‘Towards a Global Approach’–An overview of Harm Reduction 2008: IHRA’s 19th International Conference

Human rights 

One of the most pervasive and complex themes we identified running through the conference was that of human rights. The opening ceremony established the centrality of this issue when Professor Paul Hunt, the United Nations Special Rapporteur on the Right to the Highest Attainable Standard of Health, delivered the ‘2008 Rolleston Oration’. His address noted that human rights violations against people who use drugs are common around the world and rarely attract protest. Drawing attention to human rights is timely as 2008 marks the 60th anniversary of the Universal Declaration of Human Rights. Professor Hunt argued that there is a need for a more mature human rights-based approach to development, trade and related issues in drug policy with the concomitant need for new tools for measuring the impact of such programmes, such as human rights impact assessments.

Beyond the opening plenary session, human rights issues and concepts were frequently addressed throughout the conference and questions of the role of civil society in harm reduction were emphasised. For example, Graciella Touze (Abstract #1358) presented on the Latin American experiences in the Plenary Session entitled ‘The Global State of Harm Reduction’, and pointed out that many countries face external pressure to alter their drug policies and strategies from the USA (highly influential in terms of bi-lateral and multi-lateral funding).

On a slightly different but related tack, Gemma Calvet Barot (Abstract #1336 in the Plenary Session on ‘Criminal Justice, Human Rights and Drugs’) also addressed the issue of human rights, arguing that concepts and policies of human rights have been used to link drug policies, justice and security in Spain. This session also introduced a key issue for human rights foundations for harm reduction. As Damon Barrett from IHRA pointed out in his presentation in this same session, interpretations and concepts of human rights vary. As principles they are open to interpretation in a range of ways, and in some national contexts they are interpreted in ways that actually preclude drug users from being able to lay claim to their rights. Extreme examples of these variations in national approaches to rights were then supplied by Rick Lines from IHRA (Abstract #310 in a Major Session entitled ‘Human Rights and Harm Reduction’), who pointed out that 60 countries – including most nations in the Middle East, some in North Africa and the Asia Pacific region – still retain the death penalty for drug offences. By way of explanation for the relevance of this issue to harm reduction, Rick Lines noted that in Malaysia, 36 out of the 52 executions carried out between July 2004 and July 2005 were for drug offences. He went on to argue that given the death penalty is restricted by international law to the “most serious crimes” (such as murder) and that drug offences are not an appropriate basis on which to impose it. Douglas Bruce (Abstract #1256) also contributed to this debate by discussing the provision of methadone maintenance treatment in prisons, noting that while technically available in some places, in practice access is restricted by stigma.

On the final day, the keynote speech by Antonio Maria Costa, Executive Director of the United Nations Office on Drugs and Crime (UNODC), also had a human rights focus. He reiterated a previous statement that “although drugs may kill we should never kill in the name of drugs”, and called for recognition of the “Three HRs”—human rights, harm reduction and health responses. He argued that a primary or sole focus on harm reduction was “not right”, as such a focus could be construed as condoning or perpetuating drug use. He went on to outline the preferred UNODC package of strategies to prevent the spread of disease associated with drug use. This included measures such as increasing attention on drug prevention (for example, focusing on those who are vulnerable to drug use), more widespread and easier access to treatment for drug dependency without fear of stigmatization, and the mainstreaming of drug treatment within high-quality health services. At the conclusion of the address the audience engaged in energetic discussion of the package and also raised questions about other policies and activities of the UNODC.

Perhaps most obviously, these human rights-related discussions conducted at the conference reminded delegates that appeals to human rights act more to open up debates than to resolve them. There is no denying that the discourse of human rights is the product of a characteristically Western, neo-liberal philosophy and carries both positive and negative implications. While it is always necessary to emphasise the importance of respect for human rights, harm reductionists face the challenge (as do others) of thinking through and framing human rights in ways that recognise the self-determination and intrinsic value of other cultures, and to acknowledge that, for some, the language of human rights registers as a form of cultural imperialism. How can we negotiate the complexities of the origins of human rights globally? No small task for harm reduction.

Complexity 

These observations bring us to the next large theme running though the conference, that of complexity. In the context of human rights this partly means thinking beyond rights as purely individual (as prompted by the neo-liberal approach) to frameworks that recognise the need to also look at rights at a community level, and to reform structural barriers to the capacity of people who use drugs to claim their rights. This issue was particularly highlighted in the Discrimination Versus Rights session, where Ekta Thapa Mahat (Abstract #181) spoke passionately about her direct experience of human rights violations and routine stigma and discrimination as a female drug user in Nepal. Ekta and other speakers in the session – including Pere Martinez from Spain (Abstract #1350) and Fredy from Indonesia (Abstract #1096) – all focused on the need to empower drug users to claim their rights through the removal of harmful policies, structural barriers and legal impediments and through educating and encouraging drug users to speak and act on their own behalf.

