THE CONCEPT OF HARM REDUCTION AND EFFECTS

JAKARTA - 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.