Needle Exchange and the Geography of Survival in the South Bronx

Abstract

This paper explores the position of needle exchange programs (NEPs) in the “geography of survival” in the South Bronx neighborhood of New York City. Stemming the spread of HIV through the provision of sterile injecting equipment, needle exchange promotes the survival of injection drug users (IDUs) in the starkest sense; yet NEPs also attract a diverse population of service users whose attendance is not necessarily related to drugs. This paper locates NEPs among a larger constellation of social services accessed by residents of poor neighborhoods, including injection drug users, the homeless, the hungry, and those in need of medical services or just safe space. Drawing on ethnographic and interview data from a needle exchange in the South Bronx, I describe how both IDUs and others employed the organization to make ends meet, elaborating four “off-label” usages of needle exchange: as a place to obtain basic necessities, as a source of income, as a safe space, and as a site of social contact. As harm reduction in the United States moves towards an increasingly clinical model of care, this paper considers these latent functions of needle exchange within the context of a larger struggle over the content and meaning of harm reduction services. By themselves, NEPs are clearly an unsatisfactory solution to the economic and political circumstances that drive a variety of individuals through their doors; yet, in a country that lacks a comprehensive welfare system, needle exchange arguably represents an important thread within a social safety net that is being woven from the ground up. This study may be used argue for a (re)expanded mission for harm reduction in the United States, in the face of constant moves to narrow its mandate and reduce its budget.

Background

Needle exchange has long been promoted as an essential, life-saving technology, which reduces the mortality of injection drug users (IDUs) through the prevention of HIV transmission and accidental overdose. Indeed, the historic slogan “clean needles save lives” is not mere rhetoric; an embarrassing wealth of studies worldwide have linked needle exchange to a drop in reported syringe sharing amongst users, as well as continued reductions in the prevalence of HIV infection (among IDUs) in cities hosting needle exchange programs (NEPs) (Hurley, 1997; Des Jarlais, 2005). Emerging research has further shown NEP-based naloxone distribution programs to predict a decline in overdose fatalities among participants (Piper et al., 2007). Yet, while evaluation efforts have traditionally focused upon the effectiveness of needle exchange as a public health tool, its virtues arguably extend beyond matters of biological life and death.

In order to fully appreciate the benefits – and gauge the potential – of needle exchange, it may be necessary to define its role in promoting its users’ survival more broadly. This is particularly the case in New York City, where stand-alone needle exchange programs (as opposed to pharmacy-based exchanges) represent the major mode of sterile syringe access for illicit drug users (Rudolph et al., 2010). In New York City, stand-alone NEPs may assume several different service models, conducting exchange from a project storefront, during outreach excursions through local streets or single-room occupancy hotels, or via peer-delivery at user-negotiated sites; many organizations in fact offer multiple modes of syringe delivery. While different NEPs may vary in the types of ancillary goods and services provided, previous research has suggested that users may seek and receive more than just sterile injection equipment (Ruefli & Rogers, 2004). In addition to other health-related goods like condoms or hygiene kits that may be available at different NEPs, all programs arguably provide opportunities for meaningful social interactions (with staff, volunteers, and other participants), and many also offer a permanent enclosed physical space to rest in (ibid, 2004). This paper is specifically concerned with a New York City needle exchange program abiding by the latter, “drop-in” model, where participants are, at minimum, allowed to sit and/or sleep for the entire duration of opening hours. The value of the drop-in model may seem modest at first, yet its significance deepens when set against a social backdrop of endemic local homelessness in a gentrifying city.

Previous studies of homelessness among needle exchange participants in the United States have revealed upwards of 50 percent to be unstably housed, with HIV-positive individuals reporting rates up to 60 percent (Song, 2000); furthermore, needle exchange programs tend to be concentrated in poor neighborhoods boasting booming drug sales and an entrenched homeless population – areas historically condemned as social service “dumping grounds,” whose residents lack the clout to resist further socio-spatial stigmatization (Takahashi, 1997; Strike et al., 2004; Williams, 2007). Nevertheless, users’ right to occupy even these spaces is threatened, as gentrification in once working class neighborhoods continues to push the urban periphery outward or invade once “abandoned” inner cities (Staples, 2004; Smith, 2010). While new community opposition may hinder the development of social service facilities in progressively gentrifying areas, the obvious hardships of homelessness are increasingly exacerbated by the movement toward its de facto criminalization through the creative expansion of trespassing, disorderly conduct, and loitering laws, a trend that may particularly chafe against active drug users (NCH, 2007; Ehrenreich, 2009). While many municipal housing services are simply overwhelmed by the growing population facing or currently suffering from homelessness, their policies may also explicitly exclude present or past substance users from receiving assistance; in New York City, public housing, city-operated shelters, and single-room occupancy hotels all abide by an official policy of abstinence, while “Housing First” programs for active substance users are severely overwhelmed by demand (Fernandez, 2007; Bosman, 2010). At the same time, injection drug users may not be able to risk remaining on the street in locales that prohibit the possession of injecting equipment (in law or reality). While Seattle’s “Stay Out of Drug Areas” ordinance represents an especially severe example of the ways in which drug users are now spatially marginalized in the US, known drug users legally carrying injection paraphernalia are routinely harassed, if not arrested by police (Bluthenthal et al., 1999; England, 2008).

