Into the ordinary: non-elite actors and the mobility of harm reduction policies

ABSTRACT

Research on policy transfer and policy mobility has focused much attention on relatively elite actors, such as politicians, international organisations, think tanks, philanthropic donors, and consultancy firms. In contrast, this article uses the case of ‘harm reduction’ drug policy, an area of practice and research that is committed to valuing ‘non-elite’ actors, to show how they are frequently involved in mobilizing policy knowledge. Focusing on the role of service providers, activists and service users in the mobilization of harm reduction models, the paper discusses four key practices associated with these non-elite actors: cooperation, convergence, disobedience and display. The article argues that the deep involvement of relatively non-elite actors in mobilizing harm reduction policies means that multi-disciplinary scholarship would be enriched by going ‘into the ordinary’ in a wide range of policy contexts.

KEYWORDS:

• Policy mobilities
• advocacy
• activism
• harm reduction

Introduction

Studies of policy transfer (e.g. Dolowitz & Marsh, 1996) and policy mobility (e.g. McCann & Ward, 2013) demonstrate an abiding interest in the roles that different policy actors play in the global circulation of policy expertise and policy models (Baker & Walker, 2019). Yet, such studies have overwhelmingly focused on elite policy actors at the expense of ordinary, or what might be called non-elite, actors who influence policy-making through prosaic practices as ‘front-line’ or ‘street-level’ members of state agencies (Lipsky, 1980; Painter, 2006) and via their advocacy for policy change, as members of activist coalitions (Baker and McCann 2018; McCann, 2008; Temenos, 2017).

In their early paper on policy transfer, for example, Dolowitz and Marsh (1996, p. 345) identify “elected officials, political parties, bureaucrats/civil servants, pressure groups, policy entrepreneurs and experts, transnational corporations, think tanks, supra-national governmental and nongovernmental institutions and consultants’ as each playing a part. Stone (2004) broadens this list to include a wider array of knowledge-generating actors, such as consultants, professional organisations and research institutes. More recently, Legrand (2012, p. 332) provides an ‘exhaustive list [that] embraces almost every sort of actor likely to get involved’ in the policy transfer process, including ‘elected officials, political parties, bureaucrats/civil servants, pressure groups, policy networks, policy entrepreneurs and experts, transnational corporations, thinktanks, supranational governmental and non-governmental institutions, quangos, and consultants’. While we will argue below that many of these categories of ‘transfer agents’ include non-elite actors, research into their role in policy transfer and mobilization has tended to focus on elite actors, with the exception of studies of NGOs and pressure groups.

This research field’s imaginative horizons have been defined by an implicit, self-limiting preoccupation with elite policy actors. While not everyone working from the perspectives described above would necessarily align themselves with C. Wright Mills’ characterization of the distinction between elites and ‘the mass’ in contemporary society, his opening salvo in The Power Elite nonetheless resonates with how much of the literatures on policy transfer and mobility is framed. For Mills (1956, p. 3),

The powers of ordinary men [sic] are circumscribed by the everyday worlds in which they live, yet even in these rounds of job, family and neighborhood they often seem driven by forces they can neither understand nor govern. ‘Great changes’ are beyond their control but affect their conduct and outlook none the less. The very framework of modern society confines them to projects not their own … in an epoch in which they are without power.

If ordinary people are conceived as powerless relative to elites within contemporary society, then it is understandable that they have not been a prominent focus in literatures concerned with the transfer or mobilization of public policy models in and among states. Yet, most contemporary elite theory accepts that elites are only relatively autonomous from the rest of society. Indeed, there is much productive work being done on the character and consequences of that relative autonomy, both within elite theory and in studies of citizen participation (Parry, 2005). Thus, following Painter (2005, 2006), we approach policy-making as a set of prosaic relations and practices that tie together the state and civil society, elites and non-elites, in ways that, in contrast to Mills’ interpretation, offer opportunities of empowerment to both.

Thus, this article makes two arguments. First, that the actions and experiences of a range of non-elite actors are deeply involved in instigating and shaping policy mobility processes and, therefore, scholarship on policy transfer and mobility would be enriched by attending to these actors. Second, that a focus on the prosaic actors, relations, and practices involved in questioning existing policy models and proposing alternative ones provides an opportunity to detail and analyze the role of non-elites in making and moving policy. To be clear, we are not suggesting that those commonly thought of as non-elite have equal or greater power than elites, nor are we advocating a withdrawal from elite-focused studies of policy transfer and mobility. Rather we highlight the relative power of non-elites and, as a result, advocate for an analytical expansion into the ordinary.

