Drug Users’ Human Rights Harm reduction – the pragmatic view on the realization of drug users’ right to health

Many drug users are occasional or opportunistic recreational user, thus they do not fit the category of “drug addict”[1]. Nevertheless, this does not save them from the related harms created by drug use such as, blood borne diseases, HIV infection, and viral hepatitis B (HBV) and C (HCV) - as public health concerns. Policies and practices based on the principles of a right-based approach and a public health perspective toward drug use -such as harm reduction, are considered to be the best approaches on realizing drug users’ right to health and their human rights in general.

This paper will present a comparative case study between Albania and Slovenia, based on their similar features they share and exceptions as well on realizing drug users’ right to health. In order to offer the reader a general view on these countries’ positions, let us list some of the reasons of the “why” of these examples. The similarities between them, as factors which determine the drug situation - such as: 1- Both experienced the crisis of post communist countries; 2- Their strategic geographical position as joint routes and a linking bridge between East-West, which facilitate the traffic of illicit drugs; 3- Considering to be two of the main supplier countries for cannabis, and other drugs in Europe, as well as; 4- The small number of population on both countries - lays the ground for a comparative case study approach between Albania and Slovenia.

Despite the fact that the determining features of drug issues are more or less comparable between tow countries, the response toward drug issues, and especially toward drug users, is not alike. The lack of preventive and treatment services attributed to drug dependents responses, is a threat for the target concerned, the network of people around them, and for the general population, on raising the vulnerability in front of the biggest world wide epidemic, that of HIV/AIDS, and other harms related to drug use. Being vulnerable facilitates the process of violating human rights, and especially that to health for the target group concerned.

Aim

This paper tends to argue that, situations where lack of services, and inappropriate responses - embodied in the criminal legal framework, and national policies – that are in full inadequacy with drug users’ needs, evolve in violation of drug users’ human rights, and in particular, in violation of the enjoyment of the highest attainable standard of health. Eeffective responses such as harm reduction philosophy, as one of the main alternative interventions on drug treatment and response, originated and based on a public health approach with respect to human rights, will be demonstrated through a comparative case study between Albania and Slovenia.

Methodology

A variety of methodological tools is used for the purpose of this paper. As was presented in the above mention background, there exist the basic criteria and principles for conducting a comparative case study. In summary, we can realize it from the facts such as: the relatively small number of population of both countries opens the ground for using a comparative research language on evaluating, analyzing, and comparing between both samples within their similarities and exceptionalities mentioned above. Slovenian example in the field of addressing drug issues and the problems related to them - specifically the accessibility and availability of a range of preventive, harm reducing, and treatment services for drug users - is one of the best representative examples in the region on creating the conditions on the enjoinment of drug users’ right to health. Due to these reasons, the above mentioned countries are confronted in a frame of comparative approach, taking into account the similarities and exceptionalities between them, hence, giving the message of a “lessons to be learned” perspective for the Albanian case. The entire performance of the paper will be elaborated in a logical manner, from describing the concepts within the context they have been developed and the way they influence each other in a context of cooperation framework.

For the comprehension of this dissertation and the necessary academic requirements of the reader from different related fields, the elaboration of the main topic will follow the below outline: first it will give an introduction of the right to health as an essential human right, followed by explanations of the specificities of drug users’ target group, and the necessary responses to them within a right-based approach framework. This will be illustrated under a comparative case study, from a legal based framework between Slovenia case and Albania; concluded then, with patterns of violation specifically of the right to health and positive responses from realities, as well as insights for the future.

In addition to the methodological scheme, this paper also relies on a vast literature on human rights, right to health, drug issues, and other relevant issue of concern. A very rich literature on policies and practices of both countries is taken in consideration. The interviews carried out with professionals, policy makers and drug users are important tools for this work, putting insights from the experiences of the every day life. This is more relevant for the Albanian case, taking in consideration the gap due to the lack of literature, surveys and researches on drug related issues, as well as on the human rights.

1. Overview of the right to health

Right to health is one of the rights set forth in the Economical Social and Cultural Rights Covenant, (ESCR) adopted on 1966, as a very useful international document of the twentieth century contribution, making it possible for all members of society to enjoy satisfactory conditions of life.[2] The interpretation and codification of the right to health in different international and regional human rights documents, such as UDHR, CESCR, ESCH, etc, shows the significant implication of the right to health for the humanity. Its substantial importance on human well being has put it as the focus of work for some prestigious international NGO-s, such as World Health Organization, (WHO) and at the same time, being present in the domestic constitutions of states party or not to the international human rights documents such as CESCR.[3]

The right to health is closely related to and dependent upon the realization of other human rights, as contained in the International Bill of Rights (UDHR, ICCPR, ICESCR), including the rights to food, housing, work, education, human dignity, life, non-discrimination, gender equality, the prohibition against torture, privacy, access to information, and the freedoms of association, assembly and movement.[4] These and other rights and freedoms address connected components of the right to health.

Despite the essential importance and the globally taken initiatives from different actors in respect to right to health, there still are uncertainties on its realization expressed on patterns of violation of right to health, thus, having its consequences and costs on vulnerable and marginalized groups in the society. The health practices and services tailored in accordance with the individual group concerned, and in harmony and respect to their universal human rights, fall under the conditions of a right-based approach perspective on health – which consider as its main values respect for human dignity and individual. A right-based approach perspective to health entails recognizing individual characteristics of the population group concerned, while there are conceptualizing policies and responses toward the target concerned. This chapter will present the challenges on enjoinment of the right to health and the types of breaches/violations.

1.1. Challenges of Right to Health and its Codification

Through out history of mankind the perception and conception of health has changed, in accordance with human development and with concern to cultural and social characteristics of human being. As long as the concept of health is relative, the disputes on defining the unifying nature are present. The best conception on unifying it is the perspective of human rights - considering right to health as an essential right – through the embodiments of universality, interdependence and interrelated, principles which characterize all human rights. Its importance for human well being and human dignity has made it present in various human rights documents, as will be presented further.

WHO’s preamble of the constitution adopted in 1946, set forth for the first time, the right to the highest attainable standard of health, referred to as the “the right to health” - “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”.[5] This extended prediction was raised later, by almost the same means, by the Declaration of Alma Ata 1978, and was repeated in the following by the World Health Declaration, adopted by the World Health Assembly in 1998. At the same time, it is well legitimated in other international human rights documents, as will be elaborated in the following.[6]

Although the definition given by WHO, to some critics is more a “wishing list” rather than a real human right, due to the fact that it is difficult to translate it into real State-responsibilities, and to some it is just an impossible goal to achieve a complete physical, mental and social-well being of the individuals.[7] Modern concept of health, however is defined, is a relative concept, which reflects features of cultural economic and social circumstances, as well as individual heritage, habits, environment and other factors unrelated directly to the health interventions. According to “social constructivist” view, concepts of biology and disease are not only neutral products of clinic or laboratory, but also emerge from social processes. Although the sense of rapidity of change will always exert pressure, impeding to stay focused on issues long enough, in order to seize and explain key social processes at work in the field of health.[8]

There widely exists the belief that, in the frame of international human rights law the most respected interpretation of the right to health is outlined in the article 12 of the ICESCR, which states:

“1- The States Parties to the present Covenant recognize the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.

2- The steps to be taken by the States Parties to the present Covenant to achieve the full realization of this right shall include those necessary for; (a) The provision for the reduction of the stillbirth-rate and of infant mortality and for the healthy development of the child;( b) The improvement of all aspects of environmental and industrial hygiene; -(c) The prevention, treatment and control of epidemic, endemic, occupational and other diseases; -(d) The creation of conditions which would assure to all medical service and medical attention in the event of sickness.” [9]

It is obvious that the definition in the article 12 of the CESCR, foresees the highest attainable standard of health, without referring to the WHO definition of health as a complexity of conditions, such as the social well-being. Although the highest attainable standard of health, as described in the covenant, is more delimited, it is still problematic. Firstly, whose level of health does it refer to? Is it an individual or a collective standard, and if the latter is applied, is it an average or a floor of minimum applicable to all the population? Secondly, who is to determine the scope of the highest attainable level of health, within a social-political and culturally relative society? Thirdly, how is this standard being determined in a daily developed technology and scientific news?[10] All these challenges are creating concerns on giving a simple definition, which set out the conditions for realizing the right to health.

