Establishing safe injection facilities in Canada: legal and ethical issues

In the face of an ongoing and escalating health crisis among injection drug users in Canada, calls are coming from many quarters to initiate safe injection facilities as a way to reduce overdoses, the spread of bloodborne diseases, and other health and community problems associated with injection drug use. This article summarizes a paper on safe injection facilities released in early 2002 by the Canadian HIV/AIDS Legal Network. The paper contributes to the policy discussion in Canada and sets out why and how the law should support the introduction of safe injection facilities.     

Barcelona 2002: law, ethics, and human rights. Global battle cry: health is a right, not a commodity

Health is a fundamental right, not a commodity to be sold at a profit, argues Irene Fernandez in the second Jonathan Mann Memorial Lecture delivered on 8 July 2002 to the XIV International AIDS Conference in Barcelona. Ms Fernandez had to obtain a special permit from the Malaysian government to attend the Conference because she is on trial for having publicly released information about abuse, torture, illness, corruption, and death in Malaysian detention camps for migrants. This article, based on Ms Fernandez' presentation, describes how the policies of the rich world have failed the poor world. According to Ms Fernandez, the policies of globalization and privatization of health care have hindered the ability of developing countries to respond to the HIV/AIDS epidemic. The article decries the hypocrisy of the industrialized nations in increasing subsidies to farmers while demanding that the developing world open its doors to Western goods. It points out that the rich nations have failed to live up their foreign aid commitments. The article concludes that these commitments--and the other promises made in the last few years, such as those in the United Nations' Declaration of Commitment on HIV/AIDS--can only become a reality if they are translated into action.     

Warsaw Declaration on HIV/AIDS and injection drug use adopted

Explosive epidemics of HIV among injection drug users are occurring in both developing and developed countries. Globally, it is estimated that 10 percent of HIV infections are attributable to injection drug use, but this proportion is increasing, and is much higher in many countries. Effective interventions exist to prevent the spread of HIV among injection drug users, but in most countries they are being adopted too slowly, or not at all. On 14 November 2003, the Warsaw Declaration: A Framework for Effective Action on HIV/ADS and Injection Drug Use, was adopted at the 2nd International Policy Dialogue on HIV/AIDS. Its purpose is to provide a framework for--finally--"mounting an effective response that will slow and eventually stop the HIV/AIDS epidemic among injecting drug users worldwide."     

Gender, sexuality, and HIV/AIDS: the what, the why, and the how

The focus of Geeta Rao Gupta's plenary presentation of 12 July 2000 at the XIII International AIDS Conference is on the what, why, and how of gender, sexuality, and HIV/AIDS. Dr Rao Gupta discusses the factors associated with women's vulnerability to HIV; and the ways in which unequal power balance in gender relations increases not only women's, but also men's, vulnerability to HIV-despite, or rather because of, their greater power. She then addresses the question of how one is to overcome the seemingly insurmountable barriers of gender and sexual inequality. How can we change the cultural norms that create damaging, even fatal, gender disparities and roles? According to Dr Rao Gupta, an important first step is to recognize, understand, and publicly discuss the ways in which the power imbalance in gender and sexuality fuels the epidemic. She provides examples of sensitive, transformative, and empowering approaches to gender and sexuality and concludes that, in the final analysis, reducing the imbalance in power between women and men requires policies that are designed to empower women--policies that aim to decrease the gender gap in education, improve women's access to economic resources, increase women's political participation, and protect women from violence.     

Human rights in Vancouver: do injection drug users have a friend in city hall?

In april 2003, the Vancouver Police Department (VPD) initiated a crackdown in the city's Downtown Eastside, an area frequented by drug users and the site of one of the developed world's worst AIDS epidemics. Human Rights Watch (HRW) visited the city and issued a report documenting first-hand accounts of unnecessary use of force by police officers and other human rights abuses. In this article, HRW staffers Joanne Csete and Jonathan Cohen describe how the initial euphoria that greeted the election of Vancouver Mayor Larry Campbell has worn off; how a crackdown that was supposed to be aimed at drug traffickers had the effect of driving drug users away from health and harm-reduction services; and how both the VPD and city tried to discredit the HRW report. Finally, the authors discuss how concerns about the VPD have led to official complaints being filed, and they question whether police forces should be allowed to investigate themselves.     

