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Journal of Urban Health : Bulletin of the New York Academy of Medicine logoLink to Journal of Urban Health : Bulletin of the New York Academy of Medicine
. 2006 Jul 20;83(5):911–925. doi: 10.1007/s11524-006-9085-y

Street Policing, Injecting Drug Use and Harm Reduction in a Russian City: A Qualitative Study of Police Perspectives

Tim Rhodes 1,✉, Lucy Platt 1, Anya Sarang 2, Alexander Vlasov 3, Larissa Mikhailova 4, Geoff Monaghan 5
PMCID: PMC2438598  PMID: 16855880

Abstract

We undertook a qualitative exploration of police perspectives on injecting drug use and needle and syringe access among injecting drug users (IDUs) in a Russian city which has witnessed explosive spread of HIV associated with drug injecting. Twenty-seven in-depth qualitative interviews were conducted in May 2002 with police officers of varying rank who reported having regular contact with IDUs. All interviews were tape-recorded, transcribed, translated and coded thematically. Accounts upheld an approach to policing which emphasised high street-based visibility and close surveillance of IDUs. IDUs were depicted as ‘potential criminals’ warranting a ‘pre-emptive’ approach to the prevention of drug-related crime. Street policing was described as a means of maintaining close surveillance leading to the official registration of persons suspected or proven to be users of illicit drugs. Such registration enabled further ongoing surveillance, including through stop and search procedures. While aware of drug users' reluctance to carry injecting equipment linked to their fears of detention or arrest, accounts suggested that the confiscation of previously used injecting equipment can constitute evidence in relation to drugs possession charges and that discovery of clean injecting equipment may be sufficient to raise suspicion and/or further investigation, including through stop and search or questioning. Our findings suggest an uneasy relationship between street policing and needle and syringe access, whereby policing strategies can undermine an HIV prevention ethos promoting needle and syringe accessibility among IDUs. We conclude that facilitating partnerships between policing agencies and HIV prevention initiatives are a critical feature of creating environments conducive for risk reduction.

Keywords: Harm reduction, HIV/AIDS, Injecting drug use, Policing, Russia, Syringe exchange

Introduction

Public health research and intervention among socially marginalised populations requires appreciation of how social environmental factors mediate individual and community capacity for risk avoidance.1–5 In Russia, as elsewhere in eastern Europe, large scale social and economic changes associated with political transition may have contributed to the creation of environments conducive to HIV epidemics.6–8 There is growing appreciation of the critical role of social structural factors in the production and reduction of HIV risk among injecting drug users (IDUs), including in relation to legal restrictions placed on the availability, distribution and exchange of needles and syringes.9–15

There is substantial evidence noting the potential for negative health effects among IDUs of intensive street policing initiatives.9,16–23 Some view anti-drug policing as a potential “public health menace.”24 Studies have associated intensive street policing, and police ‘crack-downs’ in drug market areas, with market displacement or disruption rather than eradication, little effect on drug prices and related revenue-raising crime levels, reduced access among IDUs to health services and clean injecting equipment, elevated levels of health risk including overdose and bacterial infections or vascular damage associated with hurried injection, and increased HIV risk including linked to syringe sharing.9,16–19,23,25 A perceived fear of police arrest among IDUs can be associated with reluctance to carry needles and syringes, reluctance to access pharmacies or syringe distribution points, and increased risk of syringe sharing at the point of drug use or sale.14,19,20,22,26

The HIV epidemic in Russia remains predominately associated with IDU, with explosive outbreaks reported in some cities.27,28 The majority of IDUs in Russia are reliant upon pharmacies for their access to clean needles and syringes.29,30 There are approximately 70 syringe exchanges throughout the Federation, which according to crude estimates, have low levels of coverage of local IDU populations.28 While pilot syringe exchanges since 1998 have been technically operable within Federal laws,31 the legality of syringe exchange remains under some dispute. Article 230 of the 1996 Criminal Code makes “inclining to consumption” of illegal narcotics an offence, which some have interpreted as including actions judged to be facilitative of another person's use of drugs.32 While there are no documented examples of harm reduction projects being prosecuted in relation to this article, such a policy context has not facilitated collaboration between law enforcement and harm reduction initiatives.32,33 An explanatory note to Article 230 was added in 2003 giving formal recognition to the distribution of drug injecting equipment for the purposes of HIV prevention.34

