ORIGINAL ARTICLE

 

The international scientific production on harm reduction: a comparative analysis between MEDLINE e LILACS¹

 

La producción científica internacional sobre reducción de daños: un análisis comparativo entre MEDLINE y LILACS

 

 

Vilmar Ezequiel dos Santos^I; Cássia Baldini Soares^II; Célia Maria Sivalli Campos^III

^IRN, Doctoral Student in Nursing, Escola de Enfermagem, Universidade de São Paulo, SP, Brazil. E-mail: vilmar@usp.br
^IIRN, Free Lecturer, Associate Professor, Escola de Enfermagem, Universidade de São Paulo, SP, Brazil. E-mail: cassiaso@usp.br
^IIIRN, Ph.D. in Nursing, Professor, Escola de Enfermagem, Universidade de São Paulo, SP, Brazil. E-mail: celiasiv@usp.br

Correspondence

 

 

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ABSTRACT

The objective of this study was to describe and analyze the course of harm reduction (HR) in the countries where it was diffused. I started from the assumption that HR means new way of understanding and intervening in the problems related to drug use. The method consisted in the revision of scientific publications available in the MEDLINE, in the period of 1996 to 2006 and LILACS bases, without timeframe restriction. The analysis of the publications points to the diffusion of strategies and widening of the HR field in several countries, and shows significant differences in their characteristics when compared to countries of central and peripheral capitalism.

Descriptors: Reducción del Daño, Salud Pública, Drogas Ilícitas; Literatura de Revisión como Asunto.

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RESUMEN

El objetivo de este trabajo fue describir y analizar el trayecto de la reducción de daños (RD) en los países donde fue difundida. Se partió del presupuesto de que la RD significa una nueva manera de comprender e intervenir en los problemas relacionados al uso de drogas. El método consistió en la revisión de las publicaciones científicas hechas disponibles en las bases MEDLINE, en el período de 1996 a 2006 y LILACS, sin restricción de período. El análisis de las publicaciones apunta para difusión de las estrategias y ampliación del campo de la RD en diversos países, y muestra diferencias significativas en sus características, cuando comparados a países de capitalismo central y periférico.

Descriptores: Harm Reduction; Public Health; Street Drugs; Review Literature as Topic.

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Introduction

Harm reduction (HR), in theoretical and practical dimensions, consolidates itself among the social responses to production, commerce and consumption of drugs, and the answers of the public healthcare field⁽¹⁾.

The origin of HR, as practice towards the consumption of psychoactive substances, can be located in England, in 1926, with the Rolleston Report. It was considered that even facing a dependent consumption of drugs, the user could decrease the more damaging consequences, minimizing the prejudicial effects to their health⁽²⁾.

It was during the 80's⁽³⁾, however, that HR started to be recognized as a strategy of public healthcare towards the drug user, as one of the answers to the AIDS epidemic. The healthcare policies became more flexible and tolerant with the drug user, incorporating strategies to decrease the damages related to consumption. The DR has been incorporated by the public healthcare of several countries^(4-6), taking the shape of the different social, political and economic contexts, and diffusing as a new way to understand and intervene in problems related to drug consumption. In this trajectory, several questions surfaced for the field of public policies.

It is worth mentioning that the problems related to drug consumption has presented extraordinary dimensions over the last decades, requiring answers from governments nationally and internationally. The policy adopted by almost all of the counties has, historically, emphasized repressive, punitive strategies focusing strictly on total abstinence from any type of drug consumption, especially illegal.

This study adopted the fundaments of the collective healthcare field, to understand that the prejudicial consumption of drugs has its roots tied to way social life functions, and that the complex system of production, commerce and consumption of such drugs is directly related to the productive and economic system, not only referring to the individual process of consumers (freedom of choice, individual frailty etc.). In the capitalist social formation, the drug is perceived as a type of merchandise, potentialized by legal and illegal industries, to meet the needs to increase capital⁽²⁾. Therefore, for the collective healthcare, HR would configure as a more coherent and humane answer of intervention for problems from the relation of the different social groups with drugs.

Once the HR was incorporated in policies for drug consumption, nationally and internationally, we intended, with this study, describe and analyze the characteristics of this incorporation in the several countries that adopted it.

Therefore, this study presents an analysis of the HR implementation process, from the available scientific production in the data bases MEDLINE and LILACS, characterizing differences between the countries of central and peripheral capitalism, by means of a sufficiently extensive revision, to enable the comprehension of the international course of HR, although not characterized and a exhausting systematic review of the literature.

