The first time I ever saw a person shooting up was right behind Paris’s Gare du Nord railway station in 2015. He was crouched in front of the low concrete wall in the picture (Figure 1). I had met André[1] when I volunteered at the mobile ‘drug van’ in front of the nearby hospital Lariboisière. The ‘drug van’ was the mobile antenna of a stationary drop-in center in the area for people to pick up harm reduction materials; it ran in parallel to a methadone van handing out the heroin substitute. At this point in my research with people experiencing homelessness and injecting drugs in Paris, I had been accompanying a team of support workers and medical professionals handing out harm reduction materials and providing basic health-care in the city’s North-East neighborhoods. André had showed up that day and presented himself as a “regular”; he knew exactly which kind of syringes he wanted and how many of each specific needle. He took a lot of supplies.

Some days after this first encounter, I met André again while I was out walking the streets with one of my informants. The two knew each other and André was welcoming and friendly. I spent hours with André that day walking the vicinities of Garde du Nord. At one point, André took me to the spot depicted in the first picture, a little courtyard above the station’s parking garage. Now, the area has been fully fenced off as part of the Gare du Nord’s redevelopment; however, at the time of my research, it was one of the most important injection spots in the area.

That day, one other person was sitting behind the wall, hidden from view of passers-by on the street. André greeted the other man briefly and quickly sat down in the corner between the grey fence and the wall. He opened his backpack and retrieved a kind of purse with various different bags in it. He then took out a syringe with a needle and an elastic band that he immediately put around his arm. Within a couple of minutes, André had prepared his syringe by liquifying on a spoon a half-rocky, half-powdery substance from one of the small bags from his backpack; and injected the needle into his arm. André’s whole body visibly relaxed the moment the substance entered his system but the effect was much less pronounced than I had expected; he didn’t shake or in any way seemed too touched by the drug. Just seconds later, André unpacked another little bag with tobacco, weed, and papers, then rolled and smoked a joint. When he left the little nook we just spent the last 15 minutes or so in together, he smiled at me. I only saw him a couple of times after that, randomly on the street; the encounter with André and seeing him actually shoot up right in front of me, something that I knew was happening, obviously, but had never seen, changed how I looked at the field. It was one of the starting points for me to observe injection sites – and space my informants used in general – around the train station differently.

Pascal, who called himself the “train-man,” took me to his train on one of the many afternoons we spent together in Paris. We took the métro down to the Southern end of the city and he walked me through what felt like a graveyard of unused train lines towards the furthest away, most abandoned train carriages. Pascal had arrived in Paris only a year earlier and had been living on the streets around the train station where I met him. Pascal had discovered the station and the train car he now inhabited on Google Maps while searching for a better, quieter place to sleep. He spent several months going back and forth between the train, and Gare du Nord, where he begged and visited various homeless service providers in an effort to establish a new life in France having escaped Germany just some weeks prior. When Pascal first moved in, the train was his secret, but over the months more people joined him in this sheltered accommodation. However, by the time Pascal took me to visit, he was no longer living there. Pascal told me that when more people started moving into ‘his’ train, security guards for the state-owned French National Railway company (Société nationale des chemins de fer français, or SNCF) noticed and began to check and clear the trains every morning. Likely, Pascal suggested, they were concerned about the number of drug users who had taken up residence in the train and were leaving their things behind. When we entered the train, dried up human faeces were all over the floor in one part of the carriage; in another part of the carriage, we found syringes. Going from one part of the train to another, the same pattern repeated itself. The train had become another non-safe-injection site for many of the new people that had moved in.

The syringes in Pascal’s train and around the Gare du Nord likely came from a place like the drug van with which I was conducting my research. For more than a year from 2015 to 2016, I spent several hours every week touring different spots in North-East Paris handing out harm reduction materials, mostly to people injecting and smoking a variety of different drugs, from heroin and prescription opioids (like Skeanan[3]) to crack cocaine. While most people knew what they wanted when they set foot in the van, a display unit right behind us ‘distributors’ – the volunteers who handed out drugs – clearly showed what was on offer. The display unit also made it easy for people who didn’t speak French (or English) to point to what they wanted. Nine types of needles, six types of syringes in different sizes and various auxiliary materials – from citric acid and little metal cups to types of disinfectants – were freely given out to anyone who would register with a nickname. Many people came on a daily basis, some even several times a day. Others only showed up once a month and took a larger supply; these people tended to have more stable living arrangements, such as public housing, than those who slept on the streets.

While the drug van was limited to a particular kind of harm reduction – clean works (clean drug paraphernalia, such as syringes and needles), needle exchange – it also served as a place for people to access information and basic healthcare. Many people who visited the van developed relationships with the social workers, healthcare professionals and other volunteers staffing the unit, a number of whom had used drugs and/or experienced homelessness themselves. These relationships were strengthened and deepened through the friendly exchanges and casual banter accompanying the ‘harm reduction shopping’; this rapport between van visitors and staff/volunteers created an environment in which people could raise problems and ask questions about topics not only limited to needles and syringes, such as other methods of safe drug use, infectious diseases, etc.

In this way, the people who visited the van expressed a sense of trust in those whose advice they sought. The relationships did not only have an influence on people’s physical health but eventually also on their life trajectories. By enabling safe injection in a comfortable and convenient way, the van and its staff fostered people’s trust in other parts of the healthcare and support system. While it might take months for the relationships to build, once established they became a core source of not only information and the related safety (‘what drug is this – can you test it’, ‘which needle should I best use to inject this’) but also stability. None of this was forced onto anyone, as one of the healthcare workers in the van explained to me: ‘I will never push any kind of therapy or rehab onto people but I make clear that if they want to go to rehab, they just have to ask.’ In this way, informal encounters motivated by the urgent need to obtain clean needles and syringes led to lasting relationships which enabled safe injection but also opened up a space for something else – all on the terms of the people visiting the van.

