The Incredible Story of Zürich’s Journey to Harm Reduction
The Letten district in the early 1990s. Photograph by Gertrud Vogler.
Drugs, troublemaking, bad grades. At the close of 1968, Sidi was expelled from school. Now, the party could begin in earnest.
He made music and lived in a filthy shared apartment, pretentiously calling itself a commune. Sidi deemed himself an expert on drugs. After all, he had spent time reading several books on the subject, not to mention the original Malleus Maleficarum recipes. He was surrounded by people who were dependent on heroin. They’re nearly all dead now.
Sidi completed high school on the side. And since he had always had a foible for the brain, if for no other reason than how it dealt with drugs, at some point he began to study medicine.
While cramming for his state’s exam, Sidi’s apartment was open to anyone and everyone. Üse was Evi’s boyfriend and Evi, who was also crashing at Sidi’s, was a friend of Sidi’s youngest sister.
One evening, Sidi was sitting in front of the TV, watching the evening news. Üse was lying on the mattress next to him in the flickering blue shadows. Sidi suddenly noticed that not only had Üse stopped talking, he had also stopped breathing. Sidi switched on the lights. Üse was blue in the face.
Sidi applied CPR according to every rule in the book, the whole, horrid time thinking of the tabloid headlines: “Junkie Dead, Doctor Sat and Watched.”
Well, that didn’t happen. Üse survived, and made it to the hospital. But according to the grapevine, he died of AIDS 10 years later. Shortly after that fateful evening, Sidi completed his medical studies.
Sidi, that’s me. I was a doctor for 40 years, practicing in Zürich, Switzerland. Nearly half of the city’s heroin-dependent people visited my practice at least once. I must have seen about three-and-a-half thousand. Some of them came again and again over the years. Many simply called me Sidi.
The author as a young doctor in the 1980s. Photograph courtesy of André Seidenberg.
History in the Fading
It was in 1992 that the Platzspitz city park (pictured top)—right by Zürich train station and internationally nicknamed “Needle Park”—was cleared out by the police, who had previously tolerated drug use and sales there.
This was eventually followed, however, by a far more enlightened policy. My friend and colleague Peter Grob calls that “history in the fading.” I can’t just sit back and let that fading happen.
Back then, in Switzerland alone, twice as many people died each year of overdose and AIDS as have died from terror attacks in all of Europe since 2010. The horrors and death were on our streets, right in front of our eyes.
Switzerland found itself at a crossroads, and chose to take the path of careful consideration instead of ostracization, incarceration and destruction of fellow human beings. From the mid-1990s, we vastly expanded syringe services and methadone access, and also permitted the limited prescribing of heroin—a policy with many well-studied benefits, which spawned a number of imitators around the world.
The success of Swiss drug policy exemplifies the liberal, humane side of Switzerland. I believe this is still important now, for Switzerland and elsewhere. Any society refusing to integrate its marginalized members is a looming danger to itself. Take the overdose crisis in the USA. And the catastrophe in many regions of the former Soviet Union, of which far fewer people are aware. Then there’s Iran, where so many people are drug-dependent, suffering from tuberculosis, AIDS and hepatitis.
On February 5, 1992, police cordoned off and closed Platzspitz. For years, neglected, destitute people—as well as regular Joes and well-groomed staffers from the international finance district directly behind the train station—had obtained their drugs there. Every day, more than 2,000 people were estimated to buy heroin and cocaine, and another thousand cannabis or other drugs, and many lived at the park. People openly sold drugs, shot up, conducted sex work and not rarely—thanks to unsafe practices and contaminated supplies—died there.
The reward for the filterlifixers’ efforts was the residual heroin in filters. Without exception, those I knew got HIV and hepatitis C.
Nowadays, when an aged Sidi takes his dog for a walk in Platzspitz Park, he sees the ghosts of back then. I’m overcome with sadness as I recall desperate people lying on the carousel in deepest winter, day and night at sub-zero temperatures, wrapped in thick blankets.
Peter Grob, working for the HIV prevention organization ZIPP-AIDS, would distribute sterile needles in the public toilet building. I remember the jostling crowds in front of the hand-in counter.
I gaze over at the stone bench by the Sängerdenkmal (Singer’s Memorial). The same guy would sit there all the time, his pants around his ankles, searching with a needle for a living blood vessel in his inner thigh.
