530740

research-article2014

HEA0010.1177/1363459314530740HealthDuff and Moore

Article

Counterpublic health and the

design of drug services for
methamphetamine
consumers in Melbourne

Health
2015, Vol. 19(1) 5166
The Author(s) 2014
Reprints and permissions:
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DOI: 10.1177/1363459314530740
hea.sagepub.com

Cameron Duff and David Moore

Curtin University, Australia

Abstract
This article is interested in how notions of the public are conceived, marshalled
and enacted in drug-treatment responses to methamphetamine use in Melbourne,
Australia. After reviewing qualitative data collected among health-care providers and
methamphetamine consumers, we draw on the work of Michael Warner to argue
that services for methamphetamine consumers in Melbourne betray ongoing tensions
between public and counterpublic constituencies. Our analysis indicates that these
tensions manifest in two ways: in the management of street business in the delivery
of services and in negotiating the meaning of health and the terms of its restoration or
promotion. Reflecting these tensions, while the design of services for methamphetamine
consumers is largely modelled on public health principles, the everyday experience
of these services may be more accurately characterised in terms of what Kane Race
has called counterpublic health. Extending Races analysis, we conclude that more
explicit focus on the idea of counterpublic health may help local services engage with
methamphetamine consumers in new ways, providing grounds for novel outreach,
harm-reduction and treatment strategies.
Keywords
counterpublic health, drug treatment, Melbourne, methamphetamine, public health,
qualitative research

Policy responses to illicit drug use typically emphasise law enforcement and public
health (Moore and Dietze, 2008). While the two are sometimes described in complementary ways, it is increasingly common for law enforcement and public health to be cast in
Corresponding author:
Cameron Duff, National Drug Research Institute (Melbourne Office), Faculty of Health Sciences, Curtin
University, 6/19-35 Gertrude Street, Fitzroy, VIC 3065, Australia.
Email: cameron.duff@curtin.edu.au

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more discordant terms in drug policy debates (Brownstein, 2013). Within these debates,
public health is often said to offer a progressive, humane response to contemporary drug
problems, in contrast to the punitive logic that is regarded as the basis for the enforcement of legal prohibitions (Koppelman, 2006). Going further, advocates claim that public health offers a framework for devising holistic responses to illicit drug use that are
sensitive to the interaction of social, political, economic and structural forces in the incidence of drug problems (Ball, 2007; Des Jarlais, 1995). This interest in addressing the
structural determinants of illicit drug use, and the health and social problems that often
accompany this use, characterises most public health initiatives for the reduction of drug
problems (Fraser and Moore, 2011). Yet in seeking to promote public health, such initiatives inevitably evoke a shared imaginary by which a particular understanding of the
public and its interests is enacted. Moreover, it is rare for this conception to be explicitly interrogated such that the public to which public health is oriented or the population any drug policy may be said to represent can be properly characterised.
This article is interested in how notions of the public are conceived, marshalled and
enacted in drug-treatment responses to methamphetamine consumption in Melbourne,
Australia. Drawing from Michael Warners (2002) critique of public discourse to analyse
qualitative data collected among methamphetamine consumers and service providers,
we argue that responses to methamphetamine use in Melbourne betray an ongoing tension between public and counterpublic constituencies. As a result, while the design of
local health and social services for methamphetamine consumers is largely modelled on
public health principles, the everyday experience of these services may be more accurately characterised in terms of what Kane Race (2009) has called counterpublic health.
Extending Races analysis, we conclude that more explicit focus on the idea of counterpublic health may help local services engage with methamphetamine consumers in new
ways, providing grounds for novel outreach, harm-reduction and treatment strategies.

Publics, counterpublics and counterpublic health

Prioritising prevention, supply reduction and harm minimisation (Ritter et al., 2013),
contemporary Australian drug policies, including the National Amphetamine-Type
Stimulants (ATS) strategy, address a national public understood to comprise a kind of
social totality (Warner, 2002: 49). This is apparent in the population health, education
and social marketing initiatives that comprise Australias ATS strategy, which typically
convey information, warnings and advice for a public conceived in universal terms (see
Allsop and Lee (2012) for a review). While the notion that drug policies, such as
Australias ATS strategy, address a pre-existing constituency accords with traditional
notions of democratic governance, Warner (2002) argues that this perspective ignores
public policys role in constituting a public that serves as the object of its address. Warner
(2002) thus draws a distinction between the public, conceived as people in general, and
a public or multiple publics (pp. 4950). Warner is interested in how these multiple publics ought to be characterised and the varied mechanisms by which they are brought into
being. Throughout his analysis, Warner (2002) emphasises the constitutive role of texts
(or discourses), which he takes to include not only written communication of every hue
but also visual and audio texts and the practices, habits and associations they inspire (p.

