Dr. Alex Wodak NIH Letter

April 27, 2004
Honorable Elias A. Zerhouni, M.D.
Director
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892

Dear Dr. Zerhouni,

I refer to a letter addressed to you dated April 27, 2004 from Congressman Mark E. Souder, Chairman, Subcommittee on Criminal Justice, Drug Policy and Human Resources regarding harm reduction. The multiple and serious errors of this letter should not be accepted, whether or not it is an election year in the United States.

I write as the President for the last 8 years of the International Harm Reduction Association. I have also been involved in efforts to control HIV infection among and from injecting drug users for almost twenty years in my own country as well as countries in Asia, South America and the Middle East. I am the principal author of a 16,000 word major international review of the effectiveness, safety and cost effectiveness of needle syringe programmes soon to be published by the World Health Organisation as part of their Evidence for Action series. Allow me to clarify a number of misunderstandings of Congressman Souder.

1. Harm reduction is an evidence based and pragmatic response to public health problems.

Congressman Souder claims that '"harm reduction" is an ideological position that assumes individuals cannot or will not make healthy decisions.'

'Harm reduction' is defined by the International Harm Reduction Association as 'efforts to reduce the health, social and economic costs of mood altering drugs without necessarily reducing drug consumption'. Harm reduction practitioners do not assume that 'individuals cannot or will not make healthy decisions'. We test hypotheses and if the evidence demonstrates that a particular hypothesis can be refuted, we reject that hypothesis. In the case of injecting drug users, the evidence demonstrates consistently that when provided with appropriate and timely information about the risks of HIV, the means to change behaviour and the encouragement to do so, risk behaviour generally declines and HIV incidence and prevalence also decline.

2. Harm reduction is effective, safe and cost effective.

Congressman Souder claims that 'programs driven by this ideological position have not been adequately reviewed with unbiased, scientific rigor'. Perhaps Congressman Souder is unaware of the seven following reviews of needle syringe programmes carried out by agencies of the US government (or on their behalf):

1. General Accounting Office, G.A., Needle Exchange Programs: Research Suggests Promise as an AIDS Prevention Strategy. 1993, US Government Printing Office: Washington DC.
2. National Commission on AIDS, The Twin Epidemics of Substance Use and HIV. 1991: Washington DC.
3. Lurie, P., & Reingold, A.L. (Eds). The public health impact of needle exchange programs in the United States and abroad, vol. 1. 1993, Centres for Disease Control and Prevention: Atlanta.
4. Office of Technology Assessment of the US Congress, The Effectiveness of AIDS Prevention Efforts. 1995, US Government Printing Office: Washington DC.
5. National Institutes of Health Consensus Panel, Interventions to prevent HIV risk behaviors. 1997, NIH.
6. Satcher, D., Surgeon General, Evidence-based findings on the efficacy of syringe exchange programs: an analysis of the scientific research completed since April 1998. 2000, US Dept of Health & Human Sciences: Washington, DC.
7. Institute of Medicine of the National Academy of Science, No Time to Lose: Getting More from HIV Prevention. 2001, National Academies Press: Washington DC.

All of these reviews concluded that: (1) needle syringe programmes are effective in reducing HIV infection among injecting drug users; (2) needle syringe programmes do not increase illicit drug use. Congressman Souder's claim is baseless.

3. Few studies question the value of needle syringe programmes

Congressman Souder quotes studies concluding that needle syringe programmes may increase HIV infection. He does not quote some later studies by the same authors questioning or revising their own findings in earlier papers. The overwhelming majority of papers evaluating needle syringe programmes have found that these programmes reduce HIV infection among injecting drug users. There is no convincing evidence that needle syringe programmes increase HIV.

Congressman Souder appears to be unaware of the findings of the vast majority of studies evaluating needle syringe programmes and large ecological studies in particular. A study commissioned by the Commonwealth Department of Health in Australia (Health Outcomes International Pty Ltd, National Centre for HIV Epidemiology and Clinical Research, Drummond M. Return on Investment in Needle and Syringe Programs in Australia. Commonwealth Department of Health and Ageing. Canberra. 2002.) showed that by 2000 needle syringe programmes cost Australia's governments $A130 million but prevented 25,000 HIV and 21,000 hepatitis C infections and by 2010 prevented 4,500 AIDS deaths. More Australian lives were saved by needle syringe programmes than were tragically lost in New York to terrorism on September 11, 2001. Needle syringe programmes saved governments at least $A2.4 billion or, if the conventional 5% annual discount for future benefits is not deducted, as much as $A7.7 billion. ($A 1.00 = $US 75.00) This major evaluation was based on a study of data from 103 cities around the world. Cities with needle syringe programmes had an average annual 18.6% decrease in HIV, compared with an average annual 8.1% increase in HIV in cities without such programmes.

The USA rejects harm reduction and consequently needle syringe programmes have to rely on meagre state and city resources. Thus needle syringe programmes in the USA have a fraction of the coverage of their Australian counterparts. In the year 2000, there were almost 15 new AIDS cases for every 100,000 Americans compared to just 1 new AIDS case for every 100,000 Australians. Between one third and one half of all new AIDS cases in the US are attributed to injecting drug use compared to about 5 % in Australia. The USA has today the highest AIDS incidence in the developed world and by a large margin.

