Overcoming Challenges: Roman Ledkov on his Work with Ukrainian Refugees

Roman Ledkov has more than 15 years of experience in supporting people living with HIV and people who use drugs. He is currently an active member and coordinator of the Counsellor Advisory Board on Treatment of the Eurasian Network of People who Use Drugs (ENPUD). As an active Harm Reduction activist, Roman Ledkov had to flee Russia with his family in 2022. He settled in Berlin where he has been supporting Ukrainian refugees who use drugs since the day he arrived. In this interview with the GPDPD he explains how they set up support for Ukrainian refugees who use drugs and the challenges they face. 

The GPDPD: Mr. Ledkov, can you tell us how you started working for the ENPUD and what motivated you to do so?  


Roman Ledkov: I joined ENPUD as a member in 2019, after working in drug policy issues in Russia since 2011, primarily related to HIV. In 2004, I began working on a Harm Reduction project in Siberia's Krasnoyarsk region, which led to the creation of the All-Russian Union of People Living with HIV. Through this work, I regularly provided counseling to people with a drug use disorder. In 2020, we launched a project called the Counsellor Advisory Board on Treatment, during which we met with pharmacists to share our experience with HIV treatment and apply it to substitution therapy. 


As the ENPUD Treatment Expert Council Coordinator can you explain what your daily work is? 


Well, the Council's work is mostly technical. We develop normative documents on drug treatment, protocols, and treatment standards. We also establish contacts with doctors and gather feedback from patients. My job is to act as a focal point between the health system and the network.  


In addition, in Ukraine we work with pharmaceutical companies trying to influence their work in the country and ensure that the necessary drugs are available for substitution therapy. In 2021, no one was working directly with these companies, so we have developed our own strategy for working with them. Sometimes, pharmaceutical companies are reluctant to participate in the procurement process, which can cause delivery problems. In these cases, we communicate directly with the company managers to address logistical issues. We had several successful cases where new producers have started working in Ukraine. Our project is still in the pilot phase, but we have developed a strategy for finding resources when purchases cannot be made. 


We organise an intercountry exchange within the network. This allows for an exchange of competencies and cases of successful implementation. There are ‘advanced’ countries – like Moldova, Belarus, and Ukraine – where Harm Reduction services and implementation are more established. Meanwhile, in the Caucasus and Central Asia, the processes are slower and based on an outdated model. To address this challenge, we assemble doctors, prepare presentations together with patients, and introduce a new drug protocol and how to register it.  

What challenges did you face when you started helping refugees in 2022? 


When I arrived in Germany, I quickly found myself at the Berlin Central Station, where I met refugees who were in need of assistance. Together with BerLun, a local partner that implements Harm Reduction services for Russian-speaking clients, we were the first to respond. We didn't wait for protocols or recommendations; we learned through our own experiences. Our main goal was to meet these individuals and provide accompaniment to social services, doctors, and help them apply for health insurance. It was a challenging experience, especially with the language barrier and navigating unfamiliar territory 


As someone who has worked in this field, I can say that there are definitely multiple challenges that we face. The first major challenge is the division in funding between regions. For instance, in Eastern Europe and Central Asia, there are donors and grant programs like Global Fund, which provide much-needed financial support. However, in Western Europe, such as Germany, there is no such funding available, even though there are several thousand refugees in need of assistance. This is mainly due to the assumption that these countries have the financial capacity to handle the situation independently, but in reality, this is a significant challenge that needs to be addressed. 


The second challenge we face is the lack of grassroots service providers who work in Germany. Clients are often left to navigate the system alone, collecting necessary certificates and appointments. This can be particularly difficult for patients on opioid substitution therapy who are often 50 years or older and may struggle with technology, such as registering for appointments or writing emails. Additionally, social service offices may only be open for a few hours a day, making it difficult for patients to get the help they need. This can lead to dangerous situations where patients may turn to street drugs if they are unable to access their methadone. 


