Policymakers around the world have been watching closely as a new United States administration sets out its strategies on a variety of global challenges. And in the field of international public health, President Obama's policy choices are causing a stir among those who treat drug addiction.
Reversing a decades-old policy, the Obama White House has approved federal funding of needle and syringe exchanges, which have been pioneered in liberal cities like Seattle. The police chief there, Gil Kerlikowske, is expected to be confirmed next month as national drug czar.
The shift in US policy is broadly welcomed by advocates of "harm reduction," an approach to drug use that puts public health and education before law enforcement. They see the changes as a vital step by a country that for decades has viewed illegal drugs almost exclusively through the lens of prohibition.
"The US has been a big block on harm reduction at the international political level.... It's beginning to change, and it's changed quite suddenly," says Gerry Stimson, executive director of the International Harm Reduction Association, which is holding its annual conference this week in Bangkok.
Proponents of harm reduction want to see the US go much further in overhauling its drug policy. Equally crucial, they say, is US support for international programs in developing countries where millions of injecting drug users (IDUs) are at risk of contracting HIV/AIDS, slowing other recent gains in fighting the disease.
US diplomats still object to the inclusion of harm reduction in United Nations counternarcotics declarations, though it's been adopted by virtually all UN agencies. And Obama has yet to tinker with Bush-era rules that ban the use of US foreign aid money to fund needle exchanges for drug users.
Experts on HIV/AIDS argue that needle exchanges, peer-led education, and substitute therapies such as methadoneoffer a proven way to prevent new infections among IDUs. But only a fraction of the $14 billion spent globally last year on tackling the disease went into such programs, says Michel Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
The US government is the largest single contributor to the UN-backed fund. Mr. Kazatchkine says it faces a $4 billion shortfall in funding over the next two years, as recession-hit donors cinch their belts.
Handling dirty needles
In Thailand, which won praise in the 1990s for reducing HIV infections by promoting condoms in its sex industry, up to half of surveyed drug users test positive for the disease. Outside of sub-Saharan Africa, transmission via dirty needles accounts for roughly 30 percent of all HIV cases. In eastern Europe, Russia, and Asia, this practice is blamed for the majority of new infections, say health workers and UN officials.
Yet at the same time, life expectancy for people in the developing world living with HIV/AIDS has improved dramatically, as retroviral drugs have become more available Even in countries like Botswana, where infection rates are estimated at 1 in 4 adults, life expectancy is improving.
"The latest data on survival shows amazing progress in the world, both in developed and developing world, now that we're expanding access to treatment on a large scale, but no progress on IDUs," says Kazatchkine.
From boot camp to outreach
Conservatives in the US have argued that harm reduction sends the wrong message and is a back-door route to legalizing drugs. That view is popular in Asia, where governments often send addicts to military-style boot camps that inmates say are abusive and have low success rates.
But some countries in the region are also quietly reaching out to drug users, recognizing that punitive measures don't address the health risks associated with unsafe injections. Experts say the rapid spread of HIV has shifted the approach of law-and-order policymakers: China is rolling out methadone clinics and outreach services, for example, and Indonesia is inviting activists into jails.
"It's one of the very powerful arguments that we use with governments and that they need to think about. Many of the epidemics of HIV in this region have been, and continue to be, driven by the spread of HIV among drug users because they don't have access to a comprehensive package [of services]," says Gray Sattler, a regional advisor on HIV/AIDS at the UN Office on Drugs and Crime in Bangkok.
This newfound enthusiasm doesn't mean Asian governments are going soft on drugs. In Malaysia and Indonesia, convicted traffickers can face the death penalty. The 10 member-states of the Association of Southeast Asian Nations have pledged to make their region drug-free by 2015.
"In Southeast Asia, people believe in abstinence. Even organizations that run harm-reduction programs, they don't fully believe in harm reduction," Shaharudin bin Ali Umar, a Malaysian former drug addict, told the conference.
'War on drugs' critics raise their voices
While the battle against HIV/AIDS is influencing drugs policy in Asia, reformers in the US are seizing on the upsurge in drug violence in Mexico and the shortfall in state taxes to sharpen their criticism of the war on drugs.
"These state budget crises we haven't seen since the Depression, and that's forcing a rethink on priorities. There's a notion that locking up vast numbers of people is a luxury that we can no longer afford," he says.