Medical Professionalism and its Relationship to Public Health:

Physician Advocacy and State Public Health Policy

Thomas KelloggProgram Officer and Advisor to the PresidentOpen Society Institute

October 21, 2008

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Medical Professionalism:

Public Health Responsibilities

o Physician advocacy can play a key role in changing government public health policy

o Why turn to physicians?

Prestige Special expertise Special perspective: on the front lines

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Physician Advocacy and Public Health Policy:

The Case of Harm Reduction

What is harm reduction?

A pragmatic and humanistic approach to diminishing the individual and social harms associated with drug use, especially the risk of HIV infection

Emphasis on public health approaches over criminal law approaches to drug-using communities

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Why Harm Reduction?

Connection between Intravenous Drug Users (IDUs) and HIV prevention and treatment

Spread of HIV among IDUs a key component of HIV epidemics in many countries

Countering that spread is key to stopping the spread of HIV/AIDS among the general population

IDUs as Percent of Total Registered HIV Cases (2006) China: 44.3% Poland: 50% Indonesia: 54% Malaysia: 72% Russia: 83%

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Harm Reduction in Practice

Needle exchange

Methadone therapy

Increased access to health services

Other useful steps: health and drug education, HIV and STD screening, psychological counseling, medical referrals

Harm reduction programs can serve as points of contact for drug users for other community, social services, and medical resources

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Barriers to Harm Reduction Programs

Political resistance: fear of being seen as soft on drugs

Popular support for punitive approaches Social and religious values

Lack of support among law enforcement agencies

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What Doctors Can Do

Advocate for evidence-based approaches rather than those based on political or other concerns

Highlight the role that incarceration can play in accelerating the HIV epidemic and the potential benefits of alternative approaches

Call for increased funding for and political commitment to the provision of HIV prevention, treatment, and care programs for IDUs

Sponsor policy dialogues, conferences, and study tours to demonstrate the potential benefits of a harm reduction approach

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Case Study: Malaysia

Country conditions indicate a need for a harm reduction approach

High prevalence of HIV among IDUs 76% of all HIV/AIDS cases reported between

1986-2000 were among IDUs Punitive approach failing to generate positive

results IDUs driven underground by criminal law

approach Number of IDUs continues to rise, even with

harsher penalties Social resistance to harm reduction approach:

opposition from Islamic groups

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Embracing the Harm Reduction Approach

Medical profession takes the lead

Dr. Adeeba Kamarulzaman plays a key role in organizing the response of the medical profession to change government policy

January 2004: Harm Reduction Working Group (HRWG) founded by a group of concerned physicians

January 2005: HRWG briefs the government on harm reduction techniques

January 2005: Government approves substitution treatment pilot project

2006: Government approves first needle and syringe exchange program (NSEP)

2006: Shifting responsibility for drug treatment from Ministry of Internal Security to Ministry of Health

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Initial Results

Price of methadone slashed, making it more accessible

Substitution treatment effective: high level of compliance, reduced recidivism

Methadone treatment scaled up: more than 3,000 persons treated by 2007

Expansion of NSEP: over 1700 IDUs reached by the program in first year

MoH target of reaching 20,000 IDUs by 2010