Nevertheless, access to health as an individual right does not enjoy universal recognition. For millions of people throughout the world, the full enjoyment of the right to health still remains a distant goal.[11] This is due to two reasons, first; the government restricted resources (financial as well as of human ones) to convert its entitlement into individual enjoyment; and secondly, the positive correlation with other rights and societal levels such as development, individual capacities, etc, which again show the complicated nature of health as related more with factors outside the health system, such as individual heritage and behaviors, life orientation, environmental aspects, etc. Consequently, the right to health must be understood as a right to the enjoyment of a variety of facilities, goods, services and conditions necessary for the realization of the highest attainable standard of health in accordance with State opportunities and resources as well as in compliance with cultural differences.[12]

Although there are different arguments that define the relative nature of the concept of health, the recognition of the right to health as a human right is firstly recognized by the World Health Organization, in the Preamble of its Constitution of 1946. Following the codification in the WHO Constitution, its geographical extension tends to show its importance as interpreted, codified and enumerated in a various international, as well as regional human rights instruments, as an essential human right.[13] Apart from the ESCR, as mentioned before, its presence can well be found in the figure no. 1: Figure no. 1 – see annex

Vienna Declaration and its Program of Action emphasised the necessary principles for the enjoinment of all human rights, claming that: “All human rights are universal, indivisible and interdependent and interrelated”. [14] Its presence in other international and regional human rights documents is a witness of these unifying principles. It once again emphasise human rights realization nature - dependence on itself, and dependence for itself.

The Committee on Economical Social and Cultural Rights[15] recognizes the formidable structure of the right to health as set forth in above mentioned International documents, but on the other hand admits the obstacles resulting from international and other factors beyond the control of States that impede the full realization of article 12 in many State parties. At the same time, the Committee recognizes some illustrations of the violation of the right to health from the State parties under the Article 12 of the ICSCR – breaches/violations which can have different forms on conceptualizing health policies, etc, but the outcomes can be summarized on health hazard for the groups concerned, as it will be elaborated below.[16]

1.2. Conceptualizing violation of the Right to Health

Contemporary literature shows a lack of unified perception on the violation of the right to health. First, there is not a clear picture on the definition of the scope of the right to health. Second, state parties’ ambiguous obligations toward right to health as a matter of fact, and finally (but not the last) there are many countries that do not monitor the right to health as a human right, but most of them measure it on the bases of medical ethical practices, professional codes, and health laws. On the scope and nature of the obligations of the State Parties to the Covenant, the Committee defines the violation of the covenant as a failure by the State party to comply with an obligation articulated therein.[17]

The Committee on Economical Social and Cultural Rights, in its General Comment Nr. 14, on the right to health, claims: the right to health like every human right, imposes three types of obligations or responsibilities on governments to fulfill the obligations: 1- to respect- “state party does not directly violate the right to health, especially to vulnerable or discriminated social groups ”-2- to protect -“through policies and actions, the state does not allow the violation of the right to health, from especially third parties or non-state actors” and – 3- to fulfill “the state has to take all the appropriate measures - including but not limited to legislative, administrative, budgetary, and judicial, toward the realization of the right, including the obligation to promote the right to health”.[18]

In determining violation of the right to health, it is important to distinguish the inability from the unwillingness of a State party to comply with its obligations under article 12. This follows from article 12.1, which speaks of the highest attainable standard of health, as well as from article 2.1 of the CESCR, which obliges each State party to take the necessary steps to the maximum of its available resources.[19] In accordance with the Maastricht Guidelines on violation of ESCR, there are identified several categories of violations, the below mentioned four of which, are of relevance to the right to health:

Violation of commission

Violation of omission, especially failure to fulfill the minimum core obligations

Violation of the obligation to protect

Violation related to gender discrimination[20

This sets of violations as mentioned above, can be translated under the range of the failure to respond state obligations in the compliance with the Covenant as such:

Violation of commission may fall under the failure to fulfill obligation to respect - which are State action, policies, or laws, being in breach of standard set in the covenant, and have the direct result of increasing the likelihood of bodily harm, unnecessary morbidity, and premature mortality. Violation of omission - especially failure to fulfill the minimum core obligations - State parties fail to take all the necessary steps, such as failure to adopt or implement national health policy designed to ensure the right to health for everyone based on a gender-sensitive approach to health, misallocation of public resources. To date, the Committee has not defined the minimum core contents of a right to health, but is working under such prioritizing fields as mentioned above. Violation of the obligation to protect – represents failure of a State to take all necessary measures to safeguard persons within their jurisdiction from infringements of the right to health by third parties, such as individuals, groups or corporations, thus prevent them for violating others right to health.[21]

The greater challenge is to identify effective approaches in the implementation of the ESCR, as well as respecting, promoting, and preserving the above-mentioned rights. The Covenant does not clearly states what are the adequate means. It only verbalizes the duty of “using all the appropriate means” to work toward a deserved end. Despite of this vague language, which opens the ground for violation or breaching of the obligations, such means, often are subjects to specific culture or local legal system, taking in consideration that the provisions of ESCR are well introduced and incorporated in the local legislation as well.[22]

Taking in consideration the above-mentioned range of violations, and in order to have sensitive and effective health policies, as well as a ground for a tangible implementation and enjoinment of the right to health, especially for the marginalized and vulnerable groups, a valuable weapon is the reference on, and working under the framework of the human rights holistic package. A human rights-based approach on health take in consideration the characteristics of the group concerned, and make possible the enjoinment of the right to health without discrimination through legal recognition of it, embodied in the national legislations and States’ policies.

1.3. Elements of a human rights-based approach on health

In order to make possible the enjoyment of the highest attainable standard of health, especially for vulnerable and marginalized groups, such as drug users, taking in account a right-based approach while conceptualizing health policies is of crucial importance. There is not a single, universally agreed right-based approach. Although we can claim for some unified principles for a right-based approach perspective, on the realization of different rights in particular, or the realization of a set of rights in a parallel process in accordance with the universality, interrelated and indivisible nature of the rights set forth in the human rights documents, such as UDHR, etc.[23]

A human rights approach on health implies realization and enjoyment of the right to health in a chain of rights, such as the right to information, education, development, non-discrimination, and affirmative actions, to rectify the inequities in access to health care, especially for the vulnerable and marginalized groups.[24] Therefore, a rights-based approach to health refers to the processes of:

Using human rights as a framework for health development

Assessing and addressing the human rights implications of any health policy, programme or legislation

Making human rights an integral dimension of the design, implementation, monitoring and evaluation of health-related policies and programmes in all spheres, including political, economic and social.[25]

All the above-mentioned steps and principles are applied in order to promote, protect and respect human rights and human dignity. Attention to the needs of most vulnerable and marginalized groups such as IDUs, and emphases on ensuring that health system is accessible, available, feasible and qualitative to all, is of primary importance on realizing human right to health. A right-based approach provides potential resources for those who experience violation, through possibly legal actions on redressing the infringements.[26]

A right-based approach to health, lead to recognizing and take into account the individual characteristic of the population group concerned, on respecting and responding in accordance to the services users’ needs, and the cultural or social attributes. The sensitiveness it performs, and shaping of health policies in accordance with the population concerned can be one of the most desirable approaches under which the enjoyment of the right to health can see the light for marginalized and vulnerable groups, such as drug users.[27]

