International Harm Reduction Association About the International Harm Reduction Association and HR2
The International Harm Reduction Association (IHRA) is one of the leading international non-governmental organisations promoting policies and practices that reduce the harms from all psychoactive substances, harms which include not only the increased vulnerability to HIV and hepatitis C infection among people who use drugs, but also the negative social, health, economic and criminal impacts of illicit drugs, alcohol and tobacco on individuals, communities and society. A key principle of IHRA’s approach is to support the engagement of people and communities affected by drugs and alcohol around the world in policy-making processes, including the voices and perspectives of people who use illicit drugs.
In 2007, IHRA established HR2, the Harm Reduction & Human Rights Programme. HR2 leads the organisation’s programme of research and advocacy on the development of harm reduction programmes and human rights protections for people who use drugs in all regions of the world.
IHRA is an NGO in Special Consultative Status with the Economic and Social Council of the United Nations.
About the Authors
Michel D Kazatchkine is the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. He spent the past 25 years fighting AIDS as a leading physician, researcher, administrator, advocate, policy maker and diplomat.
Before joining the Fund, besides being Professor of Immunology at University Paris Descartes and Head of the Immunology Unit of the Georges Pompidou Hospital in Paris, he played key roles in various organisations, serving as Director of the Agence Nationale de Recherche sur le Sida et le hépatites (ANRS) (1998-2005) in France, Chair of the WHO’s Scientific and Technical Advisory Committee (STAC) on HIV/AIDS (2004-2007), member of the WHO’s STAC on TB (2004-2007), and French Ambassador on HIV/AIDS and communicable diseases (2005- 2007).
Craig McClure was the Executive Director of the International AIDS Society from 2004 to 2009. A Canadian citizen, his educational background is in political science, international relations, education and counseling.
In 2003—2004, McClure played a central role at the World Health Organization headquarters as a member of the coordination team for the development of the ‘3 by 5’ strategy – WHO and UNAIDS initiative to expand antiretroviral treatment access for people living with HIV in resource-limited settings. Prior to working with WHO, McClure worked for the International AIDS Vaccine Initiative, focusing on mobilizing public sector support for vaccine research.
As a founding partner of the consultancy Health Hounds, McClure led a number of HIV policy and programme development projects for intergovernmental, governmental, non- governmental and corporate sector clients during 1997-2000. Prior to 1997, McClure worked for four years for the Canadian AIDS Treatment Information Exchange, a non-governmental organisation focused on HIV treatment information, education and advocacy.
1 Unit 701 Published by Published The ChandleryThe London SE1 7QY London United KingdomUnited E-mail: [email protected] Design by Mark by Design Joyce Website: www.ihra.net Website: Blog: www.ihrablog.net ISBN 978-0-9557754-5-1 50 Westminster Bridge Road Westminster 50 Telephone: +44 (0)207 953 7412 Telephone: Reflections on the global politics of harm reduction and HIV and HIV Reflections on the global politics of harm reduction Reflections on the global politics of harm reduction Evidence to Action Evidence to Action From From From Evidence to Action: to Evidence From International Harm ReductionInternational Association of the International Harm Reduction Association. © 2009 International Harm© 2009 International Reduction Association
This report was produced by HR2, the Harm Reduction & Human Rights Programme HR2, the Harm Reduction by reportThis & Human Rights produced Programme was
IHRA’s 20th International Conference held in Bangkok, Thailand on April 2009. 20th—24th, Thailand held in Bangkok, Conference 20th International IHRA’s Reflectionsreduction the global politics of harm on HIV and McClure, delivered respectively at the opening and closing plenaries the opening of Harm at Reduction respectively 2009: delivered McClure, This publication reproduces the texts of the keynote addresses of Michel addresses the texts Kazatchkine of the keynote Craig and reproduces publication This HR2 | Harm Reduction & Human Rights 2 International Harm Reduction Association 1. Harm Reduction – From Evidence to Action 2009 Rolleston Oration by Michel Kazatchkine, Executive Director Global Fund to Fight AIDS, TB and Malaria