To provide empirical substantiation to these general arguments, we examine prosaic actors and practices in the mobilization of harm reduction approaches to drug policy and the governance of people who use illicit drugs in ways that may be harmful (including policy frameworks and service models). Harm reduction ‘refers to policies, programmes and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. The defining features are the focus on the prevention of harm, rather than on the prevention of drug use itself’ (HRI 2018, np). Harm reduction involves ‘meeting people where they are at’ and working with them to manage safe access to health care services. This often involves services such as needle distribution or supervized drug consumption sites (SCS) that help to prevent overdose death and the spread of blood-borne diseases like HIV/AIDS or Hepatitis C; opioid substitution therapy for those who want to stabilize and perhaps reduce/stop their opiate use; and access to low-threshold drop in centres, counselling and other services.

Harm reduction is an effective policy approach and is considered best-practice public health policy (Andresen & Jozaghi, 2012; DeBeck, Wood, Montaner, & Kerr, 2006). Advocacy for harm reduction policies and programs is part of a global social movement for drug policy reform, the debates around which play out at all levels of governance, from international meetings of the United Nations and World Health Organization (Bewley-Taylor, 2012), to local NIMBY (‘not in my backyard’) politics around locating health services to people who use drugs (McCann, 2011). It is a movement influenced by a commitment to the meaningful involvement of people who use drugs in defining the problems to be addressed and the solutions to be operationalized through policy-making. In this regard, it is an ideal case study to substantiate our argument that the study of policy transfer or mobility should pay attention to the roles of non-elite actors. Yet, despite the effectiveness and inclusiveness of harm reduction, it is critiqued and contested by those who espouse criminalization or moral arguments against illicit drug use (McCann & Temenos, 2015).

Our discussion is structured around four practices – cooperation, convergence, disobedience and display – through which non-elite actors, from people who use drugs and use harm reduction services to street-level service providers, influence policy mobilization processes (often with the engagement of relatively elite actors, such as state bureaucrats and politicians). Cooperation refers to individuals and/or institutions working together; convergence happens when multiple people or groups come together to discuss, debate and share best practice; disobedience refers to the contravention of laws and norms in order to ensure that specific agendas, policies, or programs are pushed forward; and display focuses on visible actions intended to make specific issues public and worthy of action.

Painter (2006, p. 764) argues that the geographically and qualitatively uneven influence of the state on all aspects of life ‘depends on and proceeds through mundane practices undertaken by thousands of individual state officials and citizens, [leaving] considerable scope for what is seen as failure, disruption, and breakdown, as well as qualitative and quantitative social and spatial variation’. Accordingly, we draw on examples from a range of cases in order to convey the ordinary, if varied, nature of actors and practices that constitute policy mobility. Our examples are drawn from several research projects by the paper’s authors, conducted over the past fifteen years, both individually and in collaboration with one another. Methodologically, each of these projects used mixed qualitative methods: a combination of interviews with key informants; direct observation at a number of harm reduction sites and at policy meetings, hearings, protests and direct action; and analysis of secondary materials. Some projects also included participatory community-based research approaches.

Elite and non-elite actors in policy transfer and mobility studies

Before surveying extant policy transfer and mobility literatures for insights into elite and non-elite actors, it is important to clarify what ‘elite’ means in the context of our work. There is much debate over the nature of elite status and the distinction between elites and non-elites. In his classic book, Mills (1956, p. 3–4), for example, refers to the ‘power elite’, comprised of people in positions that ‘occupy the strategic command posts of the social structure’. Looking across the social sciences, Hoffman-Lange (2007, p. 910) claims that ‘elites are customarily defined by their influence on strategic (political) decisions that shape the living conditions in a society’. The influence associated with elite actors is ‘based on a variety of resources located in different sectors of society, for example, political authority, judicial discretion, economic power, academic or administrative expertise, or influence on public opinion’ (Hoffman-Lange, 2007, p. 911). We view policy elites as people in positions of relative power by virtue of their ability to access and harness resources (e.g. political authority, money, knowledge, social connections etc.) to influence the policy process. As Woods (1998: 2105, our emphasis) puts it, ‘attribution of elite status is context specific’.

