Category Archive: Harm Reduction
(by Caritas, Germany, Dhaka, November 3-5, 2008 – Suseelkumar, Newsletter April 2009)
‘Sustainability, Quality and Diversity’ was the theme of the International Workshop held by Caritas, Germany in Dhaka, Bangladesh from 3rd – 5th November, 2008. For over a decade Caritas has been involved in the sub-continent, rendering support to organizations working in the field of Drug Demand Reduction. It has aided in the development of strategies and approaches to drug treatment programmes.
The International Workshop had delegates from Pakistan, India, Indonesia, and Cambodia including representatives from local organizations in Bangladesh. It was hosted by Bangladesh Rehabilitation and Assistance Centre for Addicts (BARACA), a project of Caritas, Bangladesh established by the Catholic Bishop’s Conference of Bangladesh (CBCB).
The inaugural session was honored by the presence of several dignitaries — the Archbishop of Dhaka, the German Ambassador to Bangladesh, Addl. Director General, Dept. of Narcotics Control, Bangladesh, and the office bearers of Caritas, Bangladesh and BARACA. It was followed by country-wise presentations on the updated context of drug production, trafficking, supply and demand reduction in the countries represented. The situation in the Indian context was presented by Mr. Jacob Panmei, Diocesan Social Service Society (DSSS) from Imphal, Manipur. The presentation highlighted how India’s unenviable location between the Golden triangle (Burma, Thailand and Malaysia) and the Golden Crescent (Afghanistan, Iran and Pakistan) inevitably made it the main transit point for drug trafficking.
I represented Sankalp Rehabilitation Trust, and presented two papers the first on ‘Harm Reduction: Practices and Standard of Quality’ and the second on ‘Advocacy in the Area of Drug Demand Reduction.’
The paper on ‘Harm Reduction’ explained the principles, strategies and aims of harm reduction and how it contributes to preventing the spread of HIV among and from Intravenous Drug Users. The principles and the hierarchy of harm reduction are used to show that harm reduction services such as needle and syringe exchange, access to public health, referrals, abscess prevention and management can all work with the same or similar goals as abstinence-based programmes. Harm reduction policies, strategies and activities are aimed at limiting or reducing the nature and extent of adverse consequences in health, social, economic and legal aspects of society.
The epidemic of HIV/AIDS among IDUs remains unresolved. There is a need to think and act in innovative ways so that new policies that respond to the pandemic are developed, especially responses to the stigma and discrimination that blocks affected people from accessing care and services. For these policies to come into practice, however, advocacy skills to influence decision makers are required. My paper on ‘Advocacy in the area of Drug Demand Reduction’ dealt with the various stages and principles of advocacy activities.
Papers on concepts and practices for greater awareness, networking and fund raising were also presented. These were followed up by experience-sharing, discussions and group debates. Each group came up with findings and recommendations to be integrated into a final statement from the ‘Workshop on Standards of Quality, Sustainability and Diversity,’ which was presented as the Asia-specific view at the Berlin Conference in January, 2009.
Delegates were accommodated at the Catholic Bishop’s Conference of Bangladesh Conference Centre. The participants had an opportunity to visit BARACA and observe some of the income generation activities, such aspoultry farming, fisheries, cattle rearing and cultivation of rice and vegetables.
by Vered Kater, RN, BsN, MsN, Newsletter April 2006
When the American Jewish World Service (AJWS) asked me to come to Mumbai and volunteer for SANKALP, I was not sure what to expect. I am a nurse and normally work in Jerusalem where I teach nurses at the Hebrew University in the School of Nursing.
I was asked to work with the nurses and give a first aid course for the outreach and Drop in Centers (DIC) workers. In theory this sounded fine but in reality the needs here are rather specific. At the first meeting with the learners I asked what they would like to be taught. Requests ranged from understanding hepatitis, coping with blood spills, treating bedsores and bandaging fractures and abscesses and treatment of convulsions.
Before beginning the training sessions I worked in the DIC’s and in the city with the outreach workers, observing needle exchanges and the communications of the staff with the addicts. In addition I spent some time at the shelter I learned to differentiate between the different users, chasers, smokers, snuffers and intravenous users. This opened a whole new world for me. I also assessed the difficulties of the nurses while treating abscesses and dispensing medications and the gaps in safety awareness when treating patients.
