I recently had the good fortune to attend the 7th International Conference on the Reduction of Drug Related Harm, held this year on the remote island of Tasmania. Why Tasmania? Australia has achieved a remarkably low rate of HIV among injecting drug users under a national drug policy which specifies harm reduction as both the goal and the measure of success. Delegates assembled from 35 countries representing public health, infectious disease, drug treatment and public policy. Also included were IV drug users, Australian law enforcement and members of the Australian parliament.

The harm reduction concept was born out of the recognition that law enforcement measures were ineffective at controlling the drug use that spread HIV, hepatitis, HTLV, etc., and that an unintended consequence of the war on drugs has been to increase the spread of these viral diseases by (1) driving drug prices so high that health-endangering intravenous use became the only cost-effective way of managing addiction to opiates, (2) creating a situation where the forms of drugs most available are the most directly linked to HIV, i.e., heroin and crack cocaine (3) restricting clean needle access, and (4) driving users underground through police actions that exacerbated high-risk behaviors and impaired public health access to this infectious population.

A ‘harm reduction’ policy favors a public health approach to drug users that would research a variety of novel approaches with achievable goals and quantifiable results, whose implementation is based on only one criterion: Does it reduce total harm? Harm reduction is an empirical science- and data-based policy; not an ideological position on drugs as good or bad.

The most shocking conference presentation was by history professor Alfred McCoy, a historical analysis of the wars on opiates, their duplicity, and their paradoxical effect of increasing worldwide production and use of opiates. He originally exposed the CIA role in shipping heroin from Laos to Saigon, where it was pushed on American servicemen. My practice still has victims of this policy. He also traced the CIA protection of the heroin trade in Afghanistan and Pakistan during the Afghan war. In both cases, fighting drugs took a back seat to the fight against Communism. Afghanistan is now a major opium producer. Its production doubled the worldwide crop in just one year, 1994. And Pakistan has gone from no heroin use in 1979 to 1.7 million users today. In Asia, where opium use was once medicinal and a comparatively minor problem, the successful war on the legal opium trade has produced a flood of injectable heroin and an HIV epidemic. In Thailand, teenage daughters of heroin injectors are sold to the sex trade in Bangkok to raise money to pay family drug debts, creating a second wave of sex-related HIV. What the war on drugs has produced in Asia can only be called harm maximization to an extreme.

The HIV relationship to IV drug use is well known, but this conference focused attention on the silent epidemic of hepatitis C, a lifelong, gradually debilitating illness expected to be far more costly than HIV. A majority of ICDUs around the world are already infected with hepatitis C. A decade of methadone availability and needle exchange programs has protected Australia from HIV, but not from hepatitis C, which appears to be 10 times as infectious as HIV. This inexorable spread of needle-related infections prompted a leading Australian health authority to reflect that the international war on drugs has created the phenomenon of "injecting nations," and to propose that public health efforts should attempt to eliminate not drug use but, specifically, injection drug use by emphasizing non-injecting routes of drug administration. This proposal is in keeping with one of the tenets of harm reduction: that one can reduce harms without necessarily reducing use. Examples of this approach include designated driver education, designated smoking areas, nicotine patches, heroin maintenance and many others.

The harm reduction approach has always included drug users. In Australia, there is a very personal story behind their approach. Ten years ago, it became public that the daughter of the Prime Minister of Australia was a heroin addict. This singular tragedy for a national leader led to a far different view of drug users than that held by countries where users are uniformly portrayed as criminals. A conference consensus was that real changes in disease reduction are unlikely without a reassessment of the humanity and human rights of drug users. The presence of drug users at this conference as speakers was both moving and significant. Harm reduction encourages political activism among users as a way of assisting them to protect themselves and loved ones, empowering the powerless, increasing self-esteem, using activism as a tool for recovery. Users have a right to accurate information and access to humane, non-judgmental health care. Respect for the human dignity of users is not only morally the right thing to do, it is the most effective approach. Where users have been involved as partners in a mutual problem-solving effort, the public health is better safeguarded than by coercive or punitive measures.