Counterpublic Health and the Design of Drug Services for Methamphetamine Consumers in Melbourne

http://hea.sagepub.com/Health:

http://hea.sagepub.com/content/early/2014/05/11/1363459314530740The online version of this article can be found at:

 DOI: 10.1177/1363459314530740

published online 19 June 2014Health (London)Cameron Duff and David Mooreconsumers in Melbourne

Counterpublic health and the design of drug services for methamphetamine  

Published by:

http://www.sagepublications.com

can be found at:Health:Additional services and information for    

  http://hea.sagepub.com/cgi/alertsEmail Alerts:

http://hea.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

http://hea.sagepub.com/content/early/2014/05/11/1363459314530740.refs.htmlCitations:  

What is This? 

- Jun 19, 2014OnlineFirst Version of Record >>

by guest on June 19, 2014hea.sagepub.comDownloaded from by guest on June 19, 2014hea.sagepub.comDownloaded from

Health 1 –16

© The Author(s) 2014Reprints and permissions:

sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1363459314530740

hea.sagepub.com

Counterpublic health and the design of drug services for methamphetamine consumers in Melbourne

Cameron Duff and David MooreCurtin University, Australia

AbstractThis article is interested in how notions of the ‘public’ are conceived, marshalled and enacted in drug-treatment responses to methamphetamine use in Melbourne, Australia. After reviewing qualitative data collected among health-care providers and methamphetamine consumers, we draw on the work of Michael Warner to argue that services for methamphetamine consumers in Melbourne betray ongoing tensions between ‘public’ and ‘counterpublic’ constituencies. Our analysis indicates that these tensions manifest in two ways: in the management of ‘street business’ in the delivery of services and in negotiating the meaning of health and the terms of its restoration or promotion. Reflecting these tensions, while the design of services for methamphetamine consumers is largely modelled on public health principles, the everyday experience of these services may be more accurately characterised in terms of what Kane Race has called ‘counterpublic health’. Extending Race’s analysis, we conclude that more explicit focus on the idea of counterpublic health may help local services engage with methamphetamine consumers in new ways, providing grounds for novel outreach, harm-reduction and treatment strategies.

Keywordscounterpublic health, drug treatment, Melbourne, methamphetamine, public health, qualitative research

Policy responses to illicit drug use typically emphasise law enforcement and public health (Moore and Dietze, 2008). While the two are sometimes described in complemen-tary ways, it is increasingly common for law enforcement and public health to be cast in

Corresponding author:Cameron Duff, National Drug Research Institute (Melbourne Office), Faculty of Health Sciences, Curtin University, 6/19-35 Gertrude Street, Fitzroy, VIC 3065, Australia. Email: [email protected]

530740 HEA0010.1177/1363459314530740HealthDuff and Mooreresearch-article2014

Article

by guest on June 19, 2014hea.sagepub.comDownloaded from

2 Health

more discordant terms in drug policy debates (Brownstein, 2013). Within these debates, public health is often said to offer a progressive, humane response to contemporary drug problems, in contrast to the punitive logic that is regarded as the basis for the enforce-ment of legal prohibitions (Koppelman, 2006). Going further, advocates claim that pub-lic health offers a framework for devising holistic responses to illicit drug use that are sensitive to the interaction of social, political, economic and structural forces in the inci-dence of drug problems (Ball, 2007; Des Jarlais, 1995). This interest in addressing the ‘structural determinants’ of illicit drug use, and the health and social problems that often accompany this use, characterises most public health initiatives for the reduction of drug problems (Fraser and Moore, 2011). Yet in seeking to promote public health, such initia-tives inevitably evoke a shared imaginary by which a particular understanding of the ‘public’ and its interests is enacted. Moreover, it is rare for this conception to be explic-itly interrogated such that the ‘public’ to which public health is oriented – or the popula-tion any drug policy may be said to represent – can be properly characterised.

This article is interested in how notions of the ‘public’ are conceived, marshalled and enacted in drug-treatment responses to methamphetamine consumption in Melbourne, Australia. Drawing from Michael Warner’s (2002) critique of public discourse to analyse qualitative data collected among methamphetamine consumers and service providers, we argue that responses to methamphetamine use in Melbourne betray an ongoing ten-sion between public and ‘counterpublic’ constituencies. As a result, while the design of local health and social services for methamphetamine consumers is largely modelled on public health principles, the everyday experience of these services may be more accu-rately characterised in terms of what Kane Race (2009) has called ‘counterpublic health’. Extending Race’s analysis, we conclude that more explicit focus on the idea of counter-public health may help local services engage with methamphetamine consumers in new ways, providing grounds for novel outreach, harm-reduction and treatment strategies.

Publics, counterpublics and counterpublic health

Prioritising prevention, supply reduction and harm minimisation (Ritter et al., 2013), contemporary Australian drug policies, including the National Amphetamine-Type Stimulants (ATS) strategy, address a national public understood to comprise a ‘kind of social totality’ (Warner, 2002: 49). This is apparent in the population health, education and social marketing initiatives that comprise Australia’s ATS strategy, which typically convey information, warnings and advice for a public conceived in universal terms (see Allsop and Lee (2012) for a review). While the notion that drug policies, such as Australia’s ATS strategy, address a pre-existing constituency accords with traditional notions of democratic governance, Warner (2002) argues that this perspective ignores public policy’s role in constituting a public that serves as the object of its address. Warner (2002) thus draws a distinction between the public, conceived as ‘people in general’, and a public or multiple publics (pp. 49–50). Warner is interested in how these multiple pub-lics ought to be characterised and the varied mechanisms by which they are brought into being. Throughout his analysis, Warner (2002) emphasises the constitutive role of texts (or discourses), which he takes to include not only written communication of every hue but also ‘visual and audio texts’ and the practices, habits and associations they inspire (p.

