FoodasHarmReduction

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FoodasHarmReduction:Barriers,strategies,andopportunitiesattheintersectionofnutritionanddrug-relatedharm

ChristianaMiewald,EugeneMcCann,AlisonMcIntosh,&CristinaTemenos

Miewald,C.,McCann,E.,McIntosh,A.,&Temenos,C.(2018).Foodasharmreduction:barriers,strategies,andopportunitiesattheintersectionofnutritionanddrug-relatedharm.CriticalPublicHealth,28(5),586-595.

Abstract

Researchsuggeststhatfoodinsecurityexacerbatestheharmsexperiencedbypeoplewhousedrugs(PWUD).Therefore,improvingthefoodsecuritystatuscanhelpPWUDreducedrug-relatedharms.Thispaperidentifiesaknowledgegapinpublichealthandharmreductionliteraturesregardingtherelationshipbetweenfoodandharmreduction.Wearguethatthereneedstobeamorecomprehensiveandsystematicmodeloffoodprovisioninharmreductionservices.Ourargumentisbasedonaqualitativecasestudyof42peoplewhocurrentlyuse,orhaveuseddrugsinVancouver,Canadaandofstaffof27programsthatprovideharmreductionservicesinthecity.TheresearchdemonstrateshowPWUDexperiencetheeffectsofdruguseontheirfoodconsumption,howtheyaccessfood,andhowtheypracticeself-care.Italsoshowshowharmreductionservices,whiletheyoftenprovidefood,areunabletosystematicallyaddressthedietary-relatedharmsassociatedwithdruguse.Thispresentsanopportunityandachallengefortheseorganizationsandforharmreductionasapublichealthapproach.Wecallformoreresearchtobedoneonfoodasharmreductionandforstablepublicallyfundedfoodprovisioninharmreduction-orientedservices.

KeyWords:FoodSecurity;HarmReduction;PublicHealth;Foodscape;Vancouver,BC

Acknowledgements:Theauthorswouldliketothankeveryonewhoparticipatedinthisstudy,especiallytheindividualswhoagreedtobeinterviewed.WewouldalsoliketothanktheDr.PeterAIDSFoundationandtheFoodasHarmReductionStudyCommunityAdvisoryCommitteefortheirguidance.Thisresearchwassupported,inpart,bytheSocialScienceandHumanitiesResearchCouncilunderGrant#435-2013-2197andtheVancouverFoundationunderGrant#UNR14-0024.

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Introduction

Contemporarysocietiesaremarkedbyfoodinsecurity,characterizedbyeconomicandsocial

barrierstoaccessinghealthy,nutritious,sufficient,andculturallyappropriatefoodinwaysthat

arepersonallyacceptable(DavisandTarasuk,1994).InCanada,forexample,foodinsecurityis

moreprevalentamongcertaingroups,suchassinglemothers,newimmigrants,andAboriginal

groups(Tarasuk,Mitchell,andDachner2016).Ithasbeenwelldocumentedthatpeoplewho

usedrugs(PWUD)disproportionatelyexperiencefoodinsecurity(Himmelgreenetal.1998;

Romero-Dazaetal.1999;Anemaetal.2010,Schmitzetal.2016).Forexample,65%ofpeople

whoinjectdrugs(PWID)inurbanCanadareporteddifficultyaffordingenoughfoodand

experiencinghunger(Anemaetal.2010)and58%ofpeoplewhoinjectdrugsinLosAngeles

andSanFranciscoreportedfoodinsecurity(Schmitzetal.2016).Thisiscompoundedwhen

PWUDhavecomorbidities,suchasHIV(McKayetal.2017).Onestudyfoundthat73%of

peoplelivingwithHIVinBritishColumbia,CanadawhousedanAIDSServiceOrganizationwere

foodinsecure(Anemaetal.2016).Thestudyfoundthatparticipantswerefoundtoalsohave

poordietaryquality.

DrugusecaninfluencethenutritionalandhealthstatusofPWUD,bothphysiologically

andthroughbehavioraleffects.Physiologically,drugusehasbeenfoundtoproducedrug-

inducedanorexia(fromusingdrugsorwithdrawalsymptoms),whichinturncanresultin

micronutrientdeficiencies,malnutritionandbecomingunderweight(Himmelgreenetal.1998,

Romero-Dazaetal.1999,Saelandetal.2010).Theseconsequencescan,inturn,reducethe

abilitytofightoffinfections,leadingtoincreasedmorbidityandmortality(McIlwraithetal.

2014,Saelandetal.2014).FoodinsecurityforpeoplelivingwithHIVhasbeenassociatedwith

anumberofnegativehealthconsequences,includinglowerratesofAnti-RetroviralTherapy

adherence,decreasesinphysicalhealth,reducedviralsuppression,poorerimmunologicstatus,

andincreasedincidenceofseriousillnessandmortality(Weiseretal.2011,Whittleetal.2016).

