TVER — In her one-room apartment, as a small shelf of porcelain cats looks on and the smell of mold hangs in the air, Zoya pulls down the left shoulder of her black blouse and readies herself for her next hit.
A friend and ex-addict uses a lighter to heat a dark, pebble-like lump of Afghan heroin in a tiny glass jar, mixes it with filtered water and injects it into Zoya's shoulder. The 44-year-old widow is a wreck: HIV-positive, overweight and diabetic. After 12 years of dealing and drug abuse, the veins in her forearms and feet are covered in bloody scabs and abscesses, too weak and sore to take fresh injections.
Crimson-dyed hair frames her bloated face, which is made up to match a hot pink manicure. As the syrupy brown mixture enters her system, Zoya's eyes glass over and she ponders her fate and that of her country.
"There are a lot of us. What do they [the government] want to do? Kill us?" she says. "They want to gather us together and drown us? I worry for tomorrow's generation."
If Zoya is anything to go by, today's Russians are hardly flourishing. Russia has one of the world's biggest heroin problems, with up to 3 million addicts according to local nongovernmental organizations. Twenty-one percent of the 375 tons of heroin produced from Afghanistan's opium fields now finds its way through Central Asia into Russia, according the United Nations. (By contrast, China, with nine times more people, consumes just 13 percent.)
The Russian government estimates that its citizens bought $17 billion worth of street-traded heroin last year — about 7 billion doses. The addiction kills at least 30,000 Russians a year, which is a third of the world's total heroin-related deaths, adding to pressures on the country's already shrinking population.
So grave is the problem that President Dmitry Medvedev last year branded heroin a threat to national security.
That's one reason why last October, 21 years after the end of the decade-long Soviet war in Afghanistan, Russian troops joined forces with U.S. soldiers for a joint drug raid on four Afghan labs. The operation, which destroyed nearly a ton of heroin, was hailed a success and the Cold War foes said they would like to see more such operations in Afghanistan, which is responsible for 90 percent of the world's heroin production.
At home, though, Russia has been far less active in tackling the problem. Critics go as far as to accuse Moscow of willfully neglecting its citizens and thereby fueling what the World Health Organization says is one of the fastest growing HIV/AIDS epidemics in the world.
Unlike most countries around the world, Russia refuses to finance harm reduction programs such as needle exchanges, or to legalize methadone. Over the past few months, Moscow has decided to discontinue the work of foreign donors and nongovernmental organizations with heroin addicts. It even recently blamed foreign groups for worsening the country's HIV epidemic.
Health experts and drug addicts alike point to official inaction as the real culprit. It's as if Moscow has misinterpreted the old U.S. anti-drugs slogan "Just Say No" and turned its back on the crisis.
"My government does nothing for me. I am no longer a person in this society," says Zoya, who lives in Tver, a drab city of half a million people just off the Moscow-St. Petersburg highway and whose husband, also an addict, died from AIDS several years ago.
Anya Sarang, president of the Andrey Rylkov Foundation for Health and Social Justice, a small UN-funded Russian organization set up in June 2009, says Russia is failing its people. "For the main groups prone to the disease — drug users, sex workers, migrants — there is absolutely nothing for them," Sarang says.
The Proud Bear
Russian officials have a long history of denying crises. From the Soviet government's refusal to help during the famine of the 1920s to its delay in responding to the 1986 Chernobyl nuclear accident, responses from the top have often mixed disregard and cover-up. During last August's heat wave, as peat fires and acrid smoke killed hundreds, officials kept silent on the wider health effects of the smoke for weeks.
One of the reasons for the rush to denial lies in the national psyche. Russia has a long history of strong governments far removed from the everyday concerns of ordinary citizens. After the humiliating collapse of the Soviet Union 20 years ago and the calamity and poverty that followed, the strongman rule of Vladimir Putin has allowed the Russian bear to flex its muscles on the international stage again.
But while Moscow crows about hosting such high-profile sporting events as the Winter Olympics and football World Cup, it ignores daily reality, says health worker Sarang. "Russia is trying to preserve a certain political image, showing that everything is fine," she says. "This has shown to be nothing more than a lie."
Most Russians see the truth all around them. Zoya's story is repeated so often across the country's nine time zones that the reality is hard to ignore. Even the government estimates that there are 1.8 million heroin users; activists and doctors put the number closer to 3 million, and in a study last June, the United Nations put it at 2.34 million or 1.64 percent of Russia's population. That's the world's third-highest heroin abuse rate in per capita terms after Afghanistan and Iran. In absolute numbers, the UN says, Russia is No. 1.
Heroin was virtually unheard-of during the Soviet era, but is now easy to buy in any city in the country. In Tver, with relatively little industry and few job prospects for the young, the detritus of addiction — used syringes, needles — litters the streets. Deals are a regular sight on street corners.