I wish to dedicate my remarks today concerned about people, and to two heroes of the fight, Amar about helping people with drug and Nestor, who died of AIDS in the dependence to lead normal lives, early ’90s before triple-combination useful lives. therapy became available. They taught me so much about harm Today we would call this an approach reduction, about life and death, grounded not only in sound public patient and doctor, and about what health rationale, but in human rights. courage really means. And that is why we are all here, to In preparing my remarks for today I affirm our commitment to the human was fascinated to learn of the legacy rights of all people, in particular, the of Sir Humphrey Rolleston. rights of people who use drugs; to affirm our commitment to evidence- Many of you will know, as I did not, based approaches to HIV prevention that as President of the Royal College and treatment. And to ensure that of Physicians in 1926, he chaired the the compassionate and common- British government committee which sense principles enunciated by determined that it was legitimate Rolleston more than 80 years ago are medical practice to prescribe heroin sustained. or morphine to people addicted to those drugs. My remarks this morning will focus on some of the key challenges that More than 80 years later, it is still we face as a movement. Of course, worth returning to the language on human rights. On the political of his committee’s report. It said and ideological obstacles that still that the indefinite administration sadden and frustrate so many of us. of morphine or heroin would be On financing, including the role of permitted for those who are ‘capable the Global Fund in supporting harm of leading a fairly normal and useful reduction interventions. life so long as they take a certain quantity, usually small, of their drug of But, as we struggle in this fight every addiction but not otherwise’. day, it is perhaps easy for us to lose a sense of the progress that has been What is striking about this language made in recent years. is both its pragmatism and its compassion. Rolleston was clearly Firstly, in the fight against AIDS.
From Evidence to Action Reflections on the global politics of harm reduction and HIV 3 , since the late 1980s 1980s late the , since impressive declines in HIV-related HIV-related declines in impressive mortality such a population level, at Ababa, where Addis in a recent as the that estimates study AIDS in was 2007 in reduction deaths AIDS in Botswana, In 60around per cent*. reached 30 has where HIV prevalence mortality the per cent, now is trend most age the groups in declining affected AIDS. by A person who begins antiretrolvirol (ART) the in treatment age 20 at expectUK can now another live to 40 in years 25 years, and another countries. developing These extraordinary the are gains many of work hard the of results here. you of people, many including stepIf back and look we progress at fifteen to last the ten years,over harm made in progress have we reduction, Indeed, too. IHRA as points of out its in report, Global the State Reduction Harm popularity, acceptance, in ‘grown has scientific knowledge, advocacy methods The base. and evidence has been won,debate scientific and only ideological or moralistic remain.’ criticisms very years ago, Only five donorsfew supportingwere harm reduction countries. developing in interventions steadily have then, resources Since part large increased - in the through had that - and countries Global Fund long denied existence injecting the of scaled significantly drug use have China, including interventions, up and Indonesia, Vietnam, Taiwan Morocco. * Reniers G. et al, AIDS: 20/2/09, 23, Vol Issue 4, p 511-518 Reflections on the global politics of harm reduction and HIV and HIV Reflections on the global politics of harm reduction Reflections on the global politics of harm reduction Evidence to Action Evidence to Action From From
As Italy is hosting the G8 this year, As year, Italy G8 hosting the this is been the thinkingto back I have in last G8 meeting Italy, hosted by a very This was Genova, 2001. in important G8 for global and health, becausefor Global the it was Fund, donors major meetingthe which at Fund.made first the pledgesthe to saw we ago, Genova, years eight At extraordinaryan example the what of world can do when together it comes purpose. a common with seen sustained we’ve 2001, And since for resources annual in increases notablyhealth, which for AIDS, last year. billion exceeded $14 lastthe in With resources new bilateral new come decade have instruments in and multilateral for Global the global Alliance health: (GAVI) and Immunisation Vaccines Bank Multi-Country World and the 2000, in the (MAP) Program HIV/AIDS President’s US and the Global Fund Emergency Relief for AIDS Plan name a few. to 2003, in (PEPFAR) seen also significant have We For financing. health in innovation example, establishment the with and new 2005, in UNITAID of Red (Product) as and approaches such the finance help to Debt2Health that Global Fund. to expanding in access Progress developing in drugs antiretroviral has years last the few in countries from a been increasing dramatic, hundred thousand of dollarscouple 4 around to 2001 in on treatment dollars today. million seeing are we that is The result HR2 | Harm Reduction & Human Rights 4 International Harm Reduction Association Here in Thailand, methadone is now Civil society groups, in Russia and on the Essential Drugs List. Thailand around the world, have every reason will receive around $6 million from to be proud of their role, as advocates, the Global Fund in Round 8 to scale policy-makers and implementers of up needle and syringe programs harm reduction programs. In this of through NGOs at drop-in centres all areas in global health, civil society and street outreach in 17 provinces. has come to be seen as the repository The Department of Corrections will of expertise, and harm reduction provide methadone to IDUs in closed networks are increasingly vocal, settings, and pharmacies in major respected