How cultural attitudes, the political environment, and donor expectations shape harm reduction – and how they can divert it from its original mission as a movement.
We have been producing movies about drug policies since 2007. Through all these years, we have been traveling a lot across the world, visiting harm reduction sites and interviewing hundreds of harm reduction activists, professionals, and decision makers in various countries.
It is easy to make premature judgments about harm reduction in a country. I always have my own preconception about it before actually traveling there, based on articles and reports I have read. Most of the time, I have to admit that the reality is much more complex than my expectations. My experience tells me that sometimes countries labelled as retrograde in terms of drug policy and harm reduction can amaze you with vivid, vibrant local harm reduction scenes. And countries praised for their progressive drug policies can equally disappoint you with their rigid, medicalised systems.
Sometimes you learn the most cutting edge lessons about harm reduction and human rights among the people living in disadvantaged countries. A mistake often made is that the experience of these people is underestimated, and only success stories are highlighted and celebrated by reports from international organisations. Exchanging experiences and knowledge among decision makers and harm reduction professionals working in similar, difficult environments is often as useful as presenting best practices from Western countries. Lack of measurable success in changing policies is not necessarily a sign of the failure of advocacy efforts.
Harm reduction is of the people, for the people, and by the people. Assessing scientific data about trends of infections or access to services is necessary when measuring the social impact of harm reduction as a set of interventions. But statistical data in itself is far from sufficient to have a real insight into how harm reduction works as a movement, how is it embedded into the local political and cultural context, and how it affects the lives of individuals and communities.
We can identify some main factors shaping and framing harm reduction. These structural factors are actually not so different from those shaping the individual drug experience. Since the 1960s it has been a commonly accepted wisdom that the drug experience depends on three factors: set (the mindset of the drug user), setting (the physical and social environment), and dose (of the substance used). Similarly, three factors can largely determine harm reduction in a country:
1) Cultural environment – Social attitudes to drug use, historical development of the drug treatment system, education and attitudes of public health and social professionals, the influence of abstinence-culture, and the role of religion and church.
2) Political environment – State of democracy, freedom of association & power of civil society, type of government, the state of development of the welfare state, drug laws, law enforcement practices, public health regulations, and the external influence of neighbouring countries.
3) Funding environment – Who is funding harm reduction, what is the framework of the funding, what are the donors’ expectations about supported activities, how the money is distributed.
Western European cities are the best propagated examples of how we can reverse drug related death and disease by investing in harm reduction. Services are well funded by the government, well connected, and coordinated to municipal health, social and criminal justice systems. The political and cultural environment is tolerant or supportive. However, city leaders often embraced harm reduction from a cosmetic point of view: to get rid of street nuisance and bad press coverage. In developed countries high-tech, well-funded services often work without real mobilisation and involvement from drug user communities. The best services are sometimes not only the well funded services – but those operated by NGOs investing a lot of time and energy into advocacy, community mobilising, and peer involvement.
Harm reduction has been mainstreamed in much of Western Europe. It is business as usual, operated by technocrats or public health officials paid by the government, working according to official standards. If you attend a harm reduction conference in Europe you will meet social workers, public health pundits, and law enforcement officials discussing research findings, grant systems, and professional protocols. The contrast is stark if you attend a harm reduction conference in the US, where harm reduction is still an underground movement challenging the status quo of the mainstream abstinence culture and tough-on-drugs policies. Funding is unstable, whilst federal funding for needle exchange was banned until recently. You will see way more rebels and punks at these events who discuss social justice and structural racism. While harm reduction is – sometimes grudgingly – accepted by even social conservatives in Western Europe, it is more like a Leftish guerrilla movement in the US, driven by drug user activists and radical social workers. The opiate overdose epidemic has been recently helping harm reduction become part of the mainstream – at a terrible cost in human lives and suffering.
In most Eastern European and Asian countries you often see broken down hospitals, burnt out and underpaid health professionals, and understaffed and under-equipped services. HIV infection and overdose death rates can be rampant. Criminal laws are repressive. Drug users are often coerced into so-called treatment programs. In this hostile environment, harm reduction could only lay down roots with the help of international donors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. Its positive impact is tremendous in reducing new infections and scaling up HIV treatment and prevention among the so-called key populations. Without the support of the Global Fund, these communities would have no voice and no future.
