Data quality
What does it mean to be critical?
Thinking is skilled work. It is not true that we are naturally endowed with the ability to think clearly and logically … People with untrained minds should no more expect to think clearly and logically than people who have never learned and never practiced can expect to find themselves good carpenters, golfers, bridge-players, or pianists. Mander, 1947, p. 6)
As the above quotation suggests, critical thinking is a learned skill. According to René Van Swearingen, the ‘adjective “critical” has gradually become the demarcating line for scholars who oppose the utilitarian ethos that subordinates criminology to law and order interests’ (Van Swearingen, 1999, pp. 24–5).
But what does this mean? It means that being critical includes being curious, sceptical, and prepared to challenge the underlying assumptions and accepted rationales of the criminal justice system and their taken-for-granted nature. It means being prepared to ask such questions as
Being critical is partly about considering and representing the side of the economically and socially marginalised (Becker, 1963). It is a position that seeks to promote social inclusion, equality and human rights.
Critical criminology often finds its explanations for criminal activity in the unequal distribution of power and wealth in society and the resultant class, ethnic and gender discrimination.
The official discourses about crime, like other areas of social life, are viewed by critical criminologists as constructed through contexts of racism, sexism, classism and heterosexist.
Being critical is about much more than suggesting cosmetic or surface-level changes to existing crime-control regimes. To be a ‘critical criminologist’ is to seek out and highlight injustice, and to question the processes and practices on which laws are constructed, enforced and implemented.
It is not merely tinkering with the existing system of justice and offering administrative changes to practice. It includes serious questioning of the ideological and political foundations on which crime is defined, enforced, processed and responded to.
Part3
Limitations
The report aims to provide a global snapshot of harm reduction policies and programmes; as such it has limitations. It does not evaluate the quality of the services that are in place, although where possible it does highlight areas of concern. While The Global State of Harm Reduction 2018 aims to cover important areas for harm reduction, it focuses primarily on public health aspects of the response. The report does not document all the social and legal harms faced by people who use drugs, nor does it cover all the health harms related to illicit or licit substance use
Behind the numbers
It is a decade since Harm Reduction International began compiling the Global State of Harm Reduction. While our coverage of harm reduction policies and services has evolved and broadened in scope, the same cannot always be said for harm reduction in practice around the world.
According to a 2017 systematic review in the Lancet Global Health, injecting drug use is present in 179 of206 countries throughout the world, with HIV and hepatitis C prevalence 17.8% and 52.3% respectively among the 15.6 million people who inject drugs.[2]Despite this heavy burden of diseases, effective harm reduction interventions that can help prevent their spread are severely lacking in many countries.
The number of countries providing needle and syringe programmes (NSP) and/or opioid substitution therapy (OST) has more or less stagnated since 2014. Currently, just 86 countries implement NSP to varying degrees (drop from the 90 that did so in 2016) and 86 have OST (a moderate uptick of six countries compared to two years ago).
In 2017, two global systematic reviews on the prevalence of injecting drug use and prevalence of HIV and hepatitis, and on the coverage of interventions to prevent and manage HIV and hepatitis, were published in the Lancet GlobalHealth.
These reviews were welcomed by the international community as an independent source of data and analysis. For Western European countries and some countries in Eurasia, the EMCDDA has continued to be a crucial source of reliable data froths edition of the Global State, as in past editions. Other sources include global AIDS response progress reports submitted by governments to UNAIDS in2016/2017/2018, data published by the UNODCandacademic studies.
We have sought input from harm reduction networks, researchers, academics and other experts to inform our reporting on the existence and coverage of harm reduction. Where no update was available, data from The Global State of Harm Reduction 2016 has been included, with footnotes provided on dates of estimate where necessary.
Our data on epidemiology and coverage represent the most recent verifiable estimates available. However, a lack of uniformity in measures, data collection methods and definitions for the estimates provided make cross-national and region comparisons challenging.
How might we think about crime differently?