A secure entitlement on the right to health based on the principle of universality requires legal recognition. The challenge is to tailor a policy in harmony with the users’ needs, and elimination of all grounds of exclusion on the bases of gender, life style, group belonging, respecting freedom of choice, and at the same time, of their human rights and human dignity.[28] Harm Reduction – a pragmatic philosophy, which draw closer to the realization of the right to health for drug users - can be considered as one of the best alternative approaches on meeting drug users’ needs, and dealing with their every day problems. A public health approach toward drug users and a harm reduction perspective on offering services is the best ground for the realization of drug user’ human rights and specifically, that to health, as it will be elaborated bellow in the next chapter.[29]

2. Harm reduction philosophy – the gateway through enjoyment of varies rights - the highest attainable standard of health

Three paradigms are distinguished within international and domestic drug policies: the policy of war, the public health paradigm, and the classical liberal one.[30] Human rights of drug users have often been a subject of the global “war on drugs”. International and national drug laws and drug policies are implemented around the world in a manner that make violation of the human rights of drug users inevitable. This repression of drug users not only presents a bad practice of human rights, but in the context of HIV/AIDS, it is potentially lethal, because it drives drug users away from HIV prevention and AIDS treatment, taking in consideration their vulnerability as derived from the stigma and discrimination. It makes them matter of criminal law rather than a health issue. Thus protection of injecting drug users’ human rights is a concern for public health and a crucial one for human rights.[31]

This chapter aims to introduce one pragmatic public health approach to disease prevention - harm reduction, whose principles and practices perform with respect of drug users’ human rights and particularly that to health, on reducing the harmful consequences of drug use, without requiring being off drugs. Although there is no agreement on the final definition of the term, due to its broad nature and scope, many agree that it presents a policy aiming at reducing undesirable consequences of drug use, while the user continues to use drugs.[32]

Despite the long existing strategies of harm reduction, such as prescription of drugs for maintenance from 19-century, and methadone early 1960, as well as needle exchange programs from early 80-s in Europe, and its acceptance worldwide –US, Australia, Canada, Eastern European countries and Central Asia - the discussions on its importance, applicability and legality have never stopped. Hence, regardless the one’s rights to the highest attainable standard of health, in many countries drug users have no access to methadone maintenance therapy, or any other substitution therapy. While others still hesitate to officially declare needle exchange as their public health policy, strategies and practices which clearly and inevitably result in violation of drug users’ right to health.[33]

Prohibitions and criminalization of drugs have failed in stopping drug use, thus, serving as a barrier on relevant responses, and moreover, they exacerbate the harms related to its use. Before debating about the importance of harm reduction on making possible the enjoinment of a series of rights for drug users, it is of a crucial importance to define whether it is necessary at all to pay any attention to drug injectors, and to define their role in the spread of HIV epidemic, therefore, deciding what should be the best approach in responding to the spread of HIV, though drug injecting.[34]

2.1 Drug use and HIV/AIDS

There exist an epidemiological relation between blood borne diseases such as, HIV, HBV and HCV and injecting drugs. One of the faster and “secure” ways of transmitting blood borne diseases, is through sharing injecting equipments, thus, getting the viruses. While injecting, there always is some blood contaminating the needle and the body’s syringe, and when it is re-used from another user, or put in contact with filters, containers or any other equipments used for preparing the drug for injecting, this syringe contaminates all the equipment and the liquid; therefore, transmit the virus to the next user. Apart from their injecting partner who most of the times happen to be their sexual partner as well, they can spread the virus to other women or people who they have relations with and practice risky behaviours (ex: unprotected sex). Thus, other people are harmed as well.[35]

Estimations in a global level provided by UNAIDS and WHO show that - between 5 and 10% of HIV infections result from injection drug use; however, in some countries in Asia and Europe, over 70% of HIV infections are attributed to injection drug use, with opioids being the most commonly injected drugs in these regions. Between 4.2 and 5.8 million people were infected in 2003 alone.[36] In European countries and their neighbors, the highest rates of HIV are estimated to be in Latvia, Estonia, Russia and Ukraine; estimations which are relevant even in the global level as above-mentioned. Prevalence rates vary widely in other new EU member countries, and those that have a high rate of drug injection are at risk of experiencing a similar outbreak. HIV incidence picked in Estonia and Latvia in 2001 is in the rates of 991 and 281 cases per million populations respectively.[37]

In a glance, there naturally can be raised the question: why such a fast and dramatic spread through drug use? In North America, harm reduction attracted the attention because of the effect of drug prohibition, rather than the spread of HIV/AIDS alone. The prohibition policies enforced by the criminal laws, not even have failed to prevent the drug use, but further more, efforts to restrict drug use have created a wider range of social evil rather than the use of drug itself.[38] There are countries that do not allow the syringe exchange programs, and furthermore, they punish and prosecute users if they have in their possession drug equipments, such as needles, as it is the case of China today. As it can be seen from the story of a user: “I better share with other users than be on the hand of the police.” Policies and laws that criminalize the use of drug per se, and implementation of adequate responses for drug users, are being the best generators for stigma and discrimination toward the concerned group, consequently driving in inevitable violation of their rights, such as restriction of liberty, discrimination, barriers on health services and information, etc.[39]

Harm from drug use does not affect only the individual who uses drugs, but also his/her network of people.[40] Deducting from this, we can conclude that harm reduction practices and public health have some important common features, since the focus of a public health policy is to create conditions for prevention of adverse health to the society in general, or specifically, create conditions for protection against broad health threats, like epidemic diseases. This is one of the features that show the interdependence of the public health perspective and harm reduction practice.[41]

Furthermore, this interdependence can be translated on the language of human rights, and can be better illustrated in the following examples. Hence, human rights violations have impact on health, which are unpleasant effects in mental, physical and social well-being. This complex situation can be better understood in analyzing a bunch of related rights and drug issues. So, health damages seem evident if the right not to be tortured or imprisoned under inhuman conditions – which can easily happen in the life history of a drug user under the present laws - happens to be violated.[42]

For many other rights such as the right to information, to assembly, or to association, the impact on health resulting from these rights’ violation can not be initially visible. However, the following example can clarify the frame. In the context of HIV epidemic and needle exchange programs, the right to association is of critical concern. If a state restricts the right to association, as an essential constituent of a public health effective response (because it often requires people to gather in order to address what affect them) then, needle exchange can not be carried out in such conditions, thus resulting in sharing and spread of blood borne diseases. On the other hand, if the user is not informed and being familiar with the harms deriving from the carrying out of the risky behaviors – related to injection or unprotected sexual practices – or the information can not get to him due to the prohibition legal framework for these activities, then the results are clear – the person is vulnerable toward blood borne infections due to his/her life stile.[43]

Drug use and HIV/AIDS is attracting the attention of many policy makers and governments. Many people are being affected by the epidemic, the poor, the reach, women, men, blacks as well as whites, and as long as there is no vaccine and remedy for HIV/AIDS the only way on keep people safe and healthy is prevention. Harm reduction practices and activities offer an alternative approach on responding the drug related harms and addiction issues through prevention and treatment, thus seeing from a public health approach and an individual perspective on human rights, it creates the ground for realization or enjoinment of a varieties of human rights, with respect to that to health, as it will be presented in the following part.

2.2 Harm reduction and drug users’ human rights - right to health

Harm reduction is a composition of a set of policies and interventions, aiming at reducing the adverse consequences of mood altering drug use, without definitely aiming as final phase abstinence, even though it does not exclude it.[44] Although we lack a final definition of it, there are several principles under which professionals and other parties concerned have agree upon. Through its leading principles, with respect to drug users’ human rights, and with its focus on the responsible person equipped with inherent values and dignity, and operating through its pragmatic practices, taking into account drug users’ specificities, it became an influential and effective alternative on realizing drug users’ right to health and other human rights, closely included in the drugs dealing issues. Repression and criminalization of drugs, through draconian laws, have lost their “shining”, not only failing on addressing drug issues, but exacerbating drug related harms as well. Thus, alternative responses should be found. Harm reduction through its practices and activities, can be consider an alternative on making possible the realization and enjoinment of drug user human rights, with respect to right to health, as it will be presented in the following.