However, harm reduction dependent mostly on international donors is like a plant nurtured indoors by artificial light, with no deep roots in the cultural and political soil of the hosting society. Whilst the funding environment is favourable it may flourish. But as soon as it is deprived from international support and is exposed to the harsh outdoor environment, its fragility will be revealed. This happened when the Global Fund changed its funding policy after the financial crisis and many countries lost their eligibility. This resulted in the sudden collapse of many community-based harm reduction services and the further marginalisation of injecting drug users. Many people died as a consequence. Service providers tend to follow the flow of the money. Many abandoned harm reduction services and chose a different survival strategy. It soon appeared that by only focusing on funding services without investment into public education and community advocacy, international donors could not make harm reduction sustainable.
Donors do not only fund and shape harm reduction – they can also distort it.
For example, they often put harm reduction in the framework of HIV prevention and thus into the realm of public health interventions. National donors often subordinate harm reduction to treatment and prevention. These reductionist interpretations of harm reduction as a set of public health interventions are devoid of many other important dimensions of psychoactive substance use. For example, the social dimensions of poverty, exclusion, institutional racism and segregation, homelessness, and unemployment. Or the legal-political dimension of repressive criminal laws that are pushing substances and people who use them underground. To address these systemic factors harm reduction must go beyond public health interventions and mobilise marginalised communities against repressive and exclusive government policies and laws. Criminal justice reform must be an essential part of harm reduction – but it has not been on the agenda of many harm reduction organisations.
Second, putting harm reduction into the context of HIV prevention reduces its focus to only injecting drug use. While injecting drug users are far more marginalised than any other groups of drug users, harm reduction as a philosophy and practice must go beyond injecting use and transform the way we perceive drug use in general. It should include pragmatic and compassionate programs to reduce the harm of recreational drug use as well, for example in a party setting – even if it has nothing to do with HIV prevention directly. The vast majority of drug users are non-injecting recreational drug users, reaching them is not only important to avoid accidents, but can do a lot to promote the acceptance of harm reduction as a guiding principle among the general population. In countries where harm reduction is dependent on Global Fund, programs supporting party-going young people are underfunded and scarce. When streets were swamped with new psychoactive drugs, and new patterns of drug use and distribution started to trend among young people, programs designed to serve opiate injectors could not cope with these problems.
Third, big donors shape their grantees in their own image. It is very easy for NGOs competing for limited resources to lose sight of their mission and to follow the expectations of the donors in order to secure funding. But donor expectations about ideas, supported activities, regions and groups do not shape how NGOs and community groups work alone. To apply for grants, to manage grants, and to report to the donors requires huge investment in time and human resources. The bureaucratic processes required by donors change the perception of time, staff, services – and in the end, the mission of the organisation. Many grantees realise that for the donor it is not the real social impact that matters but organisational stability in managing and reporting grants. Community activists often transform into technocrats who lose the connection to the communities they serve. When activists speak a language full of jargon and acronyms only the selected few understand, their arguments do not appeal to the general public or to hostile neighbourhoods.
National and international donors must learn the lesson and invest more into community organising, public education, and advocacy to change social attitudes and policies about people who use drugs. Without transforming the set and setting, that is, the cultural and the political environment, harm reduction is vulnerable and cannot adapt to new challenges. Where harm reduction is not well embedded into and accepted by society, and not well connected to the community, sudden changes in the political environment can lead to collapsing services even in countries where national funding for services is available, as exemplified by my own country, Hungary.
Rigid rules by international donors about governance and co-funding favour big organisations based in wealthy countries over community activists living and working in repressive environments. These rigid rules do not guarantee the social impact of grants. Investment into people rather than just organisations, services, and projects can do. Sometimes the best ideas and initiatives come from grassroots activists and community groups without well established governance structures. Instead of requiring grantees to transform into grant processing companies, obsessed with Western-type management methods completely alien from community activists working on the ground, new flexible rules and modes of funding should be developed. Forging synergies among social movements is also important – they cannot win in isolation. They can learn a lot from each other about innovative advocacy methods to mainstream their messages. Only together they can fight austerity measures, rising right-wing populism, and the new authoritarian crackdown on civil society. In the end, the success of harm reduction as a movement depends on the larger context of social justice movements, the state of democracy, and the existence of a strong civil society.
Photo: Harm Reduction Coalition’s poster exhibition at the UN headquarters