and resourced. cities will provide more sterile needles and syringes. Policy reforms are also On the policy front, there is increased planned. attention to tuberculosis in injection drug users, and a slow but growing The Malaysian Minister of Health realisation that ways must be found recently informed me that Malaysia to tackle hepatitis C at the same time will come to the Global Fund in as we deal with HIV. Round 9 with a significant request for funding for NGOs to undertake harm And finally, the prospect that the reduction. United States could re-engage in harm reduction is tremendously These are very encouraging new encouraging and necessary. Our call developments for this region. from this conference is for the US to Last month I was in Tehran. The firmly and emphatically do so. needle exchange and methadone programs that I saw in Keraj All of these developments, all the Prison outside Tehran, and in a contributions you are making, are neighbourhood of Shiraz, were not for me a great source of hope. I just impressive, but moving, in their really believe that with the successes truly humane approaches and the we’ve achieved, the evidence deep commitment of those providing we’ve gathered, and the growing services. commitment of countries, that we are in a moment of new opportunity. Our movement has some true heroes that we should pause to To consolidate these gains, and acknowledge and celebrate. Here build on these opportunities, let me I wish to particularly acknowledge highlight what as I see as four key my many friends in Russia. Sasha priorities: human rights, evidence, a Tsekhanovitch and his colleagues at more comprehensive understanding the Bodkin Clinic in St Petersburg, of drug users’ vulnerability and are just some of the many people in financing. Russia providing compassionate and comprehensive services to drug users First, as the conference theme in a hostile political, societal and legal recognises, human rights must environment. continue to be at the forefront of everything we do.
From Evidence to Action Reflections on the global politics of harm reduction and HIV 5 observed inauspicious a rather Februaryanniversary. 2009 marked centenarythe first the of meeting known as Shanghai, in nations 13 of which The First Opium Commission, led international the to eventually system global of drug that prohibition knowwe today. meeting recent the of The outcome Viennain UN Commission the of just the is Drugs (CND) on Narcotic policy that of incarnation latest put upsets What ago. years 100 place in reduction harm the in us of so many abject CND’s the is movement have times how appreciate to failure prohibition globaldrug how changed; HIVamong made controlling has injecting drug users harder, so much HIV approaches to proven and that harm reduction, as such prevention, so important are the mitigating to impactpublic health drug of use. comfort small can from take We some the coded the of in language political and plan of CND declaration commitment action, timid the as such be may that discrimination ‘reduce to drug with use’ and itsassociated call basedprograms prevention ‘deliver to we What evidence’. on scientific framework overall an is accept cannot on reduction focuses exclusively that demandof and supply when, political the as itself declaration acknowledges, these approaches success. limited had such date to have fundamentalwith My difference endorsed approach the CND the by I a physician, as Viennain that, is Reflections on the global politics of harm reduction and HIV and HIV Reflections on the global politics of harm reduction Reflections on the global politics of harm reduction Evidence to Action Evidence to Action From From
It should not be should not It necessary for us drug rights are human that say to must users’ But we rights, well. as it loudly every at say and clearly opportunity, because many too in in cells, police many too in countries, many too prisons, and in many too services,health drug users still are human. than less as treated begin they a firm with Unless rights, efforts human to commitment with associated harms the reduce to doomeddrug use are fail. to and health to Here I mean right the to right the But also care. decent freedom The from discrimination. The equality to right before law. the work, The to privacy. right to right education. share and to The to right science. of advances the in These universal rights. are And no whethermatter it’s are, where they Melbourne, or Bangkok Moscow, Baku, drug these users’ are universal rights. to Second, must continue we must We evidence. the promote drug use why show to continue mostis effectively addressedas and challenge, a public health approaches that punitive why users, resources the drain criminalise agencies and enforcement law of and penal judicial overburden systems, futile and counter- are productive. the that remindedme has AlexWodak harm reduction community recently HR2 | Harm Reduction & Human Rights 6 International Harm Reduction Association subscribe to Hippocrates: ‘First, do health approach, including countries no harm’. Unlike the CND, we should here in Asia. Let us say, to China, never shy away from this as our first to Malaysia, to Vietnam: keep up priority, or from using language that the good work. By embracing harm speaks unequivocally of reducing reduction, you are on the right side of harm. history.
