Michel Kazatchkine

This is the third report of the Global Commission on drug policy after the first report entitled “the war on drugs has failed” and last year’s report on how repressive drug policies are fueling the HIV/AIDS epidemic.

This report is entitled: “the negative impact of the war on drugs on public health: the hidden hepatitis C epidemic”.

Indeed when we talk about hepatitis C, we talk of a hidden or silent epidemic. Silent, because the infection remains clinically silent, with no recognizable symptoms for many years but silent also, because there is so little awareness and so little public attention to it.

A silent, hidden epidemic, and yet an epidemic of huge proportions among people who use drugs: 10 of the 16 million people who inject drugs worldwide are infected with hepatitis C.

The report is available in English. It was launched at a press conference two weeks ago in Geneva – And now in Russian. It certainly is meaningful to Ruth Dreifuss, Alexander Kwasniewski and myself, three members of the Commission present here in Vilnius, to launch the Russian edition of the report at this conference.

The report shows how infection rates are particularly high in countries whose drug policies and law enforcement practices restrict access to clean needles and syringes and OST, which is of course the case in most countries in the region.

And the report emphasizes that early deaths due to hepatitis C and the global burden of advanced liver disease are increasing in people who use drugs. And yet, we know that hepatitis C is a treatable and a curable disease. But practically, very few people currently access treatment worldwide because of poor or restricted access to specialized care and because of unaffordable prices.

But our report is not just about informing on the current situation with hepatitis C. It is to explain and denounce how the war on drugs by placing people who use drugs within a criminal, rather than a public health frame, fuels the epidemic, just as it is the case for HIV/AIDS.

Just as in the case of HIV:

Fear of police and stigma drive people who use drugs away from health services and to unsafe environments for injection.

Health care systems in many countries (EECA) limit access to care for people who use drugs for example by setting arbitrary requirements around abstinence from drug use.

Restriction on the provision of sterile needles and syringes and of OST result in increased rates of injection equipment sharing.

Mass incarceration places individuals in high-risk environments for hepatitis, HIV and tuberculosis, and prisons in most places in the world do not provide harm reduction and prevention measures that would avoid virus outbreaks among incarcerated people.

So we stand against the fact that public funds continue to be wasted on harmful and ineffective drug law enforcement efforts instead of being invested in prove, prevention and treatment strategies.

The report comes with a number of recommendations:

We call on governments to acknowledge the importance of the hepatitis C epidemic and its human, social and economic costs in people who use drugs;

We call on governments to acknowledge that drug policies dominated by strict law enforcement practices perpetuate the spread of hepatitis C and of HIV by exacerbating the social marginalization of people who use drugs and undermining their access to essential harm reduction and treatment services.

We call on governments to improve surveillance and access to testing, to design and fund treatment programs for hepatitis C and to ensure that people who use drugs are not excluded from these programs.

And we call on governments to remove legal or de facto restrictions on the provision of sterile injection equipment and opioid substitution therapy, and to re direct resources away from the war on drugs into public health approaches.

There is no doubt for us that significant public health harms will be averted if action is taken now.

This conference is about the values of Harm Reduction. One of the values behind Harm Reduction is human rights.

Human rights must continue to be at the forefront of everything we do.

It should not be necessary for us to say that human rights are drug users’ rights as well. But we must say it loudly and clearly, because in too many countries, in too many police cells, in too many prisons, and in too many health services, drug users are still treated as less than human.

Unless we begin with a firm commitment to human rights, efforts to reduce the harms associated with drugs are doomed to fail.

Here, I mean the right to health and decent care. But also the right to freedom from discrimination. The right to equality before the law. The right to privacy. The right to work and to education.

The right to share the evidence and to share in the advances of science.

The evidence about why drug use is most effectively addressed as a public health challenge, and why punitive approaches that criminalize users, drain the resources of law enforcement agencies and overburden judicial and penal systems , are futile and counter-productive.

We need to continue our advocacy, maintain the moral and political pressure and above all, continue to promote the evidence. The right for all to share and benefit from the evidence.

