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‘An Irish solution to an Irish problem’: Harm reduction and ambiguity in the drug policy of the Republic of Ireland
Shane Butler a,∗ , Paula Mayock b
Addiction Research Centre, Trinity College, Dublin 2, Ireland Children’s Research Centre, Trinity College, Dublin 2, Ireland Received 12 July 2005; accepted 17 July 2005
Abstract While policy makers in the Republic of Ireland had been concerned with illicit drug use since the late-1960s, it was only from 1980 onwards that the emergence of a culture of intravenous heroin use in areas of generalised social deprivation in Dublin gave urgency to this policy process. This paper traces the gradual introduction, on public health grounds, of harm reduction practices and services – such as methadone maintenance, needle exchange and the creation of outreach and locally-based services – following the identiﬁcation in the mid-1980s of needle-sharing amongst injecting drug users as one of the key routes for the transmission of HIV in this country. It is argued that harm reduction in the Republic of Ireland has been largely implicit, in the sense that political leaders have generally not encouraged or participated in explicit public debate on this topic, nor have they ever publicly announced that this concept now underpins much of the healthcare system’s responses to illicit drug use. It is also argued that this covert style of policy making has persisted, despite the more recent proliferation of formal policy-making structures and the dominance of a rhetoric which emphasises strategic management and the allegedly transparent and evidence-based nature of drug policy. This tactic of shrouding drug policy in ambiguity is discussed in the context of the wider tendency within Irish political culture to manage sensitive and potentially divisive social issues in such a manner. It is concluded that the ambiguity which surrounds harm reduction in Ireland has been functional in that it has confused and frustrated ideological opponents of this concept, but dysfunctional in that it has not facilitated the emergence of more tolerant or respectful attitudes towards drug users and may have delayed the introduction of a wider range of harm reduction practices. © 2005 Elsevier B.V. All rights reserved.
Keywords: Harm reduction; Ambiguity; Roman Catholic Church and Irish Social Policy; Strategic management
Introduction Although there is no consensus as to its precise meaning and certainly no agreed deﬁnition, the term harm reduction has been increasingly used over the past 20 years to refer to international drug policy developments which deviate ideologically from the previous orthodoxy in which criminal justice systems and healthcare systems appeared to be largely at one in their ambition to rid society of illicit drug use (Inciardi & Harrison, 2000). It is, nonetheless, relatively easy
∗ Corresponding author. Present address: Department of Social Studies, Trinity College, Arts Building, Dublin 2, Ireland. Tel.: +353 1 608 2009; fax: +353 1 671 2262. E-mail address: email@example.com (S. Butler).
to identify the broad tenets of this burgeoning policy perspective. Firstly, harm reduction assumes that legal measures to create a drug-free society lack the popular support necessary to achieve total success and, furthermore, that such legal measures may inadvertently contribute to an increase in the scale and intensity of drug-related problems both for individual users and the wider society. Secondly, in accordance with this fundamental assumption, priority is given to strategies, practices and forms of health and social service provision which are aimed at reducing a wide range of drug-related harms while not necessarily reducing drug use per se. Thirdly, and to varying degrees, harm reduction facilitates the development of more tolerant and less moralistic attitudes – both on the part of relevant professionals and the general public – towards drug users, as well as an
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acceptance that users, even while continuing to use illicit drugs, can actively and successfully collaborate with professionals in reducing drug-related harm. These harm reduction ideas are clearly at variance with international conventions on drug control which, strongly inﬂuenced by the United States (US) (Bewley-Taylor, 1999), evolved throughout the twentieth century and which, particularly within the US, still tend to be expressed in highly authoritarian, militaristic terms – commonly including references to the war on drugs, zero tolerance towards users and dealers, and allocation of management responsibility for this entire prohibitionist regime to a drugs czar. Within the broad church of harm reduction, debates and divisions have arisen in recent years (Hathaway, 2001; Hunt, 2004; Keane, 2003; Reinarman, 2004) concerning the extent to which it is possible or desirable for the movement to agree and articulate a single, coherent philosophy – most radically one which would regard freedom to use psychoactive drugs as a basic human right – which might underpin harm reduction policy and practice internationally. To date, however, no such coherent philosophical basis for harm reduction has achieved consensus, and it would appear as though harm reduction practices – including opiate substitution programmes, needle and syringe exchange schemes, outreach programmes and the provision of safe injecting facilities – have been introduced internationally in a variety of piecemeal and pragmatic ways. Against this background, the aim of this paper is to examine the progress of harm reduction in the Republic of Ireland since the mid-1980s, with a view to identifying: the speciﬁc services which have been introduced under this rubric; the policy-making structures which brought about these changes; and the level and nature of policy debate which accompanied their introduction. It will be shown that Irish health and social service systems have, over a period of 20 years, shifted substantially towards harm reduction practices, albeit with the minimum of public debate or policy transparency. Responding to critics who believe that harm reduction practices should be based upon an explicit and unequivocal commitment to psychoactive drug use as a fundamental human right, Reinarman (2004) has argued that this position is excessively idealistic, that harm reduction can be based upon more than one foundation and that ‘a certain amount of philosophical and logical ambiguity is not an obstacle to meaningful harm reduction or drug law reform’ (240). Drawing on these views of Reinarman, this paper will explore the introduction of harm reduction strategies to Ireland as one example of ambiguity within a political culture which has long been characterised by ambiguity in relation to some of its most fundamental value systems. The primary aim of this paper is not, therefore, to asses the effectiveness of harm reduction as implemented in the Republic of Ireland, but rather to gain an understanding of how this policy approach was introduced in the ﬁrst instance to a traditionally conservative society which is signatory to the United Nations (UN) drug conventions and within which drug users are a heavily stigmatised group.
The political culture of modern Ireland The Republic of Ireland, as it is politically constituted at present, had its origins in the Anglo-Irish Treaty of 1921 which conferred a high degree of political autonomy from Britain on 26 of the country’s 32 counties; it was not until 1948, however, that this new state left the British Commonwealth and declared itself a republic (Lee, 1989). This partition of the country, with six counties in the north–east remaining part of the United Kingdom, constituted an ongoing source of internal tensions between north and south and of external tensions between Britain and Ireland. It led to a brief civil war immediately after partition and thereafter to periodic bouts of paramilitary activity, the most protracted of which – known colloquially as the ‘Troubles’ – lasted from 1969 to 1994, when a successful albeit precarious peace process was initiated. While it has retained its tradition of military neutrality, Ireland has not generally pursued an isolationist course in international affairs, participating in the League of Nations during the 1930s, joining the United Nations (UN) in 1955 and seeking membership (eventually granted in 1973) of what is now known as the European Union (EU) in 1961 (Laffan & Tonra, 2004). Following almost 70 years of unremitting economic gloom, the Irish economy began a process of dramatic growth, with improvements in all major indicators and the virtual elimination of unemployment during the ‘Celtic Tiger’ years of the 1990s. Early studies (e.g. Allen, 2000; Sweeney, 1998) of this boom were concerned with explaining why it had occurred, but a more recent study (Garvin, 2004) approaches this topic from a different angle, asking explicitly in its subtitle: ‘why was Ireland so poor for so long?’. In terms of understanding those aspects of Irish political culture which might best help to illuminate the country’s approach to drug policy, the Garvin study – which juxtaposes the image of Ireland as a modern, cosmopolitan, English-speaking society with a successful, free-market economy against that of Ireland as a stultiﬁed and inward-looking post-colonial society – offers a convenient summary of some key historic features of this society. In enumerating the various factors deemed to have contributed to such prolonged economic failure, Garvin identiﬁes two in particular: the dominant inﬂuence of an authoritarian Roman Catholic Church and the continuing political emphasis on completing the unﬁnished business of creating a 32-county and Irish-speaking republic. Garvin’s views about the nature and importance of the role played by the Catholic Church in modern Ireland are not, of course, unique but are broadly reﬂective of those of other social scientists (e.g. Inglis, 1998; Whyte, 1980). The general view is that, having achieved political freedom from Britain, the new state was less concerned with promoting individual liberties than with deﬁning itself as a moral society, with its ethical principles being drawn almost entirely from the doctrines of the Catholic Church. The elements of the Church’s social and moral teaching given greatest emphasis during the ﬁrst half-century of the new state were
