Clinical Education Initiative [email protected]

BAREFOOT CEI DUH ECHO Stacey Rubin, RN

10/28/2020

Barefoot Medicine CEI DUH ECHO [video transcript]

00:08 Cherry, we can start the slides. I have no disclosures, here's my learning objectives. I hope folks can hear me okay. Today, the goal is to define the concept of Barefoot Medicine, to identify three health interventions that grew out of the Barefoot Medicine paradigm, and to understand the practical application of Barefoot Medicine as it relates to drug user health.

00:33 I have no disclosures. That was the first one. I could tell you I'm a Virgo, I don't know if that's a disclosure.

00:40 So here we are starting with Barefoot Medicine. Next slide.

00:45 And what is a Barefoot Doctor? You know, the first term was Barefoot Doctor, and it comes from Chinese in approximately the mid 60s. And it was a belief that all persons, no matter how poor or isolated or other, should have access to as tools. And towards that end, lay persons from the community or those that were committed to being of service, were taught to provide care to their comrades. Interventions and resources that were relevant and specific to the community were made available. And literally one of the reasons the term Barefoot Doctor was termed, as you saw the crew of medical providers was in fact barefoot going through, because these are rural areas. And also, folks often had been farmers and were barefoot in the rice paddies. And these were the folks that were being trained to do health interventions. Next slide.

01:42 The concept really is that Barefoot Medicine or the Barefoot Doctor meets people where they're at. So here we see again, from rural , the doctor going into areas that would never have access to medical provision before and really meeting people on their own terms. Next.

02:03 So when we expand it out beyond the doctor, and we look at well, what is barefoot medicine? Because here, our practice would include doctors and nurses and PAs and NPs and outreach workers and social workers, and anybody that has a focus on health. So the concept of Barefoot Medicine, how does it activate here? How is it actualized here? So we reach marginalized communities that are removed from mainstream public health messages. Barefoot Medicine breaks down the hierarchy of doctor patient relationships, there's an implicit power dynamic between doctor and patient. Barefoot Medicine because it is community based and because it's often having people from the community that are in fact the providers, it breaks down some of that implicit hierarchy. It provides population specific interventions and tools because again, it's a grassroots outgrowth of health. And it focuses on empowerment and self care. Slide.

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03:06 An adjacent concept to Barefoot Medicine is the concept of Mutual Aid. And I think particularly right now in our societies with the cultural uprising, we're seeing a lot of Mutual Aid, very practical Mutual Aid that's popping up. So here you have a community member walking around, we don't know what's in her bag. I am going to assume it's food and supplies that folks need. And then often when there is disaster relief, we see it here during COVID, we've seen it during Hurricane Katrina and Sandy, disaster relief is popping up in a very practical way. Food, water, first aid, free , because these are things that folks need right away. Again, without having access to either get to the medical center, or uninsured and not having access to ongoing medicine, or just sort of expanding outreach out. And we know that paradigm of wellness includes much more than just, you know, sort of siloed medical care, right? So wellness is having food, water, warmth, a stable place to stay, because there can be no sort of more specific medical interventions without those very basic needs met first. Slide.

04:27 So I'm so excited about the increase in visible Mutual Aid. I mean, we might say oh, Mutual Aid, it's always around, we help our neighbors, we help each other. But an articulated social concept of Mutual Aid will come and go based on what's happening in society. Most recently, we have seen a very articulated push for Mutual Aid. Mutual Aid as opposed to charity, does not connote moral superiority of the giver over the receiver, again a breaking down of that power hierarchy. Mutual Aid networks can provide goods and services directly in a decentralized manner. Again, need specific, population specific, emergency specific. They are dependent on core principles of community, education, and human decency. So this is a recent poster created during COVID, Mutual Aid outreach from someplace in the heartland of the country. I had many, many more slides, of all various versions of Mutual Aid programs that were popping up all around the country right now. But for the lack of time, we're only picking the most tasty slide. So just to let you know. Next slide.

