Monday, February 20, 2017

An Intro to Harm Reduction with Jenna Mellor

Thanks for stopping by, reader.

In case you haven't known already, my name is Michael Enich and I have been the first year on The Promise Clinic's Operations Committee running point on our social media presence since October. Every once in awhile (twice, specifically) I try to whip up a piece that puts the work done at Promise Clinic in the broader health landscape.

This time I'm writing in the first person because I had the pleasure of sitting down and interviewing a close friend and community health activist, Jenna Mellor. Given our closeness and the more conversational nature of this "interview", it made the most sense to guide you through our conversation from my perspective.

Jenna Mellor is a sex-educator, successful builder of programs and teams,and passionate and thoughtful social, economic and reproductive justice activist. She currently works as a constituent services representative for Congressman Jerrold Nadler on Manhattan’s West Side.

Her work in the world of community health advocacy-- and more specifically, harm reduction--  is deeply informed by her time as Outreach Manager at HIPS in DC. HIPS works in the Washington D.C. metro area serving people engaged in sex work and/or using injection drugs. HIPS "believes that those engaged in sex work, sex trade, and drug use should be able to live healthy, self-determined, and self-sufficient lives free from stigma, violence, criminalization or oppression. [They] will achieve this through engaging sex workers, drug users and our communities in challenging structural barriers to health, safety, and prosperity."

HIPS started in the 90's; activists and DC natives recognized visible sex trade in the community and decided that they wanted to do something about it. They started as a typical non-profit organization offering resources to women engaging in sex work (a strengths-based way of speaking about what's typically referred to as "prostitution").

Through direct interactions with folks trading sex, the founders eventually came to understand the moralistic notions of sex workers that pervaded their service. After one particular interaction where a woman refused to give information about her manager (or "pimp", as it is colloquially referred to as) out of fear of judgement, the organization re-oriented its vision. "They realized that a non-harm reduction approach was not working." Mellor said, "It was creating barriers to meaningful relations and those relationships were integral to this kind of work."

"But Jenna," I asked, "What is harm reduction?"

I had some idea of what this was, but decided it would be good to ask for her definition. My idea ran with what what the words said-- harm reduction aims practices towards reducing the harm of an action on an individual's health. I had encountered it has a peer educator at St. Olaf College, my alma matter. The college was technically on a dry campus-- no one was allowed to have or consume alcohol-- but of course anyone who wanted to drink did. Our job as community health workers of sorts was to teach our fellow students strategies for safer drinking, despite the campus policy against it.

To provide illustration, Mellor walked me through an exercise.
"What are potential harms from sex?" She asked, "How about benefits?"
I outlined some of the thoughts that came to my mind. "The immediate harms that come to mind are STI's and any circumstances of assault or rape. There's some other potential for emotional manipulation, too. As far as positives, there's orgasms or other good-feeling things,  emotional and physical connection to another person, potentially being able to get money from it, I guess"

"Alright. How about drugs?" Mellor prompted. I came up with another list.

"If we look at these lists there are certain topics that get a lot of attention in our community health work," Mellor explained, "Sex-Ed, e.g. avoiding STIs and sexual assault and unwanted pregnancies probably come up the most. Same thing for drugs; the harms come up over and over."

In an effort to mitigate these negatives, community health workers often overlook the relative benefits. HIPS discovered that paying attention to those positives gives a lot of insight into how individuals make decisions about their health; this attention builds a trust-based relationship that improved sex workers’ health.

Jenna nodded. "That is what harm reduction does."

The central ethic of harm reduction work is this: the nuance and complexity of why and how we make the decisions around our bodies, especially with sex and drug use, is so individually and structurally layered that it is impossible to know all the potential benefits and harms another person is calculating at a given time. The only person who can ever know those is each of those is that person, and even that is a stretch sometimes. Potential harms and benefits are also, it is essential to remember, impacted by racism, transphobia, homophobia, sexism, nativism, ableism, and the many structures that impact our individual agency.

"The idea is to not come at someone with ‘What you should be doing…’, but rather supporting someone and engaging with understanding ‘What role do I want [X activity] to have in my life?’" 

Harm reduction emphasizes opportunities for individual agency and choice even within constrained circumstances. People always can-- and are-- making choices to keep themselves relatively healthier, and harm reduction values celebrating those choices.

This underlying value of non-judgement is one that is not foreign to any health provider, but often is harder to put into practice than one might expect. Our goals are positive outcomes, and the most positive outcomes generally come from completely stopping negative behaviors. Strictly numerically, someone who struggles with alcohol dependence would get the greatest benefit from completely stopping their consumption. The reality is that is process of quitting is complicated, and insisting on abstention against all odds often colludes a provider's non-judgement.

As another example, Mellor recognized how easy it was easy to tell folks to use a condom in order to protect themselves from unwanted pregnancy and STI's. "But people know this already," she said, "and maybe they chose not to use them because it would feel better for their male customers, which would mean they paid more, which meant more money in that person’s pocket to pay for rent or food." Without asking about why a sex worker why she wouldn’t insist her male customers use condoms, this perspective was completely lost.

Through our conversation, I often reflected on the lessons we learn in Patient Centered Medicine. Our role as Student Doctors at Promise Clinic, Steering Committee Members who interact with patients, and future physicians is to create an environment where people can be as honest as they are comfortable answering questions about their body in order to provide the best possible services.

How do we, then, establish this honesty?

There were a few ideas Mellor highlighted. The first of which was open-ended, explicit questions. In her work this meant subtle changes like asking "What drugs are you using?" instead of "Do you use any drugs?" While this may seem presumptive, it often signaled a mutual understanding between her and the people she worked with.

"I am amazed at how much people will share with just a couple-open ended questions." Mellor said. At Clinic, this emphasizes asking questions that can't just be answered with a yes or no, as well as questions that are broad enough to allow patients to give a narrative response.

The next, harder step getting in the mindset that the patient is the expert on their own body and health situation.

I told Jenna a specific story; my Student Doctor Team was working with a new patient who admitted to using heroin. We were trying to assess the extent of this person’s drug use and asked how much they take. “Oh, about ten bags a day.” they responded. The three of us in the room had no knowledge as to how much this actually was, so after a beat someone asked “How much is in a bag, would you say?”

“What, haven’t you guys ever seen a bag of heroin before?”

Instead of taking the opportunity to ask our patient to teach us and inviting them to share their health knowledge with us, we all froze and then moved on to the next question. By playing the role of health expert I know I marginalized our patient’s knowledge and maintained my position of power. This was a lost opportunity to build trust.

Finally, Mellor suggested a candid assessment of our programs. Promise Clinic doesn’t offer free condoms, a needle exchange program, or on-the-spot peer counseling in part because we don’t serve people experiencing these specific acute crises. Instead, we do our best to provide long-term support, establishing longitudinal trusting relationships with the goal of improving a patient’s health as they would like it to improve.

Beyond this though, even without patients who are actively using substances or engaging in acutely-risky health behaviors we can work as individuals to incorporate harm reduction philosophies into our practice.

"People are experts on their own lives... So much of harm reduction is showing a patient that you understand that they are multi-motivated, creating a space in which they feel they can communicate those motivations and prioritizing what they believe is their utmost need."

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