"It's about meeting people where they're at—and, like my coworker José says a lot, it's also about not leaving them there, you know? So it's like, here's where you are: What could you do right now? What small change can you make right now to be a little safer, or a little healthier? Or a little better off than you are right now? Just honoring that and holding that and acknowledging that people are not all bad—if we could accept that and move on, we could get a lot more done."

Lill Prosperino, Southern States Regional Organizer for the National Harm Reduction Coalition

Lovey Cooper, Managing Editor: In 2020, watching the way that politicians, medical providers, and the general public mobilized and responded to this new, scary public health crisis proved to me something most people in the harm reduction community already knew to be true: If the government really cared about intervening to save the lives of people who use drugs, it was already well within its power to do so. Before COVID-19 reached pandemic-status in the U.S., the opioid epidemic was supposedly the nation's top public health crisis. It was one of Donald Trump's top talking points on the campaign trail.

But now that we have a vaccine to help mitigate the deadliness of COVID-19, the same folks pushed to the margins of public health efforts are back at square one. The pandemic echoed familiar patterns for people who use drugs. People everywhere lost their jobs, which for some meant losing their medical insurance to cover their treatment for addiction. Flights in and out of the country were grounded, and as a result the drug supply coming into communities across the country was less reliable and more likely to contain contaminants that can cause overdoses. One of the biggest principles of harm reduction is to never use alone, but physical isolation was not only strictly encouraged, but enforced. As a result, deaths by drug overdose reached all-time highs nationwide last year—the largest single-year increase ever recorded, with hotspots in the South.

In recent months, as vaccination against COVID-19 became the national health care priority, even the shot's very production has amplified long standing issues in the harm reduction community. Pfizer has adapted its manufacturing lines, interrupting the same pharmaceutical supply chains responsible for the nation's supply of life-saving medications that stave off withdrawal or reverse drug overdoses, at a time when they're needed most. But before we even begin to reckon with the lasting impact of this new lack of availability and subsequent resource-hoarding of Naloxone (also known by the brand name Narcan, the device that administers it), people who use drugs already have complicated relationships with government programs, mandates, and medical care—especially when it comes through needlessly bureaucratic or commercialized channels.

"The skepticism makes sense to me," Lill Prosperino said of their community members' general reluctance to get vaccinated. "It's hard to be mad at people for that, because here in West Virginia, a lot of people just spent their time watching these lawsuits from these opioid pill companies, and there was no justice for that—they got off the hook. So of course people don't trust them."

Lill Prosperino. Courtesy photo.

Prosperino lives in rural West Virginia. Prospino is the Southern States Regional Organizer for the National Harm Reduction Coalition, a national advocacy and capacity-building organization that promotes the health and dignity of individuals and communities affected by drug use. Prospino primarily works on coalition-building with people in Kentucky, West Virginia, North Carolina, Indiana, and Tennessee—the states with some of the highest rates of Hepatitis C and lowest access to treatment. 

But even in states with more available options for drug-associated care, there are still greater obstacles to COVID-19 vaccination.

Dr. Hansel Tookes, associate professor of clinical medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine, is the founder of Miami's Infectious Disease Elimination Act (IDEA) Exchange. Founded in 2016, IDEA Exchange was Florida's first syringe exchange program and clinic designed to help people who inject drugs. Early last year, Tookes was helping legislators to structure policy to get other needle syringe exchange programs off the ground in the state, before COVID-19 delayed the implementation of his and many other programs.

To remain open during the pandemic, his team had to dramatically reduce their interactions with the public. "Harm reduction is love and smiles. And all of that went away," he said.

Dr. Hansel Tookes. Courtesy photo.

While Miami-Dade County has seen some of the highest rates of vaccination in the South, some experts are warning that relying on the populations that are already fully vaccinated might not be enough to build herd immunity as expected in the popular tourist destination.

For Tookes, the greatest challenge to actually distributing the vaccine is being unable to deliver care in a non-stigmatizing venue—a site where if withdrawal symptoms are coming, his patients can leave for a few minutes, "do what they need to do to not become sick," and come back. Instead, even as a public hospital system that takes care of mostly brown and Black people, his clinic doesn't have the COVID-19 vaccine available on site. Instead, those shots are going through commercial pharmacies and old federal vaccination sites.

