Keywords

Introduction

  • James Clover 

It was imperative for the Editors of this collection to both access and showcase the voices of practitioners, and we fully acknowledge the tremendous value these perspectives can have in thoughtfully reminding us of the complexities in the shared roles and relationship charged with serving the people we intend to support. When we have an opportunity to learn from practitioners outside our personal or professional sphere, we become enriched with a fuller understanding of what our clients and communities need. Through these dialogues we also reveal the ways our personal and organizational efforts can both complement and conflict with the activities of others, which at times can have dire health consequences for the people that look to us for essential care and support.

Michael Peters speaks to an important truth that is often underappreciated when considering a more responsive system of health and wellness delivery. Timing is a crucial factor when we engage with respective clients or the community-at-large; it is vital that engagement and support be provided when the recipient is amicable, in whatever state they present, and not when convenient for the institutions that provide the service and support. As the reader explores within this collection the shared space that law enforcement and public health occupy, we can consider Peters’ professional priority to strive to meet the client “where they are at geographically, emotionally, and mentally.”

The contributions from Donna Evans, Emily Craven, and Wayne Helfrich transport the reader to South Africa, specifically within the sex work community. Evans and Craven describe a number of initiatives including the Positive Policing Partnership—a non-confrontational and relationship-focused effort directed at police officers to humanize the sex worker. Evans and Helfrich provide a parallel description to the negative health consequences sex workers face when being policed, including violence, criminalization, and dehumanization as a result of drug addiction, health status, or their station as a sex worker. The evidence put forward in these contributions appear to reveal a common theme captured within this collection, specifically the negative health consequences marginalized communities face when in contact with law enforcement.

The final piece by Miriam Krinsky and Liz Komar eloquently demonstrates the position that punitive approaches to drug users is a false endeavor, and provides certain inspiration that supportive health strategies can be effective despite political opposition. Equally important is the recognition that any discipline which has a touchpoint to serve people, including the longstanding institution of prosecutorial services in the United States, can purposefully reflect and reform their intended contributions, learn and adjust from the unintended consequences that have proven harmful, and align themselves with others’ efforts toward a shared global mission of improving the overall public health wellness.

The Power of Collective Practices

  • Michael Peters 

Throughout my career, I have had the opportunity to work with many individuals, primarily children, youth and their families who have had varying experiences with many aspects of the health and law enforcement systems. Meeting them where they are at geographically, emotionally, and mentally has always been my top priority.

Working with children and youth has helped me understand the need for all of the supports in their life to take a harm reduction approach. People come from diverse backgrounds, family dynamics, and lived experiences. The need to continually be there to pick an individual up when they stumble is absolutely imperative for both their short-term and long-term success. Like all of us, having someone who cares for you “unconditionally” creates an environment of trust and mutual respect. This level of unconditional support can be provided through many areas of an individual’s life—from the police officer who stops by to play a game of basketball or a doctor or nurse who spends that extra minute with them to truly hear their concerns and help find a solution. When we look at the person instead of the problem, we can create a more inclusive and connected community.

The true opportunity to positively intersect law enforcement and public health or mental health support requires a bigger conversation around systemic change. Currently the system is not set up for law enforcement and public health to naturally work together to support individuals who would benefit from such collaboration. Both systems meet the individual needs they historically have, however, due to the policies and procedures each system has in place, they lack agility to meet the needs of all individuals they interact with. When the system is ready and when the individual is ready, buy-in increases as well as the chance of success, resulting in the right level of support at the right time.

If we were to broaden the academic definition of “public health” to the many community agencies striving to meet individuals where they are at on a daily basis, the chance for intersection is more likely. Surrounding an individual with the supports they select, such as mentors, cultural supports, community agencies, and faith leaders empowers them to play an active role in the direction of their life. It also ensures that these supports remain consistent as needs vary. Looking to define public health as both the system as a whole and the more specific, individualized approach, truly meets the public need.

We know law enforcement is necessary to keep the community safe. When you use the same approach to broaden the definition of “law enforcement” to include the same community agency supports, it can not only reduce recidivism but decrease negative interactions that lead to individuals becoming involved with the justice system. The common denominator here is the need to broaden these definitions to include the natural and community supports the individual identifies.

