Social Exclusion, Ethnicity and HIV in Estonia: A Social Exclusion, Ethnicity and HIV in Estonia: A Case for a Visit from the UN Special Rapporteur Case for a Visit from the UN Special Rapporteur

on the Right to Health ?on the Right to Health ?

Dr. Paul Downes Dr. Paul DownesDirector, Educational Disadvantage CentreDirector, Educational Disadvantage Centre

Senior Lecturer Education (Psychology)Senior Lecturer Education (Psychology)St. Patrick’s College,St. Patrick’s College,Dublin City UniversityDublin City University

paul.downes@spd.dcu.iepaul.downes@spd.dcu.ieUniversity College London, SeminarUniversity College London, Seminar

'Health and welfare in the Nordic and Baltic 'Health and welfare in the Nordic and Baltic States' States'

2626thth November 2010 November 2010

1. The Historical Emergence of the HIV 1. The Historical Emergence of the HIV Epidemic in EstoniaEpidemic in Estonia

2. Social Marginalization of Russian-2. Social Marginalization of Russian-speakers in Estonia: ‘Aliens speakers in Estonia: ‘Aliens

Syndrome’Syndrome’

3. Current Situation3. Current Situation

4. A Preventable Epidemic: Contrasts 4. A Preventable Epidemic: Contrasts with Other Countrieswith Other Countries

5. Problem Recognition and 5. Problem Recognition and Intervention Strategies Aided by the Intervention Strategies Aided by the

International CommunityInternational Community

The Historical Emergence of the HIV The Historical Emergence of the HIV Epidemic in EstoniaEpidemic in Estonia

Table 1. HIV positive cases in EstoniaTable 1. HIV positive cases in Estonia1988 - 20001988 - 2000

HIV

0

50

100

150

200

250

300

350

400

450

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

HIV

Table 2.Table 2.

1 3 8 8 9 5 12 11 8 9 6 12

390

1474

0

500

1000

1500

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001

HIV positives in Estonia (1988-2001)

The per capita figures for HIV in Estonia are higher thanThe per capita figures for HIV in Estonia are higher thananywhere in Eastern and Western Europe, and also the anywhere in Eastern and Western Europe, and also the Russian Federation (UN AIDS 2002) – and impact even Russian Federation (UN AIDS 2002) – and impact even more per capita upon the Russian-speaking population more per capita upon the Russian-speaking population in Estonia (Downes 2003).in Estonia (Downes 2003).

It was only in the UN Report on the global HIV/AIDSIt was only in the UN Report on the global HIV/AIDSepidemic (2002) that international reports highlighted, epidemic (2002) that international reports highlighted, not only that HIV infections in Estonia “soared” not only that HIV infections in Estonia “soared” Between 1999 and 2001, but that Estonia was the Between 1999 and 2001, but that Estonia was the country with the highest cumulative reported HIV country with the highest cumulative reported HIV infections per million population in Eastern European infections per million population in Eastern European countries 1993-2001, including Russia and the Ukraine.countries 1993-2001, including Russia and the Ukraine.

The beginning of a recognised HIV epidemic situation The beginning of a recognised HIV epidemic situation on November 1st 1999 of 612 cases in St. Petersburg on November 1st 1999 of 612 cases in St. Petersburg was still almost 3 times lower than the HIV epidemic was still almost 3 times lower than the HIV epidemic in Estonia for 11 November 2001 in Estonia for 11 November 2001 which had 1808 which had 1808 cases. cases.

Given that the population of Russians in St. Given that the population of Russians in St. Petersburg is approximately 4.7 million and the Petersburg is approximately 4.7 million and the population for all of Estonia is 1.5 million, the population for all of Estonia is 1.5 million, the proportionate rate of HIV infection was at least 9 proportionate rate of HIV infection was at least 9 times higher than in the St. Petersburg of November times higher than in the St. Petersburg of November 1999 – 9 times higher than a city which was 1999 – 9 times higher than a city which was recognised by its own AIDS centre as having the recognised by its own AIDS centre as having the beginning of epidemic level of HIV infections.beginning of epidemic level of HIV infections.

The exponential rate of increase in The exponential rate of increase in HIV in HIV in Estonia in 2000 and 2001 Estonia in 2000 and 2001 slowed to some slowed to some extent in 2002, with extent in 2002, with 823 new cases 823 new cases registered by the end registered by the end of November 2002 of November 2002 (Tallinn Aids (Tallinn Aids Prevention Centre Statistics). Prevention Centre Statistics).

An important factor in this slowing An important factor in this slowing down down regarding new cases was the regarding new cases was the wide needle wide needle exchange programme in exchange programme in the epidemic the epidemic regions – such programmes regions – such programmes have also had a have also had a beneficial impact on beneficial impact on the levels of new the levels of new Hepatitis B and C Hepatitis B and C cases in Estonia (Kalikova cases in Estonia (Kalikova 2003).2003).

The following statistics date from 19th of The following statistics date from 19th of August 2005 according to Tallinn Aids August 2005 according to Tallinn Aids

Prevention Centre.Prevention Centre.

Table 3.Table 3.

In 2000 Russian was the first language for 93% of the population of Narva.

In 2001, there were more registered HIV In 2001, there were more registered HIV cases in Estonia (1,940) than Latvia cases in Estonia (1,940) than Latvia (1,725), not simply as a proportion of the (1,725), not simply as a proportion of the population but in real terms despite the population but in real terms despite the fact that the Latvian population is fact that the Latvian population is significantly larger (2.4 significantly larger (2.4 million in Latvia million in Latvia as of December 31, 1999 compared to 1.5 as of December 31, 1999 compared to 1.5 million in Estonia as of February 1, 2000). million in Estonia as of February 1, 2000).

The rate of increase of HIV in Estonia The rate of increase of HIV in Estonia between 2000 and 2001 was fourfold – a between 2000 and 2001 was fourfold – a significantly higher rate of acceleration significantly higher rate of acceleration than in Latvia where nevertheless cases than in Latvia where nevertheless cases almost doubled during this time.almost doubled during this time.

In response to the HIV crisis situation, the In response to the HIV crisis situation, the Estonian government doubled the budget in 2002 Estonian government doubled the budget in 2002 to tackle HIV (Kalikova 2003) and this made some to tackle HIV (Kalikova 2003) and this made some impact on the crisis situation. impact on the crisis situation.

