Instead of introduction
The harm reduction concept has been around for a while. It encompasses messages, activities and warning regarding the reduction of harms from our human actions. The speed limit signs, warnings for tiny particles on children’s toys, use of medications, the use of protective clothes in many professions etc., are all there for the purpose of reducing a possible harm.
Theory and practices in the field of reduction of drug related harms globally, have had different development through time, but today, they are all based on the policies of pragmatics and harm reduction, and it is not only about the reduction of drug related harms, but also reduction of the harms caused on individual, family and the level of the community and society as a whole. These policies become widely implemented and discussed from the onset of the HIV infection threat among drug injecting individuals.
Why should there be drug use harm reduction?
We will never have a drug-free society;
Abstinence is unacceptable for many drug users;
Just as primary prevention, law enforcement has its limitations;
People can continue to use drugs, get ill and die;
What we really can do is decrease illness, suffering, mortality and other harms people face.
What is harm reduction?
The use of drugs in today’s society can be seen as a cultural, health, social and economic phenomenon that seeks intervention on several levels as such: creating services, programs and policies that include all the aspects related to the use of drugs, prevention, treatment, harms, rehabilitation and re-socialization.
Harm reduction refers to the totality of policies, programs and practices that are created with the sole purpose to decrease legal, social and economic risks and consequences from the use of legal and illegal psychoactive substances, and not the use itself. The benefit from these policies is meant for the people using drugs, their families and the society.
These policies accept that people have always used and will always use drugs. We look at these policies through the prism of public health and human rights. We do not promote the use of drugs or judge it as good or bad.
Merseyside, the first harm reduction conference and the history of harm reduction
As a European model, at the beginning of the 1980s, Liverpool implemented a pioneer approach for handling the consequences caused by the use of drugs. The Merseyside model focuses on harm reduction of the consequences from the use of drugs, which was not the case before, when the focus was on the use itself. This policy was given attention in light of the spread of HIV/AIDS among users, through the contaminated injecting equipment. The overall focus was directed towards reduction of the risks by acting on the high risk behavior and distributing sterile equipment for injection, issuing methadone as a substitution therapy (and in a small number of cases heroin) and field work in the community with drug users to help them, as well as attracting services intended for them. The police played a key part in the development of harm reduction programs. Services were quickly developed and included a large number of users who were not contacted in any way prior to that. The HIV epidemic among drug users in Merseyside was thus avoided.
The first international harm reduction conference in Europe was held back in 1990 in Liverpool, as a response to the issue. The international harm reduction association was born out of this conference.
Short historic overview of the harm reduction program movement
1920 – the first prescriptions of medications to treat dependence in Great Britain;
1960 – methadone treatment established;
1970 – the first alcohol use harm reduction programs established;
1980 – In Holland, Great Britain, Australia and Canada the first needle exchange harm reduction programs appear;
1990 – development of the education regarding harm reduction programs;
1996 – the International Harm Reduction Association officially starts working. That same year several regional harm reduction networks appear and start working: in Eastern Europe and Central Asia, Latin America, Near East and North America.
Spreading the harm reduction programs in Europe
When in 1985 the antibodies of the HIV virus was discovered, a high percentage of HIV infection among drug injecting individuals was noticed, as follows: Edinburg (51%), Milan (60%), Bari (76%), Bilbao (50%), Paris (64%), Toulouse (64%), Geneva (52%) and Innsbruck (44%). These localized epidemics among drug injecting persons come as a result of sharing used needles and syringes among people who use drugs. It becomes evident that part of Europe was facing an urgent public health problem. In 1984, a drug user organization from Holland known as „Junkesbonds“ starts the exchange of sterile injecting equipment to reduce the transmission of hepatitis B. This is widely known as the first formal program for exchange of sterile injecting equipment and it gains huge support from public health services in Holland. After these pioneers start, a wide expansion happens in Great Britain in 1986, and then in 1987 in: Denmark, Malta, Spain and Sweden. Until 1990, these programs had spread in 14 European countries, and 12 of them were financed by the public budget. Only for illustration, in 2003, 22 countries of the EU had 1.762 programs for needle exchange without the inclusion of pharmacies. Until 2003, only in France, 18.000 pharmacies function as needle exchange programs. Now, in 2014, the programs for needle exchange exist in 28 countries members of the EU, financed by state budget. These programs are officially supported by the recommendations of WHO from the meeting in Stockholm from 1986, the forming of UNAIDS from 1996, the General Assembly of UN from 2001, the EU Council from 18 June 2003 and all these years, all concerned parties have pointed out to the importance of these programs in their strategic plans and resolutions. Until 2009, 77 countries and territories of the world had at least one operating needle exchange program, and out of them, 31 countries are in Europe. Below is a tabular preview of the distribution of programs for harm reduction in Europe:
Macedonia and harm reduction programs
In the beginning of the 1990s, major cultural, social, political and economic changes started to happen. They all affected the supply and demand of drugs and psychotropic substances in Macedonia and in the region.