We must continue to reject the Unfortunately, there are still countries myth implicit in the CND outcome, that seem determined to swim that harm reduction promotes against the tide with their willful addiction. And we must expose the blindness to the evidence. false statements of governments, such as those of Russian officials in It is easy to feel that we are getting Vienna that the US still ‘prohibits nowhere with Russia on methadone, substitution therapy’ and that or with some countries in the region compared substitution therapy to that seem unable to scale up services. ‘drug legalisation’. We must demand, And there are those countries that at a minimum, that serious countries still seem determined to wage the tell the truth when discussing serious senseless ‘War on Drugs’. matters of policy. But we have no choice but to Let us nevertheless thank and continue our advocacy, maintain the support the 26 countries that moral and political pressure, and, explicitly supported harm reduction above all, promote the evidence. in Vienna. They have helped to show that the consensus that has driven We need look no further than my global drug prohibition for 100 years own country, France - where for years has actually fractured. They give now, less than 2 per cent of new HIV hope that we may eventually have a infections have been among drug more nuanced policy in the coming users - to know what works; to know years, in which countries are given the that, as with the prevention of mother flexibility to implement a drug policy to child transmission, we can come that best fits their needs, rather than close to resolving drug use as a means be constrained by the stifling ‘one size of HIV transmission. Not by picking fits all’ approach that has served us so and choosing one intervention or poorly, for so long. another, but by a comprehensive package of needle syringe exchange, And let us strongly encourage substitution therapy and overdose and support those countries that prevention. have traditionally employed a law enforcement approach to drug Of course, alarming evidence is also control but who are now moving, in a powerful tool. I referred earlier some cases cautiously, to a public to data from Egger and colleagues
From Evidence to Action Reflections on the global politics of harm reduction and HIV 7 transmission among injecting drugs transmission users far from are commensurate to million need,with perhapsat $200 perhaps 1 or 2 per million year, $300 for resources available all of percent AIDS. the that say proud to always I am largest the donor is Global Fund globally for reduction. harm Close been now has billion invested $1 to a have HIV in grants that Fund the by harm reduction component. large In parts central and Eastern of Europe Asia, virtually it is only the donor for harm reduction. less But I am undertaken satisfiedanalysis an by Secretariat that Global the in Fund quantity the these of estimates to specifically devoted resources needle syringe substitution exchange, education at and related therapy Fund the since million $250 around began. enough. not is It proposed the to I have That’s why as it consider Board that Global Fund a matter some of urgency need the about a strategic discussion have to for demand for resources increasing harm reduction from Global the Fund. with spoken also have colleagues My some about you of working together on a demand strategy. mobilisation hope workingMy that, together, is a demand year this can produce we strategy address mobilisation to injecting a not is drug use that top-down product Global the of Secretariat, but something by Fund stakeholders,and for Global Fund advantages the the of all using Reflections on the global politics of harm reduction and HIV and HIV Reflections on the global politics of harm reduction Reflections on the global politics of harm reduction Evidence to Action Evidence to Action From From
showing that life expectancy that showing for someone beginning antiretroviral can extend today treatment from 20 40to years, depending on setting. the goodThat is news, but it refers to non-IDUs. the contrast, sharp In expectancy life that study shows also for injection an drug user beginning less years 12 on average is ART today for a non-IDU.than This speaks more powerfully I’ve evidence any than seen about scandalous the lately lack effective providing attentionof to care for health and comprehensive injecting drug usersliving who are HIV. with need, we message that is third My our policyin settings, interventions a more nuanced and discussions, understanding factors the of that drug users vulnerablemake in Toooften in UN firstthe place. seedocuments we long on AIDS, lists so-calledof ‘vulnerable populations’: sex men, with men sex who have workers, prisoners, injecting with drug users often end, near the though drug use the aloneas is reality In vulnerability. of source these categories frequently overlap, the lists convey fail to and such social and economic factorsmany drug drug use, to contribute that dependence, poverty, crime and need find better to We incarceration. describes drug users that language peopleas vulnerability and their as multi-dimensional. financing. of issue on key the Finally, that only aware too all are We HIV of for prevention resources HR2 | Harm Reduction & Human Rights 8 International Harm Reduction Association Global Fund’s inclusive model and Your work is among the most flexible opportunities to strengthen important, and sometimes the most community systems. difficult, in global health.
