06/26/16 Steve Rolles

This week: we talk with Steve Rolles with the UK's Transform Drug Policy Foundation about Brexit and the future of drug policy in the UK and the EU; plus the UN's recent General Assembly High-Level Meeting on AIDS featured discussions about injection drug use and HIV/AIDS, so we hear some audio from that.

Century of Lies
Sunday, June 26, 2016
Steve Rolles
Transform Drug Policy Foundation
Download: Audio icon col062616.mp3



JUNE 26, 2016


DEAN BECKER: The failure of drug war is glaringly obvious to judges, cops, wardens, prosecutors, and millions more now calling for for decriminalization, legalization, the end of prohibition. Let us investigate the Century Of Lies.

DOUG MCVAY: Hello, and welcome to Century Of Lies. Century Of Lies is a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org.

Today, we're going to be focusing on public health and legal responses to injection drug use in the context of AIDS prevention, and we'll be hearing audio from the UN General Assembly's High Level Meeting on Ending AIDS, which took place at UN Headquarters in New York in early June.

First, however, a few days ago, the government of the United Kingdom held a referendum to decide on whether it should leave or remain in the European Union, the so-called Brexit. By now you've probably heard that, by a relatively narrow majority, the voters of the UK have decided to leave. What that actually means is something that people are still trying to understand, it's vastly complicated, incredibly nuanced. The decision could in fact be reversed, but for now, it appears that it's going to happen.

Drug policy never really made it into the discussion, though there are definitely implications for drug policy, both in the EU and in the UK. To find out more, I spoke with Steve Rolles. Steve is a good friend and a friend of the program. He's a senior policy analyst at the Transform Drug Policy Foundation in the UK. As well as writing a range of journal articles, periodicals and book chapters, Steve was lead author on many of Transform's publications, including 2009’s 'After the War on Drugs: Blueprint for Regulation'. He's a regular contributor to the public debate on drug policy and law in print and broadcast media, and has been a speaker at various events, conferences and inquiries held by, among others, the UK government, the UN, and many other high-level international bodies. I caught up with him by Skype.

STEVE ROLLES: Well, obviously, it's early days. It's hard to know. The UK has not actually pulled out of the EU yet. It's not as -- it's not like a ballot initiative in the US, it's effectively a kind of glorified opinion poll. So, it's not legally binding. The process by which we actually withdraw from the EU has not been officially triggered yet, and when it is, it's still going to be a two-year process, with the main EU structures, and it could drag on for five or ten years. So, the UK actually pulling out is not a certainty yet, because Parliament and the government have to trigger it, and it's a tricky process, and there could be another referendum. So we don't know whether it's actually going to happen yet.

But assuming it does happen, the UK is part of a EU-wide drug strategy, and whether we would remain a part of that strategy or not would be part of the renegotiation process. So there's an awful lot of detail that we don't know, whether we would stay part of EU enforcement structures, or the EU drug strategy, and some of the other EU-related drug activities, including the European Monitoring Centre on Drugs, and financing of drug-related scientific research across the EU, all of that stuff would have to be renegotiated. And whether or not we stay part of that would depend on how those negotiations pan out and the degree of our, sort of, how far we withdraw. Because a lot of people are suggesting that we'll kind of half withdraw, and actually, it will be more like a kind of EU lite. We'll have a kind of slightly disengaged version of what we currently have, but effectively most of the structures will stay in place.

So we just don't know, in terms of how close our alliances will be with the EU in the future. But, there are some interesting possibilities. If we're no longer part of the EU, it could, in theory, be easier to pursue certain reforms, such as cannabis legalization and regulation, because that's something that specifically the EU doesn't support, and if we wanted to do it within the EU, the EU would make that quite tricky. There might be penalties, there might be diplomatic costs, that if we're not part of the EU, we wouldn't face.

Having said that, the likelihood that the current government would go down that road seems very low, and the government that may well take over, the new administration that's going -- the new government staff that are going to take over now Cameron and his team are going to step down, are likely to be more rightwing, more conservative, and even less interested in drug reform.

