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5.13 p.m.

Baroness Gardner of Parkes: My Lords, today is World AIDS Day and as so many speakers have pointed out, it is a very appropriate day for this debate. I welcome the Green Paper. I notice that the Motion asks us to note it, which I do. I do not intend to speak on the Green Paper but I think it is good that we have it.

As far as drug users are concerned, a point that has not been mentioned is that HIV is only transmitted if one person already has an HIV infection. Therefore, the most important matter is to control the spread of AIDS and HIV; and to do that, early detection is of course important. Simple tests can confirm the presence of HIV and these tests should be encouraged, not discouraged.

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Any deterrent to people presenting themselves for tests must be removed. In the past, insurance application questions have been a problem. A national survey carried out in 1991 by the Department of Health estimated that the numbers being put off having HIV tests were,

    "certainly in the thousands, possibly in the tens of thousands".

The Secretary of State said at that time about testing:

    "We must remove the barriers in the interests of public health".

This has not been easy and the Terrence Higgins Trust has played a significant part in this matter, but I must give full credit to the Department of Health for its success in persuading the Association of British Insurers to change the questions on application forms. This change affects all those, heterosexual or homosexual, who are considering an HIV test. I am informed that in the past many GPs have not recorded the information that someone was seeking an HIV test for fear that it might prejudice an insurance application. Many patients still choose to use the anonymous testing centres. There is a clinic at the Royal Free. Patients may enter it in the morning, be given a number and can have the result in the afternoon. No names are asked.

On 25th July the Association of British Insurers announced in a news release the withdrawal of its previous recommended question on HIV/AIDS testing and the introduction of a new one. One of the reasons for this is that over the past two years, as the association said, testing has become much more commonplace for screening purposes. The question now only asks whether a person has had a positive test. The previous question had asked whether someone had had a negative test. On health grounds, I think it wrong that anyone should ask whether a patient has had any negative test of any type, whether it is a test for breast screening, or a chest X-ray or any other sort of test. Surely it must be good that a person should be screened for a condition rather than have that held against him when applying for insurance. I believe that it is right that the Association of British Insurers has decided that it is no longer appropriate or necessary to ask the previous question. It has produced a new recommended wording. The question now is:

    "Have you tested positive for HIV/AIDS or Hepatitis B or C, or have you been tested/treated for other sexually transmitted diseases or are you awaiting the result of such a test"?

Everyone is satisfied that that new wording protects the insurance companies. After all, they cannot give open insurance to someone who has had a positive test, no matter whether it was a positive test for cancer or HIV or any other condition. The insurance companies had a sound point in that regard when they said they would have had to increase all premiums considerably if no such questions could be asked. However, the new recommended wording was considered satisfactory and a code of practice was issued.

Some companies have already reprinted their forms, one of which is the Scottish Provident but it has still not really quite complied with the new wording. A sample form of the Scottish Provident asks:

    "Have you tested positive for HIV/AIDS or hepatitis B or C?".

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That part is all right, but then the form puts an entirely separate question:

    "Have you ever been tested or received treatment in connection with any sexually transmitted disease, or are you awaiting the result of such a test?".

That, again, is asking someone to declare a negative test and I think that attention should be drawn to that.

In the copy of Which? dated 1st December 1994 there is a section on that very point. The magazine asked 105 life insurance companies whether they had changed the wording on their forms to reflect the new code.

The article states that,

    "67 replied, and almost half said they have changed the wording on forms ... The rest said changes will be introduced from January 1995. [But] if you are sent an old form and object to the HIV/AIDS questions, contact the company and ask for the new style of question as agreed by the ABI".

Although that advice is sound, I still think that it leaves people feeling a bit vulnerable if they have to phone and ask for a new form because people would ask them why they needed a new form and why they could not complete the old one.

If the code of practice has been changed, it should be complied with. For that reason there are a few questions that I must put to the Government. Do the Government know that so far only 50 per cent. of insurers have complied with the guidance? Is that acceptable? Does the Which? information that the remainder intend to comply by 1st January 1995 accord with the Government's information on this? Are the Government satisfied that that will happen? Were they aware that that one major company--Scottish Provident--had made that something of a trick question by dividing it into two, as I pointed out?

