Greece’s Public Rehab Institution Ain’t Broke. So Why Fix It?
In a country tormented by massive corruption scandals in its health sector, its largest rehab network provides a bold example of transparency and impact. The Greek government wants to change this.
In Greece, the relationship between the state and citizens is mostly one of mutual suspicion, distrust and a good amount of cussing, exists a large, vibrant community that affects the lives of thousands and their families, delivering a tremendously important service to Greek society. Following an unexpected and rather abrupt legislative initiative, the Greek government now wants to put an end to this community, out of the blue.
KETHEA’s community is the largest rehabilitation and social reintegration network in Greece, targeting people of all ages hooked on drugs, alcohol, gambling, and even the internet. It doesn’t involve only dependent individuals seeking treatment, but also their families, friends, field experts and professionals, and a rather sizeable network of alumni. Its services are offered pro bono, in its 21 therapeutic communities, on the street, and in prisons around Greece. Under the new legislation, however, this question remains unanswered and is up to the appointed by the ministry board to decide on who and how receives treatment.
A. Christofilopoulos is a photojournalist one of the founders of AthensLive, and a KETHEA alumnus. He graduated 20 years ago and the community helped him not only overcome his dependency, but also gain a scholarship to study photography in Athens. He is actually the one who came up with the idea for AthensLive and managed to sit us down to work for a common goal. It was his organizational experience in the therapeutic community that put these skills into him. Now, he is infuriated because what saved his life is currently at stake. At 4 AM on September 30th, Health Minister Vassilis Kikilias decided to change the legal entity and structure of KETHEA with an urgent act of legislative content. He had absolutely no reason to do so, nor any justification regarding the act or without any prior consultation with stakeholders. The network is losing its autonomy and becomes part of the National Organization of Public Health.
Under the new bill pushed by the ministry, many foundational principles that made KETHEA successful for decades upon decades now vanish. What’s more, the Center is now officially left aimless without a purpose or mission, albeit positively not irrelevant in real-life terms. The new provisions deprive KETHEA of its capacities to set up new units and communities around the country, as well as to develop international partnerships, while the stipulations on its funding and entitlement to support its operations via secondments of public officials have been removed. Quite irregularly, instead of following the traditional law-making procedure, in KETHEA’s case the government chose to issue an act of legislative content, a route reserved only for extremely urgent matters relating to ultra-pressing financial matters, natural disasters or issues of public security or defense. It seems that the governing majority should have taken the issue to the parliament in the form of a draft bill, discuss it with stakeholders and MP’s, put it to the vote and pass it. But they didn’t. Now, it is left to the soon-to-be minister-appointed board to decide on who receives treatment and how such therapy is administered.
Nikos Paraskevopoulos served as Minister of Justice, Transparency and Human Rights during the SYRIZA administration and has been involved with KETHEA ever since it was founded back in 1984. He served as the Centre’s vice-president for years and believes that the new political agenda in Greece is “coordinated under a shock doctrine with political actions taken sharply, just to test the public’s reactions so that the government may reassess or proceed with reforms.” His examples include the dissolution of the Ministry of Migration Policy and the handover of penitentiaries and correctional policy from the Ministry of Justice to the Ministry of Citizen Protection. For him, the termination of KETHEA’s self-governance seems to be related to government policy in general.
The independent Board of Directors of KETHEA has provided continuity across many governments. The Centre has been targeted in the past, both in 1993 during the governance of current PM’s father, Konstantinos Mitsotakis, and in 2011, when then Minister of Health Andreas Loverdos attempted to modify the organization’s structure. Loverdos is the first politician to be officially prosecuted for his involvement in the Novartis case this year.
“KETHEA is an organization trying to change the behaviors of people based on their needs and not on market needs or KPI’s. KETHEA is basing its rehabilitation programs on its distinctive structural model that is mostly a social tool, free of charge and free of substitutes. Therefore, there have always been attempts to undermine the work of an organization which was exceptional.” Mr. Paraskevopoulos adds.
A howl that lasts for decades.
