History of Harm Reduction - Provenance and Politics, Part 2
Peter Stoker C. Eng. – Director, National Drug Prevention Alliance, UK

Abstract:

The history of ‘so-called harm reduction’ - starting with its conception in and dissemination from the Liverpool area of Britain in the 1980s - is described in comparison with American liberalisers’ ‘Responsible Use’ stratagem in the 1970s and with subsequent so-called Harm Reduction initiatives in various countries. The text takes extracts from or synopses of papers presented by various writers on both sides of the argument. As the scope of a historical review of Harm Reduction - over several decades and across several countries - is necessarily large, this paper is presented in 3 parts. Part 1 examines the developments in the USA; whilst Part 2 looks at Britain, Canada, and Australia. Part 3 considers mainland Europe, and then goes on to explore reasons why the package called ‘Harm Reduction’ has fared better than ‘Responsible Use’ as well as some possible reasons why the present, Harm-Reduction-biased situation has come about. The paper concludes by suggesting possible ways forward for those advocating a prevention-focused approach – learning from history.

Keywords: harm reduction, drug prevention, strategy, policy, politics

4. Britain in the Eighties and Since (Brittania waives the rules)
When this writer and his wife first became workers in the UK drugs field in the 1980s, for the first seven or eight years work was in ‘Street Agencies’ - face-to-face with addicts, alcoholics and others at various points along the continuum of substance abuse from experimentation onwards. There was also work to assist the families and significant others around the user, and work as specialist advisers to the teachers in more than 100 primary and secondary schools. Like most drug workers at the time (not counting the activists), we had blissful ignorance of the fomenting of unrest and radical activism from the Liverpool area, and this writer’s agency duties were pursued on exactly the same strategic basis as the American parent movement had eventually developed, that is:

• Stop it starting.
• If it’s started, stop it.
• If it’s still not stopped, then help it to stop. Full stop!

The first signs of trouble came when our agency, in concert with other Drug Education Advisers across England and Wales, started attending National Drug Education conferences. One might have expected a few radical statements in an arena populated by teachers, but one was unprepared for the virulence of what was heard. It quickly became apparent (but sadly not to enough of our contemporaries) that the Drug Education Advisers were being hijacked by a small but well-organised bunch of mainly Liverpudlian libertarians.

One of the exponents of ‘Scouse radicalism’ was former teacher and Sociology/Criminology graduate Pat O’Hare, now better known as the Director of the International Harm Reduction Association. O’Hare and colleagues were well enough resourced to be able to run a glossy magazine named The Mersey Drugs Journal which in due course became the even glossier International Journal of Drug Policy (IJDP). The list of contributing editors to the IJDP read like an international “Who’s Who” of drug libertarianism.

Liverpool in the Eighties was a swirling pool of powerful undercurrents. Anger at its social and economic situation compared to the affluent south-east had flared up into serious riots in the Toxteth area of the city in 1981. Although these eventually subsided, a sharp antagonism remained. Dislike for the Establishment as a species translated into identification with subculture – including drugs. Whether jealous comparison of economies was at the root of the next factor or not, the fact is that there was also antipathy towards all things American amongst the so-called ‘caring professions’ – not reflected in the general population – and out of this came a striving for new directions. The upswelling of libertarian philosophies at this same time seemed to fuse naturally into the process. One specific outcome was a vigorous seeding of the idea of harm reduction; a seeding which took root not just in Liverpool but also, through energetic propagation, across the rest of Britain and internationally.

Whilst other British cities with a high incidence of drug use were obvious places for the harm reduction gospel to be spread, it was by no means limited to these centres. Obviously the onset of AIDS at the start of the Eighties was a catalyst in the development of Harm Reduction. Drug agency workers at that time can vividly remember that all were deeply concerned at this new major health hazard and were invited to regard AIDS as a greater threat to society than drug abuse, a notion which helped to undermine the significance of drug abuse as something to be arrested or prevented. With hindsight it is clear that though AIDS is a terrible disease, it is also preventable - as is drug use, and that of the two, widespread drug use is in fact a much bigger threat to society at large. Prevent drug use, and you are well on the way to preventing AIDS.

Liverpool was one of the areas where AIDS was a particular threat, largely due to the already high prevalence of drug abuse. But what is not widely known is that this drug use, and in particular heroin use, did not generally involve injecting; ‘chasing the dragon’ (smoking) was the preferred method. It was then that the Liverpool harm reduction activists entered the arena. What happened next was related to this writer by the mother of two heroin addicts who later became one of UK’s leading parent campaigners. Injecting your heroin makes it go further – literally gives you ‘more bang for your buck’. With a free and limitless supply of needles and ‘works’, Liverpool changed from an area with only minority injecting use into one with the majority injecting. The activists behind this knew exactly what they were doing. In the words of one of the harm reduction crusaders, IJDP editor Peter McDermott (17):

As a member of the Liverpool cabal who hijacked the term Harm Reduction and used it aggressively to advocate change during the late 1980s, I am able to say what we meant when we used the term. Its real value lay in its ability to signify a break with the style and substance of existing policies and practice. Harm Reduction implied a break with the old unworkable dogmas – the philosophy that placed a premium on seeking to achieve abstinence…

McDermot goes on to talk about the importance of the “availability of a legal supply of clean drugs and good supplies of sterile injecting equipment”. Note that he incorporates legalisation and needles as part of the harm reduction package; note too that he talks about ‘supply’ - not ‘exchange’ - of injecting equipment.

What McDermott and his colleagues meant by good supplies was more than just a rejection of the idea of needle exchange, a process which was supposed to be associated with dialogue between the drug worker and the user, with the aim of encouraging transition to a healthier lifestyle. McDermott & Co. had much more in mind than handing out a pack of needles without dialogue. The reality was, as the Liverpool mother told me, giving out needles by the bag full, and even giving out needles to known drug dealers (whom the police had agreed they would overlook if they found them carrying bagfuls of injecting equipment) to be distributed with the drugs they sold.

What the Liverpool ‘cabal’ had as their driving force may be judged from McDermott’s editorial of the time that said:

…we must continue to guard Harm Reduction’s original radical kernel, without which it loses almost all of its political power.

This movement, piously promoted in the name of treating drug users with respect, was in fact an exercise in radical politics. Radical politics sail under many flags, but here is one passage first encountered in an American leaflet and then published in this writer’s 1992 book Drug Prevention – Just say NOW. (18) The passage vividly illustrates a radical approach to drug policy:

By making readily available drugs of various kinds; by giving a teenager alcohol; by praising his wildness; by strangling him with sex literature and advertising to him or her … the psychopolitical preparation can create the necessary attitude of chaos, idleness and worthlessness into which can then be cast the solution that will give the teenager complete freedom everywhere. If we can effectively kill the national pride and patriotism of just one generation, we will have won that country. Therefore, there must be continued propaganda to undermine the loyalty of citizens in general and teenagers in particular.

