Risk environments and drug harms: A social science for harm reduction approach

Abstract

A ‘risk environment’ framework promotes an understanding of harm, and harm reduction, as a matter of ‘contingent causation’. Harm is contingent upon social context, comprising interactions between individuals and environments. There is a momentum of interest in understanding how the relations between individuals and environments impact on the production and reduction of drug harms, and this is reflected by broader debates in the social epidemiology, political economy, and sociology of health. This essay maps some of these developments, and a number of challenges. These include: social epidemiological approaches seeking to capture the socially constructed and dynamic nature of individual-environment interactions; political–economic approaches giving sufficient attention to how risk is situated differentially in local contexts, and to the role of agency and experience; understanding how public health as well as harm reduction discourses act as sites of ‘governmentality’ in risk subjectivity; and focusing on the logics of everyday habits and practices as a means to understanding how structural risk environments are incorporated into experience. Overall, the challenge is to generate empirical and theoretical work which encompasses both ‘determined’ and ‘productive’ relations of risk across social structures and everyday practices. A risk environment approach brings together multiple resources and methods in social science, and helps frame a ‘social science for harm reduction’.

Introduction

Drug harms are shaped by risk environments (Rhodes, 2002). There is a momentum of interest in understanding how the relations between individuals and environments impact on the production and reduction of drug harms. This is reflected by broader debates in the social epidemiology, political economy, and sociology of health, as well as HIV prevention (Gupta, Parkhurst, Ogden, Aggleton, & Mahal, 2008). This essay maps some of these developments.

One way to define a risk environment is to see it as the space – whether social or physical – in which a variety of factors interact to increase the chances of harm occurring (Rhodes, 2002, p. 88; Rhodes, Singer, Bourgois, Friedman, & Strathdee, 2005, p. 1027). This broad definition has led to envisaging a risk environment as comprising types of environment (physical, social, economic, policy) interacting with levels of environmental influence (micro, macro). Table 1 illustrates this simple heuristic, using selected examples relating to HIV risk and drug injecting (see also, Rhodes & Simić, 2005). This same logic implies an ‘enabling environment’ framework of social and structural change (Table 1). This is clearly not a model which purports to delineate causal pathways. And it is not theory in the positivist sense. But it is theoretical in its offering of a generative framework into which empirical and theoretical work might give primacy to context when understanding and reducing drug-related harm. Studies have unpacked the nature of risk environments in relation to varied drug-related harms, including overdose (Green et al., 2009, Moore, 2004), syringe sharing (Rhodes et al., 2003; Small, Kerr, Charette, Schechter, & Spittal, 2006; Strathdee et al., 2008), and sex work (Shannon, Kerr, et al., 2008; Shannon, Rusch, et al., 2008).

A ‘risk environment’ framework envisages drug harms as a product of the social situations and environments in which individuals participate. It shifts the responsibility for drug harm, and the focus of harm reducing actions, from individuals alone to include the social and political institutions which have a role in harm production. This essay considers different social science perspectives on the relationships between risk environments and drug harms. It serves to introduce this journal special issue.

Social science critiques of the relations between drug harms, individuals and environments can present daunting challenges from a pragmatics of harm reduction perspective. They include the increased recognition of the ‘nonlinearity’ of interactions in the difficult to delineate pathways between environments and drug harms, the problems posed by the inseparability of ‘levels’ of environmental influence, the seemingly daunting array of ‘factors’ produced by models of risk environment, and how to capture the dynamism of reciprocal relations between environments and individuals in which individuals at once ‘embody’ their risk environments and adapt them (Agar, 2003a, Duff, 2007, Fitzgerald, 2009). The emphasis of this work is theorising the risk environment, but in order to act.

Let us remind ourselves of how a risk environment approach enables harm reduction. First, it offers a critique on a tendency in public health and the behavioural sciences to emphasise harm as a primary determinant of individual action and responsibility. Models of individual-level change are self-evidently limited in their capacity to explain, encourage or sustain sufficient change to adequately reduce or prevent harm. This shifts the focus for change from individuals alone to the social situations and structures in which they find themselves. Of key interest here is the creation and enhancement of ‘enabling environments’ for harm reduction. Second, it offers a critique to resist blame for harm being directed toward affected individuals and communities, and shifts responsibility for harm to include the social and political–economic institutions which have a role in harm production. This explains its affinity with political–economic perspectives (see below). Third, a focus on risk as socially situated offers impetus to understanding how risk environments are experienced and embodied as part of everyday practices. This helps build ground-up or ‘emic’ understandings of risk subjectivity and environment (also see below). Fourth, and by extension, it implies the incorporation of harm reduction inside broader frameworks promoting human rights approaches to public health. By making visible the social, political and economic dimensions of risk and its regulation, a risk environment approach opens up opportunities for reducing the social suffering of which drug harms are a part.