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Lesly-Marie Buer, "RX Appalachia: Stories of Treatment and Survival in Rural Kentucky" (Haymarket, 2020)
00:44:56
Buer explores the gendered inequalities that situate women’s encounters with substance abuse treatment as well as additional state interventions targeted at women who use drugs in one of the most impoverished regions in the US....
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Hello, everybody.
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This is Marshall Po. I'm the founder and editor of the New Books Network. And if you're listening to this, you know that the NBN is the largest academic podcast network in the world. We reach a worldwide audience of 2 million people. You may have a podcast, or you may be thinking about starting a podcast. As you probably know, there are challenges basically of two kinds. One is technical. There are things you have to know in order to get your podcast produced and distributed. And the second is, and this is the biggest problem, you need to get an audience. Building an audience in podcasting is the hardest thing to do today. With this in mind, we at the NBM have started a service called NBN Productions. What we do is help you create a podcast, produce your podcast, distribute your podcast, and we host your podcast. Most importantly, what we do is we distribute your podcast to the NBN audience. We've done this many times with many academic podcasts, and we would like to help you. If you would be interested in talking to us about how we can help you with your podcast, please contact us. Just go to the front page of the New Books Network and you will see a link to NBN Productions. Click that, fill out the form, and we can talk. Welcome to the New Books Network.
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Hello, everybody, and welcome back to New Books in Medicine, a podcast channel on the New Books Network. I'm Claire Clark, one of the hosts on the channel, and today we'll be talking to Leslie Marie Buer about her new book, RX Appalachia Stories of Treatment and Survival in Rural Kentucky. Leslie Murray Buer, welcome to the show.
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Thank you for having me.
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C
I wonder if you could begin by telling us a little bit about yourself.
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Sure. So I grew up in East Tennessee, have pretty strong family roots here. And then I moved sort of around the country to get education, as so many of us do, and always had a strong need to come home. And so I, at one point, I was living in Denver, Colorado, where I was working with people who use drugs and was introduced to the idea of harm reduction there through the Harm Reduction Action center in Denver. And that made me very interested in how we as a society have responded to substance use and how that has oftentimes been pretty ineffective. And during that same time period, I had some people in my life back home in East Tennessee who were really struggling with substance use. And I really wanted to come back home and apply some of the things I had learned in Denver to what I was seeing here. And for me, a first step was trying to figure out what was actually going on in central and southern Appalachia in terms of responses to substance use, which is what drew me to looking at different treatment programs in Eastern Kentucky through my work on my PhD at the University of Kentucky.
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C
How did you come to write RX Appalachia? You just gave us a hint and that it was partly dissertation research. Could you tell us a little bit more about it?
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Yeah. So it is. It is certainly focused on my or based on my dissertation, but I was. As I was writing my dissertation, I had a mentor at University of Kentucky, Mary England, and we talked a lot about the difference between writing a dissertation and writing other pieces from the field work to make it more public and how those are really different products. So obviously I needed to get the dissertation out there to complete that program. But then once that was done, I felt like what I had produced via dissertation was not really consumable by the general public as much. And I felt like because all the narratives I had seen out there about substance use that community members were reading, I felt like this was a pretty important research to get out there in a more. A way that was more easily digestible by folks in the community. And, you know, sometimes in academic work, we get really filled with jargon, and it's not about other folks not being able to conceptually understand what's happening. It's just we're so filled with jargon, it just becomes impossible for people not in our discipline to really know what we're getting at. And so I really wanted to translate my dissertation into a book that sort of anybody could pick up and read. And hopefully I've done that.
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C
It was a quick read, and I mean that in a good way. It was very, very easy to read. And the way that you wove the different women's stories throughout, I thought was really just very compelling. Can you tell us a little bit about your fieldwork for the book? So what were your expectations going. What was. You know, what were really surpri. What did you find really surprising?
