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Promoting Pro-health Policies Across Regimes: Global AIDS Institutions and the Harm Reduction Debate.

IN APRIL 2016, THE UN GENERAL ASSEMBLY HELD A SPECIAL SESSION ON the World Drug Problem (hereinafter, UNGASS 2016). As was probably inevitable, long-standing tensions between proponents of a "prohibitionist" approach to narcotic control and those promoting "harm reduction" resurfaced during this meeting. The major multilateral global AIDS institutions--the Joint UN Programme on HIV/AIDS (UNAIDS); the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); and the World Health Organization (WHO)--have long been vocal participants in this debate, seeking to draw attention to the important role that harm reduction initiatives such as needle exchange programs and opioid substitution therapy (OST) play in HIV prevention, and highlighting the extent to which prohibitionist approaches exacerbate the stigma and discrimination that present barriers to effective HIV prevention. Yet these arguments so far have not been sufficient to deliver a fundamental change in the orientation of the global narcotics control regime.

In this article, I use this ongoing policy debate as a lens to examine the complex relationships between global health governance and the global governance of other issue areas at what has been termed global health governance's horizontal interfaces. I argue that both material and ideational power matter at these interfaces and that, despite adopting what might be expected to be a persuasive advocacy approach, the change that global health actors have so far achieved has been limited. Understanding how power and influence operate at such interfaces is crucial to understanding the potential for global health institutions to successfully promote prohealth policies.

I begin the article by briefly examining the existing literature's conceptualization of global health governance and its interfaces with other global regimes. I also introduce the concept of framing, which has been seen by many as being an effective strategy for forwarding pro-health policies. Next, I sketch out the historical development of a "prohibitionist orthodoxy" in relation to narcotics control, the ways in which that orthodoxy has been attacked by proponents of harm reduction, and the progress (limited, but not entirely absent) that harm reductionists have made in recent global discussions on narcotics control. Then I look at the ways in which UNAIDS, the WHO, and the Global Fund have promoted harm reduction and argue that they have collectively pursued a two-pronged advocacy strategy that seeks to reframe the debate in terms of public health and human rights rather than law and order and security. Finally, I propose a series of insights that this case can offer to scholars of global health governance. These relate to the agency of global health governance actors, the power of framing, and the extent to which material (resource-based) levers offer alternative avenues for precipitating policy change.

Global Health Governance, Interfaces, and Framing

Although global health governance has in recent years become a growing area of scholarly interest, (1) there remain significant gaps in our understanding. In particular, I argue that although the existing literature provides a good basis for understanding the internal dynamics of global health governance (including the range of actors involved, the key fora in which decisions are made, and the ways in which the governance architecture has developed over recent decades), far less progress has been made so far on interrogating the ways in which it relates to other areas of global governance.

Examining such interfaces rests on an ability to define the boundaries of global health governance in order to determine what falls "inside" and "outside" and, thus, where the interfaces lie. Much time and ink has been expended on defining global health governance without producing a single agreed definition. Indeed, in 2014, Kelley Lee and Adam Kamradt-Scott identified over a thousand scholarly works that had used the term and a wide range of ontological variation. They categorized this variation according to three broad concepts: (1) "globalization and global health governance," which concerns the ways in which global-level health institutions respond to the challenges of an increasingly globalized world; (2) "global governance and health," which addresses "how global governance institutions outside of the health sector have influenced the broad social and economic determinants of health"; and (3) "global governance for health," a more normative term that encompasses "seeking to achieve particular goals such as access to medicines, health equity or primary health care or principles such as human rights and social justice." (2)

While such variation under a single terminological banner may bring the danger of conceptual imprecision, one of the starting points of my analysis is that all three of the categories identified by Lee and Kamradt-Scott are important for understanding the contemporary global politics of health. Global health governance actors (in which we may include multilateral bodies such as the WHO but also transnational civil society groups, global health partnerships, philanthropies, and others whose remit focuses on achieving health goals) are indeed involved in attempting to respond to globalization-related health challenges. They do so within a context in which other state-level and global-level institutions outside of the health sector have significant health impacts, (3) and they are frequently engaged in forwarding particular normative ideas in pursuit of improving health, which we might call "pro-health policies." In this article, my primary concern is with the ways in which global health institutions (Lee and Kamradt-Scott's category 1) that are attempting to promote particular pro-health policies (category 3) relate to other global-level nonhealth regimes (category 2). In the remainder of this section, I utilize existing conceptual work on global health governance (much of which in turn draws on the wider global governance literature) to set out two concepts that provide a way of interrogating these dynamics: interfaces and framing.

Drawing on the literature on multilevel governance, (4) and particularly the application of those ideas at the global governance level, (5) as well as Norman Long's work on "social interfaces," (6) Wolfgang Hein, Sonja Bartsch, and Lars Kohlmorgen use the concept of "interfaces" to examine linkages within global health governance ("vertical" interfaces between global-and national-level policymaking processes) and "horizontal" interfaces between spheres of governance. (7) These interfaces, they argue, can sometimes be characterized by cooperation, sometimes by conflict. (8) In common with the vast majority of the work in global health that has examined the relationship between global health governance and nonhealth sectors, (9) they pay particular attention to the global governance of trade, especially issues around AIDS medicines and the intellectual property regime. (10) Hein found that in this area global health governance has made progress even in the face of a "World Trade Order," but also that power disparities across various kinds of interfaces--discoursive, legal, organizational, and resource-based--continue to strongly influence policy outcomes. (11) Thus, for a variety of reasons, global health governance actors can fail to successfully promote pro-health policies. These failures, however, are not always the result of material power asymmetries and cannot (as realist scholars might argue) always be explained through the operation of state power in pursuit of predetermined national interests. Central to Long's sociological work on interfaces (12) (and equally central to social constructivist approaches to international relations (13)) is the idea that during processes of interaction, the ideas and perceived interests of the various actors involved can be changed. Thus, in the area of access to medicines, it was possible, for example, for global health institutions (including civil society actors) to make headway in the face of an intellectual property regime initially opposed to their policy prescriptions.

