Introduction

The opening of Insite in Vancouver, Canada, in 2003 was lauded as a long-overdue logical conclusion of years of activism and research efforts on the part of the harm reduction movement in North America. Insite was North America’s first sanctioned safe injection facility where drug users can, in a nonjudgemental, free, and safe way, consume drugs and recharge. Safe injection facilities are part of a harm reduction approach to drug use, which is a theory that acknowledges the inevitability of drug and substance use in society and aims to ‘minimise negative health, social and legal impacts associated with drug use, drug polices and drug laws’ (Harm Reduction International n.d.). It recognises that abstinence is often unrealistic or even undesirable, and instead advocates for the agency, wellbeing, and empowerment of the individual. Since the 1970s, harm reduction measures, which also include, among others, needle exchanges, clean works, and substitution therapy (with, for example, methadone), have become more commonplace but are far from being the standard response to drug use. While accepted widely in some European countries (e.g., Switzerland, the Netherlands, and Germany were early adopters), embracing harm reduction requires a radical rethinking in terms of how drug use is viewed. It replaces the common stereotype of people who use drugs as ‘deviant addicts’ or as people with ‘damaged brains’ with a view of addiction as a public health concern; people who use drugs become humans in need of social, medical, economic, and moral support, rather than criminals who are to be incarcerated, or lost souls that need to be reformed.

Despite the widely proven positive effects on not only users (and their health) but also on healthcare systems and law enforcement (in the form of cost and capacity savings) (Boyd 2013; Kinnard et al. 2014; Kral and Davidson 2017), harm reduction remains sidelined, and the war on drugs and on the people who use them is waged strongly across the world. Whether and how drugs belong in societies has been debated for centuries; the modern articulation of the criminalisation of drugs came in 1971 with US President Richard’s Nixon’s declaration of drugs as ‘public enemy number one’. In this Review essay, we will focus on several (anthropological) accounts that have recently explored various aspects of the antagonism between harm reduction and the historic and ongoing war on drugs. We draw lines between Travis Lupick’s (2018) exploration of Vancouver’s Insite, Kimberly Sue’s (2019) account of the intersection of treatments and prisons in the US, Nancy Campbell’s (2020) analyses on overdose and the heroin antagonist drug naloxone, and Jarrett Zigon’s (2019) observations from the international anti-drug war movement. Before moving to the international scale, let us return to Insite and learn from how this local figurehead of the harm reduction movement came about.

Vancouver and the harm reduction movement

Insite had been in the making for at least two decades, built on a strong community-driven effort. Fighting for Space, Travis Lupick’s detailed, journalistic, quasi-ethnographic account paints a vivid picture of this struggle: from offering an inside view of the drug users’ union VANDU, the Vancouver Area Network of Drug Users (2018, 124), illegal needle exchanges, and temporary safe injection facilities in drop-in centres, to observations from the political (idem, 228), legal (idem, 212, 314) and neighbourhood (idem, 243) struggles that led to the facility’s eventual establishment. VANDU and its network of supporters—including officials in Vancouver’s City Hall, universities, and the healthcare system—eventually hauled the case in front of the Supreme Court of Canada. The decision was fundamental: drug addiction, it found, is an illness that warrants public health support rather than law enforcement (idem, 314). This theoretical underpinning of viewing drug use through a medical lens enabled the establishment of Insite; however, this ‘medical view on addiction’ (Volkow, Koob, and McLellan 2016) was not without its problems, as we later explore, and is only one part of what makes Insite and similar facilities successful. The other part is the underlying culture, best captured by a frequent visitor: ‘It was about accommodating people, really understanding who people were and creatively making space work for them’ (Lupick 2018, 48); Insite was not just a site for harm reduction but a ‘space to live in the greatest degree of comfort’ (idem, 49); a greatly needed oasis for people who use drugs (idem, 64).

Jarret Zigon, in A War on People (2019), connects observations from Vancouver, where he also conducted fieldwork, with what he describes as the ‘global anti-drug war movement’. Zigon traces the connections between groups like VANDU with others worldwide fighting against the war on drugs through what he calls ‘assemblic ethnography’ (idem, 23). He focuses not on (multiple) sites but instead on the relations between sites (and people). His main findings revolve around how people in the anti-drug war movement—being themselves defined as non-human addict outsiders (idem, 52), or an internal Other for society at large (idem, 65)— form communities to resist and fight back. Zigon finds that communities emerge through the experiences of ‘dying-with’ (idem, 84): that is, observing or otherwise experiencing the death of a loved one, an experience that is shared by many of the anti-drug war activists and users. What ultimately enables the community to grow is its openness and nonjudgemental acceptance—what Zigon theorises as ‘disclosive freedom’ (idem, 100). The communities Zigon observed often emerge in specific spaces, such as Copenhagen’s safe injection facilities or the network of spaces in Vancouver’s downtown Eastside neighbourhood, where care is lived out in a specific way. The ‘attuned care’ at work there stands in contrast to the anonymous care (Stevenson 2014) of much of the usual healthcare system (Zigon 2019, 134) and is characterised by open hospitality and letting-be.

