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Harm reduction through a social justice lens
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International Journal of Drug Policy 19 (2008) 4–10
Commentary
Harm reduction through a social justice lens Bernadette Pauly ∗ School of Nursing, University of Victoria, Box 1700, Victoria, BC V8W 2Y2, Canada Received 12 July 2007; received in revised form 1 November 2007; accepted 12 November 2007
Abstract Background: People who are street involved such as those experiencing homelessness and drug use face multiple inequities in health and access to health care. Morbidity and mortality are significantly increased among those who are street involved. Incorporation of a harm reduction philosophy in health care has the potential to shift the moral context of health care delivery and enhance access to health care services. However, harm reduction with a primary focus on reducing the harms of drug use fails focus on the harms associated with the context of drug use such as homelessness, violence and poverty. Methods: Ethical analysis of the underlying values of harm reduction and examination of different conceptions of justice are discussed as a basis for action that addresses a broad range of harms associated with drug use. Results: Theories of distributive justice that focus primarily on the distribution of material goods are limited as theoretical frameworks for addressing the root causes of harm associated with drug use. Social justice, reconceptualised and interpreted through a critical lens as described by Iris Marion Young, is presented as a promising alternative ethical framework. Conclusions: A critical reinterpretation of social justice leads to insights that can illuminate structural inequities that contribute to the harms associated with the context of drug use. Such an approach provides promise as means of informing policy that aims to reduce a broad range of harms associated with drug use such as homelessness and poverty. © 2007 Elsevier B.V. All rights reserved. Keywords: Health inequities; Substance use; Homelessness; Harm reduction; Social justice
Inequities in health and access to health care for marginalised groups have received limited attention in bioethics (Brock, 2000; Daniels, 2006). Inequities are the consequence of multiple factors such as poverty, homelessness, unemployment and lack of social support (Whitehead & Dahlgren, 2006). Incorporation of a harm reduction philosophy has the potential to enhance access to health care services and creates opportunities for addressing health concerns of those who are homeless and using drugs (Pauly, 2005; Pauly, in review). However, harm reduction alone is inadequate to address the root cause of inequities in health and access to health care for those who are street involved and may even serve to further marginalise individuals. This commentary examines the underlying values of harm reduction and different conceptions of justice as a framework for addressing inequities in health and access to health care for drug users who are street involved.
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Health equity and inequity Equity in health has been defined as “the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically” (International Society for Equity in Health, 2005, p. 1). Inequities in health have been identified as a major concern in health care systems of developed countries worldwide (Crombie, Irvine, Elliott, & Wallace, 2005). Internationally, the terms inequality and inequity are often used in multiple and conflicting ways. In the U.K., for example, inequalities are often understood to be the same as inequities (Whitehead, 2007). From a population health perspective in Canada, inequality refers to differences between groups that may or may not be of concern. Inequities in health are differences of concern that can be identified on the basis of three distinguishing features (Whitehead & Dahlgren, 2006). First, health inequities “concern systematic differences in health status between different socioeconomic groups” (Whitehead & Dahlgren, 2006, p. 2). Of particular concern, is that there
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are persistent increases in morbidity and mortality as social position decreases (Whitehead & Dahlgren, 2006). A second feature of inequities is that primarily they are a product of social processes. The implication being that if differences in health are the result of social processes then it is possible to redress such inequities. A third feature of inequities is that they are considered to be unfair because they are a consequence of “unjust social arrangements” (Evans & Peters, 2001; Whitehead & Dahlgren, 2006). Those who are homeless and using drugs, are highly vulnerable to inequities in health and access to health care as a result of structural injustices. In this commentary, the term ‘inequities’ is used to refer to differences that are unfair or unjust as a result of structural arrangements that are potentially remedial (Starfield, 2006). Inequities in health status There are multiple harms associated with problematic substance use. For example, those experiencing problematic substance use are at increased risk of HIV, Hepatitis C, overdoses, soft tissue infections, and respiratory problems (Health Canada, 2003; Hunt et al., 2003; UNAIDS, 2006). HIV and Hepatitis C disproportionately affect certain groups such as those living in poverty, women and non-dominant racial groups. Women who are homeless and using drugs are at higher risk for contracting sexually transmitted diseases, Hepatitis C and HIV (Cheung & Hwang, 2004; Noell, Rohde, Seeley, & Ochs, 2001). Histories of childhood abuse, economic and social disadvantage, the presence of mental illnesses, lack of social support and family dysfunction are more likely among those who are street involved (Liebschutz et al., 2002; Stein, Leslie, & Nyamathi, 2002; Sullivan, Burnam, Koegel, & Hollenberg, 2000). Of great concern is that people on the street, including those who are homeless and using drugs, die at a much younger age than the general population (Hwang, 2001; Spittal, 2006). Causes of early death include HIV/AIDS, overdoses, accidents and suicide (Barrow, Herman, Cordova, & Struening, 1999; Cheung & Hwang, 2004; Hwang, 2000). Early death occurs irrespective of gender. Such inequities are the outcome of multiple factors beyond the health care system, with poverty being a key determinant of health (Crombie et al., 2005). Inequities in access to health care Access to health care is one determinant of health (Health Canada, 1999). Those who are street involved not only experience poorer health but they encounter multiple barriers in accessing health care services. This means that individuals have fewer resources available to deal with actual and potential health needs (Aday, 1993; Daniels, 1985; Flaskerud & Winslow, 1998; Hall, 1999; Hall, Stevens and Meleis, 1994). Those who have significant health needs often have the least access to health care. This is known as the inverse care law