Another reason for the decrease in new Another reason for the decrease in new registered cases was that many injecting drug registered cases was that many injecting drug users did not want to be tested as the HIV test is users did not want to be tested as the HIV test is perceived as bringing them additional problems perceived as bringing them additional problems without the possibility to solve such problems. In without the possibility to solve such problems. In other words, many of those at risk did not have other words, many of those at risk did not have medical insurance and could not therefore afford medical insurance and could not therefore afford to receive treatment if they were HIV positive to receive treatment if they were HIV positive (Kalikova 2003).(Kalikova 2003).

The Concluding Observations of the United Nations The Concluding Observations of the United Nations Committee on the Elimination of Racial Committee on the Elimination of Racial

Discrimination (2006) outlined its concern regarding Discrimination (2006) outlined its concern regarding the higher prevalence of HIV among the minority the higher prevalence of HIV among the minority

population in Estonia:population in Estonia:

While acknowledging the State While acknowledging the State party’s party’s efforts to implement efforts to implement programmes and programmes and projects in the field of projects in the field of health, in health, in particular, for prevention particular, for prevention and and treatment of HIV/AIDS, the treatment of HIV/AIDS, the Committee Committee is concerned at the high is concerned at the high rate of rate of HIV/AIDS amongst persons HIV/AIDS amongst persons belonging belonging to minorities.to minorities.

It is also entering South-Estonia It is also entering South-Estonia regions, like regions, like Tartumaa. HIV positive Tartumaa. HIV positive cases have been cases have been found in all Estonian found in all Estonian counties with recent counties with recent suggestions that suggestions that ‘the disease also appears to ‘the disease also appears to have spread have spread from injecting drug users and from injecting drug users and into the into the general population, with reports of general population, with reports of growing infection levels amongst growing infection levels amongst university university students in Tartu’ (Alas students in Tartu’ (Alas 2006).2006).

Social Marginalization of Russian-Social Marginalization of Russian-speakers in Estonia: ‘Aliens Syndrome’speakers in Estonia: ‘Aliens Syndrome’

18 year old Russian-speaking heroin user in 18 year old Russian-speaking heroin user in Estonia in 1998 (Downes 2003):Estonia in 1998 (Downes 2003):

I'm 18 years old and I don't have a future. My parents lost their jobs, they have so many I'm 18 years old and I don't have a future. My parents lost their jobs, they have so many

problems that my presence makes them upset. They could not take care about me when I was problems that my presence makes them upset. They could not take care about me when I was

little, and now...I prefer to come home as rare as possible. I don't have education. Of course, little, and now...I prefer to come home as rare as possible. I don't have education. Of course,

it's my fault but when I was 7 or 8 it was funny to play games, to smoke...Teachers are busy it's my fault but when I was 7 or 8 it was funny to play games, to smoke...Teachers are busy

with 'good boys and girls', I understand them. After all, their salary is too small and they have with 'good boys and girls', I understand them. After all, their salary is too small and they have

a right to forget about guys like me. I went to technical school and there I met hundreds of a right to forget about guys like me. I went to technical school and there I met hundreds of

guys with the same problems like me. Do you think some of them know Estonian? Maybe one guys with the same problems like me. Do you think some of them know Estonian? Maybe one

or two...I cannot write in Russian without mistakes, what can I say about Estonian? I will not or two...I cannot write in Russian without mistakes, what can I say about Estonian? I will not

get a passport, I will never have a job. I cannot go to Russia - there are thousands of get a passport, I will never have a job. I cannot go to Russia - there are thousands of

unemployed. I don't care what happens tomorrow, I want to have something to forget that I unemployed. I don't care what happens tomorrow, I want to have something to forget that I

live for nothing and I'm not good enough for society. I know I will die but it's goodlive for nothing and I'm not good enough for society. I know I will die but it's good

Conclusions in Downes (2003) Conclusions in Downes (2003) Living Living with Heroin:with Heroin:

Injecting heroin use in Estonia is overwhelmingly and Injecting heroin use in Estonia is overwhelmingly and disproportionately among the Russian-speaking minority, disproportionately among the Russian-speaking minority, with approximately 90% of heroin addicts being Russian-with approximately 90% of heroin addicts being Russian-speakers whereas Russian-speakers are approximately speakers whereas Russian-speakers are approximately 35% of the total population in Estonia35% of the total population in Estonia

The language of the State Integration documents describe The language of the State Integration documents describe Russian-speakers as non-Estonian or non-Latvian – even Russian-speakers as non-Estonian or non-Latvian – even though many are in fact legally Estonian or Latvian though many are in fact legally Estonian or Latvian citizens – thereby categorizing them as second-class citizens – thereby categorizing them as second-class citizenscitizens

The narrow conception of ‘social competence’ for Russian-The narrow conception of ‘social competence’ for Russian-speakers, in the Estonian programme in particular, leads speakers, in the Estonian programme in particular, leads to a failure identity for many among the minority groupto a failure identity for many among the minority group

The narrow conception of social competence which The narrow conception of social competence which is identified with State language competence is identified with State language competence overlooks the fact that social competence is a multi-overlooks the fact that social competence is a multi-faceted conception which cannot be reduced to faceted conception which cannot be reduced to simply one dimension.simply one dimension.

Neither Estonian nor Latvian Integration documents Neither Estonian nor Latvian Integration documents contain a strategic plan for the success of less contain a strategic plan for the success of less academic Russian-speaking youth to give them a academic Russian-speaking youth to give them a role in Estonian or Latvian society if they cannot role in Estonian or Latvian society if they cannot cope with learning a second language. Concern with cope with learning a second language. Concern with the labelling of students as failures if they have the labelling of students as failures if they have difficulty learning in classes in their second difficulty learning in classes in their second languagelanguage

A central goal of these respective State Integration A central goal of these respective State Integration documents is the abolition of Russian-speaking documents is the abolition of Russian-speaking schools without genuine consultation of parents of schools without genuine consultation of parents of Russian-speaking children.Russian-speaking children.

The Estonian document ignores these problems of The Estonian document ignores these problems of early school drop-out almost completely through early school drop-out almost completely through its framing the terms of its document in terms of its framing the terms of its document in terms of linguistic integration and postponing any linguistic integration and postponing any discussion of socio-economic and political discussion of socio-economic and political integration until after 2007 as it is supposedly integration until after 2007 as it is supposedly “too complicated”. “too complicated”.