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A
Yeah, I think so. I grew up in a. In a suburb of Knoxville, so definitely not the most urban place, but also also not the most rural. So all my work happened in rural eastern Kentucky. And I think I just. I had lived in small communities before, but not communities that were that small. And so that was just a little bit of a shock of, you know, and we've joked about in some of the towns I've lived in of everybody knowing everybody, but these towns are probably half the size of those. And really everybody does know everybody. And that can be Certainly a benefit as communities come together around families. But it can also be a real detriment because if you get labeled a certain way, sometimes it can be really hard to break out of that label when literally everyone knows your entire life story. And so I think the degree of rurality was something that I was not quite as used to. I think just with previous work on substance use and sort of state and community responses to that, I was expecting to see or hear a lot more stories about interactions with police and incarceration. And I definitely did hear those stories, but not to the same degree as I heard about people's stories and encounters with child services, which in Kentucky is called dcds. And so just how much my interviews centered on DCBS is, was really surprising to me.
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C
So that, that leads to my next question, which I think, I think the focus of your book on gender is really unique and really needed because there is a, I think a vast literature on, you know, drug addiction and policing and, and race related to race. But what did you learn by focusing primarily on gender and a gendered analysis?
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A
Yeah, and so there's a few reasons I even started with that. And one is especially in anthropology and ethnography, a lot of it has focused on, on men. And so I saw that gap. And I, I think another part of it is when I was doing some research for University of Kentucky before I took on my own field work, when I sat down and talked to people, I just felt a more camaraderie with the women I was speaking with, especially I'm a parent, we were taught, we ended up talking a lot about some parenting issues and just what it is to be considered a woman and Appalachia. And that just helps build rapport to me thinking about those issues. And that's sort of what got me into thinking about gender in the first place. And so I, I try not to give up the thinking about race altogether because, you know, race is, is constructed and people being considered white in Appalachia and most of the people I talked to were white, that definitely affects programming and how programming is funded because there is a certain understanding of what being white means in Eastern Kentucky and oftentimes it means those people being less criminalized, at least through the criminal justice system and also more treatment programs being funded. And a lot of folks have talked about this, about the different responses to the so called crack epidemic versus opioids. So I'm just sort of expanding on, on what other folks have already done. But in terms of gender, I, I think some different things. It shows and it's just the amount of domestic and sexual violence the women talked about. And so. And of course this happens among, among men as well, but just the degree to it. So about half the women I spoke to had experienced sexual assault of some degree, and over half had experienced domestic violence. And so there's just a level of violence there that oftentimes interpersonal violence that might go unaddressed if you're not looking at gender in particular. And as I just mentioned, the focus on dcbs. So in this area, a lot of men are incarcerated and incarcerated at higher rates than you see in other parts of Kentucky. So these very rural areas that are vast majority white, their incarceration rates for people who really are poor sometimes compare pretty closely with what you see of incarceration rates in more urban areas, which are communities that are more often black. And I mean, that's a Kentucky issue. Kentucky is very quick to incarcerate people. And so. And that's when talking about men now, when talking about women, that really changes. And the institution they come up against constantly is not necessarily the police, but is social services. And they are brought into court many times relating around DCBs, they are losing child custody and they are being asked or court ordered to go to many different types of substance abuse treatment because of this. So I think that is really the key when talking about gender. And I think the last aspect I would talk about is women's caretaking roles. And so in our society, we know that a lot of familial caretaking, whether that's of children or elderly family members or other folks in the family or in the community, really falls on women. And so that changes their trajectory of trying to go through treatment because they just have a different level of responsibilities to the home and the community than oftentimes men do because of how we define really womanhood and manhood in our society.
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C
So tell me about the types of addiction treatment and rehabilitation. And you make distinctions there, Right. Between them that were available to the women that you followed.