2.2.1 Origin and nature of Harm Reduction

Harm reduction practices expressed through Needles Exchange Programmes on preventing transmission of blood borne diseases through injecting, is a relatively new social policy with respect to drugs, which has gained popularity during the last 25 years. It first started in the United Kingdom and Netherlands, and then North America, first as a response toward an epidemic spread of drug use (mainly heroin), in early 1980, on minimizing the spread of viral hepatitis B (HBV) and C (HCV) on heroin injectors. Another parallel-crucial-important-factor, which influenced the development of the model, is the explosion of the HIV epidemic.[45]

Looking back in drug history of 19-century England, harm reduction practice through maintenance therapy for opium addicted, by prescribing other substitute drugs, has been one of the most popular strategies on treating opium dependence.[46] Moreover, continuing in early 1960, with prescription and use of methadone as a maintenance therapy in treating the heroin addiction, which first started in Canada and fast got it spread in America and other countries, show the long occurrence of maintenance therapy as a harm reduction practice in opium and heroin dependence.[47] As the tendencies of the 20- century are on treatment of addiction through maintenance methods, such as methadone and other substitution therapies, it seems that the history of drugs has entered a vicious circle, and now is turning at the starting point, but in a modern shape and expression, adapted to the time requirements and scientific news.[48]

The approach is referred to as “harm minimization” or “risk minimization”. It represent both a goal (the reduction of the considering harms associated with drug use) and a strategy (a specific public health community-based approach that focus on the negative consequences of drug use, and provide support and health promotion services to drug users without the requirement that they remain drug free). “In both definitions the persons’ uses of a drug is accepted as a fact, and recognize individual’s choice to use drug”.[49]

One working definition is the following: “an attempt to ameliorate the adverse health, social or economic consequences of mood-altering substances without necessary requiring a reduction in the consumption of these substances”… the essence can be expressed such as: “If a person is not willing to give up his or her drug use, we should assist them in reducing harm to him and others”. Harm reduction strategies meet drug users where they are at, addressing condition of use along with the use itself. It consists of five main features, each of them leaded by specific principles in accordance and respect to human rights, although we lack a final definition of harm reduction.[50]

Hence, it brings in a: pragmatic standpoint - accepting that some use of mind altering substances is inevitable, and that some level of drug use is normal in society. Although, carrying risks, drugs also provide the users with some benefits that have to be taken into account if drug using behaviour is to be understood. “Thus it recognises that licit and illicit drugs are neither good nor bad.” From a community perspective the amelioration of drug related harms may be a more pragmatic and feasible option than option to eliminate drug use entirely[51]. Followed by - humanistic values - the drug users’ decision to use is accepted as fact, as his or her choice, no moralistic judgement is made either to condemn or support the use, regardless of the level of use or mode of intake. "It recognizes that humans have intrinsic values and dignity, thus respecting their choice on using drugs”.[52] Concentrating its focus on harm - the fact or extend of a person’s drug use per se is of secondary importance to the risk of harm consequent to the use. The harm addressed can be related to health, social economic or a multitude of other factors effecting the individual, community and society as a whole. Announcing a balance cost and benefit viewpoint - through identification, measure, and assessment of drug related problems, their associated harms, and cost/benefits of the interventions impact in order to allocate resources as priority issues, in the best of individual, community and society. Leading by a hierarchy of goals - its primarily aim is the engagement of individuals, groups and communities to address their most pressing needs. Achieving the most immediate and realistic goal is usually viewed as the first step toward risk-free use, or if appropriate abstinence.[53]

The above-mentioned history and practice of harm reduction - initially documented from the 19-century England on treating addiction - recognizes and acknowledges the always presence of drugs in society, and the increasing necessity of it in treating and ameliorating the opium and heroin addicted conditions of life.[54] In the area of HIV/AIDS, and other exacerbated blood borne diseases, harm reduction and public health are complementary and indistinguishable, as long as drug related problems are helath issues, and its harms consern the general public. Protecting and promoting human rights is an important component on responding public health problems, especially in the area of HIV/AIDS.[55] Harm reductions’ practices are effective responses to this public health challenge in concern with drug injecting. The following paragraphs will present the issue in more details.

2.2.2. Practices of Harm reduction - drug users’ human rights and their right to health

»Estimations show that there is approximately 5%-10% of drug users’ population considering entering an abstinence program. Definitely we have to find ways to work with the remaining 90%«.[56] Harm reduction - through its practices such as needle exchange programs (NEP) and substitution therapy, such as methadone, leaded by its rational principles and with the focus on the free individual and the outcomes toward the public benefits - seems to be one of the best alternatives on responding and confronting drug users’ specific needs, hence, respecting and realizing the enjoyment of their human rights, with particular concern on their right to health. Its goals should be: to prevent sharing of needles and other injecting equipments, to make available and ensure the use of sterile injection and to provide treatment and rehabilitation.[57]

Methadone substitution treatment therapy, through out it history of use, has signed positive results on improving users’ lives and returning them back again in the community. Being on methadone the user can easily have a normal life in the family, regaining his/her social roles without having the craving desire for heroin, and for a good part of them, slowly reducing the dosage toward abstinence and a life free of drugs.

2.2.2.1 Needle exchange programs

Needle exchange programs aim at primarily preventing the blood borne diseases, such as HIV, hepatitis B and C deriving from a drug injecting sub-culture, that of sharing of needles and syringes or other injecting equipments. At the same time, contributing to users’ health improvement and quality of life – through empowering and raising knowledge on the health hazards by injecting practices (recuperation of veins) - and promoting changing of risky behaviors. At the same time, it makes reference on other related services with concern on drugs, such as pre and post-counseling and testing opportunities for HIV/AIDS, other blood borne diseases and Sexually Transmitted Infections, (STI) as well as the immunization for preventing HBV, and other counseling sections with concern on drug issues information and risks. Informing and offering the services to the users on bases of non-judgmental approach, fulfilling, thus, our ethical duty to serve, and improve their life conditions, and the rights of individual on information, on changing their behavior injecting, and access to health services; all serves as components on fulfilling their right to health, thus, affecting the amelioration of their life.[58]

Interventions include projects that try to ensure that those who continue injecting have access to clean injection paraphernalia. A wide variety of measures have been developed to improve and increase access to and utilization of sterile injecting equipment, including needle syringe programs (NSP), strategies for disinfecting needles and syringes where they are reused or shared (this in case that domestic legislation does not allow the NSP, or in prisons), pharmacy-based distribution, sale or exchange schemes, vending machines and other distribution programs, outreach work, and policies and programs to encourage more appropriate disposal of used needles and syringes and injecting paraphernalia legislation and condom distribution.[59]

Access to services such as needle exchange programs for IDUs, show the government obligation on fulfilling their duty to prevent the epidemics, and thus keep healthy the community, through respecting and fulfilling the individual drug users’ rights to services. Restricting or denying the needle exchange services to IDUs, you have punished them with the vulnerability toward HIV/AIDS. The harms associated with injecting drug use can have impact on the individual, him/her family, sexual partner, community and society at large.[60]

Risky behaviors such as sharing of injecting equipments and drug solution, application of unsafe sexual practices, numerous sexual partners, make them vulnerable to HIV and other blood borne infections. Although most IDUs are male, and female drug users may be more vulnerable to HIV than their male counterparts, since they are more likely to use their partner’s injecting equipment, and it is often difficult for them to negotiate low-risk sexual practices and condom use. Education and empowerment through knowledge is a necessary tool in the hands of a vulnerable user. IDUs are relatively more likely to be involved in the sex industry in order to support their habit. The vertical infection, mother to child transmission, is one of the most spread causes for the high number of HIV on new born. [61]

