Policing as public health menace in the policy struggles over public injecting

Policing as public health menace 

The recent study by Small et al. (2005) adds to an existing evidence base demonstrating the negative effects of aggressive street-level anti-drug policing (Aitken, Moore, Higgs, Kelsall, & Kerger, 2002; Best, Strang, Beswick, & Gossop, 2001; Bluthenthal, Kral, Lorvick, & Watters, 1997; Fitzgerald, Broad, & Dare, 1999; Maher & Dixon, 1999; Rhodes et al., 2003; Weatherburn & Lind, 1995; Wood et al., 2004). Outside of Europe, it seems like “groundhog day” (a never-ending repetition) when it comes to dealing with open drug scenes. Having myself only partially documented the impact of a police “clean up” operation in Australia in 1998 it is reassuring to see other studies capture the impact anti-drug policing.

Given our knowledge that aggressive styles of anti-drug policing contribute significantly to the spread of blood borne viruses, it is not too extreme to say that aggressive anti-drug street policing is itself a public health menace (Maher, Chant, Jalaludin, & Sargent, 2004; Maher & Dixon, 1999; Maher, Jalaludin, Chant,& Kaldor, 2005; Rhodes et al., 2004). Aggressive street level policing continues to be the method of choice in ‘cleaning up’ street-level injecting drug use for liberal democratic governments across the globe. Yet many policy makers (including many police) recognise the futility of aggressive street policing. In my view, it is a poor option, it produces uncertainty in the community, it spreads disease, and the results are always temporary. In my own situation, over the past month a group of harm reductionists have been working with a local community in Melbourne, Australia to try and develop a strategy to implement a low threshold injecting space as an alternative to rising levels of public injecting. In the absence of Government will to provide a public health approach to control disease spread, it is inevitable that aggressive policing will be used to displace these drug users to another part of town, again. There must be a better way.

It has become orthodoxy now in many countries for law enforcement and harm reduction strategies to coexist in national drug strategies. This is certainly the case in Canada and Australia. It sounds like a stupid question but why, with such an abundance of evidence that illustrates the negative impacts of aggressive street anti-drug policing are we faced with the continued dilemma of trying to deliver public health solutions whilst at the same time allowing this public health menace to continue to facilitate the spread of disease. We are obliged to ask why, in Philippe Bourgois’ terms, are we throwing drug users a life jacket and at the same time hitting them over the head with the oar (Bourgois, 2003).

As many policy makers would attest, aggressive street level policing is virtually immune to criticism from public health. We need to seek answers as to why, even in the face of mounting evidence does our research fail to change policy. My ethnographic research in 1999 had some local effects but overall had little impact on the capacity of law-and-order advocates to convince policy makers that this style of policing was effective. We therefore need to explore why it is that research, strong and convincing as it sometimes is, can miss the policy mark.

Why does research miss the policy mark? 

There are a number of dimensions to the response to this question. The first dimension relates to the nature of the evidence gathered to date on the impact of street level policing and displacement effects. Maybe the evidence of negative impact is incomplete or perhaps insufficient. Significant evidence must [sic] be generated to convince policy makers that these anti-drug policing strategies cause harm. The difficulty with evaluating displacement effects is that ecological data often has insufficient power and sensitivity to create causal attributions (Weatherburn & Lind, 1995), and quasi-experimental designs of anti-drug policing activities are few on the ground (Caulkins, Larson, & Rich, 1993) and of questionable ethical value. In the case of displacement, Small et al. (2005) and others have demonstrated using ethnographic data that there are multiple displacements as a response to street level policing: ‘temporal displacement’, as the market shuts down temporarily; ‘geographic displacement’ as the public injecting moves to a new area of town with less intense policing; and ‘category displacement’ across different types of harm as the criminal harm from public nuisance is displaced to a health harm to drug users in the form of blood borne virus spread. Others have reported similar findings and produced a characteristic lack of impact.

Why isn’t ethnographic evidence sufficient to convince policy makers of the case for alternative policing strategies? Harm reductionists exposed the impacts of aggressive policing in Southwest Sydney (Maher & Dixon, 1999; Maher, Dixon, Lynskey, & Hall, 2001), and yet the displacement of drug use in 2001 from Cabramatta to neighbouring suburbs was pronounced and ultimately continued regardless of the evidence (NSW Ombusdman, 2003). Five years ago I was invited to write a review of how qualitative drug research was used in policy making in Australia (Fitzgerald, 2000). I suggested that we had to start to match our research stories—our evidence—to the policy stories being told, in order for our evidence to have effect. As Bruno Latour has suggested, the facts are clear when we all agree (Latour, 1987). One possibility is that the evidence we have produced through ethnography and qualitative research, is simply not believed because there is no consensus on what level and type of evidence is sufficient to demonstrate the negative effect of policing. The evidence produced through ethnography is not the same as the evidence produced through probabilistic methods. Ethnographic data is complex, interpretative and a cultural phenomenon can be analysed quite differently by different researchers. For example, Bourgois, 2001, Bourgois, 2002 and Binford (2002), both spent time in war-torn Salvador, both have leftist politics, however, they come to different conclusions about the role of violence in social life both in and out of war time. This illustrates the epistemological complexities of ethnography and the skill it takes to bring ethnographic evidence to the policy table. To date the most detailed evidence of displacement from street-level policing have come from ethnographic studies. Perhaps it is time we tried a different type of research story that appeals to the political conditions in which we work.

