Overcoming the 'Stockholm Syndrome' pt 4: 'A comprehensive care system'

Our reports on the World Forum Against Drugs meeting in Stockholm in September have to date focused on some of the more outrageous statements or documents that emerged from the conference. Within the speeches and presentations, however, there were occasional examples of more comprehensive and measured approaches.

Of note is the speech of the Swedish Minister for Public Health, Mrs Maria Larsson. While elements of the statement are certainly questionable, and we disagree with many aspects of Swedish drug policy, the Minister's comments relating to harm reduction are welcome. This is particularly so given the forum she was addressing, where an outright denunciation would have been more than acceptable to many members of the audience.

Reaffirming first that the publicly supported vision in Sweden is a drug free society, Mrs Larsson informed the forum that Sweden's 'view is that some measures of harm reduction are a complement to other policies and efforts. Therefore, during your visit here, you will see that Sweden accepts measures aimed at limiting the adverse consequences of drug abuse. But they can never be the only policy option. They are elements in a comprehensive care system...To reduce the demand for drugs and to tackle the negative social and health consequences are complementary efforts'.

'A comprehensive care system'. We couldn't have put it better ourselves.

But there are significant gaps in Sweden. The country's harm reduction services leave a lot to be desired. Official figures show that in 2007, almost 30% of new HIV infections, 52 out of 178 that occurred in Sweden (as opposed to figures including migrants being diagnosed in Sweden) were through injecting drug use.

There is no harm reduction is prisons despite the large percentage of people in prison who are injecting drug users. There are only two 'experimental' needle exchanges in Sweden, with none in Stockholm. In 2005, new legislation was adopted which legalised local needle exchanges. It was a pyrrhic victory. Unfortunately, the legislation was so poor and so restrictive that no new needle exchanges have in fact materialised. Since 2000, Sweden has been slowly scaling up OST, with around 2,800 people currently accessing either methadone or buprenorphine. During that time there has been a decrease in drug related deaths, which is unsurprising when OST has been shown to reduce deaths from overdose by as much as 80%.

This progress on OST should be commended. However, waiting periods for opioid substitution therapy can be as long as four years – two years of documented opiate addiction being a requirement, and a further two years due to lack of resources. Most people injecting drugs in Sweden will have contracted hepatitis C in that time.

In her speech, Maria Larsson stated that 'The government's primary role is to make policy decisions, to draw up overall strategies - after listening to the NGOs - and to give the appropriate support.' This is another welcome statment and commitment to civil society engagement. The problem, however, is that the range of NGOs being listened to in Sweden is extremely narrow, as our colleagues at the Swedish Drug Users Union can attest. Nobody is listening to drug users in the formulation of harm reduction policies, which renders them at best less effective than they could be, such as the overly restrictive OST policies, and at worst completely ineffective such as the recent needle exchange legislation.

Another key element of Swedish policy, however, comes through from the speeches of both the Minister for Public Health and the Mayor of Stockholm, Sten Nordin (who set out his city's drug and alcohol strategy which includes reducing 'the injurious medical and social effects of alcohol and narcotics'). Sweden has excellent social safety nets: world class benefits for families and unempoyment assistance, top rated health care and education systems. These are all essential to any 'comprehensive care system', yet are rarely acknowledged when the 'successful' Swedish drug model is cited by harm reduction opponents as an example to be emulated (ironically many of those voices or from the US, where access to health care is dependent on your ability to pay).

Even with these social safety nets in place, however, some people will fall through. The situation of those that do use drugs in Sweden must be fully addressed, including those unwilling or unable to undergo abstinence based treatment. A drug free Sweden has no meaning for those that live in the reality of drug-taking Sweden. The 'vision' of a future drug free society does nothing to improve their health, housing or employment today. And that vision must not interfere with these immediate needs, or basic human rights.