Whittleetal.(2016)foundthatfoodinsecurityaffectedtheabilityofindividualstokeepclinic

appointmentsduetofeelingsofhungerandexhaustion.Foodinsecuritycanalsoleadto

macronutrientandmicronutrientdeficienciesaswellasincreasingtheparticipationinrisky

sexualbehaviors,whichcancontributetothetransmissionofHIV(Weiseretal.2011).Finally,

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foodinsecurityhasalsobeenassociatedwithdepressivesymptomsamongbothpeopleliving

withHIVandHIVnegativePWUD,suggestingarelationshipbetweennutritionandmental

healthoutcomes(Anemaetal.2010,2016,Davey-Rothwelletal.2014,Whittleetal.2016).

Drugusemaycontributetofoodinsecurityduetoalackofresourcestopurchasefood,the

consumptionoffoodthatishighinfatandsugarandlowinvitaminsandminerals,irregular

eatinghabitsandengaginginpotentiallyriskybehaviors,suchasstealingfood,tradingsexfor

foodorengaginginunprotectedsex(Anemaetal.2016,Nealeetal.2012,Saelandetal.2008,

Shannonetal.2011,Strikeetal.2012,Tarasuketal.2005,Vogenthaleretal.2013).Food

insecurity,then,destabilizespeople’slivesandcanputindividualsatgreaterriskfor

experiencingviolence,incarceration,andexposuretopathogens.

Harmreductionserviceprovidersoperatelow-barrierprogramsthatprimarilyservelow

incomePWUDinordertomitigatethenegativehealth,social,andeconomicconsequencesof

druguseusingpragmaticinterventionslikecleanneedleprovision,methadonetreatment,or

supervisedinjection.Whilenotdemandingabstinence,harmreductionapproachesare

successfulpublichealthinterventionsintothelivesofpeoplewhoareoftenthemost

marginalizedinsociety(JozaghiandAndresen2013,Smith2012).Inmoregeneralterms,harm

reductionapproachesseektostabilizepeople’slivesinorderforthemtodeveloplessharmful

relationshipswithpsychoactivesubstances.Thus,someinterventions,likelow-barrierhousing

provision,havealsobeenintegratedintoharmreductionprograms(Katzetal.2016,Paulyetal.

2013).Yet,foodprovisionhasnotbeensystematicallyincludedinharmreductionpracticeand

analysis,whileunevenattitudestowardtheroleoffoodinharmreductionhavebeenfound

amongpublichealthproviders(McLean,2012;McIntosh2015,2016).

Throughastudyofbothpeoplewithahistoryofdruguseandalsoofharmreduction

serviceprovidersinVancouver,Canada,wearguethatthereneedstobeamore

comprehensiveandsystematicmodeloffoodprovisionwithinharmreductionapproachesto

illicitdruguse.Wedemonstratethatserviceproviderswhouseaharmreductionmodeloften

providefoodtotheirparticipants,yettheyarenotadequatelyfundedorequippedtoaddress

thedietary-relatedharmsassociatedwithdruguse.Thispresentsbothanopportunityanda

challengefortheseorganizationsandforharmreductionasapublichealthapproach.Inthe

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followingsections,wepresentqualitativedatathatdemonstratestherelationshipsbetween

chronicdruguse,foodinsecurity,andharmreductionusingsemi-structuredinterviewswith

twogroups–PWUDandrepresentativesoforganizationsprovidingharmreduction-oriented

servicesinVancouver.WeconcludebysuggestingthatPWUDpresentauniquechallengeto

addressingissuesoffoodinsecurity.Whiletheyareinneedofhighqualityfoodinorderto

supporttheirhealth,PWUDalsooftenhavedifficultyaccessingitbecauseofdruguse.While

charitablefoodprovidersarefrequentlyusedbyPWUDaspartoftheirgeographyofsurvival,

thesesitesalsopresentchallengesandrisks.Harmreductionserviceprovidersofferaunique

positionwithinthefoodscapetoofferhealthyfoodwhichisprovidedinadignifiedmanner.

HarmreductionandfoodinsecurityinVancouver,BC

Historically,illicitdruguseamongservice-dependentpeoplehasbeenmostassociatedwiththe

DowntownEastsideneighborhoodofVancouver.Theneighbourhoodincludesaconcentration

ofsocialservices,includinganumberoffreeorreduced-costmealprogramsthatareprovided

throughdrop-incentres,religiousorganizations,andshelters.Whiletherearemanysoup

kitchensandotherfreemealprogramsintheneighborhood,therearealsohighratesof

malnutritionandfoodinsecurity,creatingaparadoxicalfoodscapeoffoodavailabilityandfood

security(MiewaldandMcCann2014).Thisfoodscapeisageographythatencompassesall

placeswherefoodisobtainedsuchasgrocerystores,restaurants,foodbanks,soupkitchens,

andgarbagebinsaswellasthesocialrelationsthroughwhichfoodisaccessed(Miewaldetal.

