#Leaving No One Behind: Addressing Substance Use in Humanitarian Settings – Providing Access to Services for Displaced Populations and Host Communities in Acute and Protracted Emergencies

Moderator:

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section

Speakers:

Anja Busse, UNODC, Program Officer in Prevention, Treatment, and Rehabilitation Section

Dr. Dzmitry Krupchanka, WHO, Medical Officer, Department of Mental Health and Substance Use

Pieter Ventevogel, UNHCR, Senior Mental Health and Psychosocial Support Officer Public Health Section, Division of Resilience and Solutions

Brian Morales, US State Department, Branch Chief, Bureau of International Narcotics and Law Enforcement (INL)

Ignacia Páez, Ministry of Public Health of Ecuador, Drug Commissioner

Mohammad Nasib Ahmadi, WADAN National NGO Afghanistan, Director

Abu Toha, Office of the Refugee Relief and Repatriation Commissioner (Bangladesh), Health Coordinator

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UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Good afternoon and good evening to all of you joining us from all over the world. Excellencies distinguished participants and Dear colleagues, it is my great honour to welcome you and open this side event. My name is Giovanna Campello. I am the chief of the prevention treatment and rehabilitation section here at the United Nations Office on Drugs and Crime. And I’m here with you to moderate and open this site event. During the 65th session of the Commission on Narcotic Drugs, a side event entitled, “leaving no one behind addressing substance use in humanitarian settings”. This event has been organised by the prevention treatment and rehabilitation section of UNODC. But with the sponsorship and support of the governments of Ecuador and United States, our colleagues in the World Health Organisation, as well as the New York and the Vienna NGO Committees on Drugs. And let me thank already in advance. All speakers are joining us from all timezones for being with us and sharing their insights and experiences. With the scene sadly, and ever increasing number of large scale emergencies around the world, associated with new record numbers of people that have had to leave their homes due to persecution, conflict and violence, or national disasters. As the experience of such adversities is associated with the onset of mental health, substance use and substance use disorders, we have brought you here together in this end side event, to explore jointly, how to best support people with substance use disorders in different types of humanitarian emergencies, and how to adapt existing healthcare standards for effective substance use disorder pre-treatment provision in both acute and protracted emergencies. UNODC may not seem a traditional humanitarian agency. However, with our mandate on the prevention and treatment of substance use disorders, as well as the reduction of their negative health and social consequences, we are already currently engaged in supporting people in need in a number of large scale emergencies with a view to ensuring that people who use drugs and people with drug use disorder are not being left behind. And believe me, it was already happening. And we also want to ensure that they are actually included in the overall humanitarian responses and have access to at least a minimum of health and social services.

While there is limited information about the epidemiology of substance use disorders, and availability, accessibility, and effectiveness of treatment and support services in humanitarian settings, we know already that globally, in the best of circumstances, seven out of eight people with drug use disorders have no access to treatment of drug use disorder, even though they would need it. That is more than 85%. And the situation is even worse for women. And we can only imagine what the situation in humanitarian emergencies looks like. That is why UNODC, in coordination with WHO and UNHCR, have been working on the development of a joint handbook that will provide key resources and guidance to support the planning and provision of substance use disorder treatment in humanitarian settings, with suggestions for different stages of humanitarian crises. During this event, you will be presented with a first preview of this handbook, as well as statements and examples on addressing substance use and substance use disorders to prevention and treatment setting. I would like to acknowledge and thank the [?]  Bureau of the State Department of the United States of America, who generously supports our work on addressing substance use disorders in humanitarian settings, together with the other donors of the UNODC programme on direct dependence, treatment and care, your continued support really makes a huge difference to vulnerable and socially marginalized populations globally. I’ve come to the conclusion of my opening statement. And I would like to close by sincerely thanking everyone once more for taking their time today to be here with us, and therefore showing their commitment and dedication to this issue. I really count on the continued fruitful cooperation so that we can ensure a better health for people who use substances and with substance use disorder in humanitarian settings, and that no one is left behind. Thank you. And it is my pleasure to start moderating the actual side event. But before I give the floor to the first speaker, let me remind all that we are recording this event and we hope that everybody is fine with this. If there are problems, please do let us know in the chat, or contacting us, but in the meantime, also, let me remind everybody to keep their microphones muted if you’re not speaking, and a plea to our dear colleagues, co-panellists to stay within their assigned time limits. thanking everybody for their understanding. My dears, it is now my great pleasure to introduce to you a colleague with whom I work day to day, Miss Anja Busse. She is programme officer in the prevention treatment and rehabilitation section. She is leading this work in our section and she will introduce to us a bit what we are developing for you. Anja, you have the floor.

 