Do the law, police, the courts and prisons have to operate the way they do?
Could ‘justice’ be conceived in other ways?
Part3
Compounding this relative dearth of services is funding crisis for harm reduction that rages in the low-and middle-income countries (LMICs) where injecting drug use is most prevalent. UNAIDS sounded the alarm in 2018 over the 20% shortfall in funding for the global HIV response. Our research found that when it comes to harm reduction in LMICs, this funding gap is close to an alarming 90%.
When juxtaposing global aspirations to end AIDS by 2030 and the vulnerability of people who inject drugs to contracting HIV, it is difficult not to question states’ genuine political commitment to the agreed-upon goals. Harm reduction is not just about commodities to address HIV and other blood-borne viruses. It encompasses a range of health and social services, policies and approaches that address the harms of illicit drug use and drug policy.
To reflect this, the2018 Global State of Harm Reduction is our most comprehensive yet, and includes for the first time dedicated sections for each region on harm reduction for amphetamine-type stimulants (ATS), overdose response and funding for harm reduction, as well as analyses of harm reduction for women.
Part4 
ATS use is increasing around the world, and harm reduction interventions for people who use these substances remain underdeveloped. Rechecking’s having a relative boom in some regions, but only in certain settings (for example, festivals and nightclubs). Drug consumption rooms in many countries, meanwhile, remain largely focused on serving people who inject drugs rather than including space for those who may smoke or snort drugs.
This says nothing of one of the most pressing crises in harm reduction today – fatal drug-related overdose. North America and parts of Western Europe continue to see overdose deaths climb, primarily those related to opioids and linked to polydrug use, while data in many regions fail to properly track these fatalities.
Though naloxone – an opioid antagonist medicine that can reverse the effects of an overdose – is increasingly being deployed in the countries most affected by this crisis, it is not always placed in the hands of those who need it most, i.e. people who use drugs and their peers.
Finally, as with the diversification of interventions based on drug used, different populations are better served by tailored approaches. This report notes, particularly the need for gender-sensitive services to address the acute vulnerability faced by women who use or inject drugs.
Most services worldwide remain male-focused. This is compounded by the fact that women who use drugs face heightened levels of stigma because of unfair (and outdated) expectations of a woman’s role in society. Sadly, the most vulnerable women who use drugs may be subject to intimate partner violence and are effectively excluded from any support services.
True equality: a work in progress
Despite the hard-fought legal victories, LGBTQ+ communities still face considerable barriers to equality and continue to suffer harms because of their identities. In the UK, hate crimes against LGBTQ+ communities continue to rise, with offences in England and Wales more than doubling in the five years to 2019 (Marsh et al., 2019).
Among the trans community, reported hate crimes have risen by 81 percent in England, Scotland and Wales, with Stonewall estimating that two in five trans people have experienced a hate crime or incident in the past year (BBC, 2019). Less visible harms also remain. The rights of transgender individuals are proving to be a particularly divisive issue, the side-lining of certain identities in the media continues, and homophobia is commonplace in many workplaces.
LGBTQ+ people are at a higher risk of experiencing mental health problems than the rest of the population, and a report by Stonewall and YouGov (2018) found that 52 per cent of LGBTQ+ people had suffered from depression in the previous year, a figure that rises to 69per cent if they had experienced a hate crime in that time (Stonewall, 2018).
LGBTQ+ individuals also face discrimination in healthcare provision (Somerville, 2015), and have higher rates of homelessness, particularly among young people. Austerity measures put into place by the UK government have had a huge impact on services for LGBTQ+ individuals (Colgan et al., 2015), impacting not only support services around issues like mental and sexual health, but also provision of services for groups within the community such as older people,
BAME communities, disabled people an in 2019, homosexuality remains criminalised in 68 countries around the world and many more have laws discriminating against LGBTQ+ people (Human Rights Watch, 2019). Of the countries that decriminalise same sex-relationships, 67 per cent were part of the British Empire and still have laws that reflect the historic attitudes that you read about earlier in this chapter. This demonstrates the way in which discourses have the power to endure in some places, while changing in others
Clearly, even when rights are enacted into law, public discourses can sometimes lag far behind, causing harm to individuals whose personal experiences might not mirror their legal entitlements. Conversely, and often the case where LGBTQ+ rights are concerned, citizens can also advocate and enact change, shaping discourses around sexualities from below.
