In 1987 the North West Regional Health Authority gave the Lifeline Project, a Manchester-based drug advice service, 45,000 to produce HIV prevention information for drug users. This chapter provides an overview of the production, distribution and evaluation of the resultant HIV prevention initiative that takes the form of an adult comic book for drug users called Smack in the Eye. The aim of the comic is to 'promote' safer drug use and safer sex. This approach is an alternative to health education 'warnings of danger' that seek to tell people what not to do without suggesting possible alternatives. In short, this is a practical initiative borne out of 'harm réductionniste', as opposed to 'abstentionist, theory and philosophy. Whereas the central goal of abstentionniste initiatives is to reduce drug use, the central goal of harm reduction initiatives is to reduce the harms (such as HIV/AIDS) that can arise from drug use. Smack in the Eye 'nudges' drug users towards safer drug using practices in the manner described by Stimson (1990) and targets drug users for information and advice on safer sex as suggested by Newcombe (1987, 1988) and ICIee et al. (1990).
This harm reduction initiative is primarily aimed at the injecting drug user 'community'. It is designed to encourage a reduction of drug-related harm, with specific reference to HIV and AIDS. As there is no cure for AIDS and no proved method of preventing drug use, the Lifeline Project has attempted to develop a strategy that both accepts and works within this reality. Some commentators have been quite shocked by the use of a comic book format to address such a serious issue as HIV and AIDS. However, it has been pointed out that the emergence of HIV among injecting drug users has given a legitimation to the harm reduction approach that was previously unthinkable. Similarly there is a growing recognition of the successful use of comic books in many different areas of public education and information.
To begin this project we arranged a series of meetings with a group of drug users with a view to establishing some basic principles that could guide our harm reduction initiatives. In-depth conversations with this group suggested that just as advice on contraception has to start from an acceptance of sexual activity as 'normal', so harm reduction messages and advice have to come from a user-friendly and non-judgemental agency which accepts drug use as an activity that may lead to problems but is not in itself pathological behaviour.
Attempts at primary prevention have often tried to scare people away from drug use. In these attempts, balanced, factual information about drugs has often been abandoned in place of an emphasis on the 'possible' dangers of drug use. This has created a 'credibility gap' between those sending messages about drug use and those drug users who receive them. Current attempts at harm reduction have to win back the confidence of drug users who have been socialized into a subculture used to discounting warnings of danger from well-intentioned but ill-informed professionals (Gilman, 1989).
The consultation process revealed that drug users had ,,grave reservations about the majority of standard drugs and HIV information. These reservations concerned both content and style. These drug users saw standard drugs and HIV education as falling into one of two categories: 'bullshit' or 'boring'. For example, a poster that merely informs you that 'DRUG ABUSE KILLS!' is an example of the bullshit variety. It is bullshit because it tells you nothing. It tells you that drug abuse can kill, but so can rock climbing, potholing or driving a motorbike too fast. In other words, a whole variety of exciting activities contain a potentially lethal risk factor. We are informed by those in high political office that the only thing that drug users can look forward to is despair and degradation. Subsequent mass media campaigns here in Britain have pursued this theme. However, such is the appeal of the 'wasted look' in youth culture that the 'HEROIN SCREWS YOU UP!' posters, featuring a suitably wasted young man, have been seen nestling beside the latest pop stars on the bedroom walls of British teenagers. Those with a more wry sense of humour have altered the wording of these posters, replacing the word heroin for unemployment so that they now read 'UNEMPLOYMENT SCREWS YOU UP!'
The 'boring' variety of standard drugs and HIV education came from well-intentioned individuals who produced materials in a style which reflected their chosen daily reading material — The Guardian (one of the 'quality' British daily newspapers). In true Guardian style, the information in these materials is thorough and accurate but very difficult to get excited about. Drug users accepted the information in these materials yet described reading these materials as 'hard work'. In other words, the information is not bullshit but the style of presentation is 'boring'. Had we not gone out and consulted drug users I suspect that we too would have produced worthy but boring materials. The result of our consultations was quite clear, we had to produce drug and HIV information in a format that was both credible and entertaining.
In relation to HIV prevention it became increasingly clear that harm reduction messages about not sharing injection equipment need to be supported by the provision of easy access to clean injecting equipment. Official exhortations to reduce or eliminate the sharing of injecting equipment will be ignored if access to the practical means of achieving this behaviour change are absent. The establishment of a needle exchange scheme, for example, can be presented as a symbolic and practical indication that, The spread of HIV is a greater threat to individual and public health than drug misuse' (Advisory Council on the Misuse of Drugs, 1988). The absence of such schemes will see drug users dismiss the HIV/AIDS 'scare' as just another attempt to scare people.away from, and out of, drug use.