 

Methodological Procedures

The bibliographic revision was made in July of 2006, focusing on the data from MEDLINE, from 1996 to 2006, and the data from LILACS, without definition of a timeframe. The descriptor "harm reduction" was not used for not been recognized by BIREME at the time of the bibliographic revision. Therefore, to widen the capture of papers on the issue at a maximum, and on the other hand, limit to papers that were written about psychoactive, legal and illegal drugs, combinations of the known descriptors were used. In the MEDLINE base: "harm reduction" and "disorders related to the use of psychoactive substances" or "illegal drugs" or "alcoholism" or "smoking"; and in the LILACS base, "reduction" or "harm" and "disorders related to the use of psychoactive substances" or "illegal drugs" or "harm reduction" or "alcoholism" or "smoking".

It is worth mentioning that the descriptor "harm reduction" was introduced in the MeSH (Medical Subject Headings), a vocabulary controlled by the National Library of Medicine, only in 2003, which posed as a difficulty factor to locate papers at MEDLINE, in the years before.

First, we read all of the abstract from the papers found in both data bases, so then, select the ones that treated directly with theory and/or practice of HR related to the field of legal and/or illegal psychoactive drugs. The selected papers were read in their entirety, enabling the formulation of a classification system for several forms of the HR is presented in different countries and localities.

 

Results

Table 1 shows a comparison between the countries of origin of the papers, indicating that almost the totality of the papers from MEDLINE came from countries with a central capitalism (92%), and the totality found in the LILACS base were from countries with peripheral capitalism (98%). The distributions of the papers presented in Table 1 is coherent with the proportionality of journals indexed in the MEDLINE data base, which is kept by the U.S. National Library of Medicine, where less than 10% of the indexes titles are from developing countries. Almost 70% of the 4,800 titles are publish in English speaking countries, and among these 90% are in the northern hemisphere, of which, 44% are in the USA⁽⁷⁾. In the LILACS base, on the other hand, 605 indexed journals were found, in the health area, published in countries from Latin America and the Caribbean.

 

 

In MEDLINE, publications on HR were only found starting from 2002. In LILACS, they date from 1994. It can be inferred that in the countries with peripheral capitalism, the concern with the diffusion of HR was earlier, due to the characteristics of the AIDS epidemic and social mobilization, which pressured the public government to see the problems as an object of governmental policies of public healthcare. This affirmation reassures the significant institutional insertion of the authors.

From the LILACS articles, 41% were tied to a governmental office in the healthcare area (26% ministries and 15% secretariats); 46% were linked to universities and 13% to non-governmental organizations (NGO).

In MEDLINE, on the other hand, 60% of the authors were tied to universities, 12% to healthcare services, 11% to agencies and institutes, 2% NGOs, 2% private companies and 2% journals. In 10% of the articles this information was not found.

From the data presented in Table 2, it is verified that in MEDLINE, most of the articles (78%) were centered in drugs - the substance, in particular, or its dependency. With a diverse proportionality, in LILACS, in only 4% of the articles, drugs were the central issue. Still in LILACS, as considerable parcel of the papers (38%) were about AIDS and program assessments, been that in MEDLINE this percentage was 4%. Regarding the theoretical and political aspects, the differences were also important, from 43% in LILACS to 15% in MEDLINE. Another data that calls the attention is that only in LILACS, papers were found dealing with the prevention of the prejudicial consumption of drugs.

 

 

Table 3 presents a classification of the papers found in MEDLINE and LILACS, by issues and sub-issues related to HR. To offer a richer content in the classification, we chose to include some papers in more than one sub-issue.

 

 

Discussion

As for the approach of theoretical aspects, the MEDLINE publications presented general principles of HR and intervention strategies, including in night clubs and raves; and the ethical aspects focused on professional conflicts in the care of abusive drug users, or the aspects of ethics in research.

In LILACS, on the other hand, in the studies approaching the theoretical aspects, especially the Brazilian papers, the authors wee linked to governmental organizations and the Federal government and dealt with concepts, legal and ethical aspects, aspects of implementation of HR programs as a public healthcare strategy. The ones that approached HR in public healthcare sought the prevention of transmittable diseases in injectable-drug users (IDU), perspective to start the implementation of HR in Brazil, only to prevent transmittable diseases in IDU, without seeking changes in the pattern of drug use. It is worth mentioning that the World Health Organization (WHO), has supported countries that adopted HR strategies, encouraging the practice of prevention for HIV-AIDS dissemination⁽⁸⁾ as well as the practices more directed to drug users that do not attend the traditional services for dependants, also therapies seeking exchanging the consumption of more damaging substances for others less harmful.