DOUG MCVAY: American audiences may not really quite get this, but, seriously, the Prime Minister, the head of government there, has announced his resignation. The likely successor is the former mayor of London, current member of Parliament, Boris Johnson. And, there's also the possibility that you'd actually have a new general election, which throws open a lot of possibilities, including the chance that you might have Nigel Farage as a prime minister.

STEVE ROLLES: Ha. I don't think that's very likely. He's not even an MP, and so he would -- there's no chance of him becoming prime minister, because he would have to have a Parliamentary majority, and they only have one MP, so, that certainly isn't going to happen. But, yes, it is quite likely that we will have Boris Johnson as the next prime minister. I mean, interestingly, Cameron, and Boris Johnson, and our Chancellor of the Exchequer, Osborne, they were all at Oxford together, and they're all kind of drinking and party buddies, and they all, I think they all took drugs, and they certainly understand the drug culture, and intellectually those three certainly don't seem hostile to drug law reform, or cannabis reform at least.

But, their problem is not an intellectual one with drug law reform, it's more of a political one, in that a lot of their audience are older people, they're Conservative audiences, they're Conservative media, who are not bought into drug law reform, and they have to work with their constituencies to a certain extent. But Boris Johnson is not hostile to drug law reform, but I very much doubt it would be one of his priorities. That said, there is also a possibility that we would have Theresa May, who is our current Home Secretary, that she would become, she will become the prime minister. It's by no means a certainty that it's going to be Boris Johnson, and she is very hardline and conservative on drugs, and would be even less likely than Cameron or Boris Johnson to do, to move. To be honest with you, none of the outcomes for this in terms of the UK politics in the short term are good from a drug law reform perspective, I have to be honest with you, it's not good news.

DOUG MCVAY: I, from what little I know of UK politics, it's bad news for progressive, for progressives in general. I mean, Theresa May is not exactly a friend of human rights.

STEVE ROLLES: Yeah, absolutely, I mean, you know, this is -- no, this is, we're experiencing a lurch towards a populist rightwing government, and it's not good news for progressives generally, or for science and evidence-based policy. We're having a lurch towards the ideological right, and, yes, it's all pretty bad news, I'm afraid.

DOUG MCVAY: Well, Steve, I know that you've got -- you're in the middle of a rainstorm and you've got a lot of stuff that you're dealing with, that you're doing right now. Do you have any final thoughts, and where can people follow the stuff that you're doing online?

STEVE ROLLES: Well, people can always follow the Transform Drug Policy Foundation twitter feed, we'll be posting updates all the time. And the Transform website as well, just search for Transform Drugs and it will pop up. I think the only other thing that's worth mentioning is the likelihood that this, if we do pull out of the EU, this could easily precipitate another Scottish independence referendum, which they would probably this time in fact win, and Scotland could break away from the United Kingdom. And I guess from another drug policy perspective, that would open some other opportunities, because we would then have a sort of progressive left government in an independent Scotland, who may be more interested in drug law reform issues, and have certainly given some signs of that. They may be more interested than the Parliamentary government that we have at the moment based in London.

So that's, I guess, one possibility. I mean, it's not something personally I'd like to see, I don't want to see the United Kingdom break up, but, you know, we have to deal with reality and take the opportunities when they come, and that may be one. So I think that's just another thing that's worth mentioning.

DOUG MCVAY: Oh, indeed. No, in fact, I've seen some of the, in some of the Scottish papers I've seen various, you know, pundits arguing against methadone, oh it's just continuing addiction, on the other hand, I know that Scotland has a, you know, a long history with heroin addiction and hard drug use, and -- it's going to be interesting. I guess you can't really call it "United" Kingdom if that happens, right? You'll just be Kingdom.

