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Beyond human rights and public health: Citizenship issues in harm reduction
International Journal of Drug Policy 22 (2011) 184–188
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Commentary
Beyond human rights and public health: Citizenship issues in harm reduction夽 Jia-shin Chen ∗ Department of Psychiatry, Shuang Ho Hospital, Taipei Medical University, No. 291, JhongJheng Rd., Jhonghe City, Taipei 23561, Taiwan
a r t i c l e
i n f o
Article history: Received 19 July 2010 Received in revised form 2 December 2010 Accepted 3 December 2010
Keywords: Harm reduction Citizenship Human rights Public health
a b s t r a c t There have been debates amongst harm reduction practitioners regarding the relationship of universal human rights vis-à-vis public health demands. The ideological debates around these two slippery concepts often obfuscate the important theme of citizenship. The author, therefore, argues for the perspective of citizenship as an alternative to comprehend harm reduction practises more thoroughly. An introduction of the concept of citizenship is followed by a case example of Taiwan’s harm reduction policy-making, wherein injection drug users were subjected to various disciplinary actions and made into citizen addicts. It is hoped that more harm reduction researchers will have increased familiarity with the notion of citizenship as a useful tool to examine the power dynamics taking place in the name of harm reduction. © 2010 Elsevier B.V. All rights reserved.
Although harm reduction has been implemented in various forms for decades, there have been debates amongst practitioners regarding the relationship between universal human rights and public health demands (Ezard, 2001). Some scholars define the two concepts as oppositional, whereas some position them on a continuum of “weak rights” and “strong rights” (Hunt, 2004). Hunt’s definition of these “rights” is based on the degree of sovereignty over the body. On the one end of the continuum (strong rights), the rights of individuals over their bodies are prioritized; on the other end (weak rights), the emphasis on collective longevity and health outweighs the primacy of individual sovereignty. These two stylized approaches sometimes create irreconcilable controversies. For example, are prohibitory measures against drug use justifiable as harm reduction? In recent few years, the global trend of harm reduction movement has leaned towards a human-rights-based approach, which is extolled in various United Nations conventions. Professor Hunt (2008) points out that the practical challenges for implementing a rights-based harm reduction policy lie in the establishment of a “strong, accessible, integrated health system that is sensitive to the distinctive needs of all, including people who use drugs” (p. 13). In other words, human rights in terms of harm reduction have to be
夽 This commentary is largely inspired by and founded on my previous Ph.D. research in the University of California at San Francisco (UCSF). I would like to thank my committee members for their insightful comments on my work. They are Professors Adele E. Clarke, Philippe Bourgois, Howard Pinderhughes, and Vincanne Adams. Also, I thank my informants for their precious time, experience, and opinion. I am especially grateful to the reviewers who helped me improve this piece of writing. ∗ Tel.: +886 2 22490088. E-mail address: [email protected] 0955-3959/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2010.12.003
realized through a non-discriminatory public health system. Therefore, it seems that, instead of being antagonistic, human rights and public health may well be compatible and even mutually constitutive. Controversies arise because universal human rights and public health demands are slippery concepts and are, therefore, not necessarily exclusive. This conceptual ambiguity is further exemplified by the fear of some critics that harm reduction, in spite of its claimed spirit of tolerance and pragmatism, may be co-opted by prohibitionist ideology and practises exemplified in the old supply reduction or demand reduction approaches (Hathaway, 2001; Miller, 2001). Helpful as it may be, debating on the issue as to whether or not harm reduction should be founded on either universal human rights or public health demands obfuscates a pivotal issue. The issue revolves around viewing injection drug users (IDUs) as active citizens vis-à-vis the state that governs them. This perspective not only offers more insight in addressing harm reduction as an issue of citizenship rather than one of ideology, but it also diversifies the ways in which we understand how harm reduction is defined and implemented. The citizenship perspective is inclusive because it entails both universal human rights and public health demands. It is also comprehensive because it covers considerations that are not only local but also universal. Nevertheless, some explanation is needed here. Although human rights may be ideologically universal, they are practically the outcome of incessant struggles between the state and its citizenry (Ishay, 2008). Moreover, the claim that certain human rights, such as drug users’ rights to adequate health care and social protection (Inciadi & Harrison, 2000), are universal is itself a time- and space-specific product of Western thought. In the case
J.-s. Chen / International Journal of Drug Policy 22 (2011) 184–188
of Taiwan’s harm reduction policy, for example, the stigmatization of IDUs has been so prevalent and profound that the discourses of universal human rights applied to IDUs have been downplayed on purpose to prevent public controversies over this policy. On the other hand, the so-called public health demands are not produced out of want but are defined and reified during a complex process which involves a plurality of actors in different sectors with different purposes. In other words, public health demands are not always simply “out there”; they are, as a matter of fact, products of continuous social interactions. Hilgartner and Bosk (1988) describe the formation of a social “problem” as an unstable interactive outcome of various participants competing for social resources in a public arena. In this regard, public health is not always antagonistic to individual rights. It is not merely a tool of discipline and control (Peterson & Lupton, 1997). On the contrary, individual needs and aspirations may be constructed as part of public health, wherever they are considered appropriate. An exemplary case is the call for embodiment in health social movement (Brown, Zavestoski, McCormick, Mayer, & Morello-Frosch, 2004). For the reasons stated above, it is not analytically productive to propose a simple antagonism between human rights and public health, as Hunt (2004) depicts. Instead, it is more empirically effective to see how people negotiate citizenship by what they do in reality. Researchers may therefore divert their attention from claims to practises, and, as proposed in this study, refine their theories by considering the perspective of citizenship, which addresses the making of citizen addicts (Chen, 2009).
