I’d like to comment on my observations as a new harm reduction worker at South Riverdale CHC and its surrounding community.
Harm Reduction is a philosophy about the human rights of people who use drugs. It says that people who use drugs deserve all the same things that everyone else enjoys: safe housing, health care, food security, and employment.
The work we do is not just for those who access SRCHC programs, but also for the larger community. Often, and especially in neighbourhoods where there is a sharp divide between people who have privilege and those who don’t, there tends to be an “us and them” mentality. When you don’t live on the streets without shelter or food, it can be hard to understand what that experience is like. But many of our service users have been living in this area for decades. In fact, South Riverdale CHC has been serving this community for over 40 years and has been providing resources and programming to people who use drugs for over 20 years. Our service users share the same sidewalks and air as folks who are well-resourced. Our clients are humans just like you.
In harm reduction, some practical strategies include educating our clients, other service providers and the local residents about safer drug use, overdose prevention, and preventing HIV and Hep C transmission. The harm reduction kits we give out are not only for distribution of sterile needles or pipes and the associated equipment to use drugs more safely, but also a way to help engage with folks who are regularly excluded from mainstream health services and housing, and who are overrepresented in child welfare, prison and other systems.
Having said that, part of the safety of the community is people properly disposing of their equipment. We facilitate that with daily needle patrols throughout the neighbourhood and by providing a yellow secure-disposal bin at the west side of the building. Pre-COVID, we organized several annual community clean-ups during which staff and volunteers cleaned up garbage, as well as drug use equipment, from local parks and laneways.
If you have any questions about harm reduction, please call The Fixed Site at (416) 461-1925, ext. 235. If you have any concerns or suggestions, please call the COUNTERfit program coordinator at ext. 388.
And please remember that “our community is your community!
(These impressions are offered by a new SRCHC staff member.)
WRITTEN BY DECLAN KEOGH • PHOTOGRAPHY BY DECLAN KEOGH AND JEFF BIERK
A few years ago, Les William Harper did what most people have done at one time or another: he sought his mother’s opinion.
The 46-year-old Cree harm reduction worker and artist, who works at a safe-injection site in Toronto, wanted to know how she thought the overdose crisis would end and what he could do to help it along.
Elder Pauline Shirt is a survivor of Canada’s residential schools for Indigenous children. She was forced to spend years away from her family, suffering abuse under a system many, including the Truth and Reconciliation Commission of Canada, call genocide.
“That was her world she was living in,” Harper says. “She never knew if it was ever going to end.”
But it did end, eventually, and she was finally able to leave and carry on with her life. She ended up in Toronto where, in 1976, she and her then-husband Vernon Harper opened Kapapamahchakwew, or the Wandering Spirit Survival School, the first Indigenous day school in Canada.
Shirt told her son to be steadfast in his commitment to the work, and to his heritage. Canada tried to erase her culture but, she said, Indigenous teachings and practices were precisely the things that kept her alive.
“It just showed that it’s not going to stay like this. If we keep on fighting and doing what we need to do, we will find that answer,” Harper says.
Today, his mother’s advice — to honour and practice cultural traditions — grounds Harper’s work as a harm reduction worker in drug user communities, as well as in his artistic practice, painting murals. Harper works with community members to paint murals around Toronto, 10 so far. He says it’s important to bring people in to create art together, whether they’re from community centres, housing co-ops, or safe injection sites. He says it allows each individual to express themselves in a shared social context.
“I’ve always believed in art,” he says. “I want to take everyone else for the ride too.”
Crisis wears on
As Canada remains in the deadly grip of an unprecedented overdose crisis, some are turning to art to raise awareness, cope with grief and trauma, or to bring power to the community. The slow drip of solutions from health and government officials have already forced those on the front line to take things into their own hands. In Toronto, illegal safe-consumption sites started popping up in 2017, eventually forcing the provincial government to fund and sanction many across Ontario.
Despite incremental progress, people are still dying at an increasing rate. There were 4,460 opioid-related overdose deaths last year, up from 3,017 in 2016 — nearly a 33 percent increase — according to the Public Health Agency of Canada. The statistics paint a grim picture: more than 11,500 Canadians died of an apparent opioid-related overdose between January 2016 and December 2018. Fentanyl or a fentanyl analogue were involved in nearly three-quarters of the deaths.
Harm reduction workers have been saying something has to give.
The two worlds, harm reduction and art, have long overlapped. But as the crisis wears on, art is emerging as its own form of harm reduction — from an individual level to a broader political response. For Harper, the connection is personal. He’s been working in harm reduction for over a decade and has a deep connection with the community.
“There are people that I’ve grown up with that come into these sites,” Harper says. “I have relatives that come into these sites.”
‘I work in my community;
my community is me’
Les Harper touches up Two Worlds, a community mural project honouring Indigenous women’s role in the overdose crisis. The centre of the piece is an outline of a syringe, swaddled in purple. This colour represents the deadly opioid fentanyl. Photo by Declan Keogh.
Wandering Spirit, which continues to operate in Toronto’s east end, is where Harper’s artistic interest blossomed. Woodland Art, originally brought to Canadian consciousness by esteemed Ojibwe artist Norval Morrisseau, remains his favourite.
Harper has adapted the Woodland style for his mural projects, an approach to painting characterized by rich, vibrant colours portraying symbolism and spirituality drawn from Anishnaabe and other Indigenous traditions.
It’s a natural fit. Woodland Style juxtaposes immemorial customs with a contemporary form; Harper, steeped in Indigenous teachings, uses them to guide his work amidst the concrete and steel of Toronto. Like his mom, he fights for life where there is death.
“My work, my passions and my personal life all connect together,” he says. “I work in my community; my community is me.”
A mural project at the Bickford Centre, in Toronto’s Koreatown, holds special significance to Harper. Two Worlds is a 20-foot-long homage to both the overdose crisis and murdered and missing Indigenous women and girls. The idea came to him during a fasting ceremony, where he prayed for guidance on how to get his message to the world.
It’s the only mural in Ontario that looks at the overdose crisis from an Indigenous perspective.
The piece depicts two faceless women in traditional pink dresses, framed by richly coloured flowers, strawberries, and a bird on a bright yellow background. In the centre is a syringe wrapped in purple. He chose purple to represent fentanyl and its role in the overdose crisis. The women represent strength and resilience.