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51). Texts galvanise or sustain publics by organising a collective body of address. They
establish a point of address (along with an imaginary public) comprising all users of
that text whoever they might be (Warner, 2002: 51). Warner goes on to identify seven
features of these imaginary publics, along with the counterpublics they exclude. We will
briefly describe these features before examining how they are articulated in drug services, and contested in counterpublic health, in Melbourne.
First, Warner (2002) argues that publics are self-organised; each must have
some way of organising itself as a body and of being addressed in discourse (pp. 5051).
It follows that publics are established in relations among strangers (Warner, 2002: 55).
Publics are self-organising insofar as their form and content are defined by the activity
of those who participate in them. Given that publics, by definition, exert no barrier to
participation other than interest or attention, publics are formed in a kind of strangersociability (Warner, 2002: 57). Organising this sociability requires a form of address that
is both personal and impersonal. One must identify oneself among the addressees hailed
by a given text without regarding oneself as the sole object of this address (Warner, 2002:
58). This is why a public may be said to be constituted in participation rather than membership or identification. Indeed, as soon as one ceases to participate in a given discourse, one may be said to have left that public. Warner (2002) next suggests that all
publics enact a social space created by the reflexive circulation of discourse (p. 62).
Any public must be understood as an ongoing space of encounter for discourse inasmuch as every public slowly develops a reflexive awareness of itself in the repetition of
modes of address directed to it (Warner, 2002: 62). All publics have a punctual rhythm
in this sense, insofar as the texts which sustain them circulate in a predictable or at least
relatively routine chronology (Warner, 2002: 63). This also gives each public a specific
historical profile to the extent that it manifests particular values, interests and modes of
address at particular times. A publics historicity is further expressed in the poetic worldmaking all texts seek to effect (Warner, 2002: 82). All texts necessarily establish a public
by determining the object of their address, while further characterising that publics salutary interests and preferences. As such, public texts serve to mediate, if not define, the
identities, values and worldviews of those assembled in their address.
Warner (2002) rounds out this discussion by developing Nancy Frasers idea of the
counterpublic to account for publics which mark themselves off unmistakably from
any general or dominant public (pp. 8489). Counterpublics differ from other publics to
the extent that they depart from the characteristic features, preferences and norms that
define mainstream publics and the social groups that comprise them. Counterpublics
vary from sub-publics, subcultures or communities of interest insofar as their members maintain some awareness (conscious or not) of their subordinate status (Warner,
2002: 86). Citing, by way of example, women, workers, peoples of colour and gays and
lesbians, addressees in each group are identified by way of their participation in counterpublic discourse (Warner, 2002: 8586). In each instance, a hierarchy or stigma is the
assumed background of practice (Warner, 2002: 87). Stigma, and the history of subordination in which it is inscribed, conditions the emergence of counterpublic discourse by
foreclosing participation in other more privileged modes of address. It follows that the
poetic world-making central to all public discourses assumes even greater importance in
counterpublics, such that the lifeworlds (practices, values, norms, identities, ethics)

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expressible in counterpublic discourse may be nurtured and sustained in the face of dominant social norms or values. All counterpublics are political in this way.
Consistent with Warners account of publics and counterpublics, a number of scholars
have recently applied his analysis to the study of public health and the discourses, norms,
values and practices that sustain it (see Fraser, 2006; Race, 2009). Scholars have been
especially interested in the claim that public health discourses enact a public rather than
respond to the needs of an existing population. This suggests the value of questioning
how the public in public health ought to be characterised. Race (2009) argues that public health is founded on a series of normative assumptions about the character, preferences, motivations and behaviour of subjects held to comprise a given social totality.
Public health serves to enact a public by conflating descriptions of healthy (or normal)
functioning with normative injunctions regarding the ways health ought to be performed,
observed or adhered to (Greco, 2009: 2124). An example may be the way drug policies
seek to distinguish healthy from harmful relationships to drugs by differentiating healthy
and unhealthy practices, behaviours and attitudes. Such distinctions rely on the invocation of norms rationality, risk aversion, self-interest, moderation, restraint and responsibility, for example that purportedly characterise healthy subjects and the public they
populate. These norms circulate via texts, practices, techniques and forms of address that
position drug policy as a particular mode of administering the health (and/or productivity) of a given population (see Rose, 2007: 35). As such, despite observing many of the
hallmarks of public address (such as stranger sociability; personal and impersonal
address; the requirement of public attention and the definition of a space of inter-textual
circulation), drug policies cannot be said to address a self-organising public because they
are articulated in state-sponsored discourses which aim to govern the conduct of their
addressees.
It is for these reasons that Race (2009: 161163) argues that public health discourses,
including drug policies, address a very specific public rather than all subjects in a given
population. Public health potentially excludes or ignores counterpublics, including
injecting drug users, people living with HIV/AIDS, lesbians and gay men, by cleaving to
a set of normative injunctions regarding the values and preferences of healthy subjects.
Hence, the individual who injects methamphetamine, or the gay man who enjoys regular
casual sex, may never be fully accommodated in public health discourse because of a
failure to fully identify with the public imagined in this discourse. This misidentification
suggests the need for what Race (2009) calls a counterpublic health more cognisant of
the care practices and corporeal pedagogies routinely invented in counterpublic settings
(p. 161). While these pedagogies may not always accord with the therapeutic logic
advanced in public health (or the drug policies informed by it), they entail a range of
experimental techniques by which well-being, pleasure, freedom, care, recognition and
resilience are nurtured in conditions of social, material and political disadvantage. Each
technique provides a sense of the practical ethics hinted at in Races (2009: 161163)
brief account of the properties of counterpublic health. More directly, each suggests that
the normative characterisation of health advanced in drug policy debates should not be
regarded as the only way in which health may be promoted in everyday experience. It is
with these insights in mind that we have explored the experience of methamphetamine
consumption in Melbourne and local service responses to methamphetamine-related

