group as opiate users, especially for heroin which is imported mainly from Russia and amphetamine and its derivatives arriving mainly from Estonia. Public discussion and different service providers have brought into attention the need for identifying the problem, and preventive work and treatment. The need to develop the service system has been recognised and new working methods have been adopted both for preventive work as well as remedial action in the social and health welfare system. Partly these new working methods have been special projects whose managerial and financial solutions were different from traditional ones and approached the problems through many levels. New projects have been founded, financed and implemented on the part of the EU, ESR, State, municipalities, Finnish Slot Machine Association, parish associations and private parties together and individually. Preventive, detoxification, withdrawal and rehabilitation units and working methods by the substance abuse service providers were included in the survey. Information was elaborated with available documentation, such as project plans, reports and statistics. 13

14 There was research material or reports on the Russian-speaking immigrants and substance use in capitol area available only in a couple of cases. According to the survey the assessments varied widely on risky or problematic drug use by Russian-speaking immigrants. Estimates were from persons to considerably less and larger figures. In the capitol area the number of persons utilizing the substance abuse welfare system has varied from few customers to around 40 persons a year. In the press estimations had been presented that there would be around 500 former Soviet Union area immigrants using heroin in the capitol area. This estimate was based on police criminal records and the number of recorded crimes. As this figure was based on criminal record system it was not comparable with apparent drug use problem however. In this context a public discussion ensued which was often stigmatized in the press as Ingrian drug problem and it was based on inadequate information and assessments. The largest problems were in Helsinki where also majority of the Russian-speaking immigrants live. Substance abuse service providers saw the situation as ambiguous because the public picture emphasised the enormity of the problem, whereas experience of the service providers and the number of customers using the services pointed into a different conclusion. Fewer instances of drug use was met in preventive work whereas according to stories by young Russian-speaking immigrants drug use, especially experimentation, was in increase among young population. In the special units of substance abuse service providers the numbers of customers seemed to remain the same or even reduced apart from few exceptions during the last year. Also the police estimated that the situation was calmer than in previous years. Clearer than before it could be perceived that Russian-speaking customers held expectations for the availability of substance abuse treatment services. These expectations were mainly directed at the availability of medical or medicine based treatments. In the light of experience help into drug use related problems would not be sought until at a very late stage, when problems would be complicated and very difficult to solve. The threshold for seeking help was high as the customers were afraid of being deported from the country. Especially families felt they could not trust public authorities and there was no knowledge of the mechanisms of the public health care system. Some had even sought private treatment from across the border, former mother country, with private funding. The cultural and linguistic problems had been recognised already for a while by the service providers and increasing services in Russian language was felt to be a step into right direction on finding solutions. In this way the customers would be able to make use of the services more easily and seek out treatment more readily as they would be able to use their native tongue. In developing substance abuse service there could be identified some conflicting and even controversial aims: traditionally in immigrant services in Finland the aim has been to integrate the immigrant by increasing language and cultural aptitude in existing services. Now the discussion was on whether it was necessary to found own, specially targeted services for Russian immigrants for all stages of substance abuse treatment. Third idea was whether it would be possible to develop co-operation across borders in neighbouring areas so that more young persons could be treated in their previous home countries. An additional challenge for the substance abuse work and developing new 14

