March 3-7, 1996
By Donald M. Topping
(Published in The International Journal of Drug Policy, 7:3)
This is the story of efforts - often frustrating - to introduce and promote the concepts and practices of harm reduction for incorporation in the official drug policies of the State of Hawai`i. The efforts I will describe are those of myself and a handful of sympathetic colleagues who shared with me the honor of serving as a member of the Hawai`i Substance Abuse Task Force, about which I will have more to say shortly.
First, it is appropriate to provide a bit of background information. Hawai`i is known for its liberal and humane policies with regard to health care and individual freedoms. For example, it is the only state jurisdiction to have mandatory employer-provided health insurance; it was the first to decriminalize abortion; it is one of the few without a mandatory motorcycle helmet law; and it may soon legalize same-sex marriages. Hawaii's multi-ethnic population overwhelmingly elects politicians from the liberal Democratic party which has established the policies since statehood in 1959. It would seem that Hawai`i is ready in 1996 for harm reduction. Is it?
Next, let me relate how harm reduction found its way to Hawai`i. In early 1993, my colleage, Pam Lichty, and I formed the Hawai`i Drug Policy Options Group. This was a town-gown organization comprised of twenty or so people who were interested in looking at questions of drug policy. In an effort to drum up more interest, we arranged for Dr. Ethan Nadelmann to visit Hawai`i to give a series of presentations on drug policy issues and challenges. The title of one of his talks included the language, "Considering the Alternatives," and it was during this talk about alternatives to prohibition that the term harm reduction was first uttered publicly in Hawai`i.
The interepretation of this term, at least by some of those in attendance, is best reflected by the article about Dr. Nadelmann that appeared on the editorial page of the Sunday edition of the Honolulu Advertiser, Hawaii's 'newspaper of record', where the writer stated that "he [Nadelmann] is in favor of an approach that 'decriminalizes' personal drug use. It's a concept he calls 'harm reduction'." In spite of efforts to correct this misstatement, including a letter to the editor, the association between harm reduction, decriminalization and legalization was established, and apparently took root in Hawai`i.
During the following year there was a gradual increase in the use of the term, mainly at the monthly meetings of the Drug Policy Options Group, letters to the editor, and in a chapter that I authored for a book titled The Unfinished Health Agenda: Lessons From Hawai`i, published in the summer of 1994. This book was written primarily for policy makers and others concerned with issues of public health.
At the same time, some of the HDPOG members began lobbying key members of the Hawai`i State Legislature with the idea of setting up an official task force which would study drug policy issues in Hawai`i and make recommendations to the legislature for policy changes. Our perseverance was rewarded with the passage of HCR 88-94 which called for the establishment of the Hawai`i Substance Abuse Task Force (SATF), whose mandate was to make recommendations to the legislature regarding "better ways to deal with Hawaii's drug problems."
During this same period of time, I applied for a grant from the Robert Wood Johnson Foundation - the country's largest philanthrophy for health-related policy research - to obtain funding to support the work of the SATF. The grant was awarded in good time, and was used to support the research staff for the SATF.
This seemed like the open door through which to move the pragmatic, sensible and appealing concepts of harm reduction for inspection and adoption by Hawaii's premier policy-making body. What we didn't realize at the time was that the road leading to this door was full of detours, delays and formidable obstacles.
To understand these problems, we need to look first at the bureaucratic structure that was imposed. The legislature mandated the SATF and the procedures for forming it, which was through the Hawai`i Advisory Committee on Drugs and Controlled Substances (HACDACS). We must also understand that HACDACS is advisory to the Governor, who appoints all of the members from the community. However, between the Chairman of HACDACS and the Governor there is another link, which includes the Director of Health and his appointee, the Director of the Division of Alcohol and Drug Abuse (ADAD). In effect, the bureaucrats were in control.
Given that bureaucrats tend to be lazy, the more active members of HDPOG took the initiative by providing names of potential Task Force members to HACDACS, several of which were selected and appointed to the thirty-three person Task Force. The major restrictive factor was that the language of HRC 88-94 demanded that specific government agencies be represented, e.g. the State Departments of Health, Corrections, and Public Safety; the Honolulu Police Department; the Prosecuting Attorney, and others. The intent was to have a well-balanced task force, with all perspectives represented. It was this mix of members that proved to be the first pitfall. There were simply too many people with vested interests in maintaining the status quo.
The second pitfall became apparent during the early structuring of the SATF into sub-committees. The intent of the Resolution was to evaluate the impact of current drug policies on social, health, economic and law enforcement issues. We expected that the sub-committees of the SATF would be established along these lines. Instead, the SATF members elected to establish three sub-committees, and then self-selected for membership. The three sub-committees were Treatment, Prevention and Law Enforcement, representing the major tripartite divisions of U.S. drug policy, and reflecting the inherent divisiveness among them. It was perhaps this structure that set the tone for the polarization was soon to develop among the thirty-three members of the SATF.
The SATF met monthly from September 1994 through November 1995, with numerous sub-committee meetings during that period. In October 1994, the First Hawai`i Harm Reduction Conference was held in Honolulu (which was also the first such conference to be held in the U.S.). All SATF members received a written invitation. Of the thirty-three members, only six attended the conference (five of whom were already advocates of HR). Although the conference was well attended and received, our efforts to promulgate harm reduction thinking among the members of the SATF through a two-day conference did not succeed.
Even less successful were our attempts to inject harm reduction language into the early deliberations of the SATF. The first two monthly meetings were largely unfocussed, rambling discussions of the intent of the legislative resolution. It was a period of "sniffing out", or trying to determine the individual hidden agendas. Suspicion of each other and avoidance of any substantive discussion prevailed. The heterogeneity of the group was clearly established, and the lines began to be drawn.
