Harm Reduction in the United States: Whose History? (Part 1)

In the fall of 2009, I was asked by an academic journal to contribute a 1,500 word editorial that outlined the history of harm reduction in the United States. I welcomed the opportunity; I also tried to be clever when writing the piece because as I was writing, the battle to remove the federal ban on the funding of syringe exchange was reaching its climax. It looked certain that the ban would finally be addressed, altering the twenty-year status quo. My fancy was to bookend the article by going back 21 years to the beginning of the ban and concluding with the end of the ban. My intention was not to produce a chronological history, but rather to highlight the significant texture that syringe exchange and the federal ban have had in the evolution of harm reduction.

My submission received negative comments and was deemed unpublishable in its submitted form.

The editor commented: "I think the main problem is that this is written in a fairly racy op-ed style, with all the passion of someone who has been evolved (sic) in the activism around harm reduction in the US. The task is to adjust the writing style so that it is more in line with a Commentary in an academic journal with a wide international audience."

Reviewer #1 said: "This short paper provides an excellent overview of the US federal governments problems with funding syringe exchange. However, this is hardly the story of "harm reduction in the United States." The coalition of activists, state and local governments, and researchers that have worked very hard to implement harm reduction programs in the US are almost absent from this paper. The effectiveness of US harm reduction programs in actually reducing HIV transmission and bringing many other health and social services to drug users is also absent from this paper."

Reviewer #2 said: "The manuscript reads like a biased paean to the pluck and inventiveness of American harm reduction activists, but that is far too simplistic. Not all HR programs are equally effective and some programs, both the "in your face" efforts and the tightly regulated programs, may have done as much harm as good. A more considered, nuanced manuscript is to be desired.

The writing is quite sloppy and the organization leaves a lot to be desired.

In sum, there is a germ of something here, but it would take a lot to have it germinate into a valuable contribution."

Staff at the Harm Reduction Coalition agreed with the criticism that the writing might be better organized and that the article was not yet in a publishable state. Conversely, there were also a couple of the reviewers to whom I showed my piece that disagreed with the slant of the comments put forward by journal reviewers and its editor, explaining that they weren't deterred by the quality of the writing. Nevertheless, I don't mind being criticized for the style of my writing; I am not a scholar and academic writing is not something I am trained in.

Looking back however, it's clear that my strategic approach to the article did not work as it shifted the focus from a broad history of harm reduction to the story of syringe exchange. No matter how interlinked the stories might be, my focus on syringe exchange eclipsed the full history of harm reduction. That said, there was a pragmatic reason for this approach in that it would be impossible for 1,500 words to do adequate justice to the story of harm reduction. The thought was that by approaching the history via the ban, most of the major initiatives would at least be given mention. Regardless of my success in meeting the journal's expectations however, the experience has got me thinking about how to ensure that the story of harm reduction in the US is told as completely as possible by the people who have actually been involved in its development.

Aside from syringe exchange, the article detailed drug user organizing, overdose prevention, the breadth of drug user based services delivered by community based organizations, the gradual acceptance of harm reduction by local and state governments, and the impact that the work has had on reducing HIV in the United States. What was central to the piece was the critical role that advocates and activists have played in promoting harm reduction and syringe exchange in the United States. A significant portion of this work has been carried out by people who use drugs or who have a history of drug use. The nature of the war on drugs makes revealing this aspect of the story and further, highlighting it, especially difficult. However, it is central to our history. Activism, and in particular the role of drug users within the activist community, will be written out of the history as only "balanced" or "nuanced" versions are constructed and published. This is exacerbated since writers and researchers often only rely on other academic publications for their background information and citations. If our history is not documented and published in some fashion then it will disappear.

By the late 1980s the activist pool that transformed the landscape for drug users and HIV in the United States was largely constituted by members of the AIDS Brigade, ACT-UP, and drug researchers, primarily from NDRI in New York and Urban Health Study in California. There have long been activist allies working within federal, state, and local governments, as well as in sectors of the research world. Foundations such as the Comer Foundation and the Foundation for AIDS Research have not only been key in supporting harm reduction programs and organizations, they have also been instrumental in maintaining support for policy change. However, without the catalytic effect of people taking syringe exchange to the streets and actually doing the work of putting sterile syringes in the hands of drug users, the research would have sat on the shelves, our government would have continued to study the feasibility of implementing syringe exchange and funders would have put their money elsewhere. While it is likely that even without the leadership of drug users and activists, syringe exchange would have started eventually, its timeliness would have been fatally compromised, even more so than it already has been.

There are many angles by which to look at the war on drugs; one angle is that it has been a massive and successful propaganda exercise to demonize drug users. Drug users are first criminalized for using outlawed substances. Then, along with their criminal use of drugs, they are continually suspect for crimes they may be about to commit to obtain drugs. Thus, a "drug user" becomes a deviant - a transgressor who is incompetent and selfish, destined for jails, institutions or death. The message is that drug users do not care about their own health, the health of their friends or colleagues and certainly not the greater public health. While abstractly we might think of drug users as visionaries and even explorers, rarely do these characterizations extend beyond the realms of art. Largely, perceptions of real-life drug users do not include them as actors for the common good. Experience shows that the result of this propaganda campaign is that when a drug user reveals their drug use publicly, nearly every aspect of their lives and work become compromised and questioned.

There have been some truly great people who have changed a little piece of history and they did so using their experience as drug users. Unfortunately, however, the vital role that they have played in addressing drug user health remains unacknowledged, buried and murky. Tomorrow I will post the piece that I originally sent to the journal, just as it was submitted and in the weeks and months that follow, I hope to post additional writings (by me and others) about key harm reduction milestones and initiatives. My goal is to honor the real history of harm reduction in the United States in more than 1,500 words.

Read Part 2 here.

Re-posted from Daily Kos