HIV/AIDS and human rights revisited

In their article, Sofia Gruskin and Daniel Tarantola demonstrate how, as the number of people living with HIV and with AIDS continues to grow in nations with different economies, social structures, and legal systems, HIV/AIDS-related human rights issues are not only becoming more apparent, but also increasingly diverse. In the 1980s, the relationship of HIV/AIDS to human rights was only understood as it involved people with HIV or AIDS and the discrimination to which they were subjected. The concerns included mandatory HIV testing; restrictions on international travel; barriers to employment and housing, access to education, medical care, or health insurance; and the many issues raised by named reporting, partner notification, and confidentiality. Almost 20 years into the epidemic, these issues remain serious and most often have not been resolved. In the 1990s, however, there was increased understanding of the importance of human rights as a factor in determining people's vulnerability to HIV infection and their consequent risk of acquiring HIV infection and their chances of accessing appropriate care and support. And most recently, human rights have also come to be understood to be directly relevant to every element of the risk/vulnerability paradigm. Gruskin and Tarantola identify three situations and three levels of governmental obligations that should be considered when identifying the specific needs and related rights of individuals in the context of HIV/AIDS. They conclude that policymakers, program managers, and service providers must become more comfortable using human rights norms and standards to guide and limit government action in all matters affecting the response to HIV/AIDS; and that those involved in HIV/AIDS advocacy must become more familiar with the practicalities of using international human rights law when they strive to hold governments accountable.     

Intravenous Drug Use and HIV in Estonia: Socio-Economic Integration and Development of Indicators Regarding the Right to Health for its Russian-Speaking Population

This article seeks to highlight some potential indicators and benchmarks for the right to health under the International Covenant on Economic, Social and Cultural Rights, ratified by Estonia. These potential key indicators, as part of a human rights based approach to health indicators being developed by the UN Special Rapporteur, are argued to be particularly important in the context of the exceptionally high HIV rates among the Russian speaking population in Estonia. The historical emergence of the HIV epidemic in Estonia is traced, comparing its development with the situations in Latvia and Lithuania. This article describes the current extent of the HIV epidemic in Estonia which is the country with the highest reported number of HIV infections per capita in Europe, a number impacting in an extremely disproportionate fashion on its Russian-speaking population, particularly in North-Eastern Estonia. Understanding of the HIV epidemic in Estonia cannot exclude the social contextual factors of the social marginalization of many among the Russian-speaking population, the ‹alien’ status of those without citizenship of Estonia or any other State, and other failures of Estonian State policy with regard to intravenous drug use and HIV in the recent past. HIV among the prison population is also examined as disproportionately impacting upon Russian-speaking prisoners. It is argued that the language and logic of the Estonian State Integration Programme, as well as Estonia’s Second Report on the implementation of the Council of Europe Framework Convention for the Protection of National Minorities (2004) which refer to its Russian-speaking citizens as ‹non-Estonians’ is discrimination based on ethnic origin. In order to develop a system of State accountability in relation to the right to health, candidate indicators and benchmarks are proposed as structural, process and outcome indicators relevant to Estonia regarding the right to health and HIV, intravenous drug use, socio-economic integration and its Russian-speaking population. Dr. Paul Downes is Director of the Educational Disadvantage Centre, St. Patrick’s College, Drumcondra, Dublin, Ireland.     

Natural helpers: a community approach to harm reduction

This paper, by Jennifer Taylor and Theresa Jasperson, looks at a successful harm-reduction initiative developed by Streetworks, a needle exchange program in Edmonton, Alberta. The Natural Helpers initiative provides and enhances the skills, knowledge, resources, and support that people who use injection drugs need in order to take care of others in their community. The evolution of the project, from its inception to the present situation, is described.     

Barcelona 2002: law, ethics, and human rights. HIV testing for peacekeeping forces: legal and human rights issues

In 2001, the United Nations Security Council established an Expert Panel to study the issue of whether the UN should institute HIV testing of peacekeeping personnel. This article, based on a 9 July 2002 presentation to the XIV International AIDS Conference (abstract TuOrG1173), reports on the findings of a paper prepared for the Expert Panel by the Canadian HIV/AIDS Legal Network. The paper examined whether it is permissible for the UN to implement mandatory HIV testing of its peacekeeping personnel, and whether HIV-positive UN peacekeeping personnel should be excluded or restricted from service on the basis of their HIV status or HIV disease progression. The article describes some of the court cases in which these issues have been considered; discusses the importance of analyzing such issues in the context of a human rights-based approach to the pandemic; and formulates a series of key principles for guiding UN decision-making. The article concludes that a policy of mandatory HIV testing for all UN peacekeeping personnel cannot be justified on the basis that it is required in order to assess their physical and mental capacity for service; that HIV-positive peacekeeping personnel cannot be excluded from service based on their HIV status alone, but only on their ability to perform their duties; and that the UN cannot resort to mandatory HIV testing for all UN peacekeeping personnel to protect the health and safety of HIV-negative personnel unless it can demonstrate that alternatives to such a policy would not reduce the risk sufficiently. In the end, the Expert Panel unanimously rejected mandatory testing and instead endorsed voluntary HIV counselling and testing for UN peacekeeping personnel.     

