Treat – don’t jail

Health ex­perts call for global drug pol­icy re­form ahead of UN spe­cial ses­sion.

The Star Malaysia - Star2 - - INSIGHT - By MAN­GAI BALASEGARAM star2@ thes­tar. com. my

LEAD­ING global pub­lic health ex­perts have urged for re­form in the global blue­print on drug pol­icy, say­ing pre­vail­ing poli­cies that put drug users through the crim­i­nal jus­tice sys­tem have had “se­ri­ous detri­men­tal ef­fects” on health and hu­man rights and led to lethal vi­o­lence.

Non- vi­o­lent, mi­nor drug of­fences such as pos­ses­sion and petty sale should in­stead be de­crim­i­nalised, while health and so­cial ser­vices should be strength­ened, a ma­jor new re­port led by The Lancet and Johns Hop­kins Univer­sity in the United States rec­om­mended.

The re­port cited “com­pelling ev­i­dence” from coun­tries that de­crim­i­nalised such of­fences, such as Por­tu­gal and the Czech Re­pub­lic, which have seen sig­nif­i­cant pub­lic health ben­e­fits, cost sav­ings and re­duced in­car­cer­a­tion.

The au­thors of the Johns Hop­kins- Lancet Com­mis­sion on Pub­lic Health and In­ter­na­tional Drug Pol­icy in­clude 22 ex­perts from both de­vel­oped and de­vel­op­ing na­tions. Prof Dr Adeeba Ka­marulza­man, dean of Univer­siti Malaya’s Fac­ulty of Medicine, is one of two co- chairs of the com­mis­sion and at­tended the re­lease of the re­port in New York on Thurs­day.

The re­port comes ahead of an im­por­tant United Na­tions General Assem­bly Spe­cial Ses­sion on April 19, dur­ing which in­tense de­bate on fu­ture global drug pol­icy is ex­pected.

Mex­ico, Colom­bia and Gu­atemala – where vast sums of money have been spent in a fu­tile and vi­o­lent at­tempt to con­trol drug sup­ply – made the ini­tial call for the spe­cial ses­sion, urg­ing the UN to “con­duct an in- depth re­view analysing all avail­able op­tions”.

The last sim­i­lar UN ses­sion in 1988 called for a “drug- free world”. The fail­ure of this goal, the in­abil­ity of puni­tive poli­cies to im­pact drug mar­kets and be­hav­iour, as well as the ev­i­dence of de­crim­i­nal­i­sa­tion in some coun­tries, has led to grow­ing mo­men­tum for an over­haul of drug laws.

“The sci­en­tific ev­i­dence has been ac­cu­mu­lat­ing over the last few decades that shows cur­rent drug poli­cies do more harm than good,” says Dr Adeeba in an exclusive e- mail in­ter­view with Star2.

She adds that “it was im­per­a­tive that ev­i­dence be put to­gether” ahead of the spe­cial ses­sion and the is­sue be viewed “through a health lens”.

For decades in Malaysia, the bat­tle against drugs has in­volved a strong puni­tive and crim­i­nal ap­proach, with hun­dreds of thou­sands of drug users ar­rested and jailed or sent to re­ha­bil­i­ta­tion cen­tres, “Pusat Ser­enti”, for two years.

Last year, roughly half of all lo­cal pris­on­ers were be­hind bars for a drug- re­lated of­fence; in Se­lan­gor’s Ka­jang Prison, the na­tion’s largest jail, that fig­ure was 60%. With re­lapse rates of 70- 90% ac­cord­ing to lo­cal re­search, many drug users end up re­peat­ing the cy­cle, and in the process, may ac­quire an in­fec­tious dis­ease.

Harsh sen­tences

The com­mis­sion, which re­viewed the health im­pacts of global drug poli­cies, said cur­rent poli­cies had led to pub­lic health crises. It blamed the “ex­ces­sive use of in­car­cer­a­tion” as the big­gest con­trib­u­tor to­wards higher rates of in­fec­tion ( namely hep­ati­tis C and tu­ber­cu­lo­sis) among drug users.

“Harsh prison sen­tences are as­so­ci­ated with higher rates of hep­ati­tis C in­fec­tion among in­ject­ing drug users,” the re­port noted. In ad­di­tion, drug users were of­ten also sys­tem­at­i­cally ex­cluded from dis­ease preven­tion and treat­ment ser­vices “on the grounds of be­ing thought un­wor­thy or un­re­li­able”.

The com­mis­sion also said that deaths from over­doses could be “greatly re­duced” by im­prov­ing ac­cess to med­i­ca­tion- as­sisted treat­ment and ac­cess to nalox­one, a medicine that re­verses over­dose.

Coun­tries that have adopted dif­fer­ent mod­els of de­crim­i­nal­i­sa­tion in­clude Bel­gium, Es­to­nia, Aus­tralia, Mex­ico, Uruguay, the Nether­lands and Por­tu­gal.

De­crim­i­nal­i­sa­tion is of­ten mis­tak­enly equated with le­gal­is­ing drugs; in fact, it usu­ally refers to tak­ing a non- crim­i­nal ap­proach to drug pos­ses­sion al­though drugs and traf­fick­ing re­main il­le­gal. ( Some Amer­i­can states have also al­lowed legally- reg­u­lated mar­kets of cannabis, which is a dif­fer­ent is­sue in this re­spect.)

