Transcript Presentation Slides - Division of Gender, Sexuality, and Health

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
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
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).
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.
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).
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.
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).
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).
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
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).”
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.
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
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)
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
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
The Importance of Place-based Research
with 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.
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.
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!