Thomas Kellogg Program Officer and Advisor to the President Open Society Institute

1. Medical Professionalism and its Relationship to Public Health: Physician Advocacy and State Public Health Policy October 21, 2008 Thomas Kellogg Program Officer and Advisor to the President Open Society Institute

2. Medical Professionalism: Public Health Responsibilities • Physician advocacy can play a key role in changing government public health policy • Why turn to physicians? • Prestige • Special expertise • Special perspective: on the front lines

3. Physician Advocacy and Public Health Policy: The Case of Harm Reduction What is harm reduction? • A pragmatic and humanistic approach to diminishing the individual and social harms associated with drug use, especially the risk of HIV infection • Emphasis on public health approaches over criminal law approaches to drug-using communities

4. Why Harm Reduction? • Connection between Intravenous Drug Users (IDUs) and HIV prevention and treatment • Spread of HIV among IDUs a key component of HIV epidemics in many countries • Countering that spread is key to stopping the spread of HIV/AIDS among the general population • IDUs as Percent of Total Registered HIV Cases (2006) • China: 44.3% • Poland: 50% • Indonesia: 54% • Malaysia: 72% • Russia: 83%

5. Harm Reduction in Practice • Needle exchange • Methadone therapy • Increased access to health services • Other useful steps: health and drug education, HIV and STD screening, psychological counseling, medical referrals • Harm reduction programs can serve as points of contact for drug users for other community, social services, and medical resources

6. Barriers to Harm Reduction Programs • Political resistance: fear of being seen as soft on drugs • Popular support for punitive approaches • Social and religious values • Lack of support among law enforcement agencies

7. What Doctors Can Do • Advocate for evidence-based approaches rather than those based on political or other concerns • Highlight the role that incarceration can play in accelerating the HIV epidemic and the potential benefits of alternative approaches • Call for increased funding for and political commitment to the provision of HIV prevention, treatment, and care programs for IDUs • Sponsor policy dialogues, conferences, and study tours to demonstrate the potential benefits of a harm reduction approach

8. Case Study: Malaysia • Country conditions indicate a need for a harm reduction approach • High prevalence of HIV among IDUs • 76% of all HIV/AIDS cases reported between 1986-2000 were among IDUs • Punitive approach failing to generate positive results • IDUs driven underground by criminal law approach • Number of IDUs continues to rise, even with harsher penalties • Social resistance to harm reduction approach: opposition from Islamic groups

9. Embracing the Harm Reduction Approach • Medical profession takes the lead • Dr. Adeeba Kamarulzaman plays a key role in organizing the response of the medical profession to change government policy • January 2004: Harm Reduction Working Group (HRWG) founded by a group of concerned physicians • January 2005: HRWG briefs the government on harm reduction techniques • January 2005: Government approves substitution treatment pilot project • 2006: Government approves first needle and syringe exchange program (NSEP) • 2006: Shifting responsibility for drug treatment from Ministry of Internal Security to Ministry of Health

10. Initial Results • Price of methadone slashed, making it more accessible • Substitution treatment effective: high level of compliance, reduced recidivism • Methadone treatment scaled up: more than 3,000 persons treated by 2007 • Expansion of NSEP: over 1700 IDUs reached by the program in first year • MoH target of reaching 20,000 IDUs by 2010