Crossing the Line: Harm Reduction Street Nursing

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I am teaching Community Health this quarter, and for the past few weeks we have discussed harm reduction: a health promotion approach that seeks to minimize negative effects (both for the individual and for the community) of continuing drug use. This is a difficult but important topic for future health care providers to understand and wrestle with. For their community health clinical rotation, some of the students are working in the Needle Exchange Program with Public Health—Seattle and King County. Our health department has operated a needle exchange program since 1989 and has helped keep Seattle’s HIV rate in injection drug users (IDU) at an enviously low rate of 3%, with a continuing decreasing trend in new infections. Meanwhile, our Canadian city just north of us continues to struggle with an HIV rate in IUDs of 17% and rising, despite having an even more aggressive public health harm reduction program. Vancouver BC’s HIV prevalence rate would be much higher if it were not for such controversial and progressive harm reduction programs as Insite, their clean injection site.

Insite is an RN supervised injection facility in Vancouver’s impoverished Downtown Eastside, which has high rates of homelessness, drug use, and survival sex work. Insite opened in 2003 and is operated by Vancouver Coastal Health, the regional health authority. The facility obtained and is fighting to maintain a federal exemption from Canada’s narcotics laws. Open seven days a week from 10am-4pm, Insite, nurses supervise clients’ injections of pre-obtained illegal or prescription drugs. They provide clean needles and other injection supplies, help clients find a safer injection site, monitor and treat for drug overdoses, provide HIV and STI testing and treatment options, and help clients enter drug rehab programs (upstairs in same building) if and when they are ready. The nurses at Insite do everything except push the plunger of the needle. That is the line they do not cross.

For my class discussion, I was helped this week by the NYT, which published an excellent article by Donald McNeil, Jr. entitled “An HIV strategy Invites Addicts In” (2-7-11), a riveting accompanying video stream “A Safe Place” and perhaps an even more riveting still photo series and accompanying commentary by the photographer Ed Ou. Mr. Ou was a NYT intern and he grew up in Vancouver. His assignment covering the Insite story was the first time he had returned to his hometown as a photographer. Of the experience, he writes “It was disorienting working there, because it felt like my professional world and this ideal that I had of home—which had been pretty much untouched—had collided (…) As a photographer, I’m pretty uncomfortable with drug stories. I think drug stories are almost exploitative in a way. But a story about a safe injection site could add to the discussion of how to treat drug users.” He goes on to talk about Lawrence, one of the people he photographed, and of the relationship he developed with Lawrence during the photographic assignment. Mr. Ou is in Cairo now, but talks with Lawrence on the phone. Lawrence is telling him that he’s going to rehab and Mr. Ou is considering going with him: “This is the line I’m not sure I crossed.”

I have a lot of admiration for the street nurses who do outreach and work at Insite: nurses such as Sammy Mullaly, who is briefly interviewed about her work at Insite and included in the NYT video. I also admire the work of Dr. Bernadette Pauley at the University of Victoria School of Nursing and her colleagues who study and advocate for harm reduction in nursing practice as a part of the social justice underpinning of nursing. Check out the article she co-authored with her nursing colleagues Beverly Lightfoot, Ciro Panessa, Sargent Hayden, Meaghan Thumath, and Irene Goldstone in the April 2009 edition of Canadian Nurse. They don’t toe the line. We need more nurses like them.

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