The per capita figures for HIV in Estonia are The per capita figures for HIV in Estonia are higher than anywhere in Eastern and Western higher than anywhere in Eastern and Western Europe, and also the Russian Federation (UN AIDS Europe, and also the Russian Federation (UN AIDS 2002) – and impact even more per capita upon 2002) – and impact even more per capita upon the Russian-speaking population in Estoniathe Russian-speaking population in Estonia

Conditions of 27 Russian-speaking prisoners in Conditions of 27 Russian-speaking prisoners in one room in Rummu prison in Estonia in 2000 one room in Rummu prison in Estonia in 2000 highlight the need for increased vigilance and highlight the need for increased vigilance and transparency in the Estonian prison system to transparency in the Estonian prison system to prevent HIV cases rising to levels comparable to prevent HIV cases rising to levels comparable to prisons in the Ukraine, especially given the fact prisons in the Ukraine, especially given the fact that over 5% of prisoners in Rummu/Murru prison that over 5% of prisoners in Rummu/Murru prison are now HIV positiveare now HIV positive

Concern at early age of hard drug use in Estonia Concern at early age of hard drug use in Estonia and Latviaand Latvia

On July 12 1993, the OSCE High Commissioner On July 12 1993, the OSCE High Commissioner Van der Stoel ‘took the unusual step of issuing a Van der Stoel ‘took the unusual step of issuing a public statement in which he listed the public statement in which he listed the assurances he had received’ (Kemp 2001) from assurances he had received’ (Kemp 2001) from the Estonian government and from the Estonian government and from representatives of the Russian community after representatives of the Russian community after the controversy of the Parliamentary vote on June the controversy of the Parliamentary vote on June 21 1993 ‘overwhelmingly in favour of a Law on 21 1993 ‘overwhelmingly in favour of a Law on Aliens that was designed to formalize the ‘alien’ Aliens that was designed to formalize the ‘alien’ status of approximately 400,000 (mostly ethnic status of approximately 400,000 (mostly ethnic Russian) long-time residents of Estonia’ (Kemp Russian) long-time residents of Estonia’ (Kemp 2001). One of these was ‘an assurance to 2001). One of these was ‘an assurance to improve the economic situation in North Eastern improve the economic situation in North Eastern Estonia’ (Kemp 2001), namely, in largely Russian-Estonia’ (Kemp 2001), namely, in largely Russian-speaking areas of Narva and Ida-Virumaa.speaking areas of Narva and Ida-Virumaa.

Gil-Robles’ (2004) report on Estonia observed the Gil-Robles’ (2004) report on Estonia observed the following following

consequences for members of the Russian-speaking consequences for members of the Russian-speaking

population of being given ‘alien’ status:population of being given ‘alien’ status: The lack of citizenship deprives these persons of a number The lack of citizenship deprives these persons of a number of rights, mainly in the field of political rights, and carries of rights, mainly in the field of political rights, and carries an increased risk of social exclusion. Although non-citizens an increased risk of social exclusion. Although non-citizens have the right to vote in local elections, they do not have have the right to vote in local elections, they do not have the right to vote in national elections, establish political the right to vote in national elections, establish political parties, or become members in political parties. Moreover, parties, or become members in political parties. Moreover, the enjoyment of the rights guaranteed under the the enjoyment of the rights guaranteed under the Framework Convention for the Protection of National Framework Convention for the Protection of National Minorities, was limited by Estonia to those who have Minorities, was limited by Estonia to those who have Estonian citizenship when it ratified the Convention. It is Estonian citizenship when it ratified the Convention. It is also to be underlined, that non-citizens, like citizens, also to be underlined, that non-citizens, like citizens, contribute to the society in a similar manner as taxpayers.contribute to the society in a similar manner as taxpayers.

Mikecz (2008):Mikecz (2008): The life expectancy of men in Estonia was The life expectancy of men in Estonia was

the lowest in the EU in 2004the lowest in the EU in 2004 In 2002, per capita income tax revenues in In 2002, per capita income tax revenues in

North Eastern Estonia were only half of North Eastern Estonia were only half of that of Northern Estoniathat of Northern Estonia

In 2005, 1.453 million tourists visited In 2005, 1.453 million tourists visited Estonia. 71% of them stayed in Tallinn and Estonia. 71% of them stayed in Tallinn and did not visit any other regions. Less than did not visit any other regions. Less than 1% stayed overnight in North Eastern 1% stayed overnight in North Eastern EstoniaEstonia

Kalikova, Kurbatova & Talu (2002, p.34) Kalikova, Kurbatova & Talu (2002, p.34) refer to ‘so-called “alien’s syndrome”’ refer to ‘so-called “alien’s syndrome”’ among Russian-speakers, whether among Russian-speakers, whether citizens or non-citizens, as ‘they feel they citizens or non-citizens, as ‘they feel they are second-rate people in Estonia, that are second-rate people in Estonia, that their knowledge and competence is not their knowledge and competence is not required by society’.required by society’.

The language used to refer to Russian-The language used to refer to Russian-speakers as non-Estonian and non-Latvian speakers as non-Estonian and non-Latvian is not the language of integration but of is not the language of integration but of separation and exclusion of Russian-separation and exclusion of Russian-speakers from Estonian or Latvian society. speakers from Estonian or Latvian society. Terms ‘non-Estonian’ and ‘non-Latvian’ Terms ‘non-Estonian’ and ‘non-Latvian’ define these groups not by what they are, define these groups not by what they are, but by what they are not, by a lack of but by what they are not, by a lack of some attribute, namely, Estonian/Latvian some attribute, namely, Estonian/Latvian ethnicity. These terms do not connote a ethnicity. These terms do not connote a parity of esteem in the eyes of the State. parity of esteem in the eyes of the State.