STEVE ROLLES: Yeah, well, we'll still be the United Kingdom but we'll have a different flag, and it will be the United Kingdom not including Scotland. So, it's -- everything would change. But, you know, we had to deal with that whole argument last year with the Scottish Independence referendum, and it looks like we may have to deal with it again, but this time it will probably happen. Last time it was narrowly defeated. But it's just another thing to clock.

DOUG MCVAY: Does drug policy ever actually get into the discussions on these, on any of these things, or is it more of a side issue?

STEVE ROLLES: Yeah, it's not featured in these discussions at all, to be honest. Occasionally some of the immigration discourse refers to drugs, but it's usually in the negative, in the, you know, these horrible foreigners are coming and bringing their drugs with them, and, you know, it's the kind of xenophobic immigration rhetoric that you're getting from Donald Trump and some of the kind of rightwing populists in the US. It's kind of similar to that.

DOUG MCVAY: And with all the heightened immigration restrictions that you're likely to be seeing, I suppose you'll end up seeing more home grown cannabis and domestically developed new psychoactive substances. Is that a thing that you're seeing now anyway?

STEVE ROLLES: Yes, I mean, that becomes a distinct possibility. But, you know, most cannabis is domestically grown now anyway, it's not imported anymore. It's all grown in, you know, under lights, in attics, and warehouses, and, you know, buried cargo containers and stuff.

DOUG MCVAY: Just like in the US, eh?


DOUG MCVAY: Not that far different after all. All right, well, Steve, thank you again so much for taking the time with us today, I am so grateful to you. The best of luck with everything as all this moves forward. My gosh.

STEVE ROLLES: Okeh, great. All right, well look, great to talk to you guys.

DOUG MCVAY: All right. Cheers.

That was Steve Rolles with the Transform Drug Policy Foundation, we just spoke with him on Skype. You're listening to Century of Lies, a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. And now, on with the rest of the show.

The United Nations General Assembly recently held the 2016 High-Level Meeting on Ending AIDS to focus the world's attention on the importance of a fast-track approach to the AIDS response over the next five years. Delegates heard from a number of experts on a variety of topics related to HIV AIDS. Among other things, they discussed populations at high risk, including drug users, and legal responses to injection drug use and the AIDS epidemic. Today we're going to hear from some of those experts.

First up, David Wilson, PhD. Wilson is the World Bank’s Global HIV/AIDS Program Director. He was previously a Professor at the University of Zimbabwe for almost 20 years and an adviser to many governments and most bilateral and multilateral agencies. David holds a PhD specifically on AIDS and has published widely on AIDS. He's worked in 41 countries on all continents and managed programs at the community, national and regional level. Here's Dr. Wilson.

DAVID WILSON, PhD: Let's just begin by reminding ourselves how serious and growing the burden associated with drug use is. And here are just some of the costs. In terms of health costs, we have almost fifteen times higher mortality, twenty times higher HIV, fifty times higher HCV rates. We have six times higher TB rates among people who inject drugs, rising to 23-fold higher TB rates among drug users in prison contexts. But the costs are wider, and they include socio-economic consequences, such as incarceration, loss of productivity, and managing crime.

I'd like to underscore a point that the minister made nicely, using Kazakhstan as an example, and that is the transition to domestic financing. This is really urgent, particularly for the highest impact interventions, the most important harm reduction interventions. And what this really illustrates, if we look at one region, the region where HIV as a result of injecting drug use is growing fastest, that is Eastern Europe and Central Asia. We see only a handful of countries finance their own HIV responses, especially the highest impact responses. So we still see high reliance on international financing in a region comprising almost all middle income countries, with the notable exception of Kyrgyzstan.

But there's also good news, and that is, if we invest in optimally evidence based policies, the costs aren't prohibitive. We can manage the costs of drug use, we can manage the costs of HIV, without serious financial repercussions. And here's a nice example from Belarus, using a topographical map generated by our Optima mathematical optimization program, which contrasts least and most optimal spending, with the least optimal being the Ural Mountains of general population programs nationally, contrasted with the optimally effective, targeted interventions for people who inject drugs, and then MSM and sex workers, in the major centers, such as Minsk, Svetlogorsk, and Zhlobin.

