(Mosaic of a phoenix done by a participant in art therapy at the Sarajevo health center) Travel notes from a “personal time” trip to Sarajevo, Bosnia and Herzogovina (B&H): glimpses of harm reduction, “treatment” for drug dependence, and controlled medicines for palliative care !Dr. Katherine Pettus (Advocacy Officer, Human Rights and Palliative Care IAHPC) !I went to Sarajevo earlier in June because I had a week of “down time” — i.e. a week with no meetings or formal work commitments. Because I live in Central Europe I took the opportunity to visit Sarajevo, the city that withstood the longest siege of a capital in the history of modern warfare. Twenty years ago, I had watched Christiane Amanpour and other celebrities reporting from Sarajevo as the shells fell around them and bloodied

bodies were carried around after mortar attacks at the markets; the name Srebrenica is synonymous with Auschwitz. !I didn’t understand much about the conflict, and wanted to see Bosnia for myself. Even the name Sarajevo holds a particular magic for me — and the city didn’t disappoint. I fell in love fast and hard the first night, walking through the main square in the old quarter, hearing the last call to prayer from the mosque, drinking the fabulous coffee and Macedonian wine. Most of all though, it was the Bosnian people who seduced me — their friendliness, willingness to connect with a stranger, even if they didn’t speak English, and relaxed manner, testified to the extraordinary resilience of spirit that saw them through the siege and will see them through this very challenging political moment. !Although I hadn’t planned to “work” during the trip, and had made no appointments to visit palliative care or harm reduction centers, my compulsive curiosity kicked in and I needed to find out how Bosnia was managing to provide opioids for palliative care and harm reduction services in this challenging context. Just as political contexts do everywhere, the Bosnian political context determines all aspects of health policy and service delivery in that tiny country. I wanted to know how this played out for access to controlled medicines such as morphine and methadone. The political context of Bosnia is particularly fraught, as the ethnic divisions that drove the brutal war that followed in the wake of the breakup of Yugoslavia, now cause political paralysis and policy stalemate at multiple levels. !Political situation Although apparently ended by the Dayton Peace Accords of 1995, the war’s legacy is stark: Bosnia has three simultaneously serving presidents, each of whom represents one of the country’s ethnic minorities (Bosnian, Croatian, Serbian). Political tensions from the top level down configure a mosaic of drug and health policy approaches at the local levels, with European-style model programs in some areas such as Sarajevo, policy vacuums in others, and harshly punitive regimes elsewhere. !The legacy of what is sometimes delicately referred to as “the aggression” explains comments such as “heroin came in after the war;” and “we have harm reduction here in the Republic of Bosnia, but we don’t know what is going on in Republic Srpska.” The latter is the “Serb” dominated unit of government that controls 49% of the country, has a separatist agenda and its own health strategy based on different cultural and religious values than those of the Muslim population in the adjoining Republic of Bosnia. Sarajevo, site of the infamous 1992-1995 “siege” is the capitol of B&H and the administrative center of the canton of Sarajevo. The Republic of Bosnia (the other 51%) is divided into ten cantons, each of which has its own separate health ministry and different list of essential medicines for which citizens can be reimbursed. !Palliative care