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 3

51). Texts galvanise or sustain publics by organising a collective body of address. They establish a point of address (along with an ‘imaginary’ public) comprising all ‘users’ of that text ‘whoever they might be’ (Warner, 2002: 51). Warner goes on to identify seven features of these imaginary publics, along with the counterpublics they exclude. We will briefly describe these features before examining how they are articulated in drug ser-vices, and contested in counterpublic health, in Melbourne.

First, Warner (2002) argues that publics are ‘self-organised’; each ‘must … have some way of organising itself as a body and of being addressed in discourse’ (pp. 50–51). It follows that publics are established in ‘relations among strangers’ (Warner, 2002: 55). Publics are self-organising insofar as their form and content are defined by the activity of those who participate in them. Given that publics, by definition, exert no barrier to participation other than interest or attention, publics are formed in a kind of ‘stranger-sociability’ (Warner, 2002: 57). Organising this sociability requires a form of address that is both personal and impersonal. One must identify oneself among the addressees hailed by a given text without regarding oneself as the sole object of this address (Warner, 2002: 58). This is why a public may be said to be constituted in participation rather than mem-bership or identification. Indeed, as soon as one ceases to participate in a given dis-course, one may be said to have left that public. Warner (2002) next suggests that all publics enact a social space ‘created by the reflexive circulation of discourse’ (p. 62). Any public must be understood as an ‘ongoing space of encounter for discourse’ inas-much as every public slowly develops a reflexive awareness of itself in the repetition of modes of address directed to it (Warner, 2002: 62). All publics have a ‘punctual rhythm’ in this sense, insofar as the texts which sustain them circulate in a predictable or at least relatively routine chronology (Warner, 2002: 63). This also gives each public a specific historical profile to the extent that it manifests particular values, interests and modes of address at particular times. A public’s historicity is further expressed in the ‘poetic world-making’ all texts seek to effect (Warner, 2002: 82). All texts necessarily establish a public by determining the object of their address, while further characterising that public’s salu-tary interests and preferences. As such, public texts serve to mediate, if not define, the identities, values and worldviews of those assembled in their address.

Warner (2002) rounds out this discussion by developing Nancy Fraser’s idea of the ‘counterpublic’ to account for publics which ‘mark themselves off unmistakably from any general or dominant public’ (pp. 84–89). Counterpublics differ from other publics to the extent that they depart from the characteristic features, preferences and norms that define mainstream publics and the social groups that comprise them. Counterpublics vary from ‘sub-publics’, subcultures or ‘communities of interest’ insofar as their mem-bers maintain some awareness (‘conscious or not’) of their ‘subordinate status’ (Warner, 2002: 86). Citing, by way of example, ‘women, workers, peoples of colour and gays and lesbians’, addressees in each group are identified by way of their participation in coun-terpublic discourse (Warner, 2002: 85–86). In each instance, a ‘hierarchy or stigma is the assumed background of practice’ (Warner, 2002: 87). Stigma, and the history of subordi-nation in which it is inscribed, conditions the emergence of counterpublic discourse by foreclosing participation in other more privileged modes of address. It follows that the poetic world-making central to all public discourses assumes even greater importance in counterpublics, such that the lifeworlds (practices, values, norms, identities, ethics)

by guest on June 19, 2014hea.sagepub.comDownloaded from

4 Health

expressible in counterpublic discourse may be nurtured and sustained in the face of dom-inant social norms or values. All counterpublics are political in this way.

Consistent with Warner’s account of publics and counterpublics, a number of scholars have recently applied his analysis to the study of public health and the discourses, norms, values and practices that sustain it (see Fraser, 2006; Race, 2009). Scholars have been especially interested in the claim that public health discourses enact a public rather than respond to the needs of an existing population. This suggests the value of questioning how the ‘public’ in public health ought to be characterised. Race (2009) argues that pub-lic health is founded on a series of normative assumptions about the character, prefer-ences, motivations and behaviour of subjects held to comprise a given social totality. Public health serves to enact a public by conflating descriptions of healthy (or normal) functioning with normative injunctions regarding the ways health ought to be performed, observed or adhered to (Greco, 2009: 21–24). An example may be the way drug policies seek to distinguish healthy from harmful relationships to drugs by differentiating healthy and unhealthy practices, behaviours and attitudes. Such distinctions rely on the invoca-tion of norms – rationality, risk aversion, self-interest, moderation, restraint and respon-sibility, for example – that purportedly characterise healthy subjects and the public they populate. These norms circulate via texts, practices, techniques and forms of address that position drug policy as a particular mode of administering the health (and/or productiv-ity) of a given population (see Rose, 2007: 3–5). As such, despite observing many of the hallmarks of public address (such as ‘stranger sociability’; ‘personal’ and ‘impersonal’ address; the requirement of public attention and the definition of a space of inter-textual circulation), drug policies cannot be said to address a self-organising public because they are articulated in state-sponsored discourses which aim to govern the conduct of their addressees.