So how we spend our money matters. And Kazakhstan's a nice example, and it's an example that's moving in this direction. With the same budget it could actually halve incidence and mortality if it could bring ART drug costs down to comparable norms, and reduce management costs, and this is achievable, and the minister has shown how Kazakhstan will do it.

We know that we have three proven priority interventions: needle/syringe programs, opioid substitution therapy, and anti-retroviral treatment, supported by other contextual interventions. And, let's just remind ourselves what we know about these three. We know from the 99 city study how effective needle/syringe programs are at the population level. We know that HIV fell 20 percent in cities with any NSP programs, and rose ten percent in cities without.

We've just completed a partnership with the government of Malaysia, in which we compared the compulsory detention programs with voluntary community based opioid substitution therapy. The differences were remarkable. The relapse rate was 83 percent in the compulsory detention arm, and much, much lower in the voluntary rehabilitation arm. Six times lower. And when we looked at the costs, we found voluntary community based rehabilitation was at least 12 times as cost effective as detention. So compulsory detention's one of the least effective ways we can respond to this public health challenge.

But, having said we've got three proven interventions, sadly, the current coverage is inadequate. And here's a recent summary. Only about 14 percent of people who inject drugs access ART, only about 10 percent access NSP, and only about 8 percent access OST, and even fewer access all three of these vital services. And even fewer women access these services. So we have proven interventions, but we haven't delivered them at scale, least of all to women.

And, when we now look at the major opportunities to invest for impact, we have a global movement to integrate HIV and health services under the umbrella of universal health coverage. What does this mean for harm reduction? Well, there's actually good news. We can integrate HIV into universal health coverage for an affordable amount. An optimized HIV response could be integrated into a universal health coverage benefits package for about two percent of the overall health budget, which is affordable.

And, we can make it even more affordable, if we have supportive laws and policies. Nothing is more conducive to efficiency and effectiveness than supportive laws and policies. If we have to work around obstructive laws, it's expensive, it's inefficient, it's ineffective, and it results in the low coverage that we saw. So, the best possible financial investment we can actually make is in supportive laws and policies. And we see this in this map, showing that where we have legal barriers, we have far fewer services and far lower coverage.

DOUG MCVAY: That was David Wilson, PhD, Director of the World Bank's Global HIV/AIDS Program. He was speaking at a side event on legal responses to drug use and the HIV/AIDS epidemic during the recent UN General Assembly High Level Meeting on Ending AIDS.

Now, let's hear from a legal expert. Professor Leo Beletsky holds a joint appointment with the Northeastern University School of Law and Bouvé College of Health Sciences in Massachusetts.

PROFESSOR LEO BELETSKY: My name is Leo Beletsky, and my focus is on the assessment of laws and policies as a structural determinant of health and specifically focusing on HIV and other disease transmission, including among people who inject drugs. And my talk actually is a very apt follow-up to Dr. Wilson's presentation, because he mentioned legal barriers as a key element of the enabling environment for HIV prevention and also how legal barriers and policy barriers can be a major challenge in implementing harm reduction and other programs, both focused on people who inject drugs and others.

And certainly, if we're going to be investing in HIV prevention and thinking about how to reach the 2030 targets that were highlighted in the proceedings in the last couple of days, legal and policy elements are, should be a very major focus of those efforts, both in thinking about how to create an enabling environment, and how to make sure that it actually reaches the goals that have been highlighted.

So, today, in my presentation, I'd like to focus first on highlighting how laws can act as barriers and enablers for HIV prevention and treatment, to talk about the role of law enforcement and police in that equation, because that's something that is often missed in these conversations, and to provide a case study of our work in Mexico as well as in other places, but today I'll focus on Mexico, in thinking about how to translate laws and policies into action on the ground, because oftentimes there's a major gap between what should be done and what actually happens.

