The history and Principles of Harm Reduction by Médecins du Monde

Between public health & social change

THE HISTORY & PRINCIPLES

OF HARM REDUCTION between public health & social change

The History & principles of

Michel Foucault, Dits et écrits

harm reduction

“My point is not that everything is bad, but that everything is dangerous, which is not exactly the same as bad. If everything is dangerous, then we always have something to do. So my position leads not to apathy but to a hyper- and pessimistic activism. I think that the ethico-political choice we have to make every day is to determine which is the main danger.”

with contributions from Christian Andréo ⁄ Olivier Bernard ⁄ Paul Bolo ⁄ Jude Byrne Anne Coppel ⁄ Marion David ⁄ Jean-Pierre Lhomme ⁄ Niklas Luhmann Olivier Maguet ⁄ Frédéric Menneret ⁄ Pat O’Hare ⁄ Fabrice Olivet Erin O’Mara ⁄ Steve Rolles ⁄ Nathalie Simonnot ⁄ Alex Wodak

10 €

THE HISTORY & PRINCIPLES

OF HARM REDUCTION between public health & social change

Christian Andréo Olivier Bernard Paul Bolo Jude Byrne Anne Coppel Marion David Jean-Pierre Lhomme Niklas Luhmann Olivier Maguet Frédéric Menneret Pat O’Hare Fabrice Olivet Erin O’Mara Steve Rolles Nathalie Simonnot Alex Wodak

Table of contents 5 Foreword 6

Preamble

Harm Reduction: archipelago thinking Frédéric Menneret

References

Harm Reduction: between a humanist approach and innovation Olivier Bernard

Harm Reduction and drug use: between prohibition, public health and societal rules Anne Coppel

Testimonies

31 From local to global: a short history of Harm Reduction Pat O’Hare

Harm Reduction at MdM: an unshakeable commitment Nathalie Simonnot

42 Sexual Harm Reduction: the experience of the organisation AIDES Christian Andréo

Harm Reduction and the evolution of the patient/doctor model, a person-centred approach Interview with Jean-Pierre Lhomme & Paul Bolo

55 Nothing about us without us? I don’t think so! Drug user activism and the International

Network of People Who Use Drugs Jude Byrne

Drug user self-support: a junky story Fabrice Olivet

Women of substance Erin O’Mara

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PERSPECTIVES

79 Contextualising Harm Reduction among female sex workers: the moral and political

issues of how society treats a stigmatised activity Marion David

90 A combined social prevention: Harm Reduction and HIV/AIDS prevention in times of

emerging bio-medical prevention methods Niklas Luhmann

What Harm Reduction needs is a seronegative status! Olivier Maguet

110

Harm Reduction and law: the impact of criminalisation on public health Alex Wodak

120

Decriminalisation and legalisation Steve Rolles

127

Table of illustrations

Foreword

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arm Reduction (HR) is a recent and remarkable development which, for thirty years, has been supported by a range of players with differing profiles: health professionals, drug users, researchers and human right activists. Médecins du Monde is among those involved in Harm Reduction in France and around the world. Working within the organization, we have observed that much of the history of Harm Reduction – remains to be written. We felt it was essential, therefore, to produce a collection of texts setting out and clarifying the history and issues relating to Harm Reduction from different perspectives. Indeed, what was needed was not only to transmit the knowledge acquired over more than twenty years but also to contribute to the debate about how HR should evolve. It is our intention in this collection to address those with HR experience and to support those just starting out in the field, who wish to enrich their knowledge. You will find several illustrations throughout this book. Certainly, there is a rich iconography on drugs, drug use and people using drugs – especially in the 20th century. Our subjective choice for illustrations was influenced by two criteria, echoing two major themes raised in the different texts. The first was to ensure that the images reflected a strong feature of the 20th century regarding drugs: negative social representations associated to “drugs” as a social behavior. Therefore, you will see some illustrations referring to “vice”, “insanity” or even “criminality”.

The second was to demonstrate how that which currently appears as forbidden has in the past been accepted – and not such a long time ago. Therefore you will discover some illustrations referring to legal consumption of what are today illegal substances. More specifically regarding the different texts, they have all been written by a different author, with all of the authors being involved in HR work and having differing experiences and roles in various contexts and countries. Once given the main theme of the work, the authors were then allowed free rein to write their articles as they chose. While they occasionally express diverging points of view, they nonetheless remain consistent as regards the fundamental principles and practices of HR. What emerges above all is the tremendous richness of the collection. The articles may be more or less read in their sequence and reflect the diversity of those with a stake in HR, which is itself a multi-faceted, democratic approach. Each reader should thus explore the articles as he or she sees fit, and should find them fascinating reading. Some of the texts are difficult, like the complex subjects they deal with. Others are more poetic, reflecting what may also emerge when we reach this innovative archipelago of HR. Equally, the work can be read as a handbook to refer to when questions arise in everyday HR experiences. Readers should feel free to dip into it, to put it aside and to resume reading it; and, above all they should enjoy the experience…

Preamble

Harm Reduction

Archipelago thinking

Frédéric Menneret 6 7

hinking risk and harm reduction is about taking a break in the action and refocusing, taking a step back and slowly noting what it is we are being made to do. There is an inseparability and unpredictability about all the relationships which endlessly engage us on a daily basis and within which the positions and positioning of each are tested against reality time and again. This is, at the same time, what gives us permission to reflect upon what binds us in relationships – always unique and diverse – with others, with individuals referred to as ‘drug users’, ‘sex workers’ or ‘migrants’. Doing harm reduction, being part of it, means not releasing the bond before the other person. Gesture, look and word are at once the tools of the trade and the substance of our attention, ways of taking care of or proving the solidity of the bond, and are thus the very means of providing protection. The force with which HIV struck, suddenly appearing and then conquering the world, and the ticking time bomb of the hepatitis C virus (HCV) forced us to grasp the full import of not making a mistake

Fédéric Menneret is currently studying for a PhD and was a social worker for 15 years, working mainly with people who use drugs and alongside professionals in the social and medico-social field. His career has cut across outreach and inclusion work, harm reduction and discussion spaces for social work, and has involved dealing with and supporting the public (approximately ten years), and then training and counselling stakeholders. In recent years, he has worked with various bodies targeting people using drugs – CSO Drogues et Société, CSO Charonne, CSO Parcours, Institut Saint-Laurent and Regional Drug and Dependence Information and Resource Centre in Lyon.

about when to speak and when to take action. It was essential to respond free from the constraints of pre-established frameworks and to remain vigilant in keeping words and actions consistent. Stigmatisation and a life of forced hiding were already becoming well established. Those who were most at risk busily striving in private to master the art of keeping going, sometimes of surviving, were not aware of the blow that was about to fall. The institutional strategies in place had not foreseen the sudden change in their situation. How can you stay in full control of the priorities in your life when a threat becomes too great, a danger immediate, resources scarce and your options reduced? How can we respond collectively to the physical, moral and political attack launched by a syndrome? To limit the damage, it was essential to construct an approach based on the relationship itself, at the point we were at, at the point we had reached. Reference frameworks had to be reviewed, resources redistributed, practice transformed. Harm reduction (HR) – an activist response – was thus created and today presents itself as a process and an institution where concrete responses are devised to inescapable problems as they are and not as they ought to be. Such a dynamic combines with the as yet fragile and shaky process of democratising society which, in the long term, operates in society’s interstices to unfailingly promote the rights of every individual, forgetting no-one and pushing no-one to the margins. The task is as immense as it is endless. The law of 31 December 1970 brought France into line with international agreements, which impose a ban on a range of

‘psychoactive’ substances. The regulatory recover, (…)’ (Glissant 2009) framework for the global ban on drugs In this sense, it is not about seeking an thus takes the form of a series, a list or a HR doctrine which would be the same table of contents. everywhere, but about basing one’s thinkWhile the explosive arrival of HIV suc- ing on the infinite detail of present situceeded in profoundly transforming social ations, all of them different. We can then relations, HR, for its part, is responding set about rallying all the necessary action, and bringing about quite another, equally putting it together in a collective, proviprofound, transformation. It has achieved sional approach; one created at a given an amazing feat not only in combating the moment. virus but also in tackling the dogmatic framework of reference itself, which is inexorably becoming obsolete. The cru- Pragmatism and the need to act cial attention focused by HR on social practices and skills, on how drugs are Harm Reduction is first and foremost taken, how one’s sexuality is lived out and about lived experiences, about the world the meaning given to this in the context as it is. That is its starting point. As an of multiple lives, how collective responses intervention practice, it looks and analhave gradually been adapted and the yses empirically from a pragmatic point strategies for adjusting and aiding social of view. participation – all these have turned the Pragmatism, practical thinking, may policy direction away from limits and be understood as the quest for cooperabans and beyond a simple Manichean tion such that action can be taken when and geostrategic list of product names reality imposes itself, when it sows doubts or a clinical table of sexualities. The task about beliefs and questions current prejuof developing regulations lies elsewhere, dices. Do we have to wait until those who locally; updating is inevitable, globally. In inject drugs are all dead before revieworder to preclude the criminalisation and stigmatisation of people whose practices or lifestyles are judged ‘deviant’, the funWhile the explosive arrival of HIV succeeded damentals of HR assume, by omission, a in profoundly transforming social relations, different type of thinking. Harm reduction, for its part, is responding So what, fundamentally, is Harm Reduction? What are its primary preand bringing about quite another, equally sumptions? For what is it accountable? profound, transformation. By following French writer Edouard Glissant, himself a migrant, we can situate our questioning within a view of the world which is ‘archipelagic’ and no ing drug addiction support and treatlonger ‘continental’: ment models? Those engaged in combat‘Archipelago thinking, experimental thinking, ing addiction would prefer to invent new of the intuitive endeavour, could be added to responses without waiting. When the situation forces a change of continental ways of thinking which may first and foremost be seen as system-based. With protective tactics, the perception of what continental thinking, the mind races boldly must or must not to be done alters, beginahead, but we believe that we see the world ning with questioning and then moving as a discrete block, or bulk, or jet, like a sort into action. Mobilising creative processes of imposing synthesis, just as we can see opens up new avenues, redrawing the streaming past from aerial recordings gen- parameters of action. This standpoint eral views of the layout of landscapes and places drug users in the foreground and reliefs. With archipelago thinking, we know presents them as resource people and the rocks in the rivers, even the smallest of policy stakeholders. Seized by the need to act, HR requires these, the rocks and rivers, and we examine the shadowy holes that they uncover and an intelligent grasp of the situation, an Preamble

Pragmatism, practical thinking, may be understood as the quest for cooperation such that action can be taken when reality imposes itself, when it sows doubts about beliefs and questions current prejudices.

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and migration likewise take place in the public sphere. By opposing two extremes, the absolute ideal of chaste emancipation from addiction (an abstinent freedom) and the reality of an absolute determinism steeped in forms of alienation (an absent freedom), we do not wholly understand what these uses, these practices, make us do. What do they do to us collectively? Do we really want others to be free despite themselves?

expertise that calls upon the stratagems of pragmatic reasoning, on Greek cunning ‘The question to be addressed is no longer or the Mètis (Détienne & Vernant 1974). whether we should be free or bound, but It is the search for short cuts and rhizowhether we are well or badly bound. (…) It matic approaches, rather than the oneforces us to consider the precise nature of way, signposted routes. As Michel Autès what makes us be. If it is no longer a ques(2004, pp. 252-259) suggests, the art of tion of opposing attachment and detachment, the Mètis applies to social work: it is the but rather of good and bad attachments, power of the weak that resists by deflectthere is only one way to decide the quality ing the dominant power. It has an intuiof these bonds: to ask of what they consist tive sense of the right moment to act and and what they do, and to learn to be affected strike a blow; it has the skill to move and by them. The old question directed attenfind its footing in dangerous areas, intertion either towards the subject or towards preting the signs around it. It negotiates the external world of potentially alienating its passage sometimes clandestinely. It forces; the new question focuses on things knows the trick of devising tools to help themselves, and it is from among these it keep control. And lastly, and above all, it things that it claims to distinguish between is skilled in the art of networking, of cregood from evil.’ (Latour 2001) ating and dissolving ties as needed. Such skills fashion social change, not Without going back over a diagnosis only to bring about changes in rep- of the age, we can grasp to what extent resentations that apportion shame and today’s globalised world presents itself as blame, but also in the ways of perceiving the contact point between the differences how we enter into relationships. And it is and diversities of situations of attachment. precisely in terms of the latter that these The frontiers that exist between comskills work to bring about a potential and munities allow comings and goings and collective coalescence. points of contact, as opposed to hermetically sealed divisions and manufactured judgments, like walls. In this, HR introduces a social counterRelational approach point that gives precedence to the value and social position of ties over any prescriptive superior attiThe anthropological presence of drugs, tude and cold distancing of others. The sex work and migration and the social practices employed reveal their social-reresponses to these elements marked by lations dimension and question how we intolerance lead us to question the posi- maintain relationships within them. It is tion occupied by HR in proposals for in the relationship that we seek to understand and to act, and thus to position action and in public policy. In a context that pays scant regard to ourselves. Relational positioning opens up an social intelligence, it is less society that gives the impression of being ‘addictive’ inter-subjective space, which is both than our use of drugs, which is perceived reflexive and active and within which we as individualist and utilitarian. Sex work seem to be actually linked and collective, Frédéric Menneret Harm Reduction: archipelago thinking

multiplying the ways of presenting ourselves and revealing so many facets of our subjectivity which is open to the unpredictable in our encounters.

Social injustice and proximity

for being in proximity, as one would say about someone who is available, who is not indifferent or distant, and who can be counted on. ‘Proximity thus characterises a way of being and of positioning oneself in relation to the other, which could be expressed as reaching out to the other, placing oneself before or even as close as possible to the other. What this means in many cases is going to where the other is; in other words into his or her geographical territory, into the street as well as other spaces, educational establishments, community centres, prisons and hospitals.’ (Roche 2007)

Even if we are able and know how to distinguish economic injustices from cultural or symbolic injustices, how can we avoid seeing countless connections between poverty and xenophobia, between insecurity and sexism, which are mutually reinforcing? To get beyond this compartmentalising, HR situates itself within a political This move towards openness demands vision that might be called bifocal, par- seeing beyond the stigma and the vulnerticipating simultaneously in the traffic ability, looking at the other person and of resources and in social recognition. looking at oneself from the point of view (Fraser 2005; Fraser uses the expression of the other’s strengths, resources and ‘perspectivist dualism’ which, according support; it means looking for good points to her critical theory, consists of ‘search- of attachment. ing behind appearances for the hidden Such an ethic confers on HR the responlinks between redistribution and recogni- sibility of demanding that political distion’). Redistributing wealth goes hand in course and action remain wholly conhand with promoting people. Otherwise, sistent. Such archipelago thinking ‘relates, one without the other lacks the essentials relays and records’; it does not ‘merge of social justice. So it is not a matter of what is identical; it distinguishes between reducing HR to a mere instrumental and different things to bring them more into technical intervention but of planning it in harmony’ (Glissant 2009). ■ the same way as, for example, participatory action research, according an active role to users or inhabitants and aiming it both at knowledge capitalisation and social transformation. References Consequently, the move from a social ›› Autès M 2004, ‘La Mètis du travail social’, Les to a political position is possible when the paradoxes du travail social, 2nd ed., Dunod, Paris, pp. 252-259. relational space for identifying needs and ›› Détienne M & Vernant J-P 1974, Les responses is open to different publics in ruses de l’intelligence. La mètis des Grecs, so far as it concerns them, in so far as Flammarion, Paris. they are fellow citizens. The collective ›› Fraser N 2005, Qu’est-ce que la justice position is political in that it comprises sociale ?, Editions La Découverte, p. 65. the possibility of institutional formalis›› Glissant E 2009, Philosophie de la relation. ing, which can answer for social justice. Poésie en étendue, Edition Gallimard, Nrf, Setting a value on action taken in the Paris. field of HR legitimises the contribution to ›› Latour, B April 2001, ‘Factures/fractures : de defining a public health policy upstream la notion de réseau à celle d’attachement’, Ethnopsy, les mondes contemporains de la that is adapted to reality. guérison, no. 2, p. 47, Les Empêcheurs de Intersecting downstream with penser en rond/Le Seuil. resources, with the process of the action ›› Roche P 2007, ‘Les défis de la proximité dans and with its institutional scope, the social le champ professionnel’, Nouvelle revue de and political approach involved in the psychosociologie, vol. 2007/1, no. 3, p.65. relationship is accompanied by concern Preamble

References

Harm Reduction

between a humanist approach and innovation Olivier Bernard 12 13

s a paediatrician, my commitment the experiences which have punctuated within a non-governmental organi- the history of HR in France and which sation (NGO) such as Médecins du have represented so many significant Monde (MdM) comes about naturally moments in forging the organisation’s as a result of international acts of soli- identity. Firstly, in 1987 there was the darity and fighting for access to health- opening of the first free and anonymous care in France. And yet, it was crossing screening and testing centre, followed paths with Dr Béatrice Stambul first in very rapidly in 1989 by the settlement of Kosovo and then in Marseille, on the the first needle-exchange programme. In needle exchange and methadone sub- 1994, MdM was once again a forerunner stitution programme, that I first became with the opening in Paris of a methadone aware of the extent of the challenge to our centre and, in particular, with the adaptorganisation – medical and campaigning ing of the ‘outreach’ concept to the care – represented by harm reduction (HR). It and treatment offered to PWUDs. Thus, a was also because friends had died too pilot project to administer methadone to young that I felt it was my responsibil- a public on the street came about in 1998 ity to extend the organisation’s commit- and a team toured the capital’s neighment to developing these approaches bourhoods with a mobile unit, going out to meet with those using drugs who had internationally. In addition to my personal commit- broken all ties with society. It was a real struggle ensued to make ment, MdM’s own story has been inseparable from that of HR, especially due to the importance of these measures and their effectiveness in terms of public health understood. This struggle was at last rewarded with the incorporation of HR into French public health law in 2004 as the culmination of years of commitment. It was a major milestone that made us able, from 2006, to transfer part of MdM’s HR programmes to statutory provision, with the creation of facilities for supporting and caring for people who use drugs (PWUD). A paediatrician, with a degree in medical anthropology Once HR proved its effectiveness among and public health, Olivier Bernard worked as a doctor PWUDs, it served other communities and in Nepal and then a postgraduate researcher (CNRSgroups whose behaviours and practices anthropology lab) in Cameroon. He subsequently worked as posed a risk. MdM has therefore devela paediatrician in Madagascar from 2000 to 2001, and then oped interventions with sex workers in as head of the paediatric department in a hospital closed Nantes and in Paris based on needle-exto Marseilles, France. After joining Médecins du Monde change programmes. The philosophy and in 2000, he was medical coordinator in Kosovo, followed principles of action behind these proby Guinea. Regional delegate for the Provence-Alpes-Côte grammes are those of HR, namely not d’Azur Region and elected in 2004 to the Board of Directors, passing judgement, listening and taking he held the position of president from 2009 to June 2012.

people’s knowledge into account. The programmes designed and set up in France have served as a field of expertise for programmes launched internationally. The story began in Russia in 1997, followed by Serbia. It was then extended to other countries such as China, Vietnam, Afghanistan, Myanmar, the Democratic Republic of Congo, Georgia, Tanzania and Kenya. Next steps will reach other African SubSaharan countries. In so many countries and in so many projects, Médecins du Monde teams have succeeded in recent years in developing and transferring expertise in the field of HR for PWUDs and sex workers mainly. Doing so, we are contributing to improving individual and collective health. But in addition to this, we are taking part in and contributing to advocacy work on a local and international level. This work bears witness to the reality on the ground and is helping change public policies which are often oriented towards repressive measures against such individuals instead of focusing on public health. This approach may be in line with strategic choices made by the organisation, but it is also one which continues to put into practice what we started in France more than twenty years ago.

Responding to health needs The AIDS epidemic at the beginning of the 1980s was a fundamental factor leading MdM as other stakeholders to take an interest in HR approaches. At this time no account of AIDS was taken in addiction treatment services, policies towards drug users were predominantly repressive and, lastly, it was extremely difficult for statutory health facilities to devise and implement innovative measures to tackle AIDS epidemic. This dreadful setting led professionals in the health and social care sector, PWUDs and HIV/AIDS activists to put forward and develop such measures outside the statutory sector. Twenty-five years later, the results have materialised and HIV infection among those who inject drugs (PWID) has virReferences

Once Harm reduction proved its effectiveness among PWUDs, it served other communities and groups whose behaviours and practices posed a risk.

tually disappeared in France. Faced with the hepatitis C epidemic, we have found ourselves confronted with similar problems to those at the beginning of the AIDS epidemic. Figures are talking by themselves throughout a seroprevalence study that was carried out in five French cities among 1,462 PWUDs by the National Institute for Health Monitoring and National French Agency for Research into AIDS and viral Hepatitis in 2004: it established a hepatitis C virus (HCV) prevalence rate of 60% among PWUDs as less on 11% of them were HIV positive (Jauffret-Roustide, et al., 2006). In 2007, intravenous drug consumption remained the primary HCV contamination route (Brouard et al., 2009). Despite such evidence, it is now becoming apparent in France that measures designed to inform and support PWUDs are neither sufficient and efficient, or even worst: non-existing. At the time of this book’s publication, drug consumption rooms have still not been implemented in France despite having been tried and tested elsewhere in the world. It is in response to the hepatitis C epidemic that an organisation such as MdM has chosen to support innovative and experimental interventions. Firstly in 2010 with an innovative programme that also serves as a field of research aiming to provide educational intervention focusing on the risks associated with injecting (namely “ERLI” for French programme name: “Education aux Risques Liés à l’Injection”). Then in 2012 with a huge political statement of MdM to promote an experimental drug consumption room in Paris – currently under designing.

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Promoting an innovative approach and helping develop public policy Since 1986, MdM has successfully maintained its ability to innovate in France and has seen a number of its programmes transformed into long-term operations, such as the free and anonymous screening and testing centres, established nationally in 1989, and reception and support centres for reducing harm among drug users, created in 2006. Innovating and transforming society within HR programmes refers to a general principle of MdM interventions. We may find other fields where MdM has contributed to adapt legislation as the framework of 1998 law concerning combating social exclusion as well as the creation of universal health cover. This way of inno-

Since 1986, MdM has successfully maintained its ability to innovate in France and has seen a number of its programmes transformed into long-term operations vating and transforming society are at the heart of the organisationâ&#x20AC;&#x2122;s mission. Despite these successes, there is a legislation that was definitely not adapted: law relating to the trafficking and use of drugs in force in France since 31 December 1970. This law appears more opposed to the HR approach than ever. It is being increasingly rigorously enforced, especially those last ten years: the number of arrests for drug offences is sixty times higher than in 1970 and the number of convictions for personal use has

quadrupled in twenty years. According to the Conseil national du sida (French National Committee on AIDS), drug-related policies have not brought about a reduction in their use â&#x20AC;&#x201C; this statement fits with the one of Global Commission on Drug Policy released in June 2011. Consumption of heroin and cocaine has risen in France in recent years. A change in the law is undoubtedly a critical prerequisite in underpinning healthcare and prevention policies with up-to-date scientific data; these policies must be primarily focused on reducing the harm caused by drug consumption. In the case of sex work too, legislation is a barrier to developing public health and community-based projects. Although prostitution is not illegal in France, in practice it is significantly hindered and restricted due to prosecution of the whole surrounding environment. The homeland security law of 18 March 2003, which notably reintroduced the crime of passive soliciting, resulted in male and female sex workers being driven into living clandestinely in no-go areas for law and order, where they are more vulnerable to violence, viewed as criminals and in less of a position to negotiate safe sexual relations. Current public policies increase the isolation of those involved in sex work, which leads to a distancing from health facilities, greater stigmatising and develops a feeling of impunity among those committing assaults. MdM reaffirms huge importance of the general HR principles that are as much valuable and efficient regarding sex workers as drug users: involve the individuals concerned in guiding public policy; redirect public resources devoted to combating sex work towards social and health HR programmes; Put public health expertise back at the heart of public policy. But specific situation applying to France fits in with a global trend: throughout the 20th century there has been a gradual implementation of an international policy that positions itself as a war on drugs. In its present format, this policy relies on controlling the availability of narcotic substances on the one hand and punitive

olivier Bernard Harm reduction: between a humanist approach and innovation

measures against the non-medical use of these on the other. The 2010 Vienna Declaration points out that this policy has the opposite of the desired effect of reducing consumption, while at the same time hampering access to prevention and treatment. The world’s scientific experts in the fight against HIV, who drew up the declaration, are requesting the United Nations and the international community to take note of the failure of this policy focusing exclusively on war on drugs policy; that it replace repressive policies with those promoting care; re-orientate legislation towards fighting organised crime and drug trafficking, instead of investing massively in measures to penalise consumption; and offer users a wider range of care and substitution treatments. From this point of view, MdM’s decision to develop a methadone centre in Kabul, in Afghanistan, is exemplary. This project helps introduce the concept of HR practices into one of the countries that has been most affected by the counter-productive consequences of the war on drugs policy – leading to a terrible situation where illegal activities linked to production and trafficking today represent major obstacles to any policy aimed at establishing peace, reconstruction and development. Furthermore, Afghanistan is paying a high price for this standard international policy which turns users into second-class citizens, on a legal, social and, finally, health level such as overdoses, infections, diseases associated with exclusion, impact of imprisonment etc.

Promoting outreach methods and questioning the biomedical model The emergence of HR approaches within a medical organisation like MdM is without a doubt fundamental to the way clinical methods are shaped. By acknowledging that others – drug users or sex workers – possess knowledge of their own practices, the healthcare worker begins to question anew some of the basics of the biomedical model. As a result, two forms of knowledge conReferences

front each other – that of the healthcare worker and that of the user – leading to the emergence and implementation of a jointly negotiated healthcare project. By restoring others to their place within the healthcare project as individuals with a stake in their own health, making them subjects not objects and thus free to make choices, this clinical approach notably questions the balance of power traditionally established in the relationship between the healthcare professional considered as the only expert and the patient. Despite MdM is a medical organisation, the place of healthcare workers is further questioned by involving peer workers. Due to their lives, peer workers have led makes them especially well placed to reach out to the most

The emergence of HaRm reduction approaches within a medical organisation like MdM is without a doubt fundamental to the way clinical methods are shaped.

excluded populations and to act as the interface between health professionals and programmes beneficiaries – such as sex workers, drug users and also those with severe mental illness. Peer workers have lived or are living in similar situations to the people involved. This means they have expertise in the practices and needs of these groups and enjoy a special level of trust. Involving peer workers and professional health mediators remains a marginal practice in France and should be developed. Furthermore a genuine professional qualification should be created. Internationally, MdM has opened the way to HR in numerous countries and has helped innovative programmes to be established. An example is Tanzania known as a smuggling route for heroin coming from central Asia; but the country became a major place for local consumption where an increasing number of people injecting drugs are confronted

MdM’s decision to develop a methadone centre in Kabul, in Afghanistan, is exemplary. This project helps introduce the concept of HaRm reduction practices into one of the countries that has been most affected by the counter-productive consequences of the war on drugs policy

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by injecting practices they are unfamiliar where prosecution level for PWUDs is and whose they are not unaware of the one of the highest all over the world. associated risks. This reason led MdM to As regards our history in France and implement the first needle and syringe recent developments in our activities program in Sub-Saharan Africa. internationally, we believe that HR is not This international development of only a medico-social concept enabling us our HR programmes for marginalised to tackle the phenomena associated with and prosecuted populations is naturally addiction, dependency and consumption aimed at responding to priority health as well as targeting sex workers and sexneeds, but is also, following the exam- ual minorities. Rather, HR can and must ple of what was achieved in Europe in be viewed as a powerful policy tool for the 1990s, aimed at raising the profile conducting care and prevention activiof these people and these issues and at ties and for proposing changes to regulainfluencing health policies. This is the tions and legislation that pay due attencase in Georgia where MdM has estab- tion to public health. ■ lished a drop-in centre in a country

References ›› Brouard C, et al. 2009, ‘Trends of hepatitis C screening in France through Rena-VHC and hepatology reference centres surveillance system, 2000-2007’, BEH, no. 20-21, InVS, p. 202. ›› Jauffret-Roustide M, et al. 2006, ‘Assessment of HIV and HCV seroprevalence and drugusers profiles, InVS-ANRS Coquelicot Study, France, 2004’, BEH, no. 33, InVS, pp. 244-247.

olivier Bernard Harm reduction: between a humanist approach and innovation

Harm Reduction and drug use

beTWeen ProHibiTion, PUblic HealTH anD socieTal rUles Anne Coppel 18 19

‘

ith the exception of foodstuffs, there are no substances on earth which have been so closely associated with the lives of people in every country and in every age. Humanity uses them deep in primeval forests, in leaf huts […] people use them in the splendour of civilisation. […] For some, they light the darkest night of passions with moral impotence, for others, they accompany hours of the purest joy, the happiest states of moral wellbeing or serenity’, wrote Louis Lewin in his introduction to Phantastica. Published in 1924, this was one of the first works to summarize psychotropic substances (Lewin 1928). For thousands of years, humans have indeed consumed what today we call drugs, but it was not until the middle of the 19th century that scientists grouped together these ‘artificial stimulants of the brain’ and implemented the first public health policies. At

Anne Coppel is a sociologist specialising in the field of drugs and HIV/AIDS policies. From researching to putting that research into action, she has been behind experimental projects which have helped bring about adoption of the harm reduction policy with community health activities in Paris region: the Bus des femmes, an early experimental methadone programme in 1989 and creation of a care and treatment centre in Bagneux in 1993, followed by another one in Paris in 1995. A committed campaigner, she has led the French public debate since 1993 as chairwoman of ‘Limiter la casse’, an inter-organisation collective and then of the French Harm Reduction Association. She has written numerous articles and publications and is the author of three books: Coppel A & Bachmann C 1989, Le Dragon domestique. Deux siècles de relations étranges entre les drogues et l’Occident, Albin Michel. Coppel A 2002, Peut-on civiliser les drogues ? De la guerre à la drogue à la réduction des risques, La Découverte. Coppel A & Doubre O 2012, Drogues, sortir de l’impasse, La Découverte.

the time, the main blight on society was alcohol, but by reinstating prohibition for opium and other narcotic substances, the international agreements of 1909 and 1912 created an exceptional regulatory system which would increase the intrinsic dangerousness of the products. In this way, the history of drugs, illicit by definition and as opposed to medicines, began exactly a century ago. Why was this exceptional regulatory system adopted? In what way were 19th-century health policies gradually diverted and used for the fight against ‘drugs’? Why is this exceptional regulatory system making such a comeback today? What regulations governing use are they based on? What future drug policies may be hoped for?

Before drugs became drugs The history of drugs is also that of their control. But until the 19th century and with few exceptions, people have lived with these substances without feeling that they were a scourge which needed to be fought against. In traditional societies, drugs were only evoked when being blessed. The Maya praised ‘the flesh of the gods’, the sacred mushrooms which opened the way to immortality; the Inca revered Mama Coca, the goddess of health and happiness; and it was ‘the plant of joy’ that Sumerian tablets celebrated in 4000 BCE. Considered by ethnologists like Peter Furst to be ‘founding experiences of human culture’, the use of psychedelic substances in traditional societies had a religious function which could also be therapeutic (Furst 1974). In some cultures, only the shaman had access to the sacred plant by which he physically

absorbed the power of the mind. But con- from the world of the living to that of the sumption could also be a collective expe- dead (Van Gennep 1992). In the West, only rience during festivals, which helped inte- alcohol is permitted this role of providing grate the individual into the group. There a passage from work to celebration, but is also evidence of individual use, at least there is not a celebration without intoxiin Antiquity. Helen, when welcoming the cation as these particular lines from the son of Ulysses, offered him Nepenthe, Bible show (Isaiah 56:12): ‘‘Come,’ each ‘a drug calming all anger and all sor- one cries, ‘let me get wine! Let us drink row’, when almost certainly the wine our fill of beer! And tomorrow will be was mixed with opium. The only refer- like today, or even far better.’’ (Also see ence made to the dangers of opium in Nahoum-Grappe 2010). It is also that Antiquity is to poisoning: it was only wine intoxication is necessary to bring about that prompted debate. Dionysus-Bacchus change: the constraints of daily life must was a stranger whom the Athenians be forgotten to enter into the celebrations, decided to honour rather than to ostra- the commandment not to kill forgotten cize. And Plato, in The Banquet, defends to become a soldier, the language of men wine in these terms: ‘Let us not disparage forgotten to speak with the gods. the present of Dionysus by claiming that it is a poisoned gift which does not merit being accepted by a republic. […] It will Establishing the problem be enough if a law forbids young people in the 20th century to taste wine before eighteen years of age and requires a man of under thirty years Drunkenness became a scourge in the to sample it in moderation, completely 19th century which was also the century avoiding becoming inebriated through of the first ‘epidemics’. Medical terminolexcess drink.’ For Plato, intoxication is the ogy was needed in the face of alcoholism, preserve of middle-aged men, ‘a remedy defined in 1849 as an illness by Swedish for the rigours of old age’, ‘to make us doctor Magnus Huss, and then in view of young again’, as it could be beneficial to the debate prompted by the widespread ‘give in to intoxication once or twice from distribution of opium in China. China had time to time, as Hippocrates recommends’ long been closed to external trade but (Escohotado 2003). began to open up certain ports where it sold tea, silk and porcelain. During the In addition to rejecting drugs, the mod- 18 th century, Great Britain gradually ern world finds something suspect in any developed profitable trade links: rather altering of states of consciousness. Ecstasy than paying for Chinese goods with and illumination are readily interpreted money, it insisted on supplying opium as symptoms of mental illness. As for grown in its Indian colonies in exchange drunkenness, at best it prompts laughter for those goods. Chinese traditionally but more often it provokes disgust and took opium as a medication, but did not opprobrium. Contemporary humanity, smoke or consume it for pleasure. This including when drinking, must demon- practice slowly became more widespread. strate the ability to control. Traditional Although the dangers of opium had not societies, in contrast, have cultivated dif- yet been properly identified, the Chinese ferent techniques for self-control, such as empire did not consider this trade to be fasting, solitude, absorption in a task, but in its interests and took the first step to also intoxication which opens a route to ban opium in 1729 and further measures divinity. In Les Rites de passage, first pub- in 1800. As the traffic in opium continlished in 1909, the ethnologist Arnold Van ued nonetheless, it was decided to close Gennep considers that drugs which alter the Chinese ports; the British circumthe state of consciousness provide a pas- vented the ban by means of a black marsage between different roles and identi- ket in opium, an increasingly profitable ties, such as the passage from childhood enterprise. This was the beginning of an to adulthood, from shepherd to soldier, or escalation of tension leading to outright References

In traditional societies, drugs were only evoked when being blessed.