UNODC, Anja Busse, Program Officer in Prevention, Treatment, and Rehabilitation Section: Thank you so much, Giovanna, and welcome again, everybody. And as announced, I will be sharing with you already some elements of our upcoming handbook on addressing substance use disorders. In humanitarian settings. There are many people I would like to acknowledge and few you see here, especially those that help us draft the handbook. And this efforts on humanitarian settings has already been part of our interagency programme with the World Health Organisation since the very onset, and there are mandates especially focusing on vulnerable members of society and vulnerable communities both from the general assembly as well as the Commission on Narcotic Drugs, and of course, the sustainable development goals and backup this work. Just to remind us of the overarching humanitarian principles which are humanity neutrality, impartiality, and independence. And the various humanitarian contexts, Giovanna already mentioned during her opening remarks, you know, which could be the camp settings where people displaced populations, or sometimes already for long times, this could be urban settings, which means a different way of working and providing services. And sometimes these are inaccessible situations, for example, due to safety considerations. In our  handbook, we will be looking more at conflict driven emergencies, so humanitarian settings, and not so much as natural disasters and humanitarian action. And I think maybe that’s important for all of us who are not coming so much from this field as it is primarily organised in sectors. Health is one of those sectors and in the health cluster, which is usually led by WHO is where all the coordination should take place. And I think one of the things we’ve really really learned is how coordination is of lifesaving importance in reality in humanitarians settings. There are a number of traditional and untraditional humanitarian actors such as the UN organisations, Red Cross and Red Crescent movements, nongovernmental organisations, of course, governments, and then non traditional actors and the InterAgency Standing Committee is really an very important group which coordinates humanitarian actions across UN and civil society partners, and the mental health. The MHPSS Group, their mental health and psychosocial support is one in which UNODC has been welcomed and we’ve had a chance to coordinate already for a while with our partners. And UN [missing] currently has them called or announced three system wide scale up responses needing humanitarian emergencies. And as Giovanna was saying in two of those, UNODC’s already participating in the health clusters, reflecting very much the need to address substance use in humanitarian settings as well. If you look at the overall protective factors and risk factors for substance use, have a look at the screen and see at the risk factors such as poverty, conflict, war, homelessness, refugee status, social exclusion, and so on. So in principle, all of these apply to people in humanitarian settings, or displaced populations. And what we need to do is enhance protective factors that you see here in blue, and those actually can be influenced, for example, to increase access to health care.

We don’t really have very good data on substance use and substance use disorders, as said, but just look at the sheer numbers of people who will need humanitarian assistance being estimated by our chair at over 270 million people for 2022. And UNHCR, Pieter will talk more about that, has estimated over 80 million forcibly displaced people in 2020. So what we know from most of the limited studies on epidemiology is there is a similar or lower prevalence levels, relative to substance use in displaced communications compared to the host community, despite these likely increased vulnerabilities, and something worse, looking at least and more into and the negative health social consequences, physical psychological, of substance user in general, were documented. And we can assume that those also applied to displace populations, or in humanitarian emergencies. Giovanna has mentioned the scandalous rate that only one in eight persons in general has access to treatment, this does not apply to humanitarian settings, that sort of say, you know, the gap, we have to address overall. And this, of course, includes people in humanitarian settings. But there the gap will likely even be much wider than it is on normal global average. UNODC and WHO in 2020, published the international standards for treatment of drug use disorders with which in principle give guidance at the service and system level on evidence based interventions and how to structure a public health informed drug treatment system. The question now was how to adapt the standards to humanitarian settings. That’s what’s kind of behind our work on the handbook. And I said there is limited information. So what we have been doing so far is, we have been conducting a number of rapid assessments in refugee settings, including in Uganda and in Pakistan, we have in 2020, hosted a very big, very inclusive, over 100 participants, expert group meeting. And additional resource mapping has been done by our consultants that we have, with our experts identified needs. We have published those in a scientific publication also, maybe to see you know, if others come to us and share more needs or more things that need to be done. Instead, we have coordinated at the level of the MHPSS Group at the InterAgency Standing Committee. And unfortunately, I have to say, we had to learn through Real World Humanitarian settings kind of how to try and start supporting people with substance use disorders in those. So and then we are learning kind of from existing emergency setting standards. And here this is for example, from the [CEA?] handbook, a kind of pyramid which is similar to the pyramid that we have also in the treatment standards, and where a number of health system standards have been announced. So you can see here service delivery, workforce, medicines, financing health information. So these are all things that will be of relevance when we’re looking at treatment of drug use disorder. So we are trying to learn and adapt kind of from what others have already developed for similar settings. Same for mental health care standards in emergencies that have been developed and that speak for example, here as you can see about minimising the harm related to alcohol and drug use and offering training  and considering for example, withdrawal and intoxication in emergencies. So here is the first preview of our handbook, which kind of will go really through the cycle, from assessment to preparation to delivery and then to monitoring and evaluation. And on this slide, you already see the four eyes that services we are looking at should be intersectorial, integrated, inclusive and interlayered.

