Injecting drug use and the right to health in Sweden

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The International Harm Reduction Association's new HR2 Harm Reduction & Human Rights programme, in conjunction with the Swedish drug users union, has today published a report examining the issues around the state's response to the growing health problems (specifically blood borne diseases) relating to injecting drug use in Sweden, and the inadequate provision of harm reduction services for Sweden's growing population of drug injectors.

The report has been produced as a shadow submission to the Swedish Government's own report to the UN Committee on Economic Cultural and Social Rights. States that have ratified the Convention on Economic, Cultural and Social rights are required to periodically submit reports to the Committee, which acts as an independent body overseeing adherence to the convention (similar bodies exist for all UN treaties).

The IHRA report background intro notes that:

This report examines Sweden’s obligations under Article 12 of the International Covenant on Economic, Social and Cultural Rights. It reviews the failure of Sweden to provide comprehensive harm reduction programmes, such as needle exchange, for people who use injecting drugs. The failure to provide such essential preventative health interventions places people who inject drugs at unnecessary and avoidable risk of HIV and hepatitis C infection, and therefore reflects a failure of the State party to respect, protect and fulfil the right to the highest attainable standard of health for this most vulnerable and marginalised population.

Sweden has one of the best domestic human rights records in the world, and in the area of economic, social and cultural rights stands above most countries in terms of life expectancy, standard of living, education and healthcare. However, there are sections of Swedish society that do not enjoy this high level of human rights protection. Some communities, like the Saami and Roma, are increasingly recognised in Swedish human rights policy as suffering from marginalisation and discrimination. Others, such as people who use illegal drugs, also experience the effects stigma and discrimination, yet this goes largely unrecognised. One illustration of this is the fact that injecting drug use and related harms such as HIV and hepatitis C infection are entirely omitted from the State’s report to the Committee, as are any references to measures taken to address drug use and reduce drug-related harms.

In 2006, Professor Paul Hunt, UN Special Rapporteur on the Right to Health, undertook a mission to Sweden. While praising the overall state of human rights, the Special Rapporteur stated that there was no room for complacency and highlighted the specific situation of people who use drugs. Professor Hunt was critical of the poor provision of harm reduction services, especially needle exchange, despite international evidence of the effectiveness of these measures in preventing HIV and hepatitis C transmission among injecting drug users (IDUs). The Special Rapporteur visited a needle exchange programme in Malmö, one of only two in the country, and confirmed that harm reduction “enhances the realization of the right to health, including sexual and reproductive health, for intravenous drug users”. He recommended that Sweden adopt, as a matter of priority, comprehensive harm reduction services throughout the country.

Swedish drug policy is fascinating. Behind the veneer of a highly developed social welfare system and operating within wider policy paradigm of public health pragmatism is a somewhat incongruous dogmatic and moralistic view of drug use. It has resulted in a zero tolerance approach to drugs and drug users involving harshly enforced prohibition and a general disdain for harm reduction principles and practice (see this recent article in Druglink magazine for more discussion) .

The IHRA report notes that (page 6):

Sweden follows a strict law enforcement approach to drug use, rather than the health-based approach utilised in many other countries. Harsh sentences are imposed, including penalties for drug use itself. Indeed, Sweden is one of the few countries in the world to impose prison sentences for the use (rather than the possession) of drugs. Coercive testing and treatment are also utilised.

It has been found by Sweden’s own National Council for Crime Prevention that “based on available information on trends in drug misuse there are no clear indications that criminalisation and an increased severity of punishment has had a deterrent effect on the drug habits of young people or that new recruitment to drug misuse has been halted”. As noted above, the number of people injecting drugs in Sweden has continued to grow despite the country’s harsh law enforcement responses.

Evidence from other parts of the world has shown that harsh criminal sanctions are counter-productive to HIV prevention efforts among injecting drug users, as they are less likely to engage with the relevant health programmes for fear of identifying themselves.

read the full report here (pdf)
includes references left out of the above quotes

Sweden's drug policy: A reality check.

The following article, in a slightly edited form, appears in this month's druglink magazine.

Swedish massage

The perception that low drug use levels in Sweden are a direct result of the country’s tough anti-drugs policy is finding considerable traction in the UK. But, argues Steve Rolles, it is both simplistic and misleading.

Ian Duncan Smith is flagging up the success of Sweden’s drug policy in his new in his role as chairman of the Social Policy Review Group, currently overhauling Tory drug policy in the run up to the next General Election. David Cameron visited the country in February in an attempt to distance himself from his days of cannabis smoking. In the words of the Daily Mail he “praised the tougher approach in Sweden, which does not distinguish between cannabis and harder drugs such as heroin, and practices a zero-tolerance policy.”