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(Hart, 1971). These are serious ethical concerns often not addressed in bioethics. Barriers to accessing health care may be financial, geographic, qualitative and/or interactional (Stevens, 1992). In countries without universal health care, financial costs have repeatedly been identified as a primary barrier to accessing health care (Barkin, Balkrishnan, Manuel, Andersen, & Gelberg, 2003; Ensign & Planke, 2002; Freund & Hawkins, 2004; Hatton, 2001; McKinney, 2002). Canada has a system of universal health care that is founded on the principles of accessibility, universality, comprehensiveness, portability and public administration (Health Canada, 2005). Despite this, financial and geographical barriers to accessing health care services persist. For example, in a study of Canadian women who were homeless and using crack cocaine, Butters and Erickson (2003) found that lack of a health care card was a major barrier to accessing health care. For those without social assistance, the cost of obtaining a heath care card or basic health care coverage may be prohibitive. Transportation, child care and pharmaceutical costs can act as financial barriers to accessing services for those living in poverty (Hwang & Gottlieb, 1999; Williamson & Fast, 1998). Dental problems are a persistent source of pain and affect nutritional status for those who are street involved. At the same time, people who are homeless and/or living in poverty may not have coverage for dental or eye care which is provided through private insurance plans in Canada. In urban centres, geographic barriers exist for those who are street involved and not within walking distance of centres that provide essential services. Qualitative and interactional factors can influence health care for those who are street involved, including the nature of individual interactions with health care providers and a person’s perception of the health care encounter (Stevens, 1992). “Health services, as one of the important determinants of health, can greatly influence the outcomes of a client’s contact because of the nature of the interaction with health professionals, both doctors and nurses” (Hilton, Thompson, Moore-Dempsey, & Janzen, 2001, p. 360). Stigma associated with drug use can negatively impact health care interactions and access to health care. In research exploring the experiences of individuals who are homeless and/or using drugs negative attitudes, judgments and perceived discrimination have been identified as primary barriers to accessing health care (Butters & Erickson, 2003; Crockett & Gifford, 2004; Ensign & Planke, 2002; Gelberg, Browner, Lejano, & Arangua, 2004; Napravnik, Royce, Walter, & Lim, 2000; Stajduhar, Poffenroth, & Wong, 2000). A past or current status as a ‘drug user’ can be a barrier to accessing health care and can affect the quality of care received (Butters and Erickson; Napravnik et al., 2000). In other research, nonfinancial barriers identified by participants included long wait times, not knowing where to access care, believing they were ineligible for health care coverage, being too ill, and facing competing priorities such as need to find food or shelter (Barkin et al., 2003; Gelberg, Gallagher, Andersen, & Koegel, 1997; Hatton, 2001; Lewis, Andersen, Gelberg, 2003). Peo-
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ple are often very ill when they access health care services resulting in increased emergency department use at times of increased acuity and for complications of drug use and homelessness (Hwang et al., 2001; Kerr et al., 2005). The invisible effect of delays and lack of access to appropriate health care is lost opportunities for health promotion and disease prevention (Pauly, 2005). Harm reduction: evidence and values There is considerable evidence that harm reduction strategies such as needle exchange and supervised injection sites are effective in reducing the harms associated with drug use (Hunt et al., 2003; Loxley et al., 2004; Wodak, 2006; Wodak & Cooney, 2005; Wood et al., 2004; Wood, Tyndall, Montaner, & Kerr, 2006). Harm reduction is both a philosophy and set of strategies that proposes a value neutral shift towards drug use in policy and practice (British Columbia Ministry of Health, 2005; Canadian Center on Substance Abuse [CCSA], 1996; Hunt et al., 2003; International Harm Reduction Association, 2006). A value neutral approach to drug use has been identified as one of the strengths of harm reduction: “Indeed, it is the refusal of moral judgment that has made harm reduction such an effective and innovative strategy in a field overwhelmed by moral discourse” (Keane, 2005, p. 551). The value neutral position on drug use does not mean that harm reduction is value free. The values embedded in harm reduction can be illuminated through an examination of the principles of harm reduction. The Canadian Centre on Substance Abuse Working Group (1996) outlines five principles of harm reduction. These principles will be examined here to highlight the underlying values of harm reduction. Pragmatism as a principle recognises that many activities in life carry risks. The underlying value expressed in this principle is that of realism and recognition that elimination of drug use is not necessarily attainable or desirable. The principle of humanistic values explicitly highlights the values of respect, worth and dignity of all persons including those who use drugs. Harsh moral judgments, particularly of those who use illicit drugs, are countered by a focus on nonjudgmental acceptance of persons as worthy of respect without judgment of drug use. A focus on reducing the negative consequences of substance use for individuals, communities and societies is promoted rather than focusing on decreasing or eliminating substance use. Harm reduction is valued as part of a comprehensive approach rather than the sole approach to drug use. The principle of balancing costs and benefits for individuals as well as society suggests a set of values that seeks to balance the tension between promoting individual and common good. Supervised injection sites (SISs) represent a balancing of these tensions. For example, individual benefits as worthy of respect and without judgment of drug use such as reduced incidence of blood borne diseases, overdoses, soft tissue infections and increased referrals to health and social services are accrued at the same time that there are benefits for society in relation to decreased
public disorder (Wood et al., 2004, 2006). The fifth principle of harm reduction focuses on the priority of immediate goals as identified by those who use substances, and speaks to democratic values of collaboration with and participation of those who are marginalised by substance use in policy and program development. Such values point to what is needed to enhance fairness and justice in reducing the harms of drug use. Embracing the philosophy and underlying values of harm reduction creates a moral context in which drug use is acknowledged but not judged and action is supportive rather than punitive. Shifting the moral context For health care providers, harm reduction as a philosophy shifts the moral context in health care away from the primary goal of fixing individuals towards one of reducing harm (Pauly, in review). This is consistent with the view that problematic substance use is better understood as a complex, relapsing and chronic condition. The moral worth of individuals is valued and harsh moral judgments of those who are experiencing substance use are not condoned. Within a context of harm reduction, respect for persons stands in sharp contrast to the disrespect often associated with the stigma of drug use. Harm reduction shifts the culture from one where resources may be rationed on the basis of deservedness to one in which everyone is seen as deserving of care. Rather than being constructed as difficult patients, people are constructed as in need of care with recognition of the multiple constraints they face in accessing care. Harm reduction opens opportunities for promoting health of vulnerable populations and enhancing access to health. However, harm reduction interventions are insufficient to address the underlying social conditions that produce inequities. Harm reduction, understood as a set of interventions that reduce the negative consequences of drug use severs substance use from the context of drug use and harms such as homelessness and poverty (Perry & Reist, 2006). As described above, the principles of, harm reduction emphasize a value of personal responsibility for staying healthy through the use of clean needles and proper injection technique, in turn creating a new moral order of individual responsibility in which the underlying social concerns contributing to problematic substance use go unaddressed (Fischer, Turnbull, Poland, & Haydon, 2004; Miller, 2005). Harm reduction as a strategy is a partial rather than comprehensive approach to reducing the harms associated with multiple inequities as a result of homelessness and drug use.
