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Article Excerpt
A May 28, 2007 New York Times story profiled Ron Daniels, director of Prevention Works, a syringe exchange in Washington, DC. The front-page story depicted Daniels' journeys through low-income neighborhoods in his Winnebago van, as he distributed sterile syringes and other supplies to injection drug users. Himself infected with HIV from a contaminated syringe, Daniels was operating Washington's only syringe exchange. Local health clinics had provided similar services until 1998, when Congress, which enjoys special authority over the United States' capital city, explicitly forbad the DC government from financing these services. * Defending such stringent policies, Missouri Congressman Sam Groves stated: "We need to fight drugs, not show people they can be used in a safe manner." (1)
Why is the United States so resistant to public health strategies that find wide acceptance in many other wealthy democracies'? This old question remains pressing. More important, given our history of missed opportunities to reduce the harms connected with HIV/AIDS, can we do better?
In part, American resistance reflects stringent views towards foundational questions of drug policy. Federal sentencing guidelines consider a 5-gram sale of crack to merit greater penalty than attempted second-degree murder that results in serious injury to the victim. (2) In some cases, nonviolent first-time offenders receive mandatory minimum sentences of 25 years or more that exceed penalties imposed for homicide, attempted hijacking, and other violent offenses. (3,4)
Although few ballot initiatives to allow medical marijuana or to overturn harsh sentencing laws ultimately succeed, their continued popularity suggests that many voters believe that American drug policy has lost its way. So, in more quiet ways, do the majority arguments in recent Supreme Court rulings that grant judges greater discretion to depart from federal guidelines in sentencing crack offenders. (5)
Some critics go further. Mill's harm principle can (but does not have to) be interpreted to support principled objection to government regulation of drug use. (6,7) Most academic researchers are critical of punitive drug policies, but nonetheless accept the right of government to outlaw or to stringently regulate some substances likely to cause severe and likely harm.(6 8,9)
Under any feasible policy regime, some citizens will consume heroin, cocaine, or other intoxicating substances. Whether such consumption occurs inside or outside legal boundaries, societies have strong practical reasons to address the accompanying harms. Striking the right balance between deterrence and compassion is an enduring tension in drug policy.
This article considers how the public health community might better-address this tension, given the embattled politics that surround efforts to assist substance users. This article mainly focuses on the United States. Several other wealthy democracies have achieved greater success in similar policy domains. I hope that this article reflects lessons learned in European, Canadian, and Australian settings, and that some insights presented here may be useful for other settings. Detailed analysis of harm reduction outside the United States is beyond the scope of the current article.
Drawing on terminology advanced by MacCoun and Reuter, this article first describes the term harm reduction, and some of its accompanying complexities. It then describes the political controversy over needle/syringe distribution programs (NSPs) within the United States, and why the term harm reduction and accompanying interventions have proved so politically embattled in this country. It suggests that the public health community has stumbled in its efforts to sidestep the moral and cultural politics of harm reduction, and that more explicit arguments rooted in the humanity of drug users are essential to enact more reflective and humane public policies.
Much confusion arises because the single term harm reduction connotes several different things to different audiences: a guiding set of questions for policy analysis, a convenient moniker for particular HIV prevention interventions, a unifying slogan of a disparate political movement of activists, public health practitioners, and scholars seeking less punitive drug policies.
The three usages overlap, though sometimes in confusing ways. Policy analysts who call themselves harm reductionists typically favor specific interventions such as NSPs or high school condom distribution programs that fall under the harm reduction label. Many, however, oppose a generalized policy of drug legalization, and would reject the premise that government regulation of a diverse range of intoxicating substances should be framed in such homogenous terms. (10) As described below, the shadow cast by harm reduction as a movement and political trope sometimes hinders efforts to engage citizens and policymakers in the analytic questions harm reduction raises. No less important, harm reductionists themselves may seek refuge in technocratic arguments to sidestep moral objections to favored policies.
Under varying definitions, harm reduction provides an explicit framework for many nations' substance abuse policies, even, in some cases, for law enforcement. (11,12) Within the United States, harm reduction enjoys strong scientific support and the endorsement of many medical and public health authorities. Yet such approaches remain politically embattled. In 1998, for example, General Barry McCaffrey the Clinton Administration's drug czar (more precisely, Director of the Office of National Drug Policy) labeled harm reduction "a hijacked concept that has become a euphemism for drug legalization." (13)
A 2003 New York Times story, titled "Certain words can trip up AIDS grants," exemplified even deeper resistance:
Scientists who study AIDS [and other sexually-transmitted infections] say federal health officials have warned them that their work may come under unusual scrutiny.... Speaking on condition of anonymity, the scientists say they have been advised they can avoid unfavorable attention by keeping certain "key words" out of grant applications to the National Institutes of Health [NIH] and [the Centers for Disease Control and Prevention]. Those words include "sex worker," "men who sleep with men," "anal sex" and "needle exchange ..." HHS spokesperson Bill Pierce said the department does not screen grant applications for politically delicate content. But an NIH official, speaking on condition of anonymity, said NIH project officers, who work with grant applicants and recipients, were telling researchers to avoid so-called sensitive language. (14)
Not long after, a congressional amendment to de-fund controversial HIV prevention studies came within two votes of passing; (15) while the Traditional Values Coalition (TVC) released a list of 157 scientists whose federally-funded studies concerned topics or examined populations TVC considers offensive. (16) HHS officials may have assisted TVC in preparing this list. (15)
TVC's efforts attracted widespread derision, in part because the group challenged funding decisions made through scientific peer review. The group was labeled know-nothings by many commentators. (17) Their views nonetheless held political currency. A 2003 letter to the National Institutes of Health by Mark Souder, Chairman of the House Subcommittee on Criminal Justice, Drug Policy and Human Resources, exemplified political opposition to harm reduction. (18) Congressman Souder began:
As you know, "harm reduction" is an ideological position that assumes individuals cannot or will not make healthy decisions. Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles--or become trapped in them--should be enabled to continue these behaviors in a less harmful manner. Often, however, these lifestyles are the result of addiction, mental illness of other conditions that should and can be treated rather than accepted as normative, healthy behaviors.
Other disputes, then Democratic victories in the 2006 election, sidetracked Congressional efforts to curtail harm reduction interventions. Yet federal funding remains unavailable for syringe exchange, while policymakers generally avoid harm reduction strategies and terminology in addressing social problems related to substance use.
Examining the scientific literature, one might wonder why harm reduction attracts such attention. Economists and public health researchers define the term in self-consciously apolitical terms. Stated blandly, harm reduction might be defined as follows: choose policies that minimize the net harm associated with both substance use and with the policies used to dissuade, deter, treat, or punish individuals who use or distribute these...
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