The front line in one of the most important battles in public health is sandwiched between a luxury hotel and a shuttered restaurant in Providence’s Downtown Historic District. Through the tall windows of a narrow storefront, visitors can get a glimpse of the future: a model Harm Reduction Center (HRC), where people who use opioids and other controlled substances can bring them to consume, protected from the risk of overdose. It is a bold project, both innovative and overdue; despite compelling evidence for its impact from other countries, it would be the first site in the US to have state approval.
The model HRC is an example of the Brown School of Public Health’s efforts to bring evidence to bear on the most pressing public health challenges. “The pandemic has made it clear that many of our current approaches in Public Health no longer work, not in the COVID-19 pandemic and not in the overdose epidemic and not on other pressing issues such as climate change, migration, and structural racism,” says Ashish Jha, dean of the Brown University School of Public Health. “And this is not a shocking statement for anyone who has been in the trenches. The question is, what are the barriers to change?”
Efforts to address the overdose epidemic face a range of barriers, from stigma to the ongoing coronavirus pandemic. After decades of growth in the prescription and extra-medical use of opioids, driven by unscrupulous pharmaceutical marketing and the struggles of America’s working class, among other factors, millions of Americans now suffer from dependency on these substances—with devastating impacts on both individuals and their wider communities as addiction can drive people from employment, undermine relationships, and pose an ever present risk of overdose and death. With increasing availability of powerful synthetic opioids, overdoses have become both more frequent and more fatal. More than 100,000 Americans died from overdoses during the last 12 months, including nearly 400 people in Rhode Island, as this complex public health challenge has been exacerbated by the isolation and economic upheaval of the pandemic.
Public health practitioners have struggled to alleviate the opioid and overdose crisis. The policy response to substance use has too often been driven by a moralistic narrative of personal responsibility that views “addiction” as an individual failing rather than a treatable health condition with complex genetic and sociological roots. Medications for treating substance use disorders are the most effective technique to support individuals in long-term recovery, but these therapies have not been effectively scaled and remain largely inaccessible to most Americans due to stigma and regulatory red tape. Supportive outreach, including syringe services programs and mobile clinics, can reach only a small proportion of those affected.
With support from the Brown University School of Public Health, Rhode Island is working to bring more tools to bear. Providence’s model HRC is a partnership between RICARES (the Rhode Island Community for Addiction Recovery Efforts) and the People, Place & Health Collective at the School of Public Health, led by Brandon Marshall, associate professor of epidemiology. As a doctoral student, Marshall helped to evaluate the first HRC in North America, which opened in Vancouver, British Columbia in 2003. The evidence that Marshall and colleagues gathered—of deaths prevented, but also reductions in infections, in public drug use, and in violent crime—has been central to the push for harm reduction interventions in the United States.
Despite a robust and growing body of evidence that HRCs prevent overdoses and save lives, the United States has continued to pursue a “prohibition” approach that views substance use and addiction as the domain of criminal justice, not public health. After Somerville, Massachusetts issued a report recommending that the town open a “supervised consumption site,” the effort stalled due to legal hurdles, including a federal law passed in the 1980s making it a crime to own or maintain a building “for the purpose of… using any controlled substance.” The United States Supreme Court recently declined to hear an appeal by Safehouse, a Philadelphia organization seeking to open a similar site, and which now plans to argue for a religious exemption to the federal statute. New York City, which opened a publicly recognized harm reduction center in November 2021 with mayoral approval, may face similar legal challenges from state and federal authorities.
Harm reduction in Rhode Island
Against this background, Rhode Island’s efforts to open HRCs represent a unique push to move from evidence to effective intervention to save the lives of Rhode Islanders. The model HRC in Providence is the culmination of a novel partnership between RICARES, the broader harm reduction and recovery community, Marshall and other researchers, and state policymakers—a singular example of how evidence, insight, and a commitment to impact can overcome challenges to implementation.
“For many years, I did not think that harm reduction centers would be a reality in the United States,” says Marshall, “but I saw Brown as a tremendous place to do work around overdose prevention and the evaluation of progressive harm reduction approaches because of the strengths of the community here, and the broader harm reduction and research community as well.” As the impact of opioids in Rhode Island became unmistakable, Rhode Islanders began urgently looking for more effective ways to help support their communities. “Most people I speak with who live in Rhode Island either know someone personally or know family members who have lost loved ones to overdose,” says Marshall.