05:53 So another adjacent concept to Barefoot Medicine and Mutual Aid is community activism. This slide is a snapshot of the Young Lords, which were a social justice, and much more than that, community activist group that was started in the 60s. With the Black Panthers that were most active in the west coast in Oakland, the Young Lords were active in the east coast in the barrio where I work, in East Harlem. And similar to the Black Lives Matter movement, which is why you're seeing a lot of this Mutual Aid vocalization coming. I think that the crossroads with the pandemic, the COVID pandemic, and the Black Lives Matter movement has started this thinking again about Mutual Aid. So back in the 60s, again, people were becoming, to use a current term, becoming woke in their communities as to like what is going on here? We are disenfranchised, we are not getting our needs met, we are being thrown under the bus. And we need to become active in our communities and make things happen. The hierarchy, whether it's the government, or the church, or the corporations, they are not meeting our our needs, right? So it's communities needing to take care of each other. So one of the things that I love so much about the Young Lords is that they were responsible for detox, acu detox becoming a lay person modality that is used ever since then and ongoing, in particularly in substance use areas, but also in HIV and in stress reduction and in alternatives to incarceration. So they took

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over a hospital in the Bronx, in the South Bronx, and there was supposed to be a detox rehab starting there for many years and it was stalled and stalled and nothing was happening. And they literally took over that building of Lincoln Hospital in the Bronx and started doing all kinds of things there, including daycare and food distribution and acupuncture detox. Next slide.

08:19 We might particularly have seen how activism, community based activism, can turn the tide in terms of health interventions. In my lifetime, AIDS activism was one of the first places that I started getting turned on myself to how we can do community activism and really ripple out changes in terms of health. So these are two, I guess they were ubiquitous in the early day of AIDS, throughout the 90s. The silence equals death imagery, and the government has blood on its hands imagery, and there was very aggressive community based activism that changed the landscape for provision of services to people with AIDS, or people at risk of getting AIDS, or marginalized populations. Next slide.

09:22 So where is this juncture? How does this all come together? For me, there's strands that create a tapestry Barefoot Medicine lying alongside the concepts of Mutual Aid, and grassroots, and community interventions, married to activism, because, you know, while we might say evidence based practice is what's gonna turn the tide and be the best things for interventions. That's something that happens once things have been funded and things have been studied and professionals have gotten involved, right? Because there's this evidence that has to be proved. So what do we do before that, and that's where community based grassroots activism with Mutual Aid comes in. And harm reduction has its roots in these tendrils. The images from early days of AIDS activism, we would take bottles of dirty needles and bring it to politicians and council members and supervisors, and it goes back to that government of you have blood on your hands. These were activists that were risking arrest and going out into the streets. Prior to the scientific piece of the evidence based practice, it was gut knowledge of what was gonna make a difference. And as we know, infection rates for injection drug users dropped from 60% infection rate of HIV, pre syringe exchange availability, fast forward a number of years with syringes available, down to something like 5%. Next slide.

11:15 So principles of harm reduction. Harm reduction is a set of practical strategies aimed at the reducing negative consequences associated with drug use. But it's also a movement for social justice built on a belief in and the respect for the rights of people who use drugs. This poster was a subway ad campaign that was sponsored by one of the syringe exchanges at the time, Positive Health Practice. And these were in the subway, in the New York City subway, similar to now you might see signs that are sponsored by the Department of Health about Naloxone and also about Suboxone and Methadone. These were posters that were in the train, my favorite. So in fact, it's a confluence of things. So you know, harm reduction is the practical strategies, but it's also a philosophy. And it's the synergy that creates the alchemy of change. Next slide.