I had the opportunity to work with a young man named JamesFootnote 1 who was incarcerated at an early age. James and a number of his peers took part in a group workshop on self-esteem offered by the YMCA Youth Transition Program. This workshop was designed to introduce the group of young males to the importance of building healthy self-esteem and surrounding themselves with positive people. When the workshop concluded, James expressed a desire to continue learning about ways to develop himself. We set up bi-weekly meetings that continued regularly for nearly 5 years.

During our time together, I grew to understand that a number of key determinants of health were not currently present for this young man to develop. He expressed his desire to have a positive future. As we worked through multiple workbooks and took part in many conversations, it became very clear that James was able to self-reflect on what he needed to do to become successful. More importantly, he was able to identify for himself which social supports he needed around him to succeed.

As James grew up and was relocated throughout the province, I was able and willing to continue to connect with him. When he had a rough day at school or in court, he would give me a call just to talk. The pinnacle of his success came when he was awarded the Gold Level Duke of Edinburgh award for his work academically, and as a peer mentor and leader. With consistent guidance and individualized support, James found the internal motivation to help him achieve this honor. He ensured I was invited to the ceremony where he was awarded this honor.

James continues to connect to this day with a holiday greeting or a quick text or call to check in.

By working together, law enforcement and public health systems have the opportunity to positively impact the lives of some of our community’s most vulnerable citizens. When working in collaboration to address the individual’s concerns, these systems have the opportunity to be more effective in their treatment and care. This requires a basic human action: empathy. When workers from these systems take the time to understand what the individual needs are and are backed by the systems they work within to offer wrap-around services, real change is possible for those who need it.

Looking at all of the determinants of health and developmental assets can be daunting for anyone, however, if all of the support systems for individuals in need can support the development of one item at a time it acts as a building block. Over time these blocks create a strong foundation that enables and empowers the individual to begin living a more positive life that they can take ownership of. It requires that the public systems they encounter develop a seamless collaboration and openness to work together.

We may not be able to change the system overnight, but we can work together, communicate and support each other to meet the needs of the individuals we serve. This will in-turn open the door for policy-makers to see a more collaborative way of supporting people, which will ultimately lead to the systemic change required.

Contested Spaces: South African Sex Worker and Operational Policing Interactions

Case Study 1: The Sex Worker Education & Advocacy Taskforce

  • Donna Maree Evans &
  • Emily Craven 

The sex work environment in South Africa is challenging, with laws criminalizing all aspects of adult consensual sex work (Sexual Offences Act, 1957; Criminal Law (Sexual Offences and Related Matters) Amendment Act, 2007). South Africa also experiences high rates of inter-personal violence, including gender-based violence and femicide (Stats, 2020; South African Police Service, 2019; Africa Check, 2019). While sex workers experience violence from clients and other community members, there is substantial evidence of violence perpetrated by law enforcement officers against sex workers including rape and sexual assault, physical assault, torture, unlawful arrest and detention, harassment and intimidation, bribery and corruption; together with policing neglect such as refusing to take complaints or open investigations for sex workers when they attempt to report crimes like rape (Human Rights Watch & SWEAT, 2019; Evans & Walker, 2018; Evans, 2017; Manoek, 2017; South African Women’s Legal Centre, 2016; Scorgie et al., 2013; Gould & Fick, 2008; Fick, 2006a; Fick, 2006b; Pauw & Brener, 2003).

SWEAT (Sex Worker Education & Advocacy Taskforce) has a 20-year history in organizing, advocating for and delivering services to South African sex workers. It has birthed two social movements: the South African Sisonke Sex Worker Movement (Sisonke), and the African Sex Worker Alliance (ASWA) now based in Kenya. SWEAT programming embraces a concept of sex worker wellness which goes beyond merely the absence of disease—it includes physical, mental, and social wellbeing. To combat the detrimental health and social impacts of negative policing behaviors, SWEAT adopts an evidence informed human rights-based approach to catalyze change in this difficult context. SWEAT’s policing partnership work takes place across two streams: the Sex Worker Empowerment & Enabling Environment Programme (SWEEP) which mobilizes sex workers advocating for service delivery; and the Advocacy & Law Reform Programme (ALRP) which strives to reduce violence, improve access to rights and to enable sex workers to actively claim their rights and advocate for law reform. The ALRP includes a sex worker legal defense center with lawyers and peer-based paralegals who provide advice, representation, and emergency responses for sex workers in contact with the criminal justice system.