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those concerned with the regulation of the body and sexual morality, and in this sphere the Church’s rigid and paternalistic views were reﬂected constitutionally, legislatively and in broad policy terms in such areas as censorship of publications and ﬁlms, prohibition of divorce, contraception and abortion, and the criminalization of prostitution and homosexuality. The Church’s inﬂuence within Irish society has gradually waned over the past 25 years (Coakley, 2004), a process which, ironically, has been hastened by continuing revelations of sexual abuse of children by priests and other religious leaders. While it might appear as though this transition to a more conventional, secular political culture would create conditions favourable to a public debate about harm reduction – possibly indeed stretching as far as to a consideration of drug use as a fundamental human right – no such debate has taken place. It will be argued here that a major reason for this failure to create a national debate about drug policy is that the process of moving towards secularism and liberalism has at times been a deeply divisive and traumatic experience for Irish society generally and particularly for the political system. For instance, since 1983 Ireland has had three referendums on abortion and two on divorce, each referendum being marked by intense and highly polarised debate on the morality of the issues; in relation to abortion, for instance, the debate focused on women’s rights to information, to travel and to actually avail themselves of abortion services. The divisive nature of these debates is reﬂected in the title of a study (Hesketh, 1990) of the so-called ‘Pro-Life’ referendum of 1983: ‘The second partitioning of Ireland’. For political leaders this debate, which coincided with the period during which the advent of HIV/AIDS made harm reduction a relevant policy issue in Irish society, was a bruising affair which may well have reinforced an already existing tendency to introduce policy change covertly and incrementally, where possible avoiding abstract and highly contentious debate about the moral principles involved in such policy change. The second element of Ireland’s political culture nominated by Garvin as having delayed economic progress was the ofﬁcial commitment to the restoration of Irish as the everyday language of the country and – although Garvin argues this less strongly – the related determination to end partition and create a 32-county Republic of Ireland. Articles 2 and 3 of the country’s Constitution, which was drafted and approved in 1937, deﬁned the six counties which remained part of the United Kingdom as part of the national territory, and Article 8 declared Irish to be the country’s ﬁrst ofﬁcial language. In 1999 Articles 2 and 3 were altered by referendum, as part of the ongoing peace process, transforming the stark territorial claim into a peaceful aspiration towards national reintegration, but Article 8 remains unchanged. What is most relevant to the analysis of drug policy is not whether these preoccupations with the restoration of Irish as the everyday language or with the ending of partition adversely affected economic development but, rather, the way in which they exempliﬁed a tendency within Irish society to pay lip-service to national
ideals or symbols without feeling any obligation to match rhetoric with actions likely to realise these ideals. While the Irish language remains the country’s ﬁrst ofﬁcial language, it has continued to decline as an everyday language of communication, is not understood by a majority of the population and is neither spoken nor understood by many political leaders. Similarly, the territorial claim to the six Northern Ireland counties was rarely seen as anything other than an aspiration, and those who sought to vindicate it by military means, rather than being applauded for such action, could expect to ﬁnd themselves subject to the full rigours of the law. Over the past decade, this situation has been complicated even further by virtue of the fact that the developing peace process has drawn into conventional democratic politics groups who were simultaneously involved in paramilitary and criminal activities. In short, Irish society may be viewed as one within which citizens have been accustomed to high-level ambiguity and within which abstract statements of political ideals are not regarded as literal truths demanding action. It can plausibly be argued, therefore, that this is a political culture where the concept of a war on drugs would be unlikely to be seen in literal terms, and where it might not arouse too much controversy if the state was seen to be implementing strategies which appeared to be ideologically at odds with its international obligations.