The author of this uplifting little piece was a Mr. Josef Stalin. At least one of the Liverpool ‘cabal’ was reputed locally to be a Stalinist. To imagine that one can disregard what Stalin said just because Russian communism has faded away is to miss the point. Radicals want to change the world to suit themselves – just like the rest of us. They will approach this by first inducing confusion, fatalism and dismay – much as Britons now regard their nation’s drug situation. They will then introduce their own solution. This is the ‘Gramscite Endgame’ described in Michael Ard’s paper (12) earlier herein.

The ‘radical kernel’ was generally masked by rhetoric around the prevention of disease (and in particular AIDS) and the dignity of the user, but their preaching across Britain was both energetic and rapid. The message was promoted to drug workers, teachers, health workers and, not least, to police forces. In 1988 this writer sat in on a presentation to a regional health authority given by Alan Parry, another leading light in the Liverpool cabal. Parry outlined their policy: money would be moved from abstinence and detoxification into harm reduction. Prevention was dismissed as ineffective, and they would therefore block any drug education scheme unless it could be proved to be innovative and with evaluation built in. When a questioner from the floor asked Parry what evaluation they were building into their own harm reduction work, he answered that there was very little funding available, so they would not be evaluating what they were doing - but they did feel it was ‘working well’.

In this context, it is enlightening to hear the comment made a decade later (in the late 1990s) to one of NDPA’s member groups by Anna Bradley, at that time Director of Britain’s Institute for the Study of Drug Dependence (ISDD). Pushed back from her opening gambit, which was to allege a lack of evidence for prevention, Bradley was forced to concede that ‘… there is no research base for harm reduction’. She has now left ISDD – and ISDD has left its own home to join the DrugScope family.

Harm reduction or use reduction?
Two weighty academics applied themselves to this question.(19) Caulkins has been known in the past to resort to complex mathematical expressions to illustrate his thinking, but not always successfully. Peter Reuter is a well-known academic in the libertarian camp. Reuter is a seasoned ‘pressure group politician’ – he forgoes aggressive outbursts in favour of a silken rhetoric – ever ready to smooth the opposition with a few compliments. His style is to wrap everything in seemingly scientific statements and implant his arguments under verbal anaesthetic.

The authors used the USA as their datum; a country where use reduction has driven policies. Opening their remarks, they frankly concede that “Measures associated with use reduction goals are poor; those associated with harm reduction are even worse,” and go on to say“… the overall objective being to minimize the total harm associated with drug production, distribution, consumption and control. Reducing use should be seen as a principal means of attaining that end”. Presumably this would screen out the ‘amateur’ or novice users, leaving the arena free for the in-crowd who ‘know what they’re doing’.

They next commented on drug policy goals in the US saying, “America’s commonly articulated goal has been a ‘Drug Free America’. Few dispute that this would be a desirable end-state. Unfortunately it is no more feasible than ‘Schizophrenia Free America’”. More predictably, they then fell back on the old liberalisation chestnut; i.e., “Use of psychoactive substances by some fraction of the population is nearly universal, spanning centuries and cultures”. That ‘some fraction’ have been users for a long time is not in dispute; the problem now derives from a ‘large fraction’ – particularly in young people. Whilst in the 1950s (and before) the fraction was around 1%, by 1980 it had risen to 10%.

Defining use and harm reduction, the authors suggested three ways of measuring ‘use’ – numbers of users, quantity of use and expenditure on use. They then suggested responses to each; e.g.:

• to reduce use, focus on light users, prevention and "soft drugs";
• to reduce quantity, treat heavy users and increase enforcement that raises prices;
• and to reduce expenditure, treat heavy users of expensive drugs and (perhaps) cut high-level enforcement so prices on the street fall.

Addressing the choice between use and harm reduction, the authors say:

Since use reduction and harm reduction are clearly different goals, it is natural to ask which is better? Keeney (1992) advises that goals are selected based on one's ultimate values. Following that argument, harm reduction makes more sense for people who do not care about drug use per se, but care about use because it contributes to health problems, poverty, spread of infectious diseases, property crime, violence, reduced productivity, etc.

Others view drug use itself as "bad". They view as bad even a hypothetical situation in which an adult user could freely choose to use a psychoactive that has absolutely zero risk of damaging self or others, directly or indirectly, in the short- or long-term. For such people, reduction may be the ultimate goal.

Caulkins and Reuter closed by offering a few opinions of their own, including:

It is our belief (see Reuter & Caulkins, 1995) that augmenting use reduction with explicit harm reduction goals and admitting the possibility that one might at times be willing to accept higher use if it yields substantially less harmful use, would encourage wiser policies.

This remark has to be a very speculative flyer, and the various other statements by these two authors, especially Reuter, strongly suggest that this whole article is a cynical construction to induce sympathy for the authors before giving the punch line – soften drug laws.

The evidence-base for harm reduction approaches to drug use

Britain can fairly claim to be the birthplace of modern harm reduction – though whether this is a matter of pride is open to debate. One of the longest reference papers encountered on this subject was published in 2003 and is “A Review of the Evidence-base for Harm Reduction Approaches to Drug Use” (20). No less than 52 pages (with some 250 references) rolled out of the computer printer, under the authorship of Neil Hunt at Kent University.

The familiar links between ‘the usual suspects’ in drug liberalisation are in evidence. Forward Thinking on Drugs, who commissioned the review, are (as already described) a Soros-financed liberalisation pressure group, with the UK’s disgraced former Deputy ‘Drug Tsar’ Mike Trace on the bridge. Principal author Neil Hunt is also a committee member with the IHRA – International Harm Reduction Alliance. Colleagues in Hunt’s review include Mike Ashton (formerly with Drugscope), Bill Nelles (organiser of the Methadone Alliance) and Gerry Stimson (another IHRA Senior: in fact, the current Executive Director). Observers of the Harm Reduction/Legalisation debate will recognise all these names.

Their listing of what comprises harm reduction is revealing in itself. The listing includes needle and syringe programmes, methadone and other replacement therapies, heroin prescribing, depenalisation and the harms associated with criminal penalties for drug use, information, education and communication, safer injecting and other ‘Drug Consumption Rooms’, pill testing and allied warning systems, and motivational interviewing.

But where are the interventions to reduce harm for people around the user, up to and including society as a whole? They refer to Newcombe (1992) whom they credit as giving:

…a widely-cited conception of harm reduction (which) distinguishes harm at different levels - individual, community and societal - and of different types - health, social and economic. These distinctions give a good indication of the breadth of focus and concern within harm reduction.

That may be so, but if it is, why are so many options solely fixated on the user and his personal harm?

Their overview considers the strength and nature of the evidence of the effectiveness of various forms of ‘harm reduction’ intervention and says:

In doing so, some consideration is also given to criticisms of harm reduction that are occasionally encountered’. (This writer’s emphasis)

In other words, they imply that very few people criticise harm reduction, and then do so only rarely – which is clearly not so, however much the authors might wish it.

What is harm reduction? (the authors ask)

In essence, they conclude, harm reduction refers to policies and programmes that aim to reduce the harms associated with the use of drugs. A defining feature is their focus on the prevention of drug-related harm rather than the prevention of drug use per se.

