João Goulão e Drauzio Varella: A dialogue on how to manage the drug issue

/ Fundação FHC auditorium

“With the decriminalization of drug use in Portugal, talking about drugs at home, in schools and even at work is no longer taboo. This was a great step forward.”

João Augusto Castel-Branco Goulão, doctor and National Coordinator for the Problems of Drugs of Portugal

“The only way to deal with drugs is to reduce consumption through education, prevention and health support for users.This takes time. It must begin now.”

Drauzio Varella, physician and author of several books, including "Carandiru Station"

In the late 1990s, the Portuguese government appointed an interdisciplinary committee of nine people, consisted of health professionals, social assistance and law professionals to develop a new strategy to deal with drug use. The consumption had grown considerably in the small European country starting in 1974, after the end of the Salazar dictatorship and the return of the military and civil portuguese that lived in Portugal’s colonies in Africa, where drug use, especially among troops, was heavier than at the Metropolis. Portuguese doctor João Augusto Castel-Branco Goulão was one of the members of the commission that, after visiting several countries, including Germany, the United Kingdom and Switzerland, formulated the National Strategy on the Fight against Drugs in 1999, which became law in the following year (Law 30/2000).

“We built our proposals based on the principles of humanism, pragmatism, openness to new experiences and the coherent articulation of various policies and actions, focusing on individual and public health, not punishment”, explained Goulão, who, since 2005, held positions as Director General of the Intervention Service for Addiction Behaviors and Dependencies (SICAD), National Coordinator for the Problems of Drugs, Drug Addiction and Harmful Use of Alcohol. Goulão was primarily responsible for putting into practice the current Portuguese drug policy that was instituted 18 years ago.

“In the beginning, there was a lot of resistance and conservative sectors tried to reverse the process, but as the results began to appear, the new strategy became a consensus in Portugal. Proof of this is that I have already gone through eight governments, from the left, from the center and from the right, and no one has sacked me", Goulão stated. He spoke at the Fernando Henrique Cardoso Foundation along with Brazilian doctor Drauzio Varella, known for his educational campaigns against smoking, excessive consumption of alcohol, drugs and sedentary lifestyle.

“Portugal is a small country with a little more than 10 million inhabitants, and I dare not make recommendations to Brazil, which has more than 200 million inhabitants and a socio-cultural, economic and historical reality totally different from the Portuguese one. But I believe that all countries have the right to experiment with new policies to deal with the drugs issue and to rigorously assess their developments in their societies”, Goulão noted.

“In Brazil, we live the worst of all worlds, because drug use is on the rise and undeterred, criminal organizations are acting freely and violence associated with trafficking is spreading throughout the country. The current approach is not working. This subject can no longer be taboo in our society and in Brazilian politics. We have to start discussing the problem and seek alternatives immediately; we cannot wait any longer”, said Varella, who  started to work with the prison population in the 1980s and is the author of several books, including Carandiru Station and Prisioneiras, both published by Companhia das Letras.

According to Goulão, “Portuguese drug policy has only succeeded because the country has created a wide network of health and social assistance services to deal mainly with drug use, with a well-trained street staff, service centers in all districts, a national coordination and a comprehensive set of instruments at our disposal.”

“The Portuguese example is a pilot study that deserves our attention. In Brazil, for the past three decades this year, we have the SUS (Unified Health System). It’s present in the entire country and despite its limitations and problems, it represents a revolution in health recognized worldwide. Why do we not adapt it so that it becomes the basis for sustaining a new way of dealing with drug use in our country?”, Drauzio suggested.

Read below the dialogue between the Portuguese and Brazilian doctors

João Goulão - In Portugal, problems with the consumption of illicit substances began later in relation to other countries of Europe, because until 1974 we were a dictatorship. We lived in a closed dome where everything was controlled, there was censorship. Unlike other countries, Portugal was little affected by phenomena such as the hippie movement in the 1960s (USA) and May 1968 (France). Our small country wasn’t even a tourist destination. In the 1960s and 1970s, Angola, Mozambique, and Guinea Bissau, which were Portuguese colonies, began their wars of independence. About 1 million Portuguese youths were sent to the wars in Africa, where, more or less similar to what happened in Vietnam, drug use was tolerated or even encouraged by the Portuguese Armed Forces. The Carnation Revolution (April 1974) put an end not only to the Salazar regime, but also to colonial conflicts. However these soldiers returned home and brought back a culture of using drugs, especially marijuana. After democratization, Portugal entered the world map. Following that, there was a cultural liberalization, and the consumption of psychoactive substances developed very rapidly in the second half of the 1970s and in the 1980s. In a short time, trafficking networks introduced other substances, such as cocaine, heroin and LSD. The country was not prepared; use of several different types of drugs spread quickly through all social classes. The speed and force of this drug movement was largely facilitated by ignorance. Although consumption was below the European average, the incidence of hard drug use was very high. In almost every family there was someone with a serious dependency problem, thousands of young people arrested, many died from overdose. And when AIDS emerged in the 1980s, the situation became even more complicated.

Drauzio Varella - In Brazil, until the 1950s, marijuana was considered “the shoe polishers’ drug”. Cocaine was expensive; it was not in reach of the poor. Though in the 1960s, marijuana use spread through the universities. Also with the spread of AIDS in the 1980s, it was revealed that in the outskirts of major cities such as São Paulo and in penitentiary systems, there was an epidemic of intravenous cocaine use. In the prisons, everyone injecting cocaine into the vein became infected with the HIV virus. When women came to visit they also became infected. It was terrible. We did a very serious job of raising awareness in the prisons and we were able to reduce the problem a lot. I was filled with pride, but then in the 90's, crack came in with everything, it spread through all the prisons and then to society. Crack today is all over Brazil. It is a cheap and very addictive drug,which nobody saves for the next day. What did we get with the criminalization of drugs? We are only watching the drugs epidemics spreading without having the tools to fight them, as Portugal decided to do.