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So who are some of the leaders that took to the streets from a grassroots place, from an activist place? Who were some of the folks that I just want to make sure people are aware of, because what we see now is based on top of the roots that they planted. So Dave Purchase was one of the first people that was high profile, he founded an organization called NASEN, the North American Syringe Exchange Network, back in 93. And NASEN, this is before there was any kind of place where people that were doing harm reduction work and syringe exchange work, there was no Nexus. And by Dave setting up NASEN, it was a place where people from around North America could gather. When I say a place that would be an annual conference, and it was a place where folks could gather and exchange ideas. He himself and his organization would send boxes and boxes of syringes throughout the country to activists that then set up grassroots programs. This is before syringe exchange was legal and before there was any availability of funds to get needles, before amfAR had it even on their radar, and certainly before there was evidence based practice that allowed for funding. So this was an activist initiative to start syringe exchange around the country. And without Dave and his crew sending out needles, there would be a lot of places that would never have had syringe exchange until at least a decade later. Next.

14:01 And now we see we've come so far, this is a vending machine in Las Vegas where you can buy your sharps. Next.

14:14 The next step in syringe exchange, and again currently we might have the evidence but we certainly don't have the practice, is the safer injection facilities or harm reduction centers. There's a bunch of different names for them. There's been some approval in different parts of the country, but there's been no out safe injection facility been able to open in the States. So there are in Holland and in Canada, they have places where folks can go and can get their harm reduction supplies. You see at the top, this is an image of one of the safe injection facilities. And then this is the kit that each person would be given upon arrival. And at the bottom you have some activists out of California, there's a referendum on this ballot now in California to get safe injection facilities open. Probably California will be the first state where they have one. Philadelphia, it's been approved, but they have so much pushback from the community that they've been unable to open a spot at this point. But again, you know, without the piece of folks doing this in the streets, without this Barefoot Medicine paradigm, without the concepts of Mutual Aid, and without the concept of activism, you know that's what it takes in order to get some of these thinking outside of the box and forward thinking interventions to happen. Because the communities that we work with, drug users, they are certainly disenfranchised. They're marginalized, disenfranchised, and regularly thrown onto the bus, right? So you know, regardless of their color, their gender, where they are in the country, the fact that they are drug users and out drug users, right away nobody wants to spend much time or energy to give them what they need. And when I say no one, I don't of course mean organizations that are married to working with disenfranchised populations, right? So we know that helping these populations helps the community at large, and we don't want to have them isolated or separated. But it takes an activist mentality and thinking outside to kind of push these things forward. Next slide.

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16:55 So we know that overdose has been the crucial issue with our population. Next slide.

17:06 And Naloxone has been the major intervention that we have at our hands, aside from information and sharing of information, and has been a concrete tool that we have available to drug users to help reduce the risks of overdose. So as we know, Naloxone is a generic drug, it works to reverse an opioid overdose by bringing back breath, that's as the layperson definition for it. There's no potential for abuse, and it's used with efficacy in emergency rooms and ambulances in the country for over 40 years. Give some stats about the numbers of people, this is a bit of an old slide. So I'm sure that there are many, many 1000s of more lives that have been saved. But barriers to accessing Naloxone remain and funding is urgently needed to ensure it gets into the hands of the real first responders who are people who use drugs, their families, and friends. Next slide.

18:03 So Dan Bigg was also another person here in the harm reduction movement, he was the co founder of Chicago Recovery Alliance and coined the term "Any Positive Change." And he was the pioneering force behind take home Naloxone. And again, taking it out of the emergency room and traditional medical settings, and putting it into the hands of drug users and their communities. He would show up at conferences with a big duffel bag of Naloxone, and just give it out to the harm reduction community and seeding what then became Naloxone distribution from Departments of Health and different funded entities. So again, it was taking that what we knew to be best practice, prior even to the evidence base, and bringing it out into the community. Without people like Dan, there would be no Naloxone programs. It's about bringing it out there and not asking permission, perhaps asking forgiveness. Next slide.