Research in Russia, as elsewhere, suggests that reluctance among IDUs to carry needles and syringes, or to access syringe exchanges or pharmacies for clean equipment, may be linked with a fear of detention or arrest.22,30 Prior to 2004, such fears of arrest were not unfounded given that the Criminal Code enabled the possession of very small amounts of street heroin (up to 0.005 g) to be punishable by incarceration. These laws were repealed in December 2003 (Article 228, Russian Criminal Code, 1996), in effect decriminalising possession of small quantities of illegal drugs, in a move rationalised to reduce overcrowding in Russian prisons.33,34 Article 228 was once again revised in February 2006, in effect recriminalising possession of 0.5 g and above of heroin as “large scale” and 2.5 g and above as “especially large scale.”

The research we report below was undertaken in Togliatti, a city in Samara region in which 2.7% of the adult population are estimated to be IDUs.35 An explosive outbreak of HIV was reported in the city in 2001, with 56% of 423 community-recruited IDUs found HIV positive and 87% found HCV positive.27,36 The same study found that 15% of IDUs had had their needles and syringes confiscated by police in the last 4 weeks, and that 83% (345) had experienced police arrest or detainment. Increased odds of receptive sharing in the city were associated with history of detention for drug-related offences.37

The negative effects of law enforcement have been found to coincide with other structural forces which together intensify not only health risk but social and economic vulnerability among IDUs.9,3,38–43 Consequently, the impact of behavioural interventions are relative and context dependent.1,2,26,44 Conscious that most published research focusing on the links between street policing, injecting drug use and HIV prevention have drawn upon studies of IDUs, we sought to explore police officer perspectives.45,46

Materials and Methods

Sampling

We undertook qualitative interviews with a convenience sample of police officers of varying rank and position in Togliatti City in May 2002. There are three main police departments with regular contact with IDUs in Togliatti: Department for Illicit Drug Trafficking (OBNON) who are a ‘drugs squad’ responsible for the control of trafficking of illegal drugs and primarily target large scale suppliers; the Community Security Patrol and the District Community Police Division who have direct and regular contact with IDUs through community patrol; and the Department for Matters relating to Minors. Policing departments with only occasional contact with IDUs were not included in the study.

A total of 27 police officers were interviewed of whom two were female. Participants were aged between 22 and 45 years. Interviewees represented the following police departments: District Community Police Division (n = 9); Community Security Patrol Unit (n = 11); Department for Illicit Drug Trafficking (n = 3); Department for Matters relating to Minors (n = 3); and Road Patrol Service (n = 1).

Data Collection and Analysis

Data collection was via loosely structured qualitative interviews. Interviews were undertaken by the authors (TR, LP, AS, GM) with one additional trained fieldworker. Interviews were confidential, lasted between 45 min and 1 h and took place at the interviewees' place of work. All interviews were tape recorded with informed consent, transcribed and translated from Russian into English. Interviews were conducted in Russian (n = 16) and in Russian via interpretation from English (n = 12). Interview conversation was framed by a topic guide, which was informed by a previous qualitative study.22 The topic guide also informed the thematic coding of transcripts.

Ethics

All participants provided informed consent to participate, and no incentives were offered for participation. The study was undertaken with ethical approval granted from Riverside Research Ethics Committee in the UK and with the support of the Togliatti City Department of Health, Department of Internal Affairs and the City Narcological Services.

Findings

We present our findings in relation to the following themes: perceptions of the drug user; drug user surveillance and registration; carriage of needles and syringes; and policing and HIV prevention.