Concepts of justice Defining inequities as unfair and in just highlights the need for a theoretical understanding of justice that contributes to the amelioration of inequities in health (Evans & Peters, 2001; Starfield, 2006; Whitehead, 2007). Different notions
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of justice can be understood as a lens through which to view concerns about inequities and enhance understanding of potential theoretical approaches to underpin action for addressing inequities such as those associated with drug use (Sherwin, 1999). Starfield (2006) observes that the definition of equity developed by the International Society for Equity in Health (ISEH), and presented earlier, is consistent with several conceptions of social justice. She states that it is consistent with Sen’s notion of social justice as the capacity to flourish, as well as Rawl’s (1971) view that the worst off not be further disadvantaged by arrangement of social institutions. Young (2001, p. 2) states that “the main reason that philosophers care about equality, however, is to contribute to assessments of social justice and proposals for promoting greater social justice”. However, there are multiple, and competing, conceptions of justice and social justice. The most common conception of justice in health care is distributive justice. Beauchamp and Childress (2001) provide a well-known definition of distributive justice. The term distributive justice refers to fair, equitable, and appropriate distribution determined by justified norms that structure the terms of social cooperation. Its scope includes policies that allot diverse benefits and burdens, such as property, resources, taxation, privileges and opportunities. Distributive justice refers broadly to the distribution of all rights and responsibilities in society, including, for example, civil and political rights (Beauchamp & Childress, 2001, p. 226). Within the distributive paradigm, conceptions of justice may be grounded in libertarian, utilitarian, egalitarian, and communitarian theories that propose different criteria, applications and justification in determining how social benefits such as health care ought to be distributed such as rights, need or merit (Beauchamp & Childress, 2001). Theories of distributive justice are primarily concerned with the distribution of material goods (Young, 1990). A utilitarian approach could be used to argue that the best outcome for the most people is abstinence from drugs. This perspective has tended to bolster the ‘war on drugs’ mentality (Keane, 2003). Egalitarian approaches tend to focus on equality of opportunity to access health care resources rather than equality in health outcomes (Young, 2001). Thus, in an eqalitatarian perspective those who use drugs should have the same opportunities as other members of society to access to health care resources. According to Aday, Begley, Lairson, and Slater (1998) achieving equity in a distributive paradigm is most often based on a libertarian perspective informed by liberal individualism with an ensuing focus on concerns related to the availability, organisation and financing of health services and satisfaction of users of the system. From a libertarian perspective, individual freedom or liberty is highly valued. The primary concern is the protection of individual rights as long as they do not interfere with the rights of others. A libertarian conception of justice focuses on questions of indi-
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vidual good—rather than beginning with questions about the common good or end goals of society and then considering individuals good in relation to the societal context (Callahan, 2003). The emphasis in a libertarian conception of justice is on ensuring autonomy and personal responsibility without recognition of the social conditions that limit individual choices and actions (Young, 2001). From a perspective of liberal individualism, substance use can be viewed as a personal failure and homelessness a consequence of the free market. The adoption of free market ideals in housing, as in health care, is a reflection of societal values that emphasize personal responsibility with the potential to create harm those marginalised in society. If homelessness and substance use are viewed through a neo-liberal lens, individuals are not only seen to be at fault but are failing to take personal responsibility for their homelessness and drug use. Such perspectives easily obscure the social and political structures that create conditions in which some individuals are more likely than others to experience poverty, homelessness, lack of education, lack of social support and so on. Fry, Treolar, and Maher (2005) have argued for the adoption of applied communitarian ethics in harm reduction practice and research. Communitarian perspectives move towards social justice through a focus on engagement with and involvement of the public and communities in the development of policy and practice. Communitarianism may be understood as engaging in processes the help to determine how good in society will be distributed through democratic processes. When communitarianism is enacted within a distributive paradigm driven by liberal individualism, there will most likely be a lack of attention to power inequities among groups or ensuring processes for fair and equitable participation of all groups. Those most vulnerable and on the margins of society are most likely to be absent or underrepresented in the policy making process. Young, a feminist philosopher, argues that it is a mistake to reduce justice to distribution, claiming that the distributive paradigm “tends to ignore the social structures and institutional context that often help determine distributive patterns” (Young, 1990, p. 15). Young highlights the importance of addressing nondistributive issues such as decision making structures and processes, division of labor and culture and nonmaterial goods such as respect and power. She argues that the conditions that produce distribution of resources and ill health are not accounted and that this has implications for rights, opportunity, power and self-respect. She states, “A large class of issues of social justice, and those that concern claims that inequalities are unjust in particular, concern evaluation of institutional relations and processes of society” (Young, 2001, p. 2). Focusing on distribution of existing resources without attention to such issues does little to help us to understand how policies, social structures and resulting practices affect those affected by homelessness and drug use. For example, the lack of a residential address or personal identification may act as additional barriers to accessing health care services or gaining coverage for pre-