Citizenship issues in harm reduction The concept of citizenship has been applied in some studies on harm reduction amongst IDUs (Jauffret-Roustide, 2009), but the engagement with theories of citizenship leaves much to be desired. Using citizenship studies and science and technology studies (STS), this commentary attempts to deepen and broaden the notion of citizenship when applied in the context of harm reduction. Sociologist Turner (1993) urges readers to start with the works of T.H. Marshall, who is well-known for his original view on citizenship evolution. In a now classic essay (originally a lecture), Citizenship and Social Class (1977), Marshall distinguished three components or dimensions of citizenship, namely, civil, political, and social. He also described a staged process in which these three components of citizenship were established (Marshall, 1977). Turner explained Marshall’s contribution, At the heart of Marshall’s account of citizenship lies the contradiction between the formal political equality of the franchise and the persistence of extensive social and economic inequality. . ..Marshall proposed the extension of citizenship [i.e., social citizenship] as the principal political means for resolving, or at least containing, those contradictions (Turner, 1990, p. 191). In other words, the notion of citizenship is invoked and substantiated as a way to assuage, if not eliminate, class inequalities. Citizenship refers not just to formal equality and membership, but also to how citizens are supposed to behave and what they expect to obtain in a specific socio-political circumstance. In this sense, citizenship as a concept encompasses broader practical and theoretical implications than human rights. Human rights discourses also imply entitlements, but they fail to illuminate the context of drug users’ rights vis-à-vis the governing state. That is to say, citizenship issues open up a more ambient problem space that allows empirical observation to re-arrange the inter-relationships of some important concepts, including but not limited to human
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rights and public health. Naturally, the space where issues of citizenship are contested is never clearly territorialized, but it is well-recognized in situations other than those of immigrant workers. More significantly, it is extended to many domains where science, technology, and policy have contributed to the fashioning of a new socio-political membership. Anthropologist Rabinow (1996) used the concept of biosociality to describe social organizations that are not founded upon common denominators, such as race, sex, and class, but upon novel biomedical diagnoses or conditions, such as rare genetic diseases (Heath, Rapp, & Karen-Sue, 2004) and radiation-related injuries (Petryna, 2002), thus forming a question of citizenship. Given that citizenship is no longer confined to the political domain but is already extended to social and even scientific domains, the focus of research has been on how it is engineered in and by practice. For example, the notion of biological citizenship aptly captures the “biologization of politics” that has been rarely explored from the perspective of citizenship (Rose & Novas, 2005). This paper argues that a similar stance of analysis can be applied to harm reduction as well. That is, the perspective of citizenship should not focus solely on the ideological foundation represented by the policy, but also on the practises, discourses, and languages constitutive of the policy, no matter how dispersed and short-lived they may seem. Therefore, its assertion is closer to, though not identical with, Keane (2003), who postulates harm reduction as an assemblage of practises and variable outcomes. The introduction of citizenship issues as a problem space, in turn, leads to a deeper insight into social order and human actions behind this messy assemblage. More importantly, the very notion of citizenship provides a conceptual ground where human rights and public health may be contested, analysed, and reconciled. As Tilly (1996) has demonstrated through his social historical approach, citizenship is mostly earned, not granted. This perspective suggests that analysis should be directed at understanding the ways citizens organize themselves for rights and identities. At the same time, however, Tilly reminds his readers of a passive form of citizenship, wherein a top–down endowment of rights and entitlements from the government could also be a focus of attention. In the following example of Taiwan’s harm reduction policy, this paper shows that the latter form of citizenship prevails.
The making of citizen addicts in Taiwan The implementation of the harm reduction policy signalled a new era of substance control in Taiwan. It was triggered by the skyrocketing increase in human immunodeficiency virus (HIV) cases in 2004. The policy mainly targeted IDUs, who were synonymous with heroin injectors because heroin was by far the most commonly injected illicit substance in Taiwan. The three-pronged policy was first implemented as a pilot programme in 2005. The first component was the expansion of extant education and screening. For example, pregnant women were asked to take free HIV tests. Second, the Taiwan Centers for Disease Control (CDC) collaborated with local pharmacies to distribute clean needles and syringes and collect used ones for safe disposal whilst highlighting the danger of needle-sharing. This part was called the Needle Syringe Programme (NSP). Third, a number of public hospitals were asked to provide free methadone as a substitute treatment (Taiwan Centers for Disease Control, 2005). The initial effects of this pilot programme were amazingly satisfactory in terms of HIV control. According to Yang, Yang, Shen and Kuo (2008), HIV incidence in sites with NSP decreased from 13.9 to 13.3 per 100,000 persons, whereas the incidence increased from 11.5 to 15.3 per 100,000 persons in sites without NSP. As a result, the Taiwanese government decided to scale up the policy and expand it into a nationwide programme in 2006.
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Fig. 1. The number of monthly newfound HIV-positive cases from January 2003 to December 2007. Note the timing of major events of harm reduction. Adapted from CDC, n.d.
