Durban, SA emphasises harm reduction to address addiction





When the coronavirus hit, many cities faced a question: how do we mitigate risk of viral spread within the homeless population? Stay-at-home orders don’t work when “home” is a transient location.

On top of that, many people experiencing homelessness also suffer from drug addictions. Lockdowns raised another challenge here — how could the city support those going through the symptoms of withdrawal and prevent them from breaking lockdown rules?

These questions shined a spotlight on an issue that has long been discussed, but often has seen little progress: How can cities take a more humane approach toward serving their more at-risk populations?

In $ Durban, South Africa$ , groups like the $ Urban Futures Centre at Durban University of Technology$  and the deputy mayor’s homeless committee, have been working to address this issue for years, but progress was a challenge. When the pandemic hit, they sprang into action, opening shelters around the city and launching the country’s first harm reduction-based opioid treatment centre to serve the city’s homeless during lockdown.

In doing so, the group has implemented the largest drug treatment programme of its kind in South Africa. It also shifted perspective among city leadership, law enforcement, and the public, opening the door for a more humane approach to governing cities overall.

As Govlaunch works to build the global wiki for local government innovation, we’re highlighting a series of Innovators — cities, towns, and counties who are implementing transformative ideas and fostering a culture of innovation. We chatted with Professor Monique Marks to talk about Durban’s shift toward a harm-reduction policy, and how cities can improve the lives of their most vulnerable residents.



Introducing harm reduction drug treatment services

The eThekwini Homeless Committee, which is chaired by the city’s deputy mayor and brings together individuals from the local government, non-profit, and university spaces to address homelessness in the city of Durban, had been working on solutions to the city’s homeless and drug challenges for some time. As city-wide pandemic orders were going into effect, the group moved quickly to organise a series of safe spaces for homeless people around Durban. These provided shelter and general medical services for the duration of the lockdown period. At their peak the shelters served around 2,100 people, and continue to house about 1,800 on an ongoing basis.

But some people in these shelters needed additional support, says Professor Monique Marks, head of the Urban Futures Centre at Durban University of Technology, and vice-chairperson of the eThekwini Homeless Committee:

“There was a recognition that about 60 percent of homeless people going into the lockdown facilities would be entering a state of withdrawal. This meant they’d be detached from the drugs that they used — mostly opiates, like brown heroin — not by choice, but by circumstance.”

Drug use, especially heroin, has been an issue in Durban for years, across people of all income levels. But this situation posed a major new problem, as lockdown orders would cut off people’s access to drugs, resulting in the traumatic mental and physical experience of heroin withdrawal.

The eThekwini Homeless Committee understood this and acted accordingly. By the beginning of lockdown, the group designated one (and shortly thereafter a second) of the city’s new homeless facilities, run on government sites, and used them to provide harm reduction services via short-term opioid substitution therapy.

Operating 7 days a week, the centres provided medical assessments, including methadone, for people having severe to moderate withdrawals. They ran a needle exchange programme and had full-time social workers on site. They also provided non-medical offerings, such as food and classes in basic computer skills.

At its high point, there were about 260 people on the programme from across the two sites.

All beneficiaries were assessed using a withdrawal assessment tool. Symptom packs were available for people experiencing mild withdrawals. Those who scored with moderate to severe withdrawals were given the option to go onto the short term OST programme. Professor Marks says:

“About five weeks later we reassessed everyone on the programme. Most scored zero on the second test, meaning that they were no longer experiencing any withdrawal symptoms. About 60 percent of the beneficiaries reconnected with their families while in lockdown safe spaces. For many this was the first time in many years that they had spoken with family members.”

Traditionally, says Professor Marks, Durban’s response has been tough law or abstinence-based treatments. The centres proved this wasn’t necessarily the best approach:

“This is a real win, because it means the city has actually recognised that a harm reduction approach is a best practice, evidence-based approach to dealing with substance use disorders, rather than the strong arm of the law or tough love or pushing for abstinence.”

There’s a shift at play here, but it didn’t happen on its own.

