Place & Space: Mapping Response to the IDU-HIV Epidemic

1. Place & Space:Mapping Response to the IDU-HIV Epidemic Barbara Tempalski, PhD, MPH ~~~ National Development & Research Institutes, Inc. New York, NY Funded by NIDA grant R01 DA13336

2. Outline • Geography? • Importance of Geographic thought and theory in Social Movements (Health) • Place, Power & Human Agency • ACT UP & Harm Reduction • Place & Harm Reduction as Disease Prevention: Examples

3. Why Geography? • The main concerns of Geography may be summarised by the words ‘place’, ‘space’ and ‘environment’. • Place: How the combination of factors found at a place make that place unique. Example?? • Space: How things vary over space, the reasons for these variations, and how spatial variations in one thing influence spatial variations in other things. • Environment: How people influence and are influenced by their environment, both physical and human (i.e. cultural, political, social, economic).

4. Importance of Geography in Social Movements • Place is not just a location in space • Place is understood in geography as space endowed with meaning(s) and experience(s). • Central to this notion, is that interactions of social, political, and economic systems give shape to place and simultaneously, space configures social relations. • And thus, systems of social relations affect the distribution of resources to individuals and groups.

5. Place, Power & Human Agency • Castells argues, that resources have been a key to motivating action; this is most evident in the struggle over quality of life issues and the desire of identity groups to be acknowledged within the broader culture. • Geographers argue that place provides an important mobilizing discourse and identity for collective action (Marston, 2003; Martin, 2003; Miller, 2000). • People and groups organized into coalitions actively shape places, and the actions, driven by institutional structures, are never the same from place to place. • Thus, people and institutions actively shape place, and simultaneously, place influences the structure of how resources are distributed to individuals and groups (Dear, 1988; Harvey, 1997; Johnston, 1991; Kearns and Joseph, 1993).

6. Human Agency & Response to HIV/AIDS: ACT UP & Harm Reduction(Change from Below) ACT UP successfully contested the stigmatization of people with AIDS by highlighting an underlying stigmatization rooted in homophobia through the use of direct action.Many of the same players adopted a similar philosophy and tactics in creating and demanding primary health care and HIV prevention services for IDUs, starting direct services as a form of direct action. The emergence of the harm reduction movement and of organizations that work toward establishing and sustaining direct services demonstrates how health-related social movements are innovators in disease prevention.

7. Human Agency & Response to HIV/AIDS: ACT UP & Harm Reduction(Change from Below) Metropolitan areas with a higher population of MSM and college educated are more likely to have SEPs, as are those with an ACT UP chapter. Of the 96 MSAs studied, 19 had an ACT UP chapter; of those 19, all but one (Houston) had at least one SEP, indicating a strong association between local ACT UP chapters and the presence of a SEP. This implies that activism influences the provision of services, as indicated by the quantitative association between ACT UP presence and organized syringe exchange (Tempalski et al, 2007).

8. From Direct Action to Direct Services In the U.S., the development and maintenance of services for IDUs, specifically SEPs, can be linked to social movements and to specific activist groups such as ACT UP and the harm reduction movement. For example, in 1989, in nearly half a dozen cities in the Northeast (e.g., New York, Philadelphia, New Haven, and Boston) and in Northwestern coastal cities (e.g., Seattle and San Francisco) the National AIDS Brigade and ACT UP organized underground SEPs and began distributing needles at a rate of 200-300,000 per year (Drucker, 1990).