A common claim in much of the existing social constructivist literature is that one of the ways in which ideas and interests may change is through successfully (re)framing an issue in persuasive ways (in Hein, Bartsch, and Kohlmorgen's terminology, this relates to the "discoursive interface" (14)). Frames are understood here as linguistic, cognitive, and symbolic devices used to identify, label, describe, and interpret problems and to suggest particular ways of responding to them. (15) The international relations literature on global health governance, much of which has explicitly pursued a social constructivist approach, has made extensive use of the concept of framing to analyze advocacy and policy change. (16) It has been argued that the concept can help us understand the ways in which global health problems are represented and come to be understood, which in turn can lead to an issue being prioritized (or not) and avenues for policy responses being opened up or foreclosed. (17)

A particular preoccupation of global health governance scholars has been with "discoursive interfaces," especially the way in which different framings of the same health problem (as an issue of security, economics, or human rights, for example (18)) compete, how some frames may be more influential than others in policy debates, and how the dominance of particular framings of a global health issue can shape global responses. The work of "norm entrepreneurs" or "policy entrepreneurs" in forwarding particular frames to justify their preferred responses has been widely studied within and beyond global health, (19) with frames being seen as important discursive tools for promoting particular courses of action either between global governance institutions and states or between different global-level institutions (i.e., across both vertical and horizontal discoursive interfaces).

In this article, I examine a case where success (so far, at least) can at best be claimed to have been limited despite the fact that global health institutions have deliberately framed the issue in ways that the existing literature might lead us to expect to be persuasive. This case, therefore, has the potential to deliver insights on the relationship between global health institutions and other global regimes across the discoursive interface.

The Global Narcotics Control Regime and Its Critics

For over a half-century, global approaches to narcotic drugs have primarily rested on a prohibitionist orthodoxy that is reflected in national policies in many countries and in international legal instruments. Domestically, many countries have maintained a prohibitionist stance for a variety of reasons: concern for the impact of drugs on the health of individual users; moral, cultural, or religious objections; fears associated with law and order and border security; and (increasingly in recent years) a discourse linking drug production and trafficking to other security issues, not least transnational organized crime and terrorism. (20) These concerns have translated into a variety of policy approaches. There have been attempts to reduce drug cultivation and production through military intervention or assistance in countries such as Colombia and Afghanistan. Efforts to tackle drug trafficking have included police forces and border agencies being supplemented by an increasingly militarized response that has used naval assets to interdict traffickers on the high seas. Policing plays a key role once drugs have entered target markets, with distributors as well as individual drug users being subject to enforcement action and criminal sanctions in most jurisdictions.

At the global level, this prohibitionist orthodoxy has been enshrined in all of the key international drug control treaties. (21) The 1961 UN Single Convention on Narcotic Drugs (22) is widely recognized as the breakthrough moment in the development of a "truly global drug prohibition system" (23) and remains the centerpiece of the global narcotics control regime. The Single Convention prohibits the production and supply of a specified list of drugs and, under Article 4, states parties are required to implement the provisions of the convention within their own territories, to cooperate with other states in carrying out the convention's provisions, and to refrain from the production or trade in drugs (save for medical and scientific purposes). The Single Convention was later supplemented by the 1971 Convention on Psychotropic Substances (24) that extended prohibition to a range of drugs that were not covered by the 1961 Convention, then by the 1988 Convention Against Illegal Traffic in Narcotic Drugs and Psychotropic Substances (25) that supplemented the range of enforcement mechanisms to prevent drug trafficking. The content and tone of these conventions are highly prohibitionist in nature, and they offer a range of political, social, economic, and health rationales in support of that approach.

Since the 1980s, however, this prohibitionist orthodoxy has found itself under attack from harm reductionists who argue that addressing and minimizing the harm that drugs cause to individuals and societies should be the primary policy objective. Although harm reduction policies began to emerge in some countries (perhaps most notably in the Netherlands (26)) in the mid-1980s, the emergence of a coherent international harm reduction movement first became apparent at the beginning of the 1990s, with most of what Tuukka Tammi and Toivo Hurme identify as being the movement's "founding texts" being published between 1990 and 1992. (27) An international conference held in 1990 in Liverpool was a key moment, (28) as the conference became an annual event held in a different city each year and played an important role in the consolidation of a global community of harm reduction advocates.

The measures that have been promoted by harm reductionists vary considerably, and there continues to be debate over the precise menu of interventions that fall under the rubric of harm reduction. However, they are commonly taken to include needle exchange programs, opioid substitution therapy, the provision of safer injection facilities, education and outreach programs, and peer-driven interventions. (29) Many of these are now evident in a significant number of countries. A report by Harm Reduction International, (30) The Global State of Harm Reduction 2014, found that "there has been slow but steady progress in the acceptance of harm reduction in national policies and in the establishment of new services." (31) The report identifies ninety-one countries and territories worldwide that incorporate some form of harm reduction into national policy, although the range and scope of provision varies widely. Despite this progress at the national level, the international drug control regime, founded on the UN conventions discussed above and supported by powerful prohibitionist states, has remained much more resistant to change--a fact that some have argued limits the ability of even pro-harm reduction states to alter their policies in a way that remains consistent with their international legal commitments. (32)

In 2009, UN member states agreed on the "Political Declaration and Plan of Action on International Cooperation Towards an Integrated and Balanced Strategy to Counter the World Drug Problem." (33) The discussions leading up to that declaration were seen by some as an opportunity for change, including by some countries such as Bolivia that were pushing for treaty amendment, and by the European Union, which was endorsing a harm reduction approach. However, the prospects for change were limited by strong opposition from key prohibitionist states, including the United States and Russia (34) as well as Japan, Colombia, and Pakistan. (35) As a result, "the same policies, with some minor amendments to language, though hard fought by some of the more progressive governments, were prescribed for the next ten years." (36) As the 2010 International Harm Reduction Association (IHRA) report notes, "At the Commission on Narcotic Drugs (CND), the term [harm reduction] was struck from the final version of the Political Declaration on Drugs in 2009, a situation about which twenty-six states formally expressed their disagreement. It also failed to be included in a resolution on universal access to HIV services in March 2010." (37) The prohibitionist orthodoxy, in other words, won out.

