Dr Matilda Mohale does street medicine. She carries her supplies in a backpack. Her office is the streets of Tshwane. Her patients are the people who live on the streets Passion and purpose is what fuels her.
Mohale was first exposed to the health issues facing homeless people while specialising in Family Medicine at the University of Pretoria. She now works in the Community Orientated Substance Use Programme (COSUP). COSUP isan initiative of the Department of Family Medicine the City of Tshwane and the provincial departments of health and social development. It is the first publicly funded, city wide response to substance use in the country
COSUP assists people who use drugs where ever they live, including those on the streets. Working from 17 sites across the Tshwane Metro, it provides screenings, assessments, brief interventions and referrals for HIV, TB, hepatitis C and drugs. These are particularly important because people who use substances are at high risk for infectious diseases, but they often are unable or unwilling to get these services.
COSUP also offers counselling, safer using practices, opioid substitution therapy (OST) and needle and syringe exchange services. These interventions are all part of a harm reduction approach to substance use. Each aims to reduce the individual and public health risks of substance use by developing safer substance use literacy without requiring abstinence. Opioid Substitution Therapy or OST is a globally recognised medical intervention used to treat heroin addiction.Without OST, heroin addiction takes over a person’s life. They often switch from smoking to injecting because they need to have more and more to get the same effect.Also, they can’t stay for more than a few hours without it. OST helps break the cycle of having to relieve the nausea, sweats, pain and anxiety that comes with withdrawal from heroin.
The needle and syringe exchange programme or NSP is also critical to reducing the harms of injecting drugs.Especially in a South Africa where over 7 million people live with HIV,it is important to do everything possible to prevent an increase infection rates.This is done by offering people who inject drugs clean needles in exchange for the ones they have used.
Like everyone else, people who use substances, need help to understand how to manage their health better and they need health care services they can trust. This is where healthcare and social work professionals, community health workers and peers come in to counsel, teach, provide and link them to services.
Dr Mohale is a familiar face along various routes within the city centre. She walks the the inner city around Bosmon, Salvokop, “Baghdad” and Marabastad without fear but perhaps a little favour. She has befriended many whom she says accompany her on her route and ensure her safety. “The streets are filled with hope. The streets tell MY Story. I’ve learnt so much about myself through these people and how I show up in life. I get to know people by name and it is quite an experience to connect in the way we do.”
All healthcare is teamwork. This is particularly true for managing harmful substance use. In Tshwane a lot of effort has been put into developing relationships with the people who are responsible for services, like the police, nurses and doctors at the clinics and hospitals and the city authorities. Not for profit organisations are key partners, providing shelter and care to many of the most vulnerable people in the city. Through the University of Pretoria’s community engagement programme, thousands of students also actively contribute to and learn from COSUP and other initiatives. And just as importantly, COSUP actively engages with and builds the capacity of families and other community members to deal with the harmful use of drugs.
The long-term goal of COSUP is to have substance use services fully integrated into generalist primary health care. In the meantime the programme is working hard to overcome the stigma and discrimination against people who are marginalised because of who they are, where they live and what they do to live and survive. Mohale says that just helping people get identity documents, write CVs and prepare for job interviews, or supporting them when they are attacked or lose their possessions during evictions, goes a long way.