International Journal of Drug Policy 18 (2007) 155–159
Editorial
Harm reduction in Tanzania: An urgent need for
multisectoral intervention
A November 27, 2006 editorial cartoon in the Tanzanian
Newspaper Majira features two muscular boxers labelled
‘government’ and ‘drug sellers’ in a boxing ring alongside
a commentator. While the ‘drug seller’ in the background
looks on, the boxer that is the ‘government’ is turned toward
the reader and leaning out of the boxing ring as he throttles
a scrawny figure labelled ‘young drug users’. The ‘government’ is saying, “Now you, haven’t I told you not to use
drugs?” The commentator replies, “Ha! That one’s only a fan
brother, don’t waste your time, [the ‘drug seller’] is who you
should be fighting” (Killagane, 2006) (original in Swahili,
translated by first author). This editorial cartoon encapsulates the attention the media has focused on the need for the
government to respond to drug barons. It also parodies the
lack of government response to the HIV prevention and drug
treatment needs of drug users.
The Tanzanian ‘war on drugs’
From mid-November, 2006 to early February, 2007, the
Tanzanian media regularly covered their government’s “War
on Drugs”. Another November 2006 editorial cartoon entitled “War on Drugs” featured a boa constrictor squeezing a
man to death. The boa’s head, symbolically shaped as a marijuana leaf, was preparing to swallow the drug user it had
crushed (Kinya, 2006). Governmental response to trafficking includes destroying farms and plots producing marijuana.
In another editorial cartoon focused on heroin trafficking, a
young Member of Parliament, Amina Chifupa, is featured
sitting on a bomb labelled ‘drug dealers’. She is lighting a
match as if preparing to light the bomb’s fuse and is thinking,
“Give me a chance, I”ll blow that!” (Danny, 2006). During mid-November, Ms Chifupa had called upon members
of Parliament to talk genuinely about the problem of heroin
trafficking and reveal the names of drug barons (Kulekana,
2006). She was hounded by the press for days with both
positive and negative stories written about her activities and
relationships.
0955-3959/$ – see front matter © 2007 Elsevier B.V. All rights reserved.
doi:10.1016/j.drugpo.2007.05.001
By December, the media began focusing reports and editorials on a list of 200+ names of high-level business and
government leaders that they reported had been circulated to
high levels of the government. Media announcements that
these individuals were being watched for their involvement
in drug trafficking dominated the news. Editorials warned of
blacklisting and a December 3rd editorial cartoon showed a
businessman and a young associate sitting at a table drinking beers. The younger man is saying, “Boss, your name is in
the drug dealers’ list, you should quit the business!” The boss
replies, “Don’t worry, lists of names are always there, nothing
can be done!” (Abeid, 2006). Media reports, editorials, pictures and the parliamentary debate about outing suspected
drug barons heightened the general public’s understanding
that Tanzania was part of an international trafficking network
and that heroin had joined the ranks of marijuana, khat, and
“gongo” as illicit substances consumed locally.
The lengths to which drug traffickers go to move their
product and the extent to which Tanzanian youths are
involved in the trade was revealed to the public in late December. During the 2006 Christmas holidays several young
Tanzanian men were arrested for transporting a corpse of
a colleague containing 59 pellets of heroin (This Day, 2007).
The idea that Tanzanians would use a friend’s or any body to
transport heroin was a shocking realization for many. Popular
music and slang reveal that these arrests were not an isolated
incident. A Swahili pop song’s tongue-in-cheek lyrics about
an IDU’s ‘friend’s’ suggestion to plead guilty and go to prison
where he would enjoy free room and board notes the reality
IDUs in Tanzania experience (Maembe, n.d.).
After injecting heroin became popular during 2001 and
cheap pure heroin began to dominate the local market during 2003, Tanzanian police and security officials focused on
both drug trafficking and local consumption. During the latter
half of 2006, the Tanzanian government’s largely successful
efforts to reduce heroin trafficking at the international airports led traffickers to focus on land routes. Escalated bursts
of police activities have resulted in roundups of sellers and
users. Arrests of drug barons included one man sentenced to
156
Editorial / International Journal of Drug Policy 18 (2007) 155–159
Fig. 1. Now you, haven’t I told you not to use drugs? Ha! That one’s only a fan brother, you’re just wasting your time, [the drug seller] is who you should be
fighting.
prison during March 2007 for 12 years (Daily News, 2007).
The sum of these actions demonstrates that the Tanzanian
government is clearly focused on reducing supply and practices associated with illicit use of narcotics. The Tanzanian
“War on Drugs” is not yet, however, accompanied by a policy
that focuses on the needs of the communities in which these
practices emerge, nor does it respond to the needs of the users
themselves (Fig. 1).
