Some inconsistencies between drug policies, public health and human rights in Brazil
In this article the author gives a medical perspective of drug policies in Brazil and their challenges. Two ethical and assistance dilemmas resulting from the current model of combating drugs in the country are addressed in more detail. First, the author examines the real application of harm reduction strategies in Brazil and the friction with the model based on abstinence. He then analyzes the public funding of therapeutic communities for the treatment of drug misusers founded on the idea of abstinence. The author concludes by pondering how these dilemmas contradict and undermine the official policy of harm reduction.
In March 2012 twelve United Nations entities issued a joint statement criticising compulsory detention and rehabilitation centres for drug users.11. ILO et al., “Joint Statement: Compulsory Drug Detention and Rehabilitation Centres” UNAIDS, March 2012, accessed May, 2015. http://www.unaids.org/sites/default/files/en/media/unaids/contentassets/documents/document/2012/JC2310_Joint%20Statement6March12FINAL_en.pdf. Despite the enormous differences in the regulatory status of these types of centres, the reports of abuse and health risks resulting from inadequate services for the treatment of drug users are monotonously similar worldwide, although more severe in East Asia, Eastern Europe and Latin America.
Nevertheless, this statement by the international organisations can be considered nothing short of contradictory. The pragmatic response conceived by the current prohibitionist framework of global agreements – and reinforced by the system of international organisations – dwarfs any attempt to find solutions to the problem of drug use that are not based, in one way or another, on the elimination of demand.22. Damon Barrett, “Security, Development and Human Rights: Normative, Legal and Policy Challenges for the International Drug Control System.” International Journal of Drug Policy 21, no. 2 (2010): 140–44; Luciana Boiteux, Luciana Peluzio Chernicharo and Camila Souza Alves, 2014. “Prohibition, Religious Freedom, and Human Rights: Regulating Traditional Drug Use,” in Prohibition, Religious Freedom, and Human Rights: Regulating Traditional Drug Use, ed. Beatriz Caiuby Labate and Clancy Cavnar, 1st ed. (Berlin/Heidelberg: Springer-Verlag, 2014), 1–23.
With a clear enemy to fight – the use of illegal drugs, regardless of evidence of their impact on public health – it is not a stretch to also brand the people involved in this context – those who use and/or sell these substances – as enemies. Several issues exemplify inconsistencies of this type between drug policy, public health and human rights. These include forced internment, the opposition to the legalisation of cannabis, the criminalisation of drug possession for personal use and resistance to the therapeutic use of prohibited substances.
Among other equally important issues in a discussion on human rights and drug policy from a health perspective, I shall address the abuse of rights in rehabilitation centres for drug users and the ineffectiveness of such centres. In this article I shall briefly examine two of the ethical and assistance dilemmas arising from the current model of dealing with drug abuse and I shall present them in the contemporary Brazilian context. First, I shall examine the real application of harm reduction strategies in Brazil and the friction with the model based on abstinence. I shall then address the public funding of therapeutic communities for the treatment of drugs misusers, which run counter to the official policy of harm reduction.
Harm reduction is a pragmatic strategy for treating drug abuse that does not assume the need for abstinence. It is – or should be – designed primarily for people who are unwilling or unable stop using drugs and it focuses mainly on mitigating the negative impacts of this consumption and promoting the health of the user. In this respect it is worth noting that there is an interesting body of literature that discusses the harm reduction approach and its interface with the rights of people who use drugs.33. Helen Keane, “Critiques of harm reduction, morality and the promise of human rights.” International Journal of Drug Policy 14, no. 3 (2003): 227–32; Neil Hunt, “Public health or human rights?” International Journal of Drug Policy 16, no. 1 (2005): 5–7. Towards the end of the 20th century Brazil pioneered harm reduction initiatives for injectable drug users. These initiatives were developed by health workers and activists from the HIV/AIDS and mental health fields. They were not introduced without controversy and those responsible for them had to contend with accusations of condoning drug use when they attempted, in the late 1980s, to establish a needle exchange programme in the port city of Santos in the state of São Paulo.
Over time the harm reduction initiatives were consolidated, although by no means did they become part of the standard procedure in Brazilian drug policy. Still, isolated harm reduction initiatives remained in place in some cities, such as Salvador and Campinas. Although Brazil’s National Anti-Drug Policy had already sanctioned harm reduction initiatives – albeit tentatively – in 2001, the strategy was only officially made the primary approach to substance abuse by the Ministry of Health in 200344. Letícia Vier Machado and Maria Lúcia Boarini, “Políticas sobre drogas no Brasil: A estratégia de redução de danos.” Psicologia: Ciência e Profissão 33, no. 3 (2013): 580–95. after the political group historically associated with supporters of harm reduction was established in power.