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Right. And so there is really three different types. So one was a drug court situation, which is in the area is mostly equally available to men and women. And of course, all of those, those treatment services, in order to access them, you have to have been in trouble with the legal system and have to be in trouble with the legal system in some sort of drug related way and very much tied to the court system. And if you don't meet some treatment goals, then you can be incarcerated. So it's a very punitive treatment model because it is tied to incarceration. The second piece is a program through the community mental health center in Kentucky that was very much tied to DCBs. So punitive in a different way. If you do not progress through that treatment program in ways that counselors deem, you know, positive or forward motion, then you can lose custody of your children, you can lose visitation rights. All these different things are connected to it. So again, you have to be sort of in trouble with DCBEs to be able to access those services. And then once you do access those services, it is very punitive in terms of your relationship with your children. And so the third thing that folks had access to, and I have to note that people had more access to it in Kentucky as compared to some other states, because Kentucky did expand Medicaid, which gave people more access to buprenorphine, which is a type of medication assisted treatment. And so a lot of folks were going to these buprenorphine clinics. And the only reason they were able to go oftentimes was because of Medicaid expansion. And the Medicaid did pay for the medication. And so these programs were. Oftentimes people saw them as more helpful, both of because of having access to buprenorphine, which people in drug court and the community mental health center were not allowed to be on mat of any sort. And so having access to the buprenorphine was helpful, but also having access to counseling services that were not tied to something punitive. And so people felt like going into those therapeutic situations. It really was therapeutic because they could open up, have trauma informed care, and not be worried that what they were telling their counselor or their therapist was going to go back to hurt them in terms of them being incarcerated or losing custody of their children.
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C
But there were problems with that, that form of treatment too, I think, that you talked about.
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A
Yeah, a huge. And one of some of the biggest problems were just lack of access. And so it's very hard when the county you're in does not have one of those programs. And so you might have to travel hours upon hours to go to that program weekly. And so there is a methadone clinic in eastern Kentucky, but where I was at it was a few hours drive. And in order to get methadone, you have to go there daily to get your dose. Or prior to COVID 19, that has changed things, but you had to go there daily to get your dose. And so you can't spend four or five hours every single day in a car. That's just not feasible. But even with the Buprenorphine clinic. One woman I rode with there every single week, it took her a full day to go get her buprenorphine prescription. And that's a lot, having to spend one day every week to do that. And then even when she came back home, you are facing a lot of stigma and a lot of judgment going to the pharmacy to get those medications. And the pharmacist can make your life very difficult by saying, no, you have to wait here a few more hours because I don't like what you're getting. Or pharmacists can deny that they even have buprenorphine and not fill it. So that becomes pretty problematic. And there's just, there's a lot of stigma against buprenorphine in the community. And so people might see that you're not really doing treatment or you're not really entering recovery because you're still on bup. When we know from a large base of evidence based medicine that mat and buprenorphine really are the best treatments for opioid use disorder. So. And other people have written about this more recently in, in Western North Carolina, Bayla Ostrich has an article out with one of their colleagues about some of the, the stigma around bup, which is very readily felt as well.
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C
One of the themes in this book, in your book was really broken systems and a term that you use, structural violence. And one thing that really came across to me was how creative and resilient the women that you spent time with were and just figuring out ways to survive amid these kind of broken systems. Can you tell us a little bit about what are some of the strategies that, that, that your participants use to just kind. To, to make it through the day and to navigate this, you know, addiction and treatment and recovery and the landscape that you lay out here. That's pretty bleak.
