Cover story
Agents of
We urgently need to
become activists once
more, argues Nick Wilson
in his contribution to
The Vision Project
The UK’s well-deserved reputation for developing gold standard harm reduction
services was the envy of many countries around the world. From modest
beginnings in the 1980s and an extraordinarily passionate and committed harm
reduction community, was crafted the level of activism which ultimately brought
harm reduction into the UK’s healthcare mainstream.
Credit must also be given to the UK government who at this time, and faced
with the emerging ‘AIDS epidemic’, committed protected funding to support the
growth and roll out of harm reduction services, most notably the provision of
needles and syringes for people who inject drugs. Rates of HIV in the UK today
(about 1 per cent of people who inject drugs) are among the lowest in the world
and testament to this partnership of activism and political pragmatism.
From the late ’80s the UK began to refine effective skills around engagement
and interventions to reduce harm among people who inject drugs. The four
cornerstones of harm reduction – needle and syringe provision, substitution therapy
and methadone, treatment for hepatitis C and HIV and the prevention and reversal
of overdose – established our role as agents of behaviour change within this
inclusive, non-judgemental, low-threshold environment.
We have been effective at reducing the risks associated with injecting drug use
and developing initiatives which deliver some of the most cost-effective health
interventions of any kind. It is estimated that for every £1 spent on harm reduction,
£4 is delivered in return in health and social gain. This was achieved by tenacity,
commitment, compassion and years of activism at a time when our communities
would rather see people who inject drugs locked up rather than understood, treated
and supported.
However, despite achieving the inclusion of harm reduction within mainstream
healthcare, the attitudes of the public have not changed towards people who inject
drugs. Look beneath the thin veneer of acceptability for harm reduction in our
communities and there remain the same pernicious and ignorant views about drug
use which are ill-informed but ensure that people who use drugs remain some of
the most marginalised in our society.
This is due in part to the UK government’s insistence that drugs and drug use
remain illegal and the fear and ignorance within our society that leads many to
believe people who use drugs should be locked up rather than helped. Society does
not see them as worthy of compassion and healthcare and resents ‘their taxes being
spent’ on injecting equipment and treatment. It’s also due to the failure of a truly
representative and sustainable model of a service user involvement movement, which
would have helped ensure service users’ views and rights were central to the planning,
funding and commissioning process at both the political and service delivery level.
A PERFECT STORM
Sadly, since 2010, England has systematically disinvested in harm reduction. The
political firestorm debate of 2008 saw the abstinence model of intervention win out
over harm reduction, and the government’s new drug policy in 2010 saw a political
6 | drinkanddrugsnews | September 2019
shift away from harm reduction. This occurred at the
same time as a move in the commissioning
responsibility for drug services from the then
primary care trusts to local authorities, just as the
authorities ran out of money. The ring-fencing of
funding for HIV, which supported drug services,
disappeared and harm reduction had to start
competing for funding against a range of other
worthy causes within public health.
There is no doubt that many people have
benefited beyond their hopes from the opportunities
delivered by the recovery model, but many people
who use drugs are so much worse off. In the UK we
are experiencing an increase in homelessness, and
drug-related deaths are higher than they have ever
been. We have now also had the worst HIV outbreak
in 30 years, a fact which outside of Scotland hardly
anyone knows or talks about.
DIMINISHED SERVICE
Many harm reduction services that traditionally provided a front door into treatment
services and, no less importantly, a safety net for people who couldn’t manage the
treatment options on offer, now provide little more than the distribution of injecting
equipment. The systematic disinvestment in harm reduction in England has left many
people alone, isolated and vulnerable, without skilled harm reduction workers to do
what they always have: engage, support and save lives.
A recent exchange on social media quoted a triage discussion with a new client
registering at a needle and syringe programme provided by a large national charity:
‘Whilst going through the triage paperwork to register he was asked his preference
regarding administration of substances. He told the worker he was an IV user. The
worker didn’t know what that was, so he expanded saying he was an intravenous
user. The worker still didn’t know what that meant.’
Does this represent what happens in most drug services? Of course not, but it
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