Professor Monique Marks, head of the Urban Futures Centre in Durban, South Africa (UFC@DUT) talks about their groundbreaking harm reduction programme for the homeless, specifically those with drug addiction.
In previous episodes, we’ve talked about how cities are addressing both opiate misuse and homelessness. We’ve covered everything from human-centered support programs to AI models aimed at homeless prevention. Today, Olivia from our team chats with Professor Monique Marks in Durban, South Africa to learn more about their first of its kind harm reduction initiative. Let’s learn how the COVID-19 crisis created an opportunity to shift culture and make the seemingly impossible happen in Durban. Read more.
Featured government: Durban, ZA & eThekwini Municipality, ZA
Episode guests: Prof. Monique Marks, Head of UFC@DUT
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Welcome to the Govlaunch Podcast. Govlaunch is the wiki for local government innovation and on this podcast we’re sharing the stories of local government innovators and their efforts to build smarter governments. I’m Lindsay Pica-Alfano, co-founder of Govlaunch and your host.
In previous episodes, we’ve talked about how cities are addressing both opiate misuse and homelessness. We’ve covered everything from human-centered support programs to AI models aimed at homeless prevention. Today, Olivia from our team chats with Professor Monique Michal-Marks in Durban, South Africa to learn more about their first of its kind harm reduction initiative. Let’s learn how the COVID-19 crisis created an opportunity to shift culture and make the seemingly impossible happen in Durban.
Hi, I'm Olivia from Govlaunch. And I'm here with professor Monique Michal-Marks from Durban, South Africa. Monique, can you tell us a little bit about your role?
I head up a research unit at a university in Durban, which is called the Urban Futures Centre and really the aim of the Urban Futures Centre is to look at how cities operate and what are likely future trends in cities. But I think also importantly, we do projects that are both research and engagement oriented, that aim towards improving the quality of life of people who live in the cities. Most particularly the most vulnerable of the city dwellers.
Excellent. And you also are very much engaged beyond just the Urban Futures Centre directly with the city of Durban. Can you share a little bit about your role there?
Sure. The Urban Futures Centre was established in 2014. So it's a fairly new entity. If one looks at university, um, entities more broadly, um, being a research center that is about cities, it was really important that we establish good partnership relations if possible with city officials and with government departments at the municipal level. The number of city based apartments, which we do work with, um, the metropolitan police, they include the department of housing, because, um, we do quite a fair amount of work on social housing in the Urban Futures Centre.
But also the department of health because many of our projects are health related. In relation to the work that we do in relation to homeless people, that is coordinated by the deputy mayor, um, in a homeless committee, which is responsible for all activities related to homeless people in the city of Durban. And, um, and I deputize the, the deputy mayor, um, in that committee. So I'm the deputy chair of that committee. Um, and it's a very vibrant committee. It includes all relevant departments in the city that need to be activated in order to address issues of homelessness. Um, but it also activates non-state entities, such as NGOs and universities in trying to pull together the resources, skills, and capacities of state and non-state entities and trying to resolve the question of homelessness in Durban, which is a big social issue.
So your team on the homeless committee for the city of Durban, as you've mentioned, are working on lots of direct interventions to protect the most vulnerable in the city of Durban. And I know that you've certainly made a lot of major changes with this team happen in a short period of time throughout lockdown. Can you walk us through and tell us a bit more about your innovative harm reduction project that you worked specifically on over the last few months?
Sure. Let me, let me just begin by saying that the issue of homelessness has been on the agenda of the city, but nothing really significant has been activated in terms of service provision to homeless people until strangely the event of lockdown on the 25th of March, it began a full lockdown in South Africa. About a week before that the homeless committee met and we were very concerned about how to deal with issues of homelessness in a state where homeless people were likely to a) be victimized for not being able to adhere to the regulations, which were about staying at home and not moving around the city, but also a concern about where the homeless people would be victors of carrying the virus into the general community and also of vice versa.
Getting the virus from the general community and bringing it into homeless spaces. And so what happened was that, uh, a very quick response was activated. 12 safe spaces were created for homeless people to stay during the lockdown and at those homeless safe spaces were a variety of services, including, um, I suppose, a roof over people's heads, sometimes in the form of tents. It also included evolution facilities, and we quickly realized that, general medical services were necessary because the many people that were part of the homeless population grouping had illnesses sometimes chronic illnesses like TB, HIV, hepatitis, which had not been receiving any medical attention. And so a fair amount of time was put on providing a linkage to services and two chronic medication for homeless people.