Filterlifixers, people who provided cigarette filters for use in preparing heroin, would bring over shopping carts from the train station. They would set up a stolen construction plank, laid over the cart, as a shop counter.
Their wares included spoons to hold the “brown sugar” (contaminated street heroin, mixed with ascorbate or lemon juice) as it bubbled over a candle’s flame, belts, water and the odd disinfectant—but most of all, those new and used cigarette filters.
The reward for the filterlifixers’ efforts was the residual heroin in filters. You could get a fairish shot from 10 or 20 filters. Without exception, the filterlifixers I knew got HIV and hepatitis C.
But how had we got there?
A Poisonous Atmosphere
At the end of the ‘60s, for the first time, two full-time police officers were assigned exclusively to drug-related offenses in Zürich; 25 years later, there were hundreds in the city, fighting the War on Drugs. Drugs were the major reason for incarceration in Switzerland. As of 1967, drug users were banished from every nook and cranny of the city. Dozens of restaurants, bars and clubs were closed—Schwarzer Ring, Odeon, Blow-up, to name just a few.
Armed police cleared squares and parks all over the city, patrolling them for days or weeks to prevent people from returning. Riviera, Bellevue, Seepromenade and Hirschenplatz were repeatedly subjected to this senseless routine.
No matter. The small-time sellers, mostly addicted themselves, stayed addicted and simply shifted their businesses to wherever the police currently were not. New and younger customers were found in these locations, rapidly expanding the market. Finally, the police resigned to the inevitable and turned a blind eye, for five years, to the Platzspitz drug bazaar.
Our society became afflicted with suspicion and hate.
By the mid-’80s, AIDS fatalities were no longer limited to the most marginalized populations. Initially, no one knew much about the new disease, who it affected and how. But it soon became clear that unprotected sex and unsafe injection were the main driving forces. At that time, 80-90 percent of injecting drug users who sought medical help had the virus. Switzerland had more HIV-infected citizens than anywhere else in Western Europe.
Fear and anxiety were logical consequences, but they often escalated into panic. Our society became afflicted with suspicion and hate. Regulars at the local bar, but also members of Parliament, cried out for branding infected people with tattoos, or even isolating them in concentration camps. Some gay people, having finally seen some easing of homophobia, were horrified at the thought of now being “lumped together” with drug users.
Fortunately, rationality would eventually win out over this poisonous atmosphere.
Initially, however, only those drug users who agreed to abstinence were given help. Those who were unwilling were denied guidance and medical care. Cold turkey, without any form of sedative or soothing support, was torture—agonizing pain throughout the body, uncontrollable shivering, diarrhea, terror.
Heroin-dependent people on turkey, wearing fluttering hospital gowns and pushing their IV poles with one hand, a cigarette in the other, could sometimes be seen racing downtown to find a fix to deliver them. Neither police, nor threats, nor even the prospect of death could dissuade them.
In 1983 and ’84, I was an emergency doctor in Zürich. People would come in from the Sihl riverbed, where they lived in huts rigged of cardboard and tin. One had festering wounds on his fingers and legs. Was it a cocaine-induced necrosis, or epidemic typhus from rat bites? Back then, it often felt like guesswork. And then there was the brand-new HIV/AIDS, to boot.
In 1984, my friend and fellow physician Andreas Roose and I began voluntarily touring the city’s shelters, where HIV-contaminated needles were passed around like joints. The danger was obvious and acute. Shelter workers and the private youth aid organization ZAGJP (Zürich Consortium for Youth Problems) helped us to spread lifesaving information and resources, distributing sterile syringes.
But Emilie Lieberherr, a Social Democratic Councilmember and director of Zürich’s social services, who suspected trouble from leftist intrigues, wanted to forbid the distribution of clean injection supplies in her institutions.
She peered down at me and said, “Aren’t you that brazen young doctor who is opposing my directives?”
We countered that we had prescribed the distribution for medical reasons. Lieberherr then appealed to the cantonal physician, Professor Gonzague Kistler, and controversy blew up. Zürich media was full of the Needle Exchange Conflict.
It escalated to such a point that, for a time, my career was at risk. But soon, a lucky coincidence turned the tables.
