Meeting the Challenge: Implementing a Comprehensive Public Health Approach to Illegal Drugs

Organized by the Canadian HIV/AIDS Legal Network and Transform Drug Policy Foundation

Donald MacPherson, Canadian Drug Policy Coalition
First principle of the treaties is protection of public health. There has been a growing discussion of public health at the CND.

Milton Romani, National Drug Coordinator, Government of Uruguay 
Public health is coherent with the objective of the conventions, but with one disclaimer. The objective in the conventions explicitly say that we have to protect the public health and welfare of humankind. Public health is more than that. It is a human right that governments are obliged to provide for their citizens. The other objective in the conventions is to combat illicit drug trafficking. In Uruguay, these objectives of public health, human welfare, and combating illicit drug trafficking are at the forefront of the new law which regulates the marijuana market. A flexible interpretation of the conventions should fit in line perfectly with human rights. In the case of incompatibility, human rights and health trump the drug control instruments. The challenge that we still have in many countries is that consumers, problematic and unproblematic, are not yet focuses of public health. Treatment and rehabilitation must be accessible in all centres of health, not only in specialized centres and certainly not in forced centres. A public health approach also needs to be applied to criminal justice. We cannot apply the criminal justice law to every aspect of the chain from drug production to drug consumption. Experiences all over the world, especially in Latin America, demonstrate that indiscriminate application of criminal law does nothing but increase the violence on individuals. In Uruguay, the use of drugs for personal use has not been criminalized since 1974. The new law allows marijuana consumers not to have to go to the black market. This proposes a safe space for consumers, where we are able to reduce ham and manage the risks of use. The complex social phenomenon relating to drugs has to be motivated and guaranteed by a human rights framework on the part of the state. Our current framework has done nothing to ensure human rights. To end with an anecdote, in 2005, I was told something that impacted me. When Donald MacPherson was responsible for drug policy reform in Vancouver, he said “Look Milton, in one year we have 180 deaths for overdose. That’s what made me institute a supervised consumption room which saved lives.” This taught me that public health has to be on the forefront.

Richard Elliot, Canadian HIV/AIDS Legal Network

Two topics: relationship between public heath and human rights, and three specific aspects of a public health approach to drug policy. First, on a basic level we need to recognize that adopting a public health approach is mandated by state’s human rights obligations. Recognized by member states themselves. In the implementation of public health programs, those programs themselves must respect human rights obligations. Now it is often said that a public health approach needs to be taken, but what that means is still quite contested. Second, there are different aspects of the public health approach including harm reduction, decriminalization, and regulation. On all three fronts, there is the need for revisiting the current regime to question how well it actually facilitates these dimensions of a public health approach. Now clear that harm reduction can be accommodated without too much difficulty in the current regime. Needle syringe programs, opiate substitution therapy, drug consumption rooms, and other harm reduction measures can be accommodated within the conventions. It is fairly well settled that you can implement harm reduction without violating the conventions, whether states actually do that is another matter. However, harm reduction alone is insufficient to a public health approach. We also need decriminalization. There is a reasonable case to be made, that in fact the existing treaties can be properly interpreted to permit decriminalization in various ways. The conventions say the obligations to criminalize certain activities are subject to the constitutional principles of member states. This is the key basis for member states to implement decriminalization. However, this is still a long way off for many member states. Regulation as the third aspect is where we run into even more difficulty. Certainly open to member states, as Uruguay has shown, to seek out a flexible interpretation. However, this is very much the exception and subject to much criticism, which means we need to revisit the regime. On all three of these elements of a public health approach, the regime acts as a barrier as it is biased against them. This is some cause of concern as the evidence amounts in favour of these elements.

Lisa Sanchez, Mexico Unido Contra la Delincuencia
Speaking from the perspective of production and transit countries, rather than consumption countries. Health and well-being of others who are not active drug users are as important as drug users. We often lose sight of the entire chain from drug production to consumption, which leads us to focus only on the end of the chain. Need to focus on the whole population when speaking about public health. Mexico has less than 1000 people dying per year of drug-related deaths. The number of homicides related to drug control or enforcement was 300 in 2007 and increased to 10,000 per year now. These are the preventable deaths that we need to focus on from a public health approach in Mexico. 8 per 100,000 in 2006, now reaching levels of 27 per 1,000 homicides. Three times above the level of homicide that we had before. Public budgets reflect a punitive approach to drug policy. Money that goes to enforcement every year has been steadily increasing in Mexico since declaring the war on drugs. Public health budget hasn’t increased at all. In designing people-oriented public policies, we are talking about rebalancing this asymmetry. Incarceration is also a problem of public health. Drug offences are considered crimes against health in Mexico. 80% of those incarcerated in Mexico are drug consumers or low profile dealers. Of all the problematic users, most don’t have access to public services to treatment, let alone harm reduction services. 97% of our injection drug users are Hepatitis C positive, with no public health response to that. Prevalence of use has only increased 0.2% and the number of people killed since declaring the war on drugs is a very significant increase. Can’t forget that in some countries, drug policies kill more than drugs themselves. Countries have obligation to protect these people, even if they are not directly related to the drug phenomenon.

Steve Rolles, Transform Drug Policy Foundation
There is a lot of public health rhetoric at these meetings. Seems that overwhelmingly the enforcement side of international drug control is counterproductive, doesn’t deliver any useful outcomes, and undermines the things we are trying to achieve. Public health approach is evidence-based. Can’t balance something that works against something that doesn’t. Public health approach deals with reality. A lot of discussions at the UN do not deal with reality. We do not live in a drug free world and are never going to. Need to start from this basic assumption. Key element of the public health approach is to do with identifying public health risks and seeking to mitigate them. Target our efforts at vulnerable groups. Enforcement approaches do not do that. They exasperate existing harms and create new harms. Harm reduction has achieved a great deal, so increasingly it is not a controversial issue. Very much the norm now and a wealth of evidence exists. Same with decriminalization. UNODC and INCB have been clear about decriminalization. Other UN agencies have advocated for this. Regulation have remained highly contentious, and to some exists outside of what is allowable within the treaty framework. Regulation is very much a core part of a public health agenda. Public health challenges are associated with the illicit nature of drug production and supply, as well as consumption. We are diverting resources from what we know works, like public health, towards enforcement which undermines public health. Need to look at regulation of licit substances and realize that in a regulated market we are able to intervene and identify risks and mitigate risks in ways that we can’t in the illegal market. Key thing about regulation is it allows you to intervene to achieve better public health outcomes, you can control potency, put health information on packages, etc. Young people can access drugs in an illegal market, but they can’t in a regulated market that has age limits. Can control the supply of that market, how late places are open, advertising, etc. The framework convention on tobacco is an international regulatory framework for non-medical and non-scientific uses of a drug. Regulation is achievable. Regulation also creates a policy and legal environment which enables other public health interventions. Facilitates public health both by freeing up resources from enforcement, but also creates an environment induced to evidence-based and rationale thinking. Driven by science, rationality, compassion and human rights. The impact ending the war on drugs can have on the nature and form of the debate on the policymaking process itself is significant.

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