2010,MiewaldandMcCann2014).Foodprogramsare,moregenerally,partofthedaily

‘geographiesofsurvival’(MitchellandHeynen2009)forPWUD,astheavailabilityand

accessibilityoffoodresourcesisacrucialcomponenttotheirabilitylive.Geographiesof

survivalencompassthe“networkofpublicandprivatespacesandsocialservices”(Mitchelland

Heynen,2009,p.611)thatprovidethenecessaryresourcesforsystematicallymarginalized

people.Foodscapeandgeographiesofsurvivalconceptuallyframeourdiscussionofthe

relationshipbetweenfoodaccessandharmreduction,aspartofaninterlinkedlandscapeof

servicesusedbyPWUDfortheireverydaysurvival.

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Whiletherelationshipbetweendruguseandpoornutritionaloutcomeshasbeenwell

documented,thereremainslittleintheacademicorpolicyliteraturesaddressingthe

intersectionoffoodsecurityandharmreduction.Ourresearchshowsthatfoodprovisionby

serviceproviderswhouseaharmreductionapproachisoftenadhocandwithoutadequate

fundingorresources.ThisisnotuniquetoVancouver.Forexample,astudyofaneedle

exchangeprograminNewYork,McLean(2012,p.298)notes,“Theimportanceoffoodin

particularwasmanifestinbothdailyandmonthlypatternsofattendancethatfollowedmeal

schedules.”Yet,therewasalsodisagreementamongstaff“aboutwhat‘harmreduction’should

orcouldinvolve,andconsequently,whattherealharmsofdrugusewere”(Ibid.).Weaddress

thisgapbydrawingouthowbothPWUDandserviceprovidersexperienceandunderstandthe

relationshipbetweenfoodandharmreduction,withaparticularfocusontheurban

geographicalcontextsoftherelationship.

MethodsandDataAnalysis

Thisstudyisbasedonsemi-structuredinterviewsconductedwith42currentandformerPWUD

whowereparticipantsatadrop-incentrelocatedintheDowntownEastside,whichprovides

supportforPWUDusingaharmreductionapproach.Additionally,weconductedinterviews

with35staffmembersat27programsthatprovideharmreductionservicesinGreater

Vancouver.PWUDwererecruitedbyaposteradvertisingthestudyatadrop-incentre,withthe

supportandconsentofcentrestaff.Thiscentrewasusedasbothasiteforrecruitmentand

interviewingbecauseitwasconsideredasafeandaccessiblesiteforPWUD.Participantswere

givena$10honorarium.Theonlyinclusioncriterionwasthattheindividualsusedthedrop-in

centre.Theinterviewwasinitiallydesignedtoassesstherelationshipbetweenhousingand

foodinsecurity,howeverdruguseemergedasasignificantbarriertofoodaccess(seeMiewald

andOstry2014).ThesestudieswereapprovedbytheofficeofresearchethicsatSimonFraser

University.

InterviewquestionsforPWUDincludedbasicdemographics(genderandage),chronic

healthconditions,historyofdruguse,currentandprevioushousingsituation,whereindividuals

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accessfoodandanybarrierstheyexperiencethatmightleadtofoodinsecurity.Themajorityof

theseintervieweesweresingleCaucasianmen,althougheffortsweremadetoincludewomen

andrepresentativesofotherethnicities.Participantsrangedinagefrom26to65,withamean

ageof41.Whilethemajorityreportedusingseveraltypesofdrugs,themostcommonwere

cocaine/crack(41%)andheroin/morphine(24%).Marijuana(14%)andalcohol(12%)werealso

reported,butusuallyassecondarytootherdrugs.Ninerespondents(21%)werenolonger

usingorindrugtreatmentatthetimeoftheirinterview.69%reportedhavingatleastone

healthproblem,includingHepatitisC(26%),mentalillness(21%),arthritisorothermobility

issues(15%),HIV/AIDS(13%),anddigestivedisorders(13%).

