We have a saying in Pakistan,” smiled the taxi driver. We were discussing two-year-olds as we drove out of St. Louis, Missouri to the airport. “If they’re not breaking something or making noise, it’s time to call the doctor.”

It struck me that something similar might be said of civil rights and social justice movements. The drug policy reform conference that I had just left vibrated with debates about the extent to which advocates should work with, or within, systems that inflict harm—criminal justice, law enforcement, Capitol Hill—and the extent to which doing so risks complicity, and civil disobedience is required.

But delegates’ widespread inclusion of public health on that list of damaging systems means that “call the doctor” might not be their chosen emergency response.

The Movement’s Big Goals

The biennial Reform conference, organized by the Drug Policy Alliance (DPA)* and held this year in St. Louis from November 6-9, brought together over 1,200 activists and experts from over 40 countries. Grassroots activists, directly impacted people, hands-on harm reductionists, researchers and lobbyists mingled in the cavernous open spaces of the Union Station Hotel. Organizers offered an array of resources—from drug-checking to safe spaces to an on-call defense attorney—for delegates who use drugs, while noting the threat of applicable laws.

A sharps container in a hotel bathroom.

“The drug war touches just about everything; it has distorted so much,” said Maria McFarland Sanchez-Moreno, DPA’s executive director, in her speech at the opening plenary. She emphasized the common cause drug policy reformers should make with advocates for racial, reproductive, housing and other forms of social justice: “We need to figure out how to reach across movements, because we will build power together.”

“I bring you greetings on behalf of the thousands of African Americans who have been criminalized or incarcerated.”

The opening address had been delivered by Rev. Kenneth McKoy, a St. Louis pastor who founded the NightLIFE Ministry. Conceived as a violence prevention program, it evolved to cover access to housing and affordable treatment, and naloxone distribution—meaning he became a harm reductionist before he knew it. “I bring you greetings on behalf of the thousands of African Americans who have been criminalized or incarcerated because of their addiction,” he said. “On behalf of those children who go to bed crying because their parents are incarcerated.”

Rev. Kenneth McKoy addresses the crowd.

The stakes had also been emphasized by a video message from Rep. Alexandria Ocasio-Cortez (D-NY), calling for changes like decriminalization and “moving money out of the DEA and into overdose treatment programs”—and by an invitation for gathered delegates to call out the names of people they had lost. It took several minutes.

McFarland outlined her organization’s three “big goals.” The first is to “truly expose the array of the harms of the drug war, in all their scale” and “working to document this; working to change those systems.” As well as drug-involved deaths, arrests and mass incarceration, she cited repealing federal bans on college aid for students with drug convictions; ending cannabis testing as a barrier to employment; and exposing harms beyond US borders.

McFarland, whom Filter profiled last year, has a background in international human rights advocacy and scholarship. She spoke of torture and other abuses, of Central American migrants fleeing due to the long reach and consequences of the US drug war, of “children torn from parents’ arms” at the US border: ”Those of us in the US need to recognize that we have a key role here.”

The second goal, said McFarland, is “to ramp up our attention and focus on some of the toughest places in this country.” Mentioning areas of the South and Midwest where reforms are “hardest to implement” but desperately needed, she cited “the devastating rise of overdose which disproportionately affects Black people in Missouri.” She also celebrated “a massive victory in Florida this year, when we got the Republican-controlled state legislature to unanimously support a bill approving needle exchange statewide.”

The third goal, she said, is “to start building out the alternative systems that we want to create—approaches grounded in people’s health, dignity and well-being.” As well as finding the best way to continue legalizing cannabis, she mentioned “finally establishing safe consumption sites in the US” and “finally decriminalizing possession of all drugs for personal use. Possession is the Number One arrested offense in this country—that’s outrageous—almost 1.5 million arrests every year, just for using drugs.”

“How do we respond to people involved in the drug trade? What do we do about safe supply? And what do we do about regulation of all drugs?”

With cannabis now legal in 11 states and rapid progress on naloxone and syringe access and Good Samaritan laws, McFarland could point to “tremendous successes” in the face of these mass violations. “This is no longer a third rail issue,” she declared. “Members of Congress are now engaging in ways that they never had before. Internationally, the conversation has also broken open.”