19:12 And we know that there's a lot of information now about Narcan and the kit on the top is from the Department of Health. We as an overdose prevention program, at our at REACH, give out those kits and do monthly trainings for the community. At least monthly and more. And then all this messaging, these are different stickers and posters that have been sort of population specific. So we know that there's a lot of messaging around Naloxone now, including government support. Next slide.

19:54 So messaging and how we talk about drugs is really important. The concept of being culturally specific and speaking language that our patients and communities can connect with, making sure that things are not alienating. So, "Fuck Safe Shoot Clean" is out of Austin, Texas. And I believe "Flood the Streets with Naloxone" is out of Philly. And these were two favorites. I love these. Next slide.

20:24 So when we talk about drug user health and communication, part of it is a reverse of the 'just say no' concept, right? So instead, it's about giving open honest information about drugs and

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drug use, not about 'the info I'm going to give you is just don't do it.' But instead, again, speaking a language and addressing practices that are real and realistic. So a lot of harm reduction programs will have portals for drug users to make their own information to share with the community. So we used to make magazines or posters that would exchange information in a way that was more palatable. Next slide.

21:10 And these are some Barefoot Medicine interventions. So Hot Pants is all about self gynecology. Coming Off Psychiatric Drugs is how to navigate that world with psych meds and herbs and other ways to come off drugs. The Drug Interaction is about what what's the connection between prescription drugs and street drugs. And then this is the old Barefoot Doctor's manual. Now the point of these is often patients are not able to speak openly and honestly with their provider about their behaviors. So it's taken this Barefoot Medicine, harm reduction intervention, kind of thought process of 'okay, so how do we talk to somebody about Prozac and heroin?' Again, not just putting the fear of God in them that you're going to have a hard time, but giving practical interventions. And that's really, if you walk away with anything about what is Barefoot Medicine, it's about access but it's also about open, honest conversations about people's behaviors, and how to help them with those behaviors. Not from the sort of hierarchical stance of, 'I know what you should do, and this is what you're gonna do,' but more in a partnership way. 'This is what's going to happen if you do this. This is what can help if you do that,' and so forth. Next slide.

22:38 So again, speaking a language and using imagery that speaks to folks from the community. So these were a wonderful series of cards that was put out, drug specific. So it had the drug on one side, but then very practical information on the other side of the card. These were outreach cards that were given out in clubs and at raves. Erowid, by the way, the organization Erowid.org is a wealth of information all about drugs, and everything related to drugs. So I invite you to go to the Erowid portal and do a little exploration. Next slide.

23:18 So drug checking again, this is something that's been happening, but is one of the sort of frontline ways of Barefoot Medicine interfacing with drug user health. It's a way of testing pills and the other things that are in the actual medication. It helps people who use drugs make more responsible decisions around risk and around consumption. Organizations like Dance Safe sell drug testing kits to the public, and some health departments and syringe exchange programs have also begun distributing fentanyl test strips. Next slide.

23:54 So this is Dance Safe at an outdoor concert, probably one of those multi day concerts. So they would set up a tent and they would have little chill out space there for safety and you know, give out water. And they would have access there to do actual drug testing. So people were able to test their ecstasy, their GBH, their ketamine, and see in fact what was in there and then make an informed choice. It also of course, was a place that people could go and get a lot of harm reduction info and a place if people were having a bad trip, could go and get medical help. And

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again, the medical help usually in like with groups like Dance Safe, were street medics. Street medics are a great example of Barefoot Medicine, street medics are trained in the community. Sometimes there'll be a few people that might have a credential, but they train a larger pool of lay folks on how to do interventions. There's a big street medic movement that are part of a lot of the Black Lives Matter protests that are happening. In some places where there's been a lot of aggressive action, there's quite a large movement of street medics. Next slide.