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scription drugs if the person is homeless. The harm created by policies and structures that constrain individuals will go unrecognised. Since notions of distributive justice cannot illuminate these issues, a focus on difference that includes the concepts of domination and oppression rather than distribution will highlight the areas in which institutional structures and processes serve to advantage those already with greater advantages and disadvantage others with less privilege (Young, 1990). In her view, this is the starting point for a conception of social justice. Institutional structures and processes “describe a set of relationships among assumptions and stereotypes, institutional policies, individual actions following rules or choosing in self-interest, and collective consequences of these things, which constrain the options of some at the same time as they expand the options of others” (Young, 2001, p. 11). It is important to note that institutional structures are not static states but lived as processes through action and interactions between persons. Young (2001) argues that comparison of social groups makes it possible to claim some inequalities as unjust as a result of structural inequalities. Structural inequalities often exist along the lines of gender, ethnicity and class among other factors. Such inequalities act as constraints on individual freedom and well-being due to the cumulative effects of institutional structures and social processes on one’s social position and in relation to others with greater social privilege (Young, 2001). According to Young, structural inequalities are unjust when they are systematic and impact well-being in several dimensions. Young and others, such as Powers and Fadden (2006), have begun theoretical work to articulate the dimensions of well-being; work which needs extending in the context of substance use.
Conclusion The intersection of homelessness and drug use contribute to multiple inequities in health and access to health care. Inequities in health and lack of access to health care are a consequence of multiple structural injustices that disproportionately affect those who are street involved. Inequities are exacerbated by lack of quality housing, poverty, unemployment, lack of social support and education. Harm reduction driven solely by reducing the harm of drug use is not sufficient to address inequities in health and access to health care for those who are street involved. An examination of the values of harm reduction highlights the limitations of this approach and the potential of harm reduction to further marginalise individuals who use drugs. Conceptions of social justice that shift from distribution of existing material resources to a focus on social structures hold promise by surfacing the root causes of problematic substance use and homelessness; conditions that harm reduction alone cannot ameliorate. In particular, a critical reinterpretation of social justice such as that of Young (1990, 2001) requires further examination as a com-
plementary moral underpinning that will facilitate a focus on reducing the harms associated with the context of drug use. Incorporation of harm reduction strategies is part of a comprehensive approach to providing accessible health care and improving the health of those who are street involved. Access to health services can be a pathway to housing income as well as other other social determinants that have the potential to impact health. Assuming that such resources exist, a better understanding of the linkages between health care services and social programmes is needed (Pauly, 2005). There is an urgent need for implementation of harm reduction philosophy and strategies in health care linked with enhanced action on the social determinants of health to ensure such resources are available. In this commentary, the focus has been on inequities and reconceptualising social justice in a primarily North American context. Significant progress has been undertaken internationally that demonstrates stronger integration of harm reduction interventions, primary health care and the social determinants of health within a social justice framework. A key area for exploration is the underlying values and ethical framework guiding such policies and practices. Specific attention is needed to engage those who use drugs in the development of policy and programmes. Social justice provides a broader framework for actively collaborating, engaging and involving those who use drugs as a means of systemic change. At all levels, increasing awareness of the harms created by policies that impact problematic substance use such as housing, welfare and income policies is needed. The harms created by social structures and policies require specific examination for the ways that they contribute to poor health of those who are street involved. In particular, anti-drug strategies reflect dominant ideologically located values and ignore the structural differences that can reduce inequities in health and access to health care. For example, stigma is a harm of drug use that arises from the illegal status of illicit drugs (Keane, 2003). Prohibitionist policies threaten the freedom of users, damage their health and constitute them as marginal and stigmatized subjects excluded from normative categories of citizenship such as ‘the general public’ (Keane, 2003, p. 229). Within a social justice framework, it is possible to address harms of drug policy not as a matter of choice but as a matter of health and well-being. Policies that are potentially harm-producing include some those policing, housing, income and employment policies, as well as organisational policies such as abstinence and zero tolerance policies. In addition, the presence of neo-liberal values that stigmatise and further marginalise those who use drugs underlying such policies requires highlighting. Taken together, the application of a social justice framework to policy has the potential to illuminate underlying values and potential harms associated with the social context of drug use. Further work is needed
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Noell, J., Rohde, P., Seeley, J., & Ochs, L. (2001). Childhood sexual abuse, adolescent sexual coercion and sexually transmitted infection acquisition among homeless female adolescents. Child Abuse and Neglect, 25, 137–148. Miller, P. (2005). Harm reduction ethics: A promising basis for drug policy. Drug and Alcohol Review, 24, 553–554. Pauly, B. (in review). Close to the street: Ethical dimensions of working within harm reduction. International Journal of Drug Policy. Pauly, B. M. (2005). Close to the street: The ethics of access to health care. Unpublished doctoral dissertation, University of Victoria. Perry S., & Reist, D. (2006). Words, values and Canadians. A report on dialogue at the National Symposium for Language. Powers, M., & Fadden, R. (2006). Social justice: The moral foundations of public health and health policy. Toronto: Oxford University Press. Sherwin, S. (1999). Foundations, frameworks, lens: The role of theories in bioethics. Bioethics, 13(3/4), 198–205. Spittal, P. (2006). Drastic elevations in mortality among female injection drug users in a Canadian setting. Aids Care, 18(2), 101–108. Stajduhar, K., Poffenroth, L., & Wong, E. (2000). Missed opportunities: Putting a face on injection drug use and HIV/AIDS in the Capital Health Region. Final report prepared for the Capital Health Region. Starfield, B. (2006). State of the art in research on equity in health. Journal of Health Politics, Policy and Law, 31(1), 11–32. Stein, J., Leslie, M., & Nyamathi, A. (2002). Relative contributions of parent substance use and childhood maltreatment to chronic homelessness, depression, and substance abuse problemsamong homeless women: Mediating roles of self-esteem and abuse in adulthood. Child Abuse and Neglect, 26(10), 1011–1027. Stevens, P. E. (1992). Who gets care? Access to health care as an arena for nursing action. Scholarly Inquiry in Nursing Practice, 6(3Bernie’s copy), 185–200.