In 2018, the South African sex work sector launched the Positive Policing Partnership (PPP) initiative to improve the health and safety of South African sex workers. The PPP approach requires a move away from the more traditional adversarial and complaint-based strategies to focus on relationship- and capacity-building partnerships, forward-focused dialogue, policy interventions, and solution-based actions. The aim of the PPP is to catalyze change through embedding an understanding of the human rights experiences of sex workers across law enforcement, government and society; and to generate and promote opportunities for positive engagement on policing issues through publishing and advocacy on evidence-based research. The origins, tenets, and learnings to date from the PPP approach have been documented in the Journal for Community Safety & Well-Being (Evans, Richter, & Katumba, 2019). The PPP and South African sex work sector continue to convene public events, create dialogue opportunities, and publish reports to ensure the human rights experiences of South African sex workers remain in the government and society’s consciousness. Recent events include the Positive Policing Practices & Sex Work Roundtable Discussion (Sonke Gender Justice & SWEAT, 2019), #SayHerName Report 2014–2017 (SWEAT, 2019), and Asijiki Coalition Sex Work & COVID-19 Webinar on Unlawful Policing (Asijiki Coalition, 2020).

A core strategy for SWEAT and Sisonke to catalyze change is their engagement in an extensive sex worker sensitization training strategy with the South African Police Service, effectively “humanizing” the stereotyped “sex worker” through individuals relating their lived experience. The resourcing for this training has primarily been funded through HIV programming which targets frontline staff interacting with sex workers, particularly law enforcement and health providers. It therefore generally has a public health focus such as ensuring sex workers do not default on their medications and treatment plans when in police custody. At a strategic level, Sisonke members participate in the large-scale harm prevention Dignity, Diversity & Policing Project conceived and funded through COC Netherlands (COC) which focuses on promoting and protecting human rights, dignity, and safety for all (Katumba, 2018). This COC project has successfully embedded sensitization training on marginalized groups within the South African Police Training College curriculum and established a delivery program for national rollout to operational police. Sisonke peer educators also deliver sensitization training at the community level, in locations where sex workers may be experiencing difficulties with a local police station. Where required, SWEAT’s lawyers and paralegals will also intervene to assist sex workers in contact with police. Very few people are actually charged or prosecuted for sex work; they are more likely to be fined for petty offences such as loitering or nuisance. In many cases, sex workers are simply unlawfully arrested and detained for extended periods without charge or fine, or are subjected to bribery demands in order to avoid arrest or secure release from custody.

One broadly anecdotal observation from this sensitization and training work is that when both sex workers and police participate in the workshops, police often gain a better understanding of the lived experience of the sex worker and some of the commonalities across their lives—they come from the same communities, and they perform underpaid and perilous work in difficult conditions. Many come to understand their personal beliefs and morality are separate from their role and responsibilities as law enforcement officers, and to view sex workers as community members rather than just stereotyping them negatively as “sex workers.” In some localities, SWEAT has observed change where sensitized police now champion the rights of sex workers and go out of their way to ensure due process occurs during the criminal justice processes.

On the negative side, there are still far too many instances of sex workers experiencing violence from police or dying in police custody without adequate investigation or accountability. Robyn was a 39-year-old South African sex worker and LGBTQI+ advocate who died in a Cape Town police cell in April 2020. Her death was referred to the Independent Police Investigative Directorate, which to date has declined to make public the findings of its investigation. This stonewalling despite sustained advocacy by the sex work sector for transparency on the circumstances and investigation of Robyn’s death reflects the lack of recourse for sex workers even when specialist police accountability mechanisms are appropriately utilized. For many South African sex workers, police are still the one thing they fear the most.

Case Study 2: The Grass Roots Practitioner

  • Donna Maree Evans &
  • Wayne Helfrich 

This case study focuses on the work of advocate and activist Wayne Helfrich, whose qualifications lie in disease management. Wayne has a long-term association with a South African non-governmental organization (NGO) which delivers group community health clinical services to key populations including sex workers, people who use drugs, the homeless and undocumented foreigners. The NGO is based in a large metropole serviced by both the South African Police Service (SAPS), and a Metropolitan Police Department (Metro Police) attached to the municipality. Originally clinical services were offered to community members who could not access government-funded services because the law would not permit it, or because they feared the stigmatizing conduct directed at them by staff in mainstream services.

