Leo Beletsky

Sequester the Drug War: Drug Control Spending and the Opportunity to Stop Throwing Good Money After Bad

Leo Beletsky — Fri, 07 Jun 2013 06:02:44 PDT

Access to syringes for HIV prevention for injection drug users in St. Petersburg, Russia: syringe purchase test study

Ekaterina V. Fedorova et al. — Mon, 04 Mar 2013 06:45:20 PST

Background

The HIV epidemic in Russia is concentrated among injection drug users (IDUs). This is especially true for St. Petersburg where high HIV incidence persists among the city's estimated 80,000 IDUs. Although sterile syringes are legally available, access for IDUs may be hampered. To explore the feasibility of using pharmacies to expand syringe access and provide other prevention services to IDUs, we investigated the current access to sterile syringes at the pharmacies and the correlation between pharmacy density and HIV prevalence in St. Petersburg.

Methods

965 pharmacies citywide were mapped, classified by ownership type, and the association between pharmacy density and HIV prevalence at the district level was tested. We selected two districts among the 18 districts -- one central and one peripheral -- that represented two major types of city districts and contacted all operating pharmacies by phone to inquire if they stocked syringes and obtained details about their stock. Qualitative interviews with 26 IDUs provided data regarding syringe access in pharmacies and were used to formulate hypotheses for the pharmacy syringe purchase test wherein research staff attempted to purchase syringes in all pharmacies in the two districts.

Results

No correlation was found between the density of pharmacies and HIV prevalence at the district level. Of 108 operating pharmacies, 38 (35%) did not sell syringes of the types used by IDUs; of these, half stocked but refused to sell syringes to research staff, and the other half did not stock syringes at all. Overall 70 (65%) of the pharmacies did sell syringes; of these, 49 pharmacies sold single syringes without any restrictions and 21 offered packages of ten.

Conclusions

Trainings for pharmacists need to be conducted to reduce negative attitudes towards IDUs and increase pharmacists' willingness to sell syringes. At a structural level, access to safe injection supplies for IDUs could be increased by including syringes in the federal list of mandatory medical products sold by pharmacies.

Advancing human rights in patient care: the law in seven transitional countries (forthcoming)

Leo Beletsky et al. — Thu, 31 Jan 2013 09:10:20 PST

Global governance of health: conference report

Scott Burris et al. — Thu, 03 Jan 2013 06:40:17 PST

“Governance” is the management of events in a social system. “Good governance” in global health requires institutions capable of effectively delivering health goods, and mechanisms of participation and accountability that maximize the extent to which stakeholders at all levels can shape both the ends and the means of health programs.

The OSI Seminar on the Global Governance of Health brought together 40 global thinkers and leaders in public health, health services delivery, health policy, and academia for two days of intensive discussion of the current state of health governance, followed by two days of collaborative brainstorming on new initiatives in governance practice, research and theory.

Over the course of the Seminar, this group of prominent practitioners and theoreticians agreed that governance was important, timely, and unduly neglected in health. Ranging in scope from the city to global levels, presentations and comments laid out a complex picture of how governance deficiencies limit the impact of efforts to promote a higher level and fairer distribution of good health around the world. There was wide agreement that most of the pivotal issues—including inefficient resource allocation, corruption, top-down program design, lack of coordination, and insufficient involvement of civil society—could profitably be conceptualized as failures of governance. Despite this agreement, attendees had much difficulty arriving at a consensus on what terms or indicators to use to conceptualize these governance failures and what efforts are needed to remedy them. This struggle paved the way to constructive ideas about the necessary next steps for an initiative to improve the global governance of health.

Five themes emerged from these proceedings:

- This is a time of opportunity for meaningful change in the governance of global health programs.
- The governance of health at the global level is weak and coordination is poor.
- Participatory rhetoric from powerful actors has fallen short of giving stakeholders and civil society a meaningful role in decision-making.
- Despite the rise in funding and interest in disease-specific programs, the core mission of promoting population health and improving health systems is being obscured.
- Major empirical and political work is needed to improve the governance of global health programs.

Participants suggested a comprehensive, well-coordinated program of action in which health leaders, practitioners, researchers and civil society stakeholders would:

1. Design and implement strategies to mobilize global health leaders to improve governance internally—in their own organizations—as well as the system on the whole;
2. Develop strategies and build coalitions for boosting support among global elites for stronger public health institutions and global governance architecture built on a properly funded “anchor” institution;
3. Provide functional mechanisms of representation and organization of civil society in global health architecture, including support for civil society at the local level to participate effectively, continued human rights advocacy, and re-thinking current frameworks (such as the Global Fund’s CCM) from a governance standpoint.
4. Conduct interdisciplinary research to advance systematic measurement of governance, and identify or develop models of good health governance at the local, national and international levels.