When the UN General Assembly met for UNGASS 2016, many harm reductionists saw this as another opportunity to push for a change in the orientation of the global narcotics regime. In reality, the result of UNGASS was a foregone conclusion, with the Outcome Document having been drafted by the fifty-four member countries of the CND in advance and adopted by the General Assembly on the first day of its discussions. Consequently, as the International Drug Policy Consortium points out, "More than 100 [UN] member states, either not part of the CND or without permanent representation in Vienna--mostly from the Global South--played no role whatsoever in the negotiations." (38) Interestingly, opinions on the progress represented by the UNGASS Outcome Document were mixed. (39) The Global Commission on Drug Policy, one of the most high-profile critics of the prohibitionist regime, declared itself "profoundly disappointed" with the outcome document (which had reaffirmed the commitment of states to "the goals and objectives of the three international drug control conventions"). (40) UNAIDS, by contrast, released a statement that put a more positive spin on the Outcome Document, welcoming the inclusion of public health language and the fact that it called on states to "consider" (note: not necessarily to implement) "medication-assisted therapy programmes, injecting equipment programmes, as well as antiretroviral therapy and other relevant interventions that prevent the transmission of HIV, viral hepatitis and other blood-borne diseases associated with drug use." (41)

Despite this positive statement, there had been hopes within UNAIDS that UNGASS 2016 might bring a more fundamental change. An issue paper put before the UNAIDS Reference Group on HIV and Human Rights in December 2014 argues that
the UNGASS process must acknowledge that the existing international
drug policy framework, and the treaties supporting it, must be
critically re-examined. Rather than continuing with a "more of the
same" approach to drug policy, the UNGASS offers an opportunity for an
open-ended discussion in which there is space to debate the larger
underlying question of whether different objectives and different norms
in a legal framework need to be established. (42) [NB--a disclaimer
states that this document "does not necessarily reflect the views of
the Reference Group, the UNAIDS Secretariat or the Co-sponsors of
UNAIDS."]


An analysis by the International Drug Policy Consortium revealed that text proposed by UNAIDS on rebalancing investments had been excluded from the Outcome Document. (43) At best, then, the progress on harm reduction made at UNGASS 2016 was a reduction in outright hostility to the concept of harm reduction rather than a more fundamental weakening of the prohibitionist orthodoxy.

Global AIDS Institutions and Harm Reduction Advocacy

AIDS institutions have been prominent in the harm reduction movement as a result of intravenous drug users (IDUs) being one of the groups at a higher risk for HIV infection: "Although people who inject drugs account for an estimated 0.2-0.5% of the world's population, they make up approximately 5-10% of all people living with HIV." (44) In the following, I examine the arguments that the three most significant multilateral global AIDS institutions--UNAIDS, the Global Fund, and the WHO--have made in support of harm reduction, focusing on the ways in which they have framed their policy recommendations. I argue that there exists among these institutions a "Geneva consensus" around the desirability of harm reduction and that they have framed their messages in the same ways through forwarding two arguments: that scientific evidence supports harm reduction as an effective public health measure ("public health framing"), and that prohibitionist policies are injurious to human rights ("human rights framing").

There is ample evidence that, in addition to a genuine belief in the public health and human rights benefits of harm reduction, framings have also been strategic. In 2004, for example, the WHO, UNAIDS, and UN Office on Drugs and Crime (UNODC) jointly published an "advocacy guide" for use by "individuals, groups, institutions and organizations throughout the world concerned about HIV/AIDS among IDUs that want to establish and maintain an environment in which HIV/AIDS prevention among IDUs can be implemented effectively." (45) The guide specifically states that its advocacy methods could be used "at the community, district and national levels, and even in the inter-country context, such as at the regional and global levels." (46) The guide set out a range of principles and strategies for advocacy, heavily stressing the use of public health evidence and human rights arguments that, it said, "can often be a useful entry point to discussing specific issues such as access to care and treatment, information and resources." (47)

The Public Health Frame

There is now a significant body of scientific evidence demonstrating the public health benefits of harm reduction measures. This evidence is routinely appealed to by global AIDS institutions, often alongside contrasting evidence showing the ineffectiveness of prohibitionism and the failure of the "war on drugs." (48)

A secretariat report to the WHO's executive board in advance of UNGASS 2016 argues that "current drug policy frameworks do not focus enough attention on reducing the individual and public health harm of drug use" and notes that
a comprehensive package of evidence-based interventions to reduce the
harms associated with (injecting) drug use has been outlined in a
technical guide issued jointly by WHO, UNAIDS and the United Nations
Office on Drugs and Crime in 2009 and revised in 2012. This publication
and the package of interventions have been widely endorsed by United
Nations bodies and major international donors. The best results are
seen where countries have implemented both needle and syringe
programmes and opioid substitution therapy, along with other components
of the package, and where these interventions are implemented on a
scale wide enough to make an impact at the population level. (49)


The joint WHO, UNODC, UNAIDS technical guidance referred to in the secretariat's report is widely seen as a touchstone for the international harm reduction movement. This guide provides strong statements on the conclusiveness of the existing evidence on the effectiveness of harm reduction in preventing the spread of HIV, referring to a number of systematic reviews published in the scientific literature. (50) Margaret Chan, director-general of the WHO, used her statement to UNGASS 2016 to echo this report, reiterating the WHO's recommendation of "the provision of sterile injecting equipment through needle and syringe programmes and opioid substitution therapy as the most effective treatment options for people dependent on opioids." (51)

UNAIDS has been similarly active in forwarding the public health evidence that underpins harm reduction as HIV prevention. Speaking to the fifty-seventh UN Commission on Narcotic Drugs in 2014, UNAIDS executive director Michel Sidibe stated that "we have all the data to demonstrate that, in combination with antiretroviral therapy, essential services--including needle and syringe programmes and opioid substitution therapy--reduce HIV transmission, decrease mortality, and improve quality of life." (52) This was reflected in UNAIDS' recommendations in advance of UNGASS 2016, which stated that "there is irrefutable evidence that new HIV infections drop sharply when people who inject drugs have access to harm reduction and other public health programmes" and that "alternatives to criminalization and incarceration facilitate access to health services and enable drug use to be treated as a health condition rather than as a crime." The document also made reference to the economic benefits of a public health approach: "Public health programmes can be fully funded for a fraction of the current investments in the criminal justice system related to drug offenses and they will produce significantly higher health and social benefits." (53)

Current Global Fund guidance, meanwhile, outlines its support for "evidence-based interventions that aim to ensure access to HIV prevention, treatment, care and support for key populations" and endorses the contents of the WHO, UNODC, UNAIDS technical guide. (54) It also strongly encourages applications for Global Fund money to resource harm reduction programs, with countries being "strongly encouraged to include interventions and activities that improve the legal and policy environment, to ensure that Global Fund-supported services are accessible to people who inject drugs." (55)

From all three of these organizations, we therefore see a concerted attempt to frame the problem of injecting drug use as a public health problem rather than a law and order problem, with reductions in HIV transmission being one of the key public health benefits.

