Ken-Marti Vaher: “Public money can only be spent on evidence-based measures”

16 June 2017

Ken-Marti Vaher, a stalwart of the conservative Pro Patria and Res Publica Union party and, until recently, a Member of the Estonian Parliament, led the country’s Ministry of Justice between 2003 and 2005 — a task made very unenviable by the world’s first nationwide fentanyl epidemic, which seemed to call for harsher punishments to large-scale drug distributors. Yet it was also he — in a new role as the Minister of the Interior between 2011 and 2014 — who headed the government commission on drug prevention tasked with outlining the rather progressive newer directions of Estonia’s drug policy.

Attending the Eurasian Harm Reduction Network’s anniversary conference in Vilnius this April, Mr Vaher found the time to answer a couple of questions.

“The White Book” — a 2014 policy paper outlining measures to reduce the usage of narcotics, the writing of which you coordinated as the Minister of the Interior at the time — might have been the first time I encountered the term “harm reduction” in mainstream public discourse in Estonia. This was a step in the right direction, even though the policy plan didn’t really describe harm reduction as one of the essential pillars of drug policy. What have been some of the more significant milestones and obstacles on the journey towards the inclusion of harm reduction in state policy?

First of all, it’s important to note that experts from all over the world have very different opinions about harm reduction. About a year ago, a fairly high-level conference took place in Tallinn, where Professor John Strang, an addiction expert from King’s College, London, pointed out that the one program that can be said to be evidence-based and that he as an expert would recommend adapting is methadone-based opioid substitution treatment. We know that it has proven effects, and it is reasonable to fund it out of taxpayer money. Estonia has done this. The program now covers about 1200 drug addicts a year. According to estimates by the national Institute of Health Development, there are currently about 7000 to 8000 injecting drug users in Estonia. The 1200 people we’ve managed to involve in methadone programs obviously constitute a minority, but it’s a significant minority.

Another measure by which Estonia excels is needle and syringe exchange. According to our figures, we’re currently providing syringe exchange services already to 60 per cent of addicts. One injecting addict goes through about 230 exchangeable syringes a year. This is well above the European average. This 60 per cent coverage by needle and syringe programs is an achievement we can be proud of.

These are the harm reduction measures that are proven to work. They have obviously borne fruit in Estonia, because the HIV epidemic, which many experts agree was the main trigger, the main motivation behind wider adoption of the principles of harm reduction in Estonia, is diminishing. Estonia is one of the very few countries in the Central and Eastern Europe and Central Asia region where the HIV/AIDS epidemic has waned during the last ten years, and I’m sure we have harm reduction to thank for a lot of that.

The level of new HIV diagnoses in Estonia is still well above the European average…

That is true. That means there is still a lot of hard work to be done. But at least we’ve managed to climb quite a way up from the very bottom of the pit. At conferences like these, I’m often asked about the reasons for Estonia’s apparent successes in this field. A very clear, very objective reason that I always point out is the fact that, at one point, Estonia fell into a very deep hole. What do I mean by the “hole?” Since the beginning of the 21st century, we’ve experienced a very stark spike in opioid-related deaths, and another spike in the number of injecting drug addicts. At the high point of the opioid crisis, there were about 15,000 to 16,000 injecting users in Estonia. By now, experts estimate that number to have halved, or to have diminished by at least 40 per cent.

The third factor was the massive HIV epidemic of the second half of the 1990s, which forced us to find efficient solutions. Joining the EU in 2004 must have been an important trigger — great efforts were taken to make that happen — and thus Estonia was at least looking for practical solutions. Other countries had similar problems, but they might not have gone as far in adopting solutions. At the very least, we decriminalized personal use of drugs, so that it’s no longer considered a felony, but a misdemeanor, which made it possible to actually start providing harm reduction services.

Obviously, there are many more harm reduction measures besides opioid substitution treatment and syringe exchange that deliver results, like, for example, take-home naloxone programs. How would you go about consolidating the region into adopting a wider selection of such measures?

The topic of naloxone that you brought up is a good example. A naloxone distribution program was indeed initiated in Estonia at the end of 2013. In fact, we were only the second European country to publicly fund a naloxone program. This was preceded by very heated, very bitter arguments. Representatives of the medical establishment were especially fierce in their fight against naloxone — doctors considered the free distribution of a prescription drug to drug addicts and their families an impossibility. It was something around which they were simply unable to wrap their heads — sure, paramedics must carry naloxone, but junkies? Not a chance!

Fortunately, after an extended period of quarreling, their resolve was broken, and today we can be sure that dozens upon dozens of lives have been saved as a result. I believe that these numbers speak for themselves, which should make it easier for other countries to adopt similar measures. It’s important to be evidence-based, to collect data, and to carry out actual scientific studies. These studies are, of course, expensive to run, but it’s extremely important to have solid figures. If we can point to trustworthy statistics from different countries, and to clear correlations with harm reduction measures adopted, we can make pretty accurate deductions. And I believe that organizations like EHRN, who have kindly invited all of us here, have the means to carry out such analyses, write reports, and lead the way. In other words, advocacy has an important role to play.

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 in Vilnius that reasonable market regulation is the logical culmination of the philosophy of harm reduction. Do you agree?

This is obviously a matter that must be very thoroughly assessed and discussed. First of all, we must find functioning examples of such models in countries that have experimented with something like that, while keeping in mind that there are many obvious differences between countries. Let’s compare, for example, the Netherlands and Estonia… although Estonia is not really an exception here — on the contrary, we are considered an exemplary case among many of the Central and Eastern European countries with similar problems. Yet harm reduction, prevention of drug use, and diversion from drug use are quite underdeveloped in Estonia. There’s just never enough money for such measures. The reasons for this have, of course, been objective. But if we compare that to the Netherlands, where for decades upon decades, dozens and dozens of millions of Euros have been invested in harm reduction, drug use prevention, youth work, awareness-raising, etc.… the difference is stark!

So, before we can start exploring such claims or experimenting with such models, we must first do the most important part of the work, which is actually work in the field of prevention and education for youth, as well as, of course, rehabilitation and harm reduction.

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 make dealers who care for the health of their clients disseminate harm reduction information, or even provide certain services?

Honestly, I can’t imagine something like that. Let’s look at how much marketers of legal narcotics — producers of alcohol and tobacco — invest in addiction prevention, customer awareness, harm reduction, etc. It’s very clear that their investment is far from noteworthy. Conversely, I would say that compared to the public money invested in prevention by the State, their investments into making people buy the drugs they produce are colossal. And even if they’re put into a situation where they’re forced to fund at least something, they will invariably choose measures that cost the least and are the least effective. Sadly, such tendencies are already entrenched in the alcohol market, and they would only become more grotesque in the context of illegal drugs. The black market has its own stigmas, its own attitudes, its own view of how things should be done, and they’re very, very difficult to break. 


Interviewer: Mart Kalvet from the Estonian drug users’ union LUNEST