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Yeah. And I think some of the things I talk about have become more popular in the, the media since COVID 19. It's just the idea of mutual aid. And we've seen a lot of talk about how that is responding to the pandemic. But mutual aid has a pretty longstanding history in Appalachia. And I think the women I spoke to really showed of that history. And so a lot of the strategies they use have a lot to do with family, friends and land. And so there's also a narrative of, well, if you don't like Appalachia and you're not thriving there, then you just need to leave. Well, that ignores some major things. One, it is assuming that there's all these grand opportunities in urban areas, which we know they're not necessarily, especially if you have something like a felony record. It's also ignoring a lot of the good things that are in rural areas. And one of those is definitely a heritage of land. So people might be able to grow really immense gardens that feed them throughout the whole year. And that can be done relatively, relatively cheaply. And. And also it's. It can provide solace for a lot of folks I talk to to be on land that their family has been on for a long time, to be able to walk that land every day. Um, I'm not trying to make it sound too idyllic, but it, you know, being able to walk your lot line every day, it provides physical access and some mental. Mental relief and also just products of the forest. So I spoke to folks who were getting ginseng seasonally and getting geodes, things like that, to sell at local markets. Now, they are not making a lot of money off this. Right. It's just an. It's barely enough to get by, but at least it is a resource that they try to use to get by. And the other aspect is caring for each other. And most oftentimes that that occurs within families of, you know, your granny has a big garden that feeds not only her, but also several of her children and grandchildren, or you have one person in the family who does qualify for disability. And of course, that disability check doesn't necessarily just support one person. It might support a whole household. And same with snap, otherwise known as food stamp benefits. And so all of. If someone can get benefits in some way, those sort of go through the family. They cycle through the entire family. And people also just finding community support. And so I see that a lot also with childcare of people sort of trading childcare duties with neighbors and with friends, because there's not a lot of commercial options for child care. It's. It's not like there's a daycare around every block or anything. And overall, just caring for each other. And of course, we see this among people who use drugs quite a bit because they are so stigmatized, it's hard for them to get proper health care. And so there's a lot of taking care of each other. And for my current work here, we see that the most with naloxone, which is the drug that reverses opioid overdoses. You know, in my work in Knoxville, the harm reduction Program, our participants are reversing or using naloxone twice as much, at least twice as much as the first responders in our town. And so there's a lot of mutual care that's happening between family members, between people in groups of people who use drugs and so forth.
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C
Tell me a little bit about the work that you're doing now and how it relates to the research that you did in your book.
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A
Yeah, so I am the research director at Choice Health Network Harm Reduction in Knoxville. And our organization began as an AIDS service organization in the 90s and has since moved to also offering harm reduction services. And so what those services look like, it's really about non judgmental care and meeting people where they're at. So going to people who use drugs and not saying that you need these services, but asking them what services do you actually need. And big parts of that have been syringe access. So making sure that people have new syringes and other supplies to use every time they inject, which we know can decrease rates of, of HIV and hepatitis C as well as abscesses and other skin infections. It's also about getting people quite a bit of naloxone. We want everybody to have plenty of that, which again reverses overdose deaths and giving people access to other medical care that they'd like. So some of that is HIV and hepatitis C screenings and also some basic wound care and primary care. And we are trying to expand on giving people more and more primary care because that is a major need for folks who have had such poor experiences with the medical system that they are not willing to go to a traditional hospital or clinic until they are unconscious. And so just trying to meet people where they're at mentally and also geographically and just giving them the services they need. And so that's kind of the work I do.
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C
Yeah, no, that's, that, that's wonderful. Did you encounter any harm reduction services in your field work?
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A
It seems.
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C
Seemed like that was a big gap.
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A
Right. And so just as I was leaving the field, they passed a syringe. They passed syringe service type law in Kentucky that allowed health departments in Kentucky to operate syringe service programs. And Kentucky single handedly went from zero to dozens. I think it, the last time I looked, I think it was in the 50s. It, it might have changed since then of syringe service programs. And they did it very quickly. They rolled it out extremely quickly. Um, and I think that was in a lot of response to the HIV outbreak that happened in Indiana with people who inject drugs. And Kentucky expanded it quickly. And so I know since I've left the health department, there does have a strange Service program. And there are definitely benefits to having something like that in a health department. One, as I just said, they, they rolled that program out so quickly in so many counties, and you're just not going to be able to see that quick spread of a program like that. And we certainly haven't seen that in Tennessee, where the health departments are not operating. But there can also be some issues with health departments operating these services. And some are great. Others might be run by people who don't actually believe in har reduction, and they might make the programs more punitive than they need to be and may not be actually following a harm reduction model. So there's definitely a lot of benefits and perhaps some limitations of offering those services through health departments as they are done in Kentucky.
