THE POLITICS OF HARM REDUCTION IN FRANCE

Patrick J. Aeberhard, Médecins du Monde, Paris, France

This is a version of a paper presented at the VIth International Conference on the Reduction of Drug Related Harm in Florence, March 1995.

Harm reduction widely proposed in most European countries has strangely been unheeded for a long time in France . It was an absolute taboo: politicians, doctors, journalists didn't dare make allusions to it Since l 987, Médecins du Monde, a medical humanitarian organisation, has challenged the State to develop a global drug policy by organising: clinics allowing access to care for excluded people, a free anonymous AIDS screening centre, needle-exchange buses, methadone programmes, as models, which could be copied by the official structures This strategy is comparable to the ones we have used in developing countries, creating a new right: 'the right of interference' .

For many years the French policy concerning harm reduction was so non-existent we defined it as 'the French syndrome'. The situation has now changed and the French government has chosen a policy promoting harm reduction, but this response was and is very late in coming. The former policy is responsible for violence, human rights abuses and thousands of deaths. The future depends on our ability to train competent personnel and to finance a global approach.

A group of people supported by friends from abroad has given non-governmental organisations (NGOs) such as MDM or AIDES the opportunity to play a considerable role in public health, in order to convince the government to change its policy and balance repression and public health. In 1987 Médecins du Monde (MDM) and AIDES, two Paris based NGOs, organised a symposium creating a 'universal declaration of rights for AIDS and seropositive patients'. The purpose was to inform and educate the public, so that every individual could acquire knowledge of existing preventive methods, to fight against discrimination and to strengthen medical confidentiality.

These imperatives constituted a guarantee for the health and the freedom of communities. They also helped to avoid collective hysteria and extreme measures on all sides which would only lead to suffering and despair and further drive affected people underground. Although the blood scandal happened in France in 1984-85 it only became a major issue in 1991; on the other hand, harm reduction was always put off.

MDM has been attempting for the past two decades to put into action a principle which would give us the right as individuals to intervene in the international order. This principle dictates an obligation to testify and to bear witness to flagrant violations of human rights throughout the world. Our work pivots around the resilient relationship between the medical profession and the protection of human rights.

MDM is a Paris-based humanitarian NGO which is driven by the principles of the Hippocratic oath namely to alleviate human suffering wherever an whenever possible. Our work is founded on an additional premise stating that where suffering is provoked by governmental neglect or oppression, we as members of the medical profession, and more precisely as members of the human community, are morally bound to bear witness. Speech has a protective power; silence, however, amounts to complicity. For years we have been working from Kabul to Johannesburg, from San Salvador to the South China Sea.

Our constant reflections on the subject c humanitarian assistance and human rights have inevitably forced us to scrutinise the injustices that exist closer to home. The recent economic crisis in the Western World has created a new class of people the inhabitants of the so-called 'fourth world', the world of the homeless and the urban poor. These reflections have been influential in the creation of a project in France and in our collaboration with experts like Dr Ernest Drucker in the USA on problems in the Bronx.

The situations were very different but because our expertise criss-crossed with one another we were in some way very useful to each other. Ironically, in New York, thousands of methadone places were opened for the drug users, but clean needle exchange was outlawed. By the same token, in France methadone programmes were not considered at all or rejected by the government and most of our physicians. For 20 year there were only 52 methadone places, whereas clean needle-exchange programmes were tolerated.

At the very beginning, 'Mission France' in 1986 by means of the media and innumerable meeting with public authorities, was able to appeal to political control centres for reflection and action concerning the evolution of the social security system and access to health care for the most needy.

In observing the situation of the needy we discovered that one of the most excluded groups was injecting drug users who were repressed by a law enacted in 1970. According to this law, all drug users should bc considered as delinquents and possession of a clear needle is illegal. Police officers could simply arrest them on presumption of use. Last, but not least, it stigmatises and marginalises access to care, mostly access to simple care at the hospital or at a GP. This, in turn, drives these people further underground. This law is still in effect.

Their criminal situation placed these drug users in a high risk group category, where 30-40% were seropositive or HIV infected. France had the saddest and worst record in Europe. By this I mean that the war against drugs, which was a total failure, and an absence of possibility of harm reduction only led to one solution - weaning off! It was very difficult for IDUs to be accepted in hospitals; there were no needle exchange programmes, only 52 methadone places, and a total taboo surrounded the whole situation. The specialised doctors, mainly psychiatrists, were against harm reduction; they did not want to become 'dealers in white coats', GPs had very little experience, and health personnel did not know how to treat or were afraid of them, or worse they did not know how to deal with them at all.

The first government step was the free access to clean needles and syringes in pharmacies by Michèle Barzach in 1987; most of the specialised doctors and pharmacists were against it. It took years before it became generally available. So MDM organised a free and anonymous AIDS screening centre, which was taken over by the government, and then the first needle-exchange bus, which led to constant battles with the police who used to wait outside the bus to arrest or destroy the syringes even though the Ministry of Health supported the programme. On the bus we were able to give a helping hand to drug users by listening to them, and counselling thousands of them on responsible attitudes, and how to avoid the spread of AIDS. As well as clean injecting equipment we also distributed condoms. Thanks to the presence of the medical and social follow-up team on the bus, in 1994, 16 530 people were seen on the Paris bus, 371 000 needles and thousands of condoms were distributed. The message we gave and still give to them is: 'don't share needles, use only your own and shoot clean.'

