Working at the Intersection of Social Justice and Public Health: Harm Reduction with People Who Use Drugs (a paper directed toward health care professionals)

Walter Cavalieri

Working at the Intersection of Social Justice and Public Health: Harm Reduction with People Who Use Drugs
(a paper directed toward health care professionals)
Walter Cavalieri, MSc, MSW, RSW

In November of 1999, the Canadian HIV/AIDS Legal Network, with the support of Health Canada published a report, both in hard copy and on the Internet, "Injection Drug Use and HIV/AIDS, Ethical and Legal Issues". (available at

This report is a necessary resource for concerned and thoughtful people, because it enumerates the depth and extent of ethical crimes which are the product of current healthcare practices with people who use drugs - practices which are in violation of their rights and dignity and a detriment of their health. It documents the terrible consequences to individual and public health that are occurring because of the lack of services appropriate for people who use drugs, not to mention the often impenetrable barriers they experience when they try to access those services which do exist. As well, it suggests ways to address them, up to and including legal action.

The report reminds us that these crimes are happening in the context of a major public health crisis regarding HIV and hepatitis C among injection drug users. The number of HIV infections and AIDS cases in Canada attributable to injection drug use has been climbing slowly but steadily. By 1996, half the estimated new HIV infections were among injection drug users. The proportion may now be even greater. As well, a very large majority of the people who inject drugs are infected with hepatitis C.

Injecting drugs is a highly efficient way of using them, and the sharing of needles and other injecting equipment is an equally efficient mode of transmission of HIV and other infections. Risky practices are not uncommon among injection drug users. Such practices are not all their fault. They are compelled to use their drugs under very difficult and unhygienic conditions - in laneways and back alleys, in the shadows - imagine yourself trying to find a good vein in the dark!

Often, disposable syringes meant for one use are used repeatedly, and sharpened between hits on matchbooks or the sidewalk. This is especially true in prisons. Sharing needles continues to occur among injection drug users, not for any ritual reason, as is the popular myth, but because they simply don't have enough new needles on hand when they need them.

The sharing of other injecting equipment, such as spoons or cookers, filters and water, is also associated with HIV transmission. This is even more common than sharing needles, in part because our educational and outreach efforts are often under-researched and incomplete.

The increasing use of cocaine is also a significant factor in the escalation of HIV prevalence and incidence in Canada. Heroin users typically inject three to four times a day. Cocaine users may inject as often as twenty or thirty times a day, often in a state of agitation or paranoia.

The number of people injecting cocaine - either by dissolving powdered coke or breaking down crack-cocaine with vinegar or lemon juice - is especially high in Vancouver, Toronto, Ottawa and Montréal, but cocaine use is also an increasing problem in other cities, including Calgary, Winnipeg, and Halifax. Programs continued to think in terms of heroin use, and didn't change their practises to address the needs of people who inject cocaine.

The dual problem of injection drug use and infection with HIV and HCV is one that ultimately affects all Canadians. However, some populations are particularly affected: women, street youth, prisoners, and Aboriginal people. There is active commerce between the worlds of all these people . . . and your world, and mine.

We do have needle exchange services in most of our major Canadian cities (though not in prisons), and this has been a blessing . . . but they vary widely in quality and effectiveness. Nowhere in Canada, however, is there a comprehensive district- or city-wide approach to drug use and disease prevention. The situation in the United States is much bleaker than it is here. Yet, we often dance to that country's tune, rather than that of more enlightened jurisdictions, and engage in the actions and rhetoric of what has come to be called the War on Drugs.

How has all this come to pass?

New York Times writer James Reston said, that "in any war, the first casualty is common sense, and the second is free and open discourse." He was writing of Vietnam, of course. He might have been writing on the War on Drugs, for in this war, common sense has been tossed out the window, and free and open discourse is, frankly, dangerous.

