Last year, more than 100,000 people in the United States died of a drug overdose. While overdose deaths slowed, plateaued and even declined in some groups, Black Americans and other communities of color were hit especially hard. In an effort to combat the persistent crisis, last Spring, the Biden administration announced that it would allocate an unprecedented $30-million toward harm reduction. With more than three decades of research behind it, harm reduction—a practical, judgment-free approach that helps people mitigate the risks associated with certain behaviors, from sex to substance use—has been repeatedly proven to save lives and improve well-being. For example, syringe services programs have been shown to reduce HIV and hepatitis C incidence by 50 percent, and many also distribute life-saving overdose reversal medications, provide drug checking kits and connect clients with resources for housing, treatment, employment and more.

Historically, harm reduction has been a community-driven effort, but the most visible programs and organizations have been largely led by white voices and white priorities. Thus, as national support for this evidence-based approach expands, so must its ability to serve those who are at the greatest risk. Organizations like the National Harm Reduction Coalition are helping ensure that harm reduction actively represents and serves the communities who need it most. We talked to Interim Executive Director Anthony Salandy, PhD, MSc, about harm reduction and the importance of BIPOC representation, voices and action—in the past and present.

What is harm reduction?

Dr. Salandy: National Harm Reduction Coalition defines harm reduction as a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Harm reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. In addition, it incorporates a spectrum of strategies that includes safer use; managed use; abstinence; meeting people who use drugs “where they’re at;” and addressing conditions of use along with the use itself. Because harm reduction demands that interventions and policies designed to serve people who use drugs reflect specific individual and community needs, there is no universal definition of or formula for implementing harm reduction.

Some talk about harm reduction from a generalist perspective. For instance, everyone uses harm reduction decision making in their daily lives—a lot. As a result, the harm reduction movement is struggling with the very question: is harm reduction specifically centered on drug use, or can it be focused on other at-risk behaviors such at sexual risk, alcohol use, etc.? Or, more broadly, how can we adhere to and sometimes introduce harm reduction principles into our daily thinking or our philosophy? And I will tell you that the principles of harm reduction, of meeting people where they are, of treating people with respect, of being non-judgmental, those are principles that should be part of any kind of public health approach, and of providing health and human services. That should be part of the way that we, as a people, interact with the public and each other.

The harm reduction movement is at a crossroads. There is a liberatory movement that really focuses on the social justice aspect of drug use and the harm caused by racialized and failed drug policies. This perspective has an abolitionist movement and takes root in past social justice movement like civil and women’s rights movements. And then there’s the public health perspective. That primarily focuses on improving health outcomes as a result of drug use. One could argue that the middle ground could focus on more upstream predictors of one’s decision to initiate drug use. For instance, we can focus on trauma experienced as a result of childhood physical and sexual abuse and neglect. We can focus on predictors of Intimate Partner Violence, racism, housing discrimination, underemployment, the impact of daily micro-aggressions, and lack of access to affordable quality healthcare.

Public health hasn’t always had the public in mind with their interventions and strategies, especially for Black and Brown communities. So, there is sort of discomfort and sometimes mistrust of the public healthcare system. It is upon the public healthcare system to engage the public, lift their voices, meet them where they are, be non-judgmental, treat them with respect, use their language and know that they are experts in what they and their community needs. These activities sound familiar. They are the principles and the bedrock of harm reduction.

What do you want people to know about harm reduction?

Dr. Salandy: It’s simple to me. People who use drugs are your neighbors. They can be people teaching your kids. They are your constituents. They are business owners. They attend church with your family, sitting next to you in the pew, praying to the same God that you do. They’re in your synagogues and mosques. They are people who make up vibrant communities. They are your dads, your moms, your kids, your loved ones. That’s what I’d like people to know. They are people who can’t be easily discarded. No one should be turned away from humanity.

When I talk to people and they say “those people,” they’re not “those,” they’re not “others.” We all share human rights! We should all be asking ourselves: “How should I engage in my community? Can I do more for my neighbor? How can I help individuals who are struggling?”

Can you talk about the historic role of harm reduction in Black and Brown communities?

Dr. Salandy: So, in the ‘60s and ‘70s when harm reduction came to the United States, it was predominantly Black and Brown people who were disproportionately impacted compared to white folks that used heroin. The ‘War on Drugs’ impacted primarily Black and Brown communities. Institutional racism continued to severely hinder the vitality of these communities. The voices of community-based organizations spoke loudly about the lack of access to services and took collective action to provide resources to our communities. To be clear, this was a continuation of efforts dating back to when Black and Brown folks were brought to this land against their will. But collective groups like the Young Lords, the Black Panthers—organizations not just in California, but New York and elsewhere—started their own community-based organizations. They operated food pantries, gave out clothing, operated afterschool programs for kids and provided resources to those who had problematic substance use. They advocated with city council members to try to get ordinances passed. So, regardless of what the public health and human services systems were doing, in terms of increasing access, the community came together and organically started those types of services. But, importantly, they also addressed some of the upstream issues that oftentimes lead to problematic substance use.