And the target group for our handbook will be both humanitarian actors but also help service providers so that there is the idea to learn from each other. So when it comes to assessment, and also my colleagues will speak about that, again, you know, there is one tool, especially available on rapid assessment of alcohol and other substance use conflict in displaced populations by UNHCR, and who has guided our work on rapid assessments recently, quite a bit. And there are other tools already available that can be further adapted, or, for example, this Hesper and needs scale includes also questions on drug use in communities. Important here is to not only look at needs and vulnerabilities, but also at resilience and local capacities available for service provision, then there will be a phase of preparation and coordinate, coordinate, coordinate will really be the mantra here. And this will focus, for example, on local agreements on ensuring financing of translation and adapting of materials, especially capacity building materials, but that’s key also in our area of substance use disorder treatment, procurements, for example of medications, and obviously, safety considerations for staff and the affected population. Here, there are again, the four eyes inclusive intersectorial in the layout. And I actually missed one, sorry, I integrated there it is, sorry. And on the left side, you kind of see the Pyramyd for service provision and mental health and psychosocial emergencies, which at the top of the pyramid has specialised services, right. And then on the other side, you see the drug treatment standard service pyramid, which in a way goes even higher up and more specialised, including inpatient services. So we just need to adjust those very well and understand the limited resources in humanitarian settings. And what helps here though, is to understand that substance use disorders are spectrum disorders. And not everybody needs the same intensity, right? A lot of people can be held on so maybe with pilot interventions and support from the community. So now we come to deliver. And here we thought we might have to differentiate a bit between acute emergencies and protracted emergencies. With the aim of acute emergencies being very much on life saving interventions, reducing excess morbidity, and mortality, we have to take into account that, you know, methods such as withdrawal management might be life saving, especially as for example for alcohol or benzodiazepine, that could be life threatening withdrawals, medication needs to be continued, we need to offer basic psychosocial support at minimum and increased self help all over. And then when it comes to protracted emergencies, to some extent, that gets closer to what we have in other settings, where we are offering community based treatment in very low resource settings, right. So all of those at applied and acute emergencies in a way has to be continued. But there will be more time for training for the delivery of really integrated services that look at both communicable and non communicable diseases and so on. And there will be likely challenges in delivery. Some of those we have already faced, like resource constraints, competing priorities, decisions have to be made with limited data available, the populations might be very mobile, and that needs to be taken into account. Coming kind of to the last circle here will be evaluation. And I think Peter will be speaking more also about data collection systems, in humanitarian settings. I mean, overall, here our idea will be again, to learn from what others have already developed and adapt this further. Here you see some clear indicators, for example, again, from this fear handbook, and kind of what else needs to be done will also be discussed in the handbook. So we will need more research and information sharing. So we are hoping to take and test elements of the handbook in a feasibility study. And we hope also, with all of you joining us today, we can establish some sort of a global network for information sharing, because that’s really what [missing] to find out if information or if interventions that have been developed elsewhere work in the same way in humanitarian settings. So I’m coming to a close. The take home message here really is that interventions for substance use disorders need to be considered as essential components of general health services in humanitarian settings, together with a number of very important other interventions. And you see in red, did we say coordinate, coordinate, coordinate that will be the mantra if the other is the take home message. So we hope that very, very soon it still needs a little bit of work from our side, we can publish this handbook on addressing substance use disorders in humanitarian settings disseminated to all of you, peer tested, learn from it, and then likely come up with a revised version. With that, thank you very much. And over to you, Giovanna again. Thank you.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you, Anja for forgiving us for framing the issue and giving us already a preview of our soon to come handbook. And I take the cue from your last word and talk about coordination; coordination starts at home. And it is my great pleasure therefore, to introduce a close colleague from the World Health Organisation, Dr. Dzmitry Krupchanka. He’s a medical officer in the alcohol, drugs and addictive behaviours team in the Department of Mental health and Substance Use. And you have already given us a big preview of some of the themes that Dzmitry will touch on. So I gave him the floor. Without further ado, Dzmitry, have the floor. Thank you.

 

WHO, Dr. Dzmitry Krupchanka, Medical Officer, Department of Mental Health and Substance Use: Thank you very much Giovanna. And thank you, Anja. And it is my pleasure to be here. And also we are grateful for the invitation to colleagues in university UCI as well as the consultants in Ecuador, the US, the Committee on Drugs, the Vienna NGO, and also to all the participants. And as Giovanna mentioned, an Anja repeated, this topic that we are discussing today is even more relevant than ever in the current realities. And to this credit more attention is allocated to this. Because also, as was said that, despite the lack of the goods, physiological data, based on WHO estimates from 2019, we see that there are more people with mental health conditions in areas affected by conflict than previously thought. So based on our data, it’s about one person in five is living with some form of mental health conditions. And these people desperately need access to help, especially in the situation of humanitarian disaster and emergencies. And what we know from anecdotal evidence and from some countries, maybe not always on the global level. But it is clear that substance use in humanitarian settings is associated with substantial harm, not only to us, but also to people around them, and very often to communities because of the violence associated with substance use because of organised crime and neglect of other vulnerable subpopulations, such as children and the elderly. And, definitely, we need to do more to provide access to essential services because quite often, the responses in humanitarian emergencies are not ideal. When it comes to people with substance use disorders, what we learned is that often they are fragmented, they are under-resourced or even forgotten in some cases. And to start with moving to the actual topic of this short presentation, I’d like to acknowledge the work of InterAgency Standing Committee and its members in strengthening humanitarian assistance to countries and here particularly, I want to refer to the IC guidelines, which highlight the key actions that should be implement that in emergency settings when it comes to alcohol and other substance use. This includes rapid assessment, prevention and treatment of people with substance use disorders, then, harm reduction interventions in community and also activities targeting the acute problems, and the WHO together with the partners has produced a range of documents and additional tools to provide further detailed guidance, how and what to do in each of these areas. In particular, what Anja already mentioned the rapid assessments and book developed together with our colleagues from UNHCR, then our screening and brief intervention packages both for alcohol and also for drugs, which is a system audit also what I mentioned the national standards which provide a good system level comprehensive overview of what kinds of interventions can be implemented. And another quite useful tool, the [Image Gap?] Intervention Guide, which might be particularly useful for non specialised settings, where the human resources are limited and there is a need to quickly produce the capacity of personnel. Then in terms of harm reduction, also double check guidelines for key populations and the global strategy to reduce harmful use of alcohol. This also should not be forgotten, because drug use is definitely happening but also in some countries, alcohol might be even a higher problem. And of course for acute conditions. We have guidelines for community management of opioid overdose and also the image gap here. In the Humanitarian intervention Guide, which highlights particularly care for alcohol withdrawal and opioid overdose. And as mentioned, these tool is provide quite a detailed framework of what to do how to plan, even providing the exact tools, how to collect data, how to analyse data, based on the data, how to do, how to plan the humanitarian response, and another useful document also jointly by WHO, the set of tools that can also be used for humanitarian settings. I also mentioned the image gap.