Many people who came into the van liked taking a few boxes of “Le Kit+” (Figure 4), which contained two full sets of clean works[4]: a 1CL syringes, a container with sterilised water and another metal spoon-like container with a small filter and a disinfectant wipe. Usually, there were also two condoms inside the box. The packaging also contained descriptions and instructions for how to safely use injectable drugs to avoid transmitting HIV, hepatitis and other infectious diseases: don’t share syringes or any other materials, disinfect your skin before injecting, take the used syringes to a needle exchange programme. In addition to “works” and safe use instructions, the boxes usually contained two condoms, as well as literature detailing safe sex practices. The printed materials accompanying the clean works concerned harm reduction in action for both the individual user and their wider network.

I encountered these Le Kit+ boxes daily, either in the hands of my drug-using informants or when handing them out myself. Over time, these boxes and the materials inside came to symbolize the comprehensive harm reduction approach I observed: while, in this particular context, harm reduction may have started with and be officially focused on providing syringes, needles and other materials, in practice the van offered advice, relationships, a certain kind of stability and reliability – both related to but beyond using drugs. I see the boxes as a kind of monad for this unfolding set of practices that accompanied their distribution.

However, not everyone was happy about the work that the ‘drug van’ team did. In particular, many of the neighbours – people who lived near Gare du Nord – did not want the van and its visitors in their arrondisement. In response to the van’s presence, some residents hung signs from their balconies protesting the “Salle de Shoot” (Figure 5). When I brought up the signs with my informants after sighting them for the first time in early 2016, the staff in the van were furious about this public display of what in their eyes was total ignorance to the existence of the people who used drugs right there, on their street, with or without a safe injection facility. But they couldn’t just take the signs down – what they had done with lower hanging ones in the past; with those ones, there was nothing they could do as the signs were hanging up so high and bright, shining right on what I came to call the ‘drug strip’ opposite the hospital where the drug van parked several times per week.  They felt the signs symbolized a stigma against drug users held by neighborhood residents (the typical NIMBY-ism – not-in-my-backyard), as well as several community advocate organizations, who argued that harm reduction ‘facilitat[ed] drug use’ and ‘attract[ed] users to the neighbourhood’. Obviously, these arguments and intuitions had little to do with a lack of data (safe injection facilities have been shown to work in various ways since the 1980s). While the signs revealed their attitudes and the stigma, the organization and the harm reduction practices promoted by the van were supported by local authorities and health ministry; in October 2016, France opened its first safe injection site overcoming not only NIMBY-ism (not-in-my-backyard) but years of administrative resistance.

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This particular story of fighting for harm reduction and safe injection came to a positive end – or start. Three years after France opened its first safe injection site, the feedback from stakeholders has been overwhelmingly positive. In 2021, a government report found that drug use has become safer (overdose risk has been drastically reduced), people don’t inject in public anymore, and users end up in the hospital less frequently. What I learned through informal conversations with the social workers and healthcare staff running the site is that the people who are happiest are the people who use drugs themselves. While André’s space behind Gare du Nord, Pascal’s train, and the drug van each provided some measure of safety and comfort, people preferred having a stable site where injecting was not only made safe but where people were protected from any type of scrutiny or disruption. Importantly, the safe injection site was located in a spot where users themselves had established their own informal sites before. As a result of the success of this first safe-injection site, in 2021 Paris approved the establishment of four new ‘salles de shoot’ in the city.

Overcoming both the original NIMBY problem as well as an underlying ideological barrier with accepting drug use and drug users as part of our society – rather than banning and criminalising it and them – is what still keeps certain geographies from embracing harm reduction. In places like London, the make-shift sites I observed through André’s eyes for the first time are as good as it gets. These informal sites are a clear indication for the need as well as a precursor of government-sanctioned sites. Hopefully examples like the journey I saw the very end of and provided a small snapshot of in this essay flatten the way for more barriers to falter fast.  The opening of the first SIS late last year in New York (the first in the US) makes me hopeful indeed that one barrier after the other for this particular kind of harm reduction is falling as we speak.

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Johannes Lenhard teaches and researchers at the Max Planck Cambridge Centre for Ethics, Economy and Social Change. While one strand of his research is concerned with survival practices of people experiencing homelessness in Paris, London and Cambridge; his most recent research is on the ethics of venture capital investors. His by-lines are with: Prospect, Sifted, Conversation, AEON, Crunchbase and Vestoj among others. He published an edited volume with Bloomsbury entitled Home – Ethnographic Encounters and his monograph ‘Making Better Lives – Hope, Freedom and Home-Making among people sleeping rough in Paris’ is about to appear in May. Twitter: @JFLenhard.

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Notes

[1] All names are anonymized.

[2] While what I call the ‘drug name’ had an official name (it was government approved and funded partly with government funds), I choose not to reveal that for reasons of anonymity.

[3] Skeanan is the trade name of what at the time was the most common prescription medicine used among my group of informants.

[4] Clean works is a common phrase used to describe drug paraphernalia; in particular, in my fieldsite, clean works would describe the combination of a clean needle and syringe but could also indicate the additional pieces of equipment that were for instance in the ‘Let Kit+’ (sterile water etc.). 

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