By Dr. Delon Human, President & CEO, Health Diplomats, Adviser to the UN Secretary General and former Secretary General of the World Medical Association; Author: Wise Nicotine
Dr. Human argues for a more evidence-based approach to harm reduction and a move away from the morals-based discussions of the past. Evidence for the benefits of harm reduction will need to be produced for harm reduction efforts to be sustainable, but these benefits cannot be ignored – as the binary ‘quit or die’ approach demands.
Unfortunately, harm reduction has engendered some debate and controversy. The majority of the public health community still advocates abstinence as the only defendable goal, paramount to a ‘control or ban’ approach. The underlying philosophy is, for example, that we should all work for a drug-free or tobacco-free world. If we accept any kind of drug use to help reduce harm, it would be tantamount to accepting drugs into mainstream society. There are also concerns that these harm reduction techniques might lead to increased initiation of use, decrease in the cessation of harmful substance abuse, relapses for former addicts and the “normalisation” of drugs in society. For many, asking them to agree to free methadone clinics is akin to asking them to legislate for drug consumption. But it is vital that the global science community fully embraces harm reduction.
On a historic note: harm reduction is just common sense science
It is incredible to think that due to the absence of harm reduction science and practice during the 19th century, women in childbirth were dying at alarming rates in Europe and the United States. Up to 25% of women who delivered their babies in hospitals died from childbed fever (puerperal sepsis, later found to be caused by Streptococcus pyogenes bacteria). In 1843, Dr. Oliver Wendell Holmes in the UK postulated that these infectious diseases were transmitted to their pregnant patients through the hands of their doctors. In the late 1840s, Dr. Ignaz Semmelweis of Vienna came to the same conclusion. In the maternity wards of a Vienna hospital, he noticed that the mortality rate in a delivery room staffed by medical students was up to three times higher than in a second delivery room staffed by midwives. The reason was simple – the students did not wash their hands after leaving the autopsy room and were transmitting an infection from their cadavers to the women in labour. Both Drs. Holmes and Semmelweis, against great resistance, ordered their staff to start washing their hands with a chlorinated solution before touching patients, one of the first examples of harm reduction in Europe. In the Vienna wards, the mortality rate eventually dropped to less than one percent.
Today, the United States Centers of Disease Control and Prevention (CDC) call “hand-washing the single most important means of preventing the spread of infection.” The World
Health Organisation (WHO) now devotes substantial time and resources to prevention in this area with such initiatives as the annual “Global Handwashing Day”. It is believed that ingraining the habit of washing hands with soap before eating and after using the toilet would save more lives than any single vaccine or medical intervention, cutting deaths from diarrhoea by almost half and deaths from acute respiratory infections by one-quarter. Habitual hand washing with soap would make a significant contribution to meeting the Millennium Development Goal of reducing deaths among children under the age of five by two-thirds by 2015.
What is harm reduction today?
It is useful to first understand the context of harm reduction within public health. Public health science aspires to prevent disease, prolong life and promote health. It does this through the organised efforts and informed choices of society, organisations in both public and private sectors, with more focus on prevention than cure. In public health, the interests of the population weigh heavier than that of the individual, which can cause tension between public health and the health professions, who tend to focus more on the interests of the individual.
The term ‘harm reduction’ refers to policies, programmes, projects and interventions, which aim to reduce the health, social and economic harms associated with the use of psychoactive substances, without necessarily expecting a reduction or cessation of use. It therefore recognises that there will probably always be people who engage in activities carrying risk. In democratic societies there are often tradeoffs to be made and harm reduction is a significant public health alternative to outright prohibitions and bans.
Below are several examples:
- The use of condoms and other preventive measures for dealing with HIV and other sexually transmitted diseases;
- Needle exchange programs to reduce disease and deaths for drug users;
- Tobacco harm reduction, where harm is reduced if consumers reduce consumption or switch from the most harmful tobacco products (combustibles such as classic cigarettes) to smokeless tobacco (e-cigarettes, snus) or even better, pure nicotine alternatives such as nicotine replacement therapy;
- Alcohol harm reduction (responsible drinking);
- Hand washing in certain hospital and societal settings;
- Reducing environmental emissions and discharges (not total elimination) as steps to controlling and improving air and water quality, including providing industry with incentives for reducing such emissions;
- Requiring the use of seatbelts and other safety requirements in automobiles etc.
Why is harm reduction often a controversial subject?
The problem is that there will always be people who engage in risky behaviour, no matter what the consequences to themselves or others might be. We do not live in a perfect world where legislation or enforcement produces the desired results. Those who support the principles of harm reduction seek to reduce or mitigate the health risks associated with these risky behaviours, rather than to eliminate them. They believe in advocating what I see as the four stages of harm reduction: don’t start, stop, don’t harm others, and don’t harm yourself. It is this fourth and final stage that is hard for many to swallow, essentially why help the people who chose this lifestyle?
