By Prof. Michel Kazatchkine, MD, (FR), Consultation Event Co-Chair & UN Secretary-General Ban-ki Moon’s Special Envoy on HIV/AIDS to Eastern Europe and Central Asia; Member of the Global Commission on Drug Policy and Former Executive Director, The Global Fund to fight AIDS, Tuberculosis & Malaria.
Most independent studies show problematic drug use increasing. As the world debates the ‘war on drugs’ and what to do next, in preparation for a special session of the UN General Assembly in 2016, it is pretty clear that the international drug enforcement regime has failed to reduce the use and harm caused by drugs. This prohibitionist approach has been a mainstay of global diplomatic relations for decades. It costs tens of billions of Euros / $ to run with many vested interests. More difficult to estimate are the health and social costs associated with addiction, mass incarcerations and the emergence of a vast criminal controlled trade. The gap between what science is telling us we should do and what is actually happening on the ground is harder for policy-makers to explain away, especially in Europe which has lost its way from a position of leadership. This imbalance between ‘policy-biased evidence’ above ‘evidence-based policy’ is the root cause of tens of thousands of avoidable deaths and millions of avoidable infections. There is no doubt that the policy-maker must share the blame.
Thankfully, the debate on drug policy reforms has more recently been prised open by increasing “activism” from opinion leaders and civil society. Harm reduction science is also gaining momentum and we members of the Global Commission on Drug Policy25 are seeing a more common sense approach developing, while being under no allusions of the tough battle ahead.
Drug use and possession remain a criminal offence in over 150 countries worldwide. A 2012 report by Harm Reduction International documents the 33 countries and territories that retain the death penalty for drug offences, including 13 in which the sentence is mandatory26. This violates our human rights conventions and international law. Around 1000 people are executed each year. This criminalisation of drugs has gained its way into national legislation and policies as a consequence of the dominance of the prohibitionist law enforcement paradigm in the design and implementation of drug policies. A biased interpretation of international drug conventions is also to blame, as those health diplomats amongst us struggle to work in a world where “conventions castrate science”.
The damage that results cannot be underestimated. It has affected millions of lives, fuelled HIV and hepatitis C epidemics, fed human rights abuses across the globe and subverted the rule of law. For example, following the Arab Spring and the wave of conservatism now sweeping across these countries, drug use, often fabricated, is being used as a handy means to have one’s opposition arrested.
To quote the current Georgian Minister of Corrections, Archil Talakvadze “Expecting to solve public health problems by enforcement-led policies can lead to a downward spiral of increased harm and ultimately death. Prisons reinforce lost health, social contacts and broken families. We need to balance active law enforcement with prevention, treatment, rehabilitation and harm reduction while never lowering our commitment to basic principles of human rights”.
At a scientific symposium I organised at Euroscience Open Forum 2014 Copenhagen, Minister Talakvadze left nothing to the imagination for delegates when describing differences between the ‘old’ prison system and the changes he is now trying to implement. From 2004 to 2012, Georgia had one of the highest incarceration rates in the world, operating a zero tolerance criminal justice policy. Overcrowding and a failure to update drug regulations and improve prisoner’s access to services, as specified by international law, went ignored under the simple logic of placing drug users in a ‘drug free zone’. Yet, thousands became addicted to sedatives and psychotropic drugs widely provided in prisons while many more moved on to new, more damaging substances. The transmission and spread of Hepatitis C got out of control with 42% of all prisoners infected. This contributed to a loss of social contacts and the break-up of families. Thousands of families paid fines and bails for their arrested family members, liquidating their personal wealth and ability to provide for wider family members in the process.
Today, Georgia has embraced harm reduction science and in only a couple of years, is seeing the benefits. Minister Talakvadze has reduced the prison population by 60%. Criminal justice policy has been overhauled and better dialogue initiated between government and civil society. Now, universal access to counselling, testing and treatment of HIV and HCV infections is provided for prisoners.
While on the same panel, Dr. Andrey Klepikov, Executive Director of the HIV/Aids Alliance in Ukraine, put forward some compelling evidence of how Russian foreign and trade policy vis-a-vis its neighbours actively seeks through politics, intervention and even annexation to undermine the uptake of harm reduction science. It ideologically opposes any form of state intervention such as free methadone. He argues that addiction is too profitable a business to let go of with $10 the daily earnings per addicted person. Dr. Klepikov estimates that Ukraine’s methadone based treatment programme alone accounted for a loss of $31 million in revenues for the illegal drugs trade in 2013. Following the Russian annexation of Crimea, some 800 patients were cut from methadone treatment programmes with dozens subsequently dying27.
