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Delving into HRI research and expertise, this submission to the Special Rapporteur on the Right to Health provides valuable input for her upcoming report on " Drug Policies and Responses: A Right to Health Framework on Harm Reduction".
The state of harm reduction
Harm Reduction International (HRI) has monitored the state of harm reduction around the world since 2008, where we report periodic updates of both services and policies in support of harm reduction. As of 2023, HRI has identified that:
- 109 countries have explicit positive reference to harm reduction in national policy;
- 92 countries implementing at least one NSPs;
- 88 countries with at least one OAT;
- 17 countries with legal and operational Drug Consumption Rooms (DCR);
- 35 countries made take-home naloxone available;
- 23 countries operate peer-distribution naloxone programmes;
- 10 countries offer needle and syringe programmes (NSPs) in prisons; and
- 59 countries make opioid agonist therapy (OAT) available in prisons.
In 2022, HRI has found an increase in the number of countries implementing key harm reduction services for the first time since 2014. This growth has been driven by new NSPs opening in five countries in Africa, as well as new countries having officially sanctioned drug consumption rooms DCRs. Three countries have introduced OAT for the first time. Unprecedently, the Global State of Harm Reduction 2022, has collected information on safer smoking and pharmacotherapy for people who smoke drugs and use stimulants, finding that 19 countries distribute safer smoking kits while 2 countries have nascent stimulant pharmacotherapy programmes.
Globally, people who use drugs continue to face criminalisation, stigma and discrimination that prevents access to services. Human rights violations continue to be committed worldwide in the name of drug control. These include the denial of access to harm reduction services, including through the criminalisation of drug paraphernalia, the prohibition of OAT (for example, in Russia), and discrimination against people who use drugs in the provision of HIV and viral hepatitis care. Such punitive approaches hinder access to and drive people away from essential services, leading to unsafe practices which could increase their risk of transmissible diseases such as HIV and hepatitis. Furthermore, certain populations experience these barriers particularly acutely, most notably, women, LGBTQI+ people, people who are migrants or refugees, young people, and Black, Brown, and Indigenous people, who lack tailored services to meet their needs.
Negative impact of policies and practices
Globally, people continue to face criminalisation that prevents access to harm reduction services. According to HRI’s Global Overview, as of 2022, the death penalty for drug offences is retained in 35 countries, with more than 285 people executed and over 3000 people on death row, drug control remaining a key tool of social control by States. Iran, a country that provides peer distribution and take-in-home naloxone, has the highest rates of executions for drug offences worldwide, recording at least 252 executions in 2022. Indonesia, which explicitly supports harm reduction in national policy and provides NSPs and OAT (including in prison), still retains the death penalty for drug offences, with at least 122 people sentenced to death and 206 people on death row for drug offences in 2022. Similarly, Vietnam also recognises harm reduction in its national policies and provides NSPs and OAT; however, 84 people were sentenced to death for drug offences in 2022.
Strict rules with high thresholds and medicalised approaches to harm reduction may further stigma and discrimination, leading to the limitation in access to harm reduction services. In Eurasia, for example, to enrol in a programme, they require people to have a psychiatrist or other supporting documentation and a government-issued identity document, which in some cases, such as in North Macedonia, involves registering a residential address. More specifically, these enrolment requirements create a barrier to certain populations such as homeless people and Roma people who may not have ID or residential address. Similarly, in Armenia, Azerbaijan, Belarus, Kazakhstan, Kyrgyzstan, Moldova, Tajikistan, and Ukraine, to enrol on OAT or other drug dependence treatment, people need to register in a drug user register, which can limit access to jobs and studies and may have repercussions in children’s custody. In Belarus, for example, children are deemed to be in a ‘socially dangerous situation’ if they are parented by a woman who either uses drugs or is on OAT, in which case a mark is put in the parent’s passport and medical records, increasing stigma, discrimination and further perpetuates sexist drug policy. Additionally, social services can take the child away from the family and parents must pay monthly fees to the state.
