Arriving in Baltimore the night before the 10th National Harm Reduction Conference the other week, I walked out of the hotel to get my bearings and buy a sandwich. Downtown was a desert, with banks and other businesses closed for the night. Turning a corner, I suddenly came upon a brightly lit cluster of exotic dance clubs and sex shops, guarded by intimidating bouncers, with people milling around with their hoods up, some intoxicated, the young women tottering on heels. There was a Subway open.
I learned at a panel the next morning that this incongruous patch is known in Baltimore as “The Block.” And since 2008 it’s benefited from an outreach program, thanks to activists, volunteers, and the city health department. A van parks up regularly to hand out syringes and other supplies to cut the risk of HIV and hepatitis C infections for people who use drugs. “On The Block are some of the riskiest dance clubs,” said Susan G. Sherman of Johns Hopkins Bloomberg School of Public Health. “Some are like unsanctioned brothels.” A study she’s engaged in found that 42 percent of the women working in these clubs exchange sex, and that 55 percent currently use heroin, or crack or powder cocaine. The concentrated nature of The Block and its high turnover of dancers and clients mean that intervening here has great potential to impact HIV and at-risk populations across Baltimore.
A woman who has worked on The Block stood up to share her knowledge: “Girls are absolutely doing things without condoms. The higher the drug use in the club, the more that is happening. The bartenders prefer it when the girls are on drugs because the girls are motivated [to make more money].”
"As a philosophy, harm reduction has expanded to all these other areas, like housing, mental health and helping pregnant people or young people."
Recently, a second van joined the needle exchange vehicle. Staffed by a doctor and an assistant, this one offers on-board pregnancy testing, STI testing, and contraception. “We learned that combining needle exchange and reproductive health is feasible and affordable,” said Mishka Terplan, an OB/GYN who volunteers on the van. The team had to learn to work fast: “Most of the women have a very brief period of time, basically a cigarette break, to do the paperwork, receive the services, and get back to work before they get in trouble.” But they now have over 500 clients. “This marriage of needle exchange and reproductive health is exciting,” said Terplan. “Preventing unplanned pregnancies is harm reduction.”
A MANY SPLENDORED THING
Inspirational discoveries, born, like that one, of “meeting people where they’re at,” were shared throughout the conference. With perhaps 100 plenaries, panels, roundtables, workshops, and official and unofficial activist meetings crammed into three and a half days, a common delegate’s lament was having to make hard choices about what to miss.
No doubt the headline news was the opening speech by U.S. “drug czar” Michael Botticelli, whose presence represented an unprecedented endorsement of this movement by the federal government. But the most important thing about the conference was probably its pluralism. Allan Clear, the executive director of the Harm Reduction Coalition, which organizes this event every two years, spoke beforehand of his hope that “it doesn’t look like our conference, it just looks like the community event that it is.”
That hope was realized by the diversity among the 1,000 attendees, and by numerous sessions addressing the concerns of racial and sexual minorities. Asha Bandele of the Drug Policy Alliance made a powerful impression during a plenary session on race and criminalization. “We have used many laws,” she said, “drugs just being the most recent incarnation of them, to justify the dehumanization of a population.” Criticizing so-called “color-blind” policies whose outcomes are anything but, she explosively contrasted the “magic moment in the streets of Brooklyn” of Obama’s election with her view, post-Ferguson, that the president “has done less to impact racial policy than even an old Southern racist like LBJ, who did at least send troops in to protect people in Mississippi.”
Further sessions about race and gender were joined on the agenda by those addressing the health needs and marginalization of LGBT people, sex workers, and other minority groups. But perhaps the best celebration of the conference’s diversity was a raucous Friday night fashion show, in which harm reductionists of every variety were cheered as they took to the catwalk. Here and throughout, there was a palpable feeling of this community being one supportive “family”—time after time, delegates used that word when they told me how this meant so much more than just a meeting of like-minded professionals.
A WIDE-ANGLE LENS
The pluralism of the event also applied to its sheer scope. The subjects ranged from the highly specialized (“Heroin Price and Purity: Implications for Soft Tissue and Vein Care”) to the macro (world drug policy). And for anyone tempted to regard harm reduction as overwhelmingly concerned with opioids via needle exchange and naloxone, the range of substances covered was broad, too.
The distribution of crack pipes to prevent, like needle exchange, the spread of blood-borne diseases through sharing, is underway on the streets of San Francisco and elsewhere, as both people who use crack and academics described. Vancouver, typically, is one step ahead—it has crack-pipe vending machines—and delegates I spoke with raved about a session on innovative practices developed in Sao Paulo’s “Cracolândia.”
