The number of individuals engaged in structured drug treatment programmes in England has declined over recent years, but this has been a trend which has occurred alongside another development, that of an increasing number of drug related deaths (DRDs), culminating last year with ONS reporting the highest number of DRDs on record. Delivery of needle and syringe programmes (NSP) in England is not monitored in the same way as drug treatment programmes, at least at a national level, but local monitoring systems provide information which points to a different picture than that which national drug treatment programme data might suggest.

In the North West of England, NSP provision within the nine local authorities which cover Cheshire and Merseyside has been monitored for over 25 years by Liverpool John Moores University’s Public Health Institute (PHI), with comprehensive coverage for the last 10 years. Over 1.9 million needles and syringes were distributed across Cheshire and Merseyside during 2016/17, and of these over 1.25 million were to people who inject psychoactive drugs (including heroin), the highest number on record. When this data is matched to that from the National Drug Treatment Monitoring System (NDTMS), the proportion of individuals injecting psychoactive substances who were not in structured treatment within the past year was 80.1%. This is the first year that we have been able to match the data looking at this cohort only, so it is not yet clear whether this is a growing issue or consistent with other years. Either way, it appears that there is a substantial proportion of individuals injecting psychoactive substances who are not currently in structured treatment.

NSP services within Cheshire and Merseyside use a client attributor comprising of initials, date of birth and gender as part of PHI’s data monitoring, and one of the regular queries concerns the authenticity of this attributor. In theory, a random fictional attributor might be supplied by clients who fear their anonymity could be breached, particularly in the case of services where the NSP is located within the same building as the structured treatment provider. Two factors we’ve explored suggest that this may not be the case, or at least not extensively so. In the first place, research undertaken by PHI over the summer of 2017 surveyed agencies and pharmacies delivering NSP from across the spread of local authorities and asked them about this specific issue. Over two thirds (72%) responded by stating that they believed individuals using their service used the same consistent attributor on each visit. Moreover, as part of the drug related death monitoring process, operational in several of the same local authority areas, a substantial number of individuals whose personal details are confirmed to be correct by both the treatment service and the coroner have matching NSP records. This suggests that there is widespread use of genuine details, and that the numbers highlighted by the system will probably not be wildly over inflated. At the least, since the same model based on attributors has been used for counting the number of individuals using NSP for the last 25 years, the direction of travel is important. If we look solely at the number of NSP transactions without looking at individuals specifically, we can see that they have doubled over the last 3 years. With only 19.9% of NSP client attributors matching to data from NDTMS, even if this figure was doubled, it would still represent a majority of individuals using NSP who are not engaged in treatment.

The 2016 report from the Advisory Council on the Misuse of Drugs (ACMD) identified a number of potential causes of the recent upsurge in opioid related deaths, including the ageing drug using population, changes in the availability and purity of heroin at street level and socio-economic changes (i.e. increasing deprivation and cuts to support services in deprived areas). However, it also suggested that changes in the commissioning and provision of drug treatment might be a factor and it is accordingly vital that the large numbers of individuals outside of the treatment system do not go unnoticed by those commissioning services. With research showing that individuals using heroin become more vulnerable to death from overdose as they grow older, the increasing proportion of people who use NSP services that are older highlights the importance of ongoing engagement in order to encourage attendance in treatment services and monitoring numbers to ensure the problem is not becoming exacerbated. It is also important to note that treatment has been identified as a protective factor by Public Health England (PHE) and other bodies: “There are risks associated with the move towards abstinence. For example, there is a higher risk of death for heroin users who have left Opiate Substitution Therapy (OST) than for those who stay in it, especially in the first few weeks.” (ACMD, 2016, p31). While elements of the latest guidelines on clinical management of “drug misuse” focus on the importance of not being solely recovery focussed, the high number of individuals outside of the treatment population make them a vulnerable group, particularly in the light of funding cuts which the ACMD warned would result in a dismantling of the drug treatment system, citing the lack of resources as “short sighted and a catalyst for disaster.”

Continued monitoring of NSP provision by local authorities is more important than ever to provide a clearer picture of service need, and to gain a more rounded picture of the prevalence of injecting substance use compared with focussing solely on nationally reported treatment data. Given the increasing move from agency to pharmacy for NSP provision, it’s vital that those delivering NSP services in whatever setting are equipped with the expertise and integration to mainstream treatment services so they can offer individuals who inject the same quality of service. People who inject drugs have a right to be well and to be able to access the same health related interventions as those who have made the decision to go down the route of recovery. Being outside of the treatment system should not make those who inject outsiders from good quality healthcare.