Policy reform to shift the health and human rights environment for vulnerable groups: the case of Kyrgyzstan's Instruction 417

Leo Beletsky et al. — Thu, 03 Jan 2013 06:40:16 PST

Background: Police activities shape behavior and health outcomes among drug users, sex workers, and other vulnerable groups. Interventions to change the policing of drug consumption and sex work in ways that facilitate public health programming and respect for human rights have included policy reforms, education, and litigation. In 2009, the Kyrgyz government promulgated “Instruction 417,” prohibiting police interference with “harm reduction” programs, re-enforcing citizen rights, addressing police occupational safety concerns, and institutionalizing police-public health collaboration.

Objectives/Methods: Although ample evidence points to gaps between intended and actual impact of policy and other structural interventions, there is little research on the impact of initiatives designed to align policing, health, and human rights. We conducted a police officer survey to assess links between Instruction 417 knowledge and legal and public health knowledge, attitudes towards harm reduction programs, and intended practices targeting vulnerable groups.

Results: In a 319-officer sample, 79% understood key due process regulations, 71.1% correctly characterized law on sex work, 54.3% understood syringe possession law, while only 44.4% reported familiarity with Instruction 417. Most (72.9%) expressed positive attitudes toward condom distribution, while only 56% viewed syringe access favorably. Almost half (44%) agreed that police should refer vulnerable groups to disease prevention programs, but only 20% reported doing so. In multivariate analysis, knowledge of Instruction 417 was associated with significantly better knowledge about (aOR=1.84, 95%CI: 1.12-3.00) and attitudes towards harm reduction programs (aOR=3.81, 95%CI:1.35-10.75), and knowledge of due process for the detention of sex workers (aOR=2.53, 95%CI:1.33-4.80). Younger, junior officers and those in rural areas may not be well-informed about the policy.

Discussion: While reflecting positively on Instruction 417 as a structural approach to aligning policing and public health, this analysis highlights gaps in policy dissemination and calls for further research to assess street-level impact of interventions on the health and human rights environment for vulnerable groups.

CommonHealth: Mass. a national leader in overdose prevention

Leo Beletsky et al. — Wed, 19 Dec 2012 04:43:24 PST

In this interview on Radio Boston, Leo Beletsky and Alexander Walley discuss their viewpoint piece, “Prevention of Fatal Opioid Overdose,” which appeared in the Nov. 14, 2012 issue of the Journal of the Medical American Association.

Prevention of fatal opioid overdose

Leo Beletsky — Thu, 15 Nov 2012 08:20:57 PST

Opioid overdose is a burgeoning public health crisis, accounting for at least 16,000 deaths annually in the United States. Opioid overdose occurs across sex, ethnic, age, and geographic strata and involves both medical and nonmedical opioid use. To date, federal government response has focused primarily on monitoring and securing the drug supply. This Viewpoint suggests various steps necessary to support a more comprehensive approach.

Advancing public health through the law: the role of legal academics: workshop report

Leo Beletsky et al. — Tue, 18 Sep 2012 08:10:13 PDT

The July 2012 workshop Advancing Public Health Through the Law: the Role of Legal Academics was funded by The Robert Wood Johnson Foundation's Public Health Law Research Program and convened by the Northeastern University School of Law Program on Health Policy and Law. The workshop brought together nationally recognized public health legal scholars, public health practitioners and advocates, and representatives of grant-making insituttions. Through interactive exercises and discussions, participants explored the value that legal doctrine and practice add to public health and ways to strengthen public health law's engagement with public health practice.

The convening of this workshop was motivated by the realization that today public health exists in a shifting institutional, political, and doctrinal environment. This environment threatens to roll back decades of health outcome improvements and advances in social welfare. At the same time, there are a number of new opportunities related to an increasing prominence of evidence-based policy in general and empirical public health law research in particular.

Throughout the meeting, there was a tangible consensus that the current adverse environment makes this a critical time to engage legal academics and their allies in protecting and advancing public health. Based on this consensus, participants were energized by the prospect of moving forwrad on a coordinated strategy to increase our influence and effectiveness as public health law scholars and advocates. A number of innovative ideas emerged for advancing this agenda: disseminating a persuasive counter narrative to the false dichotomy between "free market" choice and regulation using a variety of channels; embedding public health practitioners within law schools for knowledge transfer residencies; supporting theoretical public health law scholarship through writing competitions, mentorship, and loan forgiveness programs; and integrating public health law content in a wider variety of law and public health courses, including information on strategic litigation, externality theory, and behavioral economics. Given the broad range and scope of the discussion, it was clear that a follow-up meting should be convened to develop the mission, vision, and specific operational strategies. Drawing on these discussions, this report summarizes the proceedings and next steps to engage legal academics in improving public health.

