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Public health, human rights and the harm reduction paradigm: from risk reduction to vulnerability reduction
International Journal of Drug Policy 12 (2001) 207– 219 www.elsevier.com/locate/drugpo
Commentary
Public health, human rights and the harm reduction paradigm: from risk reduction to vulnerability reduction Nadine Ezard * Turning Point Alcohol and Drug Centre, 54 -62 Gertrude Street, Fitzroy, Vic. 3065, Australia Received 1 November 2000; accepted 1 June 2001
Abstract This paper explores the utility of expanding the harm reduction paradigm to incorporate vulnerability reduction. The thrust of harm reduction interventions to date, particularly in injection drug use, has been risk reduction. Many interventions have been designed to reduce drug-related harm by altering high-risk behaviours. Vulnerability looks behind risk. The notion of vulnerability incorporates the complex of underlying factors that promotes harmful outcomes as a result of drug use, and limits attempts to modify drug use to make harmful outcomes less likely. A conceptual framework will be introduced that looks at harm, risk and vulnerability at the three levels of individual, community and society. This paper uses illicit injection drug use as an example. This conceptual framework will be used to position human rights more centrally in the harm reduction debate. Human rights violations and infringements can contribute to drug-related harm by first creating the preconditions for risky drug use; and second, by limiting access to prevention and care. A human rights framework allows us to better understand vulnerability to drug-related harm, and provides an important advocacy tool for improved interventions. This expanded harm reduction paradigm that incorporates vulnerability and human rights allows for better development of a public health approach in harm reduction, exposes gaps in research, and allows for better development of more effective interventions. © 2001 Published by Elsevier Science B.V. Keywords: Harm reduction; Vulnerability; Human rights; Injecting drug use
Introduction The harm reduction movement for illicit injection drug use has been quick to embrace the ‘new’ public health, whereby psychologi* Tel.: +61-3-9235-9821; fax: +61-3-9416-3420. E-mail address: nadine – [email protected] (N. Ezard).
cal, social and environmental factors are incorporated into understandings of causality (Erickson et al., 1997). Nevertheless, the practice of harm reduction interventions for illicit (non-medical) injection drug use has tended to focus on risk reduction through behavioural modification. We need to reconceptualise notions of causality within harm
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reduction to separate more proximal notions of risk from more distal notions of vulnerability. By introducing the concept of vulnerability, we can hope to guide the development of more effective interventions. To ground notions of vulnerability in a practice-oriented approach, I will introduce a human rights framework. The importance of human rights in the harm minimisation debate is twofold. First, human rights infringements and violations may contribute causally to all levels of drug-related harm. Second, obligations to fulfil human rights include the provision of prevention and care by states to minimise drug-related harm. A conceptual framework that outlines harm, risk, and vulnerability at the individual, community, and social level, possible interventions at each of these axes, and relevant human rights obligations is summarised in Table 1. This paper will use illicit injection drug use as an example throughout. The paradigm, however, has relevance for many areas of public health practice, particularly those relating to substance use. The conceptual framework developed here is an expansion of earlier work, such as that by Newcombe (1992), and builds on vulnerability and human rights models developed in the HIV/AIDS field (Mann et al., 1992; Mann and Tarantola, 1996; Tarantola and Gruskin, 1998). While much work has been conducted on harms and risks, very little has been conducted on vulnerability related to drug use. I will briefly review notions of harm and risk, then examine vulnerability in more depth, before moving on to sketching, how human rights may be relevant to this framework.
Harm and harm reduction Injection drug-related harm reduction is concerned with harmful effects or conse-
quences of illicit (non-medical) injection drug use (Rumbold and Hamilton, 1998). The notion of harm reduction deflects issues of initiation into drug use or uptake of regular or dependent use. It is the harmful outcome as a result of drug use that is important. A drug-related harm can broadly be defined as a negative consequence of drug use to the individual, the immediate community or larger society (Newcombe, 1992). Whilst this definition of drug-related harm is generally accepted, the inventory of specific drugrelated harms is a contested site within harm minimisation. Determination of drug-related harms will depend on the context and the purpose of determination. Practice-oriented harms may be outlined for the purpose of evaluating programmes, for setting policy goals or for individual therapy. Harms have been determined by individual drug users, for example, when accessing services or contributing to policy debates; affected communities; or by members of the broader society, e.g., as determined by health professionals, policy makers and politicians. The reformulation of HIV transmission as an injection drug-related harm (Des Jarlais et al., 1994; Hurley et al., 1997) arguably spearheaded the harm reduction movement for illicit injection drug use. Other examples of injection drug-related harms are given in Table 1. At the individual level, examples of drug-related harm include accidental overdose (Hall, 1997), absenteeism and job loss, financial difficulties, homelessness, incarceration (Drucker, 1998), and other blood-borne virus infections, such as Hepatitis B and C. The family, social network and immediate community of a drug user can also be affected negatively by drug use (Neaigus, 1998). For example, intra-familial theft may occur to finance drug use. Activities demanded of drug dependence may conflict with child rearing responsibilities. Harms associated with
Table 1 Harm risk and vulnerability: a conceptual framework for harm reduction Term
Definition
Example
Intervention
Harm
Negative consequence of drug use
Individual: Thrombo-embolic event as a result of injection
Individual: Accessible medical services
Society: Increased level of homelessness
Risk
Likelihood of harm
Individual: Injection with used equipment (risk of blood borne virus transmission) Community: High injection drug community prevalence of blood borne viruses (increased risk of transmission) Society: Legislative restriction to accessing sterile injection equipment
Creation of conditions which would assure to all medical service and medical attention in the event of sickness (Article 12, ESC) Community: Child-care services Provision of assistance to parents and legal guardians in the performance of their child rearing responsibilities including the development of institutions, activities and services for the care of children (Article 18.2 CRC) Society: Emergency accommodation Protection of the child from services neglect including the establishment of social programmes to provide necessary support or the child and for those who have the care of the child (Article 19 CRC) Right to adequate standard of living, including adequate food, clothing and housing (Article 11 ESC) Individual: Needle-syringe exchange Prevention, treatment and control programmes of epidemic and endemic diseases (Article 11 ESC) Community: Peer-education activities
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Community: Lack of prioritisation of child-care responsibilities
Human rights obligationa
Society: Legislative changes
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Table 1 (Continued) Definition
Example
Vulnerability
Predisposition to risk
Individual: Depression and low-self Individual: Treatment of underlying Right to the highest attainable esteem depression physical and mental health (Article 12 ESC) Community: Marginalised Community: Educational Right to education (Article 13 communities with high levels of programmes targeting areas of high ESC) unemployment and low levels of drug-related harms (vocational, education English language, voter registration) Society: Structural violence, racism Society: Reconciliation programmes, Right to work (Article 6 ESC) with and other forms of discrimination improved immigration programmes, just and favourable working work with police to minimise conditions and equal opportunity discriminatory practices for everyone (Article 7, ESC) Right to self-determination of peoples (Art 1 ESC/CPR) Rights are to be respected without distinction of any kind such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status (Article 2 ESC/CPR)
The table gives one example relating to injection drug use at each axis to demonstrate the framework. a ESC refers to the International Covenant on Economic, Social and Cultural Rights (1966) (Center for the Study of Human Rights, 1994) CPR refers to the International Covenant on Civil and Political Rights (1966) (Center for the study of Human Rights, 1994) CRC refers to the Convention on the Rights of the Child (1989) (Center for the Study of Human Rights, 1994).
