Jean-Paul Grund started out in the drug users’ rights movement as long ago as 1980, when he joined the Rotterdam Junkie Union – the world’s first drug users’ union as an intern during his psychology studies. Since then, he has published extensively on drug culture, the diffusion of drug trends, HIV and other drug-related morbidity, drug policy, peer-driven harm reduction approaches, and the self-regulation of psychoactive substance use.
He is a Senior Research Associate at the Utrecht Addiction Research Center (the Netherlands), as well as a Senior Researcher at Charles University’s Department of Addiction Studies in Prague, the Czech Republic, and a guest researcher at the Freudenthal Institute for Science and Mathematics in Utrecht with a focus on new psychoactive substances, online drug markets, and the influence of technology on drug diffusion and epidemiology, public health and drug policy. He was the founding director of the International Harm Reduction Development Program of the Open Society Institute (OSI) and a Technical Advisor at UNAIDS.
You have seen first-hand the evolution of the concept of harm reduction from a hopeful idea to one of the four pillars of modern, evidence-based, progressive drug policy. What, in your opinion, have been some of the more significant milestones on that journey, and what will be the main challenges for the harm reduction movement in the next decade, especially in the region of Central and Eastern Europe and Central Asia (CEECA)?
In 1995, I was working at the Lindesmith Center with Ethan Nadelmann (the recently retired former Executive Director of the Drug Policy Alliance). At the time it was an Open Society Institute project. We saw the developments in Central and Eastern Europe in terms of the rise in drug use, infectious diseases, etc. At the time there was hardly any HIV there, except for Poland and Serbia, which had early epidemics in the 1980s. The first thing we did was to collect as much “intelligence” as possible from people working in this region. Basically, we were looking for people who would be interested in doing something for harm reduction and who could probably help get this concept accepted and embraced here.
I would highlight two important milestones from that time. The first big milestone for the region was bringing together a large number of people working in this region; I think it was in 1995, at the International Harm Reduction conference in Italy. We talked to a lot of people, and we noticed that there was no unity. …You could see that people from the former Yugoslavia, from Croatia and Macedonia, would be sitting together, and people from the Czech Republic and Slovakia, for example, would be sitting together, and all the Russians were sitting by themselves. So there was no unity — yet.
What was the next step?
Then we started working with some of these people, and about a year later — I think it was in 1997 — the International Harm Reduction conference in Paris. And you could see that within a year the atmosphere had completely changed, because everybody was sitting next to everybody else! People weren’t just sitting with the people they knew anymore! So even before there was anything tangible happening, people were already starting to see the importance of working together and talking about the issues.
At that time did you support initiatives in the CEECA region?
Although we were working for the Lindesmith Center, which was an OSI project, we decided that there should be a separate project, an International Harm Reduction Development Program, which I helped establish, and we started a funding program. I was suddenly in a position where I could support these initiatives, and so I told Judit Honti from Szeged (Director, South-Hungarian Harm Reduction Union, Szeged, Hungary; Steering Committee Member, Central and Eastern European Harm Reduction Network, and Coordinator of the Network, 1997–2000, Hungary): “Everything is possible. We’re going to do it,” and only two months later we had the founding meeting of the Eurasian Harm Reduction Network. (Back then we called it the Central and Eastern European Harm Reduction Network though — the CEE-HRN.)
At that time I travelled a lot in the region, I visited with all kinds of programs, and I talked to a lot of people about setting up needle exchanges. The concept of harm reduction was very much an imported product, but now you can see that it has really evolved into all kinds of different services, with great emphasis on human rights, and the inclusion and participation of the communities we are talking about, especially people who inject drugs.
That wasn’t so obvious in the beginning. People kept asking me to fund all kind services that were not core to harm reduction and HIV prevention. But at that time there was no basis, no critical mass of real, hardcore harm reduction services like needle exchange or opioid-assisted treatment. So at the time I was very much pushing those basic services and norms.
Harm reduction is often seen as a gadget, a trick, a service. But it’s really a philosophy, a way of looking at societal developments, at problems that are not very obviously and immediately solvable. It’s the traffic lights that we see everywhere, it’s the seatbelts. If you go skiing, you have to stay within the areas defined as safe by the ski resort. All of these things are harm reduction measures. It’s really a very old philosophy that we’re trying to apply within the context of drug use.
