Do no harm. (Spencer Platt/Getty Images)

June 28, 2022   7 mins

It seems that every large city in America has marked off a neighbourhood where drug addicts are free to die in the streets. San Francisco’s Tenderloin district, downtown Portland, Skid Row in Los Angeles, Hunts Point in New York, Kensington in Philadelphia: These are places where, by unspoken agreement between society and its outcasts, the normal rules cease to apply and the bodies are collected.

Where it’s warm enough, people sleep in tents or on the streets. Drugs and sex are openly sold and laws are enforced erratically. The result, which I observed during a 2019 trip to Skid Row, was a “hellish concentration of deprivation and disorder”, interspersed with a concentrated complex of non-profit and social service organisations.

What was already hellish was made even worse in recent years by the rapid spread of fentanyl, a synthetic opioid some 50 times more potent than heroin. Driven largely by fentanyl, which is now used to cut virtually every other drug, overdoses set a new record in the US in 2021, killing nearly 108,000 people. Up roughly 15% over 2020’s record death toll, overdoses killed more people last year than guns and cars combined. In San Francisco, an average of 53 people died every month from overdoses last year, many of them “outdoors and on sidewalks in front of buildings”.

Before the fentanyl spike, overdoses had been rising in the US for the past two decades while raising little public alarm. But now, with the scale of deaths being declared an emergency and health epidemic, public officials are embracing supposedly radical new solutions to the problem, the most popular of which is harm reduction.

Harm reduction promises reasonableness. Rather than trying to eradicate drug use, the public-health framework, which has been embraced by the White House and cities across America, works to reduce risks by prioritising the safety of individuals over curing social ills. The point is to “meet people where they are”, according to advocates, not to change them. Its appeal is that it is humane and takes the opposite approach of the failed war on drugs. But that’s only part of the story.

Look through the harm-reduction telescope and you glimpse the grand project of the therapeutic society that animates modern progressivism. At one end the individual is seen in minimalist terms, powerless to control their own desires, a victim of systemic forces far beyond their ability to resist. Look through the other end, and you find a maximalist view of the state in which a vast apparatus of administrators surveil and treat citizen-patients based on vague definitions of “wellness” and “harm”.

Look back in time, and the rise of harm reduction from the work of devoted activists to the official policy of the federal government traces a larger transformation in American politics. It is a project, in short, of the same political forces who want to defund the police, while empowering a surveillance and enforcement regime that punishes people for making sexist Facebook comments.

While harm reduction has been an official policy for decades in a number of European countries, its expansion in the US, where it began as a grassroots movement during the AIDS crisis in the Eighties, is a more recent phenomenon. San Francisco was an early adopter. In 2000, the city’s Health Commission unanimously voted to adopt a harm reduction policy for drug offences. The city effectively decriminalised drug use while at the same time shifting public funding away from enforcement and toward providing clean needles, distributing the drug naloxone, which can reverse opioid overdoses, and offering methadone and other drug treatment plans. In 2020, San Francisco led the country in overdose deaths.

Last year, New York City allowed the opening of two “safe injection sites”, a term for facilities where drug users can consume their wares under the supervision of a mix of medical professionals and former addicts who can intervene and revive them if they overdose. The clinics have intervened in more than 300 potentially fatal overdoses since they opened, according to staffers. Despite the sites being illegal under federal law, city officials have allowed them to operate without interference, setting a precedent for other cities to follow.

New York’s experiment follows the three-decade harm reduction trial in Canada, which includes the establishment in 2003 of the Insite safe injection facility in Vancouver. While advocates point to the number of overdoses averted and reversed at these facilities, it’s possible that the policy led to more overall use, potentially contributing to more overdoses outside the clinics than lives saved within it. In British Columbia overdose deaths were up 151% between 2008 and 2020, with much of the increase coming from Vancouver. In Oregon, another place where hard drugs were decriminalised in 2020, overdose deaths were up 41%, in 2021 from 2020, compared to a 16% increase nationwide.

Some harm reduction programs such as needle exchanges, fentanyl testing strips, and free testing kits for HIV, appear to have been broadly beneficial. But in the absence of a commitment to the full recovery of individuals, harm reduction morphs into a permanent method of managing chronic drug addiction by expanding the nonprofit-bureaucratic sector. Administrators count lives saved and ODs reversed without registering the broader increase in addiction they help to accommodate. Success is measured not by freeing individuals from addiction so they can live full lives, but by the growth of the treatment bureaucracy.

General Jeff, a black community activist who has lived in Skid Row for a decade described a similar dynamic in the approach to homelessness when I spoke with him a few years ago. “There’s never been a shortage of funding in modern-day Skid Row,” Jeff told me, blasting the area’s nonprofits as “poverty pimps”. “This isn’t really about trying to end homelessness. That’s just a marketing campaign. Just to make people outside of Skid Row feel good.”

