"THE NATURE OF THE DUTCH"
"The nature of the Dutch is such that if hazards or perils do not present themselves clear as day before their very eyes, it is not their predilection to exercise the necessary vigilance to safeguard their own safety."
It would seem as if this comment by Johan de Witt, a renowned Dutch statesman of the seventeenth century, has indeed been taken by his distant successors as their point of departure in combating AIDS. From the very start, the main Dutch AIDS policy aim has been to clearly inform people of the risks. Then and only then will they take steps to safeguard their own lives.
Information and prevention campaigns were organised in keeping with a model utilised in the Netherlands for centuries. Dutch citizen-oriented urban culture has always had consultations and tolerance as guidelines. Since it is consensus that is invariably strived for, neither religious nor any other differences have ever led to all out social conflicts. And in the AIDS policy, once again an approach has been adopted that does justice to the views and interests of all the groups involved.
The AIDS policy has been formulated via a comprehensive network of advisory and consulting agencies. This consensus model works in the Netherlands thanks to the centuries of experience the Dutch have had
with it, and because Dutch society is small and efficiently organised, so that contacts do not get bogged down in red tape.
The Netherlands is a densely populated country with fifteen million people. Although Amsterdam, the country's capital, has a population of less than 750,000, it exhibits all the features of a metropolis. Its progressive, tolerant climate has attracted any number of minorities. Ever since the seventeenth century, when the Netherlands developed into a progressive minded mercantile nation, there has been a tradition of giving shelter to immigrants and refugees
Up to the sixties, Dutch society was relatively traditional, small-scale, closed and very conducive to law and order. The majority of the population lived within close-knit religious groups and conformed to the prevalent views of these "pillars."
Starting in 1965, this habitual submissiveness was discarded at a staggering pace. The Netherlands soon changed into one of the world's most freethinking and "open societies". The prior group ties made way for sturdy individualism.
The state facilitated this trend by instituting a comprehensive system of social benefits. Ideas on the relation between the individual and society changed as well. In the ethics of the time, the right to individual privacy and to run one's own life as one saw fit were key features.
By the time AIDS surfaced in the early eighties, these changes had reached an advanced stage and might account for why the Dutch opted for an approach that attracted so much attention abroad.
A panoply of minorities had "liberated themselves" to impressive extents. Homosexuals had "come out of the closet." "Drug Users' Associations" championing the acceptance and legalisation of drugs were given subsidies to help them "get organised."
And in the realm of sexuality, a new openness had emerged. Everyone seemed to agree that the state had a social and public health responsibility, but should remain detached and fulfil it in a manner that was not moralistic.
This new freedom was effectuated with such enthusiasm that in some senses, things now went to the other extreme. As will be demonstrated below, the approach to the AIDS problem was only one of the multifarious aspects affected in the process.
This brief outline will hopefully not only help outsiders understand the Dutch approach to AIDS, but also caution them against generalising the Dutch findings without further ado. What might work in the Amsterdam or Dutch context is not necessarily suitable for any other social setting.
FACTS AND FIGURES
The Netherlands' first AIDS patient was registered in 1982. The number of AIDS patients initially doubled every half year. At the moment, a plateau would seem to have been reached and the figures no longer increase every year. By the end of 1991, a total of approximately 2,000 cases of AIDS had been reported, half of which were in Amsterdam.
The Dutch distribution pattern resembles that of other countries in Northwest Europe. By far most of the patients, almost 80%, are men with homosexual contacts. Intravenous drug users, another 8%, are the second largest group. The third group, 3% of the total, consists of haemophiliacs and other patients who have received blood transfusions.
Almost 7% of the AIDS cases can be traced to heterosexual contact; this percentage is exhibiting a gradual rise.
Since no active testing is done in the Netherlands and no large-scale screening is conducted, no precise figures are available on people who are HIV-positive but have not yet fallen ill with AIDS. Calculations based on the AIDS incubation period and the number of reported cases so far would tend to indicate that an estimated 8,000 to 12,000 persons are HIV-positive in the Netherlands, half of whom live in Amsterdam.
Like AIDS itself, HIV infection is mainly prevalent among men with homosexual contacts and, to a lesser degree, intravenous drug users. At the moment, less than 0.1% of the heterosexuals who have never used drugs intravenously or had homosexual contacts are HIV-positive. This has been shown by various studies, including one conducted among pregnant women.
In principle, the Netherlands has a legal apparatus that could be deployed to help combat AIDS. The Infectious Disease Law enables the state to make it compulsory for physicians to report contagious cases of certain diseases either anonymously or by name.
HIV and AIDS do not fall under this law, nor does it look as if they ever will. No new laws or regulations have been enacted in this connection. HIV and AIDS are reported anonymously and on a voluntary basis.