As Foucault (1978, p. 96), who himself died of AIDS in 1984, argues resistance rarely takes place in ‘radical ruptures. Rather, it often takes the form of a ‘plurality of resistances’: cleavages in society, smaller acts of resistance and individual conversations that grow – examples of which you have seen in this chapter.
However, it is also worth remembering that discourses of resistance are not always advocating for positive change, as the rolling back of LGBTQ+ and women’s reproductive rights in countries such as the United States demonstrates. All of this highlights the complex relationships at work within discourses and exposes the limits of power to change things unilaterally.
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The scope of critical criminology
Critical criminological perspectives or criminologist represent a dynamic, interconnected yet diverse range of theories, perspectives and methods that share a commitment to providing an alternative approach to the ways in which crime, justice and harm are examined.
Critical criminological approaches have continually pushed the boundaries and scope of criminology, creating new areas of focus and innovation in relation to its subject matter, methods and theory.
Although there is much diversity and difference between critical criminological strands, they are united in their emphasis on economic and social conditions, the flows and uses of power, the interplay between crime, ‘race’/ethnicity, gender, and/or social class, and their concern to seek out marginalised perspectives and investigate multiple truths.
Critical criminologists often prefer to be called social theorists, historians, sociologists, feminists and activists, in rejection of the arguably conservative and state-compliant label ‘criminologist’
They have sought out and examined new areas that are often excluded from governmental and mainstream criminological agendas.
For example, the critique of activities involving state and corporate harm that produce human suffering or environmental degradation and economic bias in the name of profit and power has long been the mission of critical criminologists.
Other critical criminological perspectives have focused on the global issues of human trafficking, terrorism, environmental exploitation and human rights abuses – often entailing a critique of the unlawful actions of governments and large transnational corporations.
Key features of critical criminology
Although not all of the 
following characteristics apply to all forms of critical criminology, taken together they provide a useful insight into the scope and nature of much of the work of critical criminologists.
Aims to bring about social justice – that is, the broadening of social democracy and equality through radical structural and cultural change – as opposed to a narrower conceptualisation of ‘justice’ through the criminal justice system.
Considers that societies are made up of competing groups with conflicting interests.
Often draws on Marxist analysis and begins from the premise that capitalist economic policies lead to immiseration, which thereby create conditions in which turning to crime becomes a viable survival strategy.
Views criminalisation strategies as class-, race- and gender-control strategies that are consciously used to depoliticise political resistance and to control economically and politically marginalised neighbourhoods and groups.
Highlights that powerful groups often create moral panics about street level crime being out of control to deflect attention away from much more serious harms associated with the activities of those powerful groups.
Holds that orthodox crime control strategies aimed at dealing with street level crime are incapable of tackling crimes of the powerful.
Underpinning the gaps in harm reduction is a political and legal environment in most countries that continues to demonise and/or criminalise people who use drugs. This manifests most brutally in countries that have pursued a bloody crackdown on the drug trade, notably the Philippines, where over 20,000 people have been killed (many the result of extrajudicial killings) since 2016.
Hostile political and legal contexts ensure barriers for people wanting to access health and social services and put some of the most vulnerable people in society at risk of incarceration. Prisons represent high-risk environments for the transmission of blood-borne viruses, yet there are even fewer harm reduction services on offer compared to those available in the community.
While this all paints a bleak picture of harm reduction worldwide, there are examples of innovation and perseverance in this report that give hope and demonstrate that progress is possible. It is important, too, to not overlook the fact that harm reduction has come a long way over the past two decades.