She focused on the word “compassion” in DPA’s vision statement. This drives, she said, efforts to ensure “meaningful access to treatment” for people with substance use issues, “including access to MAT [medication-assisted treatment] in prisons and jails, and heroin-assisted treatment.” It informs the right to realistic, science-based drug education, like DPA’s recently-launched Safety First high school program. And it means that for new industries created by this movement, “We need to pay attention to how they’re structured, to who benefits from them, and how they’re undoing the harms of prohibition.”

The task ahead, McFarland said, includes “pressing forward and figuring out the answers to the really tough questions: How do we respond to people involved in the drug trade? What do we do about safe supply? And what do we do about regulation of all drugs?”

“The more you look at the drug war, the more it appears like an outsourcing scam.”

A fiery speech followed from Alejandro Madrazo Lajous, a professor at the CIDE law school in Mexico who founded its drug policy program. “In the name of the War on Drugs, we have systematically been curtailing our fundamental human rights,” he said. Detailing atrocities in Mexico, including horrific murders of children and mothers in the past week, he noted that what’s happening there is indivisible from events in the US—with policies interacting and guns going south across the border as readily as drugs go north. “They are Mexico’s dead, and they are the US’s dead.”

Yet the drug war’s impact is fundamentally unequal, he observed. “That trail of blood and suffering disappears when it hits El Paso; it reappears in Ferguson and Black communities across the United States. The more you look at it, the more it appears like an outsourcing scam.”

“We are now in a moment where we cannot keep moving forward without … the people who are being left behind,” he concluded. “We have to make sure that Black men, who were arrested for possession, are not now going to be arrested for jaywalking or walking while Black … No longer can we rely on denial to allow us to sleep well while people are still being imprisoned and still dying of overdose. Push harder and broader: Look at all drugs, look at all countries, look at all the implications of this devastating drug war that is destroying lives, communities and countries’ commitments to human rights … Let’s legalize it, and legalize it right!”

Front Lines in St. Louis

The drug war is so ubiquitous that any Reform location would highlight local suffering and injustice, and different ways in which people are fighting against them. Yet St. Louis notably stands on several front lines.

One is police brutality. In August 2014, the killing of Michael Brown in neighboring Ferguson sparked protests on the streets and national outcry over police shootings of people of color.

Another is cannabis laws. Missouri, a deep-red state, overwhelmingly approved medical marijuana by popular ballot in 2018, and a 2020 push for adult-use legalization is anticipated.

Yet another is harm reduction. Drug-involved deaths, which may be falling nationally, are climbing in Missouri, and, as Mcfarland noted, “the rate of overdose for Black people is extraordinarily high⁠—it stands out in that respect.” Harm reduction here is severely curtailed, however, with syringes still criminalized and funding scarce.

Inez Bordeaux of Arch City Defenders is an organizer for the “Close the Workhouse” campaign aimed at St. Louis’s medium-security prison. She knows of its conditions first-hand. Bordeaux told a panel audience of “a seven-year journey where I was chewed up inside the criminal justice system.”

“I have been personally impacted by these oppressive systems, by white supremacy … by how traumatic locking people up in a hellhole of a facility is.”

“It began,” she said, “when my ex-husband picked up a hot skillet from the stove and burned me with it … I left, and I took my four children with me.”

With severe financial struggles, “after I lost my second job, I kept on drawing my unemployment benefits. My choices were to do that, to break the law so I could look after my children, or go back to the man who burned me with a hot skillet.”

Then one day, Bordeaux was pulled over in Oklahoma: “You guys know that feeling when it takes the officer a little too long to come back?” They turned up a felony warrant against her for larceny, relating to her claiming the benefits. Bordeaux was arrested and held, then extradited back to St. Louis. Facing prosecution and unable to retain employment, she spent the next three years living homeless and had to send her children away.

Yet she held onto hope. “I knew that I just had to make it through my five years of probation; if I could do that, everything would work out … and that’s the attitude I had until, in March 2018, I was arrested again on a technical violation and sent to the Workhouse.”

“It wasn’t until I went to the Workhouse that I felt hopeless,” she said. “I did 30 days there, the longest, most traumatic 30 days of my life—those 30 days radicalized me.”