Zigon focuses on how the anti-drug war movement, including many supporters of harm reduction measures, produces ‘clearings’ and spaces of experimentation, of ‘being human together’ (idem, 156) rather than necessarily ‘treatment’. What he finds—in line with his theoretical project of further establishing an anthropology that is perceptive of the not-yet, the imaginary, and potentiality (idem, 13)—is the hope for different kinds of being together in these spaces. While some might find his terms and theoretical arguments distracting, Zigon’s account is, while ethnographically grounded, an important step to drawing (hopeful) connections; in itself, his work points towards opportunities for different futures and inspires more examination of harm reduction and its nuances.

The criminalisation of drug use

The opposite of harm reduction is the criminalisation of drug use, which has long been the central approach of North American narcopolitics. Physician-anthropologist Kimberly Sue’s Getting Wrecked (2019) focuses on women who use drugs and the experiences they have in and out of the carceral system in the US. As with Zigon and Lupick, Sue’s ethnography is a call for other imaginings and ways of humanely treating the people who are unseen within the cultural and political systems they exist in—and specifically, the carceral state—many of whom are rendered voiceless, misunderstood, and stigmatised by these very systems.

Based on long-term fieldwork in and around Boston, Sue describes what she calls the ‘carceral-therapeutic state’, the historically grown intertwining of the prison system with drug treatment from the 1960s onwards (idem, Chapter 2). As places of ‘moral enforcement’, jails and prisons are based on a (mostly) strict culture of abstinence, building on what Sue observed as the ‘American belief’ in total abstinence (idem, 82). While, on the one hand, incarceration institutions increasingly understand themselves as ‘therapeutic’ and ‘educational’—for instance with their focus on raising awareness around and providing treatment of trauma (idem, Chapter 4)—they largely lack the comprehensive support necessary for women who use drugs. Physical withdrawal symptoms were not treated upon entering the prison system despite the proven effectiveness of opioid substitution therapy (e.g., with methadone); the norm was ‘going cold turkey’, making the incarceration not only incredibly painful but also increasing the risk of overdose after release (where little support was provided). The discourse and understanding rather focused on punishment and individual responsibility (idem, 77, 139) when it came to mental health and drug treatment, and other parts of the ‘recovery process’ such as finding work (idem, Chapter 6).

The lack of proper support and its effects lasted long after the women left jail, where they are ‘simultaneously assisted by the state carceral apparatus and yet left for dead’ (idem, 184). This was ‘a social death as well as a civil death’, with little or no medical, social, or moral support from familial social networks and state resources (idem, 188). Some women not only continue to struggle with certain drug use habits, but with the very fact of having been incarcerated and its lasting effects on the body, mind, and soul. Sue, who bears witness to the whole breadth of the women’s experience in and out of jail, comments on the ‘most tragic part’: the ‘internalized symbolic violence of [one’s] situation’ (idem, 189). The women were made to believe that their suffering was at their own hands, creating a cycle of despair and hopelessness.

What can be done?

Elsewhere, one of us (Meng 2020) has examined the embracing of acupuncture services for incarcerated people who use drugs in 128 of the 150 public sector prisons in the United Kingdom. Seen as part of a holistic approach to helping incarcerated people re-enter society, the acupuncture programmes include treatment and training where the men and women are taught how to do acupressure themselves. Much like the harm reduction approach, while abstinence is encouraged, it is not identified as the primary objective. Instead, wellbeing, empowerment, and restoration of agency are prioritised. This stands in stark difference to the approach of the American carceral state and the limited (medical) resources available to the women of Sue’s ethnography. It represents an alternative possibility in line with Sue’s concluding call for an ethic of ‘love and safety’ (2019, 199) through consistently showing up for our fellow humans, confronting our internal biases, and legalising and regulating drugs such that they are no longer a shadowed part of society.

The core question and call for other ways of structuring institutions is also central to Nancy D. Campbell’s OD: Naloxone and the Politics of Overdose (2020). Campbell traces the shift in discourse from the early 2000s to now—a once highly sensitive topic few dared to speak about, overdose is now in common vernacular, as overdose numbers in the US have skyrocketed (Centers for Disease Control and Prevention 2018). Naloxone, an antagonist to opioids and a steady resource in the toolkit of harm reduction advocates, has now entered the conversation. Touted as a ‘golden ticket’ or a ‘magic pill’, naloxone is far from being a straightforward life-saving technology. Deeply embedded in our sociopolitical world, Campbell finds, naloxone ‘operate[s] at the molecular level but ha[s] multiple effects conditioned by social, economic, and political conditions that are in turn structured by drug policy and how that state enforces policy’ (2020, 7). Campbell examines the social life of naloxone at different places and in the hands of different people across the United States and the United Kingdom. Embracing local variations, Campbell recognises what one of her protagonists terms the ‘North American disaster’ (idem, 310): despite increased advocacy, awareness, and literature on the benefits of expanding the access to naloxone, profound resistance persists everywhere. Like knowledge, ignorance—especially that springing from the harmful cognitive separation of society and science—is consistently (re)produced. The nature of what counts as solid evidence is revealed to be artificial. As a result, ‘people are dying. Naloxone is everywhere’ (idem, 307): in spite of the increased visibility of naloxone, without acceptance and accessibility, people will continue to die.

