Lithuania was at a forefront of harm reduction in thе post-Soviet аrea – first harm reduction programs were introduced in the country already in 1995. In 2006, a special decree of the Ministry of Health of Lithuania established a legal framework for harm reduction programs for people who use drugs (needle and syringe exchange, distribution of condoms, disinfectant wipes, bandages, as well as education/awareness materials and consultations at low-threshold centres).
Meanwhile, according to the latest data published by the European Monitoring Center for Drugs and Drug Addiction (EMCDDA), the number of drug-related deaths in Lithuania is twice as high as the EU average: 20.3 cases per million inhabitants; in 2015, Lithuania recorded 115 deaths from drug overdose.
The number of new cases of HIV (15.1 per one million people), according to the 2015 data, also places Lithuania on the list of EU countries with the highest incidence of HIV among injecting drug users.
About the history of harm reduction development and what is happening in Lithuania now we decided to talk to Alexandras Slatvickis, the chief physician at the Klaipeda Mental Health Center. Alexandras has been studying practical problems and theoretical issues of dependency for more than 30 years and is one of the first doctors in Lithuania to start promoting harm reduction and a humane drug policy in the mid-1990s.
Please tell us what was happening in Lithuania 20 years ago, when harm reduction only developed in the country and EHRN was founded?
I can honestly admit, that at the time, I was completely illiterate, a complete analphabet when it came to harm reduction. The autumn of 1996 saw the first case of HIV among injecting drug users in Klaipeda. It was a bombshell, the information was leaked to the media. My colleague and friend Emilis Subata calls me and says:
- Did you know about this?
- Of course I did, Emilis.
- You‘ve got to start needle and syringe exchange!
- What do you mean?
- Look into it.
I‘ve got to admit that Emilis already had a computer and an e-mail then, and I didn‘t. I thought the computer was something supernatural and I was afraid to even touch the mouse. It meant I had zero access to any information. It was an absolutely different time. Anyway, I always listened to Emilis' opinion. Then we met in Vilnius, discussed the situation and it was there and then when I first heard the term "harm reduction".
What did you think when you first heard about harm reduction? It‘s still pretty vague for those not very familiar with the subject.
I can‘t remember now whether the term „harm reduction“ was actually voiced then, maybe I'm imagining it now. I confess – I can‘t remeber when it came into use as an expression, as the name of the philosophy and services. Now it feels like as if I‘ve always known it, since childhood, although in reality, of course, this is not the case. What is true though, it‘s that Emilis clearly said then that it was time to start needle and syringe exchange for drug users. He got hold of syringes and needles for free from some foundations, he gave me a few hundred and I brought them to Klaipeda.
How did you distribute them?
In November, we began to exchange syringes and needles at the treatment room of the Center for Diseases and Addictions. We were doing it for several months, basically, on a zero budget. By coincidence we needed some money for an awareness program aimed at schoolchildren. The amount was absolutely ludicrous, two or three thousand litas, less than a thousand euros.
We came to the City Municipality (in Lithuania, it‘s local executive and legislative authorities), and they said: "Oh, where would we get such an amount of money from?!". A budget organization is a budget organization, taxpayer money doesn‘t just appear from thin air, it has to be planned for. We left. A few days later my colleague, Ausrinė Armaytīne from Klaipėda University, phones me and says: "Listen, I got a call from the municipality and they said that you could get 20,000 litas. We just need to prepare a project."
Ten times more that you asked for?
We were told that because there was money available, we had to take it all. We sat down, heads propped on hands, and we thought. Ausrinė says: "Okay, great, we can spend 3,000. And then what? What are your thoughts?". I told her that I started a syringe exchage project and it didn‘t work. It had to be separated from the Center for Diseases and Addictions.
And so we set up a two-part project. It was fantastic. One part was prevention, and it was mainly based on a negative attitude towards the very existence of psychoactive substances in the world. And the other, on the contrary, was based on acceptance and assistance to consumers. We used the rest of the money to obtain a small room at the City Municipality headquarters, we refurbished it and on May 7th, 1997 we opened the needle and syringe exchange room. From the very beginning, I thought about a name for it. A name plays an important role. If we called it a "Needle Exchange Point"... It was often called NEP in Russia. To me it sounded primitive, if not vulgar.
Yes, as it made the very idea sound vulgar, but harm reduction was growing on me, I was reading and learning new things about it. We decided to call the room an "Anonymous consulting room for drug addicts, with syringe and needle exchange services." The point was that first of all it provided help, syringes and needles were an extra, something to lure customers with.
For me, it was very important that the harm reduction room was able to operate normally, without any obstacles to it. Before the opening, I met with the chiefs of the city police. I discussed our plans with them, explained why the room was necessary and met a full understanding. I explained to the police that I really didn‘t want the consumers of illegal psychoactive substances who were coming to our facility to be ambushed there.
Why did they agree, do you think?