Late one night, long after the city police had cleared the sidewalks, I was summoned, as emergency doctor, to the Hotel Trümpy, where I found a beleaguered Emilie Lieberherr. After I assisted her, the hotel owner and I helped the tall, stately politician to the elevator.
She peered down at me and said, “Aren’t you that brazen young doctor who is opposing my directives?”
This gave the brazen young doctor the opportunity to have a nice long chat with her. Lieberherr insisted on getting the big picture and allowed me to win her over. She subsequently, and passionately, led the campaign for a mitigating drug policy in Zürich, gaining the city council majority.
In the needle exchange conflict, cantonal physician Kistler and health director Peter Wiederkehr threatened to revoke the licenses of recusant practitioners. In an inflammatory letter, Kistler told me it was imperative to protect “the upper echelon.”
In response, more than 300 of us licensed practitioners signed a document declaring we would continue to provide people with sterile syringes. We were supported by the cantonal medical association, as prohibiting the action lacked even the ghost of a legal or rational footing.
The so-called needle exchange prohibition was the act of an imperious cantonal physician, who had no authority over licensed doctors anyway. For guidance, Kistler looked no further than Professor Ambros Uchtenhagen, a University of Zürich psychiatrist, whose unshakeable opinion was that abstinence was the only treatment for addiction.
Life and Limb
In July 1986, I placed the following announcement in the Zürich Tagblatt:
“Dear Mr. Policeman, I urgently request you to refrain from collecting fresh syringes from drug users. Taking sterile syringes is against the law and may possibly lead to arrest or fines, as it has been proven that doing this poses a threat not only to the person’s life and limb, but also, by propagating viruses, to public health.”
The police had no right to confiscate injection utensils from drug users. They rescinded their confiscation directive and the so-called needle exchange prohibition faded into obscurity.
At Platzspitz, ZAGJP, the Association of Independent Physicians (VUA) and the Red Cross launched a needle and syringe distribution campaign from a bus. The police tolerated the action.
Since the onset of the ‘80s, immunologist Peter Grob had been inoculating people who used drugs against hepatitis and carrying out blood testing for epidemiological field studies. Supported by the city of Zürich, he could now install a permanent needle exchange, ZIPP-AIDS (Zürich Intervention Pilot Project against AIDS), in the Platzspitz public toilet. Approximately 10,000 sterile injection utensils were handed out daily, in exchange for used supplies, which were then properly disposed of. ZIPP-AIDS also offered anonymous HIV testing.
Amid crises of housing and poverty, the city’s shelters were overflowing. I also organized emergency aid in trailers run by Pastor Ernst Sieber. Later, in 1988, his relief organization, Stiftung Sozialwerke Pfarrer Sieber, built an emergency addiction treatment center on the Konradstrasse. Although Sieber’s primary focus was spiritual guidance, he also saw the necessity of minimizing harm however possible.
Suggestions included needle exchange, controlled consumption spaces, methadone and, taking things a step further, heroin prescribing.
At Emilie Lieberherr’s behest, the Zürich city council invited Basel Criminal Court President Peter Albrecht and myself to a drug policy hearing. Which measures could best reduce harms to individuals and to society as a whole?
Suggestions included needle exchange, controlled consumption spaces, methadone and, taking things a step further, heroin prescribing. The minimal impact of repressive tactics on drug consumption was firmly acknowledged. The city council accepted some of the ideas, publishing them as Ten Drug Policy Program Points.
Since 1988, the health department had been running the Krankenzimmer für Obdachlose (infirmary for homeless people) on the Kanonengasse. The city then opened a whole series of contact and drop-in centers for local injecting drug users. Until recently, the city health services had also revamped a dozen cigarette vending machines to dispense injection utensils.
A Funeral a Week
Zürich and the Swiss gradually came to understand that though they might not desire drug use, it cannot be eradicated. The transition from abstinence dogma to harm reduction needed time to take hold. Needle exchange reduced the risk of HIV infections, but so many were already infected that at first, things just got worse.
From 1985, my practice was located in Zürich-Altstetten. My partner Christian La Roche and I treated about 200 HIV/AIDS patients in our joint practice. Almost every week we found ourselves at a funeral. Back then, being HIV-positive was a death sentence. No one knew how long it would be until AIDS arrived.
