Switzerland, HIV and the power of pragmatism: Lessons for drug policy development
Switzerland in the 1980s was an epicentre of HIV as open drug injection became part of the urban scene, especially in Zurich. Cracks appeared in Switzerland’s long commitment to policing as the main drug-control strategy as law enforcement was unable to contain the health and social consequences of the rapid spread of drug injection. In the early stages of the epidemic, the pioneering health care providers who brought technically illegal harm reduction services into the open drug scene in Zurich helped open the exploration at the federal level of more balanced drug policy. Carefully evaluated pilot experiences in low-threshold methadone, needle exchange, and eventually heroin-assisted therapy yielded evidence of significant HIV prevention and crime reduction that was convincing not only to policy-makers but also to a skeptical Swiss public. Whilst not all countries have Switzerland’s resource base, the Swiss experience still holds many useful lessons for establishing evidence-based policy on illicit drugs.
Some 25 years ago, Platzspitz Park in the city of Zurich, Switzerland, was home to a scene of open drug use, including drug injection, that would astound visitors to today’s orderly and placid Zurich. Switzerland, which had been known both for its rigorous drug policing and for its effective public health services, became the centre of a fast-growing drug-related HIV epidemic. In the 1990s, however, through a series of policy measures supportive to a range of new services, the Swiss authorities effectively turned around the HIV epidemic, eliminated open drug scenes, and established a public health-centred national drug policy. Both the process leading to these changes and the practical results of the changes hold many lessons for countries still struggling with HIV linked to drug use and with the balance between public health and security measures in drug policy.
Those lessons and the process by which policies were revisited and reformed are the subjects of this article. As has been well documented in a 2009 German-language book with details not previously available on the Platzspitz experience (Grob, 2009), the response of public authorities and private actors to growing drug use in the 1980s and the threat of HIV would shape Swiss drug policy for years. This account draws on that book and on a subsequent related policy analysis.
An overt crisis as a spur to action
Like much of Europe, Switzerland in the mid-1970s had a drug law that criminalised individual drug possession and use with the goal of a drug-free society. The law had as a central element the requirement that all public programmes for people who used illicit drugs be abstinence-based. Although heroin was widely used, medically assisted treatment of opioid dependency was largely unavailable. Federal regulations required that government permission be sought for every person treated with methadone, and few physicians were inclined go through this.
Heroin use increased across much of Western Europe in the late 1960s and 1970s linked to counter-culture movements, but the increase was more dramatic in Switzerland compared to that experienced by its neighbours. There does not appear to be a clear consensus in published literature or opinions of expert observers on the reason for this difference. Some experts posit that organised criminal networks established effective operations in Swiss cities that led to a high number of drug transactions (Haemmig, 1995; Brehmer & Iten, 2001). Others emphasise that, especially in German-speaking Switzerland, a “youth revolution” movement that explicitly included solidarity with people who use illicit drugs survived into the 1980s, outlasting such movements in other parts of Europe (Klingemann, 1996).
In any case, and in spite of a strict drug law and rigorous drug policing, drug use grew and was a visible social concern in some Swiss cities in the1980s. By 1985, there were an estimated 10,000 people who injected drugs in Switzerland, which rose to about 20,000 in 1988 and 30,000 by 1992 (Grob, 2009). Zurich, Switzerland’s largest city, had the most significant and visible problem as people injected drugs in public toilets and on sidewalks and other public thoroughfares, becoming, to put it mildly, a “public sore point” (Seidenberg, 1999). In 1985, under pressure from residents tired of open drug use and frustrated by the ineffective chasing of drug users from place to place, the Zurich city council (the executive body of city government) decided to try to contain –and tolerate – drug use in the Platzspitz, one of the city’s important recreational parks near the central train station. At the height of the open scene at the Platzspitz, which became known as the “needle park,” up to 2000 drug users a day gathered there (Grob, 1995).
Switzerland was estimated to have the highest HIV prevalence amongst the European countries monitored in the 1980s (EuroHIV, 1999), partly due to efficient transmission by drug injection. With the availability of HIV testing, the Federal Office of Public Health first reported HIV prevalence amongst injecting drug users in 1985 at 38 percent (Hamers, Batter, & Downs, 1997). In the same year, the federal authorities estimated that 68 percent of new HIV infections were amongst people who injected drugs (Böni, Pyra, & Beghardt, 1999). In the absence of treatment for HIV, the open drug scenes included persons in later stages of AIDS. By 1990, about 22 percent of the people gathered in the Platzspitz were estimated to be HIVpositive, with prevalence of about 40 percent amongst those who reported having used drugs for at least 10 years.
In 1988, a ground-breaking intervention called ZIPP-AIDS (Zürich Intervention Pilot Project - AIDS, or Aids für Drogengefahrdete Drogengefahrdete und Drogenabshangige), initiated by Grob and colleagues, brought badly needed HIV and hepatitis prevention services to persons gathered in the Platzspitz. By this time, the Federal Office of Public Health and the Zurich city authorities were ready to support this work, which also enjoyed the cooperation of the Swiss Red Cross (Grob, 2009, p. 41). In its first three years, ZIPP-AIDS’ needle and syringe exchange provided over 7 million syringe and needle sets (sterile needles and syringes exchanged for used ones), 2.8 million additional needles, about 8 million alcohol pads, and 1.3 million sachets of ointment for vein protection (Ibid.: 46). Its volunteers intervened in 6700 cases of overdose, saving many lives, and undertook over 26,000 medical consultations. ZIPP-AIDS also complemented the work of an earlier effort in Zurich to reach drug users in the streets and public toilets with hepatitis B vaccinations; together the efforts vaccinated about 1500 at-risk persons…. (by Joanne Csete!, Peter J. Grob, in: International Journal of Drug Policy 23, 2012)