It sometimes helps to state the obvious. When countries align their drug policies more closely with public health goals, the HIV/Aids among people who inject drugs (PWID) is under control with little if no new infections occurring because of unsafe injection. This is predominantly the case in Western Europe. In countries that maintain harsh penalty-based drug policies, however, the epidemics continue to expand, and the gap emerging between health-focused and repressive countries keeps increasing. This is predominantly the case in Eastern Europe (including many new EU member states) and Central Asia. In fact, Eastern Europe now has the highest HIV growth rates in the world, not Africa. That is precisely why Ban-ki Moon chose to create the position I now hold as Health Envoy to the region to help spotlight the issues and impact change.
Criminalisation causes health-related harms
Drug policies significantly impact public health. There is no doubt that drugs may be harmful to health and I in no way wish to be seen to condone drug use. Addiction or “problematic use”, which occurs in about 10% of people who use drugs, is certainly a chronic relapsing condition associated with significant challenges for prevention and treatment. However, as reiterated by Minister Talakvadze in his frank account of the Georgian experience above, criminalisation of drugs by law and punitive law enforcement practices equally add to the health burden drug-users face.
Laws and policies have been shown to be critical in influencing HIV and Hepatitis risks among people who inject drugs (PWID). Over one in five people globally who inject drugs lives with HIV and two thirds are now infected with Hepatitis C. The figures vary between regions and between countries, from 10 to 80% prevalence of HIV and 40 to 95% prevalence of HCV (the hepatitis C virus) infection among people who inject drugs. The highest rates of HCV infection among PWID are in China, the United States and Russia28.
Unsafe injection drug use and needle/syringe sharing accounts for one third of HIV infections occurring worldwide (outside sub-Saharan Africa). It also remains the main driver of the HIV epidemic in Eastern Europe and most countries of Asia. Co-infection with HIV and HCV can reach 90% of people who inject drugs in some communities of Eastern Europe and of Asia.
There are several reasons for the high regional incidence and prevalence in Eastern Europe and Asia, most of which relate directly or indirectly to dominantly repressive drug policies:
Access to syringes is poor
Firstly, laws and policies govern access to, and the purchase and possession of syringes. Laws and policies also regulate authorisations for needle exchange programmes (NSP), for substitutive opioid therapy (OST), and for treatment diversion. These programmes are core to the package of interventions identified by the World Health Organisation (WHO), UNAIDS and the UN Office on Drugs & Crime (UNODC)29 to prevent HIV infection among people who inject drugs.
In combination with the provision of antiretroviral therapy to HIV-positive people who inject drugs who are eligible for treatment, these harm-reducing interventions have been clearly demonstrated to reduce HIV transmission, decrease mortality, reduce drug dependency, reduce crime and public disorder and improve quality of life.
Put simply, a health-based approach to drug policies must start with the implementation and scaling up of harm reduction. Needle exchange programmes for substitutive opioid therapy can also help reduce the risk of acquiring hepatitis. A further argument in favour is that harm reduction has also been shown to be highly cost-effective.
Yet, despite the scientific evidence for greater efficacy and cost effectiveness, despite the fact that UNODC has clearly stated that harm reduction is consistent with the existing international drug control conventions, and despite the fact that methadone is on the WHO list of essential medicines, restrictive legislation and policies result in substitutive opioid therapy remaining illegal in the Russian Federation. Dr. Andrey Klepikov speculates above as to why this might be the case, but the fact remains that 40% of the 1.8 million people injecting drugs in the Russian Federation are infected with HIV. Illogical examples abound in the ‘West’ too. Access to needle exchange programmes are being restricted in the United States. In a nutshell, needle exchange programmes and substitutive opioid therapies remain the exception rather than the rule, globally.
Policing is often misguided
Secondly, policing practices have a major, often negative, impact. Over-zealous law enforcement on our streets includes arrests for syringe possession, confiscation of syringes, random/arbitrary urine testing for drugs, and surveillance by police of needle exchange programmes and substitutive opioid therapy sites. This directly influences risk taking behaviours among people who inject drugs. Whereas police may engage suspected drug users in accordance with formal laws, police may also engage, at the community/street level, in practices that are not consistent with laws and policies. Fear of police, arrests and incarceration is a major factor driving people who inject drugs underground to inject in unsafe, unhygienic conditions.
The following are words from a young woman from Eastern Europe quoted in the 2012 report of the Global Commission on Drug Policy: “Fear, fear. This is the very main reason. And not only fear of being caught, but fear that you will be caught and you won’t be able to get a fix. So on top of being pressured and robbed (by the police), there is the risk you’ll also end up being sick. And that is why you’ll use whatever syringe is available right then and there”.