Building partnerships and changing perspectives

The centres are run on government sites, but they aren’t funded by the government. This is due to some legislative red tape, which Professor Marks and the Homeless Committee had to navigate:

“We were told that this could not be a government-run programme. It could be run on the state-provided facilities, because that was where homeless people were being housed, but the government would not be in any way involved in the provision of the medically assisted treatment.”

This is because, under South African law, cities aren’t able to procure the types of medication, like methadone, that are needed for the treatment centres.

A roadblock, sure, but that didn’t stop Professor Marks’ team. With help from the deputy mayor’s office, they sent out a call for private donor funding. The call was answered, and the programme was funded by private donors throughout the duration of lockdown. Now, they are looking to form more partnerships, through local banks and large companies. Professor Marks explains:

“We’re appealing to companies within the city of Durban to invest in harm reduction as a way of improving the general wellbeing of the city. In other words, understanding that in order for the city to flourish, we need to have human beings as individuals who flourish.”

They’re also appealing to the government to try to fund community projects such as this one, though that would likely still be done at the provincial or national level, not locally.

The city of Durban may not be able to fund the medicine, but they’re still supporting the programme, says Professor Marks:

“The city is currently revamping the building and putting quite a lot of investment into making it a really nice facility to use.”

In addition to working with the city, the Homeless Committee has also partnered with local law enforcement. The police protected the centre and those traveling with the methadone. They even helped administer the treatment when things were busy at the centre. Says Professor Marks:

“It’s been very important for us to get the police to see that it’s much more preferable to go the harm reduction route rather than the strong law enforcement. And so now we have a whole bunch of police officers, both high ranking and low ranking, who are very strong advocates for harm reduction.”

One of the biggest perception shifts came from the public. Professor Marks says that her team was told to expect resistance from the public, both from residents who live near the centre and businesses that are based there.

What they found was the exact opposite:

“There was a recognition that the approach being used by the city via our private team was really positively impacting the city. And we weren’t having homeless people looking for drugs during lockdown because they were receiving appropriate medical assistance.”

This support during lockdown has helped shift the public’s opinion and created support for the harm reduction approach to drug treatment. People near the centre started donating food, clothes, and other items they thought people may need. Professor Marks says she now receives daily phone calls from parents and spouses of those battling addiction, asking about the harm reduction services:

“We find that it’s actually in great demand from people across the economic spectrum.”

The need for more humane cities

Professor Marks hopes to tap into this demand for services. Part of this includes broadening the customer base and creating new funding sources:

“We want to start a harm reduction–focused private facility for high income earners, because we don’t have something like that in the city of Durban.”

The goal would be for a portion of the profits from this facility to be reinvested into the centre serving low income and homeless people.

There are signs of the harm reduction approach taking hold elsewhere in South Africa. The city of $ Tshwane$  (Pretoria), together with the University of Pretoria, also had a comprehensive approach to dealing with homelessness during Covid-19 lockdown. Their program extended the existing Community Oriented Substance Use Programme (COSUP) to include methadone to deal with withdrawals during the emergency.

This type of treatment is just one example of the humane approach Professor Marks is advocating for across urban life. The Urban Futures Centre at the Durban Institute of Technology, which Marks leads, is also dedicated to this effort, says Marks:

“We need to find ways of humanizing the street, which is where a large number of people live. And we need to ensure that people who do live on the streets, either by circumstance or by choice, are able to access services in the same way that other people would without forms of stigmatization.”

Given the rapid rate of urbanization in Africa, there’s a huge opportunity for this, says Professor Marks:

“It’s important that we think about cities as places where people will be arriving. And it’s making those arriving spaces and those spaces of aspiration as comfortable and as equal as they possibly can be.”

At Govlaunch, we’ve seen harm reduction-based services take off in other communities, too, such as $ Colerain Township’s groundbreaking Quick Response Team$  programme to address the opioid epidemic. But it’s not just about what and how services are offered. To really build more humane communities, local governments must take an honest look at what institutional and public sentiment challenges stand in the way of these efforts. By building partnerships and winning over advocates across law enforcement, local businesses, and residents, cities working to build a more human-centred way of governing will see more sustained, large-scale success.