The Drug User and Surveillance

Conscious of evidence linking the ‘stigmatisation’ of drug using populations with inequities in service access as well as elevated HIV risk,38,41,47 it is worthy of note that we found it typical for drug users to be depicted in negative terms. Accounts often invoked notions of ‘citizenship,’ with distinctions drawn between “normal citizens” and drug users, who by virtue of having transgressed boundaries of normative citizenship were portrayed as having waived a right to be treated as normal. Drug users were described as having inherent criminal potential, warranting their ongoing surveillance, often resulting in temporary detainment:

Those in a state of narcotic inebriation already violate public order with their appearance. That's why they are detained. (Senior Inspector, Community Security Patrol)

The visible aspects of drug use were depicted by some as potential violations of ‘public order,’ and these pertained to signs of inebriation (“They can even be arrested for appearing in a state of intoxification”), made obvious “by their behaviour, their walk, by the look in their eyes.” A number of Articles in the Administrative Violations Code of 1984 unrelated to drug use enabled police to conduct close surveillance of drug users, and these were described as Articles relating to “being intoxicated in a public place,” “disorderly conduct” (including “swearing” or “disobeying a police officer”), and an Article relating to a person's appearance being “offensive to human dignity and public morality.” The use of these Articles to conduct surveillance was justified largely for reasons of expedience. Articles relating to drug charges (such as Article 44: illegal acquisition and storage of narcotic drugs) were “complicated,” required “paperwork,” and “time,” and might instead be “covered with a ‘disorderly,’” often resulting in a “fine of 30–50 roubles”:

If he is walking around completely spaced out, with saliva running out of his mouth, then, I am sorry, but he's in a public place and should not disturb the public order. If he is not breaking the law, he can walk away. But most of the time, they are intoxicated [which justifies application of an administrative code] or carry drugs [which may justify arrest for possession]. (Chief Inspector, District Community Police Division)

The inherent criminal potential of drug users gave rationale for a pre-emptive approach to drug-related crime prevention. As one Senior Sergeant commented: “Not every thief is a drug user, but every drug user is a thief.” Considerable efforts were placed upon street-level surveillance in which “we don't let anyone by,” and where “we stop everyone” considered by “outward appearance” to be a drug user. The approach was said to “keep them [drug users] under surveillance, insofar as staff numbers allow.” Such a strong emphasis upon surveillance was underpinned in some units by a quasi-formal system of performance indicators, such as a “points system where the more you catch the better” or being “obliged to discover one drug den a month.” Targets set for offence reports were said to be invariably met (“They give a number like 20 for some month and everyone meets the quota for 20 reports”). Some rationalised that drug users were particularly at risk: “They are the easiest people to arrest. They never go and complain. And it is always possible to find them and write a report” (Chief Inspector, District Community Police Division).

Drug users were described as having most crime potential when in withdrawal, in which case “they start robbing all and sundry” and are “capable of committing any offence.” Interviewees thus served to protect normal citizens from such transgressions:

How does crime begin? They inject themselves, off they go, and on the next day they start getting withdrawal symptoms, but they're got no money. They start robbing all and sundry. There goes a woman with a gold chain, and they rip it off. What will she do to them? She won't do anything. It's us that have to run around and look for them. Normal people don't rip chains off people. (Sergeant, Community Patrol Service)

Drug users in withdrawal were said to become “aggressive,” “dangerous,” “unpredictable,” “capable of anything,” and may even “kill a person.” With rationality overcome (“He no longer thinks of anything, and can do anything that comes to his mind”), the protection of community safety through pre-emptive detection was paramount:

A drug addict is capable of anything when they need a fix. God forbid, of course, but they would slit anybody's throat in a doorway for money. So we try to put them away as quickly as possible, so that they should not bother anyone. There are lots of instances of this! (Warrant officer, Community Patrol Service)

A fear of the violent drug user was also linked with the need for a firm policing approach. There were ambiguities as to what this constituted, with some accounts emphasising the need for, and acceptability of, “tough talk,” if not a little “kicking” and “shoving,” and the necessity to “grab them, drag them out and take them away” when “they put up a fight”:

Well, pushing them [drug users] around and saying they are stupid. Is that really rude? That's alright. It would be rude if they [the police] beat up the drug addicts. But if they brought them in, kicked, shoved them round a couple of times, that is alright. (Patrol policeman, District Community Police Division)

Violence displayed towards drug users was not only described as an unavoidable feature of street surveillance, but by some as a means of displaying commonly held negative beliefs about drug users:

This [violence] is how they [the police] show their dislike of drug addicts. How many times have they had to cope with what addicts do? Drug addicts are scum. Bad people. And they steal. Drug users have committed most past crimes, and robberies are always down to them. (Chief Inspector, District Community Security Patrol)

