Radical Harm Reduction and the Responsibility of a World

This article is part of the following series:

Addiction is exceedingly moralized. Perhaps no other concept associated with the experience of addiction reveals this more than that of responsibility. Too often, addiction is understood in terms of a lack or failure of personal responsibility; rehabilitation is understood in terms of instilling a sense of such responsibility; and, as this collection of essays attests, public health programs aimed at drug use – such as harm reduction programs – too often smuggle in a discourse of responsibility despite their claim of nonjudgement. Indeed, even the American response to its so-called opioid crisis can be understood as embodying such moralization. Combining the perverse and uniquely American notion that corporations are individual persons with this moralizing view of addiction, filtered, of course, through the American obsession with lawsuits, the response has largely centered on holding pharmaceutical companies responsible for the ravages of the opioid crisis. While a vague nod to such social experiences as despair, loneliness, and economic precarity is occasionally given, this response suggests that the only way for 21st century Americans to conceive of the conditions that give rise to such experiences is in term of individual responsibility – in this case, the responsible self-accountability of pharmaceutical companies. 

Unfortunately, conceptualizing responsibility in terms of individual self-accountability will do little for helping us to understand – let alone address – both addiction and its underlying experiences such as despair, loneliness, and economic precarity. For, above all, what is referred to as the opioid crisis is to a great extent just one indication of a far larger crisis – the general breakdown of social life in the post-2008 United States. This breakdown is characterized by – among other things – the loss of socially recognizable meaning and value, the loss of connection and relations between persons, the loss of a common sense of what counts as real, true, or even significant, all of which has been accompanied by ever widening economic inequality and the precarity that comes with it (Zigon 2007). The experience of this breakdown takes such forms as fear, anxiety, anger, hate, despair, loneliness, and depression, and just one consequence of these experiences within this condition of breakdown is the rise of addiction. Trying to understand this broader and deeper social crisis, the ways in which it is experienced, and its consequences in our everyday lives is simply impossible in terms of responsibility as individual self-accountability. If we must continue to think in terms of responsibility – and for the sake of this essay, we will – then we must begin to conceive and enact it differently. We must begin to think in terms of the responsibility of a world.

Perhaps the defining mantra of harm reduction is “to meet them where they are at.” Like the individuality that underlies the common conception of responsibility that I have so far been addressing, this mantra tends to mean something like offering help to individual drug users according to their current needs and capacities. For example, if a drug user is currently not ready to try to stop using, then the harm reduction practitioner will not judge or attempt to force this person to stop. Rather, the practitioner will offer public health interventions such as syringe exchange to help the person use more safely, and in particular to prevent the spread of infectious disease. In terms of an individualized approach, harm reduction is one of the most successful public health programs in existence. And yet, this individualized approach forecloses the possibility of addressing the broader and deeper harms associated with addiction, including those underlying experiences I mentioned earlier. For, as I have argued elsewhere, where drug users are at, is in a world. And if one wants “to meet them where they are at,” then one needs to meet them – that is, address – the world of persons who use drugs (Zigon 2018; 2019). Meeting people in their world, then, is a practice of radical harm reduction. 

What do I mean by world?[1] As a gathering, a world is not a container, space, field, or realm in which we find humans and nonhumans standing beside one another, individualized and contained. Rather, worlds world. Worlds are a process of gathering; an assemblage that holds together temporarily as existents respond and attune with one another. Worlds gather proximate existents and assemble for a time until they recede and give way to new emerging worlds (Cf. Heidegger 1975; Stewart 2010). Such worlding is always already underway (Malpas 2012, 38). It is important to note that new worlds do not emerge within something that might be called the world. Such a notion would only be another version of the single-world ontology that I argued against in my book Disappointment (2017). Rather, new worlds emerge from the sites of potentiality within the interstices of the situations that structure and link already existing multiple worlds. In this sense, we can understand new worlds as emerging across the complex and ecstatic relationality of existence and the interstices that partially constitute this complexity.