The evidence is clearly in favour of harm reduction. It is time that more countries acknowledge this and implement the services that are proven to advance public health and uphold human rights
Opioid substitution therapy (OST)
Part1
The number of countries in which OST is available has increased since 2016, from 80 to 86. The countries that have introduced or re-introduced OST since 2016 are: Cote d’Ivoire and Zanzibar (Tanzania)in sub-Saharan Africa; Bahrain, Kuwait and Palestine in the Middle East; and Argentina and Costa Rica in Latin America. OST remains entirely unavailable in a number of countries, most notably Russia, where OST is prohibited by law. Data on the total number of sites offering OST Ina country are often unavailable,
For example in Western Europe, where there is considerable overlap with other medical services. However, according to the data that are available, 17 countries worldwide (eight of which are in Asia) have increased the number of OST sites operating since 2016. There are reported to be fewer OST sites in four countries than in 2016: Albania, Malaysia, Mexico and Serbia.
Where OST is available, methadone continues to bathe most prescribed substance, followed by buprenorphine; though in Oceania and Western Europe, buprenorphine-naloxone combinations are increasingly prevalent. Heroin-assisted therapy has been found to be highly effective in increasing adherence to OST, reducing use of illicit heroin and producing better health outcomes.
Despite this, it is currently only available in seven countries, all of which are in Western Europe or North America: Belgium, Canada, Denmark, Germany, the Netherlands, Switzerland and the United Kingdom.
As with NSPs, the geographic distribution of OST facilities is reported to be a barrier to access in Asia, the Middle East, North America and Western Europe. In some cases, this is due to a scarcity of approved prescribers, as in Germany and the United States. A lack of specialised and accessible services for women and migrants also presents a barrier in all regions, as does stigma and discrimination towards people who use drugs.
Viral hepatitis and HIV
Globally, prevalence of hepatitis C antibodies among people who inject drugs is estimated to be52.3%, prevalence of hepatitis B surface antigens is estimated to be 9.0%, and HIV prevalence is estimated to be 17.8%. Non-injecting drug use, particularly inhalation of crack cocaine and cocaine paste, has also been shown to be associated with greater risks of viral hepatitis and HIV infection.
There is significant regional variation in prevalence of blood-borne viruses among people who inject drugs. For example, the early implementation of harm reduction approaches (such as NSPs and OST) is credited with maintaining low prevalence of HIV among people who inject drugs in Australia and Switzerland, among others.
Integrating viral hepatitis and HIV care with harm reduction services, and particularly the use of peer workers in such services, is reported to be effective in increasing access to healthcare among people who use drugs in Oceania and Western Europe.
In other regions, including Eurasia, Latin America and sub-Saharan Africa, the integration of health services for blood-borne viruses is sporadic and reliant on civil society organisations. Despite the World Health Organization target of eliminating both hepatitis C and hepatitis B by 2030, countries in each world region continue to restrict access to direct-acting antivirals for hepatitis C for people who inject drugs.
The Global State of Harm Reduction 2018 highlights new efforts to ease these restrictions. In Western Europe for example, only two countries retain restrictions on access to direct-acting antivirals for people who inject drugs (Cyprus and Malta).
High costs associated with treatment for both viral hepatitis and HIV, where not covered by national health insurance programmes, have been reported as a further – sometimes prohibitive –barrier to treatment. In a positive step towards addressing the high cost of hepatitis C treatment for both individuals and national health systems,
in November 2018it was announced that the Medicines Patent Pool has signed a royalty-free licence agreement with pharmaceutical company AbbVie. The license will permit the development and sale of affordable generic direct-acting antivirals (glucopenia/parentship) in 99 low- and middle-income countries and territories.
Even where national policy dictates that people who use drugs should be able to access treatment, they continue to face stigma and discrimination from health professionals when they do so. These issues are exacerbated by a lack of specialised services for other marginalised populations, such as LGBTTTQQIAA indigenous people.