In July 2002 President Clinton acknowledged publicly that he had erred in declining an opportunity to introduce Federal funding for needle and syringe programmes in the USA in April 1998. Clinton explained that at the time he had taken political rather than public health advice.

4. Harm reduction is a well established approach in clinical medicine and public health 

The WHO Expert Committee on Drug Dependence noted in 1974 a 'concern for preventing and reducing problems rather than just drug use'. As far back as 1926 in the United Kingdom, the Rolleston Report (Ministry of Health, Departmental Committee on Morphine and Heroin Addiction, HMSO) commented that "indefinite administration of morphine or heroin would be permitted for those  ...  who are 'capable of leading a fairly normal and useful life so long as they take a certain quantity, usually small, of their drug of addiction but not otherwise'" Opponents of harm reduction are often obsessed by the potential for officially approved indefinite administration of morphine or heroin but harm reduction advocates are more interested in the possibility that these same individuals might be assisted to 'lead a fairly normal and useful life'. The debate about the primacy of harm reduction or use reduction has been raging for decades but it is now clear that the use reduction approach has lost this argument.

The influential Advisory Committee on the Misuse of Drugs in the United Kingdom commented in 1984 that 'prevention includes both the prevention of drug use and the prevention of drug related harm.' Harm reduction should embrace evidence-based efforts to reduce drug use where these are motivated primarily by a desire to reduce harm rather than a compulsion to eradicate drug use.

Harm reduction is a universal framework which has long been applied to alcohol. In 'Alcohol and Public Policy' (National Academy Press, 1981), the need was recognized to 'make the world safe for drunks' by 'modifying environments so that when drinking or drunken activities occur, they are less likely to cause or exacerbate damage.' Is this not the very spirit of harm reduction?

Wherever we look, there are examples of harm reduction. Surely, nicotine replacement for cigarette smokers is entirely comparable with providing methadone for heroin injectors. When all efforts have been made to minimize the number of car crashes including those due to alcohol, car safety belts reduce the risk of death or serious injury to the driver and other occupants of the vehicle who might otherwise be ejected from the crashed vehicle. Motorcycle helmets are based on similar principles and recognise that motorcycles cannot be prohibited despite the fact that they are far more dangerous than cars. Authorities attempt to relocate roadside poles where ever possible. Where roadside poles cannot be relocated, they are replaced by frangible poles which give a little on impact, thereby reducing the risk of death or serious injury. Condom promotion to reduce the incidence of sexually transmitted infections and unwanted pregnancy complements efforts to reduce the rate of sexual partner change but accept the reality that some irreducible level of sexual partner change exists. These days, rubber paving is often placed underneath the climbing frames for children in neighbourhood parks.

5. Widespread acceptance of harm reduction

Congressman Souder appears to be unaware that harm reduction is a mainstream and well accepted approach to drug problems around the world. The world has been changed irrevocably by the recognition of HIV/AIDS on 5 June 1981. The Scottish Home and Health Department concluded in September 1986 that 'the gravity of the problem is such that on balance the containment of the spread of the virus [HIV] is a higher priority in management than the prevention of drug misuse ... On balance, the prevention of spread should take priority over any perceived risk of increased drug use.' The Advisory Committee on the Misuse of Drugs in the United Kingdom argued in 1988 that 'The spread of HIV is a greater danger to individual and public health than drug misuse. Accordingly, services that aim to minimise HIV risk behaviour by all available means , should take precedence in development plans.'

The Mullins report of the Home Affairs Select Committee in the United Kingdom noted in 2002 that 'If there is any single lesson from the experience of the last 30 years, it is that policies based wholly or mainly on enforcement are destined to fail' ... therefore ... 'harm reduction rather than retribution should be the primary focus of policy towards users of illegal drugs'

Harm reduction is now the mainstream approach to drug problems in all countries in Western Europe (except Sweden) and will soon be the mainstream in Asia. Many United Nations organisations are now declaring unambiguous support for harm reduction. The communiqué of the UNGASS on drugs in 1998 referred to the need for 'a balanced approach' and  'reducing adverse consequences' while the communiqué of the UNGASS on HIV/AIDS in 2001 determined that by 2005 'harm reduction' would be make available' by member states. In 2000, the Director General of WHO declared that 'The key to limiting the spread of HIV lies in harm reduction among intravenous drug users.' Even the International Narcotics Control Board concluded in 2003 that 'The ultimate aim of the conventions is to reduce harm' (Report of the International Narcotics Control Board for 2003). UNICEF, the World Bank and the International Red Cross-Red Crescent Society are among major organisation to have endorsed harm reduction.

This debate divides participants into those who their base judgments on data from those who base their judgments on other considerations than data. I have confined my response to evidence supporting needle syringe programmes but could just as well have covered the evidence supported methadone treatment programmes. 

Congressman Souder's comments on harm reduction should be rejected comprehensively.

Yours sincerely,
Dr. Alex Wodak
Immediate Past President,
International Harm Reduction Association
Director, Alcohol and Drug Service
St. Vincent's Hospital, Australia