What Works: Success in Stressful Times

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.’

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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.

(#litres_trial_promo) 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.

(#litres_trial_promo) 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.

(#litres_trial_promo) 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.

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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 Switzerland’s population of seven million smoke cannabis at least once a month.

(#litres_trial_promo) In fact, it has become so widespread that at the end of 2008, the Swiss held a referendum on whether it should be made legal. The vote was against but the issue will hardly go away.

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So the programme pioneered in Zurich is not perfect. It is just the best that has yet been developed. And as such it carries practical lessons for cities and societies seeking to improve the health and welfare of their people-trying to stop them harming themselves, trying to help them escape the scourge of drugs and lead happier and more fulfilled lives.

2. WHAT ARE THE LESSONS?

At one level it is all very simple. Switzerland developed a model and applied it to the city with the most serious drug problem in Europe. So other places can pick up this model, adapt it to local conditions and roll out similar programmes. Many have done so. Particular elements of the Swiss approach now widely used elsewhere are injection rooms in pharmacies and needle-exchange programmes. The twin ideas of harm reduction and turning drug use into a medical issue rather than a law-and-order one have been widely imitated.

It has been applied, for example, in Britain. At the first stage three clinics were opened, one in south London, one in Darlington in north-west England and one in Brighton on the south coast. It has, according to Professor John Strang, the head of the National Addiction Centre at the King’s College in London, who is leading the study, been a huge success. In 2007 he reported that instead of buying street heroin every day, about 100 of the 150 volunteers were buying it only four or five times a month-while the rest of them had completely stopped ‘scoring’ the drug on the streets.

Professor Strang said: ‘This is genuinely exciting news. These are people with a juggernaut-sized heroin problem and I really did not know whether we could turn it around. We have succeeded with people who looked as if their problem was unturnable, and we have done it in six months.’

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So the medical approach works. But there is another element to the programme that is arguably just as important: alongside the medical approach, there was in Switzerland a fierce legal crackdown. Just before Letten was closed, the Swiss passed legislation giving police the power to search, arrest and detain anyone suspected of living without permission in Switzerland. All illegal foreign addicts and dealers were to be deported. These laws were dubbed ‘anti-foreigner’ but they had the authority of a referendum behind them. Two new prisons were built for foreigners suspected of committing an offence, and they were held in jail for up to a year without trial while waiting to be deported. As for Swiss drug users, if they were not from Zurich itself, they were sent to their home cantons for treatment. The tough legal approach was widely criticized-indeed by the advocates of the harm-reduction approach. The Association of Drug Specialists warned that the closure of Letten would force addicts to regroup elsewhere or go underground. Its president said the price of drugs would rise and the quality would fall as the scene was driven underground. As a result, the health of addicts would deteriorate still further. Fortunately, thanks to the treatment centres that were in place, those fears proved unfounded.

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So the Swiss approach has been a mixture of tender and tough. The Zurich experiment, focusing as it did on harm reduction and treating drugs as a medical rather than a criminal matter, was extremely liberal. But it has been more effective in Switzerland than elsewhere because it was backed by extremely illiberal legislation. The authority to hold foreigners without trial for up to a year is at the outer limits of the legal powers of Western democratic governments. Swiss powers to deport foreigners with relatively little right of appeal are much tougher than those of EU states. Even the power to force addicts to return to their home cantons for treatment is not something that other democracies would find easy to sanction.

The message therefore is a ‘both/and’, not an ‘either/or’. You must have proper anti-harm treatment but you also need tough anti-crime legislation. However, those tough laws did not focus on the crime of drug taking because that in itself is not considered a crime. Rather they focused on the dealers, and particularly the foreign dealers.

Many people will find this a difficult combination to accept. Indeed the tough elements were much criticized by many of the proponents of the emphasis on treatment rather than punishment-as the soft ones were criticized by people who put punishment first. The distinctions in the treatment of foreigners accused of drug dealing-the holding them without trial and the willingness to deport them-would be difficult for most European countries to adopt as, on the face of it at least, they breach their human rights. Switzerland has neither signed nor ratified the relevant protocol in the European Convention on Human Rights on expulsion of foreigners. In practice, it is inevitable that some people will be treated harshly and unfairly. But many will recognize there is a common-sense element here: a country is responsible for its own citizens but not for people who come to it and break its laws.

There is, finally, another tantalizing possibility. It is that you curb drug use by acting on the demand side rather than the supply. If you could cut demand, the whole drugs industry, and all the social evils associated with it, would collapse. The clever idea behind the tough/tender Swiss approach is that it has made heroin in particular less fashionable. If it has really been turned into a drug for losers, then that leads to another question: could one make other harmful activities-excessive drinking, say-something for losers too? Even if there can be no simple answer to that, a radical decline in drug use is a prize worth chasing.