IDUs’ creative responses to policing: Moving further
underground
Similar to experiences elsewhere, as the frequency of
arrests for drug possession and trafficking increased and drug
trafficking patterns changed, sellers and Tanzanian IDUs’
risky injection practices increased (Small, Kerr, Charette,
Schechter, & Spittal, 2006). Following crackdowns featuring arrests of sellers and users in seller’s homes in December,
sellers moved to the street to hawk drugs (Alasiri, 2007). During periods when heroin was scarce, or difficult to obtain, the
price increased and sellers adulterated the product. IDUs’
responses to increased police activity over the last couple
of years were to use shooting galleries less frequently, try
to inject at home, and return to injecting in open spaces,
abandoned buildings, and new construction sites. More disturbingly, IDUs began to change how they injected heroin
(Grund, Stern, Kaplan, Adriaans, & Drucker, 1992; Small &
Drucker, 2006) not only did IDUs share used needles, some
provided syringes filled with heroin-saturated blood (flashblood) to friends who could not afford to purchase heroin,
who then injected the blood to stave off withdrawal symptoms
(McCurdy, Williams, Ross, Kilonzo, & Leshabari, 2005). The
practice was first observed among female IDUs in Dar es
Salaam, but has since spread to Zanzibar (Dahoma et al.,
2006). The practice of vipoint, injecting only a measured cc
of heroin and passing on the syringe, is similar in some ways
to ‘jerking’ in Pakistan, has also been observed (Kuo, ulHasan, Galai, Zafar, & Strathdee, 2004; McCurdy, Williams,
Kilonzo, Leshabari, & Ross, 2006).
Urbanisation and economic liberalisation have facilitated
the rapid transition of many Tanzanians into some sort of
interface with the global economy. Tanzania has a population of 36.2 million people and since independence the urban
population grew from 5 to 33%. Fifty percent of those live
in Dar es Salaam. Economic liberalisation marked the opening of increased movements of young Tanzanians abroad and
increased trade opportunities with Asia and Europe. The IMF
orchestrated intervention demanded that Tanzania reduce
government expenditures and increase government revenues.
The Tanzanian government, among other measures, reduced
expenditures on education and health care and introduced cost
sharing in those sectors. By 1999 one-third of Tanzanian children did not attend primary school, 51% of Tanzanians lived
on less than a dollar a day, and most of the urban workforce
were unskilled and underemployed (UNDP, 2000). Following the reintroduction of free primary schooling in 2003, there
has been an increase in overall reported attendance rates of
90%, but required fees for other school needs still limit the
poorest Tanzanians from keeping their children in primary
school (REPOA, 2005).
The reduction of the national rate of HIV seroprevalence
to 7% during 2006 belies the higher rates of HIV in IDUs
(Tanzania Ministry of Health, 2005; REPOA, 2005). HIV
seroprevalence among IDUs in our Tanzanian HIV Prevention Project was 42 and 67% in female IDUs engaged in
Editorial / International Journal of Drug Policy 18 (2007) 155–159
sex work (Timpson et al., 2006). Attempting to police IDUs’
practices in the absence of drug treatment and harm reduction
interventions will only alienate users who need treatment or
risk reduction services (Williams et al., 2007).
Heroin is a relatively new drug in Africa and injection drug use is not even a decade old in East Africa
(Beckerleg & Hundt, 2004; McCurdy, Williams, Kilonzo,
Ross, & Leshabari, 2005). Of the 32 million estimated drug
users in Africa during 2002, approximately five million used
heroin, cocaine or psychotropic substances (UNDOC 2002).
Although there are no official statistics on drug abuse in the
country, in Dar es Salaam, which has a population of 2.5
million, we estimate, based on how quickly we were able to
recruit IDUs for our study over the first three or 4 months that
there are approximately 1500–2500 IDUs. Outreach workers
in Mombasa and Nairobi, Kenya contacted 1149 self identifying IDUs during a 15 month period in 2005–2006 (Deveau,
Levine, & Beckerleg, 2006). Despite its recent introduction,
some urban communities along the Swahili Coast are all too
familiar with the ways that heroin can impact lives. Heroin
users indicate that urban centres are no longer isolated from
heroin as they take the drug and/or works along when moving between towns (McCurdy fieldnotes 2005). After initial
reactions of shock and denial that heroin could have made
decisive inroads, there is growing demand in Tanzania for
the government to ‘do something’.
As users cycle through the prison system and end up
back on the streets and sellers change their practices to manage increased police activity, the public has grown aware
of heroin’s far-reaching consequences. Even the smallest
of children know who the local heroin users are and shout
‘mteja’ [user] as they walk by, exposing their ‘identity’. Users
tell us they hide their use and their injection practice for as
long as possible from their families and non-using friends and
acquaintances. The stigma of being an mteja, and especially
of being an IDU, is growing along with people’s heroin awareness. Yet, IDUs in Dar es Salaam deem the limited treatment
services as woefully inadequate if they want to quit. There has
been no discussion in the media about the lack of treatment
for IDUs.