NNEF

Anyone with a manager will probably recognise that situation where you’re enthusiastically presented with a ‘great opportunity’, but all you hear is a lot more work is coming your way! Two years ago my manager announced “I think you should enrol on our Public Health Masters programme”. My initial response was a slightly less than enthusiastic “I’ll think about it”. It was, after all, many years since I’d written an academic essay, sat an exam, or worse still completed a dissertation project. What if I couldn’t do it? To quote from the philosophy of Homer (Simpson): “…you tried your best and you failed miserably. The lesson is never try” ^[1]. However, that’s the other thing you might already know about managers; they aren’t so good at taking ‘No’ for an answer. So after some persuasion, I reluctantly agreed, “Okay, but I’ll just take a couple of modules, I’ll see how it goes”.

So now having just completed my final project on the Public Health Masters programme, and reflecting on the last two years, I can appreciate how much I’ve learnt. Yes, the course did involve more work, but it also built on my existing knowledge and experience. The lectures have been a great forum for discussion, and I’ve had the chance to hear many really interesting lecturers and guest speakers. And what about all those essays? Well, luckily there are some really great study support sessions available at LJMU. I’d particularly recommend the session for ‘critical essay writing’, which was one of the first support sessions I attended. As a result, I know how to structure and write those essay assignments.

In the introduction to his book ‘The Health Gap’ Michael Marmot^[2] talks about his experience whilst training as a doctor in the 1960’s. Realising that both behaviour and health are linked to people’s social conditions, he observed that “treating [the patient] with pills might help to put out the fire. But should we not be in the business of fire prevention as well” ^[2]. This revelation for Michael Marmot came with the realisation that is was possible for him to study how social conditions affected health and disease. ‘Epidemiology’ which is often referred to as ‘the cornerstone’ of public health, considers the distribution and determinants of health-related states, and the application of epidemiology is concerned with the control of diseases and other health problems.

The revelation for me was the realisation that these concepts of public health policy, epidemiology and research, that all featured as modules in my course of study were also already part of my current job. Working within the Public Health Institute’s intelligence and surveillance team, our monitoring and data collection systems provide intelligence and evidence to inform public health policy and practice.

Whether like me you’re already working in a Public Health related field, or if you’re looking to start a career in Public Health, our study programmes at the Public Health Institute ^[3] are a great opportunity to broaden your knowledge. Whether you’re interested in an Undergraduate, Postgraduate or even a Continuing Professional Development (CPD) ^[4] course, they build on your existing knowledge and experience and are really valuable for either your current role in Public Health or the one you aspire to achieve.

So “the lesson is never try” - you might surprise yourself.

References

After a lifetime of visiting cold Northern towns, the furthest place I’ve ever got to with work is Reading, and for all the many nice things you can say about Reading, it’s probably not on most people’s “places to go before I die” list unless you’re a huge Mike Oldfield fan. So when my poster was accepted at the 25th International Harm Reduction Conference which took place in Montreal last month, it was a lifetime’s dream come true of coming into work with my passport. The conference itself has its roots in Liverpool where harm reduction first came on to the agenda in the 80s and in the context of HIV’s appearance in the UK made our city one of the pioneers of a new way of thinking, endorsed by government policy which despite its calculating ruthlessness in other areas, did not want to on balance risk a panicked public fearing for their lives. The Harm Reduction Coalition describes harm reduction as “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.”[i] You could argue that the ultimate negative consequence of using drugs is death, and so at the very least, harm reduction if it’s about anything should be about keeping people who use drugs alive. So much of the conference focussed on preventing drug related deaths, and a common theme was the need for promotion of naloxone. Naloxone is a medication used to block or reverse the effects of opioids and used to treat overdose in an emergency situation, and although used in emergency departments since the 1970s, has only recently become more widely available in some areas of the world to the general drug using population and support services, a practice which is widely accepted as being one which saves lives. [ii]