To examine how this policy was made, my field work began in July 2007, about one year after its full implementation. Aside from an archival review, in-depth interviews were conducted with people who were involved in the process of policy making and implementation. In addition, treatments of IDUs in methadone clinics were also observed. The findings are discussed in another research paper I am drafting. Part of the initial research objective was to determine how biopower actually played out in the interactions between medical personnel and drug users which could account for the rapid decrease in HIV incidence. When major events of harm reduction policy were mapped onto the HIV incidence curve from 2003 to 2007, there was an inversion of the curve just before the implementation of the pilot programme (Fig. 1). Interviewers in the study gave some speculations: It could be the effect of the expanded screening programme, or it could be simply a phenomenon of saturation, i.e., the incidence curve sloped downward because all needle-sharing IDUs (that is, the at-risk population) had already been infected with HIV. These possibilities aside, there was another interpretation: IDUs were able to change their drug use behaviour through intangible yet interconnected social channels, although they had no such supporting organizations or advocacy groups as the Vancouver Area Network of Drug Users (VANDU) (Kerr et al., 2006). The provision of free methadone, along with free needles and syringes, constituted the centre of harm reduction entitlements. IDUs only paid service fees that covered the administrative cost of dispensing methadone. A rough estimate of IDUs’ daily expenses put the methadone substitution treatment cost approximately to one-tenth the price of detoxification medications and one-hundredth the price of heroin (Chen, 2009). Obviously, most IDUs would likely choose methadone treatment programmes over the other two. Nevertheless, methadone, needles and syringes were not offered for nothing. They were given exactly on the condition that these drug users served their duties, i.e., changed the ways that they injected themselves and thus avoided the likelihood of getting infected with HIV. In short, IDUs were expected to be “citizen addicts” of harm reduction who had corresponding rights and duties, entitlements, and responsibilities. Citizen addicts were produced not simply by discursive formations but also by disciplinary actions. These actions could be
illustrated most clearly in the instructional handouts for drug users about regulations of methadone treatment. For example, an information sheet from the Taoyuan Psychiatric Center (2007) read: [3. Content]. . ..You should go to the hospital everyday and take methadone as prescribed by the physician. Your absence means you voluntarily give up your rights. Your medication is given by your case manager and has to be taken immediately right there. You cannot take it away from the site of treatment, where camera recording operates all the time. . .. You need to visit the physician periodically and obtain your prescription from him/her so as to continue your eligibility for methadone. . ..Also, urine screening is mandatory for every physician visit. . .. If you are absent without informing us beforehand, our case manager will contact you by phone first. If your absence persists longer than four weeks, our hospital will discontinue your treatment plan. Your information collected by our hospital will be kept in paper and electronic forms. It will also be uploaded to the Department of Health as demanded. People who take methadone in two different hospitals will be excluded. In addition to these printed regulations, disciplinary actions also manifested themselves in the form of methadone distributed to IDUs. It was given in syrup forms, not as pills, so as to allow for dose titration and, moreover, to make oral cavity inspection easier. Diversion was thus prevented because it was difficult for IDUs to “steal” a mouthful of methadone liquid (Chen, 2009). Based on observations of local pharmacies that distributed clean needles and syringes, these drug users were not at all exempt from stigmatization. Harm reduction, as it was conceived in Taiwan, was purely utilitarian in the sense that it aimed to maximize the well-being and safety of the majority rather than safeguard those of IDUs. Although the Taiwan CDC later advanced a well-intentioned proposal for guarding the human rights of people with HIV/AIDS, the harm reduction policy was entirely bereft of human rights discourse. Instead, it was fashioned as a solution to an impending
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public health disaster. Even informants who played major roles in policy-making agreed that it was not so much a humanitarian rescue of IDUs as it was a pragmatic strategy for solving the HIV problem. However, without human rights discourses undergirding the policy, the citizenship thus formed was distinct from that in European history (Tilly, 1996). To follow Tilly’s characterization, what these citizen addicts really had was a citizenship that was at the same time thin and passive—thin, because it involved too few transactions between IDUs and the government; and passive, because the entitlements were simply endowed by the government. Whilst citizenship is invoked in STS as a form of socio-political membership for active participation (Heath et al., 2004; Leach & Scoones, 2005; Petryna, 2002), it is not so in the case of citizen addicts in this research. Instead, the case study shows that biopower deployment in Taiwan differs radically from that in early Euro-American contexts, such as the Junkiebond in the Netherlands, where harm reduction was seen from the outset as a communitybased bottom-up social movement (Inciadi & Harrison, 2000). However, whether the difference still stands now is a disputable question. Considering recent observations that also reveal the disciplinary and utilitarian features of methadone programmes in North America (Bourgois, 2000; Quirion, 2003), it is important to problematize the contrast between Taiwan’s harm reduction policy and its contemporary Euro-American counterparts. This commentary is not intended to repeat a clichéd disparity between the West and the East, but to substitute a perspective of citizenship for the antagonism of universal human rights and public health demands. The West implies a plurality of countries with diverse developmental trajectories and emergent situations, and so does the East. Consequently, to complicate the contrast more productively, dimensions of homogeneity and heterogeneity need to be addressed. Only through this approach is the perspective of citizenship able to articulate both dimensions and re-negotiate the tensions between human rights and public health. On the one hand, citizens’ health is often claimed as a collective right that must be protected by the state. On the other, human rights can also be counted as a central part of global citizenship (Turner, 1990). If Taiwan’s harm reduction policy is seen as a biopolitical project of citizen making, then both citizen addicts and the state have contributed to a new form of government. Although there are no advocacy groups in Taiwan for drug users, their needs and opinions are nevertheless recognized through sympathetic experts and organizations that participate in policy affairs. Meanwhile, it is noteworthy that the Taiwan CDC was not passively reacting to an existing social demand. Instead, the Taiwan CDC actively fashioned the issues of HIV transmission amongst IDUs and kept the policy low-profile enough to escape excessive media attention and public dispute. Although the increase in HIV incidence was statistically true, it did not land on top of the to-do list by itself. It had to be made so. In a sense, the government was constitutive of the urgency of the problem it intended to tackle. Since the policy cannot be categorized merely as a product of universal human rights claims or objective public health demands, both views are thus insufficient in explaining the foundation upon which Taiwan’s harm reduction policy has been based. As shown earlier, a perspective that examines the formation and effects of citizen addicts is an analytical alternative with an edge.