I think it‘s down to two factors. First: our police were led by clever people. They were not like what people usually think of the police officers – that they are stupid, narrow minded people. They saw perfectly that apart from the illegal substances themselves there are other problems: infectious diseases, etc. etc. Second, let‘s drop false modesty: by that time I had been working in Klaipeda for 16 years. I had been the head doctor of the Center for Diseases and Addictions for 10 years. I believe that my authority played a certain role. If I was an outsider, things would have been much more difficult. I was seen as an expert who brought undeniable truths.
How many cases of HIV were being diagnosed then and how did the situation develop? What was the reason for an increase of the incidence across the region?
Of course, we must face the truth: we were late. The first case was diagnosed in 1988, that person was not a drug user, as far as I know he was a homosexual man. So, the virus had already appeared in the population. The most vulnerable group was injecting drug users. According to the laws of epidemiology, it‘s the first group in which the virus begins to spread.
I have been dealing with HIV statistics for 20 years. In 1996, four new cases were diagnosed in Lithuania, all of them in Klaipeda. And then it started to spread. No one worked with the population, no information was available about the safe use of drugs, disinfection, there was no syringe exchange. The real work only started in 1997. The future consumers also took their time to come to us. In 1997, there were 23 new cases in Lithuania, 21 of them in Klaipeda.
Port city and the first breeding ground of infection. In 1999, out of 46 new cases only eight were in Klaipeda. That was a certain result. In general, we have gone through two periods of harm reduction. The first can be called a "wild period" or "golden age". Wild because there were no official regulations. We carried out harm reduction programs the way we saw fit, the way we knew how, and with whatever money we had. The Klaipeda City Municipality was the main source of funding, and for three years we also received funds from the Open Society Institute.
By mid-2000‘s the Ministry of Health was ready to accept the fact that it was time to do something, that we couldn‘t carry on like that. The Ministry of Health issued the first harm reduction decree. I was part of the group that drew it up. After several months of dicsussion we reached a compromise. However, when the decree was published, I was dumbfounded and shocked. Very much of what had been agreed was lost. Who did it and how is still a mystery to me. The regulation of harm reduction rooms‘ activities began in 2007.
Did it affect your work in any way?
That year, a mobile unit replaced one of the anonymous consulting offices. It was a blue bus, like in Vilnius. At some point we entered a period of stagnation, in which we remain to this day. Several years ago, the state started to fund harm reduction programs, about 40,000 euros per year for the whole country. They want small-scale thousand-euro projects. It‘s absolutely pointless. However, there is a silver lining: nobody applies for minigrants but the money has to be spent, so at least it‘s used to buy consumables.
So it was a kind of a blessing in disguise. Given the scale of the government‘s spending, is it international organisations that are the main donors of harm reduction?
Lithuania never received any money directly from the Global Fund. The other day I signed an agreement with the Klaipeda City Municipality on harm reduction program funding for the next three years. A total of about 180,000 euros. Roughly speaking – 60,000 euros per year. The City Municipality of one non-capital city allocates more funds than the entire government for the whole country. Who, then, sees the po from a nat level? has a national overview of it the problem?
In some countries of our region harm reduction is met with political resistance, in others with religious or public. Does everything plainly rest on money in Lithuania?
Of course the church is opposed to both harm reduction and substitution therapy. However, if everything was down to the church, we would have found ways to reach an agreement. Lithuania‘s trouble is paternalism which is enshrined in policies, attitudes towards society and addiction issues. It‘s a Soviet legacy: "We know what you need and we will decide what to do." Nothing‘s changed in drug policy. Moreover, there‘s been a certain tightening in drug policy. Drug use is not an administrative offence any more but a criminal one. Control over alcohol is getting tougher as well. It stems from the belief that prohibition can achieve something, belief that people are a flock of sheep, tell them where to go and they will go there. I don‘t agree with that. Numerous negative consequences aren‘t taken into account when calculating minimal positive changes.
Can harm reduction program clients become activists promoting such ideas and practices?
Consumer organizations are very weak, their voices are extremely quiet. We are trying to encourage them to be more active, so that slogans like "Nothing for us without us" and "Nothing about us without us" are heard louder. However, we can‘t do anything for them.
Does this mean that paternalism has been adopted by the community as well?
Of course, this is one of the reasons. The more loud events were organised by the community of consumers, the more influence it would have had. So far they’ve been on the sidelines.
Is the biggest problem now the community‘s inactivity?
It‘s everything combined, there is no single vector. The community must develop itself, voice its needs and defend its rights. On the other hand, the political arena needs more people who understand the problem and admit that at the moment the issue is being driven into a dead end and underground.
By and large, everything that is happening is leading to a completely irrational use of funds where no adequate solution to the problem is found. A serious economic analysis of drug policy is necessary. How much do we spend on prosecution, how much on imprisonment and how much on harm reduction?
When I started to promote the idea of harm reduction in Klaipeda, I never said: "Think about the poor people." This doesn‘t work. The usual answer is that it‘s their fault, the sooner they are finished the better for everyone. Nobody sees that nothing will ever end and the situation will only get worse. That‘s why I keep saying that harm reduction benefits all citizens without exception, but talking at the Klaipeda level is one thing, talking at the government level is quite another. The level where an allocation of even 40,000 euros is a big problem.