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Connecting
the Two Fronts
A
manifesto for a working relationship between state
and non-state sanctioned needle exchange programs.
by
Jon Zibbell
Springfield Users' Council
The ostensibly small number of state sanctioned
needle exchange programs in the United States testifies
to the fact that harm reduction is not even close
to becoming a dominant philosophy and practice in
drug services. Politicians in many cites and towns
that do not have needle exchange often formulate
their drug policy through a moralistic framework
that not only prioritizes votes over saving lives,
but ends up subsuming evidenced-based harm reduction
strategies under treatment modalities that often
miss the mark when it comes minimizing drug related
harm. Furthermore, the political climate in such
places makes it very difficult to administer practical
harm reduction interventions to people who are using
drugs; the time when most blood-borne viruses are
actually transmitted. This reality, coupled with
the fact that HIV and HCV are exponentially rising
in cities that do not have needle exchange, makes
harm reduction strategies in those cities extremely
complicated. What are the specific tactics and strategies
to deal with this life and death situation in cities
without needle exchange?
This
article will first map out the field of operations
where state and non-state sanctioned needle exchange
(NEX) programs are practiced and contested. Secondly,
I will provide a "living" model for how
both programs can work together to minimize drug
related harm while each maintaining their autonomy,
self-determination and safety.
In order for us to outline a method that will allow
independent needle exchange programs to work with
state-sanctioned programs and vice versa, we need
to situate and define exactly what these two fronts
look like. It is highly appropriate to use a military
metaphor to define the socio-political field in
which NEX is practiced in the US, so let me outline
the battlefield.
At the federal level, there is no monetary support
for NEX. At the state level there are different
syringe protocols specific to each state. Usually,
the decision to implement a NEX program is taken
by the politicians at the local level, meaning that
either the mayor can pass it through an executive
order or the city council can vote it in. This means
that in cities and towns where there is no local
approval for NEX, there is no funding and it is
illegal, albeit sometimes tolerated, to administer
a NEX without that approval.
The
federal, state and local policies /laws surrounding
NEX are what define state-sanctioned programs and
non-state sanctioned (independent) programs. Therefore,
I will define state programs as those that have
local approval and operate with state funding (via
the Department of Public Health). Independent programs
are those that do not have local approval and are
not state funded.
Of
course the relationship between state programs and
independent programs is not homogenous, meaning
that the particulars surrounding that relationship
are dependent on many factors, including location,
individual state and city laws, funding protocols,
the race, class, gender and sexuality of the drug
users and the local political climate. Therefore,
the outline for a working relationship will vary
according to each specific locale; however, you
may notice many commonalities to your particular
region.
Springfield,
Massachusetts, the city in which we operate, has
a long history of publicly grappling with the question
of needle exchange programs. Starting in 1993, when
the state of Massachusetts approved funding for
ten pilot programs. Ten years later there are only
four programs in the state. Local approval was never
granted in Springfield. Moreover, some local politicians
in Springfield have even chosen to adopt a platform
against the establishment of a pilot program.
One
of the four state programs that were established
is approximately twenty-five miles north of Springfield
and it is funded by the Dept of Public Health. Even
though the program is only a relatively short distance
away, and despite the fact that people can register
in the exchange and can possess syringes legally
anywhere in the state, the majority of Springfield's
drug users do not have the resources or the time
to travel there. This reality, combined with the
fact that the city has consistently voted against
the implementation of a NEX, motivated us to put
together an independent needle exchange program
ñ we refused to wait for the city to save
our lives.
We are the Springfield Users Council. Our harm reduction
organization is run by drug users. Following the
example of the National Drug Users Development Agency
in the UK, we define a drug user as someone with
a history of illicit drug use - including former
and current users. We define a drug user organization
as one run by and for drug users. We operate through
a set of rules that were written and are consistently
being amended by the council members. We expect
all council members to adhere to the rules, whether
they are using drugs or not. We do not distinguish
between recreational drug use, dependent drug use
and past use with regards to someoneís ability
to be a responsible council member. The only requirement
is that people adhere to and respect the rules of
the council. In other words, we do not discriminate
on the basis of people's drug use but rather on
how it affects the council's ability to operate.