Conclusion Tammi and Hurme (2007) pointed out in an earlier commentary that the harm reduction movement exemplifies a powerful rhetorical intervention, which is strongly resonant with the moral
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sensibilities of late modernity. To them, the principles of harm reduction that have been frequently invoked in literature include individualism, inclusion, pragmatism, and emancipation. This paper argues that, as a matter of fact, these principles uphold individual freedom and calculative rationality in a market-driven society, thus echoing the ideal image of an autonomous subject that underlies the neoliberal trend of privatization and deregulation (Harvey, 2005). Ironically, some scholars, such as Bourgois and Schonberg (2009), contend that neoliberalism contributes to the aggravated marginalization of drug users. In Taiwan, conflicts of internal logic in the harm reduction policy are particularly exemplary. The policy demands that IDUs become self-responsible subjects who deserve entitlements. However, to be eligible for these entitlements, they are, at the same time, categorized as dangerous individuals prone to transmit diseases. Entitlements come with less suppression but more denigration, producing a doublebind citizenship (Chen, 2009). This research in Taiwan has led to the belief that harm reduction as a concept might come in many shapes in its implementation. Therefore, it is analytically futile to stick to ideological issues instead of practical details. However, the emphasis on practice does not simply endorse a microscopic description of actions and a negation of theory. Instead, an analytically comprehensive perspective capable of grappling with the complex power dynamics in harm reduction policy-making is desperately needed as well. In this way, citizenship as a sensitizing concept becomes all the more pertinent (Blumer, 1969). The citizenship perspective can be seen as one of the many attempts to theorize harm reduction, or more broadly, drug-control policies (Moore, 2004). It has, however, particular bearing on Asian contexts, where the meanings of universal human rights and public health demands are constantly conflicting and contested. This ambiguity makes these two concepts less suitable options to analyse various power relationships in these sites. It is the author’s hope that more harm reduction researchers will have increased familiarity with the notion of citizenship as a useful tool to examine the power dynamics taking place in the name of harm reduction.
References Blumer, H. (1969). What is wrong with social theory? In Symbolic interactionism: Perspective and method. Englewood Cliffs, New Jersey: Prentice-Hall Inc., pp. 140–152. Bourgois, P. (2000). Disciplining addiction: The bio-politics of methadone and heroin in the United States. Culture, Medicine and Psychiatry, 24, 165–195. Bourgois, P., & Schonberg, J. (2009). Righteous dopefiend. Berkeley, CA: University of California Press. Brown, P., Zavestoski, S., McCormick, S., Mayer, B., & Morello-Frosch, R. (2004). Embodied social movements: New approaches to social movements in health. Sociology of Health and Illness, 26(1), 50–80. Chen, J.-s. (2009). Assembling harm reduction policy in Taiwan. Unpublished doctoral dissertation, University of California, San Francisco, San Francisco. Ezard, N. (2001). Public health, human rights and the harm reduction paradigm: From risk reduction to vulnerability reduction. International Journal of Drug Policy, 12, 207–219. Harvey, D. (2005). A brief history of neoliberalism. New York: Oxford. Hathaway, A. D. (2001). Shortcomings of harm reduction: Toward a morally invested drug reform strategy. International Journal of Drug Policy, 12, 125–137. Heath, D., Rapp, R., & Karen-Sue, T. (2004). Genetic citizenship. In D. Nugent, & J. Vincent (Eds.), A companion to the anthropology of politics (pp. 152–167). London: Blackwell. Hilgartner, S., & Bosk, C. L. (1988). The rise and fall of social problems: A public arena model. American Journal of Sociology, 94, 53–78. Hunt, N. (2004). Public health or human rights: What comes first? International Journal of Drug Policy, 15, 231–237. Hunt, P. (2008). Human rights, health and harm reduction: States’ amnesia and parallel universes. Retrieved November 19, 2010, from http://www. ihra.net/contents/550. Inciadi, J. A., & Harrison, L. D. (2000). Introduction: The concept of harm reduction. In J. A. Inciadi, & L. D. Harrison (Eds.), Harm reduction: National and international perspectives (pp. vii–xix). Thousand Oaks: Sage. Ishay, M. R. (2008). The history of human rights: From ancient times to the globalization era. Berkeley, CA: University of California Press.
