 Good evening. My name is Peter Sharusia. I'm the editor of the Drug Reporter website and the director of the Rights Reporter Foundation. Thank you for joining our new live video show today. We hope this will be the first episode of a series. So we launched this series to show the world how this current COVID-19 crisis affects the most marginalized groups of our society, such as people who use drugs. Our guests here today are helping these people in the front lines. So let me introduce our guests. I have the pleasure to have Dominic Jacekova from Bratislava, Slovakia here, from the Harvard Action NGO, Odysales. Hello, everyone. We have David Pesek from Prague, Czech Republic, who is leading the Contact Center of Samanim, which is the largest drug service provider in the Czech Republic. Hi, David. Hello. Nice to be here. And I hope soon we will be joined by Pavel Ben, who is the former mayor of Prague, and as well a community psychiatrist. Hello. Yeah, we have Pavel here, hi Pavel, and thank you again for being available and joining us now. So before we start to speak about the epidemic itself and its effects, can you guys please tell me before what did you do before the crisis happened and what kind of services did you provide for vulnerable people? How was your life before the epidemic? Okay, let's start with Dominika. Hello, everyone again. Thanks for invitation, Peter. So, Odysales is an organization based in Bratislava, and we are basically a harm reduction service provider. We provide needle exchange outreach in Bratislava streets and also we have dropped in the only open drug scene called Pentagon in Bratislava. And apart from the exchange we are providing this typical services, harm reduction services like testing for Hep C HIV or syphilis counseling, also social assistance services, where we are accompanying our clients to police hospitals, and other services. And also last year we started with social assistance to doctors by car for disabled clients. And apart from this we work also with young people in the environment of parties and festivals. There was a lot even without this crisis, so there was a lot of workload on you. Okay, so let's go to Pavel. Can you explain us how was your life before the epidemic? Can we start with David to introduce the synonym activities and interventions and then just I might probably add something from my perspective. So, go ahead, David. Well, before the crisis we were in a regular crisis mode as it's as it's usual for the NGO sector in Czech Republic. So, like always we are struggling for financing for some stable financing for our services and trying to advocacy toward broader amount of possibilities for our clients for people who use drugs. And that's something we are advocating for for many years and we are trying also to be as progressive as we can. Synonym NGO is founded in 1990 right after the Velvet Revolution and we are probably the biggest provider of drug services in Czech Republic, meaning from harm reduction services from outreach work from really low threshold facilities. Also, we provide OST, we provide all kinds of counseling, ambulance care, we have therapeutic communities, aftercare, some social enterprise, and so on. So the services we provide are a lot, we have more than 6000 clients per year. And yeah, we exchange almost two millions of needle and syringes in one year and I could say more and more numbers but let's keep it. Very impressive, very impressive especially looking from Hungary that you would change two million needles a year. That's quite a lot. Pavel, do you have anything to add? Yes, if I may add, I think synonym represents probably 25, maybe 30% of the overall HR interventions in the country, including the needle exchange schemes and HIV and hepatitis C testing. So my understanding is that, as David said at the beginning, the financial management of HR services is a crucial one, however, in the Czech Republic, we have been able in the past 20 years to stabilize the system in a way of the economic source, financial management, that means that from various sources including the municipal and the state and some sponsors, the money are covering the activities in quite well status. Certainly COVID pandemic and the state of irregular word, which we are now just placed in, is changing everything but this is Peter something probably which you will open next time. I should also say that I am a COVID positive, so I'm in quarantine as David said 10 minutes ago and fortunately I am absolutely healthy, I don't feel anything, I don't have any symptoms. Probably I'm one of those, probably many, of many of those who are undergoing through the asymptomatic progress of the disorder of the infection and I hope it will stay during the time and I even might be currently immune and I might be one of those who underwent the infection in very early stage and could let's say share some of my experience, how do I see the pandemic from the HR perspective. Thank you very much and I'm sorry to hear that you are living with the COVID virus now. I'm fine, I'm glad to hear that you have no symptoms, I hope it will stay this way. So what we see on social media you will see that how this crisis affects middle class people like self isolation and staying home and you hear this message a lot, but how does this crisis affect people who live on the street, marginalized people who use drugs, those people who you work with on the street. Can you speak about that, like how