Bordeaux said that the public defender who was assigned to her then “saved me.” He fought for her on the basis that the statute under which she had originally been prosecuted was ruled unconstitutional by the Missouri Supreme Court in 2017. Her sentence was vacated.

But rather than celebrate as planned, Bordeaux went home and wept. This despair soon turned to anger. “My life fundamentally had not changed. I have been personally impacted by these oppressive systems, by white supremacy … by how traumatic locking people up in a hellhole of a facility is.”

The unconstitutional statute she was convicted under “affected 12,000 people in St. Louis,” she pointed out. “I was one of 800 people that was able to get my sentence vacated—it was not made retroactive. How many others are in jail or prison, or on probation because of a technical violation?”

“I would love to say that I do this work from a happy, healthy and wholesome place,” she admitted. “But it doesn’t; it comes from a petty, vengeful place! I do this work because I want to make the state rue the day they ever saw my name. I told you guys my story because I want you to be angry too … and I want you to come and fight.”

Her fellow panelist is superficially on the other side of the fence. Wesley Bell is the prosecuting attorney for St. Louis County. But he described his journey in terms that left no doubt of his commitment to reform.

He became a public defender out of law school, and “never even entertained the idea of going anywhere else, because I wanted to make sure people [in my community] got fair representation.” He also taught college in Ferguson a few years before the killing of Michael Brown.

“It didn’t take me long to figure out that real impact came from the other [prosecutor] side,” he said. “When you can make the policies … that’s the kind of impact I wanted to make.” In the aftermath of Ferguson, he considered, “I think there’s a call of duty here; with my expertise I should throw my hat in the ring.”

He worked with the Obama administration on the Ferguson Consent Decree, before deciding to run for county prosecutor “with the mindset of, we’re going to be collaborative to get these reforms.” When he took office in January 2019, he became the first African American to hold the position.

St. Louis panelists Stephanie Regagnon, T-Dubb-O, Wesley Bell, Inez Bordeaux and Chad Sabora.

T-Dubb-O is a hip hop artist who has worked with Wiz Khalifa and an activist with Hands Up United, a Ferguson-based social justice organization. He described a St. Louis childhood filled with threats. “I was four years old when one of the neighborhood drug dealers approached me and asked me if I would work for him.”

At 14, “I had my first physical encounter with law enforcement. There was an ordinance back then that if you had more than four people standing on your porch, you could get a citation.”

One officer, who “used to harass us all day,” came and “screamed” at members of his family for standing on their porch. When his grandmother objected, the officer said, as T-Dubb-O related, “I’m not going to talk with you, you old bitch.”

“I said, who the fuck are you talking to? This is my grandmother, she’s 80 years old; have some respect.” For that, T-Dubb-O recounted how he was handcuffed, taken to the precinct and beaten. “From that moment, I knew that my life was in danger every time I came into contact with a police officer.”

Kicked out of school for having too much “influence” over other students and excluded from jobs, he sold drugs on-and-off for 14 years. “It got to the point where I was only selling to white people because I didn’t want to sell to people who looked like me,” he said. “My best customer was a children’s hospital surgeon!”

“But I don’t regret it,” he said, because everything I did put me in a position where I could have a conversation with President Obama and go into crack houses and negotiate ceasefires with gang members.”

“A lot of people say the system is broken. The system isn’t broken; it’s performing exactly how it was designed.”

Ferguson was a personal catalyst for T-Dubb-O’s advocacy, which includes providing tech training opportunities for disadvantaged youth. But when he first heard about Brown’s killing, he loaded his car with legal guns and drove over there, only to be dissuaded by a friend.

“I can no longer rap about these conditions,” he decided, “without making sure that I am applying myself 100 percent to changing these conditions. I think Ferguson showed that we can do this work.”

“It clicked in my mind that we’re not going to get any change from the system,” he added. “A lot of people say the system is broken. The system isn’t broken; it’s performing exactly how it was designed.”

This last comment prompted debate among the panelists. Prosecutor Wesley Bell said: “I agree that the system isn’t broken; it’s performing as it was designed. The problem is that this is the system that we have, and if you tear it down, you still have the same builders. Let’s do what we can [right now]. There’s someone sitting in jail who shouldn’t be⁠—so we gotta figure something out. If incarceration worked, we’d be the safest place in the world.”

