The man in the camouflage shirt who emerges from the cabin is drawn and thin with circles under his eyes. He tenses at my presence, especially once Jeremy tells him I am there to write an article.
It is a cloudy evening and mosquitoes patrol in full force as Nancy Bauman and I pick our way gingerly over trash-strewn ground, searching for syringes. Under a creekside bridge splashed with graffiti, a pair of neatly folded jeans, a plastic bag of food items, and a pair of shoes offer evidence of a homeless encampment.
As we search, Nancy opens up about her life as a former injection drug user. She recounts how her only brother died of a heroin overdose shortly after returning from Vietnam. Her own struggle with addiction began through recreational drug use with homecoming soldiers, and years ago she lost her husband to hepatitis C infection. Drugs ruled much of her youth, but Nancy has spunk. She entertains me with tales of how she used to run an illegal syringe exchange program with two Catholic nuns in Los Angeles.
As I listen to Nancy, I am not putting much effort into the search for syringes. Truth be told, I feel guilty about picking through someone’s home and also for the assumption that a homeless person must also be an injection drug user. Under the bridge, Nancy and I find nothing but an overturned shopping cart, bits of trash, and a spoon. When the time comes to return to the health department, I feel relieved.
Nancy and I drive back to the health department to rejoin the rest of the newly formed Substance Use Task Force of Haywood County, North Carolina. The community syringe pick-up event is the inaugural event for this group, which is comprised of public health employees, harm reduction advocates, law enforcement personnel and impacted citizens who hope to address the growing incidence of drug use in Haywood County. The dozen or so members are an eager bunch, well-intentioned but so far lacking clear direction on how to tackle such a complex problem. The group finds only two discarded syringes that evening; still, enthusiasm reigns.
We are debriefed by members of the North Carolina Harm Reduction Coalition (NCHRC), which in spring 2018 hired three staff members for the area under a grant funded by the Aetna Foundation. Haywood County, and western North Carolina in general, is relatively new territory for NCHRC, which has more established programs in eastern and central parts of the state. In one sense, this is an advantage since advocates can draw on the experience of harm reduction programs in other counties. In another sense, it is a disadvantage. Few people in Haywood County have even heard of the term “harm reduction.” Appalachian residents, often tough and resistant to change, are not easily convinced and stigma against drug users runs deep. For the three new staff members, Gariann Yochym, Virgil Hayes, and Jeremy Sharp, the task of introducing harm reduction to Haywood County is both challenge and an opportunity.
After the task force disbands, I join Jeremy Sharp to deliver supplies to participants of the mobile syringe exchange program he has helped establish. The clouds have rolled away and the sun is just beginning to set behind the backdrop of the Blue Ridge mountains. We drive past picturesque fields of hay bales and grain silos. The town is so pretty it almost looks painted. We pull up to a log cabin with a single tire swing swaying in the breeze under a tree.
But the beauty ends here. The man in the camouflage shirt who emerges from the cabin is drawn and thin with circles under his eyes. He tenses at my presence, especially once Jeremy tells him I am there to write an article. As a peace offering, I put away my notebook.
Jeremy delivers syringes and naloxone to the man and his wife, who emerges from the house. The wife gives a sobering account of her recent arrest for drug possession and the agony of opioid withdrawal she endured while in jail. She asks Jeremy for help getting Suboxone treatment for opioid use and he offers to connect her to his co-worker, Gariann, who can arrange an appointment. Jeremy is quirky but likeable, and the couple’s affection for him is clear.
When we are back in the car and I have use of my notebook again, Jeremy admits that the stories of death and despair that he encounters on a daily basis can get to him. “I walk into people’s lives for 20 minutes to do an exchange and it can be overwhelming to hear even just a description of all the things they are going through,” he says.
“But,” he adds, brightening. “There is nothing like that first naloxone reversal.”
The struggle to find hope in a grim situation is one that plagues other advocates as well. NCHRC’s Gariann Yochym, who connects Haywood County program participants to social services, lives this fight every day.
At first glance, Gariann gives off strong hippie vibes. She hails from Asheville, North Carolina’s most notoriously liberal city, but was born and raised in the hills of West Virginia. She glides easily between country twang and the Queen’s English, comfortable in both worlds but fully belonging to neither. In that way, she is well-suited to the work in Haywood County, which necessitates a level of mastery in both progressive public health policy and rural resistance to change.
Since arriving in Haywood County, Yochym has been laying foundational work to connect drug users to services that can help them improve their health. Introducing harm reduction to an often hostile political environment is not easy. When I first ask Yochym what she thinks of her job, she offers a sunny response: She loves to help people and make a difference. But with prodding, she admits that the work can be difficult.
“Trying to build relationships and respect, sometimes I don’t know when I should bite my tongue or hold my ground,” she says. “It can be challenging to build new partnerships, but I think we all recognize the importance of working together to address these complex problems.”
Haywood County is a microcosm of the challenges that harm reduction faces in general. Though the harm reduction movement has existed for decades, in many ways it is still the new kid in town, pushing back against centuries of punitive and abstinence-only approaches to drug use. Long a stronghold in northern states, harm reduction has more recently begun laying foundation in southern states, where politics can be antagonistic. For advocates, the constant dilemma of when to compromise and when to hold firm is exhausting. Bringing opposite sides together often means that neither gets what it wants, and advocates are criticized both for pushing too hard and not pushing hard enough.
Virgil Hayes, who supervises the Haywood County staff and programs, also lives under this constant pressure. “Not everyone is where you would like them to be in terms of support for harm reduction,” he says as we talk over lunch at a small diner. “We need to understand that change is inevitable, but people need time to part ways with what they have always known.”
Hayes seems to embrace the opportunity that Haywood County presents. “It’s been an adventure,” he says, smiling and shaking his head. I sense this is an understatement.
Hayes sees his most important task as working to create a seat at the decision-making table for active drug users. Even in other parts of the state where harm reduction is more accepted, there is still a tendency for non-impacted professionals to speak on behalf of people who use drugs. However, while in other counties stakeholders may have already marked their territory and become resistant to new voices, Haywood County has the opportunity to invite those voices from the beginning. Hayes and his co-workers are actively working to do just that.
Ultimately, the small team is game for the challenge of bringing harm reduction to Haywood County.
“I am inspired by the way this community has come together and opened themselves up to our program,” says Yochym. “We have been welcomed with an incredible amount of hospitality and support from unlikely partners.”
Hayes thinks that education will be key to getting people on board with harm reduction. “People’s hearts change when they realize everything is not what it seems,” he says. He hopes to draw attention and resources to rural counties, where the effects of drug use are often swept under the rug.
“I want to show how this problem impacts all areas across race, gender, class and geography,” he says. “I want to pull the covers back and show the issue is just as bad here [as in cities] and to present solutions for what we are going to do to change it.”
It is not easy being dropped into a geographically isolated area and launching a harm reduction program without much precedent or guidance, relying on intuition and experience to know when to compromise and when to stand your ground. It’s an even bigger challenge to fight centuries of stigma to bring active drug users to the decision-making table. But if anyone can do it, I think Haywood County can.
