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Latin American countries have been riddled with drug trafficking and drug use for many years. Until recently, the only option available to those that used drugs were imposed sanctions from the government and those placed in positions to make sure those sanctions were enforced. Although countries like Brazil and Argentina have a long way to go when it comes to harm reduction strategies, there are non-governmental organizations like PREVER that helping to change the way those in government and society view those individuals who use drugs. This paper takes a look at some of the non-governmental organizations and some of the programs that they are implementing in some of the countries in Latin America as well as some of the struggles that they face in implementing these programs.
Harm reduction is a public health philosophy, which promotes methods of reducing the physical, social, emotional, and economic harms associated with drug and alcohol use and other harmful behaviors on individuals and their community. Harm reduction methods and treatment goals are free of judgment or blame and directly involve the client in setting their own goals.
Related to drug use, one definition of harm reduction is " Harm reduction is any policy or program designed to reduce drug-related harm without requiring the cessation of drug use. Interventions may be targeted at the individual, the family, community or society" (CAHM, 2003, at http://www.doctordeluca.com/Library/AbstinenceHR/CAMH&HR03.pdf).
According to CAHM (2003),
"Examples of proven harm reduction programs are: server intervention programs which decrease public drunkenness; needle and syringe exchange programs which prevent the transmission of HIV among injection drug users; and, environmental controls on tobacco smoking which limit the exposure to second hand smoke. In the general population, harm reduction may help to focus efforts where real harm potential lies and guide scarce prevention resources there rather than to areas of less serious risk. Harm reduction policies might also include enforcement of criminal or regulatory laws. Punitive sanctions (prison) are reserved for drug users that are aimed at hurting themselves or others, and also at providing drugs to minors, for example. Public health regulations generally provide more flexibility in fitting the solution to the problem."
Although, not everyone would agree with CAHM's ideas about harm reduction, it seems that harm reduction policies may indeed be considered the best alternative for those persons for whom treatment, prevention or criminal sanctions have not been effective. Harm reduction is not synonymous with legalization, and in adopting a harm reduction philosophy; it does not mean support for legalization of drugs Harm reduction recognizes a balance between control and compassion within a framework of respect for individual rights. However, drug policy reform that is compatible with harm reduction initiatives has already been determined as worthy of support by CAMH (e.g. its official endorsement of the development of an evidence based cannabis policy, to replace the present reliance on criminalization of possession). The strategy is based on research. According to CAHM (2003), for example, "harm reduction is grounded in the empirical knowledge of a continuum of drug use, where harm may occur at any level. The extent of use, or use itself, is not the issue. The primary focus of harm reduction is on people who are already experiencing some harm due to their substance use. The most appropriate interventions, whether macro or micro, are those geared to movement from more to less harm."
Decriminalization is the repeal or amendment (undoing) of statutes, which made certain acts criminal, so that those acts no longer are crimes or subject to prosecution. Many states have decriminalized certain sexual practices between consenting adults, "loitering," (hanging out without any criminal activity), or out-moded racist laws against miscegenation (marriage or cohabitation between people of different races). Currently, there is a considerable movement toward decriminalization of the use of some narcotics (particularly marijuana) by adults, on various grounds, including individual rights and contention that decriminalization would take the profit out of the drug trade by making drugs available through clinics and other legal sources. http://legal-dictionary.thefreedictionary.com/decriminalization
In relation to drugs, decriminalization is a system that punishes offences by means other than prison. Fines for most traffic violations are an example. In relation to drugs, it is normally limited to possession (and sometimes growth) of small amounts (often around one ounce) and sometimes to sale of equally small amounts to adults. It is also often limited to marijuana among the illegal drugs. There is another distinction possible between de jure decriminalization, which entails an amendment to criminal legislation, and de facto decriminalization, which involves an administrative decision not to prosecute acts that nonetheless remain subject to arrest and imprisonment under the law. Some cities have simply decided de facto to specify that enforcement of some marijuana laws is the "lowest priority" for their police forces. http://www.dpft.org/policy.htm#2
It seems that the lawmakers only went as far as the social conventions would allow (versus legalization). Based on research evidence, there are no reported changes in patterns of marijuana use in youth between states who have decriminalized marijuana and those that have not. Thus, it is questionable as a deterrent, at best. And, there are some reported major problems with decriminalization:
* It leaves the illegal supplier in place. This means more availability to the young makes use more dangerous, activates the "gateway," and many of the other woes.
* It still entails law enforcement costs. Some indications from decriminalization trials in England are that many police are more willing to make stops when they know the offender won't go to prison. There is no indication that this has decreased use. It's a small source of revenue, but one unlikely to compensate for wasted police time and inconsequential when compared to potential sales taxes.