did this epidemic and the lockdown change the way of life of people living on the street? Dominic, can you speak about that in Bratislava? So if we are speaking about the drug market or drug supply until now, we don't see any difference. Our clients are not reporting any of this but we heard something from the other organizations working mostly with homeless people in the old town that they experienced. Lack of supply but like to us it hasn't gotten yet, but I think that it's a question of a few weeks, like I think that it's too soon. Here that is still quite too early. But what we see in our services and it's that our clients are really in need for food and water. Before we were not providing hot meals or this type of services because our clients, they didn't need that much but now we feel that it's real issue and real struggle to get to the water and to food. Because due to the closure of almost everything, they lost, they cannot even enter to shopping centers to maybe go to the toilet or drink water and also they lost their ways of earning money. Some people were maybe earning money by selling things on the streets or begging people so they don't have money and they don't have also food and water. This is what we see like a real struggle right now and also the lack of protective gear. But I think it's like it's normal in this situation because there is lack also normal market and also the protective gear and one more thing. And also the disinfection of hands or the hygiene, like it's really difficult to do a basic hygiene for them. So we are also providing some disinfection girls or things. Is it the same in Prague, David? Peter, have you ever been in Prague? Of course. So we of course know that Prague is like a really, really touristic city, people all around sightseeing, all the culture and history in the center, we have plenty of that. Now imagine a really empty city with no tourists, everybody at home and just people who use drugs and homeless people on the streets. So it's a completely different view of the city these days. And now imagine that a lot of these people are used to because of their poor situation are used to back the tourists and people for some money for some food or looking in the trash for finding some junk, finding some cigarettes on the streets and now there's nothing. So our people are really used to live in a crowded city and now the city is empty, so that's the biggest difference. And now you hear from the TV from everybody, go home, be with your relatives, stay safe, which is like if you don't have these values, it's totally stressful to hear all the day how you should be at the home with your closest people when all you have is the street and really no relatives. So it's tough times, it's tough times for the whole community and we are really struggling a lot and trying to help. So one of the biggest things is finding some sheltering and the other thing is the OSD because imagine closed borders, so there's much less of substances, much less trafficking of heroin, much less trafficking of precursors to make to cook crystal meth and things like this. So the drug market is getting more expensive because there is less substances on the market and the most vulnerable group of the community is much more poor than they were in the in the past. So there's like a huge gap getting huge, huge disbalance. And that's, that's really key issue nowadays, how to help people with this issue we really need to get much bigger OSD opioid substitution treatment. So we are also thinking about stimulant substitution treatment because we are one of the biggest consumers of methamphetamine in Europe. So that's the, and I could talk about more and more things but these are the two biggest. Sara, do you think that these changes in the drug market will be long term changes or everything will just go back to normal after the lockdown is over. So the drug market is able to find the way to the sources of new substances, new channels, excuse me, new channels very rapidly so my guess is that we will probably observe the changes in the channels and interventions actually and measures of black market and drug supply. But currently is the description provided by David is absolutely precise. So I think we are really just now confronted with the fact that for the first time in the history, the borders are really closed. And the traditional or standard channels and chains of the black market is affected significantly. And it brings a lot of risks from the public health perspective in services we are delivering to our clients. So, probably, I think in the first time in the history of modern history I mean of our country, we have been seriously discussing two days ago or three days ago. Should we convince the Czech government in order to open the space for the legitimate and not off label, but standardized substitution treatment within the low threshold and HR services with the legal and simulant like substances for, let's say 35 users of metamphetamine in the Czech Republic and I'm talking about Ritalin and strutter and dex amphetamine. Certainly, all these substances are somehow and very quite more and more common manner used in off label. That means that I would be prescribing for certain clients based on my assessment in terms of minimizing the risk and standardize the client. But openly, I would hardly be able to advocate for this within the, for example, the medical chamber within the ethical commission of the