They concede that:

Rather unhelpfully, no definitive definition of ‘harm reduction’ exists. A number of definitions have nevertheless been offered (for example Newcombe 1992; CCSA 1996; Lenton and Single 1998; Hamilton, Kellehear & Rumbold, 1998).

Interestingly, they comment on the relative extent of prevention and harm reduction.

In practice there is more convergence between countries that are associated with harm reduction and those that are more associated with a ‘war on drugs’ than is often acknowledged. Globally, drug prohibition is universal, but with differences in the way that it is implemented. Similarly, primary prevention efforts to discourage the use of drugs by young people have remained a feature of the drug policy of countries that have been most strongly associated with the harm reduction approach such as The Netherlands, Australia, Canada, Germany, Switzerland and the United Kingdom.

Hunt, et al then go on to review harm reduction principles. They say:

Harm reduction is partly defined by a range of principles in which policies and programmes are grounded. The Canadian Centre on Substance Abuse (CCSA 1996) offers the following:

• Pragmatism: Harm reduction with some substance use is a common feature of human experience.
• Humanistic Values: The drug user's decision to use drugs is accepted as fact. No moralising.
• Focus on Harms: rather than use – this is accepted as it stands.
• Balancing Costs and Benefits: A pragmatic process of identifying, measuring, and assessing.
• Priority of Immediate Goals: first steps toward risk-free use, or, if appropriate, abstinence.

As Hunt, et al put it:

Where it seems the most feasible way to reduce harm, harm reductionists view abstinence as a valid and legitimate goal and interventions to promote abstinence are generally thought of as ‘a special subset of harm reduction’ (IHRA 2002)

The audacity of this is breathtaking. They have reversed the whole structure of drug policy, which is that drug use is firstly to be proactively prevented, and only if this fails do the reactive measures – enforcement, intervention, treatment (of which harm reduction is a part) come into play – as a ‘subset’ of prevention.

They concede that harm reduction is not without its critics, saying that:

Despite the fact that it is an approach grounded within public health, for which a considerable evidence base now exists, there remain people with reservations about a) its effectiveness, b) its effects and c) its intentions. The reservations they cite are: ‘Harm reduction does not work’; ‘It keeps addicts stuck’; ‘It encourages drug use’; and ‘It is a Trojan horse for drug law reform’.

This writer has given workshops including the ‘Trojan Horse’ concept, also offering another metaphor for the liberalising movement as the ‘Beast with Seven Eyes’ – with the ‘eyes’ being ‘Trivialise’, ‘Sympathise’, ‘Glamorise’, Normalise’, ‘De-penalise’, ‘Decriminalise’ and ‘Legalise’.

In reviewing the impact of legal status of drugs, they concluded that “depenalisation did not result in increased rates of cannabis use but did substantially reduce the adverse social costs on apprehended individuals”. Quite why this should be so was not clear. The authors made passing reference to their case being supported by “the overwhelming weight of criminological research”. The degree of ‘overwhelm’ would of course be a function of the ease with which one party can get their arguments published – in this the libertarians have a distinct advantage; any review of publications makes this clear.

The final conclusions of the 52 page study (with some 250 references) by Hunt, et al are:

Despite the fact that the bulk of its development has occurred in just 20 years or so, there is an extensive and rapidly developing literature on interventions that can be situated within a harm reduction perspective. This evidence base reveals that there are interventions that:

• Definitely work
• Show promise and require cautious expansion
• Are widely used yet under-researched

IHRA – its background and key members
The IHRA (International Harm Reduction Alliance) capitalised on the new-found enthusiasm for harm reduction in the l990s and expanded vigorously after its formation – one benefactor being the ubiquitous George Soros. The following sections are taken from the IHRA website:

In 1990, Liverpool, England hosted the 1st International Conference on the Reduction of Drug Related Harm. The city was one of the first to open needle exchanges and had attracted hundreds of visitors each year who wanted to learn about the Mersey Harm Reduction Model. The conference was a way of dealing with this interest and the volume of visitors and it was a huge success. Accordingly, the following year, the 2nd International Conference on the Reduction of Drug Related Harm took place in Barcelona and a movement soon developed around this conference – spreading the principles behind the harm reduction approach, sharing knowledge and experiences from around the world and promoting the growing scientific evidence that supported this approach.

In 1995, Ernie Drucker outlined an idea he had for an International Harm Reduction Association, the birth of IHRA was announced the following year, at the 7th International Conference on the Reduction of Drug Related Harm in Hobart, Tasmania.

Patrick O’Hare started working in the drug field in the mid-1980s when he became Director of the Mersey Drug Training and Information Centre in Liverpool. As well as being a founder of IHRA, Pat also served as the Executive Director from 1996 until he stepped down in 2004. He is currently the Honorary President of IHRA.

Professor Gerry Stimson was appointed as the Executive Director of IHRA in 2004, taking over from Pat O’Hare. Professor Stimson is a public health sociologist. He has nearly 40 years’ experience of research in this field and has advised the UK government, World Health Organization, UNAIDS and UNODC on issues relating to drugs.

Extra to these two luminaries, there are many more names that will be familiar to anyone on the drug policy circuit. Founders (who mostly remain active) included Ernst Buning and Ernie Drucker as well as Diane Riley (Toronto), Marsha Rosenbaum (San Francisco, formerly with NIDA), Bill Stronach (Melbourne)and Alex Wodak (Sydney).The current Executive Council also includes delegates from India, Brasil, Malaysia, Uruguay, Lithuania, Canada, and from Britain – the head of Transform, a legalising pressure group, Mr Danny Kushlik.

Conferencing is a constant feature; e.g.:

18th ICRDRH- Warsaw 2007 ‘Harm Reduction- Coming of Age’. IHRA and the Conference Consortium are pleased to announce this must- attend event, which takes place in Warsaw, Poland, from 13th to 17th May 2007.

DrugScope – big ideas, big money
DrugScope as an entity was apparently the brainchild of health consultant Roger Howard during the time of the previous Conservative government (the early 1990s). Roger Howard Associates published a report titled Across the Divide in l993; the topic was how to better interrelate the various government and non-government agencies in the drugs field. This was a timely publication as the Conservatives worked towards a national drugs strategy; the strategy was published in l995 under the title “Tackling Drugs Together” (21) – and at that time it received all-party support.

The NDPA (National Drug Prevention Alliance) was one of several invited participants in working meetings with the government authors as the new drugs strategy was drafted. NDPA made the point that whilst the treatment field had a forum called SCODA (Standing Conference on Drug Abuse) for debating and voicing its views, and there was also a forum for research bodies called ISDD (Institute for the Study of Drug Dependency), no similar forum existed for prevention and education.

The outcome, as revealed in the final draft of “Tackling Drugs Together” was surprising and – as far as NDPA and other prevention bodies were concerned - depressing. SCODA and ISDD would be merged into a new charity called DrugScope – with a new director, none other than Roger Howard. Moreover, the new charity would expand its scope to also cover prevention and education, areas in which it had little experience. The government staffers (who were civil servants) told NDPA that this was only a proposal; NDPA asked why then the adverts for relevant personnel (to be funded by the Department of Health) were already published in appropriate health oriented journals. Clearly, the die had already been cast, and with it government money – anything up to £3 million per year has been seen in DrugScope’s published accounts over the years since 1995.