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Jauffret-Roustide, M. (2009). Self-support for drug users in the context of harm reduction policy: A lay expertise defined by drug users’ life skills and citizenship. Health Sociology Review, 18, 159–172. Keane, H. (2003). Critiques of harm reduction, morality and the promise of human rights. International Journal of Drug Policy, 14, 227–232. Kerr, T., Small, W., Peeace, W., Douglas, D., Adam, P., & Wood, E. (2006). Harm reduction by a user-run organization: A case study of the Vancouver Area Network of Drug Users (VANDU). International Journal of Drug Policy, 17, 61–69. Leach, M., & Scoones, I. (2005). Science and citizenship in a global context. In M. Leach, I. Scoones, & B. Wynne (Eds.), Science and citizens: Globalization and the challenges of engagement (pp. 15–40). London: Zed Books. Marshall, T. H. (1977). Citizenship and social class. In Class, citizenship, and social development: Essays by T.H Marshall. Chicago: University of Chicago Press., pp. 71–134 Miller, P. G. (2001). A critical review of the harm minimization ideology in Australia. Critical Public Health, 11(2), 167–178. Moore, D. (2004). Social theory in drug research, drug policy, and harm reduction. International Journal of Drug Policy, 15(5–6), 323–325. Peterson, A., & Lupton, D. (1997). The new public health: Health and self in the age of risk. London: Sage. Petryna, A. (2002). Life exposed: Biological citizens after chernobyl (1st ed.). Princeton and Oxford: Princeton University Press. Quirion, B. (2003). From rehabilitation to risk management: The goals of methadone programmes in Canada. International Journal of Drug Policy, 14, 247–255.
Rabinow, P. (1996). Artificiality and enlightenment: From sociobiology to biosociality. In Essays on the anthropology of reason. Princeton, NJ: Princeton University Press., pp. 91–111. Rose, N., & Novas, C. (2005). Biological citizenship. In A. Ong, & S. Collier (Eds.), Global assemblages: Technology, politics, and ethics as anthropological problems (pp. 439–463). Malden, MA: Blackwell Publishing. Taiwan Centers for Disease Control. (2005). Experimental plan for harm reduction of HIV transmission among drug use patients. Taiwan Centers for Disease Control. (n.d.). The number of monthly newfound HIV-positive cases from January 2003 to December 2007. [Data file in Excel format]. Retrieved May 23, 2009, from http://www.cdc.gov.tw/ ct.asp?xItem=11234&CtNode=1095&mp=220. Tammi, T., & Hurme, T. (2007). How the harm reduction movement contrasts itself against punitive prohibition. International Journal of Drug Policy, 18, 84–87. Taoyuan Psychiatric Center. (2007). Instructions for methadone recipients [Informational sheet]. Taoyuan, Taiwan: Taoyuan Psychiatric Center. Tilly, C. (1996). Citizenship, identity and social history. In C. Tilly (Ed.), International review of social history supplement 3: Citizenship, identity and social history (pp. 1–17). Cambridge: University of Cambridge. Turner, B. S. (1990). Outline of a theory of citizenship. Sociology, 24(2), 189–214. Turner, B. S. (1993). Contemporary problems in the theory of citizenship. In B. S. Turner (Ed.), Citizenship and social theory (pp. 1–18). London: Sage. Yang, C.-H., Yang, S.-Y., Shen, M.-H., & Kuo, H.-S. (2008). The changing epidemiology of prevalent diagnosed HIV infections in Taiwan, 1984–2005. International Journal of Drug Policy, 19, 317–323.
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Commentary
Beyond human rights and public health: Citizenship issues in harm reduction夽 Jia-shin Chen ∗ Department of Psychiatry, Shuang Ho Hospital, Taipei Medical University, No. 291, JhongJheng Rd., Jhonghe City, Taipei 23561, Taiwan
a r t i c l e
i n f o
Article history: Received 19 July 2010 Received in revised form 2 December 2010 Accepted 3 December 2010
Keywords: Harm reduction Citizenship Human rights Public health
a b s t r a c t There have been debates amongst harm reduction practitioners regarding the relationship of universal human rights vis-à-vis public health demands. The ideological debates around these two slippery concepts often obfuscate the important theme of citizenship. The author, therefore, argues for the perspective of citizenship as an alternative to comprehend harm reduction practises more thoroughly. An introduction of the concept of citizenship is followed by a case example of Taiwan’s harm reduction policy-making, wherein injection drug users were subjected to various disciplinary actions and made into citizen addicts. It is hoped that more harm reduction researchers will have increased familiarity with the notion of citizenship as a useful tool to examine the power dynamics taking place in the name of harm reduction. © 2010 Elsevier B.V. All rights reserved.
