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

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

3. 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. 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. 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. 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. 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. 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. 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. 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