In helping homeless/drug users inhabit ever more hostile urban terrains, contemporary needle exchange programs arguably take their place in the “geography of survival” theorized by Don Mitchell and Nik Heynen. The authors poignantly characterize the geography of survival as “the spaces and spatial relations that structure not only how people may live, but especially whether they may live. For very poor people, such as the homeless, the geography of survival is knitted together into a network of public and private spaces and social services” (Mitchell & Heynen, 2009, p. 611). Placed within a wider neoliberal cityscape, the brutal geography discussed by Mitchell and Heynen, and mapped in this study, is one forged by the wits its inhabitants, yet constrained overall by laws targeting not only the homeless, but also substance users. In the United States, needle exchange and other harm reduction programs are perhaps the only institutions that openly solicit the presence of active, unrepentant drug users, while not necessarily allowing on-site drug use. (Interestingly, drug treatment programs also have a place in users’ geographies of survival, serving functions that are hardly straightforward or sanctioned by their overseers, as this paper will discuss.) However, by virtue of locations in peripheral and/or impoverished communities, NEPs may serve a more diverse participant population than their mandates may immediately suggest. To the dismay of some workers and service users, harm reduction programs have long been supplementing needle exchange and substance abuse services with HIV/AIDS prevention, testing, and care targeting the “general” population, an expansion that may itself be necessitated for organizational survival in a barren funding landscape (Lune, 2002). Yet, as observed in this paper, needle exchange programs also accommodate individuals whose interests stray far from HIV/AIDS, while participants who do exchange injection equipment may employ NEP drop-ins for a much vaster range of reasons. In this way, an institution designed as a relatively limited public health tool has become reimagined by its users as a general welfare center, occupying a paramount space in their personal geographies of survival.

Using ethnography and interviewing at a needle exchange program in the South Bronx neighborhood of New York City, this research describes the “off-label” uses of needle exchange within a population of generally poor and largely homeless service users who were all trying to make ends meet. By “off-label,” I mean to refer to the exploitation of needle exchange toward ends that were not formally sanctioned, or seen as reflecting its official raison d’être as a public health, and specifically HIV prevention, program. Of course, this definition is specific to a context in which needle exchange has been progressively redefined from above as a public health technology first and foremost (McLean, 2011; Smith, 2011). In contrasting participants’ de facto uses of needle exchange with the official mission upheld by some employees, this paper also documents the strain arising from NEPs’ “flexible” position within the local geography of survival. Needle exchange programs in New York State are not currently intended (nor adequately funded) to function as sites of general public assistance or recreation, and tension inevitably underwrites many interactions between needy service users and an underpaid staff, who may hold differing conceptions of the relevant “harms” in harm reduction (NYSDOHAI, 2009). However, with no reprieve anticipated from harsh laws and frigid job markets, this paper also considers how this and other drop-in-oriented NEPs might provide a vital service within neighborhoods characterized by “urban desertification” or inadequate housing and limited social services (Wallace, 1990). As of writing, at least half of New York City’s 13 stand-alone syringe exchange programs housed an area wherein participants could simply “be,” indefinitely, over the course of opening hours; while many offered services that extended beyond the provision of injection equipment, I have chosen to refer to my study site, and similar facilities, as needle-exchange programs (as opposed to the more general label of “harm reduction programs”), a term which reflects both their legal status and also distinct streams of public health funding in New York. The drop-in model described herein may in fact represent a dying industry, as harm reduction contracts in New York (deriving largely from the state AIDS Institute) stipulate ever more medicalized models, and “syringe services” are integrated into federally-funded substance use treatment programs; however, the uses of needle exchange observed herein point to the need for a (re)expanded definition of harm reduction in the United States that addresses the social inequalities shaping already constricted geographies of survival.

Methods

This paper is based upon twelve months of participant observation at a community-based needle exchange in the South Bronx (hereafter, referred to as “Bronx Harm Reduction”), from July 2010 through June 2011; it also draws on 30 semi-structured interviews with service users and staff, which were conducted as part of a larger study of risk and its construction in harm reduction. Positioning myself as a “researcher-volunteer,” I spent an average of 20 hours each week observing, assisting, and interacting with staff and participants at Bronx Harm Reduction, in a variety of spaces and situations: the main drop-in center, support and educational groups, meals and parties, staff meetings and trainings, and administrative offices. In this particular organization, two unisex bathrooms also served as venues for (brief) sociality. As a volunteer, I helped staff with relatively mundane tasks such as food service, cleaning, reception, and simple clerical work, assistance that facilitated the development of rapport; at the same time, my status as a researcher, and not a staff member, was consistently disclosed to employees and participants alike.