Currently, we are doing the update of the core image gap intervention guide, where we’ll have a couple of new interventions for substance use disorders. And the particular very short version, which is humanitarian intervention guidance. As I said, it highlights the lethal or life threatening conditions and what to do in their case, the screening brief intervention, it’s not only about the screening tool, but also the tool for specialists and how to provide brief intervention and also self help strategies, which sometimes you know, the bottom of the pyramid is health care, where these two can also be useful. Now, I would also like to mention that this year we are launching a new online course at the open who platform, the course on introducing mental health, psychosocial support and emergencies. And there will be a special model allocated for conditions related to substance use assessment and management in humanitarian settings. But in addition to what we have now from last year, WHO Academy, launched by our DG in Leon, where we have now one course on image gap. And now another one is developed on behavioural interventions. But hopefully we can also in future, think about the special full scale course for the responses in humanitarian settings. And moving to the end, I think that it’s also important to participants to know that the last year within the ISC MHPSS, there was a launch of the new thematic group, which is called that by who UNHCR and UNODC, particularly focusing on addressing substance use and disorders due to substance use in humanitarian settings. And we also hope that this thematic group can serve as a kind of precipitation point or the platform for many partners to join efforts together, and finishing, just to show you pictures of a couple of other resources that we have. And now the final message is probably to the presentation by Ania. We welcome this initiative of putting all these resources together in one handbook, that can be a one stop shop approach to people working in the field. I think this is a wonderful idea. And we are looking forward to the final product and seeing what our role might be. Thank you for your attention.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you so much, Dzmitry. And fascinating the richness that is already there. And it will be great to, as you say, to be able to coordinate even the offer of the resources. And again, it is my great privilege to introduce a close colleague, Mr. Pieter Ventevogel. He’s senior mental health and psychosocial support officer in the public health section of the division of resilience and solutions at UNHCR, the UN United Nations High Commissioner for Refugees. And Pieter, therefore, the people that the organisation has been leading the way in the response to humanitarian settings for all of these years. Pieter, it’s my great pleasure to give you the floor.

 

UNHCR, Pieter Ventevogel, Senior Mental Health and Psychosocial Support Officer Public Health Section, Division of Resilience and Solutions: Thank you so much for these very kind words. I’m very happy to be invited here. The world of substance use interventions is a little bit new to me to UNHCR, and we are rapidly changing that because the need to do things in refugee settings is enormous. I want to make a few comments. The first one is the very basic one. Anja alluded to that already, that there are very many forcibly displaced people in the world. It’s actually one in 100. Now the numbers are really going up. That’s already 82 million people. Within that group, there is a really increased risk to develop mental, neurological and substance use problems, because of things that happened before people fled, that force people to flat loss they experienced, the things they’ve seen they’ve witnessed, but also because of the breakdown in their supportive systems. The families were disrupted. We see it now in the Ukraine crisis again happening, people living in inadequate conditions having lots of stresses about daily survival, which then leads to inadequate coping strategies, which includes also unfortunately, use of substances and illegal substances. And of course, forcibly displaced people have worries, very realistic worries about our future, what will happen, can I go back? Can I rebuild my future and if people don’t see that perspective, they may actually resort to less healthy behaviour. Now you have heard me talking about mental health and Anja and Dzmitry also did that. So mental health and psychosocial support is my field. It is important to mention a few things because it’s less well known outside of humanitarian settings. It is a multi-sectoral issue. It’s not only health, it also includes the whole social sector, education, peacebuilding, everything. And what we have seen over the last decade is a strong increase in attention for MHPSS. What is important for this meeting is how I see MHPSS as a broad concept that also includes alcohol and substance use, even though I know it is a specialised field. But we are committed in the MHPSS world to drive the issue of substance use conditions. Now was also already highlighted: we don’t know that much. But we have some information. We have some assessments that UNHCR and WHO already had 40 years ago. And what we can really safely say is that there is a problem. We don’t know enough, but we know enough to know that there really is an issue. And for us, in most countries, alcohol is the main substance of abuse, which is less the focus here. But we also see illegal substances. In Iran, Pakistan, the opioid problem is very real and very problematic, but also in Bangladesh with the yaba-yaba use and in other settings. But we also see this very strong link with social problems; with gender based violence, with family disruption, with loss of community cohesion, school dropout, etc. So we really see it is affecting refugee communities. And despite the fact that we know that is a problem we have made, I must be sorry to say, we have made limited progress in the field, we have done things but we have made limited progress in the lives of people. Now, it has already been mentioned, we have the problem mentioned in our major guidance. The ones that were mentioned, the sphere handbook and the IS guidelines, it’s clearly there is a priority. We have some tools: Dimitri mentioned the wonderful work on the MH gap, which basically is a way of task sharing and task shifting. Any health facility should be able to identify and manage issues related to mental neurological and substance use disorder. So here you see some of the points that are in the MH cab humanitarian intervention guide. Sorry, I’m going to be quick now. Wallah.