It is for these reasons that Race (2009: 161–163) argues that public health discourses, including drug policies, address a very specific public rather than all subjects in a given population. Public health potentially excludes or ignores counterpublics, including injecting drug users, people living with HIV/AIDS, lesbians and gay men, by cleaving to a set of normative injunctions regarding the values and preferences of healthy subjects. Hence, the individual who injects methamphetamine, or the gay man who enjoys regular casual sex, may never be fully accommodated in public health discourse because of a failure to fully identify with the public imagined in this discourse. This misidentification suggests the need for what Race (2009) calls a ‘counterpublic health’ more cognisant of the ‘care practices and corporeal pedagogies’ routinely invented in counterpublic settings (p. 161). While these pedagogies may not always accord with the therapeutic logic advanced in public health (or the drug policies informed by it), they entail a range of experimental techniques by which well-being, pleasure, freedom, care, recognition and resilience are nurtured in conditions of social, material and political disadvantage. Each technique provides a sense of the practical ethics hinted at in Race’s (2009: 161–163) brief account of the properties of counterpublic health. More directly, each suggests that the normative characterisation of health advanced in drug policy debates should not be regarded as the only way in which health may be promoted in everyday experience. It is with these insights in mind that we have explored the experience of methamphetamine consumption in Melbourne and local service responses to methamphetamine-related

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 5

problems. We are particularly interested in developing Warner’s and Race’s accounts of the organisation of public and counterpublic constituencies and the implications of their analysis for the design of health services. Furthermore, by extending Race’s notion of counterpublic health, we aim to indicate how health-care providers may more effectively respond to social and material disadvantage in delivering health care for methampheta-mine consumers. We start with an outline of the study methods before turning to our data.

Methamphetamines and counterpublic health in Melbourne

We analyse accounts of methamphetamine use drawn from in-depth interviews con-ducted during the ethnographic component of a mixed-methods study investigating methamphetamine use and service provision in Melbourne.1 The ethnographic research had two aims: to explore the social contexts of methamphetamine use in Melbourne and to assess the character, scale and effectiveness of service responses to methampheta-mine-related problems. Our goal in exploring local contexts of methamphetamine con-sumption was to investigate the role of social and material conditions in mediating access to health care for methamphetamine consumers. We were also interested in consumers’ lived experience of this care. Following approval from the Curtin University Human Research Ethics Committee, the data we focus on here were collected in semi-structured, in-depth interviews with 31 methamphetamine consumers (17 men, 13 women and 1 transgender woman; average and median age 36 years, range 22–56 years) and 15 ser-vice providers. Consumers had used methamphetamine at least once a week in the 6 months preceding the interview or had been using methamphetamine on a regular basis prior to entering drug treatment. In total, 26 consumers reported being born in Australia, most in Victoria, with all but 2 identifying with an Anglo/European ethnic background; 4 had attended a tertiary institution and 3 had completed secondary education; 4 consum-ers were employed full-time, with 20 in receipt of either a disability or unemployment pension; and 15 were enrolled in opioid-substitution therapy. All consumers were reim-bursed AUD30 for their time and expenses.

Interviews were conducted with drug service providers to elicit data on problems related to methamphetamine consumption in Melbourne and the effectiveness of local responses to these problems. Service providers were recruited from needle and syringe programmes (NSPs), drug treatment and residential rehabilitation centres. Of the 15 ser-vice providers who completed interviews, 5 reported working as nurses, 4 were employed as NSP workers, 2 worked in outreach roles, 2 worked as drug counsellors, with 1 social worker and 1 general practitioner (GP). Interviewees reported working in allied drug services for a period of 3–26 years (average of 13.2 years). Of the providers, 10 were currently employed in services in St Kilda, with the remainder working in Fitzroy; 3 reported being employed in management positions. Interviews with both consumers and service providers were conducted in cafes, local services and private homes and lasted an average of 1 hour (range 27–128 minutes). Interviews were digitally recorded and tran-scribed to facilitate data analysis and reporting.

All data sources were integrated using steps described by Woolley (2009). The result-ing data set was then analysed using techniques drawn from Adele Clarke’s (2005) Situational Analysis: Grounded Theory after the Postmodern Turn. Situational analysis

by guest on June 19, 2014hea.sagepub.comDownloaded from

6 Health

permitted more sensitive treatment of consumer accounts of their methamphetamine ‘careers’ and of the views of local service providers regarding the clients they serve, their lives and circumstances. The approach also availed the possibility of fresh empirical insights and novel theory development. Analysis of interview transcripts involved open, axial and selective coding (Clarke, 2005: 120–130) to identify and explore the various dimensions of methamphetamine use described by consumers and service providers. This included comparative analysis of regularities, variations and contrasts in the data to test and confirm emerging insights regarding the design of services for methampheta-mine consumers, along with consumer reports of these services. These strategies led to more refined analyses as codes were slowly established and key findings elaborated.

Serving counterpublics in a public health context

What emerged very strongly in our interview data was the sense that regular metham-phetamine consumers in Melbourne constitute a local counterpublic given their depar-ture from ‘normal’ health and their ‘awareness’ of their ‘subordinate’ status (Warner, 2002: 86). The interviews also suggested that local drug services are largely modelled on public health principles, with all their pragmatic assumptions regarding the character of good health, and the qualities, values and aspirations that impel individuals to pursue it. Following Warner’s analysis, it may be argued that these services are designed to respond to the needs of a public construed in normative terms. Despite keen appreciation of the disadvantage clients experience, and the complexity of their needs, service providers reported being bound by their agency’s funding agreements, and its broader philosophies of care, to regard clients as normal subjects with a normal capacity for self-interest, responsibility and moderation. Such commitments led to tensions in the delivery of drug services that while modelled on public health principles cater nonetheless to a mainly counterpublic clientele. Our analysis indicates that these tensions manifest in two ways: in the management of what one provider called ‘street business’ in the delivery of drug services and in negotiating the meaning of health and the methods of its restoration or promotion. We will describe each aspect before assessing some of the major implications for the design of drug services in Melbourne and elsewhere.