InordertoassesstheleveloffoodprovisionforPWUD,representativesof27

organizationsinGreaterVancouverwereinterviewed.Inclusioncriteriawerethatthe

organizationself-identifiesasbeingharmreduction-oriented,providesservicestopeoplewho

areactivelyusingillicitdrugs(afoundationalelementofharmreduction),providesharm

reductionsupplies,and/orengagesinharmreductionpolicyadvocacy.Theorganizations

includedthosefocusedonlow-barrierhousingandemergencyshelters(n=8),drop-incentres

andservices(n=6);AIDSserviceorganizationsprovidingharmreductionsupplies,supports,and

advocacy(n=5);healthservices(n=4);harmreductionanddrugpolicyadvocacy(n=2);aneedle

exchange;andalegalsuperviseddrugconsumptionsite.Interviewswithserviceproviders

focusedontheirfoodprovisionactivities(ifany),theirobservationsontheimpactsfood

insecuritymayhaveonserviceparticipants,andontherolenutritionmightplayinaddressing

drugrelatedharms.Thesefindingshighlightbothhowharmreductionprovidersviewfood

provisionandalsothegapsinservicethatshouldbeaddressedthroughmorecomprehensive

foodandharmreductionprogramsandpolicies.Allinterviewswererecorded,transcribedand

categorizedwithaprioricodesderivedfromtheinterviewguidesandemergentcodesderived

fromtheinterviewcontent.Thisprocess,groundedincriticalandfeministresearchintodrug

use,providedtextualinformationonfoodaccessandconsumptionpatternsbyactiveand

formerPWUDinalow-incomecommunitythatwouldbeunavailablethroughsurveyingor

otherquantitativemeans(Boydetal.2008,Clattsetal.,2002).

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EverydayExperiencesofFoodInsecurityamongPWUD

AfundamentalprincipleofharmreductionisthatPWUDare,canandshouldbeactive

participantsintheirownhealthcare.ThereshouldbenoblanketassumptionthatPWUDare

negligentorself-destructive.Indeed,recentstudieshavehighlightedthevariouswaysPWUD

areactiveinmaintainingtheirmentalandphysicalhealth(Greenspanetal.2011),including

theirnutritionalstatus.Drummetal.(2005)showthat,despitesignificantbarriers,PWUDpay

attentiontothequalityandquantityoffoodtheyconsumeanddevelopstrategiestoensure

theyhaveenoughfoodtoeat.Inthissectionwehighlightstructural,physiologicalandspatial

themesthatemergedinlow-incomePWUD’srelationshipswithfood,nutrition,health,and

theirsurroundingenvironments.Followingcommonpracticesofqualitativedataanalysis,the

quotationsherearerepresentativeofrespondents’answers(Clattsetal.,2002).Wediscuss

threethemesthatwerederivedfromtheinterviews1)theself-reportedeffectsthatdruguse

hasonthedietofparticipants,2)thestrategiesusedforaccessingfoodwithintheDowntown

Eastsidefoodscapeand3)PWUD’stacticsusedtoavoidsomeofthenutritionalharmsofdrug

use.

“OnceItouchit,thefooddoesn’tmatter”:theeffectsofdruguseonfoodconsumption

DespitetherelativelyabundantfoodscapeintheDowntownEastside,PWUDaresusceptibleto

foodinsecurityduetofinancialconstraints,lossofappetiteduetodruguse,timeconstraints

causedbytheneedtofocusongeneratingenoughmoneytobuydrugs,lackofabilitytostore

orpreparefoodwheretheylive,andtheirconcernsaboutpersonalsafetyinpublicspaces.For

some,theirmeagerincomewasusedtopayfordrugsinordertoavoidwithdrawal,leaving

foodasasecondaryconcern.ThiswasthecaseforBelinda1whoexplained,“Everypenny’s

gottagotodrugs,sountilIgetoverthathump,it’samatterofeatingwhatIcanwhenIcan

findit.”Respondentsalsonotedthatlackofappetitewhileusingdrugsledtomissed

opportunitiestoaccessfoodfromproviders.AsKarennoted,“onceItouch[thedrug],thefood

doesn’tmatter…ImissedmealsbecauseIdidn’tshowupattherighttimeorwhateversoI’d

gowithoutfoodalotlonger.WhenIwasdoingthedopeandthat,Iwasn’tinterestedinlining

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upforfood.”Martinechoedthissentiment,highlightingthecycleofdruguseandthesearch

formoneyanddrugsthatoftentookpriorityovereating.

“Withcrack,whenyou’rechasing,that’sthemostimportantthingtoyou,whileyou’re

highyoucan’teat,andwhenyoucomeoff,you’rejonesingandyou’rechasingitwhile

youshouldbeeatingandyou’retryingtofindsomewaytoscoretenbucks.”