Only a few days after the act of legislative content was ratified by the President of the Republic, KETHEA organized a demonstration outside the ministry premises to protest against the hurried changes. Just a couple blocks away,a riot police bus has been parked there for some years, and less than a hundred meters away from the heavily armed policemen a couple dozen worn-down addicts and drug dealers sporting multiple cell-phones and sunglasses deal in all kinds of illegal substances. The “piazza” -as Greek slang puts it to describe the illegal drug street-market- is situated at Platia Vathis, a small square hosting lots of falafel joints and drug-related transactions. Pedestrians go through them without facing any dangers, but the situation is frightful. I’m asking Dr. Gerasimos Papanastasatos about this peculiar triangle and he finds the circumstances emblematic as to how Greece is dealing with addiction in public spaces. “The police are there for the citizens, not the addicts. The police bus next to the addicts is a reminder on behalf of the state that safety is more important than public health. KETHEA is the intermediary between the addicts and the society, focusing on the prior. Under the new legislation, we will be taking orders from the ministry, meaning that we will have to work in alignment with the police, and thus protect the general society and not the vulnerable.” Dr. Papanastasatos is a criminologist and lead researcher with KETHEA’s research unit. He explains how the pioneers of rebetiko used psychotropic substances in the first decades of the previous century and how a subculture around drugs was developed in Exarchia after the sixties when arts and culture in the neighborhood were blossoming. In 1983, the spirit of “Change” transpired throughout Greek society under the social-democratic government of PASOK in power; it is at the same time that HIV is becoming a world-wide outburst. While the number of addicts grows, a group of psychiatrists and social workers realizes that the need for a solution to the problem is imminent; the first unit is founded in Exarchia, and, a few months later, the first therapeutic community (“ITHAKI”) almost squats in a building of the Greek NHS in Sindos, a seaside industrial municipality near Thessaloniki. The local community is hostile and talks about “human waste” added to the tons of industrial waste of the nearby factories thrive.
“PASOK’s government allowed KETHEA to become a public entity under private law for several reasons, as the health ministry at that time didn’t want to be burdened with “an experiment” because of the massive bureaucracy and the national healthcare system wasn’t ready to endure such an organization in case of failure; they didn’t want the blame on them.” Dr. Papanastasatos explains.
In the 90’s, Greece had almost 300 deaths from opioids annually, i.e. 8 victims per 1.000.000 inhabitants. While the public always believed that drugs were the number one scourge in Greek society, data show otherwise. Greece didn’t and doesn’t suffer from an opioid crisis, but the public seems to share this mindset because pharmaceutical companies lobby journalists to promote the belief that addiction can be perceived as a disease that exclusively calls for clinical treatment.
“The U.S. is going through a massive opioid crisis where mortality caused by psychoactive substances is rising due to the prescription of opioids over the last decade. It’s about how it was cultivated within the impression that prescriptions are innocent,” Dr. Papanastasatos ads. In August 2019, Oklahoma’s attorney general accused Johnson & Johnson of a “multi-billion-dollar brainwashing campaign” to get doctors to overprescribe opioids, downplaying the addiction risks. The company will have to pay $572.1 million (€515 million) to the State of Oklahoma in due compensation.
OKANA, another state-run organization dealing with drug addiction with a Minister-appointed president has been discovered to have abused funds on a massive scale, creating a financial black hole of 3.5 million euros in the organization’s budget. OKANA consistently promotes substitution treatment by prescribing methadone and buprenorphine during rehab.
Back to the protest, alumni and relatives were not chanting the usual mantras demonstrators come up with, but they are “howling” to the Minister who plans to eventually merge these two organizations and introduce pharmaceutical products to the rehabilitation program en masse. The “howl” isn’t about desperation, but rather a sign of health and strength, a token of existence and katharsis. In Greek, katharsis means “cleansing” or “purging”; in dramaturgy, it’s the last part of the drama, where actors liberate themselves from the burden of the morbid world. In rehabilitation, it signifies liberation from substances. While theater groups are a key component of rehab treatment, methadone won’t leave the bodies of ex-users rinsed.
While trying to get in touch with the Minister for his feedback, a few days later we pick up a press release that promises “to strengthen the mission and actions of KETHEA under the supervision of the Ministry of Health, as it is subsidized annually with € 20 million.” The ministry declares that “with respect to the money of Greek taxpayers, (we) will ensure sound financial management of the organization, without cutting a single euro off its subsidy” and promises that “the change in the way the Board is appointed will have no impact on the purpose, mission, operation, and funding of the organization, as it is clear that the management of the organization does not interfere in matters related to the implementation of its scientific role. The new Board of Directors will have the necessary plurality and its members will carry the experience required to continue KETHEA’s very important social activity with even greater commitment.” […] “The General Assembly will also be transformed from a body limited to the election of the Board of Directors, to the central decision-making body that delineates and shapes the organization’s strategy on action planning issues in specific areas of treatment, and ideological issues, but also the selection of detox programs,” the press release concludes.