Given my anomalous appearance, it is likely that some participants initially perceived me as a figure of authority or official surveillance in the drop-in, an image I attempted to counter by allowing service users to first approach, and interrogate, me. Upon first meeting, many participants asked if I was a social worker, while others guessed me to be a visiting representative of the New York City Department of Health, or the Centers for Disease Control. Such labels stuck even after multiple corrections, while my self-identification as “researcher” was often questioned or amicably mocked by participants and staff alike. Several service users teased me about being an undercover journalist seeking to capture the “real story” of drug addiction, while one man joked that I was little more than a “spy” or “busybody” – terms that I myself sometimes used in describing my research method. In trying to be reflexive about the disciplinary effects of my presence, I generally engaged in non-directive conversations with participants, which allowed them to control the disclosure of personal information. Prior to the onset of both research and volunteering, this study was approved by the City University of New York (CUNY) Graduate Center Institutional Review Board.

Where much of this paper derives from informal conversations with staff and service users in the above contexts, I also cite formal interviews with 19 staff members and 11 program participants; this numeric imbalance in interview subjects reflects the research aims of the larger study, which focused on the “work” of harm reduction. Interview subjects were recruited via flyers posted throughout the agency, and brief announcements at one staff meeting, and one Participant Advisory Board Meeting. All staff members, peer workers, volunteers, and participants who were able to converse in English were eligible for inclusion as interview subjects. It should be noted that this linguistic requirement, reflecting my own lack of Spanish language skills, excluded a unique demographic from interviewing. Mostly representing recent arrivals from Puerto Rico, participants who spoke only Spanish were more likely to be homeless, and may have mobilized larger or more diverse geographies of survival, as compared to English-speaking participants at Bronx Harm Reduction. All interviews were digitally-recorded, and ranged in duration from 8 minutes to 2.5 hours; service users were given a 2-ride transit ticket (worth $4.50) in exchange for their interviews, while employees were not offered any incentive. Interviews focused on the construction and negotiation of risk messages in harm reduction, however, subjects were also asked comment on what service users “got out of” coming to Bronx Harm Reduction; they were further asked to define and describe the purpose of harm reduction, in their own words and opinion. Often eliciting individuals’ beliefs about the normative uses of needle exchange, these interviews also reflected subjects’ mixed feelings around its de facto functions for its users. Data analysis was inductive and iterative, with four major categories ultimately emerging to characterize participants’ off-label uses of Bronx Harm Reduction.

Site Background

One of three local needle exchange programs, Bronx Harm Reduction occupies several floors of a converted warehouse in the South Bronx, inhabiting a quiet side street, yet minutes away from several major thoroughfares. While staff members often refer to needle exchange as the “heart” of the organization, Bronx Harm Reduction offers an extensive, and expanding, roster of services related to drug use and HIV/AIDS. At the time of writing, HIV-positive participants were able to access case management, mental health care, medical escort services, and housing placement assistance; all participants were allowed to attend educational and support groups, obtain sterile injecting equipment, and receive free HIV testing and medical/social service referrals. A small onsite primary care clinic, offering limited medical services to all participants, was also poised to open in the near future. Perhaps Bronx Harm Reduction’s most distinctive feature, the multi-floor drop-in represented another space open to all individuals, and might be framed as a service in itself.

During this study, Bronx Harm Reduction was engaged in an ongoing total-facility renovation, which drastically altered the appearance and atmosphere in its main “public” spaces. Overall, the physical transition might be summarized as a move from a quirky, hodge-podge décor to a cleaner, more clinical, and streamlined aesthetic. This makeover was particularly noticeable in the main drop-in space, which was repainted a serene blue from a shocking green, and outfitted with two flat-screen televisions and two dozen padded chairs. The only space continuously open to all participants, the primary drop-in was typically the busiest, and noisiest, area in the building, adjacent to the needle exchange and a large group meeting room; it is also the first room one enters at Bronx Harm Reduction, and as a result, the drop-in often had the feel of a hospital emergency room. A participant bathroom was also situated on the first floor, boasting three stalls, a double sink, and a large shower for sign-up. During regular business hours, a second floor drop-in space was also accessible by participants, and offered a somewhat more relaxing, or less frenetic environment. Three vinyl couches were open to individuals who wanted to sleep, or establish a more elaborate camp, while another flat-panel television pegged to the “History Channel” was turned to an audible volume for most parts of the day. The second floor public space also contained a smaller group meeting room, and a tiny kitchen, from which lunch was served each day at noon.