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Intervention
Human rights obligationa
Term
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drug use can also be determined at the broader social level (Drucker et al., 1998). For example, homelessness associated with drug use, dependency and resultant financial difficulties is a drug-related harm. Studies examining the social costs associated with drug use have been carried out, for example, in Australia (Collins and Lapsley, 1996). Interventions have been designed to minimise the harms associated with drug use. Interventions can target different levels of harm— individual, community and social. For example, accessible treatment services (Herman and Gourevitch, 1997) may be established for injection drug users to treat injection site infections, blood-borne virus infections and thromboembolic events. At the community level, provision of childcare services and parent education could be established in communities affected by drug use. For example, emergency accommodation and services for homeless people seek to decrease the social impact of drug-related harm. There is clearly a level of overlap between the three levels, individual, community and social, and that each of the levels feeds back on to each other. This is the limitation of overlaying a rigid grid onto an amorphous and changing organic network of interactions that combine to shape individual identity within a social network, and that combine to link individuals into a community with a net effect that is larger than the sum of the individuals. Nevertheless, the exercise of disassociating the different levels, however artificial, is a useful one to identify gaps. Once gaps are identified, then areas for further research and targeting of interventions can follow.
Risk and risk reduction To design interventions, the harm reduction movement has looked beyond harm to min-
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imise the risk of developing harmful outcomes as a result of drug use. Debate around the concept of risk does not rest solely within the harm reduction movement. The socio-cultural and political context of risk has been a topic of investigation in social theory for more than 20 years. So too is the notion of risk itself (Douglas, 1985; Beck, 1995). Indeed, arguments have been made (following Foucault) that the concept of risk is a powerful tool for the exercise of the apparatuses of power (Lupton, 1999). O’Malley has argued that the notion of risk has been used to reinforce the dominance of a kind of prudential individualism (O’Malley, 1996). Fox (1999) makes a distinction between risk and hazard. For Fox, a hazard is the set of naturalised factors resulting in the harmful outcome, whereas risk is the likelihood of the harmful outcome. For Fox, both risk and hazard are socio-culturally determined (depending on the position of the observer). In harm reduction, we need to tread the line between an objectively quantifiable ‘real risk’ that is influenced by social and political forces, and ‘risk’ itself as a socio-political construct. I will define risk for the purposes of this paper in practice-oriented terms: risk is the likelihood of harmful consequences as a result of drug use. Like harms, risks can be considered at three levels: individual, community and the broader society. For example, at the individual level, use of unsterile injection equipment will place the user at risk of infection with bloodborne viruses and other infections (Moss et al., 1994; Van Ameijden et al., 1994). At a community level, high prevalence of blood-borne viruses will increase the risk of viral transmission through the sharing of injection equipment. Sub-cultural (community level) practices around injection behaviour can influence equipment sharing and safe injection technique. At the social level, restriction of availability of clean injection equipment, e.g.,
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through legislation will increase the risk of sharing injection equipment and therefore of HIV transmission. An unregulated illicit drug market will increase the risk of accidental overdose through dosing irregularities and problems associated with contaminants (Maher and Dixon, 1997; Rhodes et al., 1999; Drucker, 1998) Needle-syringe exchange programmes are good examples of individual risk reduction programmes by decreasing injection drug equipment sharing behaviours (Hurley et al., 1997), as are methadone maintenance in a variety of national settings (Ball et al., 1988; Metzger et al., 1993). Community risk reduction programmes (Broadhead et al., 1998) might include peer education strategies often associated with exchange programmes (Latkin, 1998) and environmental strategies, such as planning safe injection facilities. Society level risk reduction programmes could include legislative changes to allow unrestricted access to drug injection paraphernalia and to regulate the drug market (Drucker, 1998). However, the main thrust of harm reduction interventions in the illicit injection drug use field to date has been in the minimisation of risk primarily through behavioural modification. Harm reduction has tended to focus on risk reduction. There are, however, limitations to risk reduction through behavioural modification alone. For example, work from the Netherlands has shown a persistent HIV incidence of 3–4% per year among people, who inject drugs despite long standing availability of sterile injecting equipment through syringe exchange programs (van Ameijden and Coutinho, 1998). Similarly, a Vancouver study demonstrated persistent unsafe injecting practices unrelated to syringe access through needle exchange (Strathdee et al., 1997). Limitations to the behavioural modifica-
tion approach have been highlighted by the new public health movement, which seeks to expand the scope of interventions to those that underscore the essentially socially determined nature of health (Petersen and Lupton, 1996; Marmot, 1998). Limits to narrowly defined epidemiological technologies with increasingly sophisticated mathematical models and increasing abstraction from ‘root causes’ has called for a rethinking of the nature of epidemiological questioning (Krieger and Zierler, 1996). In the field of injection drug related HIV transmission, Barnett and Whiteside have underscored the importance of the environmental context in influencing, whether a particular behaviour is risky or not (1999). Recent work by Rhodes et al. (1999) in the field of injection drug related HIV spread has pointed to the importance of taking into account the underlying social and economic context of HIV transmission. This ‘risk environment’ contains both the preconditions for spread of HIV and for the tempering of interventions designed to minimise the spread of HIV. These environmental preconditions influence 6ulnerability to drugrelated harm.