KETHEA’s decision-making process is directed through a general assembly that is open to everyone: therapists, workers, clients and their families. After years of drug abuse, Stamatis Bourikos is soon to graduate from the program in December, after having hopefully completed almost two years there. He is close to 50, and he transitioned from “softer” to “harder” drugs during his life because of tragic losses in his family. He decided to join the program after his brother died of an overdose in his hands some years ago. Now, he is in the social integration phase, ready to earn his high school diploma, and will take his entry-exams in May to study Theater at the University of Athens. He was one of the committee members who met with the Secretary-General of the Ministry, Mr. Panagiotis Prezerakos, during the protest. The minister was too busy to accept them on that day. His question to the Secretary-General was simple and straightforward: “Why all this rush without any prior debate?” Mr. Prezerakos had no answer.
“The government’s call for ‘the restoration of good governance and financial management’ is at least comical, as it is well known throughout the political world and in the Greek society that KETHEA has never created “black holes”, has never received credit, has never been involved in scandals, and is the first Greek public health and social care organization to publicize its annual financial reports since 1995.” Mr. Bourikos adds.
The ministry’s number one argument to support its actions is that KETHEA is using taxpayers’ money. The counter-argument provided by KETHEA is transparency. Professor Nikos Paraskevopoulos, a long-time board member, says that “this is fake news because the ministry is talking about a 20 million euro annual budget while the actual numbers show a number of 16 and a half million. Moreover, KETHEA is audited by chartered accountants on a yearly basis, it operates under a double-entry book-keeping system, and it has established an internal compliance and inspection department. KETHEA’s excellent performance in this field has also been substantiated by the recent audits conducted by the State Auditor General. Likewise, KETHEA submits an annual Action Plan, Budget and Report to its supervising authority, i.e. the Ministry of Health.”
All in all, instead of promoting KETHEA’s management model to other areas of the public sector as an exemplary best practice, the Government chooses to abolish it and replace it with the traditional rigid and obscure structure of politically-appointed administrators who basically abide by the Minister’s instructions.
What is very interesting with the case is that while the government is pushing forward for more privatizations and investment in the country, in the case of KETHEA, the ministry is taking a sustainable organization under its wing. This doesn’t sound at all like New Democracy, where most of its agenda is built around the idea of an “executive” and efficient state. So, why “nationalize” a cost-effective organization when the new cabinet is pursuing a smaller state in its public proclamations?
A leading example worldwide.
Many experts agree that, from a purely managerial perspective, the current way the organization is run appears to be optimal. This was one of the reasons for the United Nations Office on Drugs and Crime to consider KETHEA as a model organization, both clinically and administratively.
Dr. Sandy Brown is the Vice Chancellor for Research and a Distinguished Professor of Psychology and Psychiatry at UC San Diego, internationally acknowledged for her developmentally focused alcohol and drug research. She currently directs the National Consortium on Alcohol and Neurodevelopment in Adolescence and investigates the effectiveness of novel approaches to intervention with the youth. She has been involved in the clinical service training of KETHEA, which is conducted by top-tier instructors from the United States.
She finds that a risk in the new law is that “the model of government-related appointments for the Board of Directors may jeopardize the independent leadership necessary to ensure consistent cost-effective services for those with complex and protracted disorders. It would be much more challenging to measure the success of government expenditures and value to Greek citizens with chronic disorders.”
One of her colleagues is Igor Koutsenok, Professor of Practice in Psychiatry at the same university and the director at the Center for Criminality & Addiction Research. For him, it is difficult to make an accurate judgment regarding the intentions of the Government of Greece, but according to his experience “multiple examples in the US, Argentina, Thailand, Bulgaria, Italy where the government intervened in the reintegration programs have not resulted in any benefit to the country and the patients. In fact, these attempts typically result in increased cost of services and a decline in quality.”
Mr. Koutsenok is a leading global expert in prevention, treatment, and rehabilitation. He has headed the Directorate of Prevention, Treatment, and Rehabilitation of UNODC, and underlines that “It took years in development for KETHEA to become one of the model treatment organizations in Europe, and the Greek community should be proud of this success and the visibility of the program around the world. However, these accomplishments can be decimated very quickly by imprudent administrative decisions. Considering the current economic and political climate in Greece and around the world it will be very difficult, if at all possible to restore the operations to the current qualities.”