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problems. We are particularly interested in developing Warners and Races accounts of

the organisation of public and counterpublic constituencies and the implications of their
analysis for the design of health services. Furthermore, by extending Races notion of
counterpublic health, we aim to indicate how health-care providers may more effectively
respond to social and material disadvantage in delivering health care for methamphetamine consumers. We start with an outline of the study methods before turning to our data.

Methamphetamines and counterpublic health in Melbourne

We analyse accounts of methamphetamine use drawn from in-depth interviews conducted during the ethnographic component of a mixed-methods study investigating
methamphetamine use and service provision in Melbourne.1 The ethnographic research
had two aims: to explore the social contexts of methamphetamine use in Melbourne and
to assess the character, scale and effectiveness of service responses to methamphetamine-related problems. Our goal in exploring local contexts of methamphetamine consumption was to investigate the role of social and material conditions in mediating access
to health care for methamphetamine consumers. We were also interested in consumers
lived experience of this care. Following approval from the Curtin University Human
Research Ethics Committee, the data we focus on here were collected in semi-structured,
in-depth interviews with 31 methamphetamine consumers (17 men, 13 women and 1
transgender woman; average and median age 36 years, range 2256 years) and 15 service providers. Consumers had used methamphetamine at least once a week in the 6
months preceding the interview or had been using methamphetamine on a regular basis
prior to entering drug treatment. In total, 26 consumers reported being born in Australia,
most in Victoria, with all but 2 identifying with an Anglo/European ethnic background;
4 had attended a tertiary institution and 3 had completed secondary education; 4 consumers were employed full-time, with 20 in receipt of either a disability or unemployment
pension; and 15 were enrolled in opioid-substitution therapy. All consumers were reimbursed AUD30 for their time and expenses.
Interviews were conducted with drug service providers to elicit data on problems
related to methamphetamine consumption in Melbourne and the effectiveness of local
responses to these problems. Service providers were recruited from needle and syringe
programmes (NSPs), drug treatment and residential rehabilitation centres. Of the 15 service providers who completed interviews, 5 reported working as nurses, 4 were employed
as NSP workers, 2 worked in outreach roles, 2 worked as drug counsellors, with 1 social
worker and 1 general practitioner (GP). Interviewees reported working in allied drug
services for a period of 326 years (average of 13.2 years). Of the providers, 10 were
currently employed in services in St Kilda, with the remainder working in Fitzroy; 3
reported being employed in management positions. Interviews with both consumers and
service providers were conducted in cafes, local services and private homes and lasted an
average of 1 hour (range 27128 minutes). Interviews were digitally recorded and transcribed to facilitate data analysis and reporting.
All data sources were integrated using steps described by Woolley (2009). The resulting data set was then analysed using techniques drawn from Adele Clarkes (2005)
Situational Analysis: Grounded Theory after the Postmodern Turn. Situational analysis

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permitted more sensitive treatment of consumer accounts of their methamphetamine

careers and of the views of local service providers regarding the clients they serve, their
lives and circumstances. The approach also availed the possibility of fresh empirical
insights and novel theory development. Analysis of interview transcripts involved open,
axial and selective coding (Clarke, 2005: 120130) to identify and explore the various
dimensions of methamphetamine use described by consumers and service providers.
This included comparative analysis of regularities, variations and contrasts in the data to
test and confirm emerging insights regarding the design of services for methamphetamine consumers, along with consumer reports of these services. These strategies led to
more refined analyses as codes were slowly established and key findings elaborated.

