Inspiring speech of the head of the International AIDS Society at the International Harm Reduction Conference in Bangkok. Raminta

 

Raminta Stuikyte

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NGO in Special Status with Economic and Social Council of the United Nations (ECOSOC)

 

From: This e-mail address is being protected from spambots. You need JavaScript enabled to view it [mailto: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ] On Behalf Of Ron MacInnis
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Subject: ITPC Closing Keynote Address at the International Harm Reduction Conference in Bangkok - Reflections on the Politics of Harm Reduction and the Global Response to HIV [1 Attachment]

 

[Attachment(s) from Ron MacInnis included below]



Reflections on the Politics of Harm Reduction and the Global Response to HIV

Closing Keynote Address

International Harm Reduction Conference (Harm Reduction 2009)

Bangkok, Thailand

23 April 2009

Craig McClure

Executive Director, International AIDS Society

Embargoed until 3pm (Bangkok) 23 April 2009

 

Sawa dee Kap. Good afternoon.

Distinguished, compassionate and determined fellow harm reduction advocates.

Let me first thank the organizers, and Professor Gerry Stimson in particular, for providing me the opportunity to make some reflections on the politics of harm reduction and the global response to HIV.

Five years ago this week I became the Executive Director of the International AIDS Society. It was just three months before the International AIDS Conference in Bangkok, and the IAS was about to relocate to Geneva and restructure its operations, staff and strategic vision. Needless to say, things were somewhat of a mess, and believe me, I was terrified, despite having worked in HIV for close to 15 years at the time.

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On July 11, the conference opened in Bangkok, the first time the meeting had ever been held in South-East Asia. Close to 30,000 people had registered, and, as the Asian bird flu epidemic had only recently been contained, I sighed with relief that the conference was not cancelled. I’m sure Gerry can relate that feeling to this week’s conference! Though bird flu was under control, the war against drug users in Thailand was not. It was estimated that thousands had been killed as part of then-Prime Minister Thaksin Shinawatra’s attempts to rid the country of drugs. The dead were mostly individual drug users and small-time dealers, certainly not the powerful mafia that control the production and distribution of illegal drugs in Thailand. They remained of course untouched.

At the opening session, Prime Minister Thaksin, former-UN Secretary General Kofi Annan, and, who could forget, Miss Universe, made strong commitments to the fight against AIDS. Dignitaries and celebrities were falling over themselves to say how much they cared.

And then it was time for the substantive part of the opening session – a global overview of HIV epidemiology and the current response, and a passionate call for humanity and harm reduction by one of Thailand’s bravest and strongest HIV-positive drug user activists Paisan Suwannawong. Paisan, if you are in the room today, I pay tribute to you. Inexplicably, the dignitaries, led by Prime Minister Thaksin, ceremoniously filed out of the stadium before the substantive discussions began. Paisan was left on the stage with a dwindling audience that, having seen all the dignitaries leave, thought the opening was over, and emptied the hall.

Needless to say, there was an outcry. Behind the scenes over the following days were angry meetings between the IAS and community leaders, and difficult meetings between the IAS and Thai government representatives. I realized that the IAS had made

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a mistake in allowing Paisan’s talk to be scheduled at the end of the programme, even though we did not know that the Prime Minister would leave early. I learned that it was not considered appropriate for a Thai Prime Minister to listen to a drug user. I learned a lot of things that week.

In the end, Paisan was given the opportunity to speak again, this time at the Closing Session, but the damage was done.

One of the many things I learned from that experience, that has been compounded over the past five years in the work I have done related to drug use, harm reduction and HIV, is the enormous fear that underpins the world’s approach to drugs, drug use and people who use drugs.

At the end of this year I will be leaving the IAS, after six IAS conferences and some dramatic progress in the response to HIV. I’d like to offer three observations I have made related to the response to HIV as it relates to drug use and harm reduction.

All three are about fear.

The Person Who Uses Drugs as “Other”

My first observation is how all of us continue to talk about people who use drugs as “other”. We use terms like “drug abuser”, “drug user” and even “person who uses drugs” as if some of us do not use drugs. But which one of us does not use a drug that alters our mood, our consciousness of pain, our physical or emotional state? A joint, a dab of speed, a line of coke, a tab of ecstasy, a shot of heroin. Even the last three Presidents of the United States between them have admitted using some of these. A pint of beer, a glass of wine, a shot of whisky. A cigarette. A cup of coffee or tea. A pain relieving medication, an anti-depressant, a valium, a sleeping pill.