Given inseparable connections between public policy and the apparatuses of state, it is understandable that policy transfer and mobility scholars have directed much of their efforts into understanding the roles of elites in the context of state institutions, such as elected officials, political operatives and bureaucrats (cf. Batory and Lindstrom 2011; Bunnell, Padawangi, & Thompson, 2018; Rapoport 2015b; Schäfer, 2017). Three roles of state-based elites have garnered particular interest. First, and perhaps most obviously, are the decision-making roles vested in elected and unelected state actors. Circulating policy ideas do not implement themselves on the basis of their innate attractiveness or inherent effectiveness; they are implemented because they resonate with the ideological and material interests of state-based actors. Second, state-based elites shape policy mobilization through their technical-administrative capabilities (Nay, 2012). Implementing policy ideas from elsewhere requires technical and administrative ‘know-how’ that politicians and public bureaucracies possess. This know-how can also become a circulating commodity itself when politicians and public officials cooperate with, or sell, their expertise to other jurisdictions (Montero, 2017; Mountz & Curran, 2009). Third, state-based elites engage in ideational coordination. International organisations are particularly adept in this regard. Speaking about the World Bank, Webber (2015, p. 27) points to its ‘unparalleled ability to influence the terms of development debate through persuasive paradigm maintenance’. The Organisation for Economic Cooperation and Development has similarly been analysed for its role in ‘the strategic selection and purposeful circulation of policy norms’ (Theodore & Peck, 2011, p. 21), which privileges certain circulating policy ideas over others (see also Pal, 2012).

A key feature that differentiates previous eras of policy-making and mobility from the contemporary one is the pervasive intermediating roles of non-state elites (Cook, Ward, & Ward, 2014). Recent years have seen researchers attend to the roles of think tanks, philanthropies, academics, consultancies and corporations (cf. Jacobs & Lees, 2013; Pow, 2018; Prince, 2012). Possessing no formal political authority, non-state elites draw on combinations of intellectual, economic and social resources to shape the mobilization of policy. Consultants, for example, trade on universal knowledge and their global reach. Prince (2012, p. 199) discusses how consultants ‘play a central role in making global connections by using their techniques to create equivalence between different places, making policy transfer, and global policy networks, possible’ (cf Rapoport 2015a; Vogelpohl, 2017). Where consultants are influential through their commissions with state agencies, think tanks operate as ‘principled outsiders’ (Peck, 2006), steering public and expert discourse through empirical and/or values-based reports, books and media commentary (cf Stone, 2001). Philanthropies wield considerable power in the mobilization and implementation of policy ideas, combining financial resources and autonomy with a benevolent public image (Jolkkonen, 2019), often generating influence through grants that capacitate grass-roots, non-elite organisations and actors. Smith (2013) cautions that philanthropic foundations engage in elite-driven policy development and mobility, shielded from democratic deliberation and public participation: what he calls ‘oligarchic diffusion’ or what might be termed ‘astro-turfing’.

As these brief summaries suggest, there are well-established subsections of literatures on policy transfer or mobility that attend to state and non-state elites. The same cannot be said for relatively non-elite actors: those that fall somewhere below the upper echelons of political, economic and intellectual authority. Non-elite actors frequently appear as bit players or ‘scene extras’ in accounts of policy transfer or mobility, but rarely as the main focus of analysis. There are few notable exceptions, of course, and we discuss them next. State-based non-elites, such as ‘street-level bureaucrats’, are notably absent from policy transfer or mobility literatures. Despite the now widespread acknowledgement of the need to understand policy transfer or mobility as an open-ended and contextually-inflected process of translation and mutation, rather than simple transmission (McCann & Ward, 2013; Stone, 2012), there is little explicit discussion of street-level bureaucrats, whose everyday activities are concerned precisely with the translation of abstract ideas into grounded practice. Lipsky (1980, p. 13) argues that street-level bureaucrats should be considered active policy-makers, not passive and instrumental policy appliers, where they have ‘relatively high degrees of discretion and relative autonomy from organizational authority’. While the agency of street-level bureaucrats is invariably constrained by legislation, regulation and organisational norms, there often remains room, either by design or necessity, for professional judgement. A study of municipal inspectors enforcing bylaws on property use, health and licencing in Vancouver, Canada (Proudfoot & McCann, 2008), for instance, examines how municipal inspectors negotiate the multiple, and often competing, expectations of policy frameworks and residents. Street-level bureaucrats actively mediate between the intent and implications of policy, thereby translating or mutating it. There is significant scope for policy transfer and mobility scholars to better understand the role of state-based non-elites, and the sizeable literature on street-level bureaucrats is an ideal place to start (for an overview, see Northdurfter & Hermans, 2018).