Although harm reduction has been implemented in various forms for decades, there have been debates amongst practitioners regarding the relationship between universal human rights and public health demands (Ezard, 2001). Some scholars define the two concepts as oppositional, whereas some position them on a continuum of “weak rights” and “strong rights” (Hunt, 2004). Hunt’s definition of these “rights” is based on the degree of sovereignty over the body. On the one end of the continuum (strong rights), the rights of individuals over their bodies are prioritized; on the other end (weak rights), the emphasis on collective longevity and health outweighs the primacy of individual sovereignty. These two stylized approaches sometimes create irreconcilable controversies. For example, are prohibitory measures against drug use justifiable as harm reduction? In recent few years, the global trend of harm reduction movement has leaned towards a human-rights-based approach, which is extolled in various United Nations conventions. Professor Hunt (2008) points out that the practical challenges for implementing a rights-based harm reduction policy lie in the establishment of a “strong, accessible, integrated health system that is sensitive to the distinctive needs of all, including people who use drugs” (p. 13). In other words, human rights in terms of harm reduction have to be
夽 This commentary is largely inspired by and founded on my previous Ph.D. research in the University of California at San Francisco (UCSF). I would like to thank my committee members for their insightful comments on my work. They are Professors Adele E. Clarke, Philippe Bourgois, Howard Pinderhughes, and Vincanne Adams. Also, I thank my informants for their precious time, experience, and opinion. I am especially grateful to the reviewers who helped me improve this piece of writing. ∗ Tel.: +886 2 22490088. E-mail address: [email protected] 0955-3959/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.drugpo.2010.12.003
realized through a non-discriminatory public health system. Therefore, it seems that, instead of being antagonistic, human rights and public health may well be compatible and even mutually constitutive. Controversies arise because universal human rights and public health demands are slippery concepts and are, therefore, not necessarily exclusive. This conceptual ambiguity is further exemplified by the fear of some critics that harm reduction, in spite of its claimed spirit of tolerance and pragmatism, may be co-opted by prohibitionist ideology and practises exemplified in the old supply reduction or demand reduction approaches (Hathaway, 2001; Miller, 2001). Helpful as it may be, debating on the issue as to whether or not harm reduction should be founded on either universal human rights or public health demands obfuscates a pivotal issue. The issue revolves around viewing injection drug users (IDUs) as active citizens vis-à-vis the state that governs them. This perspective not only offers more insight in addressing harm reduction as an issue of citizenship rather than one of ideology, but it also diversifies the ways in which we understand how harm reduction is defined and implemented. The citizenship perspective is inclusive because it entails both universal human rights and public health demands. It is also comprehensive because it covers considerations that are not only local but also universal. Nevertheless, some explanation is needed here. Although human rights may be ideologically universal, they are practically the outcome of incessant struggles between the state and its citizenry (Ishay, 2008). Moreover, the claim that certain human rights, such as drug users’ rights to adequate health care and social protection (Inciadi & Harrison, 2000), are universal is itself a time- and space-specific product of Western thought. In the case
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of Taiwan’s harm reduction policy, for example, the stigmatization of IDUs has been so prevalent and profound that the discourses of universal human rights applied to IDUs have been downplayed on purpose to prevent public controversies over this policy. On the other hand, the so-called public health demands are not produced out of want but are defined and reified during a complex process which involves a plurality of actors in different sectors with different purposes. In other words, public health demands are not always simply “out there”; they are, as a matter of fact, products of continuous social interactions. Hilgartner and Bosk (1988) describe the formation of a social “problem” as an unstable interactive outcome of various participants competing for social resources in a public arena. In this regard, public health is not always antagonistic to individual rights. It is not merely a tool of discipline and control (Peterson & Lupton, 1997). On the contrary, individual needs and aspirations may be constructed as part of public health, wherever they are considered appropriate. An exemplary case is the call for embodiment in health social movement (Brown, Zavestoski, McCormick, Mayer, & Morello-Frosch, 2004). For the reasons stated above, it is not analytically productive to propose a simple antagonism between human rights and public health, as Hunt (2004) depicts. Instead, it is more empirically effective to see how people negotiate citizenship by what they do in reality. Researchers may therefore divert their attention from claims to practises, and, as proposed in this study, refine their theories by considering the perspective of citizenship, which addresses the making of citizen addicts (Chen, 2009).
Citizenship issues in harm reduction The concept of citizenship has been applied in some studies on harm reduction amongst IDUs (Jauffret-Roustide, 2009), but the engagement with theories of citizenship leaves much to be desired. Using citizenship studies and science and technology studies (STS), this commentary attempts to deepen and broaden the notion of citizenship when applied in the context of harm reduction. Sociologist Turner (1993) urges readers to start with the works of T.H. Marshall, who is well-known for his original view on citizenship evolution. In a now classic essay (originally a lecture), Citizenship and Social Class (1977), Marshall distinguished three components or dimensions of citizenship, namely, civil, political, and social. He also described a staged process in which these three components of citizenship were established (Marshall, 1977). Turner explained Marshall’s contribution, At the heart of Marshall’s account of citizenship lies the contradiction between the formal political equality of the franchise and the persistence of extensive social and economic inequality. . ..Marshall proposed the extension of citizenship [i.e., social citizenship] as the principal political means for resolving, or at least containing, those contradictions (Turner, 1990, p. 191). In other words, the notion of citizenship is invoked and substantiated as a way to assuage, if not eliminate, class inequalities. Citizenship refers not just to formal equality and membership, but also to how citizens are supposed to behave and what they expect to obtain in a specific socio-political circumstance. In this sense, citizenship as a concept encompasses broader practical and theoretical implications than human rights. Human rights discourses also imply entitlements, but they fail to illuminate the context of drug users’ rights vis-à-vis the governing state. That is to say, citizenship issues open up a more ambient problem space that allows empirical observation to re-arrange the inter-relationships of some important concepts, including but not limited to human
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rights and public health. Naturally, the space where issues of citizenship are contested is never clearly territorialized, but it is well-recognized in situations other than those of immigrant workers. More significantly, it is extended to many domains where science, technology, and policy have contributed to the fashioning of a new socio-political membership. Anthropologist Rabinow (1996) used the concept of biosociality to describe social organizations that are not founded upon common denominators, such as race, sex, and class, but upon novel biomedical diagnoses or conditions, such as rare genetic diseases (Heath, Rapp, & Karen-Sue, 2004) and radiation-related injuries (Petryna, 2002), thus forming a question of citizenship. Given that citizenship is no longer confined to the political domain but is already extended to social and even scientific domains, the focus of research has been on how it is engineered in and by practice. For example, the notion of biological citizenship aptly captures the “biologization of politics” that has been rarely explored from the perspective of citizenship (Rose & Novas, 2005). This paper argues that a similar stance of analysis can be applied to harm reduction as well. That is, the perspective of citizenship should not focus solely on the ideological foundation represented by the policy, but also on the practises, discourses, and languages constitutive of the policy, no matter how dispersed and short-lived they may seem. Therefore, its assertion is closer to, though not identical with, Keane (2003), who postulates harm reduction as an assemblage of practises and variable outcomes. The introduction of citizenship issues as a problem space, in turn, leads to a deeper insight into social order and human actions behind this messy assemblage. More importantly, the very notion of citizenship provides a conceptual ground where human rights and public health may be contested, analysed, and reconciled. As Tilly (1996) has demonstrated through his social historical approach, citizenship is mostly earned, not granted. This perspective suggests that analysis should be directed at understanding the ways citizens organize themselves for rights and identities. At the same time, however, Tilly reminds his readers of a passive form of citizenship, wherein a top–down endowment of rights and entitlements from the government could also be a focus of attention. In the following example of Taiwan’s harm reduction policy, this paper shows that the latter form of citizenship prevails.
