Julian Hows, the Programme Officer of the Global Network of People Living with HIV for the past seven years, seemed to be the busiest person at the EHRN regional anniversary conference in Vilnius, managing the abstract-writing workshop for three consecutive days, keeping an audience of (mostly) Russian-speaking activists on their toes, cracking jokes and answering very serious questions simultaneously. This jovial, ageless gentleman was is one of the important figures in from the past and present of the harm reduction movement that Mart Kalvet from the Estonian drug users’ union association LUNEST interviewed in the course of the “Harm Reduction in the New Environment” conference in April, 2017.
You have seen firsthand the evolution of the concept of drug harm reduction from a hopeful idea to one of the four pillars of the modern, evidence-based, progressive 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 CEECA region)?
Just to give you a bit of the background: — I started working in the field of HIV as a volunteer in 1983 in the UK. That was before we had a proper name for it; it used to be called “the 4-H disease” — for heroin users, people from Haiti, homosexuals, and hemophiliacs. That was before it actually became known as HIV, before HIV had been identified.
What we found really soon on, was that in the UK — a country which is being split up at the moment, possibly — there were different health systems in different parts of the kingdom. In England and Wales there had always been needle exchange, whereas in Scotland, where the system was different, there had been no needle exchange. Interestingly enough, the majority of people living with HIV in Scotland were drug users, because they had no access to safe injecting, whereas in the rest of England and Wales, the proportion of drug users was small, albeit significant. That really brought home the necessity that people’s right to health must be indivisible. And this is something that this conference also underlines: if you give people access to the tools that they need to take substances safely, whatever these substances may be, then you are winning the public health war, and you are winning the war of people being able to choose, and have rights, around what they might want to do.
The situation in the region of Central and Eastern Europe and Central Asia is incredibly patchy. Most of what is in fact available — whether it be clean needles, clean injecting equipment, overdose remedies, or something else — is still based on the moral that people shouldn’t be doing this. Yes, I shouldn’t smoke, I shouldn’t have so much sugar, and the government taxes me, but it does not take away my right to services. Yet that is precisely what it does to everybody who wants to use illicit drugs. So, we have not gone very far in changing the moral set of thinking that by prohibiting things we are going to stop these things from happening — of course we’re not. Until we actually get people to shift that attitude, we’re buggered. GNP+ has been monitoring this on a site at http://legalbarriers.peoplewithhiveurope.org/index.php We would welcome input from people reading this to see if we have the situation in their country right
I’ll give you another example. If you look at the changes in the rhetoric of the Federation of Red Cross, you’ll see that they have advised several countries and regions to decriminalize drugs. They’ve actually come out and said that, and at the same time they are going in and doing harm reduction programs and programs reducing addiction. But mostly they are doing it in a good way, which doesn’t have a moralistic attitude around it. They’re not saying that drug users are, by their very nature, bad people.
One has to look at it this way: that drug users are people who use drugs. Whether there is a pathology around somebody’s drug use is an entirely different issue. On Tuesday, I might be a drug user. On Wednesday, I’m an alcoholic. You know, we are not the substances we take. And that’s another thing:. wWhy do people take drugs? — bBecause they are nice. It’s as simple as that!
As you’ve pointed out, 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 think the reason for this is political, cultural, and religious expediency. For a politician, it’s always convenient to scapegoat some group of people for the problems a society might be experiencing at any given time. In one country, it would be foreigners of a particular sort;, in another country it will be drug users. And when election time comes around, the rhetoric will be: “We must take this scourge of drugs away from our youth in order to protect them!” But, hold on a second! Wouldn’t outlining the options — acknowledging that people are going to experiment anyway, but making sure that they do it safely — actually be a better way to protect them?
It’s interesting, isn’t it, that in countries where there’s a liberal, laissez-faire, decriminalization-based approach to drug policy, like the Netherlands, there aren’t very many injecting heroin users anymore? They’ve dealt with the problem not by prohibition, but by outlining that, well, it’s there, yes, it’s still illegal, but if you’re going to do it, this is how you do it safely. You take away the glamour, to a certain extent, of doing something dangerous, and the result is that people make more informed choices, and also have a wide range of highs, whatever they might be, to experiment with. When they look at the hassle of injection — even in the context of such milder forms of prohibition that we call decriminalization —, they might go down another route, have a different sort of high. If you look at all of the highs you can take that do not carry the risk of blood-borne diseases, and you lay out the options, and acknowledge that people can get as high on other things, then they actually will choose these options… to a certain extent. But if you say to them that they can’t do it, they shouldn’t be doing it, and you make it very, very difficult, then you don’t just criminalize the behaviour, but you end up criminalizing the individual as well. And that is something that a lot of the countries, in this region as well as elsewhere, have yet to sort out.
Mr. Michel Kazatchkine, the United Nations Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, said in his keynote speech that reasonable market regulation is the logical culmination of the philosophy of harm reduction. Do you agree?
Quite possibly, yeah. I think there might be some real challenges, some real dangers, and some real damage on our road towards that, but ultimately, in the long term, those challenges, those dangers, and that damage are actually going to be much, much better than what we have now.
Let’s look at Amsterdam, for example, where I’ve lived now for six years. You see the tourists come there and light up in coffee shops and get off their heads. A small but significant amount of injectable drugs, like heroin, and snortable cocaine — of varying quality, of course — are available on the streets quite easily, without the police cracking down on the dealers too hard. But when there was some nasty, very strong white heroin coming around which was sold as coke, because it’s cheaper, or in some other cases of “mislabeled drugs” making it to the streets, or drugs being too pure for the market and the supply chain not realizing that, then the first thing that the Amsterdam police did was put up big flashing banners of public health warnings, saying “There have been overdoses because there is too pure cocaine going around at the moment. Be very weary of buying this!”. And next to that, it said “If this does happen to you and you have an overdose, here is the emergency number you can call.” Now, would you find that in any other city? Really?
In a regulated market, consumer protection is at least partially financed, if not provided, by the producers, the importers, and resellers. Do you think it’s possible to incentivize the grey and black markets to compensate for some of the health and social consequences of their trade — in a manner similar to the way that deep web marketplaces have been motivated to provide safe use tips and list the exact contents of their produce? In other words: how can we make dealers who care for the health of their clients to disseminate harm reduction information, or even provide certain services?
I think it’s something that the Dutch in some ways are quite good at, in that they turn the other eyechoose to ignore certain things, even with things that are still illegal. But I think they could do more. For example, in Amsterdam I can make a phone call and get drugs delivered to my door in ten minutes — a bit like ordering a Domino’s pizza. But I can’t get any safe injecting equipment; the people who sell drugs will not carry it, because it’s too bulky. And if they do get stopped, they’re fucked. Whereas, if they’re getting out of their car and walking a hundred yards to somebody’s house to make a delivery, they’re only carrying what they know they’re going to be selling. Consequently, that can always be ditched, if there’s an entrapment or anything like that. There’s no black market for naloxone.
One useful thing to do would be to provide drug-testing services. On-site testing of substances still happens in some clubbing situations, where it’s possible to check the purity of MDMA and ecstasy tabs being taken on the premises. Once again, a blind eye is turned so that harms can be reduced. And some dealers might go to the trouble of checking the purity of what they are selling in this way, or by other methods, but that is not a very rigorous situation, of course, because it is not regulated. How you would you work with people to make it more regulated, and actually get their trust? I really don’t know.
If you want to find out more about GNP+ please go to their website at www.gnpplus.net
Julian, living with HIV themselves for 30 years, is also happy to respond to queries on a personal basis. He can be contacted at firstname.lastname@example.org