As of 2010, Bronx Harm Reduction estimated its current participant population at around 3,000 individuals, including over 750 people living with HIV/AIDS. On average, around 200 participants signed in to the drop-in daily. Across all service users, approximately 60 percent reported past or present injection drug use, while 75 percent were homeless or unstably housed at intake; nearly all participants were currently unemployed, and receiving less than $10,000 in official annual income. Located in an area of intense migration from Puerto Rico and Latin America, Bronx Harm Reduction further claimed a participant population that was two-thirds Latino/a, nearly half of whom were monolingual Spanish; the remaining 33 percent of participants were largely African-American. As in most local needle exchange programs, participants were majority male, at 72 percent, with a mean age of 45. While showing a more balanced gender breakdown, Bronx Harm Reduction’s 33 staff members closely mirrored the ethnic composition of its service users. As a relatively young, white female, I was often the most conspicuous feature of the drop-in.

In locating Bronx Harm Reduction within its users’ geographies of survival, the unique landscape of the South Bronx must also be briefly described. Situated in the poorest Congressional District in the U.S., the South Bronx featured the highest levels of unemployment in New York City (13.4 percent), and the lowest median household income ($20,000) as of 2009 (Calahan, 2009; Fiscal Policy Institute, 2009). Borough-wide, Bronx residents represent about 1 in 4 people with newly diagnosed HIV in New York City, but account for more than 1 in 3 deaths; as of 2008, nearly 8,000 people in the South Bronx specifically were living with HIV/AIDS (Project Samaritan, 2009). These dire statistics may be perhaps summarized in others relating to the neighborhood’s status as a “social service ghetto” (Dear and Wolch, 1987). Within Bronx Harm Reduction’s 1.1 square mile zip code alone, at least six drug treatment programs - including five opioid maintenance programs - operated at the time of this study. While a new general intake center for the New York City Department of Homeless Services was still under construction as of March 2011, the South Bronx is presently home to several public and private shelters, and at least 10 single-room occupancy hotels – transitional housing sites reserved for individuals living with AIDS or symptomatic HIV who are eligible for subsidized shelter from the New York City HIV/AIDS Service Administration (HASA).

Results

In the following paragraphs, I describe the ways in which various individuals (e.g., housed and homeless, HIV-positive and HIV-negative, active and former substance users) used Bronx Harm Reduction to survive during my twelve months of research. Participant observation and interviews revealed four latent functional aspects of needle exchange, which are elaborated below: Obtaining Basic Necessities, Hustling/Income, Safe Space, and Sociality. Other organizations and spaces situated within participants’ local geographies of survival are addressed in a subsequent section. After depicting the “multiple logics” of needle exchange, and other social service organizations, for their users, I consider employee’s reactions to the flexible exploitation of their agency. The final discussion ponders the implications of these user-end functions of needle exchange for the philosophy and practice of harm reduction in the United States, which is simultaneously being molded from the “top-down,” by funding streams.

Obtaining Basic Necessities

Perhaps the most legible latent function of the Bronx Harm Reduction needle exchange was the provision of basic sustenance to a sizable population of hungry and often homeless individuals. By “sustenance,” I mean to refer not only to food and drink, but to the basic tools of survival more generally, including toiletries, clothing, and blankets. This usage of needle exchange may appear unremarkable at first, until one considers the ways in which these mundane resources structured participants’ relationships to and time at Bronx Harm Reduction, while attracting a diverse group of service users.

The importance of food in particular was manifest in both daily and monthly patterns of attendance that followed meal schedules. Asked what initially brought her to, and kept her at Bronx Harm Reduction, one participant exclaimed, chuckling, “free food!” On a daily basis, the drop-in population would spike without fail around 11:30 AM and 4:30 PM, when sign-up sheets for lunch and dinner were respectively made available. Similarly, festive dinners and parties for major and minor holidays alike drew participants rarely or never seen on a regular basis; indeed, infrequent visitors called in advance of Thanksgiving, Christmas and Easter to confirm the dates and times of special dinners. Consisting largely of microwavable meals, the quality of everyday lunch and dinner was often disparaged, and sometimes denounced as an indignation. Service users of greater means often held out for the “outside” food ordered for participants in certain support groups or service programs; indeed, take-out pizza or fast food often served as a carrot promised to potential attendees at bimonthly community meetings.

