Getting Out of the Ghetto: Harm Reduction, Drug User Health, and the Transformation of Social Policy in New York

Abstract

This dissertation is a qualitative study of the emergence and evolution of harm reduction drug policies in New York City. It examines harm reduction as a case of the institutionalization of a public health policy movement. Harm reduction seeks to treat the medical and social consequences of drug use without requiring abstinence. The dissertation examines the process by which harm reduction has managed, in the words of one informant, to \u27get out of the ghetto\u27 and become increasingly integrated into New York\u27s public health establishment. Harm reduction has undergone three stages of institutionalization. It began as an activist policy movement. This was followed by a period of partial institutionalization, characterized by grant funding, organizational autonomy and limited state support. Finally, with harm reduction\u27s integration into Medicaid as well as the widespread adoption of naloxone overdose prevention strategies, it has assumed a mainstream position within the health system. This dissertation argues that institutionalization has changed harm reduction at the grassroots level and also contributed to wider changes in the design and delivery of public health in New York State. While some activists remain skeptical of what they see as harm reduction\u27s co-optation, the process has created new relationships between marginalized communities and the state, and led to new forms of social and political inclusion for drug users. This research demonstrates the effectiveness of social movements as policy actors and provides a case study of progressive policy change during a period marked by the privatization and restructuring of social welfare provision. The harm reduction approach, pioneered by drug users and public health activists, is now being applied to the health system more broadly