Dr. Koutsenok emphasizes the two key components of KETHEA’s success at becoming one of the leading treatment and rehabilitation agencies in Europe — “1. Flexibility as an independent non-governmental agency; 2-Interest in and ability to implement the most scientifically validated and evidence-based practices. The second component is partially a direct result from the first one.”
KETHEA issue taken to the EU Parliament and Commission.
Greek EU MP Kostas Arvanitis is taking the issue to the European Parliament and to the Commission. Arvanitis is a former journalist that jumped into politics during the last EU elections with SYRIZA, because he wanted to be more engaged with the decision-making process. He sat on KETHEA’s administrative board for years, even serving as vice-president, up until 2017. What he took away, is “a unique experience of efficient and transparent self-administration with KETHEA’s therapeutic work producing tangible results, with no loans or financial “black holes” in its administration.” Arvanitis believes that the distortion of KETHEA’s defining features by the Greek government is something that is not simply a Greek issue, but a rather European one. “In fact, it is in breach of basic principles of the European legal order, as put forth in the EU Charter of Fundamental Rights.” he believes, and this is why he has filed a question with the European Commission. “The European legal order explicitly protects KETHEA’s capacity for self-administration, and it is up to the European Commission to make sure the order is respected. Protecting KETHEA is not just about the situation in Greece. It is a battle between the European Rule of Law and the observance of its rules, and the arrogance of a government that, despite its short life, is already “dependent” on authoritarianism, verging on despotism.” he adds.
Parents are now on a double struggle, supporting their kids and now also fighting to annul the act.
Alexandros Alexandropoulos is 52 years old, an ex-construction worker now juggling between two jobs: a driver and a dishwasher. “I wanted to see my son the way I dreamt. I was a construction worker and wanted my son to be a civil engineer working at a multinational construction company,” he tells us. But life had other plans for the Alexandropoulos family. They had to move from the island of Andros to Athens because he discovered drugs in his underaged son’s bedroom. He asked a family friend who is a doctor about a hotline he could get help for his son, and over the weekend he was in Athens seeking support. When we met Mr. Alexandropoulos, his son was in the Reggio Emilia province of Italy as a member of the Greek delegation in an international jamboree of therapeutical communities, and he had just completed three years onboard KETHEA STROFI, a community for underaged users. “Drugs are a symptom of our societal decay, not the disease,” he tells us and describes how cannabis is becoming a lifestyle and habit for youngsters in Greece. “We are being bombarded with messages that weed is a good thing,” he goes on and explains how his family was deeply affected by the financial crisis and how the number of parents looking for help has multiplied. “During the crisis, the establishment wants the younger generation in limbo, while unemployed Greeks around their fifties need a getaway addiction because they are not able to find jobs anymore. Sometimes, it can be gambling or alcohol” and “drugs have nothing to do with class, you see all kinds of different people coming here.” he continues. “We are a community with no class boundaries, poor or rich parents share the same fears and work together, and they mostly learn how to listen to the needs of their kids and set limits,” he says. He was dominated by fear when he discovered that his son was using drugs, and he is now afraid that rehabilitation won’t be as inclusive as it used to be, and that substitute medication will be introduced.
At a KETHEA community center in downtown Athens, two mothers, both retired educators, are worried and getting ready for an emergency assembly. KETHEA DIAVASI began operating in 1990 in Athens and its services are aimed at adults who are substance users and their families. It is an outpatient programme which supports its members while they remain with their families and continue their professional or educational activities.
Both mothers are “leaders” in the community, meaning that they now help other parents go through the necessary process to help their kids and themselves. “The most magical thing is that we connected to each other through our kids,” they say. As leaders, they teach other parents how to learn to listen to their kids and people around them, control their emotions and appreciate diversity and democracy. “These two things are intertwined and cannot function separately,” Mrs. Zacharopoulou says. She had worked as an au-pair in Strasburg and saw families smoking cannabis in their living rooms. She thought that this was very progressive at that time and never thought that she would encounter such behavior until her son was stuck in front of their TV-screen playing video games for hours, had psychotic episodes and got violent. She realized something was wrong and asked for help. Her son never confessed that he was using drugs. Today, after four years in the community, her son is completely functional, autonomous and lives with his girlfriend. “Our community is attacked by the minister in a very vulgar way,” she says.