Yes. So we are working on that so I can give you some data. These are some data, the absolute numbers are still lower. But what we see is they say I infer information from the Health Information System in the refugee camps that UNHCR uses. And you see that there is overall an increase in the number of consultations for substance use disorders in general health settings, but in absolute numbers, it’s still low. I think there are very many people we miss and we know that because not everyone with a substance use condition (who would) be identified in a health centre will even go there. So that is an issue. So while we know that is an issue, still, I should not use the word forgotten, but I should say it doesn’t have enough priority. Why is that? And I think it’s not so much that we don’t know that there is an issue, but it’s it’s a way of bringing the different approaches together in a doable way. And that requires multi sectoral approaches, including community based protection, education, etc. It needs adapted tools for humanitarian settings, brief, simple, doable, and it needs multiple stakeholders. That’s why this meeting is so important. And the rapprochement between UNODC, WHO and UNHCR on this topic is super important, because I think that will really make the difference. We are committed, seriously committed to do this, we have put it in our global public health strategy that we need to do more on substance use interventions. But we cannot do it alone. That’s very clear, we lacked a specialised expertise. That’s why this toolkit that we are developing that you will notice he is leading on, it’s really a game changer, or let’s hope it is a game changer. Because I think once the toolkit is published, we need to implement it. And that definitely the humanitarian agencies need to do but as much and perhaps most of all, the member states themselves, opening up services to refugees, making sure that the systems are strengthened for all; that’s what I wanted to say. Thank you, sorry for taking too long.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you so much, Peter, and no need to apologise for raising the expectations around our our joint work, but also reminding us especially that we need to come up with a tool that is simple and doable; yes, integrated intersectorial, and so on, but doable, so that we can actually go to implementation level. Thank you so much. And it’s now my great pleasure to give the floor to somebody who has been promoting, advocating and supporting for evidence based drug prevention and treatment for the most majority of his career, and specifically, is very much behind this very initiative that we are presenting to you today. Mr. Brian Morales is Branch Chief at the Counter Narcotics of the Office of Global Programmes and Policy. We’re sorry, Brian, at the Bureau of International Narcotics and Law Enforcement of the State Department of the United States of America. It’s my great pleasure to give you the floor Brian.

 

US State Department, Brian Morales, Branch Chief, Bureau of International Narcotics and Law Enforcement (INL): Thank you so much Giovanna. I want to thank the UNODC team, the team from WHO, the government of Ecuador, New York NGO Committee and Vienna NGO Committee on Drugs for their joint coordination on the site event. I’ll try to keep my remarks brief and to the point. I think we’ve already heard very important directions and views. I hear the message that the world is experiencing humanitarian crises that are unprecedented in our lifetimes resulting from violence, hunger, natural disaster, disease outbreaks, and political conflicts. As Anya mentioned, that figure from 2022, 274 million people will need humanitarian assistance and protection. That’s an enormous amount. And it’s a significant increase from last year, which was 235 million, just one year ago, which was already the highest figure for decades. More than 1% of the world’s population, as we’ve heard from Peter, is now displaced, about 42% of whom are children. Over 26 million people have been forced from their home countries, many with specific needs, whether that is accommodation for disability access to documentation or living arrangements. The humanitarian system, with support from the United States, provides key services to support refugees, almost half of whom are women and girls. This includes provisions of safe drinking water, shelter, food, cash assistance, and vital care including mental health services. A growing body of evidence shows that mitigating the long term socio economic impacts of displacement and addressing poverty require targeted health, including mental health, education and other basic services, particularly for women and children. So we admire the dedication and the extensive efforts of the UN agencies and the NGOs that work with these populations. Get people with substance use disorders, as we’re hearing in humanitarian settings, experienced the barriers of double stigma that can impact their ability to utilise and access potentially life saving services they may need. That includes treatment. And displacement represents a key factor for substance use and substance use disorders. Populations in vulnerable situations include those forcibly displaced and they can take many different forms. And that’s where I wanted to really highlight Yes, it’s refugees, but it’s also victims of human trafficking. It’s migrants. Its internally displaced persons. And it’s also child combatants. To integrate these peoples effectively in society, drug prevention and treatment services are really vital. That is why the United States has actively participated in UNODC’s missions to study this dynamic in Africa and Latin America and has supported the development of the handbook that we’re highlighting today. This new handbook to address substance use disorders in humanitarian settings helps bring awareness to an issue that is critical to mainstream and to other areas of development and failure to integrate treatment and recovery support into services for refugees, victims of trafficking, or migrants, can have disastrous consequences for these vulnerable populations. As we’ve seen in recent decades, refugees are in some of the most vulnerable situations in the world; alcohol and drug use disorders can compound those vulnerabilities. The consequences of this include increased domestic violence, worse health conditions, and lost economic opportunities. Separately for former combatants, when drug treatment and recovery support is not integrated into disarmament, demobilisation, and reintegration, the restructuring of post conflict societies is in jeopardy. I witnessed this and firsthand in West Africa were drug related crime and violence by former child soldiers now in adulthood, risked destabilising fragile democracies and economies.

