When Drug Treatment Met Harm Reduction

Psychologist Sueli Santos says professionals, too, had lots to learn in Brazil

By Adriana Veloso
Reporting from São Paulo, Brazil

June 12, 2003

Sueli Santos is a pioneer in Harm Reduction – the philosophy that seeks to reduce the harms potentially caused by the use of prohibited drugs. Her presence in the Health Department of the state of São Paulo guarantees the expansion and continuance of these projects

In a chat held at the headquarters of the Center for Coexistence and the Law, located in the center of the city of São Paulo, this courageous woman tells, lighting a cigarette, how she was trained to work with the theory of abstinence or “just say no to drugs.”

She describes how she “rebelled,” because she couldn’t neglect reality each day, and ended up getting involved in one of the country’s first harm reduction campaigns: needle exchange. The programs collect used needles and distribute clean ones to injected drug users, thus diminishing the needle sharing and consequently the epidemic of HIV – the virus associated with AIDS - that is transmitted through blood contact.

From her job at the Santa Casa of São Paulo, where she specializes in psychopharmacology, Santos works with drug users. She came to know about Harm Reduction, and later brought its methods to a treatment center, modifying the work philosophy and action, and became an important figure in the Brazilian movement for a more humane drug policy.

Narco News: How did you become involved with Harm Reduction?

Sueli Santos Photo D.R. 2003 Al Giordano

Sueli Santos: I got to know the history of what happened in Santos in 1989 from what drug users who were my patients told me, as well as through the media. I found that the repression that happened in that occasion was an absurdity. Some years later, in 1993, the Health Ministry contracted some services for the first official Harm Reduction training session in Brasilia. In this epoch, I was the state coordinator in combating Sexually Transmitted Diseases, or STDs, and AIDS, the illness associated with the HIV virus. I was invited to participate in a training session conducted by the Australian Dr. Alex Wodak. He was the first international reference that we had about how Harm Reduction was being applied in other countries to combat the AIDS epidemic. It was very important toward obtaining the support of the Health Ministry and to begin to develop research and action with drug users.

Narco News: Harm Reduction project began to be elaborated with this training session?

Sueli Santos: Yes. Twelve pilot projects in Harm Reduction in the country came out of this experience in Brasilia. Needle exchange programs began in 1994 in places like Bahia and Rio Grande do Sul. Here in São Paulo we had to elaborate a political and administrative strategy to be able to start Project Bocada, to start the needle exchange in São Paulo in the field. However, as a state official, I needed the security to be able to go into the street with the Harm Reducers that we were training. But we could not confront a state hierarchy and become prisoners or charged with crimes like what occurred in Santos.

Narco News: The repression that occurred in Santos in 1980 still existed in 1994?

Sueli Santos: The suspended charges from 1989 had been reopened. There were people sending threats of prosecution in Santos, which is also part of the state of São Paulo. This impeded us from acting in 1994. Even still, in the state health department everyone was involved with Harm Reduction, including Paulo Teixeira, who later sponsored the law approved in 1998 that gave the necessary backing for Harm Reduction activities.

Narco News: And when did you finally go into the streets of São Paulo?

Sueli Santos: The first needle-exchange work in the capital was done by Andréa Domanico, who was part of a non-governmental organization. Later, in the second half of 1997, we finally went into the streets with the Bocada Project. We had already conducted a study with patients at the Center of Psycho-Social Treatment and Attention (CRT, in its Portuguese initials, to locate drug users. They showed is the nine locations of heavy drug use in the center of the city of São Paulo, but none of them would take us directly there. We needed intermediaries, and so it was important to have Harm Reduction workers who were also already drug users.

Narco News: And how did the Bocada Project develop?

Sueli Santos: It was an ideal learning experience, because we finally went into the field. At the same time it was very difficult, because the injected drug user is an “invisible” subject. In other words, we knew that they were there because of the AIDS epidemic, but they were not easily found. The way in which an injectable drug is used makes access to these people more complicated, because the drug isn’t used in the street, or on a bridge, like marijuana or crack. The use of the drug, that is, the injection occurs only among other users. They don’t use their substance in front of other people, as other drugs are used.

Narco News: What myths were shattered through this experience?

