Side event: Addressing drug-related problems among people experiencing homelessness: Key elements for human right approaches

Pablo Cymerman, Intercambios A.C.: We feel sometimes the topics that the CND addresses are a bit removed from what we experience on a daily basis. This event responds to this by focusing on pathways to address the vulnerabilities of people who are homeless, and what the Argentinean government is doing in this regard.

Jorgelina Di Iorio, Intercambios A.C.: This presentation will discuss continuities and breaks in terms of how we consider homelessness. For us, it’s a health issue that speaks of persistent inequalities of Latin America, the Caribbean and worldwide.  These characteristics in terms of population translates into increased inequality in access to healthcare in general. This is a general overview on how wwe think about this issue, although homelessness is usually discussed in terms of dwelling and housing – the name of the term is usually focused on homes and dwellings; but it’s a global health issue. No only in terms of the social determinants of health but also in relation to how the insecurity of housing translates into problems with physical and mental health. Homelessness is one of the expressions of insecurities in terms of housing. So it’s part of the human rights agenda. There’s continuities and differences in Argentina where I’m based, and different countries of the region. There’s differences in terms of profiles, heterogeneity of homelesness as a problem, but also the characteristics of populations. But also similarities in terms of violence and criminalisation and barriers in access to healthcare. Also for people who also have problems related to the use of drugs. This is visible socially and politically because there’s an increase in the design of policies and programmes that lead people to live in the streets. Policies tend to focus on individuals, singular dimensions, that have to do with the biographies of the people who are homeless. This individual dimension obscures socio-structural issues in our countries, like poverty and stigmatisation. People living with precarious lives as Butler says, lives who are not ‘worthwhile’ are systematic victims of violence, not just structural but also physical and social just because of their condition, because they don’t have access to dwellings / housings. These populations, because of their characteristics, are characterised as hard to reach. But these populations have to move to survive. Homeless people also exist in rural areas. Great heterogeneity. I’d like to underline the term ‘hidden population’ – in relation to their needs in the public space. For instance, practices of public drug use attract police violence; and so homelessness becomes a crime. In Argentina, we have criminal laws against the use and possession of drugs. In the region, not only in Argentina, we approach drug use punitively, through criminalisation. The criminalisation affects homeless people and this only potentiates inequality and vulnerabilities. The use of drugs in general, we cannot say that people living in the street are drug users, of course. But people who are homeless and use drugs are more likely to live with HIV and health problems, engage in the sex trade, be affected by police violence, etc. They face a disproportionate degree of violence. They also usually are marginalised or distanced from families and networks of support. In terms of gender, highly stigmatised not only by the population in general but also healthcare services which are meant to guarantee care.  We have been studying this phenomenon for a region. This raises questions as to how to design approaches / interventions that accompany / support rather than punish people who use drugs. It also makes the problem more complex because it alludes to the fact that drug use isn’t just related to questions of physical and mental health, but also questions about eixsting legal and socieoecostructrual barriers to healthcare. For instance, people who have problems with their drug use face stigmatising social representations and beliefs by homeless people themselves but also healthcare providers. Homeless people are still concerned by the moral sanction that they may face from reaching out to support services. This translates into more vulnerability and risk. Another barrier is in beliefs around their lifestyle: ‘they don’t accept help, stick to treatment, etc.’ This creates a double stigmatisation, as people who use drugs and as homeless people. Another barrier has to do with the fact that homelessness can be considered a diagnostic factor, which leads to pathologising all homeless people and creating barriers in providing tailored responses. Another barrier has to do with the fact that abstinence is a condition to access housing services, for instance. This is what’s called ‘staircase model’: fulfil requirements in order to get care. We need to differentiate between people who are in shelters, who are literally in the public streets… We need evidence based information, consider the ways how different policies affect people who are homeless, we need epidemiological information in terms of drug use, the legal impact on this population, social impact. We should also generate training programs focused on reducing stigma among homeless people and people who use drugs to generate programmes changing this ‘staircase model’. Access to housing or healthcare isn’t a privilege but a part of any system of provision. We have the Housing First model that can serve as an example. And harm reduction programmes that leverage existing knowledge and health-protecting practices within the homeless community. And decriminalisation of drugs. Without decriminalisation, there’s no access to healthcare.

Gabriela Torres, SEDRONAR: We thought about different proposals to present jointly at the beginning of our mandate and the pandemic torpedoed this. We do not want to change what civil society believes. We have points in common. These events create possibility and is also a political position as well, that we are engaging. Jorgelina’s presentation was wonderful in letting us know who these people are who are homeless. To understand the problem, it’s important to think of the person before us. I’d like to underline that something has been changing in the region, because we need to start understanding drug use problems as human rights problems, it has to do with the context of the country, of the individuals. We must keep on working. This is not an individual problem. In this framework, we have to think of these persons lives, where they live. How do they brush their teeth? Inequality affects all countries, in a country like ours, in Latin America in general, the whole world has to talk about inequality. We cannot talk about these topics without considering social injustice. In terms of strategies and interventions, I’ll say a few things on top of Jorgelina’s points. We have families who are homeless; how do we sustain schooling in that context? Houselessness compounds human rights violations. We’re working on legislation and guidelines, including the legal framework for this topic, that can be used for this approach. The street is not a place to live; it’s a place for everybody. And we should never naturalise this situation of people living in the streets. So we need shelters. You cannot access these if you use drugs, which makes it more complex. So we need to approach this issue integrally. This is our position as a state. Not the governments, but the state – the instruments regulating society and the general wellbeing of the people. We think we all have rights and so all states should have policies where we do not normalise inequality. We have two programmes: community shelters for support/accompaniment – this takes a lot of time; becoming autonomous requires interventions. It’s important to underline that not all people in the street use drugs. Let’s leave stigma aside. There are stories about how this homelessness, intolerable life and loneliness in the public streets need some comfort. And drugs are able to provide some sort of peacefulness for some of these people. So we have guidelines designed with working groups working in shelters and people who work with homeless people. We call this ‘community shelter’ – a place for support. It’s a low-threshold centre for people to go in and out as they wish. The needs vary from place to place and so the schedules are different from centre to centre. In these places they can have lunch, leave valuables, birth certificates, their money. A place for accommodation. How can we accompany/support these lives. Listen, not in a hierarchical way but with the active participation of the person. We have to build autonomy. The person should not feel lonely. Not invading their lives, not telling them what to do. Peer work can be helpful in this regard. We have this for people with tuberculosis who are homeless and who have achieved support. How do we foster empathy, even when the other person sounds like they are talking nonsense – there’s plenty of tools to support communication. All these shelters and houses are involved in these programmes, which foster links between each other. This takes time. We have to build trust. A person who’s homeless has to respond for themselves and that creates challenges to building trust. Until this bond of trust is established, building trust is very important. We should take all of this into account. People can come and go, in and out of this situation; it’s OK – We should be there for them whenever needed. SEDRONAR was created 30 years ago in the framework of the ‘war on drugs’. We are moving to a paradigm of healthcare. We work on research, support, prevention. We are not a punitive institution. We open places of support and understand drug use as a symptom. We must create opportunities to rebuild their lives.

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