Over the past few years there has been a steady increase in harmful drug use in the city of Tshwane. Doctors, clinical associates and social workers from the University of Pretoria (UP) realised that there is a major shortage of services in the city to help people who use drugs. This led UP’s Department of Family Medicine and the City of Tshwane to come together to create a safer healthier city. Research shows that existing drug related programmes, such as rehabilitation and going “cold turkey” have little positive effect. In fact, they often create more damage by further isolating people who use drugs and accentuate the social stigma. Research also shows that while there is a lot of harmful drug use in the city, substance use is often a coping strategy for underlying problems in the home and community.
The Community Orientated Substance Use Programme, or COSUP is an initiative between UP’s Department of Family Medicine, the City of Tshwane (who funds the programme), and the Gauteng Government (the Department of Health and the Department of Social Development). It aims to provide meaningful and effective community based support for the people who use, support or are affected by harmful substance use. It focuses on evidenced based approaches to restoring functionality, improving health and reducing the social destruction of harmful substance use.
In COSUP, harmful substance use is regarded as a medical condition rather than as a criminal activity. Rather than forcing people to stop using drugs, it works closely with users to find out what their goals are and what they need to do to achieve them. Where users do not want to stop taking substances, COSUP helps them to access health services and support from their clinics. COSUP pays particular attention to both informing and responding to users’ high risk of contracting HIV, TB and Hepatitis C. Sister Linda Makala, based at the COSUP sites in Mamelodi, says harm reduction and safer use of drugs is a fundamental teaching and practice of COSUP. Makala even teaches users how to tie their injection site is in a way that is less damaging to the veins. The Needle Syringe Programme (NSP) offers new clean needles in exchange for dirty ones. “The evidence that a NSP is effective is there and COSUP is showing that it can be implemented in a South African context,” says the Head of Department of Family Medicine, Prof Jannie Hugo. Opioid substance therapy (OST) is prescribed by the COSUP medical team to people who want to get off heroine. Results from both NSP and OST are proving effective.
Taking a harm reduction approach to substance use may seem controversial, but in fact, it is consistent with centuries’ old health care practice that in present day South Africa has led to the successes in HIV/AIDS management.
COSUP is part of a larger Community Orientated Primary Care approach to integrated district health. Through the combination of public health and clinical care, COPC is designed to provide generalist primary care that extends from a community based tier of service rendered by clinically supervised community health workers to people in their homes and facility services to health care facilities and services. Social workers and Clinical Associates play a pivotal role in the COSUP team of experts. They work through each person’s unique background and help them deal with the issues that are often the cause of their drug problem. The peer support component of the programme is also critical in keeping the individual in the programme. Peers are people who come from similar backgrounds whose lives have improved (as a result of the programme). Peers provide support and assistance and make sure individuals are on track to achieve their goals. Peers are a fundamental asset to the programme as the individual sees them as relatable and trustworthy. Peers stand as a beacon of hope for the person wanting a better life. The skills development component equips people with skills to be able to find a job and this has shown that often people will stop using drugs when their lives improve.
COSUP is a first-of-its-kind programme in the world and it is making incredible strides to ensure a safer and healthier city for all. This programme works because it is relevant and non-judgemental. It sees people who use drugs as human beings and helps them feel worthy again.
Dr Lorinda Kroukamp, Public Health Specialist in the Department of Family Medicine and Project Manager of COSUP, says that for sustainability of the initiative beyond the project’s period, the community based approach to harmful substance abuse needs to be integrated into the existing primary health care model. In order for a sustainable project to flourish that provides real support to people in need, collaboration between all sectors of primary health care needs to ensue.