With funding from PEPFAR (President’s Emergency Plan for AIDS Relief), the NGO expanded to become a large-scale community clinic focusing on HIV, initially through harm reduction and later through harm prevention. It quickly became clear that HIV was only one of a range of critical issues affecting their clients. As sex workers and drug users were less likely to access the NGO building for service delivery, the program called Community Orientated Primary Care was developed where the clinic would conduct “home” visits to overcome this barrier. The program concept was based on a South African Research Council study of children who were presenting with HIV symptoms yet were not sexually active and were not receiving treatment. The NGO started looking for these children in order to provide services, only to discover many children were being marginalized due to their parents’ status as sex workers, drug users, homeless persons, or undocumented foreigners. The NGO was able to respond agilely to meet these newly discovered community needs through their mobile service delivery strategy. Where the client’s “home” was a park bench, staff would provide the clinical services at that park bench. Where the sex worker operated from bushland, the clinical services staff would deliver services in that bushland setting.

Over the years, the NGO has been in continual contact with law enforcement concerning the negative impacts of operational policing behaviors on both clients and clinic staff. One of the very first engagements arose from sex worker complaints that after the mobile clinic staff left the site, police were destroying the condoms and antiretroviral (ARV) medications the clinic had just supplied by setting them on fire, as well as beating and harassing the sex workers. The NGO contacted the local police station and arranged a meeting. This proved to be a very unsuccessful strategy as once SAPS realized the clinic was providing services at various mobile sites, the police would then attend the locations to harass both the sex workers and staff. The NGO obtained a letter for the National Department of Health explaining the staff were providing clinical services which were approved by the Department. When the clinic’s peer educators would produce a copy of the letter to police on the scene, the letter would often be ripped up and thrown to the ground, with police then arresting the NGO’s Peer Educators and holding them without charge at the station for extended periods of time. The NGO then convened a further multidisciplinary meeting with Metro Police and various NGOS including SWEAT, Sisonke Sex Worker Movement, Homeless Forum, Drug Users Forum, etc. The training focused on human rights compliant policing and sensitization on key populations. At the conclusion of the workshop it was clear little progress had been achieved, when a police official commented that as long as there were whores in this city, (we) will arrest them.

The NGO then changed strategy and began documenting the harassment through videos and photographs of the offending police behavior. At a subsequent meeting with the local Police Station Commander attended by both SAPS and Metro Police, agreement was reached to meet monthly to discuss incidents on a case-by-case basis. After three such meetings the Police Station Commander was transferred, with the police harassment of the clients and clinic staff immediately resuming. This frequent rotation of police officers and station commanders means NGOs routinely have to re-establish relationships and protocols to maintain fundamental legal protections and rights for their clients and staff, a process which continually drains scarce NGO resources from direct clinical services. Police are often focused on meeting arrest targets, with key populations offering high reward for little effort in this endeavor. The connections between health, police, and social development are simply not understood and crimes against sex workers often remain un-investigated. It is no surprise that at a site close to this same police station, a serial rapist and suspected murderer has been preying on sex workers over years. Despite local sex workers identifying who the suspected offender is, efforts to report information and provide witness statements to police have only resulted in threats to arrest the sex workers themselves. Three sex workers have now lost their lives, with at least five more sex workers raped and a confirmed case of HIV transmission from one assault. A clear and enforceable national policing directive and training on the rights of key populations in contact with law enforcement may provide some relief from these recurring issues of non-rights compliant policing and refusal to act on sex worker crime reports.

Disillusioned with the possibilities of effecting change through NGO advocacy, Wayne had approached many politicians for assistance over the years; however, in conservative South African society sex work is a sensitive topic and sex workers simply do not vote. Only through becoming active in the country’s political space was he able to effect more sustainable change. With a human rights focus to the advocacy, politicians from the municipality held a roundtable event and established two units within Council, one to provide sensitization to police on sex worker issues and the other being a drug unit which sensitizes police on drug use as a form of disease. These specialist units promote strategies such as police assisting sex workers and drug users by conveying them to appropriate clinics to access services rather than to a police cell. Over time a good informal working relationship has developed where sex workers in particular locations now voluntarily report suspicious activities to police involving crimes such as theft of copper cables and hot water systems from houses—in effect, sex workers act as strategic assets for police to detect crime. Trust has been established between specific sex workers and specific police, but the relationship is ad hoc and dependent on the individuals involved. In some cases, a sex worker who feels he or she is in danger might contact the police officer on their personal cell phone, and that officer will arrive to assist even they are off duty. While there will always be rogue behavior, success can be difficult to achieve and we should celebrate these incremental changes as steps along the pathway to a fairer, safer and more inclusive South Africa.

