by Alan Greig and Sara Kershnar
Roxbury is the poorest neighborhood in Boston. Over half of its population, primarily African-American and Latino, live below the poverty line. People living in Roxbury suffer more ill-health and are more likely to die from heart disease and cancer than people who live in other, wealthier parts of Boston. They are also more likely to die of AIDS – twice as likely. If you look at women and men separately, the women of Roxbury are over three times as likely to die of AIDS than women living elsewhere in Boston (Boston Public Health Commission 1998).
This local situation is repeated in poor, urban communities across the nation. The highest rate of new cases of HIV infection in the USA is now among young women of color. Official reports will tell you that the greatest risk factor for these young women is sex with a male injection drug user. But this is to miss the larger picture. Drug policy, in the form of the War on Drugs, has denied people access to life-saving clean injection equipment. Incarcerating nearly a whole generation of young men of color from the inner city, the bulk for non-violent drug offenses, has damaged their life prospects for good. Not only can prison increase their chances of getting HIV, through sharing dirty needles and having unprotected sex (both common realities inside), but it also reduces their options for making a better life for themselves on the ‘outside’.
More fundamentally, US social and economic policies over the last 30 years have worsened poverty and social disintegration in the inner city, depriving their communities (mainly people of color) of the resources and opportunities to deal with the problems that drugs can bring. Widening income inequalities, the flight of jobs and investment, rollbacks in affirmative action, coupled with welfare ‘deform’ and lack of access to basic health care and drug treatment have laid the groundwork for a drug-related HIV epidemic in communities like Roxbury all over the USA.
These realities birthed and continue to confront the harm reduction movement in the USA. Born of syringe exchange and HIV/AIDS activism in the late 80s, the movement continues to grow as a coalition of syringe exchange workers, AIDS activists, health and social service providers, drug policy reformers, researchers, women’s rights advocates, local and state politicians and progressives on health care and criminal justice reform (some of whom are current or ex-drug users). Telling the story of the US harm reduction movement is to document a unique coalescing of a diverse group of individuals, institutions and interests around an analysis of and resistance to regressive and repressive public policy of the last 30 years.
Outlaw public health
“The first syringe exchange programs in New York City were set up by ‘grass roots activists’”(Henman et al 1998). Harm reduction as a self-identified practice in the US began on the street, in the mid to late 1980′s, as HIV prevention. Its first ‘programs’ were outreach bleach and teach, peer education and syringe exchange on street corners, in violation of a range of prescription and paraphernalia laws designed to deprive drug users of clean injection equipment and to punish those who tried to provide them with it.
Faced with official denial and hostility, and recognizing the explosion of an HIV epidemic in poor urban communities related to the sharing of injection equipment, activists took their clean syringes and sharps containers on to the streets, as direct action public health and civil disobedience. They were inspired and influenced by the politics and strategies of both ACT-UP and the civil rights movement. ACT-UP members, front-line workers in AIDS service organizations, civil rights activists and frustrated drugs workers came together to get the syringes and the message out to everyone who wanted them. Their goal was saving lives through prevention of HIV transmission, and they explicitly rejected the ‘abstinence’ orthodoxy of the time – that drug users could only be helped by getting them off drugs. They described their work as “harm reduction” – in other words, working to reduce the harms related to drug use (in this case HIV/AIDS) without necessarily reducing the consumption of drugs.
Harm reduction as an ‘outlaw practice’ was in stark contrast to the experience in other countries. As a self-conscious approach and philosophy, it first emerged in the Netherlands in the early 1980s as a pragmatic partnership between drug users and city officials to start needle exchange in order to tackle the growing problem of Hepatitis B among users. In the late 80s, Reagan’s ideological soul-mate, Margaret Thatcher, founded and funded a network of syringe exchange and broader harm reduction programs as a part of the United Kingdom’s (UK) National Health Service. This development was echoed in other parts of western Europe, Canada and Australia. The distribution of clean injection equipment to drug users in those countries was, and continues to be, supported and frequently sponsored by the state. In such countries, the consensus remains that AIDS constitutes a greater immediate threat to the public health than drug misuse.
