There are approximately 11.3 million people who inject drugs around the world. A new nation with that many residents would rival Greece, South Sudan and the US state of Pennsylvania for population size. But this scattered population is instead at the mercy of governments wherever they live. It is only in the last few decades that harm reduction entered mainstream human rights discourse, which has brought positive change.
Harm Reduction International’s 2020 Global State of Harm Reduction report, released on October 28, documents how many governments around the world have moved in a more humane direction, yet simultaneously shows the vast scale of the work still to be done.
At the biggest-picture level, 86 countries report the existence of needle and syringe exchange programs (NSP), a figure that has remained constant since last year. Eighty-four countries—two fewer than in 2019—report the presence of opioid agonist therapies (OAT), such as buprenorphine or methadone programs.
HRI also examined whether harm reduction programs are available in prisons and jails. OAT is more often found in carceral environments than NSP, which seldom exist in these settings outside of Canada and Western Europe.
According to the report, harm reduction services in general are much more likely to exist in the Global North, particularly in wealthy, Western democracies. Yet even nations like the Netherlands and Portugal, often celebrated for their commitment to harm reduction, struggle to provide access to their residents who live in more rural areas.
Some regions of the world appear to be responding to the most immediate health issues related to drugs, while ignoring or taking missteps on others. For example, in Latin America, there are now harm reduction programs for people who use non-injectable cocaine—a larger subset of the population of people who use drugs than in many other regions. That said, the report explains how, “[i]n Latin America and the Caribbean, OAT is only available in Argentina, Colombia, Mexico and Puerto Rico, and it is increasingly administered in abstinence-focused settings rather than harm reduction ones.”
Other regions, such as the Middle East and North Africa (MENA), have still barely adopted harm reduction at all. Only nine of 19 nations there have employed any sort of harm reduction program. Looking at the Middle East alone, that ratio becomes even weaker. Two of the three nations that shut down OAT programs in the last year, Bahrain and Kuwait, are located there.
Countries that buck trends likely contain stories that could teach us lessons about how to successfully integrate harm reduction into differing cultures.
Faith and its interpretations play a role here. Similar to its fellow Abrahamic religion of Judaism, Islam has a complex system of religious law that “minutely regulate[s] every aspect of the believer’s life.” Unlike the contemporary Jewish population, polling shows that people in various majority-Muslim nations support a significant degree of unification between church (and religious law) and state. HRI found that Israel implemented more harm reduction programs than all other MENA nations, with the notable exception of Iran.
Religious law, with its traditional understanding that drug use is both forbidden and illegal, complicates the implementation of harm reduction in the Islamic world. Through the lens of both Islamic theology and law, Professor Mansur Ali of Cardiff University posits that the abstinence-based Alcoholics Anonymous model could be an acceptable move from the status quo in the Muslim world. While this idea falls painfully short of the human rights orientation of harm reduction, it illustrates how the implementation of harm reduction in the MENA region will likely depend on finding ways to communicate its ideas in theologically and culturally sensitive ways.
Trends are ultimately generalizations, and countries that buck trends likely contain stories that could teach us lessons about how to successfully integrate harm reduction into differing cultures. Just as Iran is an intriguing exception in the MENA region from which we could learn more, Ukraine could play that role in Eurasia. Out of the seven types of harm reduction program assessed by HRI, Ukraine has implemented five, putting the country in the top achievement category, along with Estonia and North Macedonia.
Ukraine’s adoption of harm reduction could be seen as surprising for a few key reasons. The European Union, which Estonia is a part of and which North Macedonia is on a quick route to join, embraces human rights discourses in official governmental documents. But Ukraine is not an EU member. Additionally, the eastern part of that country prefers a closer binding with Russia, which often opposes liberal human rights discourses and only embraces one of HIR’s seven recorded harm reduction methods. International advocates could therefore learn much from Ukraine’s harm reduction successes and shortcomings in light of its geopolitical situation.
HRI’s report, which provides both good and bad news for harm reductionists, is a vital trove of information for both academics and activists. Even considering disappointments, like some OAT rollbacks, there is a lot to be hopeful for. As Dr. Tlaleng Mofokeng writes in the foreword, “Everyone has a right to health and to be treated with respect and equality—regardless of gender, sexuality, race, nationality, legal status or drug use.” Even if much too slowly, it seems like much of the world is getting there.