As it can be understood from the previous paragraph, the target affected by drug use is not only the user itself, but all the network of connections and relations he/she has. Hence, the center of attention of a successful needle exchange program, as a public health community-based approach, should apply to a range of vulnerable groups, apart from the injectors themselves, trying to fulfill in this frame a range of needs and rights. Information and education of non-users, as part of an intimate relation with an injecting drug use is one of its main focus. The prevalence number of HIV infection on non-users - partner of a user, is increasing every day. The right to information and the right to be informed is one of the states demand reduction strategies objectives, which has to be effective in accordance with the targets’ level of education and on transmitting the right information to them, on reducing the drug-demand.[62]

The issue of a gender balanced approach guides the activities of a needle exchange program. Thus, the lack of the empowerment of women through education and knowledge about the harms from drug using, and the risks of non-protected sexual practice with unknown partners, position a much disfavored state of vulnerability toward STD and sex work abuses. Distribution of condoms and information on their effective use is an important activity of the program. The availability and accessibility to the services keep them informed about the risks, and improve their health on adapting and applying healthy behaviors, with respect to drug use or their sexual activities.[63]

Since 1980s, when the first needle exchange activity rose, there are 110 countries where these activities are present. Estimations on the global level show that there are around 10 million people of injecting drugs, out of which 2-3 million are HIV positive. The numbers of countries reporting injecting drug use in 1998 were 138, with 114 countries reporting HIV infection among IDU population. Studies indicate that in the absence of preventive measures the prevalence rate can rise up to 40% in 1-2 years of introduction of infection HIV into the community. One evaluation carried out in 99 cities showed a reduction in the risk of HIV transmission of 19% per year in cities with such projects compared with an 8% increase in cities without them.[64]

The effectiveness of the needle exchange programs is unchallenged and definitely necessary in today never-drug free society and in the presence of new drugs and harmful pattern of consumption.[65] As long as the present responses are not reaching all drug consumers, due to the drug dependence multi-faces matter, and the restricted resources toward a free drug society, which is never deserved or reachable, availability of these responses is the crucial condition on realizing drug users’ rights and improvement of their lives. Nevertheless, as far as drug users are not a homogeneous group, and their needs vary, there has to be a range of available services on meeting users’ needs, such as treatment. In the language of harm reduction it is represented by substitution maintenance therapy, and for the heroin dependents - methadone maintenance therapy.

2.2.2.2. Substitution therapy – methadone maintenance

“Substitution therapy (“agonist pharmacotherapy”, “agonist replacement therapy”, “agonist-assisted therapy”) is defined as the administration under medical supervision of a prescribed psychoactive substance, pharmacologically related to the one producing dependence, to people with substance dependence, for achieving defined treatment aims”.[66] Agents suitable to substitute opioid dependence, have opioid properties so that they have the capacity to prevent the emergence of withdrawal symptoms and reduce craving, they diminish the effects of heroin or other opioid drugs, because they bind to opioid receptors in the brain. In general, they have a longer duration of action than the drug they are replacing, so as to delay the emergence of withdrawal and reduce the frequency of administration, thereby, resulting in less disruption of normal life activities by the need to obtain and administer medicines. All these effects of pharmacology tend to improve the health conditions of the user if the treatment is done under the professionals’ supervision with adequate dosages for the treatment; thus, affecting the creation of stability of life in the individual user.[67]

The aim of the substitution treatment with respect to individual user and its drug related issues can be stated such as, assist the user who want to get off illicit drugs, and improve his/her quality of life. It can be translated in more detailed aims and interpreted in the same time in the human rights language. Hence, substitution treatments assist the patient to: remain healthy and have a life free of illegal drugs or non-prescribed drugs, and empowering him/her in cooping with drug related misuse and harms, particularly the risk of death by overdose, and blood borne diseases such as HIV, HVB and HVC, etc.[68]

Other benefits are related to the community and the network of people the user affect. So, being on methadone reduces the chances for criminal activities and persecution from the restricted legal framework, as long as the user is under prescribed drugs, consequently not more a subject of the stigma associated with criminal behaviors and discrimination deriving from the users’ status of illicit drugs. By and large it improves personal social and family functioning of the user. Therefore keeping him/her back in the community, and giving the chance to live a life in dignity and in harmony with others.[69]

Apart from its importance and effectiveness of harm reduction as a public health strategy toward drug issues, here starts one of the greatest contradictions with the individual rights. “In the name of public safety and its well being, the state can take action on restricting any right of individual”.[70] Such approaches based on total imbalance principles, which effect the relation of the individual and the group, have derived from the moralistic and stigmatized opinions of policy makers, strongly supported by public attitudes, materialized in the label of criminal laws on drug control.[71]

These elements, which create an unfriendly environment, form the barriers for relevant responses toward drug use, such as harm reduction. Even in the moment we are talking these barriers are establishing an unhealthy, degraded and inhuman environment for drug users’ human rights enjoyment and their safeties, even in the most developed countries as USA, or others as Russian Federation, China or Albania.

2.2.3 Criminalization of drugs - Barriers to Harm Reduction

The ways how drug use is perceived and conceptualized has strongly affected the formation of International and domestic legal and public policies on responses to drug use. Many states implement their repressive policies on criminalizing drug use. One of the best examples through the history of the 20-century, for illustrating failure of the drug war and criminalization of drugs, is the USA drug policy. Historically its laws and policies have been established on the bases of prohibition and restriction with respect to drugs, morally motivated, which lack reasoned arguments and scientific evidence.[72] This is reflected in the “zero tolerance” approach to drug use, emphasis on abstinence, resistance on methadone maintenance and legal requirements for mandatory treatment for drug use, thus creating legal barriers for alternative approaches. This approach is leaded by idealistic principles, and reflects society’s failure to accept the drug use as a legitimate form of risk taking - hence, being a great barrier to harm reduction.[73]

Another barrier to harm reduction is the relative ease of applying the different approaches. As far as the supply reduction has attracted the governmental attention, and all the efforts are concentrated on criminalizing drug traffic and its use, (incorporating the criminal justice system) all these make the frame inflexible toward other alternatives on shaping responses. [74] There is not a balanced approach with demand reduction, which aims on educating public and users, and treating the dependents, including other harm reduction strategies, thus, preventing the demand for drugs. Since the supply of and demand for illicit drugs are inextricably connected, programmes aimed at reducing the drug problems should be integrated, complementary and mutually reinforcing rather than isolated or competing activities.[75]

“The illegality of drug use makes it inescapably harmful, regardless of whether or not any other harm derives from the use of drug”. [76] Harms which derive from the control of drug use include: stigmatization and discrimination against users, generating shame and guilt in drug users, fostering a black market that promotes crimes and violence, and driving drug users’ underground due to the fear of being discovered, prosecuted and recognized as criminals. Under these conditions they become vulnerable, and can claim for any kind of protection and even for the protection of their human rights. Vulnerability is a perfect ground for violation of drug users’ human rights with respect to the complexity of their problematic.[77]

Drug dependence is recognized by the World Health Organization as a form of disorder or disability. Much of the policies justified criminalization of drug users and their throwing to jail, rather than prioritizing human health services for them and treating drug use and addiction as a health problem. As the UN Committee on Economic, Social and Cultural Rights has stated, policies that “are likely to result in…unnecessary morbidity and preventable mortality” are breaches of governments’ obligation to respect the right to the highest obtainable standard of health. As Aryeh Neier, president of the Open Society Institute claims: “There is no way to use the criminal law to deal with drugs, except in a very abusive way” including other outsider factors such as social marginalization and racial discrimination as well.[78]

