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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