"Investing in the health of marginalised people is a critical necessity."

GPDPD: AHRN is based in Myanmar. In which regions are you mainly active and how is the drug policy situation there?

Murdo Bijl: AHRN works especially in the rural Northern parts of Myanmar, specifically in hard-to-reach conflict border regions and mining areas. The latter are often so-called not state-controlled regions. In Myanmar, approximately 300,000 people use drugs and an estimated 93,000 people inject drugs. The government of Myanmar, the Ministry of Health and Sports as well as the Ministry of Home Affairs have a very good understanding of the drug and health crisis issues and how to best respond. The work of AHRN is very well understood and supported from a policy and national strategic perspective, especially with regards to health policy. The Central Committee for Drug Abuse Control (CCDAC) within the Ministry of Home Affairs recognizes Harm Reduction as an important part of drug control and displays a liberal public health approach. However, while the Drug Control Policy from 2018 is quite progressive, the 1993 Narcotic Drugs & Psychotropic Substances Law is very strict, which is quite paradox.

Could you explain in more detail what you mean by that?

The 1993 legislation continues to focus on criminal justice responses and endorses harsh prison penalties for both drug users and small-scale subsistence poppy farmers. Due to the punitive legal regimes, the threat of punishment hinders access to health services for drug users.

And the law is tough. The vast majority of prisoners in Myanmar has been convicted for drug-related offences. The paradox is that the positions are rooted in the 60 years-long War on Drugs, resulting in a situation where lawmakers still do not fully understand drug use as a social phenomenon: Drug users routinely become the victims of repressive drug policy. Luckily, the CCDAC and the Ministry of Health and Sports in Myanmar have shown real leadership in terms of developing outstanding evidence-based guidelines on Harm Reduction intervention components, including psychological, medical and clinical approaches. This includes, among others, large-scale needle syringe programs, HIV/antiretroviral therapy (ART), TB and viral Hepatitis C prevention as well as methadone substitution treatment.

Myanmar is, like other countries, very much linked to the international situation. Drug policies remain focused on prohibition and punishment instead of public health, despite the fact that in 2019, all 34 Chief Executives of the Common United Nations System Board endorsed the position of decriminalising drug possession for personal use. The Commission on Narcotic Drugs (CND) in Vienna – the legal reference for States, however, has a conservative prohibition position, so countries like Myanmar are looking at Vienna to assess the policy and legislative spaces. While there is no common international formative legislative consensus or guidance on how to deal with illicit drug use from a public health perspective and its health consequences, the existence of different approaches and cultural backgrounds hinders major changes on a national level.

What does the daily work of AHRN look like?

We run 85 fixed and mobile clinics and drop-in centres, 20 projects throughout the country and we undertake clinic-based, mobile and community medical work. We are one of the two organisations in Myanmar that is allowed to work with mobile X-Ray machines in order to go to the most remote rural areas. Those areas have very limited public transport and often feature weak health infrastructure. We go to the local communities and do tuberculosis testing and treatment, for example. The medical team goes to peripheral areas and works with local communities to support them through community health prevention workers, so that they can become increasingly self-sustained.

Could you give an example of where you have successfully implemented the health-oriented approaches and how this may have triggered further discussions?

We provide health services in Camps for Internally Displaced Persons (IDP). We also work closely with the prison system and assist selected prisons with their health care, do HIV and Hepatitis C testing and treatment, as well as undertaking basic primary health care.

If you think about where Myanmar is coming from, it was a very isolated, semi-democratic country and what it has achieved despite this, in the last years, is remarkable. You can see the profound transition they have been going through if you consider the health programs introduced. For example, health care in prison is one of the new approaches. There is now a discussion in Myanmar taking place on whether to allow people who have been partaking in a methadone program before and are going to prison to be able to continue their program there. The discussion always needs to be assessed in the light of international law: If drug use would be seen from an evidence-based public health point of view, we would be in an entirely different situation. If the present legislation in Myanmar would allow a pragmatic health program, the use of low-threshold (Harm Reduction) services in prisons might be considered, which has proven highly effective in other countries. This would contribute to a different debate on the need for expansion of public health approaches in response to the drugs and health crisis in Myanmar.

The GPDPD-funded program recognised, at an early stage, that if you do not have the support of the community, you cannot move. Hence this is critical also for local communities understanding and involvement in the needed responses.

How is your work affected by the Corona crisis?

When Covid-19 hit China – as we are working on the border to China – we were anticipating that it would become a problem and we already started to prepare contingency planning in February. Therefore, we were completely equipped by March. We brought all the necessary materials, such as protective clothing and masks from our warehouses to the facilities, thus increasing our stocks and were well-supplied, especially for the time of lockdowns.

As indicated, we organise training sessions with prevention workers in the communities, to educate them on the topics of drugs, drug policy and HIV prevention. Thereby, they are enabled to work preventively in their communities and share that information. Luckily, together with our local partner Best Shelter, we had undertaken information sessions and some trainings before the pandemic, so that the local workers could work in the villages and do the trainings themselves. We supported them in the project sites as well as remotely from Yangon.