Enrique spent his days sitting on the waiting room sofa. He had nowhere else to go. His flesh wasted away to the bone, his long-lashed eyes were deep caverns, blinking in slow motion and his smile as delicate as a whisper. Occasionally, he’d take a sip through a straw before dragging himself to the toilet again. He died of extreme diarrhea.
Marie, a single mother of a delicate little girl, had AIDS. Triggered by her immune deficiency, she suffered from the Cytomegalovirus, threatening her with blindness and suffocation. Twice a day, Marie had to inject ganciclovir into a rubber depot implanted under her skin. Her sweet little girl would lead her half-blind, feverish and trembling mother through their stuffy, hot apartment. Marie soon died of pneumonia.
Gundula was an office worker. She also had an implanted catheter depot under the skin of her collar bone, into which she injected not only medication, but cocaine and sugar cocktails. Gundula had an ivy-entwined tattoo that read “For You: In Life and Death.” She was HIV-positive. She worked up to the very end, in the office during the day, and doing sex work at night, on cocaine. She died of a bacterial valvular suppuration.
I remember Marco, Mona, Bodo, E.T., Jösi, Lisa. Hundreds of stories of miserable death.
Then there was Long-finger, a pianist. He came to my practice much later, but we knew each other from our wild youth, living together in Zürich’s Enge district. Ten pianists and one cellist shared the villa. The pianists lived in spacious salons, each with their own piano. I was the cellist; the nursery was enough for me.
Of course, Long-finger had a different name back then. He was the youngest among us and lived with a beautiful older pianist of 21. She didn’t notice when he began to shoot up; when she did, she wanted to throw him out.
Long-finger soon applied his sensitive fingers to breaking into drugstores. It took the police 12 years to catch him. Long-finger did not have HIV; he shot only the best, always using fresh needles. Wishing to avoid street heroin after his long prison term, he came to me for methadone treatment. I recognized him immediately but was surprised to hear he had been using heroin for so long—I had never known.
Long-finger came at the right time because I was finally able to treat people with methadone. The cantonal physician had been forced, by a legal decision, to approve the treatment. With methadone, Long-finger’s life was saved.
I also remember Annaliese, her twins and her husband Pino. I remember Marco, Mona, Bodo, E.T., Jösi, Lisa. Hundreds of stories of miserable death.
Deadly Promises, Another Platzspitz
For a long time, there was no effective medical treatment against HIV/AIDS. What was also truly unbearable was the torture heroin-dependent people suffered at the hands of the state. Even though methadone was a viable option to provide relief and reduce harm, it wasn’t a cure-all.
Despite admitting in his early 1980s WHO assessment that methadone was an effective treatment for opioid addiction, Professor Uchtenhagen considered the methadone program a threat to his ultimate goal of permanent abstinence. All the way up to 1987, even terminally ill heroin users had to wait more than three months before being granted methadone treatment. For many, this came too late. They were already dead.
Even now, in my older, supposedly milder days, I cannot hide my rage at the cluelessness and obstinate ignorance of our former health officials. I fought and won every dirty legal conflict with the health authorities. They were powerless to revoke my license and were obliged to grant me authorization for methadone treatment. Soon, I was a common media figure, taking pleasure in exposing my opponents publicly. Their promises weren’t just empty, in some cases they were deadly.
At the end of the ‘80s, many doctors had one or two patients in methadone treatment. In our shared practice in the Altstetterstrasse, Christian La Roche and I had up to 50 at any one time. Many city practices were overwhelmed by the enormous numbers of heroin-dependent people.
So, we founded an association for low-risk drug use (Arbeitsgemeinschaft für risikoarmen Umgang mit Drogen, or Arud) and, in 1992, opened the first low-threshold methadone dispensary. We ignored the high-handed cantonal regulation that required proof of a failed withdrawal attempt before approving methadone treatment—for a limited time, and solely as an emergency measure aiding withdrawal.
Armed police continued to drive heroin users through downtown Zürich, even over the genteel Bahnhofstrasse.
After Platzspitz was shut down in February 1992, the drug scene did not, of course, disappear. With truncheons, shields and tear gas, armed police continued to drive heroin users through downtown Zürich, even over the genteel Bahnhofstrasse.