“[Women are] why our culture is still here,” Harper says.
Harper, one of only a handful of Indigenous harm reduction workers on the front line of the overdose crisis, hopes his art will help foster dialogue between those inside and outside his community.
“People will walk by that mural and they’ll see that syringe and that Indigenous artwork and they’ll be a part of that now,” he says.
Nearly one million Canadians reported using illegal drugs in 2017, according to Statistics Canada — not including then-restricted marijuana. Yet, drug users are often imagined as a monolith. Harper hopes community art can disrupt commonly held stereotypes.
“When people first see people or think of people that are using drugs, they see them as one person,” he says. “They see them as a drug user, not as a person that’s an artist or … writer.”
“My work, my passions and my personal life all connect together,” says Les Harper, left. The harm reduction worker collaborates with community members like Bradley Nolan, pictured, on public art projects. Nolan says art helps distract them from thinking too much about loved ones who have died as a result of opioid overdose. Photo by Declan Keogh
Bradley Nolan, an Ojibwe service user originally from Garden River First Nation, helped Harper paint Two Worlds. Like Harper, 31-year-old Nolan has lost a lot to fentanyl: their brother, partner, and best friend.
“[Art] gets me out of the frame of mind of thinking about loved ones who have passed away from opiates,” says Nolan. They get a good feeling when they see the mural, because they know they contributed to something that stands out in the community.
“Somebody can make a piece of art and it can mean the world to them,” Nolan says. “A powerful piece of art makes people think.”
Honouring the lives of loved ones while they’re still living is an important part of Indigenous culture, Harper says, which is why the mural at the Bickford Centre is so meaningful to him.
“No matter what is happening in Indigenous culture and our lives, we’re still going on forward,” he says.
Grief and the canvas
On Jan. 7, 2019, Kira Hamilton cried throughout the night for no apparent
reason. “I didn’t have anything to cry about but I just knew something was wrong,” she says.
The next day, Hamilton, 38, went in to work at Sistering, an agency supporting at-risk women, where she does harm reduction and housing support.
I had a rough night, she thought. But I’m at work with my people. But people were staring at her, and no one said a word to her as she made her way to her office. What the hell is going on here, she asked herself.
Then she received the call. “You need to sit down,” the coworker said. “Crystal died. They found her last night. I’m so sorry.”
Crystal Papineau was found dead in a clothing donation bin. The 35-year-old’s death became front page news for months, as advocates demanded better housing and support for street-involved people — even sparking a public consultation in Toronto on the safety of donation bins.
Papineau was Hamilton’s closest client at work. “Every day … when she went off to use, or I would go home from work, she’d say ‘I love you.’” Hamilton recalls. “And, I said, ‘I love you back.’ Because she needed to hear that from somebody.”
“When you work that closely with somebody, they kind of become your family,” she says. “I cried, but I knew she wasn’t in pain anymore.”
Hamilton echoes what many in the harm reduction community describe: an impossibly complex relationship with their clients. One where the duty of care intermingles with human nature, emotion and camaraderie.
Eight more of Hamilton’s clients have died this year, many of them as a result of overdoses. When Broken Pencil reached out to Hamilton for this article, she was attending a funeral for a client. As a multi-disciplinary artist who studied fine arts at Georgian College, she feels somehow duty bound to use her paintbrush to eulogize Papineau. She envisions a darkly baroque and realistic image of a skeleton floating through the air, thick and textured like red velvet. In the skeleton’s stomach is a bright red balloon, representing “the person she was when she was alive, [and which] will keep her alive in my mind,” she says.
But when she sits down in front of her easel, Hamilton can’t bring herself to do what she had done hundreds of times: press the bristles into the paint, and gently apply it to the canvas.
Hamilton says she feels stuck, badly wanting use art to cope with the trauma of her work but, ultimately, being unable to do so. She likens it to the feeling she gets at work: spending every day trying to keep her clients alive, while faced with stagnating political action, funding cuts, and increasingly dangerous drug supplies.
Hamilton talks with a lot of her clients about art; what they’re working on, and her paintings that hang in her office. She’s planning to start an art group at work for some of her clients.
“It’s healing without realizing it, because when you’re putting the paint on the can- vas, you’re not thinking about the stuff that we have to deal with.”
Truth to power
Jimmy, pictured, often appears in the photography of Jeff Bierk. The Toronto artist has become a default documentarian for communities directly hit by the terrifying surge in overdose deaths. Photo courtesy of Jeff Bierk
The first time Jeff Bierk tried to get sober was after his mom died while he was in his early 20s. Shortly after, his partner at the time was in and out of the hospital.
“I felt new to the world because I was clean,” says Bierk, a Toronto-based photographer. “I had no idea who I was, I had not processed or even dealt with all the grief of both my parents dying at a young age.”
He needed a way to grieve without using drugs again. So Bierk, now 38, started to take pictures of hospital curtains between 2009 and 2010. The photos were mounted as an exhibit called Curtain at a gallery in Brantford earlier this year.
A decade after he took them, he says he’s happy to show the photos with the privilege of reflection. “I was able to re-contextualize it with all the time in between. All these ways I’ve been able to heal outside of an art practice,” Bierk says. “At the root of it was talking about my experience with death and addiction.”
Bierk is best known for his honest photos of people he knows. Many of these friends come from far-flung places but wound up in Toronto. Many struggle with housing or health; many are drug users. The images candidly depict life on the streets, a world many never experience. It’s easy for people to project assumptions onto the photos. When people see a picture of Jimmy, one of Bierk’s best friends who frequently appears in his work, they see a tough man, covered in blown-out DIY tattoos. They see salt-and-pepper hair and deep lines on his face that come with years of alcohol consumption and cold winters. It’s easy to simply read Jimmy as a drug addict or a homeless person. An undesirable.
Bierk sees beauty; he sees his friend.
“Jimmy is an example of how to be. He’s the example to me of all these beautiful things that I don’t see in a lot of other people,” Bierk says. “It’s just this freedom.”
Bierk emphasizes that the people who appear in his images are his friends and his collaborators, disavowing the term “subject.” Bierk is seen in the self-portrait Me and Jimmy in an intimate, stylized embrace with his most frequent collaborator. Photo courtesy of Jeff Bierk.
Bierk has worked hard to get away from the traditional way photographers interact with their subjects. Jimmy is not Bierk’s subject; they are collaborators, and they split any profits. Often, Jimmy will come to an exhibit of Bierk’s work and visitors will get to meet and talk with him.
