This year’s Harm Reduction International Conference in Lithuania brought together delegates from across the globe to discuss the need to provide sufficient political and financial support for harm reduction.
More reports can be found here.
To read the full HRIC daily update magazines, please click here.
The conference was an opportunity for different voices from many different countries to be heard. Below are reports that were not featured in the July 2013 issue of DDN magazine.
‘Our policies are not our own’
Corruption and weak institutions are driving forward drug problems in Africa
Weak institutions and high levels of corruption were exacerbating the drug problem in Africa, Isidore Obot of the Centre for Research and Information on Substance Abuse in Nigeria told delegates in the final day’s opening plenary session.
Sub-Saharan Africa had a very youthful population, which had implications for drug use, and there were also obviously significant issues of poverty. ‘There is economic growth and rapid urbanisation,’ he said. ‘But basically the rich are getting richer and the poor are staying poor.’
West Africa had become a drug trafficking hub, and although less than 0.5 per cent of Africans had reported use of heroin or cocaine, there was increasing availability of both, along with amphetamine-type substances, he stated. There were also significant levels of injecting reported in Kenya, Mauritius, South Africa and Tanzania, alongside high levels of HIV and hepatitis C.
However, in terms of drug policy the focus remained that of law enforcement, he said, with drug control bodies coming under the supervision of ministries of justice. ‘The laws are severely punitive, and policies are not guided by evidence of effectiveness.’ They also tended to be driven by external considerations, he pointed out. ‘There’s limited ownership of policies. We’re doing what we’re doing because it’s what’s expected of us by other countries.’
While surveys showed little support for harm reduction at the policy level, however, there were now several coalitions, networks and youth groups active in harm reduction and advocacy.
The Economic Commission of West African States (ECOWASS) had also been active on drug issues in recent years, as had the African Union. The latter’s Plan of action on drug control 2013-17 explicitly mentioned scaling up evidence-based services to address the health and social impact of drug use, and there was also now a West Africa Commission on Drugs, launched by the Kofi Annan Foundation, and the example of Tanzania’s medication-assisted treatment for people who used drugs.
‘People are taking another look at policy on the continent – at African Union and national level,’ he said. ‘With more knowledge, the fear will dissipate. The need for harm reduction is growing, and the language of evidence is growing. People are now talking more and more about public health and human rights. I think the future is bright for harm reduction, simply because we can’t run away from it.’
Be the voice of change
We should be investing in the things that improve public health, concluded speakers at a session on Researching the values and impacts of harm reduction
Although the scientific evidence for harm reduction interventions was incontrovertible, the interventions had not been scaled up, said Douglas Bruce of Yale University.
‘Often there’s a call to ethics – is it right to give people syringes? We’re going to remove suffering by reducing HIV and hepatitis C rates, so surely that’s good?’ he said. Often the arguments put forward by governments were simply that it was wrong to support anything that promotes addiction, as that would ‘violate a moral imperative’. Rather than causing harm, however, NSPs were a link to treatment and other services, he stated, ‘so failure to provide NSP is more likely to violate an imperative to protect human life’.
For some societies, it was simply a case of adhering to traditional values and the social norms of previous generations, he said. ‘So you don’t think about ethics – you just do what your elders did. But what if your elders had endorsed slavery? If it’s ethical, then we should be the voice of change.’
Other societies, meanwhile, while quick to agree that harm reduction interventions were ethical, were slow to provide the funding. ‘But needles are cheap, and HIV treatment and drugs for hepatitis C are very expensive. So, even economically, we should be investing in NSP. Governments and society should invest in the things that improve public health.’
On that subject, Andrea Wirtz of the Johns Hopkins Center for Global Health told delegates about a report commissioned by the World Bank on how interventions in four countries could impact on risk behaviours.
The countries – Kenya, Ukraine, Pakistan and Thailand – were chosen partly for their political diversity, she said. The researchers established both a conservative and optimistic impact matrix for each country, and found that impressive reductions in the number of new infections were possible when harm reduction and antiretroviral therapy programmes were ‘expanded to ambitious yet achievable targets’.
‘Not all programmes are alike,’ she said. ‘The implementation of NSPs may have different impacts in different countries – if programmes aren’t accessible and acceptable, then they won’t be used. And while antiretroviral therapy is powerful, people who use drugs often have the least access to treatment. That’s something we must all work to change.’
Policies must be based on ‘human rights, dignity and health’
The conference debate was a lively exchange on drug policy reform and harm reduction
The final day saw the conference debate the motion ‘this house believes that drug policy reform advocacy and harm reduction advocacy are in sync as we approach the 2016 UNGASS review’. For the motion were Steven Rolles of Transform and Damon Barrett of HRI, and against were Niamh Eastwood of Release and Anya Sarang of the Andrey Rylkov Foundation.
Chair Daniel Wolfe, however, pointed out that the participants were not always necessarily speaking from their own, deeply held convictions, but rather making provocative statements designed to stimulate debate.
‘Dignity, health and human rights are the values that come through time and again in harm reduction,’ said Damon Barrett. ‘Harm reduction advocacy and drug policy advocacy share core values.’
What did ‘in sync’ actually mean, he asked delegates. ‘Increasingly in our movement it seems as though we have to say the same things – I don’t think that’s helpful. It fails to go to the core strengths of the different movements, and it effectively reduces our numbers to one. What’s going on in Latin America is not the same as in Eurasia, or even on the streets of London. But we do agree on what matters – and that puts us in sync. The human rights violations associated with prohibition are making harm reduction impossible.’
The danger, however, said Niamh Eastwood, was that the 2016 UNGASS could focus almost solely on cannabis reform. One possible consequence was that cannabis could become normalised, like tobacco or alcohol, and so further entrench the stigma against other drug users.
‘Cannabis reform does not address mass incarceration, for example,’ she said. ‘And, from a public health perspective, should we be concerned about big business getting involved in cannabis? Nation states and the UN might also see cannabis reform as a loss they’re willing to take, and then further entrench their positions on other drugs.’
With 2016 approaching it was important to recognise that there were different advocacy strategies, she said. ‘That’s not a bad thing. But it’s essential that we do coordinate our calls for drug policies to be based on human rights, dignity and health.’
The harm reduction and drug policy movements were increasingly in sync, Steven Rolles told the conference. When harm reduction had begun in the 1980s it was very much concerned with crisis management, but as time had gone on the discourse had become more nuanced and harm reduction had expanded its remit ‘to look at what’s causing the crisis in the first place’.
The drug policy debate had become an increasingly important part of harm reduction, he said. ‘There will be obstacles and bumps in the road, but we can learn from them and move along. Being in sync doesn’t necessarily mean saying the same thing.’
Power of the personal
Before speaking at the ‘Evidence is not enough’ session, Kate McKenzie talked to DDN about fighting for fair treatment
I don’t have a political axe to grind – it’s a personal story. But that’s what the general public can relate to,’ says Kate McKenzie, ahead of her session on the factors that led people from different backgrounds to harm reduction.
For Kate, it was her daughter Hannah’s struggle with heroin, the subject of the 2008 documentary Mum, Heroin and Me. Since then Hannah has entered treatment, relapsed, and is now being treated in a French psychiatric hospital for mental health problems.
‘They’re treating her mental health rather than her addiction – rather than the symptom, they’re going to the cause. I’m very passionate about dual diagnosis – I feel very strongly that often services are just putting a plaster on a wound and not getting to the root of the problem.’
Kate was also a member of the Brighton Independent Drugs Commission, one recommendation of which was a feasibility study into the establishment of consumption rooms in the city – something unsurprisingly seized on by the British press.
‘Of course that’s what they focus on, even though there were 20 recommendations, including around dual diagnosis. It’s whipping up hysteria. My mantra is that the information out there is flawed, and a lot of misinformation is peddled by the popular press. It’s down to people like myself to inform other families that this can happen to anyone.’
Her other mantra is that drug users need treatment rather than punishment, she states. ‘I get very angry. Even among drug treatment – I felt that their attitude was sometimes not wholly supportive and rather patronising. You don’t always get the support when you need it.’
