key: cord-0780967-7pk2mb7m authors: Chang, Judy; Agliata, Jake; Guarinieri, Mauro title: COVID-19 - Enacting a ‘new normal’ for people who use drugs date: 2020-07-03 journal: Int J Drug Policy DOI: 10.1016/j.drugpo.2020.102832 sha: 1c400361976c70ea4ff61e34149cb36125d56cc3 doc_id: 780967 cord_uid: 7pk2mb7m The COVID-19 crisis has magnified existing social, economic and political inequities. People who use drugs are particularly vulnerable due to criminalisation and stigma and often experience underlying health conditions, higher rates of poverty, unemployment and homelessness, as well as a lack of access to vital resources – putting them at greater risk of infection. On the other hand, COVID-19 presents an opportunity to confront the mistakes of the past and re-negotiate a new social contract. The International Network of People who use Drugs (INPUD) believe that this crisis must be an occasion to rethink the function of punishment, to reform the system and to work towards ending the war on drugs. This commentary presents a set of recommendations to UN agencies, governments, donor agencies, academics and researchers and civil society, challenging these actors to work alongside people who use drugs to enact a new reality based on solidarity and cooperation, protection of health and restoration of rights and dignity and most importantly to mobilise to win the peace. On the 3rd of April, 2020 the Financial Times editorial opined that the COVID-19 virus has laid bare the frailty of our contemporary social contract, compelling humanity to consider the radical reforms required to forge a society that will work for the common benefit (2020). Much like other cataclysmic moments in history such as the Spanish Flu, the Great Depression and two World Wars, the COVID-19 pandemic forces us to confront the shortcomings of the world we have created. The COVID-19 crisis has exposed the unpreparedness and brittleness of our health systems and economies, a result of the failures of our political, legal and social structures and institutions. Competing ideas, visions and influences are jockeying for political primacy as we collectively grapple with the question of what kind of society will, and what kind of society we want to emerge from COVID-19 induced changes and disruptions. On the one hand, ideas and proposals previously considered fringe or eccentric such as universal health care, universal income and wealth taxes are being considered as viable policy changes to bridge ever more visible disparities and inequalities (King, 2020; Hirsch, 2020) . On the other hand, draconian COVID-19 emergency measures may be indefinitely extended to further entrench these same inequalities, silence opposition and suppress dissent. The decisions and actions we take now will have profound ripple effects on our future economy, politics and culture, as well as shape social relationships and the ways in which we approach public and civic space. Simply put, the opportunity to construct the post-COVID world is here and now. The COVID-19 crisis has highlighted that political realities are not fixed, but emergent and therefore open to change. As political commentators and opinion leaders urge us to re-think, renegotiate and renew our social contract in the time of COVID-19 we must turn our efforts to righting political wrongs, particularly those perpetrated against the most marginalised. From its beginnings the War on Drugs has had devastating health, economic and social consequences on the lives of people who use drugs (Jensen, Gerber & Mosher, 2004) . The global pandemic is escalating the human cost of this policy failure. A revitalised social contract has to reconsider the function of punishment and invest in creating a new normal for and with people who use drugs. People who use drugs, of which there are an estimated 35 million globally, are particularly vulnerable during times of crisis (UNODC, 2019). Criminalisation has pushed people who use drugs to the margins of society, with a disproportionate number experiencing poverty, homelessness, incarceration, work in the informal economy, underlying health conditions and lack of access to vital resources; making the community highly susceptible to the secondary impacts and fallout of COVID-19 (Dunlop et al. 2020; UNODC 2020; Farhoudian et al., 2020) . Many, especially those whose circumstances deter compliance with lockdown measures, are easy scapegoats for police and authorities. Whilst COVID-19 cases amongst people who use drugs remains still unknown, there is no doubt the community of people who use drugs have been inordinately impacted by ongoing waves of epidemics, including HIV, Hepatitis C and the opioid overdose epidemic. The figures are joltingly stark; in 2017 an estimated 585,000 died of a drug overdose (UNODC, 2019). People who use drugs are 24 times more likely to be living with HIV than the general population, with 17.8% of the estimated 15.6 million people who inject drugs living with HIV and 52.3% living with Hepatitis C (UNAIDS, 2016; Degenhardt et al., 2017) . Despite the loss of life and devastation wrought by these extant epidemics, people who use drugs have emerged as resilient, applying community survival strategies and becoming highly attuned to the politics of life and death. Hard-earned lessons on managing public health crises and their inherent tensions with individual human rights imperatives have been collected along the way. These can be applied in