When it comes to the questions of health and drug use, as with all drug policy, there have been many different frameworks that have been used to analyze the question, security development, law enforcement, health and rights. Of these, there are two that have really dominated the discussion: the first is law enforcement and the second is health and human rights, which for the purposes of this discussion, I will put together. Though, as we will see in a moment, they don't always go so comfortably together. Law enforcement often looks at people who use drugs almost as something like drugs themselves, something to be controlled and contained, to be locked away for the benefit of society. It focuses on the legal status of the controlled substance and those who use it. Health and rights, by contrast, actually focuses on the health risks associated with the substance. So it may, for example, look at cannabis, which carries much less health risk much differently than heroin or cocaine, and it focuses on reducing the risk. Oftentimes, this tension between these two approaches is evident in government policy, in how doctors think about drugs, and even in how all health systems respond to drugs. So, let me give you an example of what I mean. The first slide here is a billboard in Vietnam, one of the countries in which I have worked, that's put out by the Department of Social Evils Prevention. That's the government department that is in charge of responding to drug use, and even the name gives you a sense of some of the challenges of the framing. The billboard says stopping harmful culture and social evils are the responsibility of all society. It has a large red fist that's coming down to crush the drug user. That little figure in the bottom is the drug user, and you see the drug user going off to the graveyard. The next picture shows a nightclub in Russia. Everyone in this nightclub has been rounded up by the police who have come over the walls. Everyone in the nightclub will be tested for drug use. Their urine will be tested. Those who test positive will be added to a government list, where they are denied the possibility of a driver's license, where they are sometimes denied the possibility of child custody, where they are supposed to report regularly for a forced medical inspection. So, that gives you some sense of the law enforcement frame. The next slide shows a different relationship between a drug user and a figure of authority. This is a harm reduction program in a different country, in Romania. You'll see the drug user, who's the man on the right. He is sitting and getting a referral to a sexually transmitted infection test because he thinks he may have a sexually transmitted infection. There is a worker on the left. You will note, and many of my colleagues in public health, which is my training, will disapprove, but you will note that there is a carton of cigarettes on the table because the service actually will provide people with cigarettes if they need. You will see that there is a carton of clean syringes, which can also be distributed. Obviously, the relationship between the drug user and the health worker in this picture is quite different than the relationship in the previous picture between the drug users or potential drug users and the state. So, what does this mean and why am I telling you this? In my field, there is a tension between harm reduction and abstinence-based approaches, and this is attention that is not as simple as criminalization in the law or law enforcement in health because there are some health facilities and practitioners who are very focused on the achievement of a drug-free state and there are others, whether that's in prevention, treatment, care, who focus on what is called the harm reduction approach. Let me explain what harm reduction means because we say it often, but its meaning is often unclear. Harm reduction is really, for me, not a question of a number of medical interventions, though people often talk about provision of sterile injecting equipment or provision and prescription of methadone and buprenorphine to relieve craving for or injection of illicit heroin, but harm reduction is rather a philosophy that recognizes that stopping drugs should not be and need not be a prerequisite for seeking help or receiving supports and further that the idea of a drug-free world, whether that's practiced by a policeman, or by a physician, or a drug dependence treatment provider who insists that only if you stop using drugs can we define that as success, is actually so rigid that in many cases, it fails the people that it's supposed to help. So, for example, you can have a harm reduction approach to drug prevention, which may be about preventing people from progressing to a more harmful form of drug use. So, when we think of drug prevention, we often think it's about getting people to never use drugs, to prevent drug use, but it's also actually about, for example, preventing someone who smokes heroin from progressing to injecting heroin, where they run the risk of hepatitis C infection or HIV infection. You can have a harm reduction approach to drug treatment, drug dependence treatment, which recognizes that it's very common for people to relapse, to return to drug use, and that that may not be a failure. You can have a harm reduction approach to bloodborne illness prevention, and these are probably some of the most common and familiar interventions. For example, if I give you a clean syringe today and you use it to inject, you will not get HIV or hepatitis C as a result of that injection. For hepatitis C, you'll also need clean water, something clean to cook the drugs in. Some people say this is giving the wrong message, it sends the message that drug use is acceptable or okay. I think what I and other public health practitioners familiar with the approach would say is that it's giving people the message, that protecting you from life-threatening illness is our first priority and "meeting you where you are, starting with what you identify as your need is key to building what we call a therapeutic alliance, which can then continue and be used to progress toward healthier outcomes." One of the great paradoxes of harm reduction is that by allowing people to be honest about their drug use and engaging them about it, you can actually sometimes lead people to better health outcomes than you would if you started by giving them a lecture about being drug-free. So, for example, I'm talking to you right now from North America and particularly Canada. Here in Canada, which is the only place in North America, where there is a supervised injection site, they have exactly on top of that site a place where people can go, who wish to detoxify and stop using drugs. Paradoxically, they found that people who came to the injecting site, who were allowed to bring their own drugs into the site and inject under medical supervision and talk openly with the staff about what they were doing had a higher rate of progression to abstaining from drug use and going into the detoxification than those programs that just started with the insistence that you be drug-free. So, one of the things that harm reduction challenges us to do is to ask ourselves, are we concerned about the well-being of the patient or our loyalty to the idea of a drug-free state, which may actually be interfering with our ability to reach, care for, and support the patient?
