Here’s how to make drug addiction a health issue, not a criminal one

It’s still early when Bridget Munnik walks to work. The streets of Westbury in Johannesburg are eerily quiet. 

“If it’s daylight, then it’s their time to sleep. For us it’s day and for them it’s night.” When the darkness falls, drug users come out to roam the neighbourhood in the west of Johannesburg, she says. “They’re running around like mad people in the community.”

Auntie Brie, as she’s known by those who come to the skills development programme she runs in the neighbourhood, grew up watching illicit drugs shape her community. Her brothers used dagga and Mandrax, a depressant with sedative and hypnotic effects, which, she says, at least kept her siblings calm. 

But today’s methamphetamines, known as tik or crystal meth, are different. These are stimulants that are snorted, smoked or injected and are known for causing violent and bizarre behaviour.

When her sons struggled with drugs, she saw them transform. “I didn’t know they were on drugs. And then I saw the monsters, where they became very aggressive, very, very aggressive.”

It’s a cycle that has trapped generations. Arrests and heavy-handed police crackdowns have done little to break it and drugs continue to flood the community. Today, Westbury is known as one of the city’s deadliest areas, plagued by gangs, violence, unemployment and poverty.

Part of what’s fuelling the addiction crises there and across the country, say experts who Bhekisisa spoke to for its monthly TV programme Health Beat, is that our conflicting approaches to drugs are undermining each other.

A disease or a crime? 

Seven years ago, the country launched a revised National Drug Master Plan. It recognises addiction as a chronic disease affecting the brain and behaviour and that approaches to treating it should include what’s known as harm reduction. 

Harm reduction is not about expecting drug users to just quit using the substances they’re dependent on; it’s about trying to make sure that they don’t overdose or don’t pass viruses like HIV to other drug users. But in practice, police follow the Drugs and Drug Trafficking Act of 1992, which says drug use is criminal. 

“The tragedy of Westbury and other parts of western Johannesburg is the same as the tragedy we see playing out in gang areas in the Western Cape and the Eastern Cape,” Julian Rademeyer, the former director of the Global Initiative Against Transnational Organised Crime’s East and Southern Africa research observatory, told Health Beat.

 “There’s a cycle of abuse, a cycle of violence that has been continuing for decades.”

He says police focus their efforts on easy targets, including drug mules caught at borders or at points of entry into the country. But Rademeyer, who has reported extensively on organised crime, argues the strategy is doomed to fail.

“These are low-level people, some of the most vulnerable people in the supply chains,” he says. “Many of them are women. Many of them are coerced or threatened or are in such a position of vulnerability that they have no other choice. No one willingly gets on a plane and shoves 200 pellets of cocaine in their stomach.”

Rademeyer says quick and easy arrests of drug mules or low-level drug dealers and users don’t get to the root of the problem — the complex organised crime networks that are fuelling a health crisis that is getting worse and addiction treatment isn’t keeping up. 

“Rehabilitation facilities in Africa are a business, and for the poorest of the poor, there are very few opportunities or places for people to go.”

Harm reduction

One of the public facilities that helps people dependent on opiate drugs like heroin or nyaope or whoonga (most commonly a mixture of substances including heroin and cannabis which can be smoked or injected), is Cosup, the Community Oriented Substance Use Programme. 

Funded by the City of Tshwane and based at Mamelodi Hospital, the harm reduction clinic is run by the University of Pretoria. There, addicts are also tested for HIV, assisted with wound care and given methadone to treat opiate addiction. 

Methadone doesn’t cause as much of a high as heroin or nyaope, and helps curb heroin withdrawal symptoms. Because it is taken orally instead of through needles, which drug dependent people often share, it also lessens the possibility of transmission of HIV between users. 

Years of research have repeatedly shown that methadone and similar treatments reduce both HIV and hepatitis C infections among drug users, with the strongest protection when combined with needle exchange programmes. 

It’s part of a health-first approach that focuses on the user’s physical and psychological health, taking into account the ways drugs can wreak havoc on relationships with family and friends; a person’s desire or ability to stay in school or keep a job; and the legal problems related to illicit drug use, including buying or selling illegal substances to feed their addiction. 

The fundamental principle of harm reduction: you can’t recover if the drugs have killed you. By keeping people who use drugs alive and engaged with services, they’ve got the basic support for all these interconnected harms when they decide to make changes or attempt sobriety.

But public harm reduction clinics like Cosup, whose funding is uncertain from June, are far and few between. 

Andrew Scheibe, who works in harm reduction research and policy, isn’t convinced that expensive inpatient detoxification programmes covered by medical aids work. “Because if people come out of one of those 20-day inpatient facilities, they lose their tolerance. If they return to use, they’ve got an increased risk of overdose if they inject. 

“But the major issue is that people can’t easily change long-standing habits and deal with long-term trauma over 20 days.”

Harm reduction programmes are among the least expensive public health solutions — including needle exchange programmes and opiate agonist therapy, using methadone treatment — according to the UK-based Harm Reduction International. 

Its 2024 report points to modelling in the US, which found that for every dollar invested in a needle exchange programme, $6.38 to $7.58 (about R105 to 124.50) would be saved in HIV treatment costs alone. 

In Vietnam, community-based methadone maintenance therapy was more cost-effective than centre-based compulsory rehabilitation, saving an estimated $2 545 (about R41 900) a person over three years, with centre-based compulsory rehabilitation costing over three times more.

Scheibe says that because we only have about 82 000 injecting drug users in South Africa, a small investment would go a long way. 

“With every person who becomes HIV infected, we have large numbers of people who need lifelong treatment, increased likelihood of TB treatment, increased likelihood of transmission to other people and the elevated risk of death.”

Scheibe told Health Beat that addiction needed to be treated as a chronic condition, just like hypertension and diabetes, which don’t go away, but can be managed with healthier eating, exercise and medication. “Can we cure hypertension? Can we cure diabetes? [But] some people may shift their life so that it’s no longer a problem.”

The drug economy

Charity Monareng, the director of Students for Sensible Drug Policy International, says she sees promise in the health department’s recognition of drug dependency as a chronic condition that can be treated. 

Over the past 15 years, she’s been advocating for drug policies like harm reduction since she first got interested in the work through studying gangs in Cape Town’s Lavender Hill.

“I was always very interested in how young people got involved in gangs and also what they think would be needed to stop gangs,” Monareng says. “And as I delved deeper, I realised that gangs actually fulfil a certain purpose in communities. They create an economy in communities, even though it’s illicit.”

It’s something Munnik constantly sees fuelling drug addiction in Westbury. “If you’re a teenager, you will see that your mom is struggling and here comes a drug dealer and puts something in your hand and that’s easy money,” says Munnik, whose project offers coding, performance art and women’s empowerment programmes. 

“That starts with being on the corner selling drugs; then you don’t even realise that your life is in danger.”

It’s helping people stay out or get out of that cycle that helps her keep the faith. “I work with the strength of people. Even if somebody on drugs walks into my space, I don’t see the negativity, the drug. There’s a soul in this body and there’s a brain in this body and these children have dreams, they’ve got visions.”

This story first appeared in Bhekisisa’s monthly television programme Health Beat. Additional support from the Health Beat team, Thatego Mashabela, Yolanda Mdzeke, Ruan Visser and Floris Kotze.

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.