In September last year the UN Office of Drugs and Crime produced a report titled 'Sweden's successful drug policy: a review of the evidence'. Launching the document, UNODC Director Antonio Costa repeated his catch phrase that 'societies have the drug problem that they deserve', noting specifically that “in the case of Sweden, the clear association between a restrictive drug policy and low levels of drug use, is striking”.

Sweden's 'successful' policy closely follows, in both letter and spirit, that espoused by the UNODC. Because Sweden has comparatively low European levels of drug use it is perhaps unsurprising that the UN’s drugs office chooses to proclaim the country as a model of good practice, especially given the backdrop of rising drug use globally. Sweden, perhaps not coincidentally, is the UNODC's third largest state funder (nine per cent) after the US (13 per cent) and Italy (11 per cent)*, and has the clearly stated and unambiguous aspiration to a 'drug free society'. This manifests in its tough zero-tolerance approach involving heavy handed policing, the widespread rejection of harm reduction principles, and a focus on coerced abstinence-based treatment.

However, by putting the emphasis so heavily on prevalence success, the UNODC conveniently brushes over some of the less positive aspects of Sweden’s drug policies. According to the country’s nascent user movement, the aversion to harm reduction (shared with the UNODC but notably not the WHO, and UNAIDS) has contributed to Sweden's drug death figures doubling from around 200 to 400 since 1990, placing it high in the Euro rankings. Problematic drug use has also almost doubled since 1980 to a level hovering around the European average.

Furthermore, Costa's suggestion that there is a obvious causal relationship between prevalence and UNODC-style drug control policy appears unsustainable. Various countries have comparable or lower levels of drug use than Sweden but have very different drug policies. Greece, for example, (according to the EMCDDA), has the lowest level of drug use in Europe but spends approximately one-fiftieth on per capita drug-related expenditure that Sweden does. Holland, also has well below the European average drug use, spends more than Sweden per capita, but has a tolerant / harm reduction-led policy that is the polar opposite of the Sweden UNODC model. Conversely, another repressively oriented country - third in the Euro drug-related expenditure tables - is the UK, which sits at the top of most European drug use prevalence tables. We have yet to see a UN report titled 'The UK’s unsuccessful drug policy: a review of the evidence', indeed if the UK Government buys into Costa's analysis they must be wondering what they have done to 'deserve' our high prevalence rates.

The alternative theory, one not based on the UNODC's public relations crisis and overtly political prerogatives, would be that levels of drug use are determined by a complex and highly localised interplay of multiple social, cultural, economic and demographic variables, and that government drug policies, specifically enforcement and prevention efforts, have, at best, only marginal impacts.

Dr Peter Cohen, Director of the Centre for Drugs Research at the University of Amsterdam, has argued that Sweden's low level of drug use and repressive drug policy, rather than being causally linked, are in fact both merely expressions of its historically temperance oriented culture, noting that Sweden also has historically low levels of alcohol, tobacco and prescription drug use. It is also worth pointing out that Sweden has low levels of social inequality, social deprivation, and unemployment, combined with a very high level of health and social welfare spending. There's a lot to admire about Sweden, but even they can play drug-war politics.

* since publication of this article a new UNODC annual report has been published with the UNODC funding rankings shifting slightly (see page 89). Creeping into the number one spot for individual state donors, coincidentally in the year the glowing Sweden report is published, is.....Sweden (9%). The US slips to number two (8%) and straight in at number three is.....The UK, at 7% - a shade under 11 million US dollars. Bargain.

Steve Rolles is information officer for Transform

Sweden: a prohibitionist success story?

Sweden is often regarded by many people as having some of the most progressive social policies in Europe. So it may come as a surprise to those who lack an encyclopaedic knowledge of European drug policy to learn that Sweden operates one of the most staunchly prohibitionist drug control policies in Europe.

It is probably less of surprise to learn that Sweden’s orthodox drug policy, and relatively low level of drug use, means that prohibitionists often use it as an example of a successful prohibitionist drugs policy.

In September 2006 the United Nations Office for Drugs and Crime (UNODC) published a report praising Sweden’s drug control policies claiming that Sweden’s low drug use was a direct result of it’s drugs policy.

A comment piece by Peter Cohen, published on the Centre for Drug Research website, has questioned much of the UNODC report. His main criticism is that the report lacks scientific legitimacy because it fails to provide any evidence for a link between drug policy and drug use. He also criticises it for hand picking data, failing to make a distinction between drug use and drug abuse, and ignoring some of the negative consequences of Sweden’s drug policy.