Ben Scher talks to Dr Thomas Brothers about how social and structural factors can influence adverse health outcomes among people who use drugs.

People who have more power and more privilege have more autonomy and independence to navigate the world and take care of their health.

In season two, episode six of the Addiction Audio podcast, Dr Thomas Brothers talked to Ben Scher about the factors that make some people who use drugs particularly vulnerable to bacterial infections. His research, published in Addiction, examined sources of risk and practices of care to better understand how health inequality can be minimised or navigated by people who use drugs.

Bacterial infections are caused by bacteria (e.g. from non-sterile injecting equipment, or the person’s own skin) entering the body through a needle and infecting the skin, a heart valve, joint, bone or other organ. Tommy’s paper maps out the different points or moments at which a person who injects drugs can develop a bacterial infection, and furthermore, how they can go from having a superficial infection at the injection site, to developing a serious or invasive bacterial infection and experiencing adverse health outcomes afterwards.

In the podcast, Ben asks Tommy if he could discuss the reported rise in the rate of bacterial infections in Australia, Canada, the UK, and the US, and what factors could be contributing to this. Tommy explains that the rise can’t be attributed to just one thing. In some countries, the increase in bacterial infections has coincided with an increase in the prevalence of injecting, while in others, the rate of injecting drug use has remained stable. In some countries, the increase in bacterial infections has coincided with a change in the unregulated drug supply from heroin to fentanyl and uptake in methamphetamine injecting, while in others, the use of heroin has remained stable. However, there are some overarching factors that Tommy says are influencing people’s healthcare practices and outcomes.

Tommy examined 26 studies qualitative studies about experiences of injecting-related bacterial and fungal infections, and identified four themes:

  • The unregulated drug supply is leading to poor drug quality and poor solubility, which is damaging people’s veins.
  • Funding and policy restrictions on harm reduction programmes are preventing effective service provision, which is causing people to reuse contaminated equipment.
  • Policing practices and insecure housing mean that some people are resorting to injecting in unclean, public places, and are rushing the preparation and injecting process, which leads to accidents and physical harm.
  • Healthcare policies and practices are giving people such negative experiences that they avoid accessing care, which leads to infections getting worse.

These points demonstrate very well how a person’s ‘risk environment’ is a product of the interaction between macro-environmental factors (e.g. poverty, criminalisation of drugs) and micro-environmental factors (e.g. supply of sterile needles and syringes, access to supervised injecting sites). The macro-environmental factors are also known as ‘social and structural determinants of health’, which are conditions that can exert an influence on someone’s health outcomes regardless of, or over and above, their individual choices or lifestyle factors.

“Social and structural determinants of health are all the different things that affect the way we live and grow up and take care of ourselves or are less able to take care of ourselves: living conditions, income, racism, sexism. And they affect all of us in different ways. There’s different ways to think about them and one way is that people who have more power and more privilege have more autonomy and independence to navigate the world and take care of their health and so that affects people who use drugs to a great degree.”

Tommy says that most harm reduction interventions for people who use drugs are ‘micro interventions’, in that they aim to change people’s immediate or local environments to reduce the harm they experience while using drugs. However, he suggests that these are ultimately trying to minimise the effects of problems at the macro level (i.e. state, country, society) that make certain groups of people vulnerable to harm in the first place.

“[Micro interventions] can make a huge difference in people’s lives, but really what they’re trying to do is counteract the macro-environmental determinants, so when there’s not enough housing and when people don’t have safe places to access healthcare, those micro-environmental interventions are trying to solve those problems. And, you know, maybe those are more feasible, maybe we’re better able to organise and deliver those on a small scale. But at the same time, our findings suggest that macro-environmental factors like criminalisation and settler colonialism and racism are all playing a role in determining and patterning who’s getting these injecting related infections”.

A “powerful finding” from the research, Tommy says, was the “ways in which people who use drugs care for themselves and others to try to prevent infections”. Tommy describes examples of people giving sterile injecting equipment to others, assisting their peers in injecting in safer ways, sharpening ‘blunt’ needles when new needles were not available, and treating wounds and abscesses.

“I think can be really powerful for health professionals like myself to try to understand the other things going on in people’s lives and how hard they’re working to try to stay healthy.”

It is important to highlight practices of self-care and mutual care because they run contrary to the narrative that people who inject drugs are unconcerned about risk. It is also important to highlight practices of self-care and mutual care because of the evidence that they may be filling a vacuum created by the absence of medical treatment and harm reduction programmes.

Due to the transmission route of bacterial infections, it can be easy to focus on interventions at an individual level, and specifically on interventions that equip people with the knowledge, skills, and equipment to inject as safely and hygienically as possible. But as Tommy’s paper suggests, “individual-level behavioural interventions alone are probably insufficient to reduce risk without changes to the social and material conditions within which people prepare and inject drugs, and receive treatment for infections”.

Listen to the full episode of the Addiction Audio podcast to hear more from Dr Thomas Brothers, including about how to conduct a ‘thematic synthesis’ and how stigma manifests in the lives and interactions of people who inject drugs.

Original article: Social and structural determinants of injection drug use-associated bacterial and fungal infections: A qualitative systematic review and thematic synthesis. By Thomas D Brothers and colleagues. Published in Addiction (2023).

by Natalie Davies

Editor’s note: Quotes have been condensed and edited for clarity.

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