I spent my adolescent years growing up in New York, and before gentrification hit the south Bronx and Harlem, there was tremendous problematic substance use in those areas. And it wasn’t just in NYC, it was in all of the larger cities in the United States. The introduction of crack cocaine and racialized drug policies decimated Black and Brown communities. And the public health system’s “Just Say No” anti-drug campaign was a collective failure! Furthermore, the enormous amount of prescription opioids manufactured and given by providers was another public health failure, and subsequent policies that shut off that pipeline was amazingly bad policy. White communities who had access to providers who were prescribing these pills now all of a sudden had to go elsewhere. And the underground street and online drug markets filled the void.

You had a lot of individuals who were probably once on prescription opioids, now not being able to access it from their providers, took to the streets to get their drugs. White folks were using and dying in large numbers—not just in large cities but in rural America and now it has become “an opioid epidemic.” Trace the coining of the term in mainstream public health. The term first started getting used in the late 1990s during the first wave of opioid overdose deaths, when prescription opioid overdose deaths started hitting mainstream America. Now the voices of white America grew louder and louder especially in the harm reduction community. Black and Brown people were saying that this has always been an issue in our community, but now all of a sudden, there’s a plethora of money in harm reduction services.

Quite frankly some of the wrong people are doing harm by claiming to do harm reduction. Harm reduction is more than just giving Narcan [an overdose reversal medication] and clean syringes. Harm reduction is about radical love regardless of what you choose to do with your body.

Why is it so important to center BIPOC voices?

Dr. Salandy: Voice is power. And Black, Brown and Indigenous folks have limited power in this country. It’s important to be in the room when it happens, because you will be representing your interests and the interests of your community. I am a Black man with a PhD who’s been in academe, worked in the federal and state government, in international organizations around the world, in philanthropy, and I will tell you that I’m often one of very few BIPOC individuals at the table if not the only one, and it’s very rare that Black and Brown folks’ interest are brought up when discussing policy. When you talk about centering Black and Brown folks, you’re talking about centering their experiences, their unique experiences… What you’re centering is a unique group of people with unique cultures, unique languages, unique music and a unique history with equally unique needs and strengths.

The vast majority of SSPs (syringe services programs) in the United States are led by white men and women. We did a rolling point-in-time survey in California with about 40 SSPs and we asked individuals at the SSPs to complete a survey—about 500 persons who use drugs completed the survey—and what we found was when we asked Black folks who used drugs, where do they get their clean needles, there was a difference between Black and white folks. Black folks didn’t use the SSPs as much as white folks did. Which led us to ask the question, why? Is it because they don’t want to be walking around with clean needles in case they get stopped by the police? Or is it because the “harm reduction” principles may not be equally applied across SSPs? People across the harm reduction landscape may not be fully following those principles when it comes to Black folks coming into their service program? We don’t know the reason why, but NHRC is making concerted efforts around training and working with their grantees around centering the experiences of Black, Brown and Indigenous folks, and making sure that they are keenly aware of their own biases and that those biases are not negatively impacting who comes to receive services. Because it would be a shame if the harm reduction movement is only effective for white folks who use drugs but not Black folks who use drugs. That would be a terrible thing!

We just have to understand from Black and Brown folks, is there a reluctance to access SSPs in your community? How can we make HR spaces more inclusive? How do you work with law enforcement to not target Black and Brown folks for having drug wares? Or how do you work with secondary sources to make sure that they have the tools and agency to do peer outreach in the community?

It goes back to what I said earlier, to centering Black and Brown voices who can help inform policies. They know what services they need and how they feel comfortable getting them. The onus is on me in the harm reduction community to get people the services they need how they need them. That requires us to listen and act and listen again. My background is in HIV, and when ARTs (antiretroviral therapies) were developed, some HIV+ individuals were in remote places couldn’t get these lifesaving medications. They couldn’t get to the providers, clinics and hospitals. So public health officials developed community health workers system—that didn’t require medical training—and trained them. They didn’t need to have a degree, we just trained folks who were interested in making a difference and addressing a need. And that’s what we need to be doing with people who use drugs, is actually sending willing people out to meet people where they’re at.

Last thoughts

Dr. Salandy: Harm reduction is a big tent. There are a lot of people under that tent, and we all have to work together towards shared goals and objectives. And one of those big goals is zero overdose deaths. We don’t have to have anyone die because of drug use. We have the tools to prevent it. We have to work towards zero infections of HIV and Hep C because of unclean needles and improper smoking tools. How do we prevent and treat experienced trauma as a result of abuse and neglect and the corresponding links to problematic substance use? And how do we love each other? How do we love our fellow neighbors?

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