In the period from 1994/95, a research was carried out about the condition with the use of drugs in Republic of Macedonia, by two experts in this area, Jean-Paul Grund and Dushan Nolimal. A key finding of the report is that there is an increase in the trend of drug use, especially in injecting heroin. The report itself receives the name „Heroin epidemics in Macedonia”. In accordance with the recommendations from the Report, and as a response to the needs and challenges/problems, at the end of 1996 the organization „М.А.S.К.А.“ was established, a harm reduction program which since 1997 continues to be carried out by the newly formed Association HOPS – Healthy Options Project Skopje, officially registered in April 1999. As in many other cities across Europe, thus in Macedonia, with the support from the „Open Society Institute – Macedonia”, at the end of 1996, the first needle exchange program opens in Skopje as the basis for the policies for harm reduction programs in order to prevent HIV/AIDS and other blood or sexually transmitted diseases.
In the first three years of the functioning of the Program in which, in addition to service users from Skopje, people come from other towns, an anonymous and free exchange of sterile needle is provided. Other services such as: social, medical, legal and psycho-social have been developing and are included in the Program through the years all the way to the present, as a result of the needs and problems that drug users face.
In the period from 2000 to 2002, the citizen associations Izbor and Via Vita, with the support from HOPS, open and start operating two more harm reduction programs in Strumica and Bitola.
During 2003, for the first time in Macedonia, a National Strategy on HIV/AIDS is being developed, and including in the process, the needle exchange programs as key intervention programs towards prevention of HIV/AIDS among drug injecting people. HOPS was involved as an organization which develops strategic areas of support for drug users and sex workers.
That same year the National coordinative mechanism was formed, with representatives from civic organizations, ministries, religious organizations and representatives from the communities as a part of the preparation of a request for project support for financing the National Strategy for HIV/AIDS of the Republic of Macedonia (2003-2006) to the Global Fund to fight AIDS, tuberculosis and malaria. The support was gained for a three year implementation of the Strategy starting with the implementation on 1 November 2004.
In the period from 2004–2007, again with the support of the Global fund, HOPS opened 5 more harm reduction programs, which are now lead by the organization Puls-Kumanovo, Mladinski Klub – Stip, Zona-Kavadarci, Opcija-Ohrid and Help-Gostivar. All these programs include activities for needle exchange and field work, as well as medical and social services, the operation of which also includes the drug users and expert personnel.
Until 2005, а program for drug dependence treatment with substitution therapy existed only in Skopje. In the period from 2005 to 2006, centers for treating dependences with substitute (methadone) open up in 10 cities across Macedonia and in two correctional facilities in Skopje, while in other towns, the substitution therapy for prisons is provided by the local dependence treatment centers, according to the needs of the inmates.
Macedonia received support for its activities in this field from the Global Fund for the period from 2007–2011 as well, specifically to implement the following strategy. In that period, HOPS opened up a harm reduction program in Tetovo, now lead by the organization “Center for development and improvement of public life”, and Izbor from Strumica opens its own program in Gevgelija.
The program for dependence treatment with substitute (buprenorphine) becomes operational at the Toxicology Clinic in 2011, for 110 clients, and in the last two years, it has grown to 220 annually. The latest two treatment programs open in Skopje in 2010, at the Clinical Centre and in April 2012 in the General City Hospital „8 September“.
All these programs cover more than 3.000 people in the harm reduction programs via the needle exchange programs and more than 1.500 people in substitute treatment, including those treated in the four private health organizations for dependence treatment available only in Skopje.
Currently in Macedonia there are 15 harm reduction centres in 13 towns, carried out by citizen organizations, 14 state programs for treatment with substitute (methadone), of which 2 are in correctional facilities in Skopje, one state program for treatment with substitute (buprenorphine) and 4 private institutions for treatment with substitute (methadone and buprenorphine). All activities of the programs foreseen by the National HIV/AIDS strategy of the Republic of Macedonia in the period 2012–2016, which implementation is still financially supported by the Global Fund to fight AIDS, tuberculosis and malaria, above all, for the activities performed by the civic organizations. Activities for harm reduction are also part of the National drugs strategy 2006–2012. Since Macedonia is a country with mid to high economic growth and low HIV rate, it will not be able to submit requests to the Global Fund any more.
Why was it important to open these programs and why should they receive support for their survival in Macedonia!?
The first HIV case in Macedonia was registered in 1987. From year to year, the number of cases has been growing, but the most frequent way of transmitting the disease is by heterosexual intercourse. Since 1987, until September 2014 a total of 232 cases of HIV/AIDS have been recorded. Of them, only 12 are persons who injected drugs. In the last couple of years, since the opening of most harm reduction programs, no cases of HIV transmission through drug injection have been registered.