Viktor Ivanov, who heads the Federal Drug Control Service, blames the country's porous Central Asian borders for the heroin hunger.
"Unfortunately, in 1991 we suddenly found ourselves without borders," Ivanov told reporters in December, referring to the Soviet collapse.
Tajikistan, which borders Afghanistan and is one of the world's poorest countries, has long been a haven for drug smuggling out of Afghanistan, where the Tajiks have ethnic ties. From there the heroin flows through Kyrgyzstan and Kazakhstan and into Russia.
Intertwined With AIDS
The drug problem has now become an AIDS problem. Officially, Russia has 520,000 registered HIV-positive people. The UN and local NGOs say there are probably closer to a million, maybe even more.
HIV/AIDS has spread rapidly over the past decade, especially among drug users who regularly share dirty needles. The government estimates that about a third of all drug users in Russia are HIV-positive, and international and Russian health experts worry that the disease is beginning to spread to the general population through heterosexual sex.
The biggest problem, say health experts, is the government's refusal to address the country's drug addiction. The lack of official intervention is remarkable. There are currently just 70 needle exchange and distribution programs in Russia, reaching a mere 7 percent of heroin addicts according to the London-based International Harm Reduction Association, or IHRA. In terms of needle exchanges, "Russia is not even scratching the surface," says Rick Lines, executive director of the IHRA.
All the programs are run with foreign funding. Government support: nil. It's not as if the government is powerless. In the one area of the HIV/AIDS epidemic where it is active — mother-to-child transmission — it has reduced transmission rates to almost zero.
In the face of government inaction, grassroots groups have mushroomed across the country.
Outside Tver, Yury Suring parks his beat-up black Toyota at a truck stop along the Moscow-St. Petersburg highway every night. There, between 7 p.m. and 4 a.m., he surreptitiously doles out clean needles and condoms to prostitutes, many of whom work to support their drug addictions.
"If I were not here, where would these girls go? Who would help them? No one," Surin says as a trio of prostitutes in knee-high boots and bomber jackets approaches the car.
Suring's organization, We And AIDS, consists of himself, a second outreach worker and a driver. The supplies he hands out every night and the kits he uses to test women come, he says, from sympathetic doctors and Western groups who want to help.
On a cold night in November, 20-year-old prostitute Olga slips into Surin's car for an AIDS test. Surin rubs a five-centimeter indicator on her gums and inserts it into a small plastic tray while Olga nervously smokes a cigarette and shakes her black-bobbed head from side to side in anger at her fate, her gold leaf-shaped earrings swaying.
After studying the result — negative — the prostitute flings the indicator out of the car window and then hops across the gravel into a truck cabin where customers — two large middle-aged truckers — are waiting.
The Health and Social Development Ministry says it spent 10 billion rubles ($320.5 million) on HIV/AIDS testing and treatment — mostly antiretroviral drugs — in 2010. But activists and health experts say this amount compares badly with other countries in the Group of 20 leading nations, and sufferers are routinely ignored.
In a 2010 report, the World Health Organization said just a fifth of Russians who needed AIDS drugs were receiving them. South Africa, which has the biggest HIV-positive population in the world — and whose government until recently was criticized as being in denial on AIDS — gives AIDS drugs at almost twice that rate.
"Appeals, trials and public action — nothing works," says Alexandra Volgina, head of The Candle Foundation for HIV-positive people, a nongovernmental organization in St. Petersburg.
When asked why so many sick Russians lack access to AIDS drugs, the health ministry's spokesman responds: "The amount spent was deemed sufficient."
Russians often blame alcohol for their health problems. Official data shows that the average Russian drinks 18 liters of pure alcohol every year, compared with 14 liters in France and eight in the United States.
Official campaigns against drinking have been pursued sporadically since tsarist times, usually with little success. In September last year, Russia banned night-time sales of hard alcohol, following on from a proposal to double the minimum price of vodka over the next two years in an effort to curb drinking.
"They [the government] are nicer to alcoholics than they are to us," says 32-year-old heroin addict and Tver resident Valera, whose scaly hands and face are covered in bright pink scabs from a decade of use. Like many drug addicts, Valera does not work and refuses to say how he funds his $300-a-day habit.
The Geneva-based International Aids Society Aids Society, or IAS, warns that if Moscow continues to take no measures, the number of new HIV infections is likely to grow by 5 percent to 10 percent a year, pushing the problem to "an endemic level." IAS president Elly Katabira said the rate will stay constant even without any additional infections from outside the country.
That would hit Russia's already dwindling population — recently called a "demographic crisis" by Medvedev. Heavy smoking, alcoholism, pollution, poverty, low birth rates in the years after the fall of communism, as well as HIV/AIDS underpin UN projections that the population will shrink to 116 million by 2050 from 142 million now. The government — which now gives money to mothers bearing two or more children — targets a population of about 145 million by 2025, but concedes that it could fall to as low as 127 million by 2031.