AIDS can be contained in a way that is not feasible with other more contagious infectious diseases such as tuberculosis: the epidemic can be stopped by a simple change in people's behaviour. This is why in the
Netherlands, it is the private citizen who bears the basic responsibility for avoiding infection.
In treating other venereal diseases, notifying the patient's sexual partners IS something that is done more or less automatically. In some countries, the same approach is taken to HIV and AIDS, but in the Netherlands it has always been viewed as being too much of an interference in people's private lives. What is more, at first AIDS seemed to be a "gay disease" and gay men were already keeping each other informed, looking out for themselves and forming networks.
Heterosexuals have always been much less aware that they too could become infected. When heterosexuals are infected, the Amsterdam Municipal Medical and Public Health Department has decided to take more active steps to see that their sexual contacts are notified. "We try to talk to patients about their contacts," a physician at the Department said. "There is nothing else we can do. If someone is uncooperative, we can not force them."
THE "TURN A BLIND EYE" PRINCIPLE
In the Netherlands, there is a great deal of leeway to enforce laws flexibly. Although they are officially prohibited, in practice a "blind eye" is turned to abortion, euthanasia and drug use.
This mentality has a lengthy history. Behind the neutral-looking facades on the canals of Amsterdam, conventicles can still be viewed where Catholics attended clandestine services after the Protestants ascended to power at the end of the sixteenth century. As long as they did not make a show of it in public, Catholics were free to say Mass there.
Nowadays the same blind eye is turned to prostitution, though there is a difference; of all the professional groups in the Netherlands, prostitutes are perhaps the most apt to make a show of it in public. After all, one of Amsterdam's major tourist attractions is the Red Light District, where girls sit at giant-size windows smiling at passing strangers
It is prohibited to run a brothel in the Netherlands. Parliament is now considering a bill legalising brothels, but even it is passed. all it will do is legalise the existing situation.
There are about 15,000 prostitutes in the Netherlands, and easily twice as many if part-timers are counted. Prostitutes have taken their first steps toward emancipation and founded an organisation that works in conjunction with the public health authorities. The same holds true of the organisation founded by and for men who go to prostitutes to remove the stigma they feel they live under. Its members can be found on Red Light District street corners distributing pamphlets on safe sex.
Brothel owners soon followed suit and elected spokesmen who meet regularly with the Building Inspectorate. "It is a question of trusting each other," one of the inspectors said. "You have to be flexible without losing sight of what you want to achieve."
Why is the city so reluctant to enforce the law prohibiting brothels? Probably for much the same reason it turns a proverbial blind eye to other groups it does not want to break its contact with, groups that would then disband to less visible spots where it is far more difficult to keep any kind of check on them.
For physicians, social workers, police officers and tax collectors, all held in high esteem in the Netherlands, this would make these groups virtually impossible to get to. And in the background, there is often the fear of a confrontation with the organisations representing their interests, which would endanger any chance of further co-operation.
The drug policy is based in part on the same "turn a blind eye" principle. It is mainly dealers who are the target of the criminal prosecution system. Possession of small quantities of soft or even hard drugs for one's own use is not a matter anyone is really interested in.
In actual practice, soft drugs for personal use - not for resale - are freely available at any number of "coffee shops." The idea is that these coffee shops are supposed to refrain from selling hard drugs, and since the police will otherwise close down the premises, indeed they generally do.
But even in the Netherlands, it is not feasible to turn all that much of a blind eye. One of the Amsterdam policy aims is in fact to keep non-Dutch intravenous drug users out of the city and have them return to their own country. Only limited medical and social work facilities are open to them.
According to Dutch standards, the regulations enforced within the prison system are also far from lenient. Needles and drugs are strictly prohibited, though there are plenty of cases of drugs being illegally smuggled in. Needles are scarce in prison, which only means more of a chance users will share them.
Side by side with mushrooming individualisation, since the sixties new taboos have burgeoned as well. Notions of tolerance, the good of amicable negotiations, respect for privacy and the turn a blind eye principle have become well nigh sacrosanct. One might even wonder whether the widely lauded non moralistic approach had not gone full circle here. Relations between the state and the individual were couched in a strict moral code, with the right to individual privacy as a central tenet.
An aversion to discrimination grew into something very close to an obsession. "In the Netherlands, it is no longer acceptable to speak of high risk groups. Nowadays you can only refer to high risk acts," said Roel
Coutinho, AIDS specialist at the Amsterdam Municipal Medical and Public Health Department. "But where sexual contact is concerned it is not only the act that is important, but also the person you are performing it with: what is the chance he or she has been infected by the virus? In Amsterdam, the chance for a gay man is maybe 25% and for a heterosexual maybe one in a thousand. But even a statement like this is almost viewed as a sign of discrimination."