public health service providers. So, this is one of aspects which from my perspective is an open window or a challenge. So, I totally agree with David that the drug supply and the black market is changing. And part of this change are risks of new synthetic drugs with unknown quality with higher mortality and morbidity risks. The other aspect is the need to search for interventions which could somehow substitute some of services which are limited by the restrictions. So, our low threshold treatment centers, contact centers, drop in centers and outreach is providing the needle exchange schemes, but the additional services like counseling, for example, etc. are limited and to certain extent restricted or even banned by the government. So, we are trying to search for some alternatives. What, from certain perspective, the, for example, substitution treatment with very low threshold as far as opiate users are concerned, or substitution treatment through Ritalin, Strattara, Dexanphetamine, substitution for stimulant users. And this is exactly something that we are confronted with and trying to get through the system. So, we can say actually that this epidemic also opens some new possibilities to break down some of the barriers which actually were unnecessary even before the crisis. David, you sign all that you want to add something to that? Just one little note. This gap, this dangerous gap can be the biggest risk. We are afraid of raising of new psychoactive substances, which can, which can be used for stimulant users, like this alpha PVP, catenones and all this stuff. Someone could also use this gap on the black market to bring some fentanyl and some other potent opioids. So, this is the biggest risk and the biggest challenge and the biggest opportunity we should take now and advocate toward the government is to make the substitution treatment as most available as possible. And that can be now a strong opportunity to do this because the situation can get really dangerous. Yeah, well, let's look at Slovakia because Slovakia was not as progressive in terms of harm reduction as the Czech Republic. And Dominika, what do you think is this crisis also gives you a new window of opportunity to maybe to change the process of OST and to maybe to broaden OST programs and how did it change the way, how it is, how it is, how it is possible now? To be honest, I don't really think that there will be a possibility to advocate for OST or for broader use of OST. The OST is quite problematic in Slovakia and we are not as progressive as our neighbors from Czech Republic and basically the OST is not available really in most of the cities in Slovakia, to be honest. The methadone program is available just in two big cities, in two centers for the treatment. And then the Suboxone or Nalox is available theoretically in every psychiatric clinic or ambulance, but we know that the psychiatrists they don't want to prescribe this treatment and it's really difficult to actually find one. So this is a really difficult task. And also like last year we faced really crisis because there was a lack of Suboxone in Slovak market and we were getting phone calls or mails from people all around Slovakia which had jobs, kids, it's home like people completely integrating society and they were calling us like what they can do like they have treatment just for two weeks and then there is nothing in Slovakia and the doctors they know nothing and it was really difficult. And the situation was that we had like two distributors of this treatment and the Slovakia is small market. So one distributor left and the another one didn't expect this so they didn't provide us with enough of the treatment. So it was like we didn't have it maybe for like one or two months. So, you know how the one way how the opiate substitution programs cope with this new crisis is that they prescribe a take home longer take home doses for the clients. But I also hear reports that this actually has its own problems like you know clients were not used to economize on drugs for a longer time. So, power, can you speak about that that how can how can OST programs manage this problem like how can you support clients you know not to overdose your drugs how can you prevent that or how can you help them to you know to keep the doses as it is prescribed for a longer time. Peter this is a good question actually. First of all, I think, even though the system in most of European countries react on the conduit covid epidemic. In a sort of a panic manner in from many perspective and I am just now talking about the public health and I'm talking about the prevention perspective. Many of these restrictive interventions are nonsense. And very likely will have to be stopped. Otherwise, the public health social system and the economics of the states would be just in total collapse. So my understanding currently actually is that we have and we need to keep the services in as much as possible working order. That means hardly we can go against the restrictions, but we need to merge at the maximum of possibilities in other words. We need to keep not only needle exchange schemes, but the face to face contacts with our clients, we need to inform them and probably raise an awareness. Not only about covid and about the public health measures about the protection, for example, about the need to use the disinfection and how to use the disinfection in even though they would be homeless. Even in these absurd living contexts