The strategy should link with the work But together, all of you and the of the International Development organisations you represent, have Law Organization, the Open Society saved many thousands of lives. Institute and others to increase access to legal services through Global Together, you are bringing hope to Fund-supported programs. It should millions more. support the efforts of drug users themselves to organise, so that more So for every step back, as in Vienna, programmes are designed by them let’s take two steps forward. and fewer programmes are imposed on them. It should prompt countries No matter how often the evidence is that claim to prioritise injection drug denied. No matter that we are told users to actually seek resources for it’s too difficult, that it won’t work, programmes that serve them. And that it’s forbidden. it should not neglect Africa, where the rapidly expanding availability of We must continue, to maintain the illicit drugs is of growing concern and hope, and keep up the fight. where early intervention could have a major impact. Thank you very much.
My final word on financing concerns eligibility for Global Fund resources.
Many of you are rightly concerned about the future of harm reduction programs in Russia. I have repeatedly made clear my view that if eligibility for Global Fund resources is based primarily on GDP, then it is not in fact a Global Fund to fight epidemics. Although eligibility is ultimately a matter for the Global Fund Board to determine, I will continue to strongly advocate for a Global Fund in which the primary eligibility criterion is epidemiology, and not GDP.
Let me conclude then, with a simple word of thanks, to all of you.
From Evidence to Action Reflections on the global politics of harm reduction and HIV 9 commitments to the fight against against fight the to commitments Dignitaries were celebrities and AIDS. how say to themselves over falling cared. they much for time the And then it was partsubstantive opening the of a global – session overview HIV of epidemiology current and the for call and a passionate response, humanity and harm reduction one by and strongest bravest Thailand’s of drug userHIV-positive activists, if Paisan, Suwannawong. Paisan I pay room the in today, are you the Inexplicably, you. to tribute Minister dignitaries, led Prime by Thaksin, filed ceremoniously outof stadiumthe before substantive the began. left was Paisan discussions on stagethe audience a dwindling with seen dignitaries the having all that, opening the over, thought was leave, and emptied hall. the outcry. an was there Needless say, to following the Behind over scenes the angry were days meetings between IASthe and community leaders, and difficult meetings between the IAS representatives. and Thai government IAS the had made a that I realised talk Paisan’s allowing in mistake be scheduledto end the the of at did not though we programme, even would Minister Prime the know that I learned not it was that early. leave for a Thai appropriate considered a drug user. to listen to Minister Prime week.I learned that things of a lot Reflections on the global politics of harm reduction and HIV and HIV Reflections on the global politics of harm reduction Reflections on the global politics of harm reduction Evidence to Action Evidence to Action From From
Five years ago this week I became ago this years the Five Executive Director International the of SocietyAIDS (IAS). before months the just three was It in Conference AIDS International Bangkok, about IAS and the was to Genevarelocate to and restructure its operations, staffand strategic were things vision. Needless say, to me, a mess,somewhat of and believe worked terrified,having I was despite time. the at years 15 HIVin for to close 2004, conference the On July 11 opened Bangkok, in first the time been meetingthe had ever held in 30,000Asia. to Close people had registered, Asian flu the bird and, as beenepidemic had only recently I sighed reliefcontained, with that cancelled. not was conference the control, Thoughunder was flu bird drug users war against the in not. estimated was was Thailand It thousands had beenthat killed as part then-Prime of Thaksin Minister attempts