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We are all people who use drugs. Our refusal to acknowledge this is all about our fear that “we” might become, or be seen as, one of “them”.

Throughout history human beings have been people who use drugs. We will always be people who use drugs. As human beings we strive to develop the knowledge and technologies to control our environment and to manage our circumstances. The drug user, the person who uses drugs, is not the “other”. She or he is you and me.

It seems to me that what we really need to focus on is the difference between drug use and drug addiction or dependency. Global drug policy continues to focus efforts primarily on the substances alone. This is wrong.

Of course, the harms associated with some drugs are worse than others. Sometimes these are due to the degree of addictiveness of a particular drug. But most of the harms are due to the way that a particular drug is acquired (for example in a dark back alley versus from a pharmacy) the way in which it is used (as a pill, for example, versus smoking, snorting or injecting), and, even more importantly, the way in which society treats people who use drugs. The vast majority of the horrific harms associated with drug use – crime, HIV and other infections, violence, incarceration, death – are clearly fuelled by the drug policies our governments pursue. It doesn’t take a rocket scientist to show that criminalizing drugs and drug use leads to a dramatic increase in drug-related crime, and that controlling and regulating the production and distribution of all drugs would go a long way towards reducing that crime.

If we are all people who use drugs then the critical questions seem to me to be:

Why is it that some people who use drugs go on to have problematic drug use?;

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How we can prevent that from happening?;

How we can help those that already have dependence problems?

and How can we change the social and economic conditions that drive many people into drug dependence?

The reasons for drug use per se seem at least fairly well-characterized. We use drugs out of curiosity, to feel good, to feel better, to do better, or to manage physical, emotional or psychological pain. One might add to dance better, to have sex better, to relax more, to switch off, to switch on or to escape from the misery of social and economic deprivation. As to why some people go on to become drug dependent, the answers are less clear. There is some evidence, though still weak, that genetic factors, including the effects of our environment on gene expression and function, may contribute to vulnerability. People with mental health problems are at greater risk for drug dependency. This is not surprising, considering the generally pathetic state of mental health services around the world that drive people to self-medicate, and the neglect of the poor and the marginalized. How and why some people become drug dependent and not others and how we can prevent drug dependency is an area that still requires much research. But no reason should be used to blame or belittle anyone who is drug-dependent.

So long as we continue to define the drug user as “other” and define the drug itself as the problem we will be trapped in our misguided and harm-inducing programmes and policies.

The Wilful Denial of Evidence and the Abuse of Medical Authority

My second observation relates to the wilful denial of evidence by policy makers throughout the world and the abuse of power by some members of the medical profession who support this denial.

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The most obvious example of wilful denial of evidence is of course the fact that methadone remains illegal in Russia, thereby preventing the introduction of substitution therapy for people dependent on opioid drugs. The International AIDS Society has made the issue of access to methadone in Russia and throughout Eastern Europe and Central Asia a policy priority. Across the region, over 3.7 million people inject drugs, with over two million people injecting in Russia alone, the highest per capita in the world, with four times the overall global prevalence of injecting drug use. Close to 70% of all HIV infections in Russia are linked to injecting drug use, versus 30% globally outside of sub-Saharan Africa.

We all know that there are decades and decades of research showing that opioid substitution therapy is the most effective intervention to reduce injecting and prevent HV infection among people dependent on opioids, particularly if delivered as part of a comprehensive package of harm reduction interventions, including education and counseling, needle and syringe exchange programmes, provision of condoms, HIV diagnosis and treatment and TB and STI diagnosis and treatment.

But in Russia methadone remains illegal, and the Russian government maintains that there is no evidence that it works to prevent HIV infection or reduce the harms associated with injecting opioids. This denial of evidence is so profound that the government even dares to boldly distort the facts in international fora, such as at the high level meeting of the Commission on Narcotic Drugs in Vienna last month.

This kind of blatant and wilful denial of the evidence can only be based on deep-seated fear. Remember, this is a society steeped in denial due to fear. For decades the horrors of Stalin’s regime were denied by not only the Russian government but ordinary Russian

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citizens, until long after the death of Stalin, and despite the disappearance of tens of millions of people.

But this kind of denial of the evidence is by no means limited to Russia. Even in my own home country of Canada, a supposed bastion of democracy and human rights, there is a concerted and organized state-supported campaign to deny evidence related to harm reduction. For a number of years now a number of studies in the Downtown Eastside of Vancouver have struggled against the odds to scientifically determine the impacts of a number of harm reduction interventions, including a supervised injection site and heroin maintenance therapy. These studies have been dogged by government interference since their inception, including unwarranted attempts to shut trials down, spending of public funds on harm reduction-denialist organizations to write negatively about the trials, misrepresentation of the evidence of the studies’ results, and interference in the peer review process.