Vulnerability and vulnerability reduction Like risk, the idea of vulnerability has been explored in many settings. For example, in the development literature, vulnerability has been defined as the set of factors that limit the ability to respond to an adverse event (Jelligos, 1999). In the context of HIV/AIDS, Tarantola and Mann have developed a vulnerability paradigm (Mann et al., 1992; Mann and Tarantola, 1996). Here, vulnerability is described as a restriction of individual capacity to effect control over one’s life with factors, such as youth,
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gender and poverty influencing vulnerability (Tarantola, 1997). A similar vulnerability paradigm can be adapted to fit harm minimisation. We need to consider factors underlying risk, factors influencing vulnerability to drug-related harm. Vulnerability can be defined as predisposition to the risk of drug-related harms. The notion of vulnerability incorporates the complex of underlying factors that promotes harmful outcomes as a result of drug use, and limits attempts to modify drug use to make harmful outcomes less likely. Vulnerability factors constrain choices and limit agency. Vulnerability factors arise out of and are reinforced by past and present social context and experience. The relationship between vulnerability and risk is much like the mathematical relationship between acceleration and velocity— acceleration is the change in velocity. Acceleration cannot be described without making reference to velocity, but it is not the same thing. So too with vulnerability and risk: we cannot understand or describe vulnerability without describing risk. Vulnerability determines risk, but it is not the same thing. Changes in vulnerability will determine changes in risk. This analogy can be extended further: a static acceleration implies a steadily increasing velocity. A situation of static vulnerability may mean a continually increasing risk. As with notions of harm and risk, I will consider examples of vulnerability and possible interventions at three levels; individual, community and societal. Vulnerability to drug-related harms at an individual level could be influenced by a number of factors. Personal features, such as a sense of future, self-efficacy and self-esteem may be important in mediating individual vulnerability to harmful drug use. For example, one Canadian study found factors, such as depression
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and history of sexual abuse to be associated with increased likelihood of unsafe injection practices (Strathdee et al., 1997). These factors may be likely to impact on a sense of self-esteem and self-efficacy, which in turn may impact on the capacity and desire to protect the self from harm. Drucker et al. (1998) argue that syringe exchange programmes can encourage safer injection drug use by users through decreasing individual drug users’ sense of marginalisation. Vulnerability factors have an impact on collective as well as individual vulnerability. At the community level, issues such as community cohesion and collective efficacy (Kawachi and Kennedy, 1997; Kawachi et al., 1997) may mediate collective vulnerability to harmful drug use. In the former Soviet Union, rapid cultural shifts from collective to individual level social understandings has undermined existing civil society and eroded community cohesion (Rhodes et al., 1999). By incorporating notions of collective vulnerability into the harm reduction framework, we may be able to address some concerns about the harm reduction paradigm raised by marginalised communities. Particularly relevant here are concerns expressed by many communities of colour in the US (Thomas and Quinn, 1991). Needle exchange and other harm reduction efforts have been regarded with suspicion by many communities, concerned that the likely outcome of such efforts will be further fragmentation and dispossession of already disenfranchised communities. A complex and comprehensive harm reduction paradigm that addresses fragmentation and dispossession may respond to some of these concerns. Societal level or structural factors mediating vulnerability to drug-related harms are
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also relevant here. Whilst drug users are found in all socio-economic strata and cultural groups, many of those engaging in high risk behaviour are from marginalised groups (Drucker, 1992). For example, one New York City capture–recapture study suggests that there may be a considerable population of dependent opiate users, who experience no health-related harms as a result of their drug use (Eisenhander and Drucker, 1993). The subjects of this study, however, were private health insurance subscribers: membership of a private health insurance scheme not only assures access to health care services, but reflects a certain degree of affluence. Concentration of areas of high unemployment and low education, often associated with ethnic minorities (Fullilove, 1993a,b), can also contribute to community level vulnerability to drug-related harms. For example, employment opportunities in the illicit drug sector may far exceed those in the licit sector, particularly for those marginalised from the formal economy (Bourgois, 1996). Community members may be confronted with a wide range of risks (such as gang warfare) that make other drug-related risks such as bloodborne virus transmission or accidental overdose seem less important. These structural factors may well mediate individual vulnerability to harms as a result of drug use. Rapid deterioration in economic and social conditions associated with the break up of the Soviet Union has been associated with increased vulnerability of communities to spread of HIV as an injection drug related harm. Rhodes et al. (1999), Barnett et al. (2000) have cited economic decline, increased economic inequalities, decreased household income, reduction in quality health and social services, lack of formal sector employment ‘globalisation’ of drug markets, diffusion of injecting drug cultures, growth in trade and transport, and
population movement as ‘macro-level’ vulnerability factors. Vulnerability refers to both the likelihood of harmful drug use (drug use that results in deleterious outcomes) and limitations in conditions that may mitigate drug related harms (access to health and social services). Thus interventions can be designed to target vulnerability factors. For example, at the individual level, treatment of underlying depression and work on building self-esteem may strengthen individual drug users’ abilities to protect themselves from harm. Arguments have been made to expand the ‘enabling’ environment so that individuals have more scope to act out HIV prevention behaviours (Tawil et al., 1995). At the community level, educational and child care activities targeting geographical areas affected by high levels of drug-related harm or community development activities, such as drugfree discos can be considered vulnerability reduction strategies. Finally, at the social and structural level, work to improve educational opportunities and to combat racism may reduce structural vulnerability to drugrelated harms. Each level of vulnerability interacts with each level of risk and harm. Therefore, a social level vulnerability factor, such as racism or unemployment, may be one of the factors underlying the engagement of a group of young migrants in the illicit drug market, who share injection equipment and subsequently show high prevalence of HIV infection. Alternatively, stigmatisation of drug users may be one reason why a group of drug users fails to call for emergency medical assistance, resulting in fatal accidental overdose. Homelessness was shown in one study (Klee et al., 1990) to be an individual level risk factor predisposing to risky drug use: homelessness can also be reinterpreted as a failure of social welfare mechanisms and
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therefore a reflection of a societal-level vulnerability factor. Clearly at each point there are multiple influences. The vulnerability paradigm is not an attempt to develop a reductionist cause-and-effect model. Instead, it can aid the building of complex pictures of drug-related harms in different settings and at different times. Gaps in knowledge can be exposed to guide future research, such as looking at which vulnerability factors underlie individual risk taking behaviours among a group of high-risk drug users. Gaps in interventions can also be determined, such as alternative employment and educational opportunities. The advantage of the vulnerability paradigm is that it does not simply accept the inevitability of drug-related harm. Rather, it tries to eliminate harm altogether by dealing with the sources of high-risk behaviour.