The United States international drug demand reduction efforts support the reduction of global drug consumption and its consequences including through collaboration with foreign governments, civil society, and international organisations centred on prevention and education by increasing access to evidence based treatment and recovery support services. And by helping to address drug use among displaced persons. The United States supports communities around the world in finding and achieving long term opportunities for displaced persons and communities in which they live. So I want to conclude by saying that the US looks forward to continuing support for UNODC in this important endeavour, and its partners WHO, UNHCR, and others, to endeavour to innovate programming, which more holistically addresses the needs of vulnerable populations worldwide, and really call other donor states to give a lot of attention to this issue and also support the efforts of UNODC. Because this will have such an impact. In so many other areas of mutual interest that we have around the world, it cannot be separated or considered as an afterthought. It absolutely must be integrated and absolutely must be resourced by the donor states. Thank you.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you, the Brian , for your personal passion and commitment and the one of the government that you represent and for calling to action all of us, including other donor countries, in our common efforts. It’s now a great pleasure to move maybe to a second part of this event, where we hear from more from around the world from the countries and from the people themselves. And it’s my great pleasure to introduce Miss Ignacia Páez. She’s the drug commissioner in the Ministry of Public Health of Ecuador, and I had the honour to listen to her yesterday in presenting about the health centred approach of her government, and it’s my great pleasure to give her the floor to hear about the efforts of her government also in this very special setting. Ignacia you have the floor and I see your slides are already appearing.

 

Ministry of Public Health of Ecuador, Ignacia Páez, Drug Commissioner: Thank you so much, Giovanna, for your introduction. Let me tell you, that it’s an honour to share the floor with the experts that are there today, sharing their experiences, it’s incredible. It’s so important to realise that mental health is the umbrella of all kinds of symptoms that show that the illness of the soul of people. Mental health is the whole thing about being humans. And a use disorder, a drug use disorder is a symptom. So it’s perfectly well done, to think of systems of use as a mental health problem. Of course, we need a specialisation because it’s completely acceptable in our society to have some kind of use of different drugs such as alcohol. So even telling in this in these places in these opportunities to share it to the world, that alcohol is a huge problem also, in use and in use disorder, it’s good for everyone, because it’s kind of normalised around the world. And also, of course, with migrants and people in immobility. So I want to really appreciate the words that we’re saying in this opportunity, so we can understand that the whole thing is mental health. And the symptoms, one of the most interesting ones, we can say is drug use disorders. So let’s just start: the Ministry of Public Health on behalf of the Ecuadorian government and of the members of the inter-institutional community of drugs, greets the assistance to this commission, and applauds all the efforts by the UNODC and country members, observed in it year by year, in creating and expanding the debate on uses and problematic conceptions of drugs and alcohol also, especially on vulnerable populations, such as migrants and immigrants. In Ecuador, government intervention has allowed a full and human and human rights approach with principles of universality and quality, and it’s free for any person, regardless of nationality, without discrimination. This topic is in our Constitution. Our Constitution protects everyone in our territory. This little tiny territory in South America says to the world that everyone is accepted in our services and in our country. The provision of services in Ecuador is integral and universal for treatment, rehabilitation and social inclusion. The services available include inpatient and outpatient care, as well as services provided through residential centres with a community focus.

There is even the possibility of having access to classrooms within the facilities for those who want to continue their studies. A couple of days ago, several young adults in one of our centres were able to take the example University of Michigan within the centre. Our main focus is to strengthen and protect the initiatives for quality of life and the development of aptitudes as well as social, emotional, and cognitive skills through strategies of alternative, integrative and sustainable development. In this regard, courses of individual and collective development are offered. Next, please. We are convinced of the importance of Article eight in all the efforts Ecuador, thanks to the UN support, and it’s currently investigating the actual impact of drugs, immigrants and immigrant population with the goal of unsafe enhancing intervention strategies for this type of population. We highlighted paramount importance of continuing the debate on the importance of the ability, availability of means, and resources necessary to properly care for drugs related issues for every person without discrimination. We are honoured in co-sponsoring this important space and to leave no one behind and to facilitate the study and learning from international experiences and good practices further, advancing in the collective knowledge on the provision and access to service for migrants and immigrants population. The Ecuador government has cemented its position on this regard with principles of human rights, quality, and universal access to free health services. For everyone, Ecuadorian, or not. Okay. Now, allow me to show you a brief video exploring the free and universe of services in Ecuador. In this specialised centres for treatment of problematic conceptions of alcohol and other drugs. These centres and services are available to anyone. And they’re there 12 In our country And then on the on, on the North in Esmeraldas we have in the centre of this a colour like in the Sierra, another three Moors at the coast, and one in the jungle, two in the jungle. So we tried to have the 12 residential centres all over the country and we also have this ambulatory services in every single Public Health Centre. So if you may, allowed me to show you the video that is going to speak more and better than I do. Thank you. Would you please turn on the video are you having trouble with the video

 

Video from Ecuador Ministry of Public Health:

Speaker 1:

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Speaker 2:

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Speaker 3: 

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Speaker 4:

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Ministry of Public Health of Ecuador, Ignacia Páez, Drug Commissioner: Okay, thank you so much.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you, Ignacia. And thank you for sharing with us an excellent example of services that are open to everybody with an open embrace and our challenges now are to think about how to transform these services into something useful in very difficult circumstances. And I know that we have great plans to join forces together. And I’m looking forward to that. I thank you, again, for sharing your experience with us. We are running a tiny bit late, but please stay with us for the next two speakers that are actually speaking from the experience of emergency and in an humanitarian situation. It is my great pleasure to give the floor to Mr. Mohammed Nasib Bagmati. He’s the director of an NGO in Afghanistan, Wadan, and it’s my great honour to give him the floor to hear his experience on providing services in a real humanitarian crisis. Mr. Nasib you have the floor.

