Environmental justice in the therapeutic inner city

From scary places to therapeutic landscapes: Voices from the community of people living with schizophrenia

This article discusses how people living with schizophrenia experience, understand, and respond to their urban environment. Our study relies on experiential photo-voice data gathered with a sample of six people diagnosed with schizophrenia and living in non-institutional settings in Montréal, Canada, to identify how individuals in this community perceive the urban landscape. We adopt a therapeutic landscapes' framework that explores the urban fabric at three levels: physical, social, and symbolic. Research participants identified both health-denying and health-enhancing places within ordinary urban landscapes. Landscapes identified as health-denying are characterized by environmental stressors and loss of control, with construction sites an example highlighted by participants. Healing and restorative landscapes, as identified by participants, were physically attractive or quiet, socially safe and welcoming, and symbolically affirmative of one's identity, all factors worthy of further study. The findings are also policy-relevant: they suggest that people living with schizophrenia and their clinicians can develop strategies to make health-enhancing uses of urban landscapes; and that urban policies and practices can foster urban environments conducive to enhanced health and well-being, both for the community of people living with schizophrenia and the wider population of urban dwellers.

Therapeutic landscape experiences of everyday geographies within the wider community: A scoping review

As community dwelling populations of older people and those living with chronic and life limiting conditions continue to grow, the role of everyday geographies, particularly of community based settings and activities, in supporting health and wellbeing has become a focus in both research and policy development. The therapeutic landscape scholarship provides a holistic view of how place promotes health and wellbeing, and has in recent years expanded its focus from reputable places of healing to everyday geographies. Based on a scoping review of 45 studies on everyday community based therapeutic landscapes, this paper identifies and critically examines the settings, populations and mechanisms of therapeutic experiences. It presents critical summaries of the scales and boundaries of landscapes; the diverse and dichotomous characteristics of places; the therapeutic benefits of proximal and distal socio-spatial interactions; the role of everyday settings and activities as sources of refuge, anchor and resonance and finally the broader social, cultural, political and economic contexts in which everyday therapeutic landscapes are embedded. In so doing the paper highlights the complex nature of everyday therapeutic landscape experiences and how this research can further inform the development of community based settings and activities that promote health and wellbeing. It also identifies areas for future research on everyday therapeutic landscapes.

Characterization of Bodily Pain and Use of Both Prescription and Non-Prescription Opioids in Tenants of Precarious Housing

opioid use, which includes both prescribed and non-prescribed drugs, is relatively common amongst marginalized populations. Past research has shown that among those who use non-prescribed or diverted opioids recreationally, many were first exposed to the drug as prescribed pain medication. Objective: to better understand the relationship between pain and opioid use in tenants of precarious housing. Methods: in the present study, 440 individuals from a cohort living in homeless or precariously housed conditions in a neighborhood with high rates of poverty and drug use were interviewed for their bodily pain and opioid use. We examined the relationship between bodily pain levels, assessed using the Maudsley Addiction Profile questionnaire, and prescribed, non-prescribed and combined self-reported opioid use in the prior 28 days assessed using the Timeline Followback and Doctor-Prescribed Medication Timeline Followback questionnaires. Results: Analysis of the results indicated that sex (female), age (younger) and early exposure to opioids (≤ age 18) predicted current opioid use, but there was no association between current bodily pain levels and opioid use. Conclusions: these unexpected findings indicate the complex nature of the relationship between pain and opioid use in this population.

"You need to just provide health services:" navigating the politics of harm reduction in the twin housing and overdose crises in Vancouver, BC

BACKGROUND

Since harm reduction's origins as a grassroots, activist movement, cooperation and compromise among people who use drugs, bureaucrats, politicians, and other actors have been critical to its advancement in Canada. Critics have argued, however, that the institutionalization of harm reduction practice within the context of a politically sensitive environment has eroded its radical potential. The overdose crisis in Vancouver's Downtown Eastside (DTES) community has led to innovative harm reduction organizing that has been replicated globally. In this paper, we explore how one such intervention, the Tenant Overdose Response Organizers (TORO) program, has supported a resurgence in tenant-led harm reduction organizing in Single Room Occupancy (SRO) buildings in the DTES.