Drug policy in contemporary Ireland Butler (1991) suggested that the historical evolution of Irish drug policy could be understood as consisting to this point of three identiﬁable phases: • an early phase (1966–1979) in which the state gradually came to the view that illicit drug use, in retrospect of a relatively low prevalence and low risk variety, was a feature of Irish society which demanded a policy response; • a middle phase (1980–1985) in which the state, again with some reluctance accepted that Ireland now had an established heroin-injecting scene; • a third phase (1986–1991) dominated by public health fears stemming from an awareness that injecting heroin users, by virtue of their sharing of needles and other paraphernalia, were a high risk group for the transmission of HIV amongst one another and, ultimately, through sexual contact into the wider community. Public health concerns have continued to be a major inﬂuence on Irish drug policy in the period since 1991, so, notwithstanding the necessity to extend the third phase by 14 years, this chronological framework may still be regarded as a valid and convenient tool to be used in understanding the introduction of harm reduction strategies in this country. It is perhaps understandable that a society which traditionally had such a strong emphasis on the moral importance of controlling the body found it difﬁcult to accept that what were perceived to be hedonistic patterns of psychoactive drug
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use could become established here. A journalistic account of the early phase of drug use in Ireland (Flynn & Yeates, 1985) describes the reluctance of the Department of Health, the central government department with primary responsibility for legislation in this area, to accept that illicit drug use could become an enduring feature of Irish life, and Butler (2002a) has a similar account of that department’s lengthy disbelief concerning the wave of intravenous heroin use which characterised the second phase. However, from a harm reduction perspective, what emerges as being most important in considering these ﬁrst two phases of the Irish drug experience is the way in which all of the underlying assumptions about ‘drug abuse’ were accepted without critical scrutiny in debate which took place both amongst voluntary – and largely religious-based – groupings and in ofﬁcial policy discourse. An early pamphlet (O’Byrne, 1969), written by a wellknown Franciscan priest who styled himself ‘The Teenagers’ Priest’, presented drug use as a self-evidently problematic phenomenon about which medical doctors and moral theologians were in full agreement, and which the author proposed to tackle through a Catholic Youth Crusade. Three years later an inter-church committee (Irish Council of Churches/Roman Catholic Joint Group on the Role of the Churches in Irish Society, 1972) published a more reasoned discussion of this issue but stopped considerably short of raising fundamental questions about the morality of drug use. Similarly, the report of the ﬁrst governmental committee (Report of the Working Party on Drug Abuse, 1971) to consider this matter accepted as a given that ‘drug abuse’ existed and that civil society and the state were at one in their determination to stamp it out; the report also assumed that, within the state sector, healthcare would reﬂect and reinforce criminal justice supply reduction measures by only providing treatment and rehabilitation systems which were abstinence oriented. During the early and middle phases, therefore, service provision was centralised in one specialist medical facility – designated the National Drug Advisory and Treatment Centre – which operated on an abstinence model, while the ﬁrst voluntary, non-medical programme was an American-style therapeutic community – the Coolmine Therapeutic Community – which started in Dublin in 1973.
From the mid-1980s, however, Ireland was faced with the same dilemma as that confronting other societies which had an injecting drug scene: it could continue to offer healthcare interventions based solely on abstinence models or, alternatively, it could move pragmatically towards what was coming to be referred to as a harm reduction approach, one which prioritised HIV prevention and was prepared to tolerate varying levels of ongoing drug use among its clients. In line with this paper’s stated aim, therefore, there are now two questions which need to be addressed: the ﬁrst asks whether the Irish healthcare system moved away from its historical commitment to abstinence-only interventions, while the second asks to what extent the adoption of harm reduction strategies was presented to the public in clear, unambiguous terms as representing a policy shift. The ﬁrst question will be answered brieﬂy in the remainder of this section, while the second question will be considered at some length in the next section which deals with policy-making structures. It is clear from Table 1 that despite its apparent dogmatism about the moral evils of drug use and commitment to abstinence-only treatment systems, Irish drug policy changed considerably, albeit incrementally, from the mid1980s onwards. The changes listed in Table 1, which should be considered as indicative of major changes rather than as a comprehensive list of all change occurring during this period, are obviously reﬂective of many of the main features of harm reduction discussed in the introduction to this paper. They included the use of speciﬁc harm reduction strategies, such as needle exchange and methadone maintenance, as well as changes in the style of service provision – such as the establishment of locally-based services and the regularisation of the role of family doctors and community pharmacists – which may be considered as constituting a form of normalisation of addiction treatment. Interestingly, the Ana Liffey Project and the Merchants’ Quay Project (later renamed Merchants’ Quay Ireland), the ﬁrst two voluntary drug projects to adopt harm reduction principles, were founded by Catholic priests, with the latter being physically located in an inner-city Franciscan monastery previously home to Fr. Simon O’Byrne, the ‘Teenagers’ Priest’ referred to above.