9. Syringe Exchange as a Social Movement: A Case Study of Harm Reduction, Oakland, CA(Bluthenthal, 1997) • Existing HIV service providers unwilling to start SEP’s due to environment created by federal and state opposition • Formation of small group of activists made up of volunteers with backgrounds in HIV prevention, civil disobedience and drug use that were deceptively effective at starting and maintaining programs, and at winning political support • Initial political opposition leading to arrests by Oakland police only strengthened the unity of activists • Achievement of political backing lessened opposition from police officials

11. Uneven Geography:The Politics of Place & Services • SEPs often result from political pressure or direct action by grassroots activists.The first publicly funded SEP in Tacoma, Washington, resulted from the direct action of Dave Purchase and others. After recognizing that many IDUs were dying of AIDS and government inaction, Purchase set up a the first publicly funded street-based SEP in Tacoma in 1988. • “People were going to die. I had some time on my hands. I had some friends that did help out a lot and never got the credit they deserved. We started in the summer of '88 and every couple of years there's another brouhaha with the same old argument. The fact of the matter is that there have been enough local political people with backbone that have supported us and so has the health department, and so we've weathered attacks. And politics is still a number one problem. AIDS is all politics, it's not science and stuff like that, its all politics (Purchase, 2002).”

12. Uneven Geography:The Politics of Place & Services • In other places, such as New Jersey, Massachusetts, and California,local direct action efforts for establishing SEPs have been less successful. • For example, in 1999, New Jersey reported over 19,000 cumulative IDU-related AIDS cases (second only to New York State), and 2.3% of the Jersey City metropolitan area population was injecting drugs. However, the governor and city officials were opposed to distributing sterile syringes to IDUs, and used arrests to suppress the state’s only publicly visible SEP.

13. Political & Legal Barriers • “War on Drugs”: Abstinence-based approaches to illicit drug use. Are drug users criminals or medical patients? • Institutional and legal opposition: • Federal ban on distribution of sterile needles for IDUs. Seems that federal opposition to syringe exchange is “data-proof.” (Bluthenthal, 1997) • Police arrest – SEP volunteers and consumers subject to arrest, prosecution and imprisonment • State and local legislation – drug paraphernalia & local anti-OTC laws

14. Social Opposition and Barriers • Community opposition: • “NIMBY” • Clergy, neighborhood and business associations, politicians • Negative Media Portrayal: • Drug users as dysfunctional, lost causes, criminals “These forms of opposition are neither mutually exclusive nor static. A change in opposition from one source can affect support from others… [R]esistance…does not exist in isolation.” (Tempalski et al, 2007)

15. State and local government (in)action or opposition “We are trying to override the city council vote because you basically have politicians who are embedded in their conservative morality and that morality is driving politics, not public interest or health care. So it's pretty scary.” Harm reduction activist “As a matter of fact, state employees under the [current] administration were required, and I mean required, to not support it [SEP] publicly or privately, we were warned to not say anything favorable about it and in fact were required to vote against any motion to support it. They weren't kidding. So they forced us underground, most of us.” Ex-government employee

16. Political & law enforcement issues “If you work for it (the SEP) they arrest you. There’s that kind of harassment. There are people being arrested all the time for possession of syringes. Even if they have a card…They can show a card and they’re told that’s no good here. I don’t know of any workers going to jail, but I know participants have gone to jail for possession of syringes.” SEP director “The Chief of Police would probably go out and personally shoot any SEP workers. The Chief doesn’t even believe in drug treatment…he’s been the chief for 20 years…” Public health official

17. The Importance of Place-based Researchwith regard to Social Movements (1) Expands our knowledge of the political and social processes that have led to variations in harm related services for IDUs; (2) Illustrates how local grassroots movements respond to government inactions and how place-based actions affect whether particular areas confront and adopt an intervention; (3) Place-based research emphasizes the importance of local grassroots activism in influencing the establishment and success of harm reduction services.

18. Thank you to the individuals who generously gave their time to this research From the NDRI, Center for Drug Use & HIV Research: Dr.Samuel Friedman Community Vulnerability team Beth Israel Medical Center: Dr.Don Des Jarlais Courtney McKnight And individual activists and outreach workers who kindly gave their time to be interviewed.

19. ACKNOWLEDGEMENTS • Dave Purchase and everyone involved with the North American Syringe Exchange Network, Syringe Exchanges and the Harm Reduction Coalitions around the country, thank you for doing the right thing and saving lives!