The same struggle rings true in Lill's community in West Virginia.

"Locally, where I live, I'm around a lot of unvaccinated people. What's complicated about it is like, it is frustrating, right? I am frustrated—I want people to get the vaccine, and the people that I am around day-to-day for the most part experience a level of poverty that I think most people could never understand," Prosperino said. "For all intents and purposes, these people live an hour from the grocery store, they don't have a car, they have 100 barriers to even get their driver's license back if they ever were to get a car. There's no jobs here. Maybe they don't have a cell phone, maybe they don't have internet, and what they hear about this place is what they see on the news on the TV, which is a very skewed reality."

As the vaccine first became available in Florida, Tookes would have to sign letters affirming that his patients should be included in the state's groups of prioritized populations. Some patients were easily included in the state's most-vulnerable criteria—many of them smoked cigarettes, or had a record of substance use disorder or HIV—but even with that one bureaucratic hurdle cleared, they were still tasked with getting to a public vaccination site, most of which are remote from the clinic where they are already receiving care.

"I think that [conversation] is important for people who inject drugs who have profound distrust for the government, because it has used a carceral system to punish them, or the healthcare system, because it has stigmatized them and treated them horribly for years."

— Dr. Hansel Tookes, associate professor of clinical medicine in the Division of Infectious Diseases at the University of Miami Miller School of Medicine

In West Virginia, Prosperino said that although some people in their community jumped at the opportunity to get vaccinated—or intend to get the shot but haven't been able to because of a lack of transportation or because they can't afford to miss a day of work to deal with side effects—they have also heard others echo anti-vax sentiments, down to the microchip line.

"While I do think that that's ridiculous, at the same time, I do not think that that level of distrust for the government is ridiculous," Prosperino said. "From a poor person, it is not ridiculous. It makes all the sense in the world."

Tookes said that the people he sees at his clinic have been targeted with such misinformation, too. Some religious groups in Miami are even handing out anti-vaccine pamphlets under the overpasses where some of his unhoused patients gather.

"My patients really trust me—you know, I'm the doctor that thought to make it so that they can have clean needles—and when they come in and say, 'I heard this about the vaccine, I don't want to get it,' My response is always: Who told you that? Who said that?" Tookes said. "When they say it was the guy at the bodega, I say, 'Okay, well, that was not your doctor. And luckily, we're here together now."

But getting into those medical settings to start those conversations is already another barrier for those without access to clinics like the IDEA Exchange.

"The people that I see regularly, they will have an abscess so big on their leg that there's a huge hole in their leg, or they can't walk, and they still won't go to the hospital, because they don't want to be treated poorly," Prosperino said. "I think they think that that same person who's gonna jab them in the arm with the vaccine is going to treat them the same way every medical provider has for the last however many years of their life. It's a trauma response. It's a response to stigma and shame and being beaten down and taught that you don't have any worth. More so than anything with people who use drugs, what I hear about the vaccine is just people not really having the time. Because nobody's making it easy for them."

One unintentional pandemic-win for the harm reduction movement was that masking policies and social distancing practices forced many to consider their own actions as having consequences outside of themselves in a public health setting—in itself a basic principle of harm reduction—for the first time.

"Nimbyism rhetoric is pretty prevalent in the South," Prosperino said. "But the uniqueness about the South is not so much the conservative aspects, or just the awesome liberatory organizing, but it's the struggle of both. And that's true in harm reduction, too."

Breaking Through COVID is a collection of stories focused on illuminating the ways the pandemic has realigned our communities and put sharper points on the crises the South was already facing.

We understand how wide open the door has been flung for the spread of misinformation and disinformation. We understand how deep the mistrust of the media is right now, too. Help us help each other. Tell us about the radical Southerners doing this work in your community. Especially in places without formal organizing infrastructure, how can we adapt some of their lessons in our own communities? Let us know.

breaking through covid

Lovey Cooper is Scalawag's Digital Editor and the voice behind This Week in the South. Follow her on Twitter: @LoveyCooper.