The radical roots of harm reduction

I recently (Jan 23, 2025) checked out the Index entries in three very important books for those who would understand the beginnings of harm reduction in North America or, indeed the world. These three books were Maia Szalavitz, Undoing Drugs: The Untold Story of Harm Reduction and the Future of Addiction; Travis Lupick, Fighting for Space: How a Group of Drug Users Transformed One City’s Struggle with Addiction; and Sarah Schulman, Let the Record Show: A Political History of ACT UP New York, 1987-1993. All of these are excellent books—yet none of them includes any entries in their indexes for anarchism, Marxism, radicalism, or socialism. Yet many key figures in the early harm reduction movement in English-speaking North America and, indeed, much of the world, would have described themselves in exactly such terms.

The fact that none of these three books discusses this is symptomatic of the extent to which these forms of politics were stigmatized in much of the Western world in the 1980s and 1990s; the extent to which harm reductionists were forced to masquerade as “just following the science” and as non-political during this period (and since); and the politics within the movement in which access to money and, to some extent, political protection, depended on alliances with public health officials and researchers with deep convictions that they were “objective scientists.”

This gap in the history parallels many similar gaps in which people with left politics, and the contributions of the Left to movements, life, and culture, are erased from the historical record. Alan Wald, for example, has done wonderful work in showing that this was done in the field of American literature. It is also true for many histories of the struggles of workers/labor in the United States, and histories of Black and other antiracism struggles as well.

This article is in many ways a memoir. I was a fairly prominent figure in research on HIV/AIDS among people who inject drugs from early in the AIDS epidemic, a major proponent of the idea that people who use drugs should be a central component of harm reduction, and the lead author of a paper on “Harm reduction—a historical view from the left” that incorporated a plenary speech I gave at the Geneva meeting of the International Harm reduction Conference in 1998. I also took part in many meetings, both informal and formal, around related issues in many cities of the United States, in Canada, in the Netherlands, Britain, and many other locations. I received the top honor of the International Harm Reduction Association, the International Rolleston Award, in 2009. In the course of this work, I met and became deeply friendly with many leaders of harm reduction in many countries.

These conversations and activities led to my knowing the political views of many leading people in the harm reduction field, as well as knowing those of many who were not leaders but who were deeply involved in harm reduction. What I say here is based on that knowledge. In that sense, this paper is a “primary source document” rather than a deeply-footnoted piece of academic writing. This is both its strength and its weakness, since it depends on the fidelity of my memory.

Harm reduction from the beginning was based on three somewhat overlapping groups of people. Most visible were the public health officials and researchers. They also were disproportionately represented in the decision-making and the plenary speaker spots at various harm reduction and needle exchange (as it was then called) conferences. A second group was those who worked in the field, whether for pay or as volunteers. A third group was drug user activists. The beliefs and commitments of the public health officials and researchers tended to differ from those of the other two groups, although, again, there was some overlap. The public health officials and researchers tended to view harm reduction as a set of programs like (again in the language of the times) syringe exchanges and substitution therapy for opioid use. They also tended to place high value on scientific evidence about their efficacy and cost-benefit ratios in helping avoid HIV infections and helping people who use drugs avoid criminal involvement, overdose, or other harms. The frontline workers and drug user activists tended to be more interested in preventing infections, in helping people who use drugs cope with their problems, and less interested in scientific evidence or cost-benefit issues.

They also differed in their politics. A personal/political anecdote will make this clear. The first international harm reduction meeting I attended was in Barcelona in 1991. It was the second such conference. On the last day I was there, the conference had a plenary session that (as I remember it) discussed the state of the harm reduction movement. The presenters were noted researchers and public health officials, and they were expressing the state of the movement in terms of scientific evidence and program effectiveness. The discussion period started out as more of the same. I was able to get recognized to speak from the floor. I suspect that this was facilitated, in a large meeting room with many hands raised, because the people on the rostrum knew my research. I made a simple political point, based on my observations and conversations at the conference and at other meeting and events in the years before: That although the leaders were social democratic and liberal scientists and public health officials, the people “on the floor” of the conference were primarily anarchists and left socialists, and that the health of the harm reduction effort required that this be reflected in leadership and plenary speakers of conferences and other activities. As I remember it, this was greeted from the floor by sustained applause.

By 1991, I already knew a great many frontline workers and drug user activists in the United States, Canada, Western Europe, and Australia, as well as a scattering of people (mainly researchers) from Latin America, Asia, and Africa. We got to know each other at meetings around HIV/AIDS, particularly the International AIDS Conferences where sessions on people who inject drugs tended to be somewhat insular. My close colleague (not at all a leftist), Don Des Jarlais, led efforts to set up an international working group on AIDS among injection drug users, and he and I were leaders in a World Health Organization Global Programme on AIDS research collaboration of research projects in 13 cities (Athens; Bangkok; Berlin; Glasgow; London; Madrid; Naples; New York; Rome; Rio de Janeiro; Santos (Brasil); Sydney; and Toronto). I was a leader of a National Institute on Drug Abuse set of 61 research projects. In addition, starting in 1986, I had worked closely with drug user activists in the Netherlands, other European countries, North America, and Australia, and knew many of their leaders very well. Within the United States, I also was attending meetings of the North American Syringe Exchange Network, which were gatherings of the cutting edge of harm reduction in the Americas. My revolutionary socialist stance was pretty evident to many of these people, and I almost never got and pushback on it, although I did have many political discussions around drug and HIV policy and broader issues.