The implications for the future of prevention and education engendered serious concerns in those advocating prevention as the primary strategy. SCODA had already expressed its liking for harm reduction and its scorn for primary prevention, whilst ISDD (Dorn and Murshi) had produced a major report for government alleging that prevention was impossible – another example of adroit cherry picking. Subsequent developments did nothing to allay these concerns. DrugScope has been active in advancing harm reduction, but its prevention and education unit has for the most part been under the management of personnel well known in the field for their anti-prevention standpoint - Adrian King, Vivienne Evans, Ruth Joyce - whilst other relevant bodies such as the DEF (Drug Education Forum) and DEPF (Drug Education Practitioners Forum) have been heavily influenced by the same people. There has consequently been a stranglehold on drug education and an unjustified emphasis on harm reduction over prevention.

DrugScope has also been active in the international scene, as well as prominent in Wilton Park international drugs conferences and in Europe, where it has pro-actively cooperated with such as:

• ENCOD (European Coalition for Just and Effective Drug Policies) - 140 NGO members, born 1993;
• SENLIS (international policy think tank) - offices in Brussels, London, Paris, Ottawa and Kabul; the Kabul office was recently shut down by government – present situation uncertain. The UK member of parliament Chris Mullen, who earlier had chaired a UK government Select Committee which in 2002 suggested liberalising Britain’s drug laws, now works with SENLIS – although his role is unknown;
• TNI (Trans National Institute) - key contact is Martin Jelsma;
• IAL (International Anti-prohibition League);
• CEDRO (Centre for Drug Research, Amsterdam University) - key contact is Peter Cohen;
• Beckley Foundation (UK-based) - key contact is Mike Trace.

DrugScope activist Axel Klein, who is now based at Kent University but maintains his contact with DrugScope, was particularly enthusiastic in his involvement with the above (and other) groups in the European arena. He showed his ability to think structurally rather than emotionally or opportunistically and is quite clearly an adversary to be respected.

DrugScope likes to describe itself as “the leading British drug agency … internationally recognised” - and is not above positioning itself as a judge of others in the field. In his blog on Monday, November 27, 2006, entitled ‘Smoke, mirrors and the death of objectivity’ (22) DrugScope veteran Harry Shapiro published his thoughts on the integrity of information we each have to deal with in this field. Quoting from his blog, here are his main points:

Back in 1968, the Institute for the Study of Drug Dependence (now DrugScope) was set up in the UK to try and gather what little information was 'out there' about illegal drugs. Now enter ‘illegal drugs’ into Google and you'll net nearly seven million hits in half a second. So is that job done - is drug information now ‘sorted?’ Absolutely not. We have simply moved into a post-modern world where there are no longer any wrong answers, simply alternative truths - often mired in scientific and statistical obfuscation:

• Studies are cherry-picked to suit an argument.
• Over-reliance is placed on studies where samples are small or unrepresentative, or fail to take into account other factors which might account for the result
• There are researchers who have the veneer of objective scientific respectability, but come to the work with their own moral agenda with the inevitable outcome for the results.
• Findings are refracted through the prism of spin. Medical journals announce new ‘shock’ research about drugs and by the time they hit the tabloids, what might have started out as considered work has been reduced to scary headlines.
• And of course, there are straightforward lies, exaggeration, the promotion of potential risk to a small group of users as the actual risk to most users and so on.

As an organisation DrugScope will not sit on the fence in highlighting the dangers of drugs, but neither will we condone or support drug information which lacks credibility and is detached from evidence.

All good salutory stuff, but it is only reasonable to suggest to DrugScope that they consider the time-honoured rubric: “Let him who is without sin cast the first stone”. (John 8:7)

ACMD (Advisory Council on the Misuse of Drugs)
There is a natural human tendency to assume that any committee formed in the government field is competent, objective and unbiased in that it has no agenda of its own. Sadly, this has been shown to be far from the case with the ACMD. With very few exceptions (such as former school headmaster Peter Walker, who served on the ACMD for many years and is now advising the government on drug testing in schools), there is a heavy bias in the membership of the council. Of the thirty or so members in the 2002/2003 period when the government was reviewing UK drug policy, not far short of half of them were found to be linked in various ways to liberalising bodies (as reported in Hansard), and yet there were no members linked to any prevention bodies. To become a member of the ACMD it seems that in effect one has to be approved by the people who are already in – clearly, this is open to a self-serving approach.

How has harm reduction influenced education?
At the time that this writer took on additional work as an education advisor, assisting local schools with their drug education work (if any), the whole of England and Wales, a population of some 50 million people, had its drug education coordinated by just over 100 people. Most of these were teachers who had moved sideways into becoming Drug Education Coordinators. They had little or no knowledge of drugs, and they were therefore eagerly looking for guidance from those they considered to be more experienced. One hundred is a very small number for a group of determined radicals to penetrate and persuade; this could be seen taking place at drug education conferences and training sessions at the time, without it being apparent to anyone other than the activists just how wide-reaching and profound it was to become.

The British harm reduction movement did not content itself with staying in Britain -it soon established links elsewhere. It could be seen that those involved were using electronic means of communication globally, long before e-mails were common. One of the ‘travelling salesmen’ was Julian Cohen, co-author of the ambiguously-titled Taking Drugs Seriously. Cohen (23) argues for the ‘plusses of drug taking’; a typical item in Julian’s carpetbag is:

The primary prevention approach ignores the fun, the pleasure, the benefits of drug use … drug use is purposeful, drug use is fun for young people and drug use brings benefits to them.

Prevention or promotion?
Scouring the various libraries for data on drug prevention proved a low-yield exercise for drug professional Ann Stoker, herself the director of two local government drug agencies in west London. Her agencies counselled and helped problem users and their families but also worked in local schools, with Ann appointed as the government-funded Drug Education Co-ordinator. Attendance at national drug conferences highlighted the creeping emphasis on harm reduction rather than preventive education - this at a time when the two largest preventive education bodies in the UK (DARE UK and Life Education Centres UK) were under constant fire from the libertarian trenches.

Stoker decided that a detailed audit of the UK drug education scene was needed and set about producing one. Her book, entitled Drug Education: Prevention or Promotion?, was published in 2000 (24) and examined all programmes that could reasonably be collected within the literature, identified approaches known to be in use in England at that time and compared them with works in other countries as known to the author. The findings were bleak and salutary; the Education sector had clearly embraced the harm reduction approach, and the lobbying work of the ‘Liverpool cabal’ (as described in the opening paragraphs of Section 3 of this paper) had been an unqualified success.