This long-term commitment to sharing evidence and fostering policy innovation eventually paid off last year. In July 2021, the Rhode Island legislature authorized a pilot HRC program—the first time a state has taken such a step. “This was cooked in a crockpot, it wasn’t cooked in a microwave,” says Dr. James McDonald, medical director of the Overdose Prevention Program at the Rhode Island Department of Health, who collaborated with Marshall in supporting the HRC initiative.
The best public health interventions—whether improving nutrition, smoking cessation, or preventing the spread of infectious disease—meet their community members where they are, paying close attention to the underlying vulnerabilities and structural conditions that undermine health. Rather than blaming individuals for poor health, effective public health works together with communities to improve people’s health by putting evidence into practice. As a result, Rhode Island HRCs will not be identical to those in Vancouver or New York. Marshall and his team are supporting efforts to make sure HRCs meet the needs of Rhode Islanders.
“Harm reduction centers can look like a lot of different things,” says Marshall. Whether they emphasize social services, housing, or support groups, for example, will depend on the goals of the local harm reduction community, state regulations, and epidemiological dynamics. “Ideally, they should be designed to address specific public health goals and meet the needs of the community in which they’re located.”
Policies to tackle prior drug crises have often been racially motivated, with deadly and disastrous consequences for Black, Indigenous, and Latinx communities. No single public health intervention can undo the structural racism in US drug policy, but HRCs can do more than just reverse overdoses. “These facilities are much more than just supervised consumption,” Marshall points out. “They provide wraparound services to people—referrals to treatment, hepatitis C testing, social services—helping increase access to services for people who have historically been mistreated and harmed by health, social, and criminal justice institutions.”
Steps to address the great contemporary public health challenges must be based on practical research into both the significant behavioral influences on health—from misinformation to deaths of despair—and the formidable structural barriers to good health, including structural racism.
This evidence-driven commitment to the health of all is at the core of what public health must bring to new public health challenges such as climate change and pandemics. During the COVID pandemic, for example, Stefanie Friedhoff, associate professor of the practice of health services, policy and practice, has led an SPH team working with community organizations and other partners focused on securing equitable access to COVID vaccines for Black and brown communities. “The key to building vaccine confidence is that we don’t make any moral judgments about people,” she says. “If you’re not currently open to getting vaccinated, blaming you will not be motivating. We need to listen, and work to understand what stands in the way, and what could help you access a vaccine to protect your health. When we do that, we often find that this is less about ‘bad choices’ and more about misconceptions and ‘bad options.’”
The Equity-First Vaccination Initiative recognizes that the struggle to vaccinate all Americans equally has its roots in history, systemic challenges, and novel technologies. Structural racism and socioeconomic inequality impede vaccine access for many Americans who are gravely vulnerable to infection, heightening long standing mistrust of the medical system based on centuries of marginalization and mistreatment. Meanwhile, new media ecosystems leave Americans immensely vulnerable to health misinformation, and targeted disinformation, which is often politicized. At the same time, the coronavirus pandemic, which can only be managed through collective action, has forced Americans to confront the reality that the health of all Americans is inextricably linked.
The future of public health
To train a new generation of public health leaders equipped to address such complex challenges, the Brown University School of Public Health will ensure that evidence, leadership, and innovation drive urgently needed systemic interventions to safeguard the health of all. The School is taking immediate steps towards this vision. The Health Equity Scholars program, for example, aims to change the face of public health leadership by ensuring that the full diversity standing up a new effort on Pandemic Preparedness and Response, led by international pandemics expert and incoming faculty member Jennifer Nuzzo, the School is able to turn the many lessons learned from the coronavirus pandemic into concrete models to improve our ability to manage future outbreaks.
Similarly, the School is rapidly scaling up action-oriented research in health misinformation and global health, with particular attention to the impacts of climate change. Complementing the School’s strengths in behavioral sciences, biostatistics, and implementation science, faculty and students look to disrupt pre-existing public health approaches by collaborating with colleagues from across Brown University.
“To meet this moment and the challenges to come, we need more public health researchers working to implement novel approaches and generating evidence on what works. We need to take a hard look at the failures and weaknesses in our public health systems,” says Dean Jha. “At our school, we’re going to do that: pinpoint the lessons learned and translate them into ambitious new ideas, new approaches, new policies. But we can only succeed when we collaborate with people, communities, practitioners, government, and other partners. We are in the most important public health moment of our lifetimes, and it demands that we think differently, and that we act differently. Brandon Marshall’s work and Rhode Island’s Harm Reduction Centers are important examples of this mindset.”