“A place that basically treats users in search of abstinence cannot be considered as being geared towards harm reduction”
However, despite the official policy, the range of state-funded services for the treatment of substance abuse – the Psychosocial Treatment Centres for Alcohol and Drugs (CAPS-AD) – were created within other programmes whose primary model was the treatment of severe mental disorders. According to the official discourse, primary care – comprised of the network of professionals at health centres that provide essential treatment to the population – should also provide treatment for demands associated with substance abuse. Nevertheless, Brazil’s primary care professionals have proven to be ill-equipped to treat users that abuse substances and generally refer them to specialised services.55. Bruno J. B. Fontanella et al., “Os usuários de álcool, atenção primária à saúde e o que é ‘perdido na tradução.’” Interface - Comunicação, Saúde, Educação 15, no. 37 (2011): 573–85.
In addition to the potential criticisms of the relative inefficiency of the CAPS model for the “AD clientele,” since it was originally developed to cater to the social reintegration needs of patients diagnosed with psychosis, the CAPS-AD centres also have a paradoxical mission. While these centres are supposed to focus on the harm reduction model – a strategy aimed primarily at controlled use instead of abstinence – their public consist almost exclusively of users who have reached the stage of their addiction in which their personal preference is often for abstinence, as has already been demonstrated in other countries.66. Neil McKeganey et al., “What are drug users looking for when they contact drug services: Abstinence or harm reduction?” Drugs: Education, Prevention, and Policy 11, no. 5 (2004): 423–35.
It should be noted that although abstinence-based treatments can also form part of a harm reduction approach,77. G. Alan Marlatt, “Harm reduction: Come as you are.” Addictive Behaviors 21, no. 6 (1996): 779–88. a place that basically treats users in search of abstinence cannot be considered as being geared towards harm reduction. As such, the friction resulting from the “official” affiliation with a model within a context that is not well suited to its application is not something that can be ignored.
On the other hand, until the Brazilian Ministry of Health issued the decree that established the Psychosocial Care Network (RAPS) in 2011,88. Brasil, Ministério da Saúde, Portaria 3.088 de 23 de dezembro de 2011, Brasília-DF, 2011. there were no clear forms of federal funding for harm reduction initiatives. After the formation of RAPS, these initiatives could be applied for the first time, to an extent, in a programme known as Street Clinic (Consultório na Rua), a primary health care project for homeless people that features many components of harm reduction for drug use in its services.
Nevertheless, despite being official, harm reduction is far from being a consolidated policy in Brazil. The harm reduction profession has never been regulated and the initiatives that are not covered by the Street Clinic programme are funded at the local level. Services that do not require abstinence by users are the exception, there are no rooms allocated for the safe use of drugs and innovative programmes such as Open Arms (De Braços Abertos) launched in 2014, which provides accommodation, food and employment for crack misusers in the city of São Paulo without requiring abstinence in exchange, are admirable but rare exceptions.
There has been a recent growth of conservative political forces in the country that often have ties with religious groups and are closely associated with models of treatment that focus on abstinence. This has jeopardised the acceptance and the potential of harm reduction and has not helped the progress and expansion of this approach, which has nevertheless continued resolutely as an official policy of the Brazilian state.
Photo by Esther Simpson / CC BY-NC-SA 2.0
Brazil has seen a dramatic increase in the number of CAPS-AD centres: from zero in 2002 to more than 400 today.99. Brasil. Datasus. Cadastro Nacional de Estabelecimentos de Saúde, accessed June, 2015. http://cnes.datasus.gov.br/. Although this constitutes an investment that deserves to be recognised, the country is still clearly deficient when it comes to catering to the demands generated by people who use the health system and who want treatment for drug abuse.
The most traditional service in the context of care for these people in Brazil undoubtedly consists of therapeutic communities (TCs). The model of recovery for drug users proposed by Brazilian TCs is similar to the one inspired by the system in the US and combines the therapeutic community model, which served as one of the pillars for the movement to reform the country’s mental health service, with elements of the 12-step programmes of Alcoholics Anonymous (AA) and Narcotics Anonymous (NA).1010. Laura Fracasso, “As mudanças no processo de criação das comunidades terapêuticas,” in Capacitação para comunidades terapêuticas: curso para líderes, voluntários, profissionais e gestores de comunidades terapêuticas, ed. Florence Kerr-Corrêa e Vitore A. Z. Maximiano (Brasília-DF: Secretaria Nacional de Políticas sobre Drogas, 2013), 37–45. These programmes make several assumptions, but in particular that drug abuse is without exception a chronic and incurable illness and an opportunity to develop spiritually. Both notions are essential to the working structure of the therapeutic communities and the second establishes a link with groups that, given the almost complete vacuum left by the state until the 21st century, have invested in these types of treatment centres: Evangelicals, Catholics and Spiritualists.