Table 1 Introduction of harm reduction strategies into the Irish healthcare system, 1985–2005 1985 1987 1989 1989 1991/1993 1995 1996 1997 1998 Provision of statutory ﬁnancial support for the Ana Liffey Project, Dublin’s ﬁrst voluntary drug service based on harm reduction principles Increased availability of methadone maintenance in the National Drug Treatment Centre Beginning of a new service system under the aegis of the regional health authority for Dublin (the Eastern Health Board), designated an AIDS Resource Centre and offering needle exchange, methadone maintenance and outreach work with drug users Provision of statutory ﬁnancial support for the Merchants’ Quay Project, which was to become the largest voluntary drug service based on harm reduction principles Establishment by Eastern Health Board of localised ‘satellite’ clinics, offering addiction counselling, methadone maintenance and needle exchange Training of drug users as Peer Support workers by Eastern Health Board Introduction of mobile clinics in Dublin Creation of the Dublin Safer Dancing Initiative by the Eastern Health Board Enactment of legislative provisions (commonly referred to as the Methadone Protocol) creating a national register and regulating the prescription of methadone by family doctors and its dispensing in community pharmacies
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Policy-making structures and the policy process Given this evidence of the introduction of harm reduction strategies, the question which now needs to be addressed concerns the way in which Irish policy-making structures handled this transition. The answer, which will be spelt out in some detail here, is that the changes were introduced gradually and covertly; those involved in the process made no effort to create a national debate on the merits of harm reduction, nor did they ever formally announce that harm reduction had now been enshrined as the new philosophical basis to Irish drug policy. By way of contrast, it should be noted that in England, which because of geographic proximity would have been familiar both to Irish drug users and policy makers, the debate about and transition to harm reduction was considerably more transparent; a much-quoted principle from England’s Advisory Council on the Misuse of Drugs (ACMD) concluded that: [T]he spread of HIV is a greater danger to individual and public health than drug misuse. Accordingly, services which aim to minimise HIV risk behaviour by all available means should take precedence in development plans. (1988, p. 17) It would be misleading to suggest that this statement, issued by an advisory body rather than a central government department involved in policy implementation, marked a deﬁnitive and unequivocal shift towards harm reduction on the part of the English government. It did, however, constitute the publicly stated and unambiguous policy preference of an authoritative advisory group, and it may also be seen in the wider history of English drug policy as reﬂecting a return to the pragmatism of the so-called ‘British System’ which existed for 40 years after the Rolleston Report of 1926 (Strang, 1990). The clarity and logic of this statement by the ACMD is such that one might imagine it providing an acceptable basis for policy change in Ireland, but the reality is that no comparable statement about Irish drug policy or its de facto acceptance of harm reduction principles has ever been issued by any Irish policy-making body. In fact, what emerges from a historical review of drug policy-making bodies in this country is that ambiguity has been a feature of the policy-making process just as it has been a feature of policy content; specifically, as will be explored here in some detail, it has never been clear that those bodies which have nominally been at the heart of the policy-making process have in fact played the kind of role which might rationally be expected of them.