METHODS

We draw on 15 months of ethnographic fieldwork conducted between May 2017 and August 2018, over 100 hours of participant observation of TORO activities, and 15 semi-structured interviews with key stakeholders in the program.

RESULTS

TORO's leaders attempted to mobilize harm reduction intervention towards collective action on SRO risk environments underlying drug-related harms, but their efforts were constrained by the necessity of meeting practical expectations of funders regarding health education and supply distribution. Navigating these constraints ultimately shaped the development of the TORO program, helping to secure its longevity but also limiting its ability to organize a coordinated harm reduction and tenants' rights response to the dual housing and overdose crises.

CONCLUSION

Our examination of TORO demonstrates how the harm reduction movement continues to be shaped by conflict, cooperation, and compromise between the state and grassroots groups. Even as actors strive to work collaboratively, the unequal distribution of power inherent in this relationship may contribute to the reinscription of a depoliticized harm reduction approach. We discuss the potential role of the risk environment framework in lending political legitimacy to grassroots harm reduction initiatives.

"There is a Place": impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness

BACKGROUND

The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA).

METHODS

We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs.

RESULTS

Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing.

CONCLUSIONS

In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.

"I do my best to eat while I'm using": Mapping the foodscapes of people living with HIV/AIDS who use drugs

Food insecurity can have negative health impacts on people who use drugs and are living with HIV/AIDS (PLHIV). These include both physical effects, including poorer health outcomes and morbidity, and also behaviors that can increase the risk of physical or psychological harm. This study used a semi-structured survey of 60 PLHIV who use drugs and service access mapping (SAM) interviews of a 20-person subset. The mapping helped to illustrate the daily routines used to access food and how food provision may contribute to both spaces of risk and care for a cohort of PLHIV who use drugs in Vancouver, BC. Study participants mapped the daily routes used to access food and discussed whether they felt that these routines increased their risk of physical harm. Additionally, study participants noted which food provision spaces provide social and health supports, which may protect against the nutritional and other harms of drug use. This study revealed that having access to space providing stable and reliable sources of food may protect individuals from experiencing certain risks associated with accessing food, including violence in food line-ups, having to enter areas of the city they considered unsafe or 'triggering' and engaging in risky behaviors in order to access food. These "spaces of care" not only provide nutrition but also social support and connections.

Informal Recyclers' Health Inequities in Vancouver, BC

We explore informal recyclers' perceptions and experiences of the social determinants of health in Vancouver, Canada, and investigate the factors that contribute to the environmental health inequities they experience. Based on in-depth interviews with 40 informal recyclers and 7 key informants, we used a social determinants of health framework to detail the health threats that informal recyclers associated with their work and the factors that influenced their access to health-related resources and services. Our analysis reveals that the structural factors influencing environmental health inequities included insufficient government resources for low-income urbanites; the potential for stigma, clientization, and discrimination at some health and social service providers; and the legal marginalization of informal recycling and associated activities. We conclude that Vancouver's informal recyclers experience inequitable access to health-related resources and services, and they are knowledgeable observers of the factors that influence their own health and well-being.

Perceived harms and harm reduction strategies among people who drink non-beverage alcohol: Community-based qualitative research in Vancouver, Canada

BACKGROUND

There has been increasing interest in harm reduction initiatives for street-involved people who drink alcohol, including non-beverage alcohol such as mouthwash and hand sanitizer. Limited evidence exists to guide these initiatives, and a particular gap is in research that prioritizes the experiences and perspectives of drinkers themselves. This research was conducted to explore the harms of what participants termed "illicit drinking" as perceived by people who engage in it, to characterize the steps this population takes to reduce harms, and to identify additional interventions that may be of benefit.