It is an understandable aspect of any educational area in conflict that some charitable (NGO) agencies will feel the pressure and adjust their position in order to protect their market or their funding. For drug education in UK this has been seen several times over. Both Life Education Centres UK and Hope UK were founder members of the NDPA (which is firmly based in primary prevention). As pressure on NDPA mounted, both these organisations reviewed their positions, adjusted their missions and sent NDPA a ‘Dear John’ letter along the lines of "We can still be friends but we can't sleep together anymore".

In Hope UK's case, their materials now extend into the harm reduction field as well as prevention. Life Education Centres took a more radical route by largely removing themselves from the ‘discomfort zone’ which is drug education, focusing instead on other aspects of personal health. (This contrasts interestingly with Life Education Centres Australia, which some years earlier had taken on harm reduction as a key component of its curriculum after being threatened with loss of its funding. Life Education Centres New Zealand and Life Education Centres UK at that time dissociated themselves from Life Education Centres Australia).

When you wish upon a tsar …
In 1998 a Labour government came to power, and one of its first tasks was to review the previous (Tory) National Drugs Strategy, which had been published in 1995 under the title Tackling Drugs Together (21) and had received all-party support. The new strategy was at first encouragingly close to its predecessor - even in its choice of title – Tackling Drugs Together to Build a Better Britain.

The new government pinned its hopes on their innovation - the establishment of a ‘Drugs Tsar’ (Anti-Drugs Co-Ordinator) to co-ordinate the various government departments in respect of drug policies. The drugs tsar job went to Keith Hellawell, a former Chief Constable with considerable insight in drugs matters, but he was surprised by an insistence from a government Minister on the eve of his appointment that he must take on a specified deputy, a Mr. Mike Trace from the treatment field.

This less than auspicious start to the tsar's office was not the last of its troubles. The media predominantly favoured a harm reduction approach, seeing this as closer to its own liberal philosophies. This meant that Hellawell would constantly take scrutiny and criticism on any enforcement/prevention missions he introduced, while his deputy would receive that much easier a ride on his work in harm reduction and treatment.

In 2001 the scene changed again. Jack Straw was replaced as Home Secretary by David Blunkett, and scarcely had Blunkett entered his office than he announced he was ‘minded to reclassify cannabis’. The mechanisms applied to progress this idea were the Home Affairs Select Committee (HASC) and the Advisory Council on the Misuse of Drugs (ACMD). HASC, which is an All-Party Committee, embarked on a review of the whole UK strategy, The Government’s Drug Policy – Is It Working?, (25) under the chairmanship of Labour MP Christopher Mullen (now with SENLIS). In May 2002 HASC concluded that reclassification was a jolly good idea. ACMD also endorsed the notion - hardly a surprise, given that they had been pushing precisely this change for years.

Another radical move by new Home Secretary Blunkett on entering his office was to sideline his Drugs Tsar, moving him into a nebulous backwater called ‘International Affairs’. Hellawell was clearly not happy with this sidelining nor with the downgrading of cannabis, and he took the unusual action of resigning his post on national radio - BBC's 4’s Today programme.

Several have since wondered how David Blunkett had come up with such a radical idea as cannabis downgrading when he had clearly had little or no time to ‘read himself in’ - a process that would inevitably take much longer for him, given that he was profoundly blind. Clearly, he would have had to be helped, and equally clearly, Hellawell would not have been in a helpful mood. It is therefore a fair assumption that Mike Trace’s team did much of the briefing, and the consequent shift in UK strategy towards harm reduction is therefore more understandable. This shift in emphasis was also self-evident in the Strategy Update of Christmas 2002 and prior to this at a conference in Ashford, Kent, southeast of London, in the summer of 2002 in a speech by Drugs Minister Bob Ainsworth where he committed the government to taking harm reduction to the core of its policies.

National journalist Melanie Phillips was at the Ashford conference and subjected it to a lacerating criticism. Phillips is a professional journalist and one of Britain’s leading social commentators, producing articles and books full of thoughtful and forthright comment on social affairs. She also runs a public access website - www.melaniephillips.com. In October 2002, after attending the Ashford conference, she issued a trenchant piece entitled “The Drugs Policy of Harm Production”, (26) from which the following extract is taken:

A silent coup has taken place in drugs policy. The legalisers have captured the Home Office. The government has quietly downgraded its attempt to reduce the number of people taking illegal drugs. This astonishing development became clear last Friday, when the Home Office minister Bob Ainsworth told a conference that the government was going to place ‘harm minimisation’ at the centre of its revised drugs strategy, to be unveiled in a few weeks’ time.

Dutch drug legalisers were in great evidence; Peter Cohen, Freek Polak. Hans Visser, all took their turn. This group was described to Melanie by Hans Koopmans, of the De Hoop psychiatric hospital for drug users in Dordrecht in Holland, as ‘the nucleus of the legalisation movement in the Netherlands’,

It was apparent that most drug agencies now promote ‘harm reduction’. The Home Office listens to them. And some of the most prominent of these agencies — Turning Point, DrugScope, and the International Harm Reduction Association (IHRA) - were involved alongside the Home Office in organising this conference. Of these, one at least had the honesty to admit that ‘meaningful harm reduction’ inevitably requires legalisation.

Winston, Wiston, Wilton ....
Just after the Second World War, Winston Churchill perceived the idea of a "calm, residential environment”, in which democracy-building could be nurtured.

Wilton Park classifies itself as “… an academically independent agency of the British Foreign and Commonwealth Office” (albeit financially underwritten by the FCO) . Around 60 conferences are organised each year and typically bring together 50-60 policy makers and opinion leaders from 25 countries. Generally, around half attendees are government officials – people “in a position to make direct impact on government policy”. Wilton Park sees itself as “helping to move forward international policy agendas”.

Over the past five years there have been yearly conferences on drug policy. (27) At first sight this seems laudable, but closer examination shows that Mr Soros’ Open Society Foundation has been a major funder of these drug policy conferences, would most certainly have been involved in planning the agendas and libertarian/harm reduction speakers have been to the fore; e.g., “Keynote speech by Ethan Nadelmann”, “Rapporteur supplied by TNI” and so on. Key speakers in the past in addition to Ethan Nadelmann have included Peter Reuter, Mike Trace, Axel Klein, Martin Jelsma, Peter Cohen, Dennis Peron and more with a similar leaning. There have been few representatives of prevention-based policies - conceivably due to the £800 registration fee. Britain's NDPA has had representatives at five conferences, but acting very much as a "voice in the wilderness". The US State Department has withdrawn from speaker slots at the last two conferences - presumably in disgust.

A regular at Wilton Park has been Carel Edwards, head of the European Commission’s Drugs Branch, based in Brussels. It might seem that his department has little influence on member states’ drug policies, given that drug strategy is something that states decide for themselves (which must multiply the difficulties he faces in running his department). However, there is no doubt that Carel’s own series of conferences and statements are influential, especially on nations that are relatively undecided about their drug strategies.

The sum total therefore is that we have the bizarre situation of the British government funding an event which substantially undermines its own strategy - and the strategy of the USA - and gives unfettered promotion of the libertarian view in front of senior representatives from other countries who are unaware of the background machinations. Typical of the confusion created has been the remarks made to this writer by a foreign delegate who thought that Mr. Nadelmann was officially representing the government of the USA!