The War on Drugs has spanned the 20th century, with no successes. It has been waged with evangelical zeal, using "whatever means necessary", often by folks who wave the duplicitous banners of moral rectitude and total abstinence. Billions of dollars have been spent, millions of people have been incarcerated, thousands of people have perished - murdered, shot by police, died of overdoses, of disease - especially now of AIDS and Hepatitis. And then, there is the "collateral damage" to families, communities and society, not to mention civil liberties. The commandants in this War continue to stifle the truth of its failures with the fierce but stealthy deceptions worthy of totalitarian ministers of propaganda, which is what they really are.

Like all wars, especially enduring ones, the War on Drugs has also made some people rich. Many industries and many national economies are being bloated by this war. The whole of the correctional system is one such industry. Like all wars, especially enduring ones, it has corrupted the combatants - on all sides. It is very much a class war, often a racial war. It is both an assault on people and on the civil society. The War on Drugs is the Vietnam of the millennium.

Wherever we look, however, we see that people continue to use drugs . . . feeding the ranks of citizens at risk, of citizens unable to access the health care services which might help them, for whom treatment services, as they are constituted, do not work, citizens who are trapped and imprisoned, citizens who have become ill . . . who die. It is these people, these citizens, for whom abstinence may not be possible or even desirable, who must be our concern, not just because they are the so many in number, but because all life is precious.

Harm reduction offers an alternative to this madness. In its classic definition, by Dr. Diane Riley, harm reduction is an approach to drugs in which "policies or programs [are] directed towards decreasing the adverse health, social and economic consequences of drug use without requiring abstinence from drug use". This is an excellent definition, but it must be amended to embrace as well the harmful consequences of the way drugs must be distributed - the crime and stealth... the variable strength of drugs purchased on the street, the adulteration of the drug with dangerous substances ... incarceration and its consequent degradation.

In the harm reduction approach, the reduction of drug-related harm is both a goal of harm reduction programming and a philosophy which underpins service delivery. From the vantage point of each of these, the person's use of drugs is accepted as fact. Where it is being implemented honourably, and not merely nominally, harm reduction is succeeding in improving the health and safety of individuals . . . families . . . and communities.

Harm Reduction has credibility and currency, particularly in Europe and Australia, even in parts of the former Soviet Union and Asia. It is reviled by stakeholders in the War on Drugs particularly in the United States and to a degree in Canada, who continue to hold on to ideologies which focus on incarceration or abstinence as the only options, despite the obvious costs in human lives and scarce funds.

Typically professionals and service providers claim to know what is wrong and how to treat a problem. Actually, this is a reactionary and tyrannical approach, one which enforces and perpetrates an unequal distribution of power, not to mention the misuse of power . . . and one which shoves people who use drugs to the margins of society. Marginalising people is harmful to them.

Harm reduction is revolutionary in that it relies on a shared analysis of the difficulties faced by the person or community stigmatised or impaired through their use of illicit drugs . . . and in that it respects the unique strengths of each person and the collective strength of the community, and calls on these strengths to assist in the process of achieving health.

I am a social worker, and I chose this profession because it is compatible with my personal values. The social work profession holds that, given their circumstances, people by and large make the best choices for themselves from the range of options available to them. It also affirms the competency of the individual and of the community. Affirming people's mastery over their environment allows them and us alike to focus on their inherent health and that of their community, and not on the "pathology". The expectation of success is key to the outcome of success.

This statement would be comfortably at home in most social work textbooks. It is what I was taught and what I believe. Now, look at what happens when you add the words drugs and drug user to the text:

As a social worker, working in this field I hold that, given their circumstances, people who use drugs by and large make the best choices for themselves from the range of options available to them. As well, I affirm the competency of the individual who uses drugs and of the drug?using community. Affirming the drug users' mastery over their environment allows them and us alike to focus on their inherent health and that of their community, and not on the "pathology". The expectation of success is key to the outcome of success.

Harm reduction is simply "social work" applied without discrimination - which is how I came to embrace harm reduction.

