For six weeks this summer I had the extraordinary opportunity to visit harm reduction programs all over Western Europe. In Belgium I toured a safe consumption site where people smoke and inject drugs under medical supervision. In Switzerland I explored Geneva, where physicians prescribe heroin to mitigate the dangers of unregulated street drugs. In Amsterdam I stopped by the drug user union credited with launching the world’s first official syringe exchange program.
Coming from North Carolina, where harm reduction programs have barely begun to take root, I considered the European tour akin to visiting the motherland. Finally I would see “real” harm reduction programs, evolved after decades of fine-tuning. But Europe also showed me something I hadn’t expected.
“Everything has been professionalized, so the basic idea of harm reduction has faded away.”
Every program I visited was clean and medical, government-funded and seamlessly integrated into public health policy. But to my surprise, I saw little evidence of drug user-led activism. The edgy, scrappy side of harm reduction—that agitation for change so visible in the United States—seemed absent.
In Western Europe “everything has been professionalized, so the basic idea of harm reduction has faded away,” said Katrin Schiffer of Correlation European Harm Reduction Network, whom I interviewed at her office in Amsterdam. “Even the people who work in harm reduction have trouble explaining what it is.”
At first I wondered if these programs had always lacked an active drug user component. But after interviewing experts in several countries and researching the history of European harm reduction, I found that drug user-led activism was critical to launching the programs that exist today.
A Proud History of Activist-Driven Harm Reduction
Until the late 20th century, Europe approached drug policy like the rest of the world—with handcuffs, prisons and stigma. During the 1970s these repressive policies collided with an influx of imported heroin, and the subsequent arrival of HIV ignited a public health catastrophe. By 1985, more than half of people injecting drugs in some cities had contracted HIV—52 percent in Geneva, Switzerland; 60 percent in Milan, Italy; 62 percent in Paris, France.
Dutch harm reductionist Jean-Paul Grund recalls that during the ‘70s, the drug market around Centraal train station in Amsterdam was so out of control that police posted signs telling people to enter at their own risk.
“In Rotterdam and Amsterdam heroin was introduced in ’72 and it quickly grew into significant street scenes,” he said during an interview at his home in Rotterdam. He described buzzing crowds of people near Centraal train station “buying drugs, using drugs, selling drugs.”
During the 1980s open-air drug markets emerged across Europe. In Frankfurt, Germany over a thousand people bought and sold drugs each day at Taunusanlage Park. Zurich, Switzerland became infamous for its drug scene in the “Platzspitze,” or needle-park, where several thousand drug users gathered daily. Pockets of heavy public drug use, called “supermarkets,” sprang up all over Lisbon, Portugal.
But today, public drug use in these cities has all but disappeared. In Amsterdam I strolled the neighborhood around Centraal, now a thriving scene of glittering canals, tree-lined streets and bicycle lanes. And it was Dutch drug users who played a critical role in this turnaround.
“We took over their office with a list of demands, and we didn’t leave until we had some agreement.”
Grund recalls that in 1981, activists from a drug user union in Rotterdam stormed the national office in charge of drug treatment centers to demand better access to methadone.
“We met at the railway station and marched over there,” he said. The union “took over their office with a list of demands, and we didn’t leave until we had some agreement.”
Soon after, the Netherlands began rolling out mobile methadone clinics—low-threshold services offering treatment to opioid users from buses. Eventually, the union even began dispensing methadone from its own office. Then in 1984, members of another drug user union, MDHG, began distributing sterile syringes to their peers in Amsterdam—launching the world’s first official needle exchange program.
Throughout the 1980s and ‘90s, countries across Western Europe implemented a series of innovative harm reduction programs that are now replicated worldwide.
These initiatives have achieved remarkable results everywhere you look.
The first safe consumption site, where participants can use illicit drugs under the supervision of trained staff, opened in Bern, Switzerland in 1986. Researchers credit these programs with reducing overdose deaths, lowering disease transmission rates and alleviating drug use in public areas.
The Swiss also pioneered heroin-assisted treatment (HAT) in 1994, allowing doctors to prescribe heroin to heavily dependent people for whom other treatment methods had proven ineffective. HAT results include lower overdose rates and reduced disease transmission, as well as disengaging people from illegal activities associated with acquiring street heroin.
Then in 2001, Portugal took the plunge to decriminalize the personal possession of all drugs.
These initiatives have achieved remarkable results everywhere you look. In the Netherlands, HIV prevalence among people who inject drugs dropped from 28 percent in the 1980s to near zero today—prompting the 2016 UNGASS Country Progress Report to declare that people who inject there “are not considered a major risk group” for HIV.
Since the widespread adoption of harm reduction, Switzerland has seen a 64 percent decline in drug-related deaths. The percentage of new HIV cases originating from injection drug use also plummeted from 50.7 percent during the ‘90s to 2 percent in 2014.
Portugal’s decriminalization experiment has resulted in lower rates of problematic and injection drug use, fewer HIV transmissions and a general decline in past-year and past-month use of illicit drugs.
Diminished Activism and Unaddressed Problems
But Europe’s prime innovative years reached their zenith long ago. Of course drug-user led activism still exists—particularly in the former Soviet Bloc, where harsh drug policies are igniting action. But in Western and Central Europe, drug user organizing has largely lost its presence and power.
“Harm reduction interventions in the main in Western Europe are delivered either by national health services or by non-governmental agencies that focus on health interventions,” said Niamh Eastwood, executive director of Release, the UK’s center of expertise on drugs and drug laws. Harm reduction “has become more contained within the medical model … at the expense of funding for grassroots activism.”