Non-elites outside the state are also under-appreciated within policy transfer and mobility literatures. Only a small number of accounts identify the important roles that ordinary civil society actors, such as activists, residents, advocacy organisations and social service agencies play in mobilizing, resisting and implementing policy knowledge from jurisdictions further afield (cf. Baker and McCann 2018; Baker & McGuirk, forthcoming; McCann, 2011; McCann & Temenos, 2015; Temenos, 2017). Drawing on social movement scholarship for example, Temenos (2016) demonstrates how non-elite and non-state actors extend their networks and learn from peers through conferences. These meetings provide them with new resources which can be used in their own local and national contexts. In another example, Vancouver, Canada’s widely publicized harm reduction drug policies were a result of coalition-building among people who use drugs, their community-activist allies, service providers, health researchers, some members of the local police force, and bureaucrats and politicians at the local, Provincial, and Federal levels (McCann, 2008, 2011). Among this coalition, non-elite, non-state actors were a driving force. Larner and Laurie (2010), for their part, examine how New Zealand telecommunications bureaucrats and English water engineers were key actors in implementing neoliberal privatization policies in these two arenas. By charting their career movements, the authors demonstrate that these non-elite actors brought with them specific policy philosophies which they were then able to enact across a wider range of institutions through their career progression, which included movement among different institutions. Alternatively, McArthur (2018) examines the politics of knowledge associated with active transport policies in Auckland, New Zealand, focusing on the role of non-expert community advocates greatly informing a newly-elected government’s transport priorities. These accounts offer insights into a broader range of ‘transfer agents’ (Stone, 2004) than most policy transfer and mobility studies recognize as playing a significant role.

The differentiation between elite and non-elite actors is a heuristic device, not a neat ‘actually existing’ binary. Elite and non-elite designations are a product of institutionally and geographically context specific relationships among actors, institutions, and the political situations in which policy is mobilized, constructed and implemented. Our call for attention to non-elite actors in the mobilization of policy therefore contributes to a deeper understanding of the differential power-laden roles that actors within and beyond the state play in the construction of best-practice policy models and in advocacy for certain polices over others. Social movement scholarship, for example, has long focused on the role of non-elite actors in creating political change through attention to grassroots activists, the professionalization of advocates, and the state and non-state tactics employed to initiate policy and other forms of social and institutional change (Jenkins, 2008; Laurie, Andolina, & Radcliffe, 2005; Routledge, 2003).

Within the public health harm reduction literatures there has been acknowledgement of the role and expertise of drug users and peer groups in establishing public health precedence and services (McNeil, Small, Lampkin, Shannon, & Kerr, 2014; Smith, 2012). Harm Reduction studies have also acknowledged, albeit in an ad hoc manner, the role of experts such as nurses and other medical professionals, who by their education, professional and social status hold positions of relative power, yet do not have the authority to construct policy (Gold, 2003; Sherman and Purchase 2001). Some of these actors could be considered elite in certain situations; for example, in local political arenas or in their role as experts in the development of ‘evidence based’ policy (e.g. Downing et al., 2005). Yet, they are also acting apart from the policy making arena, stepping in most frequently to give evidence within a policy making process, and therefore most practicing medical professionals would not be considered embedded within the policy cycle. In the interdisciplinary field of policy transfer/mobility research, attention to non-elite actors has been lacking. In the next section we draw on four broad areas of practice in which non-elite policy actors engage, and that emerged through our observation and analysis of harm reduction policy-making in various global contexts over the course of our research.

Ordinary actors and practices in the mobilization of harm reduction drug policies

Ordinary actors and practices have long been central to creating and circulating harm reduction policies and programs. This is the case even in a field that emphasizes the importance of evidence-based policy-making and the role of high-quality scientific evaluation (e.g. DeBeck et al., 2006). Indeed, the mobilization of harm reduction approaches to illicit drug use among various cities represent what might be called ‘counterhegemonic’ mobilization (Massey, 2011) or ‘countermobility’ (Temenos, 2017) of policy – a deliberate attempt to counteract hegemonic approaches that criminalize low-income and racialized drug users. Crucially, harm reduction activists effectively knit together various constituencies, forms of evidence and experience (from clinical and public health research to frontline understanding of the effectiveness of particular interventions like needle distribution), and political strategies (from lobbying and formal legal procedures, to public protest, to civil disobedience).

In this section, we discuss four ordinary practices that non-elite actors engage in – often with the involvement of elites – to effect and influence the mobility of harm reduction policy: cooperation, convergence, disobedience, and display. Cooperation refers to the ways in which individuals or institutions work with each other: sharing their expertise one-on-one, discussing what worked for one party and how it might work for the other party. Convergence practices widen these relationships out to focus on the networks of technical experience that bring multiple people or groups together in order to discuss, debate and share best practice for (in this instance) harm reduction. Convergence is place-based, bringing people together through meetings and conferences, but it is also always relational, focusing on building networks and social movements among actors who are often geographically dispersed. Disobedience practices revolve around contravening laws and norms in order to ensure specific agendas, policies, or programs are pushed forward. Display practices are intentionally visible actions intended to make public specific issues. Closely related to disobedience, display practices are specifically outward looking in their intention to force policy or program change. These practices are not comprehensive, teleological, or hermetically separate, however we argue that they help to analyse and understand many of the practices that non-elite actors undertake to mobilize and implement harm reduction.