Jeremyalsonotedthatfoodwasrarelyimportantandwasonlyconsumedwhenitwasreadily

available.“Like,ifI’dseestuff,ifI’dbepassingthroughandthey’dbehandingoutsandwiches,

I’dgraboneofthosebut,actualmeatandpotatoesstuff?Iwouldn’thavetheopportunityorI

wasn’thungryorIwassick.”Theseaccountsillustratethatdruguseisabarriertoaccessing

foodforPWUD,evenwhenitisavailablefromcharitablefoodproviders.Thesefindingsuggest

thatPWUDhaveuniquechallengestoaccessingfoodthatcannotberemediedbyrelyingona

charitablemodeloffoodprovision.

“It’samatterofeatingwhatIcanwhenIcanfindit”:negotiatingtheurbanfoodscape

PWUDhavethedailychallengeofnavigatingthefoodscapeaspartoftheirdailygeographiesof

survival.Belinda,Karen,Jeremyandotherrespondentsindicatedthattheyusedavarietyof

strategiesinordertoaccessfood,oftenrelyingheavilyonfreeorreducedcostmealsprograms.

Infact,allrespondentsreportedusingcharitablefoodproviders(includingsoupandcommunity

kitchens,andmealsprovidedthroughsupportivehousingandrehabilitationfacilities)forat

leastoneoftheirdailymeals.Moreover,60%ofrespondentsreportedusingfreeorlow-cost

foodmealprogramsforthemajorityoftheirmeals.Atthesametime,simplyaccessingfood

canputindividualsatriskfromfightsandinter-personalconflictswithothersaccessingthesite,

stressfromdealingwithstaffwhomayenforcerulesandregulationsthatbarcertain

individuals,orencounterswithlawenforcement.Theseriskscanresultinphysicalor

psychologicalharmorincarceration.Womeninparticularnotedthattheydidnotliketostand

infoodlinesbecauseofharassmentfromothersintheline-up,andpreferred“womenonly”

foodproviders.Cynthiaepitomizesthisview:

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"Idon’thavetoworryaboutguysbuggingmeandit’sasafeplacetoeat…NotthatI’ma

prissoranythingbutthere’salotofdrugaddictsanddrunksandstuffandeventhough

I’moneofthosepeopleIdon’tliketobeinanenclosedspacewithalotofthem."

Forthosewhoearnedmoneyintheundergroundeconomy,eitherthroughsexworkor

sellingdrugs,findingasafespacetoeatcouldalsobechallenging.Forexample,althoughJack

usuallyhadmoneyforfoodduringhisstintasalow-leveldealer,heoftenfounditdifficultto

findasafeplacetoeatwherehewouldn’tbethreatenedbyotherdealers,customersorthe

police.Henotedthat“If[thepolice]wanttopickupsomeoneonawarrant,[they]justgoby

thefreefoodplaces.”ConvenienceandprivacywerefactorsinwhereandwhenJackaccessed

food.Standinginlongfoodline-upswasviewedasawasteoftimeandalsoexposed

individualstoboththepoliceandrivalsintheneighborhood.“Ihadtoreally,reallyforcemyself

toeat.Iwouldgoto[low-costprovider]andpayformyownmealsbecauseIwouldn’thavethe

timeorthepatiencetowaitinthefoodlines.Iwouldalwayshave$2forthe[low-cost

provider].It’snottoohardtoputtogether$2whenyouhaveapocketfullofdope.”Thus,

purchasingfoodratherthanrelyingoncharitablemealprogramswasonestrategytoavoidline-

upsandotherbarriers.Itwasoftenpreferredoveraccessingcharitablefoodprovidersdueto

greaterchoiceandflexibilityoverwhatandwhentoeat(seealsoGaetzetal.2006,Miewald

andMcCann2014).Amongstudyparticipants,76%saidthattheysometimesateat

inexpensiveorfast-foodrestaurantswhentheyhadthemoneyand86%reportedshopping,at

leastoccasionally,forfoodiftheyhadmoney.

“ItakealotofvitaminsanddrinkalotofGatorade”:Self-carestrategiestoavoidnutritional

harms

Acknowledgingthenegativeconsequencesofdruguseonfoodintake,somerespondentssaid

theywereawareoftheproblemsofweightlossanddehydrationandreporteddeveloping

strategiestoavoidtheseeffects.Theseincludedtakingvitamins,drinkingsportsdrinkstoavoid

dehydration,smokingmarijuanatostimulateappetiteorbuyingfoodinadvanceofusingdrugs

toguaranteethattheyhadsomethingtoeatiftheywereunabletoaccessfoodproviders.Tony

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describedsomeofthestrategiesheusedtoavoidnegativeeffectsonfoodaccessthatcan

resultfromdruguse.

“ItakealotofvitaminsmyselftooanddrinkalotofGatoradeifI’monalongjag

smokingcrack.You’vegottokeepyourbodyhydrated.Yougottamakesure,evenif

you’relosingtheweight,thatyou’regettingessentialvitaminsandstuffyouneed‘cause

that’swhatwillcausemorelongtermdamageorproblemswithmentalbreaks.”

