Another way to understand Harm Reduction is to examine its many practical forms, ranging from establishing needle exchanges, supplying bleach to sterilize needles and other supplies used to take drugs; promoting safer sex, providing referrals to primary health, psychotherapy and alternative treatments, to providing access to housing, advising on drug use management including safer drug use, the substitution of less harmful drugs, and advocating for policy change (Marlatt, 1998). Erin Graham (2007) reports that HR initiatives In the Downtown Eastside have included:

a needle exchange service (initiated by the Downtown Eastside Youth Activity Society (DEYAS) in 1989) and methadone maintenance programs , drug court (2001) , a safe injection site (September, 2003 — currently operated by the Portland Hotel Society, or PHS), and recently, a one year trial run of the NAOMI project (North American Opiate Medication Initiative, Spring, 2005) operated by the Vancouver Coastal Health Authority), which prescribes heroin to addicted people who meet certain criteria (Graham, 2007: 12).

A criticism of Harm Reduction approaches is that they condone or even support drug use, thus standing in the way of users who genuinely want to get off drugs, off the streets, or out of a violent relationship. Erin Graham (2007) draws on her experience as a mental health worker in the Downtown Eastside to write a thesis that is critical of Harm Reduction, and particularly the Four Pillars policy. She writes:

watching the implementation of the four pillars drug policy in Vancouver has been rather like watching Michael Jackson’s face — beginning beautiful, with some kind of hope, some kind of will to make changes and slowly taking the twisted and uneven shape it has today, with Harm Reduction and Law Enforcement squaring off in a ring of fire that is the DTES, with no real winners but the human services industry (Graham, 2007: 168)

She argues that Harm Reduction as it is currently practiced in the Downtown Eastside may reduce the spread of disease, visibility of drug-users and social disorder, but does not reduce harm. Her arguments are both practical and political. Practically, she points out that while resources have gone into Harm Reduction services, there is still a shortage of detox and residential treatment services, particularly for women and women with children. She is also critical of projects like InSite and the NAOMI project^{Footnote 3} because they focus on medical services only, “(t)hough several studies and reports highlighted poverty, social isolation and attendant political disengagement as ‘social determinants of health’” This criticism seems to ignore the partnerships throughout the Downtown Eastside that allow groups with different expertise to work together, providing a continuum of care. For example, people who use InSite go to other programs for social support, and staff at the Carnegie Learning Centre recently provided training for workers at the new detox centre at InSite so that they could provide better support for people who want to work on their education while they are in treatment.