Harm reduction via E-cigarettes was addressed in a talk by Helen Redmond, who has written about the subject for Substance.com, and alcohol got a big look-in, too. For example, Jessica Lin of the San Francisco AIDS Foundation spoke about their extensive study conducted among the gay bars of San Francisco. It identified the risk factors of binge drinking, including unsafe sex, and the reasons most binge drinkers want help to drink in a more controlled way. The many practical measures suggested included working with bars to establish water stations that are separate from the bar area (so you can drink water any time without the pressure to buy a drink or tip the bartender).
But harm reduction is also broadening way beyond drugs. “As a philosophy, it has expanded to all these other areas,” said Allan Clear, “like housing, mental health, and helping pregnant people or young people.” Panel subjects including parenting, holistic self-care for sex workers, and “The Science of Violence” were further evidence of this.
FRONT LINES: POLICY
Standing at the intersection of policy and health, harm reduction is challenging the dominant paradigms of both. This causes plenty of friction.
Harm reduction activists have rarely waited for laws to change before taking action to protect the health of people who use drugs, and this remains so. For example, safe injection facilities (SIFs) are illegal in the U.S., but the bathrooms of most needle exchange programs are used by clients to shoot up, meaning that de facto SIFs already exist. And people who work at legal needle exchanges told me of their efforts to ship syringes and other supplies to underground needle exchanges in states where they’re still not permitted.
One harm reductionist working in an inhospitable environment is Jonny Walker of Allies Linked for the Prevention of HIV and AIDS (ALPHA) in Boise, Idaho. “I have the privilege of living in a very, very red state,” he said at a panel. In Idaho it is a crime “to deliver drug paraphernalia knowing it is likely to be used to ingest an illegal substance.” Having previously been involved in underground needle exchange, Walker and his colleagues have now found a way to sidestep the law, rather than break it: At their center they created a “display” of syringes and other supplies, “for educational purposes only, of course.” If staff members happen to leave clients in the display room unattended, the syringes “tend to walk off. About 300 a week.” Likewise, “we have the opportunity to watch naloxone walk out of our door.”
"One of the amazing things about the conference is that even if people don’t know each other, there are these underground roots that bind people together so they can share experience about how to allow drug users autonomy over their own lives."
Walker tells those seeking change, “Don’t shut out possible allies.” His team’s biggest supporters now include “two middle-aged white women.... Both have lost sons to overdose. They can go into meetings and say, ‘You have to fucking listen to me!’ If I said that with my neck tattoo, I would be asked to leave.”
Activists from Nevada described their long campaign for a needle exchange law there. Following a failed attempt in 2011, legislation was finally passed in 2013, enabling the state’s first legal exchange to open in Reno early this year. The Nevadans continually stressed the importance of gaining local knowledge and seeking unlikely allies. One advocate’s inability to pronounce “Nevada” with a short “a” in the middle, as the locals do, held back their cause, they said, only half-joking. Their recruitment of a Republican state lawmaker to co-sponsor their bill, however, pushed it forward.
Elsewhere in the U.S., one dream is to pass laws to legalize SIFs—for now, the only example in North America is Insite in Vancouver. At a panel about making this happen, Pete Davidson of the University of California made a telling point: “Legislators are much more interested in the arguments [made by middle-class parents] than they are in evidence.” As a good side effect of a bad thing, the experience of opioid-related overdoses across all layers of U.S. society in recent years has won harm reduction new advocates of the sort—white and rich—that lawmakers tend to listen to.
Harm reductionists have policy change in their sights on a world level, too. The ultimate goals include decriminalizing all drugs, but given the current impossibility of that in many parts of the world, incremental steps are the focus. Kasia Malinowska-Sempruch, director of the Open Society Global Drug Policy Program, spoke at one of the plenary sessions about the importance of the U.N. General Assembly on Drugs (UNGASS), which will take place in New York in 2016. She used the example of the 2001 UNGASS, which addressed AIDS, to demonstrate that jargon-filled, slow-moving international bodies can bring about life-saving changes: “Today, 6.6 million people are on anti-retrovirals as a result of Global Fund funding,” she said. Reminding us of “the racist implementation of very punitive drug policies” and the labor camps, beatings, and executions routinely used to persecute drug “offenders” around the world, she urged, “My plea to you is that you get as outraged about global drug policy as you were about AIDS.”
One lunchtime, leading activists crowded into a room to talk about how to make this outrage count. Discussion separated the “inside game”—the stuff that might or might not get done inside the U.N. building—and the “outside game.” As Patrick Gallahue of the Open Society Global Drug Policy Program put it, “What we can control is not necessarily what happens in UNGASS, but what the impression of UNGASS is.” The discussion focused on ways to create mass public and media engagement. One suggestion was to create “strange bedfellows” by linking apparently unrelated groups with aspects of drug policy—for example, bringing religious organizations on board because of their opposition to the death penalty.
