Register Thursday | June 27 | 2019

Estonia's Epidemic

History and heroin in a Baltic capital

Druzinin tours Tallinn with a backpack full of condoms and syringes. Our first stop is the train station. He hands out clean needles to four clients, all Russian speakers. He used to shoot up with one of them. Next is a trolley ride to Kopli, a Russian area of town where heroin dealers work out of rotting wooden houses and the city’s poorest live in complexes that had been intended as temporary shelters for soldiers during the Second World War. Roman becomes quiet when he steps off the trolley. He passes a house with three walls and no roof. Two more clients, again Russian-speaking, ask for clean needles and condoms.

“This is Estonia’s Harlem,” he says.

It’s in places like this that the country’s HIV epidemic is concen-trated and where the need for outreach workers like Roman is highest. Estonia has a total of twenty-one needle-exchange units, but these only reach 30 percent of the intravenous drug users—a number its National Institute for Health Development says needs to reach 60 percent before the spread of HIV can be curbed. And so, the epidemic continues to grow at the fringe, threatening to break into the general population.

UNAIDS estimates that approx-imately 8,000 Estonians are currently infected with HIV. That number seems relatively small until you consider that six years ago just twelve cases had been recorded and that the country’s population is only 1.35 million. In other words, around 0.6 percent of Estonians are infected—double Western Europe’s average of 0.3 percent. But what’s alarming about the HIV situation in Estonia is not only this percentage, it’s who has the virus. The country is composed of two main ethnic groups: Estonian speakers who make up two-thirds of the population and Russian speakers. For the past five years, the epidemic has been overwhelmingly concentrated among drug injectors in Russian-speaking communities.

Understanding the ethnic dimen-sion of HIV in Estonia requires a look back at the rise and fall of the Soviet Union. How Stalin invaded Estonia, how ethnic Estonians dealt with Russian speakers once their country was reclaimed, and how individuals like Roman now suffer for the sins of an empire.

 

Estonia came out of the Second World War controlled by Stalin. The country’s strategic position between East and West has always made it desirable to the power-hungry and the Soviet occupation was one in a long line. Stalin handed over top government positions to Soviet administrators and Russians poured in to fill new jobs created as the country was industrialized. Estonians who resisted collective farming or displayed nationalistic sentiments were killed or deported to Siberian work camps. Over the years, they learned to hide their flags and hope for the West, which they called the “White Ship,” to save them—but no one came.

Decades later, the tables turned.
As the Soviet Union unravelled, Estonians saw a chance to assert sovereignty and protect their vulnerable language and culture. The country declared its independence in 1991 and the new government chose Estonian as the sole official language. New citizenship laws are exclusive: if you immigrated to Estonia after 1940, you and your descendents do not automatically qualify for citizenship. At the time of independence, there was more than half a million ethnic Russians in the country, most of whom had lived in Estonia for over twenty years. Only 100,000 of these qualified for citizenship. Some Russian-speakers chose to return to Russia. For those who stayed, life was tough. It became difficult for Russian-speaking parents to support their children: the Soviet jobs that had brought them to Estonia were disappearing as factory after factory closed down; the language barrier limited future job prospects. (Today, it has become less difficult for Russian speakers to clear the hurdles for citizenship.)

People like Evgenia Druzinina felt the effects of independence. Evgenia is Roman’s fiancée (though not yet married, she goes by his name), and when she talks about her past, he takes her hand. “I trust Roman even more than I trust my mother,” she says to me.

Sitting on her bed at an Estonian hospital, Evgenia touches the scars on her arms—a web of healed track marks and a stack of white lines where she slit her wrist. She was a child when independence was declared. Her mother lost her job as a health worker and started to drink heavily. By the time she was a teenager, Evgenia couldn’t handle the family strain anymore and started to take drugs: cocaine at fourteen, heroin at sixteen. She’s now nineteen, a recovering heroin addict and infected with HIV. She has no choice but to take things day by day. As her body and drugs fight off her current flu, she knits a scarf for Roman and makes tea for visitors but feels like her life is on hold.

Roman had much farther to fall. He played on Estonia’s national junior hock-ey team until he was fifteen—then was forced to quit. Estonians receive their citizenship at this age, but Roman wasn’t automatic-ally eligible because, though he was born in Tallinn, his parents came to Estonia after 1940. He learned some Estonian at school but found it extremely difficult—a feeling shared by most Russian speakers since the two languages don’t share the same alphabet. Roman also explains how little opportunity to practise he had because Estonians and Russians don’t usually mix. Hockey was his motivation for working hard, and his life went downhill after he had to leave the team. The rest of his story mirrors that of his fiancée: cocaine at sixteen and heroin at twenty. Now twenty-five, he’s HIV-positive and has a criminal record that bars him from ever applying for citizenship.