Criminalisation of harm reduction tools
Despite data indicating that 29 countries and 49 jurisdictions have adopted some form of decriminalisation for drug use and possession for personal use, ‘war on drug’ paradigms still prevail. Criminalisation not only includes the production, sale and use of illegal substances but also encompasses the penalisation of the use and possession of drug paraphernalia. This approach reinforces stigmatisation and discrimination, and, in many cases, it translates into the denial or limitation of harm reduction services. That is the case in the United Kingdom, where it is a criminal offence to supply or offer an object for providing or preparing a controlled drug, including crack pipes, grinders, spoons, bongs and tourniquets, among others. Despite safer smoke kits being essential harm reduction equipment, both for engaging people who use stimulants with harm reduction services and reducing transmission risks for HIV, hepatitis C and tuberculosis, its distribution is illegal in the country. The only exemption is aluminium foil, which is the only harm reduction equipment that is distributed for smoking
Harm reduction and other human rights
The implementation of harm reduction strategies and services can lead to furthering other human rights by advancing social justice, gender equality, poverty, among others. Harm reduction is grounded on principles of social justice, equity and non-discrimination, and dignity while acknowledging that all systems of oppression are interlinked. It also recognises that ending the ‘war on drugs’ involves addressing racial and patriarchal structures of power, including in the criminal justice system.
Harm reduction and proverty
Drug use occurs across all demographics; however, those with economically and socially excluded background are disproportionately impacted by the harms of punitive drug policies, limiting access to essential health care and social services, among others. Poorer socio-economic groups are over-represented in the criminal justice system, being a root cause of women’s imprisonment, with many being convicted of minor petty crimes driven by economic necessity. In the US, it has been found that women in State prisons are more likely than men to be imprisoned for a drug or property offence.
Despite international donors’ funding playing a pivotal role in the initiation and expansion of harm reduction programmes at a national level, it is still insufficient. Many low- and middle-income countries (LMICs) depend on international funding to secure the provision of harm reduction services. HRI’s report, Failure to Fund, shows that in 2019, international donor funding constituted a substantial 52% of the total funding allocated to harm reduction efforts in LMICs, underlining its ongoing significance. Donor funding was identified in 50 out of 135 LMICs, with the largest share found in Asia, Eastern Europe and Central Asia (EECA), and sub-Saharan Africa. Relying heavily on foreign aid can be challenging since support may abruptly stop or decrease if donors’ priorities change, resulting in a lack of sustainability. Additionally, despite the reliance in international funding, HRI’s monitoring of the funding landscape shows a dearth of funding for life-saving services. In LMICs, funding for harm reduction is only 5% of the level needed to meet the estimated service needs for people who inject drugs by 2025. The gap between the required funding and the available funding has only grown wider in recent years.
Innovations in time of crisis
The COVID-19 pandemic caused death and suffering and significantly disrupted access to health services around the world, including harm reduction services. Some governments and service providers –especially peer-led services, demonstrated an incredible resolve and agility in this challenging context, adapting to unprecedented conditions with innovative responses and showing that it is possible to operate harm reduction services with fewer restrictions and greater client autonomy.
The most profound example of this was the change in OAT delivery across all regions. Out of the 84 countries worldwide where OAT was available in 2020, 47 countries changed rules to allow for longer take-home periods. For example, in the UK most people were moved onto 7 to 14 days prescriptions instead of a daily or supervised pick-up OAT medication. Civil society reports that most of the clients receiving take-home OAT found this was an improvement in the service experience, while feeling more trusted and in control of their treatments. Similarly, in the US and Canada, take-home and mail-order OAT and initiating buprenorphine over telephone appointments were introduced in Canada and the US during the pandemic. Additionally, 23 countries made distribution more accessible with home delivery of OAT medication, offering dosing at community pharmacies, or distributing OAT in outreach settings. Online consultations replaced some face-to-face meetings in the Middle East and North Africa; in Eastern and Southern Africa, mobile van dispensing and buprenorphine. Service providers set up online shops for injecting equipment in the United Kingdom and New Zealand; and service providers introduced home delivery of harm reduction equipment in Eurasia and Western Europe.
In line with these international standards, and with the information provided through this submission we encourage the Special Rapporteur to recommend Member States to:
- Decriminalise drug use and drug possession and promote evidence-based and health- and human-rights centred alternatives to incarceration;
- Critically evaluate States’ spending on drug control, divest from punitive drug control, and invest in evidence-based harm reduction programmes, ensuring the availability of funding for peer-led and community-led harm reduction initiatives, research, and innovation;
- Recognise harm reduction as essential element to the right to health in national policies and strategies;
- Guarantee equal access to harm reduction services and programmes in a no-discriminatory and non-stigmatizing way and consider the particular needs of the most vulnerable and marginalised groups, such as Black, Brown and indigenous population, LGTBQ+ people, sex workers, women among others;
- Eliminate all form of forced drug dependency treatments;
- Eliminate all legal and practical barrier to accessing harm reduction services, including those that affect marginalise populations including Black, Brown and ethnic minorities and indigenous populations, migrants, women, homeless and people living in poverty, and;
- Abolish the death penalty for drug offences; and further address all causes of racial and gender discrimination, including in criminal justice system.