Ernst Buning argues that those advocates of harm reduction now need to realise that their ideas are part of mainstream thinking in drug policy and it is only by adapting this stance that further advances will be made
Harm reduction is 'mainstream thinking'. Many may raise their eyebrows reading such a title. The outreach worker who has just had a conflict with the neighbourhood about handing out needles to drug users may wonder if it is really true that harm reduction is mainstream thinking. The workers in the drop-in centre that had to close down because politicians didn't want drug users to gather, take a shower and get something to eat, may wonder if it is true that harm reduction is mainstream thinking.
Although it is realised that the practice of harm reduction is still difficult, it is nevertheless argued that harm reduction is mainstream thinking. In this paper, this is clarified and thoughts given on what can be done to make politicians, policy-makers and the public accept harm reduction among drug users as a real option.
When cars were first introduced, they were seen as hazardous to public safety. Soon, cars were made safer and, in the last 20 years, a whole range of measures has been introduced to reduce the harm effects of cars. Examples of measures are: safety belts, traffic lights, viaducts, mandatory regular check-ups, speed limits etc. With these measures it is hoped that less harm is done to motorists themselves and other road users. Then, some 10 years ago environmental issues came about. Although some people still say that cars should be banned, more emphasis is given to developing cars that are less hazardous to the environment- including measures such as the production of cars that run more economically, the introduction of unleaded petrol, and the introduction of cars with catalytic converters and even cars with electric motors. Measures taken towards improving safety and towards protecting the environment can both be seen as classic forms of harm reduction.
Another example is smoking. Everybody knows that smoking is bad for the health. Mass media campaigns bombard the public with information about the dangers of smoking and yet a considerable percentage of people continue to smoke. When it became apparent that a smoke-free society was not a feasible goal, harm reduction measures were introduced, such as low-nicotine cigarettes, no-smoking zones in public buildings, reduction in health insurance for non-smokers etc. Again, a classic example of harm reduction.
The third example is alcohol consumption. Although some people are still striving for an alcohol free society, most people in Western society accept the idea that moderate alcohol consumption is not harmful and even pleasant. But it is realised that alcohol consumption in certain settings is more dangerous than in other settings. In most Western countries, measures have been taken to reduce or even forbid alcohol consumption in certain settings, such as alcohol and traffic, alcohol and work, and alcohol and football games. The alcohol policy at the World Cup Football in 1990 in Italy was a good example of the latter. So, in the alcohol field, harm reduction is an accepted option.
The harm that drug users cause to themselves and
others can take various forms:
| Type of harm | Individual level | Societal level | |||
|---|---|---|---|---|---|
| Social harm | Relations Imprisonment | Nuissance Crime | |||
| Economic harm | Loss of productivity | Loss of productivity costs (treatment, prison, police) less income through tourism | |||
| Medical harm | AIDS, tuberculosis, hepatitis B | Source of infection |
Based on this overview, one can formulate aims at which the harm-reduction projects are targeted and develop research methods to assess whether or not the aims are met. Comparing the harm caused by drug use to the examples given previously, one major difference is clear, drug use and drug dealing are illegal. Clearly, this makes it more difficult to come up with comprehensive harm-reduction measures. Nevertheless, one may wonder why many people still see harm-reduction measures in the drug field, taken within the legal framework, as something which is unethical, refutable and something that should not be done per se. And one may wonder why workers, who promote harm reduction, are often seen as representatives of a counter-culture. Maybe, this is due to the fact that harm reduction in the drug field was not promoted properly
How can the harm-reduction approach in the drug field be promoted? Amsterdam has a long history of harm reduction projects. When the first low-threshold methadone programme in Amsterdam was set up in 1979 (the methadone bus) (Buning et al., 1990), many workers felt embarrassed having to explain the programme to experts from abroad, and having to say that urine checks were not done, that the goal of the programme was not to strive for drug-free lives (Buning, 1990). And the same happened in 1984, when the Amsterdam experts had to explain the needle and syringe exchange scheme to visiting experts from abroad. It took some time to be open about the goals of these programmes, which are helping drug users who are not-yet capable or able to stop using drugs not to harm themselves and their environment (Buning et al., 1988).
