FIFTEEN YEARS OF HARM REDUCTION: A REFLECTION
Ernst Buning looks back on 15 years in the drug field and asks what have we learned and what can others learn from us
I was first introduced to the principles of harm reduction in 1917. Then, we called it secondary and tertiary prevention. Dr Wijnand Mulder, social psychiatrist and head of the Mental Health Department of the Amsterdam Municipal Health Service (GG&GD), looked at problems arising from drug abuse from a public health point of view. He did not believe in changing people through psychotherapy. 'People change themselves. Our role is not to block the process of natural recovery,' he used to say. As a young psychologist, I strongly opposed this view. We were trained to give people insight into their behaviour and, through therapy, we could bring about changes. But Wijnand Mulder would see this differently: 'You guys are thinking you're God himself. If a drug user comes to you, he may come for your tablets, your coffee or because he likes to talk to your secretary and maybe, I repeat maybe. he comes to you because he likes to talk to you.'
THEORY AND PRACTICE
In the period 1977-1979, I learned a lot as an outreach worker. I found myself knocking on doors of squattered buildings, talking to people who were asking me what the hell I wanted from them. And I realised that theories about the psychotherapist being the 'one-up' and the clients being the 'one-down' were fine in the books, but useless for an outreach worker in the Amsterdam drug scene.
In that same period, I met many drug users who had been to a therapeutic treatment programme and relapsed again. Talking to them, I started to realise the importance of tertiary prevention. And then, together with people like Wijnand Mulder, Giel van Brussel and Gerrit van Santen, we started to develop the ideas of tertiary prevention further. What can we do for drug users who are not motivated to give up their drug use? How can we integrate interventions for this group in our public health activities? How do we communicate this change to our local politicians? The concept of harm reduction for drug users was born.
Now, 15 years later, it is time to reflect. Was what we did right? Would we do it again? What have we learned and what can others learn from us?
POSITIVE EFFECTS OF HARM REDUCTION
Clearly, many positive effects of harm-reduction interventions can be given. The situation in Amsterdam is relatively quiet as compared to the early 1980s. The average age of drug users keeps on increasing; the percentage of young drug users is decreasing; we have not seen an explosion of AIDS cases among drug users; the estimated number of drug users is slightly declining; there are no indications for a new wave of drug users; and neighbourhoods are scarcely complaining about the nuisance of drug users.
Not all of these effects can be attributed to the harm-reduction approach. Clearly, the social-cultural climate in the Netherlands, together with autonomous developments in any trend (and therefore also in drug use), have contributed to this more stable situation. However, the influence of the harm-reduction message from the public health side has not been disputed in the Netherlands.
NEGATIVE EFFECTS OF HARM REDUCTION
Unfortunately, there are also negative effects attached to the Amsterdam harm-reduction approach.
In the early 1980s, the fine line between harm reduction and a 'laissez faire' policy was sometimes not recognised. Some of us thought that harm reduction meant that everything should beJolerated. Experiences in the period 1979-1983 with 'cafe-achtige ruimten' (drug users' rooms), where drugs could be consumed, taught us some hard lessons. Many of us thought that such places would help to manage the drug problem. On the contrary: dealers were in charge and the group norm within these centres was aimed at maintaining high levels of drug use and criminality. The Mayor, Ed van Thijn, put things back into perspective when he was appointed in 1983. The centres were closed and more emphasis was given to police interventions and public order problems.
Another negative effect of the Amsterdam harm reduction policy was the major influx of drug users from other countries. To date 25 per cent of the 6000 Amsterdam drug users originate from other west European countries.
HARM REDUCTION IN THE 1990S
Although the negative effects of too much tolerance are clear, I believe that there is a definite place for harm reduction interventions in the 1990s. Low-threshold methadone programmes, needle-exchange schemes next to shelters, social assistance and soup kitchens for street addicts, will be a necessity for every major city in the Western World.
But caring for drug users who are not ready to give up their drug use, does not mean that everything should be tolerated. If drug users are approached as responsible human beings, we have to make clear that we can offer certain assistance, but also expect something in return. We expect drug users not to throw their needles in places where children could hurt themselves, we expect them not to give their used needles to other injectors and we expect them to respect other inhabitants of the city. I think these expectations are not too high if we take ourselves and drug users seriously.
Bureau International Contacts Drugs/AIDS, CG8GI), Amsterdam, The Netherlands