Personal stories can be an immensely powerful way of changing opinions, however. ‘You see people become far less hardline, whereas if you say it’s government policy or this or that commission, they tend to glaze over. If you can get the majority to be more understanding, then politicians wouldn’t be so scared of changing policy.’
But she remains optimistic that this will change. ‘More and more people in a position of authority are beginning to advocate the prescribing of heroin, for example. You just need a few more and for them to join up and put the pressure where it’s needed. Politicians are still running scared, although often privately they agree.
‘It’s a complex, frustrating situation, but that doesn’t mean we shouldn’t try. We’ve got to keep battling.’
The power of evidence
Criminalising the possession of drugs was a mistake admits former Polish president
‘This region is shaped by its recent history and the transition to democracy,’ former Polish president Aleksander Kwaśniewski told the conference.
While accomplishments in addressing HIV had been more successful in some areas than others, there were nonetheless many examples of good practice, he said – in Moldova, Poland, the Czech Republic and elsewhere. ‘But we need to work to make sure evidence-based interventions are accessible across the region.’
During his presidency he had passed a law criminalising the possession of drugs, he told delegates. ‘A decade later, I know that was a mistake. Drug users became invisible in Poland, and we engaged the resources of the Polish criminal justice system to arrest people for small amounts of drugs for personal use.’
This meant that young people had been needlessly criminalised at a time of high youth unemployment, he said, and the punitive approach had done nothing to deter people from using drugs. Portugal, however, was a powerful example of how a national drug policy could work to everyone’s benefit.
Evidence was vital, he stressed. ‘It helped to convince me of the need for new policies and I know it’s convincing other leaders too. Scientific evidence helps to convince not just politicians and policymakers, but the general public as well. In this era of fiscal austerity, we have to think about whether policies such as prosecuting people for minor drugs offences are cost-effective.’
However it was also vital that austerity was not allowed to become an excuse for not investing in evidence-based programmes, he stated. ‘A quarter of a century ago human rights changed this region. It’s vital that they do so again. We as the international community will fully support you in your fight.’
Changing core beliefs
Moralising has no place in drug treatment and harm reduction, said Father Sean Cassin
‘My belief is that the drug policy of any society is decided by the taboos and morals of the civil population,’ said Fr Sean Cassin of Ireland’s Drug Policy Action Group. ‘The big challenge for harm reduction in the future will be to interfere with the core beliefs that exist there in terms of disease and morals and harm.’
He had established, and still managed, Ireland’s first church-owned services for drug users, based at an inner-city Franciscan friary in Dublin. ‘To be truthful, the founder was actually a drug user who would come into the church in the early ’90s, because the police usually wouldn’t follow him in there,’ he said. ‘He started to bring his friends because it was a safe place, and we would distribute needles and syringes before the health services were doing that.’
In terms of public perception, the 12-step model had also helped to propagate a notion of powerlessness, he said, ‘even though there is no basis in science or fact for the disease model’. Worldwide there were 230m drug users, of whom just 27m were problem users, he said. ‘There are massive markets for drugs and a perception about harm that is worldwide and the biggest obstacle to initiating harm reduction policies.’
Harm reduction ‘purists’ tended to avoid any debate ‘that gets into the moral poles about decriminalisation or prohibition’, he said, and ‘they’re able to operate effectively because of that’. There was also an accusation of ‘surveillance medicine’ levelled at some workers – ‘why are medicine professionals getting involved in the area of pleasurable drugs?’ Most deaths by overdose had to do with the context of the market, meanwhile – ‘the illegality of drugs, the rushing to use, lack of control over content’.
Many harm reduction services operated a ‘field hospital’ model, he said. ‘While the war goes on around us and the bullets are flying, the hospital does its work but doesn’t comment or raise any moral issues. But my worry about that is that the underlying moral belief that drug use is evil goes unchallenged.
‘We could do no better than to shift our ethos to that of John Stuart Mill’s “greatest happiness” principle,’ he concluded – that actions are right in proportion to how much they promoted happiness, and wrong in proportion to how far they produced the opposite. ‘Happiness means pleasure – and the absence of pain.’