Serving counterpublics in a public health context

What emerged very strongly in our interview data was the sense that regular methamphetamine consumers in Melbourne constitute a local counterpublic given their departure from normal health and their awareness of their subordinate status (Warner,
2002: 86). The interviews also suggested that local drug services are largely modelled on
public health principles, with all their pragmatic assumptions regarding the character of
good health, and the qualities, values and aspirations that impel individuals to pursue it.
Following Warners analysis, it may be argued that these services are designed to respond
to the needs of a public construed in normative terms. Despite keen appreciation of the
disadvantage clients experience, and the complexity of their needs, service providers
reported being bound by their agencys funding agreements, and its broader philosophies
of care, to regard clients as normal subjects with a normal capacity for self-interest,
responsibility and moderation. Such commitments led to tensions in the delivery of drug
services that while modelled on public health principles cater nonetheless to a mainly
counterpublic clientele. Our analysis indicates that these tensions manifest in two ways:
in the management of what one provider called street business in the delivery of drug
services and in negotiating the meaning of health and the methods of its restoration or
promotion. We will describe each aspect before assessing some of the major implications
for the design of drug services in Melbourne and elsewhere.

Designing public health services for counterpublic clients

The interviews revealed much about the experience of drug treatment in Melbourne, and
the ways in which methamphetamine use is characterised in the design of drug services.
Most service providers were wary of the idea of tailoring treatment to individual substances, preferring a more holistic approach. Others thought that the methamphetamine
problem had been exaggerated in local media and policy responses. In light of these
sentiments, a number of service providers explicitly endorsed the need for holistic public health philosophies in the design of drug treatment and allied services for methamphetamine consumers. Despite this agreement, providers and consumers offered varying
accounts of how public health principles inform the design and delivery of drug services
in Melbourne. Noting her agencys adoption of a public health approach to drug treatment, Marie2 spoke of the need for a social model of health that incorporated physical,

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emotional, social, spiritual and preventative aspects in the design of drug services. She
added that it was more important to address these underlying issues than to focus too
much on clients day-to-day drug use. This distinction between drug use behaviours and
deeper underlying issues concerning the social and material disadvantage experienced
by consumers was a common feature of providers descriptions of the principles that
informed the design of health services at their place of work.
For example, in describing his own service programme, Mark emphasised the need
for health services to be strengths-based, non-judgemental and destigmatising as a
way of breaking down the barriers to treatment and support among individuals who
have mostly just been pushed aside by society, like nobody wants them. Clarifying this
argument, Sarah spoke of the need for services to recognise that drug takers in Australian
communities are marginalised, prejudiced, discriminated against and because of that getting work, getting housing, staying healthy can be really hard. She added that, for these
reasons, services need to remember that people often turn to drugs because of socially
unjust outcomes in their lives. Consistent with this view, another service provider, Lisa,
argued for a public health approach to drugs, not a punitive one. When asked to elaborate on this difference, she spoke of the need for health care that is really client focused,
non-paternalistic and respectful something that treats the whole person and doesnt
just focus on the drugs. Other service providers endorsed public health and/or harmreduction approaches to drug treatment because of the ways each approach works to
empower disadvantaged or marginalised people in the community, as Joseph put it.
Kim added that she thought it was important that the health care system respects peoples choices and empowers them to improve their own health. Indeed, almost all service providers emphasised the need for respect and understanding in order to
empower individuals to take control of their own lives, with most explicitly referring
to various public health principles in making these arguments.
In keeping with these views, a number of service providers argued that consumers
should be treated no differently than any other member of the public, as Simon put it.
Providers defended the importance of non-discrimination as a way of reducing stigma
and the barriers to care associated with it. All the same, providers routinely acknowledged how much service users differed from what Mark called the general public. Sue,
who had worked in local treatment services for many years, observed,
We dont get too many office workers popping in during their lunch break for a counselling
session. We see some from time to time in the NSP, and some tradies [those working in various
trades] in the morning some times. But mostly its just people who are that desperate for help, you
know, theyre fed up with the drugs and the struggles and the problems, all the dramas in life.

For this reason, most providers spoke of the need to differentiate specialist drug treatment from mainstream health care, such as hospitals and GPs. Some providers noted
that their clients either felt unwelcome in mainstream health services or had been
actively excluded from them. Mick explained that
I think once theyve [consumers] had, especially at the hospitals, once theyve had one bad run
in they dont want to go back, which is fair enough. They get treated pretty badly. So I guess

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going into a normal doctors room where everything is a bit more professional, they dont feel
comfortable in there.

Similarly, Jennifer, who described working in drug services around Melbourne for many
years, spoke of the need to differentiate drug services from mainstream care:
A lot of people theyve been burned so many times in their experience, they wont go to general
health services, theyre wary of Centrelink, they resent the system. Thats why I dont wear a
uniform and we try to be as informal as possible while at the same time providing facilities that
are nice and shows them that this place is for you and you deserve it. So people trust us and they
can talk to us about things that they probably dont tell a regular doctor.

