The author of this post, Francis Joseph, is the Programme Manager of the Nirantar project at India HIV/AIDS Alliance in New Delhi. He is also a member of the Indian Drug Users’ Forum. http://www.allianceindia.org/avoidable-tragedy-ending-overdose-deaths/
The Delhi Police van took the defendants back to Tihar Prison after their hearing. Ramesh (name changed to protect identity) was happy at the thought that he would soon be able to reunite with his wife and meet his two-year-old son for the first time. He had spent the past two years in jail. During the judgement, the Metropolitan Magistrate acquitted him of the criminal charges against him. He had been arrested on fabricated charges of a petty crime, but due to his criminal record and history of drug use, his detention had been extended for two years due to trial delays.
As soon as Ramesh was released, he boarded the local bus and excitedly started his journey. When his station came, he got off the bus and headed home. The walk was long, and Ramesh started reminiscing about his drug use days when he would get high. Remembering made him crave “just one fix.” He met his old friend Samir who had been anxiously awaiting his return. He hugged Ramesh and said, “It’s been ages since we had a high together. I have the best stuff.” Ramesh was unable to resist and decided to take a quick hit before finally heading home. Samir took him to a nearby half-constructed building and took out his paraphernalia. Ramesh lit a beedi (cigarette) and watched him prepare the dose. Samir prepared a 5 ml dose for Ramesh and injected him. Ramesh could feel the rush of warm chemicals moving in his veins and could feel his eyes closing as he disappeared into darkness.
Samir was horrified when he realized Ramesh’s unresponsive condition and tried all possible ways to wake him up. Samir ran for help and got his parents who took Ramesh to a nearby private doctor. The doctor gave him a medication by saline drip in the hope that it would help him regain consciousness. After six hours, the outcome was clear. Ramesh was dead. He died from an overdose that night without meeting his newborn baby or seeing his wife and the rest of his family. I remember Ramesh so clearly. He had been my drug-using partner, and we were friends for many years.
There are many Rameshs – in Delhi and across India – who die from injecting greater doses of opioids than required in an attempt to get high. Added with other sedatives and cocktails of depressants, they often experience overdoses that go unnoticed by the users themselves and by others around them. Often their deaths are attributed to other factors like HIV infection and malnutrition. A newspaper article reports that nine recent homeless deaths in Delhi were likely due to addiction. People who inject drugs (PWID) all too often die unexplained deaths, and these numbers are increasing. In 2005, the number of unidentified PWID deaths in Delhi was 2,202. By last year, this figure had risen to 3,285.
Overdose is an urgent condition that requires immediate intervention. A simple 1ml injection of Naloxone is a life-saver. It is not at all costly, and the WHO has included it on its list of essential medicines. Overdose deaths are all too common and avoidable. Naloxone is a game-changer. All healthcare facilities should have this drug ready and available.
31st August is International Overdose Awareness Day, so it is especially timely to raise these issues. Let this be a wake-up call to government to end inaction and scale up evidence-based and cost-effective interventions like naloxone that can reduce overdose deaths among PWID. People from drug-using backgrounds are assets to these efforts and should be actively engaged as implementation partners in awareness raising, dissemination of information, and ensuring the availability of naloxone free-of-cost to PWID in need.
G. Charanjit Sharma was selected to represent India as a civil society speaker at the Commission on Narcotic Drugs (CND) on the world drug problem, which took place on 10-11 October 2016 at the United Nations Office at Vienna, Austria. (http://www.allianceindia.org/support-rights-centric-programs-drug-use-vienna-commission-narcotic-drugs/). He presented the following remarks:
My name is Charanjit Sharma and I work with the India HIV/AIDS Alliance, an organisation that implements programs for people who inject drugs, their partners and families. I am also privileged to be a part of the global Harm Reduction movement of the International HIV/AIDS Alliance and its consortium partners, the Asian Network of People who Use Drugs (ANPUD) and the Indian Drug Users Forum (IDUF).
From my experience with a range of drugs and drug related programs, access to and quality of harm reduction services still continue to be a challenge. Interventions such as needle syringe programs and opioid substitution are yet to be implemented to the scale required in many countries. While TB and Hepatitis C are major health problems among PWID and have resulted in the deaths of many of our friends, most national programs for TB, Hepatitis and HIV continue to function in silos. Overdose remains a major threat among PWID because of barriers in access to life-saving drugs like Nalaxone.
Therefore, as part of larger network of NGOs, we wish to call upon member states to earnestly consider the operational recommendations on prevention and treatment for HIV and drug use programming. The comprehensive package recommended by WHO and other UN bodies is evidence-based and rights-sensitive.