But more significantly in relation to the work that I was doing was that there was a recognition that about 60% of homeless people going into the lockdown facilities would be sort of detached from the drugs that they were using, mostly opiates not by choice, but by circumstance. And that we would then have a major issue with people going through a very traumatic period of having to live through the excruciating pain, but mental and physical withdrawal from heroin. And what was the concerns that if people were withdrawing and they were looking for a fix, they would be breaking lockdown regulations by trying to get out of the safe spaces to, to acquire drugs. So, um, you know, they could have been two approaches to this. The one could have been a hard law enforcement approach, which was that anytime somebody was trying to access illicit drugs, they would be arrested by the police and held in various forms of holding cells, or we could take a more harm reduction approach, which was to provide people with Medicare system treatment, which would allow them to stop experiencing the terrible withdrawal symptoms which they were having and also to facilitate during the period of lockdown and some form of normalization of their lives. So from basically day one of our full lockdown, we began as a private entity on two government sites providing harm reduction services in the form of short term opiate substitution therapy.
This is the first of its kind in the country, because previously in relation to government, the approach to drug use has always been one of prohibition and abstinence. And I think it was a very novel and new experience for a government department. In this case, the it plan in municipality under the guidance of the deputy mayor to say, let's do this in a more humane way with the specialists who understand what needs to be done. And the specialists, meaning people who have worked closely with people who use drugs in a more human rights, approach and specialist, medical doctors. In particular, we have a psychiatrist on board who specializes in pain management and in substance use disorders who came together to form this program actually in an underground parking lot of a sports stadium, which is where 260 of the close to 2000 homeless people were located.
We ran throughout the 10 to 12 weeks that we were in and very strong lockdown a very structured program of providing medical assistance through using methadone for people that were having severe and moderate withdrawals. This was all by the way, funded by private donors, not by government. And we were able to fortunately get enough donor funding to run this program for the entire lockdown period. But our program continues and now in a building, which has been awarded to us, and we're not talk about us, I talk about the harm reduction team in Durban by the council of the municipality. This is for us a real win, because it means that the city has actually recognized 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 excellence.
Absolutely. I always find it fascinating how innovation and, you know, really meaningful change in society can come about from sometimes the most unlikely sources, such as a pandemic and subsequent lockdown. So, as you've mentioned, of course the drug dependence problem was a huge problem prior to lockdown. I didn't just suddenly appear once we went into lockdown. I think it'll be really interesting for our listeners to learn more about, you know, beyond COVID-19 being the catalyst. How did your team and the people that were passionate about this approach really change people's minds?
Look, I think let me say, firstly, that heroin use in particular, in the city of Durban as a port city has been on the increase for about, I would say roughly the last 10 years, but I think has not been taken very seriously, but it's become almost an epidemic in the last five or six years. What has been evident to us is that the traditional ways of dealing with heroin use disorders in the city of Durban and actually throughout the country, which has been through so-called rehabilitation programs, which pushed for abstinence. There are a couple that do use medication, but they're very few and far between, and they're very expensive, have generally not had very good results. What's been needed not just in Durban, but throughout the country is the provision of harm reduction services to people who use drugs.
When lockdown began, there was a general anxiety, I would say amongst probably middle class, um, South Africans about what would happen to the drug use population when they wanted their fix. Were they going to engage in, um, acts of, of crime in order to get their fix? I think strangely that was when public support for harm reduction became very, very strong because there was a recognition that the approach that was being used by the city via our private team was really positively impacting in the city and that we weren't having homeless people looking for drugs during lockdown level five and four, because they were receiving appropriate medical assistance. Um, and so now I think what we have in Durban is a much more considered approach to, um, to harm reduction. I get daily phone calls from parents and from sponsors of people who are heroin users about our accessing our harm reduction services. And so even though our facility, our harm reduction facility is really meant to target homeless people. We find that it's actually in great demand from people across the economic spectrum right through to the middle class because the provision of these services are so scant in South Africa and the demand is so high.
