November 2021

‘That could be your brother or your sister or yourself’: Q&A with Allan Ragi

As executive director of the Kenya AIDS NGOs Consortium (KANCO), Allan Ragi now works across national borders. Established in the early 1990s, KANCO has a membership spanning non-governmental, community-based, faith-based, network organisations and learning institutions throughout East Africa that share a focus on health advocacy and/or health program implementation. Allan has held his current position since 1994 and previously managed health education for the Red Cross in Kenya.

How did you come to be in this role, Allan?

I have been involved in HIV for a long time; I used to chair the program’s committee for the National AIDS Control Council in Kenya and also chair the East African network of NGOs, based in Arusha, Tanzania.

One thing we found very challenging was how to bring on board into the HIV programming men and women who use drugs, men who have sex with men, and female sex workers, including transgender people – it was very difficult.

Many times we got funding for key population programming but the money was never utilised, especially along the Coastal and Nairobi regions where communities were of the notion that this was not important.

That was my most frustrating piece of work: that we were leading from the front in terms of everything else but any time we talked about people who used drugs it was not possible to get support, one, because it was said to be a choice; two, because of the link to men and women who had money because they trafficked drugs; and, finally, the level of stigma that would not allow even us in programs to engage them.

We had to hire specific staff to help us tackle these issues. As we went down we realised there were people who had been working on these issues for a long time but behind the scenes – ‘under the table’. This was because people did not see it from a disease point of view.

Fortunately, because of what we used to do, we had very close working relationships with politicians and some senior administrators.

When we did research we realised that about 18 per cent of new infections were among men and women who used drugs. It was then that we started asking questions. Were they propagating or were they victims of the environment we were living in? The reports showed that even if you lived in a gated community, even if you were one of those high-profile-community individuals, you were still affected.

We had to create a national team bringing together higher learning institutions, the government, and the civil society. Many times when we wanted to engage people we would advise, “If you’re asked who sent you, respond it’s me who has sent you”; this way we were able to build the confidence of the group drug users.

We now have people and organisations who have grown in this and have taken over most of these programs and I’m quite proud to have started this. My role was to try to mine the resources we had, because they had the interest, they had the commitment, so all they required was a better working environment.

The second thing was the money. To get that money we had to say, “Look, this is the evidence – these are the men and women who use drugs. Can we have a meeting to determine how we can work togther?”

We’re not just working in Kenya now but I’ve seen us expand out into the East Africa region. We have good leadership from some of these countries and I’m very proud.

The work you started with people who used drugs, how long ago was that?

We are looking at more than 10 years ago.

How would you describe the drug market now in Kenya: is it the same as it was 10 years ago or is it changing, getting bigger or smaller? What are the drugs of choice – not alcohol and cannabis, but the other drugs that are popular?

Of course, it changes. It’s changed in the sense that we’re able to define the drugs that are commonly used right now; we’re able to discuss it openly. We’re able to put in place support for people who are using drugs. And the government is being quite helpful.

The drug market’s getting bigger and more sophisticated and we’re seeing more people getting into using drugs, and using different types of drugs. The numbers are much more than they were initially. The drug that’s commonly used in terms of injection is heroin but we’re seeing an increasing trend in the use of stimulants, especially amphetamines, and cocaine is also coming in. We also have quite a big number of people getting into methadone and buprenorphine. That’s 8–10 per cent.

Generally the number of people using drugs is increasing and spreading across all the counties in Kenya currently.

The majority of people use alcohol in Kenya; the proportion of people who use these other drugs, like opiate drugs, is small – 10 per cent of the overall.

What do you think is influencing this?

There’s a growing young population here and, secondly, there’s the level of unemployment and the availability of drugs – there are more sources, more ways of getting drugs in this country. Therefore, even though there has been substantial progress in terms of how we manage and provide access to some of the resources – naloxone and others – we’re still not there.

But what does make me happy is that we’re not just talking to ourselves, we’re not just talking to the people who use drugs, but we’ve been able to bring in the institutions of government and they’re not afraid of speaking about it. We’re also not afraid to speak to the senior people in security and therefore we’ve seen a certain level of tolerance by the government and the public as well.

One of my leadership styles is seeking to ensure that we enter in a softer way and create a voice of representation. It’s not speaking ‘on behalf of’ but facilitating the groups to acquire and be able to sustain some of the work we’re doing. As an example, one of my jobs in the next four years would have been to advocate on the issue of men and women who use drugs but instead we’ll be supporting a group that will take up that level of advocacy.

For me this is where it becomes important, because now we can do something else and at the same time the voices of communities can be heard from the ground to the boardrooms. When we meet there now we meet as colleagues. It is about ensuring we bring on board people who can be the best facilitators to create a good working environment for everybody and not just say “Do this” but say “We need to do this because of…”.

You mentioned unemployment – what’s the youth unemployment level in Kenya generally, and in cities like Nairobi and Mombasa?

It’s 40 per cent. There are men and women who lost their jobs four years ago and haven’t had another one. It’s more visible in the urban areas but it’s also spread through the rural areas so there’s no geography that’s left out. COVID-19 has made the employment levels even higher.