(Downes 2007)(Downes 2007)

It is remarkable that Estonian and Latvian It is remarkable that Estonian and Latvian State documents which purport to be about State documents which purport to be about integration adopt such non-inclusive integration adopt such non-inclusive language regarding its ethnic minority language regarding its ethnic minority citizens. Moreover, it is arguable that the citizens. Moreover, it is arguable that the dimensions of ‘alien’s syndrome’ apply not dimensions of ‘alien’s syndrome’ apply not only to those with ‘alien’s’ passports but to only to those with ‘alien’s’ passports but to many other Russian-speakers who are many other Russian-speakers who are socially marginalized in Estonia – and are socially marginalized in Estonia – and are considered as alien in the sense of being considered as alien in the sense of being ‘non-Estonian’ despite obtaining Estonian ‘non-Estonian’ despite obtaining Estonian citizenship. ‘Alien’s syndrome’ … the lack of citizenship. ‘Alien’s syndrome’ … the lack of parity of esteem is a mental health issue parity of esteem is a mental health issue (Downes 2007).(Downes 2007).

Current SituationCurrent Situation

Poleshchuk (LICHR 2010, personal Poleshchuk (LICHR 2010, personal communication). From 1 October communication). From 1 October 2009 the Register of Communicable 2009 the Register of Communicable Diseases started to collect data on Diseases started to collect data on HIV-positive population: HIV-positive population:

From 1 October 2009 - 7 June 2010, 115 new From 1 October 2009 - 7 June 2010, 115 new persons were registered as HIV-positive persons were registered as HIV-positive (Estonia/Ministry of Social Affairs, e-mail of 7 June (Estonia/Ministry of Social Affairs, e-mail of 7 June 2010 – see attached). Among them:2010 – see attached). Among them:

Ethnic originEthnic origin 90% - ethnic Russians90% - ethnic Russians 8% - ethnic Estonians8% - ethnic Estonians 2% - others2% - othersRegionRegion 13% - Tallinn (capital city)13% - Tallinn (capital city) 70% - Ida-Viru County 70% - Ida-Viru County Non sterile syringe as a Non sterile syringe as a

source of HIVsource of HIV 33% 33%

Social-economic statusSocial-economic status 3% - students of higher 3% - students of higher

education institutions education institutions 44% - 44% - prisonersprisoners 1% - do not work, stay at 1% - do not work, stay at

homehome 2% - on maternity leave2% - on maternity leave 18% - working18% - working 30% - unemployed30% - unemployed 2% - disability pensioners2% - disability pensioners 1% - age pensioners1% - age pensioners

Estonia ranks in second place in the Estonia ranks in second place in the list published in the World Drugs list published in the World Drugs Report 2010, made by the United Report 2010, made by the United Nations Office on Drugs and Crime Nations Office on Drugs and Crime (UNODC).(UNODC).

With 1.52% of the adult population With 1.52% of the adult population using them, only Scotland has a using them, only Scotland has a higher use of opiates (1.54%) in higher use of opiates (1.54%) in Europe than Estonia.Europe than Estonia.

The rest of the countries of the The rest of the countries of the European Union do not reach1%.European Union do not reach1%.

Major risk groups are intravenous drug addicts Major risk groups are intravenous drug addicts and prostitutes. Ethnic minorities are and prostitutes. Ethnic minorities are considerably overrepresented in both groups considerably overrepresented in both groups (Estonian Health Board 2010).(Estonian Health Board 2010).

In 2008 In 2008 545 545 new HIV positive people new HIV positive people have have been diagnosed. This is an increase compared been diagnosed. This is an increase compared with the 2004-2005 figure of with the 2004-2005 figure of 417417

52 52 AIDS casesAIDS cases From them From them 60 60 prisonersprisoners Through the years Through the years 250 250 people have beenpeople have been

diagnosed with AIDSdiagnosed with AIDS Between 1988 and 2008 Between 1988 and 2008 6,9096,909 people have been people have been

diagnosed with HIV in Estonia diagnosed with HIV in Estonia

The high number of HIV positive The high number of HIV positive persons in prisons can be attributed persons in prisons can be attributed to the fact thatto the fact thatmany prisoners coming from Ida-Viru many prisoners coming from Ida-Viru County have been infected with HIV County have been infected with HIV before coming to prison. HIV/AIDS before coming to prison. HIV/AIDS prevention in prisons takes place in prevention in prisons takes place in accordance with the national accordance with the national HIV/AIDS strategy (Estonian Ministry HIV/AIDS strategy (Estonian Ministry of Justice 2007).of Justice 2007).

A Preventable Epidemic: A Preventable Epidemic: Contrasts with Other CountriesContrasts with Other Countries

The epidemic among intravenous drug users in The epidemic among intravenous drug users in North Eastern Estonia was predicted by Tallinn North Eastern Estonia was predicted by Tallinn Aids Prevention Centre as early as 1996 but due Aids Prevention Centre as early as 1996 but due to lack of financing preventive measures were not to lack of financing preventive measures were not introduced prior to the epidemic (Kalikova 2001). introduced prior to the epidemic (Kalikova 2001).

The contrast between Slovenia and the The contrast between Slovenia and the Baltic States Baltic States is regarding methadone is regarding methadone substitution treatment. It is substitution treatment. It is widely available in widely available in Slovenia and has been Slovenia and has been established there since established there since 1991 (EMCDDA 2004), 1991 (EMCDDA 2004), whereas Estonia and whereas Estonia and Latvia in particular have been Latvia in particular have been slow to react. slow to react. For the Baltic States in the recent For the Baltic States in the recent past, past, intravenous drug users have constituted 73% intravenous drug users have constituted 73% of of HIV cases in Estonia (Official statistics December HIV cases in Estonia (Official statistics December

2000), 70% of HIV cases in Latvia and 2000), 70% of HIV cases in Latvia and 54.5% in 54.5% in Lithuania (2000). The contrast with Lithuania (2000). The contrast with Slovenia is stark. Slovenia is stark.

Current rates of HIV among IDUs is less Current rates of HIV among IDUs is less than 1% in than 1% in Slovenia with figures from local Slovenia with figures from local studies in studies in Estonia and Latvia estimating that Estonia and Latvia estimating that rates of HIV rates of HIV among IDUs is still as high as among IDUs is still as high as 40% in Estonia and 40% in Estonia and 20% in Latvia (EMCDDA 20% in Latvia (EMCDDA 2004).2004).

In Romania, the Ministry of Health is In Romania, the Ministry of Health is the body providing funds for a the body providing funds for a detoxification programme and post-detoxification programme and post-detoxification support programme, detoxification support programme, as well as a planned methadone as well as a planned methadone programme for 2002 (Romano 2001). programme for 2002 (Romano 2001).

