Harm reduction interventions have been introduced in a large and growing number of countries. Fundamental components of harm reduction programmes are the need to raise \u2018awareness\u2019, to \u2018contact\u2019 people, to provide them with the \u2018means\u2019 to change their behaviour, and to gain \u2018endorsement\u2019 for this work. The UK provides a case study of public health harm reduction measures which to date appear to have successfully averted an epidemic of HIV infection. In broad terms, the basic techniques for harm reduction projects and programmes are now known, and there is substantial research and practical evidence to indicate their successful implementation and impact. The global public health challenge in the next decade of harm reduction is therefore to \ufb01nd ways to implement harm reduction. Many elements of good public health practice are found in harm reduction. Harm reduction can learn from public health, and public health can learn from harm reduction. \u00a9 1998 Elsevier Science B.V. All rights reserved.
This paper started life as an opening talk at the International Conference on the Reduction of Drug Related Harm in Paris in 1997. That confer- ence marked nearly 10 years of harm reduction. It was therefore a good opportunity to re\ufb02ect on developments, to assess what has been achieved, and for participants to be rather self-congratula- tory. That congratulation is justi\ufb01ed, because, de- spite all the challenges facing harm reduction, and the times when no progress seems to be made, it is important to recognise that there have been some notable practical successes in reducing drug-re- lated harm.
Harm reduction has come a long way in the last 10 years. Progress in the UK provides an apt metaphor. In the UK, the \ufb01rst syringe exchange in Liverpool in 1986 was in the Mersey Region Drug Training and Information Centre. It was located in a small toilet cubicle, the only spare space within the agency. In those days, harm reduction was very much an \u2018act of faith\u2019. Since then harm reduction has \u2014 to risk a cliche \u2014 \u2018come out of the closet\u2019. Harm reduction projects have been imple- mented in many places in Europe, Australasia, South East Asia, the Newly Independent States, and in North and South America. There is grow- ing evidence that they have had a signi\ufb01cant impact on the health of drug users.
key components of harm reduction. I will then take a case study of successful harm reduction with respect to HIV and drug injecting. Finally I will try to draw out some themes about public health and harm reduction in the future.
There is a wealth of theorising and model build- ing about the nature and practice of harm reduc- tion, despite the fact that it was\u2014and continues to be\u2014a grass roots and bottom-up social move- ment. Different writers have tried to set out the basic principles of harm reduction. In my modest contribution here, I am trying to keep things simple. I have reduced harm reduction to four key components which I think are its essence in prac- tice. I think that most harm reduction pro- grammes and projects comprise these four components, although the way they are combined and the prominence given to each will vary from project to project, and over time. (An overview of types of harm reduction interventions can be found in Rhodes and Hartnoll, 1996; Ball, 19981).
The four key components can be remembered by the word ACME (Fig. 1)\u2014the need to raise awareness, to make contact with populations, to provide the means for people to change their behaviour, and to get endorsement for harm re- duction measures. There are numerous ways in which these components have been delivered in practice, i.e. the speci\ufb01c techniques that have been used.
For example, techniques for raising \u2018awareness\u2019 about health risks include individually targeted methods such as mass and local media campaigns or counselling, or through community and subcul- turally targeted strategies for facilitating changes in social norms such as outreach and peer education.
Harm reduction has been typi\ufb01ed by innovative methods for \u2018contacting\u2019 populations, by having appropriate, attractive and accessible services, by using outreach to the hard-to-reach, and facilitat- ing the passing of health promotion information through social networks. In many treatment mod- els, failure to complete treatment entails being dismissed from the programme. Harm reduction emphasises the need to retain contact with people and to offer them ongoing help, services and advice in anticipation that they will eventually change their behaviour. In harm reduction, ejec- tion of unsuccessful clients would be a failure of the programme rather than the client.
Those promoting harm reduction suggest the importance of providing drug users with the \u2018means\u2019 to change their behaviour, through the provision of sterile injecting equipment or the means to de-contaminate this, such as bleach; and condoms for safer sex. Treatment and help for drug problems is also a means for behaviour change. Appropriate drug treatment and mainte- nance programmes facilitate contact with drug users and help them change their drug use. The most common approach has been methadone maintenance. Maintenance programmes using other substitute drugs (e.g. buprenorphine) have also been tried.
And \ufb01nally projects include ways of gaining endorsement for harm reduction activities. This includes creating alliances between target popula- tions, local communities, social activists, social scientists, and government. A major activity for many projects is gaining support for harm reduc- tion activities from the local community, other health workers, and government.
There is an accumulation of international evi- dence about the importance, feasibility and effec- tiveness of different techniques for reducing drug related harms. Much of that evidence comes from projects designed to reduce the risks of HIV trans-
Policy\u2019, references have been kept to a minimum. Apologies to the many people who have in\ufb02uenced me and upon whose work I have drawn.
mission. Looking back over the 10 years it is extraordinary how much we now know about techniques to prevent problems connected with drug use. Harm reduction techniques work not only in developed countries, but also in coun- tries with very different economic and social conditions\u2014harm reduction activities have been implemented,
Nepal, Bangladesh, Thailand, Manipur, and in Central and Eastern Europe. Evidence for success has come from practical experience of people run- ning projects, from the accumulating interna- tional scienti\ufb01c evidence about the effectiveness of different interventions, from comparative in- ternational studies, and from individual case studies (see for example overviews in Stimson et al., 1998). An earlier International Conference on the Reduction of Drug Related Harm led to a book called \u2018Harm Reduction: from Faith to Science\u2019. Harm reduction in the last 10 years has now moved from faith to science.
There are a number of case studies which could be selected to show governments and pol- icy makers that harm reduction is not only a philosophical and practical approach to drug problems, but that it can deliver the goods. There is now evidence for successful HIV pre- vention in many countries\u2014as has been demon- strated by the WHO Multi-City Study on Drug Injecting and HIV Infection (Stimson et al., 1998) and many other studies.
One of the problems facing harm reduction has been that it is dif\ufb01cult on grounds of ethics, costs and time to subject it to tough scienti\ufb01c scrutiny using, for example, randomised con- trolled trials. Country and city-wide case studies are therefore important, because they may help us understand the interaction between national and local policies, the interventions that are de- veloped, how these interventions in\ufb02uence risk behaviours, and in turn the history of epidemics (Fig. 2). The task is dif\ufb01cult, but not insupera- ble. It requires piecing together information
from a wide number of sources about national policies, the kinds of projects that were devel- oped, risk behaviours, and the direction that the epidemic has taken over time. It takes some imagination\u2014because if we argue that the course of an epidemic has been altered by the intervention, we have to argue what might have happened without the intervention. This we can- not know\u2014but we can imagine what could have happened by looking at the histories of epidemics elsewhere. The question is: would things have turned out differently, but for the policies and interventions? (The problem is akin the Max Weber\u2019s attempt to argue the link be- tween the rise of protestantism and the develop- ment of capitalism.) The analytic task is aided by comparisons between countries and cities with different polices, practices, risk behaviours and epidemic histories. We may be therefore be able to learn as much from comparative na- tional and city analyses as from the more fo- cused evaluation of speci\ufb01c interventions. This level of analysis also helps us to begin to under- stand the circumstances under which harm re- duction
The UK provides a useful case study that can contribute to this comparative analysis\u2014with strong evidence that HIV infection among injec- tors has been averted through public health risk reduction measures. It will be for others to as- sess whether a case has been made that what was done in the UK helped avoid a major epi- demic of HIV infection among IDUs.
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