Somerespondentssaidthatthey“loadup”onfoodbeforeusingdrugstohaveenoughenergy

tolastseveraldayswithouteating.Belindadescribedherstrategytoensureshehasatleast

somefoodavailable:“ItryeverymonthIgoanddomygroceriesfirst-offforstuffforthe

month,likepoweredmilkandcannedstuffandpeanutbutter.”Jackdescribedacycleof

bingeingonfoodwhenhewasnotusingandthenforcinghimselftoeatanddrinknutritional

supplementswhilehewas:

“IwouldtrytoeatonceadayandIwasdrinkingalotofEnsure…Butitwasreally

difficulttomakemyselfeatbecauseIwasneverreallyhungry...Iwouldbinge[ondrugs]

foradayortwoandthenafterwardsIwouldeatnon-stopasmuchasIcouldforafew

daystoreplenishwhatI’dlost.”

Ourstudysuggeststhatself-carestrategiesareimportanttolowincomePWUDseffectiveuse

offoodresources.Yet,thesestrategiesarereliantonindividuals’resourcesandtheknowledge

theyhavegainedthroughtheirlivedexperience.

FoodandHarmReductionServiceProvision:Perceptions,Practices,andBarriers

Becauseofthecriticalrolethatharmreductionserviceprovidersplayinsupportingand

maintainingthehealthofPWUD,itisimportanttoaddresshowtheseprovidersperceivethe

roleoffoodintheirprogramsandhowtheyenactstrategiestosupporttheirparticipants’

nutrition.InVancouver,harmreductiontakesvariedforms,fromlow-barrierhousingand

drop-incentresthatoffersupplieslikeneedlesandpipestosuperviseddrugconsumptionsites.

Despitetheadhocnatureoffundingforfood,wefoundfoodprovisiontobeubiquitousin

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thesesites.Ofthe27sitesandprogramsinterviewed,only2didnotprovidefoodorfood

preparationspaces.Thetypeoffoodprovidedandthecharacterofprovisionvaried

dramatically–fromgranolabars,tofullmealprogramming,communitykitchens,andtake-

homefoodbags.

Serviceprovidersrevealedthattheyprovidedfoodprimarilybecausetheysawacute

nutritionneedsintheirparticipants.Forinstance,whenaskedaboutthemotivationforfood

provision,thedirectorofanHIV-specifichealthsupportprogramargued,

“thehealthierapersonis,thebettertheyare[able]tofightoffopportunisticinfections

andsuch.Secondly…weknowthatifwedidn’toffer,therewouldbepeoplewho

[would]nothavefood.”

Mostharmreductionserviceproviderssharedthisrationale.Atthesametime,whilefoodwas

viewedasimportanttomaintaininghealth,itwasalsoseenasameansofattracting

participants,openinglinesofcommunication,andasagatewaytootherservices.Forexample,

aswellasprovidingfullmealservicesattheirmainfacility,adrop-incentreandoutreach

programforstreet-involvedyouthprovidedgranolabarsandjuiceboxesaspartoftheir

outreach.Oneoftheirstaff,notedthat,“Theidea[ofprovidingfood]wasjusttostartgivingit

tothem,andthen[asking],“heyhowareyoudoing?”Thiscontactwould,theyhoped,leadthe

participanttostayaroundthecentrelonger.“Andthen,halfanhourlater,itmight[be]that

[wefind]theyhavetogotothehospitalbecausetheyhadathrobbingpainintheirlegthat

theyhadn’tgonetakencareof.”

Foodprovision,forthisorganizationandothers,isbothanutritionalinterventionand

alsoacaringsocialgesturethatcouldpromptconnectiontootherhealthservicesand

resources.Othercommonlystatedbenefitsofprovidingfoodincludeditsabilitytoimprove

participants’moodandbehaviour,promotesocializingamongparticipants,encouragehealthier

nutritionalchoices,and,inprogramsusingcommunitykitchensorsupportworkerstoteach

cookingskills,increaseindependenceandskills-building.

Despiteattentiontofood,harmreductionserviceprovidersgenerallystruggletofund

theirfoodprograms.InBritishColumbia,serviceproviders’operatingfundscanrarelybeused

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tofundfoodprograms.Providerstypicallyrelyoncombinationsoffundingfrommultiple

sources,suchasProvincialandFederalgovernments,healthauthorities,foodbanks,and

reallocatedgeneralprogrambudgets(seealsoSlateretal.2015,Pettesetal.2016).