I want to take a moment to touch on the funding element. You mentioned that private donors actually supported this initiative as opposed to receiving funding directly from the city of Durban. How will you and your team ensure the viability of this project in the long term?
Going forward, it becomes really complicated because we now have to appeal to the international donor community for funding for this particular service. And we are also in conversation with the national department of health who are still in the process of, I suppose, releasing the guidelines on opiate substitution therapy. They have not been released yet, but more than that, medications used for opiate substitution therapy are still not on our essential medicines, which means that they are incredibly expensive in South Africa, about 10 times more expensive than they are in the United States.
So what we are doing at the moment is working with the department of health to get these medications onto the essential medicine list. We quite far down the road in that and to get the guidelines out as soon as possible. And then to try to work with government in identifying community located projects, such as ours, which will be funded hopefully by provincial governments, the reason that it's provincial or national government is because cities are not able to procure, um, level a schedule five and six medication. So it has to go through higher levels of government, but that is the goal. The goal is to bring in government to, to at some point funders, but that's not going to be immediate. So in the interim, we have the short term, which is, which is still dependent on donor funding.
Then in the interim, we are going to be establishing a second harm reduction center in the CBD. And what we're going to be doing is appealing to new large conglomerates and 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. That expenditure cannot just be put into infrastructure. That alone will not work. There has to be an investment in individuals and their wellbeing. So it's for us, I think the sustainable way forward is to involve the private sector, but in a way that commits them to providing services.
Well, you’ve certainly shown that when there's a will and an evidence based approach, of course, there is a way. Great to hear that a lot of different actors are coming to the table to ensure this great program sustainability in the long term. I think that's a really great lesson for our listeners to always remember that even in this case, as you mentioned, it's actually the rules, the legislation, the city of Durban can’t actually even procure some of this stuff. So there's, there needs to be a creative way to, to get this done and to think about the long term, um, viability of the program. But of course, if there's passion behind it, um, it can happen. So thank you so much for sharing.
I just want to share another thing that I think is important for the listeners is that one group that we got on board very, very, um, early on was law enforcement. And so we have a very, very positive relationship with the police. They protected the harm reduction program during lockdown. In other words, they ensured that the methadone was secured, that the nurses were safe when they were traveling with the methadone onto the site. They actually got involved in, in helping us provide doses when things were very busy in the program. And so that's been very important for us is to get the police to see that it's a much more preferable, um, route to go the harm reduction within, to go the strong law enforcement route. And so we now have a whole bunch of police officers who have become very, very strong advocates of harm reduction. And I think that that is incredibly exciting. Um, you know, because police can, can often obstruct harm reduction access to harm reduction services, um, and what we have at the moment in Durban for the most part is the opposite.
That's great. So that's a testament to the power of this innovation and the work that you've done. That's really interesting that you were able to build this really strong partnership and that both the community and law enforcement were able to ensure that this program was a success. Great. So really the power of partnerships is one of the main lessons that I'm hearing from what you've, what you've shared with us today. Shifting gears a bit, I want to learn more about the Urban Futures Centre and all the great work that you do just broadly. You have a wealth of experience when it comes to inclusive city building. Just for our listeners, how do you see the role of urbanists in society?
For me, you know, engaging with the urban is a very it's by virtue of what cities are, which are vibrant spaces of flow. If you want to call it that. They are places of multidisciplinarity and transdisciplinarity. Given that the, the biggest, um, rate of, of urbanization will be happening in Africa, um, or currently is, and will be in the future, it is really important that we think about cities as places where people will be arriving, they are arriving spaces and it's making those arriving spaces and those spaces of aspiration, um, as comfortable, um, and as equal as they possibly can be. Now at the moment that that's not the case at all. Cities are, are places where you most visibly see inequality, not just in South Africa, but across the world. And that's because you have a high concentration of both wealth and poverty in major cities, including in South Africa. It's hard to redesign projects and programs that allow for, um, the reduction of harm, not just in relation to, to drug use, but reduces harms in every aspect of people's daily lives as urban dwellers. And part of that is actually about designing hard infrastructure, such as buildings and roads and spaces that are open and allow the public to feel that they are spaces where they can engage and connect. Um, but it's also about, you know, creating facilities and programs that allow human beings to flourish in the best way that they can. And often that is through providing the right opportunities to people which can be in terms of employment, not just in the formal sector, but in the informal sector as well, providing places to live.