When Evgenia and Roman have a baby, which they hope to some day, the child will have an easier life than its parents, at least in the citizenship department. The laws were loosened in 1998. Children born in Estonia after February 1992, whose parents have lived in Estonia for at least five years, will be granted citizenship automatically. But this still leaves close to 40 percent of Estonia’s Russian-speakers without citizenship. They are permanent or temporary residents who cannot vote in national elections, helping to explain why fewer than ten ethnic-Russian politicians currently sit in the 101-member Estonian parliament.

By the end of the nineties, difficult family lives, citizenship problems, political alienation and ruined pro-spects were leaving the Russian-speaking youth in a vulnerable social position. These social determinants have been compounded by the fact that Estonia is located on a heroin trafficking route, which connects central Asia to Nordic markets. The stage was set for an intravenous drug crisis and an HIV epidemic.

 

Narva was the first city to suffer. It lies on the eastern border of Estonia, only 130 kilometres from St. Petersburg; 90 percent of its population speaks Russian and unemployment hovers around 18 percent, eight points above the national average. Drug use and crime are big problems. Of the 390 new HIV cases diagnosed in Estonia in 2000, 302 were registered there.

“Don’t go to that place,” Evgenia warns me. It’s where she was infected with HIV. She always used clean needles, but one day she was feeling too depressed to care. The guy she was with said he was clean, so Evgenia shot up using his syringe.

The number of new HIV cases in Estonia peaked in 2001, the same year Evgenia was diagnosed. Over 1,470 cases were counted, compared to 390 cases in 2000. Since then, the incidence of new cases has steadied, though the total number of HIV infections continues to rise.

There were signs of an impending HIV crisis in 1998 when hepatitis B and hepatitis C started spreading quickly among intravenous drug users, showing that addicts were sharing needles. Infectious-disease specialists like Nelli Kalikova, an ethnic Russian who eventually founded several HIV prevention organizations, be-came worried. She warned that the number of new HIV cases was about to explode. The government didn’t listen. Though a national AIDS pro-gram was created in 1992, Kalikova says it was little more than words on paper, with no real funds to back up the program.

It wasn’t until late 2001, after the peak in HIV cases, that the government started to support programs like needle exchanges. That year, it contributed approximately cdn$700,000 to a national HIV/AIDS prevention program, which Kalikova estimates was a quarter of what was needed. A 2002 World Health Organ-ization evaluation of Estonia’s HIV/AIDS programs supports Kalikova’s claims. The report states that harm-reduction programs were “financially unsustainable” and couldn’t reach enough drug users to stop HIV from spreading. One government-funded project in Narva was so strapped for cash that employees couldn’t afford to restock condoms and weren’t paid for months at a time.

The situation started to improve in 2003 after the government successfully applied for a grant from the Global Fund to Fight AIDS, an international subsidy organization. The grant provided us$10.25 million over four years, to cover the cost of antiretroviral medication for all patients and to scale up education campaigns and prevention programs. While the grant is in place, the government continues to provide its own funding, which will total almost cdn$7 million for 2006. Kalikova is starting to notice improvements and she’s optimistic that the government will increase its funding even more when the grant expires.

There’s no easy way to explain
why the Estonian government wasn’t more proactive with HIV prevention in the beginning. The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) says part of it has to do with the general stigma attached to drug users. Most Eastern European countries, including Estonia, have only just started to think of drug abuse as a health problem rather than a criminal offence. The sooner this new perspective takes hold, the sooner the public will begin to support needle exchanges and other programs.

Kalikova feels it was lack of vision. The number of HIV cases in the late nineties was small and politicians felt that other health issues were more pressing. There wasn’t a lot of money to go around either. Estonia was falling apart when it declared independence. Factories, schools and the social security system were in shambles. To attract investment, the government made the transition to a market economy, privatizing businesses and removing trade tariffs. Estonia survived Russia’s 1998 economic collapse by cutting business taxes and social spending. Now, its economy is booming with a projected GDP growth of 6 percent for 2005 (Canada’s is 2.5 percent). Getting to this point left social programs out in the cold, something Estonian president Lennart Meri admitted to in 2001, at the end of his tenure.

Convictus Eesti (Convict Estonia), the HIV-prevention organization Roman works for, has scraped through its first four years of existence without any government funding. Its budget in 2004 was cdn$225,000; this sum finances prison education programs and three needle-exchange units that serve around 350 regular clients. After his route in Kopli, Roman takes the trolley back to the centre of Tallinn. He hands out a few more condoms and needles outside a mall. Then it’s back to the office to record his statistics.