Organised crime controls drug access & quality
Thirdly, under our prohibitive law enforcement, drug production and clandestine retail are in the hands of organised crime. This logically increases the chances that products are of unknown purity and potency with higher risks. This has been the case for e.g. cocaine cut with levamisole, or else, ‘crocodile’, a clandestine ‘homemade’ injectable cocktail that has been ravaging drug user communities in Eastern Europe.
Mass incarcerations multiply exposure
Fourthly, punitive laws and policies have led and continue to lead to mass incarcerations. And prisons are not drug-free. A recent study in Ukraine has shown that incarcerated people who inject drugs share syringes with four other users in prison, on average. Furthermore, there are almost no harm reduction programmes inside prisons, not to even dream of needle exchange programmes or substitutive opioid therapies. Inexplicably, this is the case even in several countries that have moved to health-focused drug policies. In Western Europe, needle exchange programmes are only available in Spain, Switzerland and Germany (1 women’s prison)30 so do not be shy in asking your government why?
The result is death
Finally, restrictive policies increase the risk of death from overdose as people inject in unsafe environments. There are an estimated 20,000 deaths/year from overdose in the U.S and at least one and a half times more in the Russian Federation. Until Minister Talakvadze changed the law recently, people witnessing a possible overdose in Georgia were required, by law, to call the police even before they would call an ambulance. Naloxone, the drug that can immediately stop the effects of overdose and save lives, is far from being universally available as if “let them die” is the easier option. We often forget that our drug control regimes have banned the provision of ‘legal’ opiates for pain relief for innocent citizens too, as a collateral damage of the ‘war on drugs’. These medications, although on the list of essential medicines, are unavailable in 150 countries worldwide. Ethical questions abound.
At the same time, a large body of evidence has shown that the repressive approach to drug control has failed to reduce the supply and the use of drugs, and that, in settings with aggressive drug control measures, more drugs are now available that are of increased purity, and are available at cheaper retail prices.
Human rights, human wrongs
Punitive approaches to drug policies are severely undermining human rights. This is true of every region of the world. However, here again, the gap is increasing between countries with predominantly repressive or health-focused drug policies.
Repressive prohibition law has led to a dramatic increase in the number of people in detention, in prisons, as pretrial detainees, or people held in administrative detention. As mentioned above, incarceration has been associated with syringe sharing and unprotected sex, and documented as a risk factor for acquiring HIV infection in countries in Western Europe, Canada, Brazil, Russia, Iran and Thailand. In the U.S, where ethnic minorities are much more likely to be incarcerated for drug offences than whites, prison has been identified as a key factor for the markedly elevated HIV infection rates among African Americans.
Some countries maintain compulsory drug detention programmes where evidence-based treatment of addiction is absent. In China and South East Asia, an estimated 235,000 people are held in such centers. Just to remind you, around 1000 people are executed each year.
At the community level, there are many examples of policing practices, beyond and often against the law, that have imposed abusive punishments on people using drugs, and particularly women, young people and ethnic minorities. Allow me to share with you one example of evidence given by Elana, a young woman from Poltava, Ukraine as part of the Eurasian Harm Reduction Network’s submission to the UN Special Rapporteur on violence against women (October 2012).
“I will never forget one incident that happened in December 2010. We were standing as always near the belt line road, it was freezing and getting dark. A minibus drove up to us. Several policemen from the Special Designation Police Department wearing uniforms grabbed me and the other three girls and pushed us into the minibus. They drove us to the suburbs, stopped by a lake, and despite it being very cold they ordered us to take off all our clothes. Then they poured gas over a pile of our clothes and burnt them. They forced us into oral sex with each of them and then with burning torches they started pushing us into the freezing lake. Then they left and we had to get back to the city with no clothes on. After this incident one of us had pneumonia and died, another girl’s feet was frost-bitten and was amputated. I stayed in the hospital with pleuritis that progressed into tuberculosis”.
Social violence comes as a third area where the gap is increasing between countries with a repressive focus and those that have opted for policies prioritising health and human rights. Countries that have been fighting the ‘war on drugs’ in Latin and Central America have seen a major wave of violence, corruption and instability. At least 60,000 violent deaths are estimated to have occurred in Mexico, for example, in the last ten years since the war on drugs was scaled up.
The gaps mentioned above keep widening in all regions. As the world now prepares for a special session of the UN General Assembly on drugs in 2016, it is time that the consequences of criminalising drugs are acknowledged by the international community. And it is also time for the international community to consider shifting drug policies towards decriminalisation of drug use and possession.
REFERENCES IN THIS ARTICLE
28) DOI: http://dx.doi.org/10.1016/S0140-6736(11)61097-0
29) UN Office on Drugs & Crime: http://www.unodc.org/
30) The Global State of Harm Reduction 2014. Harm Reduction International