Q&A w/ HHHRC Director Heather Lusk on harm reduction in Hawai‘i


Nicole Pasia


Heather Lusk is the executive director of the Hawai‘i Health and Harm Reduction Center (HHHRC). HHHRC has stayed open throughout the pandemic, serving communities at the intersection of houselessness, chronic diseases such as HIV, and behavioral health and substance use.

In this Q&A, Lusk speaks on how HHHRC was able to pivot its services to adapt to the pandemic, advocacy for reimbursing “street medicine,” and addressing burnout in the health care workforce.


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Nicole Pasia: How has HHHRC shifted its resources to prepare for and address the pandemic? How has operating as a community-based organization helped with your response efforts? 

Heather Lusk: “In many ways, us as an agency working in a public health crisis, we were able to pivot, very quickly in COVID, because of our experience in working with HIV, and then also given that we’re already in public health and we’re used to things like universal precautions and disease transmission and prevention. It seemed like a natural [fit] for us. Harm reduction is a public health approach that acknowledges that there’s complex reasons why — whether it’s trauma or behavioral health — people do what they do. We also use a hierarchy of needs. We need to meet people’s basic needs before we can ever address things like substance use, mental health, if they’re not getting food, [if] they don’t have shelter. 

… In addition to providing services, we saw ourselves as a very important part of educating, particularly people that might be outside that traditional communication channels, around COVID. Around that time we started increasing our food, our collaboration with the food bank, and we’ve distributed almost half a million pounds of food during COVID …

We’ve been running our case management and COVID-in-isolation site in Waikiki, where we’ve seen almost 900 people that have had COVID or been at risk of COVID where they needed to quarantine and our specialty there is houselessness and behavioral health. So a lot of what we were trying to do was not only keep them safe, but also try to help them leave, and for lack of a better term, leave in better shape than they came in.” 

NP: Can you talk more about the on-the-ground services you’ve provided for the community?

HL: “We have a medical mobile unit, and we’ll be taking that out into the streets. We really found through the pandemic that … it just makes a lot of sense to keep our services to where people are. Then [it’s] building relationships [with them] and then eventually once they build relationships they need to be willing to come to Kakaako in our clinic. I’m sure you’ve heard this from other health care providers, but the hard part is getting them to come in and make the appointment. We’re now taking our behavioral health through our iPads out into the field through our medical mobile unit. Outreach workers, substance abuse counselors, people focusing on homelessness, and our medical assistants are out there and then they can then telehealth back to our providers here in the office to get whatever the person in the field may need to get. 

One thing I love about the work that you all do, is that you’re aware of reform. So one policy issue is that street medicine is not reimbursable in the United States, let alone in Hawaii. It’s not considered a site, right? We’re not at the clinic site and we’re not at someone’s home. So, I can’t pay for all of the mobile street medicine I do until that gets changed.”

NP: As an organization that works with people experiencing homelessness, how have the recent eviction moratorium expirations affected your work and the communities you serve?

HL: “We’re very worried about the eviction moratorium that was struck down by the Supreme court. I’m actually the chair of the Homeless Coalition here, and we are actively trying to both keep our people that are already housed, housed … Because the last thing we need, on top of the homeless crisis we have, is even more people going into homelessness because of the eviction moratorium.

You may know that there’s a new Medicaid program or med-QUEST program called CIS, or community integration services. The state of Hawaii got an 1115 waiver from CMS to basically start reimbursing housing-related issues through the Medicaid plans in Hawaii. So that’s rolling out right now. It should be rolling out by the end of the year or early next year. And that’s going to allow providers like me and other health care providers to start to bill for things like housing support and transportation and checking on people, to still make sure they’re still housed. 

So we’re really trying to not only get ready for ourselves, but help provide technical assistance and support to other agencies that are serving the homeless community that maybe don’t have relationships with the plans, to get accredited with the health plans, because this is going to be a major support for some of the gaps … I think collaboration is more important than ever in COVID, and we’re continuing to try to build bridges.” 

NP: What other health issues do you feel are not being addressed enough?

HL: “The one [issue] that I think is actually the most important, that I do not feel is getting talked about enough, is the vicarious trauma that our health care workforce is going through, and the compassion fatigue and burnout that that is leading to. I see it in my own staff because we’ve been running an isolation and quarantine site. I see it in the providers that I know that work at the hospitals. I don’t feel like as a sector, we’re addressing wellness for health care workers. 

So one thing I’m particularly proud of is that I started a wellness program here. I pay my staff two hours a week just for wellness time, where they’re on the clock, but I’m paying them to do a yoga class. We do meditation classes, we do a Zumba class, we do mindfulness teachings and we do grief support. We support people to talk to their therapist during that time. I’ve seen a few other agencies do it and I talked to a few of the hospitals that seem to be trying too, but I would just like to really remind everybody that our health care workforce is not only burned out. They have carried the burden of the compassion and the work and the trauma they’re seeing. [It’s] really impacting their wellness.

How do we as a sector, especially those of us like me, that’s in administration … How can we create opportunities, both in our own systems but also community-wide, to make it more normal to talk about health care worker wellness? [Normalize talking] about compassion fatigue and talk about how important it is that we provide opportunities for our health care workers to build resilience and build protective factors to offset all of the incredible amount of suffering they have seen, witnessed, and experienced themselves over the past year and a half. To me that is such an important piece, and health care workers are suffering and they need support.”

This interview was edited for clarity and length.