Seminarium 2008 – Massimo Barra

Swedish Drug Users Union
Seminar on Narcotic Politics
Stockholm, 27 March 2008

”HARM REDUCTION”

Speech by Dr. Massimo Barra, President of the Italian Red Cross

Mr Chairman, Ladies and Gentlemen, dear friends,
it is a pleasure to speak today at this Seminar on Narcotic Politics, promoted by the Swedish Drug Users Union. I would like to express my particular thanks to Mr. Berne Stalenkrantz for allowing me to talk here today about my experience as a medical doctor who has been working for more than 30 years with and for drug users, having been and still being a volunteer of the Red Cross since the age of 8.

And I want to do so by briefly rising some issues that I hope could help our debate, in the interest of the most marginalized ones.

1. Harm Reduction

Since I founded Villa Maraini Anti Drug Centre in 1976, I have met more than thirty-five thousand drug users, and I have learned that if on the one hand substance abuse is a disturbing but real fact of the human nature, which needs an accurate, humanitarian, rationale and scientific-based response, on the other hand ideological prejudices and pre-judgments continue dominate the political debate all over the world.
Too many politicians continue to look at this issue as it was the story of Red Riding Hood, Cappuccetto Rosso in Italian. While crossing the wood of temptation, Cappuccetto Rosso meets the bad wolf – or drug dealer –  and gets addicted, until the good hunter saves her live by organizing a therapeutic community and eventually providing her  with a certificate…
The experience of working in this field demonstrated me that reality is not as simple as a fairy tale and that  generalisation on drug use is dangerous as it fails to grasp the complexity of the relation between drug and the individual.

Frankly speaking, I have to admit that I still have not understood and I do not have a clear idea of which is the dominant factor to create a drug addict. I mean that I do not know which factor is more important among the Substance, the Individual and the Context. I do not know which of these 3 elements has the majority quota. Substances, of course, are of a fundamental importance. If cavies take one of the main five substances mankind grow and take since Noah’s times, i.e. opium and then morphine or eroine; cocaine, alcohol; nicotine; and finally tetraidrocannabinol, derivated from cannabis, they start behaving as drug users. For them, substances become fundamental and more important than food or sex.

This means that substances have the capacity to create dependence. How is it possible, then, that the same substance can create addiction in some subjects but not in other ones? Evidently, to create a drug dependent the Individual is important as well as the Substance. And by ”Individual”, I mean the genetic inheritance and the dinamic events of a person’s life; his/her conditions before birth; the trauma of birth, that many call the birth of trauma; what has happened in the person’s early childhood and after; who the person has been meeting with; the school; the pressure of the group of peers; the experiences…

Also for the Individual, I do not know which of all these factors has the majority quota. Substance, that in some circumstances can objectively create dependence, in others, is less powerful. As a painkiller to treat traumas, british orthopaedists suggest spray diamorphine – which is the most acceptable name for heroine – to be inhalated, even by teenagers.

By changing the context, the effects change as a consequece. Substance is the same; the Individual is the same, the Context is different. This means that also the Context – and, in particular, the active or passive role of the intaker – i.e. his power- can contribute to create a drug addict.
There is no magic treatment or simple answer in the field of substance abuse. But a treatment that works is a treatment that we can adapt to the special circumstances of the individual. It is important that the policy framework addressing drug use also reflects this flexibility.

Unfortunately, communication errors, misunderstandings and too radical positions still give an ideological value to therapeutic strategies, with the consequence that especially in some parts of the world, harm reduction is still a very sensitive issue. It is like there were two different and completely opposite strategies, one totally against drugs and drug users, the other one more flexible, and in my opinion realistic, with the consequence that supporters of the first approach consider supporters of harm reduction as facilitators and partners in crime with consumers.

As UNODC Executive Director Antonio Maria Costa recently said in Vienna during the last UN Commission on Narcotic Drugs, “Scientific evidence shows that drug addiction is an illness that can and must be treated. There are no ideological debates about curing cancer or diabetes, Left and Right are not divided on the need for treating tuberculosis or HIV. So why are there political contrapositions about drugs?” .

I invite you to reflect on this quote, which represents a new, important step forward for the UN towards harm reduction and a more enlightened policy.
But what exactly is a harm reduction strategy, in reality? A harm reduction strategy is the opposite of a harm increase strategy, which humiliates, mortifies, criminalizes and stigmatizes drug users, producing negative effects both at the individual and public health levels, as well as at the social one.

A harm reduction strategy opposes the wrong ideas that punishment and deprivation are the right answers to the problems of the more than 200 million drug users worldwide, 25 millions of which Costa in his recent report to the UN describes as “hardcore drug addicts”.

There is no other field in medicine in which doctors have the objective to increase the harm of patients. It seems therefore unfeasible to speak about harm increase as a possible therapeutic strategy, although we should try to understand which philosophy lies behind it. Many people think, in good faith, that associating a form of harm, or punishment, or violence, to the action of taking drugs could help “unconditionate” the positive conditioned reflex associating drugs with pleasure.
According to this point of view, if the memory of pleasure makes it easier to continue taking drugs, the memory of sorrow and grief should act as a deterrent. In the reality, it does not work like that. On the contrary, the more an individual is treated with violence, the more he looks for substances that can give him comfort, that can help him, that can give him back serenity and calm, that can love him. 
 
Many relatives, friends and doctors turned themselves into persecutors when they adopted the philosophy that nobody can revive if he has not reached rock bottom. Unfortunately, many drug users could not revive from the evil consequences of sadistic and unqualified therapeutic treatments, which have increased, and not decreased, the damages related to drug consumption.

What I am asking you to do, now, is to keep well in mind that harm increase is as dangerous as substances, and that a harm increase approach implies and justifies stigma and discriminations of drug users.

2. Stigma and discrimination

As I told you before, my ideological and cultural background, which has influenced all my life, is constituted by the Red Cross, the International Movement present in 186 Countries and based on the respect of Seven Fundamental Principles. The Principle of Neutrality has as a consequence that the Red Cross can not take sides in hostilities or engage at any time in controversies of a political, racial, religious or ideological nature.

But the Red Cross Red Crescent Movement is not neutral in front of human suffering and discrimination, and has the moral duty to speak loudly on behalf of those who can be considered as the most vulnerable ones.

Within our Movement we say that stigma kills. We have the proves that discrimination and indifference kill even more than substances. Moreover, stigmatisation and lack of care for drug addicts are unwise and destructive not only for the users themselves, but also for the communities in which they live. A drug user is already dangerous to himself. But a drug user who is not known and taken care of by the institutions in a human way is twice more dangerous.

‘Spreading the light of science and the warmth of human sympathy’ were the words used in Paris in 1919 by the founders of the League of Red Cross and Red Crescent Societies. “Spreading the light of Science” is now the title of the document on harm reduction related to injecting drug use published in 2003 by the International Federation of the Red Cross/Red Crescent Societies, in which the Red Cross calls on the international community to be “guided by the light of science and not by the darkness of ignorance and fear”. You can find this document at the Federation Web site (www.ifrc.com).

In our international movement, we believe that it is in the interest of any State and any Government to get in touch with and to know as many drug users as possible; even all, if this is feasible. It is for this reason that what we need is not targeted interventions only reaching the top of the iceberg.
A drug centre waiting for its clients already makes a selection, by meeting only those who have the strength to bear the frustration to ask for assistance.  But if those who  want to quit are sick persons, those who do not want or can not quit are twice as sick and need alternative, more aggressive strategies. It is for this reason that we need low-threshold interventions, reaching drug users in the streets and in the dark and isolated places, where drug users live their daily tragedy.
If Governments understand what they normally do not want to understand, that it is in the public interest to invest resources in order to know and to take care of all drug users in a given place, the quality of life will improve dramatically, not only for those under care, but for the whole community.
That’s why we should privilege care and health over judgment about whether a substance is good or bad. Health-based interventions and fight against stigma represent the first, most effective approach to drug abuse problems. Because caring for drug users – regardless of their conditions and their type of addiction – is the best option not only for them, but also for the society in which they live.

And I am particularly proud to say you that most of the social workers employed by Villa Maraini are former drug users who have completed their rehabilitation programme. They work in the streets of Rome, in close cooperation with police, and intervene upon request, in cases of overdose or where the arrested person is a drug user. Their role as cultural mediators and peer educators is of an incomparable importance, as they are the doors through which the Red Cross can get into a drug user’s word and through which a drug user can exit his world and find alternatives.

3.RC/RC Movement

The work of the International Red Cross Red Crescent Movement does not stop at harm reduction and fighting again stigma. Since the Bangkok Conference in 1922, the Red Cross Movement has systematically called on the governments to bring their moral and material support to actions fighting vulnerability in the field of substance abuse. Our core rationale is a humanitarian one, which embraces both public health and human right rationales. This broad humanitarian basis provides the Red Cross a unique convening power. In the case of drug policy and especially of drug users, we intend to use our humanitarian approach to conduct a diversified strategy: to fight the criminalisation ofdrugs users, as well to prevent the causes of this criminalization.

And I am very happy to quote Mr Costa again, when he says that “Drug control has an image problem: too much drug-related crime; too many people in prison, and too few in health services; too few resources for prevention treatment and rehabilitation; too much eradication of drug crop, and not enough eradication of poverty” and finally, “although drugs kill, I don’t believe we need to kill because of drugs.”

The Red Cross could have not expressed its opinion in a better way in its documents of the “Rome Consensus for a Humanitarian Drug Policy”, which was launched in Rome in December 2005 by the Italian Red Cross with the support of the Senlis Council.

4. The Rome Consensus initiative

The Consensus now commits 107 National Societies of Red Cross and Red Crescent from Europe, the Middle East, Africa, Latin America, Asia and the Pacific, basing their actions on three key points:
·    Advocacy among the International community, the national governments, authorities and communities
·    Peer education and peer activities specially among young people
·    Treatment, rehabilitation and harm reduction activities.

When I talk about harm reduction, I mainly intend substitution therapies and needle exchange. I am not talking about buprenorphine, that I have never used, and to which I definitely prefer methadone, that is in my experience more effective.

Substitution therapies – and in particular Methadone – represent the best way to change in better the quality of life of heroine users and finally to empower them, as they allow drug users to conduct a fully normal life, keeping them away from committing crimes. Denying Methadone therapy to drug users is a sensational own-goal.

Needle exchange, which differently from what some misinformed say does not provoke an increase of drug users, is still the best way to avoid the AIDS pandemic and also the Hepatitis C spreading among injecting drug users.

5. Conclusion

Ladies and Gentlemen, many associations advocate for the rights of emarginated groups. But advocacy alone is not enough. As the Red Cross strategy for the 2000 – 2010 decade says, “Advocacy is on a safer ground when supported by activities.

It is now time for listening to the voices of the most vulnerable ones and to advocate a new way, beyond prohibition and even harm reduction. A new global approach based on humanitarian principles that empowers people to make healthy choices.

Civil society organisations such as the Swedish Drug Users Union  and international movements such as the Red Cross and Red Crescent, can play a key role in this change and for the adoption and implementation of policies free from dogma ,that are aimed at saving lives without prejuduces.

Thank you.