Similar value statements can be drawn from medicine, nursing, psychology and health promotion, and I call on these professions to ensure that their value statements apply equitably. Harm reduction is about doctoring, nursing, providing therapy and promoting health. . . with respect and ruly without discrimination.

As well, harm reduction is an everyday occurrence. You could make a list of things you do in your practice and in your lives to reduce harm in the face of things you are unable to change, and it would be quite long. I invite you to take a moment do this.

Harm reduction is also an active part of medicine and health care. Every time you provide a poor, pregnant women with vitamins . . . that is harm reduction. You may not do be able to do anything about the women's poverty, but you do understand that the children will have a better chance of being born healthy, and you act on this understanding . Every time a doctor gives a person one medication to counter the side effects of another, she or he is practising harm reduction. Every time the doctor gives a person on methadone advice or medication to mitigate constipation . . . that doctor is practising harm reduction. They don't advise giving up methadone to allay the constipation. A harm reduction approach might also mean giving that same medication or advice about constipation to a person who is not on methadone but is simply injecting heroin. Few doctors do that, however.

Every time you put on a seat belt, or paste on a nicotine patch, every time you designate a driver, every time you wear a helmet when you ride a bike or a motorcycle, you are practising harm reduction. And every time you butt out a cigarette half smoked, or have just one drink instead of your usual two or five, you are practising harm reduction.

Pick up a typical, inexpensive ball point pen. This is about harm reduction (and not exclusively because the pen is mightier than the sword).

Do you have any idea why?

Because of kids.

Try as you might . . . it is very difficult to get little kids NOT to put things in their mouths. And often to swallow them. Sometimes with fatal results.

Now, blow through the cap.

You will notice that there is a little hole on the top of the cap. There wasn't always holes there, not when ball points ere first produced. Holes were put there to buy time, to allow breath to flow if the cap were swallowed, to prevent the death of a curious child.

Actually, harm reduction is pretty commonplace and straight-forward. But, then, add to the mix "Drugs", and suddenly harm reduction becomes complex and political and subversive.

The reality of harm reduction work is that when we remove the obligation to impose temperance morality, to "cure" the junkie or "save" the sinner before we offer services, we come face to face with the essential issues of a democratic and civil society - freedom of choice, personal and social responsibility, justice. We are, as well, called on then to promote individual and public health and to face up to the impact of stigmatisation and ostracism, poverty and homelessness on people who use illicit drugs. These are the everyday experiences of the typical drug user.

Here are some of the principles of harm reduction, in the context of drug use:

* Harm reduction holds that some use of mind-altering substances is inevitable and that some level of drug use is normal in a society (e.g., coffee, tea, cigarettes, alcohol, temperament-altering drugs such as the SSRIs). (For some sort of verification you may consult: Dr. Andrew Weill's book, From Morphine to Chocolate.) It acknowledges that, while carrying risks, drug use also provides the user with benefits that must be taken into account if drug using behaviour is to be understood. From a community perspective, containment and amelioration of drug-related harms may be a more pragmatic or feasible option than efforts to eliminate drug use entirely.

* Harm reduction holds that the fact or extent of a person's drug use is of secondary importance to the harms directly and indirectly resulting from drug use - to the individual, her / his family, and the greater community. We must work together to mitigate these harms, whatever they are. The harms addressed can be related to health, social, economic or a multitude of other factors affecting the individual, the community and society as a whole. Comprehensive community-based harm reduction programs, such a exist in Frankfurt and Liverpool, are examples of this. There, programs were developed through the collaboration of all the key players - judiciary, police, businesses, treatment experts, people who use drugs, etc. There is indisputable evidence of their success and public acceptance.

* Harm reduction holds that what we call addiction is a recurring behaviour and that, to manage it, the individual may need long-term support. It is an approach that in the short term does not rule out abstinence in the longer term . . . and vice versa. It also recognises that the use or non-use of drugs may be permanent or episodic. In this light, lapse from abstinence is not seen as a failure, and the person is not labelled as a failure. In harm reduction, success is measured in terms of health and the quality of life for the individual, the family and the community, not in terms of achieving total and unrelenting abstinence.