* It deprives the state of tax revenues. Potential revenue could be used for tax relief, education or treatment.
* It cannot make much difference in use. Above we saw that where decriminalization took place, the removal of what many thought was a deterrent had no apparent effect on use or attitudes. It is a shorter step in terms of theoretical deterrence to move to legalization. We stress that if some 75% have tried marijuana by age 22, there's very little room for an increase of any consequence.
* It sustains the hypocrisy inherent in the double standard for alcohol.
Drug users are considered intolerable in Latin America. Legal sanctions are used to deal with the problem, using such tactics as suppression and mandatory abstinence-based treatment. Most of the countries in Latin America have detailed drug laws and corresponding legislation. Until a short time ago, harm-reduction policies were totally disorganized and inefficient, and needle-exchange programs were rare (Weissennbacher, et al., 2000). With the exception of their effort to promote abstinence, few non-governmental organizations were involved in activities focused on prevention for drug users that inject. Still today, harm-reduction related events are essentially limited to Brazil and Argentina (Mesquita, et al., 2000) Infection control strategies in Brazil that are related to the use of psychoactive drugs is strongly supported by the Ministry of Health (Marques & Doneda, 1998). Beginning in 1997 the Southern Cone, which is comprised of such areas as Argentina, Chile, and Paraguay, analytical findings and interventions related to HIV in injecting drug users began. In Buenos Aires, the non-governmental organization, Intercambios, created a quick assessment and response study, and characterized community interventions with the first needle exchange program in Argentina (Touze et al., 1999). The non-governmental organization, International Disaster Emergency Service (I.D.E.S), created a study to ascertain substance use and sex information, attitudes and practices in Uruguay (Latorre, Osimani, & Scarlatta, 1999). In Paraguay, PREVER, a non-governmental organization, contacted drug users who reported injecting drugs up to ten times a day. Of those that were contacted, PREVER found that 15 percent were HIV positive and/or reported engaging activities that are considered high risk (ONUSIDA-PREVER, 1999).
According to the online journal article, HIV and Drug Injection Use in Latin America,
"In 2000, the regional project 'HIV Prevention among Injecting Drug Users in the Southern Cone' began with the participation of NAP and non-governmental organization from each country. Its objective is the adoption of legal instruments that can facilitate prevention activities. It hopes to sensitize journalists and policy- makers, promote access to healthcare networks for injection drug users, promote research and intervention projects, and involve communities in interventions, particularly drug users and their networks. Argentina implemented preventative interventions that included syringe and condom distribution. In addition, it developed a seroprevalence study for HIV and hepatitis B and C. Chile developed a rapid assessment and response study and educational activities for communities and injection drug users. Paraguay worked to plan interventions in prisons. Uruguay began an ethnographic study of IDU, and surveyed the healthcare services available to drug users and HIV-positive individuals. All projects trained healthcare professionals. In 2002, the United Nations Office for Drug Control and Crime Prevention (UNDCP) and UNAIDS are HIV and injection drug use in Latin America supporting the second phase, integrating Brazil into its activities" (Rodriguez, Dec. 2002, p.S37)
In spite of its shared culture, South America is comprised of great diversity. The area is home to economies that range from weak, like that of Bolivia, to very strong economic countries like Argentina and Brazil. Even within the more developed countries, deep societal and regional disproportions are noticeable (Hacker, Malta, Enriquez, & Bastos, 2005) and have had an effect on responses to the HIV/AIDS epidemic on a local and national level, resulting both astounding success and regrettably slow advancement. Until recently, legal sanctions were used to handle the problems that arose with substance abuse.
Despite the successful of many initiatives, the harmful use of illicit drugs, especially cocaine, has been on the rise in different parts of South America, and has been associated with the spread of HIV/AIDS and other sexually transmitted and blood-borne infections. The situation is of special concern in southern Brazil (Pechansky et al., 2006) and the Southern Cone (i.e. Argentina and Uruguay). While injecting drug is a well known major risk factor for hepatitis C (HCV) and HIV infections, non-injecting drug use (e.g. inhaled or smoked cocaine) has been described as a risk factor for both infections, with consistent findings of higher prevalence of HIV and HCV infection among non-injecting cocaine users than in the general population (Caiaffa et al., 2006; Howe et al., 2005). The harms and risks associated with non-injecting drug use have been seldom targeted by integrated harm reduction initiatives in South America.