Goulão - Heroin had become the main problem in Portugal in the late 80’s and 90’s. In 1993, we started the first syringe exchange program to try to contain HIV and other viruses. At the same time, the European Monitoring Center for Drugs and Addiction was set up in Portugal. In 1997, we began to build support and treatment networks, with at least one center in each district. Simultaneously, we were investing in intimidating anti-drug campaigns, like the “Drugs Kill” message. Even among the doctors there was no consensus on what to do, but we felt it necessary to clarify the way forward. So the government appointed a group of nine people, made up of lawyers, judges, psychiatrists, psychologists and social workers, to come up with a new approach to coping with the problem. In 1999, we introduced the new National Drug Strategy, which became law the following year. The main change was in the article on drug possession. Trafficking remains a crime, but possession of an amount considered for self-consumption (up to ten days of use, the exact amount depends on the type of drug) has become a civil offense, similar to not wearing a seat belt. The user may receive a fine or be required to do community work, but will not go to the criminal system. However, he or she should introduce him or herself to a Drug Addiction Deterrence Commission, made up by doctors, psychologists and social workers that analyze the state of physical and mental health and  the circumstances surrounding the use of drugs. Is the user out of work? Does he or she have family problems or struggle with any personal issues like gender identity? All these factors may contribute to a person developing a habit of consumption considered problematic. Deterrence is an important prevention tool and the most important thing is to stop the abuse before it turns into a severe addiction. If this is the case, the person is invited to have treatment. About 80% of those who are considered dependent accept treatment.

Varella - In Brazil, the State does nothing like this in a structured and coordinated way. It is a highly complex problem that requires diverse approaches, like all chronic diseases. There is no miracle measure that solves the problem. We deal with drugs as if they were all the same, when drugs have very different repercussions on an individual's life and society. We use only moral criteria that do not take into account the unique conditions to each person, as if all consumption were equally problematic. Even we doctors know little about what compulsion really is, and how it works. Compulsion may be manifested not only in the use of drugs, but also in the consumption of alcohol, in gambling. Someone may even have a spending compulsion that leads to them being indebted. It requires a total change of philosophy. And this is a process that takes time, takes decades. That is why it is so urgent to start immediately.

Goulão - Decriminalization in Portugal had the very positive effect of breaking the stigma of drugs. Dependents are seen and treated as sick people, with the same dignity as those who suffer from other pathologies. These are little things that make the difference. Talking about it is no longer taboo in families, in schools, even in business. Before, people feared being fired, but today they recognize that they have a problem and seek treatment. By 2016, we had 27,000 people on treatment. Companies receive fiscal stimulus if they employ dependents under treatment. But all these advances have only come true because there is a clear connection between all policies and actions. These policies and their enforcement must be based on the health of the individual and the society, rather than simply punishment. It only works if there are well-trained street teams, a wide service network, a range of tools available; a very present national coordination. We have an inter-ministerial council, with representatives of the Ministries of Health, Justice, Economy and Agriculture, among others, all to work thoroughly and precisely. Drug use continues to exist in Portugal, but there has been a significant drop in overdose, drug problems and drug deaths (see statistics in the Related Content section on the right of this page). There is much greater knowledge and control on the issue.

Varella - Brazil also has a very successful experience related to the problem of addiction. Nicotine is the most addictive drug of all, and within a few decades we have been able to heavily reduce smoking. Through successful educational campaigns, a ban on cigarette advertising and laws that have restricted smoking in public places, making smokers lives much more difficult. Brazil is now one of the countries with the lowest percentage of smokers in the world, much lower than in Europe and the USA. That proves that the best way to reduce consumption is through education and prevention. It is no use sending consumers to jail. Jails are too crowded, and can’t fit anybody else. Drugs in general cannot be taboo. We need to see what other countries are doing, attend congresses around the world, and join the debate. It is clear that the example of Portugal should be seen as a pilot study, as Brazil is a much larger and more complex country. It will take years, decades, to find our own way, but we have to start now. There is no more time for waiting.

Goulão - The international drug conventions on drug combat in force help create the prohibitionist and criminalizing paradigm. And when Portugal decided to change its approach in the late 1990s and early 2000s, it did not have prior authorization from anybody. We were very criticized when we chose to decriminalize possession until a certain amount. We reached the limit and were accused of violating international agreements that had been signed by Portugal. It took a while, but the coherent and well-structured work done since then came to be recognized. In 2008, the International Narcotics Control Board said that Portuguese drug policy was in line with international agreements and, in 2016, the UN praised our program. We are a small country, but we paved the way for other countries to take steps in this direction. Uruguay, some US states, Canada, and Spain are also experimenting new paths.I believe that all nations have the right to test new policies and rigorously assess their progress in their societies. UN treaties also need to evolve or they will become outdated.

Otávio Dias, journalist, is the content editor of the Fernando Henrique Cardoso Foundation. He was the Folha’s correspondent in London, editor of estadã and chief editor of the Brasil Post, a partnership between the Huffington Post and Grupo Abril.

Translated by Thomas Garman.