The reports offered by Mark, Mick, Sue and Jennifer exemplify the tension noted
earlier between public and counterpublic health in the provision of drug services for
methamphetamine consumers in Melbourne. In particular, they suggest that the attempt
to treat consumers like any other member of the public is not always consistent with the
goal of distinguishing drug treatment from mainstream health care. The most revealing
example of tensions between public and counterpublic health was observed in the negotiation of what one service provider called street business in the delivery of drug treatment and related services in Melbourne.

Managing street business in the everyday delivery of drug treatment

Managing street business emerged as one of the main ways public health providers
attempt to accommodate the needs of counterpublic clients. Describing her own service,
June said,
Its often hard to manage things, to keep the place safe for the staff but also accessible for the
clients. And Ive got to be the one who goes out and interrupts them if theyre dealing or using
to tell them to move on. I guess they feel its a safer place to deal. But still, theyre usually smart
and hide around the corner where I cant see them.

Simon spoke of similar challenges at the NSP where he worked as staff tried to manage illegal activities on-site and off-site while maintaining a safe space for clients:
What happens is that people have often scored, or they might even have a taxi running outside,
so theyre quite self-conscious coming in. We do have things put in place with the police where
one of our managers liaises with one of the police regarding them being within a certain area
around the NSP. But obviously were sort of a hot spot so there is a lot of police activity around
so its not really a space people hang around in. So we really have to make people feel as safe
as possible no matter what else they might be doing.

This attempt to maintain a safe site for consumers, no matter what else they may be
doing, highlights the tension between public and counterpublic health. More broadly,
the informal strategies described by Simon provide useful examples of what we understand counterpublic health to mean. Offering further indications of the character of

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counterpublic health, another provider, Caitlin, spoke of the importance of balancing the
demands of the mainstream health-care system with the needs of a disadvantaged client
group. She noted that
We target marginalised adults who have an illicit drug problem so the most important thing is
to create a safe, stable place for care. We try to balance some of the street based chaos with all
the psychosocial stuff going on for clients with some level of stability really to try and create
space for change.

Providers attempts to manage street-based chaos emerged as one of the most telling
sites of conflict between public and counterpublic health in our data. No issue was more
prominent in this respect than the problem of managing client access to benzodiazepines. Describing arrangements at his place of work, Malcolm spoke of the need to
follow formal prescription protocols while remaining sensitive to the needs of some
really disadvantaged people. He added that
Theres so much street business that flows into every organisation like this, mostly people are
stressed about their script. They stretch the chemist out for a few days and then they come in to
see us [and say] give me pills, give me benzos. We cant prescribe, thank God, but we do
sometimes tell people if you say this to the doctor and say you just want a limited quantity and
say you havent slept for three days, theyll probably help you out. Heres my card, you can
have them [doctor] call me and say that Ill supervise it or whatever. But that would be a rare
case. We dont pull out the stops to get people pills.

Malcolms description of the informal strategies he uses to manage conflict over access
to benzodiazepines provides a further example of the character of counterpublic health in
the delivery of health care for methamphetamine consumers. William, a GP with a long
list of drug patients, had a pragmatic view of this issue:
Weve become a sort of legal drug dealer in a way. I mean these people have a daily commitment
to intoxication and to be quite honest most of my patients are real pros at this, the big benzo
fight, trying to get their Xanax script or whatever. But my attitude is that if we can reduce the
harm a bit with regards to them making some progress, such as getting work, thats a big deal
for us.

Instances like these involving the management of street business in the provision of
drug services highlight an abiding tension between the tenets of public health that reportedly inform service design in Melbourne and the exigencies of delivering care to a counterpublic clientele. While, as providers noted, services in Melbourne are largely modelled
on public health principles, the normative assumptions that govern these principles
such as rationality, self-interest, responsibility, moderation and risk avoidance do not
always reflect the needs, interests, experiences or preferences of counterpublic clients.
This is not to argue that the methamphetamine consumers involved in our study do not
value health, rationality or moderation, only that these terms or qualities are subject to
recurrent negotiation in the context of significant social, economic and personal disadvantage. Our analysis suggests more directly, therefore, that health does not always mean

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the same thing in public and counterpublic settings. Indeed, the struggle to determine the
everyday meanings of health, and the method of its restoration or promotion, emerged as
the second key source of tension in our data between public and counterpublic health in
the delivery of health and social services for methamphetamine consumers in Melbourne.

Public health and counterpublic health in tension

One of the most significant instances of conflict over the meaning of health occurred in
discussions of the relationship between methamphetamine use, health and illness. While
almost all service providers and consumers made some reference to problems associated
with methamphetamine use, most described functional benefits as well. This was especially common in discussions of mental health, as one provider noted,
A lot of my clients are really trying to medicate their mental health symptoms. Theyre
constantly trying to balance all the drugs theyre taking, both prescribed and street drugs, with
the management of their mental health. So speed can give them that up that increases their
function for a period of time. It helps them achieve things they want to achieve or just pulls
them out of that low depressive rut. I think the drugs are mostly just a response to that [rut].