Colombia is the world's leading coca cultivator and largest producer of coca derivatives; supplying most of the US market and the great majority of cocaine to other international drug markets (Thoumi, 2003). A recent report by Stimson et al. (2006) evaluated the impact of the World Health Organization's rapid assessment and response method in several settings, including in Bogota. According to the study, Colombia does not have government programs aimed at preventing health problems in drug using and specifically drug injecting populations. The authors identified three main gaps in the available interventions targeting drug using population in Colombia: (1) need to develop policies and actions to prevent transition to injecting drug user and address the risks involved in injecting drug user; (2) need to develop educational and preventive policies addressing specific problems and gaps in information levels and risk perceptions of drug users; (3) need to develop programs and actions to reduce the adverse health consequences of drug use.
In Uruguay, around 80% of drug treatment centers are private and strictly oriented toward abstinence (Osimani, 2003). During 2000, UNAIDS and UNDCP developed a project in Argentina, Chile, Paraguay and Uruguay to foster a broader response to HIV/AIDS and drug use in the Southern Cone countries. The project funded a series of activities in the fields of prevention and care for drug users and vulnerable populations; awareness creation for the general public as well as for specific groups; research in the four countries under a common approach developed jointly with governmental institutions, non-governmental organizations, UNAIDS and UNDCP (Riley, 2003). In 2001, IDES organized an intervention program targeting the injecting and non-injecting drug users and their sexual partners who frequented a high-risk neighborhood. The intervention provided training, information materials, and condoms, but did not provide injection paraphernalia, since there is no legal support for such an activity in Uruguay. To the best of my knowledge, until now, Uruguay does not provide sterile syringes and needles to injecting drug users, regardless of the growing injecting drug user population accessed by researches and interventions targeting general drug using population.
According to data from Argentina's Ministry of Health, the shared use of injection paraphernalia has been the main transmission route of HIV/AIDS in Argentina until recently, and corresponds to approximately one-third of the accumulated 30,498 AIDS cases (up to 2005). Currently, the most frequent transmission route is unprotected sex among heterosexuals (Argentina Ministry of Health and Environment, 2006). The implementation of harm reduction polices in Argentina has been erratic, combining major achievements with setbacks (Hacker et al., 2005; Inchaurraga, 2003). Although facing an HIV/AIDS epidemic among injecting drug users, Argentina still lacks large-scale harm reduction programs at national and state (provincial) levels (Inchaurraga, 2003; Rossi et al., 2003). As in Brazil, cocaine is the most frequent injected substance in Argentina while heroin injection has been negligible (Hacker et al., 2005). Sero-prevalence studies carried out in the 1980s/1990s pointed to disquieting levels of needle- sharing and HIV infection rates (ranging from 27 to 80%), depending on the specific sub-population and region under analysis (Sosa-Estani et al., 2003).
The prevailing drug policy in Argentina is still based on strict abstinence, and starting in the mid-1970s, there have been harsh punishments for drug possession. Following a pattern seen in several Latin American countries, the Argentinean military dictatorship during the 1970s/1980s highly influenced interventions and policies related to the re-education and rehabilitation of drug users. Psychiatric hospitals and prisons have been responsible for drug dependence treatment (Hacker et al., 2005). Since the mid-1980s, non-governmental rehabilitation centers have piloted alternative treatment approaches, mainly following Therapeutic Community models. Also, during the mid-1980s, penal punishments for drug possession were reviewed. If those caught in possession demonstrated that drugs were only intended for personal use, they might be required to complete compulsory treatment without incarceration (Siri & Inchaurraga, 2000). Nevertheless, most of the drug-related criminal convictions in Argentina are still related to possession of small amounts of illicit drugs for personal use (Inchaurraga, 2003). Until recently the majority of harm reduction initiatives have been implemented in the two largest cities in Argentina, Rosario and Buenos Aires (Siri & Inchaurraga, 2000), where the distribution of sterile injection equipment began in 1999 (Inchaurraga, 2003).
In recent years, with the central role of international cooperation agencies, such as UNAIDS, and benefiting from the South-South cooperation with other Latin American countries, Argentina's drug policy became more dynamic and open to reform. Non-governmental organizations' central role has been recognized by the government and the international agencies, and has been key in the effort to reach hard-to-reach populations, such as injecting drug users, and to increase the effectiveness of interventions implemented in the country. A good example of such activities, carried out by the non-governmental organization Intercambios, from Buenos Aires, comprise several rapid assessment and response studies. Intercambios organizes training in the field of harm reduction, coordinates pharmacy-based syringe exchange programs, and provides a broad range of community interventions, including educational materials (Intercambios, 2006).
