Open letter – Urgent action required to ensure the equitable application of public health protections for people who use drugs and are impacted by structural inequalities in Manitoba.

On April 23, 2020, Manitoba Harm Reduction Network delivered the following letter to politicians and public health officials on behalf of 40 organizations and 317 individuals including physicians, nurses, academics, social service providers and community members throughout Manitoba, calling on the Manitoba Government to ensure that people who use drugs in the province have equitable access to public health protections during COVID-19 and to address structural inequities that impact their health and safety.

While this letter has been delivered, if you would like to add your support and have your signature reflected on this website you can still sign here.

April 23, 2020

To:

• Honourable Brian Pallister, Premier, via email only: premier@leg.gov.mb.ca

• Honourable Cameron Friesen, Minister of Health, Seniors, and Active Living, via email only: minhsal@leg.gov.mb.ca

• Honourable Cliff Cullen, Minister of Justice, via email only: minjus@leg.gov.mb.ca

• Honourable Eileen Clark, Minister of Indigenous and Northern Relations, minindnr@leg.gov.mb.ca

Cc:

• Dr. Brent Roussin, Chief Medical Officer of Health, brent.roussin@gov.mb.ca

• Dr. Karen Herd, Deputy Minister, MHSAL, Karen.Herd@gov.mb.ca

• Avis Grey, Assistant Deputy Minister, MHSAL, Avis.Gray@gov.mb.ca

• Tom Ormiston, Assistant Deputy Minister, Transitional Division, Tom.Ormiston@gov.mb.ca 

• Wab Kinew, Leader of the Manitoba NDP and Leader of the Opposition, wab.kinew@leg.gov.mb.ca

• Ben Fry, Acting CEO, Mental Health and Addictions, Shared Health, B.Fry@sharedhealthmb.ca

• Lanette Siragusa, Chief Nursing Officer, Shared Health, L.Siragusa@sharedhealthmb.ca

• Dr. Marcia Anderson, Medical Officer Of Health, WRHA, manderson5@wrha.mb.ca

• Dr. Pierre Plourde, Medical Officer Of Health, WRHA, pplourde@wrha.mb.ca

• Dr. Joss Reimer, Medical Officer Of Health, WRHA, jreimer4@wrha.mb.ca

• Dr. Michael Isaac, Medical Officer Of Health, NRHA, Michael.isaac@gov.mb.ca

• Dr. Amy Frykoda, Medical Officer Of Health, PMH, amy.frykoda@gov.mb.ca

• Dr. Mahmoud Khodaveisi, Medical Officer Of Health, PMH, mahmoud.khodaveisi@gov.mb.ca

• Dr. Tim Hilderman, Medical Officer Of Health, IERHA, Tim.hilderman@gov.mb.ca

• Dr. Karen Robinson, Medical Officer Of Health, IERHA, karen.robinson@gov.mb.ca

• Dr. Davinder Singh, Medical Officer Of Health, SHSS, davinder.singh@gov.mb.ca

• Dr. Mike Routledge, Medical Officer Of Health, First Nations and Inuit Health, michael.routledge@canada.ca

OPEN LETTER – Urgent Action Required to Ensure the Equitable Application of Public Health Protections for People Who Use Drugs and are impacted by Structural Inequalities in Manitoba

Dear Premier Brian Pallister, Minister Cameron Friesen, Minister Cliff Cullen, and Minister Eileen Clark; 

The impact of COVID-19 in Manitoba is further complicated by another ongoing crisis - the overdose and drug poisoning crisis. If we are to support a ‘flatten the curve’ approach in Manitoba, addressing the inequalities of the most structurally disadvantaged must be an urgent priority, both as human rights and as public health measures. 

People who use drugs (PWUD) who are impacted by structural inequities are particularly vulnerable to COVID-19. They often experience underlying health conditions, higher rates of poverty, unemployment, homelessness resulting in overcrowded living conditions, and a lack of access to vital resources. This creates barriers to meeting public health recommendations to practice physical distancing, limit public gatherings, reduce movement in the community, and practice self-isolation. This puts PWUD at greater risk of infection and increases their likelihood of requiring hospitalization and critical care.  