At the main office, his boss, Julia Vinckler, answers the phone in Russian and Estonian. She’s been running Convictus Eesti since its founding and does so with the grit of a Russian gymnast and the speed of an Estonian waitress. Her parents are a mixed couple, which is unusual in Estonia. Vinckler is convinced she would have become a heroin user if she had been Russian rather than mixed. She’s seen her Russian-speaking childhood friends in jail for drug offences. She’s seen them coping with HIV.

With Estonian and Russian speakers still geographically and economically segregated, areas like Kopli and Narva remain under-serviced. When asked about the government’s slow reaction time to the HIV crisis, Vinckler says there’s one explanation that colours all others: discrimination against Russian-speaking Estonians. She cups her hands around her eyes, like blinders. These are the politicians, she says. If there isn’t a problem in their communities, there isn’t a problem. And since so few Estonian politicians are ethnic Russians, HIV has only started to reach the government’s line of sight.

 

Estonians celebrate Independence Day on February 24. Over 900 soldiers drum their way into Freedom Square in Tallinn. The speeches are in Estonian. The signs are in Estonian. The crowds sing the national anthem as they would a love song. Then the sharp winds and frigid temperature sink in. In a nearby café, a group of Estonian university students sit in a sea of blue, black and white stripes—the paper flags that were handed out at the military parade.

All but one of the students launch into a political discus- sion. They talk about how, even now, many Estonians have a hard time separating Russian speaking communities from the occupying Soviet army of yesteryear. “We have Russian-speaking friends,” one says, “and Russian speakers should be treated like Estonians as long as they learn Estonian.”

A middle-aged man overhears the conversation and stands up. His voice is shaky. He says the students’ opinions aren’t representative of the country. “Ask her, ask the quiet girl,” he says. “What does she think of Russian speakers?” People in the café are staring. The quiet girl says she doesn’t want anything to do with Russians.

“See?” the man says. “She disagrees with her friends.” He argues it isn’t Estonia’s duty to care for people left behind by an occupying power. When the man leaves, the quiet girl says she doesn’t want to talk about Russians anymore.

 

If politics are at the root of Estonia’s HIV epidemic, they may also be at the heart of the solution. Estonia joined the European Union in May 2004, and now a whole continent has a vested interest in its citizens’ health. The accession process has helped accelerate improvements in medicine and integration. As a condition for membership, the EU required Estonia to provide more money to Russian-speakers for Estonian language training. This change, combined with the attraction of an EU passport and a faster application process, helped the number of naturalizations shoot up from 3,700 in 2003 to 6,500 in 2004.

EU negotiations also gave Estonia the impetus to develop tools for monitoring drug use and epidemics. Further, the country had to improve the quality and coverage of its drug-use and infection statistics and set up a focal point to report to the EMCDDA. For its part, the EMCDDA brought attention to Estonia’s HIV epidemic. The centre worried that outbreaks in Eastern Europe could result in a pan-European epidemic, so new members have been pressured to improve harm-reduction measures like needle exchanges and methadone treatment. With the EMCDDA continually monitoring the situation and the Global Fund and the Estonian government providing funding, control of the HIV epidemic is getting on track.

There is one area, however, in which the EU seems powerless: it cannot erase the stigma against Russian-speakers. The Russian Federation’s policies toward Estonia don’t help the situation. To this day, Russia continues to play mind games with its neighbour to the west. The Kremlin put off signing a border treaty with Estonia for almost a decade. Having finally agreed to sign in 2004, the Russian Federation reneged on its intent after Estonia ratified the treaty with a preamble (of no legal bearing) referencing the “Soviet aggression against Estonia in 1940.” Estonia has little to fear from these antics as its borders are now also those of the European Union, but Russia’s actions give plenty of fodder for ethnic Estonians looking to validate their mistrust of Russian-speakers.

Now that the pieces are in place to bring the HIV epidemic to a halt, the question of who has a right to be Estonian still lingers. From one point of view, citizenship is a basic human right that should not be denied. From another, countries have a right to protect their sovereignty, especially after years of occupation. Unfortunately, many like Roman have been stuck in the middle of this and suffered for it. And yet, they are clearly resilient. When the world doesn’t make sense, they make their own sense out of it.

Roman knows for sure that he will never apply for Russian citizenship. It would be easy for him to get but he doesn’t want it. He was born in Tallinn. He feels Estonian, not Russian. “It’s difficult,” he says, “but it’s my country.”

Without citizenship, it’s still hard for him to travel, and he’s heard rumours that prices will skyrocket when the euro replaces the Estonian kroon in 2007. Yet every night, he continues to perform the ultimate patriotic act: protecting his country from the disease that will eventually end his own life. His therapy is the night route, and each condom and needle he hands out, a way to make up for what he did as a heroin addict. He hopes that God and Estonia will be forgiving.