Table 2 Ireland’s National Drug Strategy 2001–2008 Four pillars Supply reduction Prevention (education and awareness) Treatment Research Organisational structure
Butler (1991) has detailed how in each of the ﬁrst two phases of Ireland’s drug policy history the two apparently key policy structures (the Inter-Departmental Committee on Drug Abuse during the early phase and the National Coordinating Committee on Drug Abuse during the middle phase) had a largely nominal existence, being effectively sidelined by the Department of Health and by occasional interventions from senior politicians. By far the most clearly deﬁned policy structures, however, are those which have emerged over the past decade, based on recommendations of the First Report of the Ministerial Task Force on Measures to Reduce the Demand for Drugs (1996) and formally presented again in Building on Experience: National Drug Strategy 2001–2008 (2001). This latter publication, which is by far the most lengthy and detailed drugs policy document ever produced in Ireland, is presented in the format of a ‘national drug strategy’ broadly in line with similar national strategies being produced in EU countries (European Monitoring Centre for Drugs and Drug Addiction, 2004). What is most striking about this national drug strategy, presented in summary form in Table 2, is its rational, managerial tone. This was not the ﬁrst time that an Irish drugs policy document emphasised the importance of coordinating the activities of a range of governmental sectors; indeed rhetoric of this kind had been a feature of policy discussion since the ﬁrst ofﬁcial committee was set up to consider illicit drug use in 1968. What was different on this occasion, however, was that debate on the creation of appropriate policy structures for managing drug problems was now being explicitly couched in the terminology of the Strategic Management Initiative (SMI), an Irish version of ‘new public management’ (Byrne et al., 1995; Delivering Better Government, 1995) which saw itself as reforming an old-fashioned, fragmented and inefﬁcient civil service system. One of the main applications of SMI to the drug strategy centred on the necessity for coordinating the activities of all governmental sectors and agencies which contributed to societal management of drug issues. The First Report of the Ministerial Task Force on Measures to Reduce the Demand for Drugs (1996, p. 12) had argued that: ‘The drugs problem is what the Strategic Management Initiative in the Public Service describes as a “cross-cutting” issue which cannot be dealt with satisfactorily by any one Department . . .. It is absolutely essential that practical and workable arrangements be put in place to ensure a coherent, co-ordinated approach’. In accordance with this new concern for having a strategic, ‘cross-cutting’ approach to societal management of drug issues, the structures named in Table 2 were set in place. These included the identiﬁcation
Cabinet Committee on Social Inclusion; ‘Lead’ Department; Minister of State allocated speciﬁc responsibility for coordinating the national strategy; Inter Departmental Group of senior civil servants; National Drug Strategy Team with regular, ongoing responsibility for implementation of the strategy
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of one central government department, amongst many involved with drug issues, as a ‘lead’ department, allocation of political responsibility for coordinating drug policy to a named Minister of State (junior minister) within this department, and the creation of a range of structures – up to and including a Cabinet sub-committee – all ostensibly aimed at formulating and implementing a single national drugs policy. Implicit in the managerial discourse within which drug policy was now discussed was the idea that policy making was an essentially rational process and that research – identiﬁed as one of the four ‘pillars’ of the national strategy – would play a signiﬁcant role in informing policy decisions. A National Advisory Committee on Drugs (NACD) was established in 2000 (National Advisory Committee on Drugs, 2003) and charged with the responsibility for developing policy-relevant research in Ireland, while the Drug Misuse Research Division of the Health Research Board was designated a ‘focal point’ for the European Monitoring Centre for Drugs and Drug Addiction. While it is clear that, by and large, these structures have an ongoing operational existence, it cannot be said that they have dealt decisively and unambiguously with the substantive issue of harm reduction in Ireland. Although harm reduction practices have been used here since the mid-1980s, the only ofﬁcial publication to deal explicitly with this topic to date is a review commissioned by the NACD (Moore et al., 2004), which largely concerns itself descriptively with research evidence on the efﬁcacy of various harm reduction strategies and almost entirely ignores the attendant policy conﬂicts and dilemmas. The primary dilemma is that harm reduction policies and strategies appear to condone, if not positively encourage, styles of drug use which are illicit, both in national and international legal terms, and a secondary but important dilemma is that drug users are popularly regarded (Bryan, Moran, Farrell, & O’Brien, 2000; MacGreil, 1996) as deviant and immoral. On this latter point, it should be noted that despite state investment in and promotion of ‘bottom-up’ community participation in drug policy, there are ongoing difﬁculties for public health authorities in establishing locally-based treatment services such is the depth of popular animosity towards drug users. Furthermore, there is no reason to believe that these dilemmas can be resolved by objective, scientiﬁc research any more than Ireland’s ongoing policy dilemma over abortion can be resolved by scientiﬁc research. In short, current management-speak – with all its rhetoric of strategies, key performance indicators and crosscutting structures – conceals what is essential: that is, that national drug policies are complex and difﬁcult because of fundamental moral or ideological disagreements rather than because of poor administrative systems. From a strategic management perspective, it might appear as though the two main choices open to Irish policy makers are: (1) to commit themselves anew, in a public, transparent way, to the fundamental truths of the war on drugs and to the sole implementation of abstinence-based healthcare strategies; (2) to inform the public that healthcare interventions for illicit drug