Designing public health services for counterpublic clients

The interviews revealed much about the experience of drug treatment in Melbourne, and the ways in which methamphetamine use is characterised in the design of drug services. Most service providers were wary of the idea of tailoring treatment to individual sub-stances, preferring a more holistic approach. Others thought that the ‘methamphetamine problem’ had been ‘exaggerated’ in local media and policy responses. In light of these sentiments, a number of service providers explicitly endorsed the need for ‘holistic’ pub-lic health ‘philosophies’ in the design of drug treatment and allied services for metham-phetamine consumers. Despite this agreement, providers and consumers offered varying accounts of how public health principles inform the design and delivery of drug services in Melbourne. Noting her agency’s adoption of a ‘public health approach’ to drug treat-ment, Marie2 spoke of the need for a ‘social model of health’ that incorporated ‘physical,

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 7

emotional, social, spiritual and preventative’ aspects in the design of drug services. She added that it was ‘more important’ to address these ‘underlying issues’ than to focus ‘too much on client’s day-to-day drug use’. This distinction between drug use behaviours and deeper ‘underlying issues’ concerning the social and material disadvantage experienced by consumers was a common feature of providers’ descriptions of the principles that informed the design of health services at their place of work.

For example, in describing his own service programme, Mark emphasised the need for health services to be ‘strengths-based’, ‘non-judgemental’ and ‘destigmatising’ as a way of ‘breaking down the barriers’ to treatment and support among individuals who have ‘mostly just been pushed aside by society, like nobody wants them’. Clarifying this argument, Sarah spoke of the need for services to recognise that ‘drug takers in Australian communities are marginalised, prejudiced, discriminated against and because of that get-ting work, getting housing, staying healthy can be really hard’. She added that, for these reasons, services need to ‘remember that people often turn to drugs because of socially unjust outcomes in their lives’. Consistent with this view, another service provider, Lisa, argued for ‘a public health approach to drugs, not a punitive one’. When asked to elabo-rate on this difference, she spoke of the need for health care that is ‘really client focused, non-paternalistic and respectful … something that treats the whole person and doesn’t just focus on the drugs’. Other service providers endorsed public health and/or harm-reduction approaches to drug treatment because of the ways each approach works to ‘empower disadvantaged or marginalised people in the community’, as Joseph put it. Kim added that she thought it was important that the ‘health care system respects peo-ple’s choices and empowers them to improve their own health’. Indeed, almost all ser-vice providers emphasised the need for ‘respect’ and ‘understanding’ in order to ‘empower’ individuals to ‘take control of their own lives’, with most explicitly referring to various public health principles in making these arguments.

In keeping with these views, a number of service providers argued that consumers should be treated no differently ‘than any other member of the public’, as Simon put it. Providers defended the importance of non-discrimination as a way of reducing stigma and the ‘barriers to care’ associated with it. All the same, providers routinely acknowl-edged how much service users differed from what Mark called the ‘general public’. Sue, who had worked in local treatment services for many years, observed,

We don’t get too many office workers popping in during their lunch break for a counselling session. We see some from time to time in the NSP, and some tradies [those working in various trades] in the morning some times. But mostly it’s just people who are that desperate for help, you know, they’re fed up with the drugs and the struggles and the problems, all the dramas in life.

For this reason, most providers spoke of the need to differentiate specialist drug treat-ment from ‘mainstream’ health care, such as hospitals and GPs. Some providers noted that their clients either felt ‘unwelcome’ in mainstream health services or had been actively excluded from them. Mick explained that

I think once they’ve [consumers] had, especially at the hospitals, once they’ve had one bad run in they don’t want to go back, which is fair enough. They get treated pretty badly. So I guess

by guest on June 19, 2014hea.sagepub.comDownloaded from

8 Health

going into a normal doctor’s room where everything is a bit more professional, they don’t feel comfortable in there.

Similarly, Jennifer, who described working in drug services around Melbourne for many years, spoke of the need to differentiate drug services from ‘mainstream’ care:

A lot of people they’ve been burned so many times in their experience, they won’t go to general health services, they’re wary of Centrelink, they resent the system. That’s why I don’t wear a uniform and we try to be as informal as possible while at the same time providing facilities that are nice and shows them that this place is for you and you deserve it. So people trust us and they can talk to us about things that they probably don’t tell a regular doctor.

The reports offered by Mark, Mick, Sue and Jennifer exemplify the tension noted earlier between public and counterpublic health in the provision of drug services for methamphetamine consumers in Melbourne. In particular, they suggest that the attempt to treat consumers ‘like any other member of the public’ is not always consistent with the goal of distinguishing drug treatment from ‘mainstream’ health care. The most revealing example of tensions between public and counterpublic health was observed in the nego-tiation of what one service provider called ‘street business’ in the delivery of drug treat-ment and related services in Melbourne.

Managing ‘street business’ in the everyday delivery of drug treatment

Managing ‘street business’ emerged as one of the main ways public health providers attempt to accommodate the needs of counterpublic clients. Describing her own service, June said,

It’s often hard to manage things, to keep the place safe for the staff but also accessible for the clients. And I’ve got to be the one who goes out and interrupts them if they’re dealing or using to tell them to move on. I guess they feel it’s a safer place to deal. But still, they’re usually smart and hide around the corner where I can’t see them.