In Croatia, the Croatian Parliament In Croatia, the Croatian Parliament established special centres for drug established special centres for drug treatment at county and at city level treatment at county and at city level where treatment of drug addicts where treatment of drug addicts includes counselling, detoxification, includes counselling, detoxification, methadone treatment, needle methadone treatment, needle exchange and is covered by the exchange and is covered by the national health insurance (Kuzman national health insurance (Kuzman 2001). 2001).

In contrast to Romania and Croatia, the In contrast to Romania and Croatia, the Concluding Observations of the Committee Concluding Observations of the Committee on the Rights of the Child for Latvia (2001) on the Rights of the Child for Latvia (2001) noted the limited availability of noted the limited availability of programmes and services in the area of programmes and services in the area of adolescent health, including mental health, adolescent health, including mental health, and in particular treatment and and in particular treatment and rehabilitation programmes for alcohol and rehabilitation programmes for alcohol and drug addiction as well as prevention drug addiction as well as prevention programmes. programmes.

The Estonian Drug Monitoring Centre The Estonian Drug Monitoring Centre National Focal Point Report (2002) National Focal Point Report (2002) observed that drug treatment observed that drug treatment funding from the Estonian State was funding from the Estonian State was decreaseddecreased. This decrease was . This decrease was despite the recognised outbreak of despite the recognised outbreak of the HIV epidemic in Estonia in 2001, the HIV epidemic in Estonia in 2001, predominantly among Russian-predominantly among Russian-speaking intravenous drug users. speaking intravenous drug users.

Problem Recognition and Problem Recognition and Intervention Strategies Aided by Intervention Strategies Aided by

the International Communitythe International Community The following account of the new strategy is given The following account of the new strategy is given in Estonia’s Second Report on the implementation in Estonia’s Second Report on the implementation of the Council of Europe Framework Convention for of the Council of Europe Framework Convention for the Protection of National Minoritiesthe Protection of National Minorities : :

In April 2004, the national drug prevention strategy In April 2004, the national drug prevention strategy until 2012 was adopted. The strategy is aimed at until 2012 was adopted. The strategy is aimed at strengthening the rehabilitation system and strengthening the rehabilitation system and treatment for drug addicts, and improving the treatment for drug addicts, and improving the quality and accessibility of services. The strategy quality and accessibility of services. The strategy emphasizes regional differences in creating a drug-emphasizes regional differences in creating a drug-free environment.free environment.

The following principles will be implemented within the The following principles will be implemented within the strategy:strategy:

In planning the prevention activities and In planning the prevention activities and implementing the methods, the specific implementing the methods, the specific characteristics of target groups need to be taken characteristics of target groups need to be taken into account (age distribution, sex, ethnic origin, into account (age distribution, sex, ethnic origin, social, cultural and economic background, social, cultural and economic background, experience and expectations, availability of drugs, experience and expectations, availability of drugs, etc.);etc.);

All information materials, study aids and handbooks All information materials, study aids and handbooks are developed depending on needs of the target are developed depending on needs of the target group (including national minorities) and are tested group (including national minorities) and are tested on the relevant target groups;on the relevant target groups;

Information for drug prevention is available for all Information for drug prevention is available for all population groups in Estonian and Russian;population groups in Estonian and Russian;

Services must be oriented to the age, sex, ethnic Services must be oriented to the age, sex, ethnic origin and socio-cultural background of persons origin and socio-cultural background of persons coming for treatment and/or rehabilitation.coming for treatment and/or rehabilitation.

Despite the progress made by the Despite the progress made by the development of this strategy on development of this strategy on paper, the strategy in 2005 ‘only paper, the strategy in 2005 ‘only received about a quarter of the received about a quarter of the government funding it needs’ government funding it needs’ (Charles 2005).(Charles 2005).

A key feature of Estonia’s Second A key feature of Estonia’s Second Report on the Implementation of the Report on the Implementation of the Council of Europe Framework Council of Europe Framework Convention for the Protection of Convention for the Protection of National Minorities (June 2004) was its National Minorities (June 2004) was its central recognition of the problem of central recognition of the problem of unemployment – in effect the problem unemployment – in effect the problem of socio-economic integration – in of socio-economic integration – in North-Eastern Estonia:North-Eastern Estonia:

Amnesty International (December 2006)Amnesty International (December 2006)

Persons belonging to the Russian-speaking Persons belonging to the Russian-speaking linguistic minority do not enjoy linguistic minority do not enjoy

internationally internationally recognized minority rights; recognized minority rights; current current employment policies mean that employment policies mean that Russian-Russian- speakers speakers are disproportionately are disproportionately affected by unemployment affected by unemployment and by extension and by extension often by social exclusion; often by social exclusion; upcoming upcoming secondary school reforms risk increasing secondary school reforms risk increasing the the number of Russian-speakers who drop out of number of Russian-speakers who drop out of school and thus put them at risk of further social school and thus put them at risk of further social

exclusion; and current provisions and exclusion; and current provisions and practices practices in place are not able to guarantee in place are not able to guarantee that no one is that no one is discriminated against in the discriminated against in the workplace.workplace.

Recommendations to Estonian government:Recommendations to Estonian government:* monitor levels of drop-out rates in * monitor levels of drop-out rates in

secondary schools where Russian is secondary schools where Russian is replaced by Estonian as the language of replaced by Estonian as the language of teaching;teaching;

* take concrete measures to combat any * take concrete measures to combat any potential increase in drop-out rates in potential increase in drop-out rates in secondary schools where Russian is secondary schools where Russian is replaced by Estonian as the language of replaced by Estonian as the language of teaching; teaching;

* take concrete measures to reduce the risk of * take concrete measures to reduce the risk of Russian-speakers who drop out of Russian-speakers who drop out of secondary schools become socially excluded secondary schools become socially excluded and marginalizedand marginalized

Ms. Kristiina Luht (September 2006, Ms. Kristiina Luht (September 2006, personal communication), personal communication), Chief Chief Specialist Ministry of Social Affairs, Specialist Ministry of Social Affairs, EstoniaEstonia notes that ‘ notes that ‘around half of the around half of the women trafficked into Tallinn come women trafficked into Tallinn come from Ida-Virumaa according to the from Ida-Virumaa according to the unofficial opinion of the policemen unofficial opinion of the policemen who work with those caseswho work with those cases’.’.