•Mix tender and tough •Act on the demand side rather than the supply side •Seek balance between extremes

3. WHAT COULD GO WRONG?

One difficulty will be obvious from the above: Switzerland has a serious cannabis problem. While the treatment of heroin addiction has been very effective, there has been less success in the treatment of softer drugs. But the bigger question mark over the Swiss experiment is the extent to which its success was down to the special circumstances of the Swiss drug problem at the beginning of the 1990s and therefore how much of this model can be replicated elsewhere.

Those circumstances included a sense of desperation and public shame. The Zurich authorities were forced to confront their failure but were also given the legal tools, backed by a national referendum, to take the tough steps as well as the soft ones. Now other places can do bits of the policies it pioneered. The treatment centres are relatively simple to transplant and prescription and administration of heroin, rather than substitutes, is easy in the sense that it merely requires legal consent.

But if the soft side is relatively easy to scale, the tough side is much harder. There is a political problem in that the places where there is a willingness to regard drug taking as a medical condition rather than a criminal one are not those where there is support for, say, holding foreigners without trial for a year. Conversely, perhaps an even bigger problem is that the places where there is support for the tough measures are unlikely to have the funds, facilities or political impetus for the medical approach. The USA, where 55 per cent of the people in federal prisons are serving time for drugs, is the obvious example of the latter.

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There are also a number of ‘third rail’ issues-the ones that people are afraid to touch in case they are electrocuted. Switzerland does not have historic connections with areas with a long history of the production and transfer of hard drugs. It has a huge immigrant population, more than 20 per cent of the total, but relatively few are from Latin America, West Africa or the Caribbean.

(#litres_trial_promo) So Switzerland does not feel the same need as other Western democracies to tiptoe round the racial associations of the drug trade, or indeed crime generally. Some 70 per cent of the inmates of Swiss jails are foreign-born.

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It is hard, then, to transplant the Swiss experience wholesale. Harder still is the chase for the greatest prize of all: having a real impact on drug demand. But that goes beyond the realms of both medical intervention and law enforcement and into marketing, psychology, brand advertising and so on. No one has yet succeeded there. Advertising can project the notion that drug taking is harmful but it has yet to succeed in convincing young people that it really is an illness. There are some elements, though, in what Zurich has achieved that point in this direction. It is not glamorous to have to make a daily appointment at a drug clinic to get one’s fix.

All our experience of drug taking through the ages is that it does not head forever in one direction. It goes in cycles. One form of drug abuse, or more broadly one set of social problems, recedes while others take its place. But well-designed policies can have an impact. We know what does not work; we know that the hands-off approach of Zurich in the 1980s did not work; it is pretty obvious that the turning of drug taking into a criminal offence, as in the USA, does not work either. The way forward must be some balance between the two extremes, and this experiment is as good an example of that as any in the world.

CHAPTER SIX (#ulink_bd4c5d39-2331-513d-abe5-3418e6200d96)

I. WHAT IS THE STORY?

Germany is the world’s most successful goods exporter. In 2008 it sold more manufactured goods to other countries than the USA, more than China, more than Japan-all countries with far larger populations.

(#litres_trial_promo) It did so despite not being particularly strong in the new electronics industries and it has managed to overcome the problem that most of its European neighbours are slow-growing markets.

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So what is its secret? Part of the answer is that there are many great German corporations-the household names such as BMW, Siemens or Volkswagen. But another part of the answer is that it is home to thousands of medium-sized companies-ones that most people have never heard of, but that are wonderfully successful in their own specialist fields. They each employ perhaps a few hundred people (though some have staff counts running into the thousands) and are usually family-owned

(#litres_trial_promo) and managed, so they do not have huge resources behind them. Yet they dominate the markets in which they operate, often being number one or two in the world. They are the German ‘Mittelstand’.

Notions about their size and their dominance of the German economy vary. On one count they employ more than two-thirds of all employees in private business, according to the Institut für Mittelstandsforschung in Bonn, the research body that studies and promotes their activities.

(#litres_trial_promo) They contribute half the value-added of the entire country and produce directly a third of all exports. All other countries, of course, have small and medium-sized businesses, but no other nation has anything on this scale. Perhaps most surprising of all, this sector has survived the devastation of defeat in two world wars, the hyper-inflation of the 1920s and the challenges of lower-cost companies in Eastern Europe and Asia. Germany is an expensive place to make things-on some counts the most expensive in the world.

(#litres_trial_promo) Yet while there have obviously been individual corporate casualties, as a sector these small and medium-sized companies have survived and prospered.

Why and how? Mittelstand businesses have a number of common characteristics. One is that family plays a core role. In some instances the same family has carried on for generations, both owning and managing the firm. In others the family ownership has become diluted, with other shareholders being brought in. In still others the family owns the firm but has it run by professional managers. The point in common is that families are able to take a very long view of a company’s future-far longer than the shareholders of publicly quoted businesses.

A second characteristic is that most of the firms are in manufacturing rather than services and they usually have highly specialized, intermediate products that are part of the manufacturing process, rather than being finished goods. So the products are invisible to the consumer. The companies focus on a narrow market niche, aiming to dominate that niche worldwide. Typically a firm might have 70 to 90 per cent of the world market for that product.