Harm Reduction in the Time of Coronavirus

The contents of a needle exchange kit (photo by Todd Huffman)

For Felanie Castro, it was like the world had just stopped.

The first Shelter in Place order had just been announced, and she was stuck in her office at Glide Memorial Church with no marching orders and no messaging about safety precautions. But she worried for the unhoused communities she worked with.

“We still have people out there, and they still have needs” she remembers thinking. So she grabbed a coworker and the two of them hit the streets, loading up the OPT-IN mobile outreach van and making the rounds, driving through eerily deserted streets of Bayview and Hunter’s Point. From Third Street down to the waterfront, they passed out supplies to everyone they could find, sometimes hopping the curb and driving through the dirt to access encampments hidden off the beaten track. Dressed in full PPE, she distributed food, water, and hand sanitizer to everyone she could. She also passed out two things that were just as important as PPE, and in just as short supply: clean needles and doses of naloxone (aka Narcan).

Photo of Felanie Castro by the author

Within the Venn diagram of peripheralized populations in San Francisco, from the unhoused to the formerly incarcerated to those who engage in sex work, People Who Inject Drugs (PWID) sit at a special nexus of risk and stigmatization. As it turns out, the pandemic has only exacerbated this dynamic, intensifying pre-existing conflicts and creating what one outreach worker described as a crisis within a crisis. Since March 2020, there have been 699 accidental overdose deaths in San Francisco, almost triple the number of deaths from COVID19.

Outreach workers point to two underlying causes for this. The first is a disruption in the drug supply chain which has led to a market flooded with lethally-strong fentanyl. The second is more obvious but perhaps even more disturbing: more people are using alone. One of the unintended consequences of the Shelter in Place hotel program put in place by Mayor London Breed at the start of the pandemic was a silo-ing off of support services that usually work in tandem.

Ensuring that clients are safe from infection or overdose is one piece in a broader strategy of support that begins with necessities like food, water, tents, and sanitary supplies, and ramps up to include options like testing, counseling, and housing assistance once trust has been established. This strategy of meeting clients where they are at and offering mitigation strategies for drug use without enforcing abstinence is part of a broader philosophy known as harm reduction. Celestina Pearl, who manages outreach for St. James Infirmary, describes harm reduction as “a philosophy of support that centers the participant’s experience, affirming that a person’s pain is what they say it is, and a person’s experience is what they say it is” instead of centering the assumptions of the care providers.

But for many outreach workers, that wrap-around approach to service was disrupted in March 2020. The early days of the pandemic were a time of dislocation when clients went missing and communities were severed. For example, there was no initial access to naloxone, or even awareness of why naloxone might be necessary, for those in the SIP hotels.

“It took people overdosing in those rooms for everyone to be like oh right, people are still gonna use drugs” Ryan Dalporto, a harm reduction consultant, told me. “They’re at even more risk because they’re used to using on the streets in groups, and now they’re by themselves with no one to watch out.” Multiple harm reduction workers I spoke to echoed this sentiment.

Activists working to get houseless folks into empty hotel (photo from SF Public Press).

“You can’t just put someone in a room and call it done,” says Felanie, “in the best-case scenario, if they get somebody who wants to go with them into this hotel, guess what? They didn’t resolve anything, they’re starting the next part of their lives and they’ve got a whole lot of challenges they didn’t have before.”

Rio, who works with homeless youth in the Tenderloin, concurred. “I can’t be like stay inside your unit, stay inside this small, confined space with no bathroom and don’t do anything.” An outreach worker at an encampment in the Haight, who did not wish to be named, said that she believed people were self-medicating to deal with the stress caused by social isolation. “People who weren’t using, or weren’t using as much, all of a sudden they’re doing it again,” she says. “It’s that isolation piece, you don’t know what someone is doing inside their tent.”

Ironically for the age of social distancing, many harm reduction advocates point to safe injection sites, spaces where people can use under supervised conditions, as being the best hope for dropping the overdose rate. In October Rep. Scott Weiner vowed to resurrect AB 362, which would authorize San Francisco to pilot a safe injection site. The bill has been vetoed twice before, but advocates hope that the current crisis will change the conversation.

It wouldn’t be the first time a public health emergency shifted drug policy. Pauli Gray, a longtime harm reduction activist and consultant,  brought up the fact that needle exchanges themselves were once illegal. Unsanctioned and guerrilla-operated, they began as a mutual aid operation created in reaction to the HIV epidemic.

“Sharing needles was putting the highest-risk fluid directly into the highest-risk opening, but there was no help for that population because they were just nasty drug users,” Gray remembers, recounting how he used to push a baby carriage full of clean needles through the Haight Ashbury. Eventually, however, the drop in HIV infections from needle sharing began to speak for itself, and the communities doing the work gained city authorization. Today, many people in the harm reduction community hope that safe injection sites will follow the same trajectory.

After a year of being told that we are in it together while watching the structural realities of the crisis push our outcomes farther and farther apart, it seems only fitting that the way forward should lie in mutual aid. As Drug Overdose Prevention and Education (DOPE) Project Manager Kirsten Marshall put it:

“If anything, the pandemic highlighted two things that our communities were already well aware of: There are still glaring and gaping healthcare and resource disparities drawn almost entirely down racial lines, and we take care of each other best because we’ve always had to.”