Through The Lens of Harm Reduction

The last two months I’ve been fortunate to have been given the opportunity to see the world through new eyes – through the eyes of former and current IV drug users and their community. Their professional framework is harm reduction; a distinctively different lens than Free To Grow, whose focus was less on the user, and more on the impact of use and abuse on families and communities. While Free To Grow’s work certainly included strategies to provide support to those experiencing the negative consequences of addiction, its bias was undeniably towards abstinence, at least in the case of drugs. After all, as many in the community reminded us, the sub-title was, “Head Start Partnerships to Promote Substance-free Communities.”

The community in which I have been living would argue that use, whether it be alcohol or drugs, has been part of society since its beginnings, and that abstinence is an unrealistic, and not necessarily legitimate goal. That people can make informed choices about their use, and should be encouraged to use in a way that doesn’t harm themselves or others. That the line between legal and illegal drugs is often fuzzy and arbitrary – that marijuana is no more dangerous used in moderation than alcohol or legal amphetamines and anti-depressants. That drugs like opium, heroin and cocaine have historically been used responsibly, and, like alcohol, are only problematic when misused or abused – and subsequently bring harm to individuals, their families and their communities.

As a field, harm reduction is committed to putting in place strategies that are open and accepting of all persons – that don’t demonize or stigmatize people for their drug use, and meet people where they are. In a world where the transmission of HIV through infected needles is one of the most significant sources of new HIV cases and AIDS deaths, it’s easy to feel the discrimination and punitive nature of policies that don’t permit clean needle exchanges. People shouldn’t die just because they’re drug users. We don’t put policies in place that are life-threatening to people who smoke or drink to excess. Yes, these behaviors are legal. But the fact that prostitution is illegal in Thailand didn’t stop the government from launching a broad-based pragmatic condom distribution campaign for sex workers, reducing the prevalence of HIV in sex workers and their partners dramatically. (Of course, the cynical take on the decision to distribute condoms to sex workers could argue that the government was worried less about the sex workers than their clients, who represented all walks of Thai society, to say nothing of the Western men who have for years flocked to Thailand to find the girls of their dreams.)

Some aspects of harm reduction have been easy to embrace: that all people deserve to be treated with respect, that all deserve equal access to preventative measures that can reduce the harm of their risky behaviors, and all should have equal access to ARV and other health treatments if they are sick. It’s easy to see a world that is filled with double standards regarding use and abuse, with wealthy people able to check themselves in to Betty Ford if their use becomes out of control, while poor people more likely to land in jail, without access to humane treatment options. Harm reduction, at its core, demands equity.

Yet, the little time I’ve spent in the harm reduction world has also raised many questions for me. How much use is too much? And who decides? If it is up to the individual, how does one deal with the denial that is often part of addiction? These are not only my questions, but questions that come up day after day in my work here. If an organization is committed to hiring former and current IV drug users, what happens when people begin coming to work too high to function? What is the appropriate intervention? And what of the impact on families and communities, particularly of drugs like methamphetamine or yabaa (or “crazy drug”, as it is called here) which destroy brain cells and increase violent behavior? How effectively does the harm reduction community speak to the crime that is sometimes related to securing money to purchase drugs?

These are not easy questions, and I have engaged in many discussions with those with much greater expertise and background in the approach than me. They, too, acknowledge the complex nature of the issues – that accountability and responsibility are just as much a part of the equation as compassion and acceptance. There is a danger of romanticizing “responsible use”, and turning away from some of the more difficult consequences of any life that includes a reliance on intoxicants – legal or otherwise. But it is a complexity that is, I think, too often neglected, and whose perspective brings a more nuanced framework that could bring greater honesty to our broader prevention work on the ground.

Songkran: The New Year Thai Style

We have been drenched for four days now. It is Songkran, the Water Festival, the lunar New Year in Thailand. We are in Northern Thailand in Chiang Mai, where the Water Festival originated – and it is celebrated with abandon here. A walled city, with moats on all sides, one cannot walk ten feet in the Central city without being “blessed” with water. Young children and their parents line the streets with buckets and water guns, pouring water over the shoulders of passers-by wishing them well in the New Year. We have taken to returning the gesture – reaching into young children’s buckets and sprinkling water on their shoulders, as we say, Sawasdee bee mai kah! (Happy New Year!) The children giggle, their elders smile, and bless us, clearly happy that we understand that the water is meant to be more than just an opportunity to get cool in the hot season.