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medicine – morphine – was being enthusiastically received by doctors and their patients, since, when injected, it immediately soothed pain. Used for the first time during the 1870 Franco-Prussian war, the miraculous drug escaped from the doctor’s surgery during the decade from 1880 to 1890 to become genuinely fashionable and associated with 19th-century fin-de-siècle decadence. The diagnosis of ‘illness’ was thus applied and morphine addiction became the first Western drug addiction. Whether involving alcohol, opium or morphine, these historical addictions were the product of industrialisation; the peasant obliged to work in the factory, the Chinese people confronted by Western culture, the countess who had to bow before the triumphant middle classes, all were forced to give up their traditional identity and the values which went with it. Adherence to traditional cultural values was to some extent overwhelmed by intoxication, but in contrast to ritualised uses, nothing guided those who were consumers towards constructing a new identity. For the peasants, as for the Chinese or the morphinées (young French women addicted to morphine) of the 19th century, the Western industrialised and individualist world was confronted by a leap into the unknown (Coppel & Bachmann 1989).

war, which the British conducted in the name of free trade, while the number of opium addicts continued to rise. China proved unable to resist and was obliged to capitulate. First came the signing of the Treaty of Nanking [or Nanjing] in 1842, which obliged China to open five ports and to pay war reparations. The financial consequences of the war proved a heavy burden, but the distribution of opium continued. Even in Great Britain a debate opened up on the freedom of trade demanded by merchants and the disastrous effects of opium, condemned by religious leaders, in particular the Quakers, who supported the ban. In China, a new emperor decided once again to close the ports to foreign traders who, nevertheless, continued their illegal trade by corrupting officials. In 1856, the boat of an English smuggler was seized and Great Britain then decided to take up arms with the support of the French. In 1857, the city of Canton was bombarded by the British and Abuse of psychotropic substances was French, and then Peking [or Beijing] fell thus directly linked to the suddenness of in 1860. The Treaty of Peking opened the social change, imposed particularly viodoors of China to foreigners, to the British, lently on peasants and Chinese alike. The but also to the French, Russians and relationship with drugs played out differAmericans. China was devastated; in the ently for the elite classes who, in the West, face of Western culture, it no longer had went looking for this change. From the the means to resist. Some one hundred middle of the 19th century to the end of million Chinese would become dependent the 1920s, most artists and writers experon opium, a phenomenon that has often imented with drugs which, like hashish or been described as ‘the greatest epidemic opium, opened the doors of exoticism and in the world’ (Coppel & Bachmann 1989). which, in the discovery of the other, also led to self-discovery through the doorColonial powers had no scruples about ways of one’s own internal consciousness. selling opium, including by force, to col- During the 19th century, drugs functioned onised nations, as is demonstrated by as a laboratory for constructing new the example of France and the control subjectivities. Experimentation followed of opium in Indochina, which lasted until experimentation and represented the the end of colonisation (Dudouet 2009). origins of the drug-inspired imagination At the same time, in the West, a modern which, in turn, provoked fascination and Anne Coppel Harm reduction and drug use: between prohibition, public health and societal rules

rejection, individual passions and collective fears, freedom and subservience. Added to symbolic demand was the purely practical demand for pain relief. Morphine, obtained by isolating an opium alkaloid, became more effective as a medication when injected. The reason why, from 1870 onwards, doctors and patients enthusiastically embraced this miracle drug was because it promised a world without pain, whether physical or mental. With psychotropic drugs, contemporary humanity wanted to escape from ancestral damnation, a demand that was to profoundly alter our relationship with the body and suffering. However, doctors quite quickly discovered, often from their own experience, that this drug could awaken an insatiable craving. Giving up pain relief was out of the question, but the craving contributed to a realisation that there needed to be regulation. This was all the more essential given that new chemical substances were multiplying in even more potent forms – morphine, ether, cocaine and lastly heroin at the end of the 19th century – before research could explore all the potential of psychotropic substances. One final factor contributed to establishing drugs as a problem – the global circulation of goods, including drugs. Such circulation of goods existed well before the industrialisation of society but, until the 19th century, they were distributed slowly, at the pace of the caravans, and left time for modes of drug consumption to be adopted. New means of transport, associated colonial conquests, the global distribution of goods and industrialisation increased exchanges without the methods for using the products becoming known. Their international distribution was also linked to pharmaceutical industrialisation which rationalised the manufacturing processes as well as the sales techniques.

gave rise to modern drug addicts who evade the traditional rules of use. These processes are the source of the first intervention measures along with a fourth process, the invention of health and social policies. Once the social order was not longer viewed as untouchable, society had to invent itself and the State acquired a new responsibility: to protect citizens from ills, such as poverty, which were henceforth seen as social. The first legislation was not specifically to do with drugs. In the United States, the Pure Food and Drug Act of 1906 treated drugs under the same heading as all other products for consumption: the consumer had to be informed of the nature of the products being bought. In Europe, regulatory measures formed part of emerging health and social provisions. The first measures were aimed at controlling artisan preparations of syrups, potions and other medicines, dangerous because they were poorly administered: products had to be regulated and quantities indicated on labels, and control of this was delegated to health professionals organised into administrative bodies. These professionals were also made responsible for monitoring the good health and hygiene of the populations. Armed with social statistics, doctors kept records of sick people, noticed developments and proceeded to give clinical descriptions. Lastly, they took charge of educating the popular masses. Without overemphasising them, the dangers of drugs were thus condemned: while the poisons of the mind interested doctors, they did not make the subject their hobbyhorse and more readily committed themselves to fighting the three scourges of the times – venereal diseases, tuberculosis and alcoholism.

Drug prohibition: a policy originating in America

The European intervention model is anchored in professional, essentially medical, expertise and is closely linked to the The three processes – growth in demand, State. In the United States, another model increase in methods of circulation and was devised, based on banning a product invention of new chemical substances – considered as a drug, criminalising the

19th century public health policies

References

Morphine, obtained by isolating an opium alkaloid, became more effective as a medication when injected.

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were victims of the appalling depravity of maniacal yellow men; black men were renowned for consuming cocaine which led them into crime. The first prohibition measures were taken against opium dens in San Francisco in 1875 and against the sale of cocaine in Illinois in 1877. While Dr Hamilton Wright, a puritan preacher, also campaigned against opium, it was not so much the Chinese he was targeting as middle-class white Americans, more than a million of whom he estimated in 1911 were consumers of opium-based medication. It was true that, in addition to the opium-based preparations sold in promotional campaigns by so-called doctors, new medicines from the German pharmaceutical industry – heroin and morphine – had benefited from extensive advertising. Dr Wright wanted to secure a federal prohibition law but understood that, firstly, the international opium trade had to be controlled. Along with the Anglican bishop Charles Brent, Dr Wright was the linchpin for the first international agreements. Following the non-binding declarations in Shanghai in 1909, the Hague Opium Convention in 1912 obliged the twelve signatory States to draw up national legislation and it was armed with this agreement that Dr Wright secured the Harrison Narcotics Tax Act in 1914. Although this piece of legislation was presented as simply a tax on medicines, it was in effect a prohibition law, as those products which had to be prescribed by a doctor became medicines. Professional health bodies thereafter had the monopoly on narcotic substances; they were in favour of this new regulation and also contributed to the ban on alcohol which was in force from 1919 to 1933. But the legislative framework went on to impose a logic of its own and gradually forced medicine to submit to it.

user and mobilising public opinion with melodramatic messages. While health professionals were not very organised and much less powerful than in Europe, three social forces collaborated to produce this model: the temperance leagues of social reformers, essentially Quakers, unions of white workers and, lastly, the popular press. These three social forces were not concerned with the same issues, but their combination brought about a demonization of drugs which was also a demonization of ‘the Foreigner’. Social reformers were not particularly racist; the temperance leagues they led basically condemned the ravages of alcohol in the name of Christian and Humanist values. These ‘moral entrepreneurs’, to use the expression of the American sociologist Howard Becker, were aimed at protecting people from themselves (Becker 1963). In no way was their motivation the same as that of the white workers’ unions. The latter found themselves in competition with the Chinese, recruited in large numbers by railroad companies in the West, along with black labourers, who were former slaves from the South, and Mexican workers – or Chicanos – from along the frontier with Mexico. It was in this climate that measures were demanded to ban ‘Chinese opium’, ‘Blacks’ cocaine’ and, during the 1930s, ‘Chicanos’ marijuana’ (Szasz 1998). The reformers, like the unions, appealed to public opinion through melodramatic promotional campaigns. The American popular press, When health was made which was experiencing rapid growth to serve prohibition at the time, illustrated these campaigns with news items which exploited popAn infernal machine was on the move; ular fears by linking drugs, crime and it was behind the national and internarace. The scenario was always the same: tional bodies whose development obeyed young white men, and more often women, their own internal logic. And yet, most Anne Coppel Harm reduction and drug use: between prohibition, public health and societal rules

of the countries signing up to the initial agreements were in no way convinced of the need for this international control. France, like Great Britain, earned enormous profits from the production and distribution of opium in their colonies, while Germany was keen to preserve the interests of its pharmaceutical industry. Above all, these countries ensured their profits would be maintained. The harmonising of national and international policies was achieved in stages throughout the 20th century and progressively altered the balance of power between medicine and justice. Drug policies had been dominated by medicine in the 19th century, but, as non-legal consumption gradually increased, policing practices became dominant. The change in the balance of power between medicine and justice was initially imperceptible, because in Europe the medical professions remained powerful. In Great Britain, drug addiction was defined as an illness by the Rolleston Committee in 1926, and, as with any illness, it was a matter for public health experts. Considered a chronic complaint, doctors were given the task of prescribing their patients the products to which they were addicted. Until the end of the 1960s, this health policy was considered entirely satisfactory; the drug addicts in Britain were few in number, in good health and well integrated, in contrast to American drug addicts who were treated as criminals. This is why, moreover, at the beginning of the 1960s, American doctors took up the ‘British system’, referring to it in order to justify experimenting with methadone. But the British medical model was undermined by drug-taking among young people in the 1960s and 1970s. General practitioners, for the most part, refused to prescribe to these young users and the black market rapidly developed. The public health tradition persisted, however, enabling Great Britain to respond rapidly to the AIDS epidemic.

fessionals known as alienists in the 19th century and subsequently psychiatrists. At the end of the 19th century, prohibition was demanded by medical officers, who also wanted to see alcohol banned. But the first prohibition law, passed in 1916, limited itself to banning absinthe. Alcohol producers closely watched what was happening and their voice was heard all the more loudly as the French did not want to give up drinking wine. In the 1920s, cocaine became fashionable despite being banned by law. But in the 1930s and until the end of the 1960s drug users in France, as in Britain, were few in number and confined to a handful of artists, soldiers returning from the colonies and some doctors and pharmacists. Classic drug addictions – the decadent morphine of the 1890s, the opium of aesthetes and the fun-time or dissolute cocaine of the 1920s – had dropped out of sight, without anyone knowing quite how this first cycle of drug consumption had come to an end. Political leaders, medical experts, magistrates and police were in no doubt that they were seeing proof of the effectiveness of prohibition.

So, when the first young drug users appeared in 1970, it seemed obvious that punitive measures should be increased. Medical experts consulted by the Ministry of Health were not convinced that imprisonment was the correct response to drug use, but they hoped that the fear of punishment would protect France from an epidemic which, at the time, was essentially affecting Britain and the United States. Punishing drug use, limited ‘Sayno-to-drugs’ prevention and treatment to ‘Get over addiction’ were officially the three strands of the policy to fight drug addiction following the 1970 law. What is drug addiction? Is there a dependency specific to illegal drugs? These questions were not asked because banning drugs was the obvious solution. Officially, the law was working for health. And yet, The set-up in France was very different when the United Nations gave the World because drug addiction was not tradition- Health Organisation the task of providally seen as a public health problem, but ing a medical definition of drug addiction, as a phenomenon arising from an individ- the experts, despite all their efforts, had ual’s clinical profile and treated by pro- to abandon this terminology in favour

References

Fear had to be instilled and the war on drugs was fed by the demonising mythology that was supposed to exorcize the evil.

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of adopting in 1969 the term ‘pharmacodependency’, which does not distinguish between illegal and legal drugs and medicines. These experts, admittedly, were careful to signal their disagreement with the legal definition of drug addiction – which those working in the legal profession attributed to doctors. There is no medical justification for prohibition, but it took a real threat to public health in the form of the AIDS epidemic for the experts to apply to the field of psychotropic substances the concepts and methods that belonged to them and that were getting noticed.

health providers, it is now clear that the fight to combat drug addictions should not be the exception: it should be a matter of public health whether the psychotropic substances are legal or illegal. This is to recognise that there is not a dependency that is specific to illegal drugs; it is to recognise, too, that every psychotropic drug has its own characteristics, depending on its pharmacological properties and the risk and harm associated with its use. This represents a first step towards changing drugs policy, as ultimately it must be acknowledged that the user is a concern for the health-care and not the justice system. At the very least, it is a change in the balance of power between health and justice (Coppel 2002).

For Dr Gerry Stimson, one of the promoters of the policy in Great Britain and subsequently around the world, this new policy is in fact a ‘return to the roots’ of the first public health policies, well before drugs were banned, as in Great Britain the first regulation dates back to the 1868 Pharmacy Act. At that time, the sale of Use-related harm reduction: back to opiates was entrusted to pharmacists; the products, which had become medicines, the origins of public health policy were labelled in relation to their composiChange drug policy by distributing tion. Regulating the products, training the syringes? This was an ambition which professionals and informing the public appeared to be out of the question. It were the principal tools of this health polneeded the threat of AIDS and the disas- icy – a policy still in force for legal prodtrous situation for heroin users from the ucts. Aimed solely at eradicating drugs, 1980s to the mid 1990s for France to agree prohibition was effectively substituted to try out a Harm Reduction (HR) strategy, for health policies. What was the point of officially limited to infection risks. In 1994, informing the public of various risks and the then Minister of Health, Simone Veil, harmful effects in relation to the products secured authorisation from the govern- if it was enough to ban their use? Fear ment to develop this approach, with the had to be instilled and the war on drugs essential proviso that there would be no was fed by the demonising mythology that change to the drugs policy. The issue was was supposed to exorcize the evil. Drugs that distributing syringes implied using were presented as irresistible: one taste them and there was a real contradiction was enough to become enslaved – ‘Once between penalising use and recognising an addict, always an addict’ was the claim it as a fact. Given the excellent results in the United States. obtained, HR was officially incorporated into the 2004 public health law, but the institutional mechanism involved was Regulations governing drug use strictly marginalised. Nonetheless, adding this one extra element was enough Junkies almost seemed to provide a carfor health-care practices and prevention icature of collective fears. And yet, it practices to be profoundly changed. For should be remembered that almost 60% Anne Coppel Harm reduction and drug use: between prohibition, public health and societal rules

of those injecting heroin on the street – considered a priori as the users least likely to be able to control their consumption – chose in the face of the AIDS threat to give up needle sharing in New York from 1985 onwards, as was noted by researchers Samuel Friedman and Don DesJarlais. HR would have been impossible had the users not demonstrated that they were capable of protecting their own health, albeit at a minimal level, in order to be able to continue their drug use. Collective fears were so great that they overshadowed the most everyday experience. Use cannot exist without control which determines the quantity and frequency in accordance with consumption methods, including instructions for use, which the users pass on to each other. Criminalising use and stigmatising users are the origins of drug subcultures which tend to imprison users in the most extreme forms of behaviour. The beliefs used to justify prohibition make us forget that the general rule is one of control instead of one of excess. For illegal drugs, as for alcohol, the greatest numbers experiment without becoming heavily dependent; and even after periods of dependency, many give up consumption, usually without treatment. Those who do not succeed are precisely those who are in search of medical treatment and for whom this usage undoubtedly has a therapeutic function. Outside these specific pathways, the history of drugs is made up of a series of crazes and rejections and of changes in methods of consumption, which are not determined by law but by the choices made by those who consume them. Alcohol prohibition was a failure because the Americans did not want to give up consuming alcohol. From the 1930s in Europe, artists and intellectuals gave up drugs (morphine, opium, heroin and cocaine), having experienced the consequences of excess. Between the rise of Fascism and Communism, political passion won out over self experimentation. Prohibition seemed to be working, but in reality it was the demand during this first cycle of consumption which had run its course. References

The situation today is quite different. Since the end of the 1960s, demand for psychotropic products has not stopped spreading among a wider and wider public. Without access to information it can trust, each generation has experimented for itself with a type of product associated with a method of use, and each in turn has discovered the consequences of abuse and dependency. This is what enables us to understand the successive cycles of consumption, which range from the experimental use of the first counter-culture generation to heroin use and dependency in the 1980s. Next came the impact of abusing stimulants, cocaine and crack, which the Americans experimented with first, leading to a decline or at least a steadying of levels of consumption. This is what some European users seem to be discovering at present. If there is one lesson to be learned from the history of drugs beyond the simplistic rhetoric which is also a rhetoric of war, it is the multiplicity of methods of consumption, of social significance that is conveyed by these methods, of types of problems with which they are closely associated and also the ways in which it has been possible to respond to them. ‘Drug, set and setting’ – that is product, personal equation and environment – are the three factors which sum up different usages, according to the theory formulated by American psychiatrist Norman Zinberg in a book of that name (Zinberg 1986). His research concerns the controls placed on the use of opiates, usually considered the least controllable type of drug. As his work shows, the pathways followed by users are not inevitable. Some take heroin for a period in their lives then give up without recourse to treatment (which does not mean that this was easy). The belief at one time that ‘Once an addict, always an addict’ is therefore shown to be false, as studies of veterans returning from the Vietnam War revealed. The majority of them gave up taking heroin, with the most common exception being among those who lived in ghettos; context thus appears to be a determining factor. Other heroin users continue to take the

For health providers, it is now clear that the fight to combat drug addictions should not be the exception: it should be a matter of public health whether the psychotropic substances are legal or illegal.

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given the flood of products accessible on the Internet. Consumer information thus becomes the only tool regulating use. This information now circulates basically from peer to peer, user to user; these exchanges of experience are crucial, but they are not enough. Facilities such as Trend in France, which collects products consumed and then carries out toxicology analyses, forge an essential alliance between drug users and researchers.

drug throughout their lives and neverPublic health policies have already theless find ways of controlling their use, even when dependent. This is not to deny helped reduce the influence of the black the properties of the product, nor to deny market with opiates and therapeutic that users can find themselves out of their cannabis medically prescribed for users depth, but it is to reject the inevitability who need them. As regards purely recof degeneration as described by medical reational use, consumer information remains the principal tool for controlling theories in thrall to prohibition. use; indirectly, it is also a tool for regulatIt is a fact that we live with multiple ing the market. It is undoubtedly inadetypes of drugs and medicines, including quate, but there is the hope it may lead to tobacco and alcohol, and the distribu- product regulation commensurate with tion of these products is more globalised the task of protecting health. Until now, than ever. We can choose to refrain from the only policies which have been capataking a particular drug, but we have to ble of effectively protecting health have acknowledge that the majority of our been public health policies combining contemporaries coexist with these dif- medical expertise and the experience of ferent drugs and, in most cases, manage using drugs. The mass of evaluations to to do so without putting themselves in which HR activities has been subjected danger. Norman Zinberg’s objective is has demonstrated this. There is agreeto identify those factors facilitating an ment among experts in the health field ability to control use. And because he about two established facts: sanctions mobilises users’ resources instead of for drug use and imprisonment for perrendering them powerless, this psychi- sonal use should be removed on the one atrist remains a major reference for HR hand and HR measures introduced on the other. Banning drugs thus loses its origpolicies relating to use. inal justification. It would be difficult to question prohibition if it had succeeded in what it was presented as capable of Towards a future drug policy doing, namely eradicating drugs. But it Norman Zinberg has described sponta- has not even succeeded in limiting the neous controls or societal rules relating global distribution of drugs; on the conto drug use. ‘The war on drugs’ strived to trary, it is contributing to this with the discredit these regulations, but this was development, as a reaction, of internot the case with public health policies. national trafficking fed by ever-growWhat has made HR policies concerning ing demand. The escalation of the war drug use so effective is the way they have on drugs over the past twenty years acknowledged the experience of taking has, moreover, given rise to increasingly drugs, adding accumulated scientific and powerful and violent mafias, which, along medical expertise to that experience. HR with corruption, threaten public security, tools are the result of an alliance among democracies and sustainable development users, practitioners and researchers. This policies. This disastrous track record justialliance is more essential than ever today fies drug policy reform. One of the pitfalls Anne Coppel Harm reduction and drug use: between prohibition, public health and societal rules

of an international policy is that it would require consensus among nations and good governance within international bodies. In other words, hope of rapid change is an illusion. But at least we now know how to go about changing the way of thinking: by linking HR with drug use, by bringing experience of consumption and scientific achievements together, we have learned to acknowledge the realities of usage. Taking note of the reality of drug trafficking by reducing the risk and the harm opens up a new way ahead. It is to be hoped that this will lead to a more effective and more robust drugs policy that complies with what human rights require of a democratic society (Coppel & Doubre 2012). ■

references › Becker H 1985 (first ed. 1963), Outsider.

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references

Études de sociologie de la déviance, Métailié, Paris. Coppel A & Bachmann C 1989, Le Dragon domestique. Deux siècles de relations étranges entre la drogue et l’Occident, Albin Michel, Paris. Coppel A 2002, Peut-on civiliser les drogues ? De la guerre à la drogue à la réduction des risques, La Découverte, Paris. Coppel A & Doubre O 2012, Drogues, sortir de l’impasse, La Découverte, Paris. Dudouet F-X 2009, Le Grand Deal de l’opium. Histoire du marché légal des drogues, Editons Syllepse. Escohotado A 2003, Histoire générale des drogues, vol. 1, L’Esprit frappeur, Paris. Furst PT 1974, La Chair des dieux. L’usage rituel des psychédéliques, Le Seuil, Paris. Lewin L 1928 (French ed.), Les Paradis artificiels, Editions Payot; 1996 (later French ed.), Phantastica. L’histoire des drogues et de leur usage, Société Édifor. Nahoum-Grappe V 2010, Vertige de l’ivresse. Alcool et lien social, Descartes & Cie. Szasz T 1998, Le Mythe de la drogue, L’Esprit frappeur, Paris. Van Gennep A 1992, Les Rites de passage, J Picard, 1992. Zinberg N 1986, Drug, Set, and Setting. The basis for controlled intoxicant use, Yale University Press, New-York.

Testimonies

From local to global

a short history of Harm Reduction Pat O’Hare 30 31

n the mid-1980s the Mersey Health Region, which consisted of the counties of Merseyside and Cheshire in the UK, became the focus of attention because of its radical and pioneering approach to dealing with the problems connected with drug use. It was mainly focussed on Liverpool, the biggest city in the region. Liverpool has a proud history of public health and was the first city in the world to appoint a Medical Officer of Health in 1847. At the time, it was known as the unhealthiest city in Britain. In the early to mid-1980s, John Ashton of the University of Liverpool’s Department of Public Health and later Mersey Regional Director of Public Health, and Howard Seymour, Head of Health Promotion of the Mersey Regional Health Authority (MRHA), had been developing the ideas of the New Model for Public Health. This brought together the old ideas of environmental change, prevention and therapeutic interventions, but went further and recognised the importance of “those social aspects of health problems which are caused by lifestyles. In this way, it seeks to avoid the trap of victim blaming” (Ashton

Professor Pat O’Hare started working in the drug field in the mid-1980s when he became Director of the MDTIC (later renamed HIT) in Liverpool. In 1989 he founded the International Journal of Drug Policy and was Editor from 1992-2000 and started the First International Conference on the Reduction of Drug Related Harm in 1990. In 1996, along with colleagues, he founded the IHRA, now known as Harm Reduction International and was Executive Director until 2004. From 2004 until 2010, he was Honorary President. He is now Executive Director of HIT in Liverpool and Visiting Professor in Drug Use and Addiction at Liverpool John Moores University.

& Seymour, 1988). They were interested in applying it to a then-emerging public health problem: drugs and AIDS. In the mid-1980s, an influx of cheap brown heroin gave Liverpool another bad reputation as ‘smack city’. ‘Smack’ is a colloquial term for heroin. So ‘smack city’ was a place where heroin was widespread and the nickname given to Liverpool. Other parts of the Mersey Region, including the areas of Wirral and Bootle had similarly high levels of heroin use (Parker et al., 1998). It was estimated that there were about 20,000 drug users in the region in a population of about two and a quarter million (Drugs and HIV Monitoring Unit 1985). Services were much as they were in the rest of the UK, with detoxification being the prevalent treatment, which was not very effective. A new approach, harm reduction, was pioneered based on public health principles that influenced the later historic recommendations of the UK’s Advisory Council on the Misuse of Drugs report (Raistrick D 1994). Services were created from 1985 involving the consumer that gave drug users the information and the means to protect themselves, especially drug injectors who were most at risk. The Mersey Harm Reduction Model was taking shape. In 1985, the Mersey Drug Training and Information Centre (MDTIC), which later became HIT, was opened in direct response to a request from, among others, the two Archbishops of Liverpool. It was a drop-in centre. Its brief was to give clear information to anyone who requested it, and training to the public and professionals. The creation of the MDTIC preceded the awareness of the risk of HIV in the region. It was situated next door to the Liverpool Drug Dependency Unit (LDDU),

which in 1984 was brought from the bowels of a local hospital to the centre of the city. This helped to increase its prescription of methadone and, in a few cases, of heroin. It was mainly aimed at prevention rather than treatment and based on “the premise that this can best be achieved through involving the population at risk in the solution to problems of public health (being consumer-led); that they be informed of the risk and be able to make healthy choices” (Eaton et al., 1998). The realisation that HIV could be contracted through sharing contaminated injection equipment was met with an immediate pragmatic response based on public health principles. If the danger was infected equipment, then clean equipment had to be made available. Following the example of the Netherlands, where the measure had been introduced in 1984, a syringe exchange service was started in 1986 in a converted toilet at the MDTIC. People had to be attracted to services to find out how to reduce risk and get clean equipment. Methadone was also used to attract people to services. There were still people who had not approached services, so the services had to go to them. Approachability was a key concept. Services had to be easy to access (low threshold), and open at the right times with a committed non-judgmental staff. The key idea was identification of the target group, making and maintaining contact with that target group, and delivering specific interventions to the population at risk, the ‘population’ rather than an ‘individual’ approach. Co-operation was sought from the target group, the public, professionals (which was indeed the hardest group to convince, with many doctors using their clinical freedom to provide what they thought was best for their patients) and the police. The objectives were very simple: reduce the sharing of injection equipment; reduce intravenous drug use; reduce street drug use; reduce drug use; and if possible, increase abstinence. This was the hierarchy of objectives. The emphasis was very much on the more achievable aims of reducing risk rather than reducing drug use. Testimonies

The means used were needle exchange, prescription mainly of methadone, outreach, and the dissemination of information. Service uptake in the MDTIC was rapid, with 733 people making 3,117 visits to the Syringe Exchange Service in the first ten months. In the first two years, 1,090 people attended the Drug Dependency Unit. Before then, an average of only 200 people per year came to a conventional service. Soon, the converted toilet reverted to its original use and a new entity, the Maryland Centre was opened to provide basic health care as well as HIV prevention services. This became known as the Mersey Harm Reduction Model. The approach of the police was very interesting. They were becoming disillusioned with arresting the same people time after time. They recognised that this new approach could reduce the amount of crime associated with heroin use, which would make their job easier. They made the decision not to target drug users coming to services, to stay away from the vicinity of services, and to refer drug users they arrested to those services. They began to adopt a public health role as well as a public order role and they were fully committed to the approach. They didn’t use possession of injection equipment as evidence of drug use and referred people to needle exchanges. As far as I know, they never went as far as the police in Amsterdam where all police stations “are involved in the needle exchange programme. Intravenous drug users can obtain a new needle in a police station” (Zaal 1992). How successful was it? As far as behaviour change is concerned, there was a reduction in the sharing of needles and syringes and in the use of street drugs. Many more people were attracted into services who had never been before. Some people who had been injecting heroin for twenty-five years made their first appearance at a drug service. A range of physical problems related to intravenous drug use were found and dealt with. The drug-using population of Mersey became healthier and more knowledgeable. In the late 1980s, Liverpool was responsi-

The Harm Reduction conference was in turn the birthplace of the International Harm Reduction Association (IHRA), which was established in 1996. The IHRA

A range of physical problems related to intravenous drug use were found and dealt with. The drug-using population of Mersey became healthier and more knowledgeable. 32 33

ble for about one-third of the methadone prescribed in England. Contact was made with over 50% of the high-risk population. An HIV epidemic did not occur among intravenous drug users in Mersey. By 1996, twenty people had contracted the virus through injecting drugs, and some of these seem to have contracted the virus before moving to Liverpool. The development of harm reduction services in the late 1980s led to many visitors from every part of the world visiting Mersey. I was told by Dr. Thomas Zeltner, Director-General of the Swiss Federal Office of Public Health, that a visit by a delegation of politicians, policy-makers and public health officials from Switzerland, around 1988, had been one of the key factors in that country’s decision to press ahead with harm reduction measures (Zeltner 2002, personal communication). These visits played a key role in providing an impetus for the development of international activities and the launch of the annual International Conferences on the Reduction of Drug Related Harm. The international dimension was seen as an important part of the strategy of strengthening the credibility of the policy in Mersey, whose at-risk drug users were its prime target. But of course, we believed that we were doing the right thing, and wanted to spread our message to internationalise the concept to convince others to follow suit. The First International Conference on the Reduction of Drug Related Harm took place in Liverpool in 1990 in response to the interest shown in what was happening in the region. Over the years, the conference has become a powerful instrument in exporting the concept of harm reduction.

was set up to build on the success of the conferences and to advocate globally for harm reduction policies. It is now called Harm Reduction International and is a leading non-governmental organisation working to promote and expand support for harm reduction worldwide. It is an influential global source of research, policy/legal analysis and advocacy on drug use, and health and human rights issues. Harm reduction is now mainstream in many parts of the world. It is accepted by almost all UN bodies (the WHO has a member of staff who has global responsibility for harm reduction and one in each of its regional offices) and by the International Red Cross. Opioid substitution therapy (OST) and Needle and Syringe Programmes (NSP) are available without exception in the European Union. The scientific evidence now supporting NSP and methadone maintenance treatment is overwhelming. This proves the efficacy, safety and cost effectiveness of the programmes. But other interventions are lacking, especially in drug law enforcement, and this is becoming increasingly apparent and remarked upon. There is an increasing acceptance of harm reduction in parts of the world that were extremely hostile twenty years ago. For example, in Asia – home to half of the world’s population – most countries accept harm reduction in principle and are slowly starting to implement programmes. In the Middle East and North Africa, the ministers of health have accepted harm reduction as effective strategies for HIV prevention and care, and countries such as Iran, Lebanon and Morocco have included harm reduction in their national policies. The Middle East and North African Harm Reduction

Pat O’Hare From local to global: a short history of Harm Reduction

Association (MENAHRA) has now been created. More countries around the world are willing to try modest reforms - prison needle syringe programmes, prison methadone maintenance treatment, medically supervised injecting centres, prescription heroin treatment, repeal of criminal penalties for personal possession of all illicit drugs, and vending machines for needles and syringes. Harm reduction has spread to over seventy countries in twenty years, despite enormous cultural, political, and economic obstacles, which is a clear indicator of its merit. A striking exception is Russia, home to the biggest epidemic of HIV among people who inject drugs. Russia steadfastly refuses to accept the evidence for OST while the epidemic rages. Finally, and most importantly, the voices of people who use drugs are being heard. The International Network of People who Use Drugs (INPUD) has become an important participant in international meetings. In their own words, “We are people from around the world who use drugs. We are people who have been marginalised and discriminated against; we have been killed, harmed unnecessarily, put in jail, depicted as evil, and stereotyped as dangerous and disposable. Now it is time to rise our voices as citizens, establish our rights and reclaim the right to be our own spokespersons striving for self-representation and self-empowerment.” (INPUD 2006). For us professionals, however committed, harm reduction is our job. For those who use drugs and who are stigmatised, marginalised and denied the human right to health, it is their lives. ■

Testimonies

References ›› Ashton J & Seymour H 1988, The new public health, Open University Press, Milton Keynes.

›› Eaton G, et al., 1998, ‘The development of services for drug misusers on Mersey’, Drugs: Education, Prevention and Policy,vol. 5 no. 3, pp. 305–318. ›› INPUD 2006, Vancouver Declaration. www. inpud.net/index.php/statements-and-positionpapers/12-vancouver-declaration.html. ›› Mersey Regional Health Authority, Drugs and HIV Monitoring Unit, 1985. ›› Parker H, et al., 1998, Living with heroin: the impact of a drug’s epidemic on an English community, Open University Press, Milton Keynes. ›› Raistrick D 1994, ‘Report of Advisory Council on the misuse of drugs: AIDS and Drug Misuse Update’, Addiction, vol. 89, pp. 1211-1213. ›› Seymour H & Eaton G 1997, ‘The Liverpool model: a population-based approach to harm reduction’, International Journal on Drug Policy, vol. 8, no. 4, pp. 201-206. ›› Zaal L. (1992). ‘Police Policy in Amsterdam’ (From Reduction of Drug-Related Harm, pp.9094, 1992, P.A. O’Hare, R. Newcombe, eds. et al., – see NCJ-138254).

Harm Reduction at MdM

an unshakeable commitment Nathalie Simonnot

rom the outset, one of the striking features of harm reduction at Médecins du Monde has been the similarity between the teams involved and the programme users: all are on the margins.

Harm reduction action: on the margins of the law and beyond In 1986, volunteers from Médecins du Monde (MdM) founded the first anonymous testing centre offering a free, voluntary service. It was a place where marginalised drug users and those better integrated into society (such as students) would cross paths, all of them wanting to maintain complete anonymity in the process. This was MdM’s first involvement in harm reduction (HR) and it would rapidly have an impact: in 1988, the government set up a public system of free, anonymous testing centres across the country. The following year, MdM’s first Needle Exchange Programme (NEP) was established in Rue Ramponeau, in the 20th district of Paris. At the time, distribution of needles on the street was prohibited. MdM’s NEPs remained illegal until March 1995, at which point there were six teams operating needle exchanges on the streets. During this period, we lost count of the number of times team members were arrested and carted off for a few hours to the police station! The need, in a sense, to train the police, by talking to them about harm reduction, seemed crucial, as they were ultimately the ones in contact with users too. In 1992, the NEP team in Paris created the first health prevention kit for intravenous drug users. On users’ advice, it was

packed into a tube that fit easily inside a jacket and contained two needles, a bottle of sterile water, a condom and a health prevention message. This experimental tool was taken up by others working in the field and Médecins du Monde made over the licence for the kit to the Ministry of Health in 1996. MdM continued, however, to improve the contents, adding a filter, a teaspoon and citric acid (to avoid lemons being used). This enabled the number of both viral and bacterial infections to be reduced.

Nathalie Simonnot started life in Paris then moved to London (among homeless people and drug users). Sinologist, cabinet-maker, craftswoman, lecturer, professor, she became a cabinet member of the Ministry for Young People and Sport, responsible for “relegated neighbourhoods”, AIDS prevention and international relations. She was in charge of Médecins du Monde’s programmes in France (19932008), responsible for creating the observatory on access to healthcare in France and then in Europe, for organising ongoing advocacy to secure a law against childhood lead poisoning and in support of universal state sickness and medical coverage, progress for drug users, changes in legislation and practice based on relying on the people concerned and on involving broad inter-organisation platforms, etc. Since 2008, she has been head of national programme coordination in fifteen countries in Médecins du Monde’s network, as well as of advocacy and joint communication within the network. She has been a volunteer with MdM on the programme to eliminate childhood lead poisoning and subsequently on the programmes to reduce harm among drug users and male and female sex workers.

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Aside from devising tools, the NEP also developed by recruiting the first salaried staff in 1991, once government funding had been secured. This was also the year that the programme acquired a mobile unit. During this time, the Paris NEP team was learning its trade and establishing its guiding principles. The first locations for the mobile unit were therefore decided on following discussion with users. But the team ran into difficulties with partners and key players, namely with health pro-

In 1992, the NEedle exchange Program team in Paris created the first health prevention kit for intravenous drug users.

fessionals and social workers, over setting up a network to provide services to users encountered on the NEP, and with police forces, who hindered the work of those supporting drug users. These difficulties did, however, have the considerable merit of raising the question of the place of public health in French drugs policy. Over and above outreach interventions undertaken to offer services to the most marginalised individuals, the fight moved into the political arena too. The first public action in France relating to HR was organised on 30 November 1993: almost 500 people gathered in Place Stalingrad in Paris having crossed the capital in a long procession of NEP mobile units arranged by the collective “Limiter la casse” (Damage Limitation). This collective brought together a drug users’ self-support group (Asud) and anti-AIDS

organisations (Aides, Arcade, Bus des femmes, etc.) as well as health professionals (Médecins du Monde and Repsud). For the first time, drug users and ex-users spoke openly in public and were thus able to express what had long been withheld. A genuinely innovative alliance was formed between drug users and those combating AIDS, including health professionals. “Limiter la casse” was a civil society movement which sought, in its actions, to promote harm reduction as a global, alternative approach in the field of drug policy and AIDS prevention. A joint platform was thus established and, from then on, no HR player operated as before. In 1994, Médecins du Monde’s HR programmes took off, notably with the opening of four methadone centres. It was also at this time that MdM found itself setting up a steering committee, called “Sidatox” (SIDA for AIDS) and subsequently renamed the Harm Reduction Group, specifically for these activities. But the new alliances launched by “Limiter la casse” were still not evident inside the organisation. The first meeting of the HR group started badly: there was terse discussion about the need to set up automated needle exchanges. One of the organisation’s heads considered automatic needle distributers to be machines that encouraged young people to take drugs, whereas HR workers saw them as an obvious public health measure for those working in the field. For them it was as obvious as providing cash machines to make it easier to withdraw money rather than going into a bank to face a teller. The measure involving needles was the same: a drug user could access needles without having to submit to the gaze of whoever it might be, even a well-meaning HR worker. In the mid 1990s, work in the field and in advocacy undertaken by civil society organisations, including MdM, began to bear fruit: the Government recognised the effectiveness of these initial HR responses in France and began to fund them, starting with the NEP and methadone programmes. But this success was potentially concealing a threat: some in MdM saw it as a good opportunity to quit the field of

Nathalie simmonot Harm Reduction at MdM: an unshakeable commitment

HR. Vigilance was therefore still required and the withdrawal of MdM from existing programmes, negotiated by those responsible for coordinating projects in France, led to two positive outcomes: on the one hand, MdM ensured that the programmes it had set up were fully funded by the government (when until that point they had been supported essentially by the organisation’s own funds) and that they would be empowered. On the other hand, these new circumstances enabled MdM activists to take HR into other areas.