Paradigm shift coming?
There is some brighter news on the horizon, though the liberalisers are already anxiously decrying it. Under the leadership of Professor Neil McKeganey at Glasgow University’s Centre for Drug Misuse Research, authoritative questions are being asked about harm reduction (28): Where and what are the significant results, if any, after fifteen to twenty years of substantial investment? And why were we so ready to emasculate primary prevention? Moreover, CDMR interviewed a large cohort of drug addicts and asked them what services they wanted: needles? syringes? methadone? and so on. A sizeable majority answered, “We want none of the above – what we really want is help to give up using drugs”. McKeganey is not alone in raising these concerns, and it does seem that a reappraisal of policy priorities, with benefit to all concerned, is on the cards.

Cameron on substance
A recent blog by a Conservative party advisor (29) explores the new leader David Cameron’s current attitude on drugs and drug policy. Cameron, before his selection as party leader, served his time on the HASC, which reviewed the whole of Britain’s drug policy. According to the blog writer:

He was a tight-lipped as ever about his possible past use of illegal drugs, and seemed unwilling to recant his utterances when on the HASC – downgrade cannabis and ecstasy, set up shooting galleries, issue heroin on prescription – ideas which had provoked strong reaction amongst right-wing Tories. But he was anxious to dispel any notion that he was soft on drugs, saying: ‘Whoever you are, wherever you live, drugs wreck lives. And they wreck the lives not just of those who use drugs, but the lives of their families and the lives of the many people who are victims of drug-related crime.’

He suggested two priorities:

1. ‘Proper education about drugs’ – ‘The Government sends mixed messages with too much on reducing the harm and not enough on reducing the use.’
2. ‘Treatment and rehabilitation’ – He cited good models of rehab in Sweden, Holland and the USA. ‘We have to make it available – indeed, we have to make it compulsory for each and every young addict. That is both tough and compassionate.’

5. O, Canada!
Whilst the USA has remained implacably opposed to almost every liberalisation of drug laws (the exception being a few states where cannabis laws have been relaxed in relation to what is loosely termed ‘medical use’), north of the 49th Parallel the situation is very different. There is considerable pressure to go soft on cannabis. A British company, GW Pharmaceuticals, has been awarded a Canadian government licence for its synthetic cannabinoid-based product Sativex, but GW Pharmaceuticals insist that this licensing “has no direct consequences for the legal status of herbal cannabis for research and medical use”.

Vancouver has been a focal point in the conflict over drug policy with much volatile rhetoric on liberalising as the solution to the problems of the city – especially on the Lower East Side, but also with the sterling outreach work of Vancouver’s police ‘Odd Squad’ as a balancing factor. Perhaps the most damaging aspect of cannabis in Canada has been hydroponic cultivation in domestic properties – nowadays known as ‘Home Grow’. Domestic properties are filled with light systems and produce hundreds of high-grade plants. Electricity and water are illegally ‘boosted’ from the mains supplies in the road outside. Unsuspecting buyers or landlords of properties, after the home-growers have moved on, find themselves saddled not only with enormous services bills but also severe structural decay to the timber framework from the effects of sustained high humidity. In 2006/7 scores of similar homes used to grow cannabis hydroponically have been found in the UK – many set up and run by Vietnamese.

A major customer for the Canadian product is that large country just south of the 49th. Canada is not without internal conflicts as to its relationship with its southern neighbour, and the situation is further complicated by the internal tension between the Quebecois and the rest of the country. Randy White is a former Member of Parliament and is now the President of the Drug Prevention Network of Canada, the only Canadian national organization that promotes prevention, treatment and enforcement as its primary goal. It believes that those who are addicted are best served by treatment that does not accommodate or encourage their addiction. Asked for his summary of how ‘so-called harm reduction’ came to grow so fast in Canada, he replied with the following statement:

I was a Member of Parliament in Canada when the concept of harm reduction appeared on the Canadian scene around 1994. It wasn’t a concept really - it was an effort to accept drug abuse as another sickness that Canadians couldn’t avoid, so attempts began to accommodate addiction. An extremely weak National Drug Strategy at the federal level, virtually non existent prevention programs, treatment as a minimum effort, and judges and lawyers sentencing offenders like they were selling candy on street corners all led to legalization efforts and “harm reduction” becoming a theory that might work better than past political failures.

First a needle exchange began, then more needle exchanges as governments at all levels jumped on the band wagon with money but without looking at a long term strategy. Money was easier to get for a new concept and people looking for more incomes for their own existence began to invent more and more accommodating programs like medical marijuana, crack inhalation sites, wet houses, legalized prostitution, heroin programs, addicts shooting up other addicts and on it goes under the umbrella of “harm reduction”. No one questioned, no one understood and no one watched as the scene developed.

I initiated a House of Commons special committee to study the non medical use of drugs in 2001. At each meeting [and there were many] I asked witnesses “What was harm reduction”? Virtually every witness answered differently, and to this day most people are not consistent with what it is and what it has accomplished. A common thread with those who wanted “harm reduction” was that they believed in legalization of drugs.

So today in Canada “harm reduction” has a tenuous foothold - achieving very little but soaking up tax dollars that could otherwise be used for prevention, treatment and enforcement. Canada, unlike most other civilized nations, followed the programs of Holland and Switzerland in such “harm reduction” concepts even when those two countries started to realize the failure in their approaches.

The "harm reduction movement" has come to represent a philosophy in which illicit substance use is seen as largely unpreventable and, increasingly, as a feasible and acceptable lifestyle - as long as use is not "problematic". At the root of this philosophy lies an acceptance of drug use into the mainstream of Canadian society.

As an example, a pilot project was established with government money for an injection site; the organizers then built in a smoke site [crack] within the confines of this building. Addicts did not just inject heroin, they injected ‘meth’ and other drugs. All this in the face of law enforcement, parents and friends as well as government expecting addicts would eventually kick the habit. This did not happen. When it came time for the Government to close the site, significant outcry began. Who was at the center of it? The workers and legalization advocates and even harm reduction/legalization advocates from other countries as well. The government, concerned about a noisy public lobby, did not close the facility, so there it stands - extending the harm to addicts and flying in the face of prevention and treatment. Such political expediency hardly deserves the term ‘philosophy’ – but if it were, then it would be a philosophy which is fatalistic and faulty at its core. The idea that we can use drugs ‘safely’ is a dangerous one – and in no way is substance use inevitable.

The Canadian movement into "harm reduction" crept into our society because people, governments and organizations failed to recognize the real agenda of the organizers. Canadian families and communities have considerable power to prevent substance use if they have the will and resources and the support of governments. As a world society, we should be concentrating on prevention, treatment and enforcement now.

Reason and Rights (Be reasonable – we’re right)
As an example of the environment in which the Drug Prevention Network of Canada has to work, there is a relatively uninhibited contribution from the modestly-named British Columbia ‘Centre of Excellence’ (in HIV/AIDS). Author Richard Elliott (30) takes no prisoners.