In the Netherlands, there has been a reluctance to introduce a legislative approach, i.e. making the HIV test compulsory for certain groups, closing down premises where unsafe sex is common practice, prohibiting HIV-positive prostitutes from working, adopting a less tolerant attitude to HIV- positive individuals with high risk conduct or HIV-positive women who are pregnant or want to be.
The antipathy to restrictive state intervention is widespread among the post-war generation. There was a baby boom all across the continent after 1945, but it was especially sizeable in the Netherlands. This is one of the factors that has enabled baby boomers to exert such sweeping influence. Ever since the seventies, when they ascended to prominent positions in society, the ideology of individual autonomy has been instrumental in shaping official policies.
Prosperity produced "the kind of thing people like," as Social Democratic Prime Minister Den Uyl once put it. Already a wealthy nation, now the Netherlands appeared to have rich natural gas reserves to boot. The revenues were largely utilised to perfect the social security system.
Despite extensive budget cuts implemented in recent years, compared with the systems in other countries this one is still excellent.
RESEARCH AND PRIVACY
The emphasis on privacy and individual autonomy has limited the opportunities for research on the HIV epidemic. Since AIDS itself often does not emerge until after a long incubation period, it is essential to gather as much data as possible on the course
Studies of this kind are easy to conduct by examining anonymous blood samples taken for other purposes. This is standard practice in the Netherlands as regards other infectious ailments such as legionnaire's disease.
Up to now, however, permission has not been granted for large-scale Studies on HIV. This is why less information is available in the Netherlands on the spread of HIV than in other countries such as Great Britain or the United States.
The anonymous medical screening of a specific group takes place without the informed consent of the individuals blood samples are taken from. In a purely practical sense, it would be unfeasible to ask each of them for permission. What is more, their anonymity is guaranteed. In the United States, this method of large-scale AIDS surveillance has been instituted without raising any objections, and in Great Britain a similar programme was launched several years ago.
In this respect the Dutch, who pride themselves on their sensible and pragmatic approach, have fallen behind precisely where this pragmatism is concerned. The American reasoning is that whatever privacy objections there might be to anonymous studies are far outweighed by the public health interests involved. After all, the test results have no ramifications whatsoever for any of the individuals.
In the Netherlands, specialists in the legal and ethical aspects of health issues countered by noting that medical studies of this kind do include a number of personal features such as the sex, age, religion and nationality of the individuals whose blood samples are tested. This means the test results for certain groups can serve to stigmatise them, and this in turn could have repercussions, for example when members of these groups want to take out an insurance policy.
The opinions of legal and ethical specialists are taken very seriously in the Netherlands. Many of them view every use of data or physical material that is not directly instrumental for the care of the patient as a potential offence against the constitutionally guaranteed right to privacy and the inviolability of one's body. This is why a blood sample can only be used for studies of this kind if and when the patient has given express permission.
When several important advisory and co-ordination committees proposed periodic large-scale anonymous HIV surveys in 1989, the ethical and legal specialists protested and government officials were quick to agree with them. Without the express permission of the persons involved, they did not feel it was advisable to conduct studies on a disease that had discriminatory connotations and which there was no treatment for.
In an effort to nonetheless get as accurate an impression as possible of the course of the epidemic, the Amsterdam Municipal Medical and Public Health Department set up a series of voluntary surveys. An anonymous blood survey was conducted among patients at venereal disease clinics, 93% of whom agreed to cooperate.
A survey is also being conducted on HIV infection among pregnant women. "It took us years," said Roel Coutinho, "because each and every woman had to give her permission. Actually we do have blood samples of all the pregnant women here at the laboratory. In one week, we would be able to come up with a complete picture on the virus among pregnant women in Amsterdam. But at the moment, that is something we are not allowed to do."
The Dutch Parliament is now considering a new bill on the medical treatment agreement that would make it possible to anonymously use existing blood samples for scientific surveys without having to first ask permission. Patients would have the right to express any objections they might have.
In essence, this would mean that at some point in the future, the same "opting out" system would be introduced that is now in use in other countries including Great Britain. However, there would be no access to already existing blood samples, since the patients they were taken from were not given an opportunity to express their objections.
AMSTERDAM. BIRTHPLACE OF THE AIDS POLICY
Although just an ordinary city department, the Amsterdam Municipal Medical and Public Health Department has been instrumental in the formulation of AIDS and drug policies. Before the emergence of AIDS, there was already close co-operation between the public health authorities and the various gay organisations in Amsterdam.
During a survey on the effectiveness of a vaccine against hepatitis B, another sexually transmitted disease particularly widespread among gay men, mutual trust had grown. Based on this trust, as far back as 1984 a survey could be launched focused on the spread of HIV and AIDS among gay men.