For instance, the nurses managed to infect all the utensils in the treatment box while treating a patient with maggots. In addition the gloves were thrown away in an open wastepaper basket, after which the nurse returned to the task of dispensing medicines without washing her hands.
On the streets of the city the SANKALP staff while exchanging needles, were also endangering themselves by carrying the used needles in a plastic bag. Jumping on crowded trains and busses increased the dangers of getting pricked by needles. With these observed needs together with staff requests, the training sessions were designed. My goal was to help the staff of Sankalp to help themselves and to teach them how to prevent getting infected while providing care. First Aid, First Us became a slogan, at all interventions, the implementation of universal precautions was practiced.
Staff training took place in the office and the attendance was very good. Each theoretical discussion was immediately followed by a practical session. The first topic was maggot care. A head was made from newspapers around a pot, medicine bottles were wrapped in white toilet paper and filled with food-colored water (3 different colors representing peroxide, setavlon and bethadine). One of the learners volunteered to demonstrate how to treat the “patient”. The end result was as expected, each bottle had 3 colors, as well as the anti-septic ointment (a plastic tube). Small basins are now used to pour the medications in before starting the treatment. By visualizing the effect of non-clean working practices the message was clearly understood by everybody.
Another session was dedicated on dressing and undressing a patient. This decision was taken after I had assisted with this task when we hospitalized one of the SANKALP clients. With a lot of laughter the staff discovered that pushing a floppy arm or leg in a sleeve is not the best way. Bedsores, massage and changing sheets with a patient in the bed were also practiced. One might argue that none of these subjects were related to first aid, according to my philosophy first aid is what is needed first and these were the identified needs.
I decided to work also directly with the clients that are on the replacement treatment and that stay in the DIC during the day. I taught them relaxation, positive imagery, affirmations and laughing meditations. These activities were appreciated and several clients are continuing these practices by themselves. The sessions took place every day and were frequently led by one of the learners who was tutored by me.
Small first aid kits were put together for the outreach staff, after a session on wound care they can now put to practice their newly learned skills.
Being with SANKALP workers not only gave me the opportunity to share my knowledge. I learned much from my learners, I admire their courage to work with the addicted clients in spite of or perhaps because of the fact that many have been on this road themselves. Their strength to continue to stay clean with all the temptations around them every day is amazing. SANKALP has apparently found the magic formula to help people to rehabilitate themselves.
by Lipi Chowdhury, Newsletter November 2005
A Workshop on “SELF CARE” for PLWHA sponsored by DOH International, organized by Sankalp Rehabilitation Trust was held on 4th October, 2005 at the Mumbai Central YMCA. As the name suggests the workshop looked at the multifaceted aspects of self care especially with respect to Drug users living with HIV.
It was an all day long workshop divided in to various different sessions, each dealing with an important aspect of Self Care. To begin, since the participants were relatively unknown to each other, the workshop was started with an ice breaking introductory session which seemed to induce ease and relaxation about the workshop, which was a first time for a lot many participants.
The first session was on “ACCEPTANCE” and was taken by Eldred Tellis. Here certain stark things came to be known of, the very first thing was that ‘denial’ is a very important emotion which stems even before any other and is felt by one and all. It is an emotion that is felt by not only the addicts or the seropositive person but also the family and the social fabric around the individual. The individual instead of seeking out for help feels he can deal with whatever the problem is by himself and secludes himself due to the intrinsic ego pressure as well as the social stigma attached to their behaviour or situation. All this is coupled when there is an association of drug addiction and HIV/AIDS. The common escape routes for both family and individual are either to be put in the prison to force rehabilitation or marriage as it is seen as a social institution said to be a remedy for such issues of addiction.