 

WADAN National NGO Afghanistan, Mohammad Nasib Ahmadi, Director: Well, thank you. Thank you, Giovanna. I want to be very brief. Actually, yes, I’m working for an NGO. But here I am talking on behalf of a consortium of an NGO Chatter. There are like eight civil society organisations and as Anja mentioned, very rightly, coordination, coordination. The reason that we created Chatter was to coordinate among ourselves and have a common response. You know, we know that Afghanistan is one of the largest humanitarian crises in the [world]. According to UNDP, 97% of Afghans will go below the poverty line by mid 2022. UNHCR also estimated that there are 3.4 million internally displaced people in Afghanistan still. And [UNHCR], reported that only in the last part, in 2021, there were like 700, internally displaced people in one year. And this number is basically increasing, because the major factor is poverty. Poverty is a common denominator for migration, internally displaced people in substance, drug use problems. Also, according to the UN Secretary General, one in five refugees are IDPs, women have faced some sexual violence, and IOM estimates shows that only in 2021, there were there were 1.3 million people who migrated to Iran, Pakistan, European Turkey, so that trend is still on the rise. And we expect that in 2022, there will be more migration of internally displaced people and the rise in substance use disorder as well. Next, please. And Afghanistan produces 85% of the global opium. And Afghanistan is still the largest opium producing country in the world. And according to the 2021 survey, there are like 6800 metric tonnes of opium produced, and this may even rise in 2022, because I think there is more cultivation and there will be more opium in Afghanistan, unfortunately. And according to the UNODC, the previous number of 3.5 million substance drug users that according to the survey in 2015, was conducted by Enel, that number is increasing, and then that brings vulnerable people to trafficking in person. So, actually, that problem is increasing as well. 

Um, yeah, the survey is actually an old survey in 2015. And the number shows like from 2.9 to 3.6 million people. But we believe that the number is more than what they survey shows because substance use disorder is on the rise. And there is a huge addiction problem. And almost 11% of the people are substance use users. And one of the other problems that we have is actually with the use of stimulus and methamphetamine. And recently, there are like 55,000 people who are registered to be using those things. And that is also a major, major problem, though the opium and opiates are the most frequently used substances. But actually, this methamphetamine is also very prevalent in Afghanistan. And the services that we have, actually currently there are like 84 drug treatment and rehabilitation facilities. And out of the 84, 70 were run by the government, they were transitioned to the government over the last few years, and out of the 70, 63 are mostly closed, there are no services and no clients and they do not have the resources to run those services. It’s a very unfortunate situation. The remaining 14 facilities are run by the NGOs, the consortium of this NGO, the Chatter, they are still operational. Actually, our services continued during the crisis. And we know when the government collapsed, our services continued, and they are still providing those services. 

Even before less than 1% of the population had access to services, but that is decreasing because of the treatment facilities that are being closed and are closing and also the situation, the collapse of the government in the humanitarian crisis. The only donor right now is the [missing] state department actually, through the Colombo Plan, they are providing those funding to the civil society organisations. And as I mentioned, the substance drug use problem is on the rise. Services in funds are on decline. Poverty is spreading, and that is directly correlated to drug use disorder in IDPs. One of the positive things was that during the previous Taliban regime, they were thinking that the drug addicts are criminals, but now they accept that those are patients and but their treatment modality that what they do is, is not science-based and not evidence-based. And it is mostly like prison-like treatment, which doesn’t really work and it’s not sustainable. Next please. Biggest challenges: we do have financial challenges, lack of funding, but we also have cash flow problems because of the banking sectors that collapsed. And now getting in money is a major problem,only the United Nations can do it, not the other donors. We also have psychosocial problems. There are a lot of people, we are having mental problems, psychosocial problems, physical security problems, particularly some of the women, they do not feel very secure, you know, working due to the situation. Of course, governance is a major problem; inclusivity and it’s not recognised by the international community, and they do not have the recognition, environmental problems, the protracted drought that we do have in so many other issues. There are also not clear policies and drug control in women rights, you know, by the de-facto government of Afghanistan. Of course, lack of guidelines in inadequate coordination because I think there are still differences of opinion. But also there is lack of coordination among the Taliban and also the civil society organisations. Also, the lack of adequate capacity to provide evidence based treatment services. Evidence based treatment services are very important and science based, but what the Taliban or some of the other people are promoting, it doesn’t really work. So we do have a problem about that, too. And also lack of sustainable recovery management intervention to provide continuum of care. Thank you. 

I think UNODC and [INCB?] they can take the lead. But in the current circumstances, I think UNODC is the most important one because they have access and they have resources to be working practically in Afghanistan. Also, the involvement of civil society organisations and expanding Chatter, but also empowering NGOs as well. One of the most important thing that the NGOs wanted to suggest was if the funding could be channeled through the UN because they can get the funds inside Afghanistan. And right now, we do have funding from INL, but we cannot get the funds into Afghanistan, and also involving grassroot people and building trust and confidence and, of course, promoting accountability and transparency. And thank you very much.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you so much Mr. Nasib for reminding us of what the situation is on the ground. And apologies for having to cut your intervention a tiny bit short, is also to support a good cause to also give some space to our last speaker. Pieter was reminding us before that the MHSSP does not only cover health, but it’s really a broad concept that encompasses social protection, and UNODC has been fortunate to join forces with the Government of Bangladesh in addressing a humanitarian emergency there, from the point of view more of prevention of substance use and the social protection of children. And it is therefore my great pleasure to give the floor to Dr. Abu Toha. He is the Health Coordinator in the Office of the Refugee Relief and Repatriation Commissioner in Bangladesh. For a short intervention giving us the flavour of what we are managing to do in Bangladesh not only on treatment, like we have been talking so far, but on prevention as well: Dr. Toha you have the floor.

