When I hosted the first City Health conference in 2012, my hope was we might manage three or four events in different cities. I never dreamt we’d get to nine (and counting) or that City Health would reach the great city of Melbourne. Great credit must go to the Progressive Public Health Alliance for hosting a fascinating two days that provided energy, enthusiasm and challenge. Personally, I learnt a great deal and found myself questioning somehow of my own views. I met people doing amazing things in the most challenging environments. I heard of situations that made me feel a sense of despair but came away reassured that we have the knowledge, networks and commitment to positively change lives for the better.

Australia played a vital role in the development of harm reduction in the 1980s and 1990’s. Melbourne has shown it retains an appetite for exploring fresh approaches with its recently opened Medically Supervised Injecting Facility. Talking to politicians, researchers, practitioners and members of the public there was an energy and enthusiasm about tackling drug issues that is in rather short supply within much of the UK. We will see if we might use some of that Australian energy and experience to fire things up a little in London, it may not just be English rugby that can benefit from such input.

A central theme of the event was how effective and humane approaches, informed by harm reduction principles, have a great deal to offer beyond the established confines of illegal drugs. When it comes to alcohol, gambling, prescribed drugs or smoking there is so much we could do to reduce harm for millions of people. That’s one of the great assets of harm reduction approaches; it provides an opportunity to make an impact at scale. I was taken by the comment made by Adam Drake, who works as an advocate for young people in the justice system, that we should “deal with people at the point of need not at the point of crisis”. Many of us will be able to think of cases where individuals and communities are clearly struggling but intervention only occurs when a threshold of significant harm is reached. Often harm that is hugely costly in financial as well as human terms. As numerous City Health presenters demonstrated we do have an increasing evidence base for a range of effective interventions, many of which require modest financial commitment but do require a willingness to challenge established and occasionally entrenched views.

Fiona Patten, in delivering the Alison Chesney and Eddie Killoran lecture that concluded the conference, reminded the audience that the great achievements of the eighties and nineties were built on radical approaches, that within the establishment and media there had been great opposition to initiatives which have been proved to save lives. Times have changed but challenges and opportunities remain if the courage to take on entrenched positions is found.  As Fiona said, if we have identified ways to reduce harm its not an option to implement them, it becomes a duty. I think for the UK there are some real opportunities to apply Australian experience as a step toward reducing drug related deaths. We might repay the favour by sharing our practical and evidence-based experiences around tobacco harm reduction. Viewed from afar this is an area where the UK still does lead the world.

Oddly enough it was during a visit to Melbourne’s historic gaol that I came across an example of a pragmatic response to smoking related harms. Now this is an imposing but inevitably rather grim visitor attraction. It is full of reminders of the horrors of imperialism, savage punishment and miscarriages of justice. In the 1930’s the prison was being decommissioned but was brought back into use during the Second World War to serve as detention centre for military prisoners. During this period, to improve their health and enhance the punishment of those who had gone Absent Without Leave, it was decided to cease the supply of cigarettes. This led to a black market and ingenious smuggling methods, often aided and abetted by locals who would tie individual cigarettes to strands of cotton hanging from cell windows. While this no doubt displeased the prison authorities it was not this which led to a reversal of the decision to ban cigarettes. Rather it was concerns that prisoners were smoking homemade cigarettes, using vegetable matter and any other vaguely smokable substance. There were concerns about the harms this could cause and so the ban was over turned. It’s a reminder of the unintended consequences that can arise from seeking to ban things, without considering safer alternatives, especially in populations experiencing hardship. It must be hoped that others can show the mental flexibility exhibited by the Australian military authorities some 75 years ago!

City Health in Melbourne provided some powerful messages, great food for thought and fire for the belly. For those unable to attend its well worth looking at https://cityhealthinternational.org/conferences/previous-events/2019au-melbourne.  I will certainly be following up new contacts and friends to explore opportunities for further collaboration. Hopefully we will see some of these, and many of you, in Warsaw next year for our 10th anniversary event.