Come to Harm

Politics—and electoral politics most flagrantly—is the projection of the illusion of competence onto the illusion of understanding. Its field of concern is what are called “issues,” a large part of which comprises the aspects of a society it refuses to recognize as its own and that it tells itself it can ameliorate without changing its most basic nature. Many of these issues are lingering but fluctuate around a threshold of tolerability, so that a temporary drop in crime may lead to an increased focus on immigration, or rising unemployment may draw voters’ attention away from entitlement reform. Because issues tend to be structural rather than incidental, they often seethe for years or decades even as the public’s attention is turned elsewhere, only to reemerge as outrage bait to discredit whoever happens to be in power.

In Philadelphia, in 2023, the issue that towered above all others was lawlessness, and its symbol was Kensington, a poor, mostly Hispanic neighborhood in the city’s near northeast. Kensington has been notorious for drugs, deprivation, and abandonment since the 1970s; but the cliché of Kensington as a wasteland of drug-addled zombies, the Kensington that tops the Google and YouTube search results, dates from the summer of 2017, with then-mayor Jim Kenney’s decision to clear out a long-established homeless encampment along the abandoned Conrail tracks running parallel to Gurney Street between Kensington and neighboring Fairhill.

Not long before then, an episode of the Dr. Oz Show entitled “A Festering Epicenter of Heroin That Will Shock You” aired with footage of its host visiting the trash-laden woods around the train tracks and coming away with the verdict, “I just walked into hell.” In July and August of that same year, articles on the Kensington encampments appeared in Time and The Atlantic. By 2018, The New York Times Magazine was calling Kensington the “Walmart of Heroin,” and the Drug Enforcement Agency allegedly considered the Badlands, which encompass parts of Kensington and Fairhill, to be the largest open-air drug market on the East Coast.

The destruction of the Conrail encampment displaced its homeless residents to a series of nearby underpasses, two of which were subsequently targeted for clearing in the Encampment Resolution Pilot undertaken in April 2018. The city-commissioned report on the pilot’s outcome makes for instructive reading. Whereas the mayor’s office highlighted its success in “[clearing] all major encampments in Kensington” and “[coordinating] services including housing, health services, and treatment,” the report’s authors, working under the aegis of the University of Pennsylvania, found that clearing encampments had no effect on the numbers of the homeless in Kensington. Substantial churn meant that new arrivals quickly took the place of those transferred to shelters, permanent housing, or residential rehabilitation, while people who refused these options simply continued to sleep outside and took their belongings away in the morning with the implicit blessing of the police, who were reluctant to arrest them and had no mandate to force them into treatment.

The efficacy of greater outreach in addressing homelessness and addiction was called profoundly into question by researchers’ findings. “Most of the individuals in the encampments were . . . known to the various City services systems, and made substantial use of healthcare, housing, treatment and criminal justice services,” they write; 73 percent of respondents had been in rehabilitation; 55 percent were covered by Medicaid; and virtually everyone willing to use shelters was familiar with and had stayed in them. From April to June 2018, Encampment Resolution workers assembled a list of 192 persons eligible for long- or short-term housing and rehabilitation. By October of that same year, 29 percent of them had been received placements; the rest had refused services, had received and subsequently abandoned them, or had lost contact with outreach workers (this leaves aside the 6.3 percent who had been incarcerated or had died). Though the majority of respondents claimed to be interested in rehab, the number that availed themselves of drug treatment were minimal.

It feels almost quaint to note the orthodoxies that underlay the Encampment Resolution and that would continue to govern Philadelphia’s drug policy with virtually no official public resistance for the next five years. They are assumptions that go almost unquestioned in popular debates on addiction and in the academic literature that informs drug policy, and they constitute a key expression of the contemporary progressive worldview, which attempts to account, in exculpatory terms, for an entire suite of behaviors that half a century ago sociologists would have described as deviant. These are: that the addict’s behavior is symptomatic, not of a moral failing, but of a disease; that this disease is attributable to “root causes,” prominent among which are poverty, trauma, and social exclusion; that stigma against addiction is a major impediment to addicts seeking help. (It is generally taken for granted, on no very firm evidence, that addicts do want help, although increasingly there are voices calling into question the idea of addiction as a social ill, which range from sensible advocates of opioid substitution therapy as a method of managing addiction to self-parodying celebrations of drug injection as a “a socio-technical dispositif of passion.”) A corollary set of beliefs is that the war on drugs has been both inhumane and fruitless; that any earnest attempt to address addiction and, specifically, the opioid crisis, requires a public-health focused, harm reductionist approach; and, implicitly, that solid data exists supporting the efficacy and scalability of such an effort.