But policy development does not occur in a vacuum and part of the reason for the intense interest around the urgent roll out of naloxone is the massive increase in drug related deaths, both locally and internationally. Drug related deaths recently reached the highest level ever recorded in England and Wales, with 3,674 drug poisoning deaths registered in 2015 including 1,201 heroin related poisonings, a doubling of the 579 deaths recorded in 2012. The picture is the same globally, with opioid overdose deaths in the USA increasing by around 180% since 2002. In Vancouver alone, 174 individuals died in one week in 2017, with fire and rescue services in some provinces stating that they now regularly deal with more call outs for overdose than for tackling fires. [iii]

Canada’s Minister for Health Jane Philpott was invited to speak at the conference opening ceremony and accepted the invitation but was met with a small but significant number of people holding up protest banners and turning their backs to her as she spoke. I turned to my colleague Howard who was out there with me and said something along the lines of “they don’t know how lucky they have it. Can you imagine Jeremy Hunt turning up to a conference about harm reduction?” (Let’s face it, Jeremy Hunt probably doesn’t know what harm reduction is). But then one of the activists spoke – this wasn’t about protest for the sake of protest. They were making a public stand because this wasn’t just something that should be on the agenda, this was an urgent national crisis. If any other group were dying in the numbers that drug users were, people would be up in arms about it. When the SARS disease hit Canada, affecting less than a dozen people, emergency task forces were quickly established and millions of dollars were made available for a rapid national response, billions of dollars in some countries [iv]. And yet here were thousands of people dying, some of the most vulnerable members of the population, and the government’s response was thoughtful and serious, yes, but not anywhere near rapid enough or well enough resourced to potentially do anything about the hundreds of people who would die each week without action.

And so I came away from the conference thinking about the work that we do here at PHI to support local authorities with looking at drug related deaths and what they can do locally to at least attempt to stem the rising tide. Chairing those panels feels like the most important work I do within PHI since for all the data I stare at on a screen each day, these are real life individual cases, people who aren’t here anymore, and they should be but as a country we don’t allocate proper resources to this issue. If it was my brother or a parent or best friend, I’d want to stand up and shout – FFS, do something about this. The war against the poor and vulnerable as we’ve seen in the last two weeks can be a passive thing more than anything. To populations that are hidden away from the general public and whose deaths are so common that they don’t even make the inside pages of newspapers, the problem isn’t a group of activists disrupting a sympathetic conference to shout about it, it’s that more people don’t do that. If we don’t demand action in the same way we would for any other emergency, then those deaths become one more avoidable statistic. Fighting inequality and supporting people to live well is at the heart of public health, so we need to say: this is a crisis which demands national action now.

[i] http://harmreduction.org/about-us/principles-of-harm-reduction/
[ii] https://injepijournal.springeropen.com/articles/10.1186/s40621-015-0041-8
[iii] http://globalnews.ca/news/3122510/fentanyl-overdoses-killed-hundreds-of-canadians-this-year-experts-say-2017-could-be-deadlier/
[iv] https://www.ncbi.nlm.nih.gov/books/NBK92479/

In both the developed and developing world poverty is linked to poor health, whether biological, psychological or environmental. Economic disadvantage is a cause of poor health (people are deprived of education, resources, or access to healthcare) and a consequence of poor health (good health is an asset upon which livelihoods depend).

The World Health Organization defines poverty using five core dimensions, which incorporate income and work, health and education, empowerment and rights, status and dignity, and security and risk. However, increasingly the harms associated with poverty are being shown to be proportional to the size of the gap between rich and poor, implying it is socioeconomic inequality which drives health harms rather than poverty itself. In other words, the key determinant is the distribution, not the absolute level, of wealth.

At a fundamental level poor environments are less healthy; the urban poor in developed countries have more fast food outlets, more off licences and less green space than their rich friends. As a consequence, people of lower socioeconomic groups have poorer diets, drink more alcohol and exercise less. But the difference in behaviour between the rich and poor cannot simply be explained by their environments; socioeconomic health gradients are found even where health behaviours are free. People of lower socioeconomic positions use less preventative healthcare services and have stronger beliefs in the influence of chance on their health.

Consider the glass ceiling effect of poverty on intelligence. Among those of favourable opportunities, variation in IQ is almost entirely due to genetic differences, among those of less favourable opportunities, variation is almost entirely due to environmental factors. Whether you are a product of nature or nurture depends on whether you are rich or poor. More profound than that, an individual may be both an expression of nature or nurture at different times of the same year. A study by Mani and colleagues[1] found that Indian farmers showed diminished cognitive performance before harvesting their crops (when poor), compared to after harvest (when rich). Their study implies that poverty itself impairs cognitive function; they argue poverty-related issues consume mental resources leaving less for other functions.