Lessons from around the world
Hoffman, Boler, and Dick (2006) argue that youths at the
centre of concentrated epidemics who engaged in risky HIV
behaviours require urgent attention and interventions that are
based on good practice, including both facility and outreach
components, and a focus on information and services. They
report that Nepal, India, Thailand, Brazil, and Puerto Rico
successfully reduced the needle-sharing practices of IDUs.
In Argentina, where 60% of IDUs already had HIV, the
harm reduction program initiated included offering substitution treatment and organizing drug users into an association
(Incharraga et al., 2002). In addition, heroin interventions in
Canada, Germany, the Netherlands, Spain and Switzerland.
157
Vancouver have been associated with reduction in criminal
activity, reduced HIV risk practices, and the reintegration of
the heroin user into main stream society (Small & Drucker,
2006).
Given that governments in sub-Saharan Africa were dedicated to getting anti-retroviral medications for their people
infected with HIV, it is reasonable to assume that if knowledge
and resources were offered, they would also establish viable
drug intervention programs. What will it take to generate an
international response to help sub-Saharan African governments provide effective treatment to heroin injectors? Heroin
dependent IDUs in Dar es Salaam are requesting assistance
and members of Parliament have asked for direction. What
suggestions, options, and assistance can be provided as Tanzanians determine what their response will be to the heroin
epidemic?
What lessons can we learn from drug control services, drug
dependence treatment, harm reduction and HIV/AIDS prevention, treatment and care programs and policies focused on
responding to the needs of IDUs in other developing countries that might help those attempting to shape policy and
programming in Tanzania?
At first glance, attempting to control the supply of heroin
seems a faster and less expensive response than building a
public health infrastructure that can respond to dependence.
It is not surprising that a number of governments initially
took this approach. However, it is futile to take only one
stance. Attempts to control supply must be accompanied by
a multisectoral intervention approach that addresses drug use
at a community and individual level. It is crucial to respond
to the needs of the community to help those already engaged
in drug use to reduce potential harm through supportive HIV
prevention and interventions.
The need for local harm reduction strategies and
services
Services for drug users in Dar es Salaam are currently provided by non-governmental organizations (NGOs),
community-based organizations (CBOs), district health services, and mental health services at the Muhimbili National
Hospital. A number of NGOs in Dar es Salaam and the
Infectious Diseases Clinic of the Dar es Salaam City Health
Department provide counselling or support for drug users.
These services, however, have never been evaluated and
have not been consistent over the years (Mndeme, Magimba,
Kaaya, Mbwambo, & Kilonzo, 2006).
In the public health system, mental health clinics in district
hospitals provide counselling support for substance abusers
with the support of the Drug Control Commission. The
Muhimbili National Hospital Psychiatry and Mental Health
Department provides detoxification services, individual and
family counselling services, and runs a weekly abstinence
support group for out-patients. In-patient services for detoxification are provided in the context of other mental health
158
Editorial / International Journal of Drug Policy 18 (2007) 155–159
services. This has been a major barrier to access to services
for persons with substance dependence disorders (Mndeme
et al., 2006).
Part of the hesitation of larger international entities to get
involved in the IDU situation is the lack of a mandate from
the Tanzanian and other African governments on acceptable
ways to proceed. Nations and local communities must set the
agenda for local strategies. Low resource countries with limited funds want scientific evidence prior to establishing policy
and programming initiatives. The United Nations Office for
Drug Control and Crime Prevention (1999) provided initial
assistance to determine what drug practices were emerging
in sub-Saharan Africa, and the CDC has actively participated
in Rapid Situational Analysis in several sub-Saharan African
countries. When we presented our data on HIV seropositivity
among IDUs in Dar es Salaam on World AIDS Day, the participants from government, NGOs, and CBOs were shocked.
Until this point neither the state nor international agencies had
a clear mandate to respond to the HIV crisis among heroin
injectors.
Current harm reduction measures
In sub-Saharan Africa, Mauritius has taken the lead by
passing the HIV and AIDS Act in late 2006, and establishing
a needle exchange and a methadone maintenance program
(Ackbarally, 2007). In neighbouring Kenya, the United
Nations Office on Drugs and Crime (UNODC) received a
PEPFAR funded USAID grant during 2004 for a communitybased outreach programme for drug users (Deveau et al.,
2006). The project focused on reaching IDUs and referring
them to VCT and HIV and drug treatment. Funds also covered
developing two NGO networks and Ministry of Health services for drug users. This initiative followed 2001 UNODC
regional initiatives called Local Expert Networks in East,
North and West Africa to develop demand reduction skills
and knowledge. Ten experts from six countries in East Africa
published materials on peer-to-peer prevention education and
treatment and rehabilitation standards. This Demand Reduction Approach is a priority of the new Organization of African
Unity’s Drug Control Action Plan. After creating peer education materials and standards of treatment and rehabilitation,
each expert was charged with facilitating prevention projects
in their own countries (UNODC, 2002).