Here the issue is about the complex risks we run by focusing only on efforts to change the behaviour of people who use drugs. In doing so, do we neglect the structures that fundamentally shape behaviour? For example, Sophie Pinkham (Abstract #1210) described access to confidentiality in health service use as a commodity for sale rather than a right that all clients possess. This presentation (in a session on ‘Women, Harm Reduction and HIV: Obstacles and Opportunities’) described some of the ways that structural barriers to accessing health services can be created. Other presentations that explored structural barriers to accessing harm reduction included Scott Burris’ address (Abstract #859) in the ‘Criminal Justice, Human Rights and Drugs’ Plenary Session—on policing as an epidemiological force (that is, the role of policing practice in producing risk behaviour).

Another challenge to developing and delivering sophisticated harm reduction approaches is the need to recognise and address the multiple contexts in which drug use can occur and the multiplicities of identities and social positions occupied by people who use drugs. If we understand that contrary to some service provision, policy and research practice, people do not live their lives in fragmented ways – they do not neatly fit into our ‘special interest groups’ such as youth, women, prisoners, indigenous – we will work towards harm reduction responses which are recognisable to the people (in all their complexity) they seek to engage.

A further force in shaping drug using identities – the pleasure associated with drug use – was largely missing from this conference. This gap in the programme was noted in the acceptance speech of the winner of the 2008 Travis Jenkins Award, Theo van Dam, who highlighted the importance of pleasure in many aspects of drug use. Harm reduction needs to develop ways in which pleasure can be acknowledged in policy, service delivery and research without endangering funding and programmes based on conventional medical approaches.

Evidence 

The third theme running through the conference was that of evidence. This echoes the previous theme of complexity in that it throws up some very challenging and complex issues for harm reduction strategising. Two main issues emerged here: the lack of means for gathering the evidence required to support harm reduction measures, and the broader question of evidence and its relationship to traditional approaches to drug use that would otherwise condemn harm reduction. On the first point, Michael Bartos from UNAIDS (in one of the early-morning ‘Global Issues’ keynote sessions) argued that there is a lack of evidence of the harms emerging from contradictory policy spheres. For example, the responses necessary to address HIV transmission (such as needle and syringe programmes) may be at odds with the values and attitudes which underpin responses of other sectors to drug use – particularly those of justice and policing – which may oppose or obstruct access to sterile injecting equipment. There is little effort currently directed to examining the impact of such responses of police on the harm reduction goals of HIV prevention and to other areas where policies have opposing goals and processes.

Taking a slightly different approach, Louisa Degenhardt (Abstract #1354) noted in her address (as part of the Plenary Session on ‘The Global State of Harm Reduction’) that evidence for global (or even national) drug use is poor, and where there is evidence it is often used in ways that do not serve the legitimate health, social and justice interests of people who use drugs. Poor evidence can produce a lack of confidence in research and policy responses alike, and can result in the mis-targeting of resources as the state of evidence is currently not strong enough to guide global policy. In the same session, Lanre Onigbogi (Abstract #1357) made a similar point with specific reference to harm reduction in Sub-Saharan Africa.

Beyond this lack of good evidence is the issue of the distortion of evidence to serve political and moral agendas. Thomas Kerr (Abstract #705) described an example of this issue in the Major Session on ‘Evidence in Harm Reduction’, presenting a case study of the perversion of evidence surrounding ‘Insite’ (the supervised injection facility in Vancouver, Canada). Here, the positive evaluation reports were not only derided by various groups, but other data were generated to show different (and more negative) findings and to provide a basis for opposing such facilities. Thomas Kerr’s presentation included a description of his use of free media and processes of government (such as the Freedom of Information Act), and their reliance on their own institutions to influence the debate and eventual outcome. While researchers should never consider their work to be divorced from social, historical and political forces, the lessons from Vancouver are sobering. The researchers in Vancouver were able to harness institutional, media and governmental resources to defend their work. Researchers working in harm reduction programmes in most countries of the world may also be subject to such assaults but will have not have access to such commanding but expensive resources.

This issue also has more far-reaching implications. The Concurrent Session entitled ‘Ethno-Epidemiological Approaches to Understanding and Reducing Drug-Related Harm’ gave rise to a lively debate in which the audience and presenters grappled with broader epistemological questions of evidence. Prompted by David Moore’s presentation (Abstract #349) on collaborative work bringing together ethnography and epidemiology, discussion ensued as to the different ways in which evidence can be interpreted. Informing the discussion was a critique of evidence as being intrinsically political (despite many researchers’ best efforts to maintain ‘unbiased objectivity’) and the implications of this when calling for the ‘evidence base’ for harm reduction to increase. How should we understand evidence? Critiques of scientific objectivity have rendered simple claims about the value of evidence untenable. Research and the evidence it produces is always shaped by, and can never be separate from, politics and the historically and socially shaped perspectives of the researchers. From this point of view, claims that evidence per se can counter the corrupting influence of politics do not make sense.

