delhi roma&drugs

Marel o Del, kas kamel, le Romes duvar

(God hits whom he chooses; the Rom gets hit twice)

An Exploration of Drug Use and HIV Risks among the Roma of Central and Eastern Europe

Jean-Paul C. Grund, Hans Verbraeck, Paul Öfner

Project Group Roma & Drugs,

DV8 Research, Training & Development,

Rotterdam/Amsterdam, The Netherlands,

Frankfurt/M, Germany

04/03/01, 12TH IHRC, New Delhi, India J-P Grund, DV8-RTD

Acknowledgements

• Funder: International Harm Reduction program,

Open Society Institute, New York.

• Conducted by: DV8 Research, Training & Development.

• We thank the board of DV8 for their intermediary efforts

and general support, and Anita van der Hulst for managing

the financial side of the project.

• We thank all our interview respondents in the Czech and

Slovak Republics, Hungary and Poland.

• Likewise, our gratitude extends to the respondents of the

Internet survey in cities across Central and Eastern Europe.


Acknowledgements

• We also wish to thank our three interpreters, Ruben Pellar

(CZ), Molnár Gábor (HU), Hanna Sokolowska, (PL) for

their excellent services.

• We thank Natalia Bobrova for her help with translating,

managing and analyzing the Internet-based survey.

• Josef Radimecky from the Czech Republic, Danica

Klempova and Katarína Jiresová, both from the Slovak

Republic, are thanked for providing additional data on

access to treatment of Roma drug users.


Acknowledgements

• During the writing process we benefited from the

contributions of several people from all points of the

compass, who deserve our gratitude.

• These include the anonymous reviewers within the OSI

network and Sue Simon who collected these reviews;

• Dave Burrows (AU), Richard Braam (NL), Tomás

Zábranski (CZ), Andor Ürmös (HU) and Natalia Bobrova

(USA) for reviewing draft versions.


Background

• Roma migrated from India in the late Middle Ages

• They are probably the first, but certainly the largest

“Ethnic Minority” in Europe.

• Roma have a Long history of being subjected to

Exploitation, Segregation and Persecution, not much

unlike the history of the Jewish People.

• After the social political changes in Central Eastern

Europe and the Newly Independent States (CEE/NIS),

Roma were hit hardest by the economic consequences

of the newly evolving free market.


Background

• Long history of problem use of alcohol and solvents.

• Anecdotal Reports suggest rapid diffusion of Illicit

drugs into Roma communities in all corners of Central

Eastern Europe and the Newly Independent States.

• Almost complete lack of research.


Research Questions

• Main project goal: To describe the state-of-the-art

information among experts and other key informers on

the extent and nature of injection drug use and

associated health risks among Roma in Eastern Europe.

• Resulting research questions:

– What is the extent and nature of (injecting) drug use in the

Roma communities in Eastern Europe;

– What is the extent and nature of HIV/AIDS risk behaviors

among Roma drug injectors.


Research Questions

• To inform the development of pragmatic community-

based HIV prevention and treatment activities for Roma

drug users, the study also explored: – Existing initiatives and strategies in Roma communities that

address drug use related health problems;

– The level of awareness of the hazards to community health of

an injecting drug use epidemic in Roma communities;

– The interest among Roma organizations and activists to

develop pragmatic community-based HIV prevention and drug

treatment strategies.


Overview of Methodology

Explorative Pilot Study

• Literature Review

• Internet-based Survey of Experts and Key Respondents

(Treatment and HIV Prevention Providers)

• In-depth Interview Study of Key Respondents in Czech

Republic, Slovakia, Poland and Hungary

• Key Respondents: National Policy Makers, Journalists,

Representatives of Roma Self-Organizations, Treatment

and Needle Exchange Providers, and (Peer) Outreach

Workers



• The Internet survey instrument was based on the

original research questions and preliminary findings.

• The survey aimed to generate a bird’s eye view of the

total region—to get an impression of the extent of drug

use; not to generate statistically analyzable data.

• Survey data were entered into Excel and presented in

table form.

• Statistical analysis was not conducted, but data was

cross-tabulated to compute approximations of addiction

rates and participation in treatment and HIV prevention.



• Interviews were conducted in English, German,

Romanes, Czech, Hungarian and Polish.

• Interviews lasted from one hour to more than

two and a half hours.

• All interviews were recorded on mini disk.

Phase Country

Hungary Czech Republic Slovakia Poland

Telephone Interviews 13 15 6 6

In-Depth Interviews 15 (4) 19 (11) 7 (2) 3 (1)

Table 1. Respondents of the Interview Study



• All telephone and in-depth interviews were transcribed

verbatim into word processor files.

• After cleaning, the data was subjected to a qualitative

“Content Analysis,” guided by a formal analysis

protocol and code book.