Simon spoke of similar ‘challenges’ at the NSP where he worked as staff tried to man-age illegal activities on-site and off-site while maintaining a ‘safe’ space for clients:

What happens is that people have often scored, or they might even have a taxi running outside, so they’re quite self-conscious coming in. We do have things put in place with the police where one of our managers liaises with one of the police regarding them being within a certain area around the NSP. But obviously we’re sort of a hot spot so there is a lot of police activity around so it’s not really a space people hang around in. So we really have to make people feel as safe as possible no matter what else they might be doing.

This attempt to maintain a safe site for consumers, ‘no matter what else they may be doing’, highlights the tension between public and counterpublic health. More broadly, the informal strategies described by Simon provide useful examples of what we under-stand counterpublic health to mean. Offering further indications of the character of

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 9

counterpublic health, another provider, Caitlin, spoke of the importance of balancing the demands of the ‘mainstream’ health-care system with the needs of a disadvantaged client group. She noted that

We target marginalised adults who have an illicit drug problem so the most important thing is to create a safe, stable place for care. We try to balance some of the street based chaos with all the psychosocial stuff going on for clients with some level of stability really to try and create space for change.

Providers’ attempts to manage ‘street-based chaos’ emerged as one of the most telling sites of conflict between public and counterpublic health in our data. No issue was more prominent in this respect than the ‘problem’ of managing client access to benzodiaz-epines. Describing arrangements at his place of work, Malcolm spoke of the need to follow formal prescription protocols while remaining sensitive to the needs of ‘some really disadvantaged people’. He added that

There’s so much street business that flows into every organisation like this, mostly people are stressed about their script. They stretch the chemist out for a few days and then they come in to see us [and say] ‘give me pills, give me benzo’s’. We can’t prescribe, thank God, but we do sometimes tell people ‘if you say this to the doctor and say you just want a limited quantity and say you haven’t slept for three days, they’ll probably help you out. Here’s my card, you can have them [doctor] call me and say that I’ll supervise it’ or whatever. But that would be a rare case. We don’t pull out the stops to get people pills.

Malcolm’s description of the informal strategies he uses to manage conflict over access to benzodiazepines provides a further example of the character of counterpublic health in the delivery of health care for methamphetamine consumers. William, a GP with a ‘long list of drug patients’, had a pragmatic view of this issue:

We’ve become a sort of legal drug dealer in a way. I mean these people have a daily commitment to intoxication and to be quite honest most of my patients are real pros at this, the big benzo fight, trying to get their Xanax script or whatever. But my attitude is that if we can reduce the harm a bit with regards to them making some progress, such as getting work, that’s a big deal for us.

Instances like these involving the management of ‘street business’ in the provision of drug services highlight an abiding tension between the tenets of public health that report-edly inform service design in Melbourne and the exigencies of delivering care to a coun-terpublic clientele. While, as providers noted, services in Melbourne are largely modelled on public health principles, the normative assumptions that govern these principles – such as rationality, self-interest, responsibility, moderation and risk avoidance – do not always reflect the needs, interests, experiences or preferences of counterpublic clients. This is not to argue that the methamphetamine consumers involved in our study do not value health, rationality or moderation, only that these terms or qualities are subject to recurrent negotiation in the context of significant social, economic and personal disad-vantage. Our analysis suggests more directly, therefore, that health does not always mean

by guest on June 19, 2014hea.sagepub.comDownloaded from

10 Health

the same thing in public and counterpublic settings. Indeed, the struggle to determine the everyday meanings of health, and the method of its restoration or promotion, emerged as the second key source of tension in our data between public and counterpublic health in the delivery of health and social services for methamphetamine consumers in Melbourne.

Public health and counterpublic health in tension

One of the most significant instances of conflict over the meaning of health occurred in discussions of the relationship between methamphetamine use, health and illness. While almost all service providers and consumers made some reference to problems associated with methamphetamine use, most described functional benefits as well. This was espe-cially common in discussions of mental health, as one provider noted,

A lot of my clients are really trying to medicate their mental health symptoms. They’re constantly trying to balance all the drugs they’re taking, both prescribed and street drugs, with the management of their mental health. So speed can give them that ‘up’ that increases their function for a period of time. It helps them achieve things they want to achieve or just pulls them out of that low depressive rut. I think the drugs are mostly just a response to that [rut].

A number of consumers made similar observations regarding what they perceived to be the functional and/or therapeutic effects of methamphetamine. Jennifer added,

My medication, I have to take that, but that’s why I like taking speed on top of the medication because I get really tired, lethargic and I just need something to pick me up. Otherwise, I won’t get out of bed. I can sleep for 15 hours a day.

Another consumer Sarah was even more direct: ‘it’s a bonus if I get out of it. I really just use it [methamphetamine] to function’. The point here is that the frequent claim that methamphetamine use is unhealthy or dangerous, a common claim in public health, drug policy and service delivery debates, is routinely contested, if not rejected outright, among regular consumers and some service providers. It follows that one of the major tasks confronting service providers is to engage clients in conversations about their health-related beliefs and goals such that appropriate care plans can be devised. Describing how this task is managed at her own service, Sue argued that

The fact that clients are really involved in their health is critical. Like how do we make health accessible to those who need it the most but have the least of it? So we have to start with a conversation about what people want, do they want to stop using drugs, cut down a bit, how does their drug use affect their health, that kind of thing. What I mainly find is that people just need a break. So treatment is just about getting some help to manage for a while.

