This thesis shows that illicit drug consumers in Vietnam who administer product via injection are vulnerable actors in a paradoxical global/glocal phenomenon rooted in historical complexities of globalisation. Therefore, responsibility for HIV risks should be shifted upstream from the level of individuals toward institutional processes that manufacture environments of harm. At the global level, the UN Milennium Development Goals do not provide the required level of leadership on HIV prevention for drug injectors. Association between globalisation, opiates and blood-born disease in Vietnam is not new and is inseparable from historical transportation, migration and trade processes. As a key locale in the Cold War, after 1975, and 1979 in particular, Vietnam was 'at distance' from increasing intra-regional trade flows across its western frontiers and northern border. As a consequence, it was hermetically sealed to nearby HIV sub-epidemics unfolding among heroin cons umers. A latent HIV risk environment awaited Vietnam should geopolitical grievances be resolved and it became re-integrated among Mekong sub-regional flows. Neo-liberal financial flows returned to Vietnam in 1993 and the Mekong was spanned in 1994. In 1995 it normalised relations with the United States, joined ASEAN and announced the resurrection of transportation linkages across the northern border with China. Mid-decade, its borders were made more porous at the same time as local opium production was reduced as part of the UN global programme against drugs. Exploiting enhanced trans-boundary mobilities intended for goods, opiate traffickers quickly transformed Vietnam into a transit nation and a marke for high-quality heroin well suited to a youthful population experiencing socio-economic change including new consumerism. Following traditional pathways, a radical transformation in the fluidity of drug consumption environs ensued, enabling more widespread and efficient flows of blood across complex boundari es. Analysis reveals that a spatio-temporal confluence of structural factors has created conditions which enabled this process. These factors are overlapping and they range from global influences, such as the collapse of the USSR, to micro-economic reform such as privatisation and modernisation of the domestic pharmaceutical sector. The transformation in opiate consumption from injecting opium to heroin injecting occurred faster than expert-driven prevention systems responded, even in time and space where this was most forseeable. Although the opiate transformation was highly predictable, there has been a time-lag of almost a decade between risk transformations and policy responses equated with harm reduction principles. The thesis shows that blame for HIV sub-epidemics in Vietnam should not be attributed to vulnerable youths and young adults. Expert-driven economic transition associated with global inegration has manufactured circumstances in which drug availability has risen dramatically at a time when emp loyment growth has been insufficient and a commercial sex industry has expanded. This research confirms the cimportance of new methods of risk environment analyses, particularly in relation to trans-boundary hazards associated with global flows, including trade and human mobilities.

Artwork / Streetlives is a community-based, arts-informed, research project which addresses harm reduction amongst street youth in Thunder Bay, Ontario. Nine street-involved participant researchers (supported by a team of researchers and community organizations) used art making and storytelling as ways of understanding the risks specific to street-involved youth in Thunder Bay. Due to the heterogeneous nature of the participant researcher group and a majority of Aboriginal research participants, a novel approach was used to create principles of research collaboration, in pursuit of the principles of ownership, control, access and possession for ethical research with Aboriginal peoples. The participant researchers found that their most common experience was their vulnerability to governmental social services and law enforcement personnel and policies. They further agreed that the risk of losing their children to child protection services is a source of increased vulnerability and a barrier to accessing treatment. They all agreed that the process of art making was fruitful and were surprised by the clarity and evocative nature of their artwork, finding that meeting weekly to do art is gratifying and therapeutic. They were interested to discover that the art they created, just by telling their stories, contained strong prevention messages they would have been influenced by as younger people. As such the participants want to continue making art, and showing their work, particularly to young people, social service providers, and law enforcement officers, who they think are in the best position to learn from it. This project is building capacity in the community (by teaching artmaking, group work, organizing, critical thinking, and presentation skills), is contributing to scholarship, and significantly and positively impacting the lives of the participant researchers. This work is represented in traditional academic prose and as collaborative fiction.

Artwork / Streetlives is a community-based, arts-informed, research project which addresses harm reduction amongst street youth in Thunder Bay, Ontario. Nine street-involved participant researchers (supported by a team of researchers and community organizations) used art making and storytelling as ways of understanding the risks specific to street-involved youth in Thunder Bay. Due to the heterogeneous nature of the participant researcher group and a majority of Aboriginal research participants, a novel approach was used to create principles of research collaboration, in pursuit of the principles of ownership, control, access and possession for ethical research with Aboriginal peoples. The participant researchers found that their most common experience was their vulnerability to governmental social services and law enforcement personnel and policies. They further agreed that the risk of losing their children to child protection services is a source of increased vulnerability and a barrier to accessing treatment. They all agreed that the process of art making was fruitful and were surprised by the clarity and evocative nature of their artwork, finding that meeting weekly to do art is gratifying and therapeutic. They were interested to discover that the art they created, just by telling their stories, contained strong prevention messages they would have been influenced by as younger people. As such the participants want to continue making art, and showing their work, particularly to young people, social service providers, and law enforcement officers, who they think are in the best position to learn from it. This project is building capacity in the community (by teaching artmaking, group work, organizing, critical thinking, and presentation skills), is contributing to scholarship, and significantly and positively impacting the lives of the participant researchers. This work is represented in traditional academic prose and as collaborative fiction.

People who use illegal drugs all too often experience stigma and discrimination, criminalization and marginalization in Canada. Substance use has both immediate and chronic health consequences that may require healthcare. However, people who use illegal drugs often experience difficulty accessing equitable care, and stigma has been identified as a key barrier to access. This study explores the provision of health care by nurses in an emergency department for people who use illegal drugs, and the impact of hospital policies and procedures on nurses’ capacity to provide care. The study uses data from in-depth interviews with nurses and policy leaders, and analyses policy documents discussed by nurses in the interviews. This study found that neoliberal policies that result in downsizing of social programs means that patients come to emergency departments with a broad set of health and socials needs that extend beyond what nurses can do. The study also uncovered a lack of cultural safety for Aboriginal patients seeking care. Finally, the study discovered the existence of a culture of stigma in the emergency department. The culture of stigma is transmitted and taken up through individual attitudes, relations of power, intake and treatment protocols, critical policy absences and problematic policy. This study concludes with recommendations for policy development and for future research in this area. / Graduate / 0680 / 0573 / 0569 / heyriver@shaw.ca

The prevalence of crack use among illicit drug users has dramatically increased in Canada over the past decade. The sharing of crack pipes and other crack use paraphernalia is common among users of crack cocaine and is associated with unique negative health harms and costs (Haydon & Fischer, 2005). This thesis explores the phenomenon of crack pipe sharing among crack users in Victoria, British Columbia. The study uses data from in-depth interviews with thirteen self-reported crack users who regularly share crack pipes. Interviews explored the experiences of participants around crack pipe sharing, focusing on contextual, social and environmental factors that influenced the sharing of pipes. Crack pipe sharing is presented as a largely social act around which shared meanings have emerged. The findings illustrate the social context of crack pipe sharing, which is mediated by informal rules and etiquette, as well as distinct sanctions and consequences for deviating from the generally accepted norms around sharing pipes. Further, three distinct dimensions of crack pipe sharing are proposed - mutual, distributive and receptive sharing - each associated with various costs and benefits, and framed by relations of status and power. The results of this study also demonstrate that crack pipe sharing serves a number of real and distinct purposes in crack users’ lives, providing economic, control and social functions. My findings illustrate that, despite the various health and social harms related to crack pipe sharing, sharing pipes makes sense in the reality and lived experience of the participants.

People who use illegal drugs all too often experience stigma and discrimination, criminalization and marginalization in Canada. Substance use has both immediate and chronic health consequences that may require healthcare. However, people who use illegal drugs often experience difficulty accessing equitable care, and stigma has been identified as a key barrier to access. This study explores the provision of health care by nurses in an emergency department for people who use illegal drugs, and the impact of hospital policies and procedures on nurses’ capacity to provide care. The study uses data from in-depth interviews with nurses and policy leaders, and analyses policy documents discussed by nurses in the interviews. This study found that neoliberal policies that result in downsizing of social programs means that patients come to emergency departments with a broad set of health and socials needs that extend beyond what nurses can do. The study also uncovered a lack of cultural safety for Aboriginal patients seeking care. Finally, the study discovered the existence of a culture of stigma in the emergency department. The culture of stigma is transmitted and taken up through individual attitudes, relations of power, intake and treatment protocols, critical policy absences and problematic policy. This study concludes with recommendations for policy development and for future research in this area. / Graduate / 0680 / 0573 / 0569 / heyriver@shaw.ca

Thesis (Ph. D.)--University of Hawaii at Manoa, 2004. / Includes bibliographical references (leaves 157-169).

O objeto deste estudo é a Unidade de Redução de Danos (URD) da Secretaria Municipal de Saúde de Santo André, compreendida como instrumento do trabalho em saúde, que tem por finalidade transformar a situação de saúde de sujeitos, que fazem parte de um grupo social marginalizado; são indivíduos que circulam ou trabalham nas ruas - usuários de drogas, michês, mulheres profissionais do sexo, homens que fazem sexo com homens, adolescentes em situação de exploração sexual, transexuais, travestis, lésbicas e mulheres que trabalham em casas de programas. O objetivo geral foi: avaliar a URD sob a ótica dos sujeitos que são alcançados pelo programa. Partindo da compreensão de que a \"questão social\" tomou na contemporaneidade novas feições, advindas do processo de reestruturação produtiva, que em maior ou menor grau repercutem na vida dos sujeitos alcançados pelo programa, e partindo do pressuposto de que a URD vai além da distribuição de insumos e orientações para prevenir doenças transmissíveis, procurando assegurar aos indivíduos o direito à saúde e apoiar o acesso a outros direitos sociais, esta pesquisa buscou compreender a situação familiar, de trabalho e de vida dos usuários, verificar como eles avaliam o programa e analisar as repercussões do trabalho da URD em suas vidas. Trata-se de uma pesquisa estratégica de natureza avaliativa que utilizou um método qualitativo para apreensão do objeto. Foram realizadas 19 entrevistas semi-estruturadas com usuários dos diferentes segmentos atendidos pelo programa. Os entrevistados mostraram que: encontram-se em composições familiares muito diversas; trabalhar nas ruas é conseqüência de uma trajetória marginal e da impossibilidade de acessar outros tipos de trabalho; almejam uma vida melhor. Como potencialidades da URD foram apontadas: melhora do cuidado com a saúde e do uso de preservativos; diminuição do consumo de drogas; melhora da procura e do acesso a serviços de saúde; diminuição do compartilhamento de material para uso de drogas; melhora da capacidade de decisão; a URD foi considerada um espaço humanizado, que dispõe de um trabalho regular e contínuo, o que dá aos usuários uma sensação de segurança e de proteção; a ação da URD perpassou a prevenção de danos à saúde, promovendo transformações mais amplas como a consciência de direitos sociais em geral e de saúde em particular, bem como ações no sentido de fazer valer esses direitos; os usuários sentem-se mais fortalecidos para a vida, procurando estudo, trabalho e moradia. Entre as fragilidades da URD estavam: presença inconstante e demora do programa em retornar em alguns dos campos; falta de profissionais de psicologia para acompanhamento dos usuários. Os serviços de saúde do município foram bastante criticados, sendo relatados vários episódios de preconceito e até mesmo de negligência na atenção à saúde. Sugeriu-se: expandir e divulgar o trabalho desenvolvido, agregando ações de RD nas unidades básicas de saúde; apoiar a implementação de associações para reunir as reivindicações dos que trabalham nas ruas ou nas casas de programas; um local mais adequado para o atendimento, entre outros / The subject of this study was the Harm Reduction Unit (HRU) of the Municipal Health Department of Santo André, taking it to be a working tool for healthcare that has the purpose of transforming the health situation of individuals forming part of socially marginalized groups. These are individuals who spend their lives or work on the streets: drug users, prostitutes, female sex workers, men who have sex with men, sexually exploited adolescents, transsexuals, transvestites, lesbians and women working in brothels. The general objective was to evaluate the HRU from the viewpoint of individuals that the program reaches. This study started from the understanding that the \"social question\" has now taken on new features coming from production restructuring processes that, to a greater or lesser degree, impinge on these individuals\' lives, and from the presupposition that the HRU goes beyond distributing supplies and guidance for preventing transmissible diseases, through seeking to ensure individuals\' rights to health and support their access to other social rights. It sought to understand the users\' family, work and life situations, find out how they rated the program and analyze the repercussions of the HRU\'s work on their lives. This was a strategic study of evaluative nature using a qualitative method to grasp this subject. Nineteen semi-structured interviews were held with users in the different segments attended by the program. The interviewees showed that: they were in a wide variety of family setups; working on the streets was consequential to their marginalized path through life and their impossibility of accessing other types of work; and they craved a better life. The HRU\'s potential benefits were indicated to be: improved healthcare and condom use; decreased drug use; improved seeking and access to healthcare services; and decreased material sharing for drug use; improved decision-making capacity. The HRU was deemed to be a humanized space performing regular and continuous work that gave users a sense of security and protection. The HRU\'s actions went beyond prevention of damage to health, through promoting broader transformations such as awareness of social rights in general and health rights in particular, along with actions towards making these rights apply. The users felt strengthened for life and for seeking education, work and housing. Among the weak points of the HRU were: non-constant presence and delay in program response in some of the fields; lack of psychology professionals to follow up users. The municipal health services were greatly criticized, and various episodes of prejudice and even negligence in healthcare attendance were reported. The following suggestions are made: expansion and dissemination of the work developed, adding the HRU\'s actions to primary healthcare units; support for the implementation of associations to bring together the demands of those who work on the streets or in brothels; and provision of a more suitable place for attendance, among others

Esta dissertação teve como objetivo descrever e analisar o objeto/sujeito da redução de danos, a partir da literatura brasileira, tendo como perspectiva teórica os fundamentos da Saúde Coletiva. A literatura internacional mostra que a redução de danos vem sendo adotada e difundida em vários países. A América do Norte e a Europa focalizam o debate na avaliação de estratégias em alguns segmentos populacionais, mas o debate teórico e político parece se concentrar na América Latina, notadamente no Brasil. Para compreender as tendências desse debate no Brasil, selecionou-se 44 publicações nacionais, no período de 1994 a 2006, tendo como referência o LILACS. A análise do material mostrou que a redução de danos tomou inicialmente como objeto as doenças transmissíveis, especialmente a AIDS sendo a finalidade do trabalho a prevenção desses problemas entre usuários de droga injetável. Com o objeto assim circunscrito, atingia-se populações usuárias de drogas consideradas marginalizadas ou excluídas. As primeiras formulações teóricas que orientaram as práticas encontravam-se entremeadas de críticas às abordagens e terapêuticas que unicamente perspectivavam a abstinência. Apesar da crítica por vezes contumaz aos modelos rígidos e intolerantes de combate às drogas, a finalidade de abstinência persistia nos discursos de uma parcela considerável daqueles que acabavam adotando, em maior ou menor grau, a orientação da redução de danos. Dada a envergadura que o fenômeno do consumo de drogas assumiu contemporaneamente, o que levou ao envolvimento de diversas áreas com esse objeto, o debate teórico em torno da redução de danos se ampliou. A adoção de práticas de redução de danos, diante das crescentes contradições sociais e de saúde que envolvem o complexo sistema das drogas, colocou para a arena das discussões acadêmicas e dos serviços, o tema da ética, dos direitos humanos, do engodo proibicionista, entre outros. A redução de danos foi se constituindo então como um \"movimento\" político, que procurava dar respostas a essas contradições. Dessa forma, o desenvolvimento de práticas de redução de danos - majoritariamente apoiadas por ONGs e organismos internacionais - passou a ser tolerado pela sociedade civil e legitimado pelo Estado. Assim, aceita pela nova saúde pública, passou a incorporar os conceitos de estilo e qualidade de vida e de promoção da saúde, imprimindo então mudanças no objeto de atenção. Nessa perspectiva, o que se busca é a melhoria \"dos modos de vida\" dos usuários, conquistada pela qualificação e preparação da \"comunidade\" para cuidar de sua saúde. Esvazia-se, dessa forma, o debate político, confinando-se a discussão do problema do consumo de drogas à dimensão particular, responsabilizando-se indivíduos, famílias e comunidades por um problema cujas raízes encontram-se no mal-estar contemporâneo. Alternativamente, a Saúde Coletiva vem se apresentando como um campo importante de resgate do caráter social e político da redução de danos que impeça sua transformação em um mero acessório de manutenção dos interesses capitalistas. Sugere-se, portanto, neste trabalho que a construção dos saberes e das respostas sociais relativas ao complexo sistema das substâncias psicoativas vincule-se, através de categorias de análise totalizantes, aos processos globais da sociedade contemporânea e às suas contradições / This essay had the goal of describing and analyzing the object/subject of harm reduction, based on Brazilian literature, having as theoretical perspective the Collective Health bases. International literature shows that harm reduction has been adopted and spread in several countries. North America and Europe focus the debate on the evaluation of strategies in some population segments, but the theoretical and political debate seems to be massed in Latin America, remarkably in Brazil. To understand the tendencies of this debate in Brazil, 44 national publications were selected, from 1994 to 2006, having LILACS¹ as reference. The analysis of this material showed that harm reduction initially objectified contagious diseases, especially AIDS, aiming the prevention of these problems among injecting drug users. Having circumscribed such object, marginalized or excluded drug users were considered. The first theoretical conclusions that guided the practices were highly critical of the approaches and therapeutics that only focused on abstinence. Although criticism being recalcitrant to the tough and intolerant models of drug combat at times, the focus on abstinence was supported by most of those who ended up adopting, totally or partially, harm reduction orientation. For as much as the increase on contemporary drug use, which has lead several areas to study this phenomenon, the theoretical debate on harm reduction was extended. The adherence to harm reduction practices, in the face of increasing social contradictions, brought to academic and service discussions the topic of ethics, human rights, prohibitionist decoy, etc. Then, harm reduction became a political movement that aimed at solving these contradictions. In that rate, the development of harm reduction practices - mostly supported by NGOs and international organizations - became tolerated by civil society and legitimated by the State. Thus, accepted by the new public health, it incorporated life quality and style concepts and health planning, causing great changes at the subject studied. In this perspective, the aim is improving the users\' way of life, achieved by the qualification and preparation of \"community\" to be aware of health issues. The political debate is then over, and the drug use discussion is confined to a quite particular dimension, blaming individuals, families and communities for a problem which was originally found in the contemporary malaise. Alternatively, Collective Health has been of great importance on recalling social and political awareness of harm reduction in order to inhibit its transformation in a tool of capitalism. It\'s suggested therefore, in this essay that knowledge acquisition and social answers related to the complex psychoactive substances system is linked to the global procedures of contemporary society and its contradictions

O Fluxo, que se define pela concentração de usuárias(os), os usos de drogas e a Redução de Riscos e Danos são temas centrais nesta dissertação de mestrado. Um dos objetos de pesquisa é a Craco Resiste, um movimento social contrário às violências institucionais na Cracolândia, região central de São Paulo. A etnografia é a metodologia primária e parte de experiências de mais de cinco anos de atuação e pesquisa na Cracolândia. Produções coletivas de conhecimentos foram feitas com usuárias(os), ex-usuárias(os), frequentadoras(es), profissionais e ativistas da região. O texto passa por reflexões sobre o que são as drogas e foca nas vivências das pessoas que as usam. Uma trajetória da cocaína e do crack é construída, considerando experiências de usuárias(os) tão relevantes quanto produções acadêmicas; a Cracolândia é, também, situada nessa perspectiva. Resistências organizadas por movimentos sociais e ativistas nesse território são apresentadas como precursoras de concepções e práticas da Craco Resiste que, por sua vez, é contextualizada no Fluxo do território. Esta dissertação de mestrado visa expor complexidades da Cracolândia, dos usos de drogas e dos cuidados para estes usos, além de refletir como a existência de corpos diferentes do esperado para a região reverbera de diversas formas, muitas vezes imprevisíveis. / The region known as Cracolândia, the drug use and the ethics of harm reduction are central themes in this dissertation. A Craco Resiste, a social movement of people who intervene in Cracolândia, is the object of this research. Ethnography is the primary methodology and comes from experiences of more than five years of fieldwork, activism and research in Cracolândia, supported by reports and group knowledge from drug users, ex-crack/cocaine users, workers and activists. The text goes through reflections about what drugs are and focuses on the experiences of people who use them. A trajectory of cocaine and crack/cocaine is built considering the experiences of drug users as important as academic productions; Cracolândia is also situated in this perspective. Resistances organized by social movements and activists in this territory are presented as precursors of the conceptions and practices of A Craco Resiste, which, in turn, is contextualized in the Fluxo [place of drug consumption inside the region]. This master\'s dissertation also exposes the complexities of Cracolândia, the uses of drugs and the care for these users.