Perspectives On Harm Reduction

Critical Public Health, Vol. 14, No. 4, 325–328, 2004

Introduction Perspectives on harm reduction: editorial introduction TED MYERS1, PETER AGGLETON2 & SUSAN KIPPAX3 1

HIV Social, Behavioural and Epidemiological Studies Unit, University of Toronto, Canada, Thomas Coram Research Unit, Institute of Education, University of London, UK, and 3 National Centre in HIV Social Research, University of New South Wales, Australia 2

In bringing together the papers that are contained in this special issue of Critical Public Health, our original intention had been to critically assess harm reduction in the context of HIV. As the papers developed, however, it quickly became clear that the practice of harm reduction is much broader than this—and a field in which there has been considerable growth of interest, development of thinking and understanding, and application. Despite this, harm reduction has remained, and does to some extent still remain, on the periphery of the public health literature. The defined focus of injecting drug use and HIV remains the area that is most commonly addressed, despite growth and expansion, and greater understanding of the concept. Early references to the use of the term harm reduction in the context of HIV and AIDS are difficult to trace as much that is written on the subject developed through practice—often through efforts by activists, public health practitioners, physicians and policy-makers—working around existing legal constraints. As a result, there is relatively little written documentation of these early applications, and/or many relevant sources remain outside the academic research literature. Early efforts in the field of HIV centred primarily on the provision of needle and syringe (including exchange) programmes for injecting drug users, and predominantly dealt with the epidemic in the developed world. Considering the stance that was taken and the justifications necessary, it is therefore no co-incidence that the use of the term ‘‘harm’’, strongly associated with a key ethical principle of ‘‘to do no harm’’, came to be applied to this area. Many of the early arguments for enhancing programmes for injecting drug users and others were based on these moral, ethical and practical arguments. The papers published in this issue of Critical Public Health highlight the extensive variation and penetration of the harm-reduction construct in public health practice.

Correspondence to: Ted Myers, HIV Social, Behavioural and Epidemiological Studies Unit, University of Toronto, McMurrich Building, Room 325, 12 Queen’s Park Cres W., Toronto, Ontario, Canada, M5S 1A8. E-mail: [email protected] Critical Public Health ISSN 0958-1596 print/ISSN 1469-3682 online ß 2004 Taylor & Francis Ltd http://www.tandf.co.uk/journals DOI: 10.1080/09581590400027544

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They address HIV, Hepatitis C (HCV) and other infections; drugs and injection drugs; and alcohol and sexual risk. Together, they reveal something of the cross-fertilization there has been within public health across the fields of sexuality, drug use and related behaviours. Such cross-fertilization should not come as a surprise. Increasingly, public health seeks critical understanding of issues and promotes the use of community empowerment approaches that are well beyond traditional ones, and harm reduction cannot be constructed in isolation from an understanding of the many social processes that affect health today. The papers here were written by researchers working from different perspectives and in rather different contexts. Two of them focus on the major policy and programme elements that form the basis for harm reduction. Room, drawing on his own and others’’ research on the history of alcohol control, makes conceptual links and comparisons with the current harm-reduction movement and the new public health. His analysis shows that while seemingly a new concept, harm reduction had some roots in earlier centuries. The analysis further emphasizes that there can be no single understanding of harm reduction. Room points out that it is important to distinguish harm reduction as a goal from the strategies of harm reduction. Examples of specific strategies for drug harm reduction include needle and syringe programmes, injection rooms and opiate substitution—none of which requires abstinence. While many strategies may be individually focused, others may relate to the reduction of harm to others, including increasing public order, reducing public nuisance and reducing rates of property crime. Kerr and colleagues offer an overview of policies and practices to address HIV/AIDS in prison settings. They strongly advocate for policy and practice to be based on scientific evidence applied within an international human rights and legal framework. This stance stresses the importance of and obligations for governments to respond to drug-related harms as ‘‘human rights violations’’; and, conversely, that human rights violations within the prison system contribute or lead directly to drug-related harms. They further argue, as did visionaries of many of the early needle and syringe (including exchange) programmes, which prevention measures must be constructed within the right to health, and that prevention was an essential component of good quality healthcare as described within the basic concepts of health provided by the World Health Organization. Health services in prisons would include the provision of means to prisoners to protect themselves from exposure to HIV and other forms of drug-related harm. Like Room, Kerr and his co-authors critique the control approaches that have been applied to address this major and growing public health problem around the world. A number of the papers in this special issue focus on specific strategies and populations. Van de Ven and colleagues discuss harm reduction in the context of sexual health among gay and bisexual men and highlight strategies that emerged out of systematic social enquiry, much of which they themselves conducted in the gay community of Sydney, Australia. Uniquely, in this paper the authors refer to or use the term ‘‘risk’’ more commonly that the word harm. The term risk, which is more commonly used in the area of sexual harm reduction, at the same time reflects something of the complexity and difficulties in this area of prevention. In the field of sexual practice, harm-reduction strategies are complex. Unlike injecting drug use, where the roots of transmission appear relatively clear and absolute, in the sexual arena there are more