The Human Rights Frame

Human rights-based arguments are frequently seen alongside these appeals to public health evidence. There has long been a close association between AIDS and human rights advocacy, and in some cases rights-based arguments have been credited with producing major gains. Richard Elliott et al., for example, point to the important role human rights arguments (and the use of human rights-related legal instruments) played in improving access to antiretroviral treatments in domestic contexts (most notably, perhaps, in South Africa) and internationally (e.g., through the WTO). (56) Drawing on this example, they make the case that human rights arguments could be similarly influential in the debate between harm reductionists and prohibitionists and, therefore, a good advocacy strategy for those seeking to change the orientation of the global drug control regime.

The most recent comprehensive statement of current thinking on these issues from the global AIDS community can be found in the 2016 UNAIDS document Do No Harm: Health, Human Rights and People Who Use Drugs, again published in preparation for UNGASS 2016. (57) Noting that the purpose of the global narcotics control regime is to prevent the harm that these substances do to individuals and societies, the document starts with a strident statement that "more than half a century after the Single Convention on Narcotic Drugs was agreed, the harms caused by international drug control to people who use drugs require much greater attention." (58)

The report goes on to outline a number of ways in which contemporary drug control policies are injurious to human rights, including the marginalization of IDUs, discriminatory barriers to their accessing health and other services, violent or disproportionate enforcement measures, and the imposition of compulsory treatment programs. In its conclusion, the document returns to an explicit critique of the prevailing narcotics regime:
A struggle between an increasingly violent network of organized
criminals and an increasingly militarized coalition of anti-narcotics
police has dominated a half-century of efforts to control the
production, sale and use of narcotic drugs and psychotropic substances.
Caught in the crossfire are 246 million people who use drugs. They have
been marginalized, denied health and social services, severely
punished, forced to undergo unwanted medical tests and treatment, and
exposed to HIV and a host of other harms. Hundreds of millions of
additional people have been denied access to the medicines they need
for pain relief. (59)


The WHO and the Global Fund have also been consistent in stressing the relationship between harm reduction and human rights. The WHO has issued guidance for the treatment of drug dependent people with HIV/AIDS that stresses the human rights of those individuals as the first principle of treatment. (60) The Global Fund's grant application guidance stresses the need for a legal and policy environment that avoids violating human rights (61) and identifies drug users as a specific group who, by virtue of a lack of access to harm reduction services, suffer violations of rights. (62)

Early Fruits of a Two-pronged Advocacy Strategy?

The global health governance literature might lead us to anticipate such framings to be persuasive--indeed, they are the same frames as were deployed in the debate on access to antiretroviral therapies, widely seen as one of the great victories of AIDS advocacy in the face of powerful economic interests. As Elliot et al. argue in relation to the harm reduction debate specifically, "Combining the two approaches... may strengthen such a case: public health evidence can support principled legal arguments with a sound evidentiary basis, and the principles of human rights law strengthen statistical or other data with the normative claim that states have an ethical and legal obligation to act upon that evidence." (63)

There are indications that these arguments are starting to lead to change in some places. A greater number of countries now provide harm reduction services partly as a result of the increasing availability of funding for such interventions. As Michel Kazatchkine (a previous director of the Global Fund) notes, "Only five years ago, very few donors were supporting harm reduction efforts in developing countries. Since then, resources have steadily increased--in large part through the Global Fund--and countries that had long denied the existence of injecting drug use have significantly scaled-up interventions, including China, Indonesia, Taiwan and Morocco." (64)

Importantly, there was a significant change in US policy when the Barack Obama administration lifted a long-standing ban on federal funding of domestic needle exchange programs and the President's Emergency Plan for AIDS Relief (PEPFAR), by far the largest bilateral AIDS program, issued new guidance in July 2010 (65) that allowed for a far-wider range of harm reduction initiatives to be supported--a move that was welcomed by critics of the previous US stance. (66)

Yet even the most charitable analysis would find evidence of only a slight softening in the international narcotics control regime, and there remain major obstacles to any more fundamental change in its orientation, with harm reduction facing continued and determined opposition from many states. Tim Rhodes et al. cite the example of a meeting of the Security Council of the Russian Federation at which it was stated that "we are not for harm reduction, we are for supply reduction." (67) This type of opposition is reflected at the global level where, as seen above, prohibitionist governments continue to oppose and water down attempts to include harm reduction language in key global statements.

Interfaces, Framing, and the Promotion of Policy Change: Insights from the Harm Reduction Debate

In this final section, I argue that the engagement of UNAIDS, the WHO, and the Global Fund in the harm reduction debate has the potential to provide important insights with respect to global health governance's horizontal interfaces and that, in some cases, there are limitations in the ability of global health institutions to promote pro-health policies across those interfaces--even with ostensibly well-designed advocacy strategies. I outline a number of insights that can be gleaned from the debate examined in this article that may have relevance for other intersectoral issues with which global health governance institutions are engaged.