The guiding specter of harm reduction is evidence, typically encountered in such phrases as “evidence-based interventions,” “evidence-based strategies,” “evidence-based practice,” and “evidence-based guidelines.” Little scrutinized is what precisely the evidence on combating addiction consists of. At the level of anecdote or initial impression, there are harm reduction strategies that strike one as patently good and patently ludicrous: reversing an opioid overdose with naloxone very clearly allows a person to live another day, and injecting with a clean needle in any given instance may prevent transmission of HIV and hepatitis. At the same time, how-to guides for booty bumping (squirting a drug solution into the anus) or OnPoint NYC’s exclamation-point-ridden safer use pamphlets (“TIP: the smaller the flame, the better! This helps prevent burning of lips or fingers, and makes a small amount of crack last longer.”) seem like something an agent provocateur would come up with to discredit the harm reduction movement.  More broadly, though, when one looks for actionable evidence among the hundreds of published studies on addiction and treatment modalities, one finds little reason for hope and much that is counterintuitive.

A controversial paper by Jennifer Doleac and Anita Mukherjee in The Journal of Law and Economics suggests, for instance, that widespread access to naloxone led to more opioid-related theft with no net reduction in overdose mortality; in a meta-analysis by the Cochrane Library (widely touted as the “gold standard” for clinical data), methadone maintenance therapy, a cornerstone of evidence-based drug treatment, had no statistically significant effect on criminal activity or mortality compared with non-opioid-substitute alternatives. The sheen of success that adheres to evidence-based addiction treatments frequently depends on framing: in a study of the time-released opioid antagonist naltrexone, relapse rates were significantly lower than in a control group at twenty-four weeks, but equal seventy-eight weeks after treatment, with no effect on the secondary measures of self-reported cocaine, alcohol, and intravenous drug use, unsafe sex, and reincarceration.

I have chosen these data for their shock value; they are not ironclad, but they are not uncharacteristic either. Addicts are a difficult group to study: many move frequently between hospitals, prisons, shelters, treatment facilities, and temporary dwellings; their mortality rate is high; they are prone to disappearing. The best studies acknowledge this and draw what conclusions they can; the worst game it to their advantage, ignoring the self-selecting effects of focusing on those highly motivated to stay in treatment and generalizing their outcomes as applicable to the addicted population as a whole. If any lessons can be extracted from the extant data, they are the following: relapse rates are high, and no existing therapeutic regimen is proven to be more successful in the long term than any other; most addicts do eventually quit; and the reasons why people become addicted to drugs and why they eventually stop taking them are still poorly understood.

When we speak of evidence in the context of drug abuse, then, we are talking most often, to quote Aileen O’Gorman of the European Society for Social Drug Research, of “a ‘tactic of depoliticisation’ which obfuscates the political nature of policymaking and, consequently, is a highly political strategy.” The recourse to evidence involves the incorporation into policymaking decisions of a class of ostensible experts charged not only with assessing evidence but with determining a priori what evidence is relevant. At present, research showing addiction as a possible driver rather than an outgrowth of poverty is cast aside, as is the significant overlap between drug use and violence; poor mental health is assigned an inflated role in the supposed psychology of addiction when human and animal studies repeatedly demonstrate the obvious: that addiction is a predictable outcome of the easy availability of drugs. German sociologist Michael Dellwing writes:

The first rule of organizational sociology is, of course, that institutions seek to protect and enlarge their realm of influence and responsibility. It is thus not surprising that psychiatrists will gratefully accept the competence for handling more interactional conflicts. As a scientific endeavor, the way to such expansion is to provide scientific studies supporting this expansion by showing how treatment helps ease the troubles of the affected and how brain chemistry can be linked to this particular set of troubles and to easing them.

What holds here for psychiatry holds equally well for so-called stakeholders in the rehabilitation and nonprofit sector, whose task, in the transformation of what has formerly been the domain of law enforcement into the domain of public health, is to recast the fundamentally moral question of what should be done about drug use and drug users into clinical terms around which consensus can be built.