The first major stand-off came while attempting to articulate what the State's goal should be with respect to substance abuse: 'drug free' versus the 'reduction of harm'. It was during this initial debate that the questioning and villification of harm reduction began to be heard. In spite of the recent conference, the papers distributed, and the repeated and various definitions provided, the vocal majority still claimed that a) it was still not clear, or b) that it was simply a "front for legalization." Even a report from the National Institute on Drug Abuse supporting HR, which was distributed to the SATF, did not provide relief.
The resistance to the term "harm reduction" (in all of its permutations) continued during the following monthly meetings. As late as March 1995, the members were still debating the State's goals and objectives. These debates were supported on both sides by an escalating "propaganda war" of documents distributed by the Honolulu Police Department, the Department of Health, the Attorney General, the Prosecuting Attorney, and HDPOG. While the SATF members remained polite and curteous to one another, the literature being distributed was more than mildly confrontational, especially that which espoused the official U.S. government position, which left no room for compromise.
By May, 1995, the time factor became a matter of concern. Six months had passed with little progress on substantive issues, and the date for submission of the recommendatons was approaching. Each sub-committee was then assigned the specific task to examine the issue: "What should Hawaii's objective be relative to drug abuse? No use, use reduction, harm reduction, free access." In addition, the members were directed to draw up a prioritized list of key issues. Of the twelve issues ranked by the number of votes, the following was dead last (receiving only five votes): "How can we define the philosophical ideas underlying the concept of 'harm reduction'?" Obviously, the question was not considered of very high priority.
Two versions of the SATF objectives were finally drafted and voted upon, as follows:
1. Eliminate drug abuse and its adverse effects through continuous
reduction efforts. (14 votes)
2. Reduce and eliminate, if possible, drug abuse and its adverse
effects. (10 votes)
This is as close to harm reduction as the SATF was ready to venture.
The following month (June) harm reduction got back on the agenda through action taken by the Executive Committee, which reworded the first objective as follows: "The ideal and ultimate goal of the State of Hawai`i should be an environment free of drug abuse and its consequences; toward that end we recommend that the immediate objective of the State be to adopt strategies that will reduce drug abuse and its consequences."
This modest proposal, while getting closer to a harm reduction model, was argued to death, with the major split focussed on the words "reduction" versus "elimination". This proposal also generated a renewed flurry of the propaganda war, with the Department of Health distributing an article (from the July 24, 1995 edition of "Alcoholism and Drug Abuse Weekly) which contained the following language: "An alliance of strange bedfellows (the drug culture, Libertarians, academics of non-relevant specialities and elitists) has formed and created sophistic theories to convince the public that responsible use/harm reduction /decriminalization /legalization would somehow lessen the effects of drug use on our society. They proffer that law enforcement's role be diminished or eliminated."
Obviously, harm reduction has its detractors among the SATF membership.
In October 1995, just as the SATF was in the final stages of meetings and deliberations, the Second Hawai`i Conference on Harm Reduction was held. Again, invitations were extended to all members of the SATF. And again, none but the harm reduction supporters attended, except for a few who were co-opted into making presentations: Major Michael Carvalho, head of the Narcotics and Vice Division, HPD; Kendyll Ko, Head, Drug Education Division, Department of Education. As expected, both of these speakers made clear their negative perception of harm reduction as an approach to substance abuse issues.
The SATF concluded its meetings in November 1995, and presented its report to the legislature. Eighteen recommendations were put to the vote. Fourteen of them were passed, some by the slightest of margin; four of them failed. Did harm reduction make it into the win column? The answer depends somewhat on how one defines harm reduction.
Although the proponents of harm reduction were somewhat disappointed over the final recommendations, we were pleased that at least three of them embraced the tenets of harm reduction. They are as follows:
#9. We recommend that personal drug use, abuse, and addiction.
be responded to as a health problem, but that drug use or addiction
should never be considered an excuse for otherwise separate criminal
conduct.
#10. We recommend that every drug abuser who is not yet able to discontinue
drug use should receive the help necessary to decrease harmful
effects to him- or herself or others.
#13. We recommend that the Hawai`i State Legislature should urge the
President of the United States to establish a national blue ribbon
commission to reexamine the drug problem in the United States,
and submit its recommendations to the President, the Congress,
and to the people of the United States. (Passed by a one vote
margin!)
Whether any of these recommendations will be realized through legislation remains to be seen.
The SATF experience is now behind us. Did it further the cause of harm reduction? In some small ways, yes. But, it fell short of establishing clearly defined new policy directions.
In retrospect, I ask, could the outcome have been different? Perhaps so, if we had started off differently.
The first and perhaps fatal mistake was in the makeup of the SATF. To put it succinctly, there were too many people with a vested interest in maintaining the status quo. In short, their jobs depend on continuing the War on Drugs. This applies not only to those in law enforcement, but to the specialists in prevention and treatment as well, since the bulk of their funding comes from the federal government, and their mandate is total abstinence. As a consequence, there was little interest in accepting, or even listening to proposals for alternatives.
It is unlikely that the SATF report will make a significant impact on policy change in Hawai`i in the immediate future. We believe, however, that the seeds of harm reduction have been planted, and are beginning to sprout in Hawai`i. With the proper care and nourishment, those seedlings may someday flower.
The responsibility for making that happen can not be left to the elected policy makers. Rather, it falls upon the working class -- that's us. It is this reality that led to the formation of the Harm Reduction Hawai`i Working Group in early 1996. In view of the failed experience in trying to effect change from the top down through policy makers, this new group is starting at the bottom, working directly with front-line workers. Hopefully, the philosophy of harm reduction will work its way up to those who set the official policies.
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