The first insight--a positive indication in terms of the normative desire to improve health outcomes--is that, in at least some cases, global health institutions (in this case, two UN bodies and a global health partnership) are "brave" enough to promote policies forcefully that are unpopular with a significant number of national governments, indeed with some of the most powerful governments in the international system. Technical guidelines have been established and vocal support routinely given to harm reduction by senior figures within these international institutions despite the existence of widespread opposition. It is true that the weight of scientific evidence in support of the HIV prevention benefits of harm reduction makes this relatively safe ground for such bravery. Nevertheless, in other cases where the evidence is strong, these institutions may be willing to exercise comparable leadership as policy entrepreneurs. This finding accords with those from other areas of international relations that have found the secretariats of international organizations to be capable of independent action and of promoting new international norms even in the face of member state opposition. (68)

It would be dangerous, however, to assume that scientific evidence in support of a particular policy position will be decisive in policy debates. The two-pronged framing strategy adopted by UNAIDS, the WHO, and the Global Fund suggests a recognition that scientific evidence alone may not be enough. The failure to achieve a more significant shift in the global narcotics regime despite the weight of evidence suggests the need for more investigation into the ways in which power operates across these interfaces, not only in terms of the power of national governments, but also in the power of ideas. The case I examined here offers a basis for some preliminary thoughts on this issue.

Although it makes heuristic sense to think about global health governance as having both horizontal and vertical interfaces (as Hein, Bartsch, and Kohlmorgen do (69)), in practice the two are closely intertwined. It ultimately is national governments who have the power to change (or maintain) the orientation of the global narcotics regime, and any attempt by global health institutions to promote change will hinge on their ability to successfully persuade national governments. Thus, policy entrepreneurship across global health governance's vertical interfaces becomes a crucial step in pursuing policy goals at horizontal interfaces and, as a result, global-level change may a exhibit a time lag following national-level change.

This does not, however, necessitate recourse to a realist understanding of world politics in which nation-states' (and especially the most powerful nation-states') pursuit of their own fixed interests determines outcomes. Evidence from constructivist analyses within and beyond global health suggests that reframing issues can play a role in shifting states' perceptions of their own interests, as Hein found with respect to global health governance's interface with the World Trade Order. (70) "Power" in policy debates can be ideational as well as material. This does not mean that efforts at shifting the terms of the debate will automatically be successful--here we have seen a case in which success has so far been limited. But it does suggest that issues can effectively be reframed in some cases, and that change is possible. Examining the dynamics of competition between different frames within particular political fora can deliver important insights into when and how this might be the case. (71)

While the public health and human rights framings of harm reduction might be thought to be effective methods of persuading governments to support change, this is a debate in which the countervailing framings of "the narcotics problem" are perhaps even more powerful. Drug control has been widely constructed as (at least in part) a security problem, and it is dealt with in security terms by many states and by the global drug control regime. Transnational criminality, border control, law and order, and international terrorism are all frequently used to support the claim that proscribed drugs are an (inter)national security threat that require a tough legal (and in some cases military) response. As securitization theorists argue, security is a powerful frame and something that states commonly prioritize over other concerns. (72) Health advocates face a difficult task in opposing security-based policies on the grounds of public health and human rights. Governments may accept the scientific case for harm reduction but still decide that security considerations (which they see as being best addressed through prohibitionism) outweigh their concerns with HIV prevention. As for human rights framing, arguing for policy change to protect the rights of individuals is always controversial, especially where the intended beneficiaries are an already stigmatized group. In many jurisdictions the rights of IDUs are neither accepted nor respected, as seen in the controversy over the crackdown on illegal drug use by the Philippines. (73) The common construction of IDUs as criminal and undesirable elements in society makes it extremely hard to successfully forward an argument for the protection of their rights. Although this does not mean that global AIDS institutions should move away from making the human rights case (after all, IDUs are also humans with rights), the harm reduction debate does indicate that there may be limits to the purchase that such arguments have in highly politicized contexts.

Aside from the relative persuasive power of particular framings, their embeddedness in legal and political structures can also hinder change (speaking to the links between Hein, Bartsch, and Kohlmorgen's discoursive and legal interfaces (74)). The rooting of the global narcotics regime in long-established international treaties means that, even if it can be shown to be in the best interests of global health, the degree of international consensus required to achieve fundamental treaty change is extremely difficult to meet. This can be a significant obstacle for policy entrepreneurs. At the institutional interface, this embeddedness can also determine which voices are influential in policy debates. Global health institutions are at best peripheral players in global drug control policy discussions, highlighting the continuing problem of the HIV, human rights, and drag control communities being in "parallel universes." UNODC's cosponsorship of UNAIDS has provided something of a bridge between these worlds, but in general the global drug regime remains law-enforcement focused rather than public-health or human-rights focused. At the international and (in many cases) national levels, drug policy is primarily within the remit of security- or law and order-focused institutions. Health (and human rights) advocates have an outsider status in this policy arena and play on the home turf of other policy communities. Global health governance actors operate in a complex and sometimes subservient relationship to actors from other global governances.

Finally, without abandoning the importance of ideas and their potential to change states' perceived interests, it is possible at the same time to recognize that material factors also matter. Framing is not the only lever that global health institutions have to promote policy change, and in the case examined here the ability of the Global Fund to invest resources into national harm reduction programs appears to have led to (or at least encouraged) policy shifts in some countries. While much global health scholarship has rightly focused on the downsides of global institutions using resources as a lever for promoting particular national-level policies (see, e.g., the discussions in the 1990s over the impact of the World Bank and International Monetary Fund's structural adjustment programs on national health systems (75)), here we see an instance of resources being used in support of evidence-based HIV prevention strategies. Indeed, we can find examples of funding being used as both a carrot and a stick. Rhodes et al., for example, note Tajikistan's introduction of a pilot program of OST "partly to prevent jeopardising international health funding." (76) Rifat Atun and Michel Kazatchine, meanwhile, identify the potential effects of international institutions' funding decisions on domestic policy debates even within powerful states:
In China, a significant change in the policy environment was witnessed
following the rejection of a Round 1 proposal--which failed to reflect
evidence-based harm reduction practices. This rejection stimulated a
debate amongst the key stakeholders concerned with HIV policy,
catalysing the efforts to include harm reduction in national Chinese
HIV/AIDS policies. (77)


Conclusion

The participation of the major global AIDS institutions in the debate over harm reduction represents an illuminating case study of some important issues in contemporary global health governance. In particular, it highlights the political difficulties that can be faced when arguing for what is best for health, even where there is virtual consensus among key global health institutions and scientific experts. The global AIDS institutions that I examined have pursued an advocacy strategy that has framed harm reduction in ways that would be assumed to be convincing, but they have not to date succeeded in significantly undermining the prohibitionist orthodoxy.