the here and now. Throughout history fear of the unknown and fears of contagion have preceded the imposition of authoritarian measures and restrictions which have worsened the situation. Outbreaks of syphilis and the HIV epidemic either led to, or were used as a pretext to persecute sex workers, gay men, transpeople and people who use drugs in the name of infection control (Chan & Reidpath, 2003) . Today, in a seeming repeat of history, we are witnessing the deployment of militarised language and jargon by governments, emphasising that we are fighting a 'war' in lieu of accentuating the importance of solidarity and social cohesion. The form and function of this rhetoric justifies the suspension of rights and freedoms and facilitates the introduction of exceptional measures such as curfews, forced quarantine, isolation and slum clearances. Echoing the 'war' on drugs, this language normalises the idea that war is fought between a 'good' actor and a 'bad' actor, perpetuating stigmatisation of key populations. The International Network of People who Use Drugs (INPUD) is the global peak-body representing people who use drugs. We have received multiple reports from member networks of people who use drugs being violently forced by authorities into rehabilitation centres and denied access to medication. A legitimate concern of ours is that authoritarian power is being left unchecked beyond the limits of containing COVID-19 and deployed against the most marginalised. Moreover, the imposition of social-distancing language and measures introduces the idea that social interactions are dangerous by nature, when on the contrary it is the knowledge and experience of communities that are needed more than ever. Materially, social distancing language and measures threaten to worsen the ongoing overdose crisis as peers are faced with contradictory public health messaging (never use alone/selfisolate) and community solidarity initiatives are being restricted. In recognition of such contradictions, the World Health Organization (WHO) has recommended replacing the language of social-distancing with physical distancing to emphasise the importance of social connection, solidarity and information-sharing in battling this pandemic (Aziz, 2020) . The COVID-19 pandemic throws that which is already broken into sharp relief; overextended carceral systems, neglected health systems and disregard of the social and structural determinants to health. Early on multiple actors, including UN agencies, doctors and advocates, called for prisoner release schemes to prevent COVID-19 (Holpuch, 2020) . Only a few have drawn attention to global policies that drive bodies into the criminal justice system, such as the War on Drugs itself (Cardoso, Dreifuss & Clark, 2020) . It was the global HIV movement that showed us the social shape of epidemics. Criminalisation of key populations, including people who use drugs, has driven epidemics by forcing people underground and making it harder to access health and social services (DeBeck et al., 2017) . Albeit, HIV also pointed the world to solutions, including the pathways towards more equitable health and community systems and of addressing stigma and discrimination. Since the COVID-19 outbreak, as was the case in the early days of the HIV epidemic, communities of key populations have been on the frontlines, drawing on their distinctive knowledge of community needs, to educate, empower and advocate (FLA, 2020). The political participation of people who use drugs, combined with decriminalisation and decarceration and ensuring the accessibility of funding for community-led networks will be crucial to addressing this global pandemic, along with the political leadership of UN agencies, academics and researchers, government officials and advocates for social justice. In consultation with our networks and communities, INPUD has identified the following key trends and concerns regarding the impact of COVID-19 on people who use drugs (INPUD, 2020b): Harm reduction services such as needle and syringe programmes (NSP) or opiate treatment programs (OTP) have always struggled for adequate funding and political support, leaving them under-equipped, understaffed and struggling to cope with COVID-19. From March, 2020 onwards, people who use drugs have faced further limitations in accessing harm reduction services, whether that be due to service closures, failure to sufficiently adapt to changing contexts or having already scarce resources diverted to the COVID-19 response (INPUD, 2020) . To put this in context, a 2017 Lancet journal article estimated less than 1% of people who inject drugs live in countries with high coverage of harm reduction programmes (Larney et al., 2017) . Reports of service closures and disruptions have been documented and reported by communities in the United States, Europe, sub-Saharan Africa and Latin America and the Caribbean (Sarosi, 2020; Dastmalchi, 2020; Dunlop et al., 2020; INPUD 2020b) . A U.S rapid mixed methods assessment found that 43% of NSP's reported a decrease in availability of services, whilst in the state of Ohio, more than 50% of NSP's have been shut down, with personnel and resources diverted to combat the current pandemic (Glick et al. 2020; Dastmalchi, 2020) . Such actions increase risk of HIV as well as COVID-19 due to overcrowding of existing services. Lockdown measures and movement restrictions have limited the operation of services and disrupted global