Harm Reduction interventions when implemented to scale, have been seen to effectively address the risks associated with drug use and HIV especially in concentrated epidemics. Member states need to ensure integration of HIV, HCV and TB services with other health and social protection services for people who use drugs.
We recommend the development of innovative service delivery mechanisms especially for hard-to-reach populations, women and those incarcerated.
We urge member states to consider incorporating SRH services, family support interventions and livelihood development to improve the quality of life for PWID and their families. We understand that a multi-sector approach requires considerable commitment and investment on the part of local governments.
We call upon governments to continue to take the lead, in partnership with civil society and community organisations to meet the goal of ‘Ending AIDS as a public health threat’.
We appeal to member states to end criminalization of PUD; eliminate the death penalty for offenses and ensure proportionate sentencing. We advocate for the closure of all compulsory and forced treatment centers and scale up voluntary community-based drug treatment programs that respond best to the needs of PUD.
In keeping with the spirit of meaningful involvement of PUD, we call for the establishment of community committees at local and national levels. We believe that this will enhance the quality of harm reduction programs in design and implementation.
In conclusion, I take this opportunity to appeal to all member states to adopt a non-punitive approach and appreciate the many governments that continue to support evidence-based and rights-centric programs for drug use and HIV.
The following remarks were presented on April 21st in plenary at the United Nations General Assembly Special Session on Drugs in New York.
Namaste! My name is Charanjit Sharma and I am from Manipur a state in the North Eastern part of India. I work for India HIV/AIDS Alliance, and I am also the Secretary of the Indian Drug Users Forum. I am here today because harm reduction saved my life. But I have many friends who were not as fortunate. Their lives were lost simply because they could not access harm reduction services.
We, the International HIV/AIDS Alliance family, are reaching close to 300,000 people who use drugs with community-based HIV and harm reduction services each year in nine countries in Asia, Africa and Eastern Europe. This gives us a unique perspective on what it takes to prevent HIV and hepatitis C transmission and what it takes to get treatment to people who inject drugs.
I have witnessed firsthand the negative impact of prohibition and the fallout of law enforcement as a mechanism of drug control. I have seen police action on drug users and have myself been subjected to exploitation, violence and detention for simply being suspected of using an illicit drug. As drug users, we are soft and easy targets for law enforcement while big players remain elusive. The drug trade continues despite harmful efforts to control it, and we pay the price.
It’s hard to get HIV treatment to people when they are incarcerated, detained or hiding from services for fear of arrest. How can we end AIDS when we can’t get HIV treatment to the people who need it most?
I know from my personal experience the devastating consequences of forced drug treatment and entirely ineffective rehabilitation programs. I have friends who have been tortured and publicly humiliated for days and weeks in the name of treatment. I know too many people incarcerated for years for possession of a small amount of drugs for personal use. Is this justice? Is this fair? Is this humane? Will this end AIDS?
Widespread criminalization and punishment of people who use drugs confirms that the war on drugs is, in fact, a war on drug users – a war on people – a war on us.
On behalf of people who use drugs in India, in Asia and in every country around the world, I appeal to you to put the health, rights and security of people who use drugs at the centre of international and national drug policy. I appeal to you to ensure that policy is informed by evidence of what works: accessible, holistic, people-centred services, tailored to the needs of people who use drugs. I appeal to you to stop arresting and incarcerating people for consumption and possession of drugs for personal use. The death penalty for drug-related offences must be abolished. I appeal to you to support drug users and organisations working with us to improve access to HIV and hepatitis C treatment and overdose services. Support drug users to participate meaningfully in the design and delivery of harm reduction services.
The former UN Secretary-General Kofi Annan has recognized the failure of the war on drugs, recently saying, ‘We need to accept that a drug-free world is an illusion. We must focus instead on ensuring that drugs cause the least possible harm.’
Harm reduction saved my life. Harm reduction saves lives. When lives are saved, communities thrive. When communities thrive, nations prosper. We can’t end AIDS until we scale up harm reduction and end the criminalisation of drug users. Support. Don’t punish.
The author of this post, G. Charanjit Sharma, is Technical Advisor: Drug Use & Harm Reduction at India HIV/AIDS Alliance in New Delhi.