Barcelona 2002: law, ethics, and human rights. Using the law to improve access to treatments

The XIII International AIDS Conference in Durban, South Africa in July 2000 focused worldwide attention on the problem of accessing treatments in developing countries. In the interim, thanks to the work of activists - from demonstrations to court cases, and from acts of public courage by people living with HIV/AIDS to ongoing lobbying of politicians and trade negotiators - some very significant developments have occurred. But the reality is that the vast majority of people living with HIV/AIDS still lack access to affordable, quality medicines. This article, a summary of a paper presented at "Putting Third First: Vaccines, Access to Treatments and the Law," a satellite meeting held at Barcelona on 5 July 2002 and organized by the Canadian HIV/AIDS Legal Network, the AIDS Law Project, South Africa, and the Lawyers Collective HIV/AIDS Unit, India, explores three approaches for improving access. In the first part, Richard Elliott provides an overview of the state of the right to health as embodied in international human rights law; comments on the experience to date in litigating claims to the right to health; and identifies potential strategies activists can adopt to advance recognition of the right to health. In the second part, Sharan Parmar and Vivek Divan describe price-control and drug-financing mechanisms used by industrialized countries to increase the affordability of medicines; and discuss how some of these mechanisms could be adapted for use in developing countries. Finally, Jonathan Berger describes the use of litigation in the courts by the Treatment Action Campaign in South Africa.     

Weighing both sides: morality, mortality, and framing contests over obesity

Despite recent and growing media attention surrounding obesity in the United States, the so-called obesity epidemic remains a highly contested scientific and social fact. This article examines the contemporary obesity debate through systematic examination of the claims and claimants involved in the controversy. We argue that four primary groups-antiobesity researchers, antiobesity activists, fat acceptance researchers, and fat acceptance activists-are at the forefront of this controversy and that these groups are fundamentally engaged in framing contests over the nature and consequences of excess body weight. While members of the fat acceptance groups embrace a body diversity frame, presenting fatness as a natural and largely inevitable form of diversity, members of the antiobesity camp frame higher weights as risky behavior akin to smoking, implying that body weight is under personal control and that people have a moral and medical responsibility to manage their weight. Both groups sometimes frame obesity as an illness, which limits blame by suggesting that weight is biologically or genetically determined but simultaneously stigmatizes fat bodies as diseased. While the antiobesity camp frames obesity as an epidemic to increase public attention, fat acceptance activists argue that concern over obesity is distracting attention from a host of more important health issues for fat Americans. We examine the strategies claimants use to establish their own credibility or discredit their opponents, and explain how the fat acceptance movement has exploited structural opportunities and cultural resources created by AIDS activism and feminism to wield some influence over U.S. public health approaches. We conclude that notions of morality play a central role in the controversy over obesity, as in many medical disputes, and illustrate how medical arguments about body weight can be used to stymie rights claims and justify morality-based fears.     

Drug policy in Canada--the way forward

This article is one of a series commissioned to mark the tenth anniversary of the Canadian HIV/AIDS Legal Network, discussing past developments and future directions in areas of policy and law related to HIV/AIDS. It takes a critical look at Canada's drug policy. Despite calls for a balanced approach focused on reducing drug-related harm, Canada's method of dealing with problems of illicit drug use has remained prohibitionist in nature, and by far the greatest part of federal funding is devoted to supply-reduction initiatives. Considerable changes in policy and law are needed to significantly reduce the harms associated with injection drug use in Canada. These include developing a comprehensive and integrated strategy, exploring alternative legal frameworks, piloting innovative approaches to reducing injection-related harms, and investing in broad social policies that address the determinants of injection drug use.     

Tax Court allows tax credit for herbs and vitamins, not for massage

In August 2001, the Tax Court of Canada issued its most recent judgment on the tax deductability of expenses for complementary/alternative therapies. The decision in Pagnotta v Canada is significant for people with HIV/AIDS who use such therapies. It also illustrates how provincial and federal laws regulating health-care practitioners and natural health products have a financial impact on the cost of accessing treatment.     