Progressing from the emotion of denial, one moves on to stages of anger, cribbing and discontentment wherein the emotional release is on and even from the family. This is a crucial phase where either the persons seeks for help and GOD or sinks deeper. And Sankalp plays a major role here as it teaches or helps the person with ‘Self Acceptance”. In the workshop the difference between Acceptance and Knowing was brought about and it was emphasized more than just knowing and passive acceptance of self condition, it was more important to imbibe a deep rooted and active acceptance to look at the positive and the revocable side of life. The aspect of sharing and seeking for counseling was empathized with an example of a being able to survive out of a room filled with smoke opening a window, hence opening channels of communication during the phase of denial, sadness or fear of loss.
The second session was about “SPIRITUALITY” which was taken by Rajeev who took a 10 minute meditation exercise and highlighted the various above mentioned aspects of self and how one could cleanse oneself of lack of self control from and within with the help of Spirituality. He spoke of problems arising when there is a conflict between social and sexual instinct and that Vipassana could be incorporated in daily life as it had positive effects on self well being .It was emphasized that it is only when one lives in the past or future that anxiety begins resulting to undesirable harmful behaviour and if one learns to live in the present then anxiety can be controlled. There was a difference brought out between “I” (unseen powerful) and “me” (awareness) and one understood that harmony comes only when one consciously recognizes and separates the two. The participant’s were given an idea of the Vipassana Meditation camps and how they could benefit from these.
The third session was on “RISK REDUCTION” which was taken by Mini Tomy and Dr. Malik. Herein safe ways of fixing for self and others especially with needle care ; future prevention for relapse and peer education information was imparted. Furthermore, the concept of safe sex and STI’s were explicitly talked about with a demonstration of condom wear , usage and disposal.
The next session was taken by Dr.Shantanu who spoke about the “MEDICAL AWARENESS” dealing medical aspects related to drug addiction and HIV/AIDS. This session was based on preliminary information about substitution drugs for drug rehabilitation and ARV for HIV/AIDS. It mostly dealt with questions and queries from the participants. This helped understand the fears of the participants related to the illness , physical entropy and medicines to help bring clarity and assurance.
The fourth session was of “ROLE PLAY” which was taken by Eldred Tellis. The participants were divided into four groups each had a role to play. The questions and issues which each group had to ponder and enact were all covering the various aspects of self awareness and care. These were:
- Enact a person who has just found out his seropositive status and does not want to tell partner or spouse and how one could counsel him/her
- Enact a person who is ill with HIV/AIDS and has the fear of dying , so how would one support him/her
- Enact a person who is unhappy about his being seropositive and wants to break a relationship or engagement, so how would one counsel him
- Enact a person who needs medical care but does not have the prerequisites of being eligible to receiving them and is refused by the hospital authority, so how would one intervene and support.
The issues that came out of these role enactments are very crucial to survival, handling and dealing with HIV/AIDS. These foremost issues were of prevention and not to harm or infect others ; prepare for death and be realistic in terms of being mentally agile to one fullest and making property will etc. ; highlighting the subconscious hesitance to deal/confront and cope with the above mentioned issues along with the importance of a counselor and support group in addition to the medicines.
The final concluding session was of “LEGAL AWARENESS” taken by Shezad and Santosh from Lawyers Collective. This was a very important session as the participants have been made somewhat aware of the above aspects in the various NA and support meetings they go for, but they were seldom made aware of their legal rights. The three major issues that were brought about were Informed consent; Confidentiality and Discrimination. This session covered links of all the three issues in the realm of self, family friends, hospitals, pre –post testing, residential dwellings and work.
Overall, the workshop was a very fruitful and truly an eye opener for not only the participants but also the staff of Sankalp as it brought out a holistic picture and way to deal with Self Care from its various subtleties of Self and its psyche; Mental and Physical wellbeing with Meditation and spirituality; Risk reduction; Medical and physical health advise; Responsiveness towards self and others through the Role plays and finally legal awareness. It was a very value added two way information sharing workshop which gave an insight into the understanding and practices of the clients related to HIV/AIDS and also the baseline at which workshops or information-activities could be pitched in for future. It dealt with the aspect of Self care in a cocooning way covering each and every facet of it and in future such workshops should be conducted with not only PLWHA but also drug addicts as they could be one of the catalysts in bringing about the mammoth social change that Sankalp is striving towards.
by Eldred Tellis, from a 2007 Newsletter
When Kalyan Drop-In Centre was opened in April 2006, it was the first time that Sankalp had ventured beyond the Mumbai ‘border’ and as such the staff were aware that they would be confronted with different challenges and patterns of behaviour among drug users as they worked in a new area. Initially our Outreach workers found hectic activity on the central railway route between Thane and Ambernath and even though the clients were from regular homes on this stretch, they would be found in new areas according to the quality and availability of the drug. Therefore Outreach was always a tough task with our Outreach workers facing difficulties following up on the regular NSEP (Needle Syringe Exchange Programme) clients.
