A public health crisis and the Downtown Eastside – we’re left to ask “Which one?”. We know crisis. Dare I say we’re good at it. That’s not okay. Crises are carried on the backs of those on the frontlines who are face first with both the urgency and the limitations of the response. We need to be heard and supported because we know crisis.
So which one? We can start with the pervasive systemic crises of poverty in an affluent city, of homelessness and a housing crisis, and the crisis of an inadequate mental health care system. And we can proceed to the late 1990s to a public health crisis related to skyrocketing deaths by overdose and the rampant transmission of HIV. The outcome of that crisis has been a globally standard setting network of harm reduction and HIV services that includes supervised drug consumption services. Then more recently we endured, and are enduring, the poisoning crisis due to a tainted drug supply. And now this COVID-19 pandemic with its global reach, a global reach that includes the Downtown Eastside despite regularly feeling outside of global priorities. Other communities are similarly affected but the concentrated experience on such a small community makes the weight feel so much heavier. This current public health crisis is unique in that we’re anticipating it’s inevitability, waiting. The others were crises in motion; perhaps there were prior indicators but mostly the responses were reactions to what was already happening. But now we wait in dread. But we can’t. In the days of COVID-19, the rapidity of transmission is too excessive and the symptoms too severe. As a collection of survivors of many crises, it should be acknowledged that we know something. My familiarity with facing a public health crisis fuels an urgency that this experience be incorporated into our public response.
I was one of the many frontline harm reduction workers in the Downtown Eastside when black-market fentanyl surfaced. I’ll never forget it. That incident has shaped so many of us through grief, loss, and trauma but also in pride through our resilience, and in our increased capacity to care and to endure. I was working at Insite the day it first surfaced. We had a care model at that time that was dialled in: overdoses were readily managed, we had strong community trust, and staff displayed a level of consistency and stability, amplifying the impact of Insite’s relational care model. That changed in a day. We moved from averaging 10 overdoses a week to averaging 10 per day. Unresponsive bodies were dragged into the site in those first few days as people rapidly “dropped” from unexpectedly potent and lethal levels of a drug supply.
From that time on, instead of care being done almost exclusively inside the site, staff began to regularly run from the site down alleys, up sidewalks, into SROs with the uncertainty of how long someone had been unresponsive, what they had ingested, or the security of the situation encountered. Every excursion out of the site required the remaining staff to be less supported for the crises on the inside. So many frontline workers were also doing the same from understaffed SROs and shelters, to clinics and social service locations. As we moved through Vancouver on our own, we dealt with the anxiety of venturing out without naloxone knowing that at any momentwe may encounter a critical need.
Decision makers also responded. A public health crisis was declared, and crisis funding was allocated. The onset of the overdose crisis as described above began in October of 2014. The public health crisis was declared (and remains in place) in April of 2016. And the crisis funding emerged in November of 2016. There were 2 years where drug users with naloxone kits, on the ground frontline harm reduction workers, and first responders were the only response to an exponentially greater problem. We did well. Amazingly well.
The things we did well should be noted. Despite our workplace becoming more demanding and less safe, we worked harder. We supported and cared for each other. Despite being exhausted we advocated for better care and support often on our own time. We worked beyond the original mandate of our jobs. These were responses to life and death circumstances, and we didn’t turn away.
But a long two years passed, and there were things that didn’t go quite so well. Frontline workers knew what to do yet what we encountered was silence from decision makers. It’s worth noting that the people involved in Vancouver Coastal Health, the City of Vancouver, and PHS community services at this time are no longer the same people from 2014. Calling someone out for that experience is not what I’m interested in here. It is a reflection that current decision makers primarily have an indirect experience of the crisis experience of the recent past, so my intention is to fill in the gaps of that experience.
Please hear this as a constructive criticism: frontline workers were not listened to in a meaningful way. We were told we were valued and even admired, but it took 2 years to change anything and that change came through some high-risk advocacy like the people who started Vancouver OPS.
Instead, policies were implemented that complicated frontline workers’ capacities to respond. For instance workers were directed to not respond to offsite overdoses; this meant refusing the frantic pleas of someone asking for life and death help for their friend. The ethical implications of that are a trauma in themselves. I stated clearly to upper management that as a supervisor I couldn’t and wouldn’t require that on the shifts I was responsible for and that I would personally intervene if I encountered any coworkers refusing life and death responses. Furthermore, a tent city was dismantled on the first day of subzero temperatures, when overdose rates were at an all-time high, putting further pressure on services due to the crush of a displaced and vulnerable homeless population.
Frontline workers at that time were (and still are) making $21 per hour, which is considered the base living wage marker in Vancouver. If you live in Vancouver outside of nonmarket housing that is in reality considerably below a living wage. The frontline workforce was increased exponentially 2 years after the initial response, primarily by people with lived experience, now engaged in high stress overdose response positions while living in shelters, substandard housing, and quite frequently street homeless yet being paid considerably less than the regular frontline workforce.
This crisis needs to be different. Frontline workers are spent and exhausted from this recent and ongoing overdose crisis. A year ago, we were tempted to think that things in the overdose crisis couldn’t get worse, then benzodiazapenes began to surface regularly in an already contaminated drug supply. That made things significantly worse. Overdose management became the uncertainty of victims stabilized and breathing yet remaining unconscious from 2 to sometimes 6 hours. Now we are experiencing a compounding crisis of an overdose crisis and the coronavirus pandemic (and did I mention poverty, housing crisis, and a lack of mental health supports?).
Here’s what needs to be different. We need a plan that is clearly and regularly articulated. We can’t remain in the dark. We know about handwashing, PPE, and social distancing. We need to know the broader plan as it exists now and as it changes. For social distancing to be effective in a vulnerable homeless or underhoused community it requires shelter, access to safe supply for both opiates and stimulants, food, cigarettes, and social supports. And the experiences of trauma, disconnectedness, and mental illness will amplify during these times of stress. Frontline workers know better than anyone that finding solutions are complex, but also know that maintaining them once they’re established are equally as complex.
Frontline experience also needs support. Grocery store workers and Starbucks employees are all being told their jobs are important and are being extra compensated for showing up. In contrast frontline harm reduction workers have had their tools taken away. By no longer being allowed to administer oxygen to people who are overdosing, another ethical dilemma arises: do you risk the spread of infection or watch someone, whose name you know, who you call friend, whose support we have assured day in and day out, be oxygen deprived and risk brain damage and death?
Recall the years of advocacy for safe supply, which if listened to, would enable us to better manage overdose risk and responder safety right now. Fewer overdoses by way of safe supply results in both greater stability for the drug user and decreased risk for the frontline response.
It needs to be acknowledged that frontline workers take risk on a daily basis. Responding to public health crises has been normalized for us but that’s not what the job originally required. This is inherently unsustainable. At the onset of the previous crisis the burnout levels were much lower than they are currently. Now an overtaxed working group is being asked to do more with less tools in an even more dangerous setting to their personal health, seemingly without option nor consent and certainly without added compensation. We still have to scramble through our lives with inadequate income to buy services and time that would help us recover from our work.
Please, please, please don’t be silent. Take of care of this heroic and compassionate group. Compensate them. Add to their set of tools. Listen carefully to their ideas. Hear and respond to them. And please do it urgently.