Additionally,despitetheprevalenceofsomeformoffooddistributioninnearlyeveryharm

reductionprogramsurveyed,mostserviceprovidersdidnotimmediatelyexpressclearordirect

linksbetweenfoodprovisionandtheirharmreductiongoals.Nevertheless,giventhe

opportunitytotalkthroughtheissueinaninterviewsetting,mostbegantoactivelymakethose

connections.Forinstance,thedirectorofadrop-incentreforPWUDexplainedthatfood

securityis,

“oneofthefoundationaltenetsofharmreduction,becauseharmreductionseeksto

increasesafetyanddignityforpeople,andreduceharm.Andso,helpingsomeoneto

haveahealthyphysicalbodyandawell-fuelledphysicalbodyandteachingpeopleabout

nutritionisahugepartofthat.”

Serviceprovidersrepeatedlyemphasizedthatgoodnutritionsupportedtheireffortstoreduce

drugrelatedharms.Forexample,arepresentativeofasupervisedconsumptionsitedescribed

howtheirbroaderharmreductiongoalswouldbesupportedifparticipantshadsomemeasure

offoodsecurity,saying,

“ifyoulookatharmreductionasneedledistribution,crackpipedistribution,and[the

consumptionsite],it’sreallyaone-dimensionalvision…It’sinsociety’sbestinterest,

fromacost-benefitperspective,fromahumanistperspective,tobeabletoprovide…

food.”

Althoughmanywereentirelyreliantongovernmentfundingstreams,serviceproviders

werecriticalofthecharitymodeloffoodprovision.Theyarguedthatfundershavenot

recognizedthevitalroleoffoodinthewellbeingofparticipants,thatstagnantfundingrates

wereinadequateforprovidingnutritiousfood,andthatconstantlyapplyingforfundingand

donationscreatedasenseofcompetitionamongserviceprovidersandtookuptoomuchstaff

time.Thecoordinatorofadrop-incentreforpeoplewithmentalhealthbarriersexplained,“it’s

likethesupercapitalistwayofdealingwithsocialproblems”.

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Someserviceprovidersdidindicatethatfoodsecuritywasincreasinglyontheradarof

somefunders,butthattheirfundingwasstillinsufficientandinflexible.Theactingexecutive

directoratahousingandshelterorganizationsaid,

“’Theymustbegettingfed.’That’swhatpeopleassume…Shelterscomewithfood

funding,right?Buthousingdoesn’t,andeventransitionalhousingtypicallydoesn’t…so

it’sstaff,andyouknow,friendlyneighboursbasicallysupportingthefoodneedsof

people,whichisnothowitshouldbe.”

Organizationswithfoodbudgetsreportedthattheirfundingforfoodprogramminghad

remainedstagnant,orhadincreasedatratesfarbelowthoseofthecostoffood.TheExecutive

DirectorofanAIDSServiceOrganizationforwomenexplainedthat“foodcostsgoup,

membershipgoesup,ratesofpayforstaffgoup.Therateofwhatthey[funders]contributeto

usdoesn’tgoup.”

Thus,ourinterviewssuggestthatharmreductionserviceproviders,likethePWUDwho

participateintheirprograms,understandtheimportanceofnutritioninpromotinghealth.

TheseinterviewsemphasizethatwhilePWUDsnegotiatemanybarrierstonutrition,service

providersarealsochallengedinensuringfoodsecurityfortheirparticipants,largelydueto

insufficientfunding,andothersystemicbarriers.Thesefindings,whichfocusonharmreduction

services,arelargelyinlinewithexistingcritiquesofotherformsofcharitablefoodprovision

(e.g.,Dachneretal.2009,Slateretal.2015,Tarasuketal.2005).

DiscussionandConclusion

ExaminingthelivedexperienceoffoodaccessforPWUDandtherealitiesoffoodprovisionfor

harmreductionserviceprovidersrevealsseveralsalientissues.Whilecharitablefoodproviders

areimportantfoodresources,accessingtheseservicescanplaceindividualsatrisk,either

throughlowqualityfoodorexposuretostigmaandviolence.Additionally,becauseofthe

effectsofdrugsonsuppressingappetite,PWUDhaveauniquesetofbarrierswhenitcomesto

accessingfood.Thecreationofsafespacesthatprotectagainsttheseharmsisonemeansof

improvingfoodsecurityforPWUD.Harmreductionserviceprovidersareuniquelysituatedto

FoodasHarmReduction

14

providedsuchspaces,yettheyoftenlacktheresourcesandfundingtofullysupporttheir

participants’foodneeds.