So, this won't be a surprise to anyone but the idea that HIV is a result of both individual and contextual, structural factors is something that's been gaining wider recognition in the scientific community, and my focus as well as the focus of my colleagues is in looking at the legal structures and how legal structures and policy structures shape HIV risk.

It also won't be a surprise, and it actually was highlighted in point 43 of the political declaration that was just adopted, that restrictive drug policies and drug laws, both on the international and national as well as the local level, can be major impediments to HIV prevention among people who inject drugs as well as others, and this includes laws that restrict syringe possession, laws focusing on drug possession that lead to incarceration, which Dr. Wilson just highlighted as a major source of HIV risk and other health consequences, as well as other laws that challenge the human rights of drug users, such as drug user registration, compulsory treatment, and other public health surveillance efforts that do not respect people's privacy and confidentiality, so, in other words, when drug users are afraid of contacting health services or seeking HIV testing and treatment, that acts as a major barrier to implementation of HIV prevention as well as HIV treatment and treatment of other diseases.

Those are not the only legal barriers. Dr. Wilson highlighted the role of healthcare services in the HIV prevention and HIV treatment cascade, and so there's a large set of policies that act, can act as barriers, so, including policies that restrict access to or payment for prevention and treatment services, as well as other issues that I already mentioned, such as patient confidentiality, or laws that enable healthcare service providers to discriminate against people who use drugs. And these policies, the impact of these policies on HIV risk and HIV transmission has been widely documented in the scientific literature.

There are other enabling environment elements that are critical and I won't focus on these, but suffice it to say that respect for human rights, both on the, again, the international and national/local levels is really critical to make sure that people who inject drugs and others have access to services and can vindicate their rights to other kinds of social support frameworks.

So, the good news is that we, given that these laws can act as barriers, we know what should be done to improve HIV prevention/HIV treatment around the world, and again, this was highlighted in the proceedings in the last couple of days. This includes decriminalization, legalization of syringe possession, more progressive policies related to drug possession and drug use, authorization of needle/syringe programs, opioid substitution therapy, and other harm reduction services, as well as access to evidence based HIV prevention/HIV treatment services.

So, none of that should be news to anyone, but what I'd like to highlight in the remainder of the presentation is the importance of implementation and science, and, you know, this session is focused on scientific approaches, and so the idea that we can apply epidemiological methods and other scientific methods to the issue of legal environment, the enabling legal environment, is relatively new. And in applying those methods, we have found that oftentimes what should be happening on a policy level is not actually happening on the ground. And I'm sure this is not a surprise.

But, just to highlight the importance of this translational issue, I'd like to briefly just mention that a lot of research that focuses on how police implement laws, so even if we have those laws that should be promoting an enabling environment for HIV prevention/HIV treatment, police oftentimes disregard those laws or simply are not informed about them, and so as a result, the policy that exists is not, doesn't come to bear, doesn't translate to the street level. And this is something that's been borne out in a lot of research, highlighting that police encounters with people who use drugs, people who inject drugs, is actually associated with HIV risk and HIV sero-conversion.

DOUG MCVAY: That was Professor Leo Beletsky, a legal and public health expert, speaking at a side event during the UN General Assembly's High Level Meeting on Ending AIDS.

And well, that's it for today. Thank you for joining us. You have been listening to Century Of Lies, a production of the Drug Truth Network for the Pacifica Foundation Radio Network, on the web at DrugTruth.net. I'm your host Doug McVay, editor of DrugWarFacts.org. The Drug Truth Network is on Facebook, please give its page a like. Drug War Facts is on Facebook too, give it a like and share it with friends. You can follow me on Twitter, I'm @DougMcVay and of course also @DrugPolicyFacts.

We'll be back next week with thirty minutes of news and information about the drug war and this Century Of Lies. For now, for the Drug Truth Network, this is Doug McVay saying so long. So long!

For the Drug Truth Network, this is Doug McVay asking you to examine our policy of drug prohibition: the century of lies. Drug Truth Network programs archived at the James A. Baker III Institute for Public Policy.