Human rights and harm reduction The vulnerability framework allows us to conceptualise different aspects of the development of drug-related harm and different approaches to reducing drug-related harm. However, the risk is that we will become lost in the complexity of social forces mediating drug use and drug-related harms, and become overwhelmed at the task of intervening. A human rights approach is one way of more clearly focusing the vulnerability paradigm. The importance of a human rights approach is that it underscores the responsibilities of the state. The contemporary human rights movement is concerned with states’ obligations towards individuals. The state must protect, respect and fulfill the rights of individuals: The state must not violate individuals’ human rights; the state must protect individuals from human rights violations by non-state actors; and the state must create
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conditions for the realisation of human rights and to access means of redress where violations occur (International Federation of Red Cross and Red Crescent Societies and the Franc¸ ois-Xavier Bagnoud Center for Health and Human Rights, IFRCFXB, 1995). A useful entry point into human rights in the drug and alcohol field is to examine the international human rights documents. These documents represent international consensus regarding states’ human rights obligations. The cornerstone of the contemporary human rights movement is the Universal Declaration of Human Rights (UDHR). Whilst not a legally binding document, it has achieved the level of customary law in that it is recognised by many nations and has been incorporated into many new state constitutions. Principles underlying the UDHR are outlined in the two subsequent international covenants: the International Covenant on Economic, Cultural and Social Rights (ESC; 1966) and the International Covenant on Civil and Political Rights (CPR; 1966), and expanded in further international covenants and conventions such as the Convention on the Rights of the Child (1989). The importance of the covenants is that they are legally binding for those states that have signed and ratified them: those states are therefore under a legal obligation to respect protect and fulfill rights outlined in those covenants (Mann et al., 1999). Human rights obligations have an impact on drug use in two ways: first, states have a responsibility to provide services for all people, which can minimise harms and risks associated with drug use. Second, failure of states to protect, respect and fulfil human rights obligations may contribute to the preconditions for experiencing harms as a result of drug use. These human rights obligations underlie all three levels of the harm reduction paradigm: harm, risk and vulnerability (Tarantola and Gruskin, 1998).
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For example, the state is obliged to provide all people with access to medical services. These services could include treatment for drug-induced psychosis, treatment for injection related infections and treatment for HIV and Hepatitis C. Another example is the obligation to provide institutions and facilities to assist children and their carers with childrearing. This includes people with child rearing responsibilities, who find the demands of drug dependency difficult to reconcile with the demands of child rearing. At the societal level, states have obligations to ensure that everyone has adequate standards of living, including food and shelter. In effect, these are services that will minimise the harm associated with injection drug use. States are also obliged to prevent and control diseases of epidemic potential. Epidemic diseases include HIV and Hepatitis C amongst injection drug users. In controlling these diseases, the risk of drug-related harms is reduced. Finally, human rights infringements and violations may underlie vulnerability to drugrelated harms. For example, a human rights approach has been taken to examining HIV incidence in states of the USA where drug use in pregnancy is criminalised (Zierler and Krieger, 1997). Human rights such as the right to education and adequate standards of living, the right to be free from discrimination, and the right of peoples for self-determination, all become important in influencing vulnerability to drug-related harm, be it at the individual, community or societal level. These examples are summarised in Table 1. The human rights as outlined are taken from international human rights documents that demonstrate obligations of states to intervene at each of three axes: harm, risk and vulnerability. It is important to note that while many of the economic and social rights are to be provided progressively, they are often provided differentially, with non-drug users having these rights met before drug users.
There are many other ways in which human rights are important in the drug field that are not mentioned here. In particular, in many settings drug users experience harassment, mistreatment, arbitrary arrest and detention for example in the criminal justice system (Wodak, 1998). The 28th WHO expert Committee on Drug Dependence (1992) mentions ‘compulsory treatment, the protection of rights within the penal system, data protection, …child custody, the implications of drug-testing in the workplace, and the protection of research volunteers’ (Room, 1997; 129) as important human rights issues relevant to drug users. There are a number of problems with using these human rights documents. These documents are limited by the processes of international consensus building. In particular, the human rights movement was for many years torn by cold-war politics, which lay behind the separation of the principles outlined in the UDHR into the CPR and the ESC, and the domination of civil and political rights. In addition, individual rights tend to assume ascendancy in these documents over group rights. Finally, the mechanisms for enforcing international human rights are limited. Nevertheless, as public health practitioners we should not underestimate the strategic utility of deploying a human rights framework: human rights are an important tool in advocating for change at the international and national level (Sullivan, 1995). Human rights violations and infringements can contribute to drug-related harm by first creating the preconditions for risky drug use; and second, by limiting access to prevention and care. By outlining these human rights obligations, we can more clearly articulate the ways in which a harm minimisation approach can encompass all aspects of intervention: from the individual therapeutic level and the states’
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obligations to provide such services; through to the ‘fundamental causes’ (Link and Phelan, 1995) of disease that put people at ‘risk of risks’, such as poverty, racism, and sexism. Thus harm minimisation is synonymous with a public health approach that looks at multifactorial influences and multifaceted interventions to improve health and minimise illness.
Conclusion A harm reduction paradigm that incorporates vulnerability reduction in the field of injection drug use can better operationalise the harm reduction movement’s embracing of the ‘new’ public health. The purpose of introducing ‘vulnerability reduction’ to the harm reduction paradigm is to shift the emphasis from behavioural change to place for the need and responsibility for intervention more broadly. By creating a separate category of vulnerability reduction within harm reduction, we can focus more clearly on those issues which predispose to already articulated risks, such as sharing injection equipment. If we do not step back from a narrowly defined framework of risk reduction and look more broadly at the issues underlying risky behaviours, the success of harm reduction interventions will be constrained. With limited success, we risk the future for harm reduction altogether. Drucker et al. (1998) have outlined the disproportionate attention paid by the anti-harm reduction lobby to the two studies showing an adverse effect of the impact of syringe exchange programmes on blood borne infections out of 12 studies published in 1993–1997. The rapid spread of HIV fuelled by injection drug use in many areas of the world suggest that this paradigm shift should be taken up as a matter of urgency (Mann and Tarantola, 1996; Ball et al., 1998).
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Table 1 is simply an attempt to identify some of the human rights obligations that underlie various points in the harm-risk-vulnerability continuum. This exercise can be repeated in a range of settings in which harm reduction and public health practitioners are working (IFRCFXB, 1995). For practitioners, human rights arguments can have a strategic utility: human rights arguments can have a powerful influence as a lobbying tool with governments. By coupling vulnerability reduction with human rights, we not only shift the responsibility squarely onto states, we necessarily imply a ‘scaling up’ of interventions. No longer can the minimisation of drug related harm be relegated to a handful of agencies working with a limited target population. A framework that identifies harm, risk and vulnerability at individual, community and social levels will guide research and development of interventions designed to prevent and treat drug-related harm. By embedding this complex framework of harm minimisation in human rights, we can better understand and advocate for states’ to fulfil their obligations to prevent and treat drug-related harm.
Acknowledgements Thank you to Daniel Tarantola, Sofia Gruskin and the Francois Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health; and the Commonwealth Fund for support for part of this work with a Harkness Fellowship.
