Civil Society Organizations and Harm Reduction Policy: The Mexican Case

Abstract

The present study offers an outlook on the current situation of civil society organizations (CSOs) in the field of harm reduction in Mexico. Analyzing Mexican harm reduction civil society organizations (HRCSOs) is necessary for three reasons: because they have historically represented a sensible alternative to drug policy proposals that emanate from the logic of the State; because they have the organizational and cognitive potential and the legitimacy to protect illicit substance users (with or without problematic use) from the risks and harms that drug policies may pose to this population; and because they are in a crisis that not only threatens the viability of their healthcare projects aimed at vulnerable populations but also, potentially, their own existence. The present article seeks to answer two questions—one descriptive and one explanatory: (a) What are the characteristics of Mexican CSOs that work in the field of harm reduction? (b) How do these organizations operate in a complex and dangerous environment? To answer these questions, the study uses data on the organizations’ structures and dynamics that were obtained through 20 semistructured interviews that were conducted with members of these organizations. The article describes HRCSOs on three levels: (a) the individual that establishes a radical habitus and acquires the identity of a harm reduction activist through identity construction; (b) the collective of activists that, through the creation of trust, becomes an HRCSO with its structures, programs, and resources; and (c) the harm reduction social movement that, through cooperation and conflict, becomes a field of activism. The study seeks to have two contributions to literature: (a) providing a preliminary mapping of the anatomy of HRCSOs and the field in which they operate; and (b) sensitizing society and decision-makers on the transcendence of these organizations for social and political life.

Introduction

For over a decade, Mexico has experienced an unprecedented public security crisis, expressed through multiple forms of violence (Flores Pérez, 2018; Treviño Rangel & Atuesta Becerra, 2020) and rooted in both structural flaws (Moraña & Valenzuela Arce, 2017) and erroneous policy decisions regarding drugs (Zedillo et al., 2019) and organized crime (Atuesta, 2017). This crisis is the result of the overlap between the public security and the illicit substances agendas in which the Mexican State has put its citizens in a context of unnecessary risks (Meza & Guerra, 2017). Indeed, the punitive and prohibitionist drugs regime has generated adverse effects in both public security and public health. The former is reflected in homicides, disappearances, and forced displacements, whereas the latter is reflected in the exposure of persons who use drugs to organized crime groups and high-risk use along with a lack of medical attention to their mental, physical, and social wellbeing.

Despite the social, political, and economic consequences of the current crisis, citizens have constructed important responses to the violence and terror (Kloppe-Santamaría & Abello Collak, 2019), that vary from lynchings, executions (Zamorano Villarreal, 2019), and other unorganized collective action to activities initiated by civil organization, including the creation of social movements and armed groups (Maldonado Aranda, 2018). Different varieties of collective action may be distinguished with profound differences but also great resemblances. However, together, all these initiatives of resistance seek to have a social impact on security, health, or drug policy and to elicit a governmental response to the problems they aim to address.

The current study focusses on civil organizations and collectives whose organizational activities and scope are primarily involved with substance use and harm reduction. Specifically, it seeks to describe the characteristics of these organizations and collectives. In the recent years, Mexican civil society has strengthened its capacity to increase the visibility of the problems and institutional indifference and neglect that persons who use drugs are confronted with. Since the creation of the first harm reduction program in Mexico—Programa Compañeros—in 1984, collectives, civil society organizations (CSOs), and networks have invested resources, developed information campaigns, and designed strategies to draw attention to this public health problem, as well as its causes and consequences. At the same time, harm reduction CSOs (HRCSOs), have developed concrete proposals for community interventions, assistance for persons who use drugs, information campaigns, and harm reduction programs that try to resolve a health problem that the public and governmental discourses consistently link with the public security agenda.

In the current context, organized civil society in general, and HRCSOs in particular, faces multiple risks that threaten its capacity to operate and have an impact. In the case of Mexican HRCOs, the six main threats are:

Public insecurity. Harm reduction collectives operate in complex contexts of insecurity and illicit drug markets, often in neighborhoods in the outskirts of cities or with high levels of crime. There are no institutional conditions that guarantee the safety of these organizations, their personnel, or their target population.

Legal insecurity. Federal legislation forms a barrier for the development of HRCSOs. The current legal framework for CSOs ¹ is insufficient for strengthening and protecting these civil initiatives, as it is contradictory in its objectives, weak in the mechanisms it offers, and with a limited scope.

Social stigma. Due to a lack of information in society on illicit substance use and users’ rights, both HRCSOs and persons who use drugs face stigma and even criminalization. Consequently, the general public remains indifferent, because it lacks the incentives to join these collective efforts or because of a lack of trust in institutions or civil society.

Political stigma. Since the beginning of the López Obrador Administration in December 2018, civil society in general has been subject to a stigma campaign. In the political construction of his adversaries, president Andrés Manuel López Obrador considers civil society as a part of the ancient regime that he tries to dismantle. In his discourse, civil society is an extension of the political and economic interests that governed Mexico before his rise to power. These views have resulted in campaigns that discredit civil society actors and reduced public funding.

Insufficient resources. The financial crisis of HRCSOs is directly linked to the lack of funding by the López Obrador Administration.

The COVID-19 pandemic. Social distancing, the risk of contagion with SARS-CoV-2, and its social and economic consequences have dramatically affected the activities of HRCSOs, both internally and with respect to their harm reduction work with the target population.

Despite the abovementioned threats, HRCSOs have continued to carry out their essential harm reduction work. However, many of these organizations did not survive the cancelation of government funding and the context of the COVID-19 pandemic; those that did survive operate in even harder conditions.

The body of literature on the relationship between harm reduction activists and policy makers is relatively vast. Various studies focus on how civil society cooperates with academia in the implementation of research projects in areas with a high prevalence of problematic substance use, as well as on how civil society may be a source of information for academic research (Bardwell et al., 2019; Fleiz et al., 2020; Ospina-Escobar, 2020; Ospina-Escobar et al., 2018; Ovalle, 2009; Ovalle, Balbuena Bello et al., 2010; Ovalle, Díaz Tovar et al., 2020; Stone, 2015). Shannon et al. (2006) analyzed the role of HRCSOs in the design and implementation of safe consumption sites for injectable and noninjectable substances. Similarly, Small (2012) studied how harm reduction activism may have a social and institutional impact through concrete actions, such as the protection of safe consumption sites.