The analysis of the LILACS articles indicated tendencies of the policies regarding the consumption of drugs in countries with peripheral capitalism. It was observed, in the articles of this base, higher insertion of HR in official policies, as well as the use critical referential to them, for considering the regional differences and social inequality between countries.

Articles from Brazilian authors presented HR for changing the orientation of policies; they pointed-out structural determinants of the prejudicial consumption of drugs in contemporariness, and proposed initiatives for the formation of critical and conscious subjects in the several dimensions of drug use. According to some authors⁽¹⁾, the drug is conceived as merchandise, and they proposed that "the consumption of drugs must be analyzed at the light of structure and dynamics of the capitalist production method, with confront the contexts of contemporary society".

It was also higher the number of articles at LILACS that discussed public policies and the incorporation of HR principles in policies turned to drug consumption, and consequently, in the operation of programs linked to these policies. There were, also, articles that approached the panorama of HR in international policies - one of them discussed critically the principles of the war on drugs policy⁽⁹⁾. Some articles discussed the incorporations of HR in Brazilian public policies.

The percentage of articles that presented evaluation of HR program, in LILACS were much higher than MEDLINE (15 and 3%, respectively), even if the presented Brazilian programs were restricted to injectable-drug users.

In MEDLINE, no articles turned to prevention were found. In LILACS, prevention subject was found, only in Brazilian articles, references to education models, like HR strategy for the prevention of prejudicial consumption of drugs for young people^(1,10-15).

The MEDLINE articles centered in HR policies to be adopted by the State - with the exception of policies directed on alcohol and tobacco - dealt with the control of drug supply, price increase, and new drugs entering the market, or actions turned to individuals under the custody of the State: the ones in prisons; or still, approaching actions turned to AIDS prevention. Some articles presented results for researches that examined acceptance, by the population, of incorporating HR in public policies.

In the realm of the official discussion on international policy, it was observed that HR is tolerated, when introduced as a strategy submitted to homogenous policy of war on drugs, in order to be used as the last resort, for drug dependants considered a deserter to any type of intervention turned to drug abstinence.

Coherently with a lower proportionality of MEDLINE articles dedicated to the theoretical discussion of HR and articles centered in public policies, the proportion was also lower of articles dedicated to the implementation and evaluation of HR programs. One article was fund, French in origin, that assessed a program centered in the use of strategies for decreasing the transmission of HIV (distribution of syringes and injectable-drug replacement treatment)⁽¹⁶⁾. The other articles, of American origin, examined the tendency for acceptance of HR strategies (distribution of syringes, replacement therapy, same places for drug use), in European countries and the United States.

It is also highlighted, a significant difference between the proportionality of articles that brought the association between HR and transmittable diseases (AIDS and hepatitis), in both data bases. In LILACS, this association was seen in 23% of the articles, and in MEDLINE only 2% of them. The assessment of HR programs, in LILACS was made by 15% of the articles, while in MEDLINE, in only 1% of them.

It is worth mentioning the observation that the MEDLINE articles that approached the incorporation of HR in public policies, even if restricted to punctual and specific strategies, show indications that HR is still less incorporated in countries of central capitalism. We noticed that there s a greater concern in assessing opinion, or acceptance of the population, regarding the incorporation of HR in public policies, than the concern in evaluating the impacts of the actions from these policies in individuals and social groups.

In MEDLINE, as described above, great part of the articles focused on a drug in particular (57%), mostly legal drugs. From those, 78% focused on tobacco, 20% alcohol and only 2% in illegal drugs like crack.

Among the studies related to HR turned to tobacco, most of them originated from the United States (69%) and approached issues related to the decrease in toxicity levels of the carcinogen elements in cigarettes; of regulation and control, by the State, of production, commerce and consumption of cigarettes; the treatment of the tobacco dependant; the HR policies turned to the use of tobacco; the perception of the population on the impact of HR policies in tobacco consumption, as well as reflections and ethical aspects on tobacco use.

The articles that has as focus HR related to alcohol approached it as part of treatment for dependency, but also, as strategy to decrease the harms of alcohol consumption, especially among students, and as strategy used in primary care. There were still articles related to HR policies turned to alcohol.