As noted by the Mayor of Stockholm, however, the true extent to problematic drug use in his city is unknown. He is correct. Where he is incorrect is in suggesting that this may indicate low levels of 'heavy' drug use. (Elsewhere in his speech he recognises increases in availability and experimentation among young people) The reality is that Sweden has no reliable figures on the extent of problematic drug use. The last comprehensive study was carried out in 1998. In recent years EMCDDA has relied on hospital discharge rates with drug use as a primary or secondary diagnosis as a measure of 'problematic drug use' and placing the number in 2003 at close to 26,000. These figures are in fact a better measure of morbidity and illness among those that are using drugs than the amount of actual drug users. What they show is that in a given year over 25,000 people who use drugs attended hospital because of their drug use. The real number of drug users could be much higher. Injecting drug use has never been specifically measured despite the specific health related concerns connected to injecting practices.

These are considerable limitations. If the Government does not know the extent of the problem it cannot responsibly address it. And it cannot ensure that the 'comprehensive care system' targets those in need of interventions specific to their needs and patterns of use.

We raise these issues again, for they have indeed been raised time and again, to highlight the complexities of the situation in Sweden and the Swedish model. It is not simply about zero tolerance and criminalisation. It is not simply about 'just say no'. And it is certainly not about the hystrionics of the Declaration of the World Forum Against Drugs.

While there are many concerns about Sweden's drug policy and the country's considerable shortcomings in relation to harm reduction, and although the speeches of Sweden's politicians are misguided in many ways, they are a welcome read among the material emanating from the 1st World Forum Against Drugs. It is a shame these more measured messages did not make it into the forum's declaration.

Some of the main speeches from the World Forum Against Drugs, including those metioned in above are available at www.drugnews.nu

Overcoming the ‘Stockholm Syndrome’ pt. 3: 65 words on human rights...

…and that includes the title!

The detailed human rights analysis you can see on the left was written by David Evans, Esq. as part of a report entitled 'In Support of the UN Drug Conventions: The Arguments Against Illicit Drug Legalization and Harm Reduction – A Critical Analysis'. This report was included in the conference pack at the World Forum Against Drugs in Stockholm earlier this month. In case you're wondering, Mr Evans is a Special Advisor to the Drug Free America Foundation as well as the Executive Director of the Drug Free Schools Coalition which promotes student drug testing in the US.

Now, they say that brevity is a virtue, but condensing 'A Critical Analysis' of the complexities of international human rights law and the conflicts of laws between the UN human rights and drug control treaties into a mere 65 words is truly an astonishing accomplishment.

We thought we’d have a look at his arguments, one sentence at a time.

Human Rights Issues

1. 'All UN programmes strive to protect human rights.'

Ostensibly. But the process of mainstreaming human rights into all UN programmes is an ongoing and difficult one in which the the drug control side of things lags far behind.

Also, 'strive' is not really the most accurate word to describe UN reponsibilities in the area of human rights. It would be more correct to say that all UN programes have the obligation to protect and promote human rights. Therefore, not only must UN programmes strive to expand and strengthen human rights protections, they should also never have a negative effect on human rights.

2. 'What is and is not a human right in the drug abuse context is open for interpretation.'

We’d say ‘in need of elaboration’. But in any case, some things are pretty clear.

For example, the right to the highest attainable standard of health is certainly a human right directly connected to drug policy, and it has been interpreted by the former UN Special Rapporteur on the Right to Health and the UN Committee on Economic, Social and Cultural Rights as including harm reduction programmes for people who inject drugs.

The application of the death penalty for drug offences of any kind is a violation on international human rights law according to the UN Human Rights Committee and the Special Rapporteur on Extrajudicial, Summary or Arbitrary Executions. Even UNODC Executive Director Antonio Maria Costa has spoken against the application of the death penalty for drug offences.

Crop eradiaction programmes via aerial spraying have been criticised by the UN Committee on the Rights of the Child and the UN Special Rapporteur on the Right to Health.

3. 'Some believe that they have a human right to use drugs.'

They do indeed. But as Dr Ben Goldacre said at the recent Release conference on drugs, race and discrimination 'it’s a little more complicated than that'. Hence the need for elaboration and more sophisticated human rights discourse than provided here.

4. 'Some others believe that they have a human right to a drug free society.'

Well, at the risk or repeating ourselves yet again, there is no human right to a drug free society, no matter how many times the opponents of harm reduction try to claim one.

5. 'There is nothing in the Conventions that interferes with fundamental human rights.'

Ah, now that is an interesting assertion.

Firstly, it is highly questionable indeed that nothing in the drug conventions interferes with human rights. To our knowledge no specific comparative analysis of the drug conventions and human rights conventions has been done (any PhD students out there looking for a thesis?).

Secondly, the question, in any case, is one of interpretation by national governments, and one of implementation. Crop eradication programmes so clearly and directly have the potential to interfere with human rights (and have in many cases done just that) that the relevant provision in the 1988 Drug Convention is the only one to specifically mention the need to protect them (It's found under Article 14(2) in case anyone is looking for it).

Russia interprets the Drug Conventions to exclude access to opioid substitution therapies, a violation of the right to health as interpreted by the Committee on Economic Social and Cultural Rights.

Others adopt the ‘restrictive’ nature of the Conventions and take this to extremes, including the application of the death penalty and the use of abusive coerced ‘treatment’. Indeed, the commentaries to the Drug Conventions recognise this potential, stating that they should be implemented ‘subject always’ to the requirements of human rights law.

In closing, you may note in the image above that the paragraph immediately prior to Mr Evans's human rights treatise describes him having a problem with the ‘presence a the policy table’ of certain groups. He’s talking about people who use drugs. More specifically, people who use drugs and disagree with him. So much for human rights, considering that participatory decision making is a central tenet of human rights based programming.

Why Russia says no to Methadone

From Drug Reporter, the drug policy website of the Hungarian Civil Liberties Union

By Peter Sorosi

The HCLU video advocacy team attended the Second Eastern Europe and Central Asia AIDS Conference (EECAAC) in Moscow, 3-5 May, 2008. Our main priority was to interview narcologists (addiction specialist doctors) and create a short advocacy movie on the lack of methadone substitution treatment in Russia. We believe that it is one of the biggest scandal of the world of drug treatment that substituion treatment is banned in a country with 1,5 million people living with HIV – the majority of them infected through the sharing of injecting equipment. Methadone substitution treatment is one of the best available tools of HIV prevention among injecting drug users according to all relevant international organizations (e.g. WHO, UNODC, UNAIDS), the scientific literature proving its positive impacts on public health and security can fill a whole library: it improves the health and social well-being of users, it prevents them from committing crimes, it decreases illicit drug use and needle and syringe sharing among them. Together with the majority of drug treatment specialists from all over the world we are confident that the lack of access to methadone maintenance treatment in Russia is a basic violation of the human rights of people who use drugs.

So, why Russia says no to methadone after all?

Watch our video to find the answer(s)!

Overcoming the 'Stockholm Syndrome', pt. 2 - Oh My Ghodse!

Here at HR2, we are still sifting through the various speeches and statements from the World Forum Against Drugs, held in Stockholm earlier this month. Today we came across the speech of Hamid Ghodse, President of the International Narcotics Control Board (INCB).

After passing a copy of the speech around the office, we decided we just couldn't let Professor Ghodse's comments stand without some serious fact checking.

His speech begins with the rather grand statement that:

'Throughout its forty years of existence, the International Narcotics Control Board has valued and benefited from the knowledge and actions of NGOs and other members of civil society in addressing the drug problem.'

Well, this would be great if it were true! In fact, INCB is notorious in the NGO-world for being completely closed to the participation of civil society. As stated last year by Professor Ghodse's predecessor, former INCB President Philip Emafo, the INCB's mandate is only to 'discuss with governments', and its mandate is 'not with civil society'. INCB's history of secrecy and unwillingness to engage with civil society is well documented is our report, 'Unique in International Relations?' as well as in the excellent report 'Closed to Reason: The International Narcotics Control Board and HIV/AIDS' by the Canadian HIV/AIDS Legal Network and the Open Society Institute.

We hope Professor Ghodse's comments reflect a commitment that the INCB under his Presidency will welcome civil society participation, in the way so many other similar UN bodies do. We will wait and see.