Taken together, surveillance procedures were premised on the foundation that they enabled protection of the community from the potential crimes of the drug user, both from the person exhibiting signs of use and most importantly, the person exhibiting signs of withdrawal:

An addict is always unpredictable. Who knows what he will do—steal a car or rape somebody, or something else. That is why he must be barred from the community, at least until he has recovered from narcotic inebriation. [What do you mean “barred”?] Detained for 24 to 48 h until the high has passed. (Officer, Community Patrol Service)

We detain drug users when they are in the state of withdrawal. We have to detain them in that state because if we don't they will commit crime. Drug users commit 88% of all crime. They steal, they rob... (Senior Officer, Community Patrol Service)

Registration as a Stratagem of Surveillance

A key stratagem of surveillance, often made easier by the discovery of a syringe (see below), was the official registration of a person as an addict: “They'll be put on the register if they are not on it.” As was commented:

We detain those who possess drugs or have some related information. We can also detain addicts even if they do not have drugs on them in order to register them. We keep their records in our books. (Junior officer, OBNON [Drug Squad])

Such official registration has potentially serious negative consequences for drug users associated with loss of employment and social stigma,48 but gives rationale for “preventive work” and ongoing surveillance:

I can just approach a person and say: ‘Who are you? Could I see your ID’? Suppose he shows some ID. ‘Well, Mr Ivan Ivanovich Petrov.’ I make an inquiry in our information centre. And then I get the answer: ‘Yes, he is registered with us as a drug user.’ Then I say: ‘Well, let’s search you.’ (Chief inspector, District Community Police Division)

We were told that surveillance is “what the register is for” and that registration endorses police “rights” to surveillance at the same time as waiving drug users certain rights of citizenship:

Our status allows us to check and search them [drug users]. If we have information that in certain flats drugs are being used, we put it on our books as a place of concentration for drug users. Once the flat is registered with us, we have rights to come there and search everyone. That means we have this right. (Senior Inspector, Community Security Unit)

All the addicts have to be listed. When we are dealing with them, you know that this person is an addict. You already know what sort of attitude to have. [“Attitude”? In what sense?] You can't trust an addict. You must always relate to him with a note of distrust. (Junior Officer, OBNON [Drugs Squad])

Such ongoing surveillance, and the experience of stop and search, has been described by drug users in the city as relentless.22 However, police accounts emphasised that their suspicions that an individual they target is a drug user are usually correct:

I will stop them for a little chat if they have drugs [or] their behaviour is a slightly inadequate. That is how I know they did something illegal... They get nervous, start twitching. They try to hide something. All these signs indicate that they have drugs. In 80–90% of cases I'm usually right. (Divisional Police Inspector, District Community Police Division)

It is important to note that we also found exceptions to the general depiction of drug users as potential criminals in need of close surveillance. Here an alternative view emerged in which drug use was depicted as an illness and drug users as citizens in need of help. In this minority view, drug users were envisaged as “quite normal people,” as being “drug addicts who work, who don't steal and who don't rob anyone,” and who “would not harm anyone”:

In my opinion drug use is an illness. That's why you shouldn't put him behind bars, but should give him medical treatment. Before, there were Detoxification Medical Units. Alcoholics were held there. He isn't a criminal! He bought the drug for himself and uses it for himself. He doesn't see it. He has to have medical treatment. But that's just my opinion. (Senior inspector, Department for Matters relating to Minors)

Carriage of Needles and Syringes

We found there to be ambiguity in police accounts as to whether drug users should fear detention or arrest associated with carrying needles and syringes. This ambiguity centred on distinctions drawn between clean and previously used syringes, and between principle and practice. Accounts emphasised that in theory carrying a clean syringe was “not an offence,” that “there is nothing we can prove if the syringe is cleaned” and that “we would be breaching their rights if we tried to use it as evidence.” A clean syringe should therefore not be grounds for fear of arrest or detention among drug users:

They don't get caught with clean ones. What could happen to them because of that? But if they've already used drugs, then yes. (Sergeant, Community Security Patrol)

I don't know what they're afraid of. If the syringe is empty then it is empty, and that means there is no drug in it, doesn't it? What is there to be afraid of with an empty syringe? However, if there is solution in it then they should be afraid, because there is no difference between there being traces of heroin [in a previously used syringe] and solution currently in the syringe. (Inspector of training, Community Security Patrol)