rid the to Shinawatra’s country drugs. of The dead were mostly drug individual users and dealers,small-time certainly not the powerful the control that mafia production illegal and distribution of Thailand. They in drugs remained of course untouched. Minister Prime session, opening the At Thaksin, former UN Secretary- could and,General whoAnnan, Kofi made strongforget, Universe, Miss 2. Reflections on the Politics of Harm ReductionPolitics 2. Reflectionsand the on the Global HIV Response to Director Executive McClure, Craig by Address AIDS SocietyInternational HR2 | Harm Reduction & Human Rights 10 International Harm Reduction Association In the end, Paisan was given the We are all people who use drugs. opportunity to speak again, this Our refusal to acknowledge this is time at the Closing Session, but the all about our fear that ‘we’ might damage was done. become, or be seen as, one of ‘them’.
One of the many things I learned Throughout history human beings from that experience, that has been have been people who use drugs. We compounded over the past five years will always be people who use drugs. in the work I have done related to As human beings we strive to develop drug use, harm reduction and HIV, is the knowledge and technologies the enormous fear that underpins the to control our environment and to world’s approach to drugs, drug use manage our circumstances. The drug and people who use drugs. user, the person who uses drugs, is not the ‘other’. She or he is you and At the end of this year I will be leaving me. the IAS, after six IAS conferences and some dramatic progress in the It seems to me that what we really response to HIV. I’d like to offer three need to focus on is the difference observations I have made related to between drug use and drug addiction the response to HIV as it relates to or dependency. Global drug policy drug use and harm reduction. continues to focus efforts primarily on the substances alone. This is wrong. All three are about fear. Of course, the harms associated The Person Who Uses Drugs as ‘Other’ with some drugs are worse than others. Sometimes these are due My first observation is how all of us to the degree of addictiveness continue to talk about people who of a particular drug. But most of use drugs as ‘other’. We use terms like the harms are due to the way that ‘drug abuser’, ‘drug user’ and even a particular drug is acquired (for ‘person who uses drugs’ as if some of example in a dark back alley versus us do not use drugs. But which one of from a pharmacy) the way in which it us does not use a drug that alters our is used (as a pill, for example, versus mood, our consciousness of pain, our smoking, snorting or injecting), and, physical or emotional state? A joint, even more importantly, the way in a dab of speed, a line of coke, a tab of which society treats people who ecstasy, a shot of heroin. Even the last use drugs. The vast majority of the three Presidents of the United States horrific harms associated with drug between them have admitted using use – crime, HIV and other infections, some of these. A pint of beer, a glass violence, incarceration, death – are of wine, a shot of whisky. A cigarette. clearly fuelled by the drug policies A cup of coffee or tea. A pain relieving our governments pursue. It doesn’t medication, an anti-depressant, a take a rocket scientist to show that valium, a sleeping pill. criminalising drugs and drug use leads to a dramatic increase in drug-
From Evidence to Action Reflections on the global politics of harm reduction and HIV 11 greater risk for drug dependency. risk greater the considering surprising, not This is generally mental state of pathetic serviceshealth world the around people drive self-medicate, that to neglectand the poor the of and the some why and How marginalised. people become drug dependent can others we and not and how drug dependencyprevent area an is research. much requires still that should beBut no reason used to blame or belittle who drug is anyone dependent. definethe to continue So long we as and definethe drug ‘other’ user as drug itself be problem the will as we trapped our misguided in and harm- programmes and policies.inducing The Wilful Denial of Evidence and the Abuse of Medical Authority secondMy observation to relates by wilfulthe evidence of denial policy world the throughout makers some by abuse power and the of members medical the of profession who support The denial. most this exampleobvious wilful of of denial fact course the of is evidence that Russia, in illegal methadone remains introduction the preventing thereby for people therapy substitution of dependent on opioid drugs. The Society AIDS made International has methadone to access of issue the Eastern and throughout Russia in Asia a policy and Central Europe 3.7 region, the over Across priority. peoplemillion inject drugs, over with two people million injecting Russia in highest the alone, per capita the in Reflections on the global politics of harm reduction and HIV and HIV Reflections on the global politics of harm reduction Reflections on the global politics of harm reduction Evidence to Action Evidence to Action From From