Inez Bordeaux responded, tearfully: “Do you know why they said [the ruling on the statute she was convicted under] was not retroactive? Because it’s too hard to go back and track down all of those people—it’s too hard! How do you reform a system like that? Think about that: When the highest court in this raggedy state said it was ‘too hard’ to fix an injustice.”

“And I’m a fan of Wesley—I’m a big fan,” she continued. But “I’m a big proponent of burning it all down and starting over… The roots are rotted.”

T-Dubb-O identified white supremacy as “the root cause of all of this,” but added: “I’m a chess player. Passions will get you murdered on the chess board. If everybody in the city was ready to burn this down, I’d be the motherfucker holding the blow torch…”

He urged activists to think strategically and work as one. “The fight for Black lives has to come side by side with the LGBTQ community, with criminal justice reform, drug reform, environmental reform …. You got five fingers poking a wall individually. They have to do this.”

He clenched his fist.

Safe Consumption Sites: Liberation or Control?

An analogous debate arose at another passionate session, where leading harm reductionists⁠—most of whom actively advocate for, or even operate, safe consumption spaces (SCS)—aired concerns about the limitations and appropriations of this model with unusual frankness.

SCS are shown by much evidence to save lives and improve health outcomes. They’re still illegal in the United States, but the first sanctioned site is closer than ever after a federal judge recently ruled that Safehouse, a group in Philadelphia, would not violate the so-called “crack house statute” by opening one.

Responding to a question about what “liberation” for people who use drugs really means, Monique Tula, executive director of the Harm Reduction Coalition, said, “Liberation, to me, is purpose and place and power. I [know people] who are like: Safe consumption spaces? Meh. I don’t want to be supervised in my drug use … For me, that’s why I haven’t jumped on the bandwagon … I think it can work in certain settings. But real talk? Let’s talk about giving people homes.”

“I’m cautious in my support,” she summarized. “I would rather focus our attention on making sure that people are housed …. Keep government in its fuckin’ place—give us the power.”

Zoe Dodd of Toronto Overdose Prevention Society has helped organize a drug user-led space without waiting for government approval, amid high death-rates. (Five people she knew, she said, died within a single week). She reported concerns about some of Canada’s sanctioned SCS. “It didn’t feel like ‘liberation’ for people sitting in a clinical setting with nurses. They feel like sites of surveillance. They feel like they’re adopting a drug war narrative that drugs are bad and you need to be supervised and watched.”

“We wanted to create something that wasn’t all those rules,“ she explained. “I’ve got nothing against nurses, they’re great for wound-care [etc.]. But people who inject drugs have seen other people inject drugs, and people responding to overdoses in the community know how to respond to overdoses.”

“One [advocacy] tactic I’ve seen that I think, ‘Pease stop doing that,’ is that SCS is a step towards treatment, and will move people to treatment,” she continued. “What the fuck is treatment? It is a profit-driven, non-evidence-based intervention … a bullshit extension of the prison-industrial complex.”

“We are messing up as a movement because we are letting the public health community dictate.”

SCS are “a limited intervention that’s more about public order than it ever was about autonomy or liberation,” said Kassandra Frederique, DPA’s managing director of policy, advocacy and campaigns. “It also shows the limits of our imagination as a movement.”

“Safer consumption spaces is not an alternative, it is an intervention,” she continued. “An alternative would be housing, or a café where people can go in and order what they want. So if it’s not an alternative, it’s not liberation—I can’t understand why we would ever give something regarding drug user health to the medical community. We are messing up as a movement because we are letting the public health community dictate.”

Frederique noted that progress on SCS initiatives is often facilitated by concerns over drug use in public spaces, rather than a desire for people who use drugs to have autonomy. “They don’t want poor people in public space.”

“I will continue to work on SCS because I think it is important,” Frederique made clear. But she also spoke to the importance of gaining community consent for these interventions—and of recognizing the many critical community needs that SCS don’t meet. For example, in New York, “125th and Lexington is a place with a lot of outside drug use, and they want to put an SCS there. They don’t even have a fuckin’ supermarket⁠.”

“Don’t be just dumping programs into Black and Brown communities that are not prepared or may not want them there,” agreed Tula.

“There are lots of people that don’t have space,” noted Miss Ian Callaghan, executive director of the San Francisco Drug Users’ Union. “But I think the drug war in general has touched so many intersections of our lives, that it is hard also [just to give someone a room to inject in and then kick them out].”