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Commentary
Public health, human rights and the harm reduction paradigm: from risk reduction to vulnerability reduction Nadine Ezard * Turning Point Alcohol and Drug Centre, 54 -62 Gertrude Street, Fitzroy, Vic. 3065, Australia Received 1 November 2000; accepted 1 June 2001
Abstract This paper explores the utility of expanding the harm reduction paradigm to incorporate vulnerability reduction. The thrust of harm reduction interventions to date, particularly in injection drug use, has been risk reduction. Many interventions have been designed to reduce drug-related harm by altering high-risk behaviours. Vulnerability looks behind risk. The notion of vulnerability incorporates the complex of underlying factors that promotes harmful outcomes as a result of drug use, and limits attempts to modify drug use to make harmful outcomes less likely. A conceptual framework will be introduced that looks at harm, risk and vulnerability at the three levels of individual, community and society. This paper uses illicit injection drug use as an example. This conceptual framework will be used to position human rights more centrally in the harm reduction debate. Human rights violations and infringements can contribute to drug-related harm by first creating the preconditions for risky drug use; and second, by limiting access to prevention and care. A human rights framework allows us to better understand vulnerability to drug-related harm, and provides an important advocacy tool for improved interventions. This expanded harm reduction paradigm that incorporates vulnerability and human rights allows for better development of a public health approach in harm reduction, exposes gaps in research, and allows for better development of more effective interventions. © 2001 Published by Elsevier Science B.V. Keywords: Harm reduction; Vulnerability; Human rights; Injecting drug use
Introduction The harm reduction movement for illicit injection drug use has been quick to embrace the ‘new’ public health, whereby psychologi* Tel.: +61-3-9235-9821; fax: +61-3-9416-3420. E-mail address: nadine – [email protected] (N. Ezard).
cal, social and environmental factors are incorporated into understandings of causality (Erickson et al., 1997). Nevertheless, the practice of harm reduction interventions for illicit (non-medical) injection drug use has tended to focus on risk reduction through behavioural modification. We need to reconceptualise notions of causality within harm
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reduction to separate more proximal notions of risk from more distal notions of vulnerability. By introducing the concept of vulnerability, we can hope to guide the development of more effective interventions. To ground notions of vulnerability in a practice-oriented approach, I will introduce a human rights framework. The importance of human rights in the harm minimisation debate is twofold. First, human rights infringements and violations may contribute causally to all levels of drug-related harm. Second, obligations to fulfil human rights include the provision of prevention and care by states to minimise drug-related harm. A conceptual framework that outlines harm, risk, and vulnerability at the individual, community, and social level, possible interventions at each of these axes, and relevant human rights obligations is summarised in Table 1. This paper will use illicit injection drug use as an example throughout. The paradigm, however, has relevance for many areas of public health practice, particularly those relating to substance use. The conceptual framework developed here is an expansion of earlier work, such as that by Newcombe (1992), and builds on vulnerability and human rights models developed in the HIV/AIDS field (Mann et al., 1992; Mann and Tarantola, 1996; Tarantola and Gruskin, 1998). While much work has been conducted on harms and risks, very little has been conducted on vulnerability related to drug use. I will briefly review notions of harm and risk, then examine vulnerability in more depth, before moving on to sketching, how human rights may be relevant to this framework.
Harm and harm reduction Injection drug-related harm reduction is concerned with harmful effects or conse-
quences of illicit (non-medical) injection drug use (Rumbold and Hamilton, 1998). The notion of harm reduction deflects issues of initiation into drug use or uptake of regular or dependent use. It is the harmful outcome as a result of drug use that is important. A drug-related harm can broadly be defined as a negative consequence of drug use to the individual, the immediate community or larger society (Newcombe, 1992). Whilst this definition of drug-related harm is generally accepted, the inventory of specific drugrelated harms is a contested site within harm minimisation. Determination of drug-related harms will depend on the context and the purpose of determination. Practice-oriented harms may be outlined for the purpose of evaluating programmes, for setting policy goals or for individual therapy. Harms have been determined by individual drug users, for example, when accessing services or contributing to policy debates; affected communities; or by members of the broader society, e.g., as determined by health professionals, policy makers and politicians. The reformulation of HIV transmission as an injection drug-related harm (Des Jarlais et al., 1994; Hurley et al., 1997) arguably spearheaded the harm reduction movement for illicit injection drug use. Other examples of injection drug-related harms are given in Table 1. At the individual level, examples of drug-related harm include accidental overdose (Hall, 1997), absenteeism and job loss, financial difficulties, homelessness, incarceration (Drucker, 1998), and other blood-borne virus infections, such as Hepatitis B and C. The family, social network and immediate community of a drug user can also be affected negatively by drug use (Neaigus, 1998). For example, intra-familial theft may occur to finance drug use. Activities demanded of drug dependence may conflict with child rearing responsibilities. Harms associated with
Table 1 Harm risk and vulnerability: a conceptual framework for harm reduction Term
Definition
Example
Intervention
Harm
Negative consequence of drug use
Individual: Thrombo-embolic event as a result of injection
Individual: Accessible medical services
Society: Increased level of homelessness
Risk
Likelihood of harm
Individual: Injection with used equipment (risk of blood borne virus transmission) Community: High injection drug community prevalence of blood borne viruses (increased risk of transmission) Society: Legislative restriction to accessing sterile injection equipment
Creation of conditions which would assure to all medical service and medical attention in the event of sickness (Article 12, ESC) Community: Child-care services Provision of assistance to parents and legal guardians in the performance of their child rearing responsibilities including the development of institutions, activities and services for the care of children (Article 18.2 CRC) Society: Emergency accommodation Protection of the child from services neglect including the establishment of social programmes to provide necessary support or the child and for those who have the care of the child (Article 19 CRC) Right to adequate standard of living, including adequate food, clothing and housing (Article 11 ESC) Individual: Needle-syringe exchange Prevention, treatment and control programmes of epidemic and endemic diseases (Article 11 ESC) Community: Peer-education activities
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Community: Lack of prioritisation of child-care responsibilities
Human rights obligationa
Society: Legislative changes
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Table 1 (Continued) Definition
Example
Vulnerability
Predisposition to risk
Individual: Depression and low-self Individual: Treatment of underlying Right to the highest attainable esteem depression physical and mental health (Article 12 ESC) Community: Marginalised Community: Educational Right to education (Article 13 communities with high levels of programmes targeting areas of high ESC) unemployment and low levels of drug-related harms (vocational, education English language, voter registration) Society: Structural violence, racism Society: Reconciliation programmes, Right to work (Article 6 ESC) with and other forms of discrimination improved immigration programmes, just and favourable working work with police to minimise conditions and equal opportunity discriminatory practices for everyone (Article 7, ESC) Right to self-determination of peoples (Art 1 ESC/CPR) Rights are to be respected without distinction of any kind such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status (Article 2 ESC/CPR)
The table gives one example relating to injection drug use at each axis to demonstrate the framework. a ESC refers to the International Covenant on Economic, Social and Cultural Rights (1966) (Center for the Study of Human Rights, 1994) CPR refers to the International Covenant on Civil and Political Rights (1966) (Center for the study of Human Rights, 1994) CRC refers to the Convention on the Rights of the Child (1989) (Center for the Study of Human Rights, 1994).