O’Gorman et al. (2014) studied European HRCSOs and showed the wide gamma of activities, tools, strategies, visions, and political programs that characterize these organizations. In addition to offering a first mapping of European HRCSOs, they presented an analytic characterization of their forms, operations, and alliances. An important finding of their study is that HRCSOs may be understood as a policy community within a field—the field of drug policy reform—that has the legitimacy to represent cases, causes, social values, and ideals. Similarly, O’Gorman and Schatz (2021) reflected on how national and subnational contexts influence the capacity of HRCSOs to generate results and have an impact on national and international drug policy. Particularly, they described the bureaucratic problems these organizations face when negotiating with political institutions. At the same time, their study shows that the structure of civil society may also be an obstacle, particularly when different actors have different ideological views.

A limitation of the literature on HRCSOs is that it tends to focus on the European (e.g., Rigoni et al., 2021), Canadian (e.g., Boyd et al., 2017), or Southeast-Asian (e.g., Sharma & Chatterjee, 2012) contexts. Few scholars have studied harm reduction collectives in Mexico (Ospina-Escobar, 2019) with the objective of making their political and social contributions visible. In that sense, there are no systematic analyses that aim to understand the characteristics of Mexican HRCSOs, their internal dynamics, and how they construct their own field of activism. Consequently, the current study on HRCSOs is a first effort to understand the characteristics and dynamics of these organizations in the current Mexican context. The analysis starts from two research questions:

What are the characteristics of Mexican CSOs that work in the field of harm reduction?

How do these organizations operate in a complex and dangerous environment?

The first question aims to understand the internal structure and operational dynamics of HRCSOs; the second aims to describe the processes that allow HRCSOs to operate in and shape their environment. The present article seeks to describe the characteristics of Mexican HRCSOs in three dimensions: the training of activists, the structuring of their organizational dynamics, and their capacity to build a field of activism.

Methods

Analytical Tools

We used conceptual tools that have been widely applied and validated in literature on collective action, social organization, and social movements for the field work design and qualitative data analysis, in order to generate robust empirical evidence and to construct valid analytical arguments. In particular, two theoretical frameworks formed the basis for the present research.

The analytical categories that we employed in this study are used in the sociology of social movements and are useful for describing the different ways in which collective action is organized and channeled, either in organizations or in social movements with their structure and identity construction processes (Davis et al., 2005; McAdam et al., 1996; Tarrow, 1998; Tilly, 1978, 2004; Tilly & Tarrow, 2006). At the same time, the analytical tools of the theory of practice (Bourdieu, 2009) allow studying the field of collective action: its civil organizations and social movements. Bourdieu's theoretic proposal represents a promising research framework for analyzing HRCSOs. Therefore, we built the present research design upon key categories from this theory, such as habitus, capital, and field (Bourdieu, 1983, 1993, 1995, 2009, 2010; Martin, 2003).

The present research is a case study (Creswell, 2013; Denzin & Lincoln, 2018). Specifically, we constructed the present case study as a type of qualitative research design that is, according to Creswell's (2013) definition, both a research object (the HRCSOs) and a method for investigating organizational processes (resources, decision making, and identity). According to Durán (2012), literature classifies case studies based on their use—method or methodology; focus or strategy—while she considers that case studies are “a multimethodological, transparadigmatic, and transdisciplinary investigation process that should not be categorized in neither of the previous concepts” (pp. 131–132). In that sense, this case study seeks to systematize the characteristics of HRCSOs over time to obtain a detailed view through various information sources that allows a case description in its various dimensions. The units of analysis are multiple cases (multisite study) to allow comparison (Yin, 2009).

CSOs that primarily work in harm reduction activities are the case that we studied. The criteria of an instrumental case (Creswell, 2013) guided our choice of cases for the current research. This approach allows understanding a specific problem (in this case, HRCSOs) and at the same time describing and explaining its internal processes and dynamics. The analysis focusses on organizations, defined as an institutionalized and formal structure, with mechanisms that allow opinions and dismissal, internal differentiation processes, and specific objectives (cf. Somuano, 2011). Many CSOs that work on security, human rights, or drug policy issues also carry out harm reduction activities. However, the case of the current study is HRCSOs: organizations that principally and primordially perform harm reduction activities. The HRCSOs that are currently most active in Mexico are: Prevencasa (Tijuana), Integración Social Verter (Mexicali), Programa Compañeros (Ciudad Juárez), and Red Mexicana de Reducción de Daños (REDUMEX; national).

Data Collection and Analysis

Data collection started through a gatekeeper: an individual who is member of one of the organizations, who knows the harm reduction activism field, and who carries out certain activities in that field. The gatekeeper established subsequent contacts with other members of the organizations. We contacted the interviewees through text and audio messages in WhatsApp.

We used various sampling strategies to select informants. Interviewees were ought to be members of HRCSOs that had clear participative experience in the field and, therefore, a story to tell and pieces of information to share about the functioning of HRCSOs. In that sense, informants were to be able to provide both subjective experience and information on the characteristics, structures, and dynamics of the organizations in which they carry out their harm reduction activities. We also used a theoretical sampling dimension to complement an axial codification. Therefore, initially, we selected similar informants and, afterwards, the sample became as heterogenic as possible in order to select informants in different positions within the organizations to delve into certain aspects, cross and verify information about others, pursue maximum variation, find diverse cases, and describe in detail the different dimensions of the cases.