A number of consumers agreed with Sue’s last point, further confounding conventional understandings of the relationship between methamphetamine use and health. For exam-ple, Bill described his most recent experience of drug treatment this way:

I just wanted a holiday. I was off speed but I had started using again regularly and bingeing and realised that I had to put the kybosh on that, and you know the first week is a bit hard so I put

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 11

my name down for the detox and they feed me and I don’t have to do anything, wipe my bum for me, whatever. So I went in there for a holiday. I just needed a break, have a rest and think about things.

Bill’s point, as we understand it, is that consumers seek drug treatment for all sorts of reasons, only some of which may pertain to their health status. It is equally true that consumers often seek treatment for their methamphetamine use without endorsing the view that methamphetamine is always unhealthy. While one consumer observed that ‘treatment only works if you’re ready to change’, he also acknowledged the conflicting motivations that may lead one to seek help. By way of example, a number of consumers reported accessing drug services for information about safer drug use or, as we have noted, to acquire ‘better’ drugs such as benzodiazepines. In a further indication of the ‘corporeal pedagogies’ central to the practice of counterpublic health (Race, 2009: 161), Sarah highlighted the importance of sharing these kinds of information and referral sources with other consumers:

I think because I’ve been using the services for so long, and they all know me and that, I’m expected to educate younger people if I see them and I think they need help. I think I put that on myself actually. That I should make sure they’re educated because if they’re going to be, if they’re going to do it and the only way I’ve stayed alive all these years is because the needle exchanges have taught me properly right from the start. That’s huge you know?

Endorsing the importance of peer education, many providers argued that services need to find ways to facilitate peer education and peer support to better assist vulnerable communities. Mark noted that

There’s definitely a culture, people, places, when people are using drugs and getting into trouble. And the longer they’ve used drugs the more they identify with this culture if you like, including the people in it, the dramas. The downside is the longer they stay identifying with that culture, the harder it is for people to get out of it, to find a home, a job, to stop using drugs. So I think part of our job is to change that culture, to get people thinking about their health in new ways, to help them access services that match their needs.

We find in this quotation the rudiments of counterpublic health-care praxis. Counterpublic health demands a pragmatic, flexible, responsive and non-judgemental approach to drug use and the problems associated with it. It does not differ in this respect from conven-tional understandings of harm reduction and its application in the design of health ser-vices for drug consumers (Marlatt, 1996). Where it does differ, however, is in its explicit recognition of how the preferences, values and needs of counterpublic subjects may vary from the ‘public’ imagined in public health discourses, including drug policy debates (Race, 2009: 161–163). Once this difference is understood, the diverse ways health is characterised in counterpublic settings ought to become clearer, along with the ways health is sustained, nurtured or protected in practice. Our analysis indicates that health in counterpublic settings is a labile, contingent concept, wrought in the struggles, disadvantage and subordination that all counterpublics endure. Far from according closely with normative ideals, counterpublic health is forever sensitive to the ways health is lived or realised in the context of endemic social, economic and

by guest on June 19, 2014hea.sagepub.comDownloaded from

12 Health

personal disadvantage. This disadvantage may explain, for example, why methampheta-mine consumption may be appealing to individuals living with mental illness. It may also explain why pharmaceutical medications like Ritalin or Xanax are so popular or why a stint in drug treatment may be regarded as a ‘holiday’. Once health is understood in a counterpublic context, the means of its restoration or promotion in the provision of care for drug consumers ought to be rethought too.

Discussion

Michael Warner’s distinction between publics and counterpublics, between normative communities of interest and those defined by their subordination, offers a means of drawing out some of the tensions inherent in all public health responses to illicit drug use. It is often noted that by identifying the norms and procedures wherein health may be maintained or promoted, public health discourses inevitably reify a normative public and a normative conception of health (Greco, 2009). These norms often enjoy a consen-sus among the subjects of public health discourse; a consensus that usually includes the various interventions by which public health is promoted. Our analysis suggests that such a consensus is not always present in public health responses to illicit drug use, mainly because these responses necessarily address both public and counterpublic con-stituencies. Caught between public health principles that emphasise the health literacy of normative subjects, and the everyday needs of subordinate communities, agencies responsible for the delivery of public health care to drug consumers must negotiate the meaning of health, and the methods of its promotion, in both public and counterpublic registers. According to the consumers and service providers who participated in our study, these negotiations expose tensions in the provision (and receipt) of drug services between the exigencies of counterpublic life and the norms of public health care and support.

In the first instance, tensions manifest in the management of ‘street business’ inside the health and social services that treat methamphetamine consumers. Examples from our research included staff efforts to establish health-care practices that differ in mean-ingful ways from mainstream services; the lack of staff uniforms and other formalities; the pragmatic management of illegal activity such as drug dealing or consumption on and around the site; consultations with local police regarding law enforcement; negotiat-ing ‘the big benzo fight’ by brokering relationships with GPs and pharmacists; and in efforts to transform local drug-using cultures. In each instance, staff members are required to interpret, transform and sometimes reject the public health principles that ostensibly ground the delivery of care in favour of a more pragmatic and experimental counterpublic ethos. In each instance, providers and consumers are required to invent the terms and practice of counterpublic health.