The making of citizen addicts in Taiwan The implementation of the harm reduction policy signalled a new era of substance control in Taiwan. It was triggered by the skyrocketing increase in human immunodeficiency virus (HIV) cases in 2004. The policy mainly targeted IDUs, who were synonymous with heroin injectors because heroin was by far the most commonly injected illicit substance in Taiwan. The three-pronged policy was first implemented as a pilot programme in 2005. The first component was the expansion of extant education and screening. For example, pregnant women were asked to take free HIV tests. Second, the Taiwan Centers for Disease Control (CDC) collaborated with local pharmacies to distribute clean needles and syringes and collect used ones for safe disposal whilst highlighting the danger of needle-sharing. This part was called the Needle Syringe Programme (NSP). Third, a number of public hospitals were asked to provide free methadone as a substitute treatment (Taiwan Centers for Disease Control, 2005). The initial effects of this pilot programme were amazingly satisfactory in terms of HIV control. According to Yang, Yang, Shen and Kuo (2008), HIV incidence in sites with NSP decreased from 13.9 to 13.3 per 100,000 persons, whereas the incidence increased from 11.5 to 15.3 per 100,000 persons in sites without NSP. As a result, the Taiwanese government decided to scale up the policy and expand it into a nationwide programme in 2006.
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Fig. 1. The number of monthly newfound HIV-positive cases from January 2003 to December 2007. Note the timing of major events of harm reduction. Adapted from CDC, n.d.
To examine how this policy was made, my field work began in July 2007, about one year after its full implementation. Aside from an archival review, in-depth interviews were conducted with people who were involved in the process of policy making and implementation. In addition, treatments of IDUs in methadone clinics were also observed. The findings are discussed in another research paper I am drafting. Part of the initial research objective was to determine how biopower actually played out in the interactions between medical personnel and drug users which could account for the rapid decrease in HIV incidence. When major events of harm reduction policy were mapped onto the HIV incidence curve from 2003 to 2007, there was an inversion of the curve just before the implementation of the pilot programme (Fig. 1). Interviewers in the study gave some speculations: It could be the effect of the expanded screening programme, or it could be simply a phenomenon of saturation, i.e., the incidence curve sloped downward because all needle-sharing IDUs (that is, the at-risk population) had already been infected with HIV. These possibilities aside, there was another interpretation: IDUs were able to change their drug use behaviour through intangible yet interconnected social channels, although they had no such supporting organizations or advocacy groups as the Vancouver Area Network of Drug Users (VANDU) (Kerr et al., 2006). The provision of free methadone, along with free needles and syringes, constituted the centre of harm reduction entitlements. IDUs only paid service fees that covered the administrative cost of dispensing methadone. A rough estimate of IDUs’ daily expenses put the methadone substitution treatment cost approximately to one-tenth the price of detoxification medications and one-hundredth the price of heroin (Chen, 2009). Obviously, most IDUs would likely choose methadone treatment programmes over the other two. Nevertheless, methadone, needles and syringes were not offered for nothing. They were given exactly on the condition that these drug users served their duties, i.e., changed the ways that they injected themselves and thus avoided the likelihood of getting infected with HIV. In short, IDUs were expected to be “citizen addicts” of harm reduction who had corresponding rights and duties, entitlements, and responsibilities. Citizen addicts were produced not simply by discursive formations but also by disciplinary actions. These actions could be
illustrated most clearly in the instructional handouts for drug users about regulations of methadone treatment. For example, an information sheet from the Taoyuan Psychiatric Center (2007) read: [3. Content]. . ..You should go to the hospital everyday and take methadone as prescribed by the physician. Your absence means you voluntarily give up your rights. Your medication is given by your case manager and has to be taken immediately right there. You cannot take it away from the site of treatment, where camera recording operates all the time. . .. You need to visit the physician periodically and obtain your prescription from him/her so as to continue your eligibility for methadone. . ..Also, urine screening is mandatory for every physician visit. . .. If you are absent without informing us beforehand, our case manager will contact you by phone first. If your absence persists longer than four weeks, our hospital will discontinue your treatment plan. Your information collected by our hospital will be kept in paper and electronic forms. It will also be uploaded to the Department of Health as demanded. People who take methadone in two different hospitals will be excluded. In addition to these printed regulations, disciplinary actions also manifested themselves in the form of methadone distributed to IDUs. It was given in syrup forms, not as pills, so as to allow for dose titration and, moreover, to make oral cavity inspection easier. Diversion was thus prevented because it was difficult for IDUs to “steal” a mouthful of methadone liquid (Chen, 2009). Based on observations of local pharmacies that distributed clean needles and syringes, these drug users were not at all exempt from stigmatization. Harm reduction, as it was conceived in Taiwan, was purely utilitarian in the sense that it aimed to maximize the well-being and safety of the majority rather than safeguard those of IDUs. Although the Taiwan CDC later advanced a well-intentioned proposal for guarding the human rights of people with HIV/AIDS, the harm reduction policy was entirely bereft of human rights discourse. Instead, it was fashioned as a solution to an impending