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Commentary
Harm reduction through a social justice lens Bernadette Pauly ∗ School of Nursing, University of Victoria, Box 1700, Victoria, BC V8W 2Y2, Canada Received 12 July 2007; received in revised form 1 November 2007; accepted 12 November 2007
Abstract Background: People who are street involved such as those experiencing homelessness and drug use face multiple inequities in health and access to health care. Morbidity and mortality are significantly increased among those who are street involved. Incorporation of a harm reduction philosophy in health care has the potential to shift the moral context of health care delivery and enhance access to health care services. However, harm reduction with a primary focus on reducing the harms of drug use fails focus on the harms associated with the context of drug use such as homelessness, violence and poverty. Methods: Ethical analysis of the underlying values of harm reduction and examination of different conceptions of justice are discussed as a basis for action that addresses a broad range of harms associated with drug use. Results: Theories of distributive justice that focus primarily on the distribution of material goods are limited as theoretical frameworks for addressing the root causes of harm associated with drug use. Social justice, reconceptualised and interpreted through a critical lens as described by Iris Marion Young, is presented as a promising alternative ethical framework. Conclusions: A critical reinterpretation of social justice leads to insights that can illuminate structural inequities that contribute to the harms associated with the context of drug use. Such an approach provides promise as means of informing policy that aims to reduce a broad range of harms associated with drug use such as homelessness and poverty. © 2007 Elsevier B.V. All rights reserved. Keywords: Health inequities; Substance use; Homelessness; Harm reduction; Social justice
Inequities in health and access to health care for marginalised groups have received limited attention in bioethics (Brock, 2000; Daniels, 2006). Inequities are the consequence of multiple factors such as poverty, homelessness, unemployment and lack of social support (Whitehead & Dahlgren, 2006). Incorporation of a harm reduction philosophy has the potential to enhance access to health care services and creates opportunities for addressing health concerns of those who are homeless and using drugs (Pauly, 2005; Pauly, in review). However, harm reduction alone is inadequate to address the root cause of inequities in health and access to health care for those who are street involved and may even serve to further marginalise individuals. This commentary examines the underlying values of harm reduction and different conceptions of justice as a framework for addressing inequities in health and access to health care for drug users who are street involved.
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Health equity and inequity Equity in health has been defined as “the absence of systematic and potentially remediable differences in one or more aspects of health across populations or population subgroups defined socially, economically, demographically, or geographically” (International Society for Equity in Health, 2005, p. 1). Inequities in health have been identified as a major concern in health care systems of developed countries worldwide (Crombie, Irvine, Elliott, & Wallace, 2005). Internationally, the terms inequality and inequity are often used in multiple and conflicting ways. In the U.K., for example, inequalities are often understood to be the same as inequities (Whitehead, 2007). From a population health perspective in Canada, inequality refers to differences between groups that may or may not be of concern. Inequities in health are differences of concern that can be identified on the basis of three distinguishing features (Whitehead & Dahlgren, 2006). First, health inequities “concern systematic differences in health status between different socioeconomic groups” (Whitehead & Dahlgren, 2006, p. 2). Of particular concern, is that there
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are persistent increases in morbidity and mortality as social position decreases (Whitehead & Dahlgren, 2006). A second feature of inequities is that primarily they are a product of social processes. The implication being that if differences in health are the result of social processes then it is possible to redress such inequities. A third feature of inequities is that they are considered to be unfair because they are a consequence of “unjust social arrangements” (Evans & Peters, 2001; Whitehead & Dahlgren, 2006). Those who are homeless and using drugs, are highly vulnerable to inequities in health and access to health care as a result of structural injustices. In this commentary, the term ‘inequities’ is used to refer to differences that are unfair or unjust as a result of structural arrangements that are potentially remedial (Starfield, 2006). Inequities in health status There are multiple harms associated with problematic substance use. For example, those experiencing problematic substance use are at increased risk of HIV, Hepatitis C, overdoses, soft tissue infections, and respiratory problems (Health Canada, 2003; Hunt et al., 2003; UNAIDS, 2006). HIV and Hepatitis C disproportionately affect certain groups such as those living in poverty, women and non-dominant racial groups. Women who are homeless and using drugs are at higher risk for contracting sexually transmitted diseases, Hepatitis C and HIV (Cheung & Hwang, 2004; Noell, Rohde, Seeley, & Ochs, 2001). Histories of childhood abuse, economic and social disadvantage, the presence of mental illnesses, lack of social support and family dysfunction are more likely among those who are street involved (Liebschutz et al., 2002; Stein, Leslie, & Nyamathi, 2002; Sullivan, Burnam, Koegel, & Hollenberg, 2000). Of great concern is that people on the street, including those who are homeless and using drugs, die at a much younger age than the general population (Hwang, 2001; Spittal, 2006). Causes of early death include HIV/AIDS, overdoses, accidents and suicide (Barrow, Herman, Cordova, & Struening, 1999; Cheung & Hwang, 2004; Hwang, 2000). Early death occurs irrespective of gender. Such inequities are the outcome of multiple factors beyond the health care system, with poverty being a key determinant of health (Crombie et al., 2005). Inequities in access to health care Access to health care is one determinant of health (Health Canada, 1999). Those who are street involved not only experience poorer health but they encounter multiple barriers in accessing health care services. This means that individuals have fewer resources available to deal with actual and potential health needs (Aday, 1993; Daniels, 1985; Flaskerud & Winslow, 1998; Hall, 1999; Hall, Stevens and Meleis, 1994). Those who have significant health needs often have the least access to health care. This is known as the inverse care law