There
is nothing romantic about being user-run. It is
extremely difficult to maintain consistency in a
climate of heavy policing and punitive drug laws
that contribute to the inability of users to maintain
their drug use so that they can engage effectively
in political organizing and mobilization. In addition,
there is little funding for drug user groups to
organize and run NEX programs and we are consistently
worried about long-term funding. Because we administer
a NEX outside of local approval, we have the constant
fear of arrest and members frequently "burn
out" from the stress associated with operating
an independent program. Moreover, the destabilizing
effects of racism, poverty and other social inequalities
create limitations on our capacity to recruit new
council members. Our motivation is fueled by our
ethical and political convictions, but with the
pressure from above constraints, sometimes the fuel
runs low.
Even
when there is a local commitment for NEX, being
a user-run program is by no means always palatable
to the state. Health departments are restricted
in their ability to fund user-run programs because
they need to adhere to the stateís rules
and regulations on the hiring of drug users and
former incarcerated peoples. Health departments
have in-built biases against giving money to drug
users to run their own programs. For example, in
some states (such as Massachusetts) there are laws
against state funded programs hiring people with
felonies and it is illegal to knowingly hire people
who are engaged in illicit drug use.
There
are numerous benefits however to having a user run
program. Recruiting drug users into a user run program
is an important facet of harm reduction, a form
Samuel Friedman terms "redemption through social
struggle." Not only are user-run programs the
most viable and effective way to reach active drug
users, the users become activists through their
work. Since becoming active in our organization,
many council members have been able to move away
from "unmanageable" drug use towards the
stability that maintenance brings. The participation
with their families and communities is enhanced
whilst producing a form of user solidarity and collective
action.
Because
we are not constrained by state rules and regulations
we can implement progressive harm reduction practices
that are often deemed inappropriate or ìnot
proven to workî by health officials or other
state authorities. Following Alain Bodiou, we can
call these practices ìprescriptions against
the stateî, meaning that we operate outside
of state laws, but we include the state in our political
field. In other words, we administer our program
without the authority of the state but we are not
exterior to it with regards to the possibility of
arrest and in terms of our demand for legal recognition
and state funding.
By
proving the necessity of our program to local politicians
and by confronting draconian and racist state drug
policies, we hope to move the debate forward whilst
saving lives. Some of the progressive harm reduction
tactics we employ include:
overdose prevention training with naloxone;
the separation of needle distribution from retrieval;
confronting the exacerbation of drug related harm
by the criminal justice system and the prison industrial
complex; direct political actions protesting the
cityís harassment of drug users, non-discriminatory
hiring practices (e.g. active drug users, sex workers
and former incarcerated people)
The
contradiction here is that independent programs
often do not have enough money to make real structural
changes, they often lack the institutional space
to set up a fixed site and they are constantly in
fear of being arrested. In contrast, state funded
programs have plenty of money to implement new and
progressive programs, but they are often limited
to make real structural change outside of the normative
public health model. This is due to the state-sanctioned
programs' relation to state laws, state funding
and their political bedfellows.
Those
state health departments that support and fund NEX
programs do not always have the best methods to
minimize drug related harm and they often prioritize
knowledge production over health benefits. However,
knowledge production (in the form of statistics
and data collection) may never directly benefit
drug users. An extreme example is the collecting
of information regarding the first time a NEX participant
used cannabis (this is actually on a state NEX form
in Massachusetts). In fact, this sort of compulsory
data collection by health departments often comes
at the expense of progressive harm reduction methods
that can bring about noteworthy positive change.
Yet,
in spite of this, compulsory data collection is
what drives many state funded programs to implement
specific 'harm reduction' strategies. The problem
is that these strategies are often more about getting
the numbers and ticking the boxes than about minimizing
drug-related harm. This method happens whether or
not the program managers want it to because funding
is most often dependent upon the production of data,
which renders the overdetermined behavior of drug
users into simplistic, statistical-based models
of behavior change. Hence, the program will continue
to be funded and supported as long as the ënumbersí
are aligned with the stateís normative health
outcomes.
Furthermore,
the funding of state programs is also contingent
on healthy state finances. In times of fiscal crisis,
like the kind we currently have in the US, prevention
programs are the first services to get cut. If social
services continue to be cut, we can envisage the
future of NEX as either all independent programs
and funded through private monies or something resembling
a neoliberal public/private relationship.
So, this is the social and political field in which
we are working. The trick then is to realize how
we can connect the two fields of operation in order
to further the harm reduction movement without reproducing
the structural inequalities we are trying to change.
Here is the start of a general outline to facilitate
one such a relationship, albeit one that needs to
be constantly critiqued and amended.