A number of consumers made similar observations regarding what they perceived to

be the functional and/or therapeutic effects of methamphetamine. Jennifer added,
My medication, I have to take that, but thats why I like taking speed on top of the medication
because I get really tired, lethargic and I just need something to pick me up. Otherwise, I wont
get out of bed. I can sleep for 15 hours a day.

Another consumer Sarah was even more direct: its a bonus if I get out of it. I really
just use it [methamphetamine] to function. The point here is that the frequent claim that
methamphetamine use is unhealthy or dangerous, a common claim in public health, drug
policy and service delivery debates, is routinely contested, if not rejected outright, among
regular consumers and some service providers. It follows that one of the major tasks
confronting service providers is to engage clients in conversations about their healthrelated beliefs and goals such that appropriate care plans can be devised. Describing how
this task is managed at her own service, Sue argued that
The fact that clients are really involved in their health is critical. Like how do we make health
accessible to those who need it the most but have the least of it? So we have to start with a
conversation about what people want, do they want to stop using drugs, cut down a bit, how
does their drug use affect their health, that kind of thing. What I mainly find is that people just
need a break. So treatment is just about getting some help to manage for a while.

A number of consumers agreed with Sues last point, further confounding conventional
understandings of the relationship between methamphetamine use and health. For example, Bill described his most recent experience of drug treatment this way:
I just wanted a holiday. I was off speed but I had started using again regularly and bingeing and
realised that I had to put the kybosh on that, and you know the first week is a bit hard so I put

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my name down for the detox and they feed me and I dont have to do anything, wipe my bum
for me, whatever. So I went in there for a holiday. I just needed a break, have a rest and think
about things.

Bills point, as we understand it, is that consumers seek drug treatment for all sorts of
reasons, only some of which may pertain to their health status. It is equally true that
consumers often seek treatment for their methamphetamine use without endorsing the
view that methamphetamine is always unhealthy. While one consumer observed that
treatment only works if youre ready to change, he also acknowledged the conflicting
motivations that may lead one to seek help. By way of example, a number of consumers
reported accessing drug services for information about safer drug use or, as we have
noted, to acquire better drugs such as benzodiazepines. In a further indication of the
corporeal pedagogies central to the practice of counterpublic health (Race, 2009: 161),
Sarah highlighted the importance of sharing these kinds of information and referral
sources with other consumers:
I think because Ive been using the services for so long, and they all know me and that, Im
expected to educate younger people if I see them and I think they need help. I think I put that
on myself actually. That I should make sure theyre educated because if theyre going to be, if
theyre going to do it and the only way Ive stayed alive all these years is because the needle
exchanges have taught me properly right from the start. Thats huge you know?

Endorsing the importance of peer education, many providers argued that services
need to find ways to facilitate peer education and peer support to better assist vulnerable
communities. Mark noted that
Theres definitely a culture, people, places, when people are using drugs and getting into
trouble. And the longer theyve used drugs the more they identify with this culture if you like,
including the people in it, the dramas. The downside is the longer they stay identifying with that
culture, the harder it is for people to get out of it, to find a home, a job, to stop using drugs. So
I think part of our job is to change that culture, to get people thinking about their health in new
ways, to help them access services that match their needs.

We find in this quotation the rudiments of counterpublic health-care praxis. Counterpublic

health demands a pragmatic, flexible, responsive and non-judgemental approach to drug
use and the problems associated with it. It does not differ in this respect from conventional understandings of harm reduction and its application in the design of health services for drug consumers (Marlatt, 1996). Where it does differ, however, is in its
explicit recognition of how the preferences, values and needs of counterpublic subjects
may vary from the public imagined in public health discourses, including drug policy
debates (Race, 2009: 161163). Once this difference is understood, the diverse ways
health is characterised in counterpublic settings ought to become clearer, along with
the ways health is sustained, nurtured or protected in practice. Our analysis indicates
that health in counterpublic settings is a labile, contingent concept, wrought in the
struggles, disadvantage and subordination that all counterpublics endure. Far from
according closely with normative ideals, counterpublic health is forever sensitive to
the ways health is lived or realised in the context of endemic social, economic and

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personal disadvantage. This disadvantage may explain, for example, why methamphetamine consumption may be appealing to individuals living with mental illness. It may also
explain why pharmaceutical medications like Ritalin or Xanax are so popular or why a
stint in drug treatment may be regarded as a holiday. Once health is understood in a
counterpublic context, the means of its restoration or promotion in the provision of care
for drug consumers ought to be rethought too.