Europeans seem aware of the missing activism component. As early as 2006, the European Commission issued a paper emphasizing the need for more civic involvement in creating and implementing drug policy. A report by the Civil Society Forum on Drugs in 2018 admitted that when it comes to developing national drug strategies and action plans, “user groups are not only less prevalent in the member states than other types of [civil society organizations] but their level of involvement is also generally lower.”
Eastwood said that the source and size of budgets partly explain the decline of user-led activism. When services are provided by large-scale organizations with big, government-sourced budgets, it “can create a sense of fear of pushing the boundary around harm reduction initiatives,” she explained. Organizations “may be more risk-adverse concerning not just innovative approaches but also approaches that wouldn’t fall technically within the legal system of the country.”
A staff nurse told me that “drug users don’t know how to inject properly.”
Harm reduction programs in Western Europe are almost all government-funded, even when private organizations run them. For example, a nonprofit called TADAM manages Belgium’s first and only safe consumption space on government funds. Drug consumption spaces are illegal in Belgium, but you’d never guess it from the gleaming ventilation systems in the facility’s smoking room, the staff of doctors, nurses and social workers, and a level of sterility to rival a surgeon’s operating table.
But I didn’t see any evidence of peers or drug user empowerment. Not only that, but some staff seemed downright appalled at the idea.
A staff nurse who led the tour of the site told me that the facility hired medical personnel because “drug users don’t know how to inject properly.”
Such a statement might lead US harm reductionists to sharpen their pitchforks. But during my trip I frequently encountered paternalistic attitudes towards drug users. (To be fair, I also met people who work to empower drug users and are frustrated at the complacency of many European harm reduction programs.)
None of the safe consumption sites I encountered in Belgium, Switzerland or the Netherlands offers take-home naloxone to laypeople. There are legal barriers—only 10 of the European Union’s 28 countries allow this—but efforts to challenge these laws appear rare. Some staff even dismissed widespread naloxone access—which unequivocally saves lives and doesn’t cause harms—as “dangerous” because of supposed encouragement of opioid use among polydrug users, or as a “flavor of the week.”
Jean-Paul Grund described this attitude as a combination of misinformation about naloxone, distrust of drug users and lack of urgency, since Western Europe is not experiencing an overdose crisis at North American levels.
“Europeans are accustomed to not seeing drug use.”
Overdose deaths are still a problem in Europe, however. In fact, Grund heads a global team, Stop Overdose Now, to bring overdose prevention tools to active drug users. The group is currently developing two digital apps: OD Buster, to connect people to naloxone-carrying volunteers in their area; and FenChecker, an interactive map where people can check for the local presence of fentanyl. Both apps are scheduled to launch in fall 2019.
Stop Overdose Now is one of many examples of current innovation efforts in Europe. But activism as a whole has largely faded from drug user services. Ironically, the success of harm reduction programs may be partly to blame.
Katrin Schiffer at Correlation explained that many harm reduction programs were designed not only to improve the health and safety of drug users, but also to reduce incidences of public drug use. As a results of efforts to move drug use indoors and away from the public eye, people who use drugs have become invisible.
“Reach is further but the involvement and dignity and respect [of people who use drugs] are often the cost of that.”
In countries where harm reduction programs have existed for a long time, “Europeans are accustomed to not seeing drug use,” said Schiffer. “They are accustomed to nice neighborhoods. Public space is becoming more exclusive, which is unacceptable, because public space should be for everyone.”
Western European harm reduction presents an interesting paradox. On the one hand, the widespread availability of effective harm reduction programs is laudable. Drug-related disease rates are low. Overdose rates are low. A variety of treatment options, from abstinence to methadone to prescription heroin, are available in many areas at no cost. Integrated care models—ones that recognize the complex stew of social, economic, psychological and familial circumstances that contribute to problematic drug use—are common. Gone are the days of begging for funding scraps to support a meager staff.
But these far-reaching successes have come at a price.
“In the US what you’ve got is local initiatives that are run by people who are directly impacted, but they are very small-scale and their reach isn’t very far,” said Niamh Eastwood. In Western Europe, “the reach is further but the issues of involvement and dignity and respect [of people who use drugs] are often the cost of that.”
Lessons for America
Medical programs reduce health-related harm. But without activism, highly damaging structures—the remaining bad drug policies and inequalities—are left unchallenged. In the absence of large-scale public health crises, impetus for progress can evaporate.
In most of Western Europe, as across the world, drug users are still stigmatized, still criminalized, still marginalized, still considered second-class citizens. This will not change without user-led advocacy.
Ironically, during my time in Europe, my home state of North Carolina succeeded in passing legislation to remove a ban on state funding for syringes. For three years we had fought to lift that ban, urging the government to allocate resources to protect its citizens from harm. But my European tour put that victory in a different light.
Among America’s drug-user activist groups and unions, there is widespread fear of harm reduction being co-opted.
Over the past several years in the US, largely due to the overdose crisis, harm reduction has catapulted from pariah status to a mainstream public health term. State after state has adopted 911 Good Samaritan laws, naloxone take-home programs, syringe exchange and low-threshold medication-assisted treatment programs. Campaigns to open safe consumption spaces are well underway in several cities. Local and state governments are allocating funding to harm reduction organizations, and new programs are developing in previously hostile territory.
But amidst the fever of progress, tensions boil. Among America’s drug-user activist groups and unions, there is widespread fear of harm reduction being co-opted by the public health system, social workers and professionals without personal experience with drugs. I’ve written about this tension at past harm reduction conferences.
If Western Europe offers a glimpse into America’s future, then US activists’ fear is more than justifiable. As harm reduction programs succeed in managing the negative consequences of drug use and the sense of crisis fades, as funding shifts to governments and professional organizations, it will be too easy for activism to dissolve into complacence.
The harm reduction movement must make a conscious effort to ensure that in pursuit of expansion, it doesn’t lose its roots.
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