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(Hart, 1971). These are serious ethical concerns often not addressed in bioethics. Barriers to accessing health care may be financial, geographic, qualitative and/or interactional (Stevens, 1992). In countries without universal health care, financial costs have repeatedly been identified as a primary barrier to accessing health care (Barkin, Balkrishnan, Manuel, Andersen, & Gelberg, 2003; Ensign & Planke, 2002; Freund & Hawkins, 2004; Hatton, 2001; McKinney, 2002). Canada has a system of universal health care that is founded on the principles of accessibility, universality, comprehensiveness, portability and public administration (Health Canada, 2005). Despite this, financial and geographical barriers to accessing health care services persist. For example, in a study of Canadian women who were homeless and using crack cocaine, Butters and Erickson (2003) found that lack of a health care card was a major barrier to accessing health care. For those without social assistance, the cost of obtaining a heath care card or basic health care coverage may be prohibitive. Transportation, child care and pharmaceutical costs can act as financial barriers to accessing services for those living in poverty (Hwang & Gottlieb, 1999; Williamson & Fast, 1998). Dental problems are a persistent source of pain and affect nutritional status for those who are street involved. At the same time, people who are homeless and/or living in poverty may not have coverage for dental or eye care which is provided through private insurance plans in Canada. In urban centres, geographic barriers exist for those who are street involved and not within walking distance of centres that provide essential services. Qualitative and interactional factors can influence health care for those who are street involved, including the nature of individual interactions with health care providers and a person’s perception of the health care encounter (Stevens, 1992). “Health services, as one of the important determinants of health, can greatly influence the outcomes of a client’s contact because of the nature of the interaction with health professionals, both doctors and nurses” (Hilton, Thompson, Moore-Dempsey, & Janzen, 2001, p. 360). Stigma associated with drug use can negatively impact health care interactions and access to health care. In research exploring the experiences of individuals who are homeless and/or using drugs negative attitudes, judgments and perceived discrimination have been identified as primary barriers to accessing health care (Butters & Erickson, 2003; Crockett & Gifford, 2004; Ensign & Planke, 2002; Gelberg, Browner, Lejano, & Arangua, 2004; Napravnik, Royce, Walter, & Lim, 2000; Stajduhar, Poffenroth, & Wong, 2000). A past or current status as a ‘drug user’ can be a barrier to accessing health care and can affect the quality of care received (Butters and Erickson; Napravnik et al., 2000). In other research, nonfinancial barriers identified by participants included long wait times, not knowing where to access care, believing they were ineligible for health care coverage, being too ill, and facing competing priorities such as need to find food or shelter (Barkin et al., 2003; Gelberg, Gallagher, Andersen, & Koegel, 1997; Hatton, 2001; Lewis, Andersen, Gelberg, 2003). Peo-
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ple are often very ill when they access health care services resulting in increased emergency department use at times of increased acuity and for complications of drug use and homelessness (Hwang et al., 2001; Kerr et al., 2005). The invisible effect of delays and lack of access to appropriate health care is lost opportunities for health promotion and disease prevention (Pauly, 2005). Harm reduction: evidence and values There is considerable evidence that harm reduction strategies such as needle exchange and supervised injection sites are effective in reducing the harms associated with drug use (Hunt et al., 2003; Loxley et al., 2004; Wodak, 2006; Wodak & Cooney, 2005; Wood et al., 2004; Wood, Tyndall, Montaner, & Kerr, 2006). Harm reduction is both a philosophy and set of strategies that proposes a value neutral shift towards drug use in policy and practice (British Columbia Ministry of Health, 2005; Canadian Center on Substance Abuse [CCSA], 1996; Hunt et al., 2003; International Harm Reduction Association, 2006). A value neutral approach to drug use has been identified as one of the strengths of harm reduction: “Indeed, it is the refusal of moral judgment that has made harm reduction such an effective and innovative strategy in a field overwhelmed by moral discourse” (Keane, 2005, p. 551). The value neutral position on drug use does not mean that harm reduction is value free. The values embedded in harm reduction can be illuminated through an examination of the principles of harm reduction. The Canadian Centre on Substance Abuse Working Group (1996) outlines five principles of harm reduction. These principles will be examined here to highlight the underlying values of harm reduction. Pragmatism as a principle recognises that many activities in life carry risks. The underlying value expressed in this principle is that of realism and recognition that elimination of drug use is not necessarily attainable or desirable. The principle of humanistic values explicitly highlights the values of respect, worth and dignity of all persons including those who use drugs. Harsh moral judgments, particularly of those who use illicit drugs, are countered by a focus on nonjudgmental acceptance of persons as worthy of respect without judgment of drug use. A focus on reducing the negative consequences of substance use for individuals, communities and societies is promoted rather than focusing on decreasing or eliminating substance use. Harm reduction is valued as part of a comprehensive approach rather than the sole approach to drug use. The principle of balancing costs and benefits for individuals as well as society suggests a set of values that seeks to balance the tension between promoting individual and common good. Supervised injection sites (SISs) represent a balancing of these tensions. For example, individual benefits as worthy of respect and without judgment of drug use such as reduced incidence of blood borne diseases, overdoses, soft tissue infections and increased referrals to health and social services are accrued at the same time that there are benefits for society in relation to decreased
