I remember the first time that I saw people injecting drugs. I had just arrived in Vancouver to lead a research project in HIV prevention in the infamous Downtown East Side. It was in the lobby of the Portland Hotel, a supportive housing project that gave rooms to the most marginalized people in the city, the so-called "difficult to house." I'll never forget the young woman standing on the stairs repeatedly jabbing herself with a needle, and screaming, "I can't find a vein," as blood splattered on the wall.
我依然记得第一次看到 别人注射毒品的场景。 当时,我刚到达温哥华, 准备在臭名昭著的东城区 领导一个防治艾滋病的研究项目。 这是一个位于波特兰酒店的大厅, 旨在为这个城市中 最边缘的人们提供房间的, 被称为“住房困难”的支持性住房项目。 我永远也不会忘记那个 站在楼梯上的年轻女性, 用针筒反复地刺着自己,并不停喊叫着, “我找不到血管,” 同时血液不断飞溅到墙上。
In response to the desperate state of affairs, the drug use, the poverty, the violence, the soaring rates of HIV, Vancouver declared a public health emergency in 1997. This opened the door to expanding harm reduction services, distributing more needles, increasing access to methadone, and, finally, opening a supervised injection site. Things that make injecting drugs less hazardous. But today, 20 years later, harm reduction is still viewed as some sort of radical concept. In some places, it's still illegal to carry a clean needle. Drug users are far more likely to be arrested than to be offered methadone therapy. Recent proposals for supervised injection sites in cities like Seattle, Baltimore and New York have been met with stiff opposition: opposition that goes against everything we know about addiction.
为应对这些绝望的事态、毒品使用、 贫穷、暴力以及飙升的艾滋病率, 温哥华在 1997 年宣布了 一项公共健康紧急计划, 这打开了扩大伤害减轻服务的大门—— 分发更多的针筒, 提高获取美沙酮 (一种阿片类药物)的机会, 以及开放一个受监管的注射点, 使注射毒品变成不那么危险的事。 但是,20 年后的今天, 伤害减轻仍被认为是 某种激进概念。 在有的地方,携带一个 干净的针筒仍是违法的。 毒品使用者更有可能被捕, 而不是接受美沙酮治疗。 最近对于在像西雅图、巴尔的摩 和纽约这类城市的 受监管注射点的提议 受到了强烈的反对: 反对所有我们已知的 与毒瘾相关的事实。
Why is that? Why are we still stuck on the idea that the only option is to stop using -- that any drug use will not be tolerated? Why do we ignore countless personal stories and overwhelming scientific evidence that harm reduction works? Critics say that harm reduction doesn't stop people from using illegal drugs. Well, actually, that is the whole point. After every criminal and societal sanction that we can come up with, people still use drugs, and far too many die. Critics also say that we are giving up on people by not focusing our attention on treatment and recovery. In fact, it is just the opposite. We are not giving up on people. We know that if recovery is ever going to happen we must keep people alive. Offering someone a clean needle or a safe place to inject is the first step to treatment and recovery. Critics also claim that harm reduction gives the wrong message to our children about drug users. The last time I looked, these drug users are our children. The message of harm reduction is that while drugs can hurt you, we still must reach out to people who are addicted. A needle exchange is not an advertisement for drug use. Neither is a methadone clinic or a supervised injection site. What you see there are people sick and hurting, hardly an endorsement for drug use.