Syringe confiscation as an HIV risk factor: the public health implications of arbitrary policing in Tijuana and Ciudad Juarez, Mexico

Leo Beletsky et al. — Tue, 10 Jul 2012 10:30:07 PDT

Female sex workers who inject drugs (FSW-IDUs) face elevated risk for HIV/STIs and constitute a key population for public health prevention. Through direct and indirect pathways including human rights violations, policing practices like syringe confiscation can compound FSW-IDU health risk and facilitate the spread of disease. We studied correlates of experiencing syringe confiscation among FSW-IDUs in northern Mexico, where formal policy allows for syringes to be available over-the-counter without a prescription, but police practices are often at odds with the law. FSW-IDUs reporting recent syringe sharing and unprotected sex with clients in Tijuana and Ciudad Juarez were administered surveys and HIV/STI testing. Logistic regression was used to identify correlates of syringe confiscation. Among 624 respondent FSW-IDUs, prevalence of syringe confiscation in the last 6 months was 48%. The following factors were positively associated with syringe confiscation: testing positive for HIV (adjusted odds ratio [aOR]=2.54, 95% confidence interval [CI]=1.11-5.80), reporting sexual abuse by police (aOR=12.76, 95%CI=6.58-24.72), engaging in groin injection (aOR=1.84, 95%CI=1.15-2.93), injecting in public (aOR=1.64; 95%CI=1.14-2.36), and obtaining syringes from pharmacies (aOR:1.54; 95%CI=1.06-2.23). Higher education level was negatively associated with syringe confiscation (aOR=0.92, 95%CI=0.87-0.98) as was frequent injection with clients within the last month (aOR=0.64, 95%CI=0.44-0.94). This analysis adds to the body of evidence linking unauthorized law enforcement actions targeting high-risk groups with HIV and other adverse health outcomes. Using a public health lens to conceptualize abuse as a structural risk factor, we advocate for multi-prong prevention, systematic monitoring, and evidence-based intervention response to deleterious police practices.

Harmonizing disease prevention and police practice in the implementation of HIV prevention programs: up-stream strategies from Wilmington, Delaware

Leo Beletsky — Sat, 12 May 2012 11:07:02 PDT

Introduction: Improving access to sterile injection equipment is a key component in community-based infectious disease prevention. Implementation of syringe access programs has sometimes been complicated by community opposition and police interference.
Case description: In 2006, the Delaware legislature authorized a pilot syringe exchange program (SEP). A program designed to prevent, monitor, and respond to possible policing and community barriers before they had a chance to effect program implementation and operation was planned and implemented by a multidisciplinary team of legal practitioners and public health professionals.
Discussion: We report on an integrated intervention to address structural barriers to syringe exchange program utilization. This intervention employs community, police and client education combined with systematic surveillance of and rapid response to police interference to preempt the kinds of structural barriers to implementation observed elsewhere. The intervention addresses community concerns and stresses the benefits of syringe exchange programs to officer occupational safety.
Conclusions: A cohesive effort combining collaboration with and educational outreach to police and community members based on the needs and concerns of these groups as well as SEP clients and potential clients helped establish a supportive street environment for the SEP. Police-driven structural barriers to implementation of public health programs targeting populations engaged in drug use and other illicit behavior can be addressed by up-stream planning, prevention, monitoring and intervention strategies. More research is needed to inform the tailoring of interventions to address police-driven barriers to HIV prevention services, especially among marginalized populations.

Mexico's northern border conflict: collateral damage to health and human rights of vulnerable groups

Leo Beletsky et al. — Wed, 07 Mar 2012 05:40:31 PST

Objectives: Given links between policing environment and infectious disease risk among vulnerable groups, we surveyed female sex workers who inject drugs in Tijuana and Ciudad (Cd.) Juarez. Data were used to 1. compare distributions of human rights violations and disease risk, 2. juxtapose these patterns against demographic and structural environment variables, and 3. formulate implications for structural interventions.

Methods: Structured interviews and testing for sexually-transmitted infections (STIs) were conducted (October 2008-October 2009). Frequency of individual and environmental factors, including police abuse, HIV risk and protective behaviors were compared between sites using univariate logistic regression.

Results: Of 624 women, almost half reported police syringe confiscation despite syringes being legal and 55.6% reported extortion (last 6 months), with significantly-higher proportions in Cd. Juarez (p<0.001). Reports of recent solicitation of sexual favors (28.5% in Tijuana, 36.5% in Cd. Juarez, p=0.04) and sexual abuse were commonplace (15.7% v 18.3%). Significantly lower prevalence of STIs in Tijuana (64.2% v 83.4%, p<0.001) paralleled lower prevalence of sexual risk behaviors there. Cd. Juarez respondents reported significantly-higher median client loads (1.5 v 6.9, p<0.001) and lower median pay per sex act (US$20 v US$10, p<0.001) (last month). Relative to Tijuana, security deployment was perceived to increase more in Cd. Juarez (last year), especially army presence (59.2% v 72.1%, p=0.001).

Conclusions: Collateral damage from police practices in the context of Mexico’s drug conflict may impact public health in the Northern Border Region. Itinerant officers may facilitate disease spread beyond the Region. The urgency for mounting structural interventions is discussed.