How Syringe Service Employees Navigate State and Non-State Service Priorities

Background/Purpose: Social workers and allied professionals occupy a unique intermediary space in our welfare system, wherein they are tasked with mediating between state demands, participant expectations, and community concerns. In this paper, I use the case of employees at syringe service programs (SSPs) to uncover the ways in which service providers in a rapidly professionalizing field negotiate the tensions working with, and against, the state. SSPs are programs that allow intravenous drug users to obtain unused needles, as such decreasing the likelihood of bloodborne infections, while creating a support system for drug users. As syringe services began as a radical peer-led movement operating outside of the state, it is important to understand what happens as these organizations have obtained increasing state and mainstream acceptance. Using Michael Lipsky’s theory of street-level bureaucracy as a theoretical framework, this paper asks: how do frontline SSP employees make everyday decisions in light of their intermediary position between state and non-state actors?

Methods: This is a qualitative interview project, involving semi-structured interviews with 26 SSP employees at 22 syringe service programs in a Midwestern US state in 2020. This particular state has seen a rapid expansion in state funding in SSPs over the past five years. Interview questions focused on definitions of harm reduction, working with state collaborators and funders, working with legislative officials, harm reduction activism, and how the SSP interacts with the community. Interviews were transcribed using NVIVO software, and thematic analysis was used when analyzing the data.

Findings: Data shows that most SSP employees are supportive of the efforts that the state, particularly the state’s department of health and human services (DHHS), has put into promoting syringe services. Indeed, while the majority of respondents were satisfied with the support they were provided from the state, they described some challenges that the state engendered in hindering direct service provision. Specifically, as street-level bureaucrats, some respondents described reducing their frontline work to maintain data collection and reporting necessary to receive funding, while also noting restrictions in hiring, particularly hiring people with current or lived experience. Others described frustrations as they had to square their individual and organizational priorities with that of the state in order to access the legitimacy and material resources state collaboration provided—a few described ceasing organizational operations as a result of these frustrations. Nevertheless, because the state was perceived as being generally supportive, there was little advocacy conducted in order to engage in pushback against state dictates.

Conclusion/Implications: This project aids in the understanding of how frontline service providers in a radical field navigate tensions engendered by state involvement. In this particular field, even as the state has outwardly been supportive through the provision and human and material resources, respondents describe difficulty in advocating against the state, and either accept conditions as is, or choose to cease their organization. These research findings have implications for understanding how frontline workers engage with state actors, and how they situate their own frontline policy work within the confines of state structures.