It is very important, as a public health issue, for us to realise that detection is an important aspect. Anything that discourages people from attending clinics is not in the interests of the public. If people are diagnosed as having HIV they will perhaps act differently towards others. However, if they are not aware of having HIV they do not give any thought to what might happen to others.

Therefore, although work is continuing worldwide to find a cure, and there is no cure for AIDS at present, I believe that the time will come when we come closer to a cure. Perhaps we shall first reach a stage where the disease is controllable. It will then be in the interests of patients for it to be known at an early stage that they have the disease. In most diseases the condition is more easily treated at an early stage.

Those are specific questions, but they are relevant to our debate on this matter of HIV and AIDS. Although drugs are one means by which the disease is transmitted this is, as many speakers have said, a much wider issue, and therefore I feel that I have to put those questions.

5.21 p.m.

Lord Rea: My Lords, I should make it clear that in this debate I am speaking from a Back Bench--although not very far back because the Benches at the very back of the Chamber are very cold. What I shall say is not yet Labour Party policy, although naturally I hope that in due course that will move in my direction.

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The Green Paper will be useful if it stimulates debate on a countrywide basis and the White Paper which follows it takes account of some of the questions--and provides some answers--which will arise as a result of that debate.

Internationally, the drugs trade is estimated to handle goods worth some 254 billion dollars to the major traffickers. That is equivalent to approximately a third of our national income and is the same as the United States defence budget. No wonder Colombian or mafioso drug barons can defy, suborn and sometimes outgun governments. I am afraid that the Green Paper gives no sign of any new policies which are likely to make any noticeable impact on the operations of those very rich international gangsters. Making 550 Customs and Excise officials redundant does not seem likely to help to achieve the Government's aims. That makes me wonder whether the Government are wholeheartedly behind the aims set out in the Green Paper.

As a general practitioner who has had a number of drug-dependent patients over the years, I should like to concentrate on the health problems created by drugs. It is important to recognise that these are in two categories: those which can be ascribed to the active principle of the drugs themselves, administered in a normal dose or, if injected, using a sterile syringe needle; and those which occur as a result of obtaining drugs illegally, in an impure state, in a cloak-and-dagger market "on the street". I say to the noble Baroness, Lady Masham, that I would place crack cocaine in that category.

It is that latter category which results in the heavy burden on the NHS--mentioned in the Green Paper--on GPs in their surgeries and accident and emergency departments throughout the country. Those problems can be due to an often fatal overdose as a result of a batch of a drug being less "cut" or adulterated and thus stronger than expected. They can be due to an abscess and septicaemia as a result of the use of shared or otherwise unsterile syringes or needles. As many noble Lords have pointed out, HIV and hepatitis B are spread by the use of shared injecting equipment.

A pure drug can have long-term effects, as indicated in the Green Paper, in the same way as nicotine--which is the most addictive of all drugs--and alcohol. However, few, if any, of the currently controlled drugs--whether opiates, including heroin, cocaine, cannabis, or other soft drugs--have worse long-term effects than nicotine, which is lethal even when used as indicated, or alcohol with its adverse social effects, liver damage and carcinogenic effects when used in excess. However, in favour of alcohol is the fact that in low doses--fewer than 21 units for men and 14 a week for women--it has been shown to be beneficial to the cardiovascular system.

Whatever may be the long-term clinical, psychological or social effects of the use of unadulterated controlled drugs, they are not the problems which concern GPs and accident and emergency departments, where the ill-effects seen are mostly due to the impurities and varied strengths of street drugs and unsterile injections.

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There is a tendency by many to regard those who use drugs as beyond the pale or morally tainted. They are stigmatised. However, that has no logical basis, any more than it would be logical to regard smokers or drinkers in that way. The Green Paper gives some statistics to show how widespread the use of illegal drugs is now in England: 44 per cent. of 20 to 24 year-olds in inner cities use drugs; 14 per cent. of those aged between 12 and 59 have experience of cannabis use. In a survey of a true random sample of patients registered in a group practice in North West London earlier this year funded by the North Thames Regional Hospital Authority, I found that 48 per cent. of females and 51 per cent. of males aged between 16 and 44 had used cannabis at some time, and 18 per cent. were current users.

