Unpublished paper
Copyright 2000: Ernest Drucker

April 23, 2000

Ernest Drucker, Ph.D.⁽¹⁾

If the World Bank and the International Monetary Fund are indeed "prepared to commit 'unlimited money' to fighting AIDS in poor countries⁽²⁾" and really mean it when they say that "no sensible program will be stopped for lack of money⁽³⁾,"  we now have a chance (perhaps our only chance) to show just what global economic might and a little political will can do. For by acting quickly there is still time to avert the huge AIDS disaster now looming over Africa, Asia, and Latin America. And unlimited funds are not needed - we can stop explosive AIDS outbreaks among large populations for less than $1 per head. The key is to intervene early and to focus on the unsterile injection of heroin.

Heroin use is sweeping across the third world - up 300% in the last 10 years, and now affecting over 100 countries. It is heroin injecting that has been the ignition point of all the recent AIDS outbreaks in Asia and South America - and now the pattern is appearing in West Africa.

While we can't do much to quell the burgeoning use of cheap heroin - the purest expression of the global marketplace - it is still possible to uncouple heroin from the spread of AIDS. And even though we don't have an AIDS vaccine yet, we can in fact "immunize" large populations against this collateral damage of the current spread of heroin markets worldwide.

It works this way. First a relatively small group of addicts (usually fewer than 5% of the adult men - and less than 2% of the total population) start shooting heroin. With very few needles available people share syringes hundreds of times. "Hit doctors" line up addicts under the bridges of the Mekong River in Saigon, along the waterside in Lagos , in the back streets of Pakistani and Indian cities, and in the rural villages of Thailand and Indonesia. One needle, hundreds of users - the perfect way to spread blood borne viruses like HIV or hepatitis.

This pattern has already repeated itself in a score of Asian cities and is now beginning in South America and Africa. We have seen dozens of cities that rapidly went from having no HIV infection among its drug users to having over 80 percent infected 18 months later. The female sexual partners are next and then these women's babies. By the time all the addicts are infected and so many women and children, it's too late.

Fortunately we now have a set of proven strategies that can nip these epidemics in the bud - clean needle distribution, inexpensive addiction treatment (using methadone and other drugs), and grass roots community outreach and education programs among drug users networks. There is ample evidence that these harm reduction measures can stop explosive AIDS epidemics and protect millions of vulnerable people.

The cost of such programs is very low. All the needles for 50,000 drug users to inject safely would cost less than half a million dollars per year. Add an equal amount for a few hundred outreach workers and that's still less than $1 million - an amount that protects not only the addicts but the entire population of a million or more in which they live. Less than $1 dollar a head to stop AIDS among one million poor people.

But if this deadly pattern is so well known, and this set of inexpensive and feasible prevention measures available to us, why are they not being more widely implemented?  

Ask the United Nations Drug Control Program (UNDCP) and Jesse Helms - both of which have a problem with harm reduction programs - UNDCP bans the use of the term itself from its own AIDS prevention documents. And Senator Jesse Helms , who has made sure that no United States funds can be used to support provision of clean injecting equipment for addicts - at home in the United States or abroad.

Australia has successfully used these harm reduction measures to keep AIDS below 2 percent among its heroin injectors. And small needle exchanges are now working in Asia and Latin America - with the support of some other UN agencies concerned with health. Yet last month the United Nations International Narcotics Control Board, part of UNDCP, claimed that such programs are "not in line with international conventions" and that their "explicit or tacit approval" are seen as a step in the direction of drug legalization". Sound familiar?

It's time we got past this futile approach to the worlds huge drug problem and focus on a struggle that we can actually win - not the elimination of drugs, but the urgent task of stopping AIDS before it cripples more poor countries.

Footnotes
(1)	Dr. Ernest Drucker is Professor of Epidemiology and Social Medicine at Montefiore Medical Center/Albert Einstein College of Medicine in New York, and Editor-in-Chief of the journal Addiction Research.
(2)	New York Times, April 18, 2000, page 1.
(3)	Editorial, New York Times, April 23, 2000, page 10.