Spring 1997: Launch of the Free Parties Programme aimed at synthetic drug users The programmes had scarcely been legalised, before MdM was once again shifting the focus with the start of health prevention activities aimed at free parties which were, for the most part, illegal. So, in the spring of 1997, the Free Parties Programme was created with the purpose of designing specific health-prevention tools and of offering appropriate healthcare support to users of synthetic drugs, such as ecstasy, at the locations where the parties were being held. At the same time as organising health-prevention and healthcare activities at these electronic music events, the Free Parties Programme conducted research into harm reduction on the electronic music party scene. This research involved surveying the population concerned, the products consumed and the methods of consumption to determine exactly what the associated risks were in order to be able to adapt action taken in the field more effectively. Those working in the party environment were thus the first to think that there was little point in offering needles to all-night partygoers and so MdM teams began, in secret, to hand out needle kits. This was a particularly opportune time for innovative action outside any legal and regulatory framework, something of an operational trademark in MdM’s case. A document just published, entitled “La Clinique Hallucinée” (Hallucinatory Testimonies

Clinic), helped doctors navigate all the different ways in which the various products interacted and provided a guide based on expertise in the field. Similarly, testing and rapid analysis of products offered a sort of crystal ball, indicating whether or not a psychoactive substance was present in a sample. This intervention was officially banned in April 2005, when the French government set out the regulatory framework for HR interventions. MdM immediately began promoting a more complex analysis technique – thin layer chromatography (TLC). This type of intervention, which still does not form part of a package of HR services either in France or within the United Nations reference framework, as well

In the mid 1990s, work in the field and in advocacy undertaken by civil society organisations, including MdM, began to bear fruit: the Government recognised the effectiveness of these initial HaRm reduction responses in France and began to fund them. as being highly technical, is not anodyne: this form of intervention meant that MdM was involved in describing the composition (and therefore the quality) of the drugs consumed and so, to some extent, was influencing the drugs market by stating what the drugs comprised. TLC analysis gave rise to a new MdM programme – the XBT (standing for bio-xenotropism) – which focused, as a priority, on products observed by users as having unexpected side effects and which enabled a genuine counselling relationship to be established. Lastly, interventions on the free party scene led MdM teams to begin informally helping minimise the risks of obtaining a fix. A tent was set aside for injecting, which provided hand-washing facilities, peaceful surroundings and support from HR workers, who discussed users’ practices with them in real time. A protocol was drawn up for teams taking part in this type of activity.

and finally convince everyone that this approach was justified. Counselling, testing and finally rapid testing were then extended to programmes across France, offering patients genuine added value.

And today

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January 1998: launch of the first methadone bus in Paris In January 1998, MdM opened its first experimental, low-threshold and on the streets methadone programme in Paris, which was the result of discussion and work by the Paris NEP. The methadone bus allowed marginalised users, who did not attend healthcare facilities, to have access to the drug substitute and required them to be part of the programme for a limited period of time only, namely the day they attended. In contrast, the majority of methadone centres set users an obstacle course, which obliged them to meet with all the specialists on the team (social worker, psychiatrist and doctor) as the only way to gain entry. A second, similar MdM programme subsequently opened in Marseilles.

HIV/hepatitis prevention: a cross-cutting project and yet one more fight When, as one way of improving the quality of services offered by healthcare and advice clinics (Caso – Centre d’accueil, de soins et d’orientation), it was suggested by those responsible for coordinating projects in France that routine activities be implemented to improve testing and access to treatment for HIV and hepatitis, a fresh outcry almost brought everything to an end. Arguments such as “incorporating voluntary free testing centres into Casos is like giving up our identity” and “when patients come because they have stomach ache, well we’re not going to talk to them about AIDS!” It took years of hard work – and funding – to gradually

So, from 1986 to the start of the 2000s, MdM wrote a whole slice of the history of HR in France in the form of its eleven needle exchange programmes, four methadone centres, two methadone buses and eight Free Party Programmes. Most of the tools developed as part of these interventions have now been distributed throughout the country, no longer requiring MdM’s active operational presence. Since the adoption in August 2004 of the public health bill, which officially made HR a government-funded and government-led part of public health policy, most of the programmes run directly by MdM have been transferred to service providers who are recognised by the government and, in most cases, set up by former teams from MdM needle exchanges and methadone centres and buses. While a large proportion of this HR expertise may have quit MdM for these providers, some of the organisation’s players continue to work on the margins and thus help MdM to retain its trademark: activities in squats which rely on mobilising the community; analysing products to empower consumers; and designing and promoting the concept of health education related to the risks associated with injecting (Erli - Education aux risques liés à l’injection), on the basis of lessons learned while supporting injecting on the free party scene. In practical terms, this involves training sessions during which users inject their product in the presence of a two-person team of educators; each session provides a breakdown of the different stages of injecting and an opportunity to give advice. These sessions are aimed at improving the user’s practice and thereby reducing the risks of infection (including HCV) and maintaining the integrity of the venous system. This project is the forerunner to

Nathalie simmonot Harm Reduction at MdM: an unshakeable commitment

However, the desire to extend the HR approach to those offering such sexual services and the creation of sex work programmes in Nantes, the island of Reunion and Paris between 2000 and 2004 emerged in a climate of tension within the organisation that was even greater than when the first drug user programmes were introduced. This tension reflected fundamentally diverging opinions about Médecins du Monde takes on the basic social and political vision within international harm reduction MdM. On the pretext of fighting for genIn 1997, a needle exchange bus took up der equality – a cause, moreover, that is position in the city of Saint Petersburg in both just and as topical as ever – the most Russia. Other projects were to follow: in outlandish theories were circulated by Serbia, China, Vietnam, Georgia, Burma official, so-called experts, always based on “numerous studies” without ever cit(Myanmar), Afghanistan, Tanzania, etc. The latter three programmes place ing the sources. A sort of latent struggle particular emphasis on the social change ensued within the organisation. In spite of MdM is seeking by focusing on two everything, harm reduction players were aspects: on the one hand, they focus on able to organise themselves and couninvolving the bulk of users in an initia- ter-attack, using their field knowledge, tive to empower, to mobilise communi- their pragmatic approach and their solties and to establish self-support. On the idarity. In this way, the first harm reducother hand, the programmes concentrate tion programmes among people offering on being able to replicate the services sexual services for payment were able offered elsewhere by training profession- to overcome the constraints and MdM als and distributing tools. In doing so, this activists succeeded in developing a global action aims to increase the acceptability approach to HR, incorporating sex work of HR in these countries. In addition to and drug use. these three examples, the organisation is seeking to make a major contribution to from 1986 to the start of the 2000s, disseminating HR in the countries where MdM wrote a whole slice of the history of HaRm it intervenes, and thus to promote quantitative and qualitative improvements in reduction in France in the form of its eleven service coverage, including securing genneedle exchange programmes, four methadone uine access to treatment for hepatitis C. consumption rooms in France, scheduled to open in 2013, although this type of facility is still banned in the country at the time of writing. This rich history has also helped create a pool of experienced activists for developing HR programmes internationally.

Harm reduction among male and female sex workers But the history of HR at MdM is not solely about a public health response to drug use and the fight for human rights among and with drug users; it is also a history that engages with male and female sex workers. It was the field teams involved in outreach programmes directed at drug users who first made the organisation aware of the need for action aimed at other marginalised people in our societies, namely those who offer sexual services in return for payment. Testimonies

centres, two methadone buses and eight Free Party Programmes.

The approach is in fact the same in both situations: individuals are the focus of attention and are offered the chance of support and respect. Even more importantly, they are acknowledged as knowing better than those intervening what is or is not good for them and knowing when they want it. The programmes in Nantes (“Funambus”), then on the island of Reunion (“Papillons de nuit”) and finally in Paris (“Lotus Bus”) had a great deal to do in order to impose this vision, but succeed they did. Their success was

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2013 – our organisation takes a stand only on sections of the law relating to protecting individuals and not relating to individuals’ rights to pursue their work as they see it. No consensus exists within MdM regarding an individual’s right to pursue the activity of paid sexual services, or even to claim to be a sex worker. Nor, it must be acknowledged, have there been any real forums in which this subject can be discussed and considered. translated into the adoption of MdM’s policy position paper in a vote by the Board of Directors, in which MdM states it will not align itself with any ideology but will stand by sex workers in an initiative to reduce the harm associated with their activity. There is still evidence of reluctance today and this is largely due to the comfortable stereotype of women as victims. As in the past when opponents of HR linked to drug use (quite often those working in drug addiction) were heard to state that drug users were “alienated”, had “bodies riddled with holes”, and so on, today we see individuals who think that “no one chooses” to offer sexual services in return for payment, that clearly these “poor women are victims of men who dominate them and force them to act”, and that generally it is not about paid sexual services but about “selling one’s body accompanied by an alienation which means that the woman’s word no longer has any value”. Male prostitution is singularly absent from discussions. It is true that this aspect would open up an uncomfortable debate in terms of the prevailing discourse, begging the question of who is dominating whom. And then things would start to get complicated. The way feminism has been hijacked is particularly painful for many of us. In the name of women, women are being crushed; they are no longer being listened to. People set themselves up as spokespersons, talking about realities they know nothing about. Some organisations, in similar vein, have arranged extremely high-powered lobbying of French MPs to assert how reliable their reductionist theories are – reductionist not in terms of risks but of rights. And still today – but after all it is only

In conclusion From the beginning, MdM’s field teams, its HR activists, have taken the organisation down paths that skirt the margins or even go beyond the margins of the law. We were convinced that we were right and that the law needed changing. But this certainty must continue to be questioned and verified from the point of view of the interests of drug users and sex workers, and their interests alone. Sometimes we went rather far, without always fully advising the organisation’s head of legal affairs. This was to avoid endangering the action we were in the process of putting together; the tented areas for supporting injecting at free parties are a good example. To be sure of the validity of our proposals and our position papers, one thing needed to be guaranteed from the start of the thirty years of campaigning: the active involvement, both in discussing and implementing the programmes, of the people concerned and the professionals with experience who needed to share their knowledge with professional trainers and vice versa. This encapsulates the whole of the paradigm shift in care brought about by harm reduction: we are fighting alongside drug users and sex workers to give them the right to decide for themselves; in this fight we are merely the sounding box, a useful one as a result of our logo and our medical and international profile. ■

Nathalie simmonot Harm Reduction at MdM: an unshakeable commitment

Sexual harm reduction

The experience of the organisation AIDES

Christian Andréo

Supported by these observations, the ince 1985, the organisation AIDES (French community-based organi- AIDES activists implemented a two-tier sation fighting HIV/AIDS) has been strategy: working hard at what would later be ›› Promotion of condom use and provireferred to as Sexual Harm Reduction sion of health prevention information (SHR), through publishing brochures on and tools; prevention and by carrying out activities ›› Listening to and supporting the differin the field’. The preventive strategies put ent prevention choices made by the forward in the early leaflets were based populations encountered. on medical knowledge available, but were Already a ‘spontaneous’ element of also inspired by changes to behaviour activities, the SHR discourse was formalthat had already taken place, particularly ised as part of the changing context of the among male homosexuals. epidemic. From 1996, progress in treatIt rapidly became apparent that dis- ment led to improvements in living contributing information and promoting ditions and life expectancy of seroposicondom use was an essential but inad- tive individuals. In addition, activists in equate prevention measure. On the one the fight against AIDS realised that the hand this was because the information epidemic was going to be a long-term did not resolve the issue of access to the phenomenon, involving a different way of means of prevention; on the other, it was thinking to that of an emergency context. because homosexuals were themselves The new approach, devised as a facet of creating and experimenting with pre- health prevention, attempted to respond to ventive strategies based on risk avoidance the fresh questions being posed at the time: (Schiltz & Adam 1995). From the 1980s, how can we envisage our long-term emothey put together a diverse range of pre- tional and sexual relationships, our interventive methods: reducing the number of dependencies, in a community affected partners, giving up anal penetration with by HIV? How can HIV p revention be casual partners, non-protection within but protection outside couples or systematic protection, and so on (Schiltz 1997). At the same time, from 1987 onwards, the policy for drug-related Harm Reduction (HR) action was experiencing Christian Andréo is director of national programmes its first success. Its undeniable achieveat AIDES. He has been extensively involved in the fight ments were hard won and were under against AIDS since 1996 and has worked, in particular, on threat from securitarian policies. Inspired prevention and screening and testing policies, as well as on by HR’s success and its principles, activists the issues surrounding selective prevention strategies. The at AIDES decided to broaden the scope of remit of the Direction of national programmes is to lead the the measures being used at the end of AIDES network, made up of 70 delegations spread across the 1990s by formalising the Sexual Harm France, and to represent the organisation in dialogue with Reduction (SHR) discourse in writing and national stakeholders: ministries, agencies, political parties, by openly committing the organisation to other French and European organisations, groups of experts, continuing with this approach. etc. A large proportion of the work centres on advocacy.

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aintained over a lifetime based solely on m changes to behaviour involving the constant, systematic and correct use of condoms, with every partner, in every sexual practice (fellatio and penetration)? How can we talk about prevention without getting caught up in the ‘cliché discourse of safe sex’ (Defert 1990)?

to renew contact in the field with men who had problems with prevention and who avoided the arrival of the ‘condom preachers’. At the same time, the notion of Sexual Harm Reduction found its legitimacy in the double imperative of sexual health: having sexual relations which were both a source of satisfaction and of wellbeing but which, equally, had no damaging impact on health. In the context of HIV, managing sexual health can be a heavy burden.

1984-2008: evolving and enhancing preventive action Put simply, during the early years of AIDES, our action could be seen as having focused as a priority on informing vulnerable populations of the methods of transmitting HIV and the means of protecting themselves. This effort at awareness-raising and informing, in which all those involved in combating AIDS shared, was essential and urgent in the context of an emerging epidemic and, to an extent, produced results. Condom use spread within sexual p ractices and serological testing

developed as a way of finding out one’s HIV status, adopted as a necessary and common practice by a large proportion of homosexuals after having taken a risk. At the same time, in our outreach activities – in bars, at external meeting places and in saunas – we observed an emerging need for homosexuals to be supported in how they incorporated this information into their sexual practices and took responsibility for it, as a way of reducing the risk of being infected by or of transmitting HIV. Distributing information and making condoms available was not enough to help homosexuals adopt protective behaviour; we needed instead to take account of other issues raised by the emotional and/or sexual relationship. Protecting oneself against HIV presupposes adequate individual and collective self-esteem; protecting oneself presupposes anticipating risky situations associated with one’s practices; protecting oneself relies on questioning the place of risk in one’s life choices; and protecting oneself demands having recognised and assumed a social existence and position. A method of individual and collective intervention, which we called Sexual Harm Reduction, gradually emerged from supporting homosexuals on a daily basis in their concern for prevention. This approach proved to be much more demanding for AIDES’ workers than straightforward health education. In addition to getting across a fixed information message, we had to adapt, in close proximity to those being helped, to each individual’s constraints in the face of the challenge posed by prevention. We often had to try with these individuals to transform a prevention ‘failure’ (having taken a risk for example) into a first step towards acknowledging the risk or towards a minimal-risk strategy for another occasion. The ethical question of prevention became crucial: ‘Who am I to say to another person what he/she must do?‘, ‘Have I, as a prevention worker, not also had occasion to take risks?’ and ‘Is sex with a condom so easy in the long-term’? Our objectives perceptibly altered to the extent that we developed an empathetic

Christian andréo Sexual harm reduction: The experience of the organisation AIDES

approach to preventive intervention and six months, perfect adherence and the developed individual empowerment: how absence of sexually transmitted infection. could all the capacities of the public be These criteria were considered as ‘caumobilised to ensure they adopted the best tious’ and ‘conservative’ by the authors of the article themselves. possible health strategies? In August 2008, alongside the proceedImplementing this approach also allowed us to renew contact in the field ings of the International AIDS Conference with men who had problems with preven- in Mexico, the Swiss hammered home the tion and who avoided the arrival of the message: the risk was of course not zero, ‘condom preachers’, as the AIDES’ work- but neither was it zero with a condom. ers were potentially seen. From then on, They compared estimated residual risks: it was a matter of leaving people free to 1 in 30,000 with a condom, 1 in 100,000 choose, but providing and supporting if the seropositive person was receiving them with information that was as reliable, full and as scientifically accurate as possible, enabling them to formulate their At the start of 2008, a new preventative tool own strategies, adapted to their needs, capacities, way of life and desires. appeared to assist people – treatment as

The future of Sexual Harm Reduction also has a biomedical basis At the start of 2008, a new preventive tool appeared to assist people – treatment as prevention (TasP) – and forced its way into France via sexual harm reduction. The spark which ignited the flames of controversy was an item in an obscure publication, Bulletin des médecins suisses (Swiss Doctors’ Bulletin), which was advice directed at doctors and which was popularised by a professor from Geneva, Bernard Hirschel. The title was intentionally provocative: ‘HIV-positive people with no other STIs and on effective antiretroviral therapy do not transmit HIV sexually’ (Vernazza, Hirschel et al., 2008). A flood of criticism ensued from researchers, doctors and health prevention workers, traditionally focused on the single, simple message: ‘The only way to protect oneself against AIDS is the condom’. For people concerned with HIV, whether infected by HIV or a partner of someone infected, it was doubly revolutionary: the hope of no longer being considered – or of considering oneself – to be a viral time bomb; and the option of choosing a preventive method adapted to one’s needs. These statements identified three criteria for a risk to be estimated at below 1 in 100,000: a viral load undetectable for Testimonies

prevention – and forced its way into France via SEXUAL harm reduction.

treatment. For them there was: ‘no question: today, treatment is the best form of prevention’. There was violent opposition and the speakers were reproached for promoting wide-scale abandoning of the condom and thus an increase in fresh cases of contamination. The French daily newspaper Libération quoted Bruno Spire, president of AIDES, as saying: ‘[we] are witnessing the upheaval but haven’t yet grasped the full consequences. Hirschel has put his finger on it. […] The question of transmission is central to the life of someone who is seropositive. It is the greatest source of distress suffered by people affected. Can they contaminate others? Have they contaminated others? If this question becomes secondary then, yes, it does change their whole life. And it changes the epidemic too’. Since then, the surprise results of HPTN 052, a random trial involving 1,700 serodiscordant couples, published five years before the scheduled date because of the significance of the results, marked a new stage: 96% reduction in the risk of transmission simply as a result of the seropositive partner being given effective treatment (without taking into account the Swiss criteria). UNAIDS and the World

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While public acknowledgement of TasP’s usefulness forced the inclusion of AIDS prevention into the HR paradigm, the mould has not yet been fully broken. In addition to public health interests, now broadly emphasised, what is also needed is full recognition of TasP as an individual HR tool which is as effective in every way as the condom. It needs to be acknowlHealth Organization believe it is essential edged as a relevant tool in itself on an ‘to ensure that couples have the option of individual level and people need to be treatment as a means of prevention and able to benefit from what it can do: reduce that they have access to it.’ Both bodies the anxiety of transmission, improve the see Treatment as Prevention as a way of quality of sex life and reduce rejection encouraging testing, discussing serolog- of people living with HIV in their daily ical status and preventive options with lives, sex lives and love lives. Treatment partners, encouraging medical monitor- does indeed seem to be a new prevening and providing leverage for reducing tive tool which is finding its place among stigmatisation and discrimination sur- the combined range of preventive tools. But it is one thing to know that a tool is rounding people living with HIV. effective and another to have access to it. Thus, the main challenge faced by health prevention actors and people affected by or exposed to the risk of HIV, depending on where in the world they live, is to have access to treatments, syringes, substitution and even condoms; and to have the right to use them in complete safety. ■

References ›› Defert D 1990, ‘L’Homosexualisation du sida’, Gai Pied Hebdo, no. 446, [29 November 1990], pp. 61-63, Paris. ›› Schiltz M-A & Adam P 1995, ‘Les homosexuels face au sida : enquête 1993 sur les modes de vie et la gestion du risque VIH’, CAMS-Cermes, report submitted to the Agence nationale de recherche sur le sida, Paris. ›› Schiltz M-A 1997, ‘Parcours de jeunes homosexuels dans le contexte du VIH : la conquête de modes de vie’, Population, vol. 52, no. 6, pp. 1485-1537, Paris. ›› Vernazza, Hirschel et al., 2008, ‘Les personnes séropositives ne souffrant d’aucune autre MST et suivant un traitement antirétroviral efficace ne transmettent pas le VIH par voie sexuelle’, Bulletin des médecins suisses, no. 5.

Christian andréo Sexual harm reduction: The experience of the organisation AIDES

Harm Reduction and the evolution of the patient/doctor model

a person-centred approach

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‘Harm reduction policy postulates an obvious fact which is often uncomfortable but impossible to deny. Drug addicts exist who cannot or will not permanently give up taking drugs. Regarding them as demons or scapegoats, or defining them in more everyday terms as criminals because they are users, simply paralyses any new way of thinking capable of respecting their existence and their right to be citizens with access to all forms of dignity, as required by the principles of democracy’ (Mino 1993).

In this chapter, Jean-Pierre Lhomme and Paul Bolo, two French general practitioners whose personal and professional experience has been enriched by harm reduction, discuss and question the link between healthcare worker and patient. This intimate and unique relationship has often been reported as difficult to establish between a patient who uses drugs and a healthcare professional. Jean-Pierre Lhomme and Paul Bolo demonstrate here that this link can be re-established, or never broken in the first place, provided each party demonstrates his or her desire to act and progress together. Interview conducted by Céline Debaulieu

hat place did healthcare workers accord drug users prior to AIDS, and how was drug addiction understood and controlled? Jean-Pierre Lhomme: The only reference point within the healthcare policy framework, which was itself shaped by morality and prohibition, was to discourage use; the only assistance provided was to help take people off drugs, dismissing those who could not, or did not want to, permanently give up their addiction. The framework imposed in this way acted as an obstacle to any other form of help, leaving a good number of potential candidates attempting to attain this ideal by the wayside, and leaving them in a terrible physical and mental state. It was like asking someone over and over again, who had never done the high jump, to jump, immediately and repeatedly, with 1 metre 80 being the required and only height. The dogma of total and definitive abstinence, with withdrawal the sole therapeutic objective and the only ‘salvation’ in the face of opiate dependency, was the framework imposed. Such a framework was ‘mandatory’ and ‘alienating’, for users and professionals alike. This was the situation in which general practitioners found themselves: in the front line because of their proximity to the patient,

seems to me to be essential in my profession is the unique encounter with the other person; it’s the human that counts What led a drug user to your surgery? above all else. Something had to be done; What brought such an individual to you? I did it and I still do it. I did it intuitively JPL: Before AIDS and at the beginning and I still do it, only more rationally. And then, it has to be said, general pracof the epidemic, drug users came to consult general practitioners, driven by an titioners were not considered experts, abscess that had worsened beyond tol- either in AIDS or drug addiction. Other erating, an erratic fever that sometimes colleagues, the specialists, relegated them headed towards septicaemia, by hepatitis to ‘lowly tasks’ such as dealing with sick B or C that ended up on occasions as alco- leaves or sometimes following up on longhol-soaked cirrhosis. More usually, tor- term treatments. This contempt among mented by withdrawal, they came to try doctors had an impact on users and did to negotiate for some medication to calm not help smooth relations. or add to the high. Difficult to know; trust was at arm’s length and it was a question of negotiating without laying one’s cards on the table. Another dialogue, another place for the doctor On occasion, a request would crop up to and for the drug-user patient were emerging be weaned off drugs to which there was through these practices of ‘caring for the no gradual solution to offer. Sudden withdrawal, in the majority of cases, ended individual’. in failure and relapse, being simply a further form of harm and not a way out. These failures merely confirmed to people their ‘inability’, plunging them yet What attitude did doctors manage to deeper into dependency, into low self-esteem. This continuum of ‘withdrawal adopt towards users to be able to offer breaks’ and relapses did little to help adequate care and treatment? JPL: For some general practitioners them ‘toughen up’, as some professional faced with this situation the solution, apart experts expected. The road map was often marked out from the somatic treatment dispensed, in this way until the day arrived when, was to hand out a few syringes to try to exhausted and worn out at the end of avert contamination or recontamination ten or fifteen years of living a health and among those who were manifestly continsocial nightmare, they more or less came uing to take drugs, ‘managing’ their injecting for better or worse. Giving ‘advice’ and through it – but at what cost! then explanations in an attempt to help Paul Bolo: It was the era of Temgesic, them step back from this life-consuming an analgesic dispensed to drug users for dependency, unofficially prescribing opiyears without ‘legally’ being a substitution ates as a substitute for street heroin. Some treatment, of morphine-type medication users were thus able to benefit from suband Neo-Codion, of codeine in syrup form, stitution ahead of time. Providing this care in difficult condiwhich drug users took in large quantities! Because we had no choice and some- tions was very uncomfortable, but diathing had to be done, at least that’s what logue was taking place. Another dialogue, I think. For me, prescribing these med- another place for the doctor and for the icines meant that at least users would drug-user patient were emerging through not end up on the street taking just any- these practices of ‘caring for the individthing. Moreover, these regular contacts ual’, through solutions adapted to habits with a health professional would open up and to the patient’s intention to get treatthe possibility of benefiting from health- ment at the time, however circumspect care when the individual wished it. What that might have been. but with these limitations imposed by an ineffectual healthcare policy framework.

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Nevertheless, the majority of general practitioners refused to treat these people who were making themselves ill. As regards hospital doctors, therapeutic responses to the AIDS pathology were beginning to appear and hospitalisation reports often concluded with the word ‘escaped’ under patient discharge. No question: with withdrawal came the need to ‘go out and score’. To sum up then, we were at a turning point in the doctor/ patient relationship, distorted by the limitations imposed by the framework, a relationship tinged with reciprocal distrust. How did the relationship between doctors and users develop during the 1980s, the decade when AIDS appeared? JPL: Towards the end of the eighties, the HIV epidemic was setting in. Of course, the hepatitis B virus had been around for a long time and the hepatitis C virus had just been identified. And of course, faggots, druggies and whores had been around for a long time too. The wholly inadequate preventative measures put forward in response to the risks being run by these populations began to show their harmful effects. These people were paying a heavy price in the face of the HIV epidemic. The healthcare reference frameworks were not functioning, in terms of public and individual health alike. Faced with this situation, what was needed was to reinvent, to demonstrate pragmatism, to show the capacity to provide health prevention solutions that were both adapted to the health risk and worthy of the people concerned. The way of taking care of the community, taking care of the individual, had to be deconstructed and reconstructed. Many put every effort

into this task – whether health professionals or not, voluntary organisations or NGOs. Médecins du Monde was among them. That’s the story of Harm Reduction (HR) relating to drug use, which has made us and continues to make us review our medicine and its Hippocratic principles. The old story of access to healthcare for all, the old story made new in the face of an epidemic. The old story ‘forgotten’ because of the moral values of religious leaders of every persuasion, always hunting down anything that could be seen as ‘deviant’, regardless of people’s health, regardless of our communities’ health. The unexpected arrival of the AIDS pandemic was in the process of suddenly changing priorities and of imposing reducing the risk of infection as a primary objective among drug users. Doctors had to recognise that they must take an interest in the users who could not or would not quit their addiction for good, had to acknowledge their essential role in helping users reduce the risks and harm at every stage of the course of their addiction. To do this, they had to envision solutions that were acceptable to the person, adapted to his or her timescale, in concert with his or her intention to get treatment at that point in time; negotiated solutions, working out in a mutual fashion, and not in a ‘laboratory of unilateral reflection’, what was the right treatment for the other person. It was necessary to reduce harm by appropriately managing habitual practices and consumption issues; to continue inviting drug users to ‘take care’ through the ‘supported dependency’ offered by substitution; to put withdrawal in its place – namely as more of a risk than a possible ‘way out’ – and certainly not a goal in itself. PB: Arriving in 1983, I fairly quickly became heavily involved in Médecins du Monde, and I knew nothing of HR before arriving. At the time, I spent a lot of time observing and looking at everything that was going on in the needle-exchange programmes. HR enabled me to get involved and to put what I was doing into words. My involvement also enabled me to

Jean-pierre Lhomme & Paul Bolo Harm reduction and the evolution of the patient/doctor model

of comfort. But what is past is past and, at that time, not only did the professionals have to explain themselves to each other, they also, and more importantly, had to do something! A pragmatic approach was what was appropriate, without, however, each having to reject his or her own form of medicine. And some managed to take this on board. This is how these same general practitioners, working hard to open the first free and anonymous HIV testing centre, became involved in the first needle-exchange programme opened in France by Médecins du Monde, and then some years later, in the opening of a methadone subThe arrival of AIDS was what trig- stitution treatment centre. What had to be gered HR practices among drug users. done then and there was to once again demonstrate a French version of what How did that translate in your case? JPL: The health disaster was brewing. many countries had already achieved. We had to reduce the harm, to ‘limit the What in your view are the founding damage’. Along with attempting unofficially and precepts of HR applied to medicine? JPL: In the ‘pedagogy of patient care’ individually to adapt medical practices, we needed to get HR practices, launched represented by HR, two fundamental in the one-to-one context of the doctor’s practices result in the person who is using drugs being placed at the centre of the care. surgery, out there and shared. Above all, we needed to demonstrate Firstly, there is the ‘taking care’ of the perthese practices on another scale than son, the attention paid by the professional the one-man band of the doctor’s sur- to the health issues encountered by pooling gery in order to have them accepted, to his or her ‘technical’ knowledge and clinihave them recognised and, one day, fully cal intuition with the person’s experience included in public health policy direc- in order to make sense. Secondly, there is tion. Of course, this had to be done first the extent to which the solutions proposed of all among colleagues who were sharing are compatible with the situation, the perthese practices. This was the beginning son’s timescale and his or her treatment of GP networks. But it was not enough. motivation, thus providing him or her with These professional practices had to be the possibility of accepting, of taking ownintroduced into specialist healthcare ership of what is proposed in order to ‘take facilities, which were very often strait- care of himself/herself’. jacketed by their single model, by the PB: For me, the cornerstone of medicourse the ‘subject’ had to follow in the toughening-up process of withdrawal fail- cine is adopting the position of ‘not doing’. ures. It was a difficult step for these facil- The practitioner steps out of the picture ities to take to break away radically from for a time and reaches out to the other a healthcare policy on which they relied, person who then teaches the practitioner as was sharing medical knowledge with how to read him, without abandoning his patients – in other words giving up part knowledge and training. It is the patient of their power. Sharing knowledge does who teaches the doctor how to care for not form part of medical training and, in him. Everyone is, to a certain extent, an the difficult task of managing the pro- expert on themselves and on the course fessional life of a doctor, certainties are their life has taken. Afterwards, everyone sometimes not a good place to look for must be able to question themselves and guidance, even if they do provide a source manage to avoid going too far. transform my relationship with any type of patient, with children and with older people. My approach changed and I put the patient’s words before the symptom: I took the time to listen. I realised that you can only hear what you are ready to hear; that you can only see what you have the capacity to see. That seems self-evident, but in fact many doctors miss the point and feel themselves to be all-powerful. HR teaches listening skills and humility. Today, my listening is attentive and focused. I say to patients, ‘Tell me about yourself’, and that enables discussion to be opened and the relationship started.

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This support is all the more necessary given the fact that various issues, insecurity and desocialisation are frequently intricately linked, and such problems are either clearly evident or sometimes masked. Insecurity is not just economic, social and civic but also psychological, ranging from straightforward low self-esteem to the deepest distress, resulting in ‘insecurity around the intention to get treated’. This insecurity has many facets, What does ‘taking care’ actually mean increasing the risks and harm associated for a doctor in relation to a drug user? with drug taking. The medical, psychological and social JPL: As with any care, with any therapeutic mediation, the ‘carer’ does not just services offered act as levers for autondeliver ‘care’ in a vacuum, as a disembod- omy provided they are carefully negoied thing. The doctor puts forward his or tiated. If not sufficiently explained, not her scientific and technical knowledge in easily adopted, they could then be expean explanatory and interactive exchange rienced as too coercive and would lead to with the person, so that he or she can take further risk-taking or to the person partly them on board and ‘equip’ him or herself or even wholly dropping out. with what is needed to take care. PB: For me, taking care of a drug user, Of course, the doctor gives advice, but it is more than advice which often takes it goes beyond sharing knowledge. The the form of a one-way and thus illusory professional is there to support the indiexchange; he or she provides explana- vidual along what is sometimes a chaotic tions presented as advantages versus pathway. The framework of the consultation in my view makes it possible to reasdisadvantages, or benefits versus risks. sure the other person of the constant provision of kindly, but not over-obliging, care. Taking care is also listening to the ‘feelHarm Reduction has made us review ings’ of users and being able to translate these into physiological responses: getting our medicine and its Hippocratic principles. away from centring on the product – ‘feelings’ – to moving towards a more intellectualised working out of ‘emotions’. By adopting this attitude, or rather role, And when that moment of compatibilthe health professional also accords a place to the person consulting. The doc- ity arrives, does this time-out in a surtor combines his or her knowledge with gery, with a doctor, represent a special that of the individual, with the individu- moment? Is it like finally coming face al’s experience, in a sharing of ‘lay’ and to face? JPL: This idea illustrates the form this medical knowledge. It is in the coherence of the exchange, therapeutic alliance might take in medwith each ‘in his or her place’ but where ical practice. There must be a continuing search for each ‘has his or her place’, in this alliance of knowledge, that this ‘taking care’ consistency between the solutions prois established in the ‘case’ that concerns posed and what is acceptable to the perboth parties. This blend of mutual knowl- son at a given moment. This involves adapting different variaedge – but blend here does not imply confusion – thus gives the care its coherence. bles to that medical practice, a process The responses and services offered that starts with an ability to put forward must be pragmatic, requiring only sim- proposals that are easily adopted by the ple initiatives and contributing to support. person and in keeping with his or her Jean-pierre Lhomme & Paul Bolo Harm reduction and the evolution of the patient/doctor model

JPL: Practising general medicine position at a given time. Next, it is a matter of helping proposals gradually emerge quickly taught me the importance of out of ‘supported dependence’: changing the role given to the individual in disrisk behaviours related to the method pensing care. And so, while the qualof drug use (clean shooting, shooting in ity of response needs to be worked on conditions and in places where it can in the relationship with the person and be clean, or adopting alternatives to in the preventative solutions and care shooting). Then, it is a question of using offered, this quality is also dependent these to formulate ‘negotiated depend- on determinants arising from the more ence’ proposals: changing from ‘prod- general context: the framework for care uct’ to what becomes prescribed medi- constrained by drug-related legislation, cation. And lastly, the possibility has to which restricts how care is oriented in be envisaged of staying at this ‘negotiated the field of dependency. All this forces the carer to manoeudependence’ stage for a given and chosen period, depending on the various meth- vre in order to shift these determining ods, or of ‘getting out’ and into ‘supported factors. For me, this meant I had to get involved in demonstrating such practice independence’. To sum up, this is equivalent to mak- elsewhere than in the one-to-one context: ing care meaningful by knowing how to needle-exchange programme, methadapt proposals, gradually increase them and put them into practice in keeping with where the person is at, throughout the It is the patient who teaches the doctor how whole course of his or her dependency. to care for him. Everyone is, to a certain extent, Such care is constructed ‘with’ and not ‘for’ the person, and differs from the care that an expert on themselves and on the course is sometimes put together based solely on their life has taken. the caring desires of the carer. This could be summed up in a phrase which most closely reflects what HR has contributed: ‘Working with and not for the individual’. adone-substitution centres, etc. Once this was achieved, it helped re-establish Lastly, is HR closely linked to medical a certain ease, calmness and comfortableness in the relationship with drug practice? JPL: The hierarchical model for clas- users, but above all it brought about a sifying risk is in general fundamental to much better quality of medical provision our work in general medicine. Risk reduc- for these people. All this work has protion relating to the use of psychoactive duced a host of results demonstrating products has naturally become part of our the value and effectiveness of the new practice, for those amongst us who want paradigm represented by HR, and in turn to really listen to these ‘specific’ patients, led to the legitimacy of these innovations going beyond any particular labelling, in being recognised and their inclusion in the same way as we listen to our other the public health law of 2004. Without this, our practice as general practition‘populace’ patients. The involvement of general practitioners would not have been altered to the ers, who are a significant majority, par- extent it has. This is how HR has enriched my practicularly in conducting opiate-substitution treatments, perhaps points to the tice as a general practitioner, as well as, existence of a certain symbiosis between perhaps, the lives of ‘my patients’. It’s a practice which takes account of general medical practice and the practice the person, but one that does not forget and natural development of HR. either to take account of the health of What would you say in conclusion the community: it’s a way of conceiving about HR’s contribution to your prac- health by trying to reconcile individual and collective health. tice as a doctor? Testimonies

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PB: For me, the main objective is to lead Jean-Pierre Lhomme is a general practitioner who, at people to, or back to, care. The essential the same time, has pursued work in hospital and as a volunteer with MdM. From 1980 to 1991, his hospital work thing is to provide access to a medical was in specialist centres providing support for pregnancy centre and, thus, to be able to offer a terminations and then, from 1991, in centres for addiction. range of care to drug users. HR has ena- Joining MdM in 1987, he did pioneer work to establish the bled me to practise what seemed to me first harm reduction programmes in France (NEP from 1989 to be crucial from the outset of my career, followed by the methadone bus) and, since 1992, has played namely the humanising of healthcare and an active role in leading and encouraging debate on HR. the promotion of the relationship with the His work with MdM has also involved him in international other person. In practice, the attitude of emergency missions (Indonesia and Haiti) and HR projects any carer can be summed up by ‘listening (Vietnam). In 2006, he became president of a treatment and unwaveringly to hear and understand the HR centre in Paris, the Gaïa association, which is today running France’s first experimental low-risk drug consumption other better’. ■ room with an educational remit, in partnership with MdM.