supply chains of essential supplies, as well as made it harder than ever for people who use drugs to travel to their harm reduction service (ENPUD, 2020; INPUD 2020b) . In some cases, personal protective equipment (PPE) remains unavailable for NGO-run harm reduction staff and clients (Glick et al. 2020; ) . Harm reduction services are often the only contact point for people who use drugs to access health services, health education, social protection and other essential life-saving services. On the other hand, the corollary effects of COVID-19 is the scrutiny brought to the apparatus of harm reduction and drug treatment. Drug user advocates have long pointed towards the often punitive, overly rigid and inflexible rules and regulations of methadone and buprenorphine programmes, protestations of which have been met with dismissal or disregard. The sudden introduction of COVID-19 protective measures has demanded a rethink, with many programmes rapidly introducing OTP take-home doses, removing arbitrary rules and regulations such as compulsory urine testing or daily witnessed ingestion and coming up with flexible and innovative ways to deliver OTP's, as well as drug-using equipment to curtail person-to-person interactions. Encouragingly some clients and programmes have reported an increase in access to needles and syringes, OTP's and naloxone, with models such as telemedicine, secondary distribution, flexible dosing and home delivery being introduced as a matter of compliance with lockdowns and physical distancing measures (INPUD, 2020b; Glick et al. 2020; Bach, Robinson, Sutherland & Brar, 2020; EMCDDA, 2020 ) . Community networks across South Asia, Eastern Europe and Central Asia and across Western Europe were central to making these changes a reality. Academics and researchers alike have long criticised the ways in which rules and regulations of drug treatment are experienced as punitive and more invested in exerting social control rather than providing humane and respectful care (Fraser & valentin, 2008) . That it took a pandemic to compel a shift in harm reduction practice, despite years of community demand is testimony to the ongoing silencing and suppression of community perspectives and demands. The work to sustain these changes post-crisis remains ongoing and will attest to what lessons have been learnt. Safe supply refers to a legal and regulated supply of drugs, such as heroin, stimulants and hallucinogens that have been traditionally been accessible only through the illicit market. Globally, border closures, travel bans and movement restrictions are impacting the predictable supply of unregulated substances, meaning more people than ever will be in need of safe supply (UNODC 2020). Sixty two percent of respondents on a survey on COVID-19 and drug markets reported changes to the availability, price and variety of products, prompting concern around the circulation of increasing harms (Crew, 2020). Worldwide people who use drugs are facing involuntary withdrawals related to changes in the drug market, inability to purchase drugs due to loss of income or restricted movement (INPUD, 2020; Guirguis, 2020) . Across North America, reports of spikes in overdose calls and deaths have been connected to COVID-19, either due to changes in drug supply, more people using alone or attempted suicide, with emergency responders in some jurisdictions receiving directives affecting their ability to respond to most overdoses (Kaur, 2020) . The targeting of people who sell drugs, of whom many are trusted sources for peers, reduces the availability of safer drugs on the illicit market. Prior to COVID-19 safe supply had been posed as a solution by peers in Canada as a means to mitigate the country's ongoing overdose crisis, to end stigmatisation of drug use, to restore dignity and to effectively reduce harms and improve quality of life (CAPUD, 2019). More than ever the safe supply of unadulterated and regulated substances will be crucial to saving lives. In March, 2020, in response to COVID-19, the British Columbia Centre on Substance Use (BCCSU) along with the provincial Ministry of Health published guidelines on the safe supply of pharmaceutical grade opioids and stimulants which emphasised flexible dispensing and client discretion to support them in the goal of physical distancing (Bach, Robinson, Sutherland, Barr, 2020) . This presents another example of where COVID-19 created space for 'experts' to adopt community-led solutions and enact changes that peers had long fought for. The COVID-19 crisis has thrown the over- Made self-evident by COVID-19, there has always been an undeniable moral case to accelerate pardons and amnesties of people incarcerated for drug-related offences, including for low-level dealing. Many people who sell drugs do so as a matter of survival. Surprisingly, early releases and amnesties have not faced major opposition nor ideological resistance, providing a rare window of opportunity to radically reform the prohibitionist agenda which drives mass incarceration. Originally borne of racism and fear-mongering of Chinese immigrants, through the passing of the Harrison Act (1914) in the United States that targeted Chinese migrant labourers, the War on Drugs has never truly been about ameliorating potential harms associated with drug use and more about justifying the denial of rights to certain populations, such as people of colour, by inculcating moral panics and criminalising behavior (McCaffrey, 2019; Provine, 2001) . The COVID-19 pandemic has generated a wave of stigma, racism and xenophobia, further entrenching racial inequalities (Coates, 2020) . Global leaders and influential commentators should commandeer the opportunity to end the global war on drugs, which is one of the most abysmal, yet entrenched, policy failures of our time. Declaring states of emergency has meant the suspension of rights and freedoms normally Moreover, the potential misuse of personal data, particularly when it comes to criminalised populations, is of acute concern. Several governments have deployed sophisticated surveillance technologies to track and monitor people. Mobile phone applications are being used to produce real-time case management of positive cases, as well as enabling digital contact tracing, warning people of their proximity to infected people in China, South Korea, Singapore, Italy and other European countries. As Davis points out, publishing location data on COVID-19 outbreaks may intensify the climate of stigma and blame towards specific minority groups (Davis, 2020) . Here, past lessons from the public health dimensions of HIV are important. Criminalised and stigmatised populations, such as people who use drugs, LGBT people and sex workers have shied away from inclusion in HIV surveillance studies out of a fear of arrest. It is important that this virus not mark a turning point in the history of surveillance, whereby the race to embrace mass surveillance tools without right to privacy safeguards may undermine the goal of epidemic control (ibid. 2020). In summary, the seriousness of COVID-19 should not be exploited to indefinitely suspend basic rights and freedoms, but be a wake up call to change and repair a broken system overly focused on the punishment and social control of people who use drugs. The COVID-19 pandemic has brought the critical role of communities into sharp relief because communities are able to detect early, respond quickly and reach those who are otherwise unreachable by the healthcare systems, easing the burden on health administrators and frontline workers. Additionally, communities play important watchdog functions when it comes to government transparency and accountability. Since early March, 2020, INPUD and its sister organisations around the world rapidly mobilised to develop online peer resources and educational materials, write statements and guidelines and provide direct outreach services (INPUD, 2020a). The COVID-19 crisis has unseated faith in the fitness of political systems and political leaders. This is the time for new solutions grounded in the realities of people facing the harshest repercussions. From the annals of lived experience, we have always known the solutions that are needed for people who use drugs. The essential role of communities during the HIV movement reshaped the global health agenda in critical ways, including drawing the world's attention to the social-structural determinants of health, biopower and biopolitics and embedding the principle of meaningful community involvement within the rigid and depersonalised corridors of public health (Foucault, 1976; (Rodriguez-García et al., 2013) . The political strategy for confronting COVID-19 is still taking shape. More than ever, community-led lessons and injunctions on navigating us out of this current crisis should be heeded by UN agencies, governments, donor agencies, academics and researchers and civil society actors. This is the time to enact and forge new realities and architecture for and with people who use drugs, and by extension wider society. Global health has never been neutral, but always embedded in and constructed through political, social and cultural contexts. In recent years, multilateralism has faced ever-growing threats to its legitimacy, but as COVID-19 is making clear, an effective response for a global pandemic cannot be mounted without an accompanying global response. Whether it is for the development of a vaccine or for handling the economic fallout or coordinating supply chains and standardising protocols, global leadership will be key in coordinating this response. However, having borne witness to the devastating impact of the global war on drugs, people who use drugs are all too aware that the promise and powers of multilateralism can be harnessed for either good or bad. Criminalisation of drug use is currently being propped up by the three drug control treaties and must be superseded by a treaty for Drug War Peace. The language of 'war' has been weaponised against people who use drugs for far too long. It is high time to shift our language and thereby our strategies from a stance of conflict to cooperation, both between and within states. In the time of COVID-19, we call on UN agencies, academics and opinion leaders to call for an end to the criminalisation of drug use. On the 13th of May, a joint statement by UNODC, OHCHR, WHO and UNAIDS on COVID-19 and prisons urged political leaders to reduce prison overcrowding by limiting the deprivation of liberty and releasing those held on minor, non-violent offences (2020), but failed to harness the political opportunity to call for an end to the War on Drugsthe policy culprit driving mass incarceration. This failure of political courage is that which is driving the problem itself. What type of world will emerge post COVID-19 is still up for contestation. 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