Results

Extent & Nature of Drug Use


Extent & Nature of Drug Use

• Both the interview study and the Internet survey

found that a comprehensive view of drug use in

Roma communities is absent in all countries.

• Illicit drug use was unknown of in Roma

communities before the “Velvet Revolutions.” – “Roma in the Czech Republic were not hard drug users.

Before the revolution there was pervitin in the Czech

republic, but Roma only sniffed toluene. After the

revolution Roma started to experiment with marihuana

and later with heroin and pervitin.” (Baron of Ostrava Olah Roma)


Extent & Nature of Drug Use Start of Drug Use in Hungarian Roma Communities

• Around 1990 drugs began to trickle into the Roma

community of Budapest. So-called “party drugs”

became available in discotheques and clubs, which

were almost exclusively frequented by young

Roma.

• According to the Hungarian Vice-Minister of

Sport and Youth Affairs, the appearance of the

first Roma heroin users came as “a complete

surprise” to Hungarian policy makers.


Extent & Nature of Drug Use Start of Drug Use in Czech and Slovak Roma Communities

• In 1995 Czech policy makers first became aware

of the use of illicit drugs in the Roma community.

• Staff of the center for Treatment of Drug

Dependencies in Bratislava described that heroin

use started among Roma in 1989, 1990 in the Olah

Roma and Hungarian Roma communities in

Bratislava.


Extent & Nature of Drug Use Prevalence Estimations: Cautionary Notes

• In most CEE countries there are no reliable data

available on the overall number of drug users.

• Estimates of the number of Roma (or other minority)

drug users are particularly problematic, as

ethnicity/cultural background is not registered in

health care facilities, including drug treatment and

syringe exchange programs.


Extent & Nature of Drug Use Prevalence Estimations: Data from the Internet Survey

City Total IDUs % ofPopulation

RomaIDUs

% of TotalNo. IDUs

% of RomaCommunity

Sofia 15-20000 1-1.5 2000 10-13 2

Szeged 2500 1 3-400 12-16 5-7

Estonia 7000-8000 0.4-0.5 100-200 1-3 3-10

Vilnius 2000-3000 0.3-0.5 50-60 2-3 6-10

Kishineu 1416 0.2 564 40 4

Novorossiisk 9000 3.6 No Information Available

Pskov 380-440 0.2 No Information Provided

Rostov Na Donu 10000 1 100 1 2.5

Volgograd 18000 1.7 2300 13 19

Odessa 25000 2 500 2 2

Poltava up to 10000 3 2 >1 3

Table 2. Total Number of IDUs and Roma IDUs by City


Extent & Nature of Drug Use Prevalence Estimations: Proxy Indicators

• 25% of Patients of the Bratislava Center for

Treatment of Drug Dependencies are Roma.

• 23% of contacts of the street-based needle exchange

program in the same city are Roma.


Extent & Nature of Drug Use Prevalence Estimations: Key Respondents

• “it is our impression that of the younger generation

Roma [in the Czech Republic] 10% is somehow touched

by the drug problem.”

(Policy Maker, Czech National Drug Commission)

• Some 25% of heroinists are Roma.”

(Chief Clinician, Drug Treatment Center, Budapest)

• In my generation and milieu, I mean, among my friends,

30% are on drugs. That includes all drugs. Personally,

I know 20 to 30 people who use hard drugs.”

(Rom respondent, working on the establishment of

Drug treatment center for Roma addicts in Budapest)


Extent & Nature Drug Use Drug Choice

• Inhalation of solvents and alcohol abuse remain

important problems in Roma communities

throughout the region.

• Solvent users are described as very young, with

starting ages even under 10.

• These youngsters reportedly switch to alcohol

during their teens, and, in many cases, end up as

alcoholics.


• In Slovakia and the Czech Republic, Roma drug users

reportedly mostly use heroin.

• In Budapest, speed, XTC and cannabis products are

regular features of certain nightlife spots, frequented

by Roma.

• But treatment providers contend that heroin is widely

used among Budapest Roma.

• Amphetamine is reportedly the drug of choice among

the Roma participants of the needle exchange

program in Szeged.

Extent & Nature Drug Use Drug Choice


Extent & Nature Drug Use Mode of Administration - Czech Republic

• Mode of drug administration seems to vary by area,

context of use, drug of choice and availability.

• In Prague, few Roma heroin users seem to inject. But

outside the capital, the picture becomes less clear.

• There may be a geographical difference:

– In Northern Moravia chasing is reportedly the norm.

– Northern Bohemian users may be more likely to inject.


Extent & Nature Drug Use Mode of Administration - Slovak Republic

• Information from Bratislava is ambiguous. Most

of the Roma sex workers reached by the local

needle exchange program are injecting.