The ones that focused on treatment of the dependency on drugs took HR as complementary strategy to be used as part of the conventional of the drug dependant, or as strategy to reach populations that do not have access to healthcare services for the treatment.

The only article centered on the illegal drug - crack⁽¹⁷⁾ - , originated from Canada, and proposed the supply of kits for dependants that could not access the traditional healthcare services.

While most (57%) of the MEDLINE articles has as focus legal drugs (tobacco, alcohol), in LILACS no articles were found on HR related to tobacco, and only 2% has alcohol as a concern⁽¹⁸⁾. These articles discussed the prejudicial consumption of alcohol and the consequences for the individual, family and society and HR strategies to minimize social damage. There was only one article (2%) in LILACS that approach the illegal drug - crack⁽¹⁹⁾.

From this study, a certain homogeneity was seen in the conception of HR, when taken as a synonym for strategy, of practice and interventions related to the individual or environment, to decrease risky behavior for their own health (traffic accidents, AIDS prevention, hepatitis, problems from using synthetic drugs), to decrease harm in individuals considered a deserter of conventional treatments and interventions, for the decrease and replacement of substances, to avoid overdoses and other health hazards. These papers, that took HR under an instrumental perspective, did not present significant discrepancies, even if coming from distinct countries and continents, captured by both studied data bases.

However, when the discussion was policies of theoretical orientation, the HR presented itself in a very diverse way. In this perspective, HR was approach as an appendix of hegemonic policy of war on drugs, presented as a tertiary prevention strategy for vulnerable populations, excluded from the alternative of traditional treatments turned to abstinence, most of them legal drugs. This approach was preponderant in the papers captured in MEDLINE, that is, published in journal of countries with central capitalism, most of them in the USA, a country which has been historically ruled by political parties that imprint a private market logic - of liberal tendencies - with little interference from the State in formulating and operating social policies, eminent character focused on the provably poor populations⁽²⁰⁾. The countries classified as liberal have, with the exception of Canada and Great Britain, after the former-fascist countries, the lowest public investments in healthcare, and the lowest coverage of public system of healthcare. It can be inferred that the Pan American Health Organization (PAHO), even if it does not publicize criticism to official policies in the field of drugs, stimulates that there a change in paradigm of the relation between healthcare professionals and users, when the conception of HR is adopted as a strategy of preventive public healthcare, which promotes a higher integration between users and healthcare services, respecting the ethical and human rights aspects, giving priority to maintaining life, and enabling the reduction of infections and other health hazards⁽²¹⁾.

Another perspective found, exclusively in the theoretical discussions in the articles of the LILACS base, was the conception of HR as a paradigm under construction, criticizing the official policy of war on drugs and goes beyond the proposal of strategies, and recognizes the user of illicit drugs as a subject with rights, it seeks articulation with other fields of knowledge - noticeably education and ethics - in the attempt to monopolize the complexity of the contemporary phenomenon of drug use.

This movement found echo in the public social policies, especially in Brazil, that has been investing in the widening of actions of user care, and in the prevention of the prejudicial consumption of drugs, and coherently in the assessment of programs.

 

Conclusion

The bibliographical revision made here showed significant variations in the conceptions and implementations of HR actions, among the countries of central capitalism and the ones of peripheral capitalism. While in the first ones the HR has been, with a few exceptions, considered as a strategy of operational order and instrumental policies; in countries with a peripheral capitalism, especially in Brazil, it has been taking a wider outline, regarding the renovation of public policies in the field of drugs.

In the present literature revision contained in this study, there were evidences that the HR moved forward, in ethical and theoretical discussions, more in countries with peripheral capitalism than in countries with central capitalism, which favored the incorporations of its concepts in the public policies turned to drug users, as well as implementation of strategies turned to prevention of prejudicial consumption of drugs, not been restricted to treatment of dependency and strategies of Access to excluded populations.

 

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Correspondence:
Cássia Baldini Soares
Universidade de São Paulo. Escola de Enfermagem
Departamento de Enfermagem em Saúde Coletiva
Av. Dr. Enéas de Carvalho Aguiar, 419
Bairro: Cerqueira César
CEP: 05403-000, São Paulo, SP, Brasil
E-mail: cassiaso@usp.br

Received: June 24^th 2010
Accepted: Sept. 9^th 2011

 

 

1 Paper extracted from Master's Thesis "O objeto/sujeito da redução de danos: uma análise da produção científica da perspectiva da Saúde Coletiva" presented to Escola de Enfermagem, Universidade de São Paulo, SP, Brazil.