A quick response
by Chloe Keraghel
Geographer UNESCO Consultant
The Kingdom of Nepal was the first State in Southern Asia to set up harm reduction programmes. These measures have resulted mainly from the efforts made by the increasingly influential non-governmental organisations in response to changes in the modes of drug consumption.
Since 1991, Harm reduction has been approached like a mode of treatment in this country.
The consumption of drugs, especially cannabis*, used to be a commonplace, readily accepted habit in Nepal, where it was tolerated even at public ceremonies and during the religious feasts celebrated by the Hindus, who account for 87% of the country's population. Until quite recently, these traditional drug consumption practices were not thought to constitute a serious problem, and licences were granted for narcotic crops to be grown all over the country.
It was during the 70's, when the drug users began to smoke heroin, that the consumption of narcotics became a real problem. The consumers numbered 25,000 at that time, including 12,000 in the Katmandu valley alone, and by now there are as many as 50,000 (1) drug abusers in the country. Public opinion has been focusing on the economic and social consequences, which led in 1986 to the creation of the NGO called Drug Abuse Prevention Association Nepal, after a series of legislative and preventive measures had been introduced by the Government. In the 1976 Narcotic Drugs Control Act, which was designed to reduce both the supply and the demand for drugs, provision was made in particular for treating and rehabilitating drug addicts at specialised centres in order to avoid having to pronounce prison sentences in some cases on drug offenders.
As far as the mode of consumption is concerned, the main changes which have occurred focus both on the method of drug administration, which is now mainly by intravenous injection, and on the substances involved, since a tendency towards multi-drug con-sumption has been observed here as in most developing countries: the abuse of illegal substances is now being combined with the misuse of pharmaceutical products. During the 80's, for example, intravenous injection became the main mode of heroin administration, and this substance was subsequently supplanted by buprenorphine at the beginning of 1991. On the other hand, it has become common practice for consumers to share their syringes. Buprenorphine*, which is commonly prescribed as a drug substitute in the treatment of heroin addicts, is often misused by addicts who continue to use syringes and are still under the influence of injectable drugs. This substance is largely responsible for the recent changes in the prevalent modes of consumption and has contributed to the spread of AIDS among the population of Nepal. Although the number of people with AIDS and HIV infection in this country was reported in the UNAIDS and WHO estimates for 1997 to be 26,000, it has been stated in the latest UNAIDS report that as many as 50% of all the intravenous drug abusers inhabiting the main urban areas are seropositive, and that 75% of all the consumers of buprenorphine inject themselves with this substance (2). The practice of buprenorphine injection has spread fast from Katmandu to other urban areas, such as the tourist resort of Pokhara and the industrial city of Biratnagar. The results of a study carried out in 1999 on the main urban centres located in the south of Nepal (Katmandu, Lalitpur and the Pokhara valley) showed that 72.7% of all the consumers injected the drugs they were taking, and that 65% of them had no hesitation in sharing their needles with other users, since they could not afford to procure new ones (3).
The shift from punishment to prevention.
In view of the risks run by these drug users, some Nepalese NGOs have set up syringe exchange programmes. In 1991, completely unknown to the authorities, the NGO called Lifesaving and Life- giving Society (LALS) launched the first preventive and educational programme of its kind to be implemented in any of the Southern Asian countries, involving a syringe replacement system, training in the sterilisation of injection equipment and medical care. Harm reduction efforts* have meanwhile been accepted and recognised as a mode of treatment in this country (4). Local initiatives no longer seem to be frowned upon in this Himalayan Kingdom, and the use of drugs is no longer held to be a legal offence. Drug users are no longer being arrested and imprisoned unless they have attempted to commit or have actually committed a crime. Those working on programmes of this kind often stress the drug users' lack of knowledge about the preventive measures available and the various possibilities at their disposal for being treated or informed about these matters. An extremely extensive network consisting of around 1,600 NGOs is now working on AIDS in Nepal, but few of these organisations are focusing on the prevention of AIDS via drug demand reduction programmes. The groups which are focusing on risk prevention in particular in Nepal have pointed out that there is a need to promote more intensive interactions between the players working in closely adjacent fields. Further efforts seem to be required to encourage all those responsible to concert their efforts, as well as to incite the authorities to define their policies more clearly drug abuse and addiction are concerned, since no consensus has yet been reached between governmental and nongovernmental bodies as to how the concept of Harm reduction should be defined.
1 Drug demand reduction report for South Asia, UNDCP-ROSA, India, 1998
2 Report on the global HIV/AIDS epidemic, UNAIDS, June 2000, p.131
3 Drugs and HIV vulnerability in seven Asian Countries, Edna Oppeinheiner and Adrian Reynolds, UNAIDS-AOICT, Bangkok, Thailand, March-May 1999, pp. 9-10
4 Drug demand reduction report for South Asia, UNDCP-ROSA, 1998, pp. 131-132.