Daniel Wolfe is Director of International Harm Reduction Development at the Open Society Foundations, an expert on the intersection of HIV and drug policy, a member of the UN Strategic Advisory Group on HIV and injecting drug use, and the author of book chapters and articles in both peer-reviewed as well as popular publications. This interview with him was conducted in April 2017, at the Eurasian Harm Reduction Network’s conference “Harm Reduction in the New Environment” in Vilnius.
You have seen first-hand the evolution of the concept of harm reduction from a hopeful idea to one of the four pillars of modern, evidence-based drug policy. What, in your opinion, have been some of the more significant milestones on that journey, and what will be the main challenges for the harm reduction movement in the next decade, especially in the region of Central and Eastern Europe and Central Asia?
For me, harm reduction is simultaneously about public health interventions aimed at reducing harms coming from drugs and from bad drug policy, and about making space to change the relationship between drug users and those government authorities that have been charged with addressing drug use and drug users. For a long time before the implementation of harm reduction measures, and even after, we’ve often seen drug users treated like drugs themselves, as something to be controlled and contained. Harm reduction has changed the idea that you need to stop using drugs before you’re entitled to support, or help, or social participation. So, for me, harm reduction is not that much about a package of nine interventions authorized by the WHO or UNAIDS; it is more about the philosophical frame that says that people who use drugs are still capable of making rational choices, that they can still act to protect their own health, the health of their families and communities, and that they have a central role to play in actually defining the kinds of programs and policies that will work.
One of the reasons why Open Society Foundations was interested in harm reduction is that the war on drugs, much like the war on terror, is used by governments to control certain people in the name of “common sense” or “public safety.” Yet very rarely have those governments tested their assumptions against the real, lived experiences of people. And if you do test such assumptions about the drug war — that it’s good to incarcerate people, it’s good to forbid people from talking openly about what they’re doing, it’s good to restrict treatment or support to those who have stopped using illicit drugs — you find that all of those propositions are false. Many people in this region began testing those propositions in their own ways, whether by starting a needle exchange in Russia, by changing the narcological system in Kyrgyzstan so that people are not put on a registry anymore and are not required to come in for monthly medical exams, or by putting a needle and syringe program in a prison in Moldova that’s actually run by prisoners. In all of these instances, what we learned is that by involving people and opening space you have a better response than by closing them down and locking them away.
The practical expressions of the somewhat stretchy principle of harm reduction vary from country to country, sometimes drastically, which can lead to controversial results. What do you think is the reason for this, and how could the problem be countered?
I don’t think that it’s just government policy that determines patchy or inconsistent responses to harm reduction. Speaking as an international funder, I think that in many ways, many harm reduction programs begin to grow toward the priorities of international donors, in the same way a plant turns towards the sun. Harm reduction became very defined by HIV deliverables — that means, by a series of grant agreements that said how many needles must be distributed or how many people will have to be reached — and we began to focus less on the content of these interactions, as well as on some important aspects that didn’t actually have to do with HIV prevention, but instead had to do with making an alliance with drug users and having open discussion.
You and I just came from a session on new psychoactive substances. One of the reasons why it was at 7.45 in the morning and didn’t have a more prominent place in the conference is that those substances haven’t been linked as closely in the public discussion to HIV transmission as, say, heroin injection, so many of the people here who are oriented towards fulfilling their HIV grant deliverables weren’t sure that they had the space to talk about new psychoactive substances or substances that aren’t injected, even though everyone who’s working with drug users knows that this is a huge issue that needs to be talked about. So I think one of the silver linings — if there is any silver lining for the retreat of the Global Fund and the international donors from harm reduction in the region — may be that it’s now possible to return to what is important, to motivating people in the streets and the clubs, and the drug scenes, not doing just what is written into your grant agreement with Geneva or New York, with Open Society Foundations or USAID.
Mr. Michel Kazatchkine, the United Nations Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, said in his keynote speech at the conference that reasonable market regulation is the logical culmination of the philosophy of harm reduction. Do you agree?
It’s very clear that the fact that drugs are illegal, and the fact that governments don’t even permit open discussion or circulation of information about drugs, or regulate their safety or production, increases risk. Again, we’ve just heard about all these new psychoactive substances that exist on the dark net, but if you go to the narcological dispensaries in the cities in the region, the narcologists actually know very little about them, and, honestly, have very little to say, because the truth is that these substances don’t come with a pharmaceutical insert the way medicines bought at a pharmacy do, where you can read about side effects, contents, counter-indications, and so on. What we have now is a situation where you get a product, you have no idea about its safety, or the way it will interact with you or the other medicines you are on, or your medical conditions, and then you bear all the risk, and the State has no responsibility for it. So it’s very clear that greater information, greater regulation, and greater openness about the contents of substances lead to reduced health risks.
Some of it seems to be developing regardless of laws. On most of the modern dark net marketplaces, you can actually see customer feedback, there are open forums where users and sellers can share safe use tips, and many dealers actually have their products tested by services like Energy Control and list the exact ingredients... In a regulated market, consumer protection is at least partially financed, if not provided, by the producers, the importers, and resellers. Do you think we can make dealers who care for the health of their clients disseminate harm reduction information, or even provide certain services?
That’s a very complicated question. On the one hand, I completely agree with Professor Kazatchkine that regulation would lead to increased safety. There is no country that regulates and supplies, except in the most limited circumstances, for example, heroin and cocaine and other so-called hard drugs. Heroin prescription is a good example of government regulation; so, to a certain extent, it has happened, but it’s only available for a very few patients who have “failed” on other treatments, and in some cases — for example, the Netherlands — heroin is prescribed along with methadone.
Once you actually talk about a large market, there are many complicated questions about whether or not it is feasible or advisable to rely on the people who have a profit incentive to actually regulate themselves and provide necessary information. Pharmaceutical medicines are a good example. For many years, in many countries, before the 1960s, you didn’t have to demonstrate the efficacy of your product; you could just rely on informal reports by patients and doctors. Clinical trials were not designed in a rigorous way. I’m not suggesting that we go back and review things that now have centuries of history of use, but I do think that the government — independent of those people who produce drugs and profit from them — has a role in regulating and examining claims of safety.
But until they do that, do you think it might be advisable to include the black market in harm reduction incentives in some capacity?
I think that for health and safety reasons it would be advisable not to have a black market at all. I mean, at the end of the day, the moment you say “black market,” what you’re implying is that there are zones where the government is not authorized to go. However, in this moment, in our reality, I think one of the strong points about harm reduction is that we have actually been able to operate in the grey zones of the law, to say we’re not going to wait for government systems to completely transform themselves or acknowledge things before we are going to intervene to try to increase safety and health for people who are using these substances.
So, in this moment, before there is government regulation, before the utopian vision of a time when we are provided with actual evidence-based information about safety and risks of all psychoactive substances by a government agency, I think we can’t wait. We have to draw on the best information that we have, including information from consumers that is not curated or produced by the profit-makers. I don’t spend a lot of time on the dark web, and I haven’t reviewed those consumer reports, but, again, I wouldn’t rely on the manufacturer of a cigarette to tell me how dangerous the cigarette is, and I wouldn’t rely on the seller of a “bath salt” to tell me exactly how dangerous that is. I would have more faith in at least some of the crowd wisdom and multiple reports from people who are working with or using these substances, since it’s the best we can do right now.
Interviewer: Mart Kalvet from the Estonian drug users’ union LUNEST