The concept of harm reduction and effects

The concept of harm reduction and effects

In conjunction with World AIDS Day which falls on Dec.1, AIDS
activist Chris W. Green has written the following two articles.

JAKARTA (JP): We live in a dangerous world. Almost anything we
do results in harm to our bodies, to other humans (living or not
yet born) and to our communities. Often there is no way to
eliminate these harmful effects, at least without changing
totally the way we live and interact with our planet. We have
learned to live with these harms and to minimize their effects.

Examples of such activities and the harm they produce are not
difficult to find. The use of motor vehicles, with their
polluting engines, results in significant real harm to any of us
living in large cities.

But although there is as yet no way in which we can eliminate
these harms completely, there are effective means to reduce them:
use of nonleaded fuel, ensuring that the engine is properly tuned
and installing catalytic converters in the exhaust system.

A simpler example is offered by the lowly ballpoint pen. Such
pens usually come with a cap that is easily swallowed by young
children given the opportunity. When this happens, the cap often
gets stuck in the child's windpipe, cutting off the supply of air
to the lungs and quickly suffocating the child. To avoid this,
the more responsible manufacturers make a hole in the cap. Then
if the cap is ingested, the child can continue to breath, albeit
with difficulty, until such time as first aid can be arranged to
remove the cap from the windpipe. There is harm; but the harm has
been reduced.

Clearly it would be even better to ensure that the child could
not swallow the cap. But how could this be done? We can explain
to the child the risks of playing with such things, but if we
allow any freedom to the child, such risks will remain and harm
will occur. So we take the complementary approach of finding ways
to reduce the harmful effects of such activities.

Another example that we are all familiar with is the fuse box
in our house. In case of an electrical overload, perhaps caused
by defective equipment, the fuse "blows" before the wires get so
hot that they cause a fire. If the fuse is replaced by a nail it
does not "blow", and the result (as we have seen all too often)
is significant harm to the building, sometimes accompanied by
loss of life. By using the correct fuse as a replacement, we can
limit the harm.

And so it is with more controversial activities, like sex. As
with most other activities, sex can result in direct harm.

Infection with sexually transmitted diseases (STDs), for
example. Of course we can avoid such harm by avoiding sex and
choosing abstinence.

Unfortunately, attempting to persuade many young people to say
no is about as easy as persuading the younger child not to suck
the cap of the pen. They may know that they shouldn't do it, but
somehow that's not enough. We may feel a responsibility to advise
them against it, but if we are not successful does our
responsibility end there? If the result is that our own children
become infected, most would agree that we must do more.

So, if we are realists, we also tell them, "if you can't be
good, be careful". Using a condom does not totally eliminate the
risk of becoming infected with STDs, but it will significantly
reduce it. Condoms are particularly effective in reducing the
risk of infection by HIV, the virus that causes AIDS, for which
there is no cure. The condom may not stop other STDs, but in
general these are less dangerous and more easily cured. Thus,
using a condom will result in the reduction of harm. And since an
infected person can go on to infect many others, this act of harm
reduction also benefits the community as a whole, not just the
individual.

The concept of harm reduction becomes even more controversial
when applied to people who use drugs, particularly IV drug users.
Many intravenous drug users share their needles with others in
their group. This may be because obtaining clean needles is
difficult or expensive, being caught with a needle results in
problems from the police or even because IV drug use becomes a
ritual of sharing, friendship and trust with other members of the
group.

Unfortunately, sharing needles is by far the easiest way to
transmit HIV. Once one member of the group becomes infected,
studies have shown that the other members will become infected
within a matter of weeks. There is ample evidence around the
world of HIV infection rates in drug-injecting communities rising
from zero to more than 50 percent in less than one year.

Sometimes the response is: so what? Drug users deserve to die.
But leaving aside our feelings of humanity, a moment's thought
will identify some problems with this response. First, perhaps
selfishly, what if it was your own child? The drug epidemic has
clearly claimed young people no less "good" than our children.
And what about the community? Drug users do get married, have
sex, produce children. If they are infected with HIV, they may
infect their partners and through them their children. Surely we
have a responsibility to reduce the harm to them?

Many young drug users are not addicts. Some are experiencing
the normal challenges of growing up, rebelling against the older
generation. Many will pass through their drug-using phase, sooner
or later, and become useful members of society. But if they are
already infected with HIV they will have little chance. Using
illegal drugs results in harmful effects -- just as tobacco does.
But we can help reduce these harmful effects by ensuring that IV
drug users have access to clean needles and an environment in
which they can survive until they are ready to change their
lives. We can offer them replacement therapies, such as
methadone. While not treating the underlying addiction, as a non-
injected drug methadone offers a safer alternative to using
needles. In this way, we can reduce the harmful effects to the
community by eliminating the risk of HIV infection and by
removing the need for addicts to become involved in criminal
activities -- including the most common, becoming drug dealers
themselves -- to support their addiction.

Experience from around the world has shown over and over again
that law enforcement approaches to drug problems are at best
ineffectual, and at worst only exacerbate the problem. By
increasing the risk of using drugs, they increase the risk of
harm. They make it more difficult to implement outreach programs
to assist drug users; they tend to lock drug users in prison,
where they are at much greater risk of harm; they have been a
major contributor to the worldwide spread of AIDS.

It is understandable that communities should feel threatened
by drugs. But as is so often the case, the best response to any
threat is to try to understand it, not just try to eliminate it.
As we better understand the threat of drugs, we will appreciate
that the threat is more one of public health and social illness
than of law and order. Until such time as we have a cure for
these ills, the reduction of the harmful effects of drug use must
be a central aspect of our response.