Ana Luíza Barezani Gomes
Assistant Director of UNODC
Throughout history, different governments and institutions have chosen different ways to handle the problem of drugs in the realm of public health. The concept of harm reduction appeared mainly as a response to the rising levels of HIV infection, and became an alternative approach to the traditional prohibitive one implemented in many places around the globe (INTERNATIONAL HARM REDUCTION ASSOCIATION, 2017). It can be defined in the following way:
Harm reduction refers to policies, programmes and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself, and the focus on people who continue to use drugs. (INTERNATIONAL HARM REDUCTION ASSOCIATION, 2017).
Or, to summarize it: “Harm reduction is a public health approach to drug use premised on the idea that the aim of policy should be to maximize health and minimize damage” (DENVIR, 2017). Many of those in favor of adopting this kind of method sees the war on drugs as a war on people itself. It is a strategy focused on caring for those who consume drugs. Its key points encompass respect for individual choice and autonomy, end discrimination and stigmatization of drug users, care for the health and growth of the individual, prioritize alternative and accessible treatment instead of incarceration and repressive actions (DRUG POLICY ALLIANCE, 2017).
Policies based on this approach are a counterpoint to the prohibitionist measures, such as forced hospitalization and repressive actions, as based in the idea of a war on drugs (GAROFALO; SOARES; CORDEIRO, 2015). Measures include “the introduction of clean needle exchanges and the rollout of naloxone, a drug that reverses opioid overdoses”, as well as supervised injection sites. The latter is one of the most controversial, it consists of a place where people have the possibility of using drugs in a secure environment with the support of health professionals, avoiding accidental overdoses and the transmission of diseases (DENVIR, 2017). They are also highly successful in referring people to drug treatment or other social services. Yet, there are only a few more than 90 of them around the world, only three of them are outside Europe (STRIKE, 2016).
Although it is still not the path most adopted by governments around the world, this specific approach has been gaining more popularity, through the support of some researchers and organizations. Below, it is mentioned the case of Canada and Brazil to discuss how different countries implemented this approach through different policies and programs.
IMPLEMENTING THE HARM REDUCTION APPROACH
Canada, Switzerland and the Netherlands have been implementing programs that carry out harm reduction measures for at least three decades, and, because of it, have become references in this area (GAROFALO; SOARES; CORDEIRO, 2015). Canada began to apply harm reduction measures in the early 1980s with controlled drinking programs in Toronto. Later that decade, in response to the rising number of HIV infections, syringe exchange programmes were implemented, and by 1990 it was also in Montreal and Vancouver. In the next years, “a number of NGOs began to conduct workshops on harm reduction and to carry out advocacy throughout Canada and then internationally”, as a result this strategy spread to different cities and gave rise to different types of policies (CAVALIERI; RILEY, 2012, p.3).
In the past years with the previous administration, harm reduction in Canada was at risk, but with recently elected prime minister, Justin Trudeau, this strategy is being reintroduced in the way the drug issue is addressed (KIELTYKA, 2015). Toronto has over 50 places through the city that provide needle and syringe distribution. Vancouver has two supervised injection sites, the only place in the American continent; Insite, as it is called, has received a high demand and has also been an important asset in British Columbia’s fight against the drug issue, which has been a troublesome topic in the region (STRIKE, 2016). Recently, in May, the federal government approved three supervised injection sites to be opened in Toronto. These come as a reaction to the increase of overdose deaths in the country, also causing other major cities, such as Alberta and Ontario, to study and urge for the possibility of opening these sites (WOO; GRAY, 2017). Trudeau has also affirmed that it is in his interest to ensure that supervised injection sites could be opened in communities around the country that wish for a supervised (KIELTYKA, 2015).
In Brazil, a few programs developed by the harm reduction approach have been implemented in a few cities; nevertheless, the focus in this part will be on the one developed by the government of the biggest city in Brazil, São Paulo. O Programa De Braços Abertos (PDBA), which is translated as Open Arms, was a program developed in 2014 by the former mayor of the city to act in the cracolândia, area in downtown São Paulo widely known for its drug traffic and occupation by drug users. The program, inspired by Canadian and Swiss public health policies, came into being under the harm reduction perspective, having as its main purposes the offer of housing, food and job opportunities. Besides that, it also provides a space to hold meetings and assemblies, physical activities and cultural events (GAROFALO; SOARES; CORDEIRO, 2015).
Through these services, the project’s aim was to use the harm reduction approach as a strategy to care for drug users and attempt to decrease consumption, as well as promote health. Moreover, this progressive program strove to make the beneficiaries to develop self-care and, gradually, become involved in society once again (GAROFALO; SOARES; CORDEIRO, 2015).
These practices are not only aimed at prevention of infections disease and damage to the individual’s health or at the harm related to drug consumption, but also at the promotion of a healthy lifestyle and improvement in quality of life, expanding the goals to be achieved in relation to more punctual harm reduction measure. This perspective is based on the understanding that the individuals in the community have autonomy for individual choices and for self-care. (GAROFALO; SOARES; CORDEIRO, 2015, v.5, p. 133, tradução minha).
The Brazilian Drug Policy Platform conducted a research to analyze the consequences of Braços Abertos, and, according to it, the program has been mostly successful in causing drug consumption to reduce and offering help for the individuals to grow on their own. the Of the 500 beneficiaries, 67% reduced crack consumption, and 95% of those interviewed claimed Braços Abertos had a positive or extremely positive impact in their lives. It contrasts with the program developed by the state government of São Paulo, which offers people access to treatment and has as its aim treat patients with outpatient measures, including compulsory hospitalization (SANT’ANNA, 2016). However, due to lack of adequate funding, its inability to reach a bigger public and the implementation of the program by the professionals involved, the program had many flaws and suffered critics from various parts of society. The current mayor, João Doria, decided to, in the end of last year, end the program, and incorporate some of its actions in the already existing state government program previously mentioned (GRAGNANI, 2016).
In conclusion, it is possible to affirm that most countries and government are still reluctant to adopt a harm reduction strategy when addressing the drug problem and its relationship with public health. Nevertheless, with the support of public health workers, NGOs, researchers, different advocate groups have been giving more voice to this alternative approach. After years of great part of the globe waging a violent and repressive war against drugs, drug consumption, overdose deaths and disease transmissions don’t seem to decrease; thus, the harm reduction approach comes into view as a possible solution that, maybe, when combined with other strategies, may just do what has not been done in years, minimizing the damage drugs can cause to our society.
CAVALIERI, Walter; RILEY, Diane. Harm Reduction in Canada: the many faces of regression. Harm Reduction in Substance Use and High-risk Behaviour: International Policy and Practice, Londres, 2012. Disponível em: <http://www.canadianharmreduction.com/sites/default/files/Harm%20Reduction%20in%20Canada_0.pdf>. Acesso em: 30 jun. 2017.
DENVIR, Daniel. Canada figured out how to win the drug war. Slate and Fair Punishment Project, 20 maio 2017. Disponível em: <http://www.slate.com/articles/news_and_politics/trials_and_error/2017/05/canada_figured_out_how_to_win_the_drug_war.html>. Acesso em: 27 jun. 2017.
DRUG POLICY ALLIANCE. Harm Reduction, 2017. Disponível em: <http://www.drugpolicy.org/harm-reduction>. Acesso em: 25 jun. 2017.
GAROFALO, Beatriz Souza; SOARES, Cássia Baldini; CORDEIRO, Luciano. Políticas Públicas Estatais na Área de Drogas: O Caso do Programa “De Braços Abertos” (PBDA). Revista Sociologia em Rede, v. 5, n. 5, p.119-142, 2015. Disponível em: <http://redelp.net/revistas/index.php/rsr/article/view/8cavalcanti5/260>. Acesso em: 25 jun. 2017.
GRAGNANI, Juliana. Doria extinguirá programa, mas manterá ações anticrack de Haddad. Folha de São Paulo, São Paulo, 24 out. 2016. Disponível em: <http://www1.folha.uol.com.br/cotidiano/2016/10/1825546-doria-extinguira-programa-mas-mantera-acoes-anticrack-de-haddad.shtml>. Acesso em: 25 jun. 2017.
INTERNATIONAL HARM REDUCTION ASSOCIATION. What is harm reduction?, 2017. Disponível em: <https://www.hri.global/what-is-harm-reduction>. Acesso em: 25 jun. 2017.
KIELTYKA, Matt. Harm reduction ‘back on the table’ with Trudeau win. Toronto Metro, 20 out. 2015. Disponível em: <http://www.metronews.ca/news/vancouver/2015/10/20/harm-reduction-back-on-table-with-trudeau-win.html>. Acesso em: 25 jun. 2017.
SANT’ANNA, Emilio. 2 em 3 reduziram o uso de crack após passar em ação de Haddad, diz estudo. Folha de São Paulo, São Paulo, 31 ago. 2016. Disponível em: <http://www1.folha.uol.com.br/cotidiano/2016/08/1808800-2-em-3-reduziram-o-uso-de-crack-apos-passar-em-acao-de-haddad-diz-estudo.shtml>. Acesso em: 28 jun. 2017.
STRIKE, Carol; BAYOUMI, Ahmed. What you need to know about safe injection sites in Toronto. Toronto Star, Toronto, 19 dez. 2016. Disponível em: <https://www.thestar.com/life/health_wellness/2016/12/19/what-you-need-to-know-about-safe-injection-sites-in-toronto.html>. Acesso em 28 jun. 2017.
WOO, Andrea; GRAY, Jeff. Federal government approves three supervised-injection sites in Toronto. The Globe and Mail, Vancouver, 2 jun. 2017. Disponível em: <https://www.theglobeandmail.com/news/national/federal-government-approves-three-supervised-injection-sites-in-toronto/article35189403/>. Acesso em: 29 jun. 2017.