为什么会这样呢? 为什么我们仍然坚持认为, 唯一的选择就是放弃使用—— 即任何的毒品使用都是无法容忍的? 为什么我们忽略无数能够证明 伤害减轻的确有效的那些真实经历 以及压倒性的科学证据呢? 批评者们说伤害减轻 并不会阻止人们 使用非法的毒品。 实际上,这就是问题的关键。 在采用了我们所能想到的 每项刑事和社会制裁后, 人们仍在使用毒品, 并且造成了很多很多的死亡。 批评者们还说, 我们放弃了这些人 因为我们没把注意力 放在他们的治疗恢复上。 然而,事实正好相反。 我们没有放弃人们。 我们知道如果有可能康复, 我们必须挽救大家的生命。 为某人提供一个干净的针筒 或是一个安全的地方去注射 是治疗与康复的第一步。 批评者们还宣称,伤害减轻 给了我们的孩子关于 使用毒品的错误信号。 上次我观察时发现, 这些毒品使用者正是我们的孩子。 伤害减轻传递的信息是, 即便毒品有害, 我们仍然必须向 那些上瘾的人伸出援手。 一个针筒交易并不是 号召大家使用毒品, 美沙酮诊所,或者一个 受监管的注射点也不是。 你们所看到的人们生病和受伤害, 并不是对使用毒品的认可。
Let's take supervised injection sites, for example. Probably the most misunderstood health intervention ever. All we are saying is that allowing people to inject in a clean, dry space with fresh needles, surrounded by people who care is a lot better than injecting in a dingy alley, sharing contaminated needles and hiding out from police. It's better for everybody. The first supervised injection site in Vancouver was at 327 Carol Street, a narrow room with a concrete floor, a few chairs and a box of clean needles. The police would often lock it down, but somehow it always mysteriously reopened, often with the aid of a crowbar. I would go down there some evenings to provide medical care for people who were injecting drugs. I was always struck with the commitment and compassion of the people who operated and used the site. No judgment, no hassles, no fear, lots of profound conversation. I learned that despite unimaginable trauma, physical pain and mental illness, that everyone there thought that things would get better. Most were convinced that, someday, they'd stop using drugs altogether. That room was the forerunner to North America's first government-sanctioned supervised injection site, called INSITE. It opened in September of 2003 as a three-year research project. The conservative government was intent on closing it down at the end of the study. After eight years, the battle to close INSITE went all the way up to Canada's Supreme Court. It pitted the government of Canada against two people with a long history of drug use who knew the benefits of INSITE firsthand: Dean Wilson and Shelley Tomic. The court ruled in favor of keeping INSITE open by nine to zero. The justices were scathing in their response to the government's case. And I quote: "The effect of denying the services of INSITE to the population that it serves and the correlative increase in the risk of death and disease to injection drug users is grossly disproportionate to any benefit that Canada might derive from presenting a uniform stance on the possession of narcotics."
以受监管的注射点为例, 这很可能是有史以来 被误解最深的医疗干预。 我们想要传达的信息是,允许人们 在一个干净、干燥的, 有关心他们的人陪伴的地方 用新的针筒进行注射, 比在一个昏暗的、远离警察的胡同, 共用受污染的针筒进行注射要好得多。 这对所有人都好。 温哥华的第一个受监管的 注射点位于卡罗尔街 327 号, 这是一个有水泥地板,一些椅子 和一盒干净针筒的小房间。 警察通常会将其封锁起来, 但是它往往总会被人用撬棍 悄悄地重新打开。 有时候,我会在晚上前往那里, 给那些注射毒品的人提供医疗服务。 注射点的经营和使用者身上的 专注和热情深深触动了我。 这里没有批评, 没有分歧,没有恐惧, 有的只是很多深切的交谈。 我体会到,不管人们经历了 多么难以想象的创伤, 生理上的痛苦以及精神折磨, 那里的所有人都希望事情会好起来。 大多数人都相信,有一天, 他们会一起摆脱毒品。 那个房间是北美第一个政府批准的 受监管注射点 INSITE 的前身。 该注射点在 2003 年 9 月开放, 是一个为期三年的研究项目。 保守党政府打算 在研究结束时关闭它。 八年后,关于是否 关闭 INSITE 的抗争 一路进行到了加拿大的最高法院。 它突出了加拿大政府与 两个拥有长期吸毒史, 深知 INSITE 好处的人, 迪恩 · 威尔逊和 雪莱 · 托米奇之间的矛盾。 法院以 9:0 的投票结果 判决维持 INSITE 开放, 并在回应中严厉地 批评了政府的这个案子。 我引用如下: “拒绝 INSITE 为它所服务的 人群提供服务的后果, 以及由此造成的毒品注射者的 死亡与患病风险的上升, 与加拿大对待毒品的一致立场 所产生的任何好处完全不相称。”
This was a hopeful moment for harm reduction. Yet, despite this strong message from the Supreme Court, it was, until very recently, impossible to open up any new sites in Canada. There was one interesting thing that happened in December of 2016, when due to the overdose crisis, the government of British Columbia allowed the opening of overdose prevention sites. Essentially ignoring the federal approval process, community groups opened up about 22 of these de facto illegal supervised injection sites across the province. Virtually overnight, thousands of people could use drugs under supervision. Hundreds of overdoses were reversed by Naloxone, and nobody died. In fact, this is what's happened at INSITE over the last 14 years: 75,000 different individuals have injected illegal drugs more than three and a half million times, and not one person has died. Nobody has ever died at INSITE.