where we have to think how can we teach our clients to use an elementary hygienic measures as far as the covid is concerned. But at the same time, it gives us the chance to, for example, talk with them about the risks of providing them with higher doses of Suboxone or Ritalin or Stratera and providing them with the information on risks. And from my perspective, the number one issue is to return to so called standard or normal context of service delivery. Or at least to get as much close to it as possible. Second, to, it's a chance for us to think about the ethics and the methodology and about the standards, for example, of the, if we start to talk about the provision of amphetamine user substitution treatment. Okay, we have never get so far to define the standards of this care. We can try to do it. And as we know, the covid pandemic is pushing the health providers to experiment. So we started to experiment with, I don't know, Placanil and Remdesivir and other pharmaceutical substances. And the same is true for us as far as HR services are concerned. So I think it's open time for experiment. So I don't have, I would say, well defined set of recommendations. But one of general recommendation would be just, yes, let's experiment. Let's open the space for experiments, even though, as for example, Dominica said, okay, we have troubles with methadone and we have troubles with Suboxone. Okay, so in the Czech Republic, we started in the early 90s with the substitution treatment to opioid users with code in derivates. Okay. It was not definitely the best possible idea to do it. But for example, Diolan or Diolan was a code in containing medicine, which was the first broadly used substitution drug for opioid users. So the suggestion for the Slovak Republic would be just, okay, look, which code in containing substances you do have on the legal market and simply do it. Start to do it. Give courage to the professionals, to health providers, to psychiatrists, or even GPs to simply do it. My suggestion number one is to experiment. It's just really time to open our mind for certainly safe experiments. And when I use the word safe, I am a little bit hesitating to define what even do I mean by that. But there is some ethic, and there definitely are many imperatives behind harm reduction philosophy. So, suggestion number one is experiment. Suggestion number two is permanent monitoring of what we are doing, even though we are introducing a new measures. The third, if some of services are being closed because of the bans and state restrictions, just we should replace them by something else. For example, it's crazy, but I started to communicate with some of my HR clients by mobile phones and certainly you say, okay, what is new here? The new here is that I provided old mobiles to three of my clients. I found three old mobiles, paid the credit and having the chance now to be in contact with them. This is absolutely non-standard intervention, but I think we have to try the experiment. Yeah, definitely that's not standard, but actually very much in line with the philosophy of harm reduction, which is like, you have to provide your clients what they really need at they are. And I just heard about a very interesting initiative from Barcelona, for example, where the harm reduction programs now they are setting up a cell phone recharging points for homeless people. You know, that's okay, you have a phone, but you can't recharge that because supermarkets are shopping malls are closed, so they just set up these points so people can keep their social networks there. Dominic, I know that you just met with your local government not so long time ago, so can I ask you to explain when you go to your government and reflecting to what Pavel said about experimentation. So what do you tell them, like what are your main needs and how open you feel that your government is to your ideas? So if we talk about the state and state government so the help or the help is none and they are not listening and they don't want to listen, but when we are speaking about the city government, city of Bratislava, there is, we have a communication and but this communication is mostly focused on homeless people. And we are on call like the organizations which work with homeless people and we are there also for the community of homeless drug users. And we are on calls twice or once a week on, I think for three weeks or one month already and the, yeah, and we are because for cities crucial that we our services are intact and that we are keep going in the same amount or even in higher, higher capacity or more services. So they are doing all what they can to help us. So they are providing us with the protective equipment for us and also for our clients. Also, they are setting up a quarantine city for homeless people. This will be like a city for 30 up to 100 people who are homeless and they cannot go to quarantine at home because they don't have. So they can they can go to this quarantine city and wait for the for the testings or if they are already positive thinking they can stay there and and cure there. There will be provide like food and all the services. What is the problem is is the needs of people who use drugs. Because this this this quarantine quarantine city will not be low threshold. So the people who entered and they cannot like live come and go as they please so and they will be isolated there. So we need to speak about the possibilities how they can survive