The civil war
No such consensus was possible in the Reagan and Bush era and remains problematic to this day in the USA. By 1996, this lack of consensus had cost the United States 146,359 cases of drug-related HIV (CDC 1996), in contrast to the UK, which with one-sixth of the US population, had just over 600 cases (Stimson 1995). The contrast in these statistics is largely a direct consequence of the civil war that has raged in the USA over the last 30 years. Its more common title, the “War on Drugs”, runs the risk of mis-defining both its intent and focus, and of course its consequences. War was declared in 1972 when Richard Nixon announced the federalizing of supply reduction and prosecution of drug offenses previously under state auspices. While a portion of the budget went into the introduction of methadone maintenance in the United States, a bulk of resources went into military and police interventions in both drug sales and drug use.
Its intent was clear from the start. “People are poor and violent not because of grand social pressures, . . . but because they are bad individuals deserving only of discipline and punishment”, Nixon declared in switching the federal budget away from social programming. Drugs, the icon of the 60s, and the “bad individuals” who used them were now defined as the problem. The drugs war became a “political spectacle that depicted social problems grounded on economic transformations as individual moral or behavioral problems that could be remedied by simply embracing family values, modifying bad habits, policing mean streets, and incarcerating the fiendish ‘enemies within’” (Reeves and Campbell 1994).
The ‘enemies within’ most feared were communities of color, those whose involvement in civil rights protest and potential for social revolution offered the most serious threat to the American political class since the radicalism of the early 30s. “The history of drugs and drug policy in the United States has always been racialized,” (Moore 1995) and the racism of the drugs war is striking. Though five times as many whites are estimated to use drugs as African Americans, the latter are five times more likely to be incarcerated for drug use than their white counterparts. While black men make up about 13% of drug users, they constitute 62.7% of all drug offenders imprisoned. Similarly, despite equal rates of drug use amongst pregnant women, and a greater absolute number of white women using drugs during pregnancy, African American and Latina women account for 80% of those prosecuted for delivering drug-exposed babies (Coffin 1997). The front lines of this new American civil war have been and remain the inner city and its main casualties, poor people of color.
Communities of interest?
But, in addition to damage from harmful social, economic and drug policies, such communities have also been devastated most by the harms caused by drug use and the drug economy. For many people in those communities, understandably, AIDS has not been the priority. Addiction and dependency, drug-related violence and criminality, and the resulting impacts on the social and economic life of the most affected communities have been experienced as more serious problems. When drugs, drug ‘addicts’ and drug ‘pushers’ are identified as the source of these problems, the War on Drugs has seemed to many to be the right response. Far from being seen as a life-saving measure, syringe exchange and harm reduction more generally was for many years resisted and denounced by the leaders and representatives of communities of color as enabling the very behavior that was killing their people and deeply damaging their communities.
In order to work with and within the most affected communities, there was a need to take harm reduction beyond HIV prevention and toward an analysis of and response to the multiple harms related to drug use, drug sales and drug policy. The formation of the Harm Reduction Working Group in October 1993 was a momentous step in meeting that need. The Working Group was a unique grass-roots think-tank, bringing together previously isolated syringe exchange and drug policy activists, and AIDS and drugs service providers, across color, gender, sexuality and class, to articulate a vision for an emergent harm reduction movement.
This vision acknowledged the very real harms associated with drug use but insisted on the innate rights and capacities of individuals and communities to deal with those harms. It castigated current drug policy and drugs service provision for denying people their rights and capacities, and argued that not only had the War on Drugs failed to reduce the supply and the demand for drugs, but that it had increased the harms associated with drugs (notably the spread of HIV and other infectious diseases). Crucially, the Working Group, informed by its developing alliances with drug policy reform movements, recognized that the War on Drugs was a key component of a resurgent neo-liberal public policy that rejected the structural explanations and social programming of the 60s. Pathologizing drug users as the cause of social problems distorted the real picture that showed that social and economic policies in the 80s had created the conditions for an explosion of drug-related harm in the inner city.