• But the experience of the local (methadone)

treatment program may be more significant:

“Roma started smoking heroin cigarettes. … They only

inject heroin when they are short of money. Right now

when they have money they are chasing the dragon.”

(Nurse, Center for the Treatment of Drug Dependencies, Bratislava)


Extent & Nature Drug Use Mode of Administration - Hungary

• In Budapest and elsewhere in Hungary drugs such as

amphetamines and heroin seem to be used in various

ways, depending on the specific context of use.

• Drug injecting is on the rise among Budapest Roma.

– “… in the last four to five years the patterns of addiction

among Roma are shifting from the classic substances, … to

intravenous drug use.”

(Hungarian vice-minister of Sport and Youth Affairs)


Results

HIV Risk Factors for Roma Drug Users


HIV Risk Factors for Roma Drug Users Prevalence of Injecting Drug Use

• The Internet Survey suggests that injecting is the norm

in the wider CEENIS region, among Roma and non-

Roma alike.

• In Hungary, Slovakia and the Czech Republic

prevalence of injecting drug use among Roma is

reportedly lower than among Non-Roma.

• In these three countries IDU prevalence among Roma

may vary from region to region and, in metropolitan

areas, perhaps from neighborhood to neighborhood.


“Between Gadjé and Roma drug users [in Budapest] there is a major difference, Gadjé injecting drug users use their own needles, but Roma injecting drug users only have one needle that goes around.”

“Needle sharing is not so popular in Usti, because they know from us the risks of HIV and hepatitis.”

“[Roma IDUs in Plzen] do not accept needles. They do not buy needles at pharmacies, but share the needles. They share needles, but they do not understand the

risks.” (Outreach Workers, Budapest, Usti nad Labem, Plzen)

HIV Risk Factors for Roma Drug Users Needle Sharing


• Roma use drugs in friendship groups.

• Drugs are used as a “social lubricant.”

• Sharing drugs is a common demeanor.

– “Pervitin is used in groups. Sometimes heroin too. I know a

case of a Rom who earned a lot of money through a

marriage. He shared his heroin with his friends. Heroin

bought with prostitution money is most of the time also

shared among Roma.”

(Outreach Worker, Plzen)

HIV Risk Factors for Roma Drug Users Group Drug Use


• Involvement in prostitution.

• Roma street prostitutes are at the bottom of the

hierarchy in the sex business.

• Taboo on condom use.

• HIV prevention campaigns are not aimed at or

attuned to Roma culture.

HIV Risk Factors for Roma Drug Users Sexual Risks


Results

Access to Drug Treatment

and HIV Prevention


• Little has been undertaken to design appropriate drugs

and AIDS policies for Roma communities in CEENIS,

or for minority communities in general.

• Treatment and HIV prevention designed for or aimed at

Roma drug users are virtually non-existent.

• The isolated position of Roma is a large barrier to

utilization, and development of services for Roma IDUs.

• Awareness among Roma self-organizations is extremely

low. Denial is a common response. As a result,

community-based initiatives are in its infancy.

Access to Drug Treatment and HIV Prevention


• Roma IDUs have limited access to clean injection equipment (both @ pharmacies and NEPs).

• Roma do not apply for HIV counseling and testing.

• Overall, participation of Roma in existing drug treatment

programs is negligible.

• In particular in high threshold facilities, such as

residential therapeutic communities, Roma do very

poorly.

• Notable exceptions are methadone maintenance programs

in some CEE cities attract many Roma heroin users.



Table 1. Proportion of Roma patients among a random sample of “Toximans”

in treatment between 1992 and 1999 at ‘CPLDZ’ Bratislava (N = 222)


Ethnicity of Patients

Treatment Modality

Roma (%) non-Roma (%)

All 25.2 74.8

Detoxification Unit:

StartSuccessful completion*

15 60

85 63

Middle Term Treatment:StartSuccessful Completion**

15 17

85 24

Methadone Program 36.5 63.5

Needle Exchange Program 18 82

*: Successfully completed 14-day detoxification **: Successfully completed 10 weeks In-Patient Treatment


Results

Drugs, Addiction and Disintegration


• Drug addiction puts pressure on traditionally strong

norms of solidarity and mutual assistance.

• Increasing numbers of Roma addicts end up on the street.

• Overdose deaths of young Roma IDUs resulted in crises in a number of Roma communities

• According to many respondents the larger social fabric

of the Roma communities starts to show cracks.

• Fear for drug-related community disintegration and a

general feeling of insecurity are not uncommon.



• Respondents associate drug addiction with the

disenfranchised status of the Roma, pointing at

discrimination, unemployment and segregation in

particular.

• From this perspective, use of drugs is said to alleviate

the agony of day-to-day life.