15 solutions and working methods was the family oriented way of life which is common to those who have relocated from the former Soviet Union area. There were quite a few service providers operating in the capitol area for the benefit of young Russian immigrants. These different providers worked in fragmented manner however and the co-operation needs arising from the customer work were often fulfilled only individually. The role of the projects was felt to be important at the interface of the substance abuse service work but the placement or position of these projects within the service structure roused questions and feelings of uncertainty as to the future of the work. In 2003 a questionnaire was sent out to immigrants from former Soviet Union area who had been involved with substance abuse services or who were the parents of customers to inquire their views, ideas and experiences (Puro 2003). The main focus for the developing the treatment service system which emerged from the questionnaire was to ensure native language and culturally relevant treatment services. Other important areas for development of treatment services were low threshold services and peer work. These points will be elaborated further in the subsequent sections of the report. According to the statistics by the National Public Health Institute (24/6/2004) of the health risks caused by use of intravenous drugs and the number of HIV infections arose in the late 1990 s. Of the reported infections (1,677) the highest number occurred in 1990 when 60 % (86) of the infections were traceable to the use of intravenous drugs. After 2000 this risk has been in decrease though: in 2000 (56) and 2001 (49) 38 % of infections, in 2002 (27) 29 %, in 2003 (23) 17% and in 2004 (2 up until 24/6/2004) only 3 % were due to use of intravenous drugs. Altogether HIV infections have been in increase every year in Finland since 2000 which has meant that about new cases have been discovered each year. Of the infected persons one third are women and more than a quarter of the total from foreign background. The highest number of infections has been recently through heterosexual sex in age bracket between 20 and 40 years old. According to the National Public Health Institute statistics (24/6/2004) altogether 392 persons have full AIDS and there have been 327 deaths due to HIV. This examination of statistics shows that in Finland there are relatively few HIV cases when compared internationally and especially with the situation in Russia and Baltic States. Instead viral hepatitides are common among drug users in Finland. Of these the most common is C-hepatitis (National Public Health Institute has followed the situation since 1995) and there are around 1,500 2,000 new cases each year. The statistics show an increase in new infections starting from age group of years. There are a few hundred new B-hepatitis cases each year. In the preventive work of the health risks associated with use of intravenous drugs attention has been given to start with for working methods aiming for reduction in the spread of infections and to lower health risks associated with drug use. Especially the information services of the health clinics are operating with the low threshold principle and they have made available for drug users for example health advice, possibility to change needles and syringes, vaccinations and testing for HIV and hepatitides. Preventive work on health risks and attempts to minimise harm associated 15

16 with drug use has also been conducted through multi-layered work: in addition to the previously described working methods important areas of work are for example distribution of current and suitable information, training peer workers, directing to treatment and especially developing withdrawal treatment services, developing social support networks for drug users and a more general aim of lessening all forms of social reclusion of drug users within the society and operations leading into decrease in demand of drugs in national level as well as work done in areas of international cooperation Situation in Stockholm In Sweden there are altogether around 1 million immigrants. In Stockholm the immigrants from the former Soviet Union have not formed a special grouping in relation to the number of immigrants or use of drugs specific drugs. Therefore there is no need to take them into account separately in the welfare system. However, attention must be paid to those who are temporarily residing and working in prostitution in Sweden. In Stockholm the HIV epidemic was as its highest between 1984 and 1986 when 350 new cases were found. After this there have been less new cases each year and in 2001 there were altogether around 700 HIV positive persons. According to the estimates % of drug users are HIV positive and around 60% of infections are through homosexual relations. The greatest number of infected drug users have used heroin as their main drug and their average age is over 30. During last year it has been estimated that half of infected have died but that most often the cause of death has been something else than AIDS. In 1986 a large campaign was commenced to prevent the escalation of the HIV epidemic in Sweden. Then many prison and social workers as well as drug users were trained to identify the risks of infection. At the same time further opportunities for testing and rehabilitation were developed and provided for drug users. However, as a phenomenon in recent years there has been increased drug use in age bracket of years old and this has lead to a second phase of HIV infections. Also the number of persons seeking testing has decreased. During last years in Sweden there has been a radical change and liberalisation in public discussion when it comes to being HIV positive. The greatest controversy relates to the discussion on programmes for change of needles and syringes and the opinion is divided on this. 16

17 4. Project Organisation and Management 4.1. Project Management and Finance Network Chart 1. Project management and finance actor chart. The project was implemented as planned and it was financed by the Nordic Council of Ministers. It has as its focus the Nordic dimension in the EU and co-operation across the borders in neighbouring areas. Also Russia-network operating in Finland which is a social and health care body coordinating cross-border co-operation in neighbouring areas was an important co-operation partner. The general management was conducted by Finnish A-Clinic Foundation and the project leader was its development manager Ari Saarto. The project group which planned and coordinated the project working methods consisted of representation by NGO Vozvratscheniye Foundation, A-Clinic Foundation, Deaconess Institution of Helsinki and Convictus organisation (see also appendix 1). There were altogether 14 project meetings of which 6 have been conducted in Helsinki and 8 in St. Petersburg not including the final seminar. Furthermore, the project 17