In Melbourne, Australia we are in the process of developing a research strategy to document the impact of public injecting on a poor inner city community. The usual data sets will be assembled through a rapid assessment approach: needle and syringe program client data, fatal and nonfatal overdose data, drug treatment and arrest data and quantitative peer-based structured interviews with injecting drug users. But in addition we are planning to ask drug users to shoot video diaries to tell us something about their lives using short video segments (no more than 90sec) suitable for broadcast news formats. There is of course great risk in the video documentary initiative, however this form of storytelling may well be the type of evidence that carries a different weight to produce political results.

A second dimension to the question as to why we are faced with the continued dilemma of trying to deliver public health solutions is a political dimension. There are four common political arguments used by harm reductionists (including myself) to try and persuade policy makers and police of the dangers of aggressive street level anti-drug policing. The first is the snowball analogy: moving drug users on will only increase drug use in another part of town and will in effect increase the overall pool of infected people and will result in a political backlash against the Government that caused this problem. The second argument is that aggressive policing simply moves it into someone else's backyard and it is not the role of government to create crime problems for communities through displacement. The third argument is one of compassion for the marginalised in society, and that includes drug users. The final argument is drawn from the Swiss and German experience of injecting rooms, where displacement from aggressive policing did not produce public order, and a more effective method of controlling public space was to create sanctioned spaces for injecting for the purposes of public order (Dolan et al., 2000, Hedrich, 2004). They all sound like fine arguments, however, they haven’t been able to convince our politicians or the local community of the need to abandon aggressive policing responses. We need to explore the political context behind the policy debate, and therein lies the problem for evidence, as politics is as much about emotion as it is about logic.

Although a number of researchers have advocated for discretionary policing (Beletsky, Macalino, & Burris, 2005; Kerr et al., 2005; Maher & Dixon, 1999), this more complex policing option simply doesn’t compare with the political frisson created by the symbolic effect of exercising the power of the state on its citizens. Many will recognise the surge of pride when we see that the State, acting through the will of its people, can excise demons, promote good health and save lives. I am sure most of us at some time would have used the successful exploits of anti-tobacco campaigns to illustrate the power of Government to protect the public health of its citizenry. At a time when many Governments are removing themselves from the delivery of services to the community, most of us would celebrate the success of the public health anti-tobacco initiatives which have had such a positive public health impact on tobacco consumption. We like to see strong Governments that act for the good of the people. Stories about strong Government, be they news stories, conversation or research stories evoke emotion and produce political effects. Katz (1987) and before him Hughes (1940) recognised the importance of emotion in stories about the power of Government to fight crime. Crime stories reassure us that the beliefs we face in our daily routines can be overcome through moral certitude and effective control. Getting tough on drug crime is a most effective political tool and sends a strong message to the community. Drug crime stories are exemplars for law-and-order Governments who seek to reassure the populace of the power of the state to save them from disorder.

Likewise public health ethnographies that demonstrate the strength of law enforcement run the risk of simply reinforcing the political weight of law enforcement. Perhaps this is why law enforcement advocates seem to be bullet-proof when it comes to evidence that shows the power of policing to cause harm to drug users. Maybe it is just the kind of story they want to hear because it reinforces the image of the state that they believe will produce the political results they desire, a populace who believes in strong Government.

What kind of evidence do we need? 

One approach is to ask what kind of evidence will assist in the task of reducing the political weight of aggressive policing in this environment. Asking this kind of question is antithetical to the scientific endeavour, as it does not ask for an answer to a question, but for the evidence. In research terms it is a transductive approach, in media terms, looking for an angle, in political terms it is looking for a research story that can match the policy story. However you describe it, it is a question worth asking. Rather than producing evidence that policing causes harm to drug users, perhaps producing evidence that policing is ineffective will be more helpful in stopping aggressive street-level policing. Evidence that shows drug users evading police, successfully using needle and syringe programs and continuing to inject will be bad news for law and order advocates. Even worse for the law-and-order types will be the newsworthiness appeal of this kind of story. If Jack Katz's media analysis is right, evidence showing the resilient power of the drug user to avoid capture will be an instant hit. According to Katz, crime stories showing the power and ingenuity of human resourcefulness are the most prevalent stories in print media. If we are able to produce evidence of drug users who can continue living their lives, evading police and continuing to inject, we would anticipate it will get lapped up by the news media.

All this speculation is well and good, but it does seem to stretch the mandate for social scientists. I would imagine a lot of epidemiologists and classical sociologists would be shaking their head at this quest for “story” rather than for “truth”. In terms of the dilemma facing us in developing a response to public injecting in inner city Melbourne, we will bring in a media expert to assist, if only to allay the fears of the scientists that they may be working outside their comfort zone.

I hope I will never again read another ethnographic or ecological study showing the negative public health impacts of street level anti-drug policing. It is a hope that springs from the slim chance that this type of policing will go out of vogue or, even less likely, that the research evidence has convinced policy makers of the folly of such misadventure. The challenge for us all is to try alternative forms of evidence in an effort to create research stories that can make a difference. This is risky, but researchers need to step outside the comfort zone of realist depiction and try to affect the policy environment on different terms if we are to shift the balance in drug policy back to public health.