Most controlled drugs, as with nicotine and alcohol, can give pleasure, and produce relaxation or increased feelings of awareness or alertness. If used occasionally, or even regularly, in a reasonable dose as a pure substance, they cause minimal or no harm. The same could be said of alcohol. Similarly, habitual or excessive use may cause harm to some people, although others seem to get away with it. The violence associated with drug use is not due to the drug itself but almost always to disputes among rival traffickers in illegal drugs. The effect of drugs is only on the person concerned, much more so than with alcohol, which has serious social effects.

It may justifiably be said that there is often social pressure, as well as pressure from pushers, on young people to start using drugs. That has been mentioned by a number of speakers. I agree with the Green Paper that, theoretically at least, health education about drugs can be useful. However, the noble Baroness must pay heed to the remarks of the noble Lord, Lord Mancroft, and take note of the Australian experience. The same applies to tobacco and alcohol, and also to sex education. We need to prepare people to handle their actions in a healthy way. We must take note of what is happening and not preach to people to stop. Of course the harmful effects can be mentioned in health education, but it is also very important for young people to be shown how to behave and how to use substances in a safe and healthy way. With regard to tobacco and alcohol, the pushers are the manufacturers themselves who promote their products through widespread and highly effective legal advertising.

Deaths and serious health problems from illicit use of controlled drugs almost always occur among heavy habitual users, although accidents happen with novices who may not yet have developed tolerance. It is for those chronic users that treatment and rehabilitation facilities need to be available in every health district, with more in those with a high prevalence. We should take note of the difficulties that the voluntary sector is having in keeping some of those centres going. Those centres should be able to assist users who genuinely want to come off drugs, as well as those who are "stuck" and cannot manage to face a drug free life, even though logically they would like to. My long experience with drug users has convinced me and many other realists

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that many users will not succeed with drug reduction programmes until they are ready--and that may be many years ahead.

The Green Paper mentions that methadone programmes--the noble Baroness also referred to them--in several centres will be evaluated. That is very good so far as it goes. But I have found that many long-term addicts are quite reluctant to use methadone as a heroin substitute. It is well known that many, perhaps a majority, of heroin users who have a regular supply of methadone sell it on, in order to help to buy the heroin that they really want. A recent Home Office statistics bulletin indicates that more deaths are now notified as due to methadone than to heroin although there are fewer methadone users.

There is a strong case for treatment centres to be allowed to prescribe heroin to certain long-term users, not necessarily to be injected but, for example, made up as reefers which give a "high" rather like an intravenous injection but without the danger.

Between 1920 and the mid-1960s confirmed drug addicts were prescribed the opiate they needed and the problem remained very small indeed. Since that policy--following the recommendation of the Rolleston Committee--was abandoned, the problem has vastly increased. The decision to offer only, or mainly, reduction programmes in drug clinics has been totally ineffective in reducing drug dependency, as the noble Lord, Lord Mancroft, pointed out.

It would be too simplistic to say that that more restricted approach has been the only reason for the rise in drug abuse. Of course, the easy availability of air travel would have increased the number of addicts in Britain, or elsewhere in the world, in any case. But the approach up to now of restricting prescribed drugs has had the effect of greatly encouraging the illegal black market as well as increasing the health hazards of drug use including the spread of AIDS. What success we have had in slowing HIV transmission in drug abusers--it is considerable, as my noble friend described--comes from the recognition that many users will not be able to give up the habit, at least in the near future. However, the very best success rates in preventing HIV transmission are achieved in clinics in which maintenance drugs are prescribed. I cite as an example the Widnes Clinic which routinely tests its clients for HIV and has yet to detect a new HIV case.