The policy on drugs implemented in Amsterdam has also been characterized for quite some time by a pragmatic approach. At the end of the seventies, for example the first replacement substances had already been administered to drug users. Not to terminate their addiction, but simply to reduce the harm for addicts and society alike.
Methadone, the most widely used substance m this connection, is administered orally and neutralises the withdrawal symptoms of heroin addiction. The addiction itself does however remain unaltered. In the early eighties, a methadone programme was effectuated throughout the country. It is estimated that more than half the drug addicts are now being reached.
For a number of reasons, it was essential to reach as large a group as possible. The methadone programme is a precondition for regular contact with intravenous drug users, and makes it possible to set up needle exchange programmes as well. Every methadone user is checked twice a year for tuberculosis. AIDS patients are also potential bearers of tuberculosis.
For all these reasons, there is easy access to the methadone programme. The low threshold has become a key notion in the Amsterdam approach, and drug users can even decide for themselves whether they want a high or a low dosage of methadone.
Methadone is administered either in pills or in liquid form. Contrary to what is generally assumed outside the Netherlands, it is only in a few exceptions that injectable hard drugs are distributed in the Netherlands. Smokable heroin, cocaine or amphetamines are never distributed.
When the epidemic first broke out, there were already needle exchange programmes in Amsterdam. New needles were provided free of charge to whoever brought in a used one, and this served to keep addicts from passing on the virus by using each other's needles. Since they had to hand in an old needle every time they wanted a new one, fewer used needles were discarded on the street and there was less of a chance of them accidentally puncturing someone else's skin.
Initially to prevent the spread of hepatitis B, Drug Users' Associations started exchanging needles at the start of the eighties. Now all that had to be done was expand the programme. In 1984, 10,000 needles were exchanged in Amsterdam, and by 1991 the figure had risen to a million. Since then, facilities have been provided that enable drug users to exchange their needles twenty-four hours a day or to purchase new ones.
The idea of exchanging needles was adopted all across the country and programmes have since been set up in sixty Dutch towns and cities. At first disapproval was widespread among many of the municipalities and agencies involved because they felt exchanging needles was not in keeping with their aim of getting addicts to stop using drugs altogether. In 1989, after repeated requests on the part of the Ministry, numerous municipalities decided to adopt the programmes after all.
IMPLEMENTING POLICIES: SELF ORGANISATION
Private organisations have traditionally played an important role in solving social problems. In the Netherlands, sizeable sums are also expended by the state via a comprehensive subsidy system.
This indeed is how the HIV and AIDS problem is now being addressed. The Ministry of Welfare, Public Health and Culture is responsible for the AIDS policy, but is advised about its formulation and implementation by the organisations specifically concerned with AIDS. In the formulation of policies, in general the authorities also conform to the views adhered to by these organisations.
The central government has spent sizeable sums of money on funding AIDS research, information campaigns and patient care facilities.
The various organisations decided to work together in a national Coordination Team. In 1987, the Co-ordination Team was replaced by the National Commission on Combating AIDS, and its members were no longer appointed as representatives of specific organisations but on the grounds of their personal expertise.
Co-operative frameworks were also set up on the regional and local level and in 1990, more than forty teams were active.
The Amsterdam AIDS platform was granted the official status of advisory agency for the municipal authorities.
At first, gay men's organisations exerted considerable influence within the national Co-ordination Team and consequently on the entire prevention policy. In the second half of the eighties, developments in Africa made it clear, however, that heterosexuals could become a risk group as well. AIDS expenditures mushroomed and prevention measures were increasingly focused on heterosexuals.
More and more people began to feel the gay and other special interest organisations had too much of a say in how the budget was being spent.
In an effort to minimise discrimination and marginalization, the treatment and care of HIV-positive and AIDS patients are integrated as much as possible into existing medical facilities. The more HIV-positive and AIDS patients there are, the harder it will be to sustain this approach.
One objective is to enable as many AIDS patients as possible to be nursed at home. In 1988, ten hospitals throughout the Netherlands were designated as special AIDS centres and were provided with extra funding and facilities for this purpose. Pioneer work is being done at the Academic Medical Centre in Amsterdam, which is also playing an instrumental role in combining nursing and treatment know how with the latest advances in research.
SAFE SEX IN A WELFARE STATE
The Netherlands is an urbanised country with an extremely high communication level and a relatively well-educated population. There have thus been ample opportunities to bring about behavioural changes by way of information campaigns.
An annual twenty million Dutch guilders are reserved for AIDS information campaigns. The goal is to keep the public informed, but without moralising. The main aim is to change behaviour, but without creating panic or discrimination. Humour and irony are sometimes used to catch the eye.
As far back as 1983, the Netherlands already began to implement its prevention policy. The first information campaigns were focused on gay men. A year later, a campaign concentrated on drug addicts was launched, and in 1987 one with the public at large as its target. Most other European countries did not start their information campaigns until AIDS was already threatening to spread from the original risk groups to the rest of the population.
