…Convention on the Promotion of Public Health Policies to Combat Drugs
Statement by Dr Massimo Barra, President of the Italian Red Cross and Federation representative, at the trilateral conference of the Benelux Parliament, the Baltic Assembly and the Nordic Council, in Liege
From: “www.ifrc.org” Liege 18 May 2006
Mr. President, Ms. Chair, Mr. Rapporteur, Members of the Parliament, Ladies and Gentlemen, it is an honour for me to speak at this trilateral conference of the Benelux Parliament, the Baltic Assembly and the Nordic Council. I would like to address my particular thanks for allowing me to address such a prestigious audience on the important links between public health and drug use.
Today, I would like to share my experience as a medical doctor who has been working for more than 30 years with drug users. I will also mention how this work relates to the broader humanitarian mission of the Red Cross. Finally, I will bring a message of hope and confidence: a new way out the drug use tragedy is possible, a way beyond the old dogma. A new way that consists of bringing drug policy and public health ever closer. The draft European convention on the promotion of public health to combat drug use is a step in this new direction. I will in fact call on to all stakeholders, from policy and law makers – and there are many today representing 11 countries – to the people on the ground to face their duty to give drug users their right to health.
Personal conviction: fighting stigmatization, the first step towards recovery
Since founding one of the first drug user care centres in Italy thirty years ago, I have met more than 30,000 users. I have lost lots of illusions but gained some few solid convictions that I would like to share with you today. A first conviction is that drug use is a very complex, changing phenomenon hard to apprehend in a single formula. It covers many different realities: from use, abuse, dependence and mania. These four levels of drug use take different forms for each person. Generalisation on drug use is dangerous as it fails to grasp the complexity of the relation between drug and the individual. There is no magic treatment or simple answer. But a treatment that works is one that is adapted to the special circumstances of the individual. It is important that the policy framework addressing drug use also reflects this flexibility.
This is the complexity that, in my opinion, the so-called ‘prohibition’ – legalization debate fails to grasp. Trying to criminalize our way out drug addiction has always backfired. I have never understood how some people think that force is an effective way to beat a drug user’s addiction. How can force be the right treatment for somebody who is essentially a sick person? One can only look at the catastrophic effects of prison on drug users to know that repression makes drug users more vulnerable and dangerous. On the other hand, the so-called ‘legalisation’ approach, which proposes to lift criminal restrictions on addictive substances, therefore limiting the criminalization of users, does not solve the problem of how to control and progressively reduce use. Both approaches focus on substances, whilst drug use is essentially the problem of the complex relationship between an individual and a substance.
The bottom line is that we should privilege care and health over judgment about whether a substance is good or bad. Care and health-based interventions represent the first, most effective approach to drug use problems. Why? Because care makes a drug user less dangerous for himself and for the society. I know for a fact that a drug user on methadone is more lucid than one on valium, which is used when proper substitution treatments are not available. But care is also the most effective step to restore calm in troubled communities and strengthen, on the long-term, Law and Order. Care is a policy in the interest of all, not only of drug users. Another conviction is that life is a difficult endeavor for everybody, but some among us are weaker and need substances to cope with the hardship of life. They need the illusions that they are stronger.
Drug addiction is a disturbing but real fact of human nature. Current policy makes the weaker individual more vulnerable and more dangerous. I have learned as a practitioner that stigmatisation and lack of care for drug victims is unwise and destructive, not only for the users themselves but for the communities in which they live. Stigmatization is the first killer disease to drug user. The first aim of any drug policy should be to lower the danger that drugs represent both for the user but also for the community as a whole. Current practices clearly do not lower this danger. On the contrary, traditional drug responses makes drug users twice more dangerous to their own and to the society’s health through transmittable disease like HIV/AIDS as well as to the safety of their communities. Violence and intolerance, which often feed our drug policy, transform drug users in violent and intolerant individuals themselves. We cannot except anything else.
A policy primarily aimed at reducing human suffering does not only save the lives of drug users, it removes the element of violence and intolerance, which often kills more than diseases themselves. Caring for drug users – regardless of their conditions and the type of addictions – does not only benefit public health but also Law and Order. I know that the police in the city of Rome with whom my drug care centre Villa Maraini works on a regular basis will agree with me; like many other actors at the frontline of the drug problem.
The Red Cross commitment to the most vulnerable groups like drug users
I would like now to say a few words on the commitment of the Red Cross to harm reduction practices. Since its foundation in 1864, the Red Cross has rigorously followed its core Principle of Neutrality. This is the reason why, today, the Red Cross can work everywhere, in every community, regardless of racial, ideological, religious or political divides. But the Red Cross has also another fundamental mission: the one of advocating for the most vulnerable people. Far from being contradictory, those two forces – neutrality and advocacy – if I may call them like this, meet at the point of alleviating human’s suffering. This is where the Red Cross finds its unique power of humanity.
The reason why I am giving this background is because at a time of disagreements – and they are many on drug policy – it is important to bring the discussion on public health policies and drug use down to a more neutral and rational ground. ‘Spreading the light of science and the warmth of human sympathy’ were the words used in Paris en 1919 by the founders of the League of Red Cross Societies. ‘Spreading the light of science’ is now the title of the 2003 report of the Red Cross on HIV/AIDS and Harm Reduction, which ensures that a wide range of prevention programmes, including access to sterile injecting equipment, are implemented throughout the world.