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Intervention
Human rights obligationa
Term
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drug use can also be determined at the broader social level (Drucker et al., 1998). For example, homelessness associated with drug use, dependency and resultant financial difficulties is a drug-related harm. Studies examining the social costs associated with drug use have been carried out, for example, in Australia (Collins and Lapsley, 1996). Interventions have been designed to minimise the harms associated with drug use. Interventions can target different levels of harm— individual, community and social. For example, accessible treatment services (Herman and Gourevitch, 1997) may be established for injection drug users to treat injection site infections, blood-borne virus infections and thromboembolic events. At the community level, provision of childcare services and parent education could be established in communities affected by drug use. For example, emergency accommodation and services for homeless people seek to decrease the social impact of drug-related harm. There is clearly a level of overlap between the three levels, individual, community and social, and that each of the levels feeds back on to each other. This is the limitation of overlaying a rigid grid onto an amorphous and changing organic network of interactions that combine to shape individual identity within a social network, and that combine to link individuals into a community with a net effect that is larger than the sum of the individuals. Nevertheless, the exercise of disassociating the different levels, however artificial, is a useful one to identify gaps. Once gaps are identified, then areas for further research and targeting of interventions can follow.
Risk and risk reduction To design interventions, the harm reduction movement has looked beyond harm to min-
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imise the risk of developing harmful outcomes as a result of drug use. Debate around the concept of risk does not rest solely within the harm reduction movement. The socio-cultural and political context of risk has been a topic of investigation in social theory for more than 20 years. So too is the notion of risk itself (Douglas, 1985; Beck, 1995). Indeed, arguments have been made (following Foucault) that the concept of risk is a powerful tool for the exercise of the apparatuses of power (Lupton, 1999). O’Malley has argued that the notion of risk has been used to reinforce the dominance of a kind of prudential individualism (O’Malley, 1996). Fox (1999) makes a distinction between risk and hazard. For Fox, a hazard is the set of naturalised factors resulting in the harmful outcome, whereas risk is the likelihood of the harmful outcome. For Fox, both risk and hazard are socio-culturally determined (depending on the position of the observer). In harm reduction, we need to tread the line between an objectively quantifiable ‘real risk’ that is influenced by social and political forces, and ‘risk’ itself as a socio-political construct. I will define risk for the purposes of this paper in practice-oriented terms: risk is the likelihood of harmful consequences as a result of drug use. Like harms, risks can be considered at three levels: individual, community and the broader society. For example, at the individual level, use of unsterile injection equipment will place the user at risk of infection with bloodborne viruses and other infections (Moss et al., 1994; Van Ameijden et al., 1994). At a community level, high prevalence of blood-borne viruses will increase the risk of viral transmission through the sharing of injection equipment. Sub-cultural (community level) practices around injection behaviour can influence equipment sharing and safe injection technique. At the social level, restriction of availability of clean injection equipment, e.g.,
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through legislation will increase the risk of sharing injection equipment and therefore of HIV transmission. An unregulated illicit drug market will increase the risk of accidental overdose through dosing irregularities and problems associated with contaminants (Maher and Dixon, 1997; Rhodes et al., 1999; Drucker, 1998) Needle-syringe exchange programmes are good examples of individual risk reduction programmes by decreasing injection drug equipment sharing behaviours (Hurley et al., 1997), as are methadone maintenance in a variety of national settings (Ball et al., 1988; Metzger et al., 1993). Community risk reduction programmes (Broadhead et al., 1998) might include peer education strategies often associated with exchange programmes (Latkin, 1998) and environmental strategies, such as planning safe injection facilities. Society level risk reduction programmes could include legislative changes to allow unrestricted access to drug injection paraphernalia and to regulate the drug market (Drucker, 1998). However, the main thrust of harm reduction interventions in the illicit injection drug use field to date has been in the minimisation of risk primarily through behavioural modification. Harm reduction has tended to focus on risk reduction. There are, however, limitations to risk reduction through behavioural modification alone. For example, work from the Netherlands has shown a persistent HIV incidence of 3–4% per year among people, who inject drugs despite long standing availability of sterile injecting equipment through syringe exchange programs (van Ameijden and Coutinho, 1998). Similarly, a Vancouver study demonstrated persistent unsafe injecting practices unrelated to syringe access through needle exchange (Strathdee et al., 1997). Limitations to the behavioural modifica-
tion approach have been highlighted by the new public health movement, which seeks to expand the scope of interventions to those that underscore the essentially socially determined nature of health (Petersen and Lupton, 1996; Marmot, 1998). Limits to narrowly defined epidemiological technologies with increasingly sophisticated mathematical models and increasing abstraction from ‘root causes’ has called for a rethinking of the nature of epidemiological questioning (Krieger and Zierler, 1996). In the field of injection drug related HIV transmission, Barnett and Whiteside have underscored the importance of the environmental context in influencing, whether a particular behaviour is risky or not (1999). Recent work by Rhodes et al. (1999) in the field of injection drug related HIV spread has pointed to the importance of taking into account the underlying social and economic context of HIV transmission. This ‘risk environment’ contains both the preconditions for spread of HIV and for the tempering of interventions designed to minimise the spread of HIV. These environmental preconditions influence 6ulnerability to drugrelated harm.