Nine out of ten Dutch people now know just exactly how AIDS is transmitted and how they can keep from getting it. Prevention campaigns are not focused on reducing promiscuous behaviour, but on safe sex, i.e. using condoms.
In actual fact, the gay and heterosexual communities alike do seem to be tending towards far fewer sexual partners. Of the people who do have numerous sexual partners, the majority still seldom or never use a condom. Reported condom sales have only exhibited a slight rise.
Anti-conception pills are widely used in the Netherlands and it is easier to get an abortion here than in most Western countries
This might explain why the younger generations have had so little experience with condoms. By the time AIDS first surfaced in the Netherlands, the condom had long been outdated.
In the past few decades, a wide scope of new behavioural options opened up in the Netherlands. An uninhibited sex life with the freedom to really "have fun" and "let go" was one of them. Compared to the untroubled days of the sixties and seventies, the return to the condom meant a giant step backwards.
At the same time, the Dutch welfare state took over more and more of what used to be the responsibilities of the individual. But faced with AIDS, for the time being the state is at a total loss. In a welfare state like the Netherlands, the AIDS prevention campaign can be summarised as follows: "People, take back the responsibility for your own lives!"
This feasibility strategy would seem to be founded upon deep-rooted realism: the spirit is willing but the flesh is weak, certainly where sexuality and addiction are concerned. When push comes to shove, unrealistic expectations should be abandoned.
That is why gay men are given the following advice:
For the authorities, this means: provide condoms, set up needle exchange programmes, distribute folders on disinfecting needles, make methadone available. And make sure there are rehabilitation programmes for anyone who wants to stop using drugs.
The tendency in the eighties was toward large-scale information campaigns focused on the public at large. In the nineties, the emphasis will be on a more intensive and personal approach to the risk groups. In a case-oriented method, the partners and clients of drug-addicted prostitutes can also be approached.
RAMIFICATIONS FOR SPECIFIC GROUPS
In the Netherlands, the social position of gay men is better than almost anywhere else in the world. There is a vast homosexual group culture which - certainly in Amsterdam - is totally out in the open and internationally renowned. Homosexuals' rights to equal treatment has been officially recognised and interest organisations are generously subsidised.
These developments, however, have all taken place relatively recently. Homosexuals still perceive their own emancipation as something fragile, and there is always the fear that the AIDS epidemic will lead back to stigmatization and discrimination. This has led to friction with other interest groups, such as haemophiliacs and public health physicians.
The Dutch prevention approach has been reasonably effective among gay men. Within the large group of gay men the Amsterdam Municipal Medical and Public Health Department has kept a check on, the new HIV-positive cases fell from 8% in 1985 to 1% in 1989. There was also a decrease in the "ordinary" sexually transmitted diseases, another indication that unsafe sex was becoming less common.
The emotional involvement in the gay community has been demonstrated by the buddy projects set up in more than twenty-five cities. Buddies are volunteers, often gay themselves, who help AIDS patients they didn't even know beforehand cope with their problems.
Ever since 1990, however, it has been evident from the renewed increase in venereal diseases that people seem to be off guard and have once again become less apt to use condoms. Among the group of men being observed by the Amsterdam Municipal Medical and Public Health Department, the percentage of new HIV infections has similarly exhibited a slight rise.
In saunas and dark rooms, high risk behaviour seems to be somewhat more in evidence again. The Amsterdam public health authorities are now considering making it compulsory for all the saunas and clubs for gay men to provide information on HIV and AIDS.
There are a good 20,000 hard drug users in the Netherlands, and this figure is assumed to have been stable for the past few years. The average age of the addicts keeps rising, and is now around thirty.
Although many other countries in Western Europe have witnessed an explosive rise in the number of fatalities due to drug overdoses, for the past few years there has been no rise in these figures in the Netherlands. About fifty people a year have died this way, many of whom were foreigners.
Approximately a third of the hard drug users live in Amsterdam and another third in the other large cities in the west of the Netherlands. In Amsterdam, three quarters of the addicts are in contact with medical or social work agencies, and the same is true of somewhat smaller percentages in other cities.
Almost a third of the addicts are from ethnic minorities, mostly from Surinam, the former Dutch colony on the northern coast of South America. Some of them are from the Moluccans, islands now part of Indonesia, another Dutch colony that became independent in 1949. In addition, some are of Turkish or Moroccan descent, the children of people who came to work here in the sixties. Addicts of Turkish and Moroccan descent are particularly hard for the medical and social work agencies to reach, and thus remain largely "invisible."
An estimated third of all the addicts take drugs mtravenously. They frequently use heroin in combination with cocaine or other drugs. Compared to other countries, the number of hard drug users is relatively low in the Netherlands. In the United States, Italy and Sweden, the number of hard drug users per million inhabitants is far higher.
