Lines of communication

Screen shot 2013-07-05 at 13.47.26HRI executive director Rick Lines has been making the case for a human rights-based approach to vulnerable populations for more than two decades. He talks to David Gilliver about getting the harm reduction message across

‘Harm reduction is consistently having to re-fight battles that we’ve won in the past,’ says Harm Reduction International (HRI) executive director Rick Lines. ‘Because in many ways it can seem counter-intuitive to the dominant zero- tolerance, abstinence-based narrative.’ This means those working in harm reduction having to explain ‘again and again’ to politicians, policy makers and the public about where it fits in ‘a continuum of comprehensive health services’, he says.

And he’s been arguing these points for a long time, having become involved in harm reduction through prisoners’ rights work. An activist in the late ’80s and early ’90s, in 1993 he took a job in what remains the only community-based HIV project in Canada working exclusively in prisons.

‘I was one of the first staff they hired when they got funding,’ he says. ‘I had no background in HIV, but I knew prisons and I was comfortable working with people in prison. I started doing HIV counselling, and obviously when you’re working with people in prison who are HIV positive you’re inevitably working with drug users. So I became, by extension, an advocate for HIV and harm reduction services in prisons – it was really my interest in prisoners’ rights that brought me into the HIV field, and pretty quickly thereafter into harm reduction.’

One of his specialisms over the years has been prison needle and syringe programmes. Is he surprised by how controversial an issue that remains?  ‘I am,’ he says. ‘I haven’t done specific work on prison needle exchange for a while but it’s a bit disappointing coming back to it seven or eight years since I did my last major piece of research and not a lot has changed. When I talk about it I always begin by saying that prison needle exchange is not a new thing. A lot of countries that have prison needle exchange – which is a small number of countries – have had these programmes operating for a decade, so it’s not a new response or an untried response.’

At the same time it’s not a response that’s been picked up by many other countries, however, and even within countries that do have programmes there’s ‘not necessarily a growth in the number of prisons doing it’, he points out. ‘For most countries it’s only in a handful of prisons – there are very few countries where it’s a generalised programme across the entire system. But it is surprising to me the degree to which, even ten years later, the same arguments against it continue to be recycled again and again, even though they’ve been shown to be false.’

These are services for a population that is ‘doubly, or triply or quadruply stigmatised’, he stresses. ‘Not just people who inject drugs, but people who are criminalised, who are incarcerated, often people who are living with HIV, people of colour, from ethnic minority communities, people who are young – almost stigmatised from every perspective. And so the response gets even further impeded by that. It’s a disappointment, given the work that so many people have been doing – not just people like myself who have done research and policy, but people who have actually done the hard work of implementing and defending the programmes.’

On the subject of the criminal justice system, one of the biggest campaigning issues for HRI has been around the death penalty for drug offences. Although countries like Iran and Saudi Arabia have increased the number of executions, fewer countries with the death penalty for drugs on their statute books are actually using it. Is the tide turning?

‘Well, the title of our last report on the death penalty was The tipping point, because we really feel that there is a growing global movement and change of attitude around the death penalty for drugs. The countries that actually use the death penalty for drugs are an incredible minority. Some of them are major, huge countries, obviously, like China and Iran, but the countries that are executing people for drug offences really are out of step – not only with the international community as a whole but even with other death penalty states.’

There is also a growing movement against capital punishment for drugs – and capital punishment generally – even within many of these retentionist countries, he points out. ‘One of the things we heard when we first started up the death penalty project – primarily from harm reductionists from the west – was that this was a Eurocentric approach and “you can’t talk about these issues in countries in Asia”. But in fact we’re seeing growing and robust debates in countries like Vietnam, China and Indonesia – not only constitutional court challenges being taken against the death penalty for drugs, but bills being introduced and debates in parliament. It certainly shows that it’s a live issue, and that’s obviously an important part of trying to move political and public opinion against the death penalty.’

Another increasingly important area of work for HRI, with support from UNICEF, is around injecting drug use and people under the age of 18. Although the numbers of children injecting worldwide may not be huge they do represent a ‘particularly vulnerable population and very much an invisible population’, he says. ‘They’re not only at increased vulnerability because of their age and their injecting behaviours, but they’re also typically denied access to harm reduction services because of age restrictions. And what we’re finding is that those young people don’t actually get recorded anywhere – they even fall between different categories in epidemiology studies, so you can’t actually quantify them.’

Although harm reduction is now widely recognised as a cost-effective, evidence-based response, there remains a major funding gap between what’s needed and what’s available, he states, with many governments still reluctant to invest in programmes aimed at people who inject drugs.

‘The focus for us on the one hand is on international donors, obviously, but at the same time they can’t be expected to carry the entire can,’ he says. ‘The other problem we’re seeing – and it’s a particular problem in the Eurasian region – is that a lot of countries, as they progress economically and move into middle income status in terms of their GDP, all of a sudden become ineligible for Global Fund aid or some of the international aid that they might have been relying on before, not just in terms of harm reduction programmes but their HIV programmes generally. So we’re left with a situation where the international donors are pulling out but the national donors aren’t stepping in, so you have services under threat. There is that responsibility of national governments to step up as well.’

As well as focusing on the economic case for harm reduction as a cost-effective public health intervention, one of the aims of this year’s HRI conference was to provide a platform to reclaim its ‘moral, ethical and philosophical basis’ in the face of efforts to portray it as a ‘morally suspect, clinical’ response that fails to fulfill people’s aspirations and potential, he says.

‘We wanted to say that harm reduction obviously works but at the same time it’s fundamentally based in recognising and respecting the dignity of people who use drugs, and to try to claim otherwise is just fundamentally wrong. So for us it’s almost trying to rebrand harm reduction a bit and not surrender that kind of moral and ethical and value-based ground to the conservative elements of the recovery agenda.’

There is also often an attempt to suggest that harm reduction likes to propose itself as ‘the sole approach to providing services for people who use drugs’, he believes. ‘Clearly none of us argue that. We do a specific and important piece of the health responses related to drug use, but it’s only a particular specialised piece that speaks to particular needs. It’s not the entirety of drug services, let alone the entirety of health and social services, so it’s important that we don’t allow ourselves to be painted into that.

‘But at the same we need to say very clearly that our services are critical and essential and life-saving.’  DDN