“De­crim­i­nal­i­sa­tion of non- vi­o­lent mi­nor drug of­fences is a first and ur­gent step in a longer process of fun­da­men­tally re- think­ing and re- ori­ent­ing drug poli­cies,” says Com­mis­sioner Dr Joanne Csete, from the Mail­man School of Pub­lic Health, Columbia Univer­sity, New York. “As long as pro­hi­bi­tion con­tin­ues, par­al­lel crim­i­nal mar­kets, vi­o­lence and re­pres­sion will con­tinue.”

Un­der Por­tu­gal’s de­crim­i­nal­isa- tion scheme, get­ting caught with drugs may mean a small file and a re­fer­ral to a treat­ment pro­gramme – not ar­rest, jail and a crim­i­nal record. De­spite fears to the con­trary, de­crim­i­nal­i­sa­tion has not led to drug may­hem. Since the scheme be­gan in 2001, drug us­age in many cat­e­gories has ac­tu­ally de­clined, no­tably among 15- to 24- year- olds; HIV trans­mis­sion and drug over­doses have also dropped.

“Gov­ern­ments should re­ally look at coun­tries where ( de­crim­i­nal­is­ing) has worked and led to enor­mous ben­e­fits,” says Dr Adeeba. She adds that mind­sets and ide­ol­ogy would be the big­gest bar­rier to change.

Drug pol­icy has al­ready shifted in Malaysia. A decade ago, amid ris­ing HIV in­fec­tion, “harm re­duc­tion” pro­grammes were in­tro­duced, in­volv­ing pro­vi­sion of clean nee­dles by NGOs and methadone treat­ment from clin­ics. The idea is first to re­duce the harm to health from drug use, and then to di­rect drug users to treat­ment.

En­cour­ag­ing re­sults

One im­me­di­ate re­sult has been a de­cline in new HIV in­fec­tions from nee­dle shar­ing. The treat­ment re­sults from Cure & Care clin­ics pro­vid­ing methadone ther­apy are also en­cour­ag­ing. Half of them do not re­lapse in a year, says Dr Adeeba. Con­versely, for­mer in­mates of Pusat Ser­enti of­ten re­lapse within weeks af­ter re­lease.

A lo­cal study on cost- ef­fec­tive­ness of these pro­grammes, done with the in­volve­ment of the World Bank, found that harm re­duc­tion had helped avert 12,600 new in­fec­tions, sav­ing the health­care sys­tem RM47mil. Over a 10- year pe­riod, up to 2023, the pro­gramme is ex­pected to avert roughly 23,000 new in­fec­tions, and sav­ings of more than RM200mil.

De­spite such re­sults, cov­er­age of these pro­grammes is lim­ited, and there is some con­cern about long- term pub­lic fund­ing. The law- and- or­der ap­proach still pre­dom­i­nates.

Dr Adeeba says the need for change is ur­gent. “Main­tain­ing the sta­tus quo means thou­sands and thou­sands of young peo­ple ( will get) in­car­cer­ated, which re­ally spells the end of any kind of op­por- tu­ni­ties and a rea­son­able life for them. Not only does it de­stroy them but also the peo­ple and fam­i­lies around them.

“It also means that we are not able to con­trol the epi­demics of HIV, HCV and TB ef­fec­tively.”

Com­mis­sioner Dr Chris Beyrer, from the Johns Hop­kins Bloomberg School of Pub­lic Health, says the ori­gin of drug pol­icy was based on ideas rather than any science or what ac­tu­ally works.

“The goal of pro­hibit­ing all use, pos­ses­sion, pro­duc­tion and traf­fick­ing of il­licit drugs is the ba­sis of many of our na­tional drug laws, but these poli­cies are based on ideas about drug use and drug de­pen­dence that are not sci­en­tif­i­cally grounded,” he says.

“The global ‘ war on drugs’ has harmed pub­lic health, hu­man rights and devel­op­ment. It’s time for us to re­think our ap­proach to global drug poli­cies, and put sci­en­tific ev­i­dence and pub­lic health at the heart of drug pol­icy dis­cus­sions.”

It re­mains to be seen whether science, not pol­i­tics or ide­ol­ogy, will win the bat­tle at next month’s UN ses­sion.

— Photos: Filepics

File photo show­ing Malaysian police per­son­nel guard­ing ad­dicts ar­rested dur­ing an op­er­a­tion last year. health ex­perts from around the world ar­gue that petty, non- vi­o­lent drug of­fences should be de­crim­i­nalised and the fo­cus put on health and so­cial ser­vices in­stead.

In nu­mer­ous coun­tries, nGos fo­cus on the re­duc­tion of dam­age suf­fered by drug ad­dicts through con­ta­gious dis­eases, and hand out free ster­ile sy­ringes and nee­dles in ex­change for used ones that the users col­lect and bring in.

It is im­per­a­tive for the is­sue of il­le­gal drug use to be viewed through a health lens, says dr Adeeba.

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