THE INTERNATIONAL JOURNAL OF DRUG POLICY, VOL 7, NO 3,1996
INTRODUCING HARM REDUCTION CONCEPTS IN DRUG POLICY REFORM
Donald M. Topping, Social Science Research Institute, University of Hawaii, USA
The language of harm reduction was first introduced in Hawaii in 1993 by the founding members of the Hawaii Drug Policy Options Group (HDPOG), a towngown organisation whose primary mission has been to bring drug policy debate to the public forum. The reaction to the term 'harm reduction' and the concepts embodied therein have been mixed, with the usual attacks from conservative supporters of the status quo. This article describes our efforts to effect a policy change towards harm reduction in Hawaii by attempting to work from the top down through educating those who influence and make public policy.
As Hawaii has adopted traditionally liberal and humane policies with regard to health care and individual freedoms, we felt that it would be receptive to harm reduction. For example, it is the only state jurisdiction in the US to have mandatory employer-provided health insurance; it was the first state to legalise clean needle exchange and to decriminalise abortion; it is one of the few states without a mandatory motorcycle helmet law; and it may soon legalise same-sex marriages. Hawaii's multi-ethnic population overwhelmingly elects politicians from the liberal Democratic party, which has dominated state politics since statehood in 1959. For these reasons it seemed that Hawaii would be ready in 1996 to embrace the sensible, pragmatic features of harm reduction. But is it?
Although harm reduction principles are fundamental in the state's clean needle exchange programme, the actual term was never used during the development and implementation of it. The term 'harm reduct ion'was first uttered in the public arena in Hawaii by Dr Ethan N adelmann, who was invited by HDPOG to Hawaii shortly after its formation in the spring of 1993, to give a series of presentations on drug policy issues and challenges. The title of one of his talks was'Drug Prohibition: Considering the Alternatives', and it was during this talk about alternatives to prohibition that harm reduction was first presented at a public forum.
The interpretation of this term, at least by some of those in attendance, is best reflected by the article about Dr Nadelmann that appeared on the editorial page of the following Sunday edition of the Honolulu Advertiser, Hawah's'newspaper of record', where the writer stated that 'he [Nadelmann] is in favor of an approach that "decriminalises" personal drug use. It's a concept he calls "harm reduction".' In spite of efforts to correct this misstatement, including a letter to the editor, the association between harm reduction, decriminalisation and legalisation was established, and apparently took root in Hawaii.
During the following year there was a gradual increase in the use of the term, mainly at the monthly meetings of the HDPOG, letters to the editor, and in a chapter (written by the author) that appeared in a book titled The Unfinished Health Agenda: Lessons From Hawaii, published in the summer of 1994. This book was written pritnarityfor policy makers and others concerned with issues of publichealth in Hawaii.
During the spring of 1994, some of the HDPOG members began lobbying key state legislators with the idea of setting up an official taskforce that would study drug policy issues in Hawaii and make recommendations to the legislature for policy changes along the lines offlarm reduction. This perseverance was rewarded with the passage of HCR 88-94, a legislative resolution that called for the establishrnent of the Hawaii Substance Abuse Task Force (SATF), whose mandate was to make recommendations to the legislature regarding 'better ways to deal with Hawaii's drug problems'.
This seemed like the open door through which to move the pragmatic, sensible and appealing concepts of harm reduction for inspection and adoption by Hawaii's premier pot icy-making body. What we didn't realise at the time was that theroad leadingto this door was full of detours, delays and formidable obstacles.
To understand these problems, we need to look first at the bureaucratic structure that wasimposed by the legislative resolution. The legislature mandated the SATF and the format procedure for forming it, which was through the Hawaii Advisory Committee on Drugs and Controlled Substances (HACI3ACS). It is important to understand that HACDACS is advisory to the Governor, who appoints all of the members. However, between the Chairman of HACDACS and the Governor, there is another link, which includes the Director of Health and his appointee, the Director of the Division of Alcohol and Drug Abuse (ADAD). In effect, the bureaucrats were in control from the outset.
