On a political level, Graham argues that current Harm Reduction projects do not address social issues and the targets of HR policies (drug users and residents of the Downtown Eastside) may become even more marginalized as a result of those policies (p. 8). She attributes this to the high amount of surveillance, including the sign-in procedures. However, my experience is that sign-in sheets are voluntary and participants are free to not sign in or to use false names. Another very serious criticism is that HR policies serve to maintain levels of addiction that prevent participation in the mainstream. :

I argue that specific policies and practices related to the Four Pillars serve to maintain people at a level of addiction that may keep them from resorting to criminal behaviour, or from contracting HIV, or dying from overdose. However, these same policies and practices may also ensure they will be unable to either participate in mainstream life or to organize with each other in order to change the conditions within which they live. (Graham, 2007:10)

Harm Reduction defenders differ. In their “Backgrounder on Harm Reduction” Robertson and Poole (1999: 1) say: “Harm Reduction… embraces recovery and abstinence as healthy options, goals, and aspirations to be explored by an substance user." Marlatt stipulates that abstinence must be freely chosen, with the user setting the time frame. For many users, abstinence simply isn’t an option — in fact, only 5-10% of the drug-using population is prepared to consider abstinence-based programs (Riley & O'Hare, 1999: 21, my emphasis). As literature in other sections shows, Harm Reduction and support for abstinence can work in partnership. Practitioners can provide support, referrals and information to participants who want to get off drugs or out of a violent relationship, but also discuss how to use drugs more safely or make a safety plan for their current living situation.

Sarah’s response: Independent, peer-reviewed scientific research shows that the opening of InSite was associated independently with a sharp increase in detoxification service use, increased rates of long-term addiction treatment initiation and reduced injecting at the Safe Injection Site. (View the research at www.communityinsite.ca).

Where possible, harm reduction programs like InSite do build bridges for addicts to access detox and recovery; however, these programs also aim simply to keep people alive long enough that they might have time to make healthier choices for themselves. Dead people do not detox.

No one is saying that it is okay, in our economically affluent society, to have people living such lives. None of us want to keep people in this place, or enable these kinds of addictions. Nevertheless, this oppression and social exclusion is a reality — and one that we as a society have not been able to address or solve. Harm reduction approaches allow us to take health care to the community and “meet people where they are at.”

With this overview in mind, the next section of this literature review looks more closely at how Harm Reduction has been applied to work with Injection Drug Users, followed by Sex Trade Workers and Survivors of Violence.