Paul Bolo is a general practitioner and divides his working life between a private practice and drug treatment and prevention centre in Nantes. He joined Médecins du Monde in the 1980s and has been involved in harm reduction work since the beginning of the 1990s. Initially, he focused his efforts on the needle-exchange programme, becoming “Responsible of Mission” (volunteer with a professional background in charge of a project) from 1993 until 1999. He then helped establish a programme aimed at sex workers, known as the Funambus. He remains committed today to creating groundbreaking programmes in France and to continuing the debate surrounding harm reduction within Médecins du Monde.

References ›› Mino Dr A 1992, ‘Évolution de la politique de soins en matière de toxicomanie : la réduction de risqué’ in Guffens J-M (ed.), ‘Première Conférence européenne de réduction des risqué (France, Saint Tropez, 14-17 octobre 1993)’, Toxicomanie, Hépatite, Sida, no. 1, 1993.

Jean-pierre Lhomme & Paul Bolo Harm reduction and the evolution of the patient/doctor model

noTHing aboUT Us WiTHoUT Us? i Don’T THink so! Drug user activism and the International Network of People Who Use Drugs

Jude Byrne 54 55

he need for the full involvement of drug users providing input at every level of the development of programmes targeting the injecting/illicit drug using community has not been fulfilled, even within the harm reduction sector. People who inject drugs (PWID) are still largely seen as a deviant group whose services are required for interaction, and this has been the case since the drug users’ movement began. Unlike the HIV/AIDS response that welcomed and saw value in our input, the drug and alcohol sector see current drug user activists as ‘failures’ of their system. And, who wants to come face-to-face with their ‘failures’ on a daily basis? The inclusion of people who use drugs in the harm reduction movement and the development of the International Network of People who use Drugs (INPUD) cannot be discussed without first looking at our history within the HIV/AIDS public health response. For it was within the context of the HIV/AIDS response that people who use drugs were first acknowledged as having any positive identity in the wider

Jude Byrne has worked as a drug user activist since the late 1980s. She has worked in peer-based local and national drug user organisations while working towards the development of an international organisation. She is currently living in Canberra, Australia, and chair of INPUD which was established to ensure the most marginalised community members have a voice at the global level on issues that affect their lives. Jude has written papers and presented at conferences on issues affecting the community of people who use drugs, she has been an intravenous drug user for nearly forty years and recently completed a successful hepatitis C treatment regime.

community - albeit in a small, specific sector - let alone a role to play in the education, support and advocacy of our own community. The premise on which HIV/ AIDS education and prevention was based was peer education. While the communities of drug users have had some early and notable successes developing peerbased drug user organisations in individual countries such as France, Germany and Australia, the majority of countries were, and are still, unable or unwilling to support this pragmatic and humane public health policy. The crux lies in the problems of implementing a public health policy that is diametrically opposed to both the drug and alcohol sectors’ philosophy of abstinence, and the legal framework of prohibition in which it has to work. I am not going to delve into the facts and figures of HIV/AIDS infection worldwide. Suffice to say, the drug injecting community is increasingly bearing the burden of this disease in an ever-increasing number of countries. In this article, while charting our accomplishment in developing INPUD and the international drug user’s movement, I will also try to answer why our journey has been so difficult. The question of why our successes have been so hard won must be discussed. It is obvious to activists in the drug using community that it has often been external factors that have hindered our progress, not, as is so often said to be the case, that drug users are not a real community. We are a community in every sense of the word; we have our own culture, language and beliefs. Most tellingly, we can come together across languages and cultural barriers and understand a universality of experiences, stigma, discrimination and, too often, shame.

Drug user activists and the HIV/ AIDS epidemic In some ways, it is difficult to describe the impact that HIV/AIDS has had on the lives of people who inject drugs on both an individual and community level. Prior to HIV/AIDS, our needs were neither understood nor noteworthy, and were rarely expressed. Current drug users were only dealt with in terms of recovery or incarceration, and as such were characterised as either sick or criminal. Given that neither of those options were particularly sought after by people who injected, most shied away from government or any potentially problematic encounters, giving rise to the myth of our being ‘hard to reach’ .The gay community’s response to HIV/AIDS was rapid and intense. Once the mechanics of disease transmission was understood, they demanded and received the right to develop campaigns and educate their community, in effect establishing peer education as best practice in HIV/ AIDS prevention. The homosexual community was well positioned to both lobby government and organise itself. Over the previous decades, the stigma towards homosexuality had been declining, and the homosexual community was known to have considerable buying power, the ‘pink economy’ - which in a capitalist economy constitutes actual power. The gay movements’ position of ‘privileging’ peer education resulted in an atmosphere that permitted current drug users to work and organise - a previously unimagined possibility. Information about the ‘new disease’ was coming at a fast and furious pace. In July 1981, Dr Curran of the American Federal Centers for Disease Control (CDC) was quoted as saying: “The best evidence against contagion is that no cases have been reported to date outside the homosexual community or in women” (Altman 1981) However, five months later, in December 1981, the first cases of what had hitherto been described as the ‘gay cancer’ were reported in intravenous drug users. The new disease had clearly established a toehold in the intravenous drug using Testimonies

community. It was particularly clear in the US where the numbers of drug users and the circumstances of injecting, i.e. ‘shooting galleries’ where you paid to ‘rent’ a needle and syringe that would already have been used by countless numbers of others, gave rise to a cohort of people that made it impossible to ignore the mode of transmission. In our community, transmission was via shared contaminated injecting equipment. Blood to blood: nothing was more suited to transmission than the sharing of injecting equipment, so it was clear that the intravenous drug using community had to be reached and educated. As I have said so often - and it is a really important point to remember when you look

We are a community in every sense of the word; we have our own culture, language and beliefs. Most tellingly, we can come together across languages and cultural barriers and understand a universality of experiences, stigma, discrimination and, too often, shame. at the trajectory of the drug users’ movement - it was not to stop transmission in our community per se that Needle and Syringe Programmes (NSPs) were established, but rather, it was to stop people who inject drugs from spreading HIV/ AIDS into the wider community through sexual transmission. We threatened to be the instigators of the so-called ‘third wave’ if governments did not act to stop HIV/AIDS transmission in the intravenous drug using community. Governments had no cachet with the drug using community; they were effectively at war with them. So we had to follow the principles the gay community had instigated as best practices: peer education. It was blindingly obvious that the involvement of drug users in the response among their own community was absolutely essential. Luckily for the government, its agenda for the prevention of HIV/AIDS and the agenda of people who inject drugs dovetailed beautifully, i.e. the use of new syringes by people who injected drugs.

a full time job! The simultaneous change in atmosphere regarding drug users and the need to engage with them combined with the stability afforded by OST allowed activism among the community of people who injected to flourish. In countries where it was made possible, drug user activists rose to the challenge, and as a consequence, in countries where peer-based drug user organisations, NSP and OST were promoted, the HIV virus 56 People who injected drugs had wanted was stopped in its tracks. Germany, the 57 and needed new syringes for decades but Netherlands, France and Australia are all these were made as difficult to procure as examples of countries in which the rollout possible. No person who injected wanted of peer-provided NSP and OST was rapid, to use old blunt needles - they hurt and and in all four the typical prevalence of they ruined your veins. The difficulty was HIV among people who inject is less than how to get the equipment to the commu- 1%. HIV/AIDS remains at low levels in nity, providing needles and syringes alone those countries as long as the peer-based was not adequate. Education about the drug user groups and the appropriate whole injecting process had to be under- equipment/programmes continue to be taken. The only people able to do that with available, supported and funded. any plausibility were the very people who We are currently witnessing the devastation wrought by HIV/AIDS in countries where injecting is thriving and where no The HIV/AIDS experience had allowed drug user HIV prevention policies are being implemented among the community of people activists a new way of seeing ourselves who inject drugs. Given what we know and our communities. about the relative ease of prevention and the spread of the virus among people who inject, it is not hyperbolic to describe failwere currently injecting drugs. Gay men ure to do so as genocidal. It is the moralism about the use of were not expected to stop having sex, sex workers were not expected to stop sex drugs that is fuelling this contempt for work. But there was an expectation from people who use drugs. This is the fight some that former drug users were the only that INPUD has had to overcome, to get ones that government should work with. their community acknowledged as havThe latter was not a credible approach, ing the right to health and prevention and it was recognised that current drug treatments. The HIV/AIDS movement provided users had to be part of the solution. Along with NSP came Methadone a focus and the platform for the trainMaintenance Therapies (MMT) that ing of activists in the international comhad previously been extremely difficult munity of people who inject drugs, who to access. Now MMT, or in some coun- were then ready to engage with the harm tries other opiate substitution therapies reduction movement as it emerged. (OST), were opening up to stop, or at least limit, the chance of exposure to the virus by limiting the need or the frequency Drug user activists and the harm of injections. The availability of mainte- reduction movement nance therapies fortuitously provided a level of stability in the lives of people who The acceptance of drug users and, more injected on a daily basis that had previ- particularly, drug user activists in the harm ously been unreachable. Chasing drugs is reduction movement, while providing our Jude byrne Nothing about us without us? I donâ&#x20AC;&#x2122;t think so!

community with a vehicle to further our development, has been fraught with tension. While the philosophical underpinnings of harm reduction were a welcome change from the beliefs of an abstinence-based sector, we struggled with the notion of accepting harm as an inherent or inevitable part of drug use. Drug user activists argued that most of the harms that arise from using drugs were a direct result of prohibition and the panoply of harsh criminalising laws that come with it. We saw and lived the ‘harms’ that came from social exclusion, economic marginalisation, the criminal justice system and the never-ending ‘micro aggressions’ that conspire to make the lives of individual drug users unbearably vulnerable. The harm reduction movement as we know it began in Liverpool as the drug and alcohol workers developed a different philosophy that responded to the needs of their clients in the face of HIV/AIDS. Many regions and countries resisted and fought this new philosophy, and many still do.The idea that drug users be educated and provided with the means to use their illegal drug was an anathema. However, Liverpool had some visionary individuals who, in the face of a potential human catastrophe, recognised the need to link the drug and alcohol sector to the HIV response. The drug and alcohol sector had to offer programmes that attracted drug users into treatment, MMT, other OST and NSP. Drug user activists utilised this burgeoning movement as a means of developing their own agenda. The HIV/AIDS experience had allowed drug user activists a new way of seeing ourselves and our communities. The privileged, but more importantly alive, activists from the few countries that had responded to the HIV/AIDS epidemic with pragmatism and humanity had seen that change was possible. We had tasted full citizenship and we would not easily relinquish the experience. We wanted our entire community to have the same rights we were experiencing; watching our friends die unnecessarily from a disease gave us impetus and rage. So, international drug user activists began to meet at harm reduction Testimonies

c onferences. It was stunning to meet people from other countries who felt as you did, and who would not accept the status quo anymore; it was liberating and inspiring. We struggled for acceptance and inclusion within the mainstream of the conference and there were a few trailblazers such as Pat O’Hare and Sam Freedman who never made us feel anything other than completely welcome. For many others, we were a nuisance demanding human rights and

Case study Australia Australia was one of the earliest countries to implement harm reduction strategies among the community of intravenous drug users. Australia has also supported one of the most active peer-based drug user’s movements in the world. The combined partnership of government and community were so successful at controlling the HIV virus among our community that at one stage it looked like our funding was under threat. The HIV/AIDS virus seemed to be under control, so why were current drug users needed? However, the peerbased drug user movement was now so entrenched and the activists so passionate that they would not back down. We had discovered another virus had been decimating our community for decades, previously known as Non-A-Non-B, and so hepatitis C appeared in the late eighties. Our experience with HIV stood us in good stead, and the rhetoric about partnership and peer education was upheld. The blood-borne virus section of the government continued to fund the Australian peer-based drug user movement and the priority was now hepatitis C prevention and later treatment. The national peer-based drug user group in Australia - AIVL - has never been funded by the drug and alcohol sector. They cannot see us as complete human beings, they want to do things to us to make us acceptable to the wider community - or kill us in the process, as it sometimes seems.

Barcelona Conference was watershed where concerns about infrastructural and administrative issues were aired. Later in 2008 BrugerForeningen (the Danish Drug

Drug use is part of the human condition. It can be a response to life circumstances or happenstance, and it can just be because some of us derive pleasure from taking drugs. 58 59

workable treatment modalities. The IHRA Conference in Melbourne in 1992 was the first time that we had organised to meet in any structured way. More than fifty activists representing seven countries attended the inaugural meeting of the International Drug Users Network (IDUN) (Albert&Byrne 2010). Our aim was to provide support to one another, exchange ideas and have our voices heard in the international arena, and push for heroin programmes and the end of discrimination against drug users. We understood nonetheless that the legalisation of drugs was a long way down the road. Organising between meetings was problematic for some years, as fax and phone calls made it difficult to maintain contact. The arrival of the Internet provided us with enormous potential to communicate and support one another between the yearly meetings. International activism began to gain momentum. The International Harm Reduction Association Conference (IHRA) in Belfast in 2005 provided a catalyst that reinvigorated the movement. The facilities for people who used drugs were woefully inadequate. It was then thirteen years since we had first mooted an International Drug Users Movement and people were getting disheartened. The IHRA Vancouver Conference of 2006 resulted in the Vancouver Declaration that became the founding document of a new movement named INPUD. A grant was provided to assist the nascent international organisation to develop. As is often the case with funders who want ‘project outputs’, the funds were inadequate to effectively shore up an infrastructure for INPUD, so it struggled while still achieving positive outcomes internationally. The IHRA Jude byrne Nothing about us without us? I don’t think so!

Users’ Union) offered to host a meeting in Copenhagen for international activists to revisit the current INPUD structures. This meeting resulted in the INPUD of today - a strong vibrant organisation that is a voice for the intravenous drug using community on the global stage.

The state of INPUD INPUD currently has over four hundred individual members worldwide and representations in Australia, India, Burma, Malaysia, Europe, Ireland, Russia, Indonesia, America, the UK, Canada, Africa, Eastern Europe, New Zealand, the Caribbean, and many Eastern European countries, to name but a few. Regional groups such as the Asian Network of People who Use Drugs (ANPUD) and the European Network of People who Use Drugs (EuroNPUD) are working with us on joint global issues. INPUD has provided funding to support the development of a Latin American arm of INPUD, as well as a network in the Middle East and North African region. We have funding for a virtual secretariat of three positions: the Executive Director, the Communications and Logistics Coordinator, and a Programme Coordinator. Filling these positions has been a challenge - most activists are employed in organisations in their own country and very few countries have supported the development of those peerbased drug user groups. INPUD has a very small pool of people from which to find employees to work at the level our funding demands. Our funding will ensure that new opportunities for activists in other countries will open up; we can only hope

that it is embraced more readily than over the past twenty years We have representatives on the United Nations AIDS Programme Coordinating Board, and various World Health Organisation committees. We are invited to speak globally on issues that affect our community. We work in concert with many other organisations in both the harm reduction and the blood-borne virus sector. On World AIDS Day 2011, INPUD coordinated an international day of protest against the Russian government’s treatment of our community outside the Russian embassies in the capital cities of eleven countries. We have run peer education and self-advocacy programmes in Georgia and Afghanistan. Over the next four years, we will be working with regional groups in India, China, Kenya, Pakistan, Nepal, Malaysia, and Eastern Europe. The scope of INPUD’s work is enormous, and as such, our workers and representatives need to be informed on a diverse and ever-expanding range of issues including all blood-bourne virus prevention and treatment strategies, including TB prevention and treatment. All the above infections and co-infections and the resulting drug interactions have to be well understood. We need to work across the drug and alcohol sector, the mental health sector, as well as the criminal justice sector and human rights. All of these sectors and innumerable others impact on the day-to-day lives of our members and community. It needs to be remembered that all of this funded activity is a public health response, and not a drug and alcohol led programme of activity. It seems highly unlikely that we would have been able to accomplish what we have if the drug and alcohol sector was responsible for our funding, even under the harm reduction rubric. The rise of the ‘New Recovery Movement’ is an issue with which INPUD and drug user groups all over the world are concerned. While undefined harms remain a feature of the drug and alcohol sectors rhetoric, people who use drugs Testimonies

will always be vulnerable to shifting government agendas and economies. Drug use is part of the human condition. It can be a response to life circumstances or happenstance, and it can just be because some of us derive pleasure from taking drugs. Let’s all be honest, no one really knows why some people take drugs and others don’t. If governments, community agencies and individuals working with both the blood-borne virus and drug and alcohol sectors don’t get the importance of the drug user movement after all these years, it speaks to a situation that is possibly beyond the remit of people who inject/ use drugs to influence. We have been trying for over twenty years, and we are still struggling for the acceptance and the right to determine our own destinies. Too many other parties assume we have no right to self-determination while vigorously defending the rights of many other groups. There must be something deeply disturbing to the mainstream psyche about injecting drugs for pleasure, for there is no other explanation for the unremitting exclusion of our community in so many countries and on so many levels. When the result of that exclusion is the transmission of preventable diseases, overdose, illness, and death, it illustrates a lack of empathy that is almost inhuman. ■

References ›› Albers E & Byrne J 2010, ‘Coexisting or conjoined. The growth of the international drug users movement through participation with IHRA Conferences’, International Journal of Drug Policy, vol. 21, no. 2, pp. 110-111. ›› Altman LK 1981, ‘Rare cancer seen in 41 homosexuals’, The New York Times, 3 July.

Drug user self-support A junky story

Fabrice Olivet

elf-support groups were originally ease par excellence. Medicine’s inexplicaunlikely gatherings of (angry) drug ble failure to eradicate the scourge was addicts, who were convinced of the also a major trauma, as medical science need to speak out about their lives in an had for ages been at the very heart of the attitude other than one of repentance or notion of progress. Finally, it should not sordidness. Begun in an atmosphere of be forgotten that AIDS struck in the midrock’n’roll and later wedged between dle of the disco era, between a couple of cemetery and prison, the self-organisa- glasses of champers and a line of coke. It tion of ‘junkies’ in the 1980s was the fruit was a nice surprise for the gay commuof the unthinkable AIDS epidemic. Today nity which, after a decade of struggle and annexed to technocrat-speak under the the beginnings of social recognition, was heading ‘patient associations’, self-sup- confronted with physical disappearance port is, for better or worse, undergoing a pure and simple. difficult period of institutionalisation. The historical impact of the discovery of acquired immunodeficiency syn- Addicts’ AIDS: avatar of the war on drome – AIDS – has still not been meas- drugs ured. Homosexuals, migrants from the Caribbean and drug addicts – according We always forget to mention that the to the terminology of the time – were the fight against drugs, or more precisely the primary target of a virus which naturally enforcing of a ban on drug-taking, is a followed in the footsteps of discrimination form of war. It is an undeclared war, an and racism. We have somewhat forgotten asymetric war, led by the State against today the twilight, end-of-world atmos- its citizens, but described as such by the phere which served as a backdrop to highest authorities. the media hysteria triggered by the pandemic. Television images showed doctors transformed into astronauts, handling ill people weighing 40kg in sterile rooms. French weekly newspaper Paris Match devoted its front page to the progress of a Kaposi sarcoma, in a full-page photograph with the caption ‘Ravages of the Fabrice Olivet is the director of ASUD – Autosupport des usagers de drogues (Drug Users’ Self-support) –, an gay cancer’. association founded in 1993, which represents consumers ‘There’s no smoke without fire’, thought of illegal psychotropic substances in France. He holds the ordinary public, paralysed by the a Masters in contemporary history and, for the past return of medieval hell-fires. The threat seventeen years, has worked hard in a professional of universal contamination peddled by capacity on harm reduction. In 1993, he was the first fringe groups put the finishing touches president of the collective Limitez la casse, which to the apocalyptic scene. An incurable promoted the policy of harm reduction in France. Since disease, transmitted by sperm and blood, 2007, Fabrice Olivet has been a member of the National decimating first and foremost sodomites Commission on Addiction. In 2011, he published La and junkies: AIDS was the political disquestion métisse, Editions Fayard/Mille et une nuits.

War on drugs: war against drug addicts

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Let us review the facts. In 1969, President Nixon declared ‘the war on drugs’ as the number one priority of American forces. More than a slogan, it was a new policy on the agenda in which the consumer of illegal substances was designated a ‘public enemy’ (sic). A year later, France adopted legislation known as the 1970 Law, strongly influenced by this philosophy, and, the French government brought in a decree dated 13 March 1972 regulating the trade and importing of syringes, which in practice prohibited the sale of sterile equipment to heroin addicts. It was this decree – now virtually forgotten – which was the origin of the AIDS epidemic and, subsequently, the spread of the hepatitis viruses among heroin addicts in France. More than collateral damage, the ban on obtaining syringes was the avatar of the war on drugs, a cursed offshoot of this policy in the form of apartheid, demanded by the State. Unlike the ban on its own, which prohibited legal access to certain compounds, the war on drugs was directed against people. It was not a difference of degree but a change of perspective: while a ban was a defensive tactic, the war on drugs was an all-out offensive which struck indiscriminately on a moral, economic, health and political level. It involved excluding a category of the population identified by its consumption of psychotropic drugs from ordinary law. By prohibiting the sale of syringes, the 1972 decree created an exclusion zone which served as a matrix for AIDS. The deadly trap which then closed on drug users soon revealed itself at the end of the 1980s to be a threat to the whole population.

Fabrice Olivet Drug user self-support: a junky story

Born in the 1970s, too late to be hippies and too early to be patients treated by addiction specialists, we were children of the crisis, busy looking for a vein to shoot up. We were punks, dropouts from the disreputable suburbs – not yet referred to as ‘caillera’, suburb slang for scum – in short we were ‘the bad guys’. We too enjoyed discoing at The Palace Parisian nightclub, but to come back down we discovered heroin. The story of this generation remains to be written. It paid a heavy price with overdoses, AIDS and violent deaths of every sort. It was the world as described by French writer Vincent Ravallec in his ‘pure rock’n’roll moment’ (Ravallec 1992). We were very familiar with the war. More than an excluded population, drug addicts were the dropouts, the majority of criminals in prison, swindlers of every sort, small-time gang leaders from the disreputable suburbs, professional armed robbers and burglars. Heroin required serious money. And that is without doubt what made them really different from today’s ‘junkies’. Before substitution, a heroin addict had to find something each day to tame the voracious beast, which, for the greediest, demanded the equivalent of 300 to 400 euros daily. It was impossible to find that on the streets or by begging. The life of an addict was therefore pushed beyond the sphere of what was legal; that was the aim of the war on drugs, a war essentially destined to transform drug users into terrorists or corpses. Aside from dealing and stealing, all means were good for finding money, even paid work, which naturally did not mean dispensing with offering sex, getting in debt, defrauding the company, borrowing from family, in short engaging in a sort of permanent combat, very different from the experience of the clientele treated by the healthcare system today. Besides, addicts didn’t grow old: before harm reduction, an old junkie was a dead junkie. This context is crucial for an understanding of how shocking the concept of an addicts’ association was. In 1992, the

date the first newspaper was published by Autosupport des usagers de drogues (ASUD – Drug Users’ Self Help Group), a meeting involving a handful of addicts demanding the right to get high was in itself an aberration. It was something of an oxymoron: addicts do not join forces except for the wrong reasons; moreover, it was as a group of criminals funded by the State that ASUD, the first ever French self-support group, started describing and promoting itself.

The politics of harm reduction: the drug addicts’ May ’68 AIDS was a political illness and the remedy was political too. For those of us who had not already died, the politics of Harm Reduction (HR) enabled us to experience a little May ’68 of our own. Since the end of the 1980s, some voices had begun to be raised in France to create a breach in the war on drugs. That breach had a name – harm reduction policy. Some European countries, like the Netherlands, out of pragmatism, or the United Kingdom, for reasons linked to legal and historical context, had already experimented with this new approach, which involved no longer passing moral judgement on the use of narcotics (non-judgemental), but attempted to reduce the most harmful aspects. France had the highest rate of HIV contamination per inhabitant and intravenous drug users played a major role in the pandemic, particularly relating to contamination among homosexuals. France was scared. The nightmare of a society ravaged by HIV began to produce cracks in the frontline of the war on drugs. As early as 1987, a courageous Minister of Health, Michèle Barzach, had broken a taboo by abolishing the notorious 1972 decree, a measure that apparently cost her her career. In addition to the over-thecounter sale of syringes in pharmacies, HR consisted in widening access to Opioid Substitution Therapy (OST), creating a national needle-exchange facility, and promoting the setting up of drug users’ groups prepared to spread information about injecting techniques that carried Testimonies

More than an excluded population, drug addicts were the dropouts, the majority of criminals in prison, swindlers of every sort, small-time gang leaders from the disreputable suburbs, professional armed robbers and burglars.

minimal risk among their peers and HIV prevention messages more generally. The rise of ASUD and promotion of HR are inseparable. In 1993, Limiter la casse (Limit the Damage), a collective led by sociologist Anne Coppel, an iconoclastic figure in the drugs debate in France, brought together three groups: drug users represented by ASUD, anti-AIDS activists from Aides and French doctors from Médecins du Monde. This was not a random tripartite grouping. This community movement led by associations provided real hope for all those wanting to change the drug policy. HR policy had brought about a transformation in the intellectual frameworks at work in relation to drugs. A dose of public health had been administered in response to the ‘scourge of drugs’ and, in doing so, a world of pure fantasy was abandoned in favour of the world of material reality. Any rational analysis, if honestly conducted, necessarily leads to common-sense conclusions. HR, in contrast to the war on drugs, relies on the principles of reason, pragmatism and effectiveness. Six months after syringes were once again sold over the counter, HIV contamination among drug users was reduced by 80%. Between 1994 and 2004, the number of heroin overdoses dropped by two-thirds, simply as a result of access to OST. This success relied on massive support from so-called ‘drug victims’. Drug addicts were the main players in a system that allowed them to take charge themselves of preventative action. In the mid 1980s, an expert commission expressed doubts as to the willingness of heroin addicts to supply themselves with sterile equipment from pharmacies, even as a means of escaping AIDS. The success of HR imposed a paradigm shift which

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broke with the previous ‘psychologising’ approach based on the ‘death wish’ theory. HR represented a genuine revolution for injecting heroin users, those vermin who, like the gay community, were threatened with extinction. Let’s be honest: without the threat of AIDS, HR would never have achieved the status of national policy. It is because drug users represented an objective danger to the whole of society that the public authorities agreed to lift a small corner of the veil concealing the ineffectiveness of the measures inherited from the 1970s. But one truth is still considered subversive: the war on drugs is not only ineffective in the fight against the disease; it also contributes in great part to the ills traditionally associated with the use of narcotics.

ASUD: citizens like any others ‘Citoyens comme les autres’ (Citizens Like Any Others) is the name of a Belgian self-support group founded in Brussels by Didier de Vleeschouwer in 1992, the same year as the ASUD newspaper. This title, referring to a programme of action, pretty well sums up the powerful idea which prevailed when our Drug Users’ Selfsupport (ASUD) was created. The notion of self-support emerged outside the French context. Abdalla Toufik, a sociologist who regularly attended conferences of the International Harm Reduction Association, the principal organisation for HR promotion in the world, was the person who really conceived of ASUD. Returning to France, he took the initiative of bringing together a few crazies who were ready to defend the idea that Fabrice Olivet Drug user self-support: a junky story

drug use was neither a perversion nor a crime, nor even an illness, but the expression of a need for rapture deeply rooted in the human psyche. A journalist, Gilles Charpy, the now deceased son of a prominent Gaullist and a major heroin user, suggested firstly founding a newspaper which would talk about drugs and which would be by addicts and for addicts. In 1992, the first edition of the ASUD newspaper put forward ten emergency measures. What is striking today is how moderate this programme was and how twenty years later it is practically realised: setting up automatic needle exchanges, extending the use of methadone, visits by a doctor during detention in custody, and even institutional support for self-support have, since 1996, become a reality. But one demand – just one – has gone unheeded: an end to prosecution for personal use. Not only is it not on the agenda, but it remains a political topic rejected by virtually all political parties. When in fact the fight for decriminalisation is what principally holds the drug users’ association represented by ASUD together. Most of us, ex-dealers, robbers, burglars and hooligans of all persuasions, had but one objective: to become full citizens in our own right, obeying the laws without having to give up drug-taking. ‘For its first issue, the ASUD newspaper is offering you a scoop, […] that is our very existence, the birth of the ASUD group and the publishing of its newspaper,’ ran the editorial in June 1992 signed by the first chairperson Phuong Thao (ASUD 1992). Decriminalisation legally refutes the idea of prosecuting an adult for freely consuming a substance in private. Decriminalisation is essentially based on human rights which affirm that individual freedom should not impinge on the freedoms of others. This desire for justice, the feeling of having been victims of State policy and the wish to shed the role of guilty party were the prime motives which brought together the first ‘ASUDians’. At our first meetings, we did not believe at all that the association, created in 1993 one year after the newspaper, had any chance of a long-term future. A meeting

in Copenhagen. This chain of solidarity was extremely gratifying on an emotional level. It enabled our groups, often subject to strong feelings of rejection in their own countries, to discover brilliant and enthusiastic counterparts from elsewhere, with little inclination for bemoaning their fate, while we tended to view ourselves as a peculiarly French phenomenon. Today this chain of solidarity enables us to evolve in partnership within the International Network of People who Use Drugs (INPUD), chaired by Jude Byrne. (See part 2 of Chapter 7 written by her). In 2003, the association took on a new dimension with the organising of the États généraux des usagers de substitution (EGUS – General Assembly of Substitution Users, 2006). This annual event was devised as a forum for exchange for all stakeholders, users, healthcare professionals and ordinary citizens. Our idea of providing users with a platform remains linked to the fundamental notion that Drug addicts of all countries…unite! drugs form part of the field of potential activity in the path through life of As we have seen, self-support was a con- any human being. As Nicole Maestracci, cept imported from abroad. Charismatic drug tsar in France from 1998 to 2002, leaders, now dead as a result of AIDS and rightly expressed it: a world without long forgotten, such as Werner Hermann, drugs does not exist. Unfortunately, this founder of the German JES group, or brief improvement in matters was fought John Mordaunt, leader of the Mainliners against by an ill-assorted alliance of oppogroup in the United Kingdom, profoundly nents to HR policy and supporters of allinfluenced the first French self-support out medicalization, namely the historically associated twin cronies of the moral activists. In 1997, the Eighth International Harm order and the health regime. Reduction Conference was organised in Paris. To mark the event, we brought together two hundred people of all Turning point of addictology, or the nationalities decked out in t-shirts bear- cuckoo-in-the-nest policy ing the explicit symbol – an Eiffel Tower transformed into a syringe – crossed out Harm reduction is a necessary condition by the slogan ‘I’m a drug user’. Two hun- for changing how drugs are represented dred jokers proclaimed their drug use at but is not enough to achieve this. One of the tops of their voices at an official con- the political messages of Limiter la casse ference addressed by three former minis- and ASUD was to insist on bringing legal ters. These shared moments created ties and illegal drugs closer together with that were strengthened through personal the aim of educating. It was necessary relationships formed with self-support to exploit the potential of identifying, for leaders such as Jude Byrne, from the example, consumption of cannabis with Australian Injecting and Illicit Drug Users traditional wine-drinking, with the objecLeague (AIVL), Mat Southwell, organiser tive at heart being to destroy negative of Respect in the United Kingdom and representations of the drug addict by Joergen Kjar of the Drug User Union stressing consumers’ responsibilities as of drug addicts for a purpose other than to share drugs seemed utopian even to us! Not only was the future to prove our worries unfounded, but the official support from the Ministry of Health in 1996 gave legitimacy to our slogan ‘Association of criminals funded by the State’. As a real HR policy was gradually implemented that included one of the most liberal systems of access to substitution treatments in the world, our audience gradually expanded. The ASUD newspaper, with a distribution of 4000 copies in 1992, then became the voice of drug addicts. In 1996, money from the ministry and funds raised by French charity fund Sidaction enabled us to produce 20,000 copies of every issue, which were distributed throughout France, gaining a wider audience and helping other ASUD groups to emerge across the country, and to infinity and beyond.

