What Works: Success in Stressful Times. Hamish McRae

       CHAPTER FIVE

      I. WHAT IS THE STORY?

      The burghers of Zurich have arguably both the highest standard of living and the highest quality of life in the world.¹ As anyone who visits will quickly appreciate, Zurich is prosperous, comfortable and calm-even, well, just a little dull. It seems like a city without problems.

      It has not always been so. In the late 1980s and early 1990s this orderly bourgeois city had the worst drug problem in Europe.

      The story goes back to the 1970s. Zurich, like so many other rich cities in the developed world, saw a gradual increase in drug use, particularly among the young. To start with, they would gather in small groups by the river and no one took too much notice. Then gradually the numbers increased. Instead of there being a dozen, there might on a summer evening be a couple of hundred. Residents and shopkeepers complained. The police would break up the groups and move them on, but then they would regroup somewhere else nearby.

      Fed up with chasing these people around, Zurich held a liberal social experiment. It allowed drug users to buy and inject drugs in one place without any police intervention. The place they chose was Platzspitz, a pretty park in the centre of the city between the principal railway station and the main river. It was contained by water on two sides and the station on the other and therefore seemed an ideal location.

      It was a disaster. The park became a magnet for drug users from all over Europe. More than 2,000 of them would congregate every day. Their discarded syringes gave it the new name of ‘Needle Park’. The citizens, who had initially supported the project, were aghast. Far from keeping the drug problem limited to one location, the social problems associated with drugs increased even faster than the number of users. There was misery, crime and prostitution. Central Zurich became horrid. Eventually the city decided that this could not continue and in February 1992 the police used rubber bullets and tear gas to disperse the drug users. The park was shut down. In the months afterwards, workers had to remove the top six feet of soil to get rid of all the syringes.

      This made the problem less visible but the drug users regrouped, first in local streets and then in the Letten railway station nearby. They were allowed to stay there because the citizens felt it was better than having them on the streets. But so many people were arrested that some 60 per cent of the inmates in the jails were drug users. Switzerland was spending more per head on law and order than even the USA. Drug abuse and the associated crime continued. Nothing worked.

      Then came a change of approach. The Swiss government had already developed a harm-reduction programme for drug addicts, with needle exchanges and treatment centres, back in 1991. So when in 1995 the crackdown came in Zurich and the station was closed, there was a programme in place to help the addicts. Treatment centres provided injection rooms. Patients could choose their own doctor and treatment was free. There was also a big methadone project, for methadone, as elsewhere, has generally been the favoured alternative to heroin.

      This initiative was called the Four Pillar programme-the pillars being prevention, treatment, harm reduction and enforcement-and it has gone on to become the model for many cities around the world. But at first there was a lot of resistance from local authorities and its first major application did not come until 1994 when Zurich began putting it into practice. In the same year the Swiss government started trials in heroin prescription, a further controversial move. But when the results of these were evaluated, it became clear that for the most strongly addicted people, it was more effective to give them heroin rather than a substitute. Addicts’ health improved, their illegal use of drugs decreased and people on the programme committed fewer crimes. So the programme was approved for general use and other regions of Switzerland introduced heroin prescription too. This scheme, while controversial, seems to have been a key advance.

      Further lessons? A number of people were involved in turning things round but perhaps the most important was Professor Ambros Uchtenhagen, president of the Addiction and Public Health Research Foundation in Zurich. He points out that the Swiss managed the shutdown of the Letten railway station much better than they had that of Needle Park three years earlier. Ahead of closure they arranged for people to have access to sheltered accommodation and to enrol on a drug-substitution programme. So when they did shut it down, very few drug users were there anyway.

      There have been many studies on the effectiveness of the initiative but let us just cite two. One, by Dr André Seidenberg, another of the key doctors behind the programme, was featured in the journal General Practitioner, published in Zurich, in 1999. In it he noted the ‘hard’ measures of success: a halving of the death rate from overdoses, for example, or the 80 per cent fall in HIV infection rates. But perhaps even more impressive were the results of one specific element of the programme: the prescription of heroin for heroin users, rather than a substitute. This produced excellent results even in patients where drug taking had become most embedded. You could see this in the ‘soft’ measures of improvement: people who had been unable to function normally for an average of ten years were able to rejoin mainstream society by receiving their drugs under medical supervision; after treatment, two-thirds found jobs; they started to pay off their debts; they gave up crime, with offences falling to a quarter of the previous level; prostitution more or less stopped; and the taking of cocaine and other hard drugs fell right away.

      Dr Seidenberg’s central message was this: ‘There is no better measure or treatment for reducing the criminality and cocaine consumption of heroin addicts than the medical prescription of heroin.’²

      That was the view of one of the people behind the scheme. But it has been backed by outside independent studies, of which one of the most recent was published in the medical journal The Lancet in June 2006.³ This looked at the statistical evidence: how many people were on the programmes and what had happened to the incidences of drug use. This was really useful because by now there were many years of hard data about drug taking in Zurich. At the peak in 1990, around one person in every 1,400 was taking up heroin; by 2002, the number had fallen to about a fifth of this figure. That peak was similar to the level reached in New South Wales in Australia, but the fall has been much faster.⁴ Not many people on the programme actually kick the addiction, about 4 per cent a year, but it seems the scheme has the effect of cutting the number of people taking up the drug in the first place.

      What seems to have happened is that by making the taking of heroin a medical issue rather than a legal one, it has become less fashionable among the young. The report explained that heroin had become ‘a loser drug’. If you can get something on prescription, it stops being glamorous. So while the programme may not have been particularly successful at getting people off heroin completely, it has been very effective in stopping the young from taking up the habit in the first place.

      But that is heroin-what about other drugs? Here the story is less encouraging. It seems, unfortunately, that the use of some drugs including cannabis, cocaine, ecstasy and amphetamines-is rising.⁵ There is also a problem with binge drinking. There is no open drug scene in Zurich, or indeed elsewhere in Switzerland, but the problem remains.⁶

      It might surprise many people but Switzerland is actually a large exporter of cannabis: it can be cultivated legally and exported as ‘hemp’. Farms have sprung up all over the country and Switzerland has become Europe’s largest hemp producer. A lot is used locally too. The Federal Commission for Drugs Issues, an independent panel that advises the government, estimates that half a million people out of