Discussion
Michael Warners distinction between publics and counterpublics, between normative
communities of interest and those defined by their subordination, offers a means of
drawing out some of the tensions inherent in all public health responses to illicit drug
use. It is often noted that by identifying the norms and procedures wherein health may
be maintained or promoted, public health discourses inevitably reify a normative public
and a normative conception of health (Greco, 2009). These norms often enjoy a consensus among the subjects of public health discourse; a consensus that usually includes the
various interventions by which public health is promoted. Our analysis suggests that
such a consensus is not always present in public health responses to illicit drug use,
mainly because these responses necessarily address both public and counterpublic constituencies. Caught between public health principles that emphasise the health literacy
of normative subjects, and the everyday needs of subordinate communities, agencies
responsible for the delivery of public health care to drug consumers must negotiate the
meaning of health, and the methods of its promotion, in both public and counterpublic
registers. According to the consumers and service providers who participated in our
study, these negotiations expose tensions in the provision (and receipt) of drug services
between the exigencies of counterpublic life and the norms of public health care and
support.
In the first instance, tensions manifest in the management of street business inside
the health and social services that treat methamphetamine consumers. Examples from
our research included staff efforts to establish health-care practices that differ in meaningful ways from mainstream services; the lack of staff uniforms and other formalities;
the pragmatic management of illegal activity such as drug dealing or consumption on
and around the site; consultations with local police regarding law enforcement; negotiating the big benzo fight by brokering relationships with GPs and pharmacists; and in
efforts to transform local drug-using cultures. In each instance, staff members are
required to interpret, transform and sometimes reject the public health principles that
ostensibly ground the delivery of care in favour of a more pragmatic and experimental
counterpublic ethos. In each instance, providers and consumers are required to invent the
terms and practice of counterpublic health.
Race (2009) argues that counterpublic health involves select care practices and corporeal pedagogies by which discrete understandings of health are negotiated or performed (p. 161). All such practices depart in one way or another from the norms
described in public health discourses. The measure of this departure reflects the scale of
the social, economic and personal disadvantage individuals experience in counterpublic
life. What we find so attractive in Races analysis, however, is the contention that the

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experience of disadvantage should not be taken to mean the absence (or rejection) of
health. Certainly, the disadvantages that define counterpublics have an immense impact
on health as it is conventionally understood in public health discourses. Yet, without
ignoring the range of public health services that make a real difference in disadvantaged
(or counterpublic) communities, these services typically ignore the lay, indigenous or
folk experiences of health that are the focus of Races analysis. Our study suggests that
folk accounts of health are central to the everyday negotiation of care in the delivery of
drug services in Melbourne, even though they are often ignored in public health models
of drug treatment and support in Australia (see Moore, 2009; Moore and Fraser, 2006).
We observed a range of folk approaches to health in our research, including lay accounts
of the therapeutic effect of methamphetamine use on various mental health symptoms,
along with its capacity to mitigate some of the unwanted effects of prescribed medications. Other participants described a folk pharmacology (Southgate and Hopwood,
2001) by way of the ideas and practices that circulate in counterpublics regarding safer
drug use, more pleasurable combinations of illicit and prescribed drugs or more effective
strategies for procuring prescription drugs from apparently sympathetic health-care providers. As such, the practices and pedagogies discernible in, for example, the preference
for dexamphetamine over methamphetamine, in the effort to procure benzodiazepines or
in the intermittent presentation at drug treatment for a break or a rest are themselves
indicative of the ways health is negotiated in the context of significant social and material disadvantage. The extent to which these practices are openly acknowledged, and
occasionally accommodated, by the service providers who participated in our study conveys some sense of how counterpublic health may potentially inform the delivery of
health care among methamphetamine consumers in Melbourne and elsewhere.

Conclusion: harm reduction and counterpublic health

The account of counterpublic health advanced in this article has obvious and important
antecedents in harm-reduction debates stretching back over many years. Counterpublic
health and harm reduction each emphasise the need for pragmatic, non-judgemental
responses to the use of alcohol and other drugs (AOD), with a strong focus on effective
action to reduce drug-related problems, and a general indifference to arguments regarding the moral status of AOD consumption (Fraser and Moore, 2011). Yet for all this
concordance, harm reduction is still generally characterised in terms of select public
health principles (Marlatt, 1996). It is typically regarded as part of a broad-based public
health response to problems associated with AOD use, particularly the transmission of
HIV/AIDS, with advocates and clinicians commonly arguing that the efficacy of individual harm-reduction strategies should be measured against public health outcomes
(Ball, 2007: 685687). The problem with the conflation of public health and harm reduction, as we have sought to indicate in our analysis, is that it inevitably mischaracterises
the social totality for which harm reduction is conceived and delivered. Characterising
harm reduction in terms of a discrete public constituency necessarily invokes a range of
normative assumptions regarding the value of health and the means of its promotion. It
inevitably invokes, for example, a normative subject committed to the maintenance of
health and the virtues required to sustain it. It is for these reasons that Moore and Fraser