Vulnerability and vulnerability reduction Like risk, the idea of vulnerability has been explored in many settings. For example, in the development literature, vulnerability has been defined as the set of factors that limit the ability to respond to an adverse event (Jelligos, 1999). In the context of HIV/AIDS, Tarantola and Mann have developed a vulnerability paradigm (Mann et al., 1992; Mann and Tarantola, 1996). Here, vulnerability is described as a restriction of individual capacity to effect control over one’s life with factors, such as youth,
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gender and poverty influencing vulnerability (Tarantola, 1997). A similar vulnerability paradigm can be adapted to fit harm minimisation. We need to consider factors underlying risk, factors influencing vulnerability to drug-related harm. Vulnerability can be defined as predisposition to the risk of drug-related harms. The notion of vulnerability incorporates the complex of underlying factors that promotes harmful outcomes as a result of drug use, and limits attempts to modify drug use to make harmful outcomes less likely. Vulnerability factors constrain choices and limit agency. Vulnerability factors arise out of and are reinforced by past and present social context and experience. The relationship between vulnerability and risk is much like the mathematical relationship between acceleration and velocity— acceleration is the change in velocity. Acceleration cannot be described without making reference to velocity, but it is not the same thing. So too with vulnerability and risk: we cannot understand or describe vulnerability without describing risk. Vulnerability determines risk, but it is not the same thing. Changes in vulnerability will determine changes in risk. This analogy can be extended further: a static acceleration implies a steadily increasing velocity. A situation of static vulnerability may mean a continually increasing risk. As with notions of harm and risk, I will consider examples of vulnerability and possible interventions at three levels; individual, community and societal. Vulnerability to drug-related harms at an individual level could be influenced by a number of factors. Personal features, such as a sense of future, self-efficacy and self-esteem may be important in mediating individual vulnerability to harmful drug use. For example, one Canadian study found factors, such as depression
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and history of sexual abuse to be associated with increased likelihood of unsafe injection practices (Strathdee et al., 1997). These factors may be likely to impact on a sense of self-esteem and self-efficacy, which in turn may impact on the capacity and desire to protect the self from harm. Drucker et al. (1998) argue that syringe exchange programmes can encourage safer injection drug use by users through decreasing individual drug users’ sense of marginalisation. Vulnerability factors have an impact on collective as well as individual vulnerability. At the community level, issues such as community cohesion and collective efficacy (Kawachi and Kennedy, 1997; Kawachi et al., 1997) may mediate collective vulnerability to harmful drug use. In the former Soviet Union, rapid cultural shifts from collective to individual level social understandings has undermined existing civil society and eroded community cohesion (Rhodes et al., 1999). By incorporating notions of collective vulnerability into the harm reduction framework, we may be able to address some concerns about the harm reduction paradigm raised by marginalised communities. Particularly relevant here are concerns expressed by many communities of colour in the US (Thomas and Quinn, 1991). Needle exchange and other harm reduction efforts have been regarded with suspicion by many communities, concerned that the likely outcome of such efforts will be further fragmentation and dispossession of already disenfranchised communities. A complex and comprehensive harm reduction paradigm that addresses fragmentation and dispossession may respond to some of these concerns. Societal level or structural factors mediating vulnerability to drug-related harms are
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also relevant here. Whilst drug users are found in all socio-economic strata and cultural groups, many of those engaging in high risk behaviour are from marginalised groups (Drucker, 1992). For example, one New York City capture–recapture study suggests that there may be a considerable population of dependent opiate users, who experience no health-related harms as a result of their drug use (Eisenhander and Drucker, 1993). The subjects of this study, however, were private health insurance subscribers: membership of a private health insurance scheme not only assures access to health care services, but reflects a certain degree of affluence. Concentration of areas of high unemployment and low education, often associated with ethnic minorities (Fullilove, 1993a,b), can also contribute to community level vulnerability to drug-related harms. For example, employment opportunities in the illicit drug sector may far exceed those in the licit sector, particularly for those marginalised from the formal economy (Bourgois, 1996). Community members may be confronted with a wide range of risks (such as gang warfare) that make other drug-related risks such as bloodborne virus transmission or accidental overdose seem less important. These structural factors may well mediate individual vulnerability to harms as a result of drug use. Rapid deterioration in economic and social conditions associated with the break up of the Soviet Union has been associated with increased vulnerability of communities to spread of HIV as an injection drug related harm. Rhodes et al. (1999), Barnett et al. (2000) have cited economic decline, increased economic inequalities, decreased household income, reduction in quality health and social services, lack of formal sector employment ‘globalisation’ of drug markets, diffusion of injecting drug cultures, growth in trade and transport, and
population movement as ‘macro-level’ vulnerability factors. Vulnerability refers to both the likelihood of harmful drug use (drug use that results in deleterious outcomes) and limitations in conditions that may mitigate drug related harms (access to health and social services). Thus interventions can be designed to target vulnerability factors. For example, at the individual level, treatment of underlying depression and work on building self-esteem may strengthen individual drug users’ abilities to protect themselves from harm. Arguments have been made to expand the ‘enabling’ environment so that individuals have more scope to act out HIV prevention behaviours (Tawil et al., 1995). At the community level, educational and child care activities targeting geographical areas affected by high levels of drug-related harm or community development activities, such as drugfree discos can be considered vulnerability reduction strategies. Finally, at the social and structural level, work to improve educational opportunities and to combat racism may reduce structural vulnerability to drugrelated harms. Each level of vulnerability interacts with each level of risk and harm. Therefore, a social level vulnerability factor, such as racism or unemployment, may be one of the factors underlying the engagement of a group of young migrants in the illicit drug market, who share injection equipment and subsequently show high prevalence of HIV infection. Alternatively, stigmatisation of drug users may be one reason why a group of drug users fails to call for emergency medical assistance, resulting in fatal accidental overdose. Homelessness was shown in one study (Klee et al., 1990) to be an individual level risk factor predisposing to risky drug use: homelessness can also be reinterpreted as a failure of social welfare mechanisms and
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therefore a reflection of a societal-level vulnerability factor. Clearly at each point there are multiple influences. The vulnerability paradigm is not an attempt to develop a reductionist cause-and-effect model. Instead, it can aid the building of complex pictures of drug-related harms in different settings and at different times. Gaps in knowledge can be exposed to guide future research, such as looking at which vulnerability factors underlie individual risk taking behaviours among a group of high-risk drug users. Gaps in interventions can also be determined, such as alternative employment and educational opportunities. The advantage of the vulnerability paradigm is that it does not simply accept the inevitability of drug-related harm. Rather, it tries to eliminate harm altogether by dealing with the sources of high-risk behaviour.