The shows “offer the potential for people to see Jimmy in the fullness of who he is … the art is a conduit for this kind of connection,” Bierk says.
In late February, Bierk took part in an open panel discussion on addiction and homelessness as part of Curtain’s run in Brantford, a city that’s been hit hard by the overdose crisis.
Between July 2017 and June 2018, Brantford and the surrounding area had one of the highest rates of overdose deaths in Ontario. Mayor Kevin Davis and other local politicians listened from the crowd as Bierk used his time on the panel to call for the city to open a safe injection site. “I remember that feeling where I was like, ‘Oh, fuck. I actually have to speak the truth to the power in this situation,’” he says.
“I spoke about my experience in a really vulnerable way,” he says, telling the crowd he was lucky and privileged — he got out of jail and was able to do a detox program where many don’t have that opportunity.
Not long after the talk, a Brantford friend messaged him with news: Brantford was going ahead with a study on opening a safe-consumption site in the city.
“It’s not that [the announcement] directly happened because of me or the art, but the art and my experience was this conduit to potentially shift the consciousness of people in the audience,” Bierk says.
Councillor Joshua Wall, whose constituency includes downtown Brantford, also attended the talk. He says the talk was one of many factors that lead the health unit to explore a safe-consumption site.
“It absolutely impacted me,” he says. “Art has the ability to inspire and elicit such strong emotions.”
“It’s unbelievably important to speak with people who have been there, who have been through turmoil and who can speak firsthand on how they’ve overcome,” Wall says. “There are so many people involved with [drug use] who haven’t been through it. There’s merit in listening to somebody who’s actually been there.”
Still, Bierk says he remains skeptical about art’s potential to foster societal change. He notes that the art world can be inaccessible. But, towards the end of our long conversation, he seems more open to the idea that the work he’s doing is creating dialogue and making people happy — even if it begins as a something for him and his friends.
‘This is the Indian that saved us’
Les Harper’s favourite colour is pink — It always has been. He says it stems from the old saying that when the evening sky is pink, the next day will be better.
He moves with an ingrained, deeply held optimism in the face of an acute crisis. Just as his mother and her generation survived, so too will he and his.
“People go through so many hardships,” he says. “Hopefully tomorrow will come and it’ll be a beautiful day.”
Harper often quotes John Trudell, a Native American activist, author and poet from Omaha, Neb., who discussed the “Drunken Indian” stereotype.
“Without them [the Drunken Indian], we wouldn’t be here today,” Trudell said in a previous interview. He said that, after centuries of forced assimilation, genocide, and oppression, there were generations that simply had to survive, by any means necessary.
“This is the Indian that saved us, because this is the Indian that said, ‘I can’t be who I am and I’m not going to be who you tell me to be, so I’ll just be nothing” he said. “I’ll be something else. I’ll just do my time and get through it. I’ll erase the pain and get through it. But I will not become you.”
Harper applies this framing to the over- dose crisis and the drug war. “We, as Indigenous people in our activism, have a great debt that we owe to the Drunken Indian because they survived,” Harper says. “We thought that one day we would be annihilated … And we weren’t.”
Harper sees parallels in the drug user community, where people remain vibrant and resilient despite terrible odds. “In this crisis that’s going on, people right now are still being the wonderful, beautiful people that they are.”
Many people in Harper’s community have died.
There is deep heartache.
But, each night, he sees pink — even in the middle of a storm.
Keren Elumir saves lives at the Moss Park overdose prevention site in Toronto. It is relentless work: a particularly bad day saw 10 people overdose in a six-hour period.
“We were kind of joking the other day that we cleaned the entire floor of the Moss Park site with our jeans because we wrestled with so many heavy overdoses,” says Elumir, a 49-year-old registered nurse.
A bit of harmless humour helps in a job where grief and trauma are non-stop.
First responders have long had to struggle with the emotional intensity of jobs meant to save lives. But rarely have on-the-job grief and trauma been as chronic — and so lacking in supports — as on the front lines of the opioid overdose crisis.
They save thousands of lives — people were revived from overdoses 2,275 times in Ontario’s 24 federally approved injection sites in 2018. Yet they are among the most precarious workers in the labour market, many struggling with low pay and no benefits.
Burnout and turnover rates are high. Others soldier on, wounded.
[CAPTION: Keren Elumir says one of the positive aspects of her work is “we have this beautiful, intimate relationship often with people that in a way almost become family.” And the support goes both ways. (Moe Doiron)]
“People care very deeply, so they’ll keep working even if it’s hurting them,” says Matt Johnson, co-ordinator of the overdose prevention site at Parkdale Queen West Community Health Centre, who estimates he’s revived more than 200 people over the years.
The emotional and physical toll on employees has a leading agency in the field questioning the future viability of the supervised consumption system.
“This type of model is not sustainable when we know the overdose crisis is getting worse,” says Julia Barnett, manager of supervised consumption services at South Riverdale Community Health Centre, which runs the Moss Park injection site and another in the Leslieville neighbourhood.
Trauma is the order of the day for Moss Park’s 11 workers.
In the first three months of 2019, the Sherbourne St. site was visited 6,484 times by drug users. Workers reversed 257 overdoses, usually by pumping oxygen into the victim, sometimes by injecting opioid-blocking naloxone. None of Toronto’s nine supervised injection sites saved more lives during that period.
With Moss Park open six days a week, six hours each day, workers save an average of one life every two hours.
Elumir recalls a day late last year that initially stood out because it was uneventful. Not a single person overdosed during her shift. She whiled away the down time by knitting a toque and looked forward to a Christmas concert after work, where her daughter was to play piano.
Minutes after the site closed at 6 p.m., a man banged on the locked front door begging to be let in. Elumir’s colleague, Sarah Greig, obliged. The man injected an opioid, dropped to the floor, and stopped breathing.
Elumir and Greig went to work. They injected him with naloxone but got no response. They injected him a second time and still nothing. They may have used a third shot but Elumir can’t say for sure. She once needed five shots to bring a victim back to life.
“It can be quite scary when a person isn’t responding,” she says. “If we don’t figure it out, they will die.”
They tried inserting an air tube down the man’s throat but couldn’t open his clenched jaw. Overdoses caused by fentanyl, a powerful and often deadly synthetic opioid, can make bodies rigid. So they placed an oxygen mask as tightly as possible around his nose and pumped air.