A comprehensive approach to HIV prevention among drug users should address the three variables of Knowledge, Attitudes and Behaviour. Provision must be made to increase factual 'knowledge' about HIV transmission and encourage an 'attitude' whereby it is fashionable to 'know' about HIV/AIDS. Perhaps the most important is easy access to the equipment (e.g. clean injecting equipment and condoms) necessary to alter 'risky behaviour'. It should be noted that the knowledge — attitude — behaviour relationship is not a linear one. An increase in knowledge will not necessarily lead to a change in attitude. A change in attitude will not necessarily lead to a change in behaviour. Smack in the Eye attempts to address all three of these variables simultaneously. We iOve factual information about HIV transmission, show that it is 'cool' to 'wise up' about HIV and advertise outlets where users can obtain the practical means (e.g. clean injecting equipment and condoms) for changing behaviour.
Having reviewed existing, contemporary material we began to look at how drug users had traditionally been informed about safer drug use. In this context we recognized the contribution made by the underground press of the 1960s and 1970s. The underground press did a better job of delivering drug education than '...an army of drug educationalists' (Lewis, 1985).
We also looked at how other agencies at home and abroad were 'selling' their safer drug use and safer sex messages. Experience from the Netherlands suggested that a more 'active' approach needs to be adopted with our target group than with general public education which makes information material freely available to be picked up or ignored. Anecdotal evidence from drug agencies and needle exchange schemes confirmed that drug users had to be strongly encouraged to take HIV/AIDS leaflets and even then these leaflets were often found discarded in adjacent streets.
The first task therefore is to produce materials that drug users themselves actually want to see and pass on to their friends. Our consultations with drug users revealed that adult comics were far more prevalent than quality newspapers among our target audience. The most popular of these comics is a publication called V/Z. The success story of V/Z is quite remarkable. It began life as a number of photocopied sheets sold around pubs and clubs in the north-east. It is now one of the most widely read publications in England, whose readership eagerly await each issue. Smack in the Eye is clearly within the V/Z genre which has provided us with a model to guide our efforts. V/Z characters and plots are wide and varied, ranging from the classic schoolboy toilet humour of 'Johnny Fartpants' to the more acidic style of humour as seen in the character of 'Postman Plod — the miserable bastard'. Smack in the Eye contains a similar range of styles and characters.
In the pilot issue we counter-posed some cartoons that originally appeared in a Dutch Aids leaflet with a depiction of cartoon characters of our design. The Dutch cartoons are headed 'The Wise Guys', because they practise safer drug use and sex, whereas the other cartoons depict 'The Daft Bastards' who do not. We chose, and have continued with, this counter-position in an attempt to ally a prevention message to positive attitudes and behaviour already evident in some drug-using subcultures. In our experience one should not underestimate the importance of variety and fashion in the lives of many of today's drug users.
The depiction of unsafe Cuntogether) use as being the preserve of 'daft bastards' seeks to reiterate and reinforce the general theme of the comic that unsafe drug use and sexual practice is anti-social and damaging to the drug user's own subcultural group. Those who refuse to share injection equipment are obviously 'Wise Guys', whilst the users of their unwanted needles are clearly 'Daft Bastards'. The targets for humour are the attitudes and behaviour of the character who wants to share someone else's injection equipment.
We have devised a character called 'Tough Shit Thomas', a cat with nine lives who is a 'Daft Bastard' of the first order, but who is always ready to learn. 'Tough Shit Thomas' has appeared in every issue of Smack in the Eye and has been used as a vehicle for general advice on: safer drug use and safer sex, overdose, dangers of injecting benzodiazepines and your rights when arrested by the police.
The practical experiences and tactics of people who already practise safer drug use could be of benefit to other users. Given the lack of organization among drug users it is quite likely that the 'successful' user may never encounter novices or 'unsuccessful' users whose practices may involve regular high-risk activities. Comics can be employed to portray scenarios where such meetings do take place and the successful user passes on harm reduction advice. Alternatively, the comic may just give us a glimpse into the lives of 'together' users. We have devised a character called 'Grandpa Smackhead Jones: The Oldest Junkie in the World' who passes on harm reduction advice to younger, less experienced users. 'Grandpa Smackhead Jones' has given advice on: safer injecting, dangers of injecting dextromoramide ('Palfium), crack cocaine and amphetamine use. _ _
From the outset of this project it was felt to be crucial that the comic carry messages about safer sexual practice in tandem with safer drug use advice. This is particularly important as many drug injectors who do use their own equipment feel that by doing this they have 'done their bit'. For many drug users 'AIDS' is about not sharing injection equipment. Having taken this message on board they appear to regard themselves as sufficiently 'inoculated' and carry on practising unsafe sex. This is evidenced by the fact that by no means all the drug users who collect injection equipment from needle exchange schemes take up the offer of condoms. In this context we are faced with all the problems inherent in encouraging safer sex among the heterosexual population in general.