“A lot of people have a lot of trauma in settings that look clinical. A lot of harm reduction organizations, we take a health approach first, and then we let people draw pictures with crayons and we put them on the wall: Look, it’s your space! We don’t do enough of asking people what they want.”

Metzineres, a harm reduction organization in Barcelona, Spain, sought to avoid that failing. Aura Roig, its director, described how they went about setting up a consumption room for women, “because they were living really isolated, because they were not going to the [male-dominated] shelters because they didn’t feel safe.”

The group asked the women, “Not ‘what do you need?’ but ‘what do you desire?” And “What we tried to do is just say ‘yes’ to everything. We have workshops, we have photography, we have dance, we have free clothes. We try not to put drugs at the center, and just welcome everybody with our heart.”

“We all know SCS is not the solution … I’m also super-clear that these programs will save lives.”

“We all know [SCS] is not the solution, but it is a part, a tool,” said Laura Thomas, director of harm reduction policy for San Francisco AIDS Foundation. “I’m also super-clear that these programs will save lives and they’re worth doing.”

In terms of winning the battles to introduce them, she said, “While no [jurisdiction] wants to be first, everyone wants to be second, third, fourth, fifth. The Safehouse case won these arguments that had never been tested in court before⁠.”

The panelists made many more criticisms of the public health establishment.

“They want to watch you inject your drugs because they don’t trust you to have autonomy,” said Dodd. “If you’re making partnerships with public health, you’re probably going to fuck it up.”

“We cannot build liberation,” said Frederique, “… in institutions that have not disabused themselves of the commitment to coercion.”

“I struggle with that co-option stuff too,” said Thomas. She mentioned how, in San Francisco, “some of the people who support SCS also support coerced treatment. It’s about trying to figure out how SCS can be part of the liberation narrative, as opposed to part of the control narrative.”

“Once we have [SCS], that opens up these opportunities for us to make them what we need them to be … getting some open is going to be a better step. Different things work for different people; we need to have different sites in different contexts. We need all of these things—and we’re not going to get them until we get the first one open.”

Vaping: “The Great New Drug War of the 21st Century”

Another area where harm reduction and the public health establishment clash is tobacco harm reduction. This has been seen in the public outcry over youth vaping, fueled by misleading messages from the FDA and the CDC and the media frenzy of a classic drug panic.

Almost half a million lives are lost to smoking annually in the US, but the US harm reduction and drug policy reform community has not always centered this issue. Reasons may include perceptions of “turf” and dislike of the industries that make vapes.

It was significant, then, that Reform featured a panel titled: “Are Tobacco and Vaping the Next Frontier of Drug Prohibition?” Among the speakers was Ethan Nadelmann, who founded DPA and led it for over 20 years, until 2017.

Nadelmann joked that this was the issue “that might just tempt me out of retirement,” and acknowledged to the audience, “I know not all of you are persuaded.”

“Cigarettes are truly deadly,” he set out, “so whatever we can do—short of prohibition and demonizing people in a terrible way—if we can be moving people to a less harmful product, that’s what we should be doing.”

He cited the evidence that vaping is around 95 percent less harmful than smoking—and almost twice as effective at aiding quitting as nicotine patches or gum. And he noted that nicotine, by itself, is not very risky.

“The evidence is clear, overwhelming,” he concluded, that tobacco harm reduction should be a priority. Vapes “may be the best cigarette cessation device ever invented.”

“You’re talking about a massive, massive misinformation campaign … It’s basically public health malpractice.”

Both the efficacy of vaping and its stigmatization, he noted, invite parallels with syringe access, methadone and buprenorphine. “But what does the public believe? Seven years ago, the majority of Americans understood that vaping is safer than smoking. Now, between 60-70 percent believe it’s as or more dangerous.”

The researchers whose work is being ignored or misrepresented by anti-vaping politicians or public health authorities remind him, he said, “of the harm reduction academics out there 30 years ago, doing courageous work and incredibly frustrated at being sold out by the majority of the public health community.”

Noting that the vast majority of recent cases of lung disease were caused by vaping of adulterated THC, not nicotine products, Nadelmann said of the failure to communicate this properly, and the general framing of tobacco harm reduction: “You’re talking about a massive, massive misinformation campaign going on right now … It’s basically public health malpractice.”

