Reclaiming Harm Reduction
Here is a piece I wrote while working for the People, Place, and Health Collective. Much has changed since with the new wave of attacks against public health, and now more than ever I believe that we must connect back to the work of liberatory harm reduction over capitalist and institutionalized forms of care to support our communities.
The U.S. is facing an overdose epidemic due to prohibitionist drug policies that created the conditions for fentanyl toxicity in the unregulated drug supply, and state violence towards people who use drugs (PWUD) upheld through intersectional forms of social, racial, and economic oppression. PWUD confront stigmatization, dehumanization, and a system of criminalization that impacts their access to healthcare, housing, resources, and community.1 In response to the overdose epidemic, government and public health institutions are employing harm reduction practices to prevent drug related death and disease. Over the years, the practice of harm reduction has expanded from a grassroots movement led by and for people with lived experience of intersectional forms of harm from drugs, poverty, sex, and disease into a top-down evidence-based approach led by institutions. As harm reduction at the institutional level expands, practitioners, researchers, clinicians, and staff need to reckon with how their institutions uphold harm towards the communities they seek to help and connect back to the political roots of harm reduction.
A Decolonial Orientation
One of the earliest forms of prohibition in the United States came with colonization and the criminalization of alcohol and sacred medicines in Indigenous communities. In the late 1800’s states banned the sacred psychoactive peyote, a medicine used in the Ghost Dance, a pan Indigenous spiritual resistance movement. These prohibitionist policies aimed to silence the Indigenous resistance forming in response to U.S. expansion and colonization across the west.2 Similarly, the 1970’s War on Drug policies sought to exert control over groups thought to be a threat to the state, including African American, latine, Indigenous Peoples, and hippies. 3 Decolonial theory argues that colonial violence is embedded within the knowledge systems, social structure, and policies that shape the modern world.4 From this understanding, decolonial theory and methods are critical in thinking about the opioid epidemic and War on Drugs, as the prohibition of drugs is directly linked to colonial practices and systems that persist today. Decolonial methodologies center the voices of marginalized communities and value forms of knowing that fall outside dominant discourses of scientific objectivity to drive decision making. Decolonial methodologies encourages researchers to question the underlying assumptions and biases they hold while working to deconstruct colonial worldviews in academic disciplines, research, health practices, and society. 5
Harm Reduction
The history of harm reduction in the United States is connected to anarchist principles, social activism, and grassroots approaches that defied state authority to pass out clean needles, safer sex supplies, and demand a change to systemic barriers to health care, among other practices.6,7 Social worker and activist Shira Hassan notes in her book, Saving Our Own Lives, harm reduction was founded by predominately queer, trans, black, brown, and Indigenous people who use drugs, sex workers, people with disabilities, people experiencing poverty and homelessness, and those living with HIV. Hassan and her colleagues created a definition of liberatory harm reduction as, “A philosophy and set of empowerment based practices that teach us how to accompany each other as we transform the root cause of harm in our lives.”7 The liberatory framework aimed to disentangle ideas around sobriety as a requisite to receive care, noting that the ultimate goal of harm reduction as a public health intervention is not sobriety and recovery, although these are important options for people who chose them. The movement is decolonial in nature, recognizing that the harms from disease, drugs, overdose, and stigmatization are directly connected to settler colonialism, racism, ableism, and structural violence. 7 Passing out clean needles, Narcan, and safer safe supplies in a nonjudgmental space are a part of harm reduction from this model. However, the definition Hassan presents shows that harm reduction is more than that, it is a community liberation practice that recognizes the roots of harm are deeper than the individual decisions a person makes, harms are embedded in a larger web of history and policy connected to colonial systems.
The Substance Abuse and Mental Services Administration (SAMSHA) defines harm reduction as “a practical and transformative approach that incorporates community-driven public health strategies — including prevention, risk reduction, and health promotion — to empower PWUD and their families with the choice to live healthier, self-directed, and purpose-filled lives.” 8 Yet, the drug information available on their site centers on the negative consequences of drugs, 9 promoting fear mongering techniques instead of a holistic understanding of the benefits and risks of drugs that liberatory harm reduction promotes. Further, notice that SAMSHA describes harm reduction as a way for individuals to make “healthier and self-directed choices.” This focus on individualism and a sense of making “better” choices points to an important underlying ideological tension between grassroots harm reduction and top-down institutional harm reduction that reflects a decolonial versus neoliberal framework at the heart of these two approaches.