users are now based on a harm reduction philosophy, and to provide a detailed ideological justiﬁcation for this position. In fact, over the past 20 years, policy makers have consistently gone for a third option, which is to shroud the policy process in ambiguity by introducing harm reduction practices without debate, announcement or a clearly presented rationale. Perhaps the most radical policy development which demonstrates how policy decisions can be made quietly outside the ofﬁcial policy structures, has been the introduction of what is known as the ‘Methadone Protocol’ in 1998. This initiative, which has been analysed in detail by Butler (2002b), created a licensing system for the prescription of methadone by family doctors, and did so in the face of much public hostility towards the extension of methadone treatment. In this instance, the policy process was orchestrated away from the public gaze, over several years, by a network of civil servants and healthcare professionals; this culminated in the issuing of a statutory instrument which, as ‘secondary legislation’, had all the force of law but none of the parliamentary scrutiny or detailed media attention attendant upon conventional legislation. It is a mark of its success, or perhaps its hypocrisy, that it was signed into law by a health minister from the country’s major party, Fianna F´ il, which while in opposia tion a year earlier had published a conservative drug policy document, criticising methadone and citing (albeit without acknowledgement) the mantra ‘drugs are illegal because they are dangerous – they are not dangerous because they are illegal’ (Fianna F´ il, 1997, p. 3) which is usually associated with a EURAD (Europe Against Drugs), Europe’s most conservative anti-drug voluntary movement.
Advantages and disadvantages of policy ambiguity If the progress of harm reduction in Ireland is measured in terms of what were described in the introduction to this paper as the three main tenets of this approach, then it is clear that there are both advantages and disadvantages to the uses of ambiguity. All of the policy initiatives summarised in Table 1 may be seen as implicitly conﬁrming the ﬁrst two tenets referred to, namely the view that legal measures to achieve a drug-free society are not succeeding and, consequently, that priority should be given to health and social service initiatives aimed at reducing drug-related harm rather than drug use per se. It is argued here that had there been a major public debate in the Republic of Ireland about the principles of harm reduction, where harm reduction was seen to challenge explicitly the wisdom of the UN conventions as well as conventional wisdom on the war on drugs, then it is most likely that strategies based upon these principles would have been deemed unacceptable. When, as has happened on a few occasions, there has been public debate about a particular aspect of harm reduction, this appears to have mainly served to evoke reactionary responses. In the summer of 2000, for example, a suggestion from Merchants’ Quay Ireland, the largest voluntary drug service based on harm reduction principles, that Dublin
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needed a safe injecting facility drew a much publicised rebuke from EURAD, as well as publicity concerning the Vatican’s effective blocking of an initiative of this kind in a facility run by nuns in Sydney; the following year, a theologian from Merchants’ Quay (Cronin, 2001) wrote a detailed – but largely unpublicised – moral defence of harm reduction in a national church publication. Similarly, in 2004, public debate on the question of introducing needle exchange – informed inter alia by research carried out by the Drug Misuse Research Division of the Health Research Board (Long, Allwright, & Begley, 2004) – to Irish prisons drew a stinging retort from the conservative Minister for Justice, who described this proposal as ‘moral fuzziness’ and promised to make the prisons drugfree within a matter of months (Irish Times, September 29, 2004). It could of course be argued that moral fuzziness (or ambiguity if one chooses to use Reinarman’s vocabulary) has provided the basis for all harm reduction initiatives in Ireland. In terms of the third harm reduction tenet referred to in the introduction – that which refers to the emergence of more tolerant and less moralistic public attitudes towards drug users – there would appear to be no advantage accruing from the relatively covert or ambiguous style of policy making discussed here. The Mid-term Review of the National Drug Strategy 2001–2008 (2005) conﬁrmed, for instance, that the strategy had been successful in increasing the number of methadone treatment places, but it also reported consistent criticism of this treatment modality and a preference for abstinence-based services. Although the harm reduction initiatives described above have obviously been aimed at urban opiate injectors, who constitute the most problematic end of the drug-use spectrum, it should be made clear that Irish adolescents and young adults, both in high-risk urban settings and in rural areas, are just as ‘drugwise’ as their counterparts in Britain and elsewhere (Hibell et al., 2004; Mayock, 2002). In this context, the covert nature of the Irish harm reduction project is severely limiting in terms of its capacity to affect public attitudes towards young drug users and service provision for these young drug users. On this latter point, Kiely and Egan (2000, p. 5), in their introduction to a booklet on the applications of harm reduction concepts to drug education projects, comment: ‘The current climate of silence around this work is not favourable to the development of realistic and effective responses to drugs in Irish society, particularly if front line workers with young people do not feel comfortable to discuss their work, or to seek endorsement or support from funders, management representatives or other bodies’.