Testimonies

they were given the place of patients suffering from a pathology known as ‘chronic recidivism’ (as explained in DSM-IV, the handbook on mental probLet’s be honest: lems), the role of their representatives without the threat of AIDS, such as ASUD being limited to relaying HaRm reduction would never have achieved problems of compliance and ‘adhesion’ to OST, considered a lifelong form of the status of national policy. treatment. The final clincher came when fundamental research in exact sciences (neurobiology and genetics) moved into 66 individuals and the celebratory nature the drugs field, which was not in itself 67 of their motives. Why should that which bad news. But this new player simply is conceivable for nine-tenths of recrea- relegated users to the world of mental tional users of good wines with a taste illness, reinforcing to some degree the of our soils not apply equally to users of social exclusion put in place by the war other psychotropic substances? A series on drugs. In forty years, we have moved of reports published by the health admin- from the notions of law-breaking (crime, istration has supported the argument counter-culture and marginality) to the that it is nonsense to legally classify a world of social precariousness, mental product on the basis of pharmacological illness and lifelong treatment. The practical consequences of this criteria alone. It might have been possible to believe conceptual reorientation were rapid. that, for once, the medical technocrats Following the disbanding of the Limiter were about to free illegal drug users from la casse collective in 1997, ASUD found a ghetto which was, from a scientific point itself alone going head to head with a of view, unproductive. In fact the opposite criminal justice system that was still more happened. From the start of the 2000s, a and more focused on increasing represnew discipline emerged from the ruins sive measures. Our ultimate reply was of harm reduction, stripped of its major the gradual transformation of ASUD into political message concerning the central a patients’ association, only permitted to role played by users, as the concept of act as spokesperson for victims of ‘addicaddictology was elaborated. This hospital/ tions’, the latest paradigm in vogue. university-based discipline was led by the new mandarins in the field, most of them psychiatrists with a background in alco- Chronically ill patients or repeat hol research. It was genuine highway rob- offenders? bery, which seized on the rationale of HR but loftily ignored its citizen-led struggle. The story of ASUD can then be summed Everything became an ‘addiction’: gaming, up as the gradual aligning of the associsex, heroin, the computer, crack, coffee, ation with the highly medicalised develcannabis, chocolate etc. The stigmatising opment of HR. In 2007, we obtained the of people, the lack of reliable informa- consent of the Ministry of Health to ‘reption on illegal drugs and the historic role resent users of the healthcare system’. played by the war on drugs in cracking This administrative compliance has, over down on working-class neighbourhoods recent years, become a political obligation. – all these topics were simply censored in The massive take-up of HR by users has the debate. The pharmaceutical industry practically removed drug addiction from (manufacturing substitution treatments) AIDS statistics: in 2010, they accounted and the hospital/university hierarchy for 0.4% of new cases of contamination, (promoting new chairs in addictology) which virtually excludes this population entered the dance, sending the pioneers from the figures. This victory of life over of HR back to their unheeded dreams of death has, paradoxically, shattered our being free from prohibition. As for users, legitimacy. The existence of drug addicts’ Fabrice Olivet Drug user self-support: a junky story

associations is no longer tolerated given 2010) Along similar lines, heads of state that we no longer represent a global threat. in Latin America are contesting the effecPrompted by a parliamentary commis- tiveness of the war conducted in their sion in 2003, an initial campaign labelled respective countries by the United States ‘Drugs, the other cancer’ called, in par- on the pretext of destroying the producticular, for an end to the funding of ASUD tion of narcotics from which the American in the name of the fight against drugs. population is the prime beneficiary. These Four years later, following the election of fresh obstacles raised against the global Nicolas Sarkozy as President of France, a crusade against drugs would seem to new drug tsar provided the first concrete indicate that the health arguments are evidence of this hard-right ukase by with- not enough to overturn a political and moral system still regarded as the United drawing part of ASUD’s funding. This epilogue is the result of the advent Nations’ official credo. ■ of a new addictology paradigm. From an association of addict activists campaigning for the right to take drugs, we have become an association of chronically ill patients destined to take up and refer requests for treatment. This essential change is doubtless down to the ideological defeat sustained by HR as a whole from the moment AIDS no longer represented a threat to society. In theory and in practice, the alliance of the truncheon and the stethoscope is curiously reminiscent of that of the sabre and the aspergillum which succeeded in keeping the dangerous elements in society outside the boundaries of democracy for centuries. Our hope now rests on the other damaging effects of the war on drugs: violence, racketeering, gang wars and ethnic riots. Michelle Alexander, an American legal expert, has just created controversy by showing, backed up by statistics, that the war on drugs instigated in 1969 by Nixon was an indirect way of retaking control of Blacks from the ghetto after the civil rights’ offensive in the 1960s. (Alexander

References ›› Alexander M 2010, The New Jim Crow. Mass incarceration in the age of color blindness, The New Press. ›› ASUD (1992), Editorial, vol. 1, [June 1992]. ›› Ravallec V 1992, ‘Un pur moment de rock’n’ roll’, Le Dillétante, Paris.

Testimonies

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Women of substance Erin O’Mara

“History demonstrates that for a long time women have consciously sought the experience of getting high, and that they have experimented courageously, lived dangerously, and written about it eloquently.” (Palmer & Horowitz1982)

And I would stare at the adjacent pichen I was a young woman growing up in Australia, I was captivated ture and into the palest of faces and I, too, by stories and images of drug use would get swept up in the image. Drawn in the media. Newspapers would regu- in by the stories that told of a life sacrilarly feature some drug exposé, grainy ficed - a path pushed brutally off course black and white photos showing some- because of some indefinable compulsion, one whispering furtively to another while a power wielded by a mere substance delivering a banned substance by a quick with a heroic name. They seemed to know something I sleight of hand. Androgynous youths leaning against lampposts, fag hanging off the didn’t. They (the ‘druggies’) appeared to lower lip, eyelids drawn, faces gaunt, all have taken a path that had been forbidthe while managing to look supremely den by society and they were out to enjoy satisfied. What secrets were they hiding themselves. Tuning in and opting out, the suit, the mortgage and the greasy pole from the rest of us? Most of all, I looked for the personal sto- were smugly kicked into touch. And the ries. The serious feature or news item that media photographed it all through a hidwould tell the story of a person’s slippery den lens, playing the role of voyeur for descent towards some far-off place where the masses who were both repulsed and they would be left stripped bare of their captivated. Junkies looked vulnerable yet former lives, unreachable, having sac- untouchable, and drugs looked cool and rificed everything for heroin or cocaine. risky. It was a role ripe for mythmaking Such stories would always be accompa- and illusion, and the public’s fear and nied by the obligatory ‘before’ and ‘after’ fascination became exploited in equal photo; a gawky adolescent smiling awk- measure. wardly in a school photo and then, a mere shadow of their former self in the ‘after’ picture. The parents would speak of the agonising worry that their child was lost to them, and the journalist would interErin O’Mara is an international activist for people who view the experts. Experts who would talk use drugs, writing, speaking and reporting on issues about the role of the ‘addict’, the manipthat affect the drug using community for almost fifteen ulation of loved ones, the lies, the loss of years. She currently writes for INPUD and Black Poppy, a control…all contributing to a growing British-based magazine and webzine by and for people societal profile of junky ‘otherness’. who use drugs, which she co-founded with Chris Drouet.

the pleasure she offered, and then led you to ruin. These metaphors follow the recurring stereotypes of women as seductive, treacherous, illusive and ulti-

Then a new woman (re)emerged – staggering into the psychedelic sunlight, carrying a syringe in one hand, Valium in the other, blinking back the hot fear of the white middle classes. 70 71

But it wasn’t just the news media. By the time I was growing up through the 70s, 80s and 90s, the illicit drugs ‘image’ was thoughtfully coloured, packaged and sold on by consumer capitalism and marketed through music, clothes, movies, brands, young people’s leisure, pleasure and even lifestyle - the romantically doomed junky, the hippy dreamer, the hedonistic raver. Then a new woman (re)emerged - staggering into the psychedelic sunlight, carrying a syringe in one hand, Valium in the other, blinking back the hot fear of the white middle classes. She had been around the block, this girl. Always portrayed in easily digestible, emotionally unsophisticated ways, when the press came to relay stories about women who took drugs, it has always been the same. Following the popularity of De Quincey’s Confessions of an English opium eater (De Quincey 1821) in the 1850s, the quintessential ‘drug addict’ was readily presumed to be male and any ideas of women being courageous enough to experiment with ‘foreign’ substances were as an unpalatable truth as a woman in charge of her own mind. However, it is interesting to note how drugs themselves were given a gendered identity, which came across in French literature, as Marcus Boon wrote in his book The Road of Excess, and which still continues today. “Drugs themselves were pictured as seductresses like Salome or the Odyssean Circe in this [French] literature. Heroin was ‘the white fairy,’ morphine ‘the grey fairy,’ opium ‘the black idol’, and absinthe ‘the green fairy’. ‘She’ (the drug) seduced with her beauty and

Erin O’Mara Women of substance

mately destructive, and take on a predictable narrative about male drug use as ruinously addictive.” (Boon 2004) Accounts of women who took drugs have followed a rather strangulated loop having done so since the mid-19th century when the first reports of over-indulgence in drugs by women would occasionally emerge in the press. At one end, we can find the female user who is a mere ‘babe in the woods’, the ‘moth to a flame’, or the ‘child in a woman’s body’. Vulnerable girls who were led astray by the one they loved (the older boyfriend). Women who tried too hard to please and were betrayed by the bad boy (of colour). At the other end, we find the tramp. The slut. The temptress. The raven-haired beauty who lures men to their confused and penniless fate. You’ve seen and read of the familiar characterisation of the foul-mouthed bag lady, the waif who frightens small children in public or, the modern ladette. And somewhere in the middle, we will find the drugged female psychiatric patient, suicidal, tearful and confused. And there you have it: representations of deviance in women who use drugs over the centuries; a far from truthful account. Historical amnesia is quick to assure us that each repetition is merely a fad and not the long-standing pattern it really is. More recently, we can add the ‘crack whore/mum’ and the ‘welfare queen’ to this list. Both are manufactured representations of drug using mothers and both have been particularly damaging to the reality of women’s lives. For example, it is these media constructs that have fuelled some particularly harsh regulations in the US, where pregnant women

who use drugs can now be charged - in some states - with attempted murder. Susan Boyd, in her book From Witches to Crack Moms, says: “Biased reporting by media and initial, unconfirmed medical claims about harm to the foetus and unfitness of mothers who use illegal drugs are used by court prosecutors as ‘facts’ rather than as social constructions.” (Boyd 2004). Pregnant women who use drugs have long been seen as poisoning their foetus on purpose and therefore have been forced to take their place amongst the most stigmatised groups in modern society. Women who use drugs continue to have their experiences transmuted through the editor’s daily manufactured histories that have been tied to the page with words to arouse public feelings of anger, shame and concern. From Billie Carleton (1920s, UK) to Marianne Faithfull (1960s, UK), and Courtney Love (1990s, US) to Whitney Houston (2000s, US). Why have women who use drugs ended up in such a misrepresented, voiceless and victimised position? More importantly, how have these disempowered images of women prevented us from gaining the critical understanding of drugs we need to take us into the next century?

From image to truth

women who are today’s brave and articulate psychonautical travellers and continues to mask the harshness and tumult experienced by thousands of drug using women every day of their lives.

Converging controls To really understand the experience of women who use drugs in the 21st century and where they stand in the drugs debate today, we must unravel the cords of gender politics, cut the chains of prohibition, and carefully deconstruct the pathology of drug treatment itself. It is true enough to say that the war on drugs and many of society’s social control mechanisms intersect directly across the bodies of women who use drugs. Criminology, medicine, psychiatry, politics, economics, sociology and drug treatment have all developed techniques for the ‘management’ of women who use drugs, and as Henderson states, each is competing for the moral high ground (Henderson et al., 1995). Drug treatment and the study of addiction is synonymous with pathology, and under its guise and the creed of prohibition we find the drug using population ‘trafficked’ within a mushrooming net of treatment centres, clinics, surgeries, hostels, rehabilitation and detoxification centres, and probation services, all aiming to manage, treat, punish or drug the drug user. For women, we see the creation of a stifling environment where society’s unyielding expectations about women have now converged with the pathology of the junky ‘otherness’ (Fagan 1994) and others argue that women and girls who use drugs are viewed as doubly deviant: social deviance from normative behaviours and gender-role deviance from the expected female role of nurturer. But for women who take drugs today, it is even more complicated than that.

For too long, women who use drugs would only appear as the betrayed and the tricked, the injected and the coerced, the sold and the bought, always playing the girlfriend, the wife, the mule. Reclining in the passenger seat and always carrying ‘his’ stash, she is driven yet never driving, towards a destination assumed. In the cleverly manufactured history of illicit drugs, disempowerment has become the default position for women users in this global war on drugs. Yet this is not the only place women carry that burden. We see elements of this repeated wherever we have women who choose to betray the passive stereotype, stepping away from their nurturing role. As a society, we label and disempower Treating women what we fear and what we don’t understand. Yet for women who use drugs, this A woman who walks into a drug treattragically obscures the voices of the many ment centre or rehab has little chance Testimonies

already have been in and out of rehab. So to expect the therapeutic process to include conversations about the aesthetics of her drug use can hardly be seen as a drug counsellor’s priority, but should not preclude it from conversations altogether. In fact, such discussions should be integral to regaining one’s authenticity and self-determination around drugs and drug use. Aside from the media, the notorious 72 of being acknowledged as an individual assessments and multiple hoops through 73 with a story to tell. Her experiments with which a woman must jump in order to drugs and her experiences of intimacy gain any state-prescribed or opiate-based whilst using drugs, of expanding aware- medication such as methadone or subness, or even of finding ways to continue oxone will quickly provide her with the to use drugs moderately and safely are harm infused language of ‘addiction’ she frequently denied room for discussion must now converse in for the duration and are not treated as therapeutic or of her treatment and beyond. Seduced into using any number of disempowered practical subjects. Many researchers in the humanities clichés whenever referring to her relationship with drugs, a drug-using woman must adopt these well-worn phrases in For too long, women who use drugs order to get through any ‘recovery’ orientated programme, and it is the accepted would only appear as the betrayed currency with which to wrestle one’s chiland the tricked, the injected and the coerced, the dren back from social services.

sold and the bought, always playing the girlfriend, the wife, the mule.

and sciences have argued that there is something primal in the desire to experiment with feelings and senses, something deep within us, and that our new drug rituals of today simply supplanted more ancient ones. Perhaps to reconsider our drug using behaviour as ‘the norm’ rather than ‘the other’, historical rather than contemporary, would put us all on a better path to moderation, pleasure and control. As Nigel South comments in his seminal book Drugs, Cultures, Controls & Everyday Life: “Is sobriety really the norm anyway”? (South 1996). Nevertheless, it is true to say that by the time a women enters drug treatment settings, her adventurous spirit is probably crushed. The laws of prohibition and her involvement with the black market will have conspired to have her broke and in debt, homeless or couch-surfing or even on probation. She may have overdosed, lost close friends to drugs and Erin O’Mara Women of substance

There is only one view of rehabilitation, and it isn’t individual In fact, in almost every drug service, a woman’s relationship with - and enjoyment of - substances will have to be cut off at the knees if she is ever to walk out of recovery’s door. Recovery is the final train on which society’s ‘druggies’ will be funnelled aboard, en route to a one-way destination. Not her way, but their way. Not another way, but the only way. The difficulty in creating an environment where women can trust those in authority about pleasurable drug experiences needs attention. Consistently, women who have entered treatment centres with drug problems have alluded to the difficulties in divulging their complete experiences - felt more acutely when a drug-using woman has children. The fear of an unwanted intervention by social services is so expected and so potentially frightening that it often prevents large numbers of women around the world

from entering drug treatment doors at and alcohol use, freeing their discussion all. Where OST is permitted for mothers from drug clichés and assumptions, and in some countries, continued illicit drug support the evolution of a new language use certainly isn’t, problematic or other- centred around awareness, of controlled wise. So our understanding of the needs and limited use and empowerment, familof drug-using mothers and their chil- iarised by women. dren remains hidden and inadequate, the Thankfully, today, in some small secresearch often lacking or flawed. What has been lacking are the very con- tions of the world, it seems support and versations that would support women to information about drug use is moving moderate, control or even to re-enjoy beyond its recent confines of public health their drug use, or to discuss the role gen- and law out to where it belongs - in socider, economics, society and prohibition, ety itself. have played in the difficulties they’ve encountered. So is it any wonder that women have had such a disempowered Politics meets the female junky and possibly dead-end role within drug treatment? The constrictive gender constructs that Yet, for a lot of women dependent on have served to mythologise a woman’s opiates and/or stimulants in Europe and experience of drug use, coupled with the around the world, services – from drop-ins prevailing victim narrative that has been to rehabs - are often wholly inadequate perpetrated on womankind by the medifor their needs -: for example, strict open- cal model, has meant that women who use ing hours for women with children, lack drugs have been sidelined, silenced or spoof access for HIV-positive women, little or ken for in the mainstream drugs discourse. no child care facilities or parental support, little or no training or staffing in the area of domestic violence, a lack of supervised dosing at chemists in front of neighbours, Women need a variety of low threshold access and few culturally sensitive drug workpoints in the community, depending on need. ers for women from diverse backgrounds - such as Muslim or Romany where being ‘outed as a drug addict’ can have grave consequences. Women who use drugs initially found Women need a variety of low threshold a contributing role for their voice and access points in the community, depend- actions through being responsive to their ing on need. We must bring positive mes- own community’s needs, particularly sages and sources of support to women through the difficult first years of HIV/ in their own environments where they AIDS, through needle exchange and outare most comfortable and feel the safest. reach. Then, as harm reduction itself grew We must utilise cost effective, yet consist- as a prevention and treatment framework, ently under-resourced peer support, peer women spoke out as drug user activists. outreach and mentoring programmes, Drug users, like others, have had to agree especially for young girls whose drug to speak about drug use in terms of harm use might be escalating towards depend- - as the only legitimate way to discuss ence or areas of increased risk or violence. drug use in public. To speak of drugs any We need to keep up with the way young other way has historically been considwomen are communicating with their ered irresponsible. Although the framepeers, modernise the way we dissem- work of harm reduction enabled drug inate information via social media out- users to band together and come up with lets, and provide challenging and creative strategies that would protect the health ways for feedback for women and girls and welfare of their disparate communito talk to one another about their drug ties, this has not been satisfactory. Why? Testimonies

The desire to either frame or ignore drug-using women even by other women’s groups is disconcerting.

Is the debate about a woman’s right to control her body and thus put whatever substance she chooses to in it so long as she doesn’t hurt another, the very same debate pro-abortionists have fought long and hard for? 74 75

Distressingly, in an effort to get to the Because the harms associated with drugs, narrative of women’s experiences as potential or otherwise, are only a small drug users, I fear even women thempart of understanding drugs and drug selves have found certain comfort in use. This means we are never getting the positioning drug-using women as pasentire story when it comes to understand- sive subjects of power. In the desire to ing drugs, a story which rarely mentions get funding for women’s services, or to women and the politics of gender, and control the rhetoric on abuse affecting even more rarely pleasure, aestheticism marginalised women, have feminists and our fascinating drug cultures of the overstepped the mark and sucked up past and the present. This only serves to all the oxygen so there is almost none obfuscate the truth about people’s rela- left to allow for the real depth and diversity of women’s drug using experiences? tionship to drugs. Are we victimising women all over again? Why is there no room in the discourse to talk, yet again, about women’s self-deThe women sidelined by feminism termination, or, God forbid, self-induced During the 1990s, when feminism finally pleasure? McLelland and Travis (2010), in their met at the crossroads with the feminisation of the HIV/AIDS epidemic, the enlightening series of blogs, have recently strands of harm reduction, sex work and begun to wonder just where the feminist the women’s movement began to slowly drug and alcohol use discourse is in the thread together. The world of the sex contemporary academy, or “…on our worker began to receive some legitimacy campuses, in the larger public health by civil society organisations, and women milieu? And, on a more traditionally started effectively pushing an agenda scholarly note, where is it in the history based on the experiences of women of feminism….or as its radical offshoot is who took part in the licit and illicit sex sometimes known, ‘women’s liberation’?” trade. Ironically, women sex workers who used or were dependent on drugs were quickly sidelined. Shunned by ‘ordinary What future for women who use sex workers’ who needed to distance drugs? themselves from the more illicit ‘junky prostitute’ in order to develop their small In conclusion, just as we are beginyet precious piece of political capital, the ning to see the women’s movement sidelined junky prostitute remained a respond to the feminisation of the HIV/ ‘voiceless victim’ whose only existence AIDS epidemic, so we have witnessed was as the subjugated, abused or traf- great strides in advancing the cause for ficked. The latter characterization (of women affected by HIV/AIDS across the sex workers) is held by many old school world. This power and friendship must feminists who are still standing strong by stretch fully into the field of women who the somewhat compelling premise that use drugs who have as much to offer, as the entire sex trade is in fact effectively each has to gain. With the development exploiting women. of the international harm reduction and Erin O’Mara Women of substance

drug user movement, now fronted by ings that are sure to transform the landsome extremely bright and courageous scape should legalisation begin to take women, the second and third wave of the shape. The critical importance of finding women’s movement must seek to interact ways for women to take part in these promore creatively, politically and honestly cesses, from London to Kabul, from New with the world of women who use drugs. York to South Africa, will help to prepare If the stigma that surrounds illicit drug us for an uncertain future. ■ use continues to undermine or destroy the fragile new beginnings that are being tentatively and painstakingly undertaken by women who use drugs and their feminist sisters, we must ask why. And then we must ask today’s women’s movement to look itself hard in the mirror. Are we not also calling for the liberation of women? Is the debate about a woman’s right to control her body and thus put whatever substance she chooses to in it so long as she doesn’t hurt another, the very same debate pro-abortionists have fought long and hard for? Yet we must also cut harm reduction loose from our obsession with drug related harm in order to find a new and inclusive approach that will enable us to fully understand the truth of the drug taking experience. This may be a controversial ideological shift, but it is essential if we are to liberate women from this pervasive misrepresentation. Although the same can be said for the ‘science of addiction’, much of the research into psychoactive drugs (canReferences nabis, research chemicals, hallucino› › Boon M 2004, The road of excess: a history gens, opioids and stimulants, entheoof writers on drugs, Cambridge, MA: Harvard genic plants and psychedelic fungi, etc.) University Press. has been male-dominated. And like the › › Boyd S 2004, From witches to crack moms: science of addiction, this has meant that women, drug law and policy, Carolina the insights and perceptions that have Academic Press, Durham, N.C. been reported through the discovery and ›› De Quincey T 1821, Confessions of an English use of these drugs have continued to be opium eater, London Magazine, London. interpreted through the male perspec›› Fagan J 1994, ‘Women and drugs revisited: tive. Legalisation, or indeed regulation, female participation in the cocaine economy’, will bring its own risks as we move into Journal of Drug Issues, vol. 24, no. 2, pp. 179–225. the hands of ‘Big Pharma’, a place where ›› Henderson DJ, et al., 1995, ‘Women and illicit women and drug users have historically drugs: sexuality and crack cocaine’, Health been pathologised and undermined. It Care for Women International, vol. 16, no. 2, will be up to all of us, and especially pp. 113–124. women, not only to maintain a height›› Palmer C & Horowitz M (eds) 1982, Shaman ened awareness of these issues and the woman, mainline lady: women’s writings on spurious drug company marketing drives the drug experience, Morrow, New York. that will follow, but to find ways to keep ›› South N 1996, Drugs: Cultures, controls and women engaged and informed in the everyday life, SAGE Publications, Thousand political and pharmacological awakenOaks, CA. Testimonies

PERSPECTIVES

Contextualising harm reduction among female sex workers The moral and political issues of how society treats a stigmatised activity

78 79

ituated at the point where tensions surrounding sexuality, gender relationships, economic globalisation and the regulation of public space meet, prostitution prompts diametrically opposed value judgements which are closely associated with irreconcilable attitudes about how a legal framework should be applied to it. Thus, the way in which this activity is conceived hovers like a spectre between two conflicting poles, depending on whether it is viewed, on the one hand, as a contractual relationship involving the supply of sexual services in return for payment or, on the other, as a form of exploitation based on making one’s body available for the gratification of another. The result of this dissent is that most expressions used are pregnant with connotations which in essence signify that the speaker belongs to one particular body of opinion: while some describe the activity concerned as ‘providing sexual services’ or ‘sex work’, others designate it as ‘selling one’s body’ or even ‘sexual slavery’, positioned within a ‘system of prostitution’. At the same time, the stigmatising of people working in prostitution is in reality redolent with meaning, as prostitution continues to be construed as a criminal activity which ‘disqualifies and prevents

Marion David is currently finishing a sociology doctorate at the University of Nantes and at the Catholic University of Leuven in Belgium. From 2007 to 2010, she received research funding from the Agence nationale de recherche sur le sida et les hépatites virales (ANRS – National French Agency for Research into AIDS and Viral Hepatitis). Her thesis concerns public action relating to prostitution and, more specifically, the health interventions undertaken with people engaged in prostitution in France and Belgium.

Marion David [individuals] being fully accepted by society’ (Goffman [Pryen] 1999). These individuals therefore have to face condemnation on a daily basis, whether in the violence to which they are exposed in their work or in their private lives where the stigma is shown to be a significant factor in social isolation. To what extent can the strength of the ideological controversy and the disgrace affecting people working in prostitution be measured? To what extent does the legal framework governing prostitution help support this condemnation? And, lastly, to what extent has the emergence of health and Harm Reduction (HR) activities represented a break with the way society has treated this practice? These are the questions we will seek to answer by taking account of the fact that prostitution is a complex social practice contingent upon society and culture.

Understanding the historical dimension of the social bases to why prostitution is condemned When examining the source of the term ‘prostitution’, it is found to have been borrowed from the Late Latin word prostitutio, meaning ‘profanation, debauchery’. As a result, from the thirteenth century in France the word has for women denoted engaging in immodest behaviour. (Rey 2006) While the meaning was gradually replaced from the end of the 17th century by ‘to give one’s body in return for remuneration’, the pejorative weight that it carries is, etymologically speaking, understood. Work by historians has therefore shown that in the Middle Ages the venal aspect was not central to applying the

status of prostitute on a woman, since it could equally well be applied to women whose attitude was judged immoral in terms of the Christian view of feminine nature and the gender system applying to matrimony. The state of being a prostitute was above all perceived as intrinsic to a person’s identity, indicating an inclination to sin and to subverting masculine authority, more than relating to a specific behaviour or a lucrative occupation. From this perspective, the fact that being a female prostitute could involve accepting money in exchange for sex seemed a secondary aspect (to the extent that some theologians saw payment as introducing an element of rationality to the debauchery and, consequently, lessening its seriousness), although indicative of her lascivious nature (Rossiaud 2010). Yet it is important to understand that for women labelled in this fashion, judged, for example, as too independent or as having had an extramarital relationship, the consequences were not just symbolic but also material. Indeed, it was not uncommon for a socially isolated woman of working-class origins, once smeared in this way, to find herself unable to marry and ultimately driven to ‘selling her body’. As well as having its origins in a dual morality – both theological and lay – (not only were women more affected than men by the censure attaching to ‘sins of the flesh’ but also their honour guaranteed the honour of blood lines), this stigma therefore proved itself to be socially selective, since women of humble origins were most exposed to it (Maugère 2011). This overly brief reference to the meaning attributed to prostitution in the medieval imagination, while it does not take account of the subjective experience of women engaged in a form of venal sexuality or provide a more nuanced vision of the heteronymous nature of their condition, nonetheless emphasises the extent to which prostitution for many centuries represented an instrument exploited by the patriarchal order. With the support of religious authorities in whose eyes the existence of a class of ‘defiled’ women free from matrimonial ties represented Perspectives

a lesser evil (as it supposedly prevented the seduction or rape of respectable women and kept men away from sodomy) (Karras 1999), Western societies continued in time-honoured fashion to distinguish between these two categories of women until the 20th century. Wives were accorded motherhood and virtue, while ‘public women’ or women leading ‘bad lives’ were assigned the dishonourable task of containing the excesses of male lust. In this sense, whatever the shifts in how prostitution was perceived throughout history, adopting a positive tone (recognising a social utility for the benefit of the common good) or a negative one (emphasising religious disapproval and fear of being contaminated with syphilis), the stigma of ‘whore’ acted as a warning for all women, dissuading them from adopting behaviour that did not comply with what was expected of the female gender (Pheterson 2001). However, with questions being raised in the name of equality about the hierarchical opposition of the sexes and with the emergence of a sexuality whose legitimacy no longer relies on marriage and filiation but simply on individual consent (Théry 2002), what explanation can be given for the ongoing condemnation of prostitution in modern societies? In spite of these major changes, it seems that traditional representations of the social relationships of sex continue to nurture the stigmatising suffered by women working as prostitutes (consider, in particular, the view that because they belong to all men they cannot be raped). Thus, at the end of the 1980s, the anthropologist Paola Tabet demonstrated that, while the existence of ‘sexual economic transactions’ between men and women represented a recurrent feature of social organisation, the category ‘prostitute’ did not refer to a universally accepted predetermined content but essentially involved transgression of rules of ownership of the person of women within the culture concerned (in other words what is admissible in a given society may be likened to prostitution in another and, as such, find itself punished) (Tabet 2010).

in the Middle Ages the venal aspect was not central to applying the status of prostitute on a woman

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This perspective focusing on gender inequalities is, however, inadequate for gaining a full understanding of the mechanisms in our modern societies involved in the social disqualification of people who are sex workers. While determining what is meant by prostitution continues to elicit a variety of interpretations (for example, should the activities of striptease artist, erotic masseuse and actor in a pornographic movie be included?), everyone is now agreed that a definition of prostitution should at least include carrying out an act of a sexual nature in return for remuneration. It is precisely in this explicit reference to sex and money that its morally problematic nature increasingly seems to lie. With the dissociation of the erotic and reproductive functions as well as the emergence of a sexual morality founded on individual development comes the inevitable idea that sexuality is intrinsically linked to the truth of the individual and the uniqueness of his/her personality (Foucault 1976). As a result, the presumption of a lowering of moral standards and a sacrificing of identity in the prostitution relationship proceeds directly from the view that sex, because of its eminently personal nature, must be preserved from a depersonalizing commercialised approach (Parent 2001; Campagna 2011). In other words, the condition of female prostitute at present embodies less the ‘fallen woman’ or ‘abnormal woman’ possessing a deeprooted otherness than the diverting of a fundamental experience rooted in the affects of the subject doing the desiring. In addition, the prostituting interaction infringes the egalitarian ideal on which the new sexual normative force is based, which promotes mutually satisfying relations and

is devoid of any form of domination (on a psychological, social, economic, etc. level). At the dawn of this evolution it is, moreover, possible to interpret the increasingly powerful spotlight turned on prostitution clients who are criticised for contenting themselves with the formal consent of a prostitute in the absence of shared sexual desire and also for gaining access to the body of another through superior financial means. Lastly, the elements which support the stigmatising of prostitution need to be replaced in the wider fabric of social hierarchies: like the courtesans of the past, the success of high-class prostitutes (call girls and escorts) seems to lessen the indignity of their activity. While this unequal treatment can be explained by the size of the amounts paid making up to some extent for the unholy nature of the transaction, it also arises from the way public policies physically and symbolically banish those women working as prostitutes who precisely do not have the social resources to escape from this form of interaction.

Between legal framework and symbolic treatment: the prominent role of public policies in shaping the prostitution experience In terms of how the law treats prostitution, a distinction is traditionally made between three regulatory systems which assign different statutes to this activity but which are all characterised by their negative representation of it. ›› Prohibition corresponds to the banning of prostitution, likened to a scourge on society, and implies punishing all those involved (prostitutes, clients and pimps). In countries which have adopted this regime (such as the United States, with the exception of Nevada), individuals who work as prostitutes are thus seen as criminals with all their activities punishable by sentences, over and above those applying to breaches of the peace, ranging from a fine to imprisonment. ›› Regulation organises prostitution, considered necessary in spite of its immoral nature, with the aim of containing the

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(virtually) an ordinary profession. This ‘nuisances’ associated with the phenomlegal approach, refusing to attribute a enon and the threat it represents for morally problematic character to the the whole of society. This system, origiphenomenon of prostitution, thus connating in France during the 19th century fers a professional status on people who (and currently in force in Greece and work as prostitutes. Controls exist too, Turkey), is based on introducing regubut are less extensive than in a purely lations to control prostitutes, in particuregulatory system and are, moreover, lar obliging them to submit to registeraccompanied by a certain number of ing as well as to regular health checks. rights aimed at protecting ‘sex workers’. It also implies fixing zones specifically In reality, the distinction made by the for the activity which are under police authorities between ‘voluntary prostitusurveillance, forcing those who do not tion’ and ‘forced prostitution’ (procurwish to conduct prostitution in the preing by force remaining a crime) can scribed areas, or who are not authorbe seen to support a currently represised to do so, to act illegally. sive policy towards persons originating ›› Abolition – enshrined in the Convention outside the countries of the EU, for the for the Suppression of the Traffic in most part presumed to be ‘victims of Persons and the Exploitation of the trafficking’ and, for this reason, threatProstitution of Others dated 2 December ened with deportation (Mathieu 2007; 1949 – authorises the practice of Maugère 2011). prostitution but punishes procuring. Historically, the abolitionist system arose as a result of criticism of the excesses of a coercive regulatory system and of the desire to see it abolished the particularly significant extent to which and then evolved to become the pursuit procuring is punishable in French law finds of the elimination of prostitution itself. its basis in the presumption that prostitution Abolitionist legislation thus tolerates the activity in so far as it is an expression of essentially violates human dignity. individual freedom, while at the same time viewing it as a form of social maladjustment and regarding those involved as victims. Although the most common ›› Neo-abolition, adopted by Sweden, official model in European Union States, punishes all forms of procuring and it remains largely theoretical as most penalises clients. Only people who national legal mechanisms tend in realwork as prostitutes are exempt from ity towards prohibition (adopting coerprosecution, as they are considered cive measures directed at prostitutes, victims of sexual exploitation and of a such as in France) or, in other cases, paradigmatic form of male domination. towards a form of regulation (tolerating This legal system, aimed at eradicating supportive and hotel-based procuring, the phenomenon, has a similar effect such as in Belgium and Spain). to the prohibition regime, notably on the clandestine nature of practices and This tripartite classification is shown to the marginalising of women working be inadequate, however, for characterisas prostitutes. Although this fact is not ing the framework for prostitution set up overlooked by those in favour of this by governments due to the emergence at model, they explicitly place the printhe end of the 20th century of new modes ciple of combating prostitution before its harmful consequences for those of public regulation. concerned, both as regards exercis›› Neo-regulation (sometimes referred to ing the activity and the right to sexas professionalization), applied in the ual self-determination (Kulick 2003). Netherlands and Switzerland, decrimFrom such a standpoint, the collective inalises activities associated with prosinterest prevails over the expression titution, which is regarded in law as Perspectives

consensual sexual exchanges, comes back to promoting an individual’s freedom to choose in the various areas of private life and to decide how he or she disposes of his or her own body.