Homosexuals and lesbians who use drugs can benefit from the high level of organization among the gay and lesbian community where safer sex messages and information are clearly evident.
While carrying out the research for the comic we were informed by gay men that, in conducting their sexual relations, they have traditionally chosen from a wide range of sexual activities that do not involve penetration and as such are examples of safer sex. Many of these acts provide all the satisfaction of penetration and are often seen as more exciting. Because many heterosexuals choose their sexual activities from a much more restricted repertoire, penetration is still of paramount importance. One of the problems with social advertising is its negativity. Because of their negative emphasis, social advertisements are perceived as threatening by the audience — they seem to substitute less attractive activities for those which are more hazardous but neverthekss more enjoyable. This means that such advertising can induce anxiety and defensiveness which prompts a dismissal of the message. The humour of the comic format clearly distances the messages contained within it from the standard serious messages which create such defensiveness.
A central aim of the comic is to promote the theme that safer sex allows pleasure without regret. The comic format is a suitable vehicle from which to sell a safer sex message and avoid a negative, moralistic attitude which informs drug users (already engaged in an activity outlawed by society via the criminal justice system) of something else that they should not do. Comics can begin to explore an alternative approach that does not insist on a reduction in sexual activity or the use of condoms but rather promotes examples of safer sexual activities as exciting alternatives to the monotony of penetration.
One of the difficulties we have experienced in encouraging the formation of drug users' organizations in the past is that both users and workers are unclear about what such a group would do. Drug users' groups can organize around a specific activity such as the distribution of relevant information. The distribution system for Smack in the Eye was designed with this in mind.
The comics were initially distributed to drug users in contact with services (including the needle exchange schemes) and then passed on by them to their drug-using friends and acquaintances. We put a small cover charge on the comic to give the drug users who distribute the comic the option of selling the comic to other users thereby utilizing the well-documented entrepreneurial skills of some drug users. The inclusion of a cover price was simply to assist distribution of the comic. As an organization we make copies of the cotnic freely available to our drug-using customers and expected other organizations to do the same.
Unlike the one-off leaflet that can be perceived as a single exercise in inoculation against HIV, the comic format can be produced regularly to repeat and reinforce harm reduction messages using different characters and scenarios. This is an important feature of the comic. Much contemporary health education draws heavily on the `Health Belief Model', which clearly identifies the need to continue to re-inform and re-inforce 'appropriate patient beliefs'. A research team from the Pentagon has found that people retain information far longer when it is presented in comic book form; and that the more dramatic the images, the better the comic succeeds.
Given drug users' dismissal of the more formal health education material, the style and content of a comic has to reflect aspects of the social milieu of groups of drug users which may be unpleasant to some; however, there is a significant lobby arguing that the presence of HIV infection poses such a fundamental threat to society that no risk reduction option should be rejected because it conflicts with our own feelings and attitudes to drug use.
However, such laudable intentions pose real dilemmas for all those who attempt to produce harm reduction materials. The producers of Smack in the Eye were not immune from this. We, too, had to find out what we were and were not prepared to publish. That meant we had to confront our own personal value systems, those of Lifeline as an organization, and those enshrined with legislation. Brave statements about risk reduction are much harder to translate into reality.
Producing Smack in the Eye has proved to be an exercise in 'boundary clarification'. By this we mean that we have had to decide what is acceptable, and more problematically, what is not. Putting together a comic that aimed to be different from all other HIV information/prevention materials meant that we were consciously aiming for a style and tone that would make the comic stand out — that would make its readers remember both the medium and the message.
In this attempt to highlight the risk of the transmission of HIV we have deliberately employed the language of the street and explicit portrayal of sexual activity and drug use. The use of explicit 'street language' clearly distances the material from more traditional health education approaches. Similarly, there is well-documented evidence that humour is evident among drug users even when the most serious of issues are being discussed. The use of humour stands in direct contrast to the traditional use of 'fear arousal', the shortcomings of which have been well documented.