 

Office of the Refugee Relief and Repatriation Commissioner (Bangladesh), Abu Toha, Health Coordinator: Honourable chairperson, distinguished speakers, and guests, good evening from Bangladesh. I am Dr. Toha [missing], health coordinator of Refugee Relief and Repatriation Commissioner of, Bangladesh. So, thank you from after many long term this is a nice presentations. And also I want to thank and UNODC (for) giving me the chance to present the pilot study performedin Bangladesh, [missing] and UNICEF and UNODC. This is my presentation on the strong families programme in [missing] among forcibly displaced Myanmar nationals. You know, there’s [missing] facts and figures you know in our [missing]. There are about 2.3 million Bangladeshi nationals there. Abbout 1 million forcibly displaced Myanmar nationals are hosted by the government of Bangladesh and in 34 camps including Hassan Shoal. There are one lakh 94 families around have food, bbout 51.5% family, female and 48.5% are male. [Missing] are one of our most marginalised and vulnerable populations in the world, pushed out of the Rakhine state of Myanmar and currently living in [missing] district in Bangladesh. You know, Bangladesh is a poor country so it is so much tougher to maintain all the things, but thank you to all the partners they’re helping us to maintain as much as possible. Next, the average family size is 4.6% and about 33,000 to 60 families of persons with specific needs, which include children at risk, single parents, or caregiver on compound on complaint, and separated children etc. Out of [location] 94,091 [ethnic group] families who have taken refuge in [location], about 52% are children living in the camps. There are about 1401 individuals with children at risk and 14,753 individuals with single parents or caregiver or about 2403 individuals with unaccompanied or separated children. The background of strong families and programming [missing] camps, high amount of traffickers and scavenging on all feigned epidemic children and recruiting them as home workers, as well as risk of children marriage and exposure to criminal elements due to COVID-19 pandemics, and others. [Location] has also been vulnerable to arms, narcotics, human trafficking, and smuggling, armed robbery, robbery and against the ships, money laundering, and transnational crime by the mechanisms from the same those who are come from the Myanmar side for a long time. So due to the influx of a huge number of [ethnic group], the drug trade dynamics in the region has taken new shape and [ethnic group] men are often involved and fall victim to illegal drug business due to a large portion of youth and adolescets. The young segment are more prone to anti-social activities for economic benefits and local power gain. Often the families are not adequately informed and the children get involved without family endorsement. That’s why the value of families is extremely important in a humanitarian context, where the other social institutions are not present; in South Asia, families being the most powerful social institution. 

This is the picture of the inauguration ceremony of the pilot study, which was held on Camp 19 where the chief guest of our Refugee Relief, the Repatriation Commissioner was the chief guest, and also me. Me and my others and so many more others, assistant director of Department of (Natural Sulak?) Narcotics Control and [missing] Mr. Assam Nyan and national programme coordinator UNODC and Mr. Nasrullah Islam [missing], were also present as a special guest. So, what we have done in the in that programme say especially strengthen the capacities of families and caregivers to prevent the social outcomes in children, to assess the parents’ parenting skills, parental confidence, to assess the children behaviour, to assess the reduction in risk behaviours, to assess the involvement of mental health and coverages and children, and the level of effect for participating parents, caregivers and children, in [location], concerning both refugee and host population. This is the pictures of 400 participants from 100 families participating in the programme in 2020. There were six sessions in three months, two cycles under the programme, the sessions were spontaneous and [missing]l. As per the project design, 11 families have been selected in pre-piloting our family skills programme in 2020. And this is the picture of this programme. I see materials given on the piloting study in the family skill programme in 2021. Some of the pictures are given there. And what is his outcome? It is working as an effective prevention mechanism in carving drugs used and risky behaviour among [ethnic group] men. It is also helping to reduce negative social outcomes among the children as well as parents and caregivers. The initiative is extremely necessary and should be scaled up among a greater number of [ethnic group] and also with the host communities. Thank you.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: Thank you so much. Dr. Kabuto. Hi. And we have also I believe some additional materials on our programme in Bangladesh that we will be sharing in the chat to give even more flavour, as to in addition to the great results that you have shared with us just now.

 

Office of the Refugee Relief and Repatriation Commissioner (Bangladesh), Abu Toha, Health Coordinator: Most welcome from my side! Please come and see and please help us from your side, and others donor side, because you know, we are in need of so much stuff for our Bangladesh, and our ambassador, honourable ambassador is also there. So, please help us. Thank you.

 

UNODC, Giovanna Campello, Chief of Prevention, Treatment, and Rehabilitation Section: It will be our pleasure to continue our collaboration. We have been very impressed by the collaboration with the Bangladeshi authorities that have made supporting families and children a real reality in this difficult setting, which we hope to be able to use in other countries as well with this good example. 

So dear friends, it’s my honour to thank you all and to conclude, we overshoot, as often happens our our schedule, but I think it was worth it, to listen to fascinating examples and experiences. And to remind us all of the work ahead. So just to say a couple of concluding words. And of course, welcome everybody that has stayed with us all this time, and everybody that has participated, our donors, and of course, my fellow co-panellists, for being with us and sharing their ideas and experiences. And for now, I just want to conclude with a message of hope, that this side event is the first step on a collaboration that does not only involve UNHCR, WHO, UNODC, and then single governments, single NGOs, but that we can all get together to really improve the health and well being of vulnerable population in humanitarian settings. They call for it and we will rise to this challenge. So thank you very much. Looking forward to being in touch. And bye bye. Have a good rest of the day. Thank you so much.