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of individual choice, when the latter leads to behaviour that is considered degrading and an attack on all women (Chaumont 2003). It seems timely, therefore, to understand these various prostitution frameworks from the point of view of the position adopted by the State towards the relations that an individual enters into with his or her body, and his or her faculty to dispose of it freely. To the extent that this activity has to do with the part of the physical self considered most intimately linked with personality, prostitution crystallizes and reveals certain tensions about the freedom to dispose of oneself in present societies which are affected by the erosion of traditional normative values. For behind the plurality of these state models, and also in the ideological dissent that arises, lie directly opposing antinomic conceptions of the common good, according to which it is a question of promoting individual autonomy in sexual ethics or, on the contrary, of affirming certain transcendent values that ought to be imposed on all. Thus, aside from the exemplary nature of Sweden, the particularly significant extent to which procuring is punishable in French law – prosecution for behaviour in which there is absolutely no element of force or which does not give rise to any financial recompense (assistance, furnishing of premises etc.) – finds its basis in the presumption that prostitution essentially violates human dignity and the consent of the person working as a prostitute can therefore justifiably be ignored (Maffesoli 2008). In contrast, the direction taken by the Netherlands, refusing to pass judgement on the legitimacy of prostitution among the different types of

In addition to the determining role played by these axiological attitudes in drawing up legal norms, politico-administrative action relating to prostitution remains highly dependent on more practical considerations involving maintaining public order and regulating population movements against a background that has, since the 1990s, been marked by the influx of women from abroad. The re-emergence of the subject of ‘human trafficking’ on the European political agenda has inevitably led to creation of a joint policy, in the guise of philanthropic aid, largely dominated by a security frame of reference (Maugère 2011). In France, the introduction of an internal security law on 18 March 2003, reintroducing passive soliciting as a criminal offence, provides a good illustration of this phenomenon (anyone practising prostitution on the public highway is now liable to two months’ imprisonment and a fine of 3,750 euros). This ‘criminalising’ of public soliciting, justified by the twofold aim of restoring residents’ peace and quiet and of combating the activities of human traffickers, represents above all a means of facilitating the deporting of foreign prostitutes while discouraging new arrivals (Vernier 2005; Danet [Danet & Guienne] 2006). Public order imperatives and the rhetoric of compassion come together around the figure of the ‘victim of trafficking’ to deny migrant prostitutes any autonomy in how they conduct their lives and to legitimise the adopting of essentially repressive measures (Chaumont 2008). The French government, in defining the content of its field of intervention which was notably aimed at satisfying the noisy demands of certain interest groups, set about formulating a particular notion of the phenomenon of prostitution. More precisely, its designation of prostitution as a public activity seems to have arisen at the cost of an artificial homogenisation

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of the social reality it claimed to represent. This social reality is the result of a plurality of unique pathways and experiences (from the diversity of women, men or transgender people exchanging a variety of sexual services in return for payment, with ‘regulars’ or strangers, in an occasional or regular way etc.) (Guienne [Danet & Guienne] 2006). Thus, the measures put in place by the French government – public support for organisations working to reintegrate prostitutes within the limits of concerns for public order – ratified a prevailing representation of the individual working as a prostitute that wavered between the status of victim (symbolising the subordinate condition of all women) and criminal (threatening moral security). Similarly, the policy implemented by the Belgian government at commune level – tolerating prostitution establishments while notably punishing its conduct on the street – has justified itself by continuing to strictly distinguish between ‘professionals’ (whose social utility is recognised) and ‘not genuine’ prostitutes (drug addicts or undocumented migrants whose visible presence remains undesirable). In other words, although this public intervention is usually presented as responding to a ‘social problem’, it contributes significantly to maintaining certain areas of mercenary sexuality on the margins and, ultimately, supports the profound disgrace attaching to the populations concerned. In France, women working as prostitutes who are unable to afford a property tend to be excluded from private space by the threat of prosecution for procuring that hangs over anyone providing them with accommodation. They are to some extent also excluded from public space, or at least from city-centre spaces, as being stopped and questioned by police for soliciting leads them to practise prostitution in out-of-the-way locations and at late hours. No matter how harmful the consequences of these legal measures for the safety of people working as prostitutes and no matter their impact on how the latter absorb the indignity of their status, they persist and have even, over recent years, tended to increase Perspectives

(extension of procuring involving hotels to cover provision of vehicles, prohibiting of private soliciting via the Internet etc.) (Vernier 2010), as they stand at the point where moral objectives and converging policies meet: abolishing prostitution, controlling the nuisances that prostitution materially and symbolically leads to in public space and, lastly, regulating illegal immigration. From this point of view, the emergence of the first action to prevent HIV and promote health represented a significant break in society’s treatment of this activity, since for the first time it involved looking not at the ‘issue’ of prostitution (in so far as it posed a problem for others) but at the difficulties encountered by prostitutes.

From preventing HIV to reducing the harm associated with prostitution: the beginnings of an ill-defined pragmatic approach Until the end of the 1980s, in accordance with the commitments made by the French and Belgian governments (which ratified the 1949 abolitionist convention), action by voluntary sector organisations and associations directed at prostitutes was handed exclusively to social work bodies whose mode of intervention was aimed at getting women to quit prostitution – expressing a willingness to stop was a precondition for the support provided – by directly encouraging individuals or by offering support to those who requested it. With the sudden upsurge in the HIV epidemic, voluntary sector organisations were approached by the government to carry out preventative activities but refused to take on this task, fearing that it would lead to setting up statutorily imposed health checks and, in particular, would supplant what were the priority objectives in their eyes, namely social rehabilitation and reintegration (Mathieu 1999). New players then appeared at the beginning of the 1990s to conduct antiAIDS activities among the female sex worker population. In France, the voluntary sector organisations and associations created at this

the measures put in place by the French government ratified a prevailing representation of the individual working as a prostitute that wavered between the status of victim and criminal. 84 85

period came within the field of community health, that is to say they adopted an approach based on social recognition and directed towards the ideal of parity (Coppel 2002). Believing that individuals with experience of prostitution were best placed to deliver a health prevention and promotion message, the organisations concerned set up a new category of personnel – ‘prevention workers’ who were working or had formerly worked as prostitutes – involved in street-based interventions alongside health and social work professionals, or supporting ‘users’ in their contact with social welfare bodies (Mathieu 2009). At the start of the 2000s, other measures also appeared to a lesser extent in some cities where there was no specific organisation. Resulting from Médecins du Monde (MdM) needle-exchange programmes or arising out of social activities among marginalised populations, these measures drew on community outreach health initiatives to implement a global medico-social programme of intervention characterised by a readiness to provide ‘low-threshold’ services which demanded nothing in return and which were provided in what was intended as a non-judgemental way (Pryen 2009). In the case of Belgium, the voluntary sector organisations which appeared right at end of the 1980s were not, in contrast to France, begun by people with a background in the world of prostitution, but essentially by doctors specialising in public health or epidemiology. The organisations in question developed health initiatives which were limited to avoiding so-called ‘professional’ risks – HIV, Hepatitis B and STIs in general – by offering medical consultations devoted to

treating these diseases. This community action model – arising from a desire to offer a space complementing and alongside the generalist healthcare system where female sex workers could talk about their ‘job-related’ problems without fear of being judged – was mainly created with those individuals in mind who were relatively well integrated into society (offering their services in windows, bars or private apartments) and who viewed their work in prostitution as a professional activity. From the end of the 1990s, another form of intervention was devised on the fringes of this benchmark provision, as a result of the restructuring of bodies which had their origins in the abolitionist movement. These organisations gradually became involved in outreach work which centred on frontline general practice consultations among the most vulnerable populations (female sex workers on the streets who were migrants or drug addicts). Their approach came not from a desire to treat the illnesses seen as specifically relating to prostitution but from a desire to enable access to basic health care, in addition to HIV and STI prevention, while promoting reintegration into the statutory system. In concluding this historical summary, it is important to emphasise the essential and extremely revealing variation in the differential status accorded prostitution within these two countries as regards the human and financial resources allocated by the governments to the health interventions. In France, the appearance of AIDS did not transform public policy terms of reference which focused on eliminating prostitution; the voluntary sector organisations involved were not accorded the same legitimacy as the social work bodies which were concerned principally with housing, employment integration and preventing ‘prostituting behaviours’. Unlike the social work bodies agencies, outreach organisations did not regularly benefit from funding and guarantees over several years (in spite of the major amounts of money released in respect of anti-AIDS work relating to other health issues), as institutionalising their intervention would have meant

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implicitly recognising and accepting the actual existence of prostitution in society. In Belgium, in contrast, against a background of greater moral tolerance towards prostitution, the implementing of prevention activities led to a reversing of the paradigm with the approval of long-term measures devoted to the sociohealth support of people who were sex workers. This process perfectly illustrates, moreover, the disappearance towards the end of the 1990s of bodies working to reintegrate this population group. Whatever recognition these various measures obtained and specific characteristics they represented, they shared a common desire to prioritise and take action on the immediate conditions surrounding the practice of prostitution in order to make them safer (Mathieu 2000). The epidemiological emergency represented by AIDS made it imperative to set aside all moral or normative considerations in the relationship forged with this population so that every effort could be put into preventing the risk of contamination. This required not only understanding the overall situation of these individuals, taking account of the social and contextual aspects which could influence individual behaviour, but also taking action at the places where prostitution happened, as close as possible to the reality experienced by those most involved. Such a stance represented a substantial change of perspective in relation to the thinking behind previous interventions, since it involved viewing female sex workers as best placed to formulate the discourse on their situation and to appreciate the difficulties they faced, in the context both of their activity and of their private lives. More than twenty years after the first prevention activities appeared, this intervention model has revealed the diversity of the aspirations and of the personal life stories of the people involved in the sex trade and the extreme insecurity of some members of this population (on the level of access to health care, housing, administrative situation etc.) and the extent of the violence to which they can be exposed when Perspectives

working in an unfavourable environment (the level of risk of physical attack varying considerably depending on the type of prostitution: on the public highway or indoors, in isolation or close to other female sex workers, in a clandestine or visible manner etc.) For this reason, the term ‘Harm Reduction’ – understood to go beyond sexual practices and to include all health and social risks – is increasingly mobilised as a label for a resolutely pragmatic approach aimed at improving the conditions of people engaged in sex work and, at the same time, is a refusal in any way to judge what prostitution means for these individuals. Nevertheless, the extent to which the content of this approach is necessarily very detailed and flexible (Deschamps & Souyris 2008) means that it may be subverted by the resonance and exceptional nature of the moral and political reactions roused by prostitution. Thus, adhesion to the ‘myth of two-tier prostitution’ (Guillemaut 2009), proceeding from a Manichean classification that distinguishes between French women who are free and foreign women reduced to slavery, has led some organisations over recent years to abandon the objective of HR among migrant women sex workers to adopt in its place a perspective similar to that of traditional abolitionist bodies. The women’s word is ignored as it is presumed to be influenced by coercion from the pimp and the uniqueness of their situation and of their individual lives disappears to be replaced by a single conceptual definition referring to the one condition – that of being a ‘victim of human trafficking’ – from which it is a matter of releasing them (David 2008). Similarly, the situation in the voluntary sector in Belgium indicates that the priority given to a definitive political commitment, where the desire to respect the equal citizenship of female sex workers translates as an activism promoting legal recognition of the ‘profession’, may encourage some of those intervening to turn away from the most deprived sections within the world of prostitution. Lastly, it should be remembered that female sex workers have always been

female sex workers have always been described as a vector for disease.

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described as a vector for disease and that ‘the health risk in its public dimension – for others –’ (Pryen 1996) is in principle dependent on the political decision to support these interventions in the prostitution environment. Questions can therefore justifiably be asked about the way in which governments can sometimes be led to exploit the activities put in place for their own ends; whether it is a question of taking over the activities as a means of legitimization (at the risk of increasing the stigmatising of the people concerned as supposed vectors of HIV), or of exercising more immediate social control over this population (notably in the context of a local policy to regulate prostitution, such as exists in Belgium).

rights and health care be promoted without providing a plethora of services (medical, social, legal etc.), compromising their integration into the statutory system and placing them in a situation of dependency with regard to the measures put in place? To what extent is it possible, given the diversity of the populations practising a form of commercial sex (particularly at a cultural and ‘generational’ level), to put an intervention in place that is adapted to the situation of these different groups? Such a wide range of questions and tensions exists partly due to the complexity of the phenomenon of prostitution, which runs through the daily practice of HR workers and which they are obliged to tackle. Should they fail to do so, commitment to HR in the world of prostitution is revealed as an outreach fiction, masked by the legitimacy of health prevention provision (condom distribution, safer sex advice, HIV and STI testing promotion etc.) at the service of the survival of the institution. ■

In the final analysis, it appears that an HR approach to the practice of prostitution is a demanding one which does not take on its full significance except within the network of outreach action choices made and drawn up on the basis of needs expressed by the individuals encountered. HR evokes ideals – supporting people in what they experience and in the pursuit of their goals, regarding individuals as experts in their own lives and removing oneself from a ‘charitable caring’ approach to form a relationship with them based on knowledge sharing – but in reality seems only to take shape where there is sustained involvement of those intervening and the inclination to adopt a reflexive attitude towards the relevance of the action taken. How far should the boundaries of intervening go in order to follow the chain of risk factors threatening the integrity of the individuals concerned, and on what bases should they be prioritised? How can their access to marion david Contextualising harm reduction among female sex workers

references › Campagna N 2011, L’éthique de la sexualité, La Musardine, pp. 186-189.

› Chaumont J-M 2003, “Prostitution et choix de

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société : un débat éludé ?”, Éthique publique, vol. 5, no. 2. Chaumont J-M 2008, “Traite et prostitution. Discours engagés et regards critiques (1880-2008)”, Recherches sociologiques et anthropologiques, vol. 39, no. 1. Coppel A 2002, Peut-on civiliser les drogues ? De la guerre à la drogue à la réduction des risques, La Découverte, pp. 85-92. Danet J 2006, “Réflexions sur deux exemples de politiques pénales locales autour de la prostitution”, Danet J & Guienne V (eds), Action publique et prostitution, PUR, p. 104. David M 2008, “Santé mentale et usage idéologique de l’‘état de stress posttraumatique’ dans les discours sur la prostitution et la traite”, Recherches sociologiques et anthropologiques, vol. 39, no. 1, pp. 55-70. Deschamps C & Souyris A 2008, Femmes publiques. Les féminismes à l’épreuve de la prostitution, Editions Amsterdam, p. 75. Foucault M 1976, Histoire de la sexualité. Tome I. La volonté de savoir, Gallimard. Goffman E 1999, quoted in Pryen S, Stigmate et métier. Une approche sociologique de la prostitution de rue, Presses universitaires de Rennes, p. 16. Guienne V 2006, “La prostitution, une catégorie sociale construite”, Danet J & Guienne V (eds), Action publique et prostitution, PUR, pp. 19-33. Guillemaut F 2009, “Prostitution et migration, une histoire conjointe”, Vacarme, no. 46, p. 40. Kulick D 2003, “Sex in the new Europe. The Criminalization of clients and Swedish fear of penetration”, Anthropological Theory, vol. 3, pp. 203-204. Maffesoli S-M 2008, “Le traitement juridique de la prostitution” Sociétés, no. 99, p. 39 and 43.

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A combined social prevention Harm reduction and HIV/AIDS prevention in times of emerging bio-medical prevention methods

Niklas Luhmann

“The current model underpinning HIV prevention is that of ‘modern’ public health, with its focus on the individual: the neo-liberal rational and the autonomous subject, who is positioned as responsible for his or her own health. Within this model of public health, informed to a large degree by psychology, the claim is that change is best achieved by providing an individual with the necessary expert information on which to base a rational response. HIV prevention is understood as educating, advising and counselling the individual to adopt safer practices. Prevention is essentially top-down from the expert to the individual, with much of it being done in the clinic (…).Risk-taking is positioned as a function of misperception of risk, a lack of information on the part of the individual, or is ascribed to psychological factors such as lack of ‘self-esteem’ or ‘self-confidence’, or to other, more pejorative factors such as ‘anti-social’ or addictive personalities that compromise the ability of the individual to make rational choices and act on the information received (…)” (Henderson et al., 2009).

f I look back to the last couple of HIV/ AIDS conferences and meetings, I feel that they have been characterised by two main topics. Firstly, the recurrent, new and interesting findings in the area of prevention science. In this field, clinical trials have shown the efficacy of the so-called bio-medical prevention methods, namely pre-exposure prophylaxis (PrEP), treatment as prevention (TasP) and male circumcision, and have opened the door for the utilisation of these new methods in combined prevention approaches. Secondly, the concern that the economic and financial crisis is posing an enormous threat to the worldwide HIV/AIDS programme funding dynamics has been discussed repeatedly. In this article, I will concentrate on the first issue and discuss the questions and implications of the new bio-medical methods for combined prevention approaches and the idea of a combined social prevention. I will try to discuss and analyse this in light of the emerging and worrying funding constraints in the field of HIV/AIDS.

Without any doubt, great changes and successes have been achieved in the last decade in the area of access to HIV/ AIDS treatment in low- and middle-income countries. The number of HIV/AIDS related deaths continues to decrease and, at the time of writing, there are around eight million people on Highly Active Antiretroviral Treatment (HAART) around the world (UNAIDS 2001). On the other hand, the overall context at the beginning of 2012 is not exactly promising, notwithstanding the enormous achievements: HIV/AIDS funding is rather stagnating, and between 2.4 to 2.9 million Niklas Luhmann is a medical doctor and completed his Master of Science (Msc) in International Public Health at the University of Berlin and Copenhagen in 2006. He has been working for many years on access to healthcare and prevention of migrant and most at-risk populations. He wrote his thesis on the HIV/AIDS related risk behaviours of male-to-female transgender persons in Khon Kaen, Thailand. He joined Médecins du Monde (MdM) in 2005 and is today working as Harm Reduction and HIV/ AIDS advisor for MdM at the headquarters in Paris.

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load demands that available resources be applied to care and treatment, at the expense of prevention. But the less emphasis there is on prevention, the faster the global caseload will expand.” Indeed, prevention efforts may have been Why has prevention potentially lost in the lobbying efforts for had such a hard time in these last years? providing treatment to HIV-infected people in the developing world (Henderson et al., 2009). Thus, the enormous and important mobilisation of civil society in people are still newly infected every the north and the south for the right to year (UNAIDS 2001). Hence, preventing treatment may have partly undermined new HIV/AIDS infections remains, more the advocacy for the right to prevention than ever, the key to altering the course in the last decade. And increasingly, the of this epidemic, beyond all its national new focus on TasP as the great and ultiand regional epidemiological differences mate game changer may have dangerous and specificities. There is no doubt: with consequences for the resource allocation regards to HIV/AIDS or other blood- and political support to effective primary borne diseases, such as viral hepatitis, prevention strategies. evidence-based and meaningful prevenBeyond these mutual and sometimes tion efforts should be a cornerstone in the global and local response efforts. This is paradoxical relationships, HIV/AIDS certainly nothing new. On the contrary, prevention (as well as viral hepatitis the fact that prevention is better than prevention) has had a rather difficult treatment is common knowledge, even time in recent times and seems to have though in reality there is a complex rela- slowly slipped down the agenda. The tionship between both, especially in the Global HIV Prevention Working Group area of blood-borne diseases. Specifically, has shown that HIV prevention efforts in the field of HIV/AIDS, treatment has remain grossly inadequate. According shown to have great potential for con- to country reports submitted to UNAIDS tributing to the prevention of new infec- in 2008, the median percentage of HIV tions, and is currently even thought to be spending directed toward preventing new the ‘game changer’ by allowing a further infections is 21% (Global HIV Prevention reduction of HIV transmission and inci- Working Group 2010). Moreover, evidence dence through rolling out HAART world- indicates that prevention programmes wide – even though its use may on the are disproportionately experiencing other hand contribute to increasing and negative effects as a result of the ongochanging risk behaviours (Henderson et ing global financial and economic downal., 2009). Moreover, in terms of resource turn. Even more importantly, the so-called allocation and HIV/AIDS financing, it is Most-At-Risk Populations (MARPs) such certainly not always easy to get the bal- as Drug Users (DUs), Sex Workers (SWs) ance right. Once an epidemic like HIV/ and Lesbian-Gay-Bisexual-TransgenderAIDS has unfolded and is threatening the Intersex (LGBTIs) persons have often survival of many millions of people world- extremely limited or no access to prewide, and most notably in the so-called vention or treatment at all. developing world, the right to treatment Why has prevention had such a hard becomes a humanitarian emergency that may, at the same time, threaten the pre- time in these last years? vention agenda. As Bowtell (The Lowy One main reason is certainly that over Institute for International Policy 2007) puts it: “We are caught in a paradoxi- many years, doubts about its effectivecal spiral: the size of the HIV/AIDS case- ness have been prevalent – especially

niklas lhumann A combined social prevention

regarding its effectiveness in the developing world - even though some societies have shown clear success in implementing prevention efforts and behaviour change with a clear impact on the epidemic. Indeed, remarkable modifications in sexual and drug use practices occurred in the 90s in most developed countries, because prevention messages and prevention policies were developed by medical and social scientists and the affected communities together (Kippax & Race 2003). Similarly, combining and scaling up prevention and treatment in the area of harm reduction for drug user populations, such as syringe exchange programmes, behaviour change communication, opiate substitution therapy, supervised injection facilities and antiretroviral treatment has shown considerable effectiveness for HIV/AIDS prevention in different contexts around the world. Often though, besides these successes, prevention policies and politics have been, and often are, dictated by conservative moral values and defined only by the medical field. But in real life, HIV/AIDS is transmitted simply in the vast majority of cases through sex or drug use. Adapted and acceptable responses must therefore engage with the social meaning of pleasure, desire and intimacy rather than with the moral high grounds of abstinence and exclusive faithfulness. It does not astonish that prevention focusing on abstaining from or delaying sex or limiting the number of sexual partners, has almost always failed. A prevention exclusively informed by the medical field and moral values that does not include the reality of the complex social practices and the contributions of the affected community is simply doomed to fail. In the US President’s Emergency Plan For AIDS Relief (PEPFAR), recipients, for example, have been obliged to state that the recipient organisation opposes prostitution and emphasises fidelity and abstinence over condom use. Moreover, monogamy was promoted as a prevention strategy – often without acknowledging that it needs to be mutual and lasting, and that the respective sexual partner needs to be sero-negative (or correctly and continuously treated) for it to work Perspectives

as primary prevention strategy (Kippax & Race 2003). In addition, epidemiological data in many contexts was often too imprecise to inform adapted prevention politics and strategies. There are two examples. Firstly, drug use and homosexuality were supposedly non-existent in some parts of the world, and only in the last few years have epidemiological data started showing that these phenomena are (obviously) existent, that the so-called MARPs are very vulnerable to HIV infection, and that transmission within MARPs networks and beyond are in reality rather prevalent in the ‘generalised’ epidemics in Sub-Saharan Africa (UNAIDS 2001). Secondly, epidemiological surveillance data has confirmed only recently that one of the main ways of HIV transmission in the generalised epidemics in Sub-Saharan Africa is transmission within sero-discordant married or cohabiting heterosexual couples (UNAIDS 2001). Indeed, targeted and effective prevention approaches that take into account the realities and social practices of the people and communities, as well as the epidemiological developments and trends, have been rather rare in the developing world. But, as stated at the beginning of this article, there is not only negative news. Indeed, excitement has been rather high these last years regarding the new developments in the area of prevention science. This excitement has been created mainly by the trials and findings regarding so-called new bio-medical prevention methods. Topical and oral pre-exposure prophylaxis (PrEP) as well as antiretroviral therapy itself (‘treatment as prevention’ (TasP)) have shown considerable efficacy in several major scientific clinical trials, and may prove to be very useful strategies and tools in reducing HIV/AIDS transmission. These new methods appear to give new impetus to the HIV/AIDS prevention agenda. PrEP means that a HIV-negative person may use an antiretroviral-based product, topically (as a vaginal or anal gel for example), or orally (as a tablet containing one or two different antiretroviral substances) in order to reduce the risk of contracting

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In conclusion, uncertainties remain regarding the efficacy and potential effectiveness of topical and oral PrEP, espeTopical and oral pre-exposure prophylaxis cially for sero-negative women. The trias well as antiretroviral therapy itself als suggest a potential, but not yet fully confirmed, efficacy of PrEP in different (‘treatment as prevention’) may prove populations and settings. Resistance and to be very useful strategies and tools safety findings have been rather reasin reducing HIV/AIDS transmission. suring. PrEP may potentially be an additional prevention tool for HIV-negative persons, especially if these persons have HIV in the case of a risk exposure. In this problems accessing or using tools such as area, the famous CAPRISA 004 trial has male or female condoms. One of the main shown an overall efficacy of a topical vag- advantages is that PrEP may provide a inal Tenofivir-based microbicide of 39% high degree of autonomy to users, such (54% in women who used the gel on more as women in general, or sex workers who than 80% of occasions) (Abdool Karim et may face difficulties in negotiating conal., 2010). On the other hand, other trials dom use and safe sex. But many questions have shown rather conflicting results, as remain, such as the limited accuracy of no significant efficacy emerged from the the first findings, contradictory results on results as compared to placebo. Topical the efficacy of the different PrEP tools, the PrEP therefore remains under develop- potential effectiveness under real operment and will not be widely available on ational conditions, risks of resistance the market for concerned persons in the development, and its long-term efficacy. It is also very questionable whether PrEP near future. In the framework of the iPREX trial will be a cost effective, safe strategy for (Grant et al., 2010), the antiretroviral developing countries in which resources drug Truvada (Tenofovir/Emtricitabine), are often scarce. or a dummy placebo pill, was adminisAs for a second biomedical prevention tered to 2,499 initially HIV-negative menhaving-sex-with-men (MsM) in nine cit- approach, i.e. treatment as prevention ies in four continents. Overall efficacy (TasP), findings are much more convinccompared with men given a placebo was ing and accurate. TasP, which means that 44%. The efficacy in participants who, by the antiretroviral treatment of an infected self-report and pill count, took the drugs and properly treated person is potentially more than 90% of the time was even 73%. protecting their sexual partners and/or But the findings are very complex, and their drug/equipment-sharing peers is efficacy in subjects reporting no receptive highly plausible from a theoretical, bioanal sex was actually negative. PrEP may logical point of view. Indeed, a person thus only make a significant difference for with a very low viral load logically seems men at highest risk, namely those who less likely to transmit HIV to partners or take the receptive role in unsafe anal sex. peers, whatever the risk behaviour or Two other trials (the Partners PrEP trial practice they may have. [Baeten and Celum 2011] and the TDF2 The HPTN 052 trial (Cohen et al., 2011), Botswana trial [Thigpe et al., 2011]) both showed a rather high efficacy of around revealed during the IAS conference in 62% - 73% of oral PrEP in heterosex- Rome in 2011, is a randomised controlled ual couples, for men and women, again, trial that has clearly proven this concept, with a strong relation to adherence. On at least for heterosexual couples, and has the other hand, seemingly contradictory shown that (early) treatment is a powerresults have been shown by a trial called ful tool for prevention. The trial has enrolled 1,763 sero-disFEM-PrEP which did not confirm efficacy among young African women and was cordant heterosexual couples, and has randomised them into an ‘early ARV’ thus interrupted. niklas lhumann A combined social prevention

or a ‘delayed ART’ group. A total of 39 HIV-1 transmissions were observed. Of these, 28 were virologically linked to the infected partner. Of the 28 linked transmissions, only one occurred in the early treatment group. The research team concluded therefore that the early initiation of antiretroviral therapy reduced rates of sexual transmission of HIV-1 by 96% and reduced clinical events, indicating both personal and public health benefits from such an early therapy. It has even been suggested by some that the results are so convincing that in stable relationships with one very properly treated HIVpositive partner it would be possible to abandon condom protection for sexual intercourse without taking unreasonable risks (see chapter 8, second part; text by AIDES). But important challenges and questions remain. Firstly, the strategy of TasP still needs to be scientifically evaluated for LGBTIs and IDUs in order to understand if, and especially to what degree, it applies in these populations, even though it is more than likely that the strategy will work. It is also unclear to what extent this efficacy can really translate into a similar effectiveness in real life, especially with the problems of long-term adherence and resistance development. Moreover, very high coverage would be necessary to have an effect on the regional and global HIV/AIDS epidemic, and the rollout and scale-up of TasP would need much more financial and human resources, which are already scarce in the current situation. However, it clearly needs to be acknowledged that TasP has great potential in helping to turn the tide, especially if it is not used as stand-alone strategy.

an important potential in helping to curb the HIV/AIDS epidemic and may allow for more effective HIV/AIDS prevention through a combination of approaches. Secondly, the emergence of these strategies may allow to reconsider prevention as a more individual, user-friendly and adapted part of HIV/AIDS work and politics, and thus lead to a real development of sexual health as a core concept for HIV/ AIDS prevention. On the other hand, it is essential that we keep in mind the behavioural component, and remember that TasP as well as PrEP need adherence and follow-up. Both rely on the knowledge of a person’s status, so counselling, testing availability and uptake would need to be considerably increased.

But even more importantly, prevention is not purely a question of tools. And whenever science pretends to make total claims it becomes unproductive. If the affected are positioned as mere objects rather than agents, the medical science will have no way of knowing, working with, or registering the significance of practices that are harmful, whether or not they are modifiable, and how such modification may be achieved. As already stated earlier in this chapter, prevention can only be successful if the medical field collaborates with the social sciences and the affected communities in order to describe and understand the collective social practices rather than just individual behaviours. Harm reduction (HR) may therefore be defined in this context as “strategies based on a mutually acceptable description of safety from the interested positions of official science (both medical and social science) and from affected communities” (Kippax & Race 2003). This collaboration between mediBesides the remaining financial and technical questions and obstacles, these cal and social sciences, as well as the new so-called bio-medical prevention affected communities on the issues of strategies, and most importantly TasP, social practices and prevention, is what certainly offer a very interesting per- Susan Kippax has called the principle spective. Firstly, we have known for of social public health. Kippax suggests many years through our work with dif- reconsidering the dominant models that ferent populations that a wide range of underpin HIV/AIDS prevention in genprevention tools is key to being able to eral: “For effective sustained HIV preoffer adapted and realistic strategies to vention, the fight must be taken from the our beneficiaries. In particular, TasP has privacy of the clinic to the public domain.

Perspectives

without being judged all the time and having their human rights abused.

prevention can only be successful if the medical field collaborates with the social sciences and the affected communities in order to describe and understand the collective social practices rather than just individual behaviours. 94 95

Prevention has worked, and will continue to work, if governments support communities in ways that make sense to those at risk rather than to powerful conservative minorities.â&#x20AC;? (Henderson et al., 2009). The effectiveness of TasP and PrEP - as for any other prevention method - will thus depend on the capacity to integrate the affected in the construction of an adapted space within the social practices and in relation to other prevention tools. Such a social public health must focus additionally on issues of social transformation in addressing the social, legal, cultural and economic determinants of the health of the communities that it is targeting and working with. That would require, in the first place, that the political and legal environment allowed for evidence-based and meaningful prevention considering the realities and social meanings of sexuality and drug use in different communities - including sexual health education, peer-based prevention approaches, meaningful involvement of people who use drugs, sex workers and LGBTIs at all levels of decision making, scaled-up needle and syringe programmes, low threshold antiretroviral care and treatment and opiate substitution therapy programmes, adapted and targeted condom programming, supervised injection facilities, and targeted mass (media) campaigns. It would mean, moreover, allowing the creation of an environment in which people are not criminalised, prosecuted and incarcerated because of their sexual orientation, their professional choices or their need or desire to consume drugs. This is the most effective way forward in order to prevent HIV and to allow people to live their lives niklas lhumann A combined social prevention

A further bio-medicalisation of the prevention arena and agenda may clearly bear the risk that prevention and harm reduction are merely seen as a question of available and accessible tools and that the work with so-called at-risk populations is further reduced to a fight for the eradication of HIV/AIDS or viral hepatitis infections. But harm reduction is, and should be, broader than that. If it were possible to add new prevention tools and methods, to show that they are cost effective, and find the necessary financial and human resources to allow for an implementation, and define together with the affected who needs them and when, it would more than welcome. But if it means pushing the agenda towards bio-medicalisation and further moralisation of the prevention agenda, we have already had enough. For effective prevention efforts, we need a legal and political environment that puts the people, their knowledge, desires, social practices and human rights first. And it is for HIV prevention to incorporate medicine and not vice versa. What we need is a combined social prevention, not a bio-medical conservative one. â&#x2013;

References ›› Abdool Karim Q, et al., 2010, ‘Effectiveness

›› Grant RM, et al., 2010, ‘Pre-exposure

and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women’, Science, vol. 329, no. 5996, pp. 1168-1174. ›› Baeten J and Celum C (2011) Antiretroviral pre-exposure prophylaxis for HIV-1 prevention among heterosexual African men and women: the Partners PrEP Study [Abstract MOAX0106], 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention July 17-20, 2011 Rome, Italy, Available at: http://pag.ias2011.org/session.aspx?s=98 [30 August 2012]. ›› Bowtell B 2007, HIV/AIDS: the Looming Asia Pacific pandemic, The Lowy Institute for International Policy, Sydney, [online] Available at: http://lowyinstitute.cachefly. net/files/pubfiles/Bowtell%2C_HIV_AIDS.pdf [30 August 2012:]. ›› Cohen MS, et al., 2011, ‘Prevention of HIV-1 infection with early antiretroviral therapy’, The New England Journal of Medicine, vol. 365 no. 6, pp. 493-505. ›› Global HIV Prevention Working Group 2010, Global HIV Prevention Progress Report Card 2010 [online] Available at: http://www. kff.org/hivaids/upload/Global-HIV-PreventionProgress-Report-Card-2010-PDF.pdf [30 August 2012].

chemoprophylaxis for HIV prevention in men who have sex with men’, The New England Journal of Medicine, vol. 363, no. 27, pp. 2587-2599. ›› Henderson K, et al., 2009, ‘Enhancing HIV prevention requires addressing the complex relationship between prevention and treatment’, Global Public Health, vol. 4, no. 2, pp. 117-130. ›› The Joint United Nations Program for HIV/ AIDS (2011) Global HIV/AIDS Response: epidemic update and health sector progress towards universal access, [online] Available at: https://www.unicef.no/Om+UNICEF/ Publikasjoner/_attachment/17693?_ ts=133f9e4d374 [30 August 2012]. ›› Kippax S & Race K 2003, ‘Sustaining safe practice: twenty years on’, Social Science and Medicine, vol. 57, no.1, pp. 1–12. ›› Thigpen MC, et al., 2011, Daily oral antiretroviral use for the prevention of HIV infection in heterosexually active young adults in Botswana: results from the TDF2 study [Abstract WELBC01] 6th IAS Conference on HIV Pathogenesis, Treatment and Prevention July 17-20, 2011 Rome, Italy, [online] Available at: http://pag.ias2011. org/Abstracts.aspx?SID=98&AID=4631 [30 August 2012].

Perspectives

What Harm Reduction needs is A seronegative status! Olivier Maguet

n recent years, Harm Reduction (HR) dimension and provides evidence too relating to drug use seems to have of an improvement in social functioning, become self-evident on a worldwide such as lower levels of crime associated scale. Here, “self-evident” is understood with illegal drug use or a positive impact not just as something that has been scien- on social reintegration. As a result, since tifically proven (which, incidentally, it has methadone was first used to treat opion numerous occasions) but also some- oid dependency in 1965 by a New York thing that exists as an organised system, medical team, it has been subject to far generally acknowledged by policy-mak- more evaluations than anticancer drugs. ers, within which interventions are imple- The basis of the scientific knowledge is a mented that target sections of the public sound one. The second sign points to the emerwhose personal practices make them particularly more exposed than other individ- gence and gradual development of a uals to the risk of transmission of an infec- social arena in which the players have tious virus such as HIV – people who use evolved. Its origins lie in the AIDS epidrugs, sex workers, etc. This system also demic which arose at the very beginning points to the presence of local and global of the 1980s: the hitherto unthought-of players promoting and developing these (being at the time unthinkable in terms interventions and of an environment in of disease classification) happened. This which HR is deployed. Several signs, relat- unthought-of is all the more unlikely ing to the interventions themselves, the and disturbing as it related to individuplayers and the environment, enable the als and groups who were marginalised origins and nature of the self-evident fact and the object of often negative social representations, beginning with homoto be defined. sexuals and drug users. This immedi-

From law-breaking to standard practice The first sign is the bulk of scientific publications demonstrating the impact of health programmes which offer HR interventions focusing on people who use drugs – such as making sterile injecting equipment and opioid substitution therapies available. Numerous indicators assessed at different locations worldwide provide objective proof of this impact: reduction in HIV transmission, decline in the number of fatal overdoses, adherence to HIV antiretroviral treatment, etc. Scientific literature on the subject even goes beyond the purely health-related

With a university background in economics and sociology, Olivier Maguet has been campaigning in the field of AIDS, viral hepatitis and Harm Reduction since the end of the 1980s. In 2006, he joined Médecins du Monde, drawing up and implementing the Afghanistan HR programme for which he remained the volunteer head of mission until January 2013. In 2010, he was elected to the MdM Board of Directors and was appointed adviser for programmes and advocacy relating to HIV/AIDS, viral hepatitis and HR. On a professional level, he founded the CCMO Conseil consultancy in October 2004, which specialises in analysis, project support, evaluation, advocacy and research in the field of health and social programmes targeting drug users and in public funding for development in the health sector.