How did you manage to get the police to be supportive? Did that come from a political – a ministerial – level, or was that actually the chief of police – the police internally?

When we engage the police and other institutions, the first thing we always do is to ask “Is it a problem?” “Yes, it’s a problem.” “Why?” “Because it affects our young people, affects families, affects professionals as well.” So we have that evidence.

The second thing is to ask what we can do. What’s our role? The role for us is to raise the issues, and there’s a role for the media to create these stories: positive stories as opposed to blaming stories.

Then we look at what policies exist and how that can happen.

We make friends with heads of government including the police and make them part of the reforms. We actually remove the barrier between us – we become true Kenyans, for the good of the people. Sometimes they want to do something but they know we’re better off pushing for it so they ask “Can you do it?”; sometimes we know it’s better if we ask them to do it.

In this country the members of Parliament are important, especially the parliamentary committees; they’re the ones who can summon ministers, cabinet secretaries and other technical teams. They can actually influence resources allocations and ask questions on the floor of parliament that may have an implication on policies.

And then we bring in the police, having seen what the senior leaders in government are doing; as well as KANCO and other likeminded partners, they are inclined to support them. It results into a win-win situation.

The other thing is to have somebody who lives and breathes harm reduction. You cannot do it without a champion of harm reduction.

Do you do much work in the media? Are drug issues something that the newspapers and television pay attention to?

Yes, they are. We create opportunities for everybody, especially the media houses that we interact with, and urge them to join us in the this cause. We argue “We’re here because this is important for you, as the media, to be engaged in”. We have to create interest with the media and look at the market they have and how they create a story out of our stories.

An example is, if you have a young mother who’s engaging in drugs and she’s pregnant, then you can see where the story is: she has a child to support; she has to ensure that she’s healthy for that child, and therefore she’s not just another Kenyan who’s abusing drugs – she needs help.

When it comes to the people who are injecting drugs – from what you say it sounds like it’s mostly younger people, under 30 or maybe under 35 – what are their key challenges in relation to HIV and other blood-borne viruses? There have been stories from Dar Es Salaam, just across the border from you, in Tanzania – that some people who inject drugs believe that if they don’t have any drugs of their own they can share the blood of someone who’s intoxicated and still get high. What are the key educational messages you need to get across to build people’s health literacy or health capacity?

We know that sharing needles and syringes is a major source of new HIV/AIDS infections in Kenya. Secondly, because people use dirty needles, this fuels infections like hepatitis and septic wounds, among others.

We start with simple management. The first thing we say is “Remember, these people do not come from nowhere; they come from families, they have friends”. This helps in reducing stigma.

Then the focus is on “Please don’t share your needles and syringes”. It’s one of the things we’ve been campaigning on: why it’s important not to share.

The stories are true, so we say “Remember, if you share blood it’s like injecting infections into yourself”. We have to dramatise some of these lessons for people to start appreciating the risk.

The level of education for some of the group members is quite low and a lot of misinformation is witnessed. There’s still need for capacity-building to identify the issues and therefore the platforms for the general community, for the community of people who use drugs, for professionals, for media, for members of Parliament, so that they can support people who use drugs to ensure that their human rights are protected.

There is a need to make access to services easy. We have to make sure there’s a peer support system and somebody available. For this to be realised we engage organisations that are closer on the ground. We push from a national level on access to bring government and other institutions on board. What we also bring from the national level is knowledge on overdose and naloxone, and policies that make it easy to manage overdose.

It’s important to track supplies. What’s going on? Are there needles? Are the people who are using drugs using the right equipment, the right needles? Are they able to get alcohol swabs and these kinds of things? That has to happen – it must be deliberately allocated resources to track the supply chain.

The drug user community is quite young in age. We have reports of them commencing drug use as early as nine years. At nine maybe they’re starting with other ways of using drugs rather than injecting, so they’ll start by smoking a cigarette, smoking bhang, and then as they move over the years, tolerance begins, they move to other types that are considered stronger – heroin. They’ll start to use it by smoking, of course, and then eventually they’ll move to injecting.

So the people who are actually injecting are older. They’re now from 25 up to 78 but the majority range from 25 to their 40s. These people have used drugs for many years – 15–16 years. So by the time they get into a medically assisted therapy treatment program they really require a lot of extensive support because of their level of addiction.

In our context there’s also a lot of transitioning of drugs. We find people oscillating from injecting to using in other ways depending on supply: when the supply is good they’ll use in other ways, more sniffing, but when the supply is running low they’ll go to injecting, or when the supply is immediately cut they’ll go for a substitute drug – maybe a cigarette for comfort – as they wait for the supply to return.

What’s your final word to sum up your approach at KANCO?

We say: “Any time we’re driving or walking and find somebody in a trench that could be you tomorrow – that could be your brother or your sister or yourself. So if you’re able to support today, it will reduce the impact of overdose, whether it’s other drugs or alcohol, because it all starts from somewhere.”

It’s important that we engage everybody and strengthen partnerships by bringing them along. If you get everybody engaged to support, then basically you reduce the pain of the impact.

Drugs are not new, but we can make the environment safer and better for ourselves and for our future generations.