Another problem presents itself in the abstract, and has manifested itself concretely in Philadelphia: addiction tends to be studied as a unitary phenomenon, with the presumption that any data arrived at has strong cross-applicability, when in fact, drug epidemics differ radically from one another, and there is no strong reason to think that any course of action is valid for all times and places. The typical morphine addict in nineteenth-century America was a well-to-do white woman in the South. Heroin has appealed in alternating waves to rich and poor and to whites and users of color. The culture of opium dens was largely peaceful; the arrival of crack contributed to the most violent decade in American history.

In Philadelphia, an addict might tell you she began with Percocets, moved on to heroin when prescription opioids became harder to find, turned to fentanyl when the heroin supply dried up around 2017, and now injects tranq dope, a mixture of fentanyl and the veterinary tranquilizer xylazine. With each shift in the drug supply, the calculations change: pill users, even heroin users, can live a more or less normal life, whereas with shorter-acting fentanyl, they must constantly chase the next high; xylazine, for reasons still unclear, produces severe soft tissue damage far from injection sites, and it is not uncommon to see regular users with suppurating wounds surrounding exposed bone. Earlier this year, numerous overdoses were traced to medetomidine, a powerful sedative, and nitazenes, a class of unregulated synthetic opioids. On the street now, many addicts will tell you they don’t really know what they’re shooting; a new batch hits the corner, freebies are offered, they get high and see what happens. To say this complicates treatment strategies is a catastrophic understatement.

In October 2018, Jim Kenney signed an executive order to combat the opioid crisis. Its aims included clearing the remaining Kensington encampments, remediating vacant properties, putting an end to open-air drug markets and streetwalking, increasing the number of individuals in medical-assisted opioid treatment, and increasing Narcan distribution. In a progress report released eight months later, abundant victories were recorded, including 24,000 needles removed from the street and “400+ meeting hours of weekly coordination by the executive leadership team.” A slight reduction in overdose deaths was taken credit for, though the executive order was unlikely to have affected them; unmentioned were the shootings and murders concentrated in Kensington and Fairhill, at a time when violent crime remained near record lows in comparable large cities.  

In his decision to treat drug use as a public health issue, Kenney had an ideal ally in his district attorney, Larry Krasner, a staunch critic of racial and class bias in the criminal justice system who had, in his thirty years as a criminal defense attorney, sued the police over civil rights breaches seventy-five times. Krasner had described the war on drugs and mass incarceration as a failure and promised a progressive’s wish list of reforms, including a near-end to cash bail, diversionary programs for low-level thefts and drug offenses, decriminalization of prostitution for first- and second-time offenders, and a pledge to “treat addiction as a medical problem, not a crime.” Both Krasner and Kenney had supported the opening of Safehouse, a supervised injection site that received withering criticism from the city council and that now seems indefinitely stalled after passage of a bill banning such facilities.

Irrespective of the benevolence of the mayor’s or the district attorney’s intentions, it was inevitable that the externalities of their policies would affect Kensington worse than other areas of town. It is not just that the area is poor, that many of its residents have a limited proficiency in English, that crime and drug use have long been deeply entrenched there. There is also an immense, if derelict, decades-old rehabilitation and harm reduction infrastructure that provides services in demand among drug users, and that few other parts of the city are willing to host. Prevention Point, founded by ACT UP Philadelphia, has been distributing clean needles there since 1991, and now offers housing, free meals, naloxone, case management, and even a place for the homeless to receive mail. Multiple shelters and medically assisted treatment facilities are nearby. Outreach workers roam the streets; there are places to shower and use the restroom. Social services attract drug users, drug users attract social services, and this cycle repeats, with dealers not far behind. 

Apart from city-sanctioned treatment facilities, there is a vast industry of unlicensed recovery houses that recruits addicts from wherever they can, sometimes housing them in unspeakable conditions. An unscrupulous owner may pack dozens of addicts into a single house, confiscating their food stamps and SSI benefits. In multiple cases, recovery house managers have received kickbacks from treatment centers to compel residents to attend overcrowded group therapy sessions that were then billed to Medicare. While Pennsylvania established a licensure program in 2017, it is only mandatory for houses that receive state funds or referrals from state-funded facilities. At present, a few dozen licensed homes in Philadelphia are listed on the state’s website, while there are estimated to be perhaps two hundred unlicensed ones in Kensington alone. How adequate this number is has been a matter of debate: beds seem to be lacking at recovery houses and for Level Four care, which treats more complicated medical cases, while standard rehab accommodations are available for those seeking it—an infinitesimal percentage of the nearly five hundred thousand addicts in the metropolitan area.