In contrast, PEPFAR/USAID funded interventions in
Tanzania are focusing on national conversations about faithfulness and zero grazing (staying with one sexual partner),
one of which was just launched in Tanzania, fail to take into
account the ways that poverty and hunger contribute to risky
sexual and drug behaviours among youths (Kivamwo, 2007).
A female IDU is likely a sex worker and her clients will offer
more money to not use a condom. Many poor young women
trying to establish a significant relationship with a man will
lobby him to quit using a condom so that he will be her partner
with all the rights and obligations accompanying the relation-
ship. For women, there is an expectation that this will mean
food and clothing, protection, and a measure of respect. For
men a relationship means an expectation of exclusive sexual
access to their partner who they trust. After two major condom marketing releases, a focus on faithfulness was the next
USAID marketing initiative. The IDU population, although
volatile in terms of HIV seropositivity and risky behaviours,
is still considered marginal enough that it does not warrant
significant funds for an intervention, although discussions
about future IDU interventions are apparently underway.
During July 2006 the Department of Psychiatry at the
Muhimbili National Hospital sent a proposal they developed – a “Service Development Proposal” – to the National
Drug Abuse Control Commission and Parliament requesting
funds for a drug institute that would provide training from
the national level to the district level as well as housing a
drug treatment program. Building social support networks
for abstinence-based programs was one aspect of the proposal
(Mndeme et al., 2006). The CDC is currently conducting a
Rapid Assessment of drug users’ practices in Zanzibar. Now
is the time for the Tanzanian government, international and
local NGOs, CBOs and local communities to begin to work
together with or without international assistance to develop
and facilitate multilevel interventions that will help empower
and educate local communities about drug use and provide
IDUs with treatment programs and a range of HIV prevention
and health services. The earlier programs that provided education at the community level need to be augmented by harm
reduction measures that respond to IDUs active use today
(Mndeme et al., 2006).
At this critical juncture, with an established high rate of
HIV seropositivity among the IDU population in East Africa,
building the African Harm Reduction Network is clearly
overdue (Coffin, 2002). The initial network was established
during 1999 in Nigeria, a coordinated effort led by Dr. Moruf
Adelekan with the help of the International Harm Reduction Association (Mesquita, 2000). Workshops and trainings
centred on the principles of harm reduction as an important
component of prevention and health promotion. Substitution
therapy was a component of this and country representatives
were charged with returning home and exploring with policy
makers the possibilities and modalities of introducing drug
substitution therapy. The main medication under consideration then was methadone. The consensus was to introduce
syringe exchange and methadone replacement in controlled
intervention study settings before recommending both for
general use. Funding for such studies was the major hurdle.
Clearly the African Harm Reduction Network must be
reinvigorated and fully developed with information accessible online to NGOs, CBOs and governments so that they can
more effectively communicate information about best practices and build strong linkages that can address regional and
local country needs. Linkages with the International Harm
Reduction Network must be renewed and the successes of the
Asian Harm Reduction Network provide many illustrations of
positive ways forward. With a well-established group of HIV
Editorial / International Journal of Drug Policy 18 (2007) 155–159
seropositive IDUs in East Africa, in a firmly entrenched AIDS
epidemic in its third decade, we desperately need to scale
up organized activities that can pull together best practices
noted elsewhere and begin to disseminate this information
and interventions throughout sub-Saharan Africa before the
new trends of reduced national HIV rates seen in East Africa
are quickly reversed (McCoy, 2002).
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Sheryl McCurdy ∗
University of Texas Houston Health Science Center,
Behavioral Sciences, 7000 Fannin, 25th Floor, Houston,
TX 77030, United States
Gad P. Kilonzo
Psychiatry and Mental Health Muhimbili University
College of Health Science, Dar es Salaam, Tanzania
Mark Williams
University of Texas Houston Health Science Center,
Behavioral Sciences, 7000 Fannin, 25th Floor, Houston,
TX 77030, United States
Sylvia Kaaya
Psychiatry and Mental Health Muhimbili University
College of Health Science, Dar es Salaam, Tanzania
∗ Corresponding
author. Tel.: +1 713 500 9633;
fax: +1 713 500 9750.
E-mail address: [email protected]
(S. McCurdy)
4 April 2007