Thirty long minutes passed before the man revived.
Elumir had no time to debrief the near-death episode with her colleagues. She rushed to her daughter’s recital.
“I beat it across town to this beautiful church that was full of candles and twinkly lights,” she recalls. “I sat down and everyone around me was so happy, listening to the singing and watching the performances.
“And the contrast between this beautiful event and the hard overdose was so enormous that I could not stop crying. I cried my eyes out.”
No one has died in supervised injection sites. Yet the body count keeps rising from overdoses on the street or in private dwellings.
There were 4,460 opioid-related deaths in Canada in 2018, a third of them in Ontario. The victims are often marginalized people the workers care for daily and know well. Sometimes it’s a colleague: in Toronto, many front-line workers use drugs or did so in the past.
Who will die next is a constant worry.
Registered nurses are a small number of this largely precarious workforce. Most others are workers from harm reduction programs, which distributed clean syringes to drug users before supervised injection sites opened in Ontario in 2017. All are close to the drug-using community.
Leaving work at the office is an option few have.
“You’re seeing multiple overdoses every single day,” says Steff Pinch, a 29-year-old harm reduction worker. “You’re seeing people who are dead and you’re bringing them back to life. You’re walking in a room full of ghosts.
“And for a lot of workers, they do this as their job and then they go home and reverse overdoses. And then they walk the community and reverse overdoses. And it never ends. And then everybody dies.”
Frayed emotions are compounded by anger, a conviction that deaths would be prevented if governments cared enough to decriminalize the possession of all drugs and make safe supplies of opioids available. (The Toronto Board of Health supports both those recommendations.)
“It feels like you’re screaming into the void,” says Marissa Martins, a harm reduction worker who helps provide stable housing for drug users with Breakaway Addiction Services. “You’re saying, ‘This is what we need! This is what we need!’ and nobody is listening.”
Greig, a harm reduction worker for the past decade, says workers have no time to heal or to process what they’re going through. “How do you keep helping people without totally losing your mind?” she asks.
Few have the workplace benefits to help them find an answer.
Shoestring provincial funding keeps wages at about $15 to $25 an hour, although the few who are registered nurses can make more. Many are on short-term contracts or working part time — positions with no benefits. Workers who need counselling services, or anything else that might help manage the job’s chronic stress, usually can’t afford it.
The exception in Toronto is the downtown supervised injection service called The Works, staffed by eight full-time and unionized city employees who have benefits and higher salaries. Tor Sandberg, a spokesperson for the CUPE local representing the employees, says the city helped ensure lower job standards for others in the field by letting private agencies do the work the city should be doing.
In an attempt to help themselves, some formed the Frontline Workers Support Group, which resorts to a gofundme campaign to help access the most basic forms of self-care, including massages.
“It’s pretty messed up that it’s being crowdfunded,” says Tave Cole, a group organizer and harm reduction outreach worker, who describes on-the-job grief as a “non-stop nightmare.”
On June 10, Toronto’s Board of Health called on the Ford government to “Provide dedicated bereavement and trauma supports for frontline harm reduction workers, family members, and others impacted by the opioid poisoning crisis.”
In a written response to questions by the Star, the Ministry of Health and Long Term Care said it is “committed to supporting front-line harm reduction workers” and others hit by the crisis.
The statement, emailed by spokesperson David Jensen, noted the ministry funds the AIDS Bereavement and Resiliency Program of Ontario (ABRPO), which has expanded its work to train agencies running injection sites on “debriefing” sessions that help workers emotionally, mentally, physically and spiritually.
The government says it also plans to invest $3.8 billion over the next decade to implement a “comprehensive and connected mental health and addictions treatment strategy, including a “Centre of Excellence” to help people access “integrated and standardized” services across the province.
Provincial funding also includes $31.3 million for up to 21 sites called Consumption and Treatment Services (CTS). It’s a new harm reduction model that continues supervised injections while adding a focus on connecting drug users to treatment and rehab. Budgets for these new sites “can include funding for benefits and training for frontline staff,” the ministry states.
Reality at injection sites is generally different. Funding that rarely lasts more than a year means requests that include benefits stand little chance of ministry approval, says Barb Panter, manager of housing and drop-in services at St. Stephen’s Community House in Kensington Market, which includes a supervised injection site staffed by six workers.
“Our model is very cost-effective, but it also means our part-time and contract staff don’t get benefits,” Panter says. “That’s just a reality in the field.”
St. Stephen’s supervised site had been funded by the previous provincial Liberal government. It was one of two agencies in Toronto that failed to get renewed funding under the new CTS model. Its injection site continues to function with federal permission and private donations.
St. Stephen’s CTS application had a budget line for transit fare so that drug users could travel to the kind of rehab the ministry considers a priority.
“They said, ‘No, take that out,’ ” Panter recalls, referring to ministry officials. “And we said, ‘How are you expecting people in Toronto, where it costs $3.25 for transit, to get to the detox centre?’ And they didn’t really have an answer.
“So to talk about benefits for something as intangible as trauma and grief support doesn’t often go very far,” she adds.
Fifteen CTS sites were announced in late March, six of them in Toronto. The proposal accepted for South Riverdale’s Moss Park site would extend service to 12 hours a day, seven days a week. But the government has yet to hand over the funds, so in March, frontline workers were placed on month-to-month contracts.
“We don’t know if that financial agreement is going to be on a one-year basis or more long-term,” Barnett says.
There’s no indication the provincial government will act on the board of health’s request to fund trauma and grief supports, Barnett adds, so South Riverdale is moving on its own.
The community health centre has siphoned $20,000 from its other programs for a one-year pilot project to give its injection site workers access to counsellors, therapists or Indigenous elders, along with self-care courses in yoga or art, for example.
Gillian Kolla, a PhD candidate at the University of Toronto’s Dalla Lana School of Public Health, who is researching the impact of opioid-related trauma on health, believes funding struggles reflect a dismissive provincial attitude.
“I don’t think this would be happening with any other health issue,” Kolla says. “It is very much linked to the stigma around people who use drugs. It’s very much the idea that these people are disposable.”
Thomas Egdorf, director of the AIDS Bereavement and Resiliency Program, links the trauma struggles of workers in the opioid overdose crisis to social attitudes prevalent during the deadly height of HIV and AIDS in the 1980s.