Vienna hosted the 59th session of the UN Commission on Narcotic Drugs (CND), a high-level commission convened by the UN Office of Drug Control (UNODC) to discuss drug policy reform. Over ten intense days, country delegations, experts and community advocates like me met to negotiate wording of a document that will guide drug policies around the world for the next decade or so. The Outcome Document from these negotiations will then be agreed at the UN General Assembly Special Session (UNGASS) on Drugs from 19-21 April at the United Nations in New York. Not all countries had representation at the CND in Vienna, raising legitimate questions about the inclusiveness and transparency of this process and whether all nations truly understand the urgency of this issue. Early on, it also became clear as country delegations spoke that we have some substantial work to do as civil society and community advocates. The Asia-Pacific Group Statement presented by H.E. Ayesha Riyaz, Ambassador and Permanent Representative of the Islamic Republic of Pakistan and the Incumbent Chair of the Asia Group in Vienna, reflected unrealistic aspirations and political popular if poorly targeted priorities as it resolved to strengthen efforts to achieve a society free of drug abuse and address the specific needs of women children and youth within balanced and integrated policies. Evidence-based harm reduction responses for people who use drugs were not mentioned. India’s position as in previous years focused on international cooperation to stem the flow of funds from drug trafficking and other transnational organised crime. Most discouraging was India’s rejection of UNODC’s recommendation to offer evidence-based and voluntary treatment, rehabilitation and care as an alternative to punishment or incarceration to individuals charged with drug offenses. On a more positive note, India described a commitment to ensure the availability of controlled substances for medical and scientific purposes through the removal of the regulatory barriers for drugs such as morphine and methadone for palliative care, pain relief and opioid substitution therapy. I was able to meet the Indian delegation and raise some concerns about our country’s position and share documents including the report from the Regional Civil Society Consultation we was held to ensure community priorities would inform the CND and UNGASS processes, along with the International HIV/AIDS Alliance‘s position paper for the Special Session. I unfortunately doubt that they actually read either through to its end. Vietnam’s statement mentioned that the country carried out harm reduction interventions for drug users. It was encouraging to see this, even while the statement used stigmatizing language such as “drug addicts” and “drug abusers” and repeated ASEAN’s misguided Zero Tolerance approach against drugs. As the Outcome Document comes into focus, it troubles me that there are still many key areas that are ‘under consideration’ – most notably paragraphs that contain terms like ’human rights’ and ‘evidence-based.’ Equally distressing is the prevalence of the escape clause – ‘in accordance with national legislation’ – which allows governments to pick and choose how the actually proceed regardless of sign-on to the Outcome Document. The news is not all bad. I take heart that in the Operational Recommendations section there is agreement on prevention, treatment and care for HIV/AIDS, Hepatitis C and drug overdose through ‘medication-assisted therapy programmes’ and ‘injecting equipment programmes’ – compromise language for ‘opioid substitution therapy’ and ‘needle and syringe exchange programmes.’ While member states once again couldn’t come to consensus around the term ‘harm reduction,’ it was also heartening to see a commitment to involve civil society and affected communities in program development. In the meantime, our team at India HIV/AIDS Alliance has been actively engaged in the run-up to UNGASS. After much behind-the-scenes effort, Alliance India’s Community Action on Harm Reduction (CAHR) project manager Charan Sharma has been selected as a civil society speaker for UNGASS where he will share his grassroots experience during a plenary session in the General Assembly Hall along with four other civil society speakers. In addition, our Indonesian colleague Ricky Gunawan from the Community Legal Aid Institute (LBH Masyarakat) has also been selected to speak at the Civil Society Forum. Coming up soon, I will report from New York with updates and insights on UNGASS 2016.
I must continue to raise the issue of criminalisation of people who use drugs and its impact on the AIDS response in the Asia region. I take this opportunity to highlight the recent happenings in the Philippines. As I recall, the Mayor and other government officials made somewhat progressive remarks at the Cities event, while now the words ‘Philippines President Calls on Civilians to Kill Drug Addicts’ and “If you know of any addicts, go ahead and kill them yourself as getting their parents to do it would be too painful”, simply shock. The Philippines’ president is asking civilians to murder drug addicts in the island nation — adding to a growing list of outrageous actions from the newly elected official.
However, the Philippines at the UN is remarkably different. On 9th March 2015, at the UNGASS Special Segment meeting, the Philippines in its official statement recognised the vital role of cooperation in implementing drug strategies, “On demand reduction, we promote prevention, education, treatment and rehab, by involving communities and conducting capacity building programmes on substance use, in collaboration with UNODC.” On 19th April 2016, at the UNGASS Roundtable 1 on Demand reduction and related measures, the Philippines in its official statement spoke of the dilemma in terms of balancing the fight against illegal drugs operations and focusing on health as well as the need to establish more alliances by sharing best practices. On 20th April 2016, at the UN General Assembly: Thirtieth Special Session of the General Assembly on the World Drug Problem (3rd plenary meeting), the Philippines in its official statement did not support capital punishment for drug offences and that it was happy to report on progress of treatment and rehabilitation of drug users and anti-drug plan of action until 2020.