What can be done? Or, as Campbell asks, ‘What’s next?’ She does not believe that the answer is more advocacy, and harm reduction has moved past the stage of being a grassroots social movement. Instead, Campbell argues the focus should be on ‘tam[ing]’ naloxone and ‘creat[ing] the social infrastructure for making it more available to those who need it’ (idem, 307). She calls for a paradigm shift in ideology and understanding, one that embraces a holistic approach in order to address the varied needs of different people. There are already enacted possibilities. Campbell examines multiple facets of the United Kingdom’s approach, wherein one such instance, the skilful use of biostatistics led to Scottish policy implementations that resulted in decreased drug-related deaths following prison release.

Towards Undoing?

There are likely to be hundreds of other local instances around the world that present alternatives to the North American mainstream approach to drug policy through the mechanisms of the war on drugs. There is increasing literature which approaches addiction through a lens of harm reduction, but we need more scholarship, particularly on non-Western approaches to thinking about the nature of drug use, addiction, and ‘treatment’. The impact of COVID-19 on developments will also remain to be seen—scholars have already begun to outline the destabilising effect of the pandemic on drug policy around the world (Alexander et al. 2020; Volkow 2020). In line with Zigon’s calls for ‘sticking and enduring’ as a way forward to enable world building (idem, 11), we find the recent anthropology on the matter highly encouraging and hope that more of such detailed and far-ranging (as well as critical) accounts will indeed move the needle. We should pick up from journalistic (and activist) accounts which are paving the way, such as Maia Szalavitz’s (2021) recent intervention. Szalavitz’s work traces harm reduction historically in the North American context, touching on many of the ‘tools’ and ‘actors’ described in the other volumes reviewed here, including naloxone (idem, 161) and VANDU (idem, 273). She makes us strongly aware of some of the more complex reasons for our reluctance to embrace harm reduction: structural racism, for instance, in the prison system (idem, 111), or the misunderstood relationship between prescription opioids and the drug epidemic (idem, 230). While (scientific) evidence almost unequivocally shows how harm reduction ‘works’, it has not been enough to shift paradigms and policies. In further embracing harm reduction what we need to understand better and consider is that its practices are not as widely spread as would be beneficial for people who use drugs (and for society more generally) because there is an ingrained technical, practical, and ideological pattern of drug policy and treatment—particularly in countries where the war on drugs still dominates. In order to undo this embrace we will have to first overcome divisions (e.g., between law enforcement, jurisdiction, healthcare and policy; see Szalavitz 2021, 265) to reform strict legislation to begin with, most importantly the Controlled Substances Act (idem, 315). Canada and US states such as Oregon are leading the charge in this direction. Instead of focusing on criminalising drugs and the people who use them, we should move towards a future that our authors call for: one that embraces the complexities of the human experience and cultivates health and wellness through fostering love, understanding, and safety for all.

Acknowledgements

We are grateful to Marlee Tichenor, Cristina Moreno Lozano, Jenny Peebles, and the anonymous reviewers for their wonderful help and feedback in preparing this review essay.

About the authors

Johannes Lenhard teaches and researches at the Max Planck Cambridge Centre for Ethics, Economy and Social Change. While one strand of his research is concerned with survival practices of people experiencing homelessness in Paris, London, and Cambridge, his most recent research focuses on the ethics of venture capital investors. His work has been published in Prospect, Sifted, The Conversation, Aeon, Crunchbase, and Vestoj, among others. He has published an edited volume, Home – Ethnographic Encounters (2019, Bloomsbury), and a monograph, Making Better Lives – Hope, Freedom and Home-Making among People Sleeping Rough in Paris (2022, Berghahn).

Eana Meng is a first-year medical student at Harvard’s MD-PhD in History of Science programme. Her research traces the lesser-known histories of the use of acupuncture by American activists (including those in the Black revolutionary movement) since the 1970s, and the legacies that emerge from them, which include a five-point ear acupuncture protocol currently used around the world for substance use and behaviour health conditions. She is interested in the histories that sit at the intersection of radical politics of health; integrative/alternative healing modalities; community healthcare; the opioid crisis and pain; and crucial dimensions of race, gender, and class.

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