Cooperation

Knowledge sharing between individuals or groups is an important way in which non-elite actors work to change policies. Often the ideas shared are of a technical nature, focusing on best-practices, or what worked for one person or organization as a way to achieve their objectives. Cooperation in knowledge sharing involves a constellation of practices, ranging from Internet searches, to personal networks, to chance or deliberate meetings at conferences, to directed study-visits. Cooperation is often mediated through ‘informational infrastructures,’ networks of knowledge sharing, learning and exchange, and manifest through bilateral, one-to-one engagements meant to enhance policy or program effectiveness (McCann, 2008; Temenos & McCann, 2014). And the actors involved in these interactions are, more often than not, non-elite actors or ‘middling technocrats’ (Larner & Laurie, 2010). Within harm reduction fields, these non-elite actors are often health service providers: social workers, nurses, peer-outreach workers or researchers (Faulkner-Gurstein, 2017; Greer, Amlani, Pauly, Burmeister, & Buxton, 2018; McLean, 2012).

In Spanish-speaking Santo Domingo, Dominican Republic, one non-profit worker explained that they made contact with a New York City harm reduction organization because the organization had posted their harm reduction principles for free online in Spanish. Appearing in a Google search when the Dominican organization was trying to set up its own harm reduction program, the language-specific resource was important for three reasons. First, it was one of the few resources in Spanish available online at the time. This meant that the Dominican organization did not have to go through the lengthy and resource intensive process of translating technical documents. Second, the knowledge that the organization already worked in Spanish gave the Dominican group confidence to reach out and contact the group. When they did, they were able to speak with practitioners, other non-profit workers working in the field who were serving a diverse population, including a large Afro-Caribbean and Spanish speaking community. The development of this one-on-one relationship between the two groups was essential for the Dominican organization to get off the ground and begin running. They found an organization willing to share resources and best-practice protocols ranging from needle exchange processes to basic data collection and accounting. Third, this relationship lent the Dominican organization a certain amount of credibility with its target population, ensuring that the service was accessible and successful. According to one non-profit worker ‘America is the dream, New York is the dream here. It’s like, we tell them we’re doing this thing [harm reduction] and we learned it from people in New York and they’re our friends, and it’s instant, it’s cool and they [the clients] trust you’ (Interview, Santo Domingo, 2012). The cultural capital of a specific connection to a place far away was undergirded by the more mundane circumstances of the cooperative relationship: the algorithmic coincidence that a Google search displayed a particular organization’s resources, and the happenstance that once contact was made, the non-profit employees in New York were willing to help those in Santo Domingo. The cooperation of non-elite actors in this example is conditioned by a particular constellation of events, places, and circumstances.

The Dominican case of cooperation is but one example. The opening, in 2003, of Insite, Vancouver, Canada’s first Supervized Consumption Site (SCS) which focused on injection, specifically, was preceded by cooperation between its designers and operators and their counterparts in Sydney, Australia’s Medically Supervized Injecting Centre (MSIC), which opened two years earlier (McCann & Temenos, 2015). By consulting with Australian colleagues, Vancouver’s architects, public health officials, and front-line service workers developed a health facility that would work to serve the needs of its users. In cooperating on the design of the physical space, the two sets of harm reductionists also discussed and refined practices of care that define most SCSs. Yet, this was not a one-off cooperation. In the early 2000s, the MSIC and Insite were the only two fully legally sanctioned low-threshold SCSs operating outside of a few countries in Europe. Reflecting the pathways that let the Dominican actors to New York City, Sydney and Vancouver see themselves as geographically isolated peers within the wider network of harm reduction organizations. As an MSIC staff member put it, the two sites are ‘natural partners,’ “because [Insite] opened after us … it’s partly modelled on us … because it’s English speaking and … because its familiar with our political struggle in terms of a [sceptical] federal government and legal challenge after legal challenge (Interview, Sydney, 2013). In practical terms, this cooperation has involved engagement via the Internet, meetings at conferences, and visits by managers and nurses from each city to the other. Cooperation, then, happens at a distance much of the time, but is undergirded by co-present interaction between ‘ordinary’ actors in specific places for the purposes of trust-building, learning, support, and advocacy (Temenos, 2016).

