Keren Elumir saves lives at the Moss Park overdose prevention site in Toronto. It is relentless work: a particularly bad day saw 10 people overdose in a six-hour period.

“We were kind of joking the other day that we cleaned the entire floor of the Moss Park site with our jeans because we wrestled with so many heavy overdoses,” says Elumir, a 49-year-old registered nurse.

A bit of harmless humour helps in a job where grief and trauma are non-stop.

First responders have long had to struggle with the emotional intensity of jobs meant to save lives. But rarely have on-the-job grief and trauma been as chronic — and so lacking in supports — as on the front lines of the opioid overdose crisis.

They save thousands of lives — people were revived from overdoses 2,275 times in Ontario’s 24 federally approved injection sites in 2018. Yet they are among the most precarious workers in the labour market, many struggling with low pay and no benefits.

Burnout and turnover rates are high. Others soldier on, wounded.

“People care very deeply, so they’ll keep working even if it’s hurting them,” says Matt Johnson, co-ordinator of the overdose prevention site at Parkdale Queen West Community Health Centre, who estimates he’s revived more than 200 people over the years.

The emotional and physical toll on employees has a leading agency in the field questioning the future viability of the supervised consumption system.

“This type of model is not sustainable when we know the overdose crisis is getting worse,” says Julia Barnett, manager of supervised consumption services at South Riverdale Community Health Centre, which runs the Moss Park injection site and another in the Leslieville neighbourhood.

Trauma is the order of the day for Moss Park’s 11 workers.

In the first three months of 2019, the Sherbourne St. site was visited 6,484 times by drug users. Workers reversed 257 overdoses, usually by pumping oxygen into the victim, sometimes by injecting opioid-blocking naloxone. None of Toronto’s nine supervised injection sites saved more lives during that period.

With Moss Park open six days a week, six hours each day, workers save an average of one life every two hours.

Elumir recalls a day late last year that initially stood out because it was uneventful. Not a single person overdosed during her shift. She whiled away the down time by knitting a toque and looked forward to a Christmas concert after work, where her daughter was to play piano.

Minutes after the site closed at 6 p.m., a man banged on the locked front door begging to be let in. Elumir’s colleague, Sarah Greig, obliged. The man injected an opioid, dropped to the floor, and stopped breathing.

Elumir and Greig went to work. They injected him with naloxone but got no response. They injected him a second time and still nothing. They may have used a third shot but Elumir can’t say for sure. She once needed five shots to bring a victim back to life.

“It can be quite scary when a person isn’t responding,” she says. “If we don’t figure it out, they will die.”

They tried inserting an air tube down the man’s throat but couldn’t open his clenched jaw. Overdoses caused by fentanyl, a powerful and often deadly synthetic opioid, can make bodies rigid. So they placed an oxygen mask as tightly as possible around his nose and pumped air.

Thirty long minutes passed before the man revived.

Elumir had no time to debrief the near-death episode with her colleagues. She rushed to her daughter’s recital.

“I beat it across town to this beautiful church that was full of candles and twinkly lights,” she recalls. “I sat down and everyone around me was so happy, listening to the singing and watching the performances.

“And the contrast between this beautiful event and the hard overdose was so enormous that I could not stop crying. I cried my eyes out.”

No one has died in supervised injection sites. Yet the body count keeps rising from overdoses on the street or in private dwellings.

There were 4,460 opioid-related deaths in Canada in 2018, a third of them in Ontario. The victims are often marginalized people the workers care for daily and know well. Sometimes it’s a colleague: in Toronto, many front-line workers use drugs or did so in the past.

Who will die next is a constant worry.

Registered nurses are a small number of this largely precarious workforce. Most others are workers from harm reduction programs, which distributed clean syringes to drug users before supervised injection sites opened in Ontario in 2017. All are close to the drug-using community.

Leaving work at the office is an option few have.