As implied above, the material goods to be gained by attending Bronx Harm Reduction served as explicit tools of organizational recruitment in a neighborhood hosting three “competing” needle exchanges. At the time of writing, Bronx Harm Reduction was commonly ranked second in terms of food provision by participants who patronized several programs. Indeed, many participants made no secret of attending a nearby exchange for its superior, “home-made” lunch, only wandering over to Bronx Harm Reduction in the late afternoon, for dinner. This second-place status was a source of light-hearted irritation to some staff members, who sought to attract individuals by offering other goods, often branded with the organizational logo: t-shirts, backpacks, sleeping bags, and coats. Participants in special training programs, such as the CDC-funded “Safety Counts,” were promised weekly “grab bags” typically containing soap, sweets, and sometimes soup; while some would joke about the predictable contents of the bags (“My weekly soap!”), others bore out each meeting impatiently, declaring openly that they only came for their grab bag. The ability to offer such resources was a point of organizational pride – and perhaps organizational survival in a time of drastic budget cuts to publicly-funded programs like needle exchange. At one observed community meeting, a peer worker fretted that Bronx Harm Reduction’s “puny” hygiene kits containing a small shampoo, soap, toothpaste, and razor were insufficient, and in fact embarrassing, by comparison to those offered by other organizations. Where participants relied upon this particular exchange for certain tangible goods, Bronx Harm Reduction also relied upon participants to show up, and justify revenue. While the agency’s funding contracts did not stipulate any quotas for daily or yearly attendance, Bronx Harm Reduction’s baseline funding was based upon the volume of individuals served each period. In light of local “competition,” and rumors of dwindling turnout, some workers at Bronx Harm Reduction realized the need to attract potential “patrons” using unique lures.

Hustling/Income

While Bronx Harm Reduction provided the above necessities gratis to its users, it also served as an informal marketplace in which participants could buy, sell, and exchange a wider array of products amongst themselves. In general, participants used Bronx Harm Reduction to generate income in ways that traversed the spectrum of legitimacy. In this setting, “income” might be considered to encompass not only money, but also “Metrocards,” i.e. New York City mass transit passes. As in many social service organizations, Metrocards were the ubiquitous currency paid for user participation in meetings, support groups, and other odd events at Bronx Harm Reduction. Consequently, the pursuit of Metrocards or “carfare” might represent the most iconic hustle at Bronx Harm Reduction, which was (for the most part) amiably tolerated by staff. It was not unusual to see staff and participants joking about occasions on which participants had “gotten over” by taking more than one Metrocard; in fact, such anecdotes were told repeatedly, like old family stories, while the “shifty request” and “adamant refusal” of extra Metrocards played like a scripted interaction between service users and staff. Likewise, the inquiry “What group is this?” was frequently met with the laughing response “The Metrocard group!” Where some participants obviously employed their carfare for transportation to and from the organization, many commanded an impressive wad of unused Metrocards that simply accumulated within their wallet or pockets, openly fretting when their stock was “running low.” It should be noted that this study also participated in the local carfare economy, offering service users a packaged $4.50 (2 ride) Metrocard as an interview incentive – resaleable at local bodegas for three dollars.

Bronx Harm Reduction also offered its users opportunities to make real money through a handful of short- and long-term jobs, whose salary ranged from $10 per day to $100 per week. All such positions were fiercely coveted, despite limited pay, often tedious work, and strict supervision. Part-time “peer” positions, garnishing the highest income, were officially held for a year, and came with lengthy application processes; the opening of one such job during the study period attracted dozens of applications, from both regular and infrequent visitors to the exchange. Less desirable day-to-day jobs in maintenance or food service were generally filled on a first-come, first-served basis, while one individual might informally claim a position for weeks or months at a time. Though less competitive than peer positions, such positions had the advantage of being “off the books” - and thus did not threaten individuals receiving cash benefits from public assistance. Many service users voiced an interest in permanent full-time (i.e., non-”peer”) work in any area of Bronx Harm Reduction, yet no such positions were made available during this research.

Populated by individuals boasting limited money and oftentimes, recreational drug habits, Bronx Harm Reduction also served as an ideal site for more entrepreneurial participants looking to engage in less-than-legal sales. While several participants were terminated and/or arrested for selling illegal drugs on-site, individuals were also observed selling cigarettes, clothing, jewelry, electronics, and medicines during the study period. Noting that they offered lower prices to individuals who lacked the time, or simply felt uncomfortable patronizing regular stores, some “salesmen” saw themselves as providing an essential service to the drop-in community. With the exception of illicit drug sales, staff typically turned a blind eye to these transactions, and occasionally succumbed to a good deal – particularly after New York State raised the cigarette tax in July 2010, resulting in a $10-plus price tag per pack.

Safe Space

When asked simply “what participants got out of” coming to Bronx Harm Reduction, nearly every staff member and service user noted the organization’s de facto service as a “safe space,” with varying degrees of approbation. In using this term, most individuals meant to refer to the use of the drop-in as a proxy home for participants lacking stable shelter. Indeed, short of providing an overnight bed, Bronx Harm Reduction mimicked many of the amenities of permanent housing for twelve hours each day. Participants were allowed to sleep, undisturbed, in chairs, on couches, and even during support groups (so long as they didn’t snore). A spacious shower and washer/dryer were available on a sign-up basis, and rarely lacked for users; the popularity of these facilities sometimes resulted in conflict between service users, and further, between staff members, particularly when “non-participants” from the community attempted to access them. Given the large number of homeless participants who visited the drop-in daily, competition extended beyond shower and laundry time to locker space, and in fact, wall outlets - for charging cell phones. Irrespective of their housing status, many service users chose to receive mail at Bronx Harm Reduction, while listing the organization’s main phone line as their primary contact.

