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Drugs: time to fight for health

Aligning drug policies with public health policies

We often hear about the ‘war on drugs’, but it is a fight that international drug enforcement is failing to win. This ailing prohibitionist approach costs tens of billions of euros in global diplomatic relations plus vast health and social costs, including thousands of deaths and millions of infections. And the root cause? Poor policy. Drug use and possession remain a criminal–often capital–offence in over 150 countries worldwide. Around 1,000 people are executed each year. This criminalisation has affected millions of lives, fuelled HIV and hepatitis C epidemics, fed human rights abuses across the globe and subverted the rule of law. So what needs to be done?

Lessons from Central and Eastern Europe

Speaking at a EuroScience conference ESOF2014 in Copenhagen, Georgian Minister of Corrections, Archil Talakvadze, put it thus: “Expecting to solve public health problems by enforcement-led policies can lead to a downward spiral of increased harm and ultimately death.” Until 2012, Georgia had one of the highest drug incarceration rates in the world. But in prison thousands became addicted to sedatives, psychotropic drugs or more damaging substances. Hepatitis C spread to 42% of all prisoners. Families broke up and lost all their personal wealth in fines and bail. Today, Georgia embraces harm reduction science. In just a few years Talakvadze has cut the prison population by 60%. Prisoners have universal access to counselling, testing and treatment of HIV and HCV infections.

At the same conference, Andrey Klepikov, executive director of the HIV/Aids Alliance in Ukraine, argued that the Russian government ideologically opposes any form of state intervention because addiction is too profitable. The Ukraine’s methadone programme caused an estimated loss of $31 (€27) million for illegal drugs traders in 2013. When Russia annexed Crimea around 800 patients were cut from methadone treatment, with dozens subsequently dying.

The evidence is conclusive. When countries align their drug policies to public health drug abuse falls. In Western Europe, for example, HIV/AIDS among people who inject drugs is under control. But in countries with harsh penalties, the epidemic continues to expand. This is predominantly the case in Eastern Europe–including many new EU member states–and Central Asia. In fact, Eastern Europe, not Africa, now has the highest HIV growth rates in the world.

HIV spreading East

There are several reasons for the high incidence and prevalence of HIV in Eastern Europe and Asia. First, is the lack of needle exchange. Needle exchange programmes are core to the package of interventions identified by the WHO, UNAIDS and the UN Office on Drugs and Crime, UNODC, to prevent HIV infection among people who inject drugs. In combination with antiretroviral treatment, needle exchanges reduce HIV transmission, decrease mortality, and reduce drug dependency, crime and public disorder. They improve quality of life.

Put simply, health-based drug policies start with harm reduction. In the face of the scientific evidence and contrary to international drug control conventions, substitutive opioid therapy remains illegal in the Russian Federation. Meanwhile, access to needle exchange programmes are being restricted in the USA. Sadly, needle exchange and substitutive opioid therapies remain the exception rather than the rule, globally.

Over-zealous law enforcement does not help either. When the police make arrests for syringe possession or put needle exchange programmes under surveillance, they simply drive drug users underground to inject in unsafe, unhygienic conditions.

What is more, under prohibitive enforcement regimes, drug production and clandestine sales are in the hands of criminals. The purity and potency of products is unregulated and unknown. Dodgy drugs are potentially dangerous, perhaps life threatening.

Finally, prisons are not drug-free so mass incarceration is bound to fail. But most prisons, even in several countries with health-focused drug policies, would never dream of needle exchange programmes or substitutive opioid therapies. In Western Europe, needle exchange is only available in Spain, Switzerland and in one women’s prison in Germany.

Human rights and wrong

Let us not pull any punches: restrictive policies increase the risk of death. Around 20,000 people die from overdose in the USA and more in the Russian Federation. In Georgia, citizens witnessing a possible overdose were required, by law, to call the police before an ambulance. And Naloxone, the drug that can immediately stop the effects of overdose and save lives, is far from universally available. Is “let them die” the easier option?

Punitive drug policies are severely undermining human rights in every region of the world. But there is a clear gap between countries with predominantly health-focused drug policies and those taking a prohibitionist approach.

Repressive laws have led to a dramatic increase in the number of people in detention, in prisons, as pre-trial detainees, or people held in administrative detention. In the USA, where ethnic minorities are much more likely to be incarcerated for drug offences than whites, prison has been identified as a key factor for the markedly elevated HIV infection rates among African Americans.

Some countries maintain compulsory drug detention programmes where evidence-based treatment of addiction is absent. In China and South East Asia, an estimated 235,000 people are held in such centres. And let’s not forget those 1,000 people executed each year for drug offences around the globe.

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Levels of social violence are also noticeably different between countries. Countries fighting the ‘war on drugs’ in Latin and Central America have seen a major wave of violence, corruption and instability. At least 60,000 violent deaths are estimated to have occurred in Mexico, for example, in the last 10 years since the war on drugs was scaled up.

In all these ways the gap continues to widen as ideology gets in the way of rational policy-making. Now, as the world prepares for a special session of the UN General Assembly on drugs in 2016, it is time that the consequences of criminalising drugs are acknowledged by the international community. And it is also time for the international community embrace policies that decriminalise drug use and possession.

Michel Kazatchkine

Michel is UN Secretary-General Ban-ki Moon’s special envoy on HIV/AIDS to Eastern Europe and Central Asia. He is a member of the Global Commission on Drug Policy and former executive director of The Global Fund to fight AIDS, Tuberculosis & Malaria.

This article is the edited version of a piece that was first published in Science in the Public interest vol. 3: Addictions: Ethics,Integrity and the Policy-Maker, published by SciCom– Making Sense of Science.

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