In the report in February 2004, by Alvaro Gil-Robles, In the report in February 2004, by Alvaro Gil-Robles, Council of Europe Commissioner for Human Rights Council of Europe Commissioner for Human Rights on his visit to Estonia, the Commissioner on his visit to Estonia, the Commissioner recognised that Estonia is:recognised that Estonia is:

‘‘the country with the highest reported number of the country with the highest reported number of HIV infections per capita in Europe. The majority of HIV infections per capita in Europe. The majority of those infected are children or young adults. In those infected are children or young adults. In response, the Estonian Government adopted in response, the Estonian Government adopted in January 2002 a National HIV/AIDS prevention January 2002 a National HIV/AIDS prevention programme for 2002-2006, which aims at stopping programme for 2002-2006, which aims at stopping the spread of the virus and at ensuring the high-the spread of the virus and at ensuring the high-quality treatment and other care and social quality treatment and other care and social services for those infected with HIV’.services for those infected with HIV’.

Estonia’s Second Report on the implementation of Estonia’s Second Report on the implementation of the Council of Europe Framework Convention for the the Council of Europe Framework Convention for the Protection of National Minorities (2004) gave the Protection of National Minorities (2004) gave the following account of the budget provided for fighting following account of the budget provided for fighting HIV/AIDS:HIV/AIDS:

‘‘In the state budget for 2003, there were In the state budget for 2003, there were approximately 12 million [Estonian] kroons for the approximately 12 million [Estonian] kroons for the fight against HIV/AIDS. Five million were spent on fight against HIV/AIDS. Five million were spent on purchasing of medicines and the remaining sum was purchasing of medicines and the remaining sum was spent on prevention activities. In the budget for spent on prevention activities. In the budget for 2004, the amount of funds is the same, but in 2004, the amount of funds is the same, but in addition to the state budget funds also other addition to the state budget funds also other resources are used for the fight against HIV/AIDS. resources are used for the fight against HIV/AIDS. The world Global Fund gives 52 million kroons to The world Global Fund gives 52 million kroons to Estonia for fighting HIV/AIDS. According to the Estonia for fighting HIV/AIDS. According to the agreement, this sum should last until October 2005. agreement, this sum should last until October 2005. In total, the Fund will provide approximately ten In total, the Fund will provide approximately ten million USD (or 136 million Estonian kroons) for AIDS million USD (or 136 million Estonian kroons) for AIDS prevention to Estonia in the period of four years’.prevention to Estonia in the period of four years’.

Estonia’s Second Report on the Estonia’s Second Report on the implementation of the Council of Europe implementation of the Council of Europe Framework Convention for the Protection of Framework Convention for the Protection of National Minorities, in June 2004, National Minorities, in June 2004, recognised the ethnic minority dimension of recognised the ethnic minority dimension of its HIV and intravenous drug use problem:its HIV and intravenous drug use problem:

‘‘Problems relating to drug addiction and HIV Problems relating to drug addiction and HIV are mostly concentrated to areas like Ida-are mostly concentrated to areas like Ida-Virumaa county and Tallinn. Approximately Virumaa county and Tallinn. Approximately 80% of all HIV positive people are Russian 80% of all HIV positive people are Russian speakers, mostly at the age of 15-25. The speakers, mostly at the age of 15-25. The spreading of HIV is closely connected with spreading of HIV is closely connected with the problems of drug abuse; the virus is the problems of drug abuse; the virus is most widespread amongmost widespread amongintravenous drug users’. intravenous drug users’.

Quite significantly, this report Quite significantly, this report amounted to Estonian State amounted to Estonian State recognition of the need to target recognition of the need to target prevention and treatment prevention and treatment programmes to its Russian-speaking programmes to its Russian-speaking national (and arguably also ethnic) national (and arguably also ethnic) minority: minority:

As HIV/AIDS are most widespread among young people and first and foremost amongAs HIV/AIDS are most widespread among young people and first and foremost among

Russian speakers, the activities for the prevention of HIV/AIDS and drugRussian speakers, the activities for the prevention of HIV/AIDS and drug

addiction are also targeted to the relevant age group. Publications and informationaddiction are also targeted to the relevant age group. Publications and information

materials for prevention are available both in Estonian and Russian. materials for prevention are available both in Estonian and Russian.

Public services for drug and HIV/AIDS treatment and rehabilitation and for the Public services for drug and HIV/AIDS treatment and rehabilitation and for the

reduction of costs are organised on uniform bases and are accessible for all people reduction of costs are organised on uniform bases and are accessible for all people

who need them, the decisive factor is the health condition of the person and the who need them, the decisive factor is the health condition of the person and the

specific needs arising from this. specific needs arising from this.

Due to the large proportion of drug addicts and HIV positive people in regionsDue to the large proportion of drug addicts and HIV positive people in regions

where the population consists mostly of persons belonging to national minorities (Ida-where the population consists mostly of persons belonging to national minorities (Ida-

Virumaa region), the development and implementation of services for the treatmentVirumaa region), the development and implementation of services for the treatment

and rehabilitation and for the reduction of costs are promoted intensively there.and rehabilitation and for the reduction of costs are promoted intensively there.

Against the backdrop of 382 HIV cases in Estonian prisons at the end of 2001 Against the backdrop of 382 HIV cases in Estonian prisons at the end of 2001 (Tallinn Aids Prevention Centre Statistics 2002), a further issue arises (Tallinn Aids Prevention Centre Statistics 2002), a further issue arises concerning conditions of at least some prisoners in Estonia in the recent past. concerning conditions of at least some prisoners in Estonia in the recent past. Kaur (2000), an ethnic Estonian, describes the conditions of Rummu prison in Kaur (2000), an ethnic Estonian, describes the conditions of Rummu prison in Estonia:Estonia:

‘‘During the visit to Rummu Prison, there During the visit to Rummu Prison, there were 27 inmates in one room. According to were 27 inmates in one room. According to [the] prisoners’ story there have been times [the] prisoners’ story there have been times where the same room contained around 40-where the same room contained around 40-44 prisoners. Basically the room was full of 44 prisoners. Basically the room was full of beds side by side. All inhabitants of this beds side by side. All inhabitants of this room were Russian-speakers. Is it a room were Russian-speakers. Is it a coincidence that Russian-speakers live in coincidence that Russian-speakers live in these conditions? It seems that inmates are these conditions? It seems that inmates are accommodated according to the preferences accommodated according to the preferences of those who are in power’.of those who are in power’.