A world is structured by a multiplicity of situations that affectively and materially hold together existents intertwined in that world, and constitute a link or a bridge to other worlds. I have written of the drug war as one such situation that structures multiple worlds (Zigon 2015; 2018; 2019).  When I write that a world is structured by situations, I intend “structure” in the sense that Jeff Malpas (2012, 40) writes of an ontological structure “that is constituted through the mutual interplay of multiple elements, a structure that encompasses the entities and elements that appear within it rather than underlying them, a structure to which belongs a unity that is given only in and through the mutual relatedness of the elements that make it up.” By world, then, I mean a multiplicity of situations structured by nothing other than this very multiplicity, and because worlds are structured by these situations that are never contained within one world, these situations constitute a link or a bridge between multiple worlds (Cf. Nancy 2007). Importantly, some of these worlds can partially overlap such that we have “worlds within worlds,” as Elizabeth Povinelli (2011, 7) has put it, echoing the words of Malinowski, which can and do slip into one another, even if temporarily. In this sense, both worlds and the situations that structure and link them can be described as ecstatically relational and emergent multiplicities. Such a notion of world is ripe with sites of potentiality, and thus open for what I have called a politics of worldbuilding (Zigon 2019).

Some anti-drug war political agonists with whom I have done long-term ethnographic research have taken up this politics of worldbuilding as their aim, which we can describe as a project of radical harm reduction.[2] Perhaps the best example of this radical harm reduction is found in the Downtown Eastside of Vancouver, British Columbia, where organizations of active and former drug users and their allies responded to a drug epidemic in the 1990s. This Vancouver model is now widely understood by agonists around the world as the best example of how to address a drug epidemic as just one aspect of a larger breakdown of sociality and economic stability.          

In May of 2013, I was sitting in a bank lobby in the Downtown Eastside (DTES) eating dinner and watching a live operatic performance that was free and open to the public. Perhaps even more unusual than its location, this event was planned by organizations of active and former drug users and their allies. Thousands of residents of the Downtown Eastside – a neighborhood of only a few square blocks – are users of drugs such as heroin. Not only did some of them help organize this operatic event, but many more in one way or another are responsible for the very existence of this bank. Pigeon Park Savings was planned, organized, and is now run by active drug users and their allies. It is a key component of the radical harm reduction response to this drug and overdose epidemic, an initiative that also includes social enterprises and small businesses meant to offer employment to active drug users, a significant increase in social and affordable housing, several health – including mental health – facilities, and abundant community events such as this operatic performance. This radical harm reduction approach focuses on building a world that is response-able to those who dwell there such that the latter become more connected with their world and one another.       

None of this would have been possible without the establishment of Insite, the first legally sanctioned safe consumption facility in North America. When Insite was first established in 2003, the DTES had been home to hundreds of overdose deaths over the previous decade. Until the recent fentanyl crisis hit, that number had been significantly reduced. As in cities and small towns across the United States and Canada, many Downtown Eastsiders are now scrambling to respond to this latest drug war induced crisis. The difference is that because of the twenty-year-long political activism led by active and former drug users, the DTES has the broadest and most integrated harm reduction infrastructure in the world from which to respond.

What makes the Downtown Eastside different from many other locations – and as a result, a global model for addressing opioid crises – is that harm reduction in the DTES goes way beyond syringe exchange, substitution therapy, safe consumption facilities, and, most recently, heroin prescription. All of these responses form a great foundation for addressing opioid crises, but what the drug using agonists and their allies recognized from the very beginning is that it simply is not enough. Most people begin using hardcore drugs like heroin for a reason: sometimes to alleviate physical pain, and oftentimes to relieve emotional and mental pain. But too often the underlying condition shared by many of these users is a deep sense of isolation and loneliness, which is too often the result of social and economic precarity and anxiety. As one of the early DTES agonists Dean Wilson put it: “addiction is a disease of loneliness.”

The real success of the Vancouver model is that it addresses this loneliness. This is what Teresa, one of the workers at a DTES social enterprise who also happens to use drugs, described to me as giving opportunities for people to become connected. That is, becoming connected with others, with a shared project, and with a future filled with possibilities. When Teresa arrived in the DTES she had been homeless, using drugs, and doing sex work for several years. After years of being uncared for, harassed by the police, and essentially left to die, Teresa was welcomed in the Downtown Eastside, where she easily found a safe and well-maintained single-occupancy-room in which to live, a social enterprise job that paid a fair wage and adjusted to the vicissitudes of her schedule, and most importantly she found people who cared about her as a person no matter her drug using habits. 