METHODS

This participatory qualitative research drew on ethnographic approaches including a series of 14″town hall"-style meetings facilitatied and attended by people who self identify as drinking illicit or non-beverage alcohol (n = 60) in Vancouver, British Columbia. This fieldwork was supplemented with four focus groups to explore emerging issues.

RESULTS

Participants in the meetings described the harms they experienced as including unintentional injury; harms to physical health; withdrawal; violence, theft, and being taken advantage of; harms to mental health; reduced access to services; and interactions with police. Current harm reduction strategies involved balancing the risks and benefits of drinking in groups and adopting techniques to avoid withdrawal. Proposed future initiatives included non-residential managed alcohol programs and peer-based supports.

CONCLUSIONS

Illicit drinkers describe harms and harm reductions strategies that have much in common with those of other illicit substances, and can be interpreted as examples of and responses to structural and everyday violence. Understanding the perceived harms of alcohol use by socially marginalized drinkers and their ideas about harm reduction will help tailor programs to meet their needs.

Interfering with therapeutic tranquility: Debates surrounding biosolid waste processing in rural Ontario

Uncertainty surrounding potential health effects of techno-industrial facilities continues to result in heightened debate about what are the best and safest options for future generations in rural places regarded by residents for their therapeutic tranquility. This research examines how a proposed biosolid processing facility in rural Ontario producing agricultural fertilizer from primarily urban sewage has in some residents elicited particularly strong concerns about potential health impacts, which are accompanied by perceptions that the tranquil and pastoral nature of their landscape is being altered. However, fueling community conflict between friends and relatives is the contested nature of the landscape's restorative qualities and the facility's disruption of this tranquil place.

Self-care and risk reduction habits in older injection drug users with chronic wounds: a cross-sectional study

Background

We surveyed a population of injection drug users (IDUs) frequenting the mobile Baltimore City Needle Exchange Program (BNEP) to investigate self-care factors associated with chronic wounds, a significant cause of morbidity especially among older IDUs.

Methods

Participants ≥18 years old completed a survey regarding chronic wounds (duration ≥8 weeks), injection and hygiene practices. Study staff visually verified the presence of wounds. Participants were categorized into four groups by age and wound status. Factors associated with the presence of chronic wounds in participants ≥45 years were analyzed using logistic regression.

Results

Of the 152 participants, 19.7% had a chronic wound. Of those with chronic wounds, 18 were ≥45 years old (60.0%). Individuals ≥45 years old with chronic wounds were more likely to be enrolled in a drug treatment program (Odds ratio (OR) 3.4, 95% Confidence interval (CI) 1.0–10.8) and less likely to use cigarette filters when drawing up prepared drug (OR 0.2, 95% CI 0.03–0.7) compared to the same age group without chronic wounds. Compared to individuals <45 years old without chronic wounds, individuals ≥45 with a chronic wound were more likely to report cleaning reused needles with bleach (OR 10.7, 95% CI 1.2–93.9) and to use the clinic, rather than an emergency room, as a primary source of medical care (OR 3.4, 95% CI 1.1–10.4).

Conclusions

Older IDUs with chronic wounds have different, and perhaps less risky, injection and hygiene behaviors than their peers and younger IDUs without wounds in Baltimore City. Because of these differences, older IDUs with wounds may be more receptive to community-based healthcare and substance abuse treatment messages.

Surveillance of social and geographic inequalities in housing-related issues: the case of the Eastern Townships, Quebec (Canada)

Even though health inequalities are conditioned by many aspects of the environment, much of the existing research focuses on the social environment. This emphasis has the effect to neglect other environmental aspects such as its physical dimension. The physical environment, which is linked to housing conditions, may contribute to the uneven distribution of health. In this study, we examined 19 housing-related issues among a representative sample of 2,000 adults residing in a Quebec (Canada) health region characterized by a mix of rural, semi-rural, and urban areas. The distribution of these issues was examined according to socioeconomic and geographic indicators of social position. Summary measures of inequalities were assessed. Our results showed that the prevalence of nearly all housing-related issues was higher among low-income households compared to more affluent ones. Highly educated individuals showed better housing conditions, whereas different issues tended to cluster in deprived or densely populated areas. To conclude, we observed steep gradients between social class and poor housing conditions. This may explain a substantial part of health inequality on the regional scale. The surveillance of housing-related issues is therefore essential to properly inform and mobilize local stakeholders and to develop interventions that target vulnerable groups on this level.