Gil-Robles’ (2004) report made the Gil-Robles’ (2004) report made the following statements regarding following statements regarding HIV and prisoners in Estonia:HIV and prisoners in Estonia:

‘‘The spread of infectious diseases in prisons and detention facilities The spread of infectious diseases in prisons and detention facilities continues to be an issue of significant concern. The Director of the Maardu continues to be an issue of significant concern. The Director of the Maardu prison informed that 29 of the 131 detainees were known to be infected prison informed that 29 of the 131 detainees were known to be infected with HIV. He noted that there had been a significant increase in HIV with HIV. He noted that there had been a significant increase in HIV infections during the past three to four years. Previously those with infections during the past three to four years. Previously those with HIV/AIDS had been separated from other inmates, but this was no longer HIV/AIDS had been separated from other inmates, but this was no longer the case. As stated in the European Prison Rules, no segregation should be the case. As stated in the European Prison Rules, no segregation should be made on the basis of HIV/AIDS, unless the health of the individual so made on the basis of HIV/AIDS, unless the health of the individual so requires. Given the exceptionally high number of HIV positive inmates in requires. Given the exceptionally high number of HIV positive inmates in the prisons, all possible measures must be taken in order to prevent the the prisons, all possible measures must be taken in order to prevent the transmission of the virus among the inmates. The authorities have transmission of the virus among the inmates. The authorities have recognised that significant efforts must be undertaken in order to tackle recognised that significant efforts must be undertaken in order to tackle the issues that are at the origins of the spread of HIV/AIDS in prisons, such the issues that are at the origins of the spread of HIV/AIDS in prisons, such a the use of drugs and violence among the inmates. It was noted that more a the use of drugs and violence among the inmates. It was noted that more and more prisoners who use narcotic substances are identified each year, and more prisoners who use narcotic substances are identified each year, and although the fight against drug addiction in prisons has strengthened, and although the fight against drug addiction in prisons has strengthened, there are still difficulties in identifying the channels through which drugs there are still difficulties in identifying the channels through which drugs are brought to prisons’.are brought to prisons’.

While welcoming the Estonian Government While welcoming the Estonian Government HIV/AIDS Prevention action plan for 2002-2006, HIV/AIDS Prevention action plan for 2002-2006, Commissioner Gil-Robles proposed in 2004 that Commissioner Gil-Robles proposed in 2004 that

such needle exchange programmes become widely such needle exchange programmes become widely available in prisons in Estonia:available in prisons in Estonia:

‘‘In July 2002, the Ministry of Justice adopted an In July 2002, the Ministry of Justice adopted an ‘HIV/AIDS prevention action plan for years 2002-2006 ‘HIV/AIDS prevention action plan for years 2002-2006 in the area of government of the Ministry of Justice’, in the area of government of the Ministry of Justice’, with the objective to prevent the spread of HIV with the objective to prevent the spread of HIV infection in prisons and among probationers and to infection in prisons and among probationers and to secure high quality anti-virus treatment for persons secure high quality anti-virus treatment for persons with HIV-infection. I welcome the strong emphasis with HIV-infection. I welcome the strong emphasis placed on information and awareness-raising in this placed on information and awareness-raising in this Plan, and would like to propose, that as long as there Plan, and would like to propose, that as long as there continue to be drugs in prisons, exceptional measures, continue to be drugs in prisons, exceptional measures, such as needle exchange programmes, be such as needle exchange programmes, be undertaken’.undertaken’.

The report submitted by the UN Special The report submitted by the UN Special Rapporteur for the Right to Health on Rapporteur for the Right to Health on Romania (2005) stated: Romania (2005) stated:

‘‘65. The Special Rapporteur emphasizes 65. The Special Rapporteur emphasizes that the right to health gives rise to an that the right to health gives rise to an entitlement to health care, including entitlement to health care, including mental health care, which is mental health care, which is geographically accessible, designed to geographically accessible, designed to improve the health status of patients, and improve the health status of patients, and scientifically and medically appropriate’.scientifically and medically appropriate’.

Gil-Robles (2004). Issues regarding socio-Gil-Robles (2004). Issues regarding socio-economic integration are treated as being economic integration are treated as being ‘too complicated’ to be dealt with by the ‘too complicated’ to be dealt with by the State Integration Programme. This State Integration Programme. This approach noticeably diverges from that of approach noticeably diverges from that of the Latvian integration document ‘The the Latvian integration document ‘The Integration of Society in Latvia’ which Integration of Society in Latvia’ which recognises that ‘the integration of society recognises that ‘the integration of society is closely linked to social and regional is closely linked to social and regional problems; the course of discussions problems; the course of discussions strengthened the conviction that a section strengthened the conviction that a section on social integration should be an integral on social integration should be an integral part of the programme’. part of the programme’.

Gil-Robles (2004) observed the need for Gil-Robles (2004) observed the need for reduction in socio-economic differences as reduction in socio-economic differences as an issue of integration in Estonia:an issue of integration in Estonia:

‘‘Despite the positive shift in mentalities Despite the positive shift in mentalities and in practice, a number of challenges and in practice, a number of challenges still remain, however, in the practical still remain, however, in the practical implementation of the laws and policies, in implementation of the laws and policies, in the efforts to reduce the socio-economic the efforts to reduce the socio-economic differences between the different groups of differences between the different groups of the population, as well as in the protection the population, as well as in the protection of the minority languages and identity’.of the minority languages and identity’.

Estonia’s Second Report on the implementation of the Estonia’s Second Report on the implementation of the Council of Europe Framework Convention for the Protection Council of Europe Framework Convention for the Protection of National Minorities (2004) states:of National Minorities (2004) states:

‘‘Social scientists have noted that the applied side of the Social scientists have noted that the applied side of the integration program in the years 2000-2003 has focused integration program in the years 2000-2003 has focused primarily on the cultural-linguistic aspect of the integration, primarily on the cultural-linguistic aspect of the integration, while other aspects have receded relatively in the while other aspects have receded relatively in the background. This approach was justified in a given period of background. This approach was justified in a given period of time. In order to secure the success of political and socio-time. In order to secure the success of political and socio-economic integration, the proficiency in Estonian language economic integration, the proficiency in Estonian language and the embedding of people in the Estonian society was of and the embedding of people in the Estonian society was of paramount importance… Alongside [language learning] paramount importance… Alongside [language learning] more attention should be paid to objectives of political and more attention should be paid to objectives of political and socio-economic integration…’.socio-economic integration…’.