Though the dangers from which Bronx Harm Reduction protected its users often remained implicit in its “safe space” labeling, they were readily apparent in group discussions and participant observation in the drop-in. The most commonly reported danger faced by housed and unhoused participants alike at Bronx Harm Reduction was police harassment. Many participants complained of being detained, questioned and searched by police regularly, for no legitimate reason; the rationale for this harassment typically proposed by participants referenced their status as often homeless, largely minority, past and present drug users. Some perhaps accurately attributed their targeting by police as consequent to their affiliation with Bronx Harm Reduction - an organization visited by local police officers with some regularity. While a recent amendment to New York City’s criminal code legalized the possession of syringes by needle exchange participants, it was not uncommon for users to report detention for syringe possession nevertheless. On multiple occasions over the study period, police vans were seen parked within a block of the drop-in, prompting staff members to dissuade participants from standing in front of the building – an act understood to be boldly courting arrest.

While thus shielding participants from treatment as criminals, the drop-in further likely protected its users from victimization by criminals. Individuals living on the street were obviously at a loss to reliably keep their belongings from thieves, particularly those whose alertness was compromised by legal and illegal substances. Overall, the individuals who appeared most vulnerable - to police harassment, muggings, or “getting punched in the face,” as one participant put it - were those maintained on relatively high doses of methadone, who were allowed to “nod” at Bronx Harm Reduction, for the most part, unperturbed. With a significant portion of service users enrolled within local methadone maintenance programs, this study in many ways illuminates needle exchange and methadone maintenance as complementary programs in unintended ways. Many studies have noted that needle exchange programs boast high rates of participant referral to substance use treatment programs like methadone maintenance, thus (in theory) advancing such individuals’ struggle toward long-term drug abstinence (Hagan, 2000; Riley, 2002). Yet, for many homeless, methadone-maintained participants, Bronx Harm Reduction remained ensconced in their geographies of survival, whether or not they continued to use illegal drugs.

Sociality

Perhaps the most moving latent function of Bronx Harm Reduction was its use as a site to reestablish or maintain social contact. Feelings of isolation and loneliness were problems that appeared to unite service users presenting with vastly different housing, medical and substance use concerns. For participants living on the streets (or within shelters that were scarcely better), the drop-in provided an opportunity to interact with others in what might be termed a “normal,” non-judgmental context (see also Macneil & Pauly, 2011). In the words of one staff members, the drop-in gave such individuals “the chance to become human again.” While this statement may read as pejorative to those described, its author meant rather to convey the dehumanizing conditions, and treatment, experienced by many homeless participants. Indeed, describing his initial enrollment within Bronx Harm Reduction, one participant admitted, “I wasn’t sure whether I was an animal or a human anymore.” By “validating the humanity” of those who feared it lost, Bronx Harm Reduction allowed such individuals to re-develop basic social skills requiring a fundamental level of trust in themselves and others.

At the same time, many participants who were housed and financially stable used Bronx Harm Reduction as a means of fending off the loneliness that came with having their own apartment. Living off public assistance and occasional part-time work, such service users reported that they came to the drop-in simply because they had nothing to do at home. Many housed participants received their apartments with the assistance of the New York City HIV/AIDS Service Administration (HASA), and had relatively limited choice regarding neighborhood. In the end, individuals thus housed were often forced to accept apartments in places far removed from friends and family. Coming to Bronx Harm Reduction to “make a group,” volunteer some hours, or just watch TV in the drop-in provided such participants with some temporal structure necessary to avoiding a sense of aimlessness or depression. The inception of Saturday drop-in hours during the study period was heralded as an obvious boon for homeless participants, who otherwise might suffer two straight days on the street; yet, housed participants also celebrated the Saturday program as a too-short antidote to otherwise too-long weekend. Such service users sometimes described extended networks of social survival, weaving beyond the South Bronx, to include other New York City social service organizations offering free classes, trainings, or weekly dinners. The situation of these individuals might be seen as pointing to enduring holes in the local geography of survival, which failed to provide full-time, permanent employment opportunities. Peer educator positions at Bronx Harm Reduction and similar organizations appeared to be the most accessible line of paid work for participants; however, these jobs too were maddeningly scarce, and stipulated lengthy applications processes that rejected candidates experienced as arbitrary or “political.” Of course, the persistent absence of work in the South Bronx may also be understood as highlighting the perfect, inescapable continuity of this geography, which guaranteed little beyond mere survival.

