Mahreb
AIDS and drug addiction a delicate subject
by Sandrine Musso
ethnologist

Few data are available on addictive practices in the North African countries. Most of the material collected on this topic so far has not been published, apart from one study (1). Drug abuse seems to be increasing steadily, however, and the AIDS epidemic is sometimes more closely correlated with this habit than it may seem to be.

Reducing drugs and drug dealing has been one of the main themes in the public health campaign which has been carried out in Morocco since the 90s.

Patterns of morbidity have changed conspicuously in the Maghreb societies during the last two decades. In addition to the persistent transmissible diseases (syphilis ravaged these countries at the beginning of the 20th. Century), diseases originally associated with the so-called "industrialised countries" have become increasingly frequent, due to poor hygiene and the wretched housing conditions generated by large-scale urban development (the French word for slums, "bidonville" was invented in Casablanca),

Despite these developments this is a period of economic crisis, and these States are still not giving priority to subsidising public health. Health accounted, for example, for only 2.4% of the whole Budget of the Moroccan State in 1990 (2). As in Tunisia, approximately 30% of the country's health expenditure is covered in Morocco by assistance from outside the country (no figures are available on Algeria in this respect). In the fields of drug and AIDS prevention, outside assistance and NGOs have played a leading role for two main reasons.
The first reason has been expressed as follows: "in the present predominantly free enterprise based economic context, in which State prerogatives tend to be regarded as relatively unimportant and 'civil societies' tend to be promoted (...), AIDS has become an important component of the 'financial markets' on which NGOs and associations are subsidised" (3).
The second reason is that apart from the use of medico-technical strategies (providing medical care for people with AIDS with the help of the ITSF (4), setting up initiatives to make blood transfusion safe, etc.), it is often difficult to introduce preventive measures into the field of "illicit sex" because of the strict morality being instigated by the Islamic extremists (5).

It is worth noting, however, that in Morocco at least, the prevention of drug abuse and drug dealing is one of the main themes in the campaign to make Morocco a more healthy country which has been carried out since the 90's (6).
Here it is proposed to focus mainly on Morocco, which is the only one of the three Maghreb countries where it is possible to observe "the existence of some political good will" (7), although the results may not have been entirely in keeping with the objectives announced.

AN ORIGINAL INITIATIVE
the experience of the Nassim association

The Nassim association for the prevention of drug addiction was created in 1997 under the aegis of a psychiatrist who was working on the national programme to control drug addiction, Professeur Driss Moussaoui.
Since the injection mode was thought to constitute only "a minor problem in Morocco", the association focused its activities mainly on reducing alcoholism, the use of psychotropic drugs and that of hashish: The association also informs members of the health professions and general practitioners about the way these molecules work, and even about "the relevance of their use in the treatment of some mental pathologies", although these questions have not yet been completely elucidated.
The association publishes a journal and organises an anti-drug abuse day every year in Casablanca. Another of the association's objectives is to carry out prevalence* studies at educational establishments.
The association takes part in radio broadcasts, and carries out radio campaigns based on interviews with real-life witnesses.
Another original initiative was set up in the framework of a partnership with the CTM (the Moroccan Transport Company). This project consisted of displaying audio-visual messages about the prevention of drug addiction and the associated risks in the Company's 400 buses, each of which has a capacity of 40 seats and makes 10 round trips a day.

Tunisia has the highest rates of AIDS among the drug injecters.

The first cases of AIDS to occur in the Arabspeaking world were due to blood transfusion. People soon began to talk about "contaminated imported blood". The fact that the disease was transmitted mainly via what were thought of as "Western" practices (homosexuality and drug injection) gave rise to the idea that "AIDS was a Western or possibly black African disease from which Arab societies were immune on the whole" (8).
The impression that AIDS was an imported epidemic persisted up to the beginning of the 90's throughout the Arab-speaking world. It was one of the stereotyped ways in which the disease was viewed everywhere, as confirmed by the authors of all the studies carried out in some very different places: "in parallel with these local images corresponding to the threatening outsider, the disease was referred to nearly everywhere in terms of Western customs, the perversity of the latter, and what one might call their high degree of contagiousness" (9).
The highest rate of AIDS infection occurring in the context of drug injection was recorded in Tunisia in 1993, where these cases amounted to almost 37% of all the officially recorded cases of AIDS.