A much larger percentage of the intravenous drug users are HIV-positive in Amsterdam - approximately a third - than in the rest of the country. The good news is that in recent years, this percentage would seem to have stabilised. In Milan, the HIV-positive percentage among intravenous drug users has gone up to sixty, and in New York it has even reached seventy. The bad news is that nowadays the main way HIV might very well be spreading is via these intravenous drug users.
In the Netherlands, the group of intravenous drug users includes relatively large numbers of Germans and other foreigners, but relatively few members of the ethnic minorities. The spread of AIDS has been relatively limited among drug users of Surinamese descent because they swallow, sniff or smoke drugs rather than take them intravenously. Since many of the first dealers were of Surinamese descent, they largely set the tone for hard drug use in the Netherlands. This helped restrict the rate at which HIV infection spread among hard drug users.
There is a vast network of social and medical facilities for drug users in the Netherlands, sometimes using methods unheard of anywhere else. In some Dutch cities, for example, ex-addicts are hired to work as "experienced experts." Active drug users are sometimes hired as field workers by social work agencies, where one of their jobs is to give "injection instructions."
In Rotterdam, one way needles are exchanged is via "users' collectives." Users put their home at the disposal of a drug dealer and are given a sharp safe container filled with new needles every time they hand in a container filled with used ones. Thus clean needles are always available on the premises, even if it is off hours for the official exchange programmes.
These premises, where the illegal drug trade takes place, can also be the target of police raids. Paradoxes of this kind are characteristic of the Dutch approach. Shutting down premises where drugs are sold has become a routine matter, but whenever intravenous drug users are released, officers at the police station make sure to give them a clean needle.
Thanks to the methadone programmes that had long been in existence and the co-operation of the Drug Users' Associations, sizeable numbers of intravenous drug users are now being reached. In some municipalities, needle exchange staffmembers go so far as to come looking for addicts in bars and other hang-outs.
In Amsterdam, there appeared to be little ground for the fear that providing sterile needles would only encourage people to use hard drugs. The needle exchange programme neither stimulated drug users to start taking drugs intravenously, nor made the ones who were already doing so use drugs to a greater extent.
Since efforts to keep the threshold low also meant a dearth of registered data, it is difficult to assess the effects of needle exchange programmes
Thus there is no tangible evidence that they have effectively slowed down the spread of the virus. The same holds true for methadone programmes.
One indication of the success of needle exchange programmes might be that ever since 1985, there has been a sharp fall in the number of hepatitis B patients among intravenous drug users. Despite the enormous rise in the number of exchanged needles, however, there does not seem to be much of a fall in the new infections prevalent among intravenous drug users. These infections are still noted among 4 to 5% of the large group of drug users observed by the Amsterdam Municipal Medical and Public Health Department ever since 1987.
Studies have also shown that addicts who get a daily dose of methadone have just as much of a chance of infection as those who only take small doses at irregular intervals. This indicates that despite what the authorities assume, methadone users do continue to take drugs intravenously as well.
Another problem is that to an increasing extent, cocaine is becoming the most preferred drug. Addicts who mainly smoke or inject cocaine are not involved in the methadone programme and are thus difficult to reach.
In the past few years, there would seem to have been a clear improvement in what is officially called "injection behaviour." However, drug users have to change their sexual behaviour as well. And here very little progress has been made. "Lately I do it so infrequently that I really want to enjoy it," one Amsterdam intravenous drug user recently commented.
There are several hundred addicted prostitutes in Amsterdam, about half of whom are German. In the other large cities and in towns on the German border, smaller numbers of prostitutes are addicted as well.
A study among addicted prostitutes in Amsterdam demonstrated that most of them use drugs intravenously, half of them are HIV-positive, and some of them already have AIDS. Certainly in view of the fact that venereal diseases are commonplace among them as well, if no condoms are used the infection risk is high.
In a number of cities, there are special zones where addicted prostitutes are "tolerated." There are low threshold centres where they can come for a cup of coffee, social and medical counselling, condoms and clean needles. Folders are distributed there stressing the importance of using condoms.
In practice, however, they take very little note of the warnings. It is usually the customer who has so little desire to use a condom. So it is just a question of waiting for an addicted prostitute to start getting withdrawal symptoms, and is then willing to do anything.
Only a small percentage of these prostitutes state that they consistently use condoms for all their customers. And for their non-commercial sexual contacts, they barely ever use them. More than a quarter of the addicted prostitutes has a boyfriend who is not addicted himself. This is another way the infection can be transmitted to the general population.
There is probably only one group of women who never stopped using condoms: professional prostitutes. In the Netherlands, very few non-addicted prostitutes are HIV-positive or have AIDS. At the moment, there is a greater chance of a prostitute infecting a client than the other way round.