related crime, and that controlling controlling and that crime, related productionthe and regulating and go would drugs all of distribution that reducing towards a longway crime. people all are If we who use drugs seem questions then critical the me to be: to some people it that is Why who use drug problematic have godrugs on to use? from that can prevent we How happening? already can help that we those How dependence problems? have and social the and change canHow we many drive that economic conditions people drug dependence? into The for drug use per reasons seem se least fairlyat well-characterised. We feel to outuse drugs curiosity, of or do good, better, to feel to better, or emotional physical, manage to psychological pain. add One might to sex better, have to better, dance to on to switch off, switch relax to more, escapeor to from misery the social of and economic deprivation. As why to some people become go on to drug dependent, clear. less answers the are There though still some is evidence, weak, genetic factors, that including effectsthe on of our environment gene expression and function, may People vulnerability. to contribute problems at mentalwith health are HR2 | Harm Reduction & Human Rights 12 International Harm Reduction Association world, with four times the overall But this kind of denial of the evidence global prevalence of injecting drug is by no means limited to Russia. use. Close to 70% of all HIV infections Even in my own home country in Russia are linked to injecting drug of Canada, a supposed bastion use, versus 30% globally outside of of democracy and human rights, sub Saharan Africa. there is a concerted and organised state-supported campaign to deny We all know that there are decades evidence related to harm reduction. and decades of research showing For a number of years now a number that opioid substitution therapy is the of studies in the Downtown Eastside most effective intervention to reduce of Vancouver have struggled against injecting and prevent HV infection the odds to scientifically determine among people dependent on opioids, the impacts of a number of harm particularly if delivered as part of reduction interventions, including a a comprehensive package of harm supervised injection site and heroin reduction interventions, including maintenance therapy. These studies education and counselling, needle have been dogged by government and syringe exchange programmes, interference since their inception, provision of condoms, HIV diagnosis including unwarranted attempts to and treatment and TB and STI shut trials down, spending of public diagnosis and treatment. funds on harm reduction-denialist organisations to write negatively But in Russia methadone remains about the trials, misrepresentation of illegal, and the Russian government the evidence of the studies’ results maintains that there is no evidence and interference in the peer review that it works to prevent HIV infection process. or reduce the harms associated with injecting opioids. This denial Fear drives the global war on drugs. of evidence is so profound that the Otherwise how could such clear government even dares to boldly evidence of the failure of the past ten distort the facts in international fora, years’ international drug policy be so such as at the high level meeting of blatantly denied? How could billions the Commission on Narcotic Drugs in of dollars be wasted on a global anti- Vienna last month. drugs programme that fuels violence, harms individuals, families and This kind of blatant and wilful denial communities, strengthens organised of the evidence can only be based crime and punishes sick people on deep-seated fear. Remember, with prison sentences rather than this is a society steeped in denial due providing them with the treatment, to fear. For decades the horrors of care and dignity that they need? Stalin’s regime were denied by not only the Russian government but Fear also drives the abuse of people ordinary Russian citizens, until long who use drugs by doctors and others after the death of Stalin, and despite in the medical system. In particular, the disappearance of tens of millions I’m referring to the continuing use of people. of forced detention and isolation,