Those of us who belong to the rational middle ground in science understand that not all of the one billion smokers the WHO expects to die from their habit in the 21st century are to blame for taking up this habit. Evidence suggests that 7/10 are trying to quit. The same can be said of ‘drug addicts’ addicted to prescribed pain-killers. Based on known science, if policy-makers can oblige the producers of harmful products to remove some of this known harm at the source (e.g. salt in processed foods, toxicants in tobacco plants etc.) or to create the research conditions for them to innovate less risky products, surely this is where common sense should be leading us? Unfortunately, this is very often the case.
Harm reduction also highlights the conflict between societal and individual interests in health care. What constitutes harm reduction for an individual may not necessarily result in a net decrease in harm for society as a whole. If a product is only marginally less harmful, but a larger proportion of the population uses it, the end result could be an increase in societal harm. A good historical example is fat-free foods. If the reductions in risk are large, however, there is likely to be a public health benefit even with a large increase in use. For example, the current UK and Irish debate on a unit-based price control on alcohol.
Broad strategies used in harm reduction
Looking at those harm reduction areas where every citizen on the planet stands to gain the most, such as drugs, alcohol and tobacco, some broad strategies are employed:
- Supply reduction: Aims to reduce the availability of substances and interventions, to target production and distribution (E.g. points of sale, liquor licensing hours, smoking bans, prosecuting the ‘traffickers’ of alcohol, tobacco or illicit drugs);
- Demand reduction: Aims to reduce demand for substances, leading to no use, less use, fewer users, or fewer high consumption users. Interventions target consumption (E.g. anti-drinking/smoking/obesity public information campaigns);
- Harm reduction: Aims to reduce harms associated with an activity or substance use and interventions target risk (E.g. distributing free condoms, wash your hands campaigns, reduced risk components e.g. improved filters).
In alcohol, further areas are targeted to reduce harm, e.g.:
- Structural: targeting macro level influences on behaviour such as laws, policies and allocation of resources designed to affect the total population or segments of it;
- Community: targeting the context in which substances are used and social norms;
- Individual: targeting the individual substance or potential user to change their behaviour. For example, in Canada some studies have shown that serving chronic street alcoholics controlled doses of alcohol reduced their overall alcohol consumption.
Tobacco harm reduction
Although nicotine is the major addictive substance in tobacco products, it is also unfairly given the major blame for the disease and death caused by tobacco products. In terms of toxicity, it is the smoke that kills, not the nicotine. Tobacco harm reduction is taken to mean encouraging and enabling smokers to reduce their risk of tobacco-related illness and death by switching to less hazardous tobacco products. This switch could be short-term or long-term, partial or full, with the understanding that every time an alternative tobacco product is used in place of a cigarette, risk of tobacco-related illness and death is reduced.
Harm reduction in AIDS
The current course of the AIDS epidemic will only change if people infected, and those at risk of infection, make a concerted effort to adopt preventive measures. Harm reduction is well suited to play a positive role in AIDS prevention. Certain types of risky behaviours, such as unprotected sexual intercourse and sharing of hypodermic needles, exponentially increase the risk of contracting HIV and AIDS. Containment of the AIDS epidemic thus depends to a large degree on effecting change in behaviour and lifestyle to break the chain of transmission. Countries such as Uganda where HIV transmission was targeted using the so-called ABC message (“abstinence, be faithful and if you can’t, use a condom”), are a good illustration of the benefits of a harm reduction programme. Abstinence is undoubtedly the most effective preventer, but condoms to practice safer sex were recognised as useful in reducing transmission rates.
The future of harm reduction
Although the need for and benefits of harm reduction science, practices and policies seem compelling, health policy needs to change and support harm reduction and “safer products” for them to become successful. The challenge will be to strengthen research, harmonise evidence-based regulation between the EU member states and foster the development of consumer acceptable safer products.
It is encouraging to see a shift from a morals-based discussion about harm reduction to its scientific roots. This will ultimately provide a more robust framework for a discussion and evaluation of risky behaviours, risk differentiation and potentially reduced harm products, and how best to manage these risks in our modern society. The sustainability of harm reduction as a policy will also depend on how evidence validates its benefits for the individual and society. What cannot be tolerated is an ongoing indifference to the potential benefits of harm reduction, especially in the field of drugs, alcohol and tobacco. If there is clear scientific evidence that individual and societal benefit is gained from harm reduction, this should be fully embraced.