This experience led eventually to seven buses in different large cities in France. The efficiency of this programme appears to us to be linked to two specific aspects: an immediate answer to the prevention needs of the injecting drug users (IDUs) and HIV prevention without any conditions.

The structure of the place itself allows direct contact between the health care and prevention workers and drug users who can find their way again to health-care channels adapted to their needs. The daily contact must also involve the task of networking with everyone involved in prevention in the neighbourhood, and the task of seeking out institutions and professionals specialised in HIV work and drug addiction, in the social and legal fields.

The medical team on the bus was able to assess the extent of any infection or disease and thus guide them towards the appropriate institutions for care and treatment. Paradoxically, this new way of medical coverage, which concentrated on risk reduction and placed abstinence second, brought many more requests than usual for detoxification by drug users who used its services. Furthermore, harm reduction has come up not as contradictory, but as complementary to access to care, substitution programmes, housing, etc. It reduces violence, renders relationships between society and drug users less conflicting and allows them to follow through with their rehabilitation.

The governmental policy started changing in 1992 under Bernard Kouchner, the then Minister of Health. A prevention kit was distributed by his ministry in our buses. The taboo concerning methadone persists after a pre election quarrel with the Minister of Interior, trying to defend once again the total war against the users. A meeting was organised inside the Ministry of Health with the Swiss director of health on harm reduction and heroin programmes under medical supervision. A further meeting, the Triville conference of professionals, politicians and users from London, Paris and New York who exchanged their experiences and difficulties, proved pivotal. I can still remember the importance of the comments made by the person in charge of Scotland Yard when he said 'the role of the police is to protect citizens: with regard to drugs we must change attitudes to better protect them' (Les Temps Modernes, 1993, p. lOI ). We were supported by foreign professionals who had the biggest experience of methadone in the world; we used their expertise to convince the French authorities, to organise TV programmes and a large debate in the press.

The new right wing government will continue Bernard Kouchner 's action and started by opening a number of methadone programmes. At the same time, a number of NGOs federated to launch an 'auto-support' coalition called Limitez La Casse (stop the slaughter) with MDM, AIDES, ASUD among 50 organisations. For the first time in France there is a large presentation of 'auto-support' groups and networks of GPs are developing. To date MDM has opened four methadone maintenance programmes, with a special consideration for very excluded patients, and seven needle-exchange programmes. In France the total number of methadone places is 2000 and by the end of the year should reach 500Q with the involvement of general practitioners.

Humanitarian NGOs, after playing their role of advocacy, find themselves as 'substitution' for the state's policy; they have acquired a know-how, they have proposed their skills, and the state finds it comfortable to rely on them. It was not without some hesitation that a humanitarian organisation like MDM engaged itself in programmes that required teams of salaried employees. The problem is to be able to do the job in hand and still have time and energy available to take part in the larger debate about drug policy, on the problems caused by crack consumption and the debate about medically prescribed heroin.

We had hoped that the blood scandal would have helped the population understand that public health should not be divided, that there does not exist one for drug addicts and a different one for the rest of the population. For example, our country has I 7 times more AlDS related blood transfusion contaminations than our British neighbours.

It is surely most regrettable that a country like France 'the Human Rights country' has made a late start. Harm reduction is not a national stake, but an international priority.

Currently, central and eastern Europe are facing a health catastrophe, while inexpensive basic tools and mainly access to sterile injection material would lave helped to curtail it. Numerous countries like :he developing countries, Brazil, Columbia, Pakistan, Zaire and Senegal are confronted with drug addiction problems. The duties of the Western countries such as France, would be to show the way. But low can France be such a role model, when it is incapable of putting in place its own public health poli cies ? I consider that its role is to promote harm reduction in France as well as in other countries. This public health fight is also a human rights fight. The lack of knowledge, the prejudices, the misunderstandings and dogmatic certitude have indirectly killed thousands of heroin addicts throughout the world.

This applies to almost all epidemic onsets. First it attacks isolated minorities who are used as expiatory victims with whom we don't identify. And by definition, when the catastrophe becomes evident, it is too late. Thus in the case that concerns us, opinion regarding the tragedy of the IDUs is changing - simply because now their illness threatens to infect any one of us as well as any one of our children. It is thus that by dint of scorning others, we end up by scorning ourselves.

Since 1970 four important reports have been ordered by the government. The latest, the Henrion Commission will come up at last with important recommendations on depenalisation of use. The prime minister who asked the commission for advice will suspend his decision because we are in an electoral period, when the only responsible attitude should be to use this period to inform the citizens of the importance of harm reduction and fight against stigmatisation of the IDUs.

Being part of a commission counselling the Minister of Health we have succeeded in developing a large number of methadone places and to allow GPs to prescribe methadone once patients are stabilised in the centres. The authorisation to selling methadone in pharmacies was signed in April 1995. Our problem is far from being solved; the tragic situation in France cannot be reversed at once and we need to train thousands of health-care professionals and we need to finance global drug policies. We still need our foreign friends. We need to create an inter national structure on drug policy and harm reduction .

I will conclude with this phrase from Albert Camus' Sisiphe's Myth:

Absurdity is born out of this confrontation between human need and the unreasonable silence of the world.

Dr Patrick Aeberhard, 22 rue de Rivoli, 75004 Paris, France.

REFERENCE

Les Tempes Modernes ( 1993 ) . Toxicomanie, SIDA, Exclusion. Paris, October, No. 1567.