The Reagan era neoliberal revolution of the 1980’s, coinciding with the War on Drugs, promoted the idea that “human well-being can best be advanced by liberating individual entrepreneurial freedoms and skills within an institutional framework characterized by strong private property rights, free markets, and free trade.” 10 Neoliberal policies promote deregulation and privatization of all aspects of social life, which contributed to the rise of the prison industrial complex, major cuts to social services, and the commodification of health care. Healthcare shifted from a human right to a product to be bought and sold, and the quality or access to care became dependent on wealth.10 Another defining aspect of neoliberal thought is that, “all forms of social solidarity were to be dissolved in favour of individualism, private property, personal responsibility and family values.” Neoliberal policies have had detrimental consequences for access to health care, and other fundamental human rights to housing, food, and safety, while using the rhetoric of individual responsibility and blame when a person cannot access these rights under capitalism.10 Harm reduction through neoliberal systems then, reinforces harms from drugs as an individual responsibility as seen through SAMSHA’s definition instead of as a decolonial approach to addressing the harms and inequities that persist as root causes of the overdose epidemic. The appropriation of harm reduction by institutions is concerning because it risks distilling harm reduction into a public health intervention that serves as a band aid over failed policies brought about through the neoliberal reforms of the U.S. economy.
Re-politicizing harm reduction
At its core, harm reduction is political and decolonial, emphasizing that larger structures of power from the medical industrial complex, prison industrial complex, and state violence that drive the overdose crisis must be dismantled to have meaningful change. 7 And, as anthropologist Christopher Smith concludes in his article, Harm Reduction as an Anarchist Practice, harm reduction must be re-politicized in the institutions that are using the practices to address the opioid epidemic.6 The re politicization of harm reduction includes researchers making, as anthropologist Gordon Roe proposes, “‘direct political critique of the social and legal systems that create harm.” 11 Like Shira Hassan, liberatory harm reduction researchers are actively engaging in disrupting social and legal systems creating harm in their communities. Zoë Dodd made headlines when she and her peers took direct action in defiance to the state in order to open up a safe injection site in a tent in the heart of Toronto during a spike in overdose deaths.12 I worked with psychedelic therapists and healers who practiced underground for years to provide lifesaving interventions with psychedelics to people suffering while creating communities of support for each other before psychedelic therapy legalization and commercialization in Colorado. As researchers, clinicians, government staff, and people in positions of power within social systems employing harm reduction methods, we have a responsibility to do the critical work of decolonizing and dismantling not only the War on Drugs, but the structures within our own organizations that work to uphold inequities against the populations that we seek to serve.
1. Antoniu Llort Suárez RCG. Public policies for people who use drugs: Strategies for the elimination of stigma and the promotion of human rights. Salud Colectiva. 2021;17. doi:10.18294/sc.2021.3041
2. Calloway CG. First Peoples: A Documentary Survey of American Indian History. Bedford/St. Martin’s; 2011.
3. Provine DM. Race and Inequality in the War on Drugs. ANNUAL REVIEW OF LAW AND SOCIAL SCIENCE. 2011;7. doi:https://doi-org.revproxy.brown.edu/10.1146/annurev-lawsocsci-102510-105445
4. Quijano A. Aníbal Quijano:Foundational Essays on the Coloniality of Power. Duke University Press; 2024.
5. Smith LT. Decolonizing Methodologies : Research and Indigenous Peoples. Bloomsbury Academic & Professional; 2021.
6. Smith CBR. Harm reduction as anarchist practice: a user’s guide to capitalism and addiction in North America. Critical Public Health. 6/2012;22(2):209-221.
7. Hassan S. Saving Our Own Lives: A Liberatory Practice of Harm Reduction. Haymarket Books; 2022.
8. Harm Reduction. SAMHSA Substance Abuse and Mental Health Service Administration. Published April 24, 2023. Accessed April 4, 2024. https://www.samhsa.gov/find-help/harm-reduction
9. Alcohol, Tobacco, and Other Drugs. SAMHSA Substance Abuse and Mental Health Administration. Published June 6, 2023. Accessed April 4, 2024. https://www.samhsa.gov/find-help/atod
10. Harvey D. A Brief History of Neoliberalism. Oxford University Press; 2005.
11. Roe G. Harm reduction as paradigm: Is better than bad good enough? The origins of harm reduction. Critical Public Health. 9/2005;15(3):243-250.
12. CTVNews. ca Staff. Unsanctioned pop-up safe-injection site opens in Toronto. CTV News. August 14, 2017.