Individualized help for intravenous drug users a needed service

Translation: Ásdís Sól Ágústsdóttir

Frú Ragnheiður (“Mrs. Ragnheiður”), the Reykjavík Red Cross’ harm reduction project, started in 2009 and is run by Svala Jóhannesdóttir. The project’s aim is to reach out to injection drug users and homeless individuals by offering them needle exchange services and health care. Frú Ragnheiður is a customized vehicle, a sort of health clinic on wheels, that drives around the capital region six nights a week from 6 to 10 PM. Roughly 80 volunteers are involved in the project. During each shift there are three volunteers on duty: one healthcare worker, one general volunteer, and one driver. In addition, there’s always a doctor on call. In 2018, 455 individuals sought out Frú Ragnheiður’s services, making a total of 3,854 visits.

Those who seek out Frú Ragnheiður’s services are marginalized individuals who often face prejudice and a lack of understanding from society. Clients can receive a variety of care-based services, like wound care, antibiotic treatment, general health checks, counseling, and psychological support. Clients can get clean needles for intravenous drug use, needed nutrition, warm clothes, sleeping bags, personal hygiene products, and more. In addition, people can bring sharps containers filled with used needles to Frú Ragnheiður, which helps keep them off the streets and out of public trash cans. In 2018, the project disposed of 2,670 litres of used injection equipment.

Student Council President Elísabet Brynjarsdóttir is a nurse who was recently hired to work for Frú Ragnheiður. Among her responsibilities, she oversees medical care provided under the auspices of the project.

A dire need for Frú Ragnheiður’s services

Elísabet says Frú Ragnheiður’s services are vital to many people. “I started out as a volunteer a year ago and what shocked me the most, with my nursing background, is how much these people need health care that comes to them. They face so many obstacles, for example just to go to a doctor’s appointment or the emergency room, there’s the opening hours, the cost, all of those things have an effect and reduce the likelihood of these people showing up. Many have had negative experiences with the healthcare system, like healthcare professionals who treat them with prejudice and don’t understand their position.”

Eliminating paternalistic attitudes

But how does Frú Ragnheiður get in contact with clients? “We offer services that clients seek out on their own terms. They call and ask to meet us. We come to them, to where they are, and provide them with a very good local service,” says Elísabet, emphasizing the importance of meeting people where they are and accepting them, no matter what they’re going through at any given time.

“We listen to their needs in the current moment and we don’t judge their circumstances or what has happened in their past. We also try to empower these individuals so they feel stronger, which may help them to take steps in a positive direction. Overall, we approach these individuals with respect, love and care, just as we would approach anyone else, really. We try to support them where they are right now. We don’t tell them what to do, we totally eliminate any paternalistic attitudes.”

Valuable experience

Elísabet believes you don’t have to look too far in our society to come across prejudice and preconceived ideas about intravenous drug users. “The biggest lesson I’ve learned is how easy it is to communicate with this group of people. Unconsciously, you’ve been taught by society that you should walk quickly past ‘those men’ at Austurvöllur and you shouldn’t look at or communicate with people who are under the influence.

“I have also discovered the strong stereotypes of our clients that exist, when in fact these people are kind and lovely people whose needs must be met, just like me or you. They are simply people who need warmth and respect, they need to be listened to, and they need to feel understood no matter where they are in life at the current time.”

A group in need of individualized service

Elísabet believes that the services injection drug users receive today need to be much more individualized. “We need to be flexible for these people; they don’t really follow the clock like everyone else. They require flexibility from a variety of services in the later hours when they’re more likely to be ‘operating,’ but the fact is most of these services close around 4 PM, like social services and many support groups.

“But I feel like federal and local authorities are becoming more conscious of the needs of this group. There are plans in motion to increase housing options specifically for homeless people battling addiction as well as to open a safe injection site. These are the first steps toward decreasing the penalty policies that society has imposed on people struggling with drug addiction.”

People who seek out Frú Ragnheiður’s aid require a plethora of services not easily accessible within the system. “What they really need is for these services that Frú Ragnheiður offers to be available locally, at a place they can easily access, where they can get help with tying up all kinds of loose ends, like scheduling an appointment with a social worker, getting help filling out paperwork, scheduling an appointment with a general practitioner, getting help finding addiction treatment, and the list goes on. Frú Ragnheiður’s services have evolved in this direction, but we can only handle emergencies,” Elísabet says.

The paradox of continuing to punish for possession

Despite steps in the right direction, there’s a certain contradiction in punishing people for having drugs on them, in Elísabet’s opinion. “A bill is being prepared for Parliament that will propose opening a safe consumption site. A consumption site is defined as a specific health and harm reduction resource where individuals can bring their own doses for consumption, inject them in a safe space where healthcare workers are present and can help in case of an emergency.

Health care and other assistance will also be available in this consumption space. The bill is based on the idea of providing this specific little group of people with a safe space to use intravenous drugs and granting immunity for possessing illegal drugs at the consumption site. At the same time, possessing drugs outside of this safe space remains illegal.

“We are certainly taking steps in the right direction by opening up a consumption space, which will decrease the number of people losing their lives to overdoses, but I think it’s inevitable that we will eventually stop punishing people for possession. I also find it important to recognize these people as independent individuals who on the one hand are either making the conscious decision to use drugs, or on the other hand are struggling with sickness, trauma and many other things,” says Elísabet.

Now offering antibiotic treatments

In the end of February in 2018, Frú Ragnheiður began offering antibiotic treatment in collaboration with the on-call doctors affiliated with the program. “Prescribing antibiotics to clients due to infections, in collaboration with our on-call doctors, is very important. This way we can intervene earlier and prevent people from ending up in the hospital and needing more complicated procedures.

“In these eight short months since we began providing antibiotic treatments, we have helped 40 individuals get antibiotics, and we’ve followed their course of treatment by recording their return visits. Of these 40 individuals, 37 completed treatment without hospitalization,” says Elísabet.

A diverse and ever-growing group

The group that seeks out Frú Ragnheiður’s services is rather diverse. “These individuals are at very different places with their drug use. Many are using daily, while others do so a few times a year. Many of our clients are homeless but others own their own homes.”

In 2018 there was a significant increase in the age group of 18- to 20-year-olds seeking help from Frú Ragnheiður, which is a very sensitive age group. “This specific group has in fact tripled in size, going from 12 individuals in 2017 to 36 individuals in 2018. This doesn’t necessarily mean that there is a bigger drug problem among this age group; it could also mean that they trust us more and are unafraid to get help from us, which is great because then we can try to assist them.

“When 18- to 20-year-old individuals come to us, we provide them with extra services. We try to follow up on their lives, check out their support network, find out where they’re staying, and ask if they want help getting into a treatment facility or to a doctor, and we connect them to social services.

“In 2019, we want to emphasize reaching out to more women. Currently, they make up only 25% of our clients, so we need to begin special operations to reach out to women and support them,” Elísabet says.

Elísabet says the need for Frú Ragnheiður’s services continues to increase. “One hundred percent. Frú Ragnheiður is the only official operating harm reduction program in Iceland. There is a Frú Ragnheiður operating in Akureyri, and there’s talk of starting up a similar program in Suðurnes. But there is a great need for more official harm reduction resources, for example we need more staff members for the project. And of course the ideology behind this program is one that the entire healthcare system should take to heart.”