Humour can be very effective, but is very often a double-edged tool as it often requires a target. The problem is to create humour with a 'sting in its tail'. Within a comic format humour can be employed to attract attention yet leave behind a meaningful harm reduction message. In identifying targets for humour one should focus on examples of unsafe practices and the attitudes that accompany them in an attempt to stigmatize these attitudes and behaviours. However, one has to be very careful that the characters depicting these target behaviours and attitudes do not develop into anti-heroes, proud of their kamikaze attitude and behaviour.
Having distributed a pilot issue of Smack in the Eye we conducted thirty in-depth interviews with drug users who had read the comic. Although our exploratory research with drug users, prior to the production of the comic, highlighted a credibility gap between those sending messages and the drug users that receive them, we have been genuinely surprised at the extent of the suspicion of official messages. We have been similarly surprised at the fond memories that today's drug users still have for the 'head comics' of the underground press.
The dominant discourse on drug issues makes much use of the terminology of war. It is our experience that a war on 'drugs' can very easily become a war on drug 'users'. Evaluative interviewing has shown that drug users perceive the production of Smack in the Eye as a positive step by the Lifeline Project to 'take sides' with them. If the target audience for health education messages 'trust the messenger' they are more likely to 'trust the message'.
In order to maintain the trust and respect of drug users we are committed to act on behalf of those who were concerned about issues of stereotyping in the pilot issue. In many ways the stereotyping issue has been the most problematic. Although we have made every effort to avoid stereotypical images in the production of Smack in the Eye it is very difficult to portray characters and scenarios that are recognizable and familiar in a cartoon format without running the risk of stereo-typing. Having been made aware of this concern, however, we have taken great care to avoid any offensive stereotypical imagery in subsequent issues.
The British Advisory Council on the Misuse of Drugs (1988) report, AIDS and Drug Misuse, recommends that drug services make contact with as many of the hidden population of drug users as possible. Smack in the Eye is being used as a tool to facilitate this contact along with outreach and detached work. Outreach arid detached workers use the comic as a way of opening up a dialogue with drug users. They are then in a position to discuss some of the points made in the comic. Drug workers have reported that this is a particularly useful way of beginning discussions about sexual behaviour with a group whose primary concern relates to reducing the harm that can arise from drug use. Similarly, those working with groups whose primary concern relates to reducing the harm that can arise from sexual behaviour have been able to use Smack in the Eye to highlight drug issues. The distribution of subsequent issues is also a clear reason for maintained contact between detached worker and client.
Prior to the production of Smack in the Eye there was much talk about the need to develop radical and imaginative health education initiatives in response to the presence of the HIV virus. However, the parameters for such efforts were never defined. Everyone who attempts to do something radical and imaginative, therefore, must be prepared to take the criticism of those who feel they have 'gone too far'. Smack in the Eye was no exception. The reaction from other workers in the 'caring professions', and indeed in the drug field itself, was mixed. There were those who thought the comic exciting and innovative, and eagerly awaited the chance to distribute it. There were also those who viewed it as irresponsible and/or pornographic.
Our critics inform us that the boundaries that we have gone beyond are those of public decency. Many possible outlets were, and still are, denied to the comic because workers or their managers find the comic 'offensive'. Although we accept that some people find the comic offensive we have prioritized the reaction of drug users. This has been overkhelmingly positive. The comic has elucidated the 'boundaries' within which radical and imaginative initiatives can succeed. It has helped to identify those people who are prepared to go beyond conference rhetoric and actually be involved in the dissemination of radical material. This project is a serious departure from standard drugs and HIV education. It is proving to be a successful attempt to face the real challenge posed to us all by the presence of HIV and AIDS in contemporary society.
Advisory Council on the Misuse of Drugs (1988) AIDS and Drug Misuse, Pan 1, London: HMSO.
Gilman, M. (1989) Comics as a Strategy in Reducing Drug Related Harm, Manchester: Lifeline Project Ltd.
Klee, H., Faugicr, J., Hayes, C., Boulton, T. and Morris, J. (1990) 'Sexual partners of injecting drug users: The risk of HIV infection', British Journal of Addiction 85: 413-18.
Lewis, R.. (1985) 'Selling smack and chasing dragons', Emergency (3).
Newcombe, R. (1987) 'High time for harm reduction', Druglink 2 (10): 11. — (1988) 'Serious fun: Drug education through popular culture', Druglink 3 (6):10-13.
Stimson, G. V. (1990) 'AIDS and HIV: The challenge for British drug services', British Journal of Addiction 85: 329-39.