The outreach method
the difficult art of reaching the very fringes of society
Anne Coppel
Sociologist, Author of (Peut-on civilises les drogues ?) éd. Syros-La découverte, march 2002
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This community approach is an outstandingly effective means of reducing HIV infection among drug users.

The team led by Dr Hughes is supported by both the municipal authorities and the Black Panther movement. But the team consists mainly of heroin users, representing the main group targeted.

In 1992, the NIDA (National Institute on Drug Abuse), an American research organisation, conducted an assessment on the preventive programmes it had been subsidising since 1987. First it was found that they had been remarkably effective. In San Francisco, for example, within less than a year, the majority of the injecters had learned to sterilize their syringes. Secondly, it was observed that information circulated much more quickly when it passed from user to user. When a user says to his companions "Be careful, that's risky!" or "For goodness sake, don't do that !" the other users generally take heed: this of course is how they often prevent each other from taking overdoses and adulterated drugs. The warning is heard because speaker and hearer both assess risks in the same terms. In addition, a drug user does not simply preach: he teaches by example.

Although having drug users participate in preventive measures may be one prerequisite for their success, there is no magic formula giving the procedure. Based on the model of homosexual associations, drug user associations have been created in the Netherlands, Australia and France, where they have been instrumental in the spread of information. However, there are very few of these associations and they often split up (see p.85). Community health projects, on the other hand, have often involved sending mixed teams composed of health workers or volunteers as well as drug users out onto the streets to reach the users on their own turf.

THE BIRTH OF THE OUTREACH METHOD

Teams of street workers or "Outreach groups" have been experimenting since the late sixties. One of the pioneer groups was set up in Chicago, in a poor, Afro-American part of the city hit by an epidemic of heroin use. Experts at the time often stated that drug addiction was an incurable disease. Dr Hughes refused to accept this fatalistic opinion and making use of all available resources, opened a care centre providing severance cures, methadone and residential treatment. To understand what was happening in the area, he launched ethnographical and epidemiological studies. Dr Hughes' team was supported not only by the municipal authorities, but also by the Black Panther movement, which had many members in the district. But it was among the local addicts themselves, the people targeted in this project, that the members of the team were recruited. At first, the situation was chaotic, with relapses and problems of unreliability among the team members. It was only upon recruiting a wellrespected member of the heroin using community that the Outreach team began to have an impact. The efforts made between 1968 and 1974 were highly successful: virtually all the local heroin addicts were offered medical treatment, some successfully overcame their habit altogether, and others started long-term methadone programmes. On this particular occasion and in this particular place, heroin consumption was perhaps curtailed, but with drug use, there is no final victory. As soon as the efforts are relaxed, drug consumption starts up once more in one form or another.

FIGHTING AIDS

Subsequent to this first experiment, another team was recruited in Chicago in 1985, to fight the AIDS epidemic. This project based on the Indigenous Leader Model again achieved some immediate results. However, those which have followed in its footsteps have not always been equally successful. The difficulties begin at the recruitment stage. What are the criteria for a suitable user-cum-collaborator? Why might users want to join an Outreach group? A priori, they must be motivated by the wish to help others, but perhaps they may also want to distance themselves from the world of drugs. This perfectly respectable motivation can conflict, however, with the work of the group, which consists of going out onto the field of action. And what is that person's reputation on the street? Although an individual's lifetime experience is certainly a source of knowledge, it is not enough to turn that person into a health professional. Ten years of heroin dependence plus five spent in prison or ten years as a prostitute are not the same thing as a vocational diploma, as one sociologist involved in the assessment concluded. "Within the team, we have had to deal with all the same problems as those we are meeting on the streets", complained one project leader.

A project leader has to make some tough day to day decisions: Should we go into that particular part? Should a user be accompanied? How should we react to violent behaviour? Common sense is sometimes not enough and the initial basic rules often have to be discarded. The working methods have to be constantly adapted to the needs of the team, and this requires detailed knowledge of local customs, cultural values and the context. This method has not yet been defined, and the necessary skills are being acquired by experience. Why do some groups survive indefinitely, while others quickly fall apart or fail to get properly started in the first place? There is no single answer. Some settings are certainly more favourable than others to the development of community projects, and the emergence of leaders is no doubt one of the main keys to success. And the quality of the relationships between all those involved in the project must surely be a decisive factor. And of course, community health projects of this kind do not work by decree: there have to be people involved at grass roots level to make these projects work. In short, of all the harm reduction tools at our disposal, the Outreach method is perhaps one of the most difficult to put into action.

THE DEVELOPMENT OF A SOCIAL TRADITION

Since 1985, when the first Outreach projects were launched, little by little, a new professionalism has evolved as the knowledge of street culture, the medical know-how and the logistics have all improved. Experience has been gained all over the world on these lines and the knowledge acquired is handed on from one project to another in the framework of informal exchanges, training courses and national and international conferences. Despite the obstacles and the often hostile and at best indifferent environments, progress is being made. For all those involved in the venture, whether professionals, voluntary workers or users, the success of a project is something almost magical or miraculous: users come out of the shadows and learn to protect themselves against the AIDS epidemic. And that is not all. What really changes, is how people look at the users and how they see themselves.

Apart from the American experiments, the Outreach method, which might be defined as "going out to meet those on the farthest fringes of society" actually originated in Europe. At the time when tuberculosis was rampant, social workers would knock on the doors of the most disadvantaged families. During the fifties, street educators began to be recruited to combat delinquency, and many of these new professionals were former "rockers". It was soon observed how readily these people were accepted by the marginalised groups. The fight against AIDS among drug users has in fact involved the resurrection of an old method of social intervention: but now the emphasis is even more on the need for marginalised people to get involved in the health issues which concern them. Outreach is not and cannot be targeted at a single problem. It is an approach which it is difficult to theorise about, but which does have a sound empirical basis. Experiments have been carried out all over the place, among prostitutes, migrants, the homeless etc. These are all groups of people who tend to be out of touch with the conventional medicosocial institutions, and are exposed to the perils of drug abuse and AIDS, as well as other mortal risks.