Porto aftertaste: populism, new allies and issue of quality

Author: Ganna Dovbakh, EHRA Executive Director

The International Harm Reduction Conference (HR19) is like a family gathering for us – it’s a regular occasion that we are looks forward to. We are getting ready for it, gathering news to share and dressing up because everyone will be there. New members who only just joined (we need to get to know each other, find common topics of conversation), as well as those we’ve known for a long time, those who only need a supportive hug like “Hang in there, brother, we’ll get through this! Proud of you, sister!”. This event can only nominally be used for advocacy because the politicians, scientists and officials who attend are mostly “our people”. They are instrumental in developing the strongest arguments for the importance of investing in harm reduction and reforming drug policy. Majority are there to share practical approaches, how they developed it, piloted and what recommend for other countries. The three days of the conference encompass everything from birth and love to death.

HR19 was very timely, taking place only a month before EHRA’s strategic planning started. It generated several important ideas not just to mull over or bemoan, but to decide what to do about them in our long-suffering post-Soviet region. I want to share my thoughts here to explore them and to encourage you to reflect on them.

  1. Populism is sweeping the planet

It’s no secret that it’s populist politicians who win elections all over the world. It’s simple – pick a few slogans that would appeal to more than 90% of the population and faithfully promise to fulfil them all (it doesn’t matter if they’re out of your competences, unachievable or would be plain harmful to the country). The majority of population usually support very simple ideas:

– I must hold onto my resources (not share it with poorer territories or groups);

– My country is for me (not for migrants, outsiders and misfits);

– I want higher income and lower spending, and

– I want to feel proud and important.

Populists have no ideology. They include these simple ideas in their campaigns, come up with catchy brands and slogans (like “Brexit”, for example – it’s punchy and simple, and no one even remembers “Remain”), and come to power. After that they must deliver on at least some of their promises. The economic aspirations often prove unrealistic but social policy is one area where it’s possible to exhibit strength and integrity. Marginal groups are minorities, sometimes less than 1%  and politicians could scarify them as  not an important group of voters. That’s when legislative initiatives to limit immigration, repressive drug policy or step up the fight against the so-called “promotion of homosexualism” appear. That’s when populism becomes extremely dangerous for people, for social policy like drug policy and harm reduction services. The masses like slogans about finally putting an end to the problem of drug use, about the need to rehabilitate or jail all the “problem” people. Our region has no tradition of democracy or tolerance towards different ways of life and as a result populism may lead to harassment and persecution.

In such circumstances, as Magdalena Dabkowska perfectly put it, public organizations either “fight, hide or unite”.

We already work well together with LGBT people, sex workers and people living with HIV. We share their vision of threats and goals (as, for example, in the public campaign for decriminalization – http://chasevirus.org/). But this is clearly not enough. We need to get in touch with other “ghettos”, with those whose principles and goals are in tune with ours, with those for whom populism is just as dangerous. Feminist movement, migrants rights protection movement, human rights activists, groups fighting for transparent budgets, democratic elections, inclusive schools and cities. Most likely, their knowledge of drug policy and harm reduction is as superficial as that of the general population, and most likely they don’t want to be associated with those issues. But we should all unite in the face of the common threat.

Here’s the famous quote of the pastor Martin Niemöller:

“First they came for the socialists, and I did not speak out—because I was not a socialist.

Then they came for the trade unionists, and I did not speak out— because I was not a trade unionist.

Then they came for the Jews, and I did not speak out—because I was not a Jew.

Then they came for me—and there was no one left to speak for me”.

It’s clear that if we don’t speak out about the Istanbul Convention, if we don’t support the LGBT rights movement, then very soon the response to HIV and provision of services to people who use drugs will stop being a health and safety issue but become an issue for political opposition.

  1. «There’re only a few of us left, us and our pain…»

At the political summit organized by UNITE before the conference, Miriam Aroni Krimsky, director of Fair and Just Prosecution from the United States, said: “I feel less depressed in comparison of US with other countries. Misery does love company.”

The key question now is – who can be our ally when we demand a drug policy reform or funding for harm reduction? There is a field that we’re already familiar with. At the conference, we talked a lot about ways to convince HIV/AIDS or TB specialists that a change in drug policies is vital for effective implementation of health care programs for people who use drugs. Feminists can be our allies. Not all of them understand the problems faced by women who use drugs, but the 120 organizations that signed the Barcelona Declaration on #Narcofeminism are a great force.