* Harm reduction holds that a person's decision to use drugs is personal; no "moralistic" judgment is made either to condemn or to support use of drugs, regardless of the level of use or mode of intake. The dignity and rights of the drug user are respected. Including the right to care and treatment.

* Harm reduction appreciates that all life is precious.

John Donne, the 17th century metaphysical poet-theologian, wrote a meditation which underpins this particular tenet. Part of it reads:

"No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend's or of thine own were. Any man's death diminishes me because I am involved in mankind; and therefore never send to know for whom the bell tolls; it tolls for thee."

Keeping this in mind gives one permission to work from a position of connectedness and love. It is admittedly a juggling act to maintain good boundaries, but the payoff is worth it. "Love" is simply one of the risks we take. I am not talking about "I love you, now change"... or I love you , now let's move in together". I am talking about love without strings. It is an under-rated and under-reported part of how we work.

The concept of showing love for one's clients - of responding from one's heart as well as one's head, of embodying one's humanity - is actually recognized and accepted in numerous contemporary psychotherapy schemata, including self-relations and narrative therapy, where it is seen as a skill and a force that can heal, invigorate, reconnect, calm and encourage. Love without strings is an especially rare commodity in programs and workers dealing with people who use drugs; yet it is a cornerstone of harm reduction. It is essential to the creation of a climate for positive change. Harm reduction is about love. And love is never simple.

* Harm Reduction programs have a hierarchy of goals, with the immediate focus on pro-
actively engaging individuals, groups and communities to address their basic, most pressing needs before dealing with the things which society has chosen to criminalise, demonise or ignore. Respecting the person and attending to basic needs leads to safer use of drugs, decreased use of drugs, sometimes even to the cessation of use of drugs, and with any and all of these consequences, a safer, healthier life, a safer healthier community. In the Threepenny Opera - an Opera for Beggars - Berthold Brecht wisely advises us to "First feed the face, and then talk right and wrong - for even honest folk will act like sinners until they've had their customary dinners."

* Harm reduction holds that the relationship between people who provide services and people who use drugs is a partnership in which the expertise of the client is given credence . In this sense, it is "bottom-up", rather than "top-down". It also recognises that the professionals in various service areas and the people who use drugs have complementary areas of expertise and must work together in a climate of mutual respect.

Better than any text book or lecture was a lesson I learned from person I worked with some years ago. He was brain damaged, schizophrenic, emotionally abused both by his family and by society, quite fond of cocaine and, above all, profoundly over-medicated.

My job was knowing his world and exploring it with him, expanding it, helping him structure it in a way which would make it less difficult to live in a society which saw him as frightening, alien and without value. He was 15 years old.

One day we were listening to a tape by the rock group, Rush, and there was this song, "Closer to the Heart" . . . and he said, "this reminds me of you and me" and he recited the lyrics:

"You can be the captain
I will draw the chart
Sailing into destiny
Closer to the heart."

I didn't like being in the role of "captain", so I asked him to explain what he meant . . . and he said, "Well, I decide where to go . . . and you make sure I am safe."

These words form not merely the essence of a good therapeutic relationship but are an important piece of what harm reduction is about: the expert decides where to journey, and the professional makes sure that the provisions are in place and that the route is safe. It means that we don't impose our priorities or attempt to control other persons' lives "for their own good" ("health fascism" is very harmful indeed); it means giving people the information and resources they need to make healthy choices; it means providing the service, support and respect people need to live meaningful lives.

* Harm reduction holds to the principles of public health, in that it does not merely address the health and well?being of individual, but also of the family, the community of people whose lives are organized around drug use, and of the broader community too. The needs of these varying constituencies must all be addressed. (E.g., needle exchange, which provide the user with supplies and keeps the streets safe from infectious litter.) At the same time Harm Reduction also addresses the social and economic factors which determine the people's health.