Morespecifically,therearethreefindingsthatemergedfromthisresearch.First,food

insecurityforPWUDisaffectedbyvariousandinterrelatedelementsthatconstituteandoften

exacerbatetheharmfulaspectsofurbanfoodscapes.WhilePWUDsufferfromsomeofthe

sameissuesthatotherlow-incomegroupsdo,suchaslowwelfarerates,theyalsoexperience

foodinsecurityduetodruguseitself.Inordertoconstructeffectivepublichealthprogramsand

policiestoaddressfoodinsecurityamongPWUD,moreresearchneedstobedoneontheways

inwhichPWUDnavigatethefoodscapeaspartoftheirgeographyofsurvivalandtherisksthey

encounterinaccessingbothnutritiousfoodandhealthservices.

Second,itisnecessarytocreatenutritionalprogramsandservicesthataddressthe

uniquechallengesthatPWUDfacewhenitcomestoaccessingfood.Todate,muchofthe

focusonfoodsecurityamongPWUDhasbeenonnutritionalinterventions“including

nutritionalstatusassessments,adviceonhealthydiets,referraltonutritionistsandfood

programsandtheprescriptionofmealreplacementsordietarysupplements”(Nealeetal.

2012,p.636,seealsoMcIlwraithetal.2014).Thesetypesofinterventionsmaynottakeinto

accountthelivedexperiencesofPWUDintheirdailyinteractionswithfood,includingissuesof

poverty,inadequatehousingandrelianceoncharitablefood,however(seealsoNettletonet

al.,2012).AsGustafssonetal.(2011,p.388)note,withinpublichealth,“thereisa‘disconnect’

betweenhealthyeatingguidelines,thatassumean‘idealised,individualisedworld’,andactual

practicesineverydaylife.”

Thisemphasisonindividualizedresponsibilityfailstoaddressunderlyingstructural

causesoffoodinsecurityandignoresthewaysinwhichPWUDunderstandtheirowndietary

practices.Criticalharmreductionliterature(Chen2011,MooreandFraser2006,Mclean2011,

2015,Smith2012,TemenosandJohnston2016)critiquesmainstream“intervention”

approachesthatfocusonindividualbehaviorchange.Instead,thisliteraturesuggeststheneed

toexaminelarger‘riskenvironments’(Rhodes2002),andpoliticaleconomicconditionswhen

assessingtheharmsassociatedwithdruguse.Similarly,afoodscapeapproachrecognizesthe

structuralcausesoffoodinsecurityaswellaspersonalagencyinnavigatingthefoodlandscape

FoodasHarmReduction

15

(MiewaldandMcCann2014)andthereforeprovidesalensthroughwhichtounderstandfood

aspartofaharmreductionframeworkthatgoesbeyondsimplyprovidingfoodthrougha

charitablemodel.Issuessuchascurrentdruglawsandlackofaffordablehousingalso

contributetofoodinsecurityforPWUD.Thus,ourinterviewsemphasizethatstrategiesto

improvefoodaccessforPWUDshouldbedesignedwiththerealitiesofdruguse,povertyand

socialmarginalizationinmind.FoodprogramsshouldbespaceswherePWUDfeelsafeand

supported,provideabufferfromtherisksofdruguseandbeintegratedwithotherharm

reductionservices.

Third,improvingthefoodsecurityofPWUDshouldbeviewedascentraltopublichealth

andharmreductionandshould,therefore,besupportedbythestate,ratherthanlefttoadhoc

charitableproviders.Giventheimpactsofdrugsonappetiteandfoodchoice,ourinterviews

showthattheexperienceoffoodinsecurityamonglowincomePWUDisqualitativelydifferent

fromotherlow-incomegroups(seealsoSchmitzetal.2016).Simplyimprovingaccessdoesnot

addressphysiologicalorstructuralissuesoflackofappetite,housinginstability,andtherisks

thatPWUD,inparticular,facewhenaccessingfoodprograms.Therefore,specificstrategies

needtobedevelopedforandwithPWUD.Forexample,theintervieweesinthisstudyuseda

varietyofself-carestrategiestomitigatethenutritionalharmsofdruguse,exhibitingstrong

agencyinachievingtheirnutritionalgoals.Thesestrategiesmayprovideabasisforpublic

healthmessagesthatareappropriateforPWUD.

Charitablefoodandharmreductionserviceproviderscompriseimportantspacesinthe

foodscapesofPWUDinVancouver.Yet,despitetheabundanceofcharitablefoodproviders,

foodinsecuritycontinuestobepartofthelivedexperienceofPWUD.Targetedapproachesto

addressingthebarrierstofoodaccessaswellasbetterintegrationoffoodandharmreduction

programmingarewaysofaddressingthisissue.Futureresearchshouldinvestigatethelived

experienceoffoodinsecurityforPWUDinordertocreatestrategiesthatfullymeettheirneeds.

1 Namesandotheridentifiershavebeenalteredtoprotecttheidentityofinterviewees.

FoodasHarmReduction

16

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