Allan Parry, Director of the Atlantic Project

Mersey Drugs and AIDS Coordinator, 1986 - 1991

Since 1986, the consistently low numbers of HIV+ injectors in Mersey, the variety of creative initiatives and the comparatively high level of service uptake, have attracted world-wide interest. A variety of official data confirms that (particularly between 1987 and 1991) there were major differences between Mersey and the other thirteen English Health Regions. Mersey Region has more injectors (up to 12,000) than any other UK health region. About 10,000 are heroin injectors, the remaining injecting, cocaine, amphetamines or benzodiazepines. Despite a steady rise in the number of UK infected injectors, a variety of testing programmes up to December 1992 has revealed only 20 HIV+ injectors in Mersey. None are believed to have contracted the infection locally. They are either Mersey injectors who shared in other cities or countries, or are infected injectors who have moved to live in Mersey. 16 of the 20 were reported before 1987, in other words there have been only three HIV+ reported injectors since 198

7 with no evidence of single case of locally acquired/transmitted infection.

In any three month period (using data collected up to Dec 1992) over 3,000 of Mersey's estimated 12,000 injectors receive injectable or oral substitute drugs. 3,000 accessed clean equipment either directly or indirectly from syringe exchange projects and pharmacies. Over 1,000 were serviced by outreach teams. Although it is not possible to determine the exact amount of overlap, this data suggests that up until 1992, 70-80% of Mersey injectors used one or more of the HIV prevention services, compared to the national rate of about 15%. Until 1992, four of the UK's largest syringe projects were in Mersey. The Mersey syringe exchange rate was consistently around 100% compared to the national rate of 62%. Less than 10% report sharing equipment during this period.

So why was Mersey so successful? What were the significant factors? In the middle seventies, the vast majority of the UK's small population of committed drug injectors were to be found in London drug clinics which still practised the harm-reduction policy of prescribing a wide range of injectable drugs. However, by the early eighties, the UK drug treatment establishment, largely consisting of the psychiatrists running London clinics, decided to totally abandon their prescribing policy and almost overnight, the vast majority of drug users attending the drug clinics were simply offered reducing amounts of mainly oral methadone, as either an in- or out-patient. This new 'Abstinence' approach was adopted as national policy. But in Liverpool, there was no specialist drug clinic or policy, as there were no more than a hundred or so heroin users living in the area. These, mainly older injectors from the sixties, were seen by general psychiatrists who, seeing no advantages in threatening the generally stable

lives of a few older junkies, simply continued to prescribe injectable drugs to this small group with the dispensing pharmacies giving sterile injecting equipment. Thus, while the rest of the UK's drug services were embracing abstinence policies, key Mersey professionals, from consultant psychiatrists, pharmacists and counsellors etc. continued practising 'harm-reduction' through the late seventies and early eighties, building up valuable experience of practises that would prove invaluable in the fight against AIDS.

So when every health region and district was given the funding to set up specialist drug clinics to deal with the UK heroin 'epidemic' in 1985, the regional decision to fund maintenance clinics as Mersey's primary response, was not regarded locally as a radical departure from national policy, but as simply extending the traditional local practice. Even before HIV, Mersey Regional Health Authority was regarded as a shining example of Thatcher's new, streamlined NHS. The Regions' Health promotion department, with its high profile projects and pioneering social-entrepreneurial style, argued that drug issue was a social and public health issue, not a medical issue and with the local medical establishment showing no great enthusiasm for taking on the drug issue, the responsibility for planning Mersey drug services and allocating government funding to each of its ten health districts, was given to a radical and innovative Health Promotion department, rather than to various committees dominated by medical profess

ions, which was the model adopted by the thirteen other UK Health regions. By 1985, the progressive Health Promotion department had the support, freedom and control of funding and policy. A Regional Drug Training and Information Centre was established to co-ordinate and train the rapidly growing services. In 1986 a Regional Drugs & AIDS Coordinator was employed to encourage innovation. Key positions in drug services were offered to those with a proven ability to 'make-it-happen', whether or not they were professionally qualified. Local drug users were employed, professionals were employed on the basis of their knowledge, experience and commitment to safer drug use. Expensive professions, such as psychology, were regarded as non-priority and all such positions made redundant. Expensive treatment only services were required to meet the new priorities or lose funding. Drug dealers were encouraged to (and did!) run their own syringe exchange projects. Drug users volunteered to keep some syringe exchange

s open at night and at weekends. The line between professional and client became blurred, drug users began to feel that these were their services, staffed by people they knew and trusted. Mersey had more injectors attending syringe exchange projects than the total attending all other UK syringe projects. Drug users were shown how to use drugs rather than enticed into therapy. Mersey police agreed to give priority to HIV, cautioning for all possession offences, giving out details of local needle exchanges. The local media were cultivated to ensure positive reporting of controversial initiatives.

Finally, in 1989 the UK government produced its recommendations on how drug services should respond to HIV. However, throughout this extensive document, and despite recommending the adoption of policies and practices already practised in Mersey, no mention was made of the region or its role in changing UK policy. The reason for this was well understood by all working in the field. However, despite the wide acclaim for its successes, the drive in Mersey to implement effective initiatives very quickly and with little 'consultation', upset many in the medical establishment particularly. Professional and often personal jealousy, political opposition locally, nationally and even internationally mounted.

Eventually central government, increasingly concerned about the radical nature of the Mersey approach and its' growing national and international influence, finally intervened. In early 1991, the Department of Health demanded that Mersey Regional Health Authority 'return its policies and practices to the mainstream of UK drug policy'. The region should now '...spend a year or two consolidating its achievements...' etc, etc. Responsibility for the strategy was now in the hands of a new Regional committee, largely consisting of safe bureaucrats. New doctors, prepared to prescribe oral methadone only, were employed to run the three largest clinics. The number of clinics prepared to prescribe the full range of drugs dropped from eight to two. Drug users (even those on prescribed drugs) were not to be employed. Mobile syringe exchanges were stopped. Drug users were only to collect equipment for themselves. Dealers were not allowed to operate their own exchanges. Qualifications became essential. Wholly

inappropriate staff were employed for outreach projects. The results are now becoming apparent. Attendance at syringe exchanges has dropped. A national evaluation of Mersey's outreach projects condemned their desperately low contact rate. Lack of vision and planning has resulted in six to nine month waiting lists at all of Mersey's clinics. The availability of cheap unwanted methadone linctus has resulted in the appearance of a new drug user - the 'Methadonian' - someone who gets a methadone habit without having used heroin previously. In 1991 the Mersey Drug Training and Information Centre, generally regarded as the dynamic co-ordinating agency for much of Mersey's initiatives, was 'privatized'. Funded largely by the new conservative Regional Health Authority, the centre became the Authority's propaganda unit, pretending that all was well, interested only in the money it could make.

However, despite this 'normalization' of the Mersey Strategy, it did demonstrate the dramatic results that can be achieved in drug policy where there is the political will. Many of the new accepted models of good practice in the UK and elsewhere, were pioneered in Mersey during the 'hot-house' period between 1985 and 1991. Ironically and perhaps unfortunately, one consequence of Mersey being so far ahead of other regions is that even if HIV prevalence etc, is adversely affected by this activity, it will still take a number of years before the data exposes any negative effect of Mersey 're-entering the mainstream of UK drug policy'.