“You’re seeing multiple overdoses every single day,” says Steff Pinch, a 29-year-old harm reduction worker. “You’re seeing people who are dead and you’re bringing them back to life. You’re walking in a room full of ghosts.

“And for a lot of workers, they do this as their job and then they go home and reverse overdoses. And then they walk the community and reverse overdoses. And it never ends. And then everybody dies.”

Frayed emotions are compounded by anger, a conviction that deaths would be prevented if governments cared enough to decriminalize the possession of all drugs and make safe supplies of opioids available. (The Toronto Board of Health supports both those recommendations.)

“It feels like you’re screaming into the void,” says Marissa Martins, a harm reduction worker who helps provide stable housing for drug users with Breakaway Addiction Services. “You’re saying, ‘This is what we need! This is what we need!’ and nobody is listening.”

Greig, a harm reduction worker for the past decade, says workers have no time to heal or to process what they’re going through. “How do you keep helping people without totally losing your mind?” she asks.

Few have the workplace benefits to help them find an answer.

Shoestring provincial funding keeps wages at about $15 to $25 an hour, although the few who are registered nurses can make more. Many are on short-term contracts or working part time — positions with no benefits. Workers who need counselling services, or anything else that might help manage the job’s chronic stress, usually can’t afford it.

The exception in Toronto is the downtown supervised injection service called The Works, staffed by eight full-time and unionized city employees who have benefits and higher salaries. Tor Sandberg, a spokesperson for the CUPE local representing the employees, says the city helped ensure lower job standards for others in the field by letting private agencies do the work the city should be doing.

In an attempt to help themselves, some formed the Frontline Workers Support Group, which resorts to a gofundme campaign to help access the most basic forms of self-care, including massages.

“It’s pretty messed up that it’s being crowdfunded,” says Tave Cole, a group organizer and harm reduction outreach worker, who describes on-the-job grief as a “non-stop nightmare.”

On June 10, Toronto’s Board of Health called on the Ford government to “Provide dedicated bereavement and trauma supports for frontline harm reduction workers, family members, and others impacted by the opioid poisoning crisis.”

In a written response to questions by the Star, the Ministry of Health and Long Term Care said it is “committed to supporting front-line harm reduction workers” and others hit by the crisis.

The statement, emailed by spokesperson David Jensen, noted the ministry funds the AIDS Bereavement and Resiliency Program of Ontario (ABRPO), which has expanded its work to train agencies running injection sites on “debriefing” sessions that help workers emotionally, mentally, physically and spiritually.

The government says it also plans to invest $3.8 billion over the next decade to implement a “comprehensive and connected mental health and addictions treatment strategy, including a “Centre of Excellence” to help people access “integrated and standardized” services across the province.

Provincial funding also includes $31.3 million for up to 21 sites called Consumption and Treatment Services (CTS). It’s a new harm reduction model that continues supervised injections while adding a focus on connecting drug users to treatment and rehab. Budgets for these new sites “can include funding for benefits and training for frontline staff,” the ministry states.

Reality at injection sites is generally different. Funding that rarely lasts more than a year means requests that include benefits stand little chance of ministry approval, says Barb Panter, manager of housing and drop-in services at St. Stephen’s Community House in Kensington Market, which includes a supervised injection site staffed by six workers.

“Our model is very cost-effective, but it also means our part-time and contract staff don’t get benefits,” Panter says. “That’s just a reality in the field.”

St. Stephen’s supervised site had been funded by the previous provincial Liberal government. It was one of two agencies in Toronto that failed to get renewed funding under the new CTS model. Its injection site continues to function with federal permission and private donations.

St. Stephen’s CTS application had a budget line for transit fare so that drug users could travel to the kind of rehab the ministry considers a priority.

“They said, ‘No, take that out,’ ” Panter recalls, referring to ministry officials. “And we said, ‘How are you expecting people in Toronto, where it costs $3.25 for transit, to get to the detox centre?’ And they didn’t really have an answer.

“So to talk about benