Let me start by saying that it is indeed an honour for me to be present here amongst all of you at this very important conference. Indeed, I am priviliged to deliver the plenary address at the opening ceremony on an issue that is very close to my heart.
I am thankful to the Harm Reduction Interntaional, especially Rick Lines for inviting me to present this address. I also want to thank the local organisers in Kula Lumpur for their generous hospitality, which I have experienced since yesterday morning.
Let me also thank the Hon’ble Minister of Health of Malaysia, Y B Datuk Seri Dr. S. Subramanium, for being present here to listen to the deliberations of this conference. It is important that communities of persons working for drug users and governments to dialgoue.
It is indeed appropriate that the 24th Interntaional Harm Reduction Conference is being held in Malaysia, which has embraced harm reduction servies for People who inject drugs. Hopefully, the conference will allow us in the Asian region an opportunity to critically examine the laws, policies and practices in vogue today in our region, reflect on them, and consider what we should do at UNGASS which will debate the issue in April of 2016. The UNGASS initiative was taken by the Latin American countries to make corrections to the disastrous laws, policies and practices relating to drug use internationally and domestically as it affected them adversely and a gross manner.
Traditionally in our region, opium, cannabis, kratom, khat and other drugs have been used for medical, religious or cultural purposes.
Opium was used for medicincal purposes across Asia from Perisa to China, including Indonesia. In Persia, Avicenna’s treatise, Canon on Medicines, discusses the therapeutic uses of opium extensively. Smoking it with tobacco, as madhak, became common in China particularly in ritualistic and social gatherings. Cannabis too, has been used for hundred of years in Asia, particularly in India, where it has been decribed as a ”way of life”, besides being a ‘medicine’ in indigenous medical systems. Kratom has been used traditionally in Thailand and Malaysia for medicinal, cultural and other purposes. Similar cultural practices existed in South America amongst native communities, particularly in regard to coca.
The present laws, policies and practices in the world are are a product of and mandated by the three UN Conventions of 1961, 1971 and 1988. Their origins lie in the nineteenth century notions among moral and evangelical groups about the use of opium and cannabis in colonies, and whose lobbying culminated in universal drug prohibition. This was despite the findings of the Opium and Hemp Commissions in the late 19th century, that the ‘mild and moderate use of these substances is not deleterious to health.’ The prejudice of westerners against local practices was so much that the therapeutic benefits of cannabis were not acknowledged in modern medicine for long time. It is ironic that countries in Europe and North America are now “rediscovering” the medical uses of cannabis and even changing law to allow medical dispensation, wheras our traditional medical practices are lost on our governments. I have no hesitation in saying that for societies in Asia, drug prohibition is an ‘historical wrong’, which needs to be corrected.
Significantly, all three conventions recognise that their primary objective is protecting the health and welfare of humankind. Surely, the measure of success of the policies adopted pursuant to these Conventions, should be judged on health and human indices. Unfortunately, evaluation of drug policies is done on the basis of enforcement measures, the amount of seizures, numbers of persons arrested and convicted etc. This is because the Convetions mandate the criminalisation of activities relating to narocitc drugs and psychotropic substances including cultivation, manufacture, trade and transport and more particularly the use and possesion of drugs, outside of ‘medical and scientific use’.
All the evidence shows that while seizeures of drugs and arrests and incarcerations have increased over the years, yet the world has not becoming “drug free”. While short term successess may have been achieved, the long term effect it actually produces is a stimulus to illiicit drug produciton. Illegal drug manufacture and use is simply increasing. Thus, global opium production has doubled every decade, 1200 tons in 1971, 2600 tons in 1987, 4800 tons in 1997 and 10,000 tons in 2007. If the present trend continues the production estimated to be 20,000 tons 2017 and 40,000 tons in 2027. The inevitable conclusion is that the prohibitionist drug laws, policies and practices have simply failed to achieve the objective of drug free world or getting rid of drug addiction. However, the irony is that most public servants – be it the Police or the Judge, believe that they are doing the “right thing” by arresting and jailing a person for drugs.