What is the basic concept according to which AHRN works?

The basic concept behind our work follows a humanitarian and right to health notion. Everybody, but especially the most marginalised and vulnerable people, need to have access to health care and treatment. For example, we have many sex workers and a significant number of women who use drugs especially in mining areas, who do their work driven by extreme poverty: You might call it “survival sex”.  To help these individuals is a big driver not only for me but also for AHRN, to implement quality health services. 

What is your understanding of Harm Reduction and how do you implement it?

Harm Reduction is grounded in international principles, practices and guidelines. There is one key document – the Implementing Comprehensive HIV and HCV Programmes with People Who Inject Drugs (IDUIT) – which was drafted by the UN agencies and the International Network of People Who Use Drugs (INPUD). The UNODC and the Joint United Nations Program on HIV and AIDS (UNAIDS) formally recommended ten evidence-based, comprehensive Harm Reduction interventions, including community distribution of naloxone for prevention and treatment of opioid overdoses. Harm Reduction means to establish or offer a space where all services are available in a one-stop-shop fashion for drug users – psycho-social, as well as medical treatment. Needle and syringe programs combined with methadone maintenance treatment are crucial and cut down infection rates by 70%. This is what the focus should be on. Our NGO is also very engaged in policymaking and consultations. We are proud to have been invited to attend and contribute to key national consultations. The most important thing is to invest in the upcoming generations, to educate them, and to provide them with a better future.

What role does the community play in your work?

It is important to understand that, in Myanmar, the drug use epidemic is a very rural phenomenon, instead of an urban one. The drugs and health crises occur in very small villages and in the conflict-prone border areas. The regions in which we are situated exhibit many differences. In Shan State and in Kachin State, for example, the situation is very dire. Drug use is widespread, in every village.  While 10% of the substance using population suffer from problematic drug use, infectious diseases are a big concern, local authorities see the problematic and chaotic drug users, it is the remainder 90% of people who use drugs and their loved-ones who are also vulnerable and affected by communicable blood-born and/or sexual transmitted infections. Thus, you need to make community education efforts, so that people realise that it is helpful referring drug users to the clinic of AHRN for example.

Awareness raising in villages and local communities is mostly limited, while people who use drugs are highly stigmatised. The moment you interact with the community, you can see a change in their attitude. But there is still such an enormous disparity in legislation and drug control strategy – if they say that drug users are criminals they are technically right, because the law says so. And that is what has complicated the work. Nevertheless, luckily, due to the work of the Ministry of Health and Sports and the Ministry of Home Affairs we are able to do our work in the communities, which is extremely important.

What is your motivation to work in this field?

At the time when I was working in psychiatry in the Netherlands, substance dependency was still seen in a very negative light, the wording in general was negative. I worked there with people who suffered from problematic alcohol and drug use and I always thought that this not where they should be.

Later on, when I worked with Médecins sans Frontières in a public health position, the logic answer for me was that we need to take a public health approach. In 1995, I started an outreach program where I assisted drug users in Moscow to adopt safer behaviour with regards to drug consumption. From a public health perspective, it is quite odd that the most vulnerable people have the least access – this represents a pressing humanitarian issue. Moreover, investing in the health of marginalised people is a critical necessity. Not doing so in the long run will be very costly.

Do you encounter resistance and prejudices in your work?

People rather have an emotional or cultural instead of logical, evidence-based understanding of drug use. I see my role in informing people about the evidence-based approaches. Fortunately, there is a growing international debate on the rationale behind prohibiting drug use. I look forward to a rebalancing by which decriminalisation and regulation of substance use will impact the public health rationale and inform legislative frameworks for the better. Now, for example, alcohol is a regulated substance that allows also for education, public health mass campaigns etc. Similarly, approaches on how to deal with other substances would benefit from a more rationality. 

To be honest, the people in Myanmar have a deeply rooted cultural and religious background. In this context and the now 60 year-long War on Drugs, health care for drug users seemed rather radical. But it is not radical, it is a universal right. Myanmar is a good example for taking these issues serious, being further ahead in the development of a public health approach to substance use than many other countries in the world.

What changes do you hope for in the future?

As mentioned, there needs to be a serious global change in the drug policy narrative and the CND should realise that the world needs a change in the social and public health perspective. All agencies need to agree that if many governments are not changing their perspective, we will be confronted with these issues for another decade. It has to be a choice, otherwise we don’t do mankind a favour.

It is also urgently necessary to recognise that Harm Reduction is an approach that pays off economically and is sustainable. The vast majority of funding goes to law enforcement punitive approaches instead of public health and education. This needs to change. The CND must change the direction of its policies and its funding – then, and only then, more countries are enabled to take legislative actions for the better. At present, the overall global investment in evidence-based preventive health is insufficient. Germany has enriched this from a political and academic perspective, and though its investments in pragmatic science, achieved great knowledge and experience in this area.

* The statements reflect the opinion of the interviewee and not that of the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH or the Federal Ministry for Economic Cooperation and Development (BMZ).