25:11 So this is a fentanyl test kit. This is fentanyl information. If you're using fentanyl, how do you do it safely. And these are little test strips. We were you know, a few years ago, the test strips were a lot more useful because the fentanyl was not as prevalent in the heroin. So you were able to test your heroin and see is there fentanyl in there or not? Now, any bag of heroin in New York I could say is going to have fentanyl in it. The test strips don't tell us how much fentanyl or what version of fentanyl, but these are still really good harm reduction interventions just to get folks thinking about drug testing. It's also not viable to test every single bag of dope. So we make the assumption now that all the dope has fentanyl in it. But this was a great intervention again, a couple years ago when fentanyl was starting to get on the scene, just teaching folks how to make positive choices. Next slide.

26:18 So opening the door to health, I mean, in a lot of ways, that's what Barefoot Medicine is doing. It's opening the door to health, so that you can have open honest conversations about drugs and drug use. It breaks down information clearly in ways that are subculture specific. One of the things that's really important is to make sure you're understood when you're sharing information. Quite often I have found, even when I use the term opiates, it's amazing how many of my opiate using clients don't know that category of drugs, that it's an opiate. So sometimes things that as professionals we might take for granted are in fact, not the way or the term that drugs are being talked about and used on the street. So it's really important to almost have that sort of translation. It's really important to offer friendly medical services with a non-judgmental, non- punitive provider. If you're using Barefoot Medicine concepts, your partner agencies have to be amenable to the way that you talk about health care. If you refer folks to places where they're going to be having a very different experience, then they're not going to be as open to continuing care. One very important thing is to provide ongoing care so that there's the opportunity to build trust. One of the things that I love about our program is that they're able to come and hopefully see the same provider or the same pool of providers. Often disenfranchised folks, when they're using only the emergency room with the urgent care, they don't have any consistency of care and they're not seeing the same people. So your Barefoot Medicine can at least provide the opportunity for that, even if you're going to be bridging folks with places that are not consistent in their care or their personnel, the Barefoot Medicine person can be the one consistency. And of course, the main goal is to promote and encourage positive choices, while also supporting self determination. Getting rid of that hierarchy and that sort of power dynamic that's often there between providers and patients. Next slide.

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So a few of the tools I wanted to share with you, some of the very specific intervention tools. Part of it is you know, there's not as clear an algorithm, right? So when you're creating tools and intervention from a street based place, you have to identify of course, the problem or the issue. You want to envision it along a spectrum, how can I reduce the harm? So Narcan, for instance, it's not getting rid of the possibility of overdose, but it's an intervention to help reduce the fatality risk with overdose. Same thing with syringe exchange, it's not getting rid of all the problems that come with injection drug use, but it's reducing the harm of a tainted needle. So you want to envision the intervention along a spectrum. You want to identify the resources available. Sometimes I'll tell folk, 'there's the Cadillac but what I have for you is the Volkswagen.' You want to develop interventions that meet needs somewhere along that spectrum. And of course, you want to evaluate your interventions and then tweak them so that they can get better or retire them. You know, like the fentanyl test strips, at a certain point those might be retired because they're not cost effective and because we already know that there's fentanyl in everything, or they might have to get tweaked so they give us a little bit more intervention of more information. Next slide.

30:13 So a safer crack smoking kit. These were, actually the first time I saw a safer crack smoking kit, it was at Bridgeport, Connecticut. And I want to give a shout out to Mark Kinsley, who used to run their needle exchange mobile unit there, and this is back in the mid 90s. And at that time, a lot of harm reduction programs were in fact not seeing injection drug users, but we were seeing crack smokers. And so it was what can we do to help reduce some of the risks of smoking crack? So what you're seeing there is a mouthpiece and a little piece of choy boy. So the choy boy is used as a filter in the crack pipe. And of course, the mouthpiece obviously, is the mouthpiece. And one of the biggest risks of actually smoking crack is that folks would get all kinds of cuts and burns on their lips, and if they were then sharing and using just the pipe without the mouthpiece, it could be really dangerous. And the same thing with the choy boy, folks often didn't have access to it and so would use really, really old ones that would eventually breathe in the particles. And so by harm reduction programs giving out safer crack smoking kits, were able to of course not get rid of the harm of crack smoking, but reduce some of the risks and the harms associated with. Next slide.