In his 2005 paper “Reason and Rights in Drug Control” from British Columbia Centre for Excellence in HIV/AIDS, Richard Elliott, et al starts by accusing countries who “enforce prohibition” and resist harm reduction of “disregarding the available scientific evidence”, and, for good measure, “contributing to the spread of AIDS”. Elliott called on WHO and UN to rise to (his) challenge – or to continue their “timidity in the face of ideological bullying”.

Canada is, Elliott concedes, bound by the human rights obligations it has undertaken as a member state of the UN. But, he says, Canada should build on its declared control objective of harm reduction, and put itself about with vigour as a “strong global advocate for harm reduction”.

6. ‘Advance Australia Fair’ (and ‘God Defend New Zealand’)

Australia has proved itself an interesting laboratory in responses to the drug problem. Not by nature inclined to match its Southeastern Asian neighbours such as Singapore in their severity of law enforcement (the death penalty being a prominent feature), Australia has several noteworthy initiatives in its casebook.

Since the role of primary prevention as a prime tool in harm reduction is (even) accepted by some liberalisers, it is appropriate to mention two Australian examples (and one New Zealand one). Australia has produced some excellent prevention materials and programmes. Life Education Centres started there under the stewardship of its author, the Reverend Ted Noffs at the Wayside Chapel in the Kings Cross area of Sydney. The Kangaroo Creek Gang programme came from Perth. Meanwhile, just across the Tasman Sea in New Zealand, one of the most approachable books ever for parents - now also available on interactive DVD is The Great Brain Robbery (31) created by Tom Scott and Trevor Grice, the latter being also a Director of Life Education New Zealand. But since those heartening days when those resources were produced, things have slid downwards, and Australia is now a strongpoint of harm reduction.
One of the most prolific current experts in the Australian drug scene is Brisbane GP Stuart Reece. From his wide-ranging output, the following extract gives a good insight into what prevention workers face in Australia. The extract is taken from his commentary on an address to the ‘National Abstinence Summit’ in San Antonio, Texas, in 1999. The full paper (32) deals in depth with sexual behaviours and diseases as well as drugs matters – only the drugs aspect is covered in the extracts which follow:

Fatigue of ‘harm minimization’ / ‘risk reduction’
Just as in its maturing years the hedonistic materialistic atheistic “drugs sex and rock and roll” culture of the ’60’s is now widely acknowledged to have spawned a multiplicity of major medical and social pathologies, so too the public health philosophy which appears to have been created to justify it seems from an international perspective to be having not only a very brief initial effect, but also major unintended consequences of harm maximization and indeed risk multiplication.

Injecting Drug Users
The other classic area in which the harm reductionists / risk reducers have been very busy is in the area of drug policy. Their touchstones are needle and syringe distribution programs and methadone. I recently had one of their leading advocates tell me that methadone is a major factor reducing the HIV transmission risk. Whilst it may be true that most methadone patients do not inject heroin as often as they used to, considering that we estimate that only about 10% of all heroin addicts are on methadone, and that most still inject occasionally, the overall protective effect of methadone is likely to be quite modest in term of its global impact on the whole epidemic. A few reports on methadone are not favourable.

As in the case of condoms, harm minimization / risk reduction appears to have begun in Amsterdam. However, there was a report from there that in fact there were some indications that the number of injecting drug users (IDU) was thought to have increased both in the estimate of the total, and in terms of the numbers of clients entering rehab facilities. The same holds true in Australia, where the estimates of the number of IDU has been creeping steadily upwards during the 1990’s from about 150,000 earlier in the decade to the order of 250,000 heroin addicts alone now, and possibly almost as many speed injectors also. However, the factual basis of any such estimates is enormously problematic. Few would deny, however, that there has been an obvious increase in the nation’s drug problems associated with a fairly “laissez faire” liberal official attitude to drug policy under a protracted period of socialist administration since the 1970’s.

HM/RR in drug policy began in Amsterdam with the introduction of a syringe distribution program to help fight the rise in Hepatitis B amongst injectors. The HIV virus and the HIV tests were discovered the following year, and the program serendipitously happened to be in place. Interestingly, the Hepatitis B incidence appeared to fall away after its introduction, but the HIV incidence rose from 2% in 1988 to 6% in 1991 and 5% in 1992! Note that a very similar pattern was observed with the HIV seroincidence amongst homosexual men. Hepatitis C incidence is not usually reported to respond well to needle and syringe programs either in Amsterdam or Australia.

Reports from Amsterdam in the early 90’s showed that the effect of the needle program on needle sharing was transient and not significant. A similar effect was noted in Sydney, Australia, when needles and syringes were introduced in that the injecting behaviour rapidly and significantly escalated both in the study needle exchange and in another program in the same city in a matter of a few weeks!

NSP City Failures
Indeed when needle and syringe programs (NSP) are studied closely there is not infrequently a very adverse finding against the program. This has been seen most dramatically in the two Canadian programs in Montreal and Vancouver where HIV seroincidence has been studied in detail amongst NSP attenders and non-attenders and the incidence found to be 2.5 fold greater amongst NSP participants. Indeed when all the cities reporting major problems with their NSP facilities are listed, it makes an impressive list of failures: Amsterdam, San Francisco, Zurich, Montreal, Vancouver, Dublin, London, Sydney, Baltimore!

Suggestive Correlations
The numbers of syringes distributed in Australia is not readily available but may be ascertained from the articles written by the leaders of HR/RR. Based on these figures, it may be said that the correlation between heroin overdose deaths and the number of syringes distributed is P = 0.0022. The correlation between the methadone registrations and numbers of heroin overdose deaths is P = 0.00825. Perhaps most frightening of all was the fact that in a recent survey of 80 heroin addicts conducted in my clinic, some 40% felt that government encourages drug using through activities such as NSP, methadone programs which persist indefinitely, and the kind of drug education which sends dominant messages like “We won’t tell you whether or not to use drugs, but if you decide to we’ll spend the next one hour telling you how to do so safely.”

Conclusions on harm minimization
In summary, from the world literature, the best that can be said about harm minimization / risk reduction (HM/RR) is that HM/RR has a transient effect lasting a few years at most. In reality, the major studies which are usually thought to support HM/RR are deeply flawed and offer little or no supportive evidence at all. Indeed, it is one of the hallmarks of HM/RR philosophies that they deliberately refuse to address the problematic underlying risky and often selfish and irresponsible behaviours which underlie the pathologies they pretend to address. Meanwhile, evidence shows clearly that the underlying problematic behaviours spread and may be transmuted into different harmful forms, such as the transformation of the Australian AIDS epidemic into a heroin epidemic with a higher annual mortality than AIDS ever had, or the degradation of the culture of Amsterdam or Zurich under the influences of the liberal risk reductionists in those cities.

