The case for safer fixing

Da: BRIDGE/WINTER 0203/UP Up Front – Dr Massimo Barra
Society needs to know its drug users, not marginalize them. Harm reduction strategies are in everybody’s interest: the users, the public and the authorities.

Harm reduction, someone said, is the meeting of public health and human rights. I like the sentiment. By helping injecting drug users to protect themselves, we can help to protect the community. Although the strategy limits the spread of HIV and bloodrelated disease through such programmes as the exchange of needles and syringes, it doesn’t have everyone’s approval. The European Regional Red Cross and Red Crescent Conference in Berlin last April gave it a clean bill of health but opposition can be found around the world. There are places where it leads to political controversy.

Some people see harm reduction as a retreat from the fight against drugs. Anything other than the repression of drugs is seen as a compromise, be it concerned with simple survival or the quality of life. Worse, harm reduction is sometimes written off as complicity with the users. For all these reasons Red Cross and Red Crescent commitment to harm reduction has to be based on facts, on scientific evidence, on the costbenefit ratio, on the overall interest of countries to keep the population in the best health conditions possible. As auxiliaries in the humanitarian services of governments, the Red Cross and Red Crescent must recommend to the authorities ways of intervention that the international scientific community has demonstrated to be both safe and the most effective.

Harm reduction belongs in this category. When in public debate I hear dogmatic and illinformed comments I always reply that harm reduction is the opposite to increasing harm and to unsound health policy that would worsen the condition of patients. Joking aside, there are people out there who believe that allowing the health of drug users to deteriorate, and their living conditions to worsen, is good for them. It is the way, they say, to end their addiction.

Drug users are sinners, isolating themselves in an intolerable false paradise. If it is true that drug users will stop injecting when the negative aspects of their habits outweigh the enjoyable, then therapists and users’ families may be happy to underline them, even violently. This is the strategy of letting the users touch bottom, reach the depths of despair, then rebuilding them, replacing their slavery to drugs with rules set by behaviourists. It is popular thinking in many countries not only undemocratic and authoritarian ones where drugs are perceived as an enemy to fight and anything goes in doing it: segregation, imprisonment, duress.

The fight against drugs becomes the fight against users, a strategy more dangerous than a drug itself. It is the antithesis of harm reduction and of one of our Fundamental Principles: humanity. The Red Cross and Red Crescent must raise their voice wherever human rights and human dignity are violated. Counselling governments isn’t expensive. The more a government is authoritarian and therapy is constrained, the more difficult it is for drug users to ask for help.

They will remain in the shadows, dangerous to themselves and to others. What society needs is to get to know them, not to marginalize a problem, leaving only the tip of the iceberg visible. Getting to know them is easy through harm reduction strategies, and yes they are in the interests of the drug addicted but also in the interests of everybody else, the public and the authorities. Following drug users with therapy means less violence on the streets, less murders, less HIV and other disease transmitted from vulnerable groups to the wider population. Harm reduction activity, be it the exchange of syringes and needles, alternative treatments with drug substitutes like methadone, the search for the addicted in public places, street overdose prevention and intervention, or health peereducation, provides us all with a major role to play. We can do it alone or in cooperation with others.

We should contact and consult with any group involved with harm reduction. We can benefit from each other’s experience and find ways of working together. The close links between intravenous drug use and the spread of HIV, especially in Central and Eastern Europe, and the Central Asian states, call for a more active and aggressive strategy. Dr Massimo Barra is chairman of the European Red Cross and Red Crescent Network on HIV/AIDS (ERNA), and director of the Foundation Villa Maraini in Rome, one of Italy’s leading centres working with drug users.