18 members have had the opportunity to meet also in other situations, such as in international seminars. The local administration and financing of the project was secured through using existing organisational structures of the project partners and making the best use of substance abuse treatment services, taking into account international, national and local legislation and customer service needs. Persons in charge of the project worked along with other tasks relating to their job description and no extra help has been hired to accomplish the project aims and needs. The co-operation between persons responsible for the project has been realised through telephone and communications in addition to the project meetings. Evaluation of the Project Organisation and Co-operation Connections The project organisation and co-operation connections were evaluated within the project group during the project and especially at the final stages of the project when evaluations where requested separately from project partners in St. Petersburg, Helsinki and Stockholm. The starting point was that the Nordic Council of Ministers had the main role in the project management and financing. Russia-network provided important support and they also provided essential working method for the project by helping to build co-operation connections and service provider network. In Finland the Social and Health Ministry has supported strongly development projects in Nordic and neighbouring areas and therefore also this project. In project organisation evaluation it was seen that the managerial backing contributed to the project considerably resulting in a successful outcome of the project from management point of view and achieving the project s aims. According to the evaluations the method employed in the project of building cooperation and networking between different organisations was appropriate and a well functioning solution and it ensured that it was possible to combine typical organisational activities and interests both locally as well as internationally. At the early stages of the project it was also possible to take advantage of prior contacts and experience by the organisations. When choosing the project partners it was possible to combine both managerial and practical experience which in its part supported the working of the project team and made it possible to evaluate the project activities from different view points and in real time. The project group succeeded also to make many necessary amendments and corrections into plans and re-focus activities. For the successful project organisation and co-operation connections a major contributing factor was the commitment of those who were responsible for the project. This commitment helped to create a confidential relationship between the project partners and it has led into a more permanent partnership where at the same time new working methods were constructively explored to combine different working methods and cultures. In practice the partnership connections grew into more permanent relationships between the persons in charge in Helsinki and St. Petersburg whereas the Swedish partners remained more remote. According to the evaluation there were many reasons for this: lack of Russian-speaking population in Stockholm placed the team in Stockholm in a 18

19 less favourable position where the real opportunities for connecting with the project s working methods were less. The multilingual nature of the project (Russian, Swedish, Finnish and English) caused some linguistic problems and even though English was first set out as the official language of the project, it was not possible to have sufficiently meaningful and succinct dialogue in English. This led into need of using translators where the Swedish partners could not be accommodated in an adequate level. As for developing project working methods for co-operation in neighbouring areas it was seen as significant that it would be possible to employ a coordinator and/or other employees whose work would make it possible to place the project also into a wider set of co-operation and service networking. The need to employ separate staff is furthermore emphasised as they could try to defuse problems relating to cultural differences, ensure continuity, practical implementation and evaluation of these types of projects. The main challenges for cross-border project building can be seen as the societal changes and impact of these changes into roles of organisational employees, the vast cultural differences between the service providers, different status given to the customers or clients and the interpretation of strategic policies in Nordic dimension and neighbouring areas Finance Funding was applied for and received altogether 735,000 DKK between 2001 and The Nordic Council of Ministers funding was targeted to finance consultation aid, training of the target groups, translation services, travel and accommodation, and publication and distribution of results costs. A-Clinic Foundation was officially responsible in the end for the financial management. It was carried out by the financial administration unit of the central office. Monthly financial reports, yearly account reports as well as the main accounts of the project if and when needed were made available for the project leader. The project team agreed on more specific use of resources and accurate allocation when the need for it arose. Evaluation of Finances The funding by the Nordic Council of Ministers was essential for the project during as for the funding opportunities in national level for projects concerning the subject matter operating neighbouring areas are less than adequate and other international funding mechanisms would have been too slow. Even if funding would be granted for Russian-speaking drug user project nationally, often this funding cannot be used on cross-border co-operation but only nationally. The yearly decision-making process by the Nordic Council of Ministers with no clear deadlines is on the one hand for the purposes of financial management very flexible but on the other hand it complicates long term planning and implementation of the project. 19