As has been noted (Zierler and Krieger 1997):
In the midst of decreasing educational and economic opportunity within the legal labor market, the allure of the illegal drug economy as a source of income became more powerful during the early 1980s. […] Residents of neighborhoods fraught with economic impoverishment, social disintegration, and boredom were, and continue to be, susceptible to use of psychoactive drugs for relief and stimulation. Not surprisingly higher prevalence of drug traffic and drug use occurs in such neighborhoods. Among the people living there are economically poorer women of color and the families that they support. Young men living in these communities also have been and remain at extremely high risk of violent death, unemployment, and arrest.
The first strategic outcome of the Working Group was the formation of the Harm Reduction Coalition (HRC), tasked with stimulating, supporting and expanding harm reduction efforts across the USA. From the beginning, HRC’s work was guided by the progressive political vision of the Working Group. Thus, in its mission statement, HRC “locates itself as part of a broader movement for progressive change that challenges social, cultural and economic structures – including current drug policy – that foster and sustain disadvantage, discrimination, and denial of civil liberties and human rights.”
In from the outside
HRC has played a key role in moving harm reduction toward a vision of social justice. Through the training activities of its Harm Reduction Training Institute (a joint project with The Lindesmith Center, a national drug policy think-tank) as well as its quarterly newsletter Harm Reduction Communication and allied educational materials, HRC has argued the case for reducing drug-related harm through progressive public policy and programming. Its biennial national conferences (three to date) have brought together an extraordinarily diverse group of individuals, institutions and interests around a common agenda of radical social change. This has included criminal justice reform (for example, ending mandatory minimums for drugs offenses and shifting to non-custodial sentencing), universal health care, AIDS policy (such as access to treatment and housing issues), women’s and reproductive rights (for example, challenging the status of the unborn child as a ‘victim’ of their mother’s drug use in prosecutions of drug-using pregnant women), as well as civil liberties (reversing the ‘creep’ of occupational drug testing and search and seizure), drug user organizing and voter registration.
The practices, strategies and philosophy of harm reduction have evolved from the experiences and efforts of people working across these issues and fields, including those currently or formerly using drugs or affected by drug-related harm. These activists have helped to move harm reduction ‘in from the outside’ , from its origins as an outlaw public health practice. Health and social service providers, law enforcement and criminal justice staff, drug policy reformers and treatment providers, policy think-tanks and political leaders now routinely discuss drug users and drug-related harm in the context of harm reduction. This was unthinkable a few years ago.
But there are tensions within such a move. Some of these have been felt most acutely at the program level. “In acquiring official status, syringe exchange programs (SEPs) have shed their spontaneous and autonomous, even sometimes overtly anarchist character, and come to resemble other ‘street-oriented’ nonprofit organizations” (Henman et al 1998). But where syringe exchange has left its outlaw origins and has been accepted by public health bureaucracies, SEPs have also come under greater official regulation and scrutiny. Far from seeing harm reduction in political terms, many such bureaucracies still regard SEPs as a technical public health intervention directed at Them (drug users) for the sake of Us (the public). The attitude appears to remain that there is “something distasteful about helping addicts to their fixes; but in public health terms, this may be an acceptable trade-off to slow the spread of AIDS” (Economist 1996).
This “Them vs. Us’ mentality is one of the clearest legacies of the War on Drugs. One of the functions of the war propaganda has been to identify drugs and drug users as the cause, rather than a symptom, of problems in society. “Drug users are extremely vulnerable to scapegoating, and such scapegoating can divide workers and neighborhoods in ways that weaken opposition to socioeconomic changes and policies…” (Friedman 1998). This issue has confronted harm reduction efforts to organize at community level. It has been hard to translate the model of gay community organizing, which was built on a clear consensus about the main problem (AIDS) and the main cause (homophobia). “Unlike the gay community, which ‘came out’ and responded to AIDS with its own autonomous organizations, drug injectors were – and still are – attempting to find a political voice in the context of drug prohibition, which generates a climate of alienation and pervasive suspicion among users, and between users and the wider society” (Henman et al 1998).
