Guest Editorial: A Necessary Distinction

Harm reduction is under siege. Just over a year ago, the President issued the executive order, "Ending Crime and Disorder on America's Streets," in which he asserted that "so-called 'harm reduction'" merely facilitates illegal drug use. In August, SAMHSA released a "Best Practices Toolkit: Addressing Homelessness and Addiction through 'Treatment First'" that contains no mention of harm reduction, effectively erasing it from the recommended continuum of care. Last month, The Atlantic published a widely circulated article about the "montage of human despair" caused by harm reduction efforts among the unsheltered homeless in "The Cities That Said Yes to Drugs."

It is nothing new for harm reduction efforts to meet resistance, despite robust evidence of their effectiveness. But the current backlash is, I think, different. The executive order, the Atlantic article, and the erasure of harm reduction language from SAMHSA's toolkit all take as their point of departure the spread of unsheltered homelessness in US cities; they conflate harm reduction with perceived support for large homeless encampments and suggest that problems associated with those encampments demonstrate the failure of harm reduction itself.

I believe that conflation is a mistake, and a consequential one, as federal support for harm reduction efforts has become increasingly restricted. Unfortunately, I think harm reduction advocates, myself included, bear some responsibility for it. Through well-meaning efforts to mitigate the forces that produce encampments—lack of housing, inaccessible health care, untreated mental illness, trauma, the arrival of fentanyl, and a profound shortage of compassion—we have often appeared to endorse an untenable status quo for cities and for the people living unsheltered within them.

Acknowledging this does not obscure the fact that bringing harm reduction services into encampments makes sense; sterile syringes, naloxone, wound care, and other health services are delivered directly to people who may otherwise be difficult to reach. But some advocates have gone further, suggesting that encampments themselves reduce drug-related harm. The proposed mechanisms are plausible: encampments may reduce isolation, allow residents to watch over one another and reverse overdoses, and give health workers a stable location for outreach.

However, the evidence isn't there. Qualitative studies do describe mutual aid and protective social networks within encampments. Yet, there is little direct evidence that encampments themselves produce a net reduction in overdose, infection, drug use, or mortality. Rather, people experiencing unsheltered homelessness suffer extraordinarily high rates of illness, violence, and premature death, while facing formidable barriers to health care. A potentially protective feature within a dangerous environment does not make the environment, taken as a whole, a harm reduction intervention. Where benefits arise from naloxone, sanitation, security, peer support, or clinical outreach, we should credit those specific interventions—not the encampments.

This is not an argument for encampment sweeps. Dispersing encampments without offering acceptable housing or shelter may cause tremendous harm. Displacement separates people from outreach workers and social networks, interrupts medical and addiction treatment, and results in the loss of naloxone, medications, identification, and other essential belongings. Modeling studies project that continual displacement increases overdoses, hospitalizations, and injection-related infections while reducing initiation of medications for opioid use disorder.

However, evidence that encampment sweeps are harmful is sometimes treated as evidence that encampments themselves reduce harm. It is not. It is evidence that destabilizing people without offering somewhere safer to go—and without ultimately changing the conditions that lead to encampments—can make an already dangerous situation worse.

And just as cities have been justifiably criticized for pouring resources into dispersals rather than into solutions that include housing, health care, addiction, and mental health treatment, a singular focus on preventing dispersals runs a similar risk. Both destroying encampments and protesting their destruction are easier—and perhaps more immediately satisfying—than the hard, sometimes enraging, often boring work of collaborating and creating durable alternatives, often in necessary partnership with people with whom we disagree.

Depending on the speaker, harm reduction may refer to a selection of interventions, an empirical claim, or even a political philosophy. But the element binding these meanings together must be a demonstrable reduction of specific harms. Otherwise, the concept loses credibility, and the consequences go well beyond presidential insults or exclusion from a toolkit. The real consequences of decreased support for harm reduction will be borne by people who use drugs who will likely suffer and die without it.