Teenagers and young adults get a little more exuberant (fueled by much drinking and merry-making), turning hoses on people, and splashing one another from the backs of pick-up trucks armed with trash cans filled with water. Go-go girls dance on stage platforms, showering the crowds below while rock and roll blares on the streets. Young farang (Westerners) have embraced this rowdier side of Sangkran – with an energy akin to Spring Break in Fort Lauderdale. They crowd the streets lined with bars in short shorts and tight tee-shirts, pouring ice water down the backs of one another and anyone else who gets close enough to be an easy target.

Religiously, Songkran is a time of cleansing – of washing away bad karma, of starting over, of making merit for luck in the New Year. Chiang Mai is home to over 300 temples. Side by side with the city-wide water fight are more traditional water rituals – the procession of the Buddhas outside of the temples, so that the people can shower them (and their elders) with water. The bringing of offerings from the local provinces and towns to the governor of Chiang Mai, with hill tribes dressed in their finest clothes, bringing their best harvest fruits as gifts. There is plenty of water here, as well – splashed with more reverence and blessings, but just as wet.

Unlike the famous temples we have visited in Bangkok, which border on tourist attractions, the temples of Chiang Mai are packed with people during Songkran – bringing offerings to the monks, saying prayers for their ancestors, snapping photos, making merit. Children from local traditional Thai dance schools perform for their families and friends, and are awarded with presents for their efforts. The temples feel close to the people here – not separate and distantly sacred, but a central part of daily life. There is a familiarity, a connectedness that we have not yet experienced. We are welcomed in almost every temple we visit, invited to be blessed, offered fruits and sweets to give to the monks. And of course, we are, once outside the temple walls, met yet again, by another well-wisher, joyously dousing us with water to honor the New Year.

Voodoo Economics

Everything costs a dollar here. The bottle of water that costs 10 baht (25 cents) in Thailand is a dollar in the Cambodia for tourists. The trinkets that street children hawk at the temples all cost a dollar, or two – for origami animals, or bamboo bracelets, or postcards to write home. The cab ride from the airport costs five dollars, a driver twenty-five – small sums by American or European standards but large sums in a country where most people make a few hundred dollars a year. Our hotel room, in a guest house not yet consumed by the new economy, costs only twenty dollars a night. Yet, down the street, in one of the dozens of new hotels that have been built in the last two years, a different trend is emerging – as rooms can now be found for over $500 dollars/night.

It is a disorienting experience being in another country – particularly one where the poverty is so great – where the preferred currency is the American dollar. In Siem Reap, the town on the outskirts of Angkor Wat, everyone wants to be paid in dollars, but will give you change in riel (which are now trading at 4000 to the dollar) if you do not ask otherwise. Because American coins are not used, the baseline starts at a dollar and goes up from there. This creates a distorted kind of inflation – with many things costing more in Cambodia than they do in its much wealthier neighbor, Thailand. I’ve grown unaccustomed to paying $5.00 for a cab ride, where even a fare to the airport won’t cost you that from my neighborhood in Bangkok. I find myself constantly comparing Thai and Cambodian prices, and feeling somehow that the fact that things are being priced in dollars has created a system with no rationale and consistency. It’s hard not to feel taken, even when the amounts are small.

It helps to get some distance and perspective, particularly with the animated entreaties from the street children. They are smart and engaging -- offering to tell you the capital of the state where you live if you promise to buy from them. They count the bracelets around their arms in English to show you that they can. They ask your name, tell you theirs, and promise to remember you when you return from visiting the temple (and they do!) Yes, the bracelets they are selling aren’t worth a dollar in Cambodia, or probably even in the US. But isn't it worth it to give a child a dollar anyway, if it will pay for school uniform and materials fees for nearly ten days? The answer to this question seems simpler, and not filled with issues of worth. I am not buying bracelets, after all.