From Prosecuting Overdoses to Preventing Them: Overdose Prevention Sites, Harm Reduction, and Prosecutorial Culture Shift

  • Miriam Krinsky &
  • Liz Komar 

The Current Landscape

Three epidemics have collided in the United States over recent months producing tragic consequences: a growing demand for reckoning with systemic racism, the novel coronavirus, and the escalating opioid overdose crisis. Prior to the COVID-19 pandemic, the USA was already besieged by deadly overdoses—over 50,000 people died from opioid overdoses in 2019 (American Hospital Association, 2020, July 16). In the wake of the pandemic, 40 states have reported increased overdose deaths and overdose deaths nationally are on track to reach an all-time high (American Medical Association, 2020). In many cities, those increases in fatalities have disproportionately been borne by the Black community (Haley & Saitz, 2020; Whelan, 2020; Bogan, 2020), echoing the health disparities made visible by COVID-19 (Centers for Disease Control and Prevention, 2020).

Philadelphia, Pennsylvania has felt these losses particularly acutely and has become the stage for the United States’ first battle in the courts over the legality of overdose prevention sites (OPSs), and elected prosecutors have become unlikely allies in that fight. The movement to open OPSs in the United States, led by harm reduction activists and people who use drugs, has historically been met by opposition from local and federal law enforcement. But as a new generation of reform-minded prosecutors takes office (Bazelon & Krinsky, 2018) and works to undo regressive drug policies that drive mass incarceration, the fight over overdose prevention sites has become emblematic of a broader shift. These prosecutors are not simply moving away from carceral approaches to drug use—they have become active proponents of preventative public health approaches, reflecting a fundamental shift in the role and values of elected prosecutors in the United States.

The Benefits of Overdose Prevention Sites

Overdose prevention sites, also called supervised consumption sites, provide a location to use drugs under the supervision of people trained to immediately reverse overdoses. They can also serve as harm reduction outreach centers where people can receive medical care, access social services, and explore treatment if desired—but they are designed and centered around saving lives (Fair and Just Prosecution, 2019).

OPSs are a proven means of decreasing fatal overdoses, and they have other beneficial outcomes that make them attractive to reform prosecutors. Research shows that they reduce the transmission of infectious diseases, public injections, and discarded syringes, and increase the number of people entering treatment programs (Singer, 2018). As of 2019, 118 OPSs operated in 12 countries, without recording a single fatal overdose in an OPS (Harm Reduction International, 2018).

Promoting OPSs Amidst the Current National Crises

In the context of the broader movement in the United States to reduce police shootings and over-policing of marginalized communities, OPSs offer a way not simply to save lives, but also to reduce police contact with the community. Police officers are often the first to respond to overdoses in US communities, creating the potential for escalation and incarceration. OPSs offer a path where people can access care rather than risk police contact, while reducing the cost and risk to police officers as well.

Given the intense focus among many taking to the streets calling for a redoubling of efforts to address racial inequity, markedly disparate overdose rates form another powerful rationale to embrace OPSs. Despite the perception that the USA’s overdose epidemic is a crisis primarily in its white rural areas, overdose rates have skyrocketed in its Black communities. From 2016 to 2017, the mortality rate among Black people rose by 25%, compared with the 11% increase among white individuals (Centers for Disease Control and Prevention, 2019). OPSs offer a means to save some of the most vulnerable Black lives.