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ately posed problems and even wrongfooted traditional health professionals in general and those working in addiction in particular. The medical emergency thus led to the emergence of a leading group of players whose atypical profile in relation to medical sector norms to some extent echoed the marginality of the groups affected by HIV. From Dutch Junkie Bonds to young humanitarian doctors, from the first activists in the fight against AIDS to political campaigners from the post-1968 protest movements, from young researchers sidelined by their institutions to

the ‘outsiders’, originally marginalised by policymakers and their peers, have become ‘insiders’, whose proposals are officially taken up and translated into legislation and good practice guides. local authority decision-makers confronted with managing the epidemic locally (such as in Liverpool), all were in some way outsiders who were getting to grips with responding to the AIDS epidemic among drug users. These first players, located essentially in Western Countries, were the ones who initiated HR programmes and created the source from which the movement was to spread; they gradually organised and even standardised their action, in order to spread HR interventions as effectively as possible. In this respect, the organising of the first international HR conference in 1990 and later the founding of the International Harm Reduction Association (IHRA) in 1996, which became Harm Reduction International (HRI) in 2011,

are milestones in the process of constructing HR’s social and political arena. Lastly, the third sign of this self-evident fact is the major change in the environment in which HR programmes operate. The social and political acceptability of HR has improved considerably in recent years. This is, moreover, as a direct consequence of the first two signs outlined above, HR players having succeeded throughout this period in promoting the scientific evidence they were producing. Since 2008, HRI has published every two years a report entitled “The Global State of Harm Reduction”, which draws up a list of top-ranked countries, showing for each the level of acceptability of HR based on four indicators: the existence of (i) official legislation issued by governments or national parliaments formally adopting HR as a public health policy, (ii) needle exchange programmes (NEP), (iii) opioid substitution therapies (OST) and (iv) drug consumption rooms. Between 2008 and 2012, the number of countries with texts enshrining HR in law rose from 82 to 97, those offering NEP from 77 to 86 and those with OST from 63 to 77. These impressive developments need to be compared to 1984 when the very first needle-exchange programme was launched in the Netherlands and can thus be seen to represent a form of sanctioning of HR by States as well as by international agencies. The United Nations published a technical guide in 2009, aimed at States wishing to establish effective anti-AIDS programmes that targeted people using drugs. The second edition of the guide, published in 2013, even incorporates the term HR to signify such interventions. Member States are now being offered an official definition which acts as a reference framework and which clearly establishes NEP and OST as the two key HR interventions. We have to keep in mind that those two measures have aroused – and continue to arouse in certain parts of the world – the greatest controversy. On a more political level, the end of the first decade of the 2000s saw a rapid rise in the number of declarations and reports in support of HR and of drug policies based on HR approaches issuing from leading

Olivier Maguet What Harm Reduction needs is A seronegative status!

public figures: former heads of state (of is effectively reduced. And, in addition, countries in South America in particular), when these techniques are applied using heads of global agencies, Nobel prize-win- a method adapted to the intervention context, this also helps promote forms ners and top researchers. This is what is meant by being “self-ev- of social reintegration. But science has ident on a worldwide scale”, a status reached its limits and there are two reaacquired in the space of thirty years. sons for this: on the one hand, because At the end of the process, the outsiders, overturning the political paradigm relatoriginally marginalised by policy-makers ing to drugs has not been enough to break and their peers, have become insiders, globally with a policy centred on represwhose proposals are officially taken up sion. On the other hand, science might and translated into legislation and good essentially contain the seeds of a norpractice guides. HR players have moved mative system, undoubtedly an alternafrom engaging in law-breaking to estab- tive to the current one but a normative lishing standard practice. This observa- one nonetheless. Indeed science might to tion does not call for some historic and some extent bring about a new technique emotional assessment, implicitly indicat- for governing individuals, for “guiding ing regret for some form of past golden conduct” as Foucault so rightly describes age of HR. On the one hand, it would be it. (Foucault 1982) Relationships of power indecent to talk of a golden age when they are one of the central themes in the work were years of what seems more like famine than feast; and, on the other hand, the But science has reached its limits because worldwide spread of HR could only happen precisely by creating an arena as an overturning the political paradigm essential precondition for its acceptance relating to drugs has not been enough by policy-makers and societies; this socioto break globally with a policy centred logical and political rule is, moreover, not specific to HR but concerns any emergon repression. Science might essentially ing social movement that is committed contain the seeds of a normative system. to introducing new categories of thinking and action. of Michel Foucault who considers that the expressions “guiding” and “governing individuals” provide a better underAn impassable frontier standing of what is specific to relationHR players successfully faced up to the ships of power. In our present case, the challenge presented by the emergency science has been largely founded on a health situation and, in so doing, man- single health topic, HIV, or rather on the aged to introduce a new paradigm for response aimed at reducing transmission drug-related interventions. However, of HIV among people who inject drugs, in this success cannot gloss over other chal- order to lessen the burden of morbidity lenges emerging today. These challenges, and mortality. But as well as being effecwhich fall within a different – longer – tive, this technical discourse poses a real time-frame than that of the emergency threat to these same drug users, imposing situation, are ultimately and implicitly on them an overwhelming obligation to revealed by where the emergency failed conform to a single model of behaviour to produce a response and by what lay and circumscribing their social existence outside the parameters of that response. as drug users responsible for protecting The success referred to was founded on themselves from the risk of infection. There is also the threat that the playscientific evidence: by making HR tools as widely available as possible – including ers themselves will think about harm-resterile consumption equipment, substitu- duction responses relating to drug users tion therapies, condoms and lubricants – and drug policies more generally – as – the transmission of infectious viruses being uniquely configured, defined by Perspectives

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hand, HR’s technical and scientific discourse leads to new exclusions generated by the normative system which HR introduces, as the single behaviour model promoted by the medical and political community before HR – “to provide a cure for drugs” – has been substituted by another behaviour model which, while undoubtedly more comprehensive, is still just as exclusive: to be compliant in one’s drug consumption and in responding to the the conjunction of two particular phe- messages conveyed by HR as defined in nomena, namely injecting and HIV. That the United Nations technical guide from being the case, the HR movement’s entire 2009. Therein lies the paradox: the same capacity for creativity, the very creativity science on which HR is founded and the that was the outsiders’ strength, is what same techniques associated with it, which is now under threat. It is in this sense made the law-breaking of the 1980s posthat HR now seems to be confronted by sible, today act as a constraining norm an impassable frontier. Over and above that limits HR thinking and action. the need to continue developing HR in untouched territory (which, if the list compiled by the HRI is to be believed, is Questioning the norm still half the world), players must apply themselves to the task of establishing Since action can only be taken on the marnew foundations that not only guarantee gins and since this marginal action is not better access to quality interventions for able to alter the boundaries of what is people in need but also tackle unwanted, acceptable in terms of drug policy, this new even counterproductive effects, which are global HR norm needs to be fundamentally emerging in the form of an apparently questioned. The best way to do this is by impassable frontier for HR. It is a ques- returning to HR’s historical roots, where tion here of setting out the terms of ref- a particular practice – injecting – and a erence for future discussion and action. health phenomenon – HIV – crossed paths. What we see emerge therefore is a This is what is meant by securing major paradox – a dual paradox in fact – a “seronegative status”. The accepted within HR as it is commonly understood. “response or responses to drugs” (or On the one hand, the current acceptance at any rate the response most widely of HR has shown it has been unable to accepted including by policy-makers) profoundly alter the worldwide system of cannot be founded solely on this crossdrug-related norms. In our outreach pro- ing-point. What is needed is to go beyond grammes, all we are ultimately doing is this point in order to rethink HR and ultitrying on a daily basis to push back the mately to reconnect with what the origiboundaries of what is politically, penally nal outsiders achieved, thereby mirroring and socially acceptable regarding the what Michel Foucault writes about in his medico-social services offered to users, original introduction to History of sexualwhile failing to act on the fundamental ity: “‘Thought’ […] is not […] to be sought reasons behind their present health and only in theoretical formulations such as social situation, namely the laws and those of philosophy or science; it can norms which exclude and repress them. and must be analyzed in every manner From this point of view, drug consump- of speaking, doing or behaving in which tion rooms as a complementary service the individual appears and acts as subject within the range of existing HR services of learning, as ethical or juridical subject, are a good example of work on the mar- as subject conscious of himself and others. gins that does not fundamentally alter the In this sense, thought is understood as the nature of the boundaries. On the other very form of action – as action insofar as Olivier Maguet What Harm Reduction needs is A seronegative status!

it implies the play of true and false, the acceptance or refusal of rules, the relation to oneself and other.” (Foucault 1984) Where is “every manner of speaking, doing or behaving” today aside from in the “theoretical formulations” of sterile syringes and substitution therapies? Where are the different dimensions of the subject today beyond that of the subject at risk of HIV? To answer these questions is to resonate with the initial fundamentals of HR: the essential place of the person, his or her history, experience of products, and so on. It is a place that, unfortunately, we have tended to dilute in the floods of data produced as scientific justification. Hence, on the question of defining HR programmes, some players, including MdM, now deliberately choose to think about action on the basis of its relationship to the norm, whether it be a law, an administrative regulation or a professional standard, rather than in terms of the drug used, the pathology associated with it or the “risk group”. For therein lies the common denominator. Not only does this choice perfectly mirror the ultimate political will for which care is a means and not an end (where it is indeed a question of changing the norm), it has the merit of re-imparting meaning to a concept of HR which has gradually been stripped of its substance as a result of the dissemination of the practices and techniques to which it leads. Yet another paradox! If benefits are genuinely to be drawn from this dissemination, we cannot remain blind to the technification and normalisation that this process intrinsically generates and, above all, blind to the risks of the process, namely the dismissing of the potential of a shared political purpose. Vietnam is a good example of a certain form of loss of direction within HR when this political purpose is not part of the picture: the country is indeed universally praised for its willingness to massively increase the rate of coverage of methadone treatment for drug users; but when the Vietnam model of HR is examined in depth, it must be acknowledged that the package of services also appears to represent an effective method of controlling populations still considered as deviating Perspectives

from the norm and, in addition, always described as a “social scourge” by the authorities. In particular, it is a far more effective method than the dismal druguser detention camps, which, however, still retain their usefulness for those individuals who are regarded as failing to conform to the new normative model introduced into the country by the official HR policy. What we have here is a concrete example of HR drifting off course, of its meaning being eluded, with policy makers retaining only an effective intervention technique that is ultimately aimed at social control. This analysis provides a view of the Vietnamese example which is a far cry from that obtained by reading it strictly in terms of a technical response to injecting in the context of HIV. This reading elicits nothing but satisfaction and praise – lavished, moreover, by observers who stick firmly to the technical mould, occasionally going as far as to use the expression “gold standard” to describe Vietnam’s huge leap forward in making sterile syringes and methadone available. Moreover, the same analysis is at work in the field of sexual and reproductive health. In this context too it is far easier to think solely in terms of the burden of morbidity and mortality: maternal mortality, the primary cause of death among women worldwide, immediately appears therefore as an essential starting-point for devising and running programmes covering a spectrum of services ranging from family planning and access to contraception and abortion methods to provision of obstetric healthcare. This is so self-evident that it formed one of the eight Millennium Development Goals defined by the United Nations in 2000 in order to eliminate world poverty by 2015. It is true that maternal health is, by definition, associated with the reproductive dimension of sexuality; but understanding sexual and reproductive health solely from the point of view of maternal health is once again to duck the issue of the relationship to the norm, the law and the rule. And, above all, the question is whether it is actually the role of HR players to confine themselves to making these services available in order to

drug consumption rooms are a good example of work on the margins that does not fundamentally alter the nature of the boundaries. 102 103

help realise the Millennium Development Goals. Clearly the answer is no. And it is for this fundamental reason that activities relating to sexuality, even more than when responding to specific health needs alone, must begin with prior consideration of the relationship to the norm. The same applies to safe access to pregnancy termination where it is against the law and to access to HIV prevention methods for male and female sex workers whose practice is criminalised or stigmatised. As regards sexuality more generally, the selection criterion to devise intervention will be based on whether the situation or the practice is governed by legal provisions or social perceptions which lead to exclusion from prevention, care and treatment services. It now becomes apparent what links drug users, sex workers and homosexuals. The point they have in common, which concerns the relationship to the norm, the law and the rule, represents a appropriate basis on which to formulate a broader concept of HR. Once again, it is a matter of going beyond providing a technical response to the conjunction of the two phenomena of injecting and HIV. And once again is about achieving a “seronegative status” for HR. Taking the law as a starting-point for discussion and action opens up other avenues: ethnic minorities and racial segregation; migrants (with or without travel and residency documentation) and fear of foreigners; lastly, the social issue and fear of the working classes. From this point of view, data relating to the crackdown on those who commit drug-related offences is, at it were, mind-blowing. American legal expert, Michelle Alexander, recently brilliantly demonstrated the overuse of

imprisonment in the case of Blacks and Hispanics in the United States and, from among these “mass incarcerations” to use her words, showed the extent of those in jail for drug-related offences. (Alexander 2010) In France, violence in so-called sensitive neighbourhoods has been exploited by several political leaders as a perfect example of the need to promote national security policies; yet, the patent failure to contain this violence has for some years led observers to point out that the violence is closely linked to mafia-style operations controlling the outlets for drugs; and, a further phenomenon, the issue of race, has also been added to the debate, since the term “sensitive” simply seeks to discreetly conceal children born of immigration among the population of the French Republic which, it is claimed, does not distinguish between its citizens. Another example shows a different form of latitude being taken: in Afghanistan, Pul e sharki prison is full, its population made up of a handful of insurgents and lots of small-scale drug users, while the heads and leaders of drug-trafficking rings live peacefully, in full view and knowledge of everyone, in their high-profile luxury villas in Kabul, which are dripping with ostentation and kitsch. Again in Kabul, ethnic Hazara drug users account for more than 80% of the active case file for MdM’s HR programme, while this ethnic group represents around 30% of the country’s total population. What we have here is the coming together of two phenomena referred to above – racial and social segregation, as the Hazara occupy manual day jobs at the bottom of the socioprofessional ladder. On the way to the HR centre in the morning, we can see poor wretches carrying shovels and wearing a few rags on their backs lining the pavements of the Kabul streets trying to sell their – feeble – manpower for one or two dollars a day. These are the same people who spend the afternoon at the centre, taking advantage of the medico-social services in one of the rare places offering them such services. All these phenomena are part of what Anne Coppel, in her work entitled Drogues : sortir de l’impasse calls “globalisation of

Olivier Maguet What Harm Reduction needs is A seronegative status!

zero tolerance”. (Coppel, Doubre 2012) Like others, the zero-tolerance trend originated in the United States. In the US, it formed the culmination of a movement that was part of the long-term constructing of an international norm for drug control, undertaken from the beginning of the twentieth century and, more specifically and recently, as part of the formulation and expression of the war against drugs from the 1960s. The Reagan years crystallised this culminating point, an epiphenomenon of which was the demonising of crack in Black American ghettos, and it is significant that it was in the course of this same decade – in 1988 – that the last and most repressive of the three international treaties defining international policy on drug control was adopted. This movement, with its origins in the United States, gradually seeped into public spaces worldwide. As Anne Coppel specifies, “in numerous European countries, it led to the reinforcing of sanctions imposed on use and, at the very least, put the brakes on the process which had prompted countries of the European Union to favour public health responses as opposed to legal sanctions”. Therein lies the substance of the matter: this worldwide movement steamrollered its way across the globe at the same time as the AIDS epidemic appeared. And it is precisely the responses to AIDS which led, as we have seen, to the emergence and then to the construction of a corpus of technical knowledge and practice known as Harm Reduction. A global review of policy clearly shows that the scientific evidence for the effectiveness of these technical responses of HR, with all the weight that it was able to bring to bear, was not alone enough to counter this globalised movement. The countries of Europe provide a good illustration: while they were historically quite advanced as regards civil society’s implementing of effective health responses and in the recognition of these by the public authorities, the countries did not know how or were unable to counterbalance the impact of the trend emanating from the United States. France is a good example of this impasse: while it was undoubtedly slower off the mark than other countries in Europe, such as Perspectives

the Netherlands, United Kingdom and Switzerland, in the 1990s France successfully devised a worthwhile HR intervention that was based on broad access to opioid substitution therapies via an extensive urban drug prescription facility, leading some to use the expression “the French model”. The wave from across the Atlantic reached its peak in France during the Sarkozy years of the 2000s and led to a major setback. Hence the reason why it is now high time to move beyond the technical approach based on public health to (re)position discussion and action in the domain of the norm, the law and the rule.

A return to law-breaking? Over and above the strictly health-related dimension in which it has its origins or, rather, which drives its implementation, HR might be seen as a powerful political intervention for understanding and analysing relationships of control and social relationships of power and which authorises action and provides the tools to act in order to transform these relationships. However, this is on one condition: that evaluating an HR action is not limited to measuring solely the health-related impact of the HR services offered on the method used to minimise morbidity and mortality, reduce criminality, improve social functions, etc. Again this is what is meant by securing a “seronegative status” for HR. The limits of “institutionalised” HR in its current format are therefore now clearly established. To continue existing and developing while remaining true to its source, HR must reposition itself with the aim of transforming society and be viewed from now on as a tool to help reform international drug control policy and, at a local level, national legislation, adopted as a way of applying a powerful normative constraint which has pushed states beyond what is required of them to put the provisions of international treaties into effect. It is twenty-first-century HR that we need to think about and put into action, namely HR aimed at this reform, and not the HR of the twentieth century,

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that is to say the one striving to combat AIDS. To some extent it is a question of rediscovering a particular type of subversion, like the subversionary approach embraced by outsiders at the beginning of the 1980s. Latin America clearly invites us to go down this route. And it is well placed so to do, being one of the regions of the world which has paid – and is still paying – a particularly heavy price for the war on drugs. This is above all the case in Mexico where

HaRm reduction must reposition itself with the aim of transforming society and be viewed from now on as a tool to help reform international drug control policy. there have been more than 50,000 deaths since 2006. The invitation is reflected in one symbolic image and two initiatives. The image is that of Columbian president, Evo Morales, chewing a coca leaf during the Commission on Narcotic Drugs in Vienna in 2009 to demonstrate support for his proposal aimed at reforming international drug control policy. He used the discrepancy between international treaties and the traditions and local economy of the indigenous peoples of the plateau as the grounds for his gesture. The two initiatives are, firstly, the publication in June 2011 of the first report of the Global Commission on Drug Policy, which also demanded reform of international policy on the basis of the scientific evidence previously referred to (the former heads of state and members of this commission all being from Latin America apart from the former Swiss president, Ruth Dreifuss); and, secondly, the Summit of

the Americas in Cartagena in April 2012, during which all the governments of Latin America made the observation that “the war on drugs has failed” and called on the USA to change tack. Plenty of other initiatives, such as the project to regulate production and consumption of cannabis in Uruguay, could be developed in support of this analysis. These examples are the outward form of an emerging movement aimed at breaking with a powerful, shameful norm dating from the beginning of the twentieth century.

A detour on the historic route The British historian Eric Hobsbawm wrote a brilliant analysis of what he called the “short twentieth century”, as opposed to the “long nineteenth century” which was marked by profound changes brought about by the industrial revolution, the end of “conquest” of the globe and liberalism. (Hobsbawm 1994) The century was short because it was historically defined by the dates of two major world conflicts. The unprecedented violence of these conflicts was in inverse proportion to the length of the period in history, which had its fair share of totalitarianism, destruction, genocide and extermination. Significantly, the history of what forms current international drug control policy is as short as that of the twentieth century described by Hobsbawm, and falls perfectly within the historical boundaries he establishes. More specifically, the date on which the process of formulating drug control policy began was 1909, the year in which the first opium conference was held in Shanghai. On the pretext of bringing the opium wars in China to a close, the conference promoted the idea of regulating and controlling opium. The end date for this period is 1971, year of the famous speech by President Nixon to the US Congress in which he declared “war on drugs”. In the space of sixty years – a mere nothing in the scale of human history – a mental and political framework was created and developed on which was based the never-discussed assumption that “Drugs are banned because they

Olivier Maguet What Harm Reduction needs is A seronegative status!

are dangerous.” This is one of the most disturbing received ideas ever to be so widely disseminated in such a short space of time on a global scale and to be taken up unopposed by all those responsible for shaping norms and opinions. In his work entitled Le Grand Deal de l’opium, François-Xavier Dudouet skilfully sets about radically dismantling this received idea concerning drugs, which is certainly one of the most damaging and pernicious towards an intelligent grasp of “drugs as social object”. (Dudouet 2009) He provides an authoritative lesson: not only does he demonstrate that this is not why drugs are banned but also, and more especially, he shows that nothing in the seeds of what forms the repressive legislative apparatuses of states today provides a raison d’être for the political drive to impose a ban. A reverse logic has even been at work which involves creating a “legal market for drugs”, to use Dudouet’s expression, starting with the market for opium, which was the principal “drug” during this early twentieth-century period. The reasons which led to the creation of this market were eminently pragmatic: a medical need for opioid-based pharmaceutical products was emerging – the physical and psychological stigmata inherited from the first worldwide conflict rather opportunely reinforcing this demand; and a pharmaceutical industry was, from the end of the nineteenth century, beginning to develop in parallel, its economic model based on the industrialisation of technical advances seen in chemistry. It is worth remembering that diacetylmorphine (the active ingredient of heroin) was first synthesised in 1874 and that the German pharmaceutical company Bayer manufactured heroin from 1898. In this field as elsewhere, morality (“drugs are bad and dangerous”) is never far from economics (profitability of a pharmaceutical market). Or rather morality acts as a screen permitting the political and social acceptance by the community of individual economic interests. The desire to create a legal drugs market led to international regulations being issued de facto throughout the first half Perspectives

of the twentieth century. These were increasingly enforced during this period, culminating in three anti-narcotics conventions adopted by the United Nations in 1961, 1971 and 1988 and the setting up of a global enforcement body in the form of the International Narcotics Control Board. The logical consequence of this movement was the banning of and then the crackdown on the use of drugs not authorised by this legal framework, that is to say the non-medical use of drugs. This in a nutshell is the real history of the “criminalising of drugs” worldwide – somewhat different from the assumption at the outset. Nascent AIDS epidemic took place in this background of increasing criminalisation. And it was precisely this increasing criminalisation that was responsible for the harm caused by the

In the space of sixty years, a mental and political framework was created and developed on which was based the neverdiscussed assumption that “Drugs are banned because they are dangerous.” epidemic among intravenous drug users – a prime route for transmitting the virus if ever there was one. Some countries – in reality very few – responded fairly quickly. Others, like France, joined the movement later. The health-related norm for HR then gradually took over as has been seen. It should be remembered that, unfortunately, in some fairly extensive regions of the world – including Russia – the situation which prevailed at the beginning of the AIDS epidemic among drug users still persists today. What does this history teach us? It reveals that since we have developed as human beings – that is to say for more than thirty thousand years – we have learned to live with the natural resources of our environment, all the resources, including those that are now referred to as “drugs” and that it took a mere sixty short years to undermine this multimillennial edifice of acculturation. Political

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and economic leaders guiding the world out of this decidedly short twentieth century thus contributed, in addition to the disasters described by Hobsbawm, to organising a monumental detour from the historical route taken by humanity in the matter of drugs.

New frontiers of HR Until now, we as HR players have undertaken to act within this hyper-normative context. If we are not careful, the natural tendency is to be carried or even diverted down a technical and managerial path. What if we refused to do as required? What if, in a sudden fit of liberated citizenship, we decided to alter the terms of the debate? And what if we finally accepted the paradox that was previously at issue as a way of overcoming it? And what if we supported a form of revolution rather than continuing to develop in the role of managers of the system? Of course access to services and tools must be guaranteed for those who are always denied it (the ‘service provision’ component). But we must always keep our sights fixed on the question of innovation and of political and social added value, over and above providing services. Innovation here means coming up with the technical means to introduce the concept of HR via actions that go beyond responding solely to the risk of HIV transmission among those injecting drugs. In so doing, we would be laying the first foundations for a break with the prevailing model. The added value would be there because all the medical and social services we put in place in our programmes would necessarily be viewed as a worthwhile and

effective form of leverage for social transformation, rather than the services being seen as an end in themselves, as is the case imposed by the current way HR is normalised. What we are ultimately being invited to do is to respond to a certain form of duty. This duty is intellectual and political and involves us in opposing the above-described paradigm rather than in taking up technical arms to fight exclusively against AIDS among those who inject drugs. It is a duty which commits us to thinking a new – long-term – unthinkable, following on from the unthinkable of the shortterm emergency of the 1980s. It is preferable to talk about “duty” rather than “courage”, which too often has echoes of the heroic. We are not heroes, not even everyday heroes; what we are is demanding citizens, whose mission is to devise Harm Reduction for the twenty-first century. And devising Harm Reduction for the twenty-first century also means putting drugs policy back on its historical track after quitting it in the twentieth century. In this sense, the concept of twenty-first century Harm Reduction and the actions it shapes must be definitively envisaged from a political and no longer a health perspective. To do this, we must abandon the technical trappings that this institutional recognition of HR has led us to acquire. We must rediscover what Italian psychiatrist Franco Basaglia has called a form of “anti-specialism” in his fight against the institution of psychiatry. (Basaglia 2012) We must guard against continuing to maintain a technical approach which justifies the most perverse forms of social control and insidiously and inevitably nurtures a slide towards a form of policing the body. The political project set out here may seem ambitious or unattainable. And yet, history has already shown us that drugs can be thought about without the pretext of AIDS and injecting. Well before the famous “Liverpool model” as described by Pat O’Hare in this publication, there was in the United Kingdom during the 1920s major reform of provision for drug users and addiction which led, among other things, to the prescribing

Olivier Maguet What Harm Reduction needs is A seronegative status!

of medical heroin being authorised at the time. This is an equally famous but now somewhat forgotten “British system”, born of the commission chaired by Sir Humphry Rolleston. It was certainly not the ambition of the notable British figures of the period to prevent the emergence of a normative model of drug control; but they must be acknowledged as having succeeded in formulating a policy without the AIDS emergency as backdrop. We therefore have proof that it is at last possible to “overcome AIDS” in order to make policy. Ultimately, this is what is meant by achieving a “seronegative status for Harm Reduction”. ■

References ›› Alexander M 2010, The New Jim Crow. Mass Incarceration in the Age of Colorblindness, The New Press, New York. ›› Basaglia F 2012, L’institution en negation, Les editions arkhê, Paris. [not translated] ›› Coppel A, Doubre O 2012, Drogues : sortir de l’impasse, Experimenter des alternatives à la prohibition, La Découverte, Paris. [not translated] ›› Dudouet F-X 2009, Le grand deal de l’opium : Histoire du marché legal des drogues, Editions Syllepse, Paris. [not translated] ›› Foucault M 1982, “The Subject and Power” in Dreyfus H and Rabinow P, Michel Foucault: beyond structuralism and hermeneutics, The University of Chicago Press, Chicago. ›› Foucault M 1984, “Preface to the History of Sexuality” in Rabinow P, ed. The Foucault Reader, Pantheon Books, New York. ›› Hobsbawm E J 1994, The age of extremes: the short twentieth century 1914-1991, Michael Joseph, London.

Perspectives

Harm Reduction and law

The impact of criminalisation on public health

Alex Wodak

rug prohibition was intended to mini- Opium Conference in The Hague in 1912 mise, if not eradicate, the recreational and then a League of Nations International use of prohibited drugs while ensur- Opium Convention in Geneva in 1925. At ing their ready availability for scientific the Geneva meeting it was agreed to proand medical purposes. It was expected hibit plant-based drugs (opium and derithat criminalising drugs would deter their vates; coca and derivates; and cannabis cultivation, production, transport, sale, and derivates). After the United Nations purchase, possession and consumption was established, three international drug while also minimising the financing of treaties were negotiated and agreed (the 1961 Single Convention on Narcotic Drugs the drug trade. (United Nations, 1961, as amended by the 1972 Protocol), the 1971 Convention on Psychotropic Substances (United The criminalisation of drug use Nations 1971) and the 1988 Convention The criminalisation of drug use has meant against Illicit Traffic in Narcotic Drugs that governments and the UN over at least and Psychotropic Substances). Almost all the last half century have regarded drugs members of the UN have signed and ratias essentially a criminal justice problem. fied the three treaties, thereby committing Governments have emphasised punitive these countries to pass domestic legislainterventions and thus generously funded tion providing criminal sanctions for perdrug law enforcement while parsimoni- sons involved in illicit drugs (cultivation, ously funding health and social interven- production, transport, sale, purchase, postions. Yet the global illicit drug market session, consumption and involvement in has grown relentlessly. The severe and financing). The commitments to also prounintended negative consequences of vide adequate treatment for drug dependthe criminalisation of drugs have recently ent persons have been generally ignored. been acknowledged. In 2008, Dr Antonio In June 1971, President Nixon intensiMaria Costa, Executive Director of UN Office on Drugs and Crime conceded that fied the focus on drug law enforcement the international drug control system is not ‘fit for purpose’ observing that ‘the second unintended consequence is what one might call policy displacement. Public health, which is clearly the first principle of drug control…was displaced into the background’ (Costa 2008). The criminalisation of drugs evolved slowly (Bewley-Taylor 2001) over more than sixty years. The process began when the US convened the 1909 Opium Commission in Shanghai. This was followed by further meetings, including an

Dr Alex Wodak, a physician working in the alcohol and drug field in Sydney, Australia, is President of the Australian Drug Law Reform Foundation and was President of the International Harm Reduction Association (1996-2004). He helped establish the first needle syringe programme and the first medically supervised injecting centre in Australia when both were pre-legal. In 2011, he contributed to the Global Commission on Drug Policy.

The criminalisation of drugs evolved slowly over more than sixty years. The process began when the US convened the 1909 Opium Commission in Shanghai.

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illicit drugs was devoted to law enforcement (Office of the Auditor General of Canada 2001). A RAND study estimated that 93% of US government expenditure in response to cocaine was allocated to eradication of coca plants in South America, interdiction of cocaine from South to North America and US customs and police (Rydell & Everingham 1994). These interventions were estimated per $US 1.00 to return 15 cents (eradication), 32 cents (interdiction) and 52 cents (US customs and police). Treatment of cocaine users was estimated to return $US 7.46 per $US 1.00 but was only allocated 7% of government funding.

by declaring a â&#x20AC;&#x2DC;War on Drugsâ&#x20AC;&#x2122;. Though this war failed miserably in achieving its objectives, it proved to be a very effective political strategy. Accordingly, the political strategy of waging a war against drugs was emulated subsequently by many polHowever, in the decades following the iticians in many countries. Increasingly, illicit drugs were considered to be crim- 1961 Single Convention or the 1971 Nixon inal justice problems. There is very lit- declaration of a War on Drugs, global cultle data on the return on investment for tivation, production, transport, sale, purgovernment expenditure on drug law chase, possession and consumption of enforcement, but the returns are likely to drugs soared. Global opium production be poor and may even be negative. There increased from 1,050 metric tons in 1980 are much better returns on investment in to 8,890 metric tons in 2007 declining to 4,860 metric tons in 2011 (UN World health and social interventions. Drug Report 2008, 2010, 2011). World Governments allocated an over- cocaine production increased from 774 whelming proportion of funds expended metric tons in 1980 to 865 metric tons in response to illicit drugs to drug law in 2008 (UN World Drug Report 2008, enforcement interventions such as cus- 2010, 2011). The number of new drug toms, police, courts and prisons. In con- types is also increasing. In the European trast, minimal funding has been allocated Union, 49 new psychoactive substances to health and social interventions to pre- were officially notified for the first time vent or treat illicit drug use. In Australia, in 2011. This represents the largest num75% of the $A 3.2 billion expended by ber of new substances ever reported in governments in response to illicit drugs a single year. There were 41 new subin 2002-03 was allocated to drug law stances reported in 2010 and 24 in 2009 enforcement with only 17% for demand (EMCDDA â&#x20AC;&#x201C; Europol 2011). Consumption reduction (10% education, 7% drug treat- of illicit drugs is also spreading to more ment) and 1% on harm reduction (Moore countries. In the first half of the 20th cen2008). A more recent study estimated that tury, the USA was the only country with 92% of the dollars expended by Australian serious drug problems. By the end of the governments in response to illicit drugs in third quarter of the 20th century, almost 2004-5 was allocated to criminal justice every developed country had serious drug measures (McDonald 2011). In a recent problems. At the end of the 20th century, EU study (Postma 2004), expenditure on almost every developing country outside drug law enforcement dominated govern- Africa had serious drug problems. Now ment spending in the UK (83%), Sweden more than a dozen African countries (78%) and the Netherlands (75%) but the report serious drug problems. World quality of data made estimates and com- prices of heroin and cocaine decreased by parisons difficult. In Canada, it was esti- more than 80% between 1980 and 2003 mated in 2001 that 93.8% of the annual (European Commission 2009). Despite national expenditure on efforts to control the well-resourced efforts to reduce Alex wodak Harm Reduction and law

drug supply, drugs are also readily avail- trafficking is not detected. If detected, the able. Since 1975, annual surveys of US processes of the law ensure that punishhigh school seniors (seventeen years old) ment is delayed and may even be avoided have found that more than 80% reported if technical aspects of the law allow the that cannabis was ‘easy’ or ‘fairly easy’ offender to escape conviction or a custo obtain (U.S. Department of Health and todial sentence. Not surprisingly, punishHuman Services 2004). After twelve years ment inflicted on people who use illicit of a heroin shortage in Australia, 86% of drugs often has limited effects on their drug users still reported in 2011 that drug use. More severe punishment does obtaining heroin was ‘easy’ or ‘very easy’ not appear to have a greater impact on with similar findings for methampheta- behaviour than less severe punishment. mine (speed) (80%), cocaine (68%), hydroThe two most commonly used definiponic cannabis (94%) and bush cannabis tions of drug dependence (ICD 10; DSM (76%) (Stafford & Burns 2011). Drug prohibition has also failed to IV) note ‘continuing use despite severe ensure the ready availability of specified adverse consequences’ as an impordrugs for scientific and medical purposes. tant if not critical characteristic of this It is now recognised that the majority of condition. Many people who use illicit the world’s population living in develop- drugs early on lose or badly damage all ing countries have inadequate access to that is dear to them. This includes their opioids for pain relief. In 2009, high-in- health, well-being, important relationcome countries (as defined by the World ships (spouse, partner, parents and chilBank) accounted for almost 93% of the dren), accommodation, financial stability, world’s medical morphine consump- employment and education. Many also tion but only represented 17% of the experience repeated episodes of incarworld’s population. Low and middle-in- ceration. Yet the consumption of drugs come countries accounted for 83% of the generally continues unchanged. It should world’s population but only consumed 7% hardly come as a surprise that inflicting of the world’s morphine (International yet further severe additional punishment has such a limited effect. Narcotics Control Board 2010).

Punishment and behaviour change As a result of the criminalisation of drug use, people who use drugs often experience severe punishment for any association with drugs. Although the punishment severely impairs many important aspects of their life, the impact on their future drug consumption is minimal. Psychological theory, supported by ample empirical data, predicts that punishment changes behaviour when it occurs promptly after a particular behaviour, and is considered to be certain and severe. Punishment has little impact on behaviour when it is delayed long after the behaviour, is considered to be unpredictable and likely to be of only mild to moderate intensity. The punishment inflicted on people who use illicit drugs is often severe but it is also usually delayed and generally uncertain. Most drug use or Perspectives

The rapid increase in the numbers of incarcerated people in the USA since the early 1980s has been without equal in any other country. While accounting for less than 5% of the world’s population, the USA has 25% of the world’s prisoners. The price of street heroin and cocaine plummeted by 80% in two decades while the number of prison inmates serving sentences for drug-related offences increased from 50,000 to 500,000. While the USA has been willing to imprison a higher rate of its population than any other country in the world, it has not been prepared to adopt harm reduction. The term itself has never been used by US officials. Congress banned the use of Federal funds for needle syringe programmes. When President Obama removed this ban, Congress re-imposed it. For many years, Congress even banned research on needle syringe programmes.

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Most people who have injected drugs have experienced at least one non-fatal drug overdose, and many have experiDespite the lack of evidence for beneficial enced several. Non-fatal drug overdoses effects from punishing drug users and are a frightening experience. They often result in severe and sometimes permathe abundance of evidence of serious nent physical and mental health damage. harms, punishment is the dominant Non-fatal drug overdoses often result in approach to drug use around the world. the use of considerable resources including the use of an ambulance, admission to a hospital emergency department, Curiously, although punishment to drug intensive care unit, or general hospital users is ineffective in achieving absti- bed. Drug overdose is the most common nence, providing financial incentives to cause of death worldwide among people drug users to become, and remain, drug- who inject drugs and exceeds the number free is often quite effective. This technique, of deaths from HIV. known as ‘contingency management’, is Drug overdose occurs commonly very unpopular with politicians and policy-makers who fear the possible creation because people buying drugs on the black of ‘perverse incentives’, i.e. encouraging market do not know the exact quantity others to start using drugs in order to or concentration of drugs they purchase. Drugs sold on the black market are often earn rewards for later abstinence. diluted by sellers to increase the profits Despite the lack of evidence for bene- of the sale and thus defray the cost of the ficial effects from punishing drug users seller’s own drug use. Drug overdose is a and the abundance of evidence of seri- rare event when the same drugs are preous harms, punishment is the dominant scribed through a medical system. Thus, approach to drug use around the world. street heroin use is often accompanied by In contrast, harm reduction for drugs is severe health, social and economic probwell supported by quality evidence, yet lems. Families of drug users also suffer, as adoption is usually delayed, and imple- do the communities of drug users. Yet the use of prescription heroin (as in Heroin mentation often very slow. Assisted Treatment) benefits most drug users and their families and communities while serious adverse effects are relFatal and non-fatal drug overdoses atively uncommon. The annual number of fatal and non-fatal drug overdoses has increased in most countries in recent decades fol- Blood-borne infections lowing the increasing reliance on drug law enforcement in response to illicit The number of people who inject drugs drugs. For example, Australia prohib- worldwide was estimated recently to be ited the production and importation of 15.9 million with an estimated three milheroin in 1953. Heroin overdose deaths lion people who inject drugs thought to be were rare at the time. Deaths from opi- HIV-positive (Mathers 2008). Intravenous oid overdose increased fifty-five-fold in drug use has been reported in 148 counAustralia between 1964 and 1997 (Hall tries with 120 of these countries also et al., 1999). In 1999, the number of her- reporting HIV infection among people oin overdose deaths in Australia peaked who inject drugs. HIV prevalence among at 1,116 (Degenhardt et al., 2004). In the people who inject drugs is 20%-40% in 21st century, there have been about 400 five countries and over 40% in nine. heroin overdose deaths each year. For The concept of ‘harm reduction’ existed every heroin overdose death, there are usually many non-fatal drug overdoses. long before the HIV pandemic and has Alex wodak Harm Reduction and law

been used widely in clinical medicine, public health and many other disciplines. But the term became widely used after HIV was first recognised and interest in the concept grew rapidly. Harm reduction is often misunderstood, sometimes wilfully. The term has now been clearly defined and the principles underlying harm reduction have been described (International Harm Reduction Association 2010).

Incarceration

Many people who have used or injected drugs have experienced incarceration. Males who inject drugs are generally incarcerated more frequently and for longer periods than females. Incarceration often accounts for a considerable proportion of the period that people inject drugs. The health of many people who use or inject drugs often improves after entering prison following The difficulties of providing adequate contact with health services. Most drug prevention, care and treatment for people users rarely use health services in the who inject drugs was noted by the United community. But incarceration often has Nations Secretary General when he said, its own health risks. Physical and sexual “in addition to criminalising HIV trans- violence is not uncommon in prisons and mission, many countries impose criminal sanctions for same-sex sex, commercial sex and drug injection. Such laws constiThe concept of ‘harm reduction’ existed tute major barriers to reaching key poplong before the HIV pandemic and has been ulations with HIV services. Those behaviours should be decriminalised, and used widely in clinical medicine, public people addicted to drugs should receive health and many other disciplines. health services for the treatment of their addiction.” (Ki-Moon 2012). Hepatitis B and hepatitis C are also this may result in impairment of physical common among people who inject drugs. and mental health. Infection with bloodThese viruses are more infectious than borne viruses, both HIV and hepatitis C, HIV by blood-to-blood transmission. In is a significant risk for people who use most countries, the prevalence of hep- or inject drugs behind bars. Many peoatitis C infection is much higher among ple who use but do not inject drugs in people who inject drugs than HIV. In some the community start to inject these drugs countries, hepatitis C infection accounts after entering the correctional system. for more deaths among people who inject The prevalence of intravenous drug use drugs than HIV. is much higher in prison than in the community, but the frequency of injecting People who inject drugs are also at drugs is much higher in the community. risk of infections from other viruses and Each episode of injecting drugs is much from other blood-borne infections includ- more likely to result in HIV or hepatitis C ing bacteria, fungi and parasites. Some in prison for several reasons. The number bacterial infections are close to the injec- of sharing partners per injecting episode tion site while others may be in distant is much higher in prison. Also, sharing organs. These infections account for many partners come from a much wider geodiseases and a large number of deaths. graphical and social network in prison. Injecting equipment is much more conApart from these microbiological agents, ducive to HIV transmission in prison street drugs are often adulterated with a because it is extremely worn and provariety of chemical contaminants. These vides many more opportunities for HIV adulterants can cause health problems, or other infectious agents to be retained but the general experience has been that between injections. health problems due to adulterants are relatively uncommon. Perspectives

studies concluded that the more intensive the implementation of drug law enforcement, the greater the degree of violence (International Centre for Science in Drug Policy 2010).

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Violence is a public health problem. The President of Mexico, Felipe Calderon, declared a war on drugs in December 2006. There have been an estimated 50,000 homicides in Mexico since 2006 with increasing numbers of murders The â&#x20AC;&#x2DC;iron law of prohibitionâ&#x20AC;&#x2122; every year. In 2011, there were 12,000 As a general rule, the more draconian homicides in Mexico. The number of kidthe punitive environment for drug use, nappings and extortion also increased the more dangerous the drugs availa- parallel with the increasing numbers of ble in the black market. More danger- murders. ous drugs replace less dangerous drugs because prohibition encourages drugs to be more highly concentrated. The higher Providing health and social the concentration of drugs, the easier it is interventions in a climate of drug to evade law enforcement authorities. But prohibition the higher the concentration of drugs, the easier it is for small errors in estimating Health and social interventions provided the amount to be consumed to have fatal in a climate of drug prohibition are often effects. Soon after alcohol was prohibited poor. The emphasis is often on the indefin the USA in 1920, beer disappeared and inite achievement of abstinence from all was replaced by wine and spirits. Soon drug use for all drug users regardless of after alcohol prohibition was repealed in the consequences, rather than the promo1933, beer re-appeared. In the ten years tion of abstinence where this is achievable, after opium smoking was banned in three not the reduction of harm for those who Asian countries, this practice virtually dis- for the time being lack the capacity or the appeared but was unfortunately replaced desire to become abstinent. Funding is by heroin injecting (Westermeyer 1976). also often poor. Consequently, the capacity Opium smoking had been largely confined of services, the range of options, and the to elderly men and had only resulted in quality of services is often limited. During minor problems. The new practice of the alcohol prohibition in the USA, treatheroin injecting involved young, sexu- ment services for alcoholism disappeared. ally active men. Heroin injecting created the conditions for widespread HIV infection in a region that accounts for half the Impact on public health worldâ&#x20AC;&#x2122;s population. Inadvertently, the pro- consequences of drug use under hibition of opium smoking turned out to drug law reform have pro-heroin and pro-HIV effects. Health and social interventions provide considerable health, social and economic Violence as a public health problem benefits for drug users, their families and communities. Redefining drugs as priand an inevitable consequence of marily a health and social issue is the prohibition threshold required for drug law reform. Drug markets are often violent. With no Much will follow from this redefinition. legal mechanisms for resolving drug mar- Increasing funding for health and social ket disputes, resolution often involves vio- interventions to the sorts of levels often lence. A recent review found that 87% of experienced by drug law enforcement Alex wodak Harm Reduction and law

is an essential part of drug law reform. Conclusions When Switzerland and Portugal changed their approach to drugs, both countries The criminalisation of drug use evolved invested much more in drug treatment slowly over the last 100 years but intento improve capacity and quality. sified considerably in the last half century. It has proved to be an expensive way Opioid Substitution Treatment (OST) of achieving poor health, social and ecowith methadone, buprenorphine or pre- nomic outcomes. There is now growing scription heroin has been extensively recognition of the comprehensive failure evaluated with many important benefits of drug policies heavily reliant on drug well documented, including a reduction in law enforcement. At first, this was only deaths, HIV infection, crime and drug use articulated by academics and clinicians. and an improvement in social functioning. Then retired senior politicians and drug It has been estimated that there is a $7 law enforcement officials began to speak benefit for every $1 invested. OST is more out. Now even serving senior politicians effective if higher doses (80-120 mg meth- and drug law enforcement officials are adone/day; 12-16 mg buprenorphine/day) beginning to call for a new consideration are prescribed for longer periods (usually of drug policy options. As Gramsci said, more than 18 months with treatment ces- â&#x20AC;&#x2DC;the old is dead but the new is not yet bornâ&#x20AC;&#x2122;. sation voluntary, slow, planned and sup- The report of the Global Commission on ported). A harm reduction orientation Drug Policy in 2011 has transformed disalso improves outcomes. In most coun- cussion about drug policy. tries at present, demand for treatment far outstrips supply. The aim should be to Part of this discussion should include encourage as many drug users who want identifying among the drug law enforceto be in OST and meet national criteria ment repertoire those interventions to be attracted and retained in treatment. which are most effective, least accompanied by severe and unintended negaNeedle Syringe Programmes (NSP) tive consequences, and most cost effechave also been shown to be effective, safe tive. Like drugs, drug law enforcement and cost effective. Yet the provision of NSP will always be with us. Just as we need and OST around the world is still very low. to reduce the harms from drugs, we also need to reduce the harms from drug law There is now strong evidence for Heroin enforcement. Assisted Treatment (HAT) for severely dependent users who have not benefited While it is difficult to identify benefits from previous multiple and diverse treat- from the criminalisation of drug use, it ment interventions. is not hard to identify severe and unintended negative consequences includA Swiss study (Nordt & Stohler 2006) ing extensive corruption among police found that substantial improvement of and other government officials. Even the drug treatment produces many worth- UNODC now accepts that the excessive while benefits for the community. The reliance on supply control in recent decestimated number of new heroin injectors ades has damaged public health. in Zurich declined 82% from 850 in 1990 to 150 in 2002. This was accompanied by Recently, interest has grown in the a considerable decline in the number of human rights costs of criminalising drugs. drug overdose deaths, HIV infections and Although human rights are beyond the crime. The quantity of heroin seized also scope of a chapter devoted to the pubdeclined, suggesting a shift from the black lic health costs of drug prohibition, these market for opioids to regulated forms of costs are also too important to ignore. supply. Even the UNODC has expressed concern about the damage to human rights of drug users from global drug prohibition Perspectives

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tion should encourage us to focus on reducing the harms associated with both drug use and policy responses to drug use. This can only be achieved if the Needle and Syringe Programmes have also dreadful mistake of criminalising drugs been shown to be effective, safe and cost is reversed. The options available vary effective. Yet the provision of NSP and OST for different drugs and, no doubt, different countries will consider different around the world is still very low. options to be in their own best interests. Under the current universal straitjacket, all countries have to have a one-size(UNODC 2012). The UN system was orig- fits-all response to drugs. This has made inally created to promote national secu- it difficult for countries to adopt harm rity, encourage economic development, reduction and resulted in the considerand protect human rights. These remain able costs to public health discussed in the highest objectives of the UN. The this chapter. Portugal, Switzerland and international drug treaties were a later the Netherlands have demonstrated the development, and drugs have never been health, social and economic benefits regarded as the same priority as the orig- of more liberal approaches, while the USA and Sweden exemplify the sizable inal objectives of the UN. costs of an approach reliant on drug law The objectives of drug policy should enforcement. ■ be to reduce deaths, disease, crime and corruption. Reducing drug consumption should not be the aim of drug policy but could be accepted as a means to reducing deaths, disease, crime and corruption, provided that reducing supply also reduces net harm. Harm reduc-

References ›› Bewley-Taylor DR 2001, The United States and international drug control, 1909-1997, Continuum, London. ›› Costa, Antonio Maria 2008, Making drug control ‘fit for purpose’: building on the UNGASS decade, Commission on Narcotic Drugs, Vienna, [online] Available at: http:// www.unodc.org/documents/commissions/ CND-Session51/CND-UNGASS-CRPs/ ECN72008CRP17E.pdf [30 August 2012]. ›› Degenhardt L, et al., 2004, 2003 Australian Bureau of Statistics data on accidental opioid induced deaths, National Drug and Alcohol Research Centre, Sydney, [online] Available at: http://ndarc.med.unsw.edu.au/sites/ndarc. cms.med.unsw.edu.au/files/ndarc/resources/ NIDIP%20Bulletin%20-%20Illicit%20drug%20 mortality%20trends%20(opiods%202003).pdf [30 August 2012]

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›› European Monitoring Centre for Drugs and Drug Addiction 2012, EMCDDA–Europol 2011 Annual Report on the implementation of Council Decision 2005/387/JHA, [online] Available at: http://www.emcdda.europa.eu/ publications/implementation-reports/2011 [30 August 2012]. ›› Hall et al., 1999, ‘Opioid overdose mortality in Australia, 1964-1997: birth-cohort trends’, The Medical Journal of Australia, vol. 171, no. 1, pp. 34-37. ›› International Centre for Science in Drug Policy 2010, Effect of drug law enforcement on drug-related violence: evidence from a scientific review, [online] Available at: http:// www.icsdp.org/docs/ICSDP-1%20-%20FINAL. pdf [30 August 2012]. ›› International Harm Reduction Association 2010, What is harm reduction?, [online] Available at: http://www.ihra.net/ files/2010/08/10/Briefing_What_is_HR_ English.pdf [30 August 2012]. ›› International Narcotics Control Board 2011, Report of the narcotics control board on the availability of internationally controlled drugs: ensuring adequate access for medical and scientific purposes, [online] Available at: https://incb.org/pdf/annual-report/2010/en/ supp/AR10_Supp_E.pdf [30 August 2012]. ›› Johnston L, et al., 2005, Monitoring the future: national survey results on drug use, 1975–2004 volume i secondary school students 2004, National Institute on Drug Abuse, Bethesda, Maryland [online] Available at: http://monitoringthefuture.org/pubs/ monographs/vol1_2004.pdf [30 August 2012] ›› Ki-Moon B 2012, Progress made in the implementation of the declaration of commitment on HIV/AIDS and the political declaration on HIV/AIDS, [online] Available at: http://data.unaids.org/pub/ Report/2009/20090616_sg_report_ga_ progress_en.pdf [30 August 2012]. ›› Mathers BM 2008, ‘Global epidemiology of injecting drug use and HIV among people who inject drugs: a systematic review’, The Lancet, vol. 372, no. 9651, pp. 1733 – 1745, [online] Available at: http://www.who.int/ hiv/topics/idu/LancetArticleIDUHIV.pdf [30 August 2012]. ›› McDonald D 2011, ‘Australian governments’ spending on preventing and responding to drug abuse should target the main sources of drug-related harm and the most costeffective interventions’ Drug and Alcohol Review , vol. 30, no. 1, pp. 96–100.

Perspectives

›› Moore TJ 2008, ‘The size and mix of government spending on illicit drug policy in Australia’ Drug and Alcohol Review , vol. 27 no. 4, pp. 404-413. ›› Postma M 2004, Public expenditure on drugs in the European Union 2000–2004. European Monitoring Centre for Drugs and Drug Addiction, [online] Available at: http://www. emcdda.europa.eu/html.cfm/index1357EN. html [30 August 2012]. ›› Nordt C & Stohler R 2006, ‘Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis’, The Lancet, vol. 367, no. 9525, pp.1830 – 1834. ›› Reuter P & Trautmann F (eds) 2009, A report on global illicit drugs markets 19982007, The European Commission, [online] Available at: http://ec.europa.eu/justice/antidrugs/files/report-drug-markets-short_en.pdf [30 August 2012]. ›› Rydell CP & Everingham SS 1994 Controlling cocaine: supply versus demand programs, Rand, Santa Monica. ›› Stafford J & Burns L 2011, Drug trends bulletin key findings from the 2011 IDRS: a survey of people who inject drugs, National Drug and Alcohol Research Centre, Sydney, [online] Available at: http://ndarc.med.unsw. edu.au/sites/ndarc.cms.med.unsw.edu.au/ files/ndarc/resources/IDRS%20October%20 bulletin%202011.pdf [30 August 2012]. ›› United Nations Office on Drugs and Crime (2010) World Drug Report 2010. [online] Available at: http://www.unodc.org/ documents/wdr/WDR_2010/World_Drug_ Report_2010_lo-res.pdf [30 August 2012]. ›› United Nations Office on Drugs and Crime 2012, UNODC and the promotion and Protection of human rights. [online] Available at: http://www.unodc.org/documents/justiceand-prison-reform/UNODC_HR_position_ paper.pdf [30 August 2012]. ›› Westermeyer J 1976, ‘The pro-heroin effects of anti-opium laws in Asia’, Archives of General Psychiatry, vol. 33, no. 9, pp.1135-1139.

Decriminalisation and legalisation Steve Rolles In response to critiques of current drug policy failings, a number of alternative approaches are being explored. Such reforms can generally be seen as moving away from the more punitive elements of the ‘war on drugs’ towards a more evidence-based approach rooted in public health and human rights principles. Revisiting and reforming outdated and ineffective legal frameworks forms a key part of this paradigm shift. Described below are two such reforms that are at the forefront of current debate.

Decriminalisation of drug possession for personal use It is possible, within the existing international legal framework, for a state or region to veer from criminal justice focused on drug control towards a less punitive and more pragmatic healthbased model. This approach has been adopted in different forms in a number of European countries such as the Netherlands, Switzerland (Csete 2011), Portugal (see below) and the Czech Republic. Key elements of such a shift generally involve: ›› A shift in the primary goal from reducing drug use to reducing drug related harm; ›› A decrease in the intensity of enforcement, particularly user level enforcement, in parallel with increased investment in public health measures; ›› Legal reforms such as decriminalisation (explored in more detail below) and other sentencing reforms such as abolition of mandatory minimums; ›› Institutional reforms, such as moving responsibility for drug policy decisions/

budgets from government departments responsible for criminal justice to those responsible for health, as has happened for example in Spain and Brazil. ‘Decriminalisation’ is not a strictly defined legal term, but its common usage in drug policy refers to the removal of criminal sanctions for possession of small quantities of currently illegal drugs for personal use, with optional use of civil or administrative sanctions. Under this decriminalisation definition, possession of drugs remains unlawful and a punishable offence, albeit no longer one that attracts a criminal record, but the term is often mistakenly understood to mean the complete removal or abolition of possession offences, or confused with more far-reaching legal regulations regarding drug production and availability (see

Steve Rolles is Senior Policy Analyst for Transform Drug Policy Foundation where he has worked since 1998. As well as publications in journals, periodicals and book chapters, Steve has been lead author on a range of Transform publications including 2009’s After the War on Drugs: Blueprint for Regulation. Steve has been a regular contributor to the public debate on drug policy and law, in print and broadcast media, as a speaker at UK and international conferences/events, and at various UN, UK government and Parliamentary Select Committee hearings and inquiries. Before Transform, Steve previously worked for the Medical Research Council and Oxfam, having studied Geography at Bristol University (BSc) and Development Studies at Manchester University (MA).

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below). The term ‘depenalisation’ is also sometimes used, but refers more generally to the reduction or elimination of punishments for an offence, rather than the removal of criminal sanctions. Decriminalisation as defined here is permitted within the legal framework of the UN drug conventions.

the more tolerant policies for cannabis possession (for example in Spain, the Netherlands and Belgium) people caught in possession under a decriminalisation model will usually have the drugs confiscated. Acknowledging this considerable variation in approach, around 25-30 countries, mostly in Europe, Latin America and Eurasia, have adopted some form of non-criminal disposal for the possession of small quantities of some or all drugs (Rosmarin and & Eastwood 2012).

Given the wide variation in these approaches and their implementation around the world, there are relatively few general conclusions that can be made about the impacts of decriminalisation beyond the observation that it does not lead to the explosion in use that many feared. While there are certainly impacts on levels of harms associated with use (see Wodak section above), and economic State regulation is not a solution to the wider impacts for enforcement and wider drug problem, only to the problems created by criminal justice expenditure, research from Europe (EMCDDA 2011), Australia prohibition and the war on drugs. (Hughes & Ritter 2008), the US (Single et al., 2000) and globally (Degenhardt et al., 2008) suggests that changes in intensity of punitive user-level enforcement have, It is difficult to generalise about decrim- at best, marginal impacts on overall inalisation because there are many var- prevalence of use. iations between countries, and often Decriminalisation can only aspire to between local government jurisdictions within countries. Significant variations reduce harms created by the criminaliexist in how measures are implemented sation of people who use drugs, and will - whether they are administered by crim- have only marginal impacts on harms inal justice or health professionals; how associated with the criminal trade or well they are supported by health ser- supply side drug enforcement. If inadvices; and the threshold quantities used equately devised or implemented - for to determine the user/supplier distinc- example if thresholds are set too low, or tion as well as the non-criminal sanctions police activity is poorly coordinated with adopted, with variations including fines, health services - decriminalisation will warnings, treatment referrals (sometimes have little impact, and even potentially mandatory), and confiscation of passports create new problems such as increasing the numbers coming into contact with the or driving licenses. criminal justice system. A distinction is also made between de The more critical factor appears to be jure decriminalisation (specific reforms to the legal framework), and de facto the degree to which decriminalisation is decriminalisation, with a similar outcome, part of a wider policy re-orientation and but achieved through non-enforcement resource reallocation away from harmful of criminal laws that technically remain punitive enforcement, and towards eviin force. With the exception of some of dence-based health interventions t argeting Steve Rolles Decriminalisation and legalisation

at-risk populations, particularly young Legalisation, regulation and control people and people who are dependent of drug production and supply or inject drugs. Decriminalisation can be seen as a part of a broader harm reduc- As the critiques of the prohibitionist tion approach, as well as a key to creating approach have gathered momentum, an enabling environment for other health the inevitable corollary debate around interventions. regulatory market alternatives to prohibition has moved to the fore. The core argument is a simple one: if prohibition is both ineffective and actively counterproductive, only retaking control of the market from criminal profiteers and bringing it within the ambit of the state can

The Portugal decriminalisation experience Portugal provides a useful case study, with over a decade of detailed evaluation to draw on since its 2001 decriminalisation. This was a policy developed and implemented in response to a perceived national drug problem with public health priorities to the fore from the outset. Portugal notably coupled its decriminalisation with a public health re-orientation that directed additional resources towards treatment and harm reduction (EMCDDA 2011). Those caught in possession are referred to a ‘dissuasion board’ that decides whether to take further action (the most common outcome), direct the individual to treatment services if a need is identified, or deploy an administrative fine. The Portugal experience has proven to be something of a flashpoint in the often highly charged debate around drug policy. The data collected during and since the reform has provided considerable scope for filtering through different political and ideological lenses with opinions ranging from it being a ‘resounding success’, to an ‘unmitigated disaster’ (Hughes & Stevens 2010). A more objective academic study from 2008 (Hughes & Stevens 2010) usefully summarises the changes observed since decriminalisation: ›› Small increases in reported illicit drug use among adults ›› Reduced illicit drug use among problematic drug users and adolescents, at least since 2003 ›› Reduced burden of drug offenders on the criminal justice system ›› Increased uptake of drug treatment ›› Reduction in opiate-related deaths and Perspectives

infectious diseases ›› Increases in the amounts of drugs seized by the

authorities ›› Reductions in the retail prices of drugs

In conclusion, the authors note: “[The Portugal experience] disconﬁrms the hypothesis that decriminalisation necessarily leads to increases in the most harmful forms of drug use. While small increases in drug use were reported by Portuguese adults, the regional context of this trend suggests that they were not produced solely by the 2001 decriminalisation. We would argue that they are less important than the major reductions seen in opiate-related deaths and infections, as well as reductions in young people’s drug use. The Portuguese evidence suggests that combining the removal of criminal penalties with the use of alternative therapeutic responses to dependent drug users offers several advantages. It can reduce the burden of drug law enforcement on the criminal justice system, while also reducing problematic drug use.” Supporting these conclusions has been the more recent European Monitoring Centre on Drugs and Drug Addiction “Drug Policy Profile of Portugal” (EMCDDA 2011), which observed that: “While some want to see the Portuguese model as a first step towards the legalisation of drug use and others consider it as the new flagship of harm reduction, the model might in fact be best described as being a public health policy founded on values such as humanism, pragmatism and participation.”

is none, with a clearly defined role for enforcement agencies in managing any newly established regulatory models. Legalisation is only a process; the goal is effective market regulation and reduced harms associated with production supply and use.

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reduce the many costs associated with illegal trade. This suggestion is premised on the idea of market control rather than market eradication, with proposals generally involving the introduction of strictly enforced regulatory models. This is in contrast to some popular misconceptions that such reform implies relaxing control or liberalising markets. In fact, it involves rolling out state control into a market sphere where currently there

Five proposed models for regulating drug availability Medical prescription model, or supervised venues for the highest risk drugs such as intravenous drugs, including heroin, and more potent stimulants such as methamphetamine. Specialist pharmacist retail model combined with named/licensed user access and rationing of volume of sales for moderate-risk drugs such as amphetamine, powder cocaine, and MDMA/ ecstasy. Licensed retailing, including tiers of regulation appropriate to product risk and local needs. This could be used for lower-risk drugs and preparations such as lower-strength stimulant-based drinks. Licensed premises for sale and consumption similar to licensed alcohol venues and Dutch cannabis coffee shops - these could potentially also be for smoking opium or drinking poppy tea. Unlicensed sales - minimal regulation for the least-risky products, such as caffeine drinks and coca tea. Steve Rolles Decriminalisation and legalisation

Advocates are clear that regulated markets cannot tackle the underlying drivers of drug dependence such as poverty and inequality. State regulation is not a solution to the wider drug problem, only to the problems created by prohibition and the war on drugs. It is argued, however, that by promoting evidence-based regulatory models based upon a clear and comprehensive set of policy principles, and by freeing up resources for evidence-based public health and social policy, legal regulation would create a more conducive environment for improved drug policy outcomes in the longer term. Moves towards market regulation are seen by its advocates as the logical end to criticism of the prohibition-based approach and a continuation of the pragmatic reforms this has already led to, including decriminalisation. But options for legal market regulation differ from other reforms in that they cannot be easily adopted unilaterally, as technically they remain strictly forbidden under the legal framework of the UN drug conventions. For any state to experiment with regulation models requires the conventions to be negotiated, a process fraught with practical and political challenges (Rolles 2009; Bewley-Taylor 2012; Bewley-Taylor & Jelsma 2011). The last decade has seen the emergence of the first detailed proposals offering different options for controls over drug products (dose, preparation, price, and packaging), vendors (licensing, vetting and training, marketing and promotions), outlets (location, outlet density, appearance), who has access (age controls, licensed buyers, club membership schemes) and where and when drugs can be consumed (KCBA 2005; HOC, 2011; Rolles 2009).

Transform Drug Policy Foundation’s reduce its scale through demand reduc2009 report “After the War on Drugs: tion, legal regulation presents the prosBlueprint for Regulation” (Ibid), explores pect of a long-term and dramatic reducoptions for regulating different drugs tion in the scale of criminal market related among different populations, and pro- harms, with positive impacts for consumer poses five basic regulatory models for and production/transit countries. discussion (see box). Lessons are drawn The ability and likelihood of states from successes and failings with alcohol and tobacco regulations in various coun- committing human rights abuses in the tries (note for example the UN Framework name of drug control would diminish draConvention on Tobacco Control), as well matically, as would harms related to the as controls over medical drugs and other consumption of unregulated products of harmful products and activities that are unknown content. In place of the opportunity, costs of enforcement would simply regulated by governments. Regulation advocates note how many of be opportunities; reallocating billions into the same drugs prohibited for non-med- a range of health and social interventions, ical use are legally produced and sup- with positive impacts that reach beyond plied for medical uses, including heroin, the confines of drug policy. The costs of cocaine, amphetamines and cannabis. developing and implementing a new regThe UN Drug Conventions provide the ulatory infrastructure would probably legal framework for both of these paral- represent only a fraction of the ever-inlel systems, the starkly contrasting levels creasing resources currently directed into of harms associated with them providing efforts to control supply and demand. the arguments for reform. Risks of unintended negative conseThe example of heroin is a useful illus- quences exist for any policy change, and tration. Widely regarded as one of the advocates of legal regulation argue that most risky and problematic of all drugs, change in this direction would need to we can compare criminal and regulated be phased in cautiously over a period of models for production and use as they years, with close evaluation and monicurrently exist in parallel. Not only does toring of the effects of the system. Key the user of prescribed heroin (for exam- risks include the potential displacement ple using a Swiss heroin clinic) eliminate of criminal activity into other areas, and the risks of unsafe environments, con- an increase in use associated with inadtaminated illicit products and HIV trans- equately regulated commercialisation. mission via needle sharing, it can also be Improved understanding of how social noted that half of the world’s opium pro- costs are influenced by the legal and duction is already legally regulated for policy environment, assisted by the use medical use and is not associated with of impact assessments, modelling and any of the crime, conflict, or develop- scenario planning, can help develop polment costs of the parallel illegal market icy models that mitigate such risks, for example by restricting commercial presfor non-medical use. sures and profit motivations in the market The primary outcome of moves towards through advertising and marketing conmarket regulation is the progressive trols, or state monopolies. ■ decrease in costs related to the criminal market as it contracts in size (Rolles et al., 2012). These impacts have the potential to go beyond those possible from reforms within a blanket prohibitionist framework such as decriminalisation which impact mostly on demand side issues. Rather than merely managing the harms of the illegal trade, or attempting to marginally Perspectives

References ›› Bewley-Taylor D & Jelsma, M 2011, Fifty

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years of the 1961 single convention on narcotic drugs: a reinterpretation Transnational Institute, Amsterdam [online] Available at: http://www.tni.org/sites/www.tni. org/files/download/dlr12.pdf [30 August 2012]. ›› Bewley-Taylor D 2012 Towards revision of the UN drug control conventions: the logic and dilemmas of like-minded groups Transnational Institute, United Kingdom [online] Available at: http://www.tni.org/ sites/www.tni.org/files/download/dlr19.pdf [30 August 2012] ›› Csete J 2010, From the mountaintops: what the world can learn from drug policy change in Switzerland, Open Society Foundations, New York [online] Available at: http:// www.soros.org/sites/default/files/from-themountaintops-english-20110524_0.pdf [30 August 2012]. ›› Degenhardt L, et al., 2008, ‘Toward a Global View of Alcohol, Tobacco, Cannabis, and Cocaine Use: Findings from the WHO World Mental Health Surveys’ PLos Medicine, vol. 5, no. 7, http://www.plosmedicine.org/article/ info:doi/10.1371/journal.pmed.0050141 [30 August 2012]. ›› The European Monitoring Centre for Drugs and Drug Addiction 2011, Annual report 2011: Looking for a relationship between penalties and cannabis [online] Available at: http://www.emcdda.europa.eu/online/annualreport/2011/boxes/p45 [30 August 2012]. ›› The European Monitoring Centre for Drugs and Drug Addiction 2011, Drug policy profiles – Portugal [online] Available at: http://www. emcdda.europa.eu/publications/drug-policyprofiles/portugal [30 August 2012]. ›› The Health Officers Council of British Columbia 2011, Public health perspectives for regulating psychoactive substances: what we can do about alcohol, tobacco, and other drugs [online] Available at: http://drugpolicy. ca/wp-content/uploads/2011/12/Regulatedmodels-Final-Nov-2011.pdf [30 August 2012]. ›› Hughes C & Ritter A 2008, A summary of diversion programs for drug and drug related offenders in Australia, DPMP monograph series, National Drug and Alcohol Research Centre Sydney [online] Available at: http:// www.dpmp.unsw.edu.au/DPMPWeb. nsf/resources/Monograph+16.pdf/$file/ DPMP+MONO+16.pdf [30 August 2012].

Steve Rolles Decriminalisation and legalisation

›› Hughes C & Stevens A 2010, ‘What can we learn from the Portuguese decriminalization of illicit drugs’, British Journal of Criminology, vol. 50, no. 6, pp.999-1022. ›› King County Bar Association 2005, Effective drug control: toward A new legal framework state-level regulation as a workable alternative to the “war on drugs” [online] Available at: http://www.kcba.org/druglaw/pdf/ EffectiveDrugControl.pdf [30 August 2012]. ›› Rolles S 2009, After the war on drugs: blueprint for regulation, Transform Drug Policy Foundation, Bristol [online] Available at: http://www.countthecosts.org/sites/default/files/ Blueprint_for_Regulation.pdf [30 August 2012]. ›› Rolles S, et al., 2009, After the war on drugs: options for control, Transform Drug Policy Foundation, Bristol [online] Available at: http://www.tdpf.org.uk/Transform_After_the_ War_on_Drugs.pdf [30 August 2012]. ›› Rolles S, et al., 2012, The alternative world drug report: counting the costs of the war on drugs [online] Available at: http://www. countthecosts.org/sites/default/files/AWDR.pdf [30 August 2012]. ›› Rosmarin A & Eastwood N 2012, A quiet revolution: drug decriminalisation policies in practice across the globe, Release, London [online] Available at: http://www.release.org. uk/downloads/publications/release-quietrevolution-drug-decriminalisation-policies. pdf [30 August 2012]. ›› Single et al., 2000, ‘The impact of cannabis decriminalisation in Australia and the United States’, Journal of Public Health Policy, vol. 21, no. 2, pp.157-186. ›› Stevens A & Hughes C 2012, ‘A resounding success or a disastrous failure: re-examining the interpretation of evidence on the Portuguese decriminalisation of illicit drugs’, Drug and Alcohol Review, vol. 31, no. 1, pp.101-113.

Table of illustrations

126 127

Opium den, French magazine Petit Journal, 1903, Paris.

French magazine Police, 1938. Cover page: “War against narcotics. Read this sensational report on pages 8, 9 and 10”.

Cough remedies, unknown, France.

Examples of syringes dating from between 1840 and 1870.

Cover illustration for Les paradis artificiels, collection of poems from French author Charles Baudelaire, Nilsson Paris, 1932. Cover illustration for La morphine, Victorien du Saussay novel, Albert Méricant, 1906, France: “Morphine. The vices and passions of morphine addicts”. French magazine L’Assiette au Beurre, 1905. Cover page.

54 61 69

French magazine Détective, 1929. Cover page: “The drug that kills. To understand the problems police forces in every country face in trying to eliminate this scourge, you have to know the devious and audacious methods employed by drug dealers. Read our revelations on pages 3 and 4”.

Dangerous passion, Studio Manassé, 1920, France.

Advertisements from the USA for products to cure opium and morphine addiction, 1896.

Public auction poster for 200 kilos of heroin hydrochloride, 1930, Paris: “Liberty, Equality, Fraternity - Republic of France. […] Public Auction of Seized Goods, Wednesday 17 December 1930. […] 200 Kilos Heroin Hydrochloride - 1 Knotted Carpet - 1 Automatic pistol - 4 Trunks”.

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Advertisement for a cough syrup medication, 1905, New York.

119

Opium warehouse in India in 1882.

126

Advertisement for perfume ‘Folie d’opium’ France, 1911.

Director of publication Dr Thierry Brigaud Edited by Céline Debaulieu, Niklas Luhmann & Olivier Maguet Editorial board Céline Debaulieu, Anne Landaës, Niklas Luhmann Marie Lussier, Olivier Maguet & Maria Melchior Translation Fanny Bourgeois & Anne Withers Iconography Jimmy Kempfer Graphic design Christophe Le Drean • rouge-rose.net Printing Centr’Imprim Printed in France in May 2013 Copyright © 2013 by Médecins du Monde ISBN 9782918362616

This book has been made thanks to the financial support of the French Agency for Development (AFD). The ideas and opinions here presented are Médecins du Monde’s and do not necessarily correspond to those of the AFD’s