Perhaps I may say a few words about drug related acquisitive crime. The Green Paper calculates that heroin abuse generates a maximum of £864 million worth of stolen goods, on the basis that a thief obtains one-third of the value of the stolen goods. In my opinion, and in that of the addicts I have questioned, the proportion is more likely to be one-fifth, or even less. That means that such thieves will need to steal nearly £1.5 billion worth of goods to raise the estimated £288 million that they need. That calculation relates to heroin alone. The total value of goods stolen to buy drugs is probably nearer to £2 billion; that is, nearer to half of all acquisitive crime than the one-fifth estimated in the Green Paper.

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Supplying long-term users with the substance that they want on a daily basis, strictly controlled, until they are ready to come off in their own time would have a remarkable effect on crime. At that same Widnes Clinic with the good HIV record, a study was done by the police on the crime records of 142 clients before and after starting maintenance treatment. The convictions dropped from 6.88 to 0.44 per person during comparable periods of one-and-a-half years before and after the treatment. That is a reduction of 15 fold. It is no wonder that senior policemen in all parts of the country are in favour of a change in the current drug policy--disappointingly a change which is not suggested by the Green Paper.

Noble Lords will no doubt be thinking that what I have suggested might lead me to the conclusion that legalisation of drugs would be a logical step. If so, they would be half right and half wrong. The noble Lord, Lord Mancroft, has referred to the annex of the Green Paper entitled "The legalisation debate". It sets up some Aunt Sallys and proceeds to knock them down. I cannot help quoting again the passage to which he referred which states:

    "Of course, taking certain laws off the statute books bring about a technical reduction in crime figures. Yet no one would suggest decriminalising armed robbery or assault on that basis".

That fatuous comparison completely misses the point. Drug use in itself harms no one except perhaps the user if he or she uses it foolishly. If drug use were decriminalised, a user would still be committing a crime if they indulged in robbery or assault or were being a public nuisance; and other legislation exists to deal with that.

Perhaps I may refer again to the same passage as the noble Lord. It is true that,

    "the blanket withdrawal of legal controls ... would be unwelcome".

That would certainly result in an increase in drug use, although whether to the same extent as use of tobacco or alcohol is doubtful. At the moment, society suffers a blanket lack of controls on tobacco and alcohol. I believe that there is plenty of room to increase such controls, as noble Lords who listened to the debate last July on banning tobacco advertising will have realised.

I believe that there is a strong case for decriminalising cannabis, but not as yet for opiates, cocaine and some other drugs, although that must be a possible future option. Three countries in Europe--Denmark, Holland and Germany--have relaxed restrictions on cannabis by looking the other way, by letting the market operate. I suggest that we do it by licensing certain outlets--for example, pharmacists--to supply cannabis under a state monopoly. In that way quality can be controlled, a record kept of the amount sold, and excise duty charged for the Government's and taxpayers' benefit. Canada and Scandinavia have a similar system for alcohol which seems to work quite well. The price must be low enough and the availability widespread enough to make a black market uneconomic, but high enough to make the buyer think twice. Cigarettes and alcohol set a precedent.

In 1991, 84 per cent. of all drug offences were concerned with cannabis. If that drug were decriminalised the police would be freed for more urgent tasks. The decriminalisation of opiates and

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cocaine cannot be done in one country alone. International agreements will be necessary among a group of nations before that is possible. The Dutch experiment indicates that one nation cannot do it alone.

However, short of legalisation, the demand for heroin and other opiates would be greatly reduced if more treatment centres were able to prescribe on a long-term basis for confirmed users. Not only would their health benefit, but they would not need to trade in heroin, as they now do to help finance their habit. That would have a major effect on reducing the amount of street heroin available to attract younger non-users, some of whom, having experimented with it, become dependent upon it.

In conclusion, I am sure that the world will eventually realise that prohibition of addictive substances is a recipe for disaster, as did the United States Congress in the 1930s after the disastrous period of alcohol prohibition in the 1920s, which resulted in an increase rather than a decrease of alcohol use and a wave of organised crime and gang warfare. That is where we are now, worldwide, in relation to drugs. Until that basic truth is accepted we shall continue to knock our heads against a brick wall and the problem will get worse. I am afraid that the Green Paper brings us no nearer to a real solution.

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