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.
Broadly, the violence people who use basuco experience can be reduced to four sets of perpetrators: criminal actors, peers in the basuco-using community, law enforcement and armed groups.
Criminal actors
The control of drug and other illicit markets in Santafé creates a kind of street-based authoritarianism. In this climate, even witnessing a crime can expose a person to direct violence. As one man, Edwin*, described to me, people can be at risk of violence just by being in the wrong place at the wrong time: “On the streets…just for seeing something, they can take your life…They call you a snitch.”
The problem, as he told it, is that people who use basuco and live on the streets are occupationally vulnerable to being in the wrong place at the wrong time because of their close engagement with criminal groups and their relatively vulnerable position in the drug market as heavy consumers.
When control of the drug trade is contested between groups, navigating the market is an even more delicate procedure. When I got back to Bogotá after a couple of weeks away in late 2022, a contact in Santafé told me, “You’ve arrived to a full-on war”. A new group was competing for control of the drug market, and dismembered bodies were being found in bags around the city. “I’ve never seen it like this before,” he told me. “This is more like Mexico than Colombia.”
The bodies were largely members of other gangs, but unaligned people who use basuco were being caught up too as the new group violently punished anyone caught buying from their rivals.
Violence on the street and in the ‘olla’
Much basuco consumption takes place in what are known as ‘ollas’. For many, these criminally-controlled centres of drug distribution and consumption are the only private space they have access to. Many retreat there to avoid more policed spaces. But the ollas themselves could be spaces of extreme violence. “Violence is our daily bread here,” Iván*, a basuco user in his sixties, told me.
In the ollas and on the streets, arguments over minor disagreements quickly turn violent. In my conversations with people, matches were a common metaphor for the senselessness and disproportionality of the violence meted out between people who use basuco.
“Let’s say you need a match to get high,” said a young man who introduced himself by his surname, Martínez*. “You strike a match and it breaks. But it was my match, and now we haven’t got anything to light up with. How am I going to get high? I get angry and I’m going to do something to you.”
“It’s the law of the knife,” another man, Bernardo*, told me. “Either you hurt me or I hurt you. That’s it, that’s the house rules.”
Law enforcement and ‘vigilantes’
Formally, personal possession and use of all drugs has been decriminalised in Colombia since 1994. Nevertheless, the thresholds for what is deemed ‘personal’ possession are low and, at the time I was in Bogotá, the policing code forbade drug use in public spaces and near schools.
The result is de facto criminalisation and interactions with police that could quickly turn violent. Police violence could be justified by basuco use alone. “Once, a police officer passed by me and hit me with his truncheon because I was smoking basuco. Just because I was smoking,” Dario* told me.
At times, neighbourhood ‘vigilantes’ would carry out violent ‘evictions’. “There are people who don’t like people who smoke basuco. So, they get sent out to kill you… They call it limpieza [cleansing],” David* explained. I heard first-hand accounts of people receiving death threats, having ice-cold water thrown at them while they slept, or being physically beaten. More dramatic, second-hand stories abounded, where people sleeping rough and smoking basuco would be given food laced with rat poison or glass, or would be soaked in gasoline and set alight. These stories are backed by media reports of homeless people being burnt alive while they slept in various cities in Colombia, all apparently motivated by ‘limpieza’.
Armed groups
Despite the 2016 peace agreement with the Revolutionary Armed Forces of Colombia (known as FARC) and pursuit of ‘Total Peace’ under President Gustavo Petro, non-state armed groups are still active in Colombia today. Armed groups most directly impact people who use basuco through forced displacement.
Marvin* is from a region close to the Venezuelan border. “A paraco [paramilitary militiaman] grabbed hold of me, and he said to me, ‘Look, I’m from such-and-such armed group…if you don’t get out of this town, we’re going to take measures against you.’”’ He left town and went to Bogotá. Others had similar stories.
People like Marvin arrived in Bogotá with little or no social network. To maintain their drug use, they often gravitated towards the drug markets of Santafé. Once there, people were even more vulnerable to violence. As Javier* explained to me: “When someone who’s not from the neighbourhood arrives, they run the risk of not knowing anyone and people not knowing them. They can go into an olla, and someone can simply say, ‘I don’t know him, he could be a rat.’ And then you’re running the risk of getting beaten up, getting killed.”
Violence and harm reduction
Physical violence is pervasive in the lives of people who use basuco in Bogotá. In this respect, Bogotá is unlikely to be unique. Drug markets, by virtue of prohibition, are predisposed to violent criminal governance and violent law enforcement.
There is a clear need for harm reduction to pay more attention to interpersonal, physical violence. These examples already point to potential first-line defences against exposure to violence for people who use basuco. For one, spaces to use and simply to exist that are neither the street nor the olla. A recent paper highlights how providing a space of safety is a key mechanism through which drug consumption rooms worldwide keep people who use drugs engaged.
Then there are the more structural changes. The physical violence people experience on the streets exists in consort with structural and cultural forms of violence. Stigma towards drug use leads to forced displacement and ‘social cleansing’. Poverty and rough sleeping make people vulnerable to police and criminal violence. A wider context of armed and criminal violence increases the risk and severity of violence against people who use basuco.
This puts an end to criminalisation, not only of drugs but also of poverty, squarely in the wheelhouse of harm reduction. Programmes to combat stigma and promote social and economic inclusion may also help to reduce people’s vulnerability to physical violence. Forms of regulation that take drug markets out of the hands of criminals could contribute to making markets less violent.
Reducing drug-related harm means reducing drug-related violence. And reducing drug-related violence requires a broad approach to changing the way we see drugs and the people who use them.
* Names have been changed for confidentiality.