Although the prevalence of AIDS seems to be fairly low on the whole, judging from the epidemiological data available, the epidemiological pattern has changed completely during the last decade. After being mainly due to the injection of drugs and homosexuality, AIDS began to be mainly transmitted during heterosexual practices. One of the only surveys available on this point was carried out by the Meknès Aids Prevention Committe (ALCS) in the towns of Casablanca, Tangiers and Tétouan. Although the authors stressed that it was difficult to obtain information from the "hidden" populations involved, the results confirmed that drug injection was quite a rare occurrence: in Casablanca, this practice was restricted to the more wealthy social circles; only 10% of the drug abusers questioned in the `` north of the country were injecters, and most of them had previously lived in Europe (10). The great mobility of the drug users is in fact the reason why some observers have stated that drug injection is on the increase (11).

Only 10% of all the drug abusers questioned were injecters, and most of the injecters had previously lived in Europe.

Heroin* and cocaine* are both being used in all three towns, however. The locally grown brown heroin (12) sold for 30 to 60 dirhams is cut and wrapped in 1/20-gramme packets and goes under the name of "papelita". The main mode of consumption involves the "plata" technique, which is known as "chasing the dragon" in Europe: this consists of inhaling the substance after heating it on a piece of aluminium foil.

Cocaine seems to be consumed more occasionally (since it is relatively rare and expensive), and this substance is usually sniffed. However, a large proportion of the cocaine users (40%) said that they smoked the drug. The method used here is similar to that used to consume "crack", and those responsible for preventive efforts are therefore afraid that the use of cocaine may be likely to spread. Apart from heroin and cocaine, the drug addicts mainly take pharmaceutical drugs. The main products used are Rohypnol®, and other members of the benzodiazepine family. Since these substances are often absorbed along with alcohol or hashish, multi-drug addiction is tending to become a worrying problem in Morocco, as in many European countries.

A national drug control programme has been set up in Morocco, in which all the sectors in the country are expected to participate (educational, youth and sports organisations, social services, aid programmes, members of the health professions, etc.). Observers have noted, however, that little has been done by way of nation-wide campaigns to inform professional public health and social workers about this initiative (13), and the "lack of involvement of civil society and the NGOs" has been deplored (14).

Harm reduction is non-existent in this country, apart from the Moroccan AIDS Control Association (ALCS), especially the Tangiers branch, where drug abusers have been trained to inform their peers and to distribute sterile syringes.

The therapeutic scene, like that in France towards the end of the 80's, has only abstinence to propose. There are no substitutive policies, and this can have particularly regrettable effects in the case of Moroccan subjects who have started to undergo drug substitute treatment in Europe but have been expelled and forced to return to their own country.

Projects have been developed, however, with European NGOs to set up health care centres involving various levels of financial coverage. The Ministry of Health proposed to open a rehabilitation centre for drug addicts in Tangiers in collaboration with SOS Drug International. ALCS also drew up a project on similar lines with a Belgian NGO with a view to housing and treating AIDS patients in Tangiers. Neither of these initiatives has materialised, however. Although both primary and secondary prevention have made great strides during the last decade, it is true to say that tertiary prevention and the level of general awareness of the problem and its implications still leave much to be desired.

1 Toufik (A.), °Pratiques et mobilité des usagers de drogue: de la dynamique du risque à celle de la prevention, in Journal du sida" Special issue on the Arab World and migrants, December 96-January 97

2 This information was based on the book edited by Kaddar (M.), "Systèmes el politiques de same au Maghreb", CIE, 1994

3 Fay (C.), "Risques, enjeux et partenaires de la lutte contre le sida", in Le sida des autres, Autrepart, cahiers de I'IRD, Editions do I'Aube, 1999

4 An international therapeutic solidarity fund, which has given Morocco access since 1998 to a triple drug therapy for treating patients with the disease, with the participation of the Ministry of Health.

5 Cf Lamchichi (A.), "Le Maghreb face 'I Fislamisme", L'Harmattan, 1997

6 Vairel (F.), "Unc histoirc sans morale? Remarques à propos du cas Benabderrazik", in Monde arabc. Maghreb/Machrek, n°167, JanMarch 2000

7 DrToufiq (J.), Peddro Grant Report, 1998

8 Huxley (C.), Arab governments wake up to Aids threat, Midle East Report, November-December 1989

9 lbid

10 This was stated explicitly by Professor Youssef Mehdi, head of the National AIDS control Committee in Algeria. Quoted by Brunet (C.), ibid

11 Leborgne (D.), Bakraoui (A.), Recherche-action prevention sida/ toxicomanie, 1995

12 Toufik (A.), °Pratiques et mobilité des usagers de drogues: de la dynamique du risque à celle do la prevention", Journal du sida, the above issue

Source: PEDDRO december 2001