Fear drives the global war on drugs. Otherwise how could such clear evidence of the failure of the past ten years’ international drug policy be so blatantly denied? How could billions of dollars be wasted on a global anti-drugs programme that fuels violence, harms individuals, families and communities, strengthens organized crime and punishes sick people with prison sentences rather than providing them with the treatment, care and dignity that they need?

Fear also drives the abuse of people who use drugs by doctors and others in the medical system. In particular, I’m referring to the continuing use of forced detention and isolation, electro-shock therapy, forced participation in medical experiments and other abuses of people who use drugs that many of us might refer to as “torture”. Doctors who administer these abuses under the guise of “drug treatment” are not just wilfully denying the evidence, they are violating human rights and the Hippocratic Oath. And make no

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mistake, as a membership association of health care professionals and researchers working in HIV, the International AIDS Society abhors and condemns these unethical and inhumane practices.

Fear drives the denial of evidence. I have seen it in the denialists who claim that HIV does not cause AIDS and the denial of the evidence that antiretrovirals work to control HIV.

Fear can induce denial of any evidence we throw at it.

The Need for Common Ground between the Harm Reduction and Anti-Drugs Movements

My third and final observation relates to the seemingly vast gulf of irreconcilable differences between those of us advocating for harm reduction approaches to drug use and those in the anti-drugs movement.

Recently I visited the INSITE supervised injecting site in the Downtown Eastside of Vancouver. It was late afternoon, a very busy time at the centre. There was actually a queue of people outside the door over 15 people deep, each waiting impatiently for his or her chance to inject in one of the supervised cubicles inside. I spoke with a few individuals. These were not happy people. They were skinny, undernourished, bruised and cut, in tattered clothing, scared, twitchy, and desperate. There was a hint, a glimmer, of hope in the eyes of one or two, but not much. The road ahead for these people looked bleak to me. God knows how it looked to them. Using the supervised injecting site was just one small but significant notch above sharing a needle and syringe in the alley up the road. Homeless and hungry, their lives pretty much devastated by the harms associated with drug use and the failure of the Canadian health and social systems. This is the

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reality of a supervised injecting site, an entry point to reduce harm amidst a sea of neglect.

To bridge the gap between the harm reduction and anti-drugs movement we harm reduction advocates must not be coy about the horrific problems that can be associated with drug use – their effects on the individual, the family, the community and humanity. Individuals in the anti-drugs movement are motivated too by their experience of the worst harms associated with drug use. Discussing these experiences openly and without prejudice could be the beginning of a common language we share. If we are not able to reach out to these groups and find common ground then our evidence will never overcome their fear.

Most importantly, our own fear that we might weaken the argument of our evidence that harm reduction works if we acknowledge and talk openly too much about the ugly side of drug dependency must also be overcome. If we let the chasm between us and the anti-drugs movement get too great then we will have to fight this battle far longer than necessary. We are not, after all, “pro-drug”, we are not “encouraging drug use”. We must reach out for dialogue consistently, with passion and compassion if we are to make further gains.

Conclusion

Next year, in July 2010, the International AIDS Conference will be held in Vienna, Austria. This will not be a repeat of the recent meeting in Vienna that has so angered us all. The conference will have a major focus on injecting drug use and human rights. There will be a special sub-focus on Eastern Europe and Central Asia, using Vienna in its historical role as a bridge between East and West. Let’s work together to ensure that Vienna in 2010 helps confront the fear that was rampant at the Commission on Narcotic Drugs in Vienna in 2009.

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Fellow people who use drugs, let us all continue to dig deep within ourselves to face our own fears about the drugs we use, how we use them, how we can continue to be curious, to feel good, to feel better and to do better. Let us continue to consider how we can prevent or reduce any harm we might cause ourselves, our families, our communities and society. Let us stop HIV infection in people who use drugs and treat, care and support those that are living with HIV. Let us move towards a unified voice where public health and human rights are two sides of the same coin. Let us fight for a more just and equitable society for all people in all places.

Finally, let us continue to search for common ground with those who are not yet on what Michel Kazatchkine referred to earlier this week as “the right side of history”? Let us find the passion and compassion to talk to our so-called enemies, show them the way, and help them overcome their fear. Because as Nobel Laureate and human rights warrior Aung San Suu Kyi said:

“Fear is not the natural state of civilized people.”

Thank you.