Since the clients often changed their hang-outs for the reasons mentioned above, Bhiwandi was discovered as a hotspot for heroin use. It is an area where migrants from all over the state especially from Malegaon, come for work on the textile looms which provide the main source of employment. In a town with a population of about 20 lakhs, there are more than 500 looms, each with a capacity of 12 to 20 machines of varying sizes. Bhiwandi is also a place where there are godowns for many industries and it goes without saying that there are quite a few similar ‘godowns’ for heroin as well which accounts for the fact that the price of the drug is half of that in Mumbai. Most people in Bhiwandi are a law unto themselves and that makes for a potentially difficult area to work in. Initially, Sankalp started only its NSEP at Bhiwandi, but when the with funding from the British Government’s Department for International Development (DFID) was coming to an end, it became important to offer the clients Opioid Substitution Therapy and a chance to detoxify before withdrawing all services. It was not easy to do this in an area with cheap heroin; we found few takers for OST and many clients continued to ask for clean needles and syringes. This is a classic instance of a donor’s agenda not necessarily meeting the needs of the client. Sankalp was forced to continue needle exchange as a service while motivating its clients to the OST.
With Government help not forthcoming for this centre, Sankalp has had to make a difficult choice — keep Kalyan going, and shut down this much-needed outpost and a service that has in the past not been offered by other NGO.
by Eldred Tellis, 2008
I was delighted to receive an invitation to make an oral presentation of our work at Arthur Road Jail, at the 1st Conference of the Connections Project.The conference titled ‘Joining the Dots – Criminal Justice, Treatment and Harm Reduction’ was the first of its kind, taking a look at drugs and infections within the European Union Criminal Justice System.It was a great honour to be selected to make a presentation for the session on International Experiences which also had contributions from Russia, Australia and the U.S.A.
Pat O’Hare, President of the International Harm Reduction Association (I.H.R.A), gave the keynote address.He emphasised the need for equal services for drug users ‘inside’ as were made available on the ‘outside’.This he said was part of human rights which need to be upheld.From his vast experience over the last 20 years, he was clear in his pronouncement that security was much higher where majority of services existed and this included ‘needles syringes programme in prison.’
Barnie, President of Swedish Drug Users Association asked a very pertinent question.“How does one try to make the world drug free, when you cannot do it in a PRISON? “ Here you have a lot of drug users, a lot of drugs and not a lot to do in prison…….so……He said that Sweden was a signatory to a WHO Charter with 50 other countries that pledge to have services with prisons similar to those on the outside.Yet there are none except a bowl of condoms.
Annette from the World Health Organisation said that it has been demonstrated that thedrug use exists in prisons and it takes placewith greater risk.Also that Hepatitis C and HIV have a higher rate of transmission in prisons.Inspite of this, there are only 9 Needles syringes programmes in Europe and only one (Iran) in Asia.
The main debate centered around looking at the prison as an opportunity which was cost effective.The main challenge was, how best to go about addressing it.Policies in most countries were inadequate to the needs that existed.
Besides the high, of interacting with experts in the field, was an opportunity to attend aMaster class ofDr. Devayne Simpson.He shared many of his secrets for Adaptive Treatment Planning and Innovative Implementation.Much can be adapted and used even for our own detox camps which is a goal I have undertaken to help build capacities of our own staff.
From the presentations it was also clear how ‘after care’ for drug using prisoners contributed to a five-fold increase in success rates and SANKALP will make a small beginning by taking our discharged clients for a 24 hour support exercise with introduction to our Drop-in centre, the Narcotics Anonymous and some ‘clean’ company on the outside.
More power to us through implementation.