1.
State funded programs need to allow independents
unlimited access to their safer injection equipment
and in turn independents need to bring their used
ones into the exchange. This will allow independents
to distribute enough syringes while raising the
number of returns for both programs.
2.
State programs need to allow independents the
means to acquire syringes even if they have none
to exchange.
3.Independents
need to document all their work, not only to get
state funds in the future (if that is their goal),
but to further the viability of harm reduction
as an evidence-based practice so as to argue against
the conservative moralism underpinning drug policy
in the US.
4.
Whenever possible, state programs need to allocate
money to independents to help support their administration.
5.
If the state has an identification card system,
state programs need to allow independents to register
people in their demographic. This will allow the
independents to distribute syringes while allowing
their participants to legally carry them. More
importantly, though, state programs need to account
for the often constrained ability for independents
to fill out long questionnaires due to the lack
of an institutional setting in which to conduct
an interview. In other words, state programs need
to accept that many independents fill out the
forms on the street amidst heavy policing; therefore
they need to find some leeway in their compulsory
data collection protocol to account for this.
6.
State programs need to recognize independents
as valuable harm reduction organizations that
have their own autonomy and political agenda.
7.
Upon local approval for needle exchange, state
programs cannot compete for funding to set up
a competing program where an independent is operating.
State programs often attempt to empire build,
meaning that their history as a state service
organization and their political connections to
the DPH often situate them as the only people
who can 'do' harm reduction. State programs need
to advocate for the funding and autonomy of independents
and not compete against them. This will allow
both programs to operate and be accountable to
the communities that they now best.
8.
State-sanctioned NEX programs need to avoid being
the authorized representatives of Harm Reduction.
This will allow independents (and user run programs
in particular) to grow into programs whose theories
and methods will be accepted, or at least listened
to, at the state level and not subsumed under
the rule of incumbent ëexpertise.í
9.
Workers in state sanctioned programs need to support
the workers in independents (and vice versa) regardless
of whether the managers allows such a relationship;
although not at the expense of losing their jobs.
This might need to occur on the "down low"
so the state organization does not lose their
funding, are not legally at risk and in order
to protect the state workers.
10.
Independents need to recognize that many state
harm reduction workers are also drug users who
do not have the supportive employment conditions
necessary to be an "out" drug user.
11.
Independents need to understand the limitations
and constraints underlying the operation of state
programs, such as compulsory data collection,
the complexities of allowing independents to register
users into the card system, the often compulsory
one for one orthodoxy, the need to account for
every piece of safer injection equipment, etc.
That way both organizations can work collectively
to find ways to negotiate the stateís rules
and regulations in order to protect the legality
of the state program and the self determination
of the independent.
12.
And finally, state sanctioned and independent
programs need to realize that they are fighting
the same battle, just on two different fronts.
Building a war of position on many different fronts
will allow us to strengthen our ability to minimize
drug related harm in cities without needle exchange
while also laying the foundation for a strong
and politically effective Harm Reduction movement
in the US.
This
outline for a working relationship is by no means
complete. My purpose here is to further the dialogue
between state programs and independents regarding
the antagonistic relationship between the politics
of independent, user-run programs and the politics
of the state. This ongoing dialogue can strengthen
the harm reduction movement in the US while maintaining
the progressive politics that facilitated its birth
in the 1980s. I believe that independent, user run
programs not only strengthen existing state sanctioned
programs but they also provide a living constitution
for a progressive harm reduction movement. A war
of position between state and non-state sanctioned
programs will, following Mat Southwell's apt metaphor,
allow the lunatics on both fronts to eventually
take over the asylum.
National
Drug User's Development Agency. 2002. National Treatment
Agency: A Guide to Involving and Empowering Drug
Users. Public Draft.
Friedman,
Samuel R, Southwell M, Bueno R, Paone D, Byrne J,
Crofts N. "Harm Reduction: A historical view
from the left." International Journal of Drug
Policy. 2001; 12(1):3-14
Badiou,
Alain. 2001. Ethics: An Essay on the Understanding
of Evil. Translated by Peter Hallward. London and
New York: Verso.
See
Donald Grove 1996. Real Harm Reduction: Underground
Survival Strategies. Harm Reduction Coalition Newsletter.
This article explains how compulsory data collection,
one-for-one exchange policies and other state ëharm
reductioní initiatives can actually be detrimental
to the health and safety of drug users and their
families.
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