1. Theory and practice of harm reduction Samuel R. Friedman National Development and Research Institutes, Inc. New York, NY

2. I would like to acknowledge P30 DA11041 (Center for Drug Use and HIV Research) R01 DA19383 (Staying Safe: Long-term IDUs who have avoided HIV & HCV) R01 DA13336 (Community Vulnerability and Response to IDU-Related HIV) R01 DA13128 (Networks, norms & HIV risk among youth) R01 DA03574 (Risk Factors for AIDS among Intravenous Drug Users ; DC Des Jarlais, PI) R01 MH62280 (Local context, social-control action, and HIV risk) Thousands of participants in these studies Many collaborators and co-authors Users’ group activists who have given me insightful ideas

3. Outline 1.Factors that create harm 2.The epidemiology and practice of prevention to reduce harm: Those at risk are key actors 3.Public health and “the people”

4. 1. Policy and social factors that can create harm Repression Scapegoating (I will discuss the following tomorrow: Transitions Dynamics of development)

5. Legal repressiveness and harm among injection drug users Next, I report on a study of legal repressiveness in metropolitan areas and its associations (at a later time) with: –the proportion of the population who inject drugs; and –HIV rates among injectors

6. Unit of analysis: Large Metropolitan Statistical Areas Sample: The 96 MSAs (in USA) with populations of 500,000+ in 1993 MSAs are defined by: –County boundaries –Central city population of 50,000 or more –Economic and social integration with surrounding areas –Commuting patterns to central city

7. Legal repressiveness is measured by three variables: Arrests per capita for cocaine or heroin use or sales, 1994-97 Police per capita, 1994-97 Expenditures on jails per capita, 1997

8. Dependent variable 1: IDUs per capita in the MSA population in 1998 Estimated by using four multipliers to allocate an estimated total number of IDUs in the USA among the 96 MSAs; and then dividing by the population of the MSA. This was described in Friedman et al, J Urban Health, 2004.

9. Dependent variable 2: HIV prevalence rate in IDUs in 1998 HIV prevalence rates among IDUs in 95 MSAs were estimated by taking the mean of two estimates: 1)estimates based on regression adjustments to CDC Voluntary HIV Counseling and Testing data (in which data from independent research samples were used to adjust C&T data for their inherent underestimation of prevalence rates) 2)estimates based on the ratio of the number of injectors living with HIV to the number of injectors living in the metropolitan area. This will be described in Friedman et al, J Urban Health, in press.

10. Legal repressiveness does not seem to deter injection drug use: Predictors of IDUs per capita, 1998 (Control variables: % unemployed & % of population who are black, 1990; laws against over-the-counter syringe sales; and USA region) Bivar- iate Beta pAdjusted Beta p Hard drug arrests per capita 1994-97 0.339.00120.123.205 Police per 10,000 population 1994-97 0.002.985-0.115..225 Corrections expenditures in dollars per capita (1997) 0.327.00180.012.902 R0.50

11. Legal repressiveness is associated with higher HIV prevalence rate among IDUs, 1998 (Control variables: % unemployed & % of population who are black, 1990; laws against over-the-counter syringe sales; IDUs per capita, 1993; and USA) Bivar- iate Beta pAdjusted Beta p Hard drug arrests 1994-97 0.292.00550.223.0106 Police per 10,000 population 1994-97 0.413.00010.358.0001 Corrections expenditures in dollars per capita (1997) 0.245.02050.2000.0277 R0.62

12. Limitations Causal mechanisms are hard to study at a single level of analysis Lack of time series data makes causal inference difficult We plan to conduct time series analyses in the near future

13. Legal repressiveness does not deter drug injection; it does seem to be associated with more HIV. Legal repressiveness appears to pose a threat to public health.

14. Scapegoating (1) Public health researchers and practitioners often are puzzled at the failure of policy makers to adapt programs (like syringe exchange or condoms) that have been shown to prevent disease transmission. Such decisions can be understood as part of a wider social-political dynamic that has to do with the potential conflicts and risks of globalization. Policy makers and corporate leaders fear rebellion; they have seen many transitions in recent years.

15. Scapegoating (2) Throughout history, divide and rule – and thus scapegoating and stigmatization – have helped prevent successful rebellions. In the current world, scapegoating often targets women, racial/ethnic “minorities,” “enemy” nations, sexual minorities, criminals, and/or drug users. Keeping drug users, gays, sex workers, minorities, or even Africa from suffering the ravages of AIDS seem to be secondary in importance (in elite priorities) to preventing rebellion and maintaining the economic health of the system. Indeed, these deaths may even strengthen the ideological barriers to rebellion. Thus, “elite non-compliance” with science may not be error or ignorance but rather enlightened self interest (which may, in turn, shape power holders’ perceptions).

16. 2. The epidemiology and practice of prevention to reduce harm

18. Informal health activism: “Intravention” and other-directed social protective action We have shown in our studies of the Bushwick section of Brooklyn, which had a long history of drugs and HIV—both of which seem to have declined in recent years—that more than half of the residents report that in the last three months they have urged others to take actions to protect themselves against sexual risks, drug risks, and/or HIV risks. These data are supported by ethnographic follow-up and by ethnographic observation. We have no reason to believe that Bushwick differs in this from similar localities elsewhere. Ordinary people are key public health actors.

19. Collective self-organization In addition to the indigenous activities by peer groups, neighbors, family members, and friends that was just described in NYC (and its analogues elsewhere), the HIV epidemic has been characterized by formal self-organization by members of socially-defined and self- defining “risk groups.” –Gay men and lesbians worldwide –IDUs worldwide (Europe, Australia, North America, South America, Asia) –Sex workers worldwide

20. Actors “from below” have consciousness, ideas, initiative, organization, efficacy—not just public health agencies

21. 3. Public health and “the people” The current social order pits science and public health versus the people as “other” –Science versus ignorance; –Non-compliance as a product of problems with the patients –The mantra of public health education: “ We need a unified message to keep the people from getting confused” (which is remarkably like the “mass line” formulations of alienated Stalinist bureaucracies)

22. Public health and “the people” (2) Given the history of HIV/AIDS epidemic, where “the people” have often led and public health followed behind, we need to think about how to create more realistic and effective relationships of public health and the people (at least for “big” issues that capture public attention.) The alienation of public health from the people slowed down scientific awareness of the existence of the AIDS epidemic by several years (NYC history), and hurts our ability to combat epidemics in many other ways as well.

23. What can public health schools do? Research that supports “the people” in their efforts to organize and to change norms and behaviors. Research and action to change policies that are repressive or stigmatizing to those at risk (such as drug users) Work with those at risk in an equal and respectful way. They may lack credentials, they may engage in behaviors you do not like—but they have often been better fighters of epidemics than public health has.

25. Levels of analysis interact dynamically Global ecology Social-economic- political-cultural Social psychological Psychological Physiological Viral Genetic Physical Chemical Macro context (capital, gender, racial/ethnic systems as contexts, war, transitions) National social structures (e.g., race/ethnicity as structure of subordination) Community and neighborhood structure & change Networks, roles, primary groups Event-specific social contexts Dyads

26. It’s not just behavior: Cities with very different HIV prevalence among IDUs report similar proportions who share syringes HIV prevalence < 5% RSS (6 mos) –Athens49% –Glasgow43% –Sydney42% –Toronto44% HIV prevalence > 30% –Bangkok54% –Madrid45% –NYC44% –Rio de Janeiro30% –Santos55% Source: Des Jarlais et al ch. 6 in Stimson et al 1998