there and not suffer there, because it's not, it's not voluntary detox, and they are. And each they shouldn't, they shouldn't request for them like the abstinence, if they don't want to. So until now we we know that people who are who are already in substitution treatment. So it will be okay that they will have their substitution treatment even there but for active drug users who don't who are not on substitution it will be difficult. There will be although GP and psychiatrists, but they, they cannot prescribe substitution treatment, they just can prescribe something which can relieve them from the withdrawal symptoms symptoms or help help them. So this will be difficult and we are still in the process of managing the quarantine city is not open yet, because they need to finish with a hiring of the staff. I hope it will be possible. Also, we are discussing about finding some way how to communicate or how to connect with the people who are testing, or if we have some symptomatic client like it's really difficult right now. If you meet, if we have clients who has symptoms, we need to call one five five and sometimes the workers are five hours on the call and waiting for instructions or waiting for for something and, and this is not. Not, not good because the clients are not waiting or for them is impossible to maybe stay five hours with us and also the services are limited sometimes they need to go to other place. So this we need to, we need to find some effective way we are also in contact with the, with the doctors who are who are in charge of the testing in front of hospital in one tent. So maybe we can call them directly or there will be some possibility to, to call them and they will provide the transport and also the city built three hygienic stations in city in the in areas where the homeless people are normally during the day. So it's it bill, it was billed like last week and probably since tomorrow there will be also a soap, so he'll be able to clean hands also with the soap. So the cooperation is, is good. We need to, we need to, but we need to think more about the drug users and about their needs and I think that this is the thing which is not solved yet and which is not taking into consideration that much, because of course the community of drug users who are homeless are smaller than the community of drug users who drink alcohol or who don't use illegal substances so yeah and the city needs to think in the bigger perspective. Definitely how to deal with homeless people I think it's a key issue here. David, can you speak about how the city of Prague deals with this issue I've heard that you also have some outdoor facilities for homeless people. What are the challenges of opportunities over there to be to be sincere practice. And the black NGOs are doing quite great work regarding finding solutions for the for the homeless people. It's a shame that the pandemic is teaching us how we should cope with the situation that is already here for many years, but it's nowadays it's like you can see it more. The people, the community of people using drugs and the homeless people is almost the only people you see in the city so now you like realize more that's a problem but this problem or this issue is here for so long time. And nowadays there is this focus on on helping these people, which we are advocating for many years and we are quite successful, but still there are some achievements nowadays that that are really great. And of course, the possibility to open some camps that are usually for tourist people for the backpackers with the pants, which are now, of course, totally empty. They can be used for homeless people to build a tent there with a sleeping bag, which we can also provide to those people and there's like Salvation Army and other NGOs running these places and there's warm food and good background for the people. Of course, we would like, for example, to have some of these camps or shelters connected with substitution treatments connected with harm reduction services, and we are working on that on educating the staff for working there and so it would be possible. It's not only about camps, it's also about hostels or hotels that are suddenly available for our community. So yeah, that's that's the model we have seen in London and other cities. There is also this possibility to for with these power banks that can that can people like borrow and exchange them like full full with energy for the possible use of mobiles and and and the progress is quite good. Nowadays, nowadays, so it's interesting for me for me for a person who is advocating for so many years in the in the field of the drug community is is quite interesting time nowadays full of opportunities that must be must be taken and there's the possibility to make the drug policy more progressive. Let's hope so, but maybe, maybe Pavel should talk after me you will be more critique you will, you will tell you more about the sessions with politicians and so on how difficult that is Okay, I'm happy I'm happy David that you don't didn't lose your optimism so you see the future in a bright color. What about the others Pavel are you are you optimistic or more skeptical about the future. Can, can our governments learn from this crisis something Oh definitely I agree with David that we should learn from this crisis. From, for me, the key question is looking at the COVID prevention and intervention measures and on the other side, looking at certain