However, given that bureaucrats tend to be lazy, the more active members of HDPOG took the initiative by providing names of potential Task Force members to HACDACS, several of which were selected and appointed to the 33 personTask Force. The major restrictive factorwas thatthe languageof HCR 88-94 demanded that specific government agencies be represented, e.g. the State Departments of Health, Corrections, and Public Safety; the Honolulu Police Department; the Prosecuting Attorney, and others. The intent was to have a well-balanced task force, with all perspectives represented. It was this mix of members that proved to be the first obstacle. There were simply too many people with vested interests in maintaining the status quo.
The second obstacle became apparent during the early structuring of the SATF into sub,committees. The intent of the legislative resolution was to evaluate the impact of current drug policies from social, health, economic and law enforcement perspectives. It was anticipated that the subcommittees of the SATF would be established along these lines. Instead, the SATF members elected to establish three sub-committees, and then selfselect for mem, bership. The three sub-committees were Treatment, Prevention and Law Enforcement, representing the major tripartite divisions of US drug policy, and reflecting the inherent divisiveness among them. It was probably this structure that set the tone for the polarisation that was soon to develop among the 33 members of the SATE
The SATF met monthly from September 1994 through to November 1995, with numerous subcommittee meetings during that period. In October 1994, the First Hawaii Harm Reduction Conference was held in Honolulu (which was also the first such conference to be held in the US). All SATF members received a written invitation to the conference. Of the 33 members, only six attended the conference (five of whom were already advocates of harm reduction). Although the conference was welt attended and received extremely positive evaluations from the participants, this effort to promulgate harm reduction thinking among the members of the SATF through a 2-day conference was not very successful.
Even less successful were attempts to inject harm reduction language into the early deliberations of the SATE The first two monthly meetings were largely unfocused, rambling discussions of the intent of the legislative resolution. It was a period of 'sniffing out', or trying to determine the individual hidden agendas. Suspicion of each other and avoidance of any substantive discussion prevailed. The heterogeneity of the group was clearly established, and the lines began to be drawn.
The first major stand-off came while attempting to articulate what the State's goat should be with respect to substance abuse: drug free versus the reduction of harm. It was during this initial debate that the questioning and vilification of harm reduction began to surface. In spite of the recent harm reduction conference, the papers on harm redi-Lction that were distributed to the members of the SATF, and the repeated and various definitions provided by knowledgeable members of the task force, the vocal majority still claimed that (1) the concept was still not clear, or (2) that it was simply a'front for legalisation'. Even a report from the National Institute on Drug Abuse supporting harm reduction, which was distributed to the SATF, did not provide relief.
The resistance to the term'harm reduction'(in all of its permutations) continued during the following monthly meetings of the SATE As late as March 1995, the members were still debating the State's goals and objectives. These debates were supported on both sides by an escalating 'propaganda war' of documents distributed by the Honolulu Police Department, the Department of Health, the Attorney General, the Prosecuting Attorney, and HDPOG. While the SATF members remained polite and courteous to one another in public, the literature being distributed was more than milcUy confrontational, especially that which espoused the official US Government's position (e.g. The Myths of Legalisation, produced by the California Narcotic Officers' Association), which left no room for compromise.
By the time of the May meeting (1995), the time factor became a matter of concern. Six months had passed with little progress on substantive issues, and the date for submission of the recommendations was approaching. Each sub-committee was then assigned the specific task to examine the issue:'What should Hawaii's objective be relative to drugabuse? No use, use reduction, harm reduction, free access.' In addition, the members were directed to draw up a prioritised list ofkey issues. Of the 12 issues ranked by the number of votes, the following was last (receiving only five votes): 'How can we define the philosophical ideas underlying the concept oPharm reduction'?'Obviously, the question was not considered of very high priority.
Two versions of the SATF objectives were finally drafted and voted upon, as follows:
1. Eliminate drug abuse and its adverse effects through continuous reduction efforts. (Fourteen votes in favour.)
2. Reduce and eliminate, if possible, drug abuse and its adverse effects. (Ten votes in favour.)
This is as close to harm reduction as the SATF was ready to venture.
The following month (June) harm reduction got back on the SATF agenda through action taken by the Executive Committee, which reworded the first objective as follows:
The ideal and ultimate goal of the State of Hawaii should be an environment free of drug abuse and its consequences; toward that end we recommend that the immediate objective of the State be to adopt strategies that will reduce drug abuse and its consequences.