Race (2009) argues that counterpublic health involves select ‘care practices and cor-poreal pedagogies’ by which discrete understandings of health are negotiated or ‘per-formed’ (p. 161). All such practices depart in one way or another from the norms described in public health discourses. The measure of this departure reflects the scale of the social, economic and personal disadvantage individuals experience in counterpublic life. What we find so attractive in Race’s analysis, however, is the contention that the

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 13

experience of disadvantage should not be taken to mean the absence (or rejection) of health. Certainly, the disadvantages that define counterpublics have an immense impact on health as it is conventionally understood in public health discourses. Yet, without ignoring the range of public health services that make a real difference in disadvantaged (or counterpublic) communities, these services typically ignore the lay, indigenous or folk experiences of health that are the focus of Race’s analysis. Our study suggests that folk accounts of health are central to the everyday negotiation of care in the delivery of drug services in Melbourne, even though they are often ignored in public health models of drug treatment and support in Australia (see Moore, 2009; Moore and Fraser, 2006). We observed a range of folk approaches to health in our research, including lay accounts of the therapeutic effect of methamphetamine use on various mental health symptoms, along with its capacity to mitigate some of the unwanted effects of prescribed medica-tions. Other participants described a ‘folk pharmacology’ (Southgate and Hopwood, 2001) by way of the ideas and practices that circulate in counterpublics regarding safer drug use, more pleasurable combinations of illicit and prescribed drugs or more effective strategies for procuring prescription drugs from apparently sympathetic health-care pro-viders. As such, the practices and pedagogies discernible in, for example, the preference for dexamphetamine over methamphetamine, in the effort to procure benzodiazepines or in the intermittent presentation at drug treatment for a ‘break’ or a ‘rest’ are themselves indicative of the ways health is negotiated in the context of significant social and mate-rial disadvantage. The extent to which these practices are openly acknowledged, and occasionally accommodated, by the service providers who participated in our study con-veys some sense of how counterpublic health may potentially inform the delivery of health care among methamphetamine consumers in Melbourne and elsewhere.

Conclusion: harm reduction and counterpublic health

The account of counterpublic health advanced in this article has obvious and important antecedents in harm-reduction debates stretching back over many years. Counterpublic health and harm reduction each emphasise the need for pragmatic, non-judgemental responses to the use of alcohol and other drugs (AOD), with a strong focus on effective action to reduce drug-related problems, and a general indifference to arguments regard-ing the moral status of AOD consumption (Fraser and Moore, 2011). Yet for all this concordance, harm reduction is still generally characterised in terms of select public health principles (Marlatt, 1996). It is typically regarded as part of ‘a broad-based public health response’ to problems associated with AOD use, particularly the transmission of HIV/AIDS, with advocates and clinicians commonly arguing that the efficacy of indi-vidual harm-reduction strategies ‘should be measured against public health outcomes’ (Ball, 2007: 685–687). The problem with the conflation of public health and harm reduc-tion, as we have sought to indicate in our analysis, is that it inevitably mischaracterises the social totality for which harm reduction is conceived and delivered. Characterising harm reduction in terms of a discrete public constituency necessarily invokes a range of normative assumptions regarding the value of health and the means of its promotion. It inevitably invokes, for example, a normative subject committed to the maintenance of health and the virtues required to sustain it. It is for these reasons that Moore and Fraser

by guest on June 19, 2014hea.sagepub.comDownloaded from

14 Health

(2006) argue that harm-reduction discourses tend to ‘inscribe a neo-liberal subject – autonomous, rational, independent, calculating – and fail to acknowledge adequately material constraints on individual human agency’ (p. 3036). Greater sensitivity to such constraint is what the idea of counterpublic health primarily affords.

Consistent with Warner’s argument that counterpublics are defined, in part, by an awareness of their collective subordination, Race’s notion of counterpublic health cites the terms of this subordination to explain how health is negotiated, contested and enacted in counterpublic settings. We would add that such efforts shed further light on the alter-native rationalities by which health is practised in counterpublics. The material con-straints that define counterpublics also constrain their capacity to conform to the normative account of health presented in public health discourses, including harm reduc-tion. The valorisation of self-interest, control, moderation and responsibility common to harm-reduction initiatives rarely acknowledges the social, material, affective, cognitive and moral resources necessary to realise such qualities (Crawford, 2006; Race, 2009). Counterpublics are defined by the scarcity of these resources – a scarcity that is largely attributable to the broader structures of material disadvantage that distinguish counter-public from public entities. Yet this does not mean that health, moderation or responsibil-ity are absent from counterpublic settings like those described in our study. Instead, health in these settings is the subject of alternative rationalities that provide a means of practicing health in a context of material constraint. This suggests, for example, that the practice described above whereby ‘street drugs’ and prescribed drugs are combined in the management of mental illness ought to be understood in the context of material dis-advantage that limits access to other forms of mental health care and support. We would make a similar claim in relation to the demand for benzodiazepines described by participants.

Our study revealed some accommodation of these rationalities in the delivery of drug services to methamphetamine consumers in Melbourne. We would like to close by exploring how this accommodation may be extended in the delivery of counterpublic health for drug consumers in Melbourne and elsewhere. From the GPs, NSP workers, nurses and support staff who described attempts to supervise clients’ ‘off-script’ use of benzodiazepines, to the eschewal of uniforms and other formalities and the pragmatism with which service providers sought to manage ‘street business’, each of these initia-tives suggests something of the way counterpublics are supported in drug services. Yet, of course, these efforts are rarely enshrined in formal procedures and so remain vulner-able to sudden reversal in the face of hostile public attention. This, indeed, is Race’s (2009: 137–141) point regarding tensions between public and counterpublic health, given the privileges of the former and the vulnerabilities of the latter. However, the primacy of public health principles in the design of drug services internationally sug-gests various strategic opportunities for the articulation of counterpublic principles to guide drug services. For example, one of the hallmarks of public health is an apprecia-tion of the social determinants of health, although effective means of combating the inequalities these determinants express remain elusive (Moore and Dietze, 2008). Counterpublic health addresses this issue directly by proposing to accommodate the care practices common to counterpublic settings within the delivery of health services including drug treatment.