restrictions, which are affecting our services. And from harm reduction perspective, the key question is, okay, for our clients are these restrictions or prevention measures introduced, providing more harm or less harm compared to the standardized service delivery. And from this, I guess, we are simply confronted with much more harm, which is associated with current state. So, I definitely agree with David that the optimism and energy for, let's say experiments and some voluntary services and unions of people and services. This is lovely. And this is very promising. On the other hand, we have to be aware of the fact that the current status is also putting our clients from many perspectives in danger. And and we should intervene. And we should, as I already said, try to replace the missing services by some alternatives, as well as all these experiments and new services and new ideas should just be in place. So I'm somehow a little bit optimistic also as David is, but at the same time I see a lot of collateral harm, which is associated with the political decisions made by the government or by the state authorities. And I'm very much afraid that if the time of all these non-standard interventions and restrictions, if the time lasts too long, I'm very much afraid of the high probability that there will be so much collateral damages affecting the economics, thus also affecting the social and health status of the society, that there will be lack of public resources for everything. And considering the options are just the high probability of financial shortages in general in the system or in the economics of our countries. My great threat is that the first who will be affected by that are harm reduction services, delivering services to drug users. So looking at what is going to happen in fall, September, October, we might be confronted and I don't want to be a prophet of the bad news. Definitely, I am optimist by my psychological status and lifestyle. However, I think we should take in our discussions the likelihood that there will be a significant effects on HR service delivery during next month, because simply of the collapse of our state economics. Yeah, thank you Davie, Pavel and what about you Dominic, how do you feel about the future? Yeah, I would like to add one thing, what Pavel said, that I feel the same about the harms, because for what I see there is a lot of hatred and the society stigmatizing the vulnerable people even more right now. We can see it in our drop-in in Pentagon where the open drug scene is and there are people also living on like. Now it's okay. Yeah, I think now it's better. Yeah. Okay, so now I can see that the society is even more stigmatizing the people who use drugs or the other vulnerable communities, the day in Pentagon where is the open drug scene and the people are actually living there in this location where it's residential area. So the people are really, they are quite frustrated and angry with them, they are scared of them that they can bring them infections and all. But on the other side, when you are providing them hygiene masks and all these things, they are jealous. Ah, so they are, you are giving this to homeless people and to me no one is giving it. So there is this discrepancy. And on the, and also I can see there is more solidarity from the individuals, like a lot of people now are volunteering, they are trying to help those in needs, but on the other side, there is less solidarity to the actually to the sources or to the possibilities of people who use drugs or people who are homeless, like, of course that they are outside, if they don't have home and they cannot go to quarantine like there is and I'm afraid of this, that this hatred and this stigmatization will cause a lot of harms to people who use drugs. And of course I agree with Pavel that probably we will feel it financially like my organization, but I think that we will feel it the next year, the year 2021 because like right now we secure the funds more or less for the year of 2020. Like the biggest donors are already the contracts are some of them signed we already have the results. So, but I can I feel that the next year will be really difficult for us to secure the funding, because due to economical crisis there, probably the budget for the social services will be smaller. So, thank you very much and I think we could speak about this issues for hours. Actually, our one hour is up and you see that it's really short one hour is really short and you have so good people and so exciting discussions. I think we need we'll need a lot of solidarity in the future that's for sure. And we need we will need people like you who are who are taking the risk to go into the front lines and working with those people who are living on the margins of society so thank you very much. Thank you to Pavel and David for being with us here today at this very first show of the drug reporter stories from front line series. And thank you for all those who were watching us on Facebook live. Please follow us on social media you follow the drug reporter page on Facebook and Twitter, and you will find out when our next show will be probably we will speak with Italian harm reductions next time and that will be another interesting example because we know that that country was pretty badly hit by the epidemic. And don't forget keep social distancing but stay solid keep solidarity with people. Stay safe, take care and goodbye for now. Goodbye. Bye.