Brazilian TCs are extremely diverse and estimates on their number in Brazil are elusive.1111. Pablo A. Kurlander Perrone, “A comunidade terapêutica para recuperação da dependência do álcool e outras drogas no Brasil: mão ou contramão da reforma psiquiátrica?” Ciência & Saúde Coletiva 19, no. 2 (2014): 569–80. One of the problems is the extremely flexible use of the term, something that some TC federations have expressed an interest in combating. Strictly speaking, a TC should be centred on voluntary attendance and not involve the administration of drug therapy. From this point of view, it makes sense that many of these communities do not wish to be considered health services. However experience shows that there are many such communities – especially private ones – that do not respect these criteria but are still called TCs.
“The potential for coercion, however subtle, towards the doctrine of one particular religion is at best questionable for a state-funded programme, especially when there are serious allegations of abuse”
Two complex problems that have still not been satisfactorily resolved by the Brazilian state are the regulation and funding of these services. Contrary to the wishes of the TCs that are organised into federations, the decree issued by the Brazilian Ministry of Health that established the Psychosocial Care Network (RAPS) considers TCs to be part of the health system. This means that they have to operate in compliance with the regulations governing the SUS (Brazil’s public health care system), which, as we have already seen, includes harm reduction strategies, something that therapeutic communities vehemently reject. Recently the National Council on Drug Policy (CONAD) issued a resolution in an attempt to organise the myriad of TCs.1212. Brasil, Conselho Nacional de Políticas sobre Drogas, Resolução CONAD n. 01/2015. Brasília-DF, 2015. The resolution prompted harsh criticisms from various social actors in the Brazilian health and human rights fields, who argued that the regulations it established are inadequate for settings where there is a risk of slave labour, among other human rights violations, and religious indoctrination as a form of state-funded treatment.
Despite the still uncertain regulation, funding for TCs is already being released by municipal, state and even federal authorities through the National Department on Drug Policy (SENAD), which is potentially problematic in a country that is constitutionally defined as secular. The existence of religious institutions that use their doctrines as a form of treatment is not in itself a problem, provided they are charities that receive no state funding and are run exclusively for the care of their faith communities. In a public health context, however, this amounts to public funding for the proselytism of any Brazilian citizen. Agnostics, atheists and people of minority faiths have no public option other than to be subjected to the treatment of a given religious creed if they are referred to a faith-based TC.
Although the spiritual component can, in theory, have a positive effect on the treatment of people with substance abuse issues, the potential for coercion, however subtle, towards the doctrine of one particular religion is at best questionable for a state-funded programme, especially when there are serious allegations of abuse.
“Currently in Brazil it is not certain whether the defence of the rights of drug users is, in practice, a priority”
A report on human rights violations at treatment centres for drug misusers prepared by the Federal Psychology Council illustrated just how far these abuses can go.1313. Conselho Federal de Psicologia, Relatório da 4a Inspeção Nacional de Direitos Humanos: locais de internação para usuários de drogas. 2a ed. (Brasília-DF: Conselho Federal de Psicologia, 2011), accessed May, 2015. http://site.cfp.org.br/wp-content/uploads/2012/03/2a_Edixo_relatorio_inspecao_VERSxO_FINAL.pdf. It is difficult to quantify how many communities present the serious situations identified in the report – forced confinement, slave labour conditions, medical neglect – but even supposing they are exceptional, this would require the Brazilian state to establish strict rules and intense oversight, since the political forces sympathetic to TCs appear not to permit – with a few rare exceptions – secular services accredited with RAPS to cater to people who need and want temporary refuge in residential facilities. These services, called Refuge Centres, do exist but generally speaking they are in the early stages of development.
As even this brief report has been able to demonstrate, we can see that the supposedly official responses of drug policies constitute a field in full dispute. Even though the political group allegedly associated with the defence of harm reduction, public health care and human rights has remained in power now for twelve years, this defence has not been strong enough to overcome the conservative mindset aligned with the ethics of the “war on drugs” that is embedded in the ideology of a nation bombarded on a daily basis by incidents of violence, but instead has turned the discussion on the official policy and the pragmatic execution of this policy into a field fraught with contradictions.
More serious than this, the firm defence of human rights is also plagued with these contradictions. Currently in Brazil it is not certain whether the defence of the rights of drug users is, in practice, a priority. Similarly, there is clearly a great deal of friction surrounding the need to introduce strict oversight and challenge the model of therapeutic communities as a public service. As a result of this situation, therefore, it is important for organisations committed to human rights in the country to be aware, active and informed, since they will definitely need to be ready to contribute and reduce the harm that will emerge from these paradoxes.