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C
But when you were doing your fieldwork, it was. There was non existent.
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A
Yeah, non, non existent. There was just nothing. No naloxone distribution either, which is really heartbreaking because a lot of people were lost that didn't have to be.
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C
So tell, tell me what happened to the women that you followed, your participants in your study. Were there patterns that you saw overall? Where were people when you met them and then where were they when you left?
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A
Yeah, some people I met them were not doing well, and now they are far worse off. And some people I spoke to I know are now serving very long sentences in prisons. And I guess some things I noticed about what was going on with those folks is that they came into it with a lot less resources than the people who are doing well. And that includes certainly material resources, having a stable place to go, housing, having some sort of family wealth, you know, people who had less material resources did not do as well. And then people who had sort of more chaotic families or communities that were close to them seemed to have some worse outcomes as well. Whereas some of the people I know, who I still follow or am social media friends with, usually they're doing great. And I think one thing that is common between them is they were able to access material resources because their family had those resources and they were able to go back to school, able to get really stable housing because maybe their parents just bought them a house they could live in or were supporting them in other ways. And they were also folks that did have that family to go back to, especially a lot of family members who were either not using at all or only using a little bit. They had that to go back to and they have just been so much more successful. And so I think when we talk about the models of treatment in the US that are oftentimes based on 12 steps or on Synanon or some of these other treatment programs that came up in the US in the early 1900s, early to mid-1900s. We see this focus on personal responsibility and this idea that if you just want to change, you will change. But I think what I saw, and not to take away from the people who have been successful because they've worked really hard, but some of the people who maybe we would consider have not been successful also worked really hard. And it's. It's not only about what the individual is doing, but it also is about what's happening around them. So do they have a stable community, a stable family? Do they have family wealth? Do they have access to jobs that pay a living wage? All of these are incredibly important when considering or thinking about someone's trajectory.
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C
And are the structures sort of built to work for you or against you?
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A
Right, Exactly. Exactly.
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C
So you close the book with appendix, which I think is really cool, listing a bunch of relevant advocacy organizations. And I thought that that was really interesting also, because the institutions, the treatment centers use pseudonyms for that appear in the body of the book. But then in the appendix, you list out a bunch of organizations that you see as, I don't know, maybe providing needed alternatives or doing more progressive work. Can you talk a little bit about why you decided to include bad appendix?
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A
Yeah, and I'll start with the pseudonyms part. And there was some back and forth between me and others about whether to use pseudonyms for the treatment programs. And I really. One, I wanted to use pseudonyms for the counties to protect participants so they weren't singled out if someone recognized a story, but also for the treatment programs, because although I have a lot of critiques for these programs, I see it as being structural issues that have made these programs not be effective. It wasn't the staff. So many of the staff gave everything they could to those programs, but there's only so much you can do when you're so limited by a lack of resources and a lack of institutional and state support for what you want to do. And so I just didn't want to put those staff and some of the administrators and managers in positions where they were being demonized or anything like that for the lack of success of their treatment programs, because I really think a lot of them had the best intentions and were doing the best they could. So that's sort of where the pseudonym comes in. And for me, when I read a book about an issue that I care about, I want action steps. I Want to know, okay, then where can I go to do something? And so that's why I wanted to include the appendix of some of those relevant organizations. And most of them are advocacy organizations. And you know, if you step away from a book like this and you are caring about wanting to support more sort of progressive efforts, then here's a list of places to go. And I think all those places are really great. And you can learn more about actions that are actually happening on the ground as well as send money to those folks, because I think they will, they will do good things with it. And so that was just important for me. And also speaking with that, you know, for this book, all of my proceeds are going into a fund, the Hellbender Harm Reduction Fund, which will support grassroots harm reduction and reproductive justice efforts on the ground in Appalachia. That's great.