* Harm reduction is an emancipatory practise. It recognises that "social problems" are a "built in" part of our current social order and that the focus of change is mainly the structures of society and not the personal characteristics of the individual. It eschews hierarchies of oppression and is - or should be - concerned with all oppressed groups. Harm Reduction encourages the worker and the agency to invigorate their practice through the development of partnerships and coalitions with active drug users. These partnerships can be transformative in that they give voice and presence to the drug using community and lead to a sense of individual and community competence. Examples: user-driven programs; community activism; etc.

* Finally, harm reduction holds that no citizen should be denied service or access to service merely because they are using a drug, licit or illicit.

. . . and the bottom line: Harm Reduction is about ending suffering and saving lives.

The philosophical roots of harm reduction can be confirmed in the writings of several contemporary thinkers. These are people who have informed my work, at any rate, One of them is Isaiah Berlin. In one of his most important papers, Berlin posits two types of liberty, or freedom - positive and negative - a concept which offers an excellent lense through which to view how we treat people who use drugs. Negative liberty is at the heart of a properly liberal political creed. Succinctly stated, within the framework of negative liberty, individuals should be left alone to do what they want, provided their actions do not interfere with the liberty of others. (This only deals, of course with what people say they want and not that which they might want "if they only knew better".) Positive liberty, on the other hand, is at the heart of all political doctrines that wish to use political power to free people so they can realize some hidden or repressed potentialities.

Tyrannies are extremist in their embrace of positive liberty. They believe that they have the right to force people to be "free" (as they define it), whether or not they want freedom in the first place. Hence, they are prone to bring about a paradoxical result: the denial of liberty. Not self mastery or self actualisation, but quite the opposite: dependence on external control. So, if we look at this in terms of how we treat drug use, harm reduction may provide a greater guarantee of negative liberty - on the whole - than positive liberty (which has brought us AA and the dictatorship of abstentionists and the higher power, not to mention the War on Drugs). Negative liberty is closer to what we call democracy, and like democracy, negative freedom is a messy, bumpy and non?linear process.

Needle distribution (nb) - a cornerstone of harm reduction - occurs within the framework of negative liberty.

Methadone distribution, on the other hand, another cornerstone of harm reduction, occurs within the framework of positive liberty. The distributors force people to be "free" through the enforcement of arbitrary, rigid, and demeaning rules (such as having to urinate in front of another person). In the course of their work, they deny liberty. This must be called to question.

Harm reduction is also an act of faith. No, I am not speaking about relinquishing oneself to a higher power.

The philosopher Alan Watts makes a keen distinction between Faith and Belief - which I propose parallels the distinction between harm reduction and the traditional, rigid approaches to dealing with people who use drugs. Watts says that "Belief . . . is the insistence that the truth is what one would 'lief' or wish it to be. . . . Faith [on the other hand] . . . is an unreserved opening of the mind to the Truth, whatever it may turn out to be. Faith has no preconceptions; it is a plunge into the unknown . . . Faith is the essential virtue of Science."

Belief is easy to grasp. It is black and white, "my way or the highway". Faith, on the other hand, embraces the variations and complexities found in the infinite subtleties of gray tones.

When communities or ideologies or professionals use Belief not as an aid to Faith but as a means to establish identity - to "own" Truth - sooner or later the guns appear. And here we are. Belief is what drives the "Just Say No" Campaigns, and the prohibitions against needle exchanges. Belief is what drives the War on Drugs. Science is jeered at, in the name of science, and the casualties are the people who are forced to drink the water from a toxic well.

So there it is . . . Harm Reduction - a pragmatic, expert-driven, community based approach to dealing with problems resulting from drug use and distribution, occurring at the confluence of the principles of public health and social justice, fired by hope and informed with respect and love. In the case of harm reduction, the pragmatic is also political.