Alex Wodak defends harm reduction, under attack from the World Forum Against Drugs

Following the recent World Forum Against Drugs in Sweden, the Executive Director of the US based Drug Free Schools Coalition , David Evans, sent an email to a number of colleagues in the field encouraging them to sign the declaration from that event (which you can read here in pdf). It is an extraordinary document in many ways, not least because of its inexplicable misunderstandings of the UN legal system (un-picked on the IHRA HR2 blog here), but also because of the alarming and sweeping disdain it demonstrates for harm reduction. We may discuss it further on the blog at some point but really, it's so exotic as to render itself almost completely irrelevant to real world debate. It's actually self neutering. And if it really is going to be the banner for the remaining defenders of the drug war, then the drug peace is probably nearer than we might have hoped.

Anyway, one of the colleagues in the drugs field who received the letter was Alex Wodak, long time harm reduction practitioner, researcher and campaigner, and board member of the International Harm Reduction Association. Unsurprisingly perhaps, he declines Evan's invitation to sign the declaration, and his considered and detailed response is copied below.

Dear David,

While I am pleased that you have opened up this dialogue, I cannot accept your invitation to support the Declaration of World Forum Against Drugs.

Let me explain some of the reasons why.

(1) In the 1300 word WFAD Declaration about illicit drugs and drug policy, neither HIV nor AIDS were even mentioned once. Yet AIDS is now the fourth major cause of death in the world. The sharing of needles and syringes now accounts for 30% of new HIV infections outside Sub Saharan Africa (or 10% of all new global HIV infections). The only known effective way of controlling HIV infection among injecting drug users is a harm reduction package including explicit and peer-based education about HIV, needle syringe programmes, drug treatment (especially methadone and buprenorphine treatment for heroin injectors) and community development of injecting drug users. Needle syringe programmes and methadone and buprenorphine treatment have been shown to be effective in reducing HIV and also to be safe and cost effective. Yet the WFAD Declaration does not even mention these interventions. The effectiveness and safety of needle syringe programmes have been confirmed by more than half a dozen reviews commissioned or conducted by agencies of the US government and a review commissioned by the WHO. WHO, UNAIDS and UNODC have endorsed methadone and buprenorphine treatment and the WHO has included these medications in their Essential Drugs List. The important association of injecting drug use and HIV has changed the way we now think about drug policy. It should also influence the way that the WFAD thinks about drug policy.

(2) In virtually all countries, the health, social and economic costs resulting from the legal drugs, alcohol and tobacco, dwarf the serious problems associated with the use of illicit and psychotropic drugs. Yet the WFAD Declaration does not even mention alcohol or tobacco, let alone the problems associated with prescription drugs.

(3) The use of mood altering drugs has been found in virtually all countries and cultures throughout history. Accepting this reality is not an endorsement of mood altering drugs. It simply reflects a preference to deal with the world as it really is rather than some fantasy world some would prefer to live in. If the WFAD believes that the objective of a drug free world is realistic and not utopian, WFAD should list the countries or cultures that have already achieved an enduring drug- free state.

(4) The WFAD Declaration ignores the substantial and growing international support for harm reduction. UN and international organizations supporting harm reduction include WHO, UNAIDS, UNICEF, the Global Fund for AIDS, TB and Malaria, the World Bank. The UNODC increasingly supports harm reduction (although this organisation still has some senior staff critical of harm reduction). About 70 countries provide needle syringe programmes and a larger number provide methadone or buprenorphine treatment. Why does the WFAD still need to refer to harm reduction as 'so-called'? Why still refer to harm reduction in quotation marks? The scientific debate about harm reduction is now over. That is why support for harm reduction is now so strong and growing so steadily. In contrast, support for zero tolerance is steadily shrinking because zero tolerance is based on belief, not science. At the 'Beyond 2008 NGO Forum' held in Vienna 7-9 July 2008, 300 NGO delegates from around the world endorsed a Declaration which supported harm reduction, the protection of human rights and the involvement of affected communities.

(5) Supporters of harm reduction recognize the importance of promoting abstinence. In some ways, abstinence is the ultimate form of harm reduction. But some are unable and others are unwilling to aim for abstinence. As a doctor it is my duty to still try and help these patients. Also, abstinence is often precarious. And when relapse occurs, it is often accompanied by very severe harms, sometimes even death. The assertion that harm reduction undermines 'the international efforts to limit the supply of and demand for drugs' is ludicrous. What undermines international efforts to limit the supply of and demand for drugs is the law of supply and demand. As former US Secretary of Defense Donald Rumsfeld said in January 2001 'If demand [for drugs] persists, it's going to find ways to get what it wants. And if it isn't from Colombia, it's going to be from someplace else.' If a kilogram of heroin is worth $US 1,000 in Bangkok and $US 300,000 in New York City, why will that kilogram of heroin not end up in Times Square? If we cannot keep drugs out of prisons, and we are unable to do this, how on earth can we keep drugs out of our communities?

(6) The assertion in the Declaration that harm reduction 'violates the UN Conventions' is also absurd. Which Conventions does harm reduction violate? The INCB commissioned a study from the Legal Affairs Section of the UNDCP entitled 'Flexibility of Treaty Provisions as regards Harm Reduction Approaches' E/INCB/2002/W.13/SS.5. 30 September 2002. This document concluded that harm reduction interventions do not breach the international treaties (with the possible exception of pill testing).

(7) The Declaration claims that there 'can be no other goal than a drug-free world. Such a goal is neither utopian nor impossible'. How can the same goal be appropriate for every country in the world despite such diverse conditions and problems? Is a drug-free world really feasible? Since the 1998 UNGASS meeting, global opium production has more than doubled from 4,346 tons to 8,880 tons while global coca production has increased by 20% from 825 tons to 994 tons. Remember the UNODC slogan for the 1998 UNGASS? 'A Drug Free World - we can do it!' Now the UNODC speaks of 'containment' and making 'drug policy fit for purpose'. As President George W. Bush said on February 12, 2002 'As long as there is a demand for drugs in this country, some crook is gonna figure out how to get 'em here...'

(8) Harm reduction is a universal approach, common in public health, clinical medicine and public policy generally. Wearing a safety belt when traveling by car or encouraging the use of motor cycle helmets is harm reduction. 'Never let the best be the enemy of the good' is a strong tradition in public health. It is also the essence of harm reduction. Nicotine gums and skin patches to assist smokers to quit smoking are other forms of harm reduction, no different in principle from the use of methadone or prescription heroin to assist heroin injectors and inhalers. I recently visited the former Nazi concentration camp in Terezin. Oscar Schindler in nearby Crackow saved many lives but did not shorten the war by a single day. We rightly revere the actions of the Allies in defeating Nazism just as we also greatly value the Oscar Schindlers of this world who reduced some of the harms of that terrible period.

(9) The WFAD Declaration rejects rigorous scientific trials evaluating heroin assisted treatment published in some of the top medical journals of the world. These trials have focused on treatment-refractory and severely dependent heroin users. Randomised controlled trials in Switzerland, the Netherlands, Germany and Spain have shown that the group receiving heroin assisted treatment did better than the control group. Trials are now underway in the United Kingdom and Canada. In the trial in the Netherlands, 58% of the group prescribed heroin improved compared to 22% of the control group. Where is the morality in denying drug users, their families and their communities the benefits of treatments demonstrated scientifically to be effective, safe and cost-effective?

Yours sincerely,

Dr Alex Wodak FRACP, FAChAM, FAFPHM,

Director,

Alcohol and Drug Service,

St. Vincent's Hospital,

Sydney, NSW 2010, Australia