We conducted semistructured interviews through the videoconferencing platform Zoom. We chose this platform because the COVID-19 pandemic did not allow physical fieldwork and because all research subjects expressed knowledge and confidence in this platform. Approval of the research by an ethics committee is not a requirement of social research in Mexico, nor does the authors’ institution have an institutional review board. However, the current research was approved by the first author's academic division staff through a process of anonymized peer-revision. Additionally, before each interview, we provided the interviewee all information about the research, its objectives and goals, as well as the conditions of the interview in terms of research ethics, anonymity, and consent. Moreover, we asked all participants to sign the informed consent and information management protocols. We video and audio recorded the interviews and manually transcribed them for analysis.

We developed the interview guide—that we based on the main analytical categories that we had selected to observe HRCSOs—in two phases. In the first phase, we tested the pilot guide with one individual, which served to prove the viability of the instrument. During the second phase, we incorporated some observations from the pilot interview and we consolidated the logic and details of the instrument. The final instrument consisted of seven sections of various questions that aimed to gather the information that we required to saturate the analytical categories and answer de research questions. The seven sections were: (a) data of the interviewee; (b) experience in the organization or the field; (c) resources and organizational structures of the collective in which the interviewee participates; (d) work plan of the organizations; (e) collective identities; (f) internal conflicts; and (g) questions on the construction of a field of activism specialized in drug policy reform in general and harm reduction policy in particular.

We examined the data through content analysis. The analysis started concurrently with the conducting of the interviews (n = 20). After each interview, we wrote a memo, which included a summary of the information, key words, and codes that would represent each of the analytical categories that we considered in the research design, as well as codes that emerged from the interviews and that might serve for subsequent interviews. During initial codification, we reviewed each interview twice, and we developed the first codifications. We used NVivo 11 as the technical software tool during this process. The codification revealed information about the interviewees’ experiences and perceptions in their daily tasks within the organization and the field, as well as about the structures and dynamics of the daily operations of the organizations they belonged to. We carried out a revision of the codification through NVivo 11 to group open and axial codes within the analytical categories and to identify nuances, grouped similar codes, patterns, and variations. This way, we identified three central analytical categories (field, organization, radical habitus), four subcategories (identity, structures, programs, resources), and four processes (identity construction, creation of trust, cooperation dynamics, conflict).

In the following sections, we will first analyze how an individual establishes a radical habitus and acquires the identity of an activist through the process of identity construction. Next, we will analyze how a collective of activists, through the creation of trust, becomes a well-established organization with its structures, programs, and resources and acquires the identity of an HRCSO. Third, we will analyze how the social movement of HRCSOs in Mexico has become a field of harm reduction through the processes of cooperation and conflict. Finally, we will reflect on these analyses in our concluding remarks.

The Harm Reduction Activist

The interviews that we conducted for this research show that activists and other members of HRCSOs have deployed their work through an individual identity that is the product of one's own self-determination, an organizational identity—which emerges from belonging to an institutional framework—and a social identity that is grounded in a political and social program. Identity is the complex interaction of different social dimensions (Dubet, 1989), which may be understood as a construct in a system of conflict in which solidarities and social bonds are shaped (Melucci, 1996) and that has its analogs in social agreements that are reinforced by socially constructed and negotiated histories (Tilly & Tarrow, 2006). Analyses on identity have particularly focused on how the identity of a member of an organization is shaped and limited with respect to other possible ascriptions. In that sense, activists do not always identify as activists that seek a social projection to position their demands, but they do identify as people who are socially committed with the community they serve. Identities are in a constant process of construction and change in which certain normative and cognitive structures are deposited that, through experience and practice in the collective, are reconsidered, reinforced, criticized, or transformed. Identity is, therefore, a social, cultural, and institutional construct that is assimilated and shaped through individual experience from life events and expectations.

Identity Construction

The field of harm reduction in Mexico is characterized by a profound connection between subjective experiences and activism. These subjective experiences do not only relate to personal experiences with problematic or nonproblematic substance use but also include being stigmatized and discriminated as a person who uses drugs or as an activist working in the field. The social imaginary links the activist to persons who use drugs, and stigmatization of persons who use drugs incites distrust toward HRCSOs through a process of moral panic (Cohen, 2002).

Part of the interviewees expressed that their engagement with activism resides in personal affectations and of their immediate social circle in the context of the current prohibitionist paradigm. As persons who use drugs, they do not only face the consequences of stigmatization and criminalization but also the insecurity of the current illicit drug markets in Mexico (cf. Ovalle, Balbuena Bello et al., 2010). These subjective experiences form the basis of their immersion in the field and help to understand their participation in HRCSOs, networks, and collectives. However, over time, their involvement goes beyond the directly affected populations and expands to the wider public problem behind it. At this point, the incentives for participation are no longer merely personal or selective but have become collective. That is, apart from the possible personal benefits of participating, the problem has gotten a social aspect that needs to be challenged, as illustrated by one of the interviewees:

“I am not a user of injectable drugs (.…) [n]or do I have a very close experience of someone who uses injectable drugs. I [do] know other substances, we all have family and friends; but injectable drugs, no. I think that I started working on the issue, I liked it, I started to know the population, their needs and the great lack [of services to fulfil them]. It was because of this lack of services and lack of attention for these populations and that there was no-one interested [in them], that basically no-one really does anything .… I think that is what motivated me to continue here.” (interview, April 26, 2021)

This testimony illustrates how working for an HRCSO strengthens the commitment with persons who use injectable drugs and the problems they face. However, it is important to emphasize that the transition toward collective activism is also deeply ingrained in the activist's personal experiences that are fundamental for further involvement in drug policy activism:

“I definitely think that being a person who uses drugs (.…) offers you this first-hand experience, which is fundamental. I mean, when you carry a joint and walk down the street and you see a cop, you become nervous, and you feel [emphasis added] that. It is not the same as simply reading the numbers. I think that (.…) it allows you to understand all these terrible consequences of prohibition first-hand. In some way, even though you don’t experience such, sorry for the word, fucked-up things that a person who uses injectable drugs who doesn’t have access to treatment that really benefits them may experience, it does produce this empathy of knowing a lot. Much of what we investigate—and like—precisely comes from these (.…) people who use drugs. I mean, the harm reduction [strategy] originates in people who use drugs. Someone who comes to this world without necessarily participating or having people close [who do], I don’t say that it's impossible, but perhaps they don’t see the complete picture or experience what a person who [does use drugs] does.” (interview, August 11, 2020)

As opposed to the first testimony, the second illustrates the importance of not only seeing but also understanding the needs of persons who use injectable drugs. Moreover, this first-hand understanding and experience of someone who uses drugs lies at the very basis of harm reduction strategies. Various studies show how individuals who use drugs may have an impact on the wider population of persons who use drugs, by reducing the risks of problem drugs use—such as of methamphetamine and crack (Jozaghi et al., 2016)—or through the very impact that the involvement of peers may have on persons who use drugs (Austin & Boyd, 2021). Similarly, Tookey et al. (2018) describe the process of transitioning from user to peer in professional teams that offer harm reduction services.