31:41 Cold remedy kits were things that were more like almost like a calling card. So outreach workers would give out little kits that had a little cough syrup, some vitamin C, some cough drops, a pack of tissues, maybe a couple of tea bags. And no, it wasn't going to cure the cold, but when we think about Barefoot Medicine, what can we do to help that's going to make somebody feel just a little bit better. Also express some concern and plant some seeds of self care. So these cold remedy kits were extremely popular and are something that is not so controversial. Right? So your program, there's nothing in there that somebody is going to say, 'oh, well, this is too risky in terms of whether it's our funding or our reputation.' We used to get, we would give out sometimes herbs on the street and there was then a lot of pushback like 'well, how do you know the herbs won't interact? Or how do you know that this is in dangerous?' Some of us as activists were willing to take that risk, but some programs that might not be okay. So something like the

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cough and cold remedy kit is pretty benign to give out. But it again, it plants those same seeds of self care and also of concern. Next slide.

33:02 Piercing kits were again developed at a particular time when a lot of our population was involved with unsafe piercing and sharing of equipment. So these were kits that had an autoclave needle, they had the tools you needed to do safe piercing that were disposable and one time use. And we made these in conjunction with a professional piercing salon. And again, a lot of it was about planting seeds of self care, and also showing our participants that we knew what they were involved in and we weren't judging it, and we wanted them to be as safe as possible. Next slide.

33:47 Boot rot was something that a lot of our participants struggled with. And so again, we would do these interventions with a foot soak, and some essential oils, clean socks, baking soda. I'm giving you these examples because they illustrate addressing a practical need, and then how to create an intervention that addresses it, and how to move forward and make it happen. So for instance, if you're not dealing with a homeless population, boot rot might not be an issue. But if you are in let's say, you know, a very cold climate up in Buffalo, frost bite might be the bigger issue. So again, if you look at the issue, and then think about what are ways to help. No, we can't fix the whole problem of homelessness and not having shoes, but I can give somebody some dignity with a foot bath, and a fresh pair of socks, and a spray bottle of medicine. When I say medicine I mean, in this case, tea tree and lavender oil. Next slide.

34:50 Basic self care can be taught alongside interventions, things like clean socks, taking off shoes, airing out feet, drying shoes and socks before putting them back on, using antiseptics if possible to prevent fungus. Encourage any small step towards healing. And again, this can be with any issue. It's about the very practical things that we can do as lay people. Next slide.

35:17 Overall, of course, we know that reducing stress is the key to wellbeing here you see somebody with the auricular acupuncture in her ear. That's a street yoga group, a group for yoga. A lot of programs now, harm reduction programs, offer yoga. I know we started doing that at REACH. And then of course, some herbs. There's wonderful herbs that can be used to help with detox and stress. And again, it's going to be based on how comfortable you or your program feel about discussing herbs, but there's a wealth of information out there. And we know that reducing stress overall is going to increase drug user health. Next slide.

35:57 Takeaway message, seek opportunities to express care and concern both in attitude and in practical intervention. A cup of tea, tissues can go a very long way. Plant seeds of self care, inspire healing and whole person awareness. The people we work with are not just drug users, they're drug users and mothers and daughters and fathers and carpenters and teachers and musicians, right? Support and reinforce people's ability for self care because as we know,

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planting seeds of self care is what helps folks to plant seeds of self love and therefore behavior change. Next slide.

36:41 Barefoot Medicine is an opportunity to plant seeds of wellness and self, somehow care got taken off that slide. But again, I don't have to say the same things. But to me, drug user health is not just about what the professionals can do, but about what we as a community can do to bring in drug users and to make people not feel as marginalized and to nurture seeds of self care and self love. Next slide.

37:13 Because of course, it's all about healing in any way, shape, or form that we can share.

[End]

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