This is reflected in palliative care delivery, since morphine is only available in Sarajevo, the capital city, and only reimbursable for residents of the canton of Sarajevo. Residents of other cantons have to come to Sarajevo to obtain morphine. They have to pay out of pocket for it, though, if it is not on their canton’s Ministry of Health’s essential medicine list. With over 40% unemployment in the country, and a stressful economic situation, this imposes severe hardship on individuals and families experiencing life-threatening illnesses and severe pain. The palliative care nurse who heads the home care service was kind enough to give me an hour of her time on my last morning in Sarajevo. She told me that the teams make do with the little that they have, and that it’s always about improvising, delivering quality care to patients at home. Because the family is so strong in Sarajevo, there is almost no demand for in-patient hospice and people are helped to die at home. !Asked about spiritual care — a big issue in end of life care in North America and Western Europe, my informant said that because most people are actively religious throughout their lives — Muslim, Orthodox, Catholic and Jewish places of worship co-exist — palliative care teams are not called on to provide a spiritual counselors at the end of life. The teams lack of funding, though, prevents them from attending conferences and continuing education events to improve their skill levels and knowledge of best practices in this developing field. !Harm Reduction and OST The political configuration of the local unit of government also governs official access to methadone and buprenorphine, which is available at government harm reduction centers in Sarajevo, but challenging in the rest of the country. Naloxone is available to emergency services in Sarajevo canton, and in hospitals. The prison in Sarajevo canton offers harm reduction, and there are plans to institute MST in all the prisons in the Republic of Bosnia. Staff training begins this month, according to the staff I chatted with at the Sarajevo government clinic. Although the number of Bosnians who are HIV positive is very low, Hepatitis C rates top 40%. Government reimbursed medicines are provided to people who test positive for Hep C. The prison harm reduction expert I spoke with in Sarajevo could not tell me what the situation was in Sprska though. !Several NGOs have NSP programs, although I was unable to visit on such short notice, since all required an appointment and I had not requested appointments in advance. Association PROI runs a drop in center in Sarajevo, with counseling, testing and other services. http://www.ugproi.com/en/about-us/proi !Heroin use, treatment, and harm reduction services are deeply stigmatized in Bosnian culture, so public information is scarce. A recent Bosnian study based on available data, which is sketchy, estimates that there are “10000-15000 opiate addicts and […] among

them 3000 to 8000 intravenous drug users” in B&H.  According to the providers I spoke 1

to at the government clinic, which provides methadone, buprenorphine, psycho-social support and art therapy, “many” NGO communities in the country also run abstinence-based long term residential “treatment” programs. Some are faith based: Muslim, Catholic, Orthodox, and Jewish, while others are secular. !Comunita Cenacola One such program is run by Comunita Cenacolo, which has two centers in Bosnia, one in Sarajevo and one in Medugorje. I visited the one in Medugorje, the Croatian section of BH. Founded in 1983 by Sister Elvira Petrozzi, an Italian nun who envisioned a place where individuals and families experiencing the negative effects of drug use could come and work and pray and live in community, Comunita Cenocolo, which now has centers all over the world, is hard core. http://www.comunitacenacolo.it/index.asp?idlingua=2 !Although I had written an email to the website contact saying I would be in Medugorje and would like to visit, I did not make an appointment. I happened to arrive on a day when some of the residents were giving “testimonies” in English about their experience at the community to an audience of pilgrims to Medugorje. It was much like any “speaker meeting” at a twelve-step program, where a person in “recovery” tells their story of descent into the chaos of substance abuse and recounts their redemption into the light and new life of sobriety. One young American man an Australian teenager talked about the difficulties and rewards of living and working in the explicitly Roman Catholic community, learning to pray several times a day, practice humility, and accept the demands of a non-self indulgent, non-materially centered, lifestyle. !The two/three year Cenacolo program promotes an austere, abstinence-based model that apparently works for those willing to give themselves totally to the regime. It certainly, as the young men testified, is not for everyone. I asked a question at the end of the program about whether they accept people who have not detoxed from heroin or other drugs, since the program has no medical or pharmaceutical component. I was reassured that they do, although they encourage prospective members to do a medical detox first, but if people choose to enter in the throes of withdrawal, one of the priests in the audience assured me that someone stays with them day and night, “never leaving their side.” \\ !The audience (except for me and my Muslim driver) seemed to be part of an Australian tour of pilgrims to Medugorje, who were familiar with the Cenacola community and were possibly parents of prospective clients. One woman commented after my question about

! N. Mehić-Basara & I. Cerić, TREATMENT OF ADDICTS IN BOSNIA AND 1

HERZEGOVINA - CONSTRAINTS AND OPPORTUNITIES, Psychiatria Danubina, 2012; Vol. 24, Suppl. 3, pp 392–397 !

heroin that “they don’t make them dependent upon another drug” (ie methadone or suboxone) – but that the community “helps them to lead a drug-free life”. The slur on MST programs and people who might not be able to tough it out in the faith based model was unmistakable. !The fact that all these visits were unscheduled and not part of an official work trip, meant that I only had a glimpse of the reality of harm reduction and treatment programs in Bosnia. Clearly there are many more conversations to be had and support to be given to PWUD in the Bosnia and the Balkans, much of which is provided by the Eurasian Harm Reduction Network. http://www.harm-reduction.org !!!