Switzerland, Medicine, Public Health, and Drug Policy Discussion with Swiss President Ruth Dreifuss

GENEVA, SWITZERLAND – Throughout my medical and research career, I have had the privilege of meeting and working with politicians, presidents, decision-makers, members of royal families, and influential global figures. Yet only a few have truly surprised me with their humility, intellectual depth, and unwavering commitment to public service. This was precisely my experience with Ruth Dreifuss – a political leader whose work helped reshape global public health and modern drug policy.

Ruth Dreifuss became Switzerland’s first female president in 1999 and remains one of the most influential figures in the development of progressive public health policy. As head of the Swiss Federal Department of Home Affairs, she played a central role in transforming Switzerland’s response to addiction, HIV/AIDS, and social welfare. Her leadership contributed to the development of Switzerland’s internationally recognized four-pillar drug policy strategy based on prevention, therapy, harm reduction, and law enforcement. Beyond drug policy, her broader political work focused on public health, social security, climate change, environment and women’s rights.

I was visiting a physician colleague from Yale University who now practices medicine in Geneva at Hôpitaux Universitaires de Genève when I had the opportunity to meet Ruth Dreifuss in person. I had long known her work through textbooks, scientific literature, and public health discussions, but speaking with her directly and discussing these issues in depth was a truly eye-opening experience.

In a world where many political figures are heavily guarded, distant, and constantly concerned with security, seeing Ruth arrive at our meeting point alone by public transportation was a surprise. In her view, it was absolutely normal and she insisted that it was one of the characteristics of the Swiss political system she enjoyed for its closeness between citizens and politicians. It reflected the values she later spoke about during our conversation: trust in society, trust in government, openness, and connection with ordinary people.

After our long discussion, we walked together toward Geneva’s supervised drug consumption facilities. Along the way, we spoke with people in the streets, exchanged small conversations, and observed daily realities that statistics and policy reports alone cannot fully capture. Those brief human interactions became an important reminder that public health is ultimately about people, dignity, and lived experience.

What struck me most was the respect and admiration people still showed her many years after her presidency and active political career. Citizens approached her warmly, recognizing not only her political role but also the impact her policies had on protecting lives and improving public health in Switzerland.

Her behavior throughout the day taught me something profound about leadership: humility, confidence, and humanity are not weaknesses in politics – they are strengths. Ruth Dreifuss embodied the kind of public servant many societies aspire to have but rarely encounter. Spending time with her was both intellectually enriching and personally inspiring.

You were instrumental in shifting drug dependence from a criminal justice issue to a public health concern. What scientific, clinical, or epidemiological evidence most convinced you that addiction should be treated primarily as a health condition rather than a crime?

The strongest evidence came directly from the reality we were seeing in Switzerland during the late 1980s and early 1990s. Open drug scenes in cities such as Zurich and Bern revealed a public health disaster: overdoses, HIV transmission, hepatitis infections, extreme poverty, and social exclusion. Traditional punitive approaches – arresting users and forcing drug use underground – had clearly failed and in fact worsened the situation. We had learned that dependence is a chronic disease, later confirmed by the World Health Organization this condition. That is very important because if addiction is a chronic disease, society has a responsibility to provide treatment and care rather than punishment.

The epidemiological evidence was also undeniable. HIV transmission among people who injected drugs was spreading rapidly and frontline physicians understood that preventing infection and preserving life had to take priority. This is why some doctors began distributing sterile syringes even before the law officially allowed it. Clinically, we also saw that when people were treated with dignity and trust, outcomes improved dramatically. Once individuals felt safe enough to engage with healthcare systems, we could stabilize their health, reduce risky behavior, and reconnect them with social support. That proved far more effective than criminalization.

Switzerland’s four-pillar drug strategy – prevention, therapy, harm reduction, and law enforcement – has become a global model. What were the key data points or outcomes that persuaded policymakers and the public to support such a paradigm shift despite strong political resistance?

The most persuasive evidence came from the results of heroin-assisted treatment and other harm reduction measures. Switzerland conducted a five-year multidisciplinary study involving approximately 1,200 individuals who had not responded to conventional treatment. The outcomes were very clear: petty crime associated with financing drug purchases dropped dramatically, HIV transmission rates fell sharply, social reintegration improved, engagement with healthcare and support services increased significantly, and people’s overall stability and quality of life improved.

It is important to understand that this was never simply about distributing heroin. The treatment model integrated medical care, psychological support, and social services with the objective of helping people regain control over their lives. Public acceptance also depended heavily on transparency. Switzerland’s system of direct democracy meant that citizens repeatedly voted on these policies. We explained openly what we were doing, why we were doing it, and what the evidence showed. Over time, people understood that these policies reduced suffering, improved public order, and protected public health. Another important factor was visibility. The open drug scenes had become impossible to ignore, and the public could clearly see that the old punitive approach was not working. That created openness to innovation.

Your policies introduced interventions like needle exchange programs and heroin-assisted treatment, which were controversial at the time. From a medical and public health standpoint, how do you define the role of harm reduction within modern medicine, and should it be considered a standard component of primary care systems?