Mapping the Larger Geography of Survival

Participants described broader geographies of survival that, for the most part, remained within the boundaries of the South Bronx, and within the purview of harm reduction or HIV/AIDS services. Such geographies were both spatially- and temporally-patterned, as participants cited daily, weekly, or seasonal schedules of attendance at different organizations and spaces. The spatial and temporal constraints fixing these geographies were clearly related, as individuals bemoaned not only the cost of moving around the vast city, but also the time required to reach other potentially fruitful services in the often far-flung, peripheral neighborhoods that tended to host them. Given otherwise baroque schedules of appointments with clinics, public assistance workers, and shelters, leaving the neighborhood seemed a near impossibility for some participants. Obviously, such “formal” institutions comprised vital links within many participants’ survival networks, granting health care, income, food, and a bed to sleep in. Yet, following the discussion above, this section will again concentrate on the off-label exploitation of different community organizations.

Fulfilling a multiplicity of participants’ needs, the two other needle exchange/drop-in centers in the neighborhood appeared to assume comparable importance to Bronx Harm Reduction in the individuals’ geographies of survival. Located less than ten minutes away in either direction, these programs may be seen as giving rise to a “participant stream” that flowed over the course of a day or week. As mentioned previously, another local needle exchange was famous for its hot, homemade lunches, resulting in a massive queue of individuals each day at noon; accordingly, some service users strategically spent their morning at this program, hoping to avoid the line, while others would attend Bronx Harm Reduction for their “first lunch,” only wandering over to their second once the crowd had subsided. Likewise, the third local drop-in was known to distribute grocery store gift cards every other Tuesday, thus drawing a biweekly turnout of informed individuals.

Despite the service similarities between these three organizations, participants often described them as representing very different, discrete, and almost insular communities. For individuals who had been officially “terminated” or unofficially alienated from one program, refuge might be sought at either or both alternatives; indeed, on several occasions, participants who felt persecuted by staff, or unfairly passed over for peer positions at Bronx Harm Reduction threatened to “take [their] talents elsewhere.” At the same time, some service users seemed to relish the relative independence of each program, describing each as comprising a unique social circle, which they visited according to the time, the day, their needs, or moods. Taken together, these drop-in centers formed a web of social obligations that kept such participants comfortably busy, out of their apartments, and/or off the streets.

Apart from such “low-threshold” organizations, which offered little in the way of formal structure or participation requirements, service users also mobilized more regulated and rule-bound institutions toward creative ends. Despite attending Bronx Harm Reduction, a site ostensibly aimed at active drug users, many individuals were simultaneously enrolled in outpatient drug treatment programs, which formally prohibited or discourage illicit drug use. While enrollment might accurately reflect an individual’s desire to achieve or maintain abstinence, such programs also met a multiplicity of user needs. For example, individuals receiving methadone were also allotted monthly transportation checks, which represented a crucial source of income for participants struggling to pay mounting bills. In fact, this seemingly modest financial incentive, intended to promote treatment adherence, was experienced by some participants as a form of treatment compulsion, binding them to a regimen they might yearn to stop. Discussing his dependence on monthly carfare checks, one individual exclaimed that he would immediately detox from methadone if he were otherwise able to pay his monthly electricity bill. Detox programs, which sent daily pick-up vans to Bronx Harm Reduction, were employed by participants not only looking to cease or reduce their habits, but by those simply seeking a warm place to sleep, particularly in the winter. For individuals’ lacking insurance, or simply wary of committing to any treatment program, the emergency room at the neighborhood hospital was also an option of last resort on a cold winter night.

Staff and Peer Reactions

Full-time employees and peer workers expressed conflicting feelings about the de facto uses of Bronx Harm Reduction, whose public health mandate was always billed first and foremost. While not obeying strict divisions, staff members’ approbation of needle exchange as a broad tool for survival often followed from individuals’ position and time at the organization/in harm reduction. In general, staff members who had spent most or all of their working lives in the field of harm reduction (sometimes at Bronx Harm Reduction alone) expressed greater tolerance for participants who used the needle exchange toward diverse ends. Often former users of illegal drugs, needle exchange, and Bronx Harm Reduction themselves, such individuals often identified with drop-in users, while citing homelessness, isolation, and lack of income as major risks for and of drug use. One staff member, who obtained his first job at Bronx Harm Reduction, went so far as to say that he was happy to give participants whatever he could, stating that he’d “rather they hustle me than hustle on the street.” By contrast, staff members relatively new to the field of harm reduction, and occupying administrative or supervisory positions, viewed such an attitude as irresponsible and potentially harmful to the organization – and its users. Viewing the organization’s provision of basic social services to be indicative of mission slippage, such staff members believed the “real work” of risk reduction thus threatened. For these individuals, harm reduction was a term exclusive to programs directly addressing individual HIV risk behaviors – like needle sharing, or unsafe sex. Overall, staff dissonance surrounding the off-label uses of Bronx Harm Reduction, particularly by non-drug users, or non-participants, exacerbated existing interpersonal tensions; they also revealed a range of understandings about what “harm reduction” should or could involve, and consequently, what the real harms of drug use were. It should be said that the many needs presented by participants were obviously overwhelming to a limited staff of modestly-paid employees. Where many staff members wished to offer as many possible life-saving services to participants, the organization was not sufficiently funded or staffed to serve such a wide mandate. This tension was encapsulated in the presence of two contradictory signs in food service areas, one reading “Feed people first. They might be on homeless on the streets” and the other stating in bold capitals “THIS IS NOT A SOUP KITCHEN.”