Finally, the language barrier is a significant issue. As an accompaniment, I have had to interpret basic questions for patients, often resorting to Google Translate to communicate. Unfortunately, there is often a shortage of Russian-speaking staff available to help, due to a lack of resources for social services. All of these challenges make it difficult for patients to get the care they need and deserve, and it highlights the urgent need for more resources and support in this area. 


To what extent have you managed to overcome these challenges now?


Despite these challenges, our network has expanded since the beginning of 2022, with roughly 30% of cases being solved through the community's support for each other. However, psychotherapy is only available in German or remotely, leaving many patients struggling with post-traumatic and pain syndromes without access to necessary services. 


The institutional issue of requiring health insurance before receiving treatment presents another challenge. Patients who arrive in Germany without insurance often must wait until they obtain it to receive treatment, which can take several weeks or even months. Some German doctors who were once receptive to treating patients without insurance have become less so over time. In addition, the housing and registration requirements for obtaining insurance have become more difficult to meet, which makes it harder for patients to access treatment. 

We have a few questions about the aims and scope of the network. How do you reach your target audience, i.e., how do you find and contact refugees who need your services?  


How do we reach our target audience? That's a good question. It's often difficult because many people don't want to disclose their status. They may live in a small town or village that doesn't have access to addiction treatment, or they might be with relatives who they're afraid to talk to about their addiction. As a result, they often wait until they're running out of medication before seeking help. The fear of negative reactions from society is a major concern for many refugees, and they may worry about what their relatives back in Ukraine would think. 


To find and contact people, we use several channels. About a third of our referrals come from the hotline in Helpnow. Another third comes from Berlin AIDS-Hilfe, which is well-known in the city and is a common transit point for refugees. The remaining referrals come from INPUD, a network that shares information about people leaving Ukraine and arriving in Germany. We also have a website and a Facebook page, where people can learn more about our services. 


In 2022 we conducted an interview with Anton Basenko who highlighted two changes needed in Germany to support people from Ukraine: standardisation of aid systems between the federal states and increased funding for local organisations. What actions and policies is ENPUD working on in relation to these topics?  


I must clarify that ENPUD is not currently involved in any work in Germany, and we do not have any projects in the country due to a lack of funding for Western Europe. 


Regarding the issues Anton Basenko highlighted in his interview, I agree that standardisation of aid systems between the federal states and increased funding for local organisations are necessary changes to support people from Ukraine in Germany. However, the German health system includes 16 federal states with different decision-makers, and it is not currently adapted to emergency situations.  


Meanwhile, the number of people on substitution therapy is increasing in Germany, while the number of drug treatment doctors is decreasing, leading to an increase in workload for the remaining doctors. To effect change, we need a systematic approach and a group of doctors who are willing to write and speak out for change. Given the hierarchical nature of the German health system, doctors will be more likely to listen to other doctors than to patients. 


How many people have you helped so far? 


As an individual, I have personally helped almost 200 people since my arrival to Germany. Out of those, over 100 were able to enroll in the substitution program, while 40% received immediate first aid. Some of the people I helped also went on to other countries. 


However, we don't have consolidated statistics for all the organisations we work with. But based on estimates, around 1000 people received support from these organisations.  


According to the European Monitoring Centre for Drugs and Drug Addiction (EMCCDA) Regional report 2022: 

  • It is estimated that some 350 000 people in Ukraine inject drugs (2020), with approximately 19 % of these being women; 

  • As of 1 May 2022, government figures indicate that 17 844 people in Ukraine were receiving opioid agonist treatment (OAT), an estimated 15 % of them being women. In addition to the national OAT programme, it is estimated that between 5 000 and 7 000 individuals were receiving this treatment in 13 facilities in the private sector in Ukraine as of 1 June 2022; 

  • In 2022, over a million Ukrainian refugees fled to Germany

  • Since February 2022, more than 100 displaced people from Ukraine receiving OAT in Germany.