Bad Policy: Good Consequences

The organization is called Korsang. Its staff: former Cambodian American gang members from the streets of San Diego, Virginia, and Kentucky—deported as “undesirable aliens” for crimes committed in the US. They are the children of Cambodian refugees whose families fled after the Vietnam War and during the Pol Pot regime. They have names like Wicked and Snot. They are in Cambodia because their parents, not understanding American citizenship rules, neglected to file naturalization papers for them. Thus, they are eligible for deportation based on the guidelines of the Patriot Act. Raised as Americans by Khmer parents, they are more hip-hop generation than Cambodian – former Bloods and Crips who know the laws of the street, and dance to the beat of the urban inner city.

But here they are – on the dusty streets of Phnom Penh, staffing a drop-in center and harm reduction outreach program that is the vision of Holly Bradford, a former IV drug user, and harm reduction expert from Boston. Grandmother to a Cambodian grand-daughter, she came to see the country of her grandchild’s roots, and has basically never left. Meeting the young deportees, she saw something different – not “undesirable aliens” or gang members – but young men who understood something about what it meant to be marginalized. Young men who knew something about the streets and what it takes to survive, and who wouldn’t be afraid to go out and try to reach others whose lives were even harder than theirs.

They are a family now – supporting one another, laughing, crying, and partying together. By day, they work with a team of trained peer educators to meet the needs of the IV drug using population of Phnom Penh, hoping to stem the spread of HIV and HepC. The outreach team provides clean needles, collects used syringes, distributes condoms, helps access HIV testing and medical care. In the Center, young users hang out, watch television, sleep, learn English, eat and talk. The staff’s American backgrounds have worked to their advantage here – giving them cache, and a mystique that is appealing to those they are trying to reach. Break dancing classes are a particularly hot activity, with street children as young as four and five twirling on their heads with abandon.

To do their work, Korsang has built relationships with the police, local NGO’s, and the American Embassy, who despite the irony involved, is an ally and supporter of these young Americans who have been thrown out of their country. Their work has been featured numerous times on the front pages of the Cambodian papers, and visitors and reporters now flock to hear about their successes, which are significant. In just a couple of years, thousands have already been reached on the streets, with broader networks and more comprehensive one stop health and education services envisioned in the future. When asked, none of the young men of Korsang could have ever imagined their lives to have taken them on the path they now travel. But for many, they have come a long way to find their way home.

City of Ghosts

People say that ghosts haunt the bridge over the river; that it's not safe to cross at 11:00 p.m. and 1:00 a.m. Our guide in Siam Reap shared that many Cambodians won't live there -- too many hungry ghosts from the Pol Pot era. Driving around the chaotic, dusty back streets of Phnom Penh in a tuk-tuk, Elaine and I could feel it in the air -- something unsettled and lawless. And yet, Phnom Penh is also a city of wide, beautifully landscaped boulevards that resemble the avenues of Paris built in the French colonial period. There is something eerie about the combination of the impact of Pol Pot and the French. This is the city of the killing fields, with skulls piled to the sky in a stupa in memorium, and clothes still rising through the dirt in the fields where mass graves have yet to be uncovered. In Tuol Sleng, the prison museum, the walls are hung with hundreds of photos of the dead, catalogued by their torturers with the same twisted conscientiousness of the Nazis. The photos represent but a fraction of those who died. All of the Cambodians we met had lost family members during those terrible years.

Out of this history of colonialism and evil has emerged a country without infrastructure -- the folks we visited shared that there is no government to speak of, no health budget, and corruption is the norm. The country's health infrastructure is run by the UN, the French, the Japanese, the Belgiums and many others. Many schools and children's progams are run by foreign governments or NGO's. People sponsor street children, paying to send them to school to try to secure a brighter future than the garbage dumps for them. There are foreign workers everywhere. In the short time we were in Phnom Penh, we ate more Western food than I'd eaten in two months in Thailand.

Phnom Penh is also a city of opportunity and refuge for many who need or choose to leave their former lives behind. Sitting in a bar overlooking the river, talking with American deportees and expats from around the world, we could have walked into a scene from Casablanca -- American and Cambodian rock and roll playing in the background, talking about times past and new beginnings -- it seemed almost as if time had stopped. The ghosts were quiet for a moment, whispering only in the breeze.