These are factors one can put a finger on. The changes wrought by the pandemic are harder to pin down, and remain a kind of Rorschach test for one’s ideological priors: law-and-order advocates point to the coincidence between an unprecedented drop in enforcement and an unprecedented rise in crime from 2020 to 2023, while others view the equally dramatic drop in crime in 2023 and 2024 as an indicator that whatever happened during the pandemic was a one-off event caused by nationwide factors and not reducible to policy decisions in any given place. This is a question likely to be argued about for decades, and so I will limit myself to subjective impressions.

In those years, the El, the Market-Frankford Line, a subway and elevated train running from the far western edge of Philadelphia to its northeast, felt like a sinister carnival ride. Through 2022 and 2023, half the public transit system’s riders had abandoned it, assaults on buses and trains exploded, and for a year straight, I never entered a station without seeing at least one person smoking or shooting dope. At Huntington, Somerset, and Allegheny, three stops along Kensington Avenue, crowds of people in rags, bodies bent like the huddled figures of Goya’s Los Caprichos, stood swaying, barely conscious, on the sidewalk, in tents, or under umbrellas. Few businesses remained apart from smoke shops and corner stores; some were burned and looted in 2020, others had just given up the ghost. A tent city stretched for nearly a mile between the train tracks, with people on the nod or openly injecting; on the residential corners to the east and west, young men offered fentanyl, Suboxone strips, and anything else you could smoke, shoot, or swallow with no apparent fear of penalty.

This is the Kensington the world knows—the Kensington family and friends in Europe ask me about, the Kensington that has become a cudgel for right-wing influencers and a golden goose for YouTubers and TikTokers profiting off the spectacular misery that reigns there. It is a site of absolute friction between the humanitarian, but humanistic, harm reduction discourse and the horror that chronic drug use can produce.

Now is as good a place as any to talk about language, and the ways discourse arrogation attempts to stifle skepticism. Addict, prostitute, drug abuse, getting high—terms of everyday language, terms everyone understands, terms I am reluctant to give up even as I recognize their negative connotations—have vanished in specialist literature on addiction. In their place we find, following the trend of person-first language common in literature on disability, PWID (people who inject drugs), PWUD (people who use drugs), PWOUD (people with opioid use disorder), and so on; the impression given, after reading a few hundred pages of Frontiers in Public Health or the International Journal of Drug Policy, is that of a population of individuals no different from anyone else who happen to use drugs the way one might happen to throw on a fancy hat. If you have personal experience with addiction, you know it is nothing like that. Addiction is existential, it can easily eclipse the virtual entirety of a person’s world, and the euphemism creep common in the harm reduction community, such as the replacement of the pejorative getting high with the anodyne getting well, is an act of willful delusion as pernicious as any slur when applied to the kinds of addicts one encounters frequently in Kensington­­—people who can barely walk or form a coherent sentence, people whose skin is literally rotting away.

Despite Kenney’s optimism, overdose deaths continued to rise during his second term in office: 1,214 in 2020, 1,276 in 2021, 1,413 in 2022 (2023 figures are not yet available). Twice the city set a record for homicides; that, at least, is getting better, but property crimes continue to rise across Philadelphia, with businesses still closing in consequence. In the right-wing media, especially, Krasner bears much of the blame—and even using his office’s own figures, arrests and enforcement have plunged under his watch—but after a failed, Republican-led impeachment, voters are stuck with him until 2026, and so the mayor became the second-best target for popular discontent.

Crime was the central theme in the Democratic primaries of 2023, and the eventual winner, Cherelle Parker, took the toughest line on it. Since her inauguration, Parker, aware of widespread cynicism across the country concerning progressive drug policy, has chosen Kensington to be a centerpiece of her administration. Her Kensington Community Revival initiative, announced this past April, made a number of commitments not substantially different from those of previous administrations. Some were concrete and improbable (“Remove the presence of drug users,” “Eliminate shooting victims”), while others were so bureaucratically vague that they may have meant nothing at all (“Identify, establish, and resource a cross-functional implementation team for Kensington”).