We are all gravely concerned about a potentially catastrophic and critical outbreak of COVID-19 in this population and therefore we call on you to: 

1. Recommend the immediate suspension of municipal bylaws which sanction the displacement of people sheltering in public spaces as well as the enforcement of public health orders on people who are gathering in public spaces due to homelessness and the closure of services;

2. Recommend expanding access to a Safe Supply of all drugs in Manitoba, an evidence-based public health measure that will reduce harms linked to the overdose crisis and provide the necessary infrastructure to help communities contain COVID-19;

3. Recommend the unscheduling of naloxone to allow distribution by service providers and people who use drugs (aka Peers) who are not regulated health professionals;

4. Recommend that police forces immediately and for the duration of both public health emergencies cease expending resources on the enforcement of simple possession of illicit drugs and related offences; 

Background: 

1. Recommend the immediate suspension of municipal bylaws which sanction the displacement of people sheltering in public spaces as well as the enforcement of public health orders on people who are gathering in public spaces due to homelessness and the closure of services;

There are legitimate fears of an outbreak in densely populated living situations throughout the province. People impacted by homelessness are one of the groups at greatest risk of contracting and dying from COVID-19 due to higher rates of chronic diseases including respiratory and heart problems. Displacing and providing fines to people who do not have access to housing is counter-productive. Communities must support efforts to ensure accessible housing options for all Manitobans. People who test positive or are at high risk for infection must be housed in order to practice self-isolation. As the United Nations Special Rapporteur on the right to adequate housing said, “housing has become the frontline defence against the coronavirus.”

2. Recommend expanding access to a Safe Supply of all drugs in Manitoba, an evidence-based public health measure that will reduce harms linked to the overdose crisis and provide the necessary infrastructure to help communities contain COVID-19;  

As Canada’s drug supply is changing and disrupted by the rapid changes to the global economy, action on the provision of a safe supply of all drugs is a critical public health measure during COVID-19. PWUD are increasingly vulnerable to an unregulated supply of toxic substances and in the context of COVID-19, are unable to self-isolate while accessing substances. Expanding treatment and withdrawal management is necessary at this time but people who are not ready to stop using will not benefit from these options. Our province urgently needs expanded access to clinical care models of Safe Supply. Safe supply of alcohol and cannabis already exists in our province and other parts of Canada have expanded safe supply to other substances such as opioids, stimulants, and benzodiazepines. 

British Columbia has demonstrated leadership in addressing these concurrent crises with new protocols providing clinical guidance to providers on expanding safe supply; "Guidelines for Risk Mitigation in the Context of Dual Public Health Emergencies". The protocols ensure clinicians “support patients in mitigating competing priorities and compounded risks and enable social distancing and self-isolation measures,” to reduce and prevent the spread of COVID-19. B.C’s proactive and evidence-based approach has been endorsed by Canada’s Chief Public Health Officer. Our province is ready for access to safe supply. The expertise to support the implementation of these strategies already exists in Manitoba. We urge you to work with leaders in this sector in developing and implementing programs that work in our context.

3. Recommend the unscheduling of naloxone to allow distribution by service providers and people who use drugs (aka peers) who are not regulated health professionals;

In the COVID-19 pandemic context and increasing burden on the health care system, opioid and overdose poisoning remain a public health priority. PWUD need viable solutions that will allow them to practice physical distancing without risking overdose and death. Providers in Winnipeg, Selkirk, Swan River, and other Manitoba communities have already reported increases in harms related to substance use as COVID-19 limits access to harm reduction facilities and services, and creates instability in the illicit drug market. Currently in Manitoba, Take Home Naloxone Kits must be distributed by a health professional (registered nurse, doctor, pharmacist, or paramedic). In both British Columbia and Alberta, naloxone has been changed to an “unscheduled” drug. Unscheduled drugs can be sold or provided without “professional supervision.” and can be distributed to people by outreach and shelter workers, para-professionals, and peers. This not only improves access, it lifts the distribution work off of health care professionals, including EMS and emergency rooms. 

4. Recommend that police forces immediately and for the duration of both public health emergencies cease expending resources on the enforcement of simple possession of illicit drugs and related offences; 

Criminalizing people for accessing the drugs they need to feel well creates fear and stigma and forces people to engage in behaviours that compound their risk and others’ risk of contracting COVID-19. Criminalization of drugs and drug use creates a barrier to PWUD to adopt public health measures - it forces PWUD to access drugs in an unregulated market, necessitating more public interaction than is recommended in the current context. Municipal police forces and RCMP must immediately and for the duration of both public health emergencies cease expending time or resources on the enforcement of simple possession offences under Section 4(1) of the Controlled Drug and Substances Act (CDSA) as well as minor related offences where dealing is merely in support of an individual’s substance use dependence. 

All of the widely accepted harm reduction interventions which are supported and validated by academics and public health experts were developed by People Who Use Drugs to save their communities, including the recommendations here. If you believe “we are all in this together” then we urge you to act strongly and proactively on these recommendations. We respectfully ask for a meeting via phone with all of you as soon as possible to discuss.

Contact: 

Shohan Illsley, Executive Director, Manitoba Harm Reduction Network, shohan@mhrn.ca

Signed: