A fine balance

IngridIn the October issue of DDN, Philippe Bonnet spoke passionately about his campaign for drug consumption rooms in the UK. Here, Ingrid van Beek shares her experience of overcoming challenges to establish such facilities in Australia.

The Sydney Medically Supervised Injecting Centre (MSIC) opened in 2001 with strong support from both the local residential and business communities – the result of a constructive dialogue between relevant stakeholders in the Kings Cross community over a decade before.

This support has continued to strengthen ever since despite the significant gentrification of the area, which has in part occurred as a result of this important public health initiative.

In October 2010 the NSW Parliament passed legislation to lift the MSIC’s trial status following several independent service evaluations demonstrating that it was meeting its service objectives.

As with all successful prevention efforts, the future challenge is to convince newcomers to the area that this initiative is still needed to maintain the status quo.

The MSIC is, I believe, a textbook example of engaging vulnerable groups and the broader communities in which they live to produce a strong public health outcome while also addressing public order concerns at the local level.

To achieve ‘health for all’, health and social welfare services for vulnerable populations need to be accessible, acceptable, affordable and equitable as originally enshrined in the Alma-Ata Declaration of 1978 and now an integral part of public policy in organisations such as the World Health Organization (WHO).

A key lesson to be taken away from the MSIC experience was that such a project needed to be sustainable over time, for the disease prevention and health promotion efforts associated with it to be effective.

Implicit in any successful public health initiative of this kind is the appreciation that the issues facing vulnerable populations are often complex. Inequities in these communities are often entrenched; the chronic relapsing nature of drug and or alcohol dependence is frequently associated with instability, which can be compounded by mental health issues, transience and high mobility, unstable accommodation, involvement in crime and risky sex work, pending legal issues and time spent in custodial settings.

At the same time it is crucial to recognise the importance of an enduring and successful coexistence of diverse groups based on the respect of cultural differences – or better still, communities should be encouraged to embrace such diversity as part of living in a rich and vibrant modern society.

However, the right to have a sense of community belonging, respect and inclusiveness should go hand in hand with a sense of social responsibility towards the community. Vulnerable populations should be considered equal (full) members of their respective communities rather than just being tolerated, or even accepted as an act of altruism/charity towards ‘the weak’.

There is also a need to ensure a balance between public health and public order. While the broader community has to understand the need and support efforts to achieve good public health, the right to live in a safe and secure community should also be acknowledged – even if these do not seem pertinent to certain individuals in that community.

It is also important to delineate real threats to public order from perceived threats and it is here particularly that law and order authorities have a central role to play. This is not to say that perceived threats should be ignored. Instead they need to be addressed in different ways, and also monitored to ensure that they are overcome.

The MSIC and indeed my ongoing work at the Kirketon Road Centre, where we deliver a comprehensive range of integrated harm reduction and sexual health services in the same area of the city, have convinced me that local solutions are needed for local problems – one-size solutions will not be a neat fit for all communities.

Experience at the local level of service delivery has also taught many of us public health practitioners that what works in a local community today may not be appropriate tomorrow, so an ongoing dialogue between the diverse community stakeholders is needed to keep checking in on existing issues and identify emerging ones, hopefully enabling intervention in a timely way.

These stakeholders should be tasked with developing community indicators of both public health and public order, to objectively monitor how well they are achieving a balance between both.

But the sustainability of harm reduction service provision on the ground will ultimately rest on the legitimacy of the provider in the eyes of the community. Providers are often considered by the community, especially in the first instance, as the default ‘representatives’ of people who inject drugs. This may be appropriate given this group’s own social marginalisation and transience, which may be a barrier to effective participation in community processes.

But providers need to be conscious from the outset of the often common perception that they are ‘outsiders’ coming into the community to foist their client base onto the ‘legitimate’ community. To be recognised as full members, service providers need to gain local community respect and understanding, which requires a genuine long-term commitment to being part of the community to achieve solutions for all its residents and not just for their particular constituency.

The supervised injecting facilities in Sydney, Europe and Canada, are, I believe, prime examples of local solutions to both public health and public order issues associated with street-based drug injecting.

Dr Ingrid van Beek was the founding medical director of the Medically Supervised Injecting Centre in Sydney, Australia, the first in the English speaking world. In 2008 she resigned from this role to continue as director of the Kirketon Road Centre in Kings Cross, Sydney. She will address the upcoming City Health 2013 conference being held in Glasgow on 4-5 November. www.cityhealth2013.org

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