The right to health includes the right to obtain health services without fear of punishment; impossible to achieve under the drug law regime in many countries. As it is mentioned in its 14 general comment, the committee of ESCR has stated: “policies that are likely to result in… unnecessary morbidity and preventable mortality, are breaches of governments’ obligations to respect the right to the highest attainable standard of health”. Policies that restrict access to sterile syringes and opiate substitute fit this description. In addition, prohibitions of access to these services discriminate against persons with drug addiction as a class of persons with a well defined disorder or disability. If the law denies syringes or medicine to the insulin-dependent diabetics, the same kind of discrimination would occur, and no one would find it acceptable.[79]

As long as there has never been a society free of drugs, we must learn to deal with the problems that drugs can cause in an intelligent and empathetic manner. The failure of the “war on drugs” has turned the page to a “war against drug users”.[80] In the eyes of the general public, the persons who are targeted as drug users are looked down upon, are stigmatized and judged for their status - drug user, they do not deserve anything, thus it does not matter if they complain or protest on the way they are treated. The same concern is shared from Szasz when he claims: “Haw can it be justified such a disproportionate punishment compared with the punishment imposed to many persons conducted of murder and the individual who inhales the product of such a plant. The answer can be found in: where there is the political will supported by popular opinion and powerful factional interest, there is a legal way, paved with the legal fictions necessary to do the job”.[81]

Harm reduction perspective is gaining terrain more and more, in the domestic and international level. This development can be well illustrated by the existing and establishing of the international and regional networks on the field such as International Harm Reduction Association, or Central and Eastern European Harm Reduction Network, and the increased activities such as International Conference on the Reduction of Drug Related Harms. Despite the effectiveness and increased popularity it has gained, there is still skepticism about its activities- sometimes expressed and understood with the language of liberalization of drugs - reflected on the domestic laws and policies on responding drug users’ needs and fulfilling their human right to health and related rights.[82]

The harm reduction advocators try to soften the frizzy frame of criminalization of drugs - taking in consideration that no prohibition has ever had successful results - i.e. promoting the medicalization of drugs as a way of controlling them through treatment and adequate services for drug users. Although many surveys witness its effectiveness and successful interventions, harm reduction has its own critic, such as intensifying drug use, and concerning the ways of its consumptions, from different forms of administration to injecting. As long as drug use concern health problems, the alternative response has to be in the same line. To illustrate this argument the cases of Albania and Slovenia will be used as examples.

3. Drug users’ human rights in the context of Albania and Slovenia

Although Albania and Slovenia have some substantial similarities with respect to the conditions that determine drug issues, the responses are not alike. This chapter’s aim is to show, how the lack of services, prohibition laws, under a chaotic political situation, can be the sources of an inadequate response to the actual problem drug use in Albania, hence, contributing on the violation of drug users’ human rights with special reference to their right to health. Although, the extension of the problem drug use, is taking large terrain, the legal framework, policies and responses are not facing the killing reality. The socio-economical and political transition through which Albania is passing creates the ground for generating and growing vulnerability of marginalized and vulnerable groups such as drug users. Such conditions contribute on violation of their human rights, and worsening the most fragile aspects of their life such as health, through prevention and denial of adequate services on managing the harmful consequences caused by their habit.

3.1. Countries profiles framework on drug issues

There are different factors determining the state of drug issues for certain countries. What make Albania and Slovenia more interesting and special on discussing drug related issues, is their post-communist heritage and its exceptional nature on effecting drug issues, beside their suitable geographical position as a path through the East and West. Another important reason from a researcher point of view is the similarities on the population number, which allow the comparisons between these countries according to the problems’ extension.

3.1.1 Elements of determining drug concern issues

From early 1990s, countries of Eastern Europe experienced the transition to post-communism, period starting from the end of 1989 beginning of 1990, with several implications for many countries.[83] The same range of events followed in Albania and Slovenia, which both experienced the post-communist era, but with different flows, and as a result different outcomes. Some countries are coping better with the transition period, as the example of Slovenia is (transition from a post-communist country to an EU member), and some others, as Albania is passing through slowly and in a chaotic way toward stability, where the democratic principles and the rule of law prevails.[84]

Geographically both are located in strategic parts of Europe. Albania’s geopolitical position in the Balkan Peninsula - located between countries of the former Yugoslavia, Montenegro, Greece and FYROM, and its proximity to Italy - gives it a unique position in the overall social development of the Mediterranean mixing bowl. Geographically speaking, it covers an area of 28.748 km2 with a population of 3,364,571 inhabitants.[85] Whereas, Slovenia lays in Central Europe, by the Adriatic Sea, at crossroads between the East and the West - “The Balkan path”, in a surface of 20,273 km2, and a population of 2,000,000 inhabitants. [86] This strategic position of both countries create adequate conditions to be used by producer and wholesalers of illicit drugs in both directions, and serve as a bridge and important transit point for drug smuggling through East to West.[87]

Apart from the trampoline position of the countries, they are considered as producers and consumption countries, feature that support the use and misuse of the substances. As the national report of the International Narcotic Control Board presents: “Albania and other countries in the area of the Balkans… as well as the Russian Federation and Slovenia, remain the main suppliers of cannabis in Eastern Europe”. In 2002, a total of 35 tons of cannabis were seized in Eastern Europe and an additional 30 tons were seized in the Russian Federation. The cultivation of opium in the countries of Central Eastern Europe is in low level; however the reported seizure of opiate indicates that the trafficking volume from Afghanistan through these countries is high.[88] While the strategic geographical position of both countries is a determining factor on the state of drug issues, there are as well other factors which further define the issue of drugs.

Recently, production, trafficking and use of drugs have been spreading rapidly through out the world.[89] The exacerbation of drug issues and drug related issues in Albania is explained by various changes of social, political and economic factors, after the opening of the country in 1990. These factors include: lack of preparedness of the society to tackle drugs, free movement across the borders, poverty, high unemployment rate, the desire to get rich quick, state’s inability to enforce law, lack of social and cultural opportunities of young people, as well as the recent Balkan’s wars. The above factors have influenced the increase of both drug supply and drug demand in Albania.[90]

Under the transition’s condition there have been generated new vulnerable groups, and exacerbated figures of the more marginalized and stigmatized ones, such as the victims of “drug play” - drug users. In a fragile situation and instable political atmosphere, the human rights infringement are the first affected. One and most of the government’s obligations under the human rights treaties and conventions, is to protect the most vulnerable in a state of instability and restricted financial resources, even on fulfilling the basic needs for them.[91]

The same features of increased drug issues and consumption are observed to be present in Slovenian society as well, and more intensified after 1991, period accompanied with its independence, thus, radical changes happened followed by a transition phase. Political analysts consider the Slovenian case a successful and exceptional example on throwing back transition. The best witness is its accession in the European Union after May 2004.[92] Nevertheless, the recent years have shown an increase in the supply of drugs; it has become more varied, and simultaneously, the availability of drugs has increased. New drugs are in use, although heroin is still keeping its position as the most frequently used one.[93]

These, in short, are some factors that determine the state of drug issues in both countries. Their effects will be more elaborated along the way; however, the changes of the political and socio-economic spheres play a great role on determining the drug issues and the drug consumption, as well as the responses tailored to the vulnerable groups generated by this chaotic environment. Further down we can see the evolvement of history of the drug use and problems related to its use, of both countries and how the implications of drug users’ human rights is taking place with reference to the right to health and its conditionality - access to adequate services for drug users’ needs fulfilment, hence enjoinment of their right to health.

3.1.2 Historical development of drug problems

History of drug use in both countries should be seen in relation to the specifics, which the political systems before 1990 were presenting. Both countries have passed through a communist system, but Albanian one was more closed and more rigid than that in Slovenia, hence, did not allow any communication or exchange of experiences with its neighbors. History of drug use in Slovenia is considered to be earlier than in Albania, although the “boom” of drug use for both has been in early 1990s, following the socio-economical and political events in both countries, and their transition period of post-communism.

