While waste and energy grab the headlines, there is another threat to our way of life whose consequences are at least as severe. Our society is sick and without the proper treatment it will only get worse.
The role intravenous drug users (IDUs) play in spreading HIV to the wider population through unsafe sex has been recognised for a long time. This is principally because IDUs have little inclination to utilise condoms. In Mauritius, nearly all IDUs inject opiates and while we have consistently had the highest prevalence of opiate use in Africa, the incidence of HIV has been relatively low. However, the rate of notified HIV infections has increased rapidly in recent years. In 2007, WHO estimated that the number of people living with HIV was 13,000 (7,000 – 28,000), equivalent to 1.7% (1% – 3.6%) of the adult population (15-49 years).
The latest UNAIDS report on Mauritius makes grim reading. While in 2000, only 2% of new cases of HIV were among intravenous drug users, this has exploded to the point that 85% of those registered as infected are IDUs, with between 30% and 60% of all IDUs being infected. The report quotes studies claiming that half of IDUs have sex with non-regular partners and one fifth with commercial sex workers; very few use condoms. Around three quarters of commercial sex workers are also IDUs and most of them have unprotected sex with their clients or partners. There is now every indication that HIV is bridging into the wider population.
SADC has recognised the risk HIV/AIDS poses to regional tourism. Mauritius has traditionally been known as a safe holiday destination. However, as the prevalence of HIV increases, its reputation as a high class resort is bound to suffer and its desirability decline. This is compounded by the inreasing rate of acquisitive crime, about which potential tourists are now being warned by their governments. The link between crime and drug use is well established and, with a typical habit costing Rs.15,000 – Rs.30,000 per month, opiate users are undoubtedly responsible for a significant proportion of attacks on tourists visiting Mauritius. Opiates not only generate the need to find additional income to feed the addiction, their very use confers the audacity to commit crimes.
It is not just the tourist industry that is under threat. Just the prescription of anti-retroviral drugs on a large scale would put great strain on our health care budget. However, these medications only slow the onset of AIDS, they do not prevent it. With an increasing proportion of the working population suffering from AIDS related health complications, the effect on every sector of the national economy, not just health care, would be significant.
Mauritians have a tendency to believe that if problems are ignored then they will probably disappear. While this may well be true for many things, from complaints made against a government department to high profile criminal proceedings, it will not be the case for HIV/AIDS. If we still have time to act, the window of opportunity is shrinking rapidly.
Sexual transmission of HIV must be reduced by redoubling our efforts to educate the population on the need to only engage in safe sex. Nowhere is this more important than the commercial sex industry. However, as already noted, IDUs are not inclined to use condoms. Therefore, it is absolutely vital to detoxify every sex worker who injects opiates.
This can be ensured by regulating sex workers: frequently screening them for every sexually transmissible disease and giving them absolute priority for treatment for opiate addiction. While our conservative society may baulk at the idea of legitimising prostitution, the very fabric of our society is threatened because sex workers are the largest conduit for HIV to pass from IDUs to the wider population. Once free from their expensive addiction, many will have no further need to engage in prostitution.
As a society, it is high time to drastically intensify our collective efforts to eliminate intravenous drug use in Mauritius. The example of America's extremely expensive, but ultimately ineffective, “war on drugs” proves that it is impossible to eliminate an established drug supply, even if there is a genuine will to do so, as long as there is demand. This should be self-evident to anyone with the most basic understanding of economics. So what is the source of demand?
While some people experiment with drugs because of coercion or peer pressure, most turn to drugs through choice, often to relieve some underlying physical or psychological condition. In Mauritius, this started amongst slaves, who used to illegally brew alcohol to momentarily escape their sense of repression. It was later augmented when immigrants from India and China introduced cannabis and opium respectively. However, drug use was contained within certain socio-cultural contexts and did not present a significant problem.
In the 1980's, as the opium supply dried up, heroin appeared on the market in the form of “brown sugar”. Within a short time, abuse of this drug became epidemic. The government responded by adopting the advice of the UN and WHO aimed at making Mauritius a drug free nation. The success of this approach has clearly been limited as both organisations have since encouraged our government to implement needle exchange programmes to reduce the spread of HIV amongst IDUs. Given this admission of failure and the risk of the spread of HIV from IDUs to the wider population, it is high time the zero tolerance approach was revisited.