Activism and engagement with persons who use injectable drugs is not only a personal issue but also, eventually, a political one, by recognizing problematic drug use as a public and, therefore, political problem that requires social participation to reduce its negative consequences and to provoke its transformation. This way, HRCSOs become involved in the wider field of drug policy activism that pursues the legalization of illicit substances. Through collectives and networks, drug policy activists share political views and semantics that allow them to fight for the rights of persons who use drugs. This politization of the field is a process of establishing political subjects that occurs in activism against drug prohibition and in favor of safeguarding rights of persons who use drugs through harm reduction programs.

Radical Habitus

The process of establishing a radical habitus (Bourdieu, 1997; Crossley, 2002) is a useful concept for studying the harm reduction activist's identity, as it allows observing a complex of dispositions that the agent acquires through learning and socialization. The constant analysis of language that seeks to destigmatize and decriminalize drugs and the acquisition and reformulation of knowledge and norms is used to interpret one's personal relationship with psychoactive substances and their social and political position in the field, which enables individuals to create a sense of identity and duty. As a result, participation creates a disposition for social activism (Searle-Chatterjee, 1999).

The relationship between the activist's identity and their position in the social order is crucial when studying civil society's actions. As Crossley (2002) has shown, the radical habitus explains the creation of new generations of activists, which, in turn, maintains the sense of collective action. Correspondingly, Mexican drug regulation activism has, in the course of over 20 years, achieved the construction of a collective history with its own narratives, foundational myths, and symbols that contribute to a collective memory and a common identity. Even though the radical habitus is the result of participation in HRCSOs and their multiple activities, over time it becomes the structure that enables members of these organizations to continue their actions and to contribute to its reproduction as a social practice. Thus, participation becomes a key factor for the politization of agents.

The Harm Reduction Collective

The radical habitus is put into practice within a wider structure of economic, social, cultural, and symbolic capitals that members of HRCSOs acquire over time. Economic capital is the number of economic resources that an organization is able to generate for, for example, the implementation of social and community projects and the organization of panels and other activities with other HRCSOs and other actors, such as academia and media. Social capital, then, is the capacity to create such collaborations with other actors; that is, the organization's capacity to construct networks and maintain its position in the field. Cultural capital, closely related to social capital, encompasses the level of professionalization that HRCSOs acquire through continuing education, which implies close ties with academia. Finally, symbolic capital is the social recognition that organizations acquire over time as a result of increased economic, social, and/or cultural capital.

The synergic relationship between HRCSOs and academia is of particular significance for understanding the field. In addition to activists participating in academic courses, HRCSOs may collaborate with academics, research institutes, and universities through internships or research projects. This way, activists do not only acquire academic knowledge—and, thus, cultural and symbolic capital—but HRCSOs may also benefit from academic funding. In addition, harm reduction scholars may at the same time also be social or political activists, which further consolidates the relationships between activism and academia and may generate an impact in persons who use drugs and their commitment with harm reduction activism (Boyd et al., 2017). It should be emphasized that the community of persons who use drugs lays the foundations of the academic field of harm reduction research. Without activists, it would have been impossible to create harm reduction programs, and there would not have been academic research that maintains and improves these programs. In that sense, persons who use drugs constitute the very essence of harm reduction, as they are both actor and subject.

Creation of Trust

Part of an organization's identity is constructed through its commitment with its program. If the organization's program is a harm reduction program, the organization's identity is that of a harm reduction organization, which brings about a series of additional presumptions, such as respect for rights of persons who use drugs. When such programmatic features are institutionalized, relationships of trust between members of the organization, staff, and the target population are gradually constructed. This process also contributes to building symbolic capital and trust between de organization and other organizations:

“At the end of the day, you trust that the essence of the organization is based on respect for people who use substances, and in two organizations I found people with whom I could have the same view on how to help people who use substances. And that's basic: having that same view of respect, support, and not judging people.” (interview, October 20, 2020)

HRCSOs have strong connections with their surroundings and specifically with persons who use drugs. Harm reduction strategies, medical attention, and affinity and familiarity with the target population allow the generation of affective bonds. These bonds have an impact on the members of HRCSOs as well: They reinforce the commitment with their tasks and eventually lead to better results and even social relationships with the target population and persons who use drugs in general.

“The topic of harm reduction in Mexico requires a certain type of individual who is willing to commit themself and to have a certain level of sensibility to a topic that may suddenly be very tough. And so, it attracts a certain type of people who (.…) [become so involved] that they end up doing much more work than they are supposed to do in theory. They create a very intimate relationship with the population; so intimate that when those people pass away, well, it causes personal pain. So, I never doubted that the people who end up working in the organization, most of the times have an authentic commitment with the organization and the people the organization currently cares for.” (interview, October 20, 2020)

HRCSOs have the particularity that their members may also form part of the population of persons who use drugs. This mutual recognition as users may generate bonds that eventually trigger an identity-based self-description as such: “There's even a certain, like, friendship and that's because maybe, like, we’re also users and from that perspective we understand, like, the silent minorities” (interview, April 5, 2021).

Structures

An organization's capacity to organize itself, utilize resources, generate results, and have an impact on its community has been a discussion point in the field of collective action, social movements, and CSOs (McAdam et al., 1996; McAdam & Scott, 2005). The question of what type of frameworks drive human group interaction toward a common goal has focused research on the analysis of organizational structures and processes. The interaction between organizational structures and resources is crucial for obtaining results: They do not only define the instrumental dimension of organizations but also their normative dimensions, as they define the norms and practices of interaction, decision-making, and collective identity construction.

Within HRCSOs, the need to build the organization's structure upon individuals with specific and demarcated functions is undisputed. These functions tend to be defined and assigned as the organization grows, learns, and adapts to different circumstances. However, when (human) resources are scarce, organizations may be compelled to suspend the distribution of functions and, suddenly, all staff needs to do “a little bit of everything.” Such changes in the organizational dynamics are directly related to the organization's economic capital and capacity to hire personnel.

Even though any organization has formal decision-making environments, such as work meetings in which its members share opinions, evaluate results, and seek to reach consensus, decision making in HRCSOs also tends to have an important informal dimension, such as informal social gatherings, where commitment and trust provide greater dynamism to the organization. Even in organizations with more formal decision-making structures, such as management and a board, evaluations tend to occur through mutual, top-down and bottom-up feedback mechanisms. Such distancing from a formalist model is not only important for an HRCSOs internal functioning but also beneficial for its external activities, which relates to the diffuse distribution of functions, too:

“We are always here, always in the community center, we are always working with the population (.…) we have to do whatever, taking care of the [drug consumption] room, exchanging tests, cleaning, everything! Well, this allows us to directly observe the needs of the population. Maybe it would be good if we had [cleaning] staff, but perhaps that wouldn’t allow us to be around, to be that close to the people, and then you really wouldn’t know what's going on, what are real necessities.” (interview, April 10, 2020)

Despite the informal dynamics within HRCSOs, leadership is also important for the organization's proper functioning:

“[X] was a charismatic leader. And when I say leader, I also mean that he delegated things to the people who had the capacity to do so, which made work a lot easier. There was a good division of work. We generally had these meetings where every now and then we evaluated the activities that we had carried out. And yes, there was quite some autocriticism within the organization. And since we also worked with other programs, it helped us, like when the feedback comes from someone who isn’t necessarily that involved in the issue.” (interview, August 11, 2020)

For an organization to put its decisions into action, a communication structure is required. At least three axes of communication may be distinguished. First, an internal, vertical axis between decision-makers (management) and the operative personnel that comprises the communication channels through which decisions are disseminated within the organization. The communication channels between the organization and the public, including the target population, form a second axis. Thirdly, a horizontal axis of communication between different HRCSOs allows defining common goals, strategies, and tactics.

Once the organizational programs have been established, the decision-making chain has started to function, and personnel has begun to operate with a certain autonomy, organizations acquire a critical mass that allows them to maintain their functions. At this point, the organization has become an autopoietic entity that goes beyond the activists who built it or the individuals who are, at any given moment, in charge. Such stability allows the organization to increase economic and build social and symbolic capital—and, thus, to further strengthen is structure.

Programs

Any CSO requires a program: an operational outline regarding the social problem it is seeking to address and the social and political changes that are needed to solve it in the long term. In the current analysis, the concept of intervention program refers to the specific objectives, goals, and strategies of HRCSOs. Analytically, this concept may be understood from two dimensions: a normative dimension that is structured by beliefs, values, and symbols and a strategic-instrumental dimension that is structured by the goals, objectives, and purposes of an organization.

The Mexican HRCSOs’ intervention programs have been developed both by international organisms and by the activists that form part of the local networks and collectives in the community. International organizations did not only provide (seed) funding and other economic resources to initiate harm reduction interventions in Mexico but also brought the programmatic components of the harm reduction agenda to the country, during the late 1990s and early 2000s. For example, with the international organization Cáritas’ financial, organizational, normative, and political support in the 1990s, a new intervention model was developed to counterbalance the hegemonic medical model that prioritizes abstinence and rehabilitation as intervention principles and in which persons who use injectable drugs are perceived as sick patients without agency whose addictive condition must be rehabilitated (Machín, 2015). Such international support set the basis for the professionalization of HRCSOs and, simultaneously, for the development of programs that specifically focused on harm reduction.

Harm reduction strategies, such as drug testing (Bardwell et al., 2019) or safe consumption sites (McCann & Temenos, 2015), are often global drug policy and public health practice models that are implemented around the world, even though the actual implementation of these strategies is local and tailored to specific populations. Therefore, each HRCSO has its own intervention program that it developed, institutionalized, and professionalized throughout the years and through different mechanisms. However, a key element of these different programs—be it drug testing programs at festivals or safe consumptions sites with needle exchange programs—is the education of responsible substance users through the provision of information, as illustrated by one of the interviewees who works in drug testing:

“So [drug testing] is a form of education. For people who went to festivals and were drug users, because it wasn’t just testing. I mean, you test, you tell them what it contains. Let's say a pill and you give them the options, right? ‘If you use this, you’re going to have these effects.’ And that was quite an interesting way to make the consumer, well, ‘responsible’. So the moment you told them ‘well, if you use this,’ this is the way that allows you to reduce harm and, moreover, in a certain way you do not only give the information to that person, but also so that he can share it with others. So it was like a form of peer education.” (interview, April 20, 2021).

As the testimony suggests, information on harm reduction does not only flow from the HRCSO to its target population but also within that population. Similarly, the construction and development of harm reduction programs also occurs on a peer-to-peer level. Members of HRCSOs constantly find themselves in a flow of new information through (international) forums, courses, and meetings, which allows mutual and continuous learning and the further development or improvement of intervention programs, as well as promoting drug policy reform (e.g., Temenos, 2016). In the end, harm reduction programs only work if the target population adopts them, so, ultimately, the population of persons who use drugs is not only at the basis of the creation of these programs but also further shapes them.