Attuned Care

What Teresa found in the DTES was a community of what I call attuned care, and this community was built by organizations of active and former drug users and their allies. Attuned care is a kind of care that doesn’t try to turn someone into something they are not, but rather cares for them as they are. This is another way of articulating the harm reduction motto of “meeting people where they are at.” The magic of attuned care is that it often opens possibilities for the person given care to become someone who is themselves more caring, connected, and attuned to others. For example, until she recently died of a fentanyl overdose, Teresa had lived in her own apartment in a quiet neighborhood near Vancouver’s lovely Stanley Park, where she was writing a book on her experiences as a homeless person as a guidebook to help currently homeless persons get back on their feet. Despite the tragedy of her death, I would argue that the life Teresa lived once she arrived in the DTES is an example of the success of the radical harm reduction approach in Vancouver, where success is marked by connecting drug users with others, with shared projects, and with a future filled with possibilities, rather than simply in terms of the cessation of drug use. That people like Teresa continue to die of overdose as the result of fentanyl poisoning does not indicate the failure of this project, but rather that it needs to become even more radical. Only once all drugs are legalized and regulated will drug users be certain that they are not using a contaminated and poisoned drug.    

What I call radical harm reduction, then, does not focus on the personal responsibility of individual drug users, but rather on the responsibility of a world. Put another way, radical harm reduction recognizes that where a person who uses drugs is at is in a world, and that world must respond – it must be built so to have respond-ability – to those who live there. Put yet another way, a world must be able to attune to itself and those dwelling there. For only when worlds are built in such a manner, can those who are a part of a world become those who are able to attune with one another – as Teresa put it, to connect with one another. The radical harm reduction movement that arose in Vancouver at the turn of the 21st century recognized the paradox of the intertwining of harm reduction and responsibility. But rather than denying this paradox, they embraced it by reconceiving where responsibility lies. For them, responsibility was no longer a capacity of the individual but rather found between us (Zigon 2021); the great discovery of these radical harm reductionists, then, is that of the responsibility of a world. 

Jarrett Zigon is the Porterfield Chair of Bioethics and Professor of Anthropology at the University of Virginia. His research interests include the anthropology of ethics, problematics of being human, the political, ontological relationality, and thinking anthropology with philosophy. These interests are taken up from a perspective strongly influenced by post-Heideggerian continental philosophy and critical theory and are explored in his most recent books Disappointment: Toward a Critical Hermeneutics of Worldbuilding and A War on People: Drug User Politics and a New Ethics of Community.


[1] The following description is largely excerpted from my book Disappointment, where the reader can find a more thorough conceptual articulation of both worlds and situations (see especially: Zigon 2018, chap. 3).

[2] The following description is partly excerpted from an article I wrote in openDemocracy (Zigon 2018b).


Heidegger, Martin. 1975. “Building Dwelling Thinking.” In Poetry, Language, Thought, 143–61. New York: Harper Colophon Books.

Malpas, Jeff. 2012. Heidegger and the Thinking of Place: Explorations in the Topology of Being. Cambridge, Massachusetts: The MIT Press.

Nancy, Jean-Luc. 2007. The Creation of the World or Globalization. Albany: State University of New York.

Povinelli, Elizabeth A. 2011. “Routes/Worlds.” E-Flux Journal 27: 1–12.

Stewart, Kathleen. 2010. “Afterword: Worlding Refrains.” In The Affect Theory Reader, edited by Melissa Gregg and Gregory J. Seigworth. Durham: Duke University Press.

Zigon, Jarrett. 2007. “Moral Breakdown and the Ethical Demand: A Theoretical Framework for an Anthropology of Moralities.” Anthropological Theory 7 (2): 131–50.

———. 2015. “What Is a Situation?: An Assemblic Ethnography of the Drug War.” Cultural Anthropology 30 (3): 501–24.

———. 2018a. Disappointment: Toward a Critical Hermeneutics of Worldbuilding. New York: Fordham University Press.

———. 2018b. “Opioid Crisis: Community and Care, Not Law and Order, Is the Answer.” OpenDemocracy, December 12, 2018.

———. 2019. A War on People: Drug User Politics and a New Ethics of Community. Oakland: University of California Press.

———. 2021. “How Is It between Us? Relational Ethics and Transcendence.” Journal of the Royal Anthropological Institute 27 (2): 384–401.