A qualitative study of the perceived effects of blue lights in washrooms on people who use injection drugs

Background

Blue lights are sometimes placed in public washrooms to discourage injection drug use. Their effectiveness has been questioned and concerns raised that they are harmful but formal research on the issue is limited to a single study. We gathered perceptions of people who use injection drugs on the effects of blue lights with the aim of informing harm reduction practice.

Methods

We interviewed 18 people in two Canadian cities who currently or previously used injection drugs to better understand their perceptions of the rationale for and consequences of blue lights in public washrooms.

Results

Participants described a preference for private places to use injection drugs, but explained that the need for an immediate solution would often override other considerations. While public washrooms were in many cases not preferred, their accessibility and relative privacy appear to make them reasonable compromises in situations involving urgent injecting. Participants understood the aim of blue lights to be to deter drug use. The majority had attempted to inject in a blue-lit washroom. While there was general agreement that blue lights do make injecting more difficult, a small number of participants were entirely undeterred by them, and half would use a blue-lit washroom if they needed somewhere to inject urgently. Participants perceived that, by making veins less visible, blue lights make injecting more dangerous. By dispersing public injection drug use to places where it is more visible, they also make it more stigmatizing. Despite recognizing these harms, more than half of the participants were not opposed to the continued use of blue lights.

Conclusions

Blue lights are unlikely to deter injection drugs use in public washrooms, and may increase drug use-related harms. Despite recognizing these negative effects, people who use injection drugs may be reluctant to advocate against their use. We attempt to reconcile this apparent contradiction by interpreting blue lights as a form of symbolic violence and suggest a parallel with other emancipatory movements for inspiration in advocating against this and other oppressive interventions.

Out of our inner city backyards: re-scaling urban environmental health inequity assessment

In this paper, we report the results of a three-year research project (2008-2011) that aimed to identify urban environmental health inequities using a photography-mediated qualitative approach adapted for comparative neighbourhood-level assessment. The project took place in Vancouver, Toronto, and Winnipeg, Canada and involved a total of 49 inner city community researchers who compared environmental health conditions in numerous neighbourhoods across each city. Using the social determinants of health as a guiding framework, community researchers observed a wide range of differences in health-influencing private and public spaces, including sanitation services, housing, parks and gardens, art displays, and community services. The comparative process enabled community researchers to articulate in five distinct ways how such observable conditions represented system level inequities. The findings inform efforts to shift environmental health intervention from constricted action within derelict urban districts to more coordinated mobilization for health equity in the city.

Therapeutic landscapes and postcolonial theory: a theoretical approach to medical tourism

This paper draws on two conceptual frameworks, therapeutic landscapes and postcolonial theory, to discuss aspects of medical tourism not addressed in extant literature. Building on the intersection between postcolonial and therapeutic landscapes scholarship, it highlights inequalities related to the production of national therapeutic landscapes located in postcolonial regions as well as their discursive (re)positioning as medical tourism destinations. As a framework, therapeutic landscapes can facilitate an understanding of medical tourism sites as curative spaces which combine modern and alternative forms of medicine with travel and leisure. Postcolonial theory critiques the economic, moral and cultural tensions emerging from the intersection between corporations that provide cheaper and more attractive medical services, and the nations on the periphery struggling to offer high medical standards that may not be accessible to their own local populations. In an effort to enhance scholarship on medical tourism, these conceptual frameworks are offered as points of departure, rather than sites of arrival, through which critical dialog on medical tourism can be sustained and broadened.