Probably one of the greatest problems that HRCSOs face is to subvert society's hegemonic understanding of illicit substance use and to challenge the associated historical and social stigmas. Harm reduction programs, therefore, do not only defy institutional frameworks but also a social, political, and historically maintained discourse on the punitive and health paradigms that criminalize and stigmatize substance users. In that sense, intervention programs ultimately seek to deconstruct those dichotomic constructs of popular belief that build upon medical and legal discourses that label users as sick subjects, lacking free will, isolated, irrational, out of control, without life projects, self-care strategies, autonomy, or liberty, and even as violent or criminal individuals. The harm reduction paradigm, in turn, demands the right to use substances, to access the healthcare system, to make free use of the body, to choose a lifestyle, to fight for being recognized as valid interlocutors and political subjects with full rights, to become organized and demand rights, to look for alliances and be qualified as activists, and to be responsible and free individuals with self-control.

A paradigm shift in which drug use and drug users are destigmatized is essential for harm reduction programs and policies to be successful (Gowan et al., 2012). Therefore, education of the target population of intervention programs is not limited to informing on harm reduction strategies but may also include education on drug policies. This way, persons who use drugs rationalize the risks they are exposed to and the harms that they may eventually experience, so the target population also starts demanding the programs. In that sense, political activism is also part of the intervention programs:

“We realized that it's important that the community knows why harm reduction is important. That they see it. We’ve always defended that part, that it's a right, it's a right to health and we’ve defended the topic of [drug] consumption from a public health perspective, because we also work from public health, from the prevention and treatment of HIV and hepatitis C.” (interview, April 26, 2020)

The way HRCSO's and their members treat the population of persons who use drugs is also crucial for the process of “legal empowerment.” Specifically, treating persons who use drugs first and foremost as persons produces immediate and profound effects when they consider themselves as subjects worthy of dignity. Thus, the HRCSOs’ recognition their target population may, over time, provoke self-recognition in persons who use drugs through which they recognize themselves as subjects to human rights.

Changing narratives is fundamental in harm reduction activism. This requires a detailed analysis of the values and beliefs about drugs, use, and their prohibition; for example, though practical anthropology (Small, 2016). Language itself may be part of a strategy to overthrow the prohibitionist and punitive paradigms that stigmatize and criminalize drug users. The interviews show the importance of using a nonstigmatizing language that abandons common terminology that is still used in media and society:

“I think that (.…) in the end, expressions like ‘drug addicts’ are very stigmatizing and it's, like, very noticeable for them. If they go to a center or they’re being told 24 hours per day ‘I’m an addict, I’m an addict, I’m an addict, I’m an addict’, well, you believe it. So I’d say, well, it's not just changing language.” (interview, April 26, 2020)

Another informant stressed the importance of not only changing the way we speak about persons who use drugs but also about the concept of “drugs” in general:

“You realize that language permeates in [people's] actions and often it's subconsciously. So language is extremely important. I mean, I do try not to use the word ‘drugs’, because the concept definitely is like that, a construct, because a ‘drug’ does not exist in nature. It's part of a social control mechanism and, well, if they leave it like that, it's like giving substances their own agency. And it leaves people as inanimate beings, without emotivity, affectivity, agency, or resilience.” (interview, April 26, 2020)

The search for a sensible language to talk about drugs has various objectives and presuppositions. The first is to introduce a human rights-based language that does not stigmatize persons who use drugs, because stigma has negative impacts on people, their psychoemotional development, social identity, and social life. Second, it is important that language be legally neutral to avoid criminalizing persons who use drugs, as this could eventually have legal consequences for this population. Finally, language is also used to dismantle the traditional biomedical model with the false dichotomy between abstinence and addiction and to move toward more complex models that acknowledge a spectrum of nonproblematic and problematic substance uses.

Resources

Economic resources are a fundamental factor for an HRCSO's proper functioning: It is required for both the organization's internal daily operations and their external outreach work and is also a means to increase their social, cultural, and symbolic capitals. They are the basis for institutional and operational strengthening of an organization, as they allow the consolidation of the organization's internal diversification and the distribution of work and functions. With economic resources, it is possible to have a department dedicated to managing the organization and thus to consolidate its administrative and financial processes and to contract specialized staff for research, intervention, management, administration, or even liaison activities. Consequently, economic resources allow an organization to develop long-term work plans, objectives, strategies, and evaluation mechanisms. However, Mexican HRCSOs are currently experiencing a severe financial crisis, which has seriously impacted their ability to accomplish their social and political agendas and has generated organizational instability and internal tensions.

In the history of HRCSOs in Mexico, three sources of funding may be distinguished. First, Mexican HRCSOs received both seed and additional funding through grants for project development by international organizations such as the United Nations, Population Services International, Open Society Foundations (OSF), and the University of California. Such grants have been used to consolidate outreach work and research lines, strengthen harm reduction community interventions, and train personnel. Considering that public funding of CSOs, and HRCSOs in particular, was virtually nonexistent in Mexico, this type of funding has been fundamental for the rise and consolidation of civil harm reduction projects. It should be noted that an important part of foreign grants has been awarded for harm reduction initiatives that are labeled as HIV prevention projects.

A second funding source was provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), partly through the (public) National Center for the Prevention and Control of HIV/AIDS (Centro Nacional para la Prevención y Control del VIH/SIDA; CENSIDA), during the first decade of the 2000s. During this period, both the Global Fund and the CENSIDA actively financed harm reduction projects, which allowed the creation of the REDUMEX. The importance of the CENISDA's funding is illustrated by one of the interviewees:

“The CENSIDA [created] specific guides for harm reduction programs where organizations could request (.…) resources to provide harm reduction in their communities. There was money, there were needles, there was personnel, there were collaborations with the other universities (.…) so it was like the perfect world.” (interview, October 20, 2020)

The third phase was characterized by the disengagement of international organizations, such as the Global Fund, with Mexican institutions, which severely impacted Mexican HRCSOs. During the decade of the 2010s, international organizations considered that the CENSIDA had sufficient institutional capacity to finance national harm reduction programs on its own and, therefore, reduced the flow of funding toward HRCSOs. However, the CENSIDA's funding lacked a long-term institutional strategy, which forced HRCSOs to operate in a hybrid funding model: The CENSIDA would provide funding for some months and HRCSOs had to resort to the scarce international funding to cover the rest of the year—or reduce their activities.