This is further emphasized by the fact that the reason for the establishment of these programs in Europe and in Macedonia was the prevention of HIV among people who inject drugs. But, these programs in their essence and pragmatism had the task to improve the health, psychosocial and economic status of drug users in the society as a whole, in order to improve human rights and to contribute to the decrease of the stigma towards these citizens and towards members of their families. Results of the prevention of HIV in Macedonia are a huge proof about the effectiveness of harm reduction programs. The justification of harm reduction programs is further confirmed by the WHO report “Effectiveness of sterile needle and syringe programming in reducing HIV/AIDS among injecting drug users”, from 2004. Based on the research carried out in 103 major cities it is confirmed that in 36 cities with needle exchange programs, the HIV rate decreased for 18,6%, ad in the other 67 towns included in the research, only in those that had no such programs, the HIV rate increased for 8,1%.
Jean-Paul Grund, Holland
Antropologist and initiator of harm reduction policies in Macedonia.
The whole idea of harm reduction, I don’t think had penetrated the whole central and south eastern European region yet. Yes, there was this question from the Foundation in Macedonia, we have a drug problem, we don’t really know what it is, and we certainly don’t know what to do with it.In the end I think we wrote 4 proposals, together with a number of stakeholders in Skopje, and I am breaking my brain cells now, coming up with them. I think it’s clear what was the best one, there was of course HOPS, because that’s still in existence, and as I understand, pretty strong. But at the time we also wrote a proposal together with one of the psychiatrists in the drug treatment center, about introducing methadone in the country, and going beyond. Actually I think there was already methadone in the centers, to be honest, at a smaller base, but to go beyond this token news of this important treatment measure, and also the discussion was how you do that, when you don’t have many resources here. We don’t want to build a separate health care structure, so I proposed, to include the primary health care centers. If I remembered well, that was one of the things that former Yugoslavia prided itself with in the WHO meetings – their well functioning primary health care system. I know that for a large part, at the time they were intact to a large degree.
One of the founders of the association M.A.S.K.A. and initiator of the harm reduction programs in Macedonia
My motive for introducing the harm reduction policies was the complete disagreement with the “War on Drugs” policy and the treatment of drug users by state institutions, including the police. Keeping marihuana on the list of illegal drugs. On the radio (Kanal 103, editor’s note) we “promoted” this even before we had heard about the “Drug related harm reduction” policy, which towards the middle of the 1990s arrived in Macedonia through Lidesmith Center in New York (today „Drug Policy Alliance“). A crucial moment for actual acting and the foundation of M.A.S.K.A. (Macedonian Association for Cultural and Social Action), pre-coursor of HOPS, were my meetings with some of the ideologists of harm reduction programs, i.е. with Jean-Paul Grund and Ethan Nadelmann in Skopje and in Florence. Those were difficult days, Skopje was going through the climax of its heroin epidemics… the rest is history.
Member of HOPS – Healthy Options Project Skopje, developer of harm reduction programs and policies in Macedonia
If the mid 1990s saw the start of harm reduction programs, the mid of the first decade in 2000s was a period of development and spreading of these programs across Macedonia. Thus, in a period of 5 years, a total of 16 programs were developed across 13 towns. Our idea was to develop programs which would offer complementary services, exchange of injecting equipment, all the way to social, medical and legal services both in drop-in centers, and on the field. And exactly this complementariness is the main feature of all programs in Macedonia. Harm reduction programs have been included in national and local strategies for HIV, in drug strategies, and finally some state authorities have started to set apart funds from the budget to carry out these programs, such as the City of Skopje. At the same period, an organization of drug users was founded. A very positive and strenuous period in which we managed to promote best practices from harm reduction in Macedonia. It now remains to have the issue of long term sustainability of these programs solved.
Member of HOPS – Healthy Options Project Skopje, developer of harm reduction programs and policies in Macedonia
It’s an undisputable fact that civic associations have key role in the realization of harm reduction programs. The services they provide to vulnerable groups should be financially supported by local self-governments and the responsible ministries. I am convinced that with good coordination and partnership among all concerned parties on local and national level, ways and means can be found to support these programs.
The author is a doctor of dentistry currently pursuing his master studies at the School of Public Health within the Medical Faculty in Skopje. His experience is focused on the prevention of HIV/AIDS for more than 15 years, on drug policies for more than 14 years and tuberculosis control in Republic of Macedonia for 8 years. As the executive director of HOPS he has been working on the development and maintenance of the services of the organization and is actively advocating for health, social and human rights of marginalized communities in local, national and international organizations as a member of the National committees for HIV/AIDS and tuberculosis of Republic of Macedonia, as well as through the delegation of citizen organizations from developing countries in the Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria.