‘Violence is our daily bread here’: Rethinking harm reduction from the streets of Colombia

What do we mean by drug-related harm? For those of us working in harm reduction, that is an essential question we rarely pause to consider.

In policy and in practice, harm reduction is often reduced to a set of ‘bio-behavioural’ interventions. It might include needle and syringe programmes for people who inject drugs; opioid agonist therapy and access to naloxone for people who use opioids. These programmes aim to minimise health harms associated with drug use. They are especially concerned with preventing HIV, viral hepatitis and overdose deaths.

This approach has saved and changed countless lives. Nevertheless, it also leaves aside the vast majority of people who use illicit drugs. What does harm reduction look like for people who use non-opioid and non-injected drugs?

This was the central question I had when I started working with people who use basuco (a form of smokeable cocaine) in the neighbourhood of Santafé in Bogotá, Colombia. I arrived, steeped in work and literature on the health harms of smoking drugs, to find people with much wider ranging concerns. Health, in fact, was not the predominant feature of my conversations with people about basuco-related harm. Stigma, poverty and lost relationships all weighed just as heavily.

But one concern did rise above all else: physical violence. This is a form of drug-related harm rarely broached in conversations about harm reduction.