“And what do you think happens when you start to ban things?” he asked of the recent spate of threatened and actual flavored vape bans. “Driving more people to the black market and killing more people? How ass-backward can that possibly be?”

“It’s reminding me of the same bullshit they put out there about ‘crack babies’ 30 years ago,” Nadelmann concluded. “My fear is, that not only are we taking a major step backwards [in cutting rates of smoking], but we may be at the beginnings of the great new drug war of the 21st century.”

The audience applause suggested little dissent.

Other panelists illustrated further repressive aspects of the new wave of tobacco and nicotine restrictions. Queen Adesuyi, a policy manager for DPA, discussed the impact of the US Department of Housing and Urban Development’s ban on smoking in public housing, impacting “people with various disabilities, people who are wheelchair-bound, and people who just want to smoke a cigarette in their apartment” but are forced to go outside or potentially face eviction.

“I do believe that folks are doing this around good intentions regarding children, second-hand smoke and health,” said Adesuyi, “but there’s no acknowledgement of how this plays out on the ground.”

“Have we not learned in this country that prohibition doesn’t work?”

Brooke Feldman, manager of the Philadelphia Center for CleanSlate Outpatient Addiction Medicine, described the “paternalistic, marginalizing” ban on smoking in publicly funded treatment facilities in Philly, which increases barriers to care and may result in people being kicked out to face fentanyl-adulterated heroin on the streets. “And it only affects the poorest Philadelphians, people on Medicaid.”

Filter Senior Editor Helen Redmond asked, of bans of flavored vapes and menthol cigarettes, “Have we not learned in this country that prohibition doesn’t work? Where will the NYPD go to enforce the ban? They’re going to go to communities of color—they will not implement it in a race- or class-neutral way. That’s not the way the drug war works.”

Fear and Moral Hazards for Researchers

The distortion, limiting and co-option of drug research were explored in depth at several panels organized by DPA’s Department of Research and Academic Engagement.

Researchers spoke of a climate of fear in their work. This is in part due to the fact that the National Institute on Drug Abuse (NIDA) funds about 80 percent of all drug research around the world, meaning that research into the pleasures of benefits of drugs is often taboo, and harm reduction sidelined.

Author and addiction expert Maia Szalavitz suggested that researchers omit the words “harm reduction” from their proposals, even if that’s what they’re seeking to study.

This climate extends to researchers who use drugs themselves. Ingrid Walker, associate professor of American Studies in the School of Interdisciplinary Arts and Sciences at the University of Washington, Tacoma, has been open about her own drug use. She and others convened a pre-conference gathering of 60 researchers to discuss these issues.

“The majority were young in career, working in community-based research and public health,” Walker told Filter. “And the fear they expressed in terms of wanting to be authentic about their own drug use with people they work with, but knowing the consequences … They knew that job loss would be immediate and felt that pressure.”

It’s a fear shared by so many people in many lines of work.

One panel of academics set out to dismantle the notion of “moral hazard” that has gained such media currency in regard to harm reduction interventions on the back of a couple of recent papers.

“Moral hazard is a term that’s been around in economics for decades,” explained Alex Kral, an epidemiologist and distinguished fellow at RTI International. “It’s the idea that something might have the unintended effect of making things worse than better. For example, driving fast is dangerous, so you invent seatbelts. But if you’re wearing a seatbelt, you might actually drive faster, causing more accidents.”

“There’s no evidence to suggest that people use more drugs or use in riskier ways if they get naloxone or overdose training.”

Translated to naloxone, said Rachel Winograd, an associate research professor at the University of Missouri’s mental health institute, this concept brings “the idea that if we give out more and more naloxone, we’ll have this safety net in society, so people will have no reason not to use heroin or fentanyl.”

However, she asserted, “There’s no evidence to suggest that people use more drugs or use in riskier ways if they get naloxone or overdose training. If anything, they use the same or less,” but are better equipped with knowledge and resources.

Winograd and other panelists critiqued both the flawed methodology of the papers that suggested this idea, and the media’s enthusiasm for them. “Drugs and morals? This is just great!” quipped Kral, who identified moral hazard arguments as another iteration of the old “enabling” trope against harm reduction.