Professor Ghodse then goes on to question 'harm reduction' (the quotation marks around the term are his).

'It is regrettable that, in some places today, injection rooms appear to be playing a similar role to that played by opium dens nearly a century ago. At best, injection rooms undermine the spirit of the Conventions which seek to limit the use of drugs to medical and scientific purposes. At worst, under the banner of “harm reduction”, they serve to normalise illicit drug use, which is both unhealthy and harmful, and violate the international drug control treaties.'

This statement raised more than one eyebrow around this office! With good reason....

In 2002, the INCB itself commissioned a study from the Legal Affairs Section of the UN Drug Control Program (UNDCP) entitled 'Flexibility of Treaty Provisions as regards Harm Reduction Approaches'. The UNDCP's own legal experts concluded that substitution treatment, needle exchange programmes and yes even safe injecting rooms do not breach the international drug control treaties.

Whatever Ghodse is basing his comments on, it clearly isn't the legal opinion of UNDCP's own legal division. How can harm reduction 'undermine the spirit of the [Drug] Conventions' when such programmes are consistent with - and not in violation of - the treaties? Seems a bit of a stretch, but we're sure it went down a treat with the harm reduction opponents behind the WFAD conference.

And while we're on the topic of the INCB and harm reduction, earlier this year the UN Office on Drugs and Crime in partnership with INCB produced a report entitled 'Reducing the adverse health and social consequences of drug abuse: A comprehensive approach'. This report explicitly supports harm reduction interventions such as needle exchange and substitution treatment. To quote from the Preface of the report:

'“Harm reduction” is often made an unnecessarily controversial issue as if there was a contradiction between prevention and treatment on one hand and reducing the adverse health and social consequences of drug use on the other. This is a false dichotomy. They are complementary.'

Apparently the notion that harm reduction is complementary to treatment and prevention has yet to trickle up to the INCB President's office. Interestingly enough, Ghodse is appointed to the INCB by the World Health Organization. As WHO explicitly supports harm reduction, one is left to wonder how and why their own appointee appears not to support WHO policy?

While Ghodse questions the validity of harm reduction, his speech lauds drug prevention programmes. However, he notes that 'prevention cannot be expected to be 100 per cent successful'.

While we certainly have no problem with drug prevention initiatives - so long as they are factual, non-sensational, non-stigmatising and properly evaluated as to their effectiveness - we have to wonder why it acceptable that prevention programmes are not expected to be 100% effective, when harm reduction programmes are criticised by the WFAD crowd when they aren't 100% effective? But as should be evident from above, internal consistency in not necessarily a strong suit of Professor Ghodse's speech.

Finally, Ghodse makes a number of statements on human rights. We certainly welcome his recognition of the 60th anniversary of the Universal Declaration of Human Rights and his statement that 'we should be mindful of the importance of protecting human rights which are universal, indivisible and unalienable.' However, he then goes on to make up his own interpretation of international human rights law, talking about a right to 'be free from drug addiction'. As explored in our previous blog post on the WFAD conference, there is no such right under international human rights law (although this fact does not stop many anti-drug groups from trying to make one up).

Hope you enjoyed part 2 of our reports from WFAD. Stay tuned for the next installment coming soon......

Overcoming the 'Stockholm Syndrome': Five questions for the World Forum Against Drugs

There was a big party in Stockholm last week to which neither we, nor many of our friends, were invited. It was titled the World Forum Against Drugs (WFAD). Actually we’re not surprised we weren’t invited, as it was mostly only those soldiers marching in lock step with the ‘war on drugs’ who were included in the conference programme.

In essence, WFAD was the zero-tolerance crowd's response to the Beyond 2008 NGO Forum on Drugs, which took place in Vienna in July. That meeting agreed a significant Declaration and Recommendations from civil society to the Commission on Narcotic Drugs. As the drug warriors were unable to get their way in Vienna, they instead decided to organise their own party. The big ‘achievement’ of this event was the production of the Declaration of the World Forum Against Drugs, signed on September 10th by 11 organisations (Yes that's them in the photo, with Calvina Fay of the Drug Free America Foundation front and centre). Given that the WFAD conference says it hosted over 600 participants from 82 countries, 11 signatories is a pretty unimpressive number. By way of comparison, the Declaration of the Beyond 2008 NGO Forum was agreed by consensus by the 300 delegates in attendance.

Before IHRA feel we can consider adding our name to this new Declaration, there are a few questions we need WFAD to clarify for us (Sorry for the delay in making our decision, but as we weren’t invited to the Stockholm shindig we didn’t have a chance to ask them earlier).

So here we go.

1. Why does the WFAD Declaration misrepresent the broad international support for Harm Reduction?

The preamble of the WFAD Declaration states that 'some organizations and local governments actively advocate...and promote policies such as “harm reduction”'.

Wow, from this description one would think harm reduction is an approach limited only to the lunatic fringes of some out of touch local governments. In fact, at least 82 countries and territories worldwide support harm reduction in official policy. Harm reduction is the official policy of UNAIDS, UNICEF, WHO and the European Union. Even WFAD’s beloved UNODC and INCB support harm reduction now. All of this is detailed in our report, Global State of Harm Reduction 2008.

Come to think of it, the Declaration that came out of the Beyond 2008 NGO Forum in Vienna earlier this year (a meeting in which many of the signatories to the WFAD Declaration participated) supported harm reduction.

2. Why does the Declaration misrepresent the content of the UN Convention on the Rights of the Child?

The WFAD Declaration in Art 1 states that it supports the UN Convention on the Rights of the Child, and suggests that the Convention supports WFAD's opposition to harm reduction. This is simply untrue. In fact, the Convention guarantees the right to access to information (Art 13) and the right to health (Art 24), which according to UN experts includes harm reduction as a means of preventing epidemic diseases.

The WFAD Declaration then misquotes Art 33 of the Convention on the Rights of the Child, suggesting it ‘stipulates…that children have the right to be protected from drug abuse.’ In reality, Art 33 states that governments ‘shall take all appropriate measures, including legislative, administrative, social and educational measures, to protect children from the illicit use of narcotic drugs and psychotropic substances’. This is really quite different than what WFAD claims. For example, the use of methadone and buprenorphine to treat opioid dependence is not an ‘illicit use’, so is outside of the remit of Art 33. Harm reduction as a part of a rights based approach to HIV prevention is supported by UNICEF (They support IHRA's conference in fact). Harm reduction is even supported by Save the Children Sweden (who supported WFAD!)

The WFAD Declaration is also against decriminalisation of drug users, even though the UN Committee on the Rights of the Child has consistently stated when discussing Art 33 that young people who use drugs should not be treated as criminals. UNICEF has also said (in their implementation handbook for the Convention) that placing harsh sentences on children who use drugs is a deeply ineffective form of protection.

The WFAD Declaration is also explicitly in favour of random school drug testing. Hard to reconcile that position with its supposed concern for the rights of children and young people. Indeed, the Convention on the Rights of the Child states that the child has the right to privacy (Art 16) and freedom from self incrimination and due process of law (Art 40).

And as an aside, given that so many of the speakers at the WFAD conference and signatories to its Declaration were from the USA (one of only two countries in the world that has not ratified the Convention on the Rights of the Child), we wonder if we can count on our US colleagues attending WFAD to lobby the US government to support the treaty!!

3. Can you explain the reference to ‘drug abuse’ as ‘slavery’ in Art 2 of the Declaration?

The WFAD Declaration states that 'Drug dependence is a modern form of slavery'.

The legal definition of slavery under international law is contained in Art 1 of the 1927 Slavery Convention. It says that:

(1) Slavery is the status or condition of a person over whom any or all of the powers attaching to the right of ownership are exercised.

(2) The slave trade includes all acts involved in the capture, acquisition or disposal of a person with intent to reduce him to slavery; all acts involved in the acquisition of a slave with a view to selling or exchanging him; all acts of disposal by sale or exchange of a slave acquired with a view to being sold or exchanged, and, in general, every act of trade or transport in slaves.