Discussion To those who would criticise the international harm reduction movement for its value-neutrality and lack of a clearlyenunciated moral basis, the Irish harm reduction experience as presented here must appear especially provocative. Not only does it show no sign of moving in the direction, favoured by Hunt (2004), of viewing drug use as a fundamental human
right, it even obscures what has been done to date and the fact that these developments have been primarily driven by public health motives. While it might be an exaggeration to suggest that this approach to harm reduction is unique, it is easy to contrast the Irish experience with that of other countries from which it clearly differs. It is not like Switzerland, for instance, which makes regular use of the referendum process (MacCoun & Reuter, 2001), nor is it like the Netherlands or the US which – although in radically differing ways ideologically – say what they do and do what they say (de Kort & Kramer, 1999; Musto, 1999). In the case of the Netherlands, the essence of its harm reduction philosophy had been articulated and justiﬁed almost a decade prior to the identiﬁcation of HIV/AIDS, and countries which had originally been sceptical or uninterested began in the HIV era to show a new interest in this Dutch experience. In a spirit of rationality, one could ask whether the Irish experience of harm reduction described here has lessons for other countries, but such a rationally framed question seems inappropriate in relation to policy ambiguity. One could expect that, at least in their public utterances, Irish politicians and senior civil servants would be likely to deny the central argument of this paper and to stick to the ofﬁcial line that Ireland’s National Drug Strategy is a transparent, evidence-based system rather than the ambiguous process described here. Looked at from a comparative perspective, Irish drug policy makers are confronted with what is a common, if not quite a universal problem, that of being stuck within the prohibitionist rigidity of the UN drug control conventions with little immediate prospect of change or reform. Cohen (2003, p. 214) has argued that ‘Drug policy reform is inextricably tied to local culture and politics. No two systems of harm reduction can ever be identical’. It appears as though the Irish approach to harm reduction is but one example of ambiguity in a society which is generally accustomed to ambiguity, and which has learnt that strident public debate on moral issues is as likely to lead to polarisation and policy paralysis as it is to agreed and effective solutions. In 1979, the Minister for Health, Charles Haughey (a controversial politician who later went on to be Taoiseach or Prime Minister) dealt with the then contentious moral issue of the sale of condoms by legislating to make them available to married couples but only on a doctor’s prescription, famously describing this as an ‘Irish solution to an Irish problem’ (Lee, 1989, p. 498). While frequently derided both for his failure to tackle the issue head-on and for this description of his legislation, Haughey has also been praised for his pragmatism in side-stepping the moral debate and for succeeding where the previous government had failed. There is a sense in which the introduction of harm reduction is an ongoing example of this ‘Irish solution to an Irish problem’. In late-2004 a new group – calling itself the Drug Reform Alliance – was convened through Merchant’s Quay Ireland. The emergence of such a group, which intends to campaign publicly for drug policy reform, can alternatively be seen as a positive step which publicises the issues and brings more transparency to the policy process, or as a development which
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