“One of the challenges is disenfranchised grief, which is grief that isn’t supported, really, by society,” Egdorf says.
“Often, when workers reach out for support outside of their community, they get responses like, ‘Well, what did you expect? They inject drugs.’ It’s like you don’t have the legitimacy to grieve because ‘of course this person was going to die.’
“So traditional places where people could go for support — grief counselling, grief groups — don’t often work in these situations because of the judgments a lot of people attach to how someone dies,” Egdorf adds.
At the entrance to the Moss Park overdose prevention site, around a wall painting of an eagle with a syringe in its claws, are the portraits of a dozen people who recently died. Some were front-line colleagues, including Angela Kokinos, who saved lives at St. Stephen’s until her death in September 2018, and Leon “Pops” Alward, a trailblazing volunteer at the Moss Park site when it began as a cluster of tents in 2017. Others are clients the workers knew well.
“Many of the people we interact with in our work have been ostracized and stigmatized and pushed away by other people,” says Marissa Martins. “We sometimes are the only safe place for people to be authentically themselves — artistic, musical, loving, funny. So you see all these beautiful things that people are finally given permission to be.
“You grow fond of them, and then you lose them,” she adds.
[CAPTION: Says harm reduction worker Steff Pinch: “You’re seeing multiple overdoses every single day. You’re seeing people who are dead and you’re bringing them back to life. You’re walking in a room full of ghosts.” (Toronto Star)]
For Steff Pinch, the death of 45-year-old client Rodney Rizun forced the need for a break.
Rizun, a talented musician and “born storyteller,” was shot dead in an Etobicoke residence on June 5, 2018. His unsolved murder capped a terrible four-month period when almost 20 of Pinch’s clients, friends and relatives died from natural causes, violence or overdoses.
At the time, Pinch was a harm reduction worker at the LAMP Community Health Centre in Etobicoke. LAMP isn’t a supervised injection site, but it offers drop-in services for drug users.
Pinch says clients would often inject in the centre’s washrooms or around the grounds, causing Pinch and co-workers to scramble in and out of the building saving lives. “For a while, it was every single week someone I knew was dying,” Pinch says. “It was overwhelming.”
Pinch’s only self-care option was short-term medical leave under Employment Insurance. That meant navigating multiple hoops, including finding a doctor at a walk-in clinic and paying for medical forms to be filled.
Pinch ended the EI “stress leave” about halfway through the 15-week period because the doctor would only continue approving it if Pinch went on anti-depressants.
“I refused to go on psychiatric medication because I don’t have a psychiatric problem,” Pinch says. “Everyone is dying! I make sense!”
Harm reduction workers are a tightly knit group and Pinch counts Liz Merlos, who heads harm reduction efforts at Parkdale Queen West Community Health Centre, as a supportive ally.
Merlos has spent months on a waiting list for subsidized counselling to deal with anxiety attacks. She initially called the employer assistance plan but a counsellor told her she needed more help than they could offer.
“There are many times when I’m like, I can’t go to work today, I just can’t,” says Merlos, who grew up in Parkdale and helped save her younger brother from an opioid overdose two years ago at her mother’s home. “I’m struggling with a lot of the things that my peers and colleagues are struggling with.”
She dreads extended breaks from the job — even long weekends — because “every time you come back, someone is gone.”
[CAPTION: Liz Merlos in a safe injection room at the Parkdale Queen West Community Health Centre. Merlos has spent months on a waiting list for subsidized counselling to deal with anxiety attacks. (Toronto Star)]
Almost 900 injections were supervised at Merlos’s site in the first three months of this year. She notes the work goes much beyond reversing overdoses. She and her five co-workers often act like counsellors, listening to heartbreaking stories of childhood trauma and loss.
“You bring it home,” Merlos says. “You bring it into your relationships and your friendships. And it has a toll because it’s so overwhelming. I tell my mom things and my son things and they’re, like, traumatized and worried for me.”
Some years ago, Keren Elumir made a deal with a colleague: “Alcohol wasn’t going to be our go-to on a really bad workday.”
She began work as a street nurse in downtown Toronto in the late 1990s at a Christian charity called Sanctuary, which operates drop-in services for the homeless and marginalized.
There were moments of acute distress, like the time Elumir cut down a suicidal client she knew well from a tree in a downtown park. But she quickly developed what she describes as “this weird, beautiful intimacy” with the people she served. It felt very much like a privilege.
“We hear their stories, their fight for self-respect, their fight against shame, their fight to stay alive today,” she says. “We witness the effects of childhood trauma, of things that nobody should have ever gone through. And we’re often the receptacles of their wishes and dreams.
“So we have this beautiful, intimate relationship often with people that in a way almost become family.”
The support went both ways. Years ago, when her first child was born, serious complications kept her baby in hospital for days.
“I would come out of Mount Sinai Hospital and there was a crew of guys waiting for me to get an update on how my baby was,” she recalls.
“The ones who are still alive — a lot of them are not — feel like they have invested in my child. They’re as excited about her graduating from high school almost as much as I am.”
As clients died premature deaths — from violence, overdoses and hard lives on the streets — Elumir began a personal act of remembrance. She listed their names in a journal.
[CAPTION: Registered nurse Keren Elumir, right and harm reduction worker Sarah Greig at the Moss Park overdose prevention site. Workers like them save thousands of lives; in 2018, people were revived from overdoses 2,275 times in Ontario’s 24 federally approved injection sites. (For the Toronto Star)]
About five years ago, the number of names rapidly grew. Fentanyl was by then commonly being used by dealers to give street drugs a more powerful high, causing a sharp rise in overdoses. In 2018, almost 75 per cent of accidental opioid-related deaths in Canada involved fentanyl.
One of the people fentanyl killed was Chris, an Indigenous man Elumir knew well. He’d greet her with a big hug and minutes later Elumir would inevitably notice one of her earrings missing.
She visited Chris one day at the Leslie Street Spit, where he camped, and saw her earrings hanging from a tree like wind chimes. “He thought it was hilarious,” she says.
Chris told her of being taken from his parents and placed in a residential school. He was maybe 6 years old. School authorities shaved his head and treated it with kerosene to make sure he didn’t have bugs.
“I don’t think he ever lost that sense of shame and fear he experienced as a little kid,” Elumir says. “He really struggled with white people. He told me numerous times that he didn’t know how to deal with wanting to hate me and wanting to love me all at the same time.”
Chris asked Elumir for help one day — his long, clumped hair was infested with lice. Combing out the bugs was impossible. Chris told Elumir to shave it off.
“He sat and cried through the whole thing,” she says, holding back tears.
Chris vanished sometime later. Rumour spread on the street that he had died. So a memorial service was held for him at Sanctuary. Chris’s street friends packed the place. In the middle of the service, a tall man walked in and asked, “Whose funeral is this?” It was Chris, fresh out of jail.
“He actually showed up at his own memorial service!” Elumir says. “It was crazy. So we used to joke that there were resurrections happening on the street.”
Three years ago, on a rainy day, Elumir found Chris lying dead of an overdose in a doorway. By then she had stopped putting names on her list of the dead. “It was too many. It was too painful.
“It’s this contrast of grief and rage,” she says. “People matter! Why can’t (governments) get that it’s not as simple as, ‘go to detox,’ it’s not as simple as, ‘go get a job.’ ”
Elumir can’t seem to shake Chris’s ghost. “I see a tall, slender, Indigenous man who walks like his feet are sore, and I think it’s him and I go to yell his name and, no …”
She needed a break after 14 years as a street nurse and joined a family health team in North York, caring for pregnant women and babies. But when tents for a safe injection site were raised at Moss Park in 2017, she immediately volunteered. And when the site moved into the Sherbourne St. building, she took a job there part time, with no benefits.
“I don’t think I really have an option,” Elumir says, when asked why she continues to do the traumatic work. “This is a community of people I love. I cannot imagine walking away from that as long as there is a need.”
By the numbers
137,711 – visits to 24 officially designated supervised drug consumption sites in Ontario in 2018
2,275 – overdoses reversed at designated consumption sites in 2018
59,257 – visits to designated consumption sites in first 3 months of 2019
1,017 – overdoses reversed at consumption sites in first 3 months of 2019
1,471 – deaths apparently due to opioid overdoses in 2018
0 – deaths at consumption sites in 2018, and first three months of 2019
Source: Ontario and Canada health ministries
Correction — July 3rd, 2019: A previous version of this story misspelled Rodney Rizun’s last name.
Sandro Contenta is a reporter and feature writer based in Toronto. Follow him on Twitter: @scontenta
For Immediate Release
June 10, 2019
BC Centre on Substance Use
Police presence near supervised consumption sites in Toronto discouraging access
Supervised consumption sites are being expanded across Canada in response to opioid overdoses and other harms related to drug use. However, recent research suggests that policing in Toronto may be a key barrier to accessing this life-saving health service.
Researchers with the University of British Columbia interviewed clients at two Toronto health sites providing supervised consumption services (SCS), Parkdale Queen West Community Health Centre and South Riverdale Community Health Centre. They found the presence of police produced anxieties and fears of arrest and harassment among clients. Findings were published in the peer-reviewed Harm Reduction Journal, the first to look at clients’ experiences with SCS in Toronto.
In addition, they found that policing practices were not applied consistently across both sites. In one neighbourhood, people who inject drugs were more likely to be profiled by police than in the other. In the neighbourhood with less police presence, clients reported feeling safer about using the services.
When asked about police presence, one participant said: “Oh, I wouldn’t even come in [to the SCS]. I would walk right past. I’m not in trouble for anything, but they’ll get ready to just stop you and talk to you for no reason. And nobody wants that.”
“It’s critical to understand how people’s experiences with police shape access to supervised consumption services,” says Geoff Bardwell, lead author of the study. “Many people who would benefit from these harm reduction programs have negative experiences with police as a result of the criminalization of drug use and poverty. As a result, the mere presence of police at a health service site may discourage them from accessing these services.”
At SCS, people are immune from arrest and criminalization related to their substance use. However, the findings point to a disconnect between the goals of policing and supervised consumption services. As a result, the study authors are recommending that police policies and practice be changed to ensure optimal access to SCS in Toronto.
“Since this study began, the dial has moved on police engagement locally and provincially and there is more opportunity now to create additional safe spaces for drug users and a stronger push for the availability of a regulated and safe supply. We know that this is a public health issue and not a criminal justice issue. The study definitely re-enforces the need for decriminalization more broadly,” said Jason Altenberg, Director of Programs and Services, South Riverdale Community Health Centre.
More than 10,000 Canadians died from opioid-related overdoses between January 2016 and September 2018. As part of the federal response, Health Canada has approved more than 40 supervised consumption sites across the country, including 10 in Toronto, identifying SCS as a critical part of a harm reduction approach to prevent overdoses and accessing treatment and social services.
The study authors recommend the establishment of a non-enforcement boundary outside of SCS in order to lessen the effects of criminalization that drive some people who use drugs away from accessing services. The findings are supported by recent recommendation from Toronto’s Medical Health Officer, who said the criminalization of people who use drugs “forces people
into unsafe drug use practices and creates barriers to seeking help.”
Ontario’s Government for the People is putting patients at the centre of our integrated health care system. As part of this commitment the Government of Ontario is ensuring those struggling with drug addiction can connect with full wrap-round supports for treatment and rehabilitation services, by approving 15 Consumption and Treatment Services sites in communities with high need and will continue to accept applications from interested organizations.
“Our government takes the opioids crisis very seriously,” said Christine Elliott, Deputy Premier and Minister of Health and Long-Term Care. “That’s why we’ve created a new Consumption and Treatment Services model that will continue to save lives by preventing overdoses and connecting people to primary care, treatment, rehabilitation, and other health and social services to ensure those struggling with drug addiction get the help they need.”
To support building a comprehensive and connected mental health and addictions treatment system, Consumption and Treatment Services applications were reviewed against the program criteria, which includes:
Addressing local needs
Offering integrated wrap-around health and social services
Providing evidence of community support and demonstrating a commitment to ongoing community engagement
Considering proximity to other Consumption and Treatment Services as well as licensed child care centres, parks and schools
Meeting accessibility criteria and laws
“This announcement is part of our commitment to invest $3.8 billion over the next 10 years to finally develop and implement a comprehensive, connected and integrated mental health and addictions treatment strategy, centred around patients, family and caregivers,” said Elliott. “We will continue to make mental health and addictions a priority and work toward creating an Ontario where everyone is fully supported in their journey toward mental wellness.”