Building a movement
This climate makes it hard to build a harm reduction movement with and within affected communities most impacted by drug-related harm. It makes it hard for drug users to articulate a legitimate community voice, when they are blamed for the problems faced by the community. And it makes it hard for people in low-income, urban communities to come together across lines of difference (drug use, HIV status, gender, sexuality and color) to name and confront the common causes of their oppression.
The harm reduction movement’s emphasis on linking individual responsibility with institutional accountability makes this possible however. Its political analysis recognizes that the 425% increase of HIV amongst African-American women in the USA between 1987 and 1995 (CDC 1996) cannot be understood simply as the result of sex with a male injection drug user, separate from the contexts of gender inequities, racism and economic disempowerment that shape such behavior. At the same time, the day-to-day practice of harm reduction acknowledges the need to work with women and men to address issues of power, responsibility and vulnerability as they play out in their lives.
Practical examples of bringing together these individual and institutional perspectives toward a vision of social justice are emerging in disenfranchised communities of color. One such example comes from Roxbury, where a group of Latino men, all self-identified current and ex-drug users, have formed Fuerza Latina. The group was started in response to the racist stereotyping of the drugs war that identifies poor, urban men of color as dead-beat dads, abusers of women, vectors of HIV and social derelicts. In understanding the role of drug use in coping with their social reality and as a self-fulfillment of such stereotyping, Fuerza realizes that the struggle to establish meaningful alternatives can only be won if men can ‘recover’ and redefine their relationships and roles within their community, and become agents of social change. They meet to share their struggles with the drug use as it has and at times continues to cause harm in their lives and for their families and the communities in which they live. But they also come together to understand and mobilize against these struggles and harms in the broader context of social and economic problems of their community and the failure of public policy to address them. Rather than divide communities into “the guilty” and “the innocent”, Fuerza Latina, like other harm reduction agencies around the country, has become a site for beginning to develop leadership from within some of the most marginalized members of an already marginalized community.
Harm reduction’s emphasis on mobilizing leadership and movement for change from within affected communities is supported by its efforts to reach out to and ally with other movements for social change. In its work defending the rights of pregnant (predominately poor, African American) drug using women, the National Advocates for Pregnant Women urges that, “we [the harm reduction movement] need to not only strengthen ties with feminist, civil rights, gay rights and civil liberties groups, we need to understand that fundamentally their issues are our issues.” Intersecting with such issues in poor, urban communities of color are basic issues of political marginalization and economic impoverishment. A more explicit class analysis offers the potential for locating the harm reduction movement’s efforts to reduce drug-related harm within “common struggles against repression, marginalization, impoverishment, cutbacks, unsafe working conditions – and FOR health and solidarity (Friedman 2001)”.
Nor should such a class analysis be confined within national borders, as an expanded harm reduction movement of social justice needs to join with international human rights and anti-imperialist efforts, such as the WTO protests, that have been activated against the global impact of US economic and social policies, including the War on Drugs. Integrating these international, national and local dimensions of social justice pushes harm reduction beyond its origins as outlaw public health practice, but holds the promise that it can continue to become a much needed site for a coalition-based progressive movement for change.
The authors would like to thank Heidi Behforouz, Allan Clear, and Denise Paone for their contributions to this chapter.
For more information on harm reduction, please access the following resources:
Harm Reduction Coalition: harmreductioncoalition.org
The Lindesmith Center: www.lindesmith.org
National Advocates for Pregnant Women: www.napw.net
This article was published in “From Act Up to the WTO: urban protest and community building in the era of globalization”, Shepard, B. and Hayduk, R. (eds), Verso: London, 2002
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