Reform Prosecutors Rallying around the Need for OPSs and Harm Reduction Strategies

Around the USA, reform elected prosecutors are using their bully pulpit and credibility to support efforts to open OPSs in their community. In Burlington, Vermont, State’s Attorney (SA) Sarah George convened a commission of law enforcement officials, medical professionals, and local leaders to study whether to recommend OPSs after the state saw an increase in opioid-related deaths. The commission ultimately supported legislation to establish an OPS in the state (Murray, 2017). King County (Seattle, Washington) Prosecuting Attorney Dan Satterberg publicly endorsed plans to open OPSs in that city. Then-District Attorney (DA) George Gascon (who has since been newly elected as District Attorney in Los Angeles, California) endorsed efforts to open an OPS in San Francisco, saying, “Sometimes when the law hasn’t caught up with the need of the community, we have to be bold and we have to act in a different direction” (Stremple, 2019). His successor, District Attorney Chesa Boudin, continued that support (Knight, 2019). Finally, Philadelphia District Attorney Larry Krasner voiced approval for the planned OPS in his community (Krasner & Krinsky, 2020).

Thus far, none of those efforts have led to the successful opening of an OPS due to strong federal opposition. Under the Trump Administration, the US Department of Justice has opposed OPSs under far-reaching interpretation of the Controlled Substances Act (CSA). OPSs were not contemplated by Congress at the time the CSA was passed, and the intent of the so-called “crack house statute” was to reduce illicit drug use, not bar public health interventions (Beletsky, Davis, Anderson, & Burris, 2008). Nonetheless, DOJ has argued that the CSA prohibits OPSs and fear of federal prosecution has derailed efforts by states to embrace OPSs, including a bill in California in 2018 vetoed by then-Governor Jerry Brown (Associated Press, 2018). However, the current litigation over the planned OPS, Safehouse, in Philadelphia, represents a viable avenue for a federal court to deem OPSs legal under the CSA, and 85 criminal justice leaders joined in an amicus brief in support of the legality of Safehouse, arguing that OPSs provide a lifesaving service critical to public safety (Fair and Just Prosecution, 2020a).

The context for this support of OPSs is a broader movement among reform prosecutors in the USA away from carceral approaches toward public health harm reduction interventions. Many chief prosecutors have embraced some level of decriminalization; choosing either to use their prosecutorial discretion to decriminalize certain substances or offences or advocating for legislative reform. For example, in Seattle, Prosecuting Attorney Satterberg has stopped charging virtually all personal possession cases of small amounts of drugs (Jouvenal, 2019), Baltimore (Maryland) State’s Attorney Marilyn Mosby decriminalized cannabis possession (Dewan, 2019), and SA Sarah George (in Burlington, Vermont) has stopped prosecuting possession of the opioid treatment buprenorphine (Aloe, 2018). Over 20 prosecutors spoke out in favor of the MORE Act, which would federally decriminalize cannabis (Fair and Just Prosecution, 2020b). And Los Angeles’s DA-elect, Gascon, has expressed support for the Portuguese model, which combines decriminalization of all drugs with a robust harm reduction infrastructure (Jaeger, 2019). Likewise, a growing number of law enforcement leaders and prosecutors are embracing more public health-oriented diversion or deflection models, such as Law Enforcement Assisted Diversion (Fair and Just Prosecution, 2017).

A Growing Prosecutorial Voice Is Embracing New Thinking

While reform-minded prosecutors represent a small fraction of the 2500 elected prosecutors in the United States, they hail from many major cities, as well as smaller communities, and represent a significant portion of the US population. Therefore, the growing support for decriminalization and public health models among these reformers reflects meaningful trends in prosecutorial culture. First, the rise of evidence-based justice decision-making has driven many prosecutors toward new solutions: the data shows that the “war on drugs” has failed and demands new approaches (Fair and Just Prosecution, 2019). Second, racial equity is a core value of the reform prosecutor movement in the USA, and many of these prosecutors are eager to move away from the carceral drug policies that have driven racial disparities (Fair and Just Prosecution, 2018). Third, these prosecutors have reached toward public health interventions as they redefine prosecutorial success, measuring “wins” not just in number of convictions, but also in improvements in the health and wellbeing of their community (Fair and Just Prosecution. (2020c). Fourth, they are also redefining their role to include preventing harm, not simply prosecuting it. And finally, they are affirming the worth and dignity of the lives of people who use drugs.

At their core, OPSs are antithetical to traditional punitive approaches to drug use because they affirm the value of the lives of people who use drugs over the strict enforcement of prohibition. By raising their voices in support of OPSs, this new generation of prosecutors in the USA are saying they agree, and signaling their support for safer, healthier, more equitable communities where the lives of even the most marginalized people matter.