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C
Can you say more about why harm reduction and reproductive justice together.
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A
Yeah, I think harm reduction for me is really a broader social justice movement. And so I think when you're thinking about harm reduction, if you're also not thinking about reproductive justice and racial justice, LGBTQ issues, then you're not really taking a harm reduction approach. And just as I mentioned earlier, focusing on gender, I think that's where the reproductive justice really, really comes in. And when I talk about that, I'm talking about people having the right not just to access reproductive healthcare, but also to raise their families in ways they see fit. And we know, um, look, some, some children are abused and need to be removed from situations. But I also know from seeing several things happening on the ground that women are being, are having their children removed for doing what they should be doing. So I document quite a few cases in the book where women were on doctor prescribed buprenorphine, were not doing anything else, and they lost custody of their children because they were doing what their doctor told them to do. And that's really where reproductive justice comes in. And also we have seen a lot of demonizing of pregnant women who use drugs, especially in the south and in Tennessee where we had a law here for a little while, it is since sunset, where if a pregnant person tested positive for drugs, they were automatically put into the criminal justice system. No one else, non pregnant people were not treated the same way. So there has been a lot of scapegoating here of pregnant people who use drugs. And that's where a lot of reproductive justice comes in as well. As you know, we know in the 80s there was this idea of so called crack babies, which is a very offensive term. But that similar terms have been applied to children who are exposed to opioids in the womb and for us, neonatal abstinence syndrome. NAS is something we shouldn't be able to talk about, but how it's talked about in this region is often overblown. And I have been at meetings where literally every single social ill has been blamed on nas, which we certainly know is not the case. And so I think using evidence based research to show the actual effects of NASA is part of reproductive justice and harm reduction combined. And I think those are just really important things to be thinking about and talking about.
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C
And it also, I mean it kind of goes back to some old to eugenist sort of notions too about people who use substances and what is being passed on and that you talk about in your book.
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A
Absolutely. And Appalachia has also been a place of quite a bit of eugenic work, which I know Elizabeth Cat has a new book focusing on the history of that which I am very intrigued to read. And there was a recent law in North Carolina which eventually got stopped, but they were trying to increase the rates of taking children away, especially if a parent has deposited for any type of substance and of expediting permanent removals. And so this is a battle we're still fighting and we still gotta be talking about who has the right to have children and who has the right to raise their children. Um, yeah.
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C
So what are, that's a great example of a, A, a way that people could get involved. Now what are some other, I would say what are, what have been the most significant structural changes since you did your research? Obviously. I mean it sounds like there is now harm reduction would be one. And then what are some changes that you would like folks to work towards?
- [34:47]
A
I think, and some of it can just be very much a community effort of letting the harm reduction program come to your community. So I've talked to a lot of other programs and nearby states where they want to have a program, but they cannot have find a place to do it because the homeowners association nearby comes in, fights them for being there. So I think graciously accepting that these programs need to exist and sometimes they need to exist in or close to your neighborhood and that's okay because they're not drawing anything negative, they are really just providing benefits. Um, and I think also just being kind to people, which seems so my, it seems like such a broad thing, but just, just because someone has a history of substance use or you know, still being willing to give them a chance and hiring and talking about substance Use and having naloxone in positive ways in our community and around our children, I think, can really start to shift the stigma because, you know, the stigma hurts, folks. But what really hurts is when that stigma becomes so widespread in our society that it becomes embedded in policies. So I think if we can start changing the stigma in our communities, then perhaps that can change some of these very negative policies, I think. And this is going to be controversial for some, not. Not to others, but I think about how would this recent protest against police brutality really make sense to the work that I've done and talking about? So how do we respond to substance use in a way that is not furthering violence? And I think we have to talk about. So what does defunding police look like? And what does funding mental health centers look like? What does funding harm reduction look like? So we are so underfunded. Every single mental health program I've interacted with in the south is completely underfunded. So I think we're coming up to a point where we can look at, okay, well, maybe we should defund these other institutions, and maybe we could actually be fully funded to do what the community wants us to do. But I think part of that is also, unfortunately, the criminal system has bled into so many other institutions to where now you look at buprenorphine programs that are really punitive, not because they necessarily want to be, but because they feel like they have to be in order to. To avoid the police investigating them, or just these ideas from the criminal justice system have spread into all these social services. So before we start, you know, funding these other programs, we have to make sure that they are no longer criminalized, that they are trying to take a harm reduction approach and not just becoming pseudo police, which I think is a real risk, is that you take actual police off the streets, put in, you know, crisis management systems or health care providers who just become de facto police because their programs still continue to be very punitive. So I think supporting these efforts to take the punitive edge off of social services, as well as putting money in the community rather than in police.