It is therefore necessary to develop a fuller account of the ways in which global health governance interfaces vertically with national policymaking processes and horizontally with other international regimes. Even when global health governance institutions are united they do not necessarily win the day. Promoting pro-health policies requires more than agreement between health institutions--it requires those institutions to operate effectively and persuasively at the interfaces with other global regimes. Over the longer term, however, previous experience has shown that continued advocacy efforts can lead to widespread policy change (and to the emergence of new norms). The harm reduction debate is certainly not at an end. In the shorter term, however, global health actors may not always be the most influential in these debates, nor the frames they forward necessarily be more persuasive than competing frames.

Notes

Simon Rushton is a senior lecturer in the Department of Politics at the University of Sheffield. He has written widely on international responses to HIV/AIDS and other diseases; the links between health and security; global health governance; and issues surrounding health, conflict, and postconflict reconstruction. He is an associate fellow of the Centre on Global Health Security at the Royal Institute of International Affairs, Chatham House.

(1.) See, for example, Kent Buse, Wolfgang Hein, and Nick Drager, eds., Making Sense of Global Health Governance: A Policy Perspective (Basingstoke: Palgrave Macmillan, 2009); Richard Dodgson, Kelley Lee, and Nick Drager, "Global Health Governance: A Conceptual Review" (London: London School of Hygiene and Tropical Medicine/World Health Organization, 2002), http://cgch.lshtm.ac.uk/globalhealthgovernance.pdf; Sophie Harman, Global Health Governance (Abingdon: Routledge, 2011); Adrian Kay and Owain David Williams, Global Health Governance: Crisis, Institutions and Political Economy (Basingstoke: Palgrave Macmillan, 2009); Kelley Lee, Health Impacts of Globalization: Towards Global Governance (Basingstoke: Palgrave Macmillan, 2003); Colin Mclnnes and Kelley Lee, Global Health and International Relations (Cambridge, UK: Polity, 2012); Colin Mclnnes, Adam Kamradt-Scott, Kelley Lee, Anne Roemer-Mahler, Simon Rushton, and Owain David Williams, The Transformation of Global Health Governance: Competing Ideas, Interests and Institutions (Basingstoke: Palgrave Macmillan, 2014); Jeremy Youde, Global Health Governance (Cambridge, UK: Polity, 2012); Mark Zacher and Tania J. Keefe, The Politics of Global Health Governance: United by Contagion (Basingstoke: Palgrave Macmillan, 2011).

(2.) Kelley Lee and Adam Kamradt-Scott, "The Multiple Meanings of Global Health Governance: A Call for Conceptual Clarity," Globalization and Health 10, no. 28 (2014).

(3.) See, for example, Simon Rushton and Owain David Williams, "Frames, Paradigms and Power: Global Health Policy-making Under Neoliberalism," Global Society 26, no. 2 (2012): 147-167.

(4.) Gary Marks, "Structural Policy and Multilevel Governance in the EC," in Alan Cafruny and Glenda Rosenthal, eds., The State of the European Community, vol. 2 (Boulder: Lynne Rienner, 1993), pp. 391-410.

(5.) Bob Jessop, "Multi-level Governance and Multi-level Meta-governance," in Ian Bache and Matthew Flinders, eds., Multi-level Governance (Oxford: Oxford University Press, 2004), pp. 49-74.

(6.) Norman Long, Encounters at the Interface (Wageningen: Wageningen Studies in Sociology, 1989).

(7.) Wolfgang Hein, Soja Bartsch, and Lars Kohlmorgen, "Interfaces: A Concept for the Analysis of Global Health Governance," in Wolfgang Hein, Sonja Bartsch, and Lars Kohlmorgen, eds., Global Health Governance and the Fight Against HIV/AIDS (Basingstoke: Palgrave Macmillan, 2007), pp. 18-37. See also Wolfgang Hein, Scott Burris, and Clifford Shearing, "Conceptual Models for Global Health Governance," in Kent Buse, Wolfgang Hein, and Nick Drager, eds., Making Sense of Global Health Governance: A Policy Perspective (Basingstoke: Palgrave Macmillan, 2009), pp. 72-98.

(8.) Wolfgang Hein, Soja Bartsch, and Lars Kohlmorgen, "Interfaces: A Concept for the Analysis of Global Health Governance," pp. 24, 28.

(9.) See, for example, Susan Sell, "The Quest for Global Governance in Intellectual Property and Public Health: Structural, Discursive, and Institutional Dimensions," Temple Law Review 77, no. 1 (2004): 363-400.

(10.) Wolfgang Hein, Sonja Bartsch, and Lars Kohlmorgen, eds., Global Health Governance and the Fight Against HIV/AIDS (Basingstoke: Palgrave Macmillan, 2007).

(11.) Wolfgang Hein, "Global Health Governance and TRIPS/WTO: Conflicts Between 'Global Market-Creation' and 'Global Social Rights,'" in Wolfgang Hein, Sonja Bartsch, and Lars Kohlmorgen, eds., Global Health Governance and the Fight Against HIV/AIDS (Basingstoke: Palgrave Macmillan, 2007), pp. 38-66.

(12.) Norman Long, Encounters at the Interface (Wageningen: Wageningen Studies in Sociology, 1989).

(13.) Alexander Wendt, Social Theory of International Politics (Cambridge: Cambridge University Press, 1999).

(14.) Hein, Bartsch, and Kohlmorgen, "Interfaces," p. 24.

(15.) Adapted from Mayer N. Zald, "Culture, Ideology and Strategic Framing," in Doug McAdam, John D. McCarthy, and Mayer N. Zald, eds., Comparative Perspectives on Social Movements: Political Opportunities, Mobilizing Structures, and Cultural Framings (Cambridge: Cambridge University Press, 1996), pp. 261-274.