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uncertainties. Some of these uncertainties arise out of the many modes of transmission associated with the plethora of sexual acts and the nature of human relationships. Van de Ven and colleagues see sexual risk management as a series of strategies varying from most safe to least safe. Specific risk-management strategies employed by Sydney gay men centre primarily on the reduction in unprotected anal intercourse, the benefits of HIV testing which permit an accurate knowledge of one’’s serostatus, and subsequently the adoption of practices of negotiated safety, positive–positive or negative– negative sex, and strategic positioning, which distinguishes the risk of insertive versus receptive sex. Sexual partner reduction and monogamy have not been strongly advocated by educators or adopted by gay men as essential elements of risk reduction. Treloar and Fraser describe a qualitative analysis centred on improving healthpromotion messages relating to Hepatitis C (HCV). While their investigation was focused on HCV, much of what they reveal may be equally applicable to HIV. These investigators analyse the language and symbols used to describe blood and the body in HCV prevention materials. Traditionally, prevention has been represented as an absolute and blood as something that should be contained within the individual, in order to arrest transmission; hence the necessity for drug injectors to maintain boundaries from other bodies. Interviews with 32 injecting drug users, however, revealed various understandings of the harms and benefits of blood for life. In this analysis, the authors suggest a movement away from traditional ‘‘fortress’’ models, based on a prohibition or protection approach, toward a ‘‘blood bank model’’, in which blood is viewed as a community resource, one which is life-giving and therefore potentially shared. Despite language and understandings that speak of harms and benefits, the authors see the latter model as one that allows responsibility and a sense of ownership, and is thus an approach that will empower individuals and communities to respond. The van Beek paper is the first to report on the Sydney Medically Supervised Injection Centre, and tackles one of the more controversial strategies for harm reduction and disease prevention among injecting drug users: medical assistance and intervention. The aims of the Centre’’s programme are multiple and include the prevention of transmission of blood-borne infections, the provision of enhanced health and social welfare assistance, and the reduction in public nuisance associated with injecting in public places. In addressing these issues, both the biological and chemical contributions to overdose and characteristics of individuals potentially at greater risk are important factors to take into account. In the authors’’ own words, they focus in this paper on ‘‘the ultimate harm: heroin overdose’’. The effectiveness of the programme in preventing the morbidity and mortality associated with overdoses appears clear. This paper clearly demonstrates that harm-reduction interventions need not necessarily be viewed as being on the fringe or provided by insurgent or activist groups but may be applied within traditional medical and clinical prevention paradigms. A common argument for the development of harm-reduction approaches, suggested by all the papers in this special issue, resides in the acknowledgement of the limitations of purely educational interventions. The papers emphasize the importance of considering the contexts of the harm and the affected populations’’ service needs. Many of the harmreduction strategies reflected in the papers represent individual and community approaches to prevention, as illustrated in the provision of clean needles, or the

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negotiation of sexual safety between two individuals. Clearly, for these to be effective a broadened service delivery base is required, one that aims to reduce the stigmatizing cycle which often contributes to sustained harm among affected groups. For this to occur requires an acceptance and support of harm reduction by policy-makers, and governments that are in the position to facilitate social change. In some countries at least, there is evidence that this is beginning to occur.