A global approach 

Indeed, in relation to the fourth theme identified in the conference, it is important to note that the evidence base informing harm reduction strategies, programmes and interventions has historically resided within epidemiology and bio-medicine—institutionally powerful disciplines which are neither politically disinterested nor merely scientific. According to some harm reductionists, the success of bio-medical interventions in improving the immediate health needs of individuals who use illicit drugs has eclipsed appeals for consideration of other forms of evidence which support larger structural change aimed at providing long-term (but politically more ambitious) solutions to global drug problems. For example, for some years the privileging of bio-medical evidence and outcomes has created tension within the harm reduction movement as activist proponents have criticised medical harm reduction for its reluctance to challenge global drug prohibition. Activists argue that many health professionals refuse to acknowledge evidence which indicates that current drug policy creates serious health problems among people who use illicit drugs.

Given this historic tension, the theme of this conference – ‘Towards a Global Approach’ – might imply a reconciliation of disparate and competing priorities within the modern harm reduction movement, as much as any mission to universalise harm reduction strategies, programmes and interventions. Arguably the attainment of an effective global approach to harm reduction is contingent on a reunification of its two pillars—activism and health-related intervention. The conference provided cause for optimism here. In a range of sessions, researchers, health professionals and activists alike argued that critical assessment of structural factors such as drug prohibition is a necessary part of ensuring that social and legal systems do not cause harm to people who use drugs. For example evidence of problems associated with a renewed emphasis on the policing of cannabis was discussed in a presentation from Jean-Pierre Gervasoni (Abstract#1102 in the Concurrent ‘Cannabis’ Session). Similarly, a lunchtime session entitled ‘Beyond Prohibition: Controversy and Tension Within Harm Reduction’ (organised by the Transform Drug Policy Foundation) presented evidence regarding the negative impacts of current global drug policies from Steve Rolles, Donald MacPherson and Mark Haden. It is hoped that IHRA will see merit in relocating this important topic from the fringes of the conference and to a more prominent position for ‘Harm Reduction 2009’ in Bangkok, Thailand (19–23 April; http://www.IHRAconferences.net). Such a move will help facilitate engagement with a diversified and expanded notion of evidence through which a global approach to harm reduction might be constituted, and will also be critical in shifting the debate about harm reduction and human rights beyond broad principles and concepts to a discussion about how we ensure practical implementation at the global, national and community levels.

Although the attainment of a just global approach to harm reduction remains some way off, the conference nonetheless provided an invaluable platform for showcasing the uniqueness of drug use and harm reduction in different contexts around the world. In seeking a unifying framework, we need to reflect on how general global messages are experienced at the local level. For example, Tim Rhodes (Abstract #248 in the ‘Double Concurrent’ session organised by the UNODC and World Health Organization, entitled ‘Universal Access to HIV Prevention and Treatment for Drug Users’) talked about the role of global declarations of intent regarding access to HIV treatment in light of severe disruptions, uncertainties and fragilities regarding the supply of treatment in low- and middle-income countries.

Likewise, in a Concurrent Session on ‘Drug Use Surveillance’, Benjamin Phillips (Abstract #742) considered the dangers of blanket responses to drug use issues. In examining global consumption patterns, he pointed to the risk that responses to over-consumption of morphine in some countries due to diversion will lead to the under-provision of morphine for those who need it for pain relief. This presentation also raises the complex issue of diversion and its relationship to unmet need for pain relief, particularly among people who have difficulty accessing health services or making their health needs appear legitimate.

It is clear that we need to be cautious about developing general or global models as they can disadvantage or exclude those with less powerful voices. We need to be aware of the potential disconnect between global declarations of intent and the capacity of systems to actually deliver on promises. We need to keep asking how this disconnect impacts on individuals.

Conclusion 

A conference of this range and diversity inevitably produces an equivalent variety of responses. In focusing on the four themes covered here (human rights, complexity, evidence and the global approach), our aim is mainly to spark further thought and to suggest areas for continued exploration next time around. While these themes can take delegates in many different directions, they also share at least one common element—they all map harm reductionists’ continuing need to refuse premature or simplistic answers. With human rights, we need to combine sensitivity with determination in applying these ideas. With complexity, we need to address people, politics and drugs themselves in all their contradictions if we are to make lasting or desirable change. With evidence, we cannot rely on simple distinctions between politics and evidence, or emotion and fact, if we are to understand effectively how knowledge about drug use and risk is generated. Finally, we cannot assume that global approaches are equitable. Indeed, to go global in ethical and effective ways, we need to work constantly to ensure that a global approach does not come merely to promote the normative. As we said at the outset, there are no simple answers here. But along with the need to address these challenging issues, the conference also revealed the delegates’ (and to some extent the harm reduction movement’s) willingness – indeed at times their humbling determination – to take on the task of doing so.