这一判决为伤害减轻 提供了一线生机。 然而,即使有这个来自 最高法院的强烈信息, 直到最近, 在加拿大开设新的注射点 才真正成为了可能。 在 2016 年 12 月发生了一件有趣的事, 面对过量注射危机, 不列颠哥伦比亚省政府 允许开设过量注射防治点。 而社区组织基本上 忽略了联邦的审批流程, 在全省开设了大约 22 个 类似但非法的受监管注射点。 一夜之间, 上千人能够在监督下使用毒品。 几百个过量注射的生命因钠洛酮 被挽救了回来,没有人死亡。 实际上,这也是过去 14 年 在 INSITE 所发生的: 75000 个不同的个体注射 非法的毒品超过 350 万次, 并且没有一例死亡。 没有人死在 INSITE。
So there you have it. We have scientific evidence and successes from needle exchanges methadone and supervised injection sites. These are common-sense, compassionate approaches to drug use that improve health, bring connection and greatly reduce suffering and death. So why haven't harm reduction programs taken off? Why do we still think that drug use is law enforcement issue? Our disdain for drugs and drug users goes very deep. We are bombarded with images and media stories about the horrible impacts of drugs. We have stigmatized entire communities. We applaud military-inspired operations that bring down drug dealers. And we appear unfazed by building more jails to incarcerate people whose only crime is using drugs.
所以大家应该明白了。 我们有科学证据, 以及针头交换,美沙酮 以及受监管的注射地点的成功案例。 这些常识和对毒品使用的同情 能够改善健康, 带来人与人之间的联系, 并极大地减少痛苦与死亡。 那么为什么伤害减轻项目 没有大规模普及呢? 为什么我们仍然认为 毒品使用是执法问题? 我们对毒品以及 毒品使用者的蔑视程度极深。 关于毒品的可怕影响的 图片和媒体故事不计其数。 我们污名化了整个团体。 我们甚至鼓励采用军事手段 来打击毒品贩子。 并且,我们无所顾忌地 建设更多监狱, 来监禁那些罪刑只是使用毒品的人。
Virtually millions of people are caught up in a hopeless cycle of incarceration, violence and poverty that has been created by our drug laws and not the drugs themselves. How do I explain to people that drug users deserve care and support and the freedom to live their lives when all we see are images of guns and handcuffs and jail cells? Let's be clear: criminalization is just a way to institutionalize stigma. Making drugs illegal does nothing to stop people from using them. Our paralysis to see things differently is also based on an entirely false narrative about drug use. We have been led to believe that drug users are irresponsible people who just want to get high, and then through their own personal failings spiral down into a life of crime and poverty, losing their jobs, their families and, ultimately, their lives. In reality, most drug users have a story, whether it's childhood trauma, sexual abuse, mental illness or a personal tragedy. The drugs are used to numb the pain. We must understand that as we approach people with so much trauma.
数百万的人陷入了漫漫无期的监禁、 暴力与贫穷的循环中, 而这个循环恰恰是由我们的毒品法律, 而非毒品本身制造出来的。 当我们所能看到的总是 枪支、手铐和牢房的照片时, 我如何向人们解释, 毒品使用者也应当得到照顾、支持, 并拥有自由的生活? 我们要清楚的一点是: 犯罪化只是将耻辱制度化的一种方式。 使毒品非法并不会 让人们停止使用它们。 我们无法从不同的角度看待事物 也是源于对使用毒品 完全错误的叙述。 我们听信了宣传,认为毒品使用者 是不负责任的人,他们只想找点乐子, 由于个人的失败,导致自己的生活 逐渐陷入了犯罪和贫困—— 丢掉了工作、家庭,甚至是生命。 然而事实上,大多数毒品使用者 之所以走到今天都有着特殊的原因, 比如童年创伤,性虐待,精神疾病 以及遭遇的不幸。 毒品只是用来麻痹痛苦的。 当我们接触遭受过很多创伤的人时, 应该理解这一点。
At its core, our drug policies are really a social justice issue. While the media may focus on overdose deaths like Prince and Michael Jackson, the majority of the suffering happens to people who are living on the margins, the poor and the dispossessed. They don't vote; they are often alone. They are society's disposable people. Even within health care, drug use is highly stigmatized. People using drugs avoid the health care system. They know that once engaged in clinical care or admitted to hospital, they will be treated poorly. And their supply line, be it heroin, cocaine or crystal meth will be interrupted. On top of that, they will be asked a barrage of questions that only serve to expose their losses and shame. "What drugs do you use?" "How long have you been living on the street?" "Where are your children?" "When were you last in jail?" Essentially: "Why the hell don't you stop using drugs?"
