Harm Reduction in Canada:
The Many Faces of Regression
Walter Cavalieri & Diane Riley
Changes in the practice of social work over the past decades shed light on the structural reduction regression taking place in harm reduction in Canada. Early social work was a magnet for progressive reformers with a strong commitment to social justice, actualised through social action. The ability to show independence of thinking and commitment to justice were the qualities that made the traditional social worker a ʺprofessionalʺ. By the 1950s, social work had virtually deserted idealistic intellectualism and in the process relinquished the utopian vision that guided early practitioners. It moved away from its vision of social justice, to a narrow preoccupation with methods and skills. Increasingly, social work strove to fit the client to the system rather than be concerned with the reduction of inequality
and social injustice which had subverted the clientʹs life in the first place. Incrementally and ineluctably, through professionalization social workers distanced themselves from the people they worked with. Social work became mainstream, increasingly routinised and standardised, with an emphasis on expert‐driven, quantitative‐research‐based practice that stressed standardized, ritualistic, empirically‐tested forms of treatment ‐ ʺBest Practicesʺ ‐ and where research and theory drove practice across the board, top‐down. By and large, social workers have earned a poor reputation with people on the street through losing their connection with the fieldʹs radical roots and buying into the new professionalism.
There is evidence that a similar process of regression is taking place in harm reduction, driven by ʺexpertsʺ, once again the people in power, the gate‐keepers who have committed themselves to maintaining their status at the expense of the other. Will harm reduction in Canada cease to be user‐driven and become distanced and impersonal? The answer at the moment would be ʺyesʺ.
In certain communities, harm reduction has already become part of ʺthe systemʺ; while not necessarily a bad thing, we must remain watchful. As it moves into mainstream organisations, academia and public policy, harm reduction is given a suit and a haircut, made presentable and told to behave. Acting within a temple of power, as part of the establishment, harm reduction can perpetuate the structure of domination by emphasizing the enforcement of social control and order and getting individuals to fit into society, rather than promoting social welfare, responding to societal changes and respecting peopleʹs human needs ..In this paradigm, the most profoundly disenfranchised users of illicit drugs are further marginalised, stigmatised and neglected in the race to make them meet the providersʹ expectations of what a client is and how a client must behave in order to get help.
In a publication from the 1990s, Ontarioʹs Centre for Addiction and Mental Health described harm reduction as the best alternative to try ʺwhen efforts to treat, prevent or punish addiction problems have not succeededʺ. Second best ‐ to punishment? The director of a street‐based youth agency funded to run a harm reduction program refuses to allow needle exchange to be done by her staff because ʺit will give the wrong messageʺ. Another states that she doesnʹt allow needle exchange on site, because the clients know that she is opposed to their injecting drugs. Harm reduction for whom?
Methadone Maintenance Programs (MMT) ‐ at least in Ontario ‐ have become big business, with quasi‐franchise operations located around the province. Though this has made MMT more accessible, programs have not been consistent in offering the supportive services or atmosphere which would make them effective. Many patients are very dissatisfied with the treatment they receive, refer to MMT as a ʺcash cowʺ for doctors who run the clinics, and see methadone itself as ʺliquid handcuffsʺ, not just because of restrictive guidelines but also because, as they report, it is difficult to get the prescribersʹ support when they express the desire to taper off it.
In the area of research, the promotion of and reliance on pilot projects can be harmful to participants, especially when follow‐up is not sufficiently thought out. In the above‐mentioned NAOMI project, even those whose lives had been turned around by having been prescribed heroin were taken off it at the end of the project and referred to MMT programs. A criterion for acceptance in NAOMI was evidence of repeated failures with MMT. Clearly both harm reduction research ethics and MMT are areas for future study.
What may keep Canadian harm reduction honest and effective is the inclusion of people with the lived experience of drug use in all phases of policy development and programming, from design through delivery through evaluation and research. This occurs in varying degrees across Canada, and continues to give harm reduction its authenticity and edge.
Harm reductionʹs regression in Canada is part of a larger context of the federal governmentʹs demonisation of drugs and the people who use them. This is a well‐funded propaganda campaign, which appeals to fear, prejudice and greed. As a result, we are experiencing a value shift which is deeply upsetting and does not augur well for harm reduction, the well‐being of people who use illicit drugs or for any marginalised people. How do we account for the public embrace of current neo‐conservative propaganda? Is it simply a case of unenlightened self‐interest and a shortage of compassion? Is it a temporary aberration, or is it a radical change in Canadian temperament?
We do know this: those who work with people who use drugs, as both clients and allies, must double and re‐double our efforts to ensure that the gains we had made are not forever lost; that harm reduction attains its rightful place among the ways
we use to address drug issues, not as a stand‐alone ʺpillarʺ but as what informs all substance‐related programming and work. This means that we give full attention to the consequences of what we do, including the unintended ones. Access to harm reduction services is both a health right and a human right. And rights for oppressed people are an anathema to our current government which ‐ for ideological reasons ‐ ignores not merely rights but also science. The result: ʺregression to the meanʺ ... in both senses of the term.
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