By Prof. Michel Kazatchkine, MD, Consultation Event Co-Chair & UN Secretary-General’s Special Envoy on HIV/AIDS in 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.
These are times for debate on drug policies. The call for debate came from the UN Secretary- General “In 2014, the Commission on Narcotic Drugs will conduct a high-level review. This will be followed, in 2016, by the UN General Assembly Special Session on the issue. I urge Member States to use these opportunities to conduct a wide-ranging and open debate that considers all options.”
Opening the debate is timely since the UN General Assembly has not met on the issue of drugs for more than sixteen years. So many changes have occurred in that period of time in terms of geopolitics, world economics and development, societal behavior, drug production patterns, biomedical research, and drug consumption and policies. These have also been the years where the AIDS epidemic has decimated the community of people who inject drugs and where, as a consequence many countries, particularly in Western Europe, shifted pragmatically their drug policies towards a harm reduction and public health focus.
Just the last two years have seen a significant inflexion towards more permissive policies in a number of countries including countries in Latin America, Uruguay, Mexico, Argentina, and in two Sates in the USA, Washington and Colorado that voted by referendum on the legalisation of a regulated production and consumption of cannabis. President Obama, President Santos of Columbia, and the Presidents of Mexico and Guatemala have openly called for revisiting drug policies. The Global Commission on Drug Policy, an independent group of high-level politicians, professionals and intellectuals has claimed that the “war on drugs” has failed and is calling for reform. At the same time, a number of countries have taken stronger public stands on prohibition law enforcement, including China and the Russian Federation. Canada has recently installed minimum mandatory sentences for drug use, while twelve countries still have drug use punishable by death. Overall, laws and policies e.g regarding syringe possession or cannabis, vary from country to country, States and often, even cities (see for example: http://www.reformdrugpolicy.com/cannabis-map/map/).
As the Global Commission has noted, it is time to bring to the international level an informed, global science-based discussion about humane and effective ways to reduce the harm to people and societies caused by drugs. Independent platforms, such as those organised by SciCom – Making Sense of Science, which I attended in 2012 and Co-Chaired in 2013, are invaluable in this respect. Furthermore, it is great to see science conferences such as AAAS and Euroscience Open Forum (ESOF) now beginning to include such re-thinking sessions on their scientific programmes.
The debate should first focus on challenging the dominant prohibitionist paradigm and the widespread but poorly informed belief that drug use should be dealt with through the criminal justice system. Prohibitionist policies have failed to deliver on their stated goals of reducing drug production, trafficking and consumption. One may further argue that prohibitionist policies have been counter-productive, fueling violence, corruption, violations of human rights, and diseases, including HIV/AIDS, hepatitis C and tuberculosis. Policies based on the prohibitionist paradigm are not based on evidence, not cost-effective, do not reduce drug dependence and directly and indirectly cause serious harm to individuals, societies and democracies, in addition to not reducing the individual harms caused by drug taking. Each year, hundreds of thousands of people globally die from preventable, drug-related disease and violence. Millions of users are arrested and incarcerated. Communities all over the world are confronted with drug-related crime on a daily basis.Early in the AIDS epidemic, many countries in Western Europe recognised the link between unsafe injections, needle sharing and transmission of HIV and hepatitis, as well as the importance of large-scale implementation of Harm Reduction as a public health intervention. The UK, Belgium, the Czech Republic, Denmark, France, Germany, Greece, Italy, the Netherlands, Portugal, Spain and Switzerland quickly implemented harm reduction programmes, including needle exchange and opioid substitution therapy, for which there is comprehensive, compelling, and conclusive evidence that these approaches significantly prevent the risk of acquiring HIV, decrease overall drug-related mortality, increase life-long prospects of quitting drugs, and increase the chances that an individual will find work and live a normal family and social life.
The epidemiological evidence is clear: in countries that have adopted harm reduction and health-based approaches to drug use and addiction, the HIV epidemic among people who use drugs has declined, as we have clearly seen in Western Europe, Australia and Canada. In countries and regions that have neglected harm reduction and relied on ineffective and aggressive drug law enforcement, the HIV epidemic has not declined among injectors, as we see in Thailand, or, in the even more worrying case of the Russian Federation, the epidemic is rapidly expanding and spreading to the general population. In just the last three years, we have also seen how a decrease in funding and implementation of harm reduction programmes can lead, within just a few months, to HIV epidemic outbreaks, as has been the case in Romania and Greece.
This is why the World Health Organisation (WHO), UNAIDS and the UN Office on Drugs and Crime (UNODC) jointly recommend a package of Harm Reduction interventions, including needle exchange, substitution therapy, information and education, overdose prevention, and engagement of people who use drugs in decision-making - to which I would add - safe injection sites. It is remarkable, as discussed in SciCom’s first compendium on Harm Reduction Science, that despite the evidence and these recommendations, a number of countries, particularly in Eastern Europe, still do not accept the evidence to base their policies. We too easily look to name and shame countries like Russia and the Ukraine which are certainly far behind in their thinking and approach, but closer to Brussels, many member and neighbouring states are failing in their duty of care.
It is highly unlikely in my view that the conventions will be revisited in 2016, but that should not prevent the international debate from largely refocusing on reducing harm as an essential component of drug policy. That implies to recognise that the goal of “a drug free world” does not make sense and that it is time to de-link the drug policy debate from the criminal issues that are just one component of the drug problem and frame it in a broader agenda of human and economic development, and public health.
It implies reframing the goal of drug policies to address the reality of drug use, and experimenting and moving to new and alternative policies. It also means establishing a new set of indicators and metrics to measure the outcomes of policies at the country and international levels. We can no longer rely on largely irrelevant data such as the number of seizures, arrests and incarcerations. Instead, we need to use indicators that really matter in civilised societies: decreasing drug addiction, expansion of health services, improved health, reduced criminal violence, and safer and more peaceful communities.
Furthermore, different drugs generate different harms, and the international community should also revisit the current classification of the “dangerousness” of drugs. This could prevent some of the shocking disproportion that exists between “objective” harm and sentencing, and serve as a basis for further experimental regulation. As proposed in the European’s Commission recently issued draft regulation, “policies on new psychoactive substances should be based upon the principle of proportionality in relation to risk of each substance”.
I applaud that approach and also the engagement shown by Directorate-General Justice, Fundamental Rights and Citizenship in accepting a presenting role on our Drugs Panel at the High-Level Consultation Event. The European Parliament’s Science & Technology Open Assessment Panel (STOA) were also represented unofficially by MEP Vittorio Prodi who made a stirring intervention, while CSA Glover sent her No2. DGs SANCO, RTD and JRC were unfortunately not represented when surely they have an obligation to get involved. We must keep this momentum going, hold our elected officials, our nominated Commissioners, Presidents and their civil services to account and get Brussels to acknowledge and take leadership in the forthcoming debates. Europe is a major consumer of drugs, and thus a major driver of the drug market. It is also the home of some of the best examples of evidence-based, people-centered, public health-driven policies.
Finally, these considerations also imply that the debate is opened around decriminalisation of possession for personal use. There is now also compelling evidence about the multiple harms caused by the criminalisation of users, ranging from the devastating consequences it has for the individual with regard to stigma, health and employment, to overburdening of courts and prison systems and rising costs for society. Many studies have documented how policing practices such as syringe confiscation and police crackdowns increase the risk of unsafe injections and how incarceration itself leads to elevated HIV risk because of ample access to drugs in prisons and absence of access to safe injection equipment. Removing the fear of criminal repercussions is also a pre-condition to the effective implementation of a public health approach. Decriminalisation means stopping the arrest and incarceration of users: it implies that the solution to the drug problem cannot be found in a criminal justice approach and that there is an urgent need for alternatives when people who use drugs have not otherwise committed crimes.
Europe has experience here and assembled evidence showing that de jure or de facto decriminalisation (which is now in place in up to 30 countries in the world) does not result in increased drug consumption and violence. Rather, it ends the poisonous and dysfunctional conflict between public health and law enforcement, and increases users’ access to prevention and treatment services. Portugal, Switzerland and the Czech Republic are particularly well placed to discuss this evidence in the public debate. Several countries in Europe can provide some of the best evidence to support the switch from prohibition and law enforcement to a comprehensive set of human rights-, social- and public health-based policies that ensure access to prevention and treatment and involve “smarter” law enforcement that safeguards human rights and ensures citizen’s security.
It is time for debate and it is time to change course. Governments must approach the UN review process with an open mind, a spirit of shared responsibility and a commitment to do drug policy better. As former President of Brazil Fernando Enrique Cardoso and Kofi Annan recently wrote: “The fact is that today we know what works and what does not. It is time for a smarter approach to drug policy. Putting people’s health and safety first is an imperative, not an afterthought”.