Parker has come out in favor of “constitutional” stop and frisk, ridiculed safe injection site proposals with the phrase “Nobody was talking about a safe crack house in our community back in the eighties and the nineties,” and has generally adopted a more hard-nosed style than her predecessor. Her first identifiable action was to make a show of clearing away the homeless again. On May 8, police closed several blocks of Kensington Avenue. Earlier in the week, representatives of the Department of Behavioral Health and Intellectual Disability Services, the Office of Homeless Services, and the Philadelphia Police Department had said those living on the street would be offered transport to shelters or medical facilities before sanitation workers and police cleared the area. In fact, the police and the garbage trucks came first, two-and-a-half hours early, and by the time most observers showed, there was nothing to be seen apart from cops standing idly on the edges of the barricade and outreach workers in reflective vests walking back and forth with nobody to minister to. Past the cordon on Allegheny Avenue, crowds were injecting within easy eyeshot of the police, either oblivious to or bemused at the goings on.

This was the “Warning and Opportunity” phase of Mayor Parker’s plan to restore Kensington. In theory, the blocks cleared will now be “held” until they can be handed back to their “rightful owners.” Beautification efforts and “nuisance abatement” (including arrests for prostitution and drug use) will permit the community to “establish long-term goals for Kensington” that will be realized in a final “Sustainability” phase when police resources will be reallocated to other areas of the city.

The effectiveness of Parker’s campaign is difficult to gauge. I’ve seen Kensington looking better, and I’ve seen it much worse. There’s still garbage everywhere, but the drug users are more dispersed: there are fewer on Kensington Avenue (where bike racks now block of much of the sidewalk), more on Allegheny and Somerset and on the residential streets bordering the El. Many people continue to sleep outside, which is unsurprising since, as Adam Thiel, the city’s managing director, admitted, the “continuum of care” the Kensington Community Revival envisions “literally doesn’t exist.” The alleged remedy—the long-term goal—is the construction of what was once called a “triage center,” then a “triage and wellness center,” and most recently a “wellness village” near the prison complex on State Road at a cost of one hundred million dollars. When it is built, addicts arrested on possession charges will be given the choice of forced rehab or prison. In the meantime, the entire 2024 graduating class of Philadelphia’s police academy has been dispatched to Kensington, but absent a real plan, they seem mostly to be wandering around and telling idlers to move along.

In truth, though, it is probably irrelevant what the mayor does. The best clue to Kensington’s fate lies in neighboring Fishtown, which Forbes declared “America’s hottest new neighborhood” in 2018. Throughout the 1990s, Fishtown was studded with empty lots and crumbling factories, and heroin and prescription drug use was rampant. As rents rose in Center City and Northern Liberties further south, the usual crop of artists, restaurateurs, coffee roasters, Pilates studios, and so on moved in. Now, the average home price there is 45 percent higher than in Philadelphia as a whole, and new construction has built a city within a city with few recognizable links to what it once was.

Kensington Avenue is currently desolate, but investment firms are sitting on huge tracts of real estate there, while local politicians work on incentives to entice new businesses to set up shop. Already there is a fancy dumpling shop just steps from a cleared encampment, along with a pet resort called Wag Days and a bookstore-coffee-shop where new arrivals to the neighborhood, who can still scoop a fixer-upper for under a hundred thousand, mingle with their own kind as they watch addicts go for their free meals to St. Francis Inn a few yards away. This is the pattern in Philadelphia, where gentrification picks up the slack for a lack of political vision. Feeling the heat, addicts in smaller bands have decamped elsewhere: under the interstate, on the pier by the Walmart on Columbus Boulevard. Just recently, leaving a fancy organic grocery store downtown, I found, in a formerly empty alleyway, everything you see in Kensington in miniature: on the ground, hundreds of syringe caps and baggies, people passed out in sleeping bags and tents, and, parked in the gap between two buildings, a late model Mercedes with presidential tint waiting on customers to come past. There are hundreds of such niches throughout the city, and thousands of empty lots and abandoned homes and factories left over from industrial glory days before one fourth of its population moved away: this, combined with the area’s bottomless thirst for drugs, means plenty of cracks remain for people to fall through.