What we miss when we criminalize pain: Rethinking drug policy through a public health lens

Like anyone killing time while waiting or riding in a car, we people-watch. We notice a person lighting a cigarette by the roadside, someone walking unsteadily past. We glance. We wonder. Sometimes we judge. Rarely do we ask what brought them there. Behind that moment is often not rebellion, but coping; sometimes survival. It might be a teenager whose “just trying it once” turned into dependence. A young woman using drugs to silence trauma when support was out of reach. A security guard working endless nights, relying on cigarettes, then stronger substances, just to stay awake. Or a young person newly diagnosed with a terminal illness, numbing a hopeless situation with drugs. These are not rare stories. These lived realities reveal substance use; whether cigarettes, alcohol, or illegal drugs as a response to trauma, exhaustion, or exclusion. Yet our legal framework continues to treat drug use as a criminal issue; responding with arrest and punishment where protection, and treatment are needed. Under the law determining offenses and penalties in general, the law’s intent is clear and well-meaning; to protect citizens, especially young people, from the harms associated with substance use. Unfortunately, intent and impact don’t always align. A 2023 pilot study by the Rwanda Biomedical Centre (RBC) offers a glimpse into the scope of the issue. Among young people aged 13–24, 4.4 percent reported cannabis use in the past 30 days, 2 percent used cigarettes, and while 0.2 used opiates. More strikingly, youth who used cannabis were 3.4 times more likely to report engaging in unprotected sex. These figures are not simply behavioural data; they are indicators of vulnerability. They point to deeper questions such as what drives young people toward these substances? What support systems exist, or don’t, to help them cope safely? This is where harm reduction enters the conversation, not as a permissive stance, but as a practical, compassionate approach. Despite misinterpretation, harm reduction doesn’t mean encouraging drug use. Instead, it requires us to ask better questions, shifting from punishment to protection and recognizing that people who use drugs are people first, deserving of support and treatment. Rwanda has already shown it can lead where others continue to hesitate. We saw it in our bold approach to HIV prevention and treatment, where stigma once dominated the conversation but was replaced with evidence, community outreach, and human rights. We’ve seen it in sexual and reproductive health policies, particularly in recent years. Just four months ago, Rwanda gazetted a progressive healthcare law that allows adolescents aged 15 and above to independently access health services including sexual and reproductive health services. That same courage and the willingness to face uncomfortable realities, can and should be applied to drug policy. Other countries have taken bold steps that Rwanda can learn from. Portugal, for example, decriminalized all drug use in 2001, treating possession for personal use as an administrative issue rather than a criminal one, which opened access to treatment and harm reduction services and helped reduce drug-related deaths and HIV transmission. In Canada, safe supply initiatives offer regulated substances under medical supervision to people at risk from contaminated street drugs, while Thailand and several other Southeast Asian countries are piloting community-based rehabilitation programs that combine mental health support, vocational training, and medical care instead of strict incarceration. To be clear, compassion for users should never be confused with leniency toward traffickers or those who profit from addiction. Drug trafficking destroys lives and families, exploits vulnerability, and fuels cycles of poverty, violence, and instability. It must remain criminalized; and strongly so. The distinction is crucial: while traffickers harm communities, users are often the harmed. Justice demands that we treat them differently. Reframing drug use as a public health issue would not mean turning a blind eye to its dangers. It would mean addressing those dangers more effectively. It would mean investing in prevention, psychosocial support, and treatment services that are accessible, affordable, and non-judgmental. It would mean creating safe spaces where people struggling with addiction can seek help before they reach a breaking point. This isn’t about abandoning values. It’s about recognizing that addiction is often a response to trauma, not a moral failure Rwanda’s legal framework is not static. While it has shown responsiveness to emerging needs in areas like health and youth services, drug policy remains an area where bold, evidence-based reforms could make a real difference. Rwanda has faced difficult choices before, and shown that we can respond with evidence, and courage. We have the opportunity to do the same here; to ask better questions, and to build a system that protects and supports those who are most vulnerable. Denise Teta is the Policy and Advocacy Officer at Health Development Initiative (HDI).

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What we miss when we criminalize pain: Rethinking drug policy through a public health lens