According to professionals in the drug field, Albania with regard to its past political system does not have a history of drug use. Pursuant to anecdotal information, there has been some use of cannabis for medical purposes by the old people - pain relief, and even for putting children asleep, which was domestically produced, and was not consider as drug abuse at all, thus no criminalization or any kind of stigma raised on its acceptance.[94]

Use and misuse of illegal drugs have been present in Slovenia since 1960s early 1970s, but it was more the case of cannabis, although the use of opiate was either non-existent, or concentrated in small pockets of users. Cannabis use in ’80-s was supported by home grown, and much of the production and trade was in the ground of reciprocity. The start of explosion heroin use in the beginning of 90-s, is attributed, among other reasons, to the police eradication of cannabis plants, thus creating the need for new and/or imported drugs, hence, creating the market for foreign products, non-domestically produced, such as heroin, cocaine, etc.[95]

This can be an analogy of the American war on opium addicts in early 1918, after Harrison Act – according to which all forms of prescription of drugs by legal means was forbidden to the addicts. The user, being an addict or just satisfying his/her pleasure, was forced to become a criminal and associate with criminals - dealers of the black market, if they want to use. As a result, the myth of users as criminals became a self-fulfilling prophecy: the laws had made him/her a criminal offence simply by being a user, and easily punish them under this status, and more important denying them the necessary services on managing their problem drug use.[96]

Afterward, these tendencies are vested and reflected in the domestic laws on prosecution of users, restricting their freedoms, and making them criminal subjects, as will be explained in a later phase of the paper. Further on, certain drug trends and epidemiological data concerning both countries will be elaborated, as bases for analyzing the network of services, in accordance with the problem extension caused by drug use, and the adequate responses to these problems in responding and fulfilling their health needs. Thus creating the conditions for the enjoyment of the right to health to one of the most vulnerable groups with concern to public health.

3.2 At a glance – an overview of the drug trends and epidemiological data of Albania & Slovenia

Estimation of problem drug use in the EU ranges between 2 and 10 cases per 1000 of a population aged 15-64, or up to 1% of the adult population. Slovenia is estimated to have a prevalence of 5.3 problematic drug uses per 1000 population of the same age with that of EU estimations.[97] The estimated number of all sort of drug user in Slovenia tend to be approximately not less than 15.000 and not more than 18.000 regular, but not necessarily injecting. The group of problematic drug user or the so-called injecting is estimated to be approximately 9.000 intravenous heroin users, which makes about 4% of total population between 15 and 30 years.[98]

Increasingly, drug use problem appears to become more divers - as poly-drug use. According to data from the questionnaire Drug Users Treatment Evidence, in 2003, there were 2.860 clients reported in drug treatment, with a ranging age of 13-54, and the average age was 26. Heroin was the primary drug problem in 90% of all clients treated, yet cannabis, cocaine and stimulants were detected as primary drug problem, and 68.3% of the treated cases were poly-users, and 74% of them used drug by injecting every day. Apart from the treatment data, in its 2003 annual report, the harm reduction project Stigma, report 913 persons included in syringe exchange, counselling and information as the main objectives of the project. [99]

Although there are trends of sharing of injecting paraphernalia, the prevalence of blood borne diseases is low. Thus, the prevalence of HIV is below 1% among the confidentially testing drug users by 2003, and the HBV stays on the levels of 10.4%, followed by a 22.2% prevalence of HCV.[100] This figure suggest for a low prevalence of risky behaviours in the country, compared to other EU countries, and implies that prevention of the spread of these diseases through harm reduction interventions may still be possible.[101]

All the presentations and introductions of epidemiological data given here, with regards to Slovenia, create a general picture to the reader for the extension of the problem drug use in the country. The same pattern of examples will follow for the case of Albania, thus, realizing that although the extension of the drug use problem and the harms related to its use are alike, the responses on offering the adequate services do not correspond, as we will see along. As it is stated before, drug users create a vulnerable group with respect to their habit and the harms it causes. There is an increase in drug use problems in Albania as well, and the data presented bellow will help to create a general view on the epidemiology of drug use.

Media estimation in early 1998, present the number of users as many as 20,000. Rapid Assessment and Response estimations on 2001, reported the number of drug users, all over Albania, ranging from 10,000-30,000 – out of a 3,087,159 population in the country[102], and now from the sources of the NGO-s acting in the field, and the Ministry of Health the number is estimated to increase up to 40.000 users of all drugs, included the so-called soft drugs.[103]

Meanwhile, the estimated numbers for the problematic drug users in the recent years, such as injecting, is recognized to be more than 10.000 mainly young people. The drug of choice is heroin. There is a real scarcity of information regarding injecting drug use and culture of needle exchange, although from self reported cases result that sharing and other risky behaviour such as unprotected sexual intercourse happen often.[104] Bleaching is not known and they do not perceive as a risk sharing of syringes. High prevalence of Hepatitis C was seen among drug users according to data provided by IPH. They report several sexual partners and the level of condom use is very low.[105]

Patients who are using a detoxification service are typically young males between 15 and 25 (55%), who make use of heroin (82%). In the majority of cases, Albanian drug users take impure drugs. Based on the treatment-demand-data, it has to be added that drug injecting is becoming more and more frequent (26.6% of drug users demanding treatment in 1999 compared to 19.5% in 1998). At the Tirana Toxicological Clinic, the percentage of injecting drug users has reached in the first half of 2001 almost 80% out of all treatment demands.[106] This Toxicological Clinic is the only one in Tirana and in all Albania, and the drug problems are treated only on their acute phase, not offering a full follow up of the problem. Further more it does not cover - at least acceptably, not all- the number of users in Albania.[107]

The figures of drug use problem-exacerbation are present in both countries, following the range of intensifying drug use also in the global level. Most of the users in both countries are of young age, and the tendencies of the patterns drug use are switching from less to more harmful – that to injection. The speed of changing of these tendencies is the impulse of re-considering the existing responses, thus preventing the prevalence of harms related to drug use.

The following presentation will discus the legal framework under which is developed the network of available services, according to the responses given to drug use and extension of problematic drug users. Considering the similar extent of the problematic, as illustrated in details above, from the examples of Albania and Slovenia, the range of responses is not alike. These practices are resulting in unnecessary morbidity and preventive mortality, within the ranks of a vulnerable group such as dependent drug users. State is the only actor who fulfills human rights of its citizens, by means of its authority given by its citizens. “That is why we ask questions and seek answers as the key of the defense of our human rights”.[108]

3.3 Responses and drug users’ human rights

One of the state obligations in making possible the enjoinment of the right to health for drug users is generating the legal framework for that purpose. From a right-based approach this is translated in the language of laws, which promote and protect, thus invest on realization of the right to health of this vulnerable group. This can be achieved through securing the range of necessary and adequate services such as harm reduction or low-threshold services of syringe exchange programs and substitution therapy as methadone treatment.[109] If the prohibition law does not allow the creation and establishment of facilities and health services for drug users – thus, influencing on increasing the vulnerability of the group concerned and violating their human right to health – nevertheless, sometime there are ways out. One opportunity can be - especially in a transition period, as the case of Albania is – establishment of legal acts and national strategies and/or policies – as a micro level policies - on the field of drug demand reduction and treatment, which could serve as a legal foundation where we can base our action for making possible the enjoinment of this right with respect to their vulnerability from the harm caused. Although the alternative solutions might be in place, other obstacles are coming on stage, such as challenges of implementation of policies and strategies. Many professionals in the field justify their stoicism with the lack of financial and human (specialized in the field of drugs) resources, taking in consideration its complexity. Let us concretize these statements through the examples of both countries in question.