public disorder (Wood et al., 2004, 2006). The fifth principle of harm reduction focuses on the priority of immediate goals as identified by those who use substances, and speaks to democratic values of collaboration with and participation of those who are marginalised by substance use in policy and program development. Such values point to what is needed to enhance fairness and justice in reducing the harms of drug use. Embracing the philosophy and underlying values of harm reduction creates a moral context in which drug use is acknowledged but not judged and action is supportive rather than punitive. Shifting the moral context For health care providers, harm reduction as a philosophy shifts the moral context in health care away from the primary goal of fixing individuals towards one of reducing harm (Pauly, in review). This is consistent with the view that problematic substance use is better understood as a complex, relapsing and chronic condition. The moral worth of individuals is valued and harsh moral judgments of those who are experiencing substance use are not condoned. Within a context of harm reduction, respect for persons stands in sharp contrast to the disrespect often associated with the stigma of drug use. Harm reduction shifts the culture from one where resources may be rationed on the basis of deservedness to one in which everyone is seen as deserving of care. Rather than being constructed as difficult patients, people are constructed as in need of care with recognition of the multiple constraints they face in accessing care. Harm reduction opens opportunities for promoting health of vulnerable populations and enhancing access to health. However, harm reduction interventions are insufficient to address the underlying social conditions that produce inequities. Harm reduction, understood as a set of interventions that reduce the negative consequences of drug use severs substance use from the context of drug use and harms such as homelessness and poverty (Perry & Reist, 2006). As described above, the principles of, harm reduction emphasize a value of personal responsibility for staying healthy through the use of clean needles and proper injection technique, in turn creating a new moral order of individual responsibility in which the underlying social concerns contributing to problematic substance use go unaddressed (Fischer, Turnbull, Poland, & Haydon, 2004; Miller, 2005). Harm reduction as a strategy is a partial rather than comprehensive approach to reducing the harms associated with multiple inequities as a result of homelessness and drug use.
Concepts of justice Defining inequities as unfair and in just highlights the need for a theoretical understanding of justice that contributes to the amelioration of inequities in health (Evans & Peters, 2001; Starfield, 2006; Whitehead, 2007). Different notions
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of justice can be understood as a lens through which to view concerns about inequities and enhance understanding of potential theoretical approaches to underpin action for addressing inequities such as those associated with drug use (Sherwin, 1999). Starfield (2006) observes that the definition of equity developed by the International Society for Equity in Health (ISEH), and presented earlier, is consistent with several conceptions of social justice. She states that it is consistent with Sen’s notion of social justice as the capacity to flourish, as well as Rawl’s (1971) view that the worst off not be further disadvantaged by arrangement of social institutions. Young (2001, p. 2) states that “the main reason that philosophers care about equality, however, is to contribute to assessments of social justice and proposals for promoting greater social justice”. However, there are multiple, and competing, conceptions of justice and social justice. The most common conception of justice in health care is distributive justice. Beauchamp and Childress (2001) provide a well-known definition of distributive justice. The term distributive justice refers to fair, equitable, and appropriate distribution determined by justified norms that structure the terms of social cooperation. Its scope includes policies that allot diverse benefits and burdens, such as property, resources, taxation, privileges and opportunities. Distributive justice refers broadly to the distribution of all rights and responsibilities in society, including, for example, civil and political rights (Beauchamp & Childress, 2001, p. 226). Within the distributive paradigm, conceptions of justice may be grounded in libertarian, utilitarian, egalitarian, and communitarian theories that propose different criteria, applications and justification in determining how social benefits such as health care ought to be distributed such as rights, need or merit (Beauchamp & Childress, 2001). Theories of distributive justice are primarily concerned with the distribution of material goods (Young, 1990). A utilitarian approach could be used to argue that the best outcome for the most people is abstinence from drugs. This perspective has tended to bolster the ‘war on drugs’ mentality (Keane, 2003). Egalitarian approaches tend to focus on equality of opportunity to access health care resources rather than equality in health outcomes (Young, 2001). Thus, in an eqalitatarian perspective those who use drugs should have the same opportunities as other members of society to access to health care resources. According to Aday, Begley, Lairson, and Slater (1998) achieving equity in a distributive paradigm is most often based on a libertarian perspective informed by liberal individualism with an ensuing focus on concerns related to the availability, organisation and financing of health services and satisfaction of users of the system. From a libertarian perspective, individual freedom or liberty is highly valued. The primary concern is the protection of individual rights as long as they do not interfere with the rights of others. A libertarian conception of justice focuses on questions of indi-
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vidual good—rather than beginning with questions about the common good or end goals of society and then considering individuals good in relation to the societal context (Callahan, 2003). The emphasis in a libertarian conception of justice is on ensuring autonomy and personal responsibility without recognition of the social conditions that limit individual choices and actions (Young, 2001). From a perspective of liberal individualism, substance use can be viewed as a personal failure and homelessness a consequence of the free market. The adoption of free market ideals in housing, as in health care, is a reflection of societal values that emphasize personal responsibility with the potential to create harm those marginalised in society. If homelessness and substance use are viewed through a neo-liberal lens, individuals are not only seen to be at fault but are failing to take personal responsibility for their homelessness and drug use. Such perspectives easily obscure the social and political structures that create conditions in which some individuals are more likely than others to experience poverty, homelessness, lack of education, lack of social support and so on. Fry, Treolar, and Maher (2005) have argued for the adoption of applied communitarian ethics in harm reduction practice and research. Communitarian perspectives move towards social justice through a focus on engagement with and involvement of the public and communities in the development of policy and practice. Communitarianism may be understood as engaging in processes the help to determine how good in society will be distributed through democratic processes. When communitarianism is enacted within a distributive paradigm driven by liberal individualism, there will most likely be a lack of attention to power inequities among groups or ensuring processes for fair and equitable participation of all groups. Those most vulnerable and on the margins of society are most likely to be absent or underrepresented in the policy making process. Young, a feminist philosopher, argues that it is a mistake to reduce justice to distribution, claiming that the distributive paradigm “tends to ignore the social structures and institutional context that often help determine distributive patterns” (Young, 1990, p. 15). Young highlights the importance of addressing nondistributive issues such as decision making structures and processes, division of labor and culture and nonmaterial goods such as respect and power. She argues that the conditions that produce distribution of resources and ill health are not accounted and that this has implications for rights, opportunity, power and self-respect. She states, “A large class of issues of social justice, and those that concern claims that inequalities are unjust in particular, concern evaluation of institutional relations and processes of society” (Young, 2001, p. 2). Focusing on distribution of existing resources without attention to such issues does little to help us to understand how policies, social structures and resulting practices affect those affected by homelessness and drug use. For example, the lack of a residential address or personal identification may act as additional barriers to accessing health care services or gaining coverage for pre-