“Bureaucracy,” wrote Christopher Lasch in The Culture of Narcissism, “transforms collective grievances into personal problems amenable to therapeutic intervention.” Lasch does not pretend that individual moral accountability is sufficient to redress collective grievances or systemic injustices, but nor does he attempt to dismiss it as an anachronism. Morality grounds the sense of dignity and self-worth that provide us with our best internal defence against the unavoidable calamities of fortune. It is not a replacement but a precondition for a meaningful politics of collective action. The transformation observed by Lasch has repurposed the minimalist ”do no harm” ethos as a maximalist licence to redesign society.

“Harm reduction was never just about the drugs or the deaths or the diseases,” wrote Daniel Raymond, a policy and planning leader at the Harm Reduction Coalition, in a March 2020 essay on Harm Reduction in the Time of the Coronavirus. Rather, writes Raymond in the morally inflationary language used by activists staking out a claim to administrative power, harm reduction “is heir to the multiple legacies of the communities and struggles we come from… the hybrid wisdom that emerges from communal survival in the face of threats of being dispossessed, disenfranchised, displaced, disappeared”.

Because harm can be found anywhere, harm reduction now appears everywhere. The framework is applied to criminal justice, diet and exercise, prostitution, curbing adults’ sexual attraction to minors — otherwise known as paedophilia — and a range of other seemingly unrelated fields. “Harm reduction, as a framework, acknowledges that white supremacy, patriarchy, classism, fatmisia, transmisia, ableism, xenophobia, and myriad other systems of oppression infuse space and structures and are a part of our socialisation,” wrote the authors of an academic journal article on Observing Whiteness in Introductory Physics in March.

The essential alchemy of progressivism is performed by converting drug addiction from a vice afflicting individuals, which they have the power to change, into the basis of an identity group with a claim to government services. The collective grievances relating to the social and economic policies that might have pushed hundreds of thousands of people into drug dependency are first privatised through addiction and then bureaucratised so they can be managed by a class of appointed supervisors. In turn, the power of the bureaucracy is redirected from enforcing behavioural norms to overseeing the consequences of their dismantling.

This transformation is consummated with a novel language that marks the new political identity within the lexicon of professional progressivism. “Following the lead of those in harm-reduction and drug-users’ rights groups, I decide to scrub the word addict from my vocabulary,” wrote Sarah Resnick in a piece featured in ​​The Best American Essays 2017 anthology. As alternatives to “addict”, Resnick finds: “person with a substance-misuse disorder”; “person experiencing a drug problem”; “person who uses drugs habitually”; and “person committed to drug use”.

The stiltedness of the language would be a small price to pay if harm reduction policies reduced drug dependency but since it’s not clear that’s the case, the effort turns on trying to alter language and perception. “Don’t be ashamed you are using, be empowered that you are using safely,” declared a poster by the New York City Health Department that recently appeared in the subway system. “Shame is a useless emotion that often keeps ppl from investing in themselves or others. We should be celebrating ppl who are taking the steps in this poster,” tweeted Kassandra Frederique, the executive director of the Drug Policy Alliance, one of the leading drug policy reform organisations in the US. Frederique’s statement was retweeted by a spokesman for the New York City Department of Health.

Instead of fostering the behaviour necessary to give someone a genuine sense of self-worth — a project that may well be beyond the power of anyone but the individual and their maker — harm reduction converts the bare physicality of “safety” into the cheap currency of empowerment. The message presumes that addicts would not and should not feel shame for their dependency absent external judgements. It minimises the ravages attendant to drug addiction — such as criminality, homelessness, despair and decay — by framing them as the consequences of “unsafe” practices, without any connection to the spiritual poverty of dependency. In the religious and humanistic view, shame is the voice of the individual’s conscience. Others may seek to shame us, but true shame arises only when the individual has transgressed against their own innate sense of decency. But the conscience has no place in the maximalist world view of the harm reductionists, except as a relic of the retrograde morality that prevents addicts from experiencing empowerment.

At what end is the policy of harm reduction aimed? The war on drug’s promised end point was, obviously, unreachable, but the harm-reduction crusade has no ending at all except the construction of a new system of power, no less punitive than the one it seeks to replace.

Many people seem to have accepted that harm reduction efforts are a temporary life-saving measure — a way of buying time for people caught in a cycle of addiction while moving them gently toward recovery. But it’s by no means clear that people doing harm reduction work all see it this way. Some are explicit about the fact that they see nothing wrong with hard drug use and and view attempts to force people into recovery as puritanical efforts to stamp out pleasure.

Others genuinely want to help drug users and other people in high-risk lifestyles by keeping them alive and guiding them toward lives free from addiction. But even those efforts are bound up in the expansionist project to “treat” an endless and ever expanding litany of harms by means of a bureaucracy in which being exposed to racism and being addicted to drugs are understood as two expressions of the same oppressive system. “Harm reduction is friends; the law is cops,” wrote one devoted adherent to the practice in a 2019 essay about sex work.

In 2022, the White House National Drug Control Strategy devoted a full chapter to harm reduction. Which is to say that, whatever its beginnings, harm reduction is now the self-talk of the state bureaucracy, not only the law but its spirit.

Jacob Siegel is Senior Writer at Tablet Magazine