This modest proposal, while getting closer to a harm reduction model, was argued to death, with the major split focused on the words 'reduction' versus 'elimination'. This proposal also generated a renewed flurry of the propaganda war, with the Department of Health distributing an article from Alcoholism and Drug Abuse Weekly, whichcontained the following language:
An alliance of strange bedfellows (the drug culture, Libertarians, academics of non-relevant specialities and elitists) has formed and created sophistic theories to convince the public that responsible use/harm reduction /decriminalization/legalization would somehow lessen the effects of drug use on our society. They proffer that law enforcement's role be diminished or eliminated. (1995)
Obviously, harm reduction had its detractors among the SATF membership.
In October 1995, just as the SATF was in the final stages of meetings and deliberations, the Second Hawaii Conference on Harm Reduction was held. Again, invitations were extended to all members of the SATE And again, none but the harm reduction supporters attended, except for two who were coopted into making presentations: the head of the Narcotics and Vice Division, Honolulu Police Department, and the head of the Drug Education Division, State Department of Education. As expected, both of these speakers made clear their negative positions against harm reduction as an approach to substance abuse issues.
The SATF concluded its meetings in November 1995, and produced its report to the legislature. Eighteen recommendations were put to the vote. Fourteen of them were passed, some by the slightest of margin; four of them failed. Did harm reductio~,,i make it into the win column? The answer depends somewhat on how one defines the term.
Although the proponents of harm reductioi.-i were somewhat disappointed over the final recornmendations, we were pleased that at least three of them embraced the tenets of harm reduction. They are as follows:
We recommend that personal drug use, abuse, and addiction be responded to as a health problem., but that drug use or addiction should never be considered an excuse for otherwise separate criminal conduct. (No. 9)
We recommend that every drug abuser who is not yet able to discontinue drug use should receive the help necessary to decrease harmful effects to himor herself or others. (No. 10)
We recommend that the Hawaii State Legislature should urge the President of the United States to establish -a national blue ribbon commission to reexamine the drug problem in the United States, and submit its recommendations to the President, the Congress, and to the people of the United States. (Passed by a one vote margin!) (No. 13)
None of the above recommendations was heard during the 1996 legislative session. (A new and longer mandatory minimum sentence for distribution of crystal methamphetamine was passed with few dissenting votes.)
A separate resolution, introduced by one of the alternate legislative members of the SATF, proposed that the state adopt a policy of harm reduction to guide its overall druigpolicy. It waspassed unanimously by the House Health Committee, but was blocked from further hearings when the Chair of the House judiciary Committee declined to hear it, thereby ending any hope of a shift in the position of the legislature as a whole or any immediate changes in policy.
The SATF experience is now behind us. Did it further the cause of harm reduction in Hawaii? In some small ways, yes. Itmoved the discussion further towards the centre of the public domain. However, like many commissions and blue-ribbon panels before, itfettshort of establishing clearly defined new policy directions. In retrospect we ask, could the outcome have been different? Perhaps so, if we had started off differently.
The first and most serious mistake was in the makeup of the SATE To put it succinctly, there were too many people with a vested interest in maintaining the status quo. In short, theirjobs depend on continuing the War on Drugs. This applies not only to those in law enforcement, but to the specialists in prevention and treatment as welt, for the bulk of their funding comes from the federal government, and their mandate is to support the party tine. As a consequence, there was little interest in accepting, or even discussing proposals for alternatives.
It is unlikely that the SATF report will make a significant impact on policy change in Hawaii in the immediate future. We believe, however, that the seeds of harm reduction have been planted, and are beginning to sprout in Hawaii. With the proper care and nourishment, those seedlings may someday flower.
The responsibility for making that happen can not be left to the policy makers. Rather, it falls upon the working class of harm reduction to initiate and imptement its principles and practices with clients. Sooner or later policy makers may get the picture, and realize the embracing harm reduction will not lead to their political downfall. Before that can happen, a broader base of support must be developed in the general population-the voters. Change in drug policy in Hawaii or anyplace else in the US is not likely to come from the top down. We tried that. Real change can only happen if we start at the bottom and work our way up.
Donald M. Topping,
Social Science Research Institute, University of Hawaii, Honolulu, Hawaii, USA
Alcoholism artd DrugAbuse Weekly, July 24,1995.