The current financial situation of Mexican HRCSOs is even more precarious. In an effort to fight corruption, the López Obrador Administration prohibited public funding of any CSO in 2019. Consequently, five of the eight organizations that had needle exchange projects in Mexico were forced to shut down operations, and the remaining three now entirely depend on private funding by organizations such as OSF.

A lack of resources, especially economic resources, may be a source of internal conflict. A lack of funding implies tougher decision making on the allocation of these scarce resources, especially when the organization's members have different opinions on how to spend the available funds. Moreover, a lack of economic resources negatively affects the structure and professionalization of the organization and the specialization of its members, which also reduces the organization's ability to consolidate mechanisms for conflict resolution:

“If you are an organization that has the capacity to hire and administrator, an accountant, well that allows you to put the mundane problems aside and focus on things like vision and the provision of services. But, if you have to do everything at the same time, it causes a lot of stress. So I feel that a lot of things now unfortunately have to do with the lack of resources because of the financial restrictions. There are moments in which you don’t have any cash, like with multiannual funding, and so you cannot keep the people. And the part of not having a constant money flow that allows you to have a multiannual program, impedes you from having people for a long time and professionalizing them.” (interview, October 20, 2021)

The Harm Reduction Social Movement

To what extent does drug policy and harm reduction activism in Mexico form a field? In literature on social movements, the concept of a field refers to connections between organizations (Curtis & Zurcher, 1973) and actors (Klandermans, 1997). From the theory of resource mobilization, a field may be defined as a relatively institutionalized space of activities of interdependent movements that compete in different movement industries (McCarthy & Zald, 1977). However, these definitions have been criticized from a Bourdieuan perspective, with the argument that this definition of a field is too economistic and do not consider relational and symbolic elements (Ancelovici, 2019) that correspond to the radical habitus. Therefore, Goldstone (2004) proposes to emphasize the relational rather than the structural within collective action and discuss a relational external field in which different actors are introduced. For the purpose of this study, a field is understood as a space in which different actors compete for capitals and positions in relation to the attainment of somewhat common goals and objectives and to more or less shared programs and identities.

Cooperation Dynamics and Conflict

Politics

In different areas of politics—governmental authorities, legislations, or institutions—the alliances, bonds, or mutual perceptions are always misleading. Politics may be the space in which the most influence is pursued and in which influence may bring about the biggest changes. However, it is also the space with the biggest inertias—the legal and institutional prohibitionist conglomerate in which the political actors’ strongest resistance is found—either because convictions or because of joint interests. The way to speak with governmental authorities about harm reduction is to present it from a public health perspective. Two important factors that influence this process result from the interviews. On the one hand, electoral, governmental, and political party alternation cycles make it difficult to maintain agreements on the long term, as these cycles make it necessary to continuously restart political negotiations from square one. On the other hand, the very authorities themselves—especially on the municipal level—also tend to instrumentalize the harm reduction discourse and to adapt it to their own political interests and electoral necessities. Both obstacles are illustrated by one of the interviewed activists:

“In my personal experience, what I had to do was to [do the tough and frustrating work]: meeting up with people—with the mayor, for example—and explain the mayor which are the benefits of seeing or addressing substance use as a public health issue and not as a public security issue. Sometimes it works and sometimes it doesn’t. And well, it's exhausting, because suddenly you convince someone and because of the electoral cycles, after three years, or a year, or a couple of months, [the civil servant] is no longer there and so you have to try again to meet up with that person [another person in the same position]—who you already convinced—and start from zero. And so, like, those small steps forward you achieved are broken down. And sometimes there are, I’d say, negative consequences of the many things we do (.…) for example, in what we achieved here in the city a couple of years ago, regarding selling the issue as a public health issue, it was a negative consequence, because what happened is that they—the authorities—arrived, they appropriated the discourse, and started to say that they are seeing it as a public health issue and that, therefore, you have to forcefully put them in rehabilitation centers, because it's a disease. And it's quite frustrating to see how suddenly you achieve that your work is seen as a public health issue, but all of a sudden you realize that [the authorities look at it] as a forced public health issue, close to human rights violations. But still they appropriate that message that you are trying to transmit, to justify many of their actions. It's a thin line.” (interview, October 20, 2021)

Naturally, each particular context has its own characteristics and stories regarding the relationship with political authorities. Each social and political environment informs and influences health policies and tolerance toward injectable substances in different ways. Each context has its own singularities and constructs is own history (cf. Ospina-Escobar et al., 2018). However, a pattern becomes clear: Activism may have an impact on policies but always under the guise of HIV prevention interventions rather than specific policies on injectable substances.

Donors

International organisms and organizations have been vital for the construction of the field of harm reduction activism. Their contributions may not only increase an HRCSO's economic capital, but also its social, cultural, and symbolic capitals, even if the relationship is merely through funding or contributing other resources. Donors often finance HRCSOs through grants that seek a specific objective. This way, they may shape an organization's programs or even political direction. In addition, in-kind donations may also steer an organization's activities in a certain direction. In that sense, the (political) agendas of donors determine, to some extent, the agendas of HRCSOs and the harm reduction field.

International donors are not only reducing their capacity to support Mexican HRCSOs, they also actively recommend those organizations to ask Mexican institutions for support. However, this is extremely difficult for programmatic reasons. In contrast with international donors, national organizations still maintain prohibitionist financing policies toward HRCSOs and consider psychoactive substances as a public security issue that requires State intervention. Even if State institutions do see it as a public health issue, they do not consider it from a human rights but rather from a traditional biomedical perspective:

“I had been trying for five years to ask Open Society [Foundations] for funding of organizations here at the border. And they said: ‘For what? If the Mexican government is giving you dough, it isn’t a priority.’ And, for example, when I was working at the supervised consumption sites, well I went with various organizations to sell it. And one of those organizations was the Carlos Slim Foundation and no, it was like: ‘No, bro, that type of interventions, like consumption sites, well that doesn’t match the values that we are trying to promote, of rehabilitating people.’ So it's difficult in a very conservative society to try to maintain these organizations if it isn’t with international money, that's very complicated.” (interview, October 20, 2021)

Other HRCSOs

As in any space of collective action, different actors and leaders, and the organizations, collectives, and networks they construct, leave a collective history behind. The history of HRCSOs only makes sense within the context of drug policy reform organizations and collectives. It is impossible to make a clear distinction between one and another, as they are part of the same field. However, HRCSOs do have their own dynamics that differ from organizations that have another main activity but carry out harm reduction activities on the side.