The epidemiological evidence would, however, strongly indicate several major conclusions including:

Knowledge imparted in the standard values free sex or drug education exercises will usually not positively impact behaviour as desired without the added variable of ‘Wisdom.’ The inculcation of wisdom, however, absolutely necessitates that character be taught; character based not on relativistic personal subjective values, but the ancient virtues of society and civilization, indeed, character traits of eternal moral and spiritual importance, and, indeed, those endorsed by most of the world’s major religions.
Perhaps my heroin patients can help indicate at least the beginnings of an answer to the classically difficult chestnuts posed by causality. When we surveyed 80 heroin patients recently, 40% said that the government encouraged them to use drugs (through methadone, syringe distribution and drug ‘education’ programs). John Saunders, Professor of Drug and Alcohol Studies in the Dept. of Psychiatry at the University of Queensland, says that in many respects Australia has traded an AIDS epidemic for a heroin epidemic.

The intrinsically behavioural determinants of the world wide epidemic of mortality from psychosocial disorders need to be formally addressed once again. Clearly the “way forward” is in some respects also the way back, to the traditional virtues which have always been shared by stable, self-perpetuating civilizations. Clearly we need together and internationally to turn from the immature selfish and self-centred hedonistic delirium which saw the explosion of various serious disorders manifested by rising trend lines in many nations and were heralded by unsafe modern contraception and followed by its many ideological offspring and cousins including condoms, needles and syringes, methadone and values-free value-less so-called “education” programs in many fields, and begin to deal with the core problems and the root social mythologies which support them and which are clearly rooted in indulgent attitudes of the human heart.

Only when we begin to marry the individual’s need for life, love and fulfilment, with a coherent code for personal conduct based on integrity, personal responsibility and commitment in relationships traditionally denoted as ‘marriage’ will the world begin to slowly climb out of its present moral crevasse. In many nations, young people are already showing the way forward. Will we follow? The responsibility for what is in essence a regime of morality and personal fulfilment based on eternal virtues and the upward appeal of goodness to the human spirit should surely begin with the leaders of world culture in the Western nations. Are we ready? Will we answer the call? As the millennium changes, will we turn over a new and clean page in the book of the history of the nations? Or will we simply acquiesce to echo the failed default public health positions of a former generation which have now been so eloquently documented on the world stage to have cost us so dear, have had so protean consequences so often unforeseen, and are now proving so hollow and so frequently counterproductive on the global stage?

Alex Wodak – Australia’s secret weapon
Having heard from some of the critics of Australia’s drug policy, no paper would be complete without an utterance or two from Dr. Alex Wodak. Australian observers of their nation’s harm reduction scene suggest that Wodak has been granted considerable leverage because of his apparent prominence in ‘saving Australia from AIDS’. They concede that Wodak’s policies have almost certainly delayed the spread of HIV, but by his failure to address the underlying social behaviours, they are left with the risk of an explosion of use in future.

In 2004 at the 15^th International Harm Reduction Alliance Conference, Dr. Wodak presented (33) on the theme of “The past, present and future of harm reduction: decades of misunderstanding”.

He set out the early history of harm reduction BA (Before Aids), the application of ‘risk compensation’ in psychiatry and of ‘moral hazard’ in economics and finance. His conclusion was that “The intellectual debate about harm reduction as a preferred policy is now over, the existing evidence is incontrovertible”. (It is strange to hear someone of his experience in effect ‘whistling in the dark’, but preventionists may take some encouragement from this).

Harm reduction has, he said, long been applied to such as alcohol consumption, and needle exchanges first emerged in response to Hepatitis B concerns in the early 1980s in Holland and Scotland.

Nicotine replacement for smokers was no different to methadone maintenance for heroin injectors – surely a very debateable assertion. Harm reduction is not without some social costs, he said, citing the likelihood of lesser risk encouraging more use, and – in a similar vein – fire insurance encourages more fires (not spontaneously, that is).

Harm reduction, opines Wodak, is neither pro nor anti-drugs; it is agnostic on the subject (This is hard to reconcile with the almost universal bonding of harm reduction advocacy with legalisation advocacy).

He mourned over the grave of ‘The War on Drugs’ – “It has undeniable intuitive appeal, but is weak empirically” (Perhaps if prevention were to get more funding, equal or close to harm reduction, this empirical equalising would be reflected in the outcomes). He went on to say “Harm reduction has an impressive empirical base … there can be no argument that the evidence strongly favours harm reduction, whilst prevention is costly, ineffective and often has unintended consequences” (whistling again).

Prevention of HIV amongst IDUs is seen by Wodak as the big battle honour on harm reduction’s flag (and on his too, presumably). He reserved his most acerbic remarks for the INCB, whom he accused of “issuing fatwas” such as the reclassification of buprenorphine, and who were, he remarked, “The geriatric dinosaurs of the drug policy world”(He would do well to avoid their Jurassic teeth in future).

He cited the 2002 UK Home Affairs Select Committee Chairman Chris Mullins MP who, in his Committee’s final report on UK drug policy, The Government’s Drug Policy: Is It Working?(published in May 2002) asserted that “any policies based mainly on enforcement are destined to fail”.Mullins was himself destined – perhaps not in something he would regard as a failure - to join SENLIS, a legalising pressure group, not long later.

There is no doubt in this writer’s mind that genuine policies aimed at reducing harm amongst users (rather than bogus policies which are a front for legalising drugs) are, within their own limits, commendable. Where they can become counter-productive is in at least the following two respects: firstly, in their obsessive focus on the user, coupled with their dismissive ignoring (in all but ‘lip service’) of everyone else; and secondly, in their abandonment of abstinence as the long term goal of all interventions and treatments.

Part 3 will appear in the next issue of the Journal and will include the following sections:

7. Europe

8. Taking stock – where are we now?

9. How did we get into this mess?

10. What should be our rational response?

11. And in conclusion …

Mr. Stoker is Director of the National Drug Prevention Alliance (NDPA), which he helped form. He has completed more than 20 years in this field and has helped three other charities to form, all running well. His first 7 years in the field were as a drugs/alcohol counsellor in a London drug agency; he also created and delivered a wide range of trainings and was a Government ‘Drug Education Advisor’ to some 100 primary and secondary schools. In 1987 he completed a one-month study tour throughout America, under the auspices of the US State Department. He has delivered workshops at more than 10 PRIDE conferences, and in 2004 he received the PRIDE International Award for services to prevention. He has completed technology transfer trainings in Poland, Germany, Portugal and Bulgaria. In 2001 he was awarded a First Prize in the Stockholm Challenge contest for websites with a health-promotion value. Mr. Stoker is often to be seen or heard on TV, radio or in national/regional newspapers and has authored many articles and papers. For 30 years prior to this career he was a professional Civil Engineer, running projects up to £5,000 million at present-day values.

References
17. McDermott P. Editorial. Int J on Drug Policy 1992.

18. Stoker P. Drug prevention – just say now. London: David Fulton; 1992.

19. Caulkins J, Reuter P. Setting goals for drug policy: harm use or harm reduction? Addiction J 1997; 92: 1143-1150.

20. Hunt H et al. A review of the evidence-base for harm reduction approaches to drug use. Forward Thinking on Drugs 2003 (commissioned research).

21. Tackling drugs together. London: The stationery office; 1995.