我们的毒品政策本质上 其实是社会公平的问题。 当媒体聚焦在类似 Prince 和 Michael Jackson 因吸毒过量而导致的死亡时, 遭受痛苦的大多数 是那些生活在社会边缘的、 贫穷的、无依无靠的人。 他们不投票,通常是独居的。 他们很容易被社会抛弃。 即使在医疗领域, 毒品使用也遭受了严重的非议。 使用毒品的人会主动避免 进入医疗保健系统。 他们知道一旦踏入诊所, 或被医院接收, 他们就会遭受不公的对待。 他们的补给线—— 海洛因、可卡因或冰毒, 将会被中断。 最重要的是, 他们会被问一连串的问题, 而那些问题只会让他们 暴露他们的失败和耻辱。 “你使用哪些毒品?” “你在那条街生活了多久?” “你们的孩子在哪里?” “你上次入狱是什么时候?” 以及最根本的: “为什么你不停止使用该死的毒品?”
In fact, our entire medical approach to drug use is upside down. For some reason, we have decided that abstinence is the best way to treat this. If you're lucky enough, you may get into a detox program. If you live in a community with Suboxone or methadone, you may get on a substitution program. Hardly ever would we offer people what they desperately need to survive: a safe prescription for opioids. Starting with abstinence is like asking a new diabetic to quit sugar or a severe asthmatic to start running marathons or a depressed person to just be happy. For any other medical condition, we would never start with the most extreme option. What makes us think that strategy would work for something as complex as addiction?
事实上,针对毒品使用的 整个医疗方法是由上而下的。 因为某些原因, 我们最终认为, 戒除毒瘾是最好的治疗方法。 如果你足够幸运, 有可能进入一个戒除毒瘾的项目。 如果你生活在一个运用 盐酸丁丙诺啡或美沙酮的社区, 有可能进入一个替代治疗的项目。 我们几乎不向人们提供 他们为了活命而迫切需要的东西: 阿片类药物的安全处方。 一开始就进行戒除,就好像 要求一个刚患糖尿病的患者戒掉糖, 或者让一个严重的 哮喘病人开始跑马拉松, 或者让一个抑郁的人 立刻变得快乐一样。 对于其他任何医疗状况, 我们决不会一开始就做出 这个极端的选择。 是什么让我们认为那个策略 会对像毒瘾这么复杂的事情起作用呢?
While unintentional overdoses are not new, the scale of the current crisis is unprecedented. The Center for Disease Control estimated that 64,000 Americans died of a drug overdose in 2016, far exceeding car crashes or homicides. Drug-related mortality is now the leading cause of death among men and women between 20 and 50 years old in North America Think about that. How did we get to this point, and why now? There is a kind of perfect storm around opioids. Drugs like Oxycontin, Percocet and Dilaudid have been liberally distributed for decades for all kinds of pain. It is estimated that two million Americans are daily opioid users, and over 60 million people received at least one prescription for opioids last year. This massive dump of prescription drugs into communities has provided a steady source for people wanting to self-medicate. In response to this prescription epidemic, people have been cut off, and this has greatly reduced the street supply
尽管意外的毒品使用过量 已经不是什么新鲜事, 当前的危机规模却是前所未有的。 疾病控制中心估计, 在 2016 年,有 64000 名美国人 死于毒品使用过量, 远超车祸或谋杀的死亡人数。 如今在北美 20 岁 到 50 岁之间的人群中, 与毒品相关的死亡 是最主要的死亡原因。 想想吧。 我们怎样,又是为什么 落到了今天这种境遇? 针对阿片类药物存在着巨大的争议。 在过去的几十年中,像奥施康定、 扑热息痛和盐酸二氢吗啡酮这样的药物 已经被广泛地用于缓解各种疼痛。 据估计,有两百万美国人是 阿片类药物的日常使用者, 并且仅仅在去年,就有超过 6000 万人 获得了至少一个阿片类药物的处方。 这种大量地向社区倾售处方药的行为 为那些想要自行治疗的人 提供了稳定的药物来源。 为应对处方药的泛滥, 人们的药物供应渠道被切断, 这大大地减少了街道层面的药物供应。
The unintended but predictable consequence is an overdose epidemic. Many people who were reliant on a steady supply of prescription drugs turned to heroin. And now the illegal drug market has tragically switched to synthetic drugs, mainly fentanyl. These new drugs are cheap, potent and extremely hard to dose. People are literally being poisoned. Can you imagine if this was any other kind of poisoning epidemic? What if thousands of people started dying from poisoned meat or baby formula or coffee? We would be treating this as a true emergency. We would immediately be supplying safer alternatives. There would be changes in legislation, and we would be supporting the victims and their families. But for the drug overdose epidemic, we have done none of that. We continue to demonize the drugs and the people who use them and blindly pour even more resources into law enforcement.