It is only on rare occasions that a prohibition for addicted prostitutes to work at all is advocated in the Netherlands. It is generally assumed that it would only make them go "underground."
The tolerant Dutch approach can however lead to any number of bizarre situations. In anticipation of the day when the law prohibiting brothels is repealed, some cities are already experimenting with a licence system for prostitutes. It would imply strict regulations requiring regular medical check-ups and stipulating the size of the room and the closing times. However, no compulsory checks for HIV infection would be required.
Approximately 170 of the 1,200 Dutch haemophiliacs have been infected via blood products; 34 came down with AIDS, half of whom have since passed away. Haemophilia is an inherited disorder affecting the coagulating power of the blood that only occurs in men. A treatment method developed in the mid-sixties extracted coagulation-related proteins from donor blood. It was not until 1985, however, that tests were developed to screen blood donations for HIV.
Before then, anywhere from 100 to 200 people had also been infected via blood transfusions, although the total percentage of people infected via blood is still lower here than in most other countries.
The reason for this is that in the Netherlands, blood donors are unpaid volunteers. HIV is much less prevalent in their donations than in "commercial" blood. However, a number of Dutch haemophiliacs were treatedwith blood products imported from the United States, and this led to much of the infection here.
In 1983, when the first HIV-positive haemophiliacs were reported, a heated "blood debate" broke out in the Netherlands. The Dutch Association of Haemophilia Patients wanted the blood supply safeguarded as well as possible. The blood banks proposed following the United States example and eliminating homosexuals, the major risk group for AIDS, from the list of donors.
This proposal was not acceptable to the gay organisations. They were afraid "the homosexuals" would be held responsible for the disease. In the end, a compromise was reached. The blood banks would request all the members of risk groups to withdraw as donors. On the condition that not all homosexual men would be viewed as a risk group, just the ones with various sexual partners, the gay organisations promised to back the request.
This compromise constituted the basis for the donor policy from 1983 to 1985, when it became possible to screen donor blood. The appeal to gay men's sense of responsibility seemed to have come in time and to have been reasonably effective. Starting in 1985, no more than one in every 30,000 donations appeared to be HIV-positive. In the years prior to 1985, the same can be assumed to have been the case.
This does not mean there were not tens of HIV-positive blood donations in the course of those years. And indeed many of these donations can be assumed to have come from the risk groups, as remained the case after L985. It is impossible to tell how many donations came from homosexual men without various sexual partners who were not yet aware that they were HIV-positive and donated blood as a gesture of gay emancipation.
Nowadays some blood banks ask donors to sign a written statement that they have read the AIDS documentation material and that as far as they know, they do not belong to any of the listed risk groups, which include all men who have had any sexual contact with another man since 1980. The gay organisations were furious and referred to it as a "statement of non-homosexuality" comparable to the certificate of non-Jewish descent required by the German occupiers in World War Two.
In various countries in Europe, governments have allocated special funds for haemophiliacs with AIDS. Up to now, no such arrangements have been made in the Netherlands. Authorities are afraid it might set a precedent if one category of patients receives this kind of compensation.
The Netherlands HIV Association, which promotes the interests of HIV- positive and AIDS patients, objected to an arrangement that would only cover haemophiliacs. The Association was afraid this might suggest that only patients who had been infected via blood transfusions or blood products were "innocent" victims.
In the Netherlands, tens of babies have been born HIV-positive. The chance that a mother's infection will be transmitted to her baby is estimated at 15 to 25%.
Although the Dutch Health Council has advised physicians to "emphatically" present the abortion option to pregnant women who are HIV- positive the final decision is always left to the woman herself.
The Health Council also advises physicians to ask about certain risk factors at the first pregnancy check-up, and in the event of affirmative answers to have the women and their partners tested. Objections have been adamant, since physicians were never advised this way in connection with any other disease.
In 1987 the Dutch Parliament decided that in view of the negligible infection rates in this category, one in 1,000 in Amsterdam and even less elsewhere, these routine tests for pregnant women were no longer called for.
MODERATE TESTING POLICY
The Netherlands has always been moderate in its testing policy. Mass screening of such groups as pregnant women or prostitutes for HIV has never been viewed as an acceptable option. Nor are Dutch authorities in favour of testing foreigners or refusing to grant a visa to anyone who is HIV- positive or an AIDS patient.
In 1990 the Dutch government decided that when an individual has a medical check-up for a new job, an HIV test can only be requested if it is needed in order to evaluate his or her suitability for the specific position.
In some countries, prisoners are systematically tested for HIV, and this too is not done in the Netherlands. This is why no precise figures are available, but an estimated 5% are HIV-positive. It is known that 30 to 40% of the prisoners are drug users. Up to now, five prisoners have been diagnosed as having AIDS and were released from prison.