‘When I’m around my people, I feel safe’: City aims to combat Indigenous overdoses amid opioid crisis
Lauren Pelley · CBC News ·
Harm reduction work ‘needs to be driven by our own community,’ says Les Harper, who is one of only a handful of Indigenous people working in the supervised consumption sphere in Toronto, despite huge rates of drug use among Indigenous residents. (Jon Castell/CBC News)
Catching up in the bustling lobby of an east-end Toronto clinic and supervised consumption site, Les Harper and Lawrence Boyer have lots to talk about — and lots in common.
Both men understand the complicated nature of drug use, from the pleasures to the potentially-deadly pains. Both have also lost loved ones to overdoses — roughly 30 friends for Boyer, and three brothers, one sister, and various cousins, aunts, and uncles for Harper.
And, like so many of those affected by addiction, both men are Indigenous.
But while Boyer is a client and two-time overdose survivor, Harper is on the other side.
Tall and soft-spoken, he is one of only a handful of Indigenous people working in Toronto’s harm reduction community, even though he estimates Indigenous community members make up at least half of all those seeking services, despite making up less than three per cent of the city’s population.
It’s a lopsided arrangement both men agree needs to change.
Harm reduction work “needs to be driven by our own community,” said Harper, a staff member at the supervised consumption site at South Riverdale Community Health Centre who is from the Saddle Lake Cree Nation northeast of Edmonton.
“I don’t know one Indigenous person it doesn’t affect,” he added. “That hasn’t had somebody pass away from an overdose.”
The city, it seems, is listening. Released this month, a new Indigenous overdose strategy, developed by an independent Indigenous contractor with input from the community and support from Toronto Public Health, stresses the need for Indigenous-led consumption and treatment spaces as a way to combat the stigma and isolation experienced by Indigenous people who use drugs.
NEW YORK, NY – OCTOBER 07: A heroin user prepares to shoot up on the street in a South Bronx neighborhood which has the highest rate of heroin-involved overdose deaths in the city on October 7, 2017 in New York City. (Spencer Platt/Getty Images)
The recommendations tie into the city’s broader overdose action plan to combat the opioid crisis, which has led to the deaths of at least 16 people in Toronto so far in 2019 and roughly 450 people over the previous two years.
The “desperately needed” strategy is also the first of its kind in Canada, according to city councillor and board of health chair Joe Cressy. He said it was more than a year in the making, and in that time, the city learned it can’t use “just a one-size-fits-all approach.”
Thanks to recommendations from Indigenous drug users, the strategy calls for Toronto Public Health to request federal and provincial funding support for Indigenous agencies, drop-in spaces, and safe consumption and treatment sites.
It also stresses the importance of weaving Indigenous elders, healing circles, and traditional medicines and teachings into the city’s health care system.
“Currently, the perception is that service workers are generally not knowledgeable about Indigenous culture and history and colonialism, including the assimilation and repression of residential schools, the 60s scoop, and Indian hospitals,” the report reads.
“This results in spaces in which [Indigenous people who use drugs] feel judged and like misfits.”
The ‘desperately needed’ strategy is the first of its kind in Canada, according to city councillor and board of health chair Joe Cressy. (Paul Borkwood/CBC)
That’s a feeling Boyer, an Ojibway father of four, knows well.
The 51-year-old began using drugs — mainly crack cocaine — roughly two decades ago. Now a regular at the Queen Street E. centre where Harper works, Boyer grew up in a home with alcoholic parents and an abusive father. Not everyone understands that experience, he explained.
“When I’m around my people, I feel safe and at ease,” he said. “When I’m not, I’m on edge, and have my guard up.”
‘We know mainstream approaches don’t work’
Research shows “mainstream” approaches don’t work well for Indigenous families, noted Jeffrey Schiffer, executive director at Indigenous non-profit Native Child and Family Services of Toronto.
While he said the city is behind the times when it comes to co-developing strategies with the Indigenous community, Schiffer also praised Toronto Public Health for the new “proactive” direction.
“We’re also at a point where we’re recognizing that Indigenous approaches and tools are beneficial to all people,” he said.
Lawrence Boyer, left, is an Ojibway father and two-time overdose survivor. Les Harper, right, is one of only a handful of Indigenous people working in Toronto’s harm reduction community. (Jon Castell/CBC News)
The strategy report, heading to the board of health for approval later this month, stresses the legacy of trauma facing Indigenous residents today — from child protective services interventions to the ongoing crisis of missing and murdered Indigenous women.
Fringe programming in care settings is not enough, the report continues, because healing can only come when non-Indigenous people are allies “rather than accomplices in continued cultural degradation.”
To implement the strategy, Toronto Public Health has pledged to dedicate an Indigenous staff resource to work with the city in collaboration with Indigenous service providers and community members, wrote de Villa in a note introducing the report to the board of health for its Feb. 25 meeting.
But with many of the recommendations hinging on funding from higher levels of government, some question what can be accomplished.
“How is it going to be implemented? What are the resources behind it?” Schiffer asked.
In particular, it’s unclear how receptive the province would be to the calls for funding and support.
Research shows ‘mainstream’ approaches don’t work well for Indigenous families, says Jeffrey Schiffer, executive director at Indigenous non-profit Native Child and Family Services of Toronto.
While federal Health Minister Ginette Petitpas Taylor has previously said overdose prevention sites “save lives,” Premier Doug Ford claimed the sites offer little long-term help for people with addictions while on the campaign trail last year.
Once elected, his government announced a freeze on the expansion of overdose prevention sites, despite calls from harm reduction workers and Mayor John Tory for a scaling-up of efforts instead.
It was only in late October that the Ford government announced it will keep funding supervised drug consumption sites, but their focus will change to help users receive treatment and get rehabilitated. And as recently as late last month, some sites were unsure if the province would accept their funding applications.
Against that backdrop, Harper also wonders about the strategy’s future.
Standing outside the jam-packed health centre where he works, he said one thing is clear: Drug use is affecting Toronto’s Indigenous communities at a far higher rate than non-Indigenous groups, meaning the city’s approach needs to shift before the crisis gets worse.
“Every Indigenous person I know who works in social work will have a relative come into their space,” Harper said. “A non-Indigenous person will work their whole life — and never have a family member walk in their door.”
CATIE includes a case study of SRCHC’s keepSIX Supervised Consumption Service in Programming Connection.