What is utterly hypocritical about our current policy, apart from failing to distinguish between various criminalised drugs, is that it totally ignores the dangers of the two most prevalent drugs: alcohol and nicotine. In addition, it fails to address the underlying causes that drive people to self-medicate with drugs in the first place. However, the concept of self-medication is implicitly recognised in society, where it is perfectly acceptable to take an alcoholic drink or to smoke to relieve stress, for example, after a tough day at work.
The table below indicates the effects and dangers associated with some drugs used in Mauritius. They are ordered according to the degree of risk they pose to society (greatest first) following a report published in the respected UK medical journal, the Lancet, (as summarised on msnbc).
|Drug||Immediate effect||Human equivalent||Addictiveness||Chemical toxicity|
|Heroin||Intense pleasure, sense of well being||Several e.g. endorphins - released during strenuous activity||High||Fatal in overdose and withdrawal|
|Cocaine||Stimulation, euphoria||None. Inhibits re-uptake of neuro-transmitters||High||Fatal in overdose|
|Alcohol||Sedation, reduces stress and inhibition||Produced by intestinal bacteria||Moderate||Fatal in overdose and withdrawal|
|Tobacco (Nicotine)||Varies with concentration – stimulation to sedation||None. Activates multiple neurological pathways||High||Nicotine is fatal in overdose|
|Cannabis||Contentment, anti-depressant, anti-anxiety||Naturally produced in the body, also found in human maternal milk||Low||Non-fatal in overdose|
|Ecstasy (MDMA)||Euphoria, intimacy||None. Complex neuro-chemical interactions, releases hormones e.g. oxytocin||Low||Fatal in overdose|
Obviously the more dangerous drugs, even if taken initially to solve a different problem, become a source of disease due to their addictive qualities and negative side effects. Heroin heads the table in terms of societal risk. However, since heroin and, more recently, Subutex (a synthetic opiate used to relieve heroin withdrawal) are the drugs used by nearly all IDUs, they are uniquely dangerous due to their involvement in the spread of HIV.
To eliminate the use of injected opiates, it is necessary to massively increase the availability of detoxification treatment. As well as being provided psychological help to deal with the problems that have resulted from drug use, ideally, ex-addicts should be given the appropriate therapy for the problems that drove most of them to use drugs in the first place. However, since many of these issues are systemic ones within society itself, the only way eliminate demand for intravenous drugs in the short term is to permit people to self-medicate with more benign drugs.
One over-looked suggestion is to temporarily decriminalise the cultivation and possession of cannabis for personal use. This would make it an accessible alternative to injectable opiates for both ex-addicts and potential new users looking for symptomatic relief from physical and psychological problems. Of course, it would be necessary to control it along the same lines as alcohol and tobacco, including prohibiting its use by minors, consumption in unlicensed public spaces and driving under the influence. It would also be important to use traditional species of plant to avoid the problems encountered in European countries with extremely potent, selectively bred variants.
There are compelling reasons to support this proposal:
The last point is important because it is vital to disrupt the supply of injected opiates. If the drugs are much more difficult to procure, it will encourage IDUs to seek treatment and ex-addicts will find it significantly easier to sustain their abstinence . This may well require a major purge of the law enforcement agencies to remove any elements within them that are currently involved in opiate distribution. One would expect them and their patrons to vehemently oppose this proposal as it would have significant impact on their income from illicit activities involving both opiates and cannabis.
In the longer term, it will only be possible to eliminate drug abuse, including alcohol and tobacco, by improving the mental and emotional health of each member of society. This will become easier as society itself changes to eliminate the structural problems that are often the context and catalysts for psychological problems in the individual.
For Maurice Ile Durable to become a reality we need to expand our vision beyond waste and energy. To
achieve a truly sustainable society we have to address everything that threatens our future. As well as pollution and climate change, this must include disease, drugs and the underlying causes that drive people to use them. One of the greatest threats is an HIV epidemic among the population at large. Can we afford to restrain ourselves from taking every step necessary to eliminate this risk?