(16.) See, for example, Ronald Labonte and Michelle Gagnon, "Framing Health and Foreign Policy: Lessons for Global Health Diplomacy," Globalization and Health 6, no. 14 (2010): 1-19; Mclnnes and Lee, Global Health and International Relations; Mclnnes, Kamradt-Scott, Lee, Roemer-Mahler, Rushton, and Williams, The Transformation of Global Health Governance; Jeremy Shiffman, "A Social Explanation for the Rise and Fall of Global Health Issues," Bulletin of the World Health Organization 87, no. 8 (2009): 608-613; Jeremy Shiffman and Stephanie Smith, "Generation of Political Priority for Global Health Initiatives: A Framework and Case Study of Maternal Mortality," The Lancet 370, no. 9595 (2009): 1370-1379.

(17.) For a more detailed discussion of this, see Rushton and Williams, "Frames, Paradigms and Power," pp. 154-156.

(18.) Colin Mclnnes, Adam Kamradt-Scott, Kelley Lee, David Reubi, Anne Roemer-Mahler, Simon Rushton, Owain David Williams, and Marie Woodling, "Framing Global Health: The Governance Challenge," Global Public Health 7 (Supp. 2) (2012): S83-S94.

(19.) Sara E. Davies, Adam Kamradt-Scott, and Simon Rushton, Disease Diplomacy: International Normas and Global Health Security (Baltimore: Johns Hopkins University Press, 2015); Adam Kamradt-Scott, "The WHO Secretariat, Norm Entrepreneurship, and Global Disease Outbreak Control," Journal of International Organization Studies 1, no. 1 (2010): 72-89; Simon Rushton, "The Global Debate over HIV-related Travel Restrictions: Framing and Policy Change," Global Public Health 1 (Supp. 2) (2012): S159-S175; Shiffman, "A Social Explanation for the Rise and Fall of Global Health Issues."

(20.) Tim Rhodes, Anya Sarang, Peter Vickerman, and Matthew Hickman, "Policy Resistance to Harm Reduction for Drug Users and Potential Effects of Change," BMJ 341 (2010): c3439.

(21.) A useful history of the development of this regime can be found in Daniel Heilmann, "The International Control of Illegal Drugs and the U.N. Treaty Regime: Preventing or Causing Human Rights Violations?" Cardozo Journal of International and Comparative Law 19, no. 2 (2011): 237-286.

(22.) UN, Single Convention on Narcotic Drugs, 1961 (New York: United Nations, 1961), https://treaties.un.org.

(23.) Global Commission on Drug Policy, War on Drugs: Report of the Global Commission on Drugs Policy (Global Commission on Drug Policy, 2011), p. 5, www.globalcommissionondrugs.org.

(24.) United Nations Conference for the Adoption of a Convention on Psychotropic Substances, Convention on Psychotropic Substances (New York: United Nations, 1971), www.unodc.org/pdf/convention_1971_en.pdf.

(25.) United Nations Conference for the Adoption of a Convention Against Illicit Traffic in Narcotic Drugs and Psychotropic Substances, Convention Against Illegal Traffic in Narcotic Drugs and Psychotropic Substances (New York: United Nations, 1988), www.unodc.org/pdf/convention_1988_en.pdf.

(26.) Sandra D. Lane, Peter Lurie, Benjamin Bowser, Jim Kahn, and Donna Chen, "The Coming of Age of Needle Exchange: A History Through 1993," in James A. Inciardi and Lana D. Harrison, eds., Harm Reduction: National and International Perspectives (Thousand Oaks, CA: Sage, 2000), pp. 47-68.

(27.) Tuukka Tammi and Toivo Hurme, "How the Harm Reduction Movement Contrasts Itself Against Punitive Prohibition," International Journal of Drug Policy 18, no. 2(2007): 84-87, at 84.

(28.) Harm Reduction International, "History," n.d., www.ihra.net/history.

(29.) Richard Elliott, Joanne Csete, Evan Wood, and Thomas Kerr, "Harm Reduction, HIV/AIDS, and the Human Rights Challenge to Global Drug Control Policy," Health and Human Rights 8, no. 2 (2005): 104-138, at 110.

(30.) Previously known as the International Harm Reduction Association (IHRA). See https://www.hri.global.

(31.) Harm Reduction International, The Global State of Harm Reduction 2014 (London: Harm Reduction International, 2014), https://www.hri.global/files/2015/02/16/GSHR2014.pdf.

(32.) Dave Bewley-Taylor, "Towards Revision of the UN Drug Control Conventions: Harnessing Like-mindedness," International Journal of Drug Policy 24, no. 1 (2013): 60-68.

(33.) UN Office on Drugs and Crime (UNODC), Political Declaration and Plan of Action on International Cooperation Towards an Integrated and Balanced Strategy to Counter the World Drug Problem (Vienna: UNODC, 2009), www.unodc.org/documents/ungass2016/V0984963-English.pdf.

(34.) Bewley-Taylor, 'Towards Revision of the UN Drug Control Conventions."

(35.) Tom Blickman, "Vienna Consensus on Drug Policy Cracks," 7 April 2009, (Amsterdam: TNI Drugs & Democracy Programme), www.undrugcontrol.info/weblog/item/2059.

(36.) Damon Barrett, '"Security, Development, and Human Rights: Normative, Legal and Policy Challenges for the International Drug Control System," International Journal of Drug Policy 21, no. 2 (2010): 140-144 at 143.

(37.) IHRA, Global State of Harm Reduction 2010: Key Issues for Broadening the Response, 2010, p. 7, www.ihra.net/files/2010/06/29/GlobalState2010_Web.pdf.

(38.) International Drug Policy Consortium (IDPC), "Diplomacy or Denialism? The Language that the UNGASS Outcome Document Overlooked" 2016, http://idpc.net/media/press-releases/2016/04/diplomacy-or-denialism-the-language-that-the-ungass-outcome-document-overlooked.

(39.) UN General Assembly, Our Joint Commitment to Effectively Addressing and Countering the World Drug Problem, Res. A/RES/S-30/1, (4 May 2016).

(40.) Global Commission on Drug Policy, "Public statement by the Global Commission on Drug Policy on UNGASS 2016, April 21, 2016," 2016, www.globalcommissionondrugs.org/wp-content/uploads/2016/04/publicstatement-forGCDP.pdf.

(41.) UNAIDS, "Press Statement: UNAIDS Urges Countries to Move Towards a Public Health and Human Rights Approach to People Who Use Drugs," 19 April 2016, http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/april/20160419UNGASS.