Furthermore, in 2006, Concluding Observations of Furthermore, in 2006, Concluding Observations of the UN Committee on the Elimination of Racialthe UN Committee on the Elimination of Racial Discrimination noted that:Discrimination noted that:

‘‘While the Committee recognises the efforts While the Committee recognises the efforts made by the State party in the field of made by the State party in the field of employment, including the action plans for 2004-employment, including the action plans for 2004-2007 under the State integration programmes, it 2007 under the State integration programmes, it remains concerned by the high rate of remains concerned by the high rate of unemployment among members of minorities, in unemployment among members of minorities, in particular Russian-speaking minorities. The particular Russian-speaking minorities. The Committee reiterates its previous concern that Committee reiterates its previous concern that the scope of the requirement of Estonian the scope of the requirement of Estonian language proficiency, including in the private language proficiency, including in the private sector, may have a discriminatory effect on the sector, may have a discriminatory effect on the availability of employment to members of this availability of employment to members of this community (art. 5 (e) (i)).community (art. 5 (e) (i)).

The new Estonia Integration The new Estonia Integration Programme Programme

2008 – 2013 2008 – 2013

recognises the priority of recognises the priority of

socio-economic integrationsocio-economic integration

The Advisory Committee on the Framework Convention for The Advisory Committee on the Framework Convention for the Protection of National Minorities, Second Opinion on the Protection of National Minorities, Second Opinion on Estonia adopted on 24 February 2005Estonia adopted on 24 February 2005

Recommendations Recommendations 55. It is essential that the authorities 55. It is essential that the authorities design and implement special programmes to tackle social design and implement special programmes to tackle social marginalization and its effects that are felt particularly marginalization and its effects that are felt particularly amongst national minorities.amongst national minorities.

Recommendations Recommendations 160. Authorities should pursue further 160. Authorities should pursue further their efforts to address the disproportionately high their efforts to address the disproportionately high unemployment rate amongst persons belonging to national unemployment rate amongst persons belonging to national minorities in Ida-Virumaa and elsewhere by launching minorities in Ida-Virumaa and elsewhere by launching regional development initiatives and measures to fight regional development initiatives and measures to fight direct and indirect discrimination in the labour market. This direct and indirect discrimination in the labour market. This should also enhance the recruitment of qualified persons should also enhance the recruitment of qualified persons belonging to national minorities in public service.belonging to national minorities in public service.

The right to health in relation to its Russian-The right to health in relation to its Russian-speaking population under the International speaking population under the International Covenant on Economic, Social and Cultural Rights Covenant on Economic, Social and Cultural Rights (ICESCR) (16 December 1966), acceded to by (ICESCR) (16 December 1966), acceded to by Estonia on 21 October 1991, and which entered Estonia on 21 October 1991, and which entered into force for Estonia on 21 January 1992 (Art. 27, into force for Estonia on 21 January 1992 (Art. 27, para. 2, ICESCR: “… three months after the date para. 2, ICESCR: “… three months after the date of the deposit of its own instrument of ratification of the deposit of its own instrument of ratification or instrument of accession”)or instrument of accession”). Through ratifying . Through ratifying the ICESCR, Estonia has committed to providing a the ICESCR, Estonia has committed to providing a form of international accountability in relation to form of international accountability in relation to the right to health of both individuals and the right to health of both individuals and communities including among its Russian communities including among its Russian speaking populationspeaking population

The The right of everyone to the enjoyment of the right of everyone to the enjoyment of the highest attainable standard of physical and highest attainable standard of physical and mental health mental health is given legal foundation by a is given legal foundation by a range of international legal instrumentsrange of international legal instruments, including , including article 25 (1) of the Universal Declaration of article 25 (1) of the Universal Declaration of Human Rights (UDHR), article 12 of the Human Rights (UDHR), article 12 of the International Covenant on Economic, Social and International Covenant on Economic, Social and Cultural Rights (ICESCR), article 24 of the Cultural Rights (ICESCR), article 24 of the Convention on the Rights of the Child (CRC) and Convention on the Rights of the Child (CRC) and article 12 of the Convention on the Elimination of article 12 of the Convention on the Elimination of All Forms of Discrimination against Women All Forms of Discrimination against Women (CEDAW), as well as the right to non-(CEDAW), as well as the right to non-discrimination as reflected in article 5 (e) (iv) of discrimination as reflected in article 5 (e) (iv) of the International Convention on the Elimination of the International Convention on the Elimination of All Forms of Racial Discrimination (ICERD). All Forms of Racial Discrimination (ICERD).

The Special Rapporteur (2006) emphasizes the The Special Rapporteur (2006) emphasizes the importance of focus on ‘disadvantaged’ individuals importance of focus on ‘disadvantaged’ individuals and communities in relation to the right to health:and communities in relation to the right to health:

‘‘25. in general terms a human rights-based 25. in general terms a human rights-based approach requires that special attention be given approach requires that special attention be given to disadvantaged individuals and communities; it to disadvantaged individuals and communities; it requires the active and informed participation of requires the active and informed participation of individuals and communities in policy decisions individuals and communities in policy decisions that affect them; and it requires effective, that affect them; and it requires effective, transparent and accessible monitoring and transparent and accessible monitoring and accountability mechanisms. The combined effect of accountability mechanisms. The combined effect of these - and other features of a human rights-based these - and other features of a human rights-based approach - is to empower disadvantaged approach - is to empower disadvantaged individuals and communities’.individuals and communities’.

The Special Rapporteur (2006) notes The Special Rapporteur (2006) notes that the right to health is subject to that the right to health is subject to progressive realization and this progressive realization and this requires development of indicators requires development of indicators and benchmarks.and benchmarks.

Pre- Bronze Soldier (April Pre- Bronze Soldier (April 2007)2007)

Council of Europe (2004)Council of Europe (2004)

UN Committee on Elimination of UN Committee on Elimination of Racial Discrimination (2006)Racial Discrimination (2006)

Amnesty International (December Amnesty International (December 2006)2006)

Yet HIV, hard drug use, social Yet HIV, hard drug use, social

marginalization of Russian speakers in marginalization of Russian speakers in

North Eastern Estonia – all increasingNorth Eastern Estonia – all increasing

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