Barbara Tempalski, PhD, MPH
National Development & Research Inst.
Center for Drug Use & HIV Research
71 West 23rd Street, 8th Fl
New York, NY 10010
Place and Space: Mapping response to the injection drug use related-HIV epidemic
Community activism can be important in shaping public health policies. The formation of
syringe exchange programs (SEPs) in the U.S. illustrates this: political pressure and direct
action from grassroots activists have been central to their formation. In the U.S., the
development and maintenance of services for injection drug users (IDUs), specifically SEPs,
can be linked to social movements and to specific activist groups such as ACT UP and the
harm reduction movement. For example, in 1989, in nearly half a dozen cities in the
Northeast (e.g., New York, Philadelphia, New Haven, and Boston) and in Northwestern
coastal cities (e.g., Seattle and San Francisco) the National AIDS Brigade and ACT UP
organized underground SEPs and began distributing needles at a rate of 200-300,000 per
year (Drucker, 1990).
ACT UP successfully contested the stigmatization of people with AIDS by highlighting an
underlying stigmatization rooted in homophobia through the use of direct action. Many of the
same players adopted a similar philosophy and tactics in creating and demanding primary
health care and HIV prevention services for IDUs, starting direct services as a form of direct
action. The emergence of the harm reduction movement and of organizations that work
toward establishing and sustaining direct services demonstrates how health-related social
movements are innovators in disease prevention. Here, local place characteristics contribute
to a process in which individual efforts by community activists and IDUs themselves,
together with institutional and structural forces, actively shape responses to and patterns of
IDU-related HIV transmission. Today the harm reduction movement consists of a diverse
group of players, including recovering drug users, AIDS activists, substance use/HIV
researchers and community health educators and workers - many of whom volunteer at
SEPs and have been arrested on numerous occasions for distributing syringes.
Social and political processes clearly shape local structures, events, and conditions, which
lead to increased exposure to disease, as well as health care inequality. This research focuses
on place characteristics that help predict local response and action to the HIV epidemic
among IDUs. Prior research on the geography of HIV/AIDS emphasized spatial diffusion
patterns and local transmission processes (Gould, 1993; Gould and Wallace, 1994), as well as
the links between HIV and urban poverty, policies and inequality (Wallace et al., 1997). Such
research was typically broad in scope, focusing on overall HIV/AIDS prevalence, while
neglecting the distinct geographic patterns for particular risk groups such as IDUs.
Additionally, few geographic studies have focused on geographic variation in response to the
HIV epidemic across cities.
Thus, it is important to understand how characteristics and processes that define place affect
whether a locality has adopted harm reduction services. Social and political processes that are
rooted in place are important determinants of social change and actions that affect health
policy, epidemiology, and prevention services. Indeed, previous research shows that social
movements were important in shaping public health policies and programs in the United
States, Canada, France, and Great Britain (Hoffman, 2003; Nathanson, 1996; Petchey et al.,
1998; Poland et al., 2000).
Here we emphasize how place-based political, social, and economic processes—such as local
economic relations and inequalities, “Not In My Backyard” (NIMBY)–type community
responses, and grassroots activism—affect the spatial distribution of harm reduction
responses to the HIV/AIDS epidemic. Action on this issue occurs locally, and the
characteristics of place-based factors will affect whether particular areas adopt harm
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