The aversion to compulsory testing was so great that in the beginning, that the Netherlands went to the other extreme. Mainly upon the insistence of the homosexual organisations, a policy of "discouragement" was implemented vis-à-vis such risk groups as gay men stressing the disadvantages of testing for antibodies.
The standpoint was that everyone, whether or not they were HIV- positive, had to start practising safe sex. And the test results would not provide any extra information about what line of behaviour to follow.
What is more, a negative result would only reinforce a false feeling of security.
This notion was propagated by the gay organisations. It was mainly under pressure from these organisations that a campaign was launched in 1985 to discourage gay men from having themselves tested.
No one denied, however, that individuals had to be able to have themselves tested if they wanted. Facilities for anonymous testing were set up that year and subsidised by the state.
In the second half of the eighties, the discouragement policy was the target of growing criticism. Research results seemed to indicate that people who were HIV-positive altered their behaviour more than people who were not ... or didn't know whether they were or not because they had not been tested. In addition, early treatment options were becoming available such as AZT and PCP prophylactics. At the end of the eighties, the discouragement policy was replaced by a neutral one that took the advantages and disadvantages of testing into consideration.
The various social work and medical agencies that worked with drug users were initially just as enthusiastic about the discouragement policy. It was not until 1987, when a third of the intravenous drug users tested in Amsterdam turned out to be HIV-positive, that they changed their attitude.
In some countries, life insurance companies try to reduce the financial repercussions of the AIDS risk by explicitly stating in their policies that no payments will be made to AIDS victims. This is not feasible in the Netherlands, where the cause of death always remains classified information.
Ever since 1988, however, anyone who wants to take out a life insurance policy for more than f200,000 or a new private disability insurance policy for more than f40,000 has to take an AIDS test first. HIV-positive individuals are either refused a policy or have to pay higher premiums.
Officially, prospective policy-holders who have more of a chance of infection because they belong to a risk group are not treated any differently than anyone else. Insurance companies can, however, require an AIDS test "on medical grounds," for example prior treatment for syphilis or haemophilia. Up to now, haemophiliacs who wanted to take out life insurance policies for less than f200,000 also had to have an AIDS test first.
This year the government decided to set up a guarantee fund to compensate insurance companies for payments on the policies of haemophiliacs who died of AIDS. This makes it unnecessary for haemophiliacs to take an AIDS test before taking out a life insurance policy. Compared to other countries, the amounts paid by Dutch insurance companies on deaths due to HIV infection via blood have not been that high.
THE DUTCH APPROACH: CAUTIOUS OPTIMISM
Based on Dutch traditions and the Dutch situation today, the Netherlands developed a distinctive approach to AIDS and drug-related problems, opting for pragmatic considerations rather than the strict enforcement of laws. This approach has been undisputed in the Netherlands, where the Parliament never failed to unanimously support the AIDS policy. In the rest of the world, however, criticism of the policy has been just as abundant as praise.
From the start, Dutch researchers have tried to assess and evaluate the effects of the policy. However, due to the dearth of research data on the whole population, this has not been simple. The most important information comes from studies that gay men and hard drug users take part in voluntarily, and it is far from certain whether the picture produced by these volunteers holds true for the entire group. In drawing conclusions, caution and restraint - traditional Dutch virtues - are thus called for.
Recent studies on needle exchange programmes indicate that their effects might have been less sizeable than was initially assumed. However, the basic tenet of the Dutch approach has been amply confirmed. This certainly holds true of the largest risk group, gay men, where substantial behaviour changes have been successfully brought about.
Ever since 1990, a slight risk awareness relapse has been observed in the gay community, which only serves to illustrate once again that information campaigns and prevention policies are only effective if policy-makers stay on the alert and constantly institute whatever innovations are called for.
The drugs world is far less open to consultations and appeals to common sense. The importance of using clean needles has been accepted among intravenous drug users and addicted prostitutes, but safe sex has yet to become a high priority.
In the efforts to cope with hard drug users, the AIDS policy dilemmas have manifested themselves most clearly. The drugs world can be a risk for the further spread of HIV and AIDS to the heterosexual population. Up to now, the "tolerant" Dutch approach has been able to reduce but not eliminate this danger.
For the time being, the Dutch see no reason to change their course. Medical, social and public information workers have all come to approach intravenous drug users and addicted prostitutes and their partners and customers in a more direct and personal manner.
Thus solutions have been sought by constantly refining, improving and adjusting the existing approach. The Dutch AIDS policy might be known as experimental abroad, but in its actual implementation, a central role is played by experience that has been acquired and applied throughout centuries of Dutch history.
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This page was produced in consultation with and for the Press,
Information and Public Relations Department of the City of
Amsterdam.