Sueli Santos: There was a fantasy that, among injectable drug users, there were “baptism rites,” a ritual in which the leader of the group used the syringe first and then passed it around to the rest of the group. This actually happened with older drug users, at a time when cocaine was very expensive in Brazil and AIDS had not yet arrived. When we started working, as we listened the younger drug users, we found that the “rite” was a myth. The sharing of needles, instead, only occurred among friends, two at a time. I heard this from newer users, from adolescents who would inject together, and share the needle. The myth about needle-sharing among a group of people in a ritual was true in another epoch, but by the 1990s needle-sharing typically occurred among just two people at a time. Beyond that, I perceived that the users had notions about hygiene that were in error.

Narco News: How was Harm Reduction, in this sense, applied with drug users?

Sueli Santos: The drug user is tired of hearing that he is harming his health, just like we know that cigarettes are bad but we continue smoking. The tactic of encouraging abstinence doesn’t work for the person who already has drugs in his life. It’s not enough to simply say “stop using.” In the majority of cases, even when the user stops using for some time, the possibility that he returns to using is very great. For example, I remember the first time that I delivered a syringe to a user inside the CRT center. He was the patient of a friend of mine, HIV positive, and with hepatitis. He arrived telling about how he had a relapse sharing a syringe with another user. I didn’t hesitate in giving him a clean syringe so that in case he had another relapse he would not, again, share one with another person.

Narco News: So you began to apply Harm Reduction techniques inside a treatment center for drug addicts?

Sueli Santos: Yes. During the day I thought of how Harm Reduction could aid in my work with drug users. In the afternoon and evening I worked with abstinence programs at the CRT. I began to change my preconceptions and to see how I could offer more to my patients beyond denial of drugs. And parallel to this, I worked in a non-governmental organization, The Mental Health Association (PROSAN, in its Portuguese acronym), where I began to see that users knew they had to clean the syringe, that they had to clean their arm, that is, they had knowledge of hygiene. The question was how to do this, whether with a piece of newspaper or with a clean sheet. This conscience on the part of users made it possible for the work to expand into education, that resulted in a change of behavior of the users in what is referred to as a healthier form of drug use.

Narco News: Did you face difficulties in establishing this Harm Reduction work inside of a treatment center? How did it happen?

Sueli Santos: Yes, there were a lot of difficulties. There were orthodox professionals who said that this was a treatment center, and who condemned Harm Reduction because they believed in the myth that the drug user was really going to quit for life. In reality, this is not what happens. To begin with, the majority of users that came did not say “I have to stop using drugs.” They said, “My mother, or my doctor, says that I have to stop using drugs.” In some cases, the users also arrived saying that they had problems with certain drugs. For example, users of marijuana, alcohol and cocaine said they had problems with drinking and cocaine, because when they drank they wanted to sniff and did so without limits, but that they did not have problems with marijuana.

In these cases, the advice from me was “if marijuana doesn’t cause you problems, keep using it, but not alcohol, if it makes you want to sniff cocaine, it is harming you, thing about the use you are making of these substances.” End when I began to do this, I coordinated, for the state Health Secretary of São Paulo, the Bocada Project, as well as the institute where this was being developed. Many of them said, “But are you going to tell the mothers of the users that you’re doing this? They want their children to be treated here!”

Narco News: And what happened to change the minds of your coworkers?

Sueli Santos: I had to bring them informational texts about Harm Reduction to show that we were working on prevention, not the primary prevention that says “just say no to drugs,” but, rather, one that shows people that are already drug users the possibilities of caring for themselves, because they are a capable of listening and learning how to reduce the damages to themselves and to others. The reduction of harm has lots to offer for professionals who do treatment, because chemical dependents don’t simply stop using drugs. The chance that they are going to continue using is great. So why not work with Harm Reduction. There are already many services that say “just say no to drugs,” but who is going to work with the individual that already uses them? There were a few people in the treatment center who understood that needle-exchange was like distributing condoms. The people didn’t now that couples, when they have sex, use protection to impede the spread of AIDS, and in the same way, with needle exchange, we know that the person was not contaminated. Because the great majority of injectable drug users are seropositive.

Narco News: How do you see this movement today?

Sueli Santos: There’s been an incredible advance. Currently, there are countless projects in the capital and throughout the state that have significantly slowed the AIDS and hepatitis epidemics. Now, I have just started working in the field with injected drug users here at the Center for Coexistence and the Law, and I notice that Harm Reduction is becoming the official policy in most of the states of Brazil.

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