Study highlights negative public health consequences of police crackdown on drug market

A police crackdown in Vancouver's Downtown Eastside (DTES) displaced the drug scene to adjacent areas and may have exacerbated the health and social harms associated with injection drug use. This is the finding of a study published in the Canadian Medical Association Journal by Evan Wood and his colleagues at the British Columbia Centre for Excellence in HIV/AIDS.     

Barcelona 2002: law, ethics, and human rights. Introducing ARVs in resource-poor settings: challenges and consequences

In most industrialized countries, AIDS mortality has plunged sharply with the advent of antiretroviral therapy. Yet the majority of people living with HIV/AIDS do not have access to modern HIV care, and some experts have argued that introducing such therapy is not a ranking priority. In this article, which is based on a plenary presentation at the XIV International AIDS Conference, Paul Farmer presents the experience of an integrated HIV prevention and care project in rural Haiti, and explores the challenges to national AIDS programs and other bodies in the "least developed" countries as more resources are made available for HIV prevention and care.     

I.v. drug use and AIDS: public policy and dirty needles

Users of intravenous heroin, cocaine, and amphetamines risk the transmission of human immunodeficiency virus (HIV) through the sharing of contaminated injection equipment. Although most users are aware of this risk, the scarcity of sterile needles and syringes, combined with various social and cultural factors, fosters dangerous sharing practices. This paper examines the legal and political contexts of proposals to ease access to sterile needles and injection equipment. The author seeks an explanation for the continued reluctance to institute such programs in the United States, while similar programs have been instituted in other countries where intravenous drug use has also contributed to the spread of HIV infection and AIDS.     

Access to treatment as a right to life and health

In some countries in Latin America, in the absence of leadership from governments, activists have had to resort to the courts to obtain access to HIV/AIDS treatments for people with HIV/AIDS. In his presentation to the XIII International AIDS Conference (abstract TuOrE458), Edgar Carrasco, of Acción Ciudadana Contra el Sida (ACCSI), discusses the process that was followed in Venezuela. The presentation describes the very limited access people with HIV/AIDS had to antiretroviral therapies and treatments for opportunistic infections under Venezuela's health and social security systems. It provides details of lawsuits that were launched on behalf of several individuals living with HIV/AIDS, and that resulted in the courts ordering the government to provide treatments for these individuals and, eventually, for all people with HIV/AIDS in Venezuela. The presentation concludes that recourse to the courts is a useful tool for activists and that civil actions launched on behalf of people with HIV/AIDS can serve as an example for people with other chronic diseases.     

Barcelona 2002: law, ethics, and human rights. An advocacy and political conference produces a consensus: effective action is urgently required

From the deep sense of frustration about the gap between what is possible and what is actually happening, a clear consensus emerged at the XIV International AIDS Conference that effective action is urgently required. This article is based on a presentation on 12 July 2002, the last day of the conference, by Terje Anderson, the rapporteur for Track G. The article presents a summary of the discussions in Track G on topics such as advocacy strategies, the use of the law, the use of a human rights framework and approach, the role of people living with HIV/AIDS, and the need to mobilize sufficient resources. The article states and then critically examines some of the consensus positions that emerged from the conference--specifically, the goal to have three million people on antiretroviral therapy by 2005; the notion that the debate around prevention versus care is over; and the idea that the key issue is no longer what we do, but how to secure the commitment and the resources to do it. The article states that the fight against HIV/AIDS must be fought on a political plane, and that it is the responsibility of everyone working in AIDS to engage our leaders. The article concludes by asking whether we really have the courage and the perseverance to turn our knowledge and our commitment into action.     

Harm-reduction activism: a case study of an unsanctioned user-run safe injection site

Due to the ongoing health crisis among injection drug users in Vancouver, Canada, there have been repeated calls for the establishment of safe injection sites (SISs) since the early 1990s. In April 2003, in response to a large-scale police crackdown and government inaction, a group of activists opened an unsanctioned SIS in Vancouver's Downtown Eastside (DTES). The 327 Carrall Street SIS operated for 181 days despite considerable police harassment and limited financial support. During the operation of the SIS, volunteers supervised over 3000 injections and demonstrated the feasibility of a user-run low-threshold SIS. The experience of the SIS provides valuable lessons for those seeking to advance the interests of injection drug users through community mobilization and direct action approaches. In this article, Thomas Kerr, Megan Oleson, and Evan Wood describe the events surrounding the establishment, operation, and closing of the unsanctioned SIS, and outline the lessons learned.