– “The drug is alleviating their deprivation.”

– “Heroin is for them the best thing that happened in their life.”



• For an unspecified proportion of the Roma community,

the drug trade provides a pathway to economic

empowerment.

• Participation of Roma in the drug economy changes the

economical balance in their communities and threatens

traditional power structures.



Results

Consequences for Human Rights


• Recent police actions suggest that repressive drug

legislation introduced in the last years may stigmatize

Roma drug users in particular. – “It is quite plausible that this new drug law is meant to,

and will be used to attack Roma”

(Representative Roma Rights Center)



• The potential negative consequences of the increasing

Roma involvement in drug use and dealing for the

already questionable human rights situation of the

Roma people are potentially immense.

• Collective criminalization.

• Labeling drugs as a Roma-specific problem.

• Scapegoating Roma communities for the spread of

drugs and HIV.



• Drug Use among the Roma may well develop into

Europe’s largest minority drug problem.

• Roma drug users are at increased risk for HIV and

other blood-borne infections.

• Through secondary sexual transmission, the entire

Roma community is at high risk as well.

• Treatment and Prevention is absent or inappropriate.

• Involvement in drug use and trafficking may seriously

aggravate the already feeble human rights situation of

the Roma.

Conclusions


Recommendations Education & Policy Advocacy

• Roma Leadership: Break the Silence!

– The potentially disastrous impact of the “Twin Epidemic” is

grossly underestimated by the majority of Roma leadership.

• UNAIDS: Support community-based interventions! – Drugs And HIV among the Roma People is positioned at the

junction of many UN, sometimes conflicting interests.

– Establish a special working group to promote HIV prevention among Roma and other minority drug users.

• the European Union: Insist on Civil Rights! – Promote the wellbeing and civil rights of Roma communities

in aspirant member states, including the development of pragmatic drug treatment and HIV prevention.


Recommendations Research

• Establishment of a “Roma Community Research

Working Group” (RCRWG)

– Development of a Roma-guided research capacity could

potentially overcome many anticipated barriers to researching

drug use and the associated harms in Roma communities.

– It would facilitate the investigation of drug use patterns and

HIV risk behaviors from within the community.

– Rapid assessment methodologies, as developed by the WHO,

could be applied by trained “community field workers.”


Recommendations Drug treatment and HIV prevention services for Roma users

• Establishment of drug treatment and HIV prevention

must be positioned within a wider context of community

development.

• Thus, Roma (users) must be involved in developing

appropriate services for Roma drug users, such as:

– Community-based low-threshold drug treatment (e.g. MMT)

– Peer-based HIV prevention strategies: secondary exchange

– Abstinence-only treatment is not in the interest of Roma

• While some traditional Roma leaders advocated coercive

approaches, these should be not be encouraged


Epilogue

"Everyone has the right to a standard of living adequate for the

health and well being of himself and of his family, including

medical care and the right to security in the event of sickness

or disability." Universal Declaration of Human Rights (Article 25.1)

“Since 1989 the Roma community is increasingly facing long-

term unemployment. Since 1989 there has been a steady

increase in drug use. The social problems among parts of the

Roma community helped the spread of the drug epidemic.” JUDr. Vincent Danihel

Slovak Government Office for Minorities


References

• Presentation:

Jean-Paul C. Grund, Paul J. Öfner, Hans T. Verbraeck: Marel o Del, kas

kamel, le Romes duvar. (God hits whom he chooses; the Rom gets hit twice.):

An Exploration of Drug Use and HIV Risks among the Roma of Central and

Eastern Europe. Presented at the Twelfth International Conference on the

Reduction of Drug Related Harm, Delhi, India, April 2001

• Full Report:

Jean-Paul C. Grund, Paul J. Öfner, Hans T. Verbraeck: Marel o Del, kas

kamel, le Romes duvar. (God hits whom he chooses; the Rom gets hit twice.):

An Exploration of Drug Use and HIV Risks among the Roma of Central and

Eastern Europe. Final Research Report to the International Harm Reduction

Development Program, Open Society Institute, New York. Amsterdam-

Rotterdam-Frankfurt/M: DV8Research, Training & Development, 2000.


Contact Information

• Jean-Paul C. Grund, Hans Verbraeck, Paul Öfner



Elkenbachstrasse 8,

60316 Frankfurt/M,

Germany

• Address requests for copies or further information to:

[email protected]

Marel o Del, kas kamel, le Romes duvar

(God hits whom he chooses; the Rom gets hit twice)

An Exploration of Drug Use and HIV Risks among the Roma of Central and Eastern Europe

Jean-Paul C. Grund, Hans Verbraeck, Paul Öfner



Rotterdam/Amsterdam, The Netherlands,

Frankfurt/M, Germany

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