Reducing the harm

‘Harm reduction’ is a politically sensitive term. After all, it means giving needles to drug addicts and condoms to prostitutes. When it came to reversing an epidemic of HIV and AIDS, however, it works.

That’s the view of Professor Michel Kazatchkine, UN special envoy to Eastern Europe and Central Asia, who was in Glasgow recently to speak at the second annual City Health conference.

Last week, City of Edinburgh Council signalled that it would stop granting public entertainment licenses to saunas and massage parlours where sex was thought to be sold. The report cited a “contentious climate”, possibly referring to increased raids on such places by a newly centralised police force.

Licensing was part of a policy framework drawn up in the 1980s to prevent the spread of HIV/AIDS, and included other harm-reduction policies of early needle exchanges, substitute prescribing and community engagement. It was a time when Scotland’s capital had been labelled ‘The AIDS capital of Europe’

Professor Kazatchkine believes that the city only got the moniker because of its pioneering work by Muirhouse GP Roy Robertson and others: “Indeed it got this reputation, but that’s because there were these pioneers who actually noticed these cases. I mean, the epidemic was everywhere, but it happened that people like Roy Robertson and others recognised it.”

Figures show considerable success in preventing the spread of the disease. “The early programmes in harm reduction, that’s how I became interested in Scotland,” said Kazatchkine.

During the 1980s, he was a practising doctor in Paris. Like Robertson, he was one of the first to recognise AIDS.

“The biggest underestimation, of course, was Africa. At the time when the disease was described in a few tens of people on the west coast of the US, there were already millions of people infected in Africa. The disease was not recognised, because the health systems were not there, the surveillance was not there, but also because there wasn’t this sort of clinical genius, that in the US a group of physicians thought, ‘Oh, this group of patients has something in common’ and in Edinburgh they recognised the epidemic very early.”

By the middle of the decade, he had set up a clinic in Paris specialising in testing for the virus, which had yet to be named. By 1988, he had set up a night clinic for treatment, which was much more “designed for people”.

“The purpose of the night clinic was something very different. It was because of the stigma and discrimination surrounding these patients. It was to allow them to come in, free of discrimination.”

Discrimination was very high after the virus was named, he says. The night clinic allowed people to come after work, and without leaving the city. It was in a hospital famous for treatment for heart disease, so not conspicuous. The health sector itself discriminated, Kazatchkine says: “To set up an HIV clinic in the 80s really brought a lot of resistance from doctors, police and nurses. People were afraid. People would dress up to enter a patient’s room. People would say ridiculous things like, ‘if we know this is an HIV patient, we need three pairs of gloves. All these precautions are just universal and not targeted.”

Not all stigma was avoidable, though: “The disease was the same disease for everyone, but everyone was putting that disease in the frame of his or her own social context. They were sitting in the same waiting room, and these were the days where we had no treatment. From the person who uses drugs that comes in with a lot of noise, and aggressiveness, sometimes, to some of the high middle-class cadre, who would come and open Le Figaro, you know, so that to hide away from the other people in the waiting room.”

Paris, like most of Europe at the time, had no harm reduction. Kazatchkine believes Scotland’s relatively small size allowed the interventions to have an impact early on, compared to small pilot schemes in a larger city or country.

Although tackling AIDS has “changed the world” with regards to changing attitudes and challenging stigma, according to Kazatchkine, there is still a long way to go.

“If you look at the detail of it, you see that when it comes to the marginalised populations – people who inject drugs, men having sex with men (MSM), sex workers, more and more migrants – when it comes to those populations, and people who are incarcerated, we’re seeing no progress, actually, we’re seeing a worsening of the epidemic. The typical case is in Eastern Europe and central Asia where the epidemic is, for the predominant part of it, concentrated within these populations.”

As more and more countries move to a ‘middle income’ status, he says, there will be concentrated epidemics among these increasingly marginalised groups.

In Africa the pattern is changing, Kazatchkine tells us. Although still overwhelmed by a heterosexual-driven epidemic, Nigeria, Tanzania and Cote D’Ivoire are recognising drug use. Some are recognising the existence of homosexuality too, “and it’s very brave of some countries, particularly Muslim countries like Senegal, and that the number of new infections among MSM is huge, in a country that only thought about heterosexual epidemics.”

In the UK, the number of new infections among men having sex with men has been stable over the last ten years, and may even be creeping up. Kazatchkine also warns that Westminster has been expressing more resistance to safe supervised injection rooms.

HIV Scotland has also expressed concerns over equality and human rights implications for people at risk of HIV. They cite current reviews of sex education in schools and regulations around healthcare workers with HIV as examples.

Attitudes around the world are dangerous, according to Kazatchkine, especially to drugs and law enforcement.

He told the conference “We have learned that since the beginning of what Nixon called ‘the war on drugs’, that drug policies based on repression, police brutality and incarceration, as in so many of the countries where I work, are fuelling the HIV and hepatitis epidemics at a horrific human and social cost.”

He is at pains to tell Holyrood that he is not talking about Police Scotland in particular, but he believes a societal shift is needed where law enforcement is an instrument of promoting health, not a barrier.

“But that requires big changes in law enforcement. If, for example, as is the case in many countries, the number of people you arrest is your performance index. What do you hear, what do you read in the press about how successful is a drug policy? It’s the amount seized, which is ridiculous. We know, anyway, what is seized is a tiny fraction of what circulates, and if you seize something in the ports of Glasgow, it will come through the port of Dundee, and if you put a wall in Dundee, it will go through Aberdeen, whatever.

“This is nonsense. And in no way is the amount of seizures related to the wellbeing of a society. So if people want health, with no HIV, no Hepatitis C when it comes to drugs, and if people want peaceful surroundings where they live, these should be the criteria.”

During his visit to Glasgow Professor Kazatchkine found an unlikely ally in his call for a change in priorities. He checks a photograph he has taken on his mobile phone.

“Our hosts here at the conference took me to a few pubs in Glasgow. One is the Horseshoe Bar. And there is a quote there from Queen Victoria. It says: “Abstinence is an impossibility, and it will not do to insist on it.” And I find this very interesting, because this new push for abstinence, for recovery, as an aim, as an objective, it’s very dangerous. Although there’s nothing wrong [with abstinence] in principle, the way that it steers policies, wrong attitudes is really worrying. I personally think it’s not an objective. The objective we must have is to acknowledge drugs exist, will always exist, will be with us, and that our primary concern is to reduce the harm from the drugs, and the harm they can bring. It’s not about getting everyone abstinent. “We’ve seen abstinence lead to human rights abuse in large scales in the rehabilitation camps in Asia. We have seen the plea for abstinence as the very basis of prohibition policies.”

The prohibition policies referred to are enshrined in the UN itself. The conventions on drugs date back to the 1960s and 1970s, before the AIDS epidemic. The next UN general assembly on drugs will be held in 2016, 20 years after the last one. Kazatchkine doesn’t expect anything to change. He predicts Russia, China, the US and others will abstain.

“If there is a change, that change will only come through a bottom-up process, and start with activism. More dialogue between the affected population, public health, the civil society, and the governments. How much governments are willing to listen to that? I don’t know. I have doubts, in the current political climate in Europe.”