All of these are universal rights. And no matter where they are, whether it is Moscow, Melbourne, Bangkok, Detroit or Vilnius.

Thank you.

We live in a world of extraordinary inequities. Poverty and inequity are the world’s greatest killers. In the 20 years after the Cold War, 360 million people have died from hunger and treatable diseases – much more than from all 20th-century conflicts.

Inequities in health are among the most visible of all in a world in which the gap between the mean GDP of rich and poor countries more than doubled in the 25 years to 2005. The developing world bears an extraordinarily inequitable burden of infectious disease, 90 per cent of it, and yet these countries represent just 12 per cent of all health spending.

AIDS is a classic example. Of the 30 million AIDS deaths since the virus that causes the disease was identified 30 years ago this week, 90 per cent have occurred in Africa.

Yet, against such odds, the face of AIDS has changed from one of desolation to one of hope.

When AIDS was first identified in fewer than 20 patients in the US who presented with unusual symptoms in the early 1980s, millions of Africans were already infected, but there was no system in place to detect this. The sub-Saharan epidemic spread unchecked for another 20 years: while science rapidly responded in the global north, barely a single patient in the developing world had access to treatment from an international program until 2001.

What AIDS has since shown us is what can be achieved when the world resolves to fight a pandemic, when the right to health is aggressively asserted, when we see and act on medicine and health care as a ”global public good”.

The global effort to defeat AIDS over the past three decades has demonstrated a long-suspected truth: health should no more be seen as a consequence of economic growth.

In 2000, the world set itself the ambitious Millennium Development Goals, endorsing that change in paradigm about how health relates to development. Experience has validated the concept. In its last report, the United Nations Development Program showed that the countries that invested the most in health and education in 2000 are also those in which the Human Development Index has progressed the most in the past 10 years.

AIDS is perhaps the pre-eminent example of successful investment in health. Eight million people have gained access to antiretroviral treatment, compared to just a few tens of thousands 10 years ago. As a result of investments in HIV prevention and treatment, mortality from AIDS and the number of new infections have decreased worldwide by 25 per cent in just the past five years.

Several factors have been key to this remarkable progress.

First, one cannot underestimate the impact of activism and social mobilisation against the inequity of access to care, as exemplified by Justice Edwin Cameron of South Africa, himself living with HIV, in his call to action at the International AIDS Conference in 2000. ”I exist as a living embodiment of the inequity of drug availability in Africa,” he said. ”I stand before you because I am able to purchase health and vigour. I am here because I can pay for life itself.”

This is an activism that began in the global north and has spread to nearly every country in the world. It is a movement that has grown beyond AIDS to a global movement of citizens who have brought new life to the idea of health as a human right and new pressure on governments to fulfil their responsibilities.

Another key factor has been the global political commitment to funding health, beginning with the G8 meeting in Okinawa in 2000 and continuing through key instruments such as the Abuja declaration in 2001 committing African heads of state to dedicate 15 per cent of their national budgets to health by 2010, the UN General Assembly special session on AIDS 2001 and the Gleneagles G8 commitment to providing universal access to HIV treatment.

A third factor is what I would call ”innovation” in the way in which aid is provided through new global mechanisms and partnerships, and in the way it is accounted for – increasingly, based on performance of programs.

In the case of AIDS treatment, delivery of what was once seen as a very complex intervention is now largely governed by simplified algorithms for health workers and nurses. Many patients receive routine care and adherence support, and have their prescriptions refilled, without ever seeing a doctor.

What the World Health Organisation calls ”task-shifting” and a ”public health approach” to treatment and care was seen as revolutionary only a decade ago and has forever changed our thinking about what can be achieved in chronic care in resource-limited settings.

The question today is whether this remarkable progress can be sustained and amplified as 8 million people are still in urgent need of treatment – in a global context that has changed significantly from what it was 10 years ago.

The world is no longer a relatively simple configuration of the G8 powers and the rest, or a global north and global south. Rather, we live in a multipolar world in which Brazil and Latin America, China, Australia and Indonesia, India, Russia, Africa, Western Europe and the US interact in complex ways, so the concept of global solidarity becomes increasingly subordinate to national and regional agendas, especially since the global financial crisis.