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(2006) argue that harm-reduction discourses tend to inscribe a neo-liberal subject

autonomous, rational, independent, calculating and fail to acknowledge adequately
material constraints on individual human agency (p. 3036). Greater sensitivity to such
constraint is what the idea of counterpublic health primarily affords.
Consistent with Warners argument that counterpublics are defined, in part, by an
awareness of their collective subordination, Races notion of counterpublic health cites
the terms of this subordination to explain how health is negotiated, contested and enacted
in counterpublic settings. We would add that such efforts shed further light on the alternative rationalities by which health is practised in counterpublics. The material constraints that define counterpublics also constrain their capacity to conform to the
normative account of health presented in public health discourses, including harm reduction. The valorisation of self-interest, control, moderation and responsibility common to
harm-reduction initiatives rarely acknowledges the social, material, affective, cognitive
and moral resources necessary to realise such qualities (Crawford, 2006; Race, 2009).
Counterpublics are defined by the scarcity of these resources a scarcity that is largely
attributable to the broader structures of material disadvantage that distinguish counterpublic from public entities. Yet this does not mean that health, moderation or responsibility are absent from counterpublic settings like those described in our study. Instead,
health in these settings is the subject of alternative rationalities that provide a means of
practicing health in a context of material constraint. This suggests, for example, that the
practice described above whereby street drugs and prescribed drugs are combined in
the management of mental illness ought to be understood in the context of material disadvantage that limits access to other forms of mental health care and support. We would
make a similar claim in relation to the demand for benzodiazepines described by
participants.
Our study revealed some accommodation of these rationalities in the delivery of
drug services to methamphetamine consumers in Melbourne. We would like to close by
exploring how this accommodation may be extended in the delivery of counterpublic
health for drug consumers in Melbourne and elsewhere. From the GPs, NSP workers,
nurses and support staff who described attempts to supervise clients off-script use of
benzodiazepines, to the eschewal of uniforms and other formalities and the pragmatism
with which service providers sought to manage street business, each of these initiatives suggests something of the way counterpublics are supported in drug services. Yet,
of course, these efforts are rarely enshrined in formal procedures and so remain vulnerable to sudden reversal in the face of hostile public attention. This, indeed, is Races
(2009: 137141) point regarding tensions between public and counterpublic health,
given the privileges of the former and the vulnerabilities of the latter. However, the
primacy of public health principles in the design of drug services internationally suggests various strategic opportunities for the articulation of counterpublic principles to
guide drug services. For example, one of the hallmarks of public health is an appreciation of the social determinants of health, although effective means of combating the
inequalities these determinants express remain elusive (Moore and Dietze, 2008).
Counterpublic health addresses this issue directly by proposing to accommodate the
care practices common to counterpublic settings within the delivery of health services
including drug treatment.

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Moves to accommodate folk practices in the delivery of drug services are rarely justified in terms of the effort to combat structural inequalities in access to care, suggesting a
novel basis for innovation in the design of (counterpublic) health care for vulnerable communities, including injecting drug users. Another argument for the merits of counterpublic
health concerns the need for more effective outreach efforts to improve the accessibility of
drug services. Counterpublics demand a mode of address that differs from public forms,
and while some of the service providers who participated in our study described attempts
to articulate such alternatives, they rarely enjoyed formal endorsement. The invention of
modes of address that bring counterpublics into drug services by accommodating their
needs, preferences and values has the potential to reshape the ways health care is provided
in the midst of profound social and material disadvantage. It may even recast how the public construes the relationship between drugs, health, pleasure, embodiment and illness.
Funding
The research reported in this article was funded by Australias National Health and Medical
Research Council (Project Grant 479208). We are grateful to Robyn Dwyer for conducting the
interviews and participant observation. The National Drug Research Institute at Curtin University
is supported by funding from the Australian Government under the Substance Misuse Prevention
and Service Improvement Grants Fund.

Notes
1. For findings from the quantitative component of the study involving population survey data,
health-care utilisation data and treatment outcomes data, see Quinn et al. (2013a, 2013b).
2. The names used in this article are pseudonyms in order to preserve anonymity.

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Author biographies
Cameron Duff is a Research Fellow in the Ethnographic Program at the National Drug Research
Institute in Melbourne, Australia. He is also an Associate Editor (Qualitative and Social Research)
at the International Journal of Drug Policy. Duffs primary research interests concern the relationship between health, place and social inclusion with a focus on the lived experience of mental
illness and substance use. Duffs first book Assemblages of Health will be published by Springer
in 2014.
David Moore leads the Ethnographic Program at the National Drug Research Institute in
Melbourne, Australia. He is Editor of Contemporary Drug Problems and is a member of the
Editorial Board for the International Journal of Drug Policy. He is the author of numerous book
chapters and peer-reviewed articles on the social and cultural contexts of alcohol and other drug
use and has co-edited various key works on drug research and policy. His most recent book entitled
Habits: Remaking Addiction (co-written with Suzanne Fraser and Helen Keane) will be published
by Palgrave in 2014.

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