All leaders in the field portray diversified trajectories that reflect the intensity of a field that has been in construction for over 30 years, which explains its current complexity, dynamism, and versatility. Some interviewees already speak of two generations of activists: “the old guard and the new guard.” In some cases, the old guard refers to historical figures that managed to position themselves in the field and construct symbolic capital; in other cases, it refers to obsolete views on drug policy. Since the beginning, tensions and conflict have been part of the drug policy reform field and, particularly, the subfield of harm reduction. Most conflicts have been over resources, visibility, and personalities:

“So many spaces were fought and, well obviously, public attention was fought, like official things, attending a meeting, knowing who was there was important (.…) for example, Regulación por la Paz assembles different people and in some way, it does push them to working on the same agenda, but reality is that everyone has different interests and different agendas. So that, in some way, well, it's cool, that the agenda is diversified, but at the same time I feel that it has been one of the discussions, like where are we going. And there are people (…) who are not interested in having any form of coordination, not even in generating a [common] discourse or whatever. Between when I started and now, it definitely has evolved, it has been more, well there's more a [drug policy] reform team.” (interview, August 11, 2020)

Notwithstanding the conflicts and diversified views, the concept of a field persists. Apart from the agendas, all activists in this field share the same difficulties that have the same origins: a prohibitionist and punitive substance control regime—articulated and consolidated in the State—that brings about different effects and exposes activists to different kinds of risks. In that sense, a common enemy allows building a common discourse, identity, and field. At the same time, with the growing body of knowledge on the various aspects of the drug issue, the incorporation of new activists, the diversification of topics, and the differentiation of functions and organizations, the field has become more complex and diverse.

Concluding Remarks

Mexican HRCSOs are currently facing a crisis that threatens their existence, which would imply the cancelation of alternatives to understand and address problems related to substance use and to defend the human rights of persons who use drugs. This would be a dramatic setback in drug policy and a heavy blow for community life in Mexico. Independent of civil society's agenda, any democratic regime that has adopted the rule of law should provide legal security and guarantee physical and patrimonial security so that organized society may adequately comply with the functions it sets for itself. However, the current federal governmental view on drug policy and substance use is based on obsolete punitive and prohibitionist ideas that are a serious threat for HRCSOs, which exposes them to unnecessary risks in their daily operations.

Even during the current “double crisis” caused by the political-institutional neglect and the COVID-19 pandemic, HRCSOs managed to build an important intellectual heritage that has allowed them to consolidate and maintain certain activity. This heritage has contributed to their capacity to develop structures and processes that have allowed them to adapt themselves to the current threatening circumstances, as well as to continue with many of the harm reduction and prevention programs in their immediate surroundings. At the same time, HRCSOs have maintained their presence and contributions to the construction of the field of activism that has become their natural environment of alliances and mutual acknowledgment. The challenges are enormous, but at the same time the social impact, such as the identification of the public problem and the change of the political discourse, that these organizations have had suggests that they will remain in the public sphere as long as drug policy and substance use-related problems are not adequately addressed from a human rights paradigm.

The literature on civil organizations and social movements is a powerful instrument for analyzing the logic of collective action. However, its potential is maximized when these midrange theories are subsumed within a more general theoretical framework that makes it possible to understand and link both individual and microprocesses, as well as the mesodynamics of collectives. That broader theory was Bourdieu's theory of practice and, in particular, two of its main instruments: the radical habitus and the field. On the one hand, the process of establishing a radical habitus (Bourdieu, 1997; Crossley, 2002) was a useful tool for studying the identity of harm reduction activists, as it allowed us to observe a set of dispositions that the agent acquires through learning and socialization. On the other hand, the relationship between the activist's identity and their position in the social order was crucial for studying the activities of civil society. As Crossley (2002) has shown, the radical habitus explains the creation of new generations of activists, which, in turn, maintains a sense of collective action. It is necessary to continue exploring the relationship between agency and structure or between habitus and field, but the results of this study indicate that it is a fruitful theoretical bet.

In the teeth of the problems it faces, civil society should not be idealized. Like any social actor, HRCSOs do not necessarily represent actors or sectors with a higher moral quality. As in all civil society, questionable and criticizable things happen in HRCSOs, too. It is also true that civil society nowadays has many internal control and accountability mechanisms. However, these mechanisms should continue to be strengthened in order to build a civil society that does not only demand rights but also respects them. Harm reduction activists should also listen to criticism from other political or ideological angles on harm reduction, civil society, and human rights, as this trinity does not automatically denote moral progress (Zigon, 2013). Even though the origins of the harm reduction philosophy are rooted in political anarchism that stood up against legal and State authorities, Smith (2012) argues that the paradigm “has become sanitized and depoliticized in its institutionalization as public health policy” (p. 209). In addition, harm reduction policy will have to shift toward emerging new psychoactive substances as well (Kurcevič & Lines, 2020). Therefore, the harm reduction field should maintain its critical spirit and its institutional strength in accountability and self-reflection.

Finally, it is important to mention that a harm reduction policy must necessarily be designed and analyzed form the perspective of assemblages (Deleuze & Guattari, 2005). This means that harm reduction strategies, be it from civil society or from government institutions, are interconnected with global communities and epistemic networks through learning and teaching about best practices, as well as through moral and financial support (McCann, 2011). Experiences, knowledge, and information flows are mobilized and locally, regionally, and internationally interconnected. All these assemblages are embedded in specific social and organizational contexts while certain actors, ideas, and technologies are updated at the global level. The development of Mexican HRCSOs must maintain this global interconnectivity to safeguard its local impact, as it has done until now.