The conference saw several inspiring sessions which highlighted the need to build relationships at the national level with child protection services and social services, with shelters for women who suffered violence. Because for now the unfortunate narrative is like “Using drugs? Do not dare give birth and raise children!”. This is the cruel message sent by governments of our region to every woman who uses drugs through social security and health care system. Violations of the reproductive rights of women who use drugs in Estonia, Russia and the eastern oblasts of Ukraine were summarized for the HR19 participants by Dasha Matyushina, EHRA’s associate and expert and adviser to UNAIDS. (https://www.facebook.com/EHRAssociation/videos/287907672152813/)

We’ve also gained new allies in the form of prosecutors. The law activist from the United States mentioned above spoke about her experience in persuading young prosecutors to introduce alternatives to imprisonment: “Our experience shows – prosecutors and law enforcement could bring public health understanding into court instead of idea of imprisonment. We need to bring prosecutors at the table with community, those who have lived drug use experience”.  With prosecutors come lawyers. I’m not at all sure that all the lawyers in our region who handle drug-related cases are aware that the law allows referrals to substitution treatment and other forms of social assistance.

What message are we sending to our allies? It’s absolutely clear that it’s not about help or pity, it’s about making governments stop preying on peoples’ lives and ruining them. Members of Parliament from different countries talked during the conference and came to a common understanding: «Decriminalization of drug use and possession is needed, but it is not enough. In many countries decriminalization is on the paper, but people are living in harsh policy on the street. In reality, decriminalization could lead to serious penalizing of people with fines so high that it ruins families and peoples’ lives».

3. «Zina, where’s the money?»

The situation with funding for harm reduction around the world is critical. About 2/3 of the total funding comes from the Global Fund to Fight HIV, Tuberculosis and Malaria. While funding for programs in middle income countries (according to the World Bank classification) is gradually being reduced and withdrawn, the only hope rests on the countries themselves, on national and municipal funding. There were quite a few pessimistic presentations given at the conference because there had been reluctance on the part of decision-makers to allocate funds for harm reduction.

We’re often told that the government has no money for harm reduction. That’s not true – it does. At the conference, EHRA shared the findings of a study on the cost of criminalization. The findings suggest that if the state provided people who use drugs with harm reduction services such as substitution therapy, counselling provided by peer community members,  and help with employment and reintegration instead of imprisonment, it would save a significant amount of public funds. The data was gathered in 26 countries of the region. It can help harm reduction activists in their advocacy effort because it supports the argument that keeping a person in prison costs more than providing them with harm reduction services. In some countries the cost of imprisonment is 2, or 4 and even 11 times higher than the cost of health and social services.

Even if the state starts paying for harm reduction services, as is already happening in Kazakhstan, Ukraine, Georgia, Moldova, it’s unlikely to fund advocacy efforts. Only genuine democracies can afford to pay for something that may be critical of them. In our case, advocacy groups and community organizations have to fight for their survival. Some pharmaceutical companies understand the role community plays in changing the market for their products and therefore are ready to support advocacy. This is quite common in European countries even though it’s associated with a difficult moral choice. Each organization need to choose how to be independent in their advocacy agenda if pharma as donor will demand or kindly ask to correct something in it. We have yet to make that choice. There are still a few private foundations that support harm reduction and advocacy in our CEECA region.

  1. We need to fix harm reduction[1]

The issue of quality has now become the cornerstone of harm reduction services in the countries where harm reduction is supported by the state or the Global Fund. Ambitious goals are set for coverage with the cost per client below minimum. Comprehencive consultations with a social worker, support with necessary legal documents, counselling and legal support have long been considered a luxury. The situation when sticking to a indicators and meeting the targets are more important to an organisation than supervising consultants and searching for the best ways to help people who use drugs has become the norm. Everyone understands that people with addiction need a safe space where they can have a cup of tea, have something to eat, wash, rest, use a drug without risking an overdose. However, this level of service has almost become a thing of the past and is perceived now as the “golden age” of harm reduction.

What technical help do we need to fix harm reduction? How do we agree on the criteria for the proper, real harm reduction, especially for the most affected groups, the 10% who need not just a syringe but social help and therefore are difficult to reach?

As new drugs appear, the principles of harm reduction based on non-judgemental help remain unchanged. What has to adjust is the information – we need to educate about the risks the new drugs usage, we need to be able to check what’s in the drug and provide other ways to use safely. For me personally one thing has become clear following our discussions – flexibility and adaptability to people’s needs are the main criteria on which we can judge the quality of harm reduction services. It’s very important to set our professional criteria for harm reduction now. We, as a regional professional association for harm reduction, will be able to use them to improve the quality of our own work.

Renardo Batista Leir, a Portuguese MP, put it very well at the opening of the conference: “Harm reduction and true love are similar – they must be unconditional in order for them to work.” And it sounds like a good slogan to support each other on our difficult path.

[1] Thanks to Dasha Matyushina for the phrasing.