3.3.1 Analyzes of the legal framework

This part will present patterns of the legal framework of both countries in a macro level, such as legislation on drugs are, and in a micro level, as strategies and other policies - tailored on responding and addressing the drug users’ needs, thus, making possible the enjoinment of their human rights and specifically the right to health. Sometimes, there are obstacles and limitations embodied in these legal bases, in tailoring the adequate services and responses to drug use and drug issues, thus often contributing on the breaches or violation of the drug users’ human rights, and specifically that to health. The inconsistencies between the legal ground and strategies on responding these needs often can be an obstacle for offering the adequate services such as harm reduction and its practices on meeting drug users’ needs. The analysis of the examples will introduce the patterns of drug users’ human rights violations through insufficient services and empathic responses.

3.3.1.1 Legal framework - the macro level atmosphere

Albania and Slovenian base their national legislations and strategies on drug, on international drug control conventions: “The Single Convention on Narcotic Drugs” 1961, “The Convention on Psychotropic Substances” 1971 (with exception of Albania which is not yet party[110]), and” The United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances 1988” – as state parties to them, in responding to their domestic drug situations[111]. The tendency of the countries that sign the conventions is to adapt their national legal framework with the international law, thus improving their responses and coordinating their actions toward a better and effective result.[112]

In these conditions, Slovenia has tailored its legal framework in the drug field by promulgating three laws accordingly:

1-The law on -“Production of and Trade in Illicit Drugs”- 1999. The law sets forth the conditions in which the production and trade of illicit drugs and psychotropic substances shall be permitted, and those of the possession of illicit drugs. Article 33 of this act provides penal provision for the act of possessing smaller quantity of illicit drugs for one-off personal use. Thus, individuals shall be liable to monetary fine or prison sentence of up to 5 days. [113]

This result in making the drug users subject of criminal law – depriving of their liberty, and discriminating against them for the sake of being a user. Hence, they can be punished because of their status of being a drug user, resulting in interfering with one of the most fragile spheres of personal life - privacy. For a drug user there is no space for privacy - he/she has to be controlled, for the sake of his/her habit. The same sanctions are foreseen in the convention of 1988, so sometime the international law becomes a supportive source for the foundation of violations translated in the domestic level.[114] Despite the law language and its theoretical frame, professionals in the field claim that: “Although the law does not allow the possession for personal use, the police are more or less liberal toward that act, it does not bother that much the users, but the law – the law does not allow that.” [115]

Following the range of penal provisions, the second paragraph of article 33 states that: the persons who commit the offences specified in the above paragraphs “…may be subject to more lenient punishment if they voluntary enter the programme of treatment for illicit drug users or social security programmes approved by the Health Council or Council for Drugs”.[116] A qualitative research from the doctoral dissertation “Drugs as an Element of Political Relations. Human Rights on the Example of the Subculture of Drug Users” states the perception of users about the “forced treatment and compulsory entering various treatment and rehabilitation programme, give no other benefit than stigma arising from that.”[117] This practice positions the users of such services in a circle they do not deserve to be put in. The practice of force treatment does not take into account the users responsible choice, does not even see him/her as full human being, and does not even give the right to chose what is best for him/her.

2- The second legal base for drug issues in Slovenia derives from the law of -“Use of Illicit Drugs and Dealing with consumers of Illicit Drugs”, 1999. This law sets forth the measures for the prevention and treatment of the use of illicit drugs, and dealing with consumers of illicit drugs, as well as specifying activities and responsibilities of the state and the establishment of a co-ordinating body at the governmental level. There are also foreseen different social programs and social support for drug addicted. [118]

3- Thirdly - “The law on Precursors of Illicit Drugs”, 2000. This law shall govern the production, trade in, user and supervision of substances which can be used as precursors for the production of illicit drugs for the purpose of preventing their abuse or use for illegal purposes.[119] If we see the examples in the light of comparison, the Albanian case does not change that much, at least in the theoretical part of the problem. The range of provisions follow those of the international legal frame, although in some points it is more liberal and “advanced”, which is to be explained in the following.

In December 2000, the Albanian Parliament passed the law on Albania’s adherence to the UN Conventions of 1961 and 1988. In March 2001, Albania acceded to the 1961 Convention, and in August 2001 that of 1988. However, it has not yet acceded to the 1971 Convention. The International Narcotic Control Board notes that, in March 2002, the Parliament of Albania passed a “Law on the control of precursor chemicals” consequently it claims “as the necessary legislation and practical control measures that conform to the provisions of the 1971 Convention have been put in place, Albania could accede to the Convention without further delay.”[120]

Being part of the international scheme of drug control does not guaranty the fulfilment of obligations. Often, it happens that the state parties do not fulfil their obligations, although the monitoring mechanisms are reacting on enforcing them. Thus, in its annual report of 2004, the International Narcotic Control Board[121], stated the failure of the state parties in the 1988 convention to submit the annual information on the substance frequently used in the illicit manufacture of narcotic drugs and psychotropic substances. “Those parties, which include Afghanistan, Albania, Morocco, Mozambique, New Zealand, the Republic of Moldova, Serbia and Montenegro, Turkmenistan and Zimbabwe, should comply with their treaty obligations as soon as possible.”[122]

Nevertheless, in accordance with the international laws, Albania established its national legal ground as such: 1- “Law on narcotic and psychotropic substances” July 26, 1995. The law sets forth conditions under which the production, manufacture, trade, and use of narcotic medicaments and psychotropic substances can be used. Also, it foresees the classification of the narcotics and psychotropic substances, based on the damages they cause, and dangers they present to people’s health.[123]

The classification is based on the international conventions of 1961 and 1971. According to both conventions, methadone, which is used as a treatment for addictive drug users, is classified in the first Schedule of the list of Drug as one of the most dangerous, and is subject of measures of control applicable to the drugs under these conventions. “For a certain period of time, Albania justified methadone denial as a treatment toward dependent drug users, thus denying one of the most profitable and effective treatment for this vulnerable group”. Although the prescription of methadone is allowed under specific provisions, not in the law, it is supervised under very strict rules. Thus, making it unavailable and inaccessible to users, and failing on fulfilling drug users’ right to health, through inaccessibility of the necessary treatment.[124] It is of great relevance to mention that in 2004, WHO and UNAIDS listed methadone and burprenorphine in the Essential Drug List, and recognized them as substitution medications for the treatment of dependent drug users.[125]

Second legal foundation with great importance is Penal Code, more precisely - “Changes of the Penal Code” in January 2001, where several other criminal drugs related activities, mostly the concern about personal use - not foreseen before - are well covered. In March 2001, the Albanian Parliament passed the “Law on the Prevention of the Illegal Trafficking of Narcotic Substances” where drug users are not found guilty.[126] With the changes foreseen there, the act for personal use is no more considered a criminal act, or in breach with the law.[127] This is a positive step further more toward liberal laws and less stigmatized, thus accepting the issue till a point, but on the other hand it is a way out on tackling the illicit drug use, or reducing the harms generated from these practices. In the same line was the conclusion of the Board stating that: “the state parties are legitimate to both criminalize drug use offences and choose other kinds of sanction of non-criminal nature, as best measure to tackle the illicit drug use of drugs and its related problems”.[128]

All the above-mentioned laws in the case of Albania focus their attention on supply reduction strategies, rather than on demand and harm reduction. Thus, not a single word is written on foreseeing the harm reduction practices as the methadone treatment and the needle exchange programs. Harm reduction practices are foreseen in special legal acts, but not in the law. Hence, the availability and accessibility of the services and the adequate response to drug addiction is very restricted, due to the state’s financial resources, as some of the professionals claim[129], or indifference toward the problem. Stigmatizing and discriminating attitudes toward drug users can be an obstacle for the allocation of funds. Basing the arguments on this ground justifies the denial of adequate services and responses to drug use and its related harms, such as the methadone treatment and other low-threshold servi