This report is a call addressed to the international community not to attach moral or political strings to public health practices aimed at drug victims. Reducing harm and preventing death is a universal cause the Red Cross intends to pursue relentlessly. The Movement achieves this through scientific evidence and by taking inspiration from the fundamental principles of humanity, neutrality and impartiality. The effort of the Red Cross to bridge the gap between public health and drug policy does not end here. Indeed, the reduction of harm and suffering must not remain the privilege of few advanced and wealthy countries.
This is simply because in Kabul, Tehran or Moscow, drug users face the same life-threatening conditions as users in the streets of Vancouver, Zurich or Glasgow – if not worse. The work of the European Red Cross Network on HIV/AIDS (ERNA), which was created in 1998, is a direct response to the HIV/AIDS threat facing drug users in countries of Eastern Europe. Not only the health but also the security and economic development of countries in Eastern Europe, the Former Soviet Union and Central Asia are under threat, and basic health measures are denied the legal and political support they deserve. More recently, 20 National Red Cross and Crescent Societies from Central Asia and Eastern Europe have signed a common declaration – the ‘Rome Consensus for a Humanitarian Drug Policy’. The Consensus, which was signed under the auspice of the Italian Red Cross and The Senlis Council, calls for putting drug policy at the forefront of social concerns. Any individual has the right to health – drug users too. This common document is a reminder to governments of this fundamental right and the duties of policy-makers but also us, civil society actors, in the humanitarian fight against drug use.
Bridging the gap between public health and drug policy
I would like now to elaborate on what I meant earlier on the idea of a new way. Drug control should not rely on violent responses be it through criminal policy or even forced treatment. It should be the policy of and designed for the most vulnerable. The principles of harm reduction are important steps in the right direction. But harm reduction is a fire-fighting strategy, a desperate attempt to limit the damage within an overall dysfunctional approach. I think the debate between the different extreme drug policy approaches has been going on for a long time now. I am not afraid to say that it has not really produced any substantial improvement in the formulation of a new response to the drug use problem. Time for a new way, beyond prohibition and harm reduction. A new global approach based on humanitarian principles and that empowers the individual to make healthy choices.
We must use all public health instruments made available by science without the inhibition of dogma or prejudice. Science has shown that substance dependency is a fact of life – it takes mild forms among most of us and more extreme forms among a vulnerable minority. Law-makers have a crucial role to play. The drug laws you pass in your own countries can enable practitioners, in fact the people on the frontline of the drug problem, to use all available public health tools to improve the conditions of vulnerable groups and reduce danger.
Today, practitioners in Western Europe, but more worryingly in Eastern Europe and Russia, the countries hardest hit by the HIV/AIDS – injection drug link, cannot fulfill their humanitarian mission adequately. 80% of the one million reported HIV cases in the Russian Federation are due to injection drug use. Yet, methadone – a cheap and effective substitution substance recently added to the list of essential medicines by WHO is banned in most countries of the Former Soviet Union and Eastern Europe. It is not a problem of scientific knowledge or even of funding. It is one of political dogma. The Red Cross is working with Eastern European countries to try to overcome those barriers and adopt simple treatment option like methadone. Against the problem of ideology and politics, we need a collective banner for public health.
The need for a strong, common ground for public health responses to drug use
Lawmakers like the members of national and regional parliaments I have the privilege to speak before today can help separate for once and for all dogma from life-saving policies. Today, there is lack of clarity about which public health practices are legal. Although we know which treatment options work. In the case of drug treatment, users are everyday victims of this lack of clarity because they are deprived from some basic treatment. Those who ignore the importance of health and care responses to drug use are guilty of ignoring the reality of scientific facts based on more than 30 years of practices. A major step is still missing.
Treatment options still lack the strong and clear legal ground that will make them available to all countries and all corners of society without political, racial or religious barriers. I see an analogy here with human rights. Despite the fact that human rights are not applied evenly throughout the world, multilateral frameworks like the European Convention on Human Rights provide invaluable benchmarks, strengthening human rights practices on the ground. Public health in the context of drug use is a matter of life or death, not only for drug users, but for their families and their communities at large. The members of the Baltic Assembly with the HIV/AIDS crisis at their doorstep, I am sure, share this sense of urgency. They know the terrible social, economic and even security consequences of the link between AIDS and uncontained injection drug use. We need some clear benchmarks to guide both policy-makers and practitioners on the most effective, humanitarian health responses to drug use.
The draft European convention on the promotion of public health to combat drug use is an important initiative in this direction. It consolidates in an international legal framework health practices on the ground like substitution treatment or clean needle exchange that have proven effective. Moreover, the framework sets the right to health as a fundamental right for drug users. And it reminds governments of their special duty to care for the most vulnerable. If not, who will do it? As a bottom-up initiative, this initiative brings together evidence of practices, which have worked on the ground. It now needs to be given the legal recognition from lawmakers of the Council of Europe. The Convention will create an international language for public health response to drug use.
From Russia, Central Europe and Western Europe, policy makers, doctors and social workers will know without ambiguity the whole range of tools available to fight the terrible health consequences of drug use. Such framework sends a strong signals to countries who are still uncertain about life-saving measures like clean needle exchange. Public health projects to combat drug use will gain in international recognition, therefore channeling more international aid.
Ultimately, providing safer health conditions for drug users is the first leg of a long journey towards their full recovery. I think this is the shape of a new drug policy consensus that proposes to reduce drug use through humanitarian, rational means away from dogma. We should all give our support to the strengthening of this consensus for the way any society treats its ill and sick reflects its state of human progress.