by guest on June 19, 2014hea.sagepub.comDownloaded from

Duff and Moore 15

Moves to accommodate folk practices in the delivery of drug services are rarely justi-fied in terms of the effort to combat structural inequalities in access to care, suggesting a novel basis for innovation in the design of (counterpublic) health care for vulnerable communities, including injecting drug users. Another argument for the merits of counter-public health concerns the need for more effective outreach efforts to improve the acces-sibility of drug services. Counterpublics demand a mode of address that differs from public forms, and while some of the service providers who participated in our study described attempts to articulate such alternatives, they rarely enjoyed formal endorse-ment. The invention of modes of address that bring counterpublics into drug services by accommodating their needs, preferences and values has the potential to reshape the ways health care is provided in the midst of profound social and material disadvantage. It may even recast how the public construes the relationship between drugs, health, pleasure, embodiment and illness.

Funding

The research reported in this article was funded by Australia’s National Health and Medical Research Council (Project Grant 479208). We are grateful to Robyn Dwyer for conducting the interviews and participant observation. The National Drug Research Institute at Curtin University is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund.

Notes

1. For findings from the quantitative component of the study involving population survey data, health-care utilisation data and treatment outcomes data, see Quinn et al. (2013a, 2013b).

2. The names used in this article are pseudonyms in order to preserve anonymity.

References

Allsop S and Lee N (eds) (2012) Perspectives on Amphetamine Type Stimulants. Melbourne, VIC, Australia: IP Communications.

Ball AL (2007) HIV, injecting drug use and harm reduction: A public health response. Addiction 102(5): 684–690.

Brownstein H (2013) Contemporary Drug Policy. New York: Routledge.Clarke A (2005) Situational Analysis: Grounded Theory after the Postmodern Turn. Thousand

Oaks, CA: SAGE.Des Jarlais D (1995) Harm reduction: A framework for incorporating science into drug policy.

American Journal of Public Health 85(1): 10–12.Fraser S (2006) Poetic world-making: Queer as Folk, counterpublic speech and the ‘Reader’.

Sexualities 9(2): 152–170.Fraser S and Moore D (2011) The Drug Effect: Health, Crime and Society. Melbourne, VIC,

Australia: Cambridge University Press.Greco M (2009) Thinking beyond polemics: Approaching the health society through Foucault.

Österreichische Zeitschrift für Soziologie 34(2): 13–27.Koppelman A (2006) Drug policy and the liberal self. Northwestern University Law Review

100(1): 279–293.Marlatt G (1996) Harm reduction: Come as you are. Addictive Behaviors 21(6): 779–788.Moore D (2009) Workers, clients and the struggle over needs. Social Science & Medicine 68:

1161–1168.

by guest on June 19, 2014hea.sagepub.comDownloaded from

16 Health

Moore D and Dietze P (eds) (2008) Drugs and Public Health: Australian Perspectives on Policy and Practice. Melbourne, VIC, Australia: Oxford University Press.

Moore D and Fraser S (2006) Putting at risk what we know: Reflecting on the drug-using subject in harm reduction and its political implications. Social Science & Medicine 62(12): 3035–3047.

Quinn B, Stoové M, Papanastasiou C, et al. (2013a) An exploration of self-perceived non-problematic use as a barrier to professional support for methamphetamine users. International Journal of Drug Policy 24(6): 619–623.

Quinn B, Stoové M, Papanastasiou C, et al. (2013b) Methamphetamine use in Melbourne, Australia: Baseline characteristics of a prospective methamphetamine-using cohort and cor-relates of methamphetamine dependence. Journal of Substance Use 18(5): 349–362.

Race K (2009) Pleasure Consuming Medicine: The Queer Politics of Drugs. Durham, NC: Duke University Press.

Ritter A, King T and Hamilton M (eds) (2013) Drug Use in Australian Society. Melbourne, VIC, Australia: Oxford University Press.

Rose N (2007) The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century. Princeton, NJ: Princeton University Press.

Southgate E and Hopwood M (2001) The role of folk pharmacology and lay experts in harm reduc-tion: Sydney gay drug using networks. International Journal of Drug Policy 12(4): 321–335.

Warner M (2002) Publics and counterpublics. Public Culture 14(1): 49–90.Woolley C (2009) Meeting the mixed methods challenge of integration in a sociological study of

structure and agency. Journal of Mixed Methods Research 3(1): 7–25.

Author biographies

Cameron Duff is a Research Fellow in the Ethnographic Program at the National Drug Research Institute in Melbourne, Australia. He is also an Associate Editor (Qualitative and Social Research) at the International Journal of Drug Policy. Duff’s primary research interests concern the rela-tionship between health, place and social inclusion with a focus on the lived experience of mental illness and substance use. Duff’s first book Assemblages of Health will be published by Springer in 2014.

David Moore leads the Ethnographic Program at the National Drug Research Institute in Melbourne, Australia. He is Editor of Contemporary Drug Problems and is a member of the Editorial Board for the International Journal of Drug Policy. He is the author of numerous book chapters and peer-reviewed articles on the social and cultural contexts of alcohol and other drug use and has co-edited various key works on drug research and policy. His most recent book entitled Habits: Remaking Addiction (co-written with Suzanne Fraser and Helen Keane) will be published by Palgrave in 2014.

by guest on June 19, 2014hea.sagepub.comDownloaded from