I have spent six years (and counting) working on my PhD which sought to understand why people behave in unhealthy ways despite knowing the risks to their long term health. I tried to quantify and interpret various behaviours in an attempt to make sense of seemingly senseless choices. My results indicated that people from socioeconomically disadvantaged environments behaved in unhealthy ways and that such behaviours might make sense given the trade-offs that people face. If you do not have good opportunities for education, employment or secure housing, behaving in a way to maximise your short term pleasures (whether eating unhealthy food, drinking or smoking) might be your best choice, despite the likely long term costs. Poor people have consistently been found to give greater weighting to present over future outcomes.

In public health we spend a lot of time picking up the pieces. We try to help people who are addicted to drugs, who are dependent on alcohol or cigarettes, and we try to make environments healthier and happier. In my day job, I collect and share accident and emergency department data, a major focus of which is preventing violence, whether directed towards oneself or others. A lot of monitoring work is nuanced and complicated but violence prevention work can often be reduced to a simple trend – violence is associated with, and predicted by, poverty. The intervention needs to be here, in this deprived area.

Thankfully violence in the UK is on the decrease but that doesn’t mean the inequality gap is reducing. The number of households that fall below the minimum standard of living has risen from 14% to 33% in the last 30 years, 18 million people currently cannot afford adequate housing, 1.5 million children live in households that cannot afford to heat their homes, half a million children live in families where their parents cannot afford to feed them, those who are poor are typically multiply deprived, and almost half of the working poor work 40 hours a week, meaning full time wages are too low to support families.[2] All the while, the wealth of the richest continues to explode.

While health is high on global and national agendas, it seems very unlikely that we can improve population health without addressing widening inequalities. The key to initiating change is perhaps to inspire others that change is possible, that the status quo does not need to be accepted and that power can be wrestled from the hands of the few and into the hands of the many. This blog was written as we approach a general election in the UK, and at a time when over one million adults are not registered to vote and 34% of those registered did not vote in 2015. I have not written this blog with the election in mind but it seems like an opportune time to consider the health consequences of policies which lead to widening inequalities.

[1] Mani, A., Mullainathan, S., Shafir, E. and Zhao, J. (2013). Poverty Impedes Cognitive Function. Science. 341. 976–980.
[2] Poverty and Social Exclusion. (2014). Key Findings. http://www.poverty.ac.uk/pse-research/facts-and-findings.

There’s been a lot in the media recently about the prisons in England and Wales. They’re overcrowded and under-staffed. There’s been an increase in violence, in terms of self-harm, suicide, rioting and assaults by prisoners on each other and on staff. New psychoactive substances (NPS) have become a popular drug choice as they’re difficult to detect through conventional drug testing methods. Spice, a synthetic cannabinoid, is the most common NPS used in prison and seems to be part of the problem with increasing violence. As well as a general interest in prisons and the history of prisons, in the past I’ve visited around 35 prisons as part of my work at the Public Health Institute. Also, my brother was a prison officer for almost a decade.

Recently when reading another news report on the issues in the prisons in England and Wales, this got me thinking about my visit to San Pedro prison in La Paz, Bolivia, when I was travelling in South America in 2009. San Pedro prison is a bizarre tourist attraction. And it’s certainly a unique prison.

Rusty Young’s book, Marching Powder, is probably what made San Pedro prison become so popular with tourists. The book describes the encounters of an English prisoner who became known for offering tours in the prison. So why did I visit San Pedro prison? I was intrigued and fascinated that you could so easily have a tour in an operational prison. At the time I didn’t know much about the prison and hadn’t yet read the book, but other backpackers I met had described it as a prison like no other and a must see in La Paz.

Although I was travelling alone, I went to San Pedro prison with some people I met earlier on my travels. I don’t think my parents would ever have forgiven me if I went there on my own. We arrived at the plaza outside of the prison and waited to be approached, as advised. We paid our entrance fee and were taken over to the prison gates. We signed the visitors’ book and then had a number written on our arms so that we could be identified and released at the end of the tour. We were introduced to our tour guide and bodyguard, both of which were prisoners. That’s how easy it was to get into San Pedro.