We're sure that equating drugs with 'slavery' is probably an effective bit of hyperbole to whip up the zero-tolerance crowd. Indeed, Robert DuPont of the US employed this nonsensical analogy to great effect in his keynote address at the conference. We particularly love the bit where he says that 'Harm Reduction policies accept and even extend chemical slavery'. (We really don't make this stuff up. It's on page 9.)

But honestly, it really is pretty hard to see how drug use fits into the definition of slavery. Sure, drug dependency can potentially be deleterious to a person's health and well-being (of course not all persons who use drugs are dependent upon them, but that's another matter). Still it is not clear to us how a person's choice to use drugs leads to slavery. Can a person enslave themselves? Can they volunteer to be a slave? If drug dependency is a 'modern form of slavery', are ‘recovered addicts’ the modern equivalent of run-away slaves?

And as an aside, given the huge over incarceration of African-Americans in the US as a result of the 'war on drugs', isn't this analogy just a little insensitive?

Of course there are indeed modern forms of slavery occurring in the world today. In case the WFAD folks - or anyone else - is interested in working to end real forms of contemporary slavery, here is a good background document produced by the Office of the High Commissioner for Human Rights.

4. Can you please point to the international treaty that states that ‘All people have the right to…have a life free of drug abuse.’?

As is perhaps evident from our previous questions, the drug warriors have a habit of playing fast and loose with the facts of international law. This is another example found in Art 2 of the WFAD Declaration. The ‘right to a drug free world’ or a ‘right to be drug free’ is one that is often claimed by the zero-tolerance, anti-harm reduction crowd to support their cause. The problem is that there ain’t one!

Whether WFAD likes it or not, you can’t just make up international law. International law is created by international treaties agreed between states. And there is no human rights treaty that enshrines a right to be drug free or to a drug free world.

While it is perhaps unfair to expect WFAD to be knowledgeable on international law, lots of the rest of us are. HR2, for one, is a programme that works specifically in international human rights law. So if WFAD can point out some human rights treaty that we have missed, perhaps they would be so kind as to do so. (And please don't cite Art 33 of the Convention on the Rights of the Child. It doesn't say this, and we'd be happy to explain why if the actual wording of the provision itself isn't clear enough.)

5. How do you reconcile the Declaration’s opposition to harm reduction with Art 5, which ‘urge[s] all people to work with their governments to strengthen, support, and encourage…the Office of Drugs and Crime, the International Narcotics Control Board…[and] the World Health Organization’. All of these bodies support harm reduction!

This question is self explanatory….

Anyway, these are the first five questions we have, and we have only gone through 5 of the 24 articles in the WFAD Declaration.

Needless to say, watch this space for more....

IHRA and Human Rights Watch to hold joint event at the UN Human Rights Council, Geneva

On Tuesday, 16 September, IHRA in partnership with Human Rights Watch will hold a side event at the meeting of the UN Human Rights Council in Geneva. The event, 'Ensuring Human Rights in Drug Policy: A Panel and Discussion on Human Rights and Public Health Challenges in Policies Relating to Drug Control' is intended to highlight human rights issues related to harm reduction and drug enforcement.

The main speaker at the event will be Professor Manfred Nowak, the UN Special Rapporteur on Torture, who will speak on the topic 'A Human Rights Based Approach to Drug Policy: A Topic for the Human Rights Council?'. Other speakers will include Susan Timberlake, Senior Human Rights and Law Advisor for UNAIDS, Eric Schneider Co-Director of Actions pour la Citoyenneté et l’Education à la Santé (ACCES), Rebecca Schleifer of Human Rights Watch and Catherine Cook of IHRA's HR2 programme. The event will be chaired by Annette Verster of the World Health Organization.

'Ensuring Human Rights in Drug Policy: A Panel and Discussion on Human Rights and Public Health Challenges in Policies Relating to Drug Control', organised by IHRA and Human Rights Watch.

Tuesday, 16 September 2008
Room XXI, Palais des Nations
Geneva
12.00-14.00

A briefing has been prepared for the event and is available for download at the IHRA website.