In lieu of an abstract, here is a brief excerpt of the content:

6 Syringe Exchange as a Practice of Governing D espite widespread evidence of their effectiveness in reducing the spread of HIV among injection drug users (IDUs), syringe exchange programs (SEPs), which provide sterile syringes to IDUs in return for used ones, remain controversial. As perhaps the most widely practiced innovation of the harm reduction movement, SEPs act on users’ actions by providing them the means to use a sterile syringe for every injection. To accomplish this, SEPs across the United States use techniques ranging from strictly enforced one-forone exchange to encouraging secondary exchange, in which individual members collect syringes from their contacts and exchange them at the SEP in bulk. In an effort to address SEP opponents’ fears of discarded syringes and needle sticks by “the innocent” (archetypically, children in a playground), few programs allow syringe distribution without any required exchange of used syringes. These variations in policy both shape the local ecology of HIV risk and manifest collective struggles over how to manage and protect the public’s health. The question of who makes up the public whose health is threatened—people addicted to drugs who risk HIV infection as they inject, or “innocent” children in a city playground—is a key component of these struggles. These debates reveal schisms and conflicts over the proper role of government, the importance of personal responsibility in individual conduct, and who counts as a citizen or a member of a community. As they seek to regulate drug users’ practices and reduce the physical Syringe Exchange as a Practice of Governing / 157 and social harm caused by illicit and injection drug use, SEPs are engaged in projects of governance similar to those described in Part I. As more-orless developed organizational outgrowths of an earlier social movement (harm reduction), SEPs work to shape the behavior of IDUs according to the harm reduction norms described in the previous chapter (e.g., use a sterile syringe every time you inject). At the same time, SEPs support the state’s larger goal of reducing drug use by providing what advocates often referred to as a “continuum of care.” In Massachusetts, the law authorizing state-funded syringe exchange mandates that SEPs make every effort to place IDUs who visit the exchange in drug treatment programs—a mandate that stands in contrast to a harm reduction orientation that “meets users where they’re at” and encourages moderation rather than abstinence from drug use (O’Hare et al. 1992; Small et al. 2010). Harm reduction programs struggle with adopting neoliberal norms of individual responsibility while they simultaneously maintain larger critiques of authoritarian approaches to drug use (Rothschild 1998; Roe 2005). SEP advocates and staff aim to provide IDUs with the tools (syringes) they can use to avoid HIV infection and to meet a broad range of other needs as well, such as housing, food, and domestic violence intervention. Like the Community Health Advocate (CHA) program portrayed in Part I, SEPs, as grassroots organizations responding to the concerns of marginalized groups, serve as a technology for both governing drug users and advancing their interests. As they work to protect the health and represent the interests of a stigmatized population, SEPs, often in partnership with AIDS service organizations and drug treatment programs, seek to expand the definition of who counts as a citizen and a member of “the public” (Shaw 2006). At the same time, SEPs regulate the behavior of an unruly population at the level of the micropractices of drug use (e.g., injection techniques and paraphernalia ). In examining SEPs as a technology of government, we can begin to pry apart the regimes of knowledge and practice that shape these programs and their effects on individuals and collectivities. I begin by looking at the racialized and economic assumptions through which drug users— particularly urban, minority IDUs—are constructed as less than full citizens because of their dependency on illicit drugs. As organizations developed by former and sometimes even current drug users, SEPs take part in the liberatory discourse of community health, mobilizing a collective identity in order to make claims on the state and on health care providers. This mobilization is accompanied by efforts to destigmatize a highly stigmatized identity (Small et al. 2010). SEPs become more institutionalized, however, as they win funding and contracts from state public health agencies and local governments. SEPs are thereby subject to demands of accountability similar to those of the community health programs described in Part I. Last, I discuss the governing mentalities...

Share