From Evidence to Action Reflections on the global politics of harm reduction and HIV 13 HR2 | Harm Reduction & Human Rights electro-shock therapy, forced queue of people outside the door participation in medical experiments over 15 people deep, each waiting and other abuses of people who impatiently for his or her chance use drugs that many of us might to inject in one of the supervised refer to as ‘torture’. Doctors who cubicles inside. I spoke with a administer these abuses under the few individuals. These were not guise of ‘drug treatment’ are not happy people. They were skinny, just wilfully denying the evidence, undernourished, bruised and cut, they are violating human rights and in tattered clothing, scared, twitchy the Hippocratic Oath. And make no and desperate. There was a hint, a mistake, as a membership association glimmer, of hope in the eyes of one or of health care professionals and two, but not much. The road ahead researchers working in HIV, the for these people looked bleak to me. International AIDS Society abhors God knows how it looked to them. and condemns these unethical and Using the supervised injecting site inhumane practices. was just one small but significant notch above sharing a needle and Fear drives the denial of evidence. I syringe in the alley up the road. have seen it in the denialists who Homeless and hungry, their lives claim that HIV does not cause AIDS pretty much devastated by the harms and the denial of the evidence that associated with drug use and the antiretrovirals work to control HIV. failure of the Canadian health and social systems. This is the reality of Fear can induce denial of any a supervised injecting site, an entry evidence we throw at it. point to reduce harm amidst a sea of neglect. The Need for Common Ground between the Harm Reduction and To bridge the gap between the harm Anti-Drugs Movements reduction and anti-drugs movement we harm reduction advocates My third and final observation must not be coy about the horrific relates to the seemingly vast gulf of problems that can be associated irreconcilable differences between with drug use – their effects on the those of us advocating for harm individual, the family, the community reduction approaches to drug and humanity. Individuals in the use and those in the anti-drugs anti-drugs movement are motivated movement. too by their experience of the worst harms associated with drug use. Recently I visited the INSITE Discussing these experiences openly supervised injecting site in the and without prejudice could be the Downtown Eastside of Vancouver. It beginning of a common language we was late afternoon, a very busy time share. If we are not able to reach out at the centre. There was actually a to these groups and find common
14 From Evidence to Action Reflections on the global politics of harm reduction and HIV International Harm Reduction Association ground then our evidence will never the drugs we use, how we use them, overcome their fear. how we can continue to be curious, to feel good, to feel better and to do Most importantly, our own fear that better. Let us continue to consider we might weaken the argument of how we can prevent or reduce any our evidence that harm reduction harm we might cause ourselves, our works if we acknowledge and talk families, our communities and society. openly too much about the ugly Let us stop HIV infection in people side of drug dependency must also who use drugs and treat, care and be overcome. If we let the chasm support those that are living with between us and the anti-drugs HIV. Let us move towards a unified movement get too great then we will voice where public health and human have to fight this battle far longer rights are two sides of the same than necessary. We are not, after all, coin. Let us fight for a more just and ‘pro-drug’, we are not ‘encouraging equitable society for all people in all drug use’. We must reach out for places. dialogue consistently, with passion and compassion if we are to make Finally, let us continue to search for further gains. common ground with those who are not yet on what Michel Kazatchkine Conclusion referred to earlier this week as ‘the right side of history’. Let us find the Next year, in July 2010, the passion and compassion to talk to our International AIDS Conference will so-called enemies, show them the be held in Vienna, Austria. This will way, and help them overcome their not be a repeat of the recent CND fear. Because as Nobel Laureate and meeting in Vienna, whose failure human rights warrior Aung San Suu to endorse harm reduction has so Kyi said: angered us all. The conference will have a major focus on injecting drug ‘Fear is not the natural state of use and human rights. There will be civilized people.’ a special sub-focus on Eastern Europe and Central Asia, using Vienna in its Thank you. historical role as a bridge between East and West. Let’s work together to ensure that Vienna in 2010 helps confront the fear that was rampant at the Commission on Narcotic Drugs in Vienna in 2009.
Fellow people who use drugs, let us all continue to dig deep within ourselves to face our own fears about
From Evidence to Action Reflections on the global politics of harm reduction and HIV 15