“You really have to dig down … to get at what’s motivating that,” agreed Winograd. “There’s this resentment: ‘Wait a second, all we have against drug use is the potential for death, and if we remove that… then what leverage do we have? People are going to go crazy, using drugs all over the place!’”

That attitude remains entrenched, as researchers’ off-the-record accounts (that fear again) of some high-ranking SAMHSA officials’ positions attested.

Echoing equivalent conference discussions, researchers questioned whether working within a biased, coercive public health framework is justifiable.

“We haven’t really made any gains in drug policy without civil disobedience.”

“The healthcare system—and I can say this because I’m a doctor—it treats people who use drugs like shit,” said Hansel Tookes, an assistant professor at the University of Miami.

Winograd described asking herself every morning if she could continue. But if she quits, “I will be replaced, and who is going to replace me? And that system will go on.”

The researchers present engage in harm reduction advocacy to push back against the routine distortion of their work. But, said Tookes, “I want you to know that’s not the norm in academia!”

“We haven’t really made any gains in drug policy without civil disobedience,” said Kral.

Like others at the conference, Szalavitz asserted that both forms of advocacy—inside and outside the system—are vital. “One of the reasons ACT UP was so successful [in winning reforms to mitigate the AIDS crisis] was they didn’t limit themselves to just outside or just inside,” she said. “They had people out on the streets and they had people in there, talking to people—and that’s what’s going to change things.”

Where the Movement Stands

Fully representing the intersecting issues explored at Reform 2019 would require not an article, but several books. Vital subjects explored at dozens of panels and meetings ranged from the persecution of sex workers under SESTA/FOSTA, to the role of faith in harm reduction, to activating people who sell drugs as a harm reduction resource, to the healing power of psychedelics, to models for legalizing all drugs.

Despite this dizzying diversity, DPA Executive Director Maria McFarland Sanchez-Moreno told Filter that the movement remains coherent—and in fact, more united than ever.

“I feel like people are very open to each other right now,” she said, of the many social justice movements represented at Reform. “A couple of years ago, maybe there was a little more friction. Right now, there’s just a lot of solidarity. I’m thrilled about that.”

Some in the movement have worried about the internal strength of DPA, arguably the most important organization in drug policy reform. Earlier this year, DPA cut a significant percentage of its staff and closed some state-level offices. McFarland has previously explained this as the result of a surge in donations, related to early cannabis legalization efforts, somewhat drying up as more states achieved legalization. She told the New Jersey Globe that by taking these painful steps, her organization sought to become “more flexible” and capable of pursuing campaigns in more states.

Asked whether we could be confident of her organization’s future growth, McFarland replied, “Absolutely.”

“DPA has had to go through a very difficult process of restructuring, and it was incredibly painful for all of us,” she elaborated. “And yet, my colleagues have really dug in and come out of it in many ways stronger, with renewed commitment to the work.”

“You’re seeing people in a movement that’s maturing. That’s exciting to me. Now we’re building from here.”

“I think you’re seeing the outcome of all of that in this conference,” she continued. “The sense of unity here flows from the sense of unity within the organization itself. You’re seeing people in a movement that’s maturing. That’s exciting to me. Now we’re building, from here, something that I think is going to be amazing.”

When I asked whether part of the movement’s “maturity” involved effectively balancing pursuit of the deep structural changes that advocates want, and winning the immediate incremental reforms that can help people right now—a tension reflected over and over again at Reform—McFarland agreed. “It’s something we continually debate internally,” she said, asserting the value of pursuing step-by-step improvements to people’s lives, while also “never losing sight” of the ultimate goals.

And in large or small steps, at every jurisdictional level and despite the Trump administration and other daunting headwinds, the progress does keep coming.

“I have great news!” Chad Sabora, executive director of the Missouri Network for Opiate Reform and Recovery, announced to one audience: “43 minutes ago, St. Louis city stepped up to the plate–we just [submitted] our bill to make syringe access legal as a pilot program.”

* The Drug Policy Alliance has provided a restricted grant to The Influence Foundation, which operates Filter, to support the creation of a drug war journalism diversity fellowship.

Top photo shows some delegates in St. Louis gathering to show solidarity with people being persecuted and killed in the Philippines’ drug war. All photos by Filter.