In the promotion of harm-reduction thinking, five points can be stressed:
A drug policy should be realistic. Data from large research programmes in the USA carried out in the 1910s (such as the DARP programme) show a moderate success of treatment programmes for drug users in terms of getting drug users off the drugs for a long period (Sells, 1919; McLellan et al., 1982). Although some drug users benefit from treatment, there is always a considerable group of people who do not enter treatment, fail to go through the programme or relapse after successful treatment. Altogether, perhaps no more than 10-25 percent of drug users have a long-term benefit from treatment. Improving programmes does help, but it still does not lead to a high success rate. Beside kicking the habit through treatment programmes, there seems to be a group of drug users who stop without any professional help. Biernacki ( 1986) has done interesting research in this area. The classic study of Stimson and Oppenheimer ( 1982 ) reports a certain percentage of drug users who manage to terminate their drug use without professional help as well.
Looking at these facts, one should realise that probably 50 per cent of drug users sooner or later manage to stop their drug use, either through treatment or through natural recovery. So what about the other 50 per cent? This is where the realism comes in. One can say 'well, that's too bad for them just let them die' or one can take an active approach to prevent further damage through harm-reduction interventions.
Another issue of concern is the fact that, in most Western countries, drugs are available in prisons. If it is not possible to prevent drug use in prison, how can one even think of preventing drug use in an open society? Presenting these realistic data and posing these questions would be the first step in selling the 'harm-reduction' approach.
The second point is being open-minded and pragmatic. Here, issues about what works and what does not work are at stake and the fact that one should keep an open mind towards new approaches. Basically, it means that one is not a 'believer'. So, one does not believe that methadone solves all the problems, or that a needle exchange is the only appropriate answer to the AIDS problem among drug users or that therapeutic communities are the only way that drug users can be helped to change their lifestyle. Open-mindedness and pragmatism mean accepting a whole range of treatment options, with harm-reduction measures as an integrated part of the whole approach.
The third point has to do with the attitude of the workers in the drug field. Harm-reduction workers should be capable of building bridges. The best way of 'selling' a harm-reduction project is to stay on speaking terms with opponents. This is not always easy. Sometimes drug users expect the workers to show solidarity with them by choosing sides against the establishment. This is a classic pitfall. However, the best way to show solidarity to drug users is making sure that proper facilities are made available. If this means bending a little bit, so be it.
The fourth point is knowing the facts and figures. Too often, workers in the harm-reduction field have no clue as to whether or not their interventions are successful. Every worker should have basic statistical . knowledge of the project, such as the number of people using the project, their average age, their risk-taking behaviour and whether or not the aims of the project were met. Simple research models are available to obtain these data quickly. In talking with (prospective opponents of the project, one can hold a much stronger position if one knows what one is talking about.
The last point is about optimism. With recent research on the behaviour of drug users in the light of the AIDS epidemic, researchers were able to demonstrate that most drug users are capable of making small changes in their behaviour to decrease the risk o becoming infected with HIV. This creates a new image of drug users. No longer can they be stigmatised as self destructing, disturbed individuals. No, just like any body else, they want to survive and make the best of life even with their drug use.
Given the above, conferences, seminars an courses on harm reduction are very important. The expertise available should be shared, not only to learn about ways to implement harm-reduction measures but also how to sell them to local politicians, policy makers and the public. In this process, it is fundamental to acquire as much knowledge as possible about the out come of harm-reduction measures. To go back to the example of harm-reduction measures in traffic: if on places traffic lights, one has to be able to show that the number of accidents decrease on that particular spot . If one cannot prove that, it either means that the measure did not work or that the builders of traffic lights are 'believers' and don't find it necessary to prove anything to anybody.
Harm reduction in the drug field should be mainstream thinking. It should be realised that people working in the harm-reduction field, are now becoming the main stream. There will be a shift from the alternative counter culture to well-dressed civil servants and politicians from political parties in the middle. They will start to talk about harm reduction in the drug field as if they invented it. Instead of feeling disappointed, one should be relieved once this pattern is seen. It means that the pioneers have done a fine job. However, it still needs a lot of hard work before this situation arises - hard work in terms of doing research, hard work in terms of building bridges to opponents, hard work in terms of explaining the benefits of harm-reduction measures for both the individual drug users and the public. Perhaps one day a situation will arise that other fields are learning from the experiences in the harm reduction field.
Bureau International Contacts Drugs/AIDS, GG&;'GD,
Amsterdam, The Netherlands
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