Convergence

Cooperation is both built by and built upon convergence practices. Convergence, or the coming together of various stakeholder groups to discuss shared problems and possible solutions, is a multi-lateral process used by policy makers, social movements, and interest groups. Convergence creates a dynamic system in which complex relationships and interactions across spatial scales can play out in face-to-face meetings (Routledge, 2003). Convergence practices happen through meetings, conferences and events such as protests or workshops. ‘Convergence spaces come into being for delimited times, so in this sense they are fleeting, or ephemeral. Yet they also have lasting effects because of their facilitation of encounter – people being able to meet and network, as well as to strengthen existing relationships – maintaining weak ties’ (Temenos, 2016, p. 128). Convergence provides key opportunities for non-elite actors to learn from one another, to have their voices heard, and, as we mentioned above, to meet face-to-face and build interpersonal connections and trust.

Meetings, such as the Annual Meeting of the United Nations Commission on Narcotic Drugs (CND) in Vienna, are key spaces where harm reduction advocates converge. While the media focus is often on drug policy ‘tsars’ and crime commissioners, other attendees such as drug policy reform advocates, addictions doctors and other service providers, civil society groups, and people who use drugs also attend these events, securing opportunities to speak to the elite experts as well as to speak to other like-minded harm reductionists. In this space, diverse interest groups interact, allowing the formation of what Granovetter (1973) calls ‘weak’ and ‘strong’ ties. An international meeting such as the CND allows for people with shared goals (e.g. effective and socially progressive drug policy) to meet and converse, thus creating ‘weak’ ties, or what we argue would better be termed ‘loose’ ties, among diverse groups with a common interest and goal rather than common value sets. It is also an opportunity for groups with shared values to build trust over time, trust in both actions and in shared value structures. In this sense, such meetings can form the basis of ‘strong’ ties, and the transformation of ‘weak’ ties into ‘strong’ ones, as parties are able to learn from one another and trust the actions of diverse groups.

Conferences are another such convergence space. Harm reduction, drug policy, and HIV/AIDS conferences are important venues for non-elite policy actors. They facilitate knowledge production, exchange, and action plans to address policy change. Conferences, like meetings, are time-limited events aimed at drawing together specific groups around a common theme. They are curated and aimed to bring both people and resources into a common space (Cook & Ward, 2012). As a point of convergence, conferences are powerful spaces, their time-limited nature and intense face-to-face contact provokes powerful experiences for those in attendance, the effects of which last far longer than the encounter itself (Routledge, 2003; Temenos, 2016; Wilson, 2017). Harm reduction conferences in particular are a mixture of knowledge exchange for public health promotion, focusing on technical practices such as point of care HIV testing or needle exchange, as well as knowledge exchange for building a social movement for drug policy reform. In the latter sense, conference sessions focus on the history of harm reduction practice, on issues of civil disobedience, and on training modules for service providers and health care managers to also act as advocates for local, regional, and national policy reform. Providing non-elite actors with advocacy training at conferences helps to build a social movement and to build knowledge about activist practices and solidarity across geographically diverse places. As previous work has shown, convergence “spaces facilitate multi-scalar political action by participant movements" (Routledge, 2003, p. 345; cf Temenos, 2016; Routledge & Derickson, 2015).

While convergence practices are primarily focused on knowledge exchange, it is important to emphasize that they are effective precisely because of their time-limited nature and face-to-face encounter. Being present and meeting new people, or renewing ties with people, provides an important relational aspect to convergence practices (the sharing of knowledge and experience) and the convergence spaces themselves (everyone being together at a particular place for a particular time). Landmark meetings, conferences and protests are almost always referred to by place. This is true of large-scale multi-lateral meetings such and the United Nations climate meetings (e.g. COP 19 in Warsaw), as well as by large conferences such as the International HIV/AIDS conference (e.g. Toronto in 2006), and by grassroots demonstrations (e.g. Tahir Square, or Seattle in 1999). The place-based significance of convergence also helps to shape other practices of non-elites focused on policy change, which we explore below.

Disobedience

The history of SCSs has been a history of civil disobedience. In many places where they have become legally sanctioned parts of the public health system, the ‘pre-history’ of SCSs included drug users and allied activists setting up sometimes makeshift and sometimes well-equipped sites. This flouting of the law has been done for practical and pragmatic reasons: SCSs are proven to reduce the harms of blood-borne disease and overdose. Yet, equally pertinent to our discussion, disobedience strategies have been employed to change policy and achieve the legalization of these spaces by establishing ‘proof of concept,’ forcing the hand of authorities. For example, Frankfurt, Sydney, and Vancouver all had sites operating illegally, often with the tacit support of local police who could see the benefits of the sites in removing drug use and drug-related litter from public spaces. Moreover, even in cities where legal SCSs exist, activists have sometimes continued to set up unsanctioned sites. There are various reasons for this form of civil disobedience; one being that the establishment of an illegal site may provide a space with fewer restrictions than a sanctioned SCS. Legally-sanctioned SCSs in Canada, for example, operate under an exemption from the Federal Controlled Drugs and Substances Act. These exemptions are often predicated on certain restrictions on access and on the practices that can occur within the facilities. For example, most prohibit access to minors, some are only available to the participants of the organizations that run them, and few operate on a 24-hour schedule. Some enforce rules around interactions and practices within the consumption room, such as prohibiting one participant helping another to inject, constructing barriers to people with physical challenges. Illegal sites, then, tend to provide a less formal, less professionalized, less medicalized, less regulated context for consuming drugs, while also providing peer support, clean supplies, and supervision for a wider range of people who use drugs.