According to some authors the failure of the “war on drugs” strategy is because of the failure to appreciate the market dynamics of drug production, the establishment and of the increasing demand. This view, in my opinion, rightly argues that in the eighteenth century opium was transformed from a luxury commodity to a commodity of mass consumption, just like coffee and tobacco. Over the last 200 years, opium has emerged a major global commodity, similar to other stimulants, such as coffee and tea, and I would add alcohol and tobacco. Suppression of demand operates like the application of pressure on a balloon. You squeeze one part of the inflated balloon and it will bulge on the other side. This is exactly what has happened in the war on drugs, where suppression of drugs in one region leads to the emergence of production and supply in other regions, as also to emergence of new psychoactive substances, which are impossible to control.
Pertinently, the prohibitionist regime spawned criminal syndicates and gangs, who thrive on the exhorbitant profits to be made in the illegal drugs market. Prohibition was also responsible for the trade shifting from opium to heroin and from opium smoking to injecting heroin and the consequential transmission of communicable diseases, including HIV and Hepatits B and C.
If one were to evaluate the prohibitionist regime in terms of health and welfare of humankind, the failure of the war on drugs is even more compounded.
Criminalisation results in the incarcetaion of large numbers of people for ‘drug-related offences’. In a number of countries, nearly half or or more of the prison population comprises drug users. Apart from the fact that it is quite a burden on the tax payers to maintain prisoners, drug users do no have access to preventive and treatment health services. The already high prevalence of HCV and HIV amongst drug users in prisons is only exacerbated.
Harm reduction, promoting and making available and accessible, needle syringe and other facilities are well known evidence based methods known to reduce the risk of transmission of communicable diseases including HIV and HCV. Similarly, evidence based treatement for drug dependance, namely Buprenorphine substitution and Methadone maintenance, or Opioid Substitution Therapay (OST), is well known.
Thankfully because of the HIV epidemic, a number of developing countries, with a significant push from UNAIDS and the Global Fund on TB, HIV and Malaria, were able to provide harm reduction and OST services for IDUs in ‘safe havens’. Thus, in most Asian countries harm reduction and OST services for do IDUs exist. However, in most of them they have not been scaled up and are not made accesible to people who use drugs. This is compounded by the fact these services exist on the margins of legality. As criminalisation of drug use persists in these countries and drug users are stigmatised, not all of them are able to access harm reduction or OST services. This increases the risk of transmission of communicable diseases. Thus, levels of seroprevalence of HIV amongst IDUs is very high in most developing Asian countries compared to, say, Austrialia, where it is very low. For Hep C, the position worse.
While Governments across the world were constrained to introduce harm reduction and OST services because of the HIV epidemic, with the waning of the HIV epidemic there is a real danger that such services may not be available in the future to drug users in developing countries. This is being exacerbated by the withdrawal of the Global Fund from middle income countries, which is a matter of urgent concern.
While HIV has been addressed in the past, Hepatitis C (HCV), a larger and a rising epidemic has been completely ignored in the developing countries. This is because we have not seen the perspective from the person affected and treat her or him holisticall but seen it only from the perspective of the disease.
The routes of transmission are practically the same as HIV but Hep C is more transmissible than HIV. Seroprevalence of HCV is over four times higher than HIV. Vulnerable groups, particularly people who use drugs are often co-infected with HIV, and TB and now with HCV and. There is an urgent need to address Hep C epidemic and make available not only facilities for testing but also make available treatment for the same.
Fortunately, now with the advent of new and better drugs, HCV is completely curable across genotypes, within a short period. The tradional treatment of injectible pegylated interferon with ribavirin, to which not all genotypes respond positively, is now supreceded by treatment by direct acting oral anti virals, amongst others with Sofusbuvir, Daclatasivir and Ledipasivir. With a combination of these drugs all genotypes can be cured.
However these drugs are prohibitively expensive. Sofosbuvir is available in the US at $84,000. In India, the MNC drug maker, Gilead, has entered into voluntary licensing with Indian generic companies with restrictive conditions. Significantly they don’t allow export to high burden HCV countries like Latin America, the MENA region, Central Asia, Eastern Europe and South East Asia. The availability of medicines from India generics to those in the developing world, which was taken for granted in the HIV context, is under threat qua Hepatitis C. This is a major problem to be addressed by treatment activists.
That apart, in some countries in the region, treatment that is administered to allegedly drug dependant persons which not evidence based OST. Authorities resort to compulsory detention and treatment programmes of persons who are allegedly drug dependant. Firstly there is no scientific basis of determination of drug dependance. Only urine analyses are resorted to. Thus even persons who are not drug dependant are forced into compulsory detention centers. These are accompanied by punishment and sometimes forced unpaid labour, solitary confinement and experimental treatment without consent. A vast majority of drug users who pass through such compulsory detention centres return to drug use after the compulsory period of detention and detoxification programmes. As the UNSR, I had reviewed the practice of compulsory drug treatment and found it incompataible with, and indeed in violation of the right to health enshrined in the International Covenant on Economic, Social and Cultural rights.
The punitive approach to drug use has resulted in a large number of countries in the world, about 33, out of which a large number are in our region, resorting to death penalty for certain drug related offences. Apart from the fact that death penalty does not achieve its stated objective of deterrence, resorting to it for drug related offences contrary to international law, which mandates – first, the progressive reduction of capital crimes, aimed at the abolition of the death penalty and second, restricting it to the most serious of crimes, such as those that result in the death of another person. International law does not recognise drug offences as the most serious crimes.
Unfortunately, despite that, death penalty continues to be used in a number of countries. Moreover, about 10 countries have mandatory death penalty for drug related offences, again majority in the Asian region. In constitutional jurisprudence, mandatory death penalty has no place as it takes away the judicial discretion in sentencing.
The other deleterious consequence of criminalization of drug use is that millions of people worldwide who require essential medicine for treatment and palliative care are unable to access them. Excessive restrictive sanctions imposed by law instils fear in the medical community of falling foul of the law. This results the lack of availability and accesibility of morphine, required as a painkiller for patients suffering extreme pain in the terminal stages of cancer and HIV. The lack of access is particularly acute in the developing countries. Now the most common used anaesthetic, Ketamine, is sought to be included as restrictive substance internationally. It has already been included in Indian law. Significantly, over 90% of all legally controlled medicine is consumed in north America and Europe. As a result over 70-90% of patients who require these essential medicines in developing countries do not have access to such medicine. Tomorrow the Global Commision on Drug Policy is releasing a report on this issue.
While all these are serious and unfortunate consequences of drug prohibition, the most profound impact of criminalization is in ‘impairing and impinging on the dignity of people who use drugs’. Seen as morally depraved and blame-worthy, drug users are treated less than human, undeserving of respect, rights and opportunities. Not only do others (state and society) treat the People who use Drugs with contempt, the persons may themselves imbibe this sense of unwothiness and denigrade one-self. Nothing can be sadder than this.
What is the way forward?
This conference in the context of UNGASS in April, 2016 in New York is an opportune moment for all of the activists here to dialogue with the government to take the issue forward and propose necessary changes in the law, policies and practices.
First of all there must be a debate on the issue of drug use in all circles, political, legal and social.
Second, People who use drugs must be accorded respect and dignity and treate without discrimination.
Third, there must be a recognition that the strategy of “war on drugs” has failed and has had disastrous consequences on the health and welfare of human kind. Unfortunately in our region, the recent Asean ministers meeting failed to do this and announced that the flawed prohibitionist policies must continue.
Fortunately, there are winds of change. US, which initiated and has been in the leadership on the “war on drugs” is seeing those very changes. A number of states there have seen the futility of it and legalized the use of marjuana.
The response must be based on the primary objective of the conventions, health and welfare of human kind and on the right to health framework enshrined in Article 12 of the the ICESR, which mandates that health goods, services and facilities be made available, accessible and be of good quality.
The punitive regimes of drug laws must be replaced with regulatory measures. If we can do this alchol and tobacco there is no reason why we cannot for other drugs.
Health goods, facilities and services must available and accessible without any discrimination. Preventive and treatment services (including Harm reduction services, OST and essential medicines for palliative care) must be made available and accessible without any discrimination and with the full informed consent of the proposed receipients.
Death penalty for drug related offences must go. It doesn’t work and is against international law.
These can form the basis of discussion with our respective governments so that they can make changes internationally on drug policy.
In the era of the HIV epidemic, we learnt that the rights based approach works. The key component of that strategy was in the involvemnt of the affected communities in the shaping of response. It our duty here and now to learn what we can, go back to our respective countries and inform and dialogue with our governments to change their policies towards drug use. I have learnt that we can change the world, only if we are passionate about our cause and believe in it. You can all do that.