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Article Excerpt
She can't be sure at first if the shade on the footstool is a trick of light or a trick of paralysis--wherein a certain floral slipcover or a love seat or a standing lamp resembles instead her fellow man. There are torsional shadows in her room. Revenants. Well, her glasses are splayed on the bedside table, atop an unopened book. Thus, this guest on the footstool is consubstantial with furnishings, with chairs, draperies, occasional tables. Edgeless and indistinct. A late Impressionist visitor. (Moody, 1998, p. 163).
In one sense all sociology is the "late impressionist visitor" as Rick Moody so eloquently puts it. His narrator is a woman dying of a debilitating disease which is gradually robbing her of her ability to distinguish reality from imagination, as well as her physical ability to respond to the world. In the narratives of illicit drugs policy and the experience of it, this description is particularly apposite. The intents and outcomes of policy becomes confusing when one reads the debates and arguments in the professional literature, the propositions and truth claims of policy documents and the outcome measurements of evaluations. All sociologists thus become late Impressionist visitors.
This article will look at the narratives and language of the medically supervised injecting centers (MSIC), or drug consumption rooms (DCRs) debate (1) and the so-called evidence-base for their existence. It will argue further that there are five narratives which emerge from the debates and discussions of medically supervised injecting centers. None can be clearly delineated from another--they all contain elements of each other. There are four narratives that emerge openly and one which is never discussed, but exists as what some might call "the elephant in the living room." The overt narratives can be categorized as:
1. The caring and humanitarian
2. The elimination of public nuisance
3. The governance of the drug-using subject
4. The neo-liberal, utilitarian, and bureaucratic.
The final story is the pleasure narrative. Since this article will be concentrating on the first four (but touching on the hidden one), this article can be accused of also denying this fundamental drug story. I will have to plead guilty, but beg the reader's indulgence by noting that this is a narrative with a huge story to tell, and one which I will leave to another time. Pat O'Malley and Marianna Valverde (2004) however, attend to this particular one and its absence in the modern professional literature about drug use.
This article will develop the trajectories of each of these narratives through a discussion of the main reports and articles related to Supervised Injecting Facilities (SIFs). Although this is not an exhaustive trawl through the literature, it does choose such literature as illustrative of the argument. The main literature to be used is the evaluation report of the Sydney MSIC (MSIC Evaluation Committee, 2003), the European Report on Drug Consumption Rooms (Hedrich, 2004), and the Joseph Rowntree Foundation report (Independent Working Group (IWG), 2006), plus other professional articles in the area. The concentration on these three reports is because the MSIC Evaluation Committee report (2003), Hedrich (2004) and IWG (2006) are reasonably exhaustive. The outline of the development of the debate uses the Australian situation as an illustration because of the author's background, but also because a medically supervised injecting center was established in Sydney and the evaluation report is comprehensive and intrinsically interesting. A side issue is also that English is the language of the author so, even though the European rooms are the longest established, most of the literature is unavailable, thus the reliance on Hedrich (2004).
Narrative and the medically supervised injecting center
Medically supervised injecting centers (MSICs) are part of the panoply of programs within the broader policy of harm minimization and include needle and syringe exchanges, drug substitution, and other such programs. Harm minimization can be described as a policy intended to reduce or ameliorate the harms associated with illicit drug use, without necessarily reducing the use of these drugs (Single & Rohl, 1997). It is also a utilitarian, risk management-oriented policy (O'Malley, 1999, Miller, 2001).
All public policies have a metanarrative which deals with contradictions while attempting to maintain some form of coherence (Roe, 1994), so the objects of those policies, such as MSICs become part of the narrative structure. Harm minimization is a metanarrative of late modernity which attempts to deal with a series of competing discourses. On the one hand the state still treats the illicit drug-user as a damaging criminal in need of control, while on the other there is also the need to treat the drug user as a governable subject, amenable to the new technologies of the subject. O'Malley (1996, p. 27) refers to these new technologies of the self as "post-social rationalities" which:
Constitute their subjects not as members of an overarching social whole, shaped by social conditions and to be governed through social interventions, but as autonomous individuals, responsible for their own fate, invested with personal agency and thus with personal responsibility for their actions (O'Malley, 1996, p. 28).
At the same time, the New Public Health (Peterson & Lupton, 1996) orientation brings in new forms of surveillance over populations, including that population whose primary activity is taking illicit drugs via dangerous (albeit efficient) means such as injecting directly into veins. So the three competing directions of the harm minimization metanarrative are: 1) State control of drug users 2) Production of the governable subject 3) The public health imperative.
With the success in the late 1980s and 1990s in the fight to limit the spread of Human Immunodeficiency Virus (HIV) in the injecting drug-using population through the introduction of clean needle and syringe programs, other programs were then introduced in the hope of ameliorating other forms of drug-related harms. These include such experiences as overdose deaths and the spread of hepatitis B and C. These are health problems for the individuals themselves. Thus we discern as the first narrative of the safe injecting facility the caring and humanitarian one. Its main characters are the intravenous drug users (IDUs) whose well-being is at the center of this particular story.
When we look at the definition of safe injecting facilities, the first blurring of the narratives becomes obvious. MSICs are state sanctioned rooms or clinics where people can inject illicit drugs.
Supervised injecting centers (SICs) are legally sanctioned health and social welfare facilities that enable the hygienic injection of pre-obtained drugs under professional supervision in a nonjudgmental environment (MSIC Evaluation Committee, 2003, p. 2).
Consumption rooms are protected places for the hygienic consumption of pre-obtained drugs in a nonjudgmental environment and under the supervision of trained staff (Hedrich, 2004, p.8).
Drug consumption facilities or rooms (DCRs) are legally sanctioned low threshold facilities which allow the hygienic consumption of pre-obtained drugs under professional supervision in a non-judgmental environment (Kimber et al., 2003, p. 227).
The term "drug consumption room" (DCR) is used to cover any room specifically set up for the supervised, hygienic consumption of pre-obtained, controlled drugs (IWG, 2006, p. 3).
Apart from what seems a very limited vocabulary, the above quotes have other common elements, in both language and intent. The word "hygienic" is an element in every definition, without exception. The protection of the consumer of (illegal) substances bought outside is another common idea, as is professional supervision and a nonjudgmental atmosphere. These official institutions are positively compared to the "shooting galleries" prominent in many U.S. cities and television programs which are not sanctioned by the state and are "unhygienic'' (2) (IWG, 2006; Wodak, 2004).
At least three of the four competing narratives described at the beginning of the article all make their presences felt in these quotes. There is the humanitarian impulse to protect people, and be respectful (nonjudgmental) while giving people safe places to inject. The governance of the drug-using subject involves the supervision of injectors by professionally trained staff. And of course, the risk-management, bureaucratic narrative exists with that same professional control. What does not appear is the nuisance narrative. There are about 65 drug consumption facilities in existence, the bulk of them in Europe...
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