Desperate for Methadone
If one thing appalls foreign health officials and activists more than anything else about Russia's response to its heroin problem, it's the ban on methadone. The WHO regards methadone as essential in combating heroin dependence, but in Russia anyone caught using it or distributing it can face up to 20 years in prison — as harsh a sentence as that for heroin.
Called a replacement drug, methadone is taken by mouth — so it reduces the risk of HIV infection by using shared needles — and is used around the world to treat opiate addiction. Russia is one of just three countries in Eastern Europe and Central Asia to ban the drug, alongside Turkmenistan and Uzbekistan, where heroin consumption is relatively low. China, which has more than 1 million registered heroin addicts, with unofficial estimates running several times that, has more than 680 methadone sites.
Methadone is a potent synthetic opiate in its own right, but it can eliminate the agonizing withdrawal symptoms that addicts experience when they quit heroin. Its main advantages are that it has to come from a health-care source, in controlled doses and without needles. That gives addicts some chance, over months or sometimes years, to go clean for good.
In Tver, Yury Ivanov, a doctor and the deputy head of the state-run Tver Regional Narcology Clinic, is dumbfounded by the ban. "Why do civil servants limit me from doing my work?" he asks in his dimly lit office in the crumbling gray clinic, which sits off an unpaved muddy lane in the center of the city. "All that they are trying to do is the opposite of what we need. It is hard for me to understand. … The situation is going backward. When there is no real medicine, they go right back to drugs."
Ivanov sometimes resorts to giving his patients tropicamide, a drug used by eye surgeons to dilate the pupils and which has a similar effect to heroin.
Addicts talk of their rare encounters with methadone users with a sense of wonder and even magic. "All of us know about this drug methadone, and all of us want it. People come through who have done it, and we can instantly see how much brighter and better they live," says Tver addict Valera in jittery sentences, high after shooting up twice by midday, in an interview in the back of his tobacco-stained car.
But Moscow won't be swayed. "The medicine has become more dangerous than the illness. It would be replacing one evil with another," said the anti-drugs tsar Ivanov. "And why on earth would we do that?" Gennady Onischenko, the country's top doctor, repeatedly dismisses methadone as "still a narcotic."
In a major government anti-drug strategy implemented last June, there was no mention of substitution therapy, even though Moscow says it is now focused on reducing the demand for drugs. That means that Russia's measly four federal and 77 regional rehabilitation centers will continue to treat addicts with psychotherapy, counseling or simple painkillers.
Chained to Bed Frames
The vacuum created by the lack of effective substitution therapies was highlighted in an incident last October in the Ural Mountains town of Nizhny Tagil. Anti-drug activist Yegor Bychkov, 23, was sentenced to three and a half years in prison for kidnapping drug addicts. Bychkov said he had received permission from the addicts' parents to forcibly take their sons and chain them to steel bed frames while they underwent a painful detox.
Anti-drug chief Ivanov praised Bychkov, saying he had acted in good will; State Duma Deputy Olga Borzova said the state was to blame for his arrest as he had become desperate.
The Russian Orthodox Church also weighed in. Though its official stance is against sex education and it regards heroin use as a sin, it has set up its own rehabilitation centers that offer religious guidance. The church also holds regular discussions with the UN over the HIV/AIDS crisis.
Unfortunately, those sorts of initiatives may be risky. Almost two years ago, the Prosecutor General's Office was ordered by the Security Council to beef up prosecutorial measures against nongovernmental organizations that advocate substitution therapy. Since then, activists distributing free needles have been detained on charges of aiding illegal drug use.
"Russian government officials consistently promote falsehoods about harm reduction, and deter those who speak in favor of them," the IHRA's Rick Lines says. "Speaking honestly about the vast body of evidence supporting the effectiveness of methadone is a dangerous thing to do" in Russia.
That may be why relations between the UN's Global Fund to Fight AIDS, Tuberculosis and Malaria — which has been pushing for methadone legalization — and the Health and Social Development Ministry ruptured at the end of last year. The global fund provides the most finance for HIV/AIDS prevention in Russia and granted $351 million to Russia for 2004 through 2011. Now $16 million of that allocation remains, and is at risk of being cut this year.
Worse, say global health experts and local NGOs, is the health ministry's decision to scrap the global fund's needle distribution, HIV awareness and medication programs. "They proved ineffective, and we shall not continue them after 2011," said ministry spokesman Alexander Vlasov.
In October, the ministry directly accused the global fund of making the HIV epidemic worse. "In the regions where these [global fund needle] programs were operating, the spread of HIV infection increased threefold," Minister Tatyana Golikova told a narcology conference.
The fund says it is keeping up a dialogue with the health ministry. But global health experts warn that the decision to end the fund's work in Russia will be catastrophic. "Russia will fall behind and lose the achievements made so far," said IAS president Katabira. "We will not be able to recover the situation."