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scription drugs if the person is homeless. The harm created by policies and structures that constrain individuals will go unrecognised. Since notions of distributive justice cannot illuminate these issues, a focus on difference that includes the concepts of domination and oppression rather than distribution will highlight the areas in which institutional structures and processes serve to advantage those already with greater advantages and disadvantage others with less privilege (Young, 1990). In her view, this is the starting point for a conception of social justice. Institutional structures and processes “describe a set of relationships among assumptions and stereotypes, institutional policies, individual actions following rules or choosing in self-interest, and collective consequences of these things, which constrain the options of some at the same time as they expand the options of others” (Young, 2001, p. 11). It is important to note that institutional structures are not static states but lived as processes through action and interactions between persons. Young (2001) argues that comparison of social groups makes it possible to claim some inequalities as unjust as a result of structural inequalities. Structural inequalities often exist along the lines of gender, ethnicity and class among other factors. Such inequalities act as constraints on individual freedom and well-being due to the cumulative effects of institutional structures and social processes on one’s social position and in relation to others with greater social privilege (Young, 2001). According to Young, structural inequalities are unjust when they are systematic and impact well-being in several dimensions. Young and others, such as Powers and Fadden (2006), have begun theoretical work to articulate the dimensions of well-being; work which needs extending in the context of substance use.
Conclusion The intersection of homelessness and drug use contribute to multiple inequities in health and access to health care. Inequities in health and lack of access to health care are a consequence of multiple structural injustices that disproportionately affect those who are street involved. Inequities are exacerbated by lack of quality housing, poverty, unemployment, lack of social support and education. Harm reduction driven solely by reducing the harm of drug use is not sufficient to address inequities in health and access to health care for those who are street involved. An examination of the values of harm reduction highlights the limitations of this approach and the potential of harm reduction to further marginalise individuals who use drugs. Conceptions of social justice that shift from distribution of existing material resources to a focus on social structures hold promise by surfacing the root causes of problematic substance use and homelessness; conditions that harm reduction alone cannot ameliorate. In particular, a critical reinterpretation of social justice such as that of Young (1990, 2001) requires further examination as a com-
plementary moral underpinning that will facilitate a focus on reducing the harms associated with the context of drug use. Incorporation of harm reduction strategies is part of a comprehensive approach to providing accessible health care and improving the health of those who are street involved. Access to health services can be a pathway to housing income as well as other other social determinants that have the potential to impact health. Assuming that such resources exist, a better understanding of the linkages between health care services and social programmes is needed (Pauly, 2005). There is an urgent need for implementation of harm reduction philosophy and strategies in health care linked with enhanced action on the social determinants of health to ensure such resources are available. In this commentary, the focus has been on inequities and reconceptualising social justice in a primarily North American context. Significant progress has been undertaken internationally that demonstrates stronger integration of harm reduction interventions, primary health care and the social determinants of health within a social justice framework. A key area for exploration is the underlying values and ethical framework guiding such policies and practices. Specific attention is needed to engage those who use drugs in the development of policy and programmes. Social justice provides a broader framework for actively collaborating, engaging and involving those who use drugs as a means of systemic change. At all levels, increasing awareness of the harms created by policies that impact problematic substance use such as housing, welfare and income policies is needed. The harms created by social structures and policies require specific examination for the ways that they contribute to poor health of those who are street involved. In particular, anti-drug strategies reflect dominant ideologically located values and ignore the structural differences that can reduce inequities in health and access to health care. For example, stigma is a harm of drug use that arises from the illegal status of illicit drugs (Keane, 2003). Prohibitionist policies threaten the freedom of users, damage their health and constitute them as marginal and stigmatized subjects excluded from normative categories of citizenship such as ‘the general public’ (Keane, 2003, p. 229). Within a social justice framework, it is possible to address harms of drug policy not as a matter of choice but as a matter of health and well-being. Policies that are potentially harm-producing include some those policing, housing, income and employment policies, as well as organisational policies such as abstinence and zero tolerance policies. In addition, the presence of neo-liberal values that stigmatise and further marginalise those who use drugs underlying such policies requires highlighting. Taken together, the application of a social justice framework to policy has the potential to illuminate underlying values and potential harms associated with the social context of drug use. Further work is needed
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