Sitting in the recovery area of a small supervised injection site, assembled from a rebranded construction trailer and bound by the borders of an inner-city shelter’s parking lot, I watched quietly as someone stumbled from their seat, with limbs still heavy from the weight of opium coursing through their veins, dulling the senses of pain and purpose.
Although I was only there to conduct a series of pre-scheduled interviews with routine volunteers and devoted caseworkers, I could feel the erratic pounding of my heart grow stronger as someone new took their place with a sterile syringe in hand. I was anxious from the possibility of overdose that came with each subsequent injection — not because I doubted the purpose of the facility, nor the capacity of its staff to respond accordingly, but simply because I couldn’t bear the thought of a life almost lost from surrender.
I had been close to that point once — not as a result of substance use or addiction, but a mental illness that took just as much advantage of a wearied mind. In many ways it was that same experience that urged me to investigate the compelling promise of harm reduction — an entire system of services designed to meet people exactly where they are, without the traditional barriers forged by misconception and entrenched by the pleas of prejudice.
The intersections of homelessness, mental illness and addiction create a troubling reality for those caught in their midst, and the associated risks extend far beyond sleeping rough and drug withdrawal. Stigmatization and criminalization of substance use and poverty contribute to a system that institutionalizes social disparity, while the propensity for infectious disease that results from poor standards of living creates a synergy of symptoms that weaken an individual from the inside out.
According to the most recent World Drug Report, published by the United Nations Office on Drugs and Crime (UNODC), approximately 11.3 million people inject drugs globally; 12.6% of them are currently living with HIV and the prevalence of viral hepatitis C encompasses nearly half of this population.
Functioning at its best, the empathic and inclusive approach that guides harm reduction efforts provides a powerful force for promoting better health and upholding a life lived with dignity for people who use drugs. But amid the unprecedented trials of a parallel pandemic, many services designed for HIV prevention, treatment and care have been hard-pressed or altogether displaced, leaving those at greatest risk at an even further disadvantage.
Under the restrictions of quarantine and perilous conditions that have left health systems overwhelmed by growing death counts attributed to a novel disease, many of the facilitators of harm reduction programmes have been redeployed and many services have closed their doors as priorities shift. It would be an unfortunate mistake to downplay the fires of COVID-19, but I can’t help but wonder what will become of the embers left burning elsewhere.
Even under less ambiguous circumstances, the global AIDS response lags behind projected targets, with cases rising steadily among vulnerable groups. According to UNAIDS, long-term impacts of the coronavirus pandemic on HIV response may result in “an estimated 123 000 to 293 000 additional new HIV infections and 69 000 to 148 000 additional AIDS-related deaths between 2020 and 2022.”
The current realities of service inaccessibility, missed targets and persistent social inequality — all compounded by COVID-19 — elucidate the faults of a fragile system. As those struggling for sobriety and others still bound to the draw of intoxication continue to fall through the cracks, it is imperative to acknowledge that investment in people-centred, human rights-informed and evidence-based HIV response and broader public health service provision has been insufficient. And the price tag is steep.
COVID-19 has exposed our capacity to strive towards health with fervour, and work together towards solutions for a problem that plagues us all.
But combatting a pandemic like COVID-19 demands so much more than just sheltering in place; it begs that we revisit the lessons HIV has taught us and reconsider those we are still learning. Protecting our communities — and among them some who are right now wading through the darkest moments of their lives — will require challenging the inequalities that allow epidemics to thrive.
Current controversies surrounding economic turmoil and support amid COVID-19 should spur discussion on the development of a basic income; evidence of persistent racial inequality, voiced again and again through pleas that wait earnestly for a long-belated repose, should inspire us to approach one another with empathy and continually check our privilege.
And the example provided by harm reduction — of how to meet people in the midst of their mess with compassion in hand — should inspire us to promote health, for the purpose of upholding dignity for all.