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C
Yeah. So it's not just a question of treatment versus punishment. Right. It's like, what kind of treatment? And some types of treatment are almost exactly like punishment, so.
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A
Exactly.
- [38:31]
C
Yeah. What's been the most significant structural change since you did your book research?
- [38:39]
A
I wish I had more to point to than I do, but I think just having. Having harm reduction services be legalized in a lot of states has been really great. So since that. Since I did the research for my book, they've been legalized in Kentucky and been legalized in Tennessee as well. So that I think that really is a positive side step. And sort of other positive things I've seen are not necessarily policy driven, but community driven. So sort of an under there. I think this is the widest margin of people you have seen who are supporting protest against police brutality, which I think is. Is really important. You also have more and more folks who are supporting things like Medicaid expansion. I mean, the fact that Oklahoma voted for Medicaid expansion is pretty surprising and I think shows a broader level of support for everyone having access to quality health care and to quality behavioral and mental health care as well. And so I think that's an important, important step. And then the law I previously talked about in North Carolina, the fact that that was defeated, I think is a very positive step. So you see these regressive laws coming up, but I think they're increasingly being defeated when they do, when they do make it out of a subcommittee or so forth. So I think those are some positive changes. And I think. So we have been trying to expand some harm reduction services into rural areas. And just if you went into those communities five years ago and told people what you were doing, they would literally yell at you and tell you to get out of their community. And I think over the past year, we've actually found many communities who are very willing to engage in that now. And I think part of it is more and more talk about harm reduction and naloxone distribution and syringe services. But also they are just increasingly seeing that their old methods are just not working at all. The this idea of just arresting, arresting, arresting, it's just not working. And so they're willing to move to things that they may have not moved to in the past.
- [40:56]
C
That seems like a big shift.
- [40:58]
A
It is. Absolutely.
- [40:59]
C
Well, Leslie Marie, we've taken up a lot of your time. What are you working on now?
- [41:05]
A
So, of course, as all of us, we had all these big plans for this year and everything has been completely shifted. So one thing we're working on doing right now is expanding services into rural areas, which just looks a little bit different than urban delivery, just in terms of geographical, transportation issues, confidentiality issues. So I think that's interesting. We're also trying to better understand how to offer a wider range of services to people who use drugs, especially in thinking about wound care, primary care, also PrEP, which prevents HIV infection, services like this. And so much of our work is still focused on destigmatization and that's not only in the community, but also trying to publish papers and academic journals that are calling for destigmatization within academia because there is still so many presentations we go to from academics that are very stigmatized towards people who use drugs. So this not only needs to happen in the community, but also among clinicians and university based researchers. So trying to work at all those different levels for stigmatization work and also trying to look at all the structural issues that are really affecting people who are our participants. And for us right now, gentrification is a huge issue and that goes along with lack of access to housing and to jobs. And so we're just trying to do the best we can with what we have and trying to figure out how to, how to make it work.
- [42:46]
C
It sounds like you're doing wonderful work and just really a model of engaged scholarship. So I want to thank you for being on the show today. I really enjoyed it.
- [42:59]
A
Thank you so much for having me. I enjoyed it as well.