这一做法无意间产生了 一个可预料的后果, 即毒品使用过量问题的蔓延。 很多依赖稳定的处方药供应的人 开始转向了海洛因。 不幸的是,如今的非法毒品市场已经 转而开始销售合成毒品,主要是芬太尼。 那些新的毒品价格低廉、 药效强,并且极其难以服用。 确切地说,人们正在被毒害。 你们能够想象出其他 类似的中毒蔓延事件吗? 如果数千人因为有毒的肉, 或婴儿配方奶粉, 或咖啡开始死亡会如何? 我们应当把这件事 当成真正的紧急事件对待。 我们应当立即提供更安全的替代品, 应当修改法律, 还应该支持 那些受害者及他们的家庭。 但是对于毒品使用过量问题的蔓延, 我们还没有采取任何行动。 我们继续妖魔化毒品和它们的使用者, 并且盲目地倾注更多的资源到执法中。
So where should we go from here? First, we should fully embrace, fund and scale up harm reduction programs across North America. I know that in places like Vancouver, harm reduction has been a lifeline to care and treatment. I know that the number of overdose deaths would be far higher without harm reduction. And I personally know hundreds of people who are alive today because of harm reduction. But harm reduction is just the start. If we truly want to make an impact on this drug crisis, we need to have a serious conversation about prohibition and criminal punishment. We need to recognize that drug use is first and foremost a public health issue and turn to comprehensive social and health solutions.
那么,下一步应该怎么办呢? 首先,我们应当全面地接受、资助, 并且在整个北美扩展伤害减轻项目。 我知道在温哥华这样的地方, 伤害减轻一直是护理和治疗的生命线。 我知道,如果没有伤害减轻项目, 死于毒品使用过量的人数将会高得多。 我个人就知道几百个 因伤害减轻项目 而得以存活下来的人。 但是伤害减轻仅仅是一个开始。 如果我们真正想要削弱毒品危机, 就必须开展一场关于禁毒 和刑事处罚的严肃对话。 我们必须意识到,毒品使用 首先是一个公共健康问题, 需要全面的社会医疗解决方案。
We already have a model for how this can work. In 2001, Portugal was having its own drug crisis. Lots of people using drugs, high crime rates and an overdose epidemic. They defied global conventions and decriminalized all drug possession. Money that was spent on drug enforcement was redirected to health and rehabilitation programs. The results are in. Overall drug use is down dramatically. Overdoses are uncommon. Many more people are in treatment. And people have been given their lives back. We have come so far down the road of prohibition, punishment and prejudice that we have become indifferent to the suffering that we have inflicted on the most vulnerable people in our society.
我们已经有了 一个关于这项措施的模型。 在 2001 年,葡萄牙 国内发生了毒品危机—— 很多人使用毒品,高犯罪率 以及毒品使用过量问题的泛滥。 他们拒绝了全球惯例, 并且将拥有毒品无罪化。 用于毒品执法的资金 转而被用于资助医疗与康复项目。 这一举措的结果则是: 毒品使用的现象急剧减少。 毒品使用过量的情况越来越罕见。 更多的人得到了及时的治疗。 人们的生活回到了正轨。 我们在禁止、惩罚 和偏见的道路上已经走得太远, 以致于我们对社会上 那些最脆弱的人们 所遭受的痛苦已经变得漠不关心。
This year even more people will get caught up in the illegal drug trade. Thousands of children will learn that their mother or father has been sent to jail for using drugs. And far too many parents will be notified that their son or daughter has died of a drug overdose. It doesn't have to be this way.
今年,甚至会有更多的人 因非法毒品交易被逮捕。 数千的孩子将会意识到 他们的妈妈或爸爸 因为使用毒品而被送进监狱。 还有更多的父母会收到 他们的儿子或女儿 因为毒品使用过量而死去的噩耗。 事情本可以不必这样。
Thank you.
谢谢。
(Applause)
(掌声)