Yes, absolutely. Harm reduction should be fully integrated into modern healthcare systems and primary care. The first responsibility of medicine is not moral judgment but protecting life, health, and dignity. Harm reduction creates the possibility of trust between patients and healthcare providers, and without trust there is no real therapeutic relationship. The first goal is often very simple: survival. Later goals may include stabilization, social reintegration, improved health, and eventually abstinence for some individuals. Addiction treatment should function as a partnership between the patient and the physician, and relapses should not be viewed as moral failure but as part of the reality of chronic illness.

Today, harm reduction must also go beyond preventing HIV or overdose. We increasingly see broader harms linked to homelessness, malnutrition, exhaustion, social isolation, and exclusion – especially with stimulant drugs such as crack cocaine and methamphetamine. Modern harm reduction therefore includes safe consumption spaces, access to healthcare, food and hydration, shelter and rest, psychological and social support, and protection from stigma and exclusion. These principles should also exist in prisons because prisons are rarely drug-free environments. Switzerland introduced needle exchange programs in correctional facilities because protecting health is more effective than pretending drug use does not exist.

You supported early implementation of heroin-assisted treatment through experimental legislation before full legal backing. How should governments balance urgency in public health crises with the need for rigorous evidence when introducing such unconventional medical interventions?

Public health emergencies sometimes require action before perfect evidence exists. During the Swiss crisis, we were facing HIV transmission, overdoses, and widespread social collapse among vulnerable populations. Waiting many years for ideal evidence would have cost lives. At the beginning, much of our knowledge came from frontline experience, physician observations, case reports, and urgent epidemiological realities rather than large, randomized trials. Doctors and social workers working directly with affected populations understood that new approaches were necessary. At the same time, we did not abandon scientific rigor. The heroin-assisted treatment program was carefully monitored through multidisciplinary medical, social, criminological, and epidemiological evaluation, and over time this generated strong evidence. Governments must therefore balance urgency with transparency, accountability, and continuous evaluation. It is possible to act pragmatically during a crisis while still collecting rigorous data and adapting policy based on results.

Switzerland’s reforms were closely tied to reducing HIV/AIDS transmission among people who inject drugs. How do you see the relationship today between drug policy and the control of infectious diseases like HIV and hepatitis C, especially in low – and middle – income countries?

Drug policy and infectious disease control are deeply connected. When governments criminalize and stigmatize drug users, people become afraid to seek healthcare. Fear drives individuals underground, increases unsafe consumption practices, and accelerates the spread of HIV and hepatitis C.

Needle exchange programs, supervised consumption services, substitution therapies, and access to healthcare are essential public health tools because these interventions reduce transmission while also creating opportunities for long-term care and social support. For low and middle income countries, the lesson is especially important. Public health systems should focus on prevention, dignity, and accessibility rather than repression. Criminalization creates distrust toward public institutions and weakens health responses.  Countries should also consider that the cost of repression and incarceration is far higher than harm reduction measures, with less positive results. specially law and middle income countries should be interested in an optimal resources allocation.

Beyond drug policy, you contributed to reforms in health insurance and access to care. In your view, what are the most critical elements needed to ensure that universal health coverage systems also adequately integrate addiction medicine and marginalized populations?

Universal health coverage is essential. I believed in it from a very young age because healthcare should not depend on wealth or social status. In Switzerland, one of the important achievements was ensuring that addiction treatment became part of the national health insurance framework. This includes methadone treatment, heroin-assisted therapy, mental health services and in more restricted way also psychological care. Addiction medicine cannot function in isolation because social exclusion, homelessness, stigma, and poverty are themselves major health determinants. A successful system must also recognize that marginalized populations often face barriers beyond medicine alone. Healthcare systems must be accessible for undocumented or socially excluded populations. They are a stakeholder of a broader system were social support, housing, community outreach, education and access to the labor market or protected labor activities for the neglected population.  A humane health system must treat vulnerable populations as members of society deserving dignity, protection, and care.

Through your work with the Global Commission on Drug Policy, you have argued that punitive drug policies have failed globally. From an ethical and public health perspective, do you believe decriminalization is now a necessary condition for improving population health outcomes worldwide?

Yes, I do. Criminalization produces fear, stigma, and distrust. When people fear punishment, they avoid healthcare services and become disconnected from society and public institutions. Punishing people for drug use does not solve addiction; in many cases, it worsens harm. We also know that incarceration creates additional health risks. People who lose opioid tolerance in prison are at high risk of fatal overdose after release.

From both ethical and public health perspectives, decriminalization is necessary because addiction is fundamentally a health and social issue rather than a moral failure. However, I also believe decriminalization alone is not enough. Governments must regulate drug markets responsibly according to addiction potential, health risks, social harms, and product safety.  Leaving drug markets in the hands of criminal organizations creates far greater harms for society. We see how they are sowing violence, corruption, disruption of entire economies and political systems in many places of the world.