The Programming Connection is an online toolkit that highlights promising approaches to frontline programs in HIV and hepatitis C prevention, testing, treatment, care and support efforts in Canadian communities.
Canadian AIDS Treatment Information Exchange (CATIE) strengthens Canada’s response to HIV and hepatitis C by bridging research and practice. CATIE connects healthcare and community-based service providers with the latest science, and promote good practices for prevention and treatment programs.
What is a Consumption and Treatment Services (CTS)? How is it different than an Overdose Prevention Site (OPS) or Supervised Consumption/Injection Site (SIS/SCS)?
Overall, these services are all quite similar. The main differences between CTS, OPS, and SIS/SCS are the expected duration of the sites, the different services they are each able to offer and which level of government (federal or provincial) approves the site to operate.
From January to June 2018, Ontario had an Overdose Prevention Site (OPS) program. This program was established to allow the rapid establishment of servicesto help address the overdose crisis. Agencies wishing to open an OPS only had to apply to the Ministry of Health and Long-Term Care for both exemption approval and funding. Exhaustive community consultation was not a requirement, nor were renovations. Supervised Injection/Consumption Services are more permanent and require a more onerous application to the federal government for an exemption under the Controlled Drugs and Substances Act (CDSA), in addition to applying to the province for funding.
In terms of service delivery, only OPS allow peer-to-peer assisted injection for people who use drugs but who cannot self-inject. OPS are also lower barrier because they had fewer reporting requirements which meant fewer intake questions for service users. Both OPS & SIS/SCS provide people with a safe and hygienic place to inject or consume pre-obtained drugs in the presence of trained staff who provide sterile equipment and safe disposal, overdose intervention and/or reversal, and safer drug use education. On-site primary care, mental health supports and referrals to health and social services (including treatment) have been part of both models in Toronto. Toronto currently has 5 OPS and 4 Supervised Injection/Consumption Services. South Riverdale CHC operates both a SIS/SCS (“keepSIX”) and OPS (Moss Park).
Consumption and Treatment Services (CTS) are the new terminology/model developed by the provincial government in November 2018. The CTS model encompasses and combines both OPS and SCS/SIS. The CTS model includes all of the services of an OPS/SCS/SIS with the exception of peer-to-peer assisted injection (which is not currently –permitted by sites with federal exemptions). The CTS model requires that each agency go through the federal exemption process, for each service site. All existing OPS and SIS/SCS must reapply under the new model and there will be a cap of 21 sites across the province. The CTS model has an emphasis on treatment (substance use counselling, referrals to methadone/suboxone providers, detox, and residential treatment programs); however, these services and/or pathways to treatment have always been available to SCS and OPS service users and are part of the harm reduction continuum of care. With CTS, more rigorous data collection and compliance measures are required, including more comprehensive enforcement and audit protocols. In addition, CTS have restrictions about how close these services can be located from one-another (not less than 600m) and require letters of support from nearby schools and child care centres.
What is the Moss Park Overdose Prevention Site (OPS)?
In August 2017, in response to a dramatic spike in overdose deaths in the area, a group of harm reduction volunteers set up a tent in Moss Park to support and care for people who use drugs. The volunteer OPS received an outpouring of public support from people who congregate in the park, local social service agencies and the general public. When the Overdose Prevention Site program was formally established by the Ministry of Health & Long-Term Care in January 2018, the Moss Park group transitioned to this new model. The Moss Park OPS now operates indoors near Queen & Sherbourne as a satellite service of South Riverdale Community Health Centre. The Moss Park OPS has a harm reduction supply distribution area, an intake/waiting area, six injection tables and a post-injection observation space. The service has operated 6 days per week since July 3/18 from 12 to 6 pm and has been staffed by nurses, overdose prevention workers (people with lived expertise of drug use) and community health workers. The Moss Park site has a daily average of 60 visits for consumption and 48 additional visits for supplies, support and referrals. 56 overdoses were reversed in its first 5 months of operation.
What is keepSIX Supervised Consumption Service?
keepSIX opened on November 27/17 at SRCHC’s Queen St East location after a very long consultation and program planning process. keepSIX is open at the same time as the rest of the Health Centre from Monday to Friday. keepSIX is a small-scale service with a daily average of 14 visits. In nearly one year of operation it saw over 400 unique visitors, supervised over 2,800 drug consumptions and reversed 8 overdoses. keepSIX is also staffed by nurses, health promoters and harm reduction workers (who have lived expertise). keepSIX means “got your back” and is an homage to Raffi Balian, founder of SRCHC’s COUNTERfit harm reduction program (established 20 years ago) and lifelong advocate for people who use drugs.
Will SRCHC apply to have Moss Park OPS and keepSIX SCS be established as CTS?
Yes. Applications were submitted for both sites to the Ministry of Health and Long-Term Care in December 2018. There will be no change to the number of service users that each site can accommodate at any one time but there may be an expansion of hours (if funding is approved). A federal exemption request was submitted for Moss Park OPS to the federal government in August and is still pending. The federal exemption for keepSIX was recently renewed for a period of 3-years.
Why do we need these services?
Unfortunately, the overdose crisis continues to get worse and we need services like these more than ever. Recently released data estimates that 11 to 12 people die per day from overdose across Canada. In 2017, 308 people died from overdose in Toronto (the most recent time period for which we have data). This represents a 66% increase in deaths compared to 2016 and a 125% increase in deaths compared to 2015. The Moss Park neighbourhood has been described as the epicentre of the overdose crisis in Toronto by Toronto’s Medical Officer of Health. The proposed CTS at our Queen St location is the only service of this kind east of the Don Valley.
Is there ongoing opportunity for community input?
Engaging with the local community and providing opportunities to raise any issues or concerns has always been important to South Riverdale CHC. If you would like more information or have questions, please contact us. The contact person for Moss Park site is Jen Ko who can be reached at 416.303.4453 or firstname.lastname@example.org. For information about the keepSIX supervised consumption site, please contact Julia Barnett at 416-461-1925 x 356 or email@example.com. keepSIX has a monthly open house from 8:30 to 9:30 am on the first Wednesday of each month. Moss Park also has bi-monthly Open House events, with the next one scheduled for January 23, 2019 from 9 am-11 am. Contact us for more information.
This exemption allows for the legal consumption of pre-obtained drugs within the service space.