Based on these experiences, I knew that much of the harm reduction movement was radical, socialist, anarchist, and/or Marxist. I might add that by and large we worked very well with public health officials and researchers with more mainstream politics. We were united by the agreed-upon need to further harm reduction and public health.

Dave Purchase was a major leader of harm reduction internationally as well as in the United States. He had started the first open needle exchange in the U.S. in Tacoma, Washington, in the late 1980s. Later, he started and led the North American Syringe Exchange Network (NASEN), which was fundamental in cohering and coordinating the development of exchanges in North America well into the 2000s. Dave and I became good friends, and often discussed the similarities between his anarchist beliefs and my Marxist ones.

The keynote speaker at the First North American Syringe Exchange Convention in Tacoma in 1990 was Nick Crofts, an Australian researcher who happened to be in the U.S. at that time. Nick gave what was in many ways a socialist speech there. He and I became fast friends and worked on many projects over the years. Later, he spent many years as Editor of the Harm Reduction Journal. One of our joint projects was an explicitly left-wing paper based on a plenary talk I gave to the 1999 Geneva Harm Reduction Conference—”Harm reduction—a historical view from the left”.

Other authors on this paper were of course on the Left. Mat Southwell was a drug user activist with a history of involvement in Marxist struggles against fascists in the streets of Britain. He has been a leader of the drug user activist movement in the British Isles and the world and within it was an openly Marxist voice. Jude Byrne was perhaps the preeminent leader of the drug users’ movement globally, and also a Marxist. Regina Bueno was an organizer and researcher on harm reduction in Brasil and openly on the Left. Denise Paone at that time was a researcher in New York and also on the Left.

Many people trace the rise of harm reduction internationally to two sources. One was the Netherlands, where many drug policy experts, drug user activists, and community groups were striving for the normalization of drug use and drug users. In Amsterdam, this led to the formation of the first syringe exchanges and mobile vans to make methadone readily available to people who used opioids. In Rotterdam, this movement was led by drug users organized in the first junkiebond. They conducted public protests, set up underground methadone distribution, and led local syringe exchange efforts. Their initiator, Nico Adriaans, was a Marxist who worked in organizing these efforts with friends who had also gone through Dutch fosterage systems as they grew up.

The second source was leftists from Liverpool, England, including Pat O’Hare who later led the International Harm Reduction for many years. Interestingly, they ran into opposition from the Militant Tendency Marxists on the Liverpool city council, who saw methadone and similar efforts as numbing “the revolutionary fervor of young people” (personal communication, Patrick O’Hare, January 24, 2025). This is particularly interesting because people who were in the International Marxist Tendency (co-thinkers with the Militant tendency) later became major leaders and organizers in South African AIDS efforts, including the Treatment Action Campaign there.

Efforts by activists to set up syringe exchanges in New York City provide more context for understanding the roots of harm reduction. The initial effort was led by Yolanda Serrano, the director of ADAPT (Association for Drug Abuse Prevention and Treatment). Yolanda had been a member of the Young Lords, a socialist revolutionary organization of Puerto Ricans, when she was younger. Although she and I never explicitly discussed her politics in the 1980s when I worked fairly closely with her on HIV prevention issues, she remained quite radical. After this effort failed to establish syringe exchange programs, other groups and people got involved in “underground” exchanges. Probably the two main groups were members of ACT UP and people who worked at National Development and Research Institutes (NDRI) on research and intervention projects that I led. I cannot speak with authority about those from ACT UP, though they were pretty radical. Among NDRI employers, Joyce Rivera, who established the syringe exchange at St. Ann’s Corner in the Bronx, was Marxist. Ric Curtis, who was involved in syringe exchange in Brooklyn, was perhaps somewhat more anarchist than socialist. Bruce Stepherson was a radical but we never discussed his views in any depth.

Efforts to organize a North American drug users’ movement in the 1990s were energized in part by Jon Paul Hammond, a Black queer harm reductionist with anarchist politics. He was also the founder of Prevention Point in Philadelphia in 1991.

One question that is hard to answer is why so many radicals got involved in harm reduction activities from early on. One reason, perhaps, is that harm reduction was a response to the HIV epidemic and other problems that began to become salient in the late 1970s and early 1980s, a period in which the radical movements of the preceding twenty years were ebbing. This meant that there were a lot of socialists and anarchists of various backgrounds who were less involved in politics than they had been. Many had learned organizing and analytic lessons from the prior years, and a great many of them cared deeply about other people and had experience working with poor or homeless people. Some of them also had histories of drug use. They also were quite willing and able to engage in activities that might be controversial and/or stigmatized, and willing to defy unjust laws in localities that tried to criminalize syringe exchange. A few of them may have thought that harm reduction activities might help spark a new radicalization with some political weight, but the belief systems that would support this perspective were far more popular in the late 1960s and early 1970s than they were when harm reduction got started, at least in the United States.

Although I could list many more radicals in the early years of harm reduction in the United States and internationally, this would be overkill. The point is that harm reduction was organized and conceptualized by a friendly alliance of scientists, public health officials, and radicals, including many Marxists and anarchists. Many histories, whether out of ignorance, or out of a desire to protect harm reduction from red-baiting, or out of a quest for respectability, have elided this reality. But for those of us on the Left, we should point to harm reduction as one of our (co)- creations.

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