FRONT LINES: ADDICTION PARADIGMS
Back on the domestic front, a clash is often perceived between harm reduction and the abstinence-based, 12-step-dominated approach of the U.S. addiction treatment establishment. A thoughtful town hall meeting, chaired by Andrew Tatarsky, a leading harm reduction psychologist, and attended by over 40 mental health and substance use providers (including Scott Kellogg, Barry Lessin, and other Substance.com contributors), repeatedly addressed the incompatibility of the “chronic, progressive, incurable disease” view of addiction with harm reduction’s client-chosen goals, and the continuing obstacles to acceptance in a field where abstinence-only thinking still prevails.
But there was also general agreement around the idea that “meeting people where they’re at” must include proponents of abstinence, and that abstinence is properly viewed as part of the harm reduction continuum. “We mustn’t bash 12-step programs,” stressed Howard Josepher, a longtime activist whose non-profit treatment center in New York, Exponents, combines harm reduction and 12-step approaches.
Similar themes occupied other panels, including one on harm reduction and recovery. Kenneth Anderson, another Substance.com contributor, who runs HAMS, an online harm reduction program for alcohol, gave a data-driven presentation about reclaiming the word “recovery” to mean the absence of clinically significant impairment, rather than abstinence. But he reminded us, “If any of you have worked in needle exchange, you’ll know that you have worked side-by-side with people who are in 12-step programs.” Audience members with experience of addiction exchanged heartfelt views about the extent to which “recovery” includes or excludes people who moderate.
RADICALISM AND THE MAINSTREAM
As the involvement of many high-powered academics, practitioners. and policy wonks shows, harm reduction’s success is fast making it mainstream. “You can see the different tribes here,” one delegate told me. “The punky-looking activists and the professional-looking types.” And for many people who have been involved since a time when it was dominated more by radical activists and less by professionals, this causes some fretting over the movement’s soul.
The widening applicability of the philosophy is one area of concern. Benjamin Phillips, the Harm Reduction Coalition’s special projects coordinator, enthusiastically supports the diverse applications of harm reduction showcased at the conference. But he admitted to worries about the potential for harm reduction being “watered down into mere ‘risk management,’” an approach applied for results—or even profit—without necessary regard for “the most marginalized and stigmatized people” who have always been the movement’s core constituency.
"Legislators are much more interested in the arguments [of middle-class parents] than they are in evidence."
At one panel, three people spoke movingly about their journeys from being homeless to being recruited as “peers” by Washington Heights Corner Project, a Manhattan needle exchange, to lead outreach efforts to other people who use drugs. They are all now staff members at different organizations. Peers, who are paid a small stipend, enable many agencies to reach out to marginalized people more effectively thanks to their specialist knowledge. Yet it emerged during the panel that some feel marginalized themselves by their “professional” colleagues. There are now discussions around unionizing peers to make sure they’re better represented. A union of this kind is set to go public in one North American soon, with the tagline: “Reducing the harms associated with work.”
“They’re pushing us out,” said Jess Tilley of the new wave of privileged, master’s degree-holding harm reductionists. Tilley, who founded the New England User’s Union, was formerly the overdose prevention coordinator at a legal needle exchange in Cambridge, Massachusetts. Disillusioned by what she saw as her subtle exclusion, she now runs an underground needle exchange in Northampton. “Harm reduction has become so institutionalized that it’s dying unless we do something about it,” she told me. “It’s become a catchphrase used by people who don’t know what it means.”
Few others I spoke with expressed that concern so strongly, but many shared it to some extent. “We hear a lot about harm reduction becoming depoliticized, more professionalized, more sanitized,” said David Frank, a researcher at the City University of New York and a methadone patient, at one panel. “I think we are becoming a little bit too de-politicized, especially in the methadone maintenance community ... there’s no critique of structures, or prohibition.” Of course, many subjects discussed at the conference were overtly political—but the culture clash is real.
Allan Clear, whose history as an activist with organizations like ACT UP long predates his two decades leading the Harm Reduction Coalition, acknowledged the importance of pre-professional values. “One of the amazing things about the conference,” he told me, “is that even if people don’t know each other, there are these underground roots that bind people together so they can share experience about how to allow drug users autonomy over their own lives.”
WHERE WE'RE AT
As the harm reduction movement grows further—ultimately, if it continues to thrive, becoming establishment, rather than anti-establishment—it will keep on having to address this tension between its values and its ambitions. But unity and shared purpose remain far more apparent than any discord.
“What always comes out of these conferences is what a genuine, giving community this is,” said Allan Clear. “The buoyancy of everybody here is overwhelming.” He reminded me “how far we’ve come,” to achieve levels of organization, of political and medical progress and of cooperation from the authorities that were once hard to imagine.
“We’ve gone from the early ’90s, when perhaps our original impetus was dealing with HIV/AIDS,” he said. “We’re now close to a cure for hep C and we’re talking about ending AIDS. We have federal involvement and involvement from health departments. We’ve taken the movement to a place where what we dreamed about is happening.”