(42.) UNAIDS Reference Group on HIV and Human Rights, "UNAIDS Leadership at the 2016 UNGASS on Drug Policy, and Beyond," 2016, p. 3, www.hivhumanrights.org/commitmenttohumanrights/wp-content/uploads/downloads/2015/07/2014RGMtg-DrugPolicy.pdf.

(43.) The text proposed by UNAIDS: "Undertake a rebalancing of investments in drug control to ensure that the resources needed for public health services are fully funded, including harm reduction for HIV infection, antiretroviral therapy, drug dependence treatment and treatment for hepatitis, tuberculosis and other health conditions" (emphasis in original). See International Drug Policy Consortium, "Diplomacy or Denialism: The Language that the UNGASS Outcome Document Overlooked," http://fileserver.idpc.net/Press%20releases/UNGASS-shadow-declaration_FINAL.pdf, accessed 19 February 2018.

(44.) UNAIDS, Report on the Global AIDS Epidemic 2013 (Geneva: UNAIDS, 2013), p. 30, www.unaids.org/sites/default/files/media_asset/UNAIDS_Global_Report_2013_en_l.pdf.

(45.) The guide was in fact prepared by the IHRA. WHO, UNODC, UNAIDS, Advocacy Guide: HIV/AIDS Prevention Among Injecting Drug Users (Geneva: World Health Organization, 2004), p. 2.

(46.) Ibid., p. 1.

(47.) Ibid., p. 12.

(48.) See, for example, British Colombia Centre for Excellence in HIV/AIDS, ICSDP, International AIDS Society, and AIDS, "The Vienna Declaration," 2010, www.viennadeclaration.com/the-declaration/.

(49.) WHO Secretariat, "Public Health Dimension of the World Drug Problem Including in the Context of the Special Session of the United Nations General Assembly on the World Drug Problem, to be Held in 2016," EB138/11, 15 January 2016, http://apps.who.int/gb/ebwha/pdf_files/EB138/B138_11-en.pdf.

(50.) WHO, UNODC, UNAIDS, Technical Guide for Countries to Set Targets

for Universal Access to HIV Prevention, Treatment and Care for Injecting Drug Users, 2012 Revision (Geneva: WHO, 2012), http://apps.who.int/iris/bitstream/10665/77969/1/9789241504379_eng.pdf?ua=1,p.11.

(51.) Margaret Chan, "Opening Remarks at the UN General Assembly Special Session on the World Drug Problem," New York, 19 April 2016, www.who.int/dg/speeches/2016/world-drug-problem/en/.

(52.) UNAIDS, "Harm Reduction Works," 2014, www.unaids.org/en/resources/presscentre/featurestories/2014/march/20140318harmreduction.

(53.) UNAIDS, A Public Health and Rights Approach to Drugs (Geneva: UNAIDS, 2015), www.unaids.org/sites/default/files/media_asset/JC2803_drugs_en.pdf.

(54.) Global Fund, "Harm Reduction for People Who Use Drugs: Information Note," 2015, www.theglobalfund.org.

(55.) Ibid., p. 2.

(56.) Elliott et al., "Harm Reduction, HIV/AIDS, and the Human Rights Challenge to Global Drug Control Policy" pp. 121-124.

(57.) UNAIDS, Do No Harm: Health, Human Rights, and People Who Use Drugs. (Geneva: UNAIDS, 2016), www.unaids.org/sites/default/files/media_asset/donohann_en.pdf.

(58.) Ibid., p. 3.

(59.) Ibid., p. 56.

(60.) WHO, Basic Principles for Treatment and Psychosocial Support of Drug Dependent People Living with HIV/AIDS (Geneva: WHO, 2006), www.who.int/substance_abuse/publications/basic_principles_drug_hiv.pdf

(61.) Global Fund, "Harm Reduction for People Who Use Drugs: Information Note."

(62.) Ibid., p. 7.

(63.) Elliot et al, "Harm Reduction, HIV/AIDS, and the Human Rights Challenge to Global Drug Control Policy," p. 106.

(64.) Michel Kazatchkine, "Harm Reduction: From Evidence to Action," address to the Twentieth Harm Reduction International Conference, 21 April 2009, https://www.hri.global/contents/361.

(65.) US President's Emergency Plan for AIDS Relief, "Comprehensive HIV Prevention for People Who Inject Drugs, Revised Guidance (July 2010)," www.pepfar.gov/documents/organization/144970.pdf.

(66.) IHRA, "Media Release: International Harm Reduction Association Calls on the Obama Administration to Fund the Procurement of Needles and Syringes in Its PEPFAR Programme," 7 April 2011, www.hri.global/files/2011/04/07/Harm_Reduction_2011Confererence_Closing_Ceremony_media_release_ENG_Thursday_April_7.doc.

(67.) Rhodes et al., "Policy Resistance to Harm Reduction for Drug Users and Potential Effects of Change," at c.3439.

(68.) Michael Barnett and Martha Finnemore, Rules for the World: International Organizations in Global Politics (Ithaca: Cornell University Press, 2004).

(69.) Hein, Bartsch, and Kohlmorgen, "Interfaces."

(70.) Hein, "Global Health Governance and TRIPS/WTO."

(71.) Rushton and Williams, "Frames, Paradigms and Power."

(72.) Barry Buzan, Ole Waever, and Jaap de Wilde, Security: A New Framework for Analysis (Boulder: Lynne Rienner, 1998).

(73.) "Philippines War on Drugs: '1,900 Killed' Amid Crackdown," BBC News, 23 August 2016, www.bbc.co.uk/news/world-asia-37162323.

(74.) Hein, Bartsch, and Kohlmorgen, "Interfaces."

(75.) See, for example, Rene Loewenson, "Structural Adjustment and Health Policy in Africa," International Journal of Health Services 23, no. 4 (1993): 717-730.

(76.) Rhodes et al., "Policy Resistance to Harm Reduction for Drug Users and Potential Effects of Change," p. c3439.

(77.) Rifat Atun and Michel Kazatchkine, "The Global Fund's Leadership on Harm Reduction, 2005-2009," International Journal of Drug Policy 21, no. 2 (2010): 103-106, at 105.
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