So what makes San Pedro prison so unique and appealing for tourists? It’s a once in a lifetime opportunity to visit a prison like no other. It’s a community within itself and you basically need to have money to survive in San Pedro. You need to buy everything; food, clothes, medicine and even a roof over your head. If you can’t afford to buy a cell, you can get a mortgage, rent one or rent a space in one. And if you can’t afford any of these options then you’re homeless within the prison. There are various zones or ‘neighbourhoods’ within the prison, and the price of housing varies from the poorest to wealthiest areas. Although it’s a prison for males, their wives and children often live there voluntarily, but are free to come and go, because it’s cheaper and deemed safer. Yes, I’m still talking about a prison.

Walking through the prison we saw a gym, restaurants, bars and shops selling groceries and souvenirs. There was a football match being played and children playing outside. The prisoners, women and children were going about their daily lives as anyone would outside of prison. Every now and again I was reminded that I was in a prison, for example, when we were shown the “swimming pool” as it was known, which is often used to drown rapists and child abusers.

Tourism is a huge income for the prison. Tourists can pay for tours, food and drink, gifts and even cocaine. Cocaine is the largest source of income for the prison. As well as selling it within the prison walls, it is sold outside. I imagine it’s easy to traffic drugs when so many visitors and family members come and go as they please.

So where were the prison officers? They were at the gate, monitoring who was entering and leaving the prison. But they were nowhere to be seen within the prison itself. The prisoners govern the prison themselves, managing everything from maintenance to healthcare to housing to education. Clearly this makes the management of the prison cheaper for the government.

Was I nervous on my tour of San Pedro prison? Of course I was, or at least I was in the beginning. I was in a prison without being escorted by an officer (I’m not sure the prisoner come bodyguard counts) and the prison was full of dangerous criminals; however the prisoners and their families were all very friendly and welcoming. Maybe the women and children being present made it a little less frightening. And because it didn’t look or feel like a prison at all. It felt like I was on a tour meeting the locals in a neighbourhood in La Paz, not in a prison.

During my degree I became fascinated by the role of culture in determining individual identity and ways of perceiving and being in the world. I had been encouraged to go beyond the commonly accepted and interrogate the taken for granted in society; perceiving the conditions, values and experiences that shape human behaviour, and how individuals used materials to construct their lives. Whether that was demystifying diverse eating practices, initiation rituals or how groups formed relationships of exchange, it required situating behaviours in a specific time and cultural context. Approaching such events relied on placing the subject of interest and their values at the centre of analysis and comparison, to understand things in their terms. I soon realised that this process provided the foundation of the research being undertaken. Both between the researcher and interlocutor in the field, and the network of varied skilled academics and students that made up the research teams at university, collaboration underpinned their ability to produce meaningful knowledge.

Leaving university I had been inspired to experience how knowledge could be applied to the solution of human problems. Joining the Centre for Public Health provided me with the chance to further develop my skills and work within a research department tackling health issues in local communities.

Initially, a daily routine of processing and analysing data, and producing reports for external partners led to a sense of disconnection from the people and issues behind these statistics. I began to wonder how much of the research and work was initiated top down perhaps at odds with the lived experiences of the subjects involved.

However, as I became immersed within the centre and have been able to witness the practices and values of the team around me I saw how the seemingly disconnected teams of statisticians, researchers, and administrators were embedded within a wider network. I observed how diverse skill sets are incorporated to tackle challenges, where the work of one team underpins and enables the work of another.

Working daily with different groups, such as those on the front line of emergency department or partners in community intervention organisations it became apparent that the needs of those affected by issues in daily life shaped the actions and values of those at the centre. As I witnessed, the taken for granted of our daily routines concealed a backstage of multiple actors that worked collaboratively to affect meaningful change in the lives of those people they studied.

As science evolves with new technology and an increasing varied society to become multi-faceted in its approach, increased collaboration provides the means through which advances are made. Indeed the progress of scientific knowledge in society can be viewed not as the intrinsic success of a particular method or model but the ability for multiple talented groups and individuals to contribute to and rigorously reassess the work of contemporaries and predecessors under shared principles and values.

The Centre for Public Health is situated at the heart of a complex web between those on the front line of health issues and the institutions seeking to affect change, utilising the skills of diverse set of people to respond to the needs of those in society. To witness the vital and impressive work that is undertaken by my colleagues and partners provides a sense connection and identity, where my own position fits into this wider collaborative network.

“No man is an island, entire of itself…” John Donne.