And while inequities between countries have decreased, and the overall proportion of people in extreme poverty has decreased, the inequities within countries are now increasing everywhere, particularly in middle-income countries and emerging economies.

There are now nearly twice as many people living below the threshold of poverty in middle-income countries as in low-income countries. Emerging economies will have to redistribute large amounts of funds to the social sector and prioritise social investments. It will make some governments feel very uncomfortable.

But there is a way forward as AIDS has shown – take the rollout of antiretroviral drugs over the past decade as a piece of inspiration. What many of us working in the field considered to be utopia not so long ago has become an achievable global target.

Finally, let’s not forget the end game: inequities in health also systematically put groups of people who are already socially disadvantaged (for example, by virtue of being poor, female, and/or members of a disenfranchised group) at further disadvantage. Health is essential to overcome the other effects of social disadvantage. AIDS has shown us there are no excuses not to do so.

C’est bien évidemment la poursuite de la croissance de la tuberculose multi résistante en Europe de l’Est et en Asie centrale qui est au centre de mes préoccupations à la veille de la journée mondiale de la tuberculose cette année.

Trois chiffres en disent long sur cette épidémie que rien ne semble pouvoir arrêter. Le premier: le fait que 18 parmi les 27 pays dans lesquels le fardeau de la tuberculose est le plus élevé dans le monde, se trouvent dans la région. Le second: la proportion que représentent les formes résistantes parmi  les nouveaux cas de tuberculose qui surviennent dans la région est maintenant de 15% (45% si l’on considère les malades qui ont besoin d’un nouveau traitement après un premier traitement incomplet ou mal suivi !). Le troisième est qu’en Russie, un usager de drogues, s’il est arrêté et emprisonné, court en milieu carcéral un risque vingt cinq fois plus  élevé de contracter la tuberculose que la population générale.

Au delà de la crise des ressources que l’OMS et le Fonds Mondial mettent aujourd’hui en avant, chacun de ces chiffres renvoie a une multitude d’autres problèmes d’ordre médical, structurel et social qui reflètent les déterminants de l’épidémie dans cette région. La tuberculose y est largement prévalente, favorisée par la pauvreté et les écarts croissants entre les riches et les pauvres, l’hygiène de vie insuffisante au quotidien, la malnutrition, le tabagisme et l’alcool. Mais aussi des programmes de lutte contre la tuberculose qui ne sont pas intégrés avec les structures de soins primaires, et l’absence de mesures de prévention efficaces de la transmission des infections par voie aérienne dans les structures de soins et les établissements pénitenciers, ou encore, l’absence de lien organique entre soins de la tuberculose et soins du sida. Et puis, l’absence, auprès des structures sanitaires et dans le milieu social de soutien communautaire, d’aide à la prise des traitements, ces traitements longs de plusieurs mois qui demandent d’être suivis sans faille et jusqu’au bout sous peine de survenue de résistances. Et si celles ci surviennent, le traitement devra se poursuivre deux ans pleins et recourir à des médicaments dont le coût est 20 a 50 fois plus élève que celui d’un traitement de première ligne.

Les défis à relever sont considérables. J’avais été heureux de faire approuver il y a un an et demi, avec Zsuzsanna Jakab, la directrice régionale de l’OMS pour l’Europe, un plan de cinq ans pour combattre la tuberculose multi résistante dans la région. Il y a des réponses à ce plan et des progrès sont enregistrés dans plusieurs pays de la région. Mais l’épidémie continue de progresser plus vite que nous ne la combattons.

La journée de la tuberculose est là pour nous rappeler que cette maladie dont certains pensent qu’elle appartient aux siècle précédents, continue de tuer à très grande échelle dans le monde, et acquiert de nouvelles formes résistantes particulièrement menaçantes. Et comme cela est si souvent le cas dans l’histoire des épidémies, ce sont les populations pauvres et marginalisées qui en sont les premières victimes.