There, at the defunct Letten train station and under the Kornhaus Bridge, the police left them to their own devices, doing their best—in vain—to contain the drug scene there.
Members of Albanian and Nigerian trafficking organizations directed their dealers from the Kornhaus Bridge. Customers would mill below, between defunct railroad tracks, in a morass of syringe packages, needles and excrement, searching for veins in the pale light of streetlamps. The district’s residences and schools degenerated. Families with children and means moved away. Access to emergency medical care and social work went backwards.
Under the direction of Judge Barbara Ludwig, the same two or three hundred people were repeatedly “deported” back to the wealthy Zürich suburbs or Aargau Canton and soon returned.
The Letten district, Zürich’s last major public drug scene, was itself cleared on February 14, 1995. But this time the outcomes were different. In between the shut-downs of Platzspitz and Letten, better infrastructure to help heroin-dependent people had finally been installed.
Photograph of Platzspitz by Gertrud Vogler
Adequately Controlled Agonist Treatment
The Arud low-threshold methadone dispensary model proved effective, and was soon copied throughout Switzerland. Richer communities were now able and obligated to tend to their own addicted children, taking pressure off the city’s care system. Over the years, blanket medical and social care has been developed.
Today, the majority of opioid-dependent people in Switzerland receive methadone treatment. Very few have entirely stopped taking illicit drugs, but most can lead entirely normal lives.
Twenty-five years ago, a thousand people died each year of drug-related causes in Switzerland—about four hundred of them died of heroin overdoses, the rest primarily of AIDS, hepatitis and purulent infections. Drug-related causes were the major factor in deaths of people in their 30s and 40s.
Today, not only are overdoses increasingly rare, but HIV, since 1996-97, can be effectively treated. Hepatitis C can not only be cured, there is hope it can be eradicated completely.
The Swiss “Four-Pillar” policy—prevention, therapy, repression and harm reduction—was an imperfect but workable national compromise. The only truly new element was harm reduction, and the efficacy of the other elements must still be viewed critically. Long-term prevention and abstinence-oriented therapy have yet to prove their worth in scientific studies. After detoxification cures, relapses are par for the course, often ending in fatal overdoses. Thus, the abstinence ideal, as opposed to long-term methadone treatment, at least doubles excessive mortality, today as much as back then.
An adequately controlled agonist treatment best meets the needs of dependent people and of society as a whole.
We proudly presented vials altogether containing a half-kilogram of pure, federally produced, Swiss-quality heroin.
In 1994, I became medical director of the first heroin dispensary at Zurich’s Arud polyclinic on the Stampfenbachstrasse.
During the grand opening media circus, we proudly presented diacetyl morphia vials altogether containing a half-kilogram of pure, federally produced, Swiss-quality heroin. Since then, I have privately called myself the biggest small-time heroin dealer in town.
The heroin pilots were highly successful. Even the most long-term, criminally involved heroin users would see their lifestyles transform nearly immediately—demonstrating that the inherent properties of the drug were not the salient issue. And most importantly, nearly all of them survived.
Switzerland’s failure to capitalize fully on this opportunity is a continuing source of regret, however. Heroin treatment never officially went beyond the test phase, and less than 3 percent of dependent people have received heroin treatment to date.
For many years, my anger was more powerful than my fear. I exposed myself and my family to considerable unpleasantness. We were subjected to telephone harassment. I was spat on, beaten and received death threats. More than once, I hurt myself with HIV-infected materials. Each time, my wife and I anxiously sat out the three-month waiting period until the laboratory results came.
Was it worth it? I’d say yes. My patients could so easily have been me. They were people just like me, struggling in life, just like I do. When I was able to help them, it meant everything.
This article was originally published by Filter, an online magazine covering drug use, drug policy and human rights through a harm reduction lens. Follow Filter on Facebook or Twitter, or sign up for its newsletter.
Translation from German by Ramey Rieger.
A significantly different, German-language version of this article was previously published in www.dasmagazin.ch / Friedhofsgefühle in 2017. © A Seidenberg.
*André Seidenberg, MD, is a physician and drug policy pioneer. His book, Das blutige Auge des Platzspitzhirschs (“the bloody eye of the Platzspitz stag”) is published in September 2020. He lives in Zürich, Switzerland.