The practical expressions of the somewhat stretchy principle of harm reduction vary from country to country, sometimes drastically, which can lead to controversial results. What do you think is the reason for this, and how could the problem be countered?
If there is a problem, it’s always political. There are a number of basic tenets of harm reduction, and I don’t see any debate about the validity of these basic tenets in other areas than drug policy. All I’m saying is that we need to be consistent in our policies, and we need the policies to be effective. True, cultural differences can also be a part of the reason for the discrepancies in the practical application of the tenets. On the other hand, the basic tenets transfer very well across cultures — unless you have a culture that doesn’t care about the well-being of its individual members, and there aren’t many such cultures.
But harm reduction is a policy that does deliver. Maybe it does not deliver someone’s idea of a perfect world, but it deals very practically and pragmatically with the issues of the real world we are living in. I would say that’s sort of the core of living together as a society with different people with different needs.
Mr Michel Kazatchkine, the United Nations Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, said in his keynote speech at the conference in Vilnius that reasonable market regulation is the logical culmination of the philosophy of harm reduction. Do you agree?
I’m going to draw something… If we put total prohibition on one end and a totally free market on the other end of the scale of regulation, what you see is that the more you prohibit drugs, and the more you repress drug users, the more the harms become pronounced. The same thing happens if you don’t have any regulation, like, for example, with new psychoactive substances and the dark net. In either of these extreme cases — when the product is totally legal, or when it’s totally illegal — you leave regulation up to market forces. You have relinquished control.
But this area here [Points to the central bulge at the bottom, low-harm region of the graph] is where you do allow use, where you do not criminalize the consumption of drugs, and you don’t prohibit the sale of drugs, but instead highly regulate it, and you have a good set of regulations aimed at decreasing the harms associated with drug use as much as possible.
In a regulated market, consumer protection is at least partially financed, if not provided, by the producers, the importers, and resellers. Do you think we can make dealers who care for the health of their clients disseminate harm reduction information, or even provide certain services?
Back in 1985, I started an outreach program in Rotterdam in a neighborhood that was in the middle of a renovation project, which meant that many of the houses were empty. And on just about every street, there were one or two dealers. You could go into their apartment, you could buy your drugs there, and you could use them on the spot. At that time, most people were already smoking heroin, but there were also still people injecting. This was a time when we had also just heard from people like Don Des Jarlais, a prominent researcher from New York, who came to the Netherlands and spoke about what was going on in New York, where more and more injecting drug users were being diagnosed with HIV. And that stirred me into thinking that we needed to do something similar. Initially, our program aimed to help people get methadone treatment with their general practitioner; we were providing them with a sort of psychosocial support. But when we realized the extent of the threat of HIV, we immediately changed our approach and started a needle exchange.
It’s a bit of a long story, but the important part is that, one day, a guy who had been coming around to exchange his needles said: “There are about five people in my apartment. They can buy there, and some of them stay over to sleep, but they are all also injecting there. So can I buy 50 needles?” …So we started what we called “collective secondary needle exchange.” We started that, and because we were developing relationships with all sorts of people, we started visiting them. In some of the places, there were also dealers working. So we gave them a container and two boxes of 100 needles, so now they were doing the needle exchange for us. So, sure, you can work with dealers! That’s one example.
Another one is a bit more contemporary. Although the Silk Road has closed, the dark web is prospering, and several of these dark net drug sites have forums where people — clients and dealers — openly discuss all sorts of things, including the quality of products and safe use. There is much more interaction than on the street, where you “run into” someone, you make a quick transaction, and you’re gone. So there is a great opportunity there to engage. The sellers have a certain responsibility, and they’re willing to pick up at least some of that. Not everybody, of course, but there are a lot of people selling drugs on the dark net market who also use drugs themselves. It’s not just these “bad men in suits who are selling drugs to our children,” but also a lot of enthusiasts who sell to peers but also use themselves. These people are very willing to discuss how to use the product as safely as possible. But, yet again, you have to have the conditions to do that. The worse the repression, the less incentive there is to have these discussions. If the repression is very bad, the only topic of discussion is how to stay out of the hands of the police. But if that is not such a big concern, there is room for other conversations.
Interviewer: Mart Kalvet, representative of the Estonian Network of People who Use Drugs LUNEST