As recently as at the Sixty-Ninth World Health Assembly 23-28 May 2016, the Executive Board recommended the adoption of the draft global health sector strategies for HIV, 2016–2021. Enshrined in this document lie probable solutions to the crisis affecting the lives of people who use drugs and their families: Para 26 seeks to overturn laws and change policies that marginalize and stigmatize populations; Para 67 is explicit on Harm reduction for people who inject drugs; Para 86 is grounded in an enabling environment that promotes health equity and human rights; Para 105 recommends enforcing laws and policies that eliminate gender inequality, protect and promote human rights and reduce vulnerability to and risk of HIV infection; Para 106 reminds us that HIV programmes have an important role in monitoring policies, laws and regulations in other sectors to determine their possible implications for the HIV and broader health response, and where barriers exist to advocate for appropriate reviews and reforms to ensure pro-health outcomes. The Government of the Philippines participated in the adoption of this document.
The Executive Board members for 2014-2016 are:
- Abou Mere, President (email@example.com)
- Nini Pakhma, V. President (firstname.lastname@example.org)
- G. Charanjit Sharma, Secretary (email@example.com)
- Ashique Ahmed, Jt. Secretary (firstname.lastname@example.org)
- V. Kartik Krishnan, Treasurer (email@example.com)
- Sunil A, Executive Member (firstname.lastname@example.org)
- Prashant Sharma, Executive Member (email@example.com)
The Board has also Co-opted the following members to the executive:
- Loon Gangte (firstname.lastname@example.org)
- Simon W Beddoe (email@example.com)
- Lalduhawma Chongthu (firstname.lastname@example.org)
- Ketho Angami (email@example.com)
IDUF is envisioned as the voice of the drug using communities from across the country. It is a National level forum that endeavours to promote the meaningful involvement of people who use drugs in policy and program development. The core belief behind the formation of IDUF is that people who use drugs (PUD) living in various parts of the country coming together with one voice can make a bigger impact on the current scenario of drug related issues, and can work more effectively towards creating a better environment for people who use drugs. IDUF’s mission is to enhance a process of social and political change with an objective to establish, promote and strengthen the rights, dignity, social status, and improvement of the quality of life of all people who use drugs.
Since its establishment in 2010, IDUF has been able to link with key stakeholders, donors as well as regional & International community networks like ANPUD, INPUD, APN+ 7 Sisters Coalition etc and have been working closely with them and receiving support and resourcing for key activities at the national and state/provincial levels. IDUF is also currently receiving financial support from INPUD & ANPUD and has been able to mobilize resources especially for key advocacy and policy interventions.
Today, thousands of people who use drugs (PWUD) in India benefit from harm reduction services. There are over 150 NGO-operated Opioid Substitution Therapy (OST) centres in the country. In addition, OST services in government hospitals have recently been scaled-up, and methadone treatment is now an option in five major cities.
While developments such as these in drug treatment and harm reduction are positive steps, the situation sadly remains grim. Minimum standards exist for private treatment centres, but these standards primarily reflect a centre’s infrastructure. Simply put: Good infrastructure does not amount to quality care. Good infrastructure does not translate to good counselling or necessary attention to withdrawal symptoms. Withdrawal is the crux – any user’s worst nightmare – and the failure of treatment centres to take care of withdrawal symptoms can and often does undermine the detox process.
If we do not receive proper care, we lose all trust.
Many families spend their hard earned money to ensure treatment for their loved ones. When users enter treatment only to meet with discriminatory attitudes, clinical incompetence, confinement and neglect, there is no rehabilitation.
Fortunately, influential stakeholders are beginning to wake up to this reality. At a panel discussion in New Delhi during the Support. Don’t Punish (http://supportdontpunish.org/) Global Day of Action on June 26th 2015, the Honourable MP Shri P.D. Rai pledged to include members of the drug-using community as partners in designing a new kind of treatment centre, one that would offer a safe platform for thousands of users to recover.
What we importantly need today are treatment standards for PWUD that ensure quality care (not just adequate infrastructure!) and the redesign of treatment centres conceptualized, created and managed by the community members themselves.
The authors of this post are G. Charanjit Sharma and Timothy G. Peters. Charan has more than 15 years of professional experience in the fields of drug use, HIV/AIDS, and human rights of people who inject drugs. He serves as Senior Technical Advisor on Drug Use & Harm Reduction at India HIV/AIDS Alliance and as Secretary of the Indian Drug Users Forum. Tim is an Intern in the Drug Use & Harm Reduction team at India HIV/AIDS Alliance.