The community was where she met Mrs. Sirinidou. She taught in Greek diaspora schools, mostly in Europe and Africa, and when she and her family repatriated to Greece in 2003 her son “integrated into Greek schools through weed”. “This familiarization with weed and drugs is lethal”, she insists; just like most of the parents, we met.
Mrs. Zacharopoulou believes that the minister’s decision is a major drawback for the community and doesn’t apply to modern therapeutical standards. “It takes us ages back, it will cancel everything we have worked so hard to achieve,” she tells us while finding it chilling that the youtube culture tells kids “It’s not that bad, give it a shot”. She doesn’t care only about her kid, but for the Greek youth in general — “I’m terrified” she adds.
“I was a good mother, but in the community, I realized I wasn’t as good as I thought. As if I was the family “General”, I couldn’t take no for an answer, so I never listened,” Mrs. Sirinidou tells us. After the rehabilitation program, her son graduated from law school and now pursues a career in the fashion industry.
All parents we met admit that they wanted to see their kids the way they imagined and were never satisfied with their choices. All grew stronger at the community and mention “autonomy” as a major achievement and foundational principle for life. Autonomy in decision-making and the ability to be functional and support oneself and the community.
Both women find this piece of legislation as the start of a struggle that will make them even better and stouter. Mrs. Zacharopoulou believes that “It’s not about politics, but then again life itself is very political, it is inevitably political.”
“Every human being can fit in our community, and this is our message: together we can fight everything, even our darkest sides.” Mrs. Sirinidou adds.
Rehabilitation and integration are about democracy providing a different example of societal structures. Some say it’s an alternative to neo-liberalism.
My colleague, Angelos, who as an addict has experienced how it feels to be considered “human garbage” with only a few months left to live, believes that the conservative neo-lib agenda is on the rise in Europe, despite the progress we have made as societies and the social struggles. Dr. Papanastasatos pensively agrees “because the now-dominant organizational paradigm in is neo-liberalism, influential voices out there will actually advocate that societies are like markets, in the sense that they will eventually self-regulate if left unrestricted. So, why bother if some people die in the process? Or die sooner? In due course, everything will regulate itself.”
And he continues: “The terms citizens, rights, human, vulnerable have an extremely different value in the dominant socio-economic model. In our era, it is obvious that everything is about the markets. In the case of addiction, there is a social cost of responding services and the efficiency of service delivery. So if the costs are not covered through performance, we do not need those services. Let’s get away from drugs which are a pretty extreme area. Take a look at the way we talk about pensions, pensioners and life expectancy during the time where the insurance system and public pensions were debated in Greece. Totally immoral. Just imagine those who weren’t able to work for 40 years and were left at the sidelines of our society and weren’t able to contribute financially to growth. Personally, I don’t even want to think about it.”
During its first 100 days, the Greek government has launched an offensive against the most vulnerable of the Greek society. With new heavily armed police units called “Black Panthers” deployed around Athens since the first month in office, New Democracy has been pointing out to public safety as a fundamental value to appeal to its conservative voters and widespread its message of the “restoration of normality” to make reforms plausible. This is why four refugee squats were evicted in Exarchia and right after the first wave of evictions a police unionist compared live on TV the new police tactics to “a silent new technology vacuum cleaner which will slowly suck up all the garbage from Exarchia.” He added that refugees are a “nuisance dust”. Characteristic of New Democracy’s approach to the issue is a statement by Minister for Agricultural Development and Food, Makis Voridis that “Illegal migrants have no right to humanitarian aid,” adding that the “refugee issue” has turned into a “migrants issue.”
While the number of refugees arriving on the Greek islands is growing day by day there a need for managing refugees and minorities is at hand for the Greek government.
Former SYRIZA minister Nikos Paraskevopoulos believes that “globally there is an effort to manage economic and social problems through social exclusion. In some countries marginalized communities are considered “trash” and this is not just a Greek phenomenon. It’s just that now in Greece we have a government that doesn’t deny that it is totally neoliberal.”
On a beautiful Saturday evening under the Acropolis on the anniversary of the liberation of Athens by the third Reich, soon-to-be alumnus Stamatis Bourikos sums up the latest developments around KETHEA “The Minister wants to replace education and relationships with methadone and buprenorphine. Education, diversity and inclusion will always be free. Like the way they are now within KETHEA”.
Despite the many question marks about the future of the organization, one is for sure. Greece’s largest rehabilitation network just started fighting for its life. Like its thousand members and their families. Their second struggle for life is only at its beginning.