Human rights and harm reduction The vulnerability framework allows us to conceptualise different aspects of the development of drug-related harm and different approaches to reducing drug-related harm. However, the risk is that we will become lost in the complexity of social forces mediating drug use and drug-related harms, and become overwhelmed at the task of intervening. A human rights approach is one way of more clearly focusing the vulnerability paradigm. The importance of a human rights approach is that it underscores the responsibilities of the state. The contemporary human rights movement is concerned with states’ obligations towards individuals. The state must protect, respect and fulfill the rights of individuals: The state must not violate individuals’ human rights; the state must protect individuals from human rights violations by non-state actors; and the state must create
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conditions for the realisation of human rights and to access means of redress where violations occur (International Federation of Red Cross and Red Crescent Societies and the Franc¸ ois-Xavier Bagnoud Center for Health and Human Rights, IFRCFXB, 1995). A useful entry point into human rights in the drug and alcohol field is to examine the international human rights documents. These documents represent international consensus regarding states’ human rights obligations. The cornerstone of the contemporary human rights movement is the Universal Declaration of Human Rights (UDHR). Whilst not a legally binding document, it has achieved the level of customary law in that it is recognised by many nations and has been incorporated into many new state constitutions. Principles underlying the UDHR are outlined in the two subsequent international covenants: the International Covenant on Economic, Cultural and Social Rights (ESC; 1966) and the International Covenant on Civil and Political Rights (CPR; 1966), and expanded in further international covenants and conventions such as the Convention on the Rights of the Child (1989). The importance of the covenants is that they are legally binding for those states that have signed and ratified them: those states are therefore under a legal obligation to respect protect and fulfill rights outlined in those covenants (Mann et al., 1999). Human rights obligations have an impact on drug use in two ways: first, states have a responsibility to provide services for all people, which can minimise harms and risks associated with drug use. Second, failure of states to protect, respect and fulfil human rights obligations may contribute to the preconditions for experiencing harms as a result of drug use. These human rights obligations underlie all three levels of the harm reduction paradigm: harm, risk and vulnerability (Tarantola and Gruskin, 1998).
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For example, the state is obliged to provide all people with access to medical services. These services could include treatment for drug-induced psychosis, treatment for injection related infections and treatment for HIV and Hepatitis C. Another example is the obligation to provide institutions and facilities to assist children and their carers with childrearing. This includes people with child rearing responsibilities, who find the demands of drug dependency difficult to reconcile with the demands of child rearing. At the societal level, states have obligations to ensure that everyone has adequate standards of living, including food and shelter. In effect, these are services that will minimise the harm associated with injection drug use. States are also obliged to prevent and control diseases of epidemic potential. Epidemic diseases include HIV and Hepatitis C amongst injection drug users. In controlling these diseases, the risk of drug-related harms is reduced. Finally, human rights infringements and violations may underlie vulnerability to drugrelated harms. For example, a human rights approach has been taken to examining HIV incidence in states of the USA where drug use in pregnancy is criminalised (Zierler and Krieger, 1997). Human rights such as the right to education and adequate standards of living, the right to be free from discrimination, and the right of peoples for self-determination, all become important in influencing vulnerability to drug-related harm, be it at the individual, community or societal level. These examples are summarised in Table 1. The human rights as outlined are taken from international human rights documents that demonstrate obligations of states to intervene at each of three axes: harm, risk and vulnerability. It is important to note that while many of the economic and social rights are to be provided progressively, they are often provided differentially, with non-drug users having these rights met before drug users.
There are many other ways in which human rights are important in the drug field that are not mentioned here. In particular, in many settings drug users experience harassment, mistreatment, arbitrary arrest and detention for example in the criminal justice system (Wodak, 1998). The 28th WHO expert Committee on Drug Dependence (1992) mentions ‘compulsory treatment, the protection of rights within the penal system, data protection, …child custody, the implications of drug-testing in the workplace, and the protection of research volunteers’ (Room, 1997; 129) as important human rights issues relevant to drug users. There are a number of problems with using these human rights documents. These documents are limited by the processes of international consensus building. In particular, the human rights movement was for many years torn by cold-war politics, which lay behind the separation of the principles outlined in the UDHR into the CPR and the ESC, and the domination of civil and political rights. In addition, individual rights tend to assume ascendancy in these documents over group rights. Finally, the mechanisms for enforcing international human rights are limited. Nevertheless, as public health practitioners we should not underestimate the strategic utility of deploying a human rights framework: human rights are an important tool in advocating for change at the international and national level (Sullivan, 1995). Human rights violations and infringements can contribute to drug-related harm by first creating the preconditions for risky drug use; and second, by limiting access to prevention and care. By outlining these human rights obligations, we can more clearly articulate the ways in which a harm minimisation approach can encompass all aspects of intervention: from the individual therapeutic level and the states’
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obligations to provide such services; through to the ‘fundamental causes’ (Link and Phelan, 1995) of disease that put people at ‘risk of risks’, such as poverty, racism, and sexism. Thus harm minimisation is synonymous with a public health approach that looks at multifactorial influences and multifaceted interventions to improve health and minimise illness.
Conclusion A harm reduction paradigm that incorporates vulnerability reduction in the field of injection drug use can better operationalise the harm reduction movement’s embracing of the ‘new’ public health. The purpose of introducing ‘vulnerability reduction’ to the harm reduction paradigm is to shift the emphasis from behavioural change to place for the need and responsibility for intervention more broadly. By creating a separate category of vulnerability reduction within harm reduction, we can focus more clearly on those issues which predispose to already articulated risks, such as sharing injection equipment. If we do not step back from a narrowly defined framework of risk reduction and look more broadly at the issues underlying risky behaviours, the success of harm reduction interventions will be constrained. With limited success, we risk the future for harm reduction altogether. Drucker et al. (1998) have outlined the disproportionate attention paid by the anti-harm reduction lobby to the two studies showing an adverse effect of the impact of syringe exchange programmes on blood borne infections out of 12 studies published in 1993–1997. The rapid spread of HIV fuelled by injection drug use in many areas of the world suggest that this paradigm shift should be taken up as a matter of urgency (Mann and Tarantola, 1996; Ball et al., 1998).
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Table 1 is simply an attempt to identify some of the human rights obligations that underlie various points in the harm-risk-vulnerability continuum. This exercise can be repeated in a range of settings in which harm reduction and public health practitioners are working (IFRCFXB, 1995). For practitioners, human rights arguments can have a strategic utility: human rights arguments can have a powerful influence as a lobbying tool with governments. By coupling vulnerability reduction with human rights, we not only shift the responsibility squarely onto states, we necessarily imply a ‘scaling up’ of interventions. No longer can the minimisation of drug related harm be relegated to a handful of agencies working with a limited target population. A framework that identifies harm, risk and vulnerability at individual, community and social levels will guide research and development of interventions designed to prevent and treat drug-related harm. By embedding this complex framework of harm minimisation in human rights, we can better understand and advocate for states’ to fulfil their obligations to prevent and treat drug-related harm.
Acknowledgements Thank you to Daniel Tarantola, Sofia Gruskin and the Francois Xavier Bagnoud Center for Health and Human Rights, Harvard School of Public Health; and the Commonwealth Fund for support for part of this work with a Harkness Fellowship.
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