Brazilian HIV/AIDS prevention and drug policies have had a significant impact upon activities in most countries of South America. The first effort to implement harm reduction policies in Brazil occurred in the city of Santos in 1989. Needle exchange initiatives were interpreted as a means to "stimulate the consumption of drugs". The first syringe exchange program in South America was implemented in Salvador, Bahia, in 1994, 5 years after that first abortive effort (Fonseca, Ribeiro, Bertoni, & Bastos, 2006). The drug scene in Brazil is experiencing substantial changes, but the current drug of choice among the Brazilian injecting drug users population is still cocaine (Cintra, Caiaffa, & Mingoti, 2006) with recent increases in the use of both cocaine powder and crack alongside newer synthetic drugs (Almeida & Silva, 2005) and the further spread of more traditional forms of drug use such as solvent sniffing (Thiesen & Barros, 2004).
The HIV/AIDS epidemic has been especially dynamic in Brazil. After a period of continuous spread of HIV among the so-called "general population" (although with a clear bias toward the dispossessed) since the mid-1990s, the epidemic is currently following a pattern we can tentatively call "partial (re)concentration". Some particularly vulnerable populations, far from the mainstream social groups who possess greater capacity for mobilization and advocacy, have been especially affected. The spread of HIV/AIDS to these more vulnerable groups such as men who have sex with other men (MSM)-injecting drug users, women-injecting drug users and injecting drug users living in dire poverty are relatively invisible to lay opinion, the media and many policymakers, but they will be especially disadvantaged because of social inequality, gender inequality and homophobia (Cardoso, Caiaffa, & Mingoti, 2006). Preliminary compilations of available information indicate that more than one hundred syringe exchange programs currently operate within Brazil in different regions, states and municipalities. These programs are being implemented by universities, governmental institutions, such as health secretaries and non-governmental organizations (Fonseca et al., 2006). No other South American country has officially endorsed syringe exchange programs, other than those implemented in Argentina. Despite funding restrictions and lack of managerial expertise of most syringe exchange programs, support for harm reduction initiatives is growing in Brazil. Advocacy activities and lobbying have helped to pass several state laws permitting the implementation of syringe exchange programs and similar activities. A recent evaluation of Brazilian syringe exchange programs operation was conducted in 2004/2005. The study reported that the 45 Brazilian syringe exchange programs evaluated usually face coverage and monitoring difficulties and struggle to find and maintains trained personnel, as the majority of Brazilian needle exchange programs personnel work on a part-time basis. In order to improve harm reduction initiatives in Brazil, the authors highlight the need to develop local and regional databanks, conduct regular monitoring and evaluation studies and develop incentives/sanctions to foster accountability of initiatives (Fonseca et al., 2006).
The challenges raised by drug use in South America have spawned proposals ranging from simply cracking down on drug users to the concerted use of a plurality of actions aimed at minimizing demand for illicit drugs and reducing the harms resulting from such consumption, focusing on education and public health. Countries like Brazil and Argentina have offered the
World, and especially the other developing countries, invaluable lessons on how to combine public policies with respect for the autonomy of social movements. Despite the deep economic and social crisis faced by Argentina in the late 1990s, the main prevention projects were slowed down, but not discontinued. Both countries have subsequently introduced policies guaranteeing universal access to antiretroviral medicines, including access for a sizeable number of drug users (Aceijas et al., 2006). Universal access has been proposed but implemented with some difficulties in other South American countries. Initiatives aiming to reduce drug related harm have been relatively cautious in the other South American countries, with some successful, but still limited initiatives, in countries such as Uruguay and Colombia.
The best practices in South America in the field of drug use and HIV/AIDS prevention and management, such as in some localities from Brazil and Argentina, comprise a broad range of HIV prevention programs ranging from HIV testing and counseling, education, behavioral and network interventions, drug use treatment, needle exchange and expanded syringe access, as well as interventions aiming to reduce transition to injection and other harmful practices. In common with drug users across the world, those in South America, face several clinical conditions in addition to HIV/AIDS, including other blood-borne/sexually transmitted infections (Caiaffa et al., 2006). In the main urban areas of South America, violence and the constant violation of basic human rights have been unacceptably high and brutal with frequent mass murders and torture.
In the near future it will be increasingly difficult, if not impossible, to ameliorate the living conditions of people who use illicit drugs and/or live with different clinical conditions, such as HIV/AIDS and hepatitis C, without reversing current unacceptable levels of structural violence and disrespect for human dignity which prevail across South America. The best efforts of community leaders, non-governmental organizations and well intentioned public health officials have been thwarted by the sheer violation of human rights and intimidation of community members, activists and health professionals by gangs, corrupt policemen and paramilitaries. In my opinion, sound public health policies must be necessarily complemented by a fundamental reform of drug policies and the implementation of broad public policies aiming to ameliorate the untoward consequences of dire poverty, discrimination, and criminalization.