However, in practice possession of a syringe, including if clean, was said to justifiably arouse suspicion of drug use, and thus also police interest:

Let's say I saw a clean syringe. And let's assume this person is not registered with us. Of course, everything depends on his explanation why he carries it. If he says that he has medical treatment and looks normal, I am not going to humiliate him. Stopping this person already means that something about him drew my attention. For example, I do not carry a syringe. (District inspector, District Community Police Division)

A clean syringe was said to signal suspicion (especially “if he's on the register” of addicts) for which possible detention might follow subject to evidence, and by some was described as constituting “direct evidence” of injecting, thus permitting further investigation. The following extract provides an instance of where distinctions become blurred between a clean syringe constituting no offence in theory but signalling ‘suspicion’ or ‘evidence’ justifying police intervention in practice:

Of course! If he is detained where there is usually a gathering of addicts, then he is a suspect right away. That's why they are afraid, because they can spend the night in the police station. [Why, if they have clean syringes?] I'm saying that they are under suspicion. If he is caught where there is a drug den that means that he has most likely come into contact with drugs somewhere... [In other words, you feel that there is truth in what the addicts have told us?] Well, of course. They know themselves, that this is direct evidence of them injecting. (Officer, Community Security Patrol)

There was consensus that a drug user discovered with a previously used syringe had a justified fear of detention or arrest. At the time of the study, the Russian Criminal Code did not distinguish between smaller amounts of possession in that any amount of street heroin or liquid opiate up to 0.005 g was interpretable as a ‘large amount’ potentially resulting in imprisonment. As a consequence, even “traces” of heroin in syringes might constitute possession: “As long as we can trace even a tiny bit of drug in it, it will be confiscated”; “We are talking milligrams”; “A little smear would be enough to be a criminal offence.” When stopping a person with a previously used syringe, it was said that they would be detained if there was “reason or some sort of suspicion,” while the syringe would be analysed for its contents:

If it's not clear what was in there [a previously used syringe], you need to do an analysis and prove that there was a narcotic in it. A loaded syringe is also analysed. A person is brought to a station, in an order established by law, with witnesses, the syringe is confiscated from him, then it is sealed and sent for analysis. Everything else is determined by the expert in narcotic substances. (Senior Inspector, District Community Police Division)

While the possession of a clean syringe is not an offence, in practice it therefore offers justification that a person already stopped or searched can be reasonably suspected of drug use, which may in turn lead to detention and further investigation. This may lead to eventual arrest, or far more commonly, the application of an administrative code (see above) for which small fines are sometimes payable and official registration as an addict.

Policing and HIV Prevention

Most we interviewed were aware of the needle and syringe distribution project which operated in two of the three districts of Togliatti:

There are points around the city where syringes are exchanged for them, they are given condoms, handed out leaflets about how to do all that right, how to look after your veins, to avoid infection or an abscess. There is that. The feelings about this are double sided. On one hand, it's very necessary. Perhaps, someone will think of their future. It's a big plus. But on the other side, it's a Russian problem: they change them [syringes] for the addicts, but old people have to buy them with their own money! I think that the government ought to solve this problem some how. (Chief Sergeant, Community Patrol Service)

Our findings indicate evidence of willingness among police officials to consider how police can best work in partnership with community-based HIV prevention initiatives, including syringe exchange:

It [syringe exchange] decreases the risk of HIV infection. If it's an illness then we have to fight it somehow. If they use drugs, then let them at least use clean syringes. (Senior Inspector, Department for Matters relating to Minors)

Positive depictions of the role or potential of syringe exchange in HIV prevention were tempered by perhaps predictable concerns that syringe exchange might encourage, or be interpreted as endorsing, drug use:

It's a double-edged sword. On one hand, it seems that we are intercepting the spread of HIV, on the other hand, that we approve: “Here are new syringes for you, inject, comrades.” On one hand, there won't be HIV, but on the other, it's a push toward drug use. (Senior Divisional Inspector, Department for Matters relating to Minors)

Importantly, pharmacies and syringe exchanges were described as providing ideal opportunities for police surveillance (and potential arrest) of drug users:

Exactly! That's what I'm talking about! Places where they are issued syringes, chemists, that is the very best place for finding drug addicts. Aha! Here he comes! Great! [...] They cast their net and wait. That happens a lot. (Warrant Officer, Community Patrol Service)

Pharmacies may present a more cost efficient point of surveillance than the street, especially important given the pressure placed upon some units in relation to offence targets, and the relative difficulties seeking formal registration of apartments as places of drug use (“To prove it's a drug den you have to catch the drug addict who must say that he has previously been in this den several times and used drugs there, and only when we have two such declarations can we hand the matter over”). Targeting pharmacies was a necessity:

We have people in pharmacies who pass on information to us about the people who buy syringes, because drug users are often involved in crime. The police are already searching for some of them. It is easier to trace them when they come to pharmacies rather than look for them on the street or in somebody's flat. (Divisional Police Inspector, Community Security Unit)

The potential tensions between opportunities afforded by undertaking police surveillance at pharmacies and syringe exchanges and this limiting the success of such interventions was recognised by some: “He knows that he will be noticed by us. He doesn't want that.” As others commented:

Of course it is a good idea [for police to target pharmacies and syringe exchanges]. However, as far as I can see, drug users rarely go to syringe exchange centres. I guess they're afraid that police might arrest them there. (Patrol Policeman, Community Security Patrol)

Despite acknowledgement that drug users in the city have cited police presence at pharmacies and syringe exchanges as a deterrent to their use, it was proffered that police presence at pharmacies was for surveillance rather than arrest purposes: “We won't arrest anyone who is just going to the chemist. We detain people for drug possession, not for the fact that they are drug users. I may stop them for a chat, ask some questions, and then let them go.” As another described of syringe exchanges:

We don't go to syringe exchange centres in order to stop and search people. We go there to talk to drug users. If the person is nice, they will tell us where and at what time drugs are sold. We go to syringe centres to get this information. We are not against people exchanging their syringes. However, we often have to work in chemists. (Patrol Policeman, Community Security Patrol)

Discussion

Policing strategy may undermine ease of access to needles and syringes among IDUs, including in Russia.10,13,17,18,49 Yet there are few studies exploring relationships between policing and HIV prevention for IDUs from police officer perspectives.45,46 This was an exploratory qualitative study which served to identify inductively key emerging themes in participant accounts, and therefore generalisability beyond this particular sample and city location cannot be assumed. Findings indicate willingness among police officers to work collaboratively alongside syringe distribution interventions, though show such voiced support potentially undermined by everyday policing strategy and practice. Interview accounts described a mainly punitive approach to the policing of drug users, based on an ethos of intensive street-based surveillance and pre-emptive action as a means of drug-related crime prevention, thus potentially undermining the efficacy of other city interventions seeking to promote HIV risk reduction among IDUs.

There have been close historical links between law enforcement and treatment services in Russia, whereby the practice of exchanging drug user registration lists between police and drug treatment services was commonplace. Current evidence suggests police and drug treatment registers have close overlap.35 Research suggests that a strong emphasis on the registration of persons seeking help for their drug use acts as a disincentive among IDUs to access drug treatment or pharmacies and syringe exchange projects for clean injecting equipment, as well as contributes to their marginalisation through loss of employment opportunity once certified an addict.22,48 Studies have found association between registration at drug treatment services and HIV or HCV infection,36 arrest and syphilis,50 and drug-related arrest and elevated odds of syringe sharing.37

Our findings capture a strong emphasis on street policing as a mechanism of pervasive surveillance in the lives of IDUs. First, accounts emphasised a depiction of drug users as potential criminals. In combination with a common belief that when in withdrawal drug users were ‘capable of committing any offence,’ this gave rationale for an ethos of intense surveillance wherein IDUs would be repeatedly stopped and searched as a means of ‘pre-empting’ drug-related crime. Second, accounts emphasised the registration of individuals suspected or proven as drug users, including as a means of enabling ongoing surveillance. While provision exists for the notification and follow-up of drug users for intelligence purposes in other countries (for example, the UK), our data suggest an intense concentration of police effort on monitoring and surveillance of IDUs as a stratagem of public order control. Third, our findings are indicative of policing strategies intersecting with a common portrayal of the drug user as a source of risk. Most accounts (there were exceptions) contrasted the drug user as ‘other’ in comparison to ‘normal citizens,’ and as beyond rights of citizenship. The rationale for intensive surveillance of IDUs was reinforced in some accounts in relation to a perceived risk of physical harm associated with street policing. In this respect, some portrayed drug users as potentially aggressive or violent, especially when in withdrawal, and this gave some rationale for accepting as permissible physical aggression (falling short of “beating up”) when policing drug users. Other qualitative studies of police officer perspectives have found relationships between police officers and drug users to be shaped by ‘misinformation’ concerning drug use as well as perceived occupational risk.46

Aside from the potential negative health effects of aggressive street policing,9,12,17,20,21 the pervasive surveillance of IDUs arguably contributes to more generalised marginalisation and social suffering.38,51 Some have described this as a form of “oppression illness” or “structural violence.”52–54 This may be felt at both an individual and community level in terms of reduced self-esteem and weakened capacity for risk avoidance, including in relation to HIV.39,40,53,54

Importantly, our data suggests that a strong emphasis upon surveillance and registration may undermine efforts to maximise IDUs' ease of access to needles and syringes. While accounts emphasised that the carriage of clean needles and syringes posed no theoretical risk in relation to detention or arrest, there was a more blurred picture of what happens in practice. Carriage of a syringe, including if clean or unused, was said by some to constitute sufficient suspicion that an individual may be a drug user, thus opening up opportunities for additional questioning and official registration as an addict. Carriage of previously used syringes was said to constitute potential evidence of possession, for which a prison sentence was a possibility. This clearly may contribute to reluctance among IDUs to carry previously used equipment or to return it to a syringe exchange, and may also contribute to drug use at the point of drug sale as well as to hiding or storing syringes for re-use at dealers' houses.22 While it was posited that relaxations made in May 2004 to Article 228 of the Criminal Code concerning drugs possession—which in effect decriminalised possession of small amounts of narcotic and psychotropic drugs—may have had some effect,33 these relaxations were again revised in February 2006, with 0.5 g and above of heroin deemed “large scale.” Surveys in Togliatti subsequent to the May 2004 revisions to Article 228 give no indication that the prevalence of drug-related arrest has diminished (personal communication, L. Platt).

There is considerable evidence underscoring the public health rationale for discretionary community policing strategies which enable IDUs' access to needles and syringes without fear of arrest.10,13,17,18 Cautioning rather than detention or arrest is one example of discretion in public health oriented policing.17 An emphasis on referral to drug treatment services as alternatives to custodial sentence55 and shifts from vertical to consultative decision-making in policing strategy56,57 are other examples. But such shifts are difficult to implement without generalised tacit approval at the community level. Shifts in policing strategy towards more public health and consultative approaches involve structural changes, and it is important to recognise that these are relative to wider structural challenges associated with police and law enforcement reform in Russia, including in relation to corruption.34 Policing and harm reduction strategies may be described as “two cultures passing in the night.”58 The strength of scientific evidence alone, and repeated calls for a shift towards public health oriented policing, is not necessarily sufficient to bring about lasting or structural change.24

Given recent evidence of shifts in legislation in Russia which some have argued open up opportunities for a more public health oriented approach,33 it is timely to consider the feasibility of local HIV prevention partnerships between policing and health agencies. Examples elsewhere demonstrate the potential impact of police training and consultation in facilitating reappraisal of the balance between law enforcement and harm reduction interventions at the local level.58,59 Critically, this has involved change that is ‘bottom-up.’58 There is an urgent need to pilot police training and intervention partnerships in HIV prevention in Russia. This is especially the case in cities where there is a combination of voiced positive support for such initiatives among police and yet policing practices which serve to undermine rather than enable access to needles and syringes among IDUs.

Acknowledgements

We are grateful for the support of the UK Department for International Development for project funding support, and to the UK Department of Health for core funding to the Centre for Research on Drugs and Health Behaviour. We also thank Alexandra Kornienko for her assistance during fieldwork. We would also like to thank the Togliatti City Department of Internal Affairs, the Togliatti City Department of Health, the Togliatti Harm Reduction Project Coordination Group, and the following individuals: Elvira Zhukova; Veronica Petrova; Yuri Pevzner; Alexander Shakhov; and Adrian Renton.

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