The impact of drug policy on public health

Side event organised by UNAIDS, OSF and Harm Reduction International

The Swiss experience

In Switzerland, the approach is humane and there needs to be a radical rethink of our drug policies.

Chair

All UNAIDS co-sponsors are on the panel at the moment. And this is really important. I am not an expert in drug policy, but I have accumulated a lot of knowledge about it. But nobody knows the UN drug conventions better than my colleague Simone.

Simone Monasebian, UNODC New York Office

This meeting is important because of the UNGASS, as well as because of the post-2015 development agenda. In Goal 3 on ensuring healthy lives, there is a goal on increasing prevention and treatment for substance abuse. I spent some of my carrier with people caught for drug use and trying to prevent them from going to prison. Today’s thematic debate is an important roadmap for the UNGASS. The 2014 JMS focuses a lot on health. We saw the importance of availability of controlled drugs for medical and scientific purposes, while avoiding their diversion. The JMS also considers addiction as a health issue and the consideration of measures to reduce health consequences of drug abuse. One of the five interactive roundtables at the UNASS will focus on health. UNDP, WHO and UNAIDS are very much engaged in the process. If you go on the UNGASS website you can find their contributions.

One of the primary aims of the conventions is guaranteeing their availability for medical and scientific purposes. The issue is the treaties’ implementation. UNODC supports member states to achieve availability of essential medicines, we also promote HIV prevention interventions as well as drug prevention and treatment. One of the ways to place health at the centre of drug control is by showing work being done on the ground, sometimes in partnership with other UN agencies and CSOs. In Cambodia for example the government is moving away from compulsory detention and we promote community-based treatment in collaboration with NGOs. In Ghana we have a pilot programme with WHO on how to promote access to controlled medicines while preventing abuse and diversion. Several workshops were implemented on drugs. We also have set up a list of high priority countries for HIV and drug use. We also conducted trainings with law enforcement officers on HIV and injecting drug use. We are organising a series of roundtables on HIV and drugs to feed into the UNGASS debate.

One of the reasons why people are being left behind is because of criminalisation. Kasia will talk about how drug policies can be changed so that we can reach out to people who are most at risk.

Kasia Malinwska-Sempruch, OSF

I come from the HIV field. At that time, when we started to work on drugs issues, I was mesmerised because there was such a potential for success. When you talked about sex work, people don’t want to use condoms. And there was no anti-retroviral treatment. So when I came in the HIV world working on drugs issues, we had something to offer that people wanted. I never met a drug user saying they didn’t want a clean needle. So HIV prevention among drug users were effective, cost-effective and people wanted them. Ruth Dreifuss showed the Swiss successful example. So why haven’t we made any progress? We are failing. The discussion about how do we inspire political will to make sure that they realise how much these interventions are needed is necessary. For overdose, we have effective interventions but people continue to die. So here again, what is going wrong? We often talk about how Western Europe has managed to deal with the issue of HIV among IDUs. We often look at the global south with more worry because harm reduction is less available. But the issue is more complicated. If you look at Eurasia, OST continues to be unavailable in Russia. In the USA, the federal government voted against funding for NSPs. So there is something happening politically that creates barriers to harm reduction.

Outside of HIV, Brazil developed interventions for stimulant use. These are not health interventions, they include availability of housing. We have an opportunity ahead of us to identify and widen the net of services to make sure that health outcomes for people who use drugs are the best possible. Some people are not ready for treatment but should be offered the services they need.

We always hear a dichotomy between health and criminal justice. But it is important to define health because we are learning that what health means in Switzerland is different from what it means in Vietnam. There are many publications documenting treatment facilities where people are in forced labour. We must be clear and articulate what is health and what is an abusive practice.

Finally, we recently read in a WHO report that aerial spraying may cause cancer. There needs to be serious discussions about the data, but at the end of the day we are talking about the health of people who are involuntarily forced into these interventions, and we should make sure that health is the leading goal. We need serious discussions with affected communities so that they are part of the debate at the UNGASS, and the discussion should be broad.

Maria Phelan, Harm reduction International

The rhetoric around drugs is not new, but we need to be very clear about what we mean about health, as was said by Kasia. There are important events taking place around the issue that we must take note of, including a high level meeting on HIV and the post-2015 development agenda.

We must see strong leadership around the UNGASS to talk about why health is so important. We need success indicators that match this. We know that harm reduction is effective, promotes dignity and human rights, have achieved consistent outcomes across the world with reductions in HIV and mortality and in crime. But full recognition of HR at international is still not achieved. This affects our capacity to reach critical health and development goals.

We talked about the UN target to halve HIV by 50% among IDUs. We will miss this target by 80%. It is a disgrace and we are now facing a full-blown hepatitis C epidemic among IDUs. Overdose deaths are also preventable and prevention measures must be scaled up across the world. If we are talking about the end of AIDS by 2030, I fail to see how this can be achieved.

We cannot end a drug free world, and in 2016 the targets should be set on what can be achieved. We are calling for a harm reduction decade, we need new measurements of success that reduce the health and social harms of drug use. It also needs increased funding. We must rebalance funding. An estimated US 100 billion is used for drug law enforcement every year. 160 million are needed for harm reduction, yet only 7% of what is needed is available. We call for 10% of current funding to be directed towards harm reduction and healthcare.

Recent shifts in funding by international donors has contributed to this concerning situation, in particular the Global Fund’s new funding mechanism. Evidence is clear that middle-income countries will not necessarily step in when global funding withdraws. There is a collective denial of the rights of people who use drugs.

We need more data on drugs, through a transparent mechanism. And finally, we must end the criminalisation of people who use drugs. It fuels HIV, overdoses and mass incarceration. People who use drugs retain all their rights, including their right to health, to be free from torture. This includes access to harm reduction in the context of human rights as recognised by a range of UN human rights entities. Harm reduction is included in the UN comprehensive package on HIV prevention among IDUs. It should be a core obligation of member states to meet their international obligations. Harm reduction has the rights and dignity of the person at its core. This is why Harm Reduction Coalition is launching a series of videos to highlight this.

Mandeep Dhaliwal, UNDP

All the UN family was brought together within a UN task force. We started our engagement and it was rather slow. We were finding connections everywhere. We were instructed to produce a UNDP position on the issue. We had a range of colleagues working with us to crystallise these findings. We know that health shapes development, and development shapes health. Sustainable drug policy also shapes sustainable development, and vice and versa. A number of member states are experimenting with new approaches. And what is interesting is that many policy solutions are found in the health and development spheres. But an area that has not been looked at is how to treat the root causes of involvement in cultivation or use. Reducing poverty and improving social inclusion can have significant positive outcomes. We must understand what draws people into the drug trade.

One of the things we found was that cultivation and involvement in the drug trade had a strong link to poverty, for groups who don’t have other opportunities. Racial and ethnic minorities are particularly vulnerable. Incarceration in turn fuels vulnerability and social exclusion. It has a negative effect on health and human rights. We heard also about forced aerial spraying and the health and environmental harms related to it. We know that most countries in the world cannot afford to treat cancer, so we really need to take the evidence from WHO seriously.

We see that women are too often involved in the drug trade because of limitations to their education and inclusion. Incarceration has a significant impact on them and their children. And for harm reduction, most services are targeted at men. We need to look at the impact of policing and incarceration. By UNGASS we should have a document that draws a picture of these impacts.

So the link between drug policy, health and development is complex. It’s not just about treatment or prevention, it requires a complex response and move beyond law enforcement focused too much on reducing supply and demand and not enough on people involved in the trade and use.

Sustainable development presents an opportunity and must work in concert with drug control policies. Both the STGs and the UNGASS present a valuable opportunity for member states, UN and NGOs to engage in a debate involving the world and focusing on evidence. But it must be driven by people affected by drug policies.

Werner Obermeyer, WHO New York Office

The definition of health by the WHO is clear. It implies a comprehensive and integrated public health approach needed to protect people from harms related to drug use. It emphasizes partnerships in health provision. It goes beyond specific interventions for specific health conditions. We must ensure access to early interventions, prevention, harm reduction, care and treatment. There are several health caveats. We work in the following areas with other UN colleagues to ensure access to controlled medicines for medical use, ensure access to prevention strategies, promote a public health response to HIV and drug use, review of substances by the ECDD and the impact of drug use disorders on the population’s health.

We are in agreement that addressing the world drug problem requires a multidisciplinary approach. WHO has worked in the field since the mid-1980s. We aim at limiting illicit drug use, limiting harms, end stigma and violations of human rights. We also focus on the protection of young people and youth from health problems. UNESCO, UNODC and others are working with WHO to disseminate prevention and substance use interventions among youth.

WHO has published several guidelines and tools that deal with addressing structural barriers to access to healthcare and alternatives to incarceration for minor drug offences, that integrate human rights standards. Access to HIV prevention and treatment is critical. We also promote access to essential medicines and work with countries to rebalance their drug policies. It is a cornerstone of WHO’s policies. At the same time, it is unfortunate that so many people die of overdoses from opiates and this needs to be addressed. Drug policies always need to be guided by the scientific knowledge we have collected to deal with health consequences. We must evaluate the impact of drug use and disorders, this is key to lead on our policies.

Ninan Varughese, UNAIDS
UNGASS presents a unique opportunity for all to discuss what has worked an whether our policies are aligned to achieve common objectives. We reaffirm our commitment to public health. Our call for a fourth pillar focused on health is in line with this objective. A public health approach to drug control saves lives and produces a return in investment and promotes human rights. Life-saving harm reduction measures should be implemented and scaled up. Decriminalising drug use can free up prisons and remove obstacles to access to services. Supply and demand reduction as well as international cooperation are important, but public health is the missing link.

Mexico
I celebrate the thematic debate and side events taking place. They foster debate. Mexico supports a health approach. At the World Health Assembly, Mexico will host a side event on the link between the world drug problem and health.

USA
A lot of good things are happening, including in the USA, with a change in rhetoric. But we need strong institutions to make this happen. Police and the military are very good, I don’t think the organisation is as good in health ministries. A better strategy is to push for better organisation within health systems.

UNDP
I respect and understand the US comment. But countries will lots of money also need to engage in partnerships responsibly.

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