And again, not just formal housing, there's been a huge push for formal housing, but we don't, especially not in a place like South Africa, which is a low income country. We don't have the capacity to build formal houses for everybody. And so what we need to do is to recognize the dignity of the informal and to give it its rightful space, but to develop ways of improving, um, spaces of informality as dignified spaces. And that includes places for homeless people and ensuring that people who do live on the street either by circumstance or by choice, um, are able to access services, um, in, in, in the same way that other people would without forms of stigmatization.
So I think, you know, as urbanists, we really need to be thinking beyond this idea of state and this idea of buildings and structures, and looking really at the non-state, and also looking beyond buildings to people as infrastructure. At the Urban Futures Centre, that's pretty much what we do. We see people as infrastructure and we take the informal very seriously and in doing so, we’re able to design models for intervention, which I think are replicable in other urban spaces, but actually hopefully also in peri urban and rural areas.
I think it's really important to have universities as part of these networks of social movement, organizations of non-government. And so society sort of groupings that are trying to advocate for dignity and change. But also working very closely with the city because as much as cities want to innovate, and I'm talking about cities as in the formal officials in cities, they’re very, very sort of strung by bureaucratic inertia by sets of procedures and red tape and also by a very real fear of risk. Academics or intellectuals and most of the members of civil society are more able to engage in risky projects, but bringing the city on board with us, um, is, is really useful because if you take ownership, um, initially of risky projects, like the one that happens in lockdown, um, when cities see that, in fact, they aren't as risky as they seem to be at the beginning, they will, um, slowly but surely buy into those.
As urbanists, I think our job is to really mobilize all the resources, capacities, and skills that are required to equalize cities and to make them more accessible.
Thank you for sharing that. I really appreciated how you described cities as arriving spaces. I think that's really important to underline, as well as, you know, humanizing the street at the end of the day, humans are very much a part of the fabric infrastructure of cities. What's something that excites you about the future of civic innovation in Durban?
Look, I think, you know, for me, um, I think what I'm beginning to want to start engaging with, um, in terms of my writing and in terms of my interactions with city officials and beyond is this idea of governing through reducing harm and how that could be applied to all areas of governance, whether it's housing, whether it's transportation, whether it's health, it doesn't really matter is how do we, is how do we as cities think about governing, not through minimizing risks, but through minimizing harm. And that is something that I think will be a very exciting way forward. And now that we have the support of the mayor and the deputy mayor in at least beginning to think about this concept of governing through harm reduction, I think that will open up a lot of opportunities for seeing things differently.
At the end of the day, we all trying to make this a place, which is more livable, more sustainable, more equal for everybody, because without that, I'll very existence is threatened in, in an everyday sense, you know, um, so long as people are unable to access services so long as their only hope is dragging news, because there is no other, at a hope point forward, we will all be in a state of insecurity.
And so for me, it's about connecting one person's insecurity to another and getting people to make sense of that. And they put to reduce that insecurity and reduce that harm and beginning to get a change in discourse that fits with harm reduction across the board, um, is exciting. Um, and, and it's new in a South African context. And I actually don't think that it's that dominant in other parts of the world, either because it is a general governing strategy, which is about responsibilization and about risk management rather than about harm minimization or harm reduction. And that makes me excited about, about what possibilities we have going forward.
It's all about, as you mentioned, working together towards this common vision for the city, and rising inequality harms everyone, not just the most vulnerable in a society. So really great that you're emphasizing that and getting that work very important work done and changing people's mindsets. It's been very educational to hear about how the city of Durban is innovating in so many meaningful ways and on behalf of our audience, thank you so much for joining us today, Monique.
Monique: No, no, I really appreciate that.
Harm reduction initiatives are an important program in a City's wellbeing. This project gives us hope for the future of social services around homelessness and drug use, looking to more evidence based and human-centered approaches.
Thanks again to Monique on behalf of the Urban Futures Center for coming on to talk about their innovative work in Durban.
I’m Lindsay Pica-Alfano, and this podcast was produced by Govlaunch, the wiki for local government innovation. You can subscribe and hear more stories like this wherever you get your podcasts.
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