Henceforth harm reduction?

Going forward…

The argument put forth by Greenfield and Paoli (2011) has the same “intuitive and perhaps innate appeal” that the authors suggest “harm reduction” has in drug consumption policies and public health. The authors suggest a bold leap in adapting the philosophy and goals of harm reduction, which have thus far mostly pertained to drug consumption, and apply them to drug supply-oriented policies. In this they are making a shift from policies and activities which aim to decrease drug related harms to individuals to understanding those which may decrease harms to macro systems including nations and regions, particularly those involved in the growing and manufacture of drugs. The premise this is built upon is that current drug supply control policies are ineffective, at times enabling political unrest, fomenting economic disruption and – at best only holding the floodgates of supply, while at worst producing paradoxical results. They strongly suggest that expanded risks and benefits analyses of current supply-reduction policies can minimize macro harms.

Their call for a rethinking of supply-oriented drug policy is timely and essential. The recent report by the Global Commission on Drug Policy highlights the failure of the so called “war on drugs” (Global Commission on Drug Policy, 2011). Specific examples of deleterious effects of supply-side policies abound, e.g., the introduction of US bound heroin from Colombia as a paradoxical effect of Andean cocaine control policies confounded by globalization (Ciccarone et al., 2009a).

The strengths of the argument include the adaptation of MacCoun's integrative model in which harm can be conceptualized at micro-practice and macro (cumulative) levels. In addition, the authors argue for a full accounting model so that one can compare policies to find those which minimize “risks net of benefits” within counties and across regions. Their proposal is bold, interdisciplinary and reveals intellectual rigor.

In discussing the limitations of the MacCoun model, the authors question the plausibility of developing per use estimates of indirect (non-user) macro-harm. However, it is essential to develop these per-use estimates of macro harm due to crime, etc and account for them in demand-reduction versus harm-reduction comparisons, e.g., sustained demand reduction may lead to decreased harm due to reduced production and distribution. These per use estimates (if I may offer a suggestion) may come about by using purity adjusted drug units (e.g., milligram pure heroin), which can be the connecting unit between supply-side and demand-side equations, making a bidirectional integrative model. Using the heroin market as an example, the proposed policy analyses should include the effects on heroin sourcing which may entail changes in heroin type/quality leading to differential public health consequences and costs (see e.g., Ciccarone, 2009b).

Looking back…

One crucial point of contention is over the use of the term “harm reduction.” As a person working as a scholar of and practitioner (indeed advocate) within Harm Reduction for 15 years, I have a clear frame of reference for what it is- based on lived experience. The authors discuss the debate over the definition of “harm reduction,” but I find their review of the well-known voices in the public health and drug policy literature as an ahistorical one. Without historical and sociocultural grounding their definition is only metaphor: reducing harm to individuals by decreasing doctrinaire moral stances on drug consumption: reducing harm to nation-states by decreasing doctrinaire moral stances on drug production.

As a scholar examining HIV prevention among marginalized populations, using and seeing Harm Reduction as a grounding point for all my work these past 15 years, this is my historical and sociological definition: Harm Reduction is a movement, a manifestation of cultural resistance to oppressive US and European drug policies which didn't adapt quickly enough to the terrible effects of the HIV epidemic. This movement, like the academic definitions, is diverse with philosophical and political heterogeneity. An underlying goal, stemming from HIV prevention, seems to connect all variants: prevention of the worst harms due to drug consumption is preferable to absolutist stances on drug abstinence. Part of this movement is based on the human rights of self-determination (e.g., having choice to use drugs) and self-preservation (e.g., acquiring tools/skills to avoid HIV). All of which brings me back to history – as a movement its point was to be contentious, righteous and resistant, and this flows outwards from the source. The liberal (in the American sense) adaptation of the principles of this once radical stance for public health policy is also contentious and has by-and-large been adopted only by large cities in democratic leaning states in the US. For example, many US states do not have any local or statewide protection for one of the basic and universal tenets of Harm Reduction: access to clean syringes.

Eyes beholden…

Greenfield and Paoli indentify many of the conceptual and technical challenges of their bold vision, but go light on political realities; e.g., how will the output of their analyses be implemented given the power differentials across drug producer, transporter and consumer countries' borders? Can the self-determination and self-preservation rules of the Harm Reduction movement make the jump from person to country, from demand- to supply-side policies? They propose realism over radicalism (taking off from this author's historical critique), but do they really suspect that global change, in a policy field so contentious, is going to be won by written argument and flowchart analyses? History is a bit hotter than that, and the epochal forces of globalization have and will continue to spark fires, both progressive and regressive. Perhaps this force coupled with the proposed rational evidence can make beneficial change. We'll see. Metaphorically speaking, time will tell…