Conclusion

Upon seeing the drop-in for the first time, one visitor to Bronx Harm Reduction asked, perplexed, “What is everyone waiting for?” Given many participants’ long-term “careers” at the organization, this question seemed particularly poignant. Seen in the worst light, the needle exchange drop-in may appear as a crowded waiting room where there is no end in sight. Indeed, for participants who were not HIV-positive, and thus ineligible for housing assistance from the New York City HIV/AIDS Service Administration, there were few prospects for improvement. In accepting its role as a way station for socially displaced individuals, Bronx Harm Reduction implicitly defined its diverse users as lives worthy of intervention; at the same time, the organization did little to openly challenge the politics of abandonment that led them there (see also Evans, 2010). This is not to blame this, or any other needle exchange programs in New York City, which are simply not authorized or paid to address the social, political, and economic factors underlying and following substance use. Instead, NEPs and other harm reduction-oriented organizations are charged with providing services and disseminating information that frame HIV as the major risk attendant to drug use. Ultimately, harm reduction programs are encouraged to empower their users as subjects of public health interventions – not to advance their basic rights as citizens and city residents. Evoking Sônia Fleury’s notion of “inverted citizenship,” these individuals are extended limited health and social assistance in the absence of real civil or political rights (cited by Biehl, 2001, p. 136).

In describing the geographies of survival mobilized by the participants of Bronx Harm Reduction, this paper does not seek to show how individuals “scam the system,” but rather endeavors to discuss how their behavior illuminates its enduring gaps. As theorized by Mitchell and Heynen, geographies of survival reflect individual attempts to live in the face of economic and social policies that may condemn them to death – from exposure, hunger, and other socially-generated pathologies, such as drug addiction and HIV. A strategy developed largely in response to the American “War on Drugs”, needle exchange has become an important tool of survival for street-based substance users, who require not only clean works, but a respite from a society that harshly punishes and stigmatizes certain types of drug use. As this paper has shown, the non-judgmental philosophy and service environment that characterize needle exchange attracts many non-users in need of basic amenities as well. Such unlikely service users speak to not only the relatively inviting atmosphere of needle exchange programs, which at this point demand little of their participants, but also to the dearth of options faced by many long-time poor individuals in a country that lacks a comprehensive and adequate system of public assistance. In New York, for example, single adults are eligible for merely two years of severely limited welfare benefits – for which over 40 percent of applicants were denied in 2007, the last year of data available (FPWA, 2009). In the absence of a public system of social protection, Bronx Harm Reduction, and other needle exchange programs, have become important threads within a social safety net that is being woven from the ground up.

While clearly unsatisfactory as a long-term solution to the economic and political circumstances that drive a diversity of individuals through its doors, Bronx Harm Reduction is a necessary site of triage in a community crippled by poverty, unemployment, homelessness, and drug use. Of course, needle exchange programs cannot alone be expected to alleviate the brutalities of late capitalism and welfare revanchism, but this study may be used to argue for a (re)expanded mission for harm reduction in the United States, in the face of constant moves to narrow its mandate and reduce its budget. In New York State specifically, a diminishing amount of public health funding increasingly demands of its needle exchange contractors the implementation of clinical models of care, a more stringent focus upon medical outcomes, and the deployment of a more professional, or credentialed staff. Funded to address the physical, and yet forced to deal with the social harms that precede and derive from drug use, organizations like Bronx Harm Reduction experience a never-ending strain on their finances and staff energies, while participants remain frustrated with the disproportionate attention to their biomedical needs. And yet, the unofficial, or “off-label,” uses of needle exchange described in this study need not remain so: with the necessary political, economic and legal support, need exchange programs may be able to offer their users a comprehensive and nutritious food service, free short-term or low-cost long-term housing, and a vastly expanded number of satisfying, fair wage jobs. Without the threat of lost contracts or political reproach, needle exchange and other harm reduction programs in the US may begin to espouse (or revert to) a more radical politics of social justice for not only drug users, but the largely disenfranchised communities from which they come (Roe, 2005). In short, harm reduction may actively engage the politics of abandonment that create and constrain its users’ geographies of survival.