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public health disaster. Even informants who played major roles in policy-making agreed that it was not so much a humanitarian rescue of IDUs as it was a pragmatic strategy for solving the HIV problem. However, without human rights discourses undergirding the policy, the citizenship thus formed was distinct from that in European history (Tilly, 1996). To follow Tilly’s characterization, what these citizen addicts really had was a citizenship that was at the same time thin and passive—thin, because it involved too few transactions between IDUs and the government; and passive, because the entitlements were simply endowed by the government. Whilst citizenship is invoked in STS as a form of socio-political membership for active participation (Heath et al., 2004; Leach & Scoones, 2005; Petryna, 2002), it is not so in the case of citizen addicts in this research. Instead, the case study shows that biopower deployment in Taiwan differs radically from that in early Euro-American contexts, such as the Junkiebond in the Netherlands, where harm reduction was seen from the outset as a communitybased bottom-up social movement (Inciadi & Harrison, 2000). However, whether the difference still stands now is a disputable question. Considering recent observations that also reveal the disciplinary and utilitarian features of methadone programmes in North America (Bourgois, 2000; Quirion, 2003), it is important to problematize the contrast between Taiwan’s harm reduction policy and its contemporary Euro-American counterparts. This commentary is not intended to repeat a clichéd disparity between the West and the East, but to substitute a perspective of citizenship for the antagonism of universal human rights and public health demands. The West implies a plurality of countries with diverse developmental trajectories and emergent situations, and so does the East. Consequently, to complicate the contrast more productively, dimensions of homogeneity and heterogeneity need to be addressed. Only through this approach is the perspective of citizenship able to articulate both dimensions and re-negotiate the tensions between human rights and public health. On the one hand, citizens’ health is often claimed as a collective right that must be protected by the state. On the other, human rights can also be counted as a central part of global citizenship (Turner, 1990). If Taiwan’s harm reduction policy is seen as a biopolitical project of citizen making, then both citizen addicts and the state have contributed to a new form of government. Although there are no advocacy groups in Taiwan for drug users, their needs and opinions are nevertheless recognized through sympathetic experts and organizations that participate in policy affairs. Meanwhile, it is noteworthy that the Taiwan CDC was not passively reacting to an existing social demand. Instead, the Taiwan CDC actively fashioned the issues of HIV transmission amongst IDUs and kept the policy low-profile enough to escape excessive media attention and public dispute. Although the increase in HIV incidence was statistically true, it did not land on top of the to-do list by itself. It had to be made so. In a sense, the government was constitutive of the urgency of the problem it intended to tackle. Since the policy cannot be categorized merely as a product of universal human rights claims or objective public health demands, both views are thus insufficient in explaining the foundation upon which Taiwan’s harm reduction policy has been based. As shown earlier, a perspective that examines the formation and effects of citizen addicts is an analytical alternative with an edge.
Conclusion Tammi and Hurme (2007) pointed out in an earlier commentary that the harm reduction movement exemplifies a powerful rhetorical intervention, which is strongly resonant with the moral
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sensibilities of late modernity. To them, the principles of harm reduction that have been frequently invoked in literature include individualism, inclusion, pragmatism, and emancipation. This paper argues that, as a matter of fact, these principles uphold individual freedom and calculative rationality in a market-driven society, thus echoing the ideal image of an autonomous subject that underlies the neoliberal trend of privatization and deregulation (Harvey, 2005). Ironically, some scholars, such as Bourgois and Schonberg (2009), contend that neoliberalism contributes to the aggravated marginalization of drug users. In Taiwan, conflicts of internal logic in the harm reduction policy are particularly exemplary. The policy demands that IDUs become self-responsible subjects who deserve entitlements. However, to be eligible for these entitlements, they are, at the same time, categorized as dangerous individuals prone to transmit diseases. Entitlements come with less suppression but more denigration, producing a doublebind citizenship (Chen, 2009). This research in Taiwan has led to the belief that harm reduction as a concept might come in many shapes in its implementation. Therefore, it is analytically futile to stick to ideological issues instead of practical details. However, the emphasis on practice does not simply endorse a microscopic description of actions and a negation of theory. Instead, an analytically comprehensive perspective capable of grappling with the complex power dynamics in harm reduction policy-making is desperately needed as well. In this way, citizenship as a sensitizing concept becomes all the more pertinent (Blumer, 1969). The citizenship perspective can be seen as one of the many attempts to theorize harm reduction, or more broadly, drug-control policies (Moore, 2004). It has, however, particular bearing on Asian contexts, where the meanings of universal human rights and public health demands are constantly conflicting and contested. This ambiguity makes these two concepts less suitable options to analyse various power relationships in these sites. It is the author’s hope that more harm reduction researchers will have increased familiarity with the notion of citizenship as a useful tool to examine the power dynamics taking place in the name of harm reduction.
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