These ‘disobedient’ sites also tend to be able to more quickly emerge and address crises. This has been particularly evident in Canada since 2016. British Columbia was in the midst of a still-continuing fentanyl-related overdose crisis, with a significant spike in the number of overdose deaths. In September of 2016 Vancouver organizers built on the existing model of unsanctioned consumption sites described above to create what they called an Overdose Prevention Site (OPS) in some tents in an alley. This model quickly proliferated through the most affected neighbourhood in the city, with tents popping up in other alleys. These were not sanctioned like Insite, but police first turned a blind eye to them and local politicians expressed support for them because they were saving lives. The sites serve both a public health and a political purpose. They operate on a peer-based format that attracts people who may be less likely to engage with more formal SCSs and they have become important centres for the distribution of naloxone, an overdose reversal drug. As one of the founders of the original OPS, speaking just over a year later, put it, ‘The death toll would be way worse if we didn’t have these sites here’ and, she continued, this form of civil disobedience is ‘pushing government officials’ by showing ‘communities that it works, that it saves lives, that it’s not hard to do’ (Blyth, quoted in Eagland, 2017). She went on to argue that the ‘“simple” and inexpensive harm-reduction model can quickly be replicated in any Canadian community that lacks an official supervised-consumption site’ (Eagland, 2017).

Soon after the original site opened, the Province of British Columbia helped set up numerous other OPSs without the necessary Federal exemption (Lupick, 2016a, 2016b), and a year after that, the Federal government provided Provinces and Territories with general temporary exemptions in order to streamline the establishment of OPSs (Government of Canada, 2018a). What started as non-elite disobedience quickly changed policy at the local, Provincial, and Federal levels. Now, numerous OPS-style sites are in operation across Canada, including many that are sanctioned, or are applying for legal status, and yet others still operating beyond the law – as what Health Canada calls ‘Interim Sites’ (Government of Canada, 2018a, 2018b).

Display

An important aspect of the broader politics of harm reduction policy mobility involves display. The problems and harms low income, racialized people who use drugs experience are often not particularly prominent in the public sphere. Thus, people who use drugs and their allies have frequently found ways to visually represent these, often life-threatening, problems. At various points in the history of harm reduction politics in Vancouver, for example, emblems of drug-related deaths have been placed in public spaces – particularly a park in the neighbourhood most affected by drug-related harms. In the late 1990s and early 2000s, many hundreds of crosses were driven into the park’s turf and inscribed with the names of overdose victims. These displays were accompanied by marches on surrounding streets. In 2017, as the contemporary overdose emergency gripped the city, people who use drugs and their allies again marched in the streets and returned to the park to hang carved wooden feathers in its trees, again inscribed with the names of lost loved ones and accompanying messages of grief and demands for better health protections. These display strategies visualize and publicize the extent of the problem. As a poem written by one of the organizers of the original protest puts it, ‘we pounded 1,000 crosses into oppenheimer park / blocked main and hastings with a heavy chain / and distributed statistics of misery / to commuters unable to get to work’ (Osborn, 2008). Their power is emphasized by the fact that similar displays of crosses have happened a number of times in Canadian cities since the 2000s, as activists have demanded more harm reduction from governments. Most recently, wooden crosses appeared outside the Provincial legislature in Toronto, Ontario as part of a protest against the Province’s Conservative government’s foot-dragging on OPSs in the face of the overdose crisis (Berman, 2018).

From 2003 until 2011, Insite operated as a time-delimited research trial before the Supreme Court of Canada eventually assured its permanence. In that period, efforts to protect the site’s future were also characterized by strategies of display. In 2008, at a time when its future was in the hands of a sceptical national government, harm reductionists returned to the cruciform imagery of a decade before but upturned its meaning. By arranging a truckload of wooden crosses they had driven from Vancouver in front of the Parliament buildings in Ottawa, they displayed symbols, not of those who had fallen victim to overdose death, but of those who were still alive because they used Insite. These symbols were in part intended to humanize what Osborn had called the ‘statistics of misery’ associated with drug-related harm. The relationship between political persuasion, display, and the humanization of those who have died and who remain under the threat of death was further emphasized that day on Parliament Hill as banners featuring black-and-white family photographs were unfurled near the crosses. These were pictures of current Insite users as children and, underneath each cherubic face, the slogan ‘Before they were “Junkies” they were kids’ emphasized the point that Insite is a health service for people like every other Canadian – people with rights, including the right to health care (Knitnut.net, 2008).

Proponents of SCSs argue they reduce some drug-related harms. Yet, they often provoke suspicion when they are proposed in new locations. Advocates have long used strategies of display to demystify the sites, how they work, and how they might relate to their neighbourhoods. During Vancouver’s debate over the proposed first SCS in North America, for example, nurses used a room in a church to create a mock-up of an SCS, similar to those in Frankfurt, Germany. With its mirrored booths, the room resembled a hair salon. This metaphor came to be used as a way of making the proposed facility more palatable among policy-makers and local residents. They ‘had people walk in and everything,’ one advocate recalled. This discursive and visual strategy was ‘just like normalizing’ the proposed solution (Interview, Vancouver 2006). Resonating with earlier attempts to use mock-ups to demystify SCSs, in the ‘Safe Shape’ project in the US has created a travelling exhibit of a ‘mock … supervised injecting facility’ intended to ‘reflect and project an image of reason and trustworthiness and instill confidence in all visitors’ (safeshapesif.com; Butler, 2017). Display is, then, a frequently repeated strategy through which non-elite actors and social movements circulate models for, and address resistance to, harm reduction.

Conclusion

Studies in a number of disciplines since the 1980s have shown that policy mobilization is an increasingly ordinary part of policy-making at all scales of government. Yet, the preponderance of those studies suggest that while the practice has become commonplace, those involved in it have largely been elites, rather than either more ordinary members of state bureaucracies, or of private or community organisations. In this sense, the majority of literature on policy transfer and mobility have tended to follow an elite theory approach, suggesting that, in one way or another, a relatively small class of privileged actors are empowered to develop mobile policy models, circulate them, and facilitate their adoption in an array of locations. Our purpose, on the other hand, has been to highlight instances of counterhegemonic policy mobility (Massey, 2011), or ‘counter-mobilities’ (Temenos, 2017) envisioned, initiated, conducted, and brought to fruition by non-elites through their prosaic engagements with one another and the state (Painter, 2006).

Harm reduction is a useful example of counterhegemonic policy mobility that has fully involved non-elites. As a public health approach and social movement aimed at improving the lives of people who use drugs, it runs counter to hegemonic criminalizing and moralizing proscriptions against the use of certain psychoactive substances. Moreover, as a philosophy, harm reduction has always foregrounded the important role of people who use drugs having a say in decisions made about their care and in advocating for changes in how their drug use is governed. In this regard, not only are people who use drugs and participate in harm reduction services important to the character of the movement, its stance on policy, and its related politics, but so are the front-line service providers who engage directly with them on an everyday basis. Therefore, as harm reductionists seek to change policies around drug use, from overturning bans on needle distribution, to achieving the establishment of SCSs, to challenging the international regulatory framework that controls drugs (Bewley-Taylor, 2012), ordinary people who would, by Mills' (1956) definition, be disempowered and lacking in understanding the forces impacting their lives are, by contrast, central to the movement’s influence on politics and policy-making.

Through strategies of cooperation, convergence, disobedience, and display, among others, harm reduction politics has developed since the 1980s into an increasingly potent challenge to hegemonic drug control regimes. In the face of a devastating fentanyl-related overdose crisis, more jurisdictions are discussing the utility of the SCS model and other harm reduction approaches. In the future, ordinary harm reductionists, among others, are likely to continue advocating for deeper changes to existing drug control regimes and for the development of regulated markets for substances that are currently only available through unregulated sources. Policy mobility and policy change are likely to continue to tie the practices and fates of elites and non-elites together as policies related to drugs are debated further.

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No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Tom Baker

Tom Baker is a Senior Lecturer in Human Geography at the University of Auckland, New Zealand. His research examines processes of change in governance and public policy. He recently co-edited 'Public policy circulation: Arenas, agents and actions' (2019, Edward Elgar) and is an associate editor of the International Journal of Housing Policy.

Eugene McCann

Eugene McCann is University Professor of Geography at Simon Fraser University, Burnaby, BC, Canada. An urban political geographer, he researches policy mobilities, urban policy-making, harm reduction, public space, and planning. He is managing editor of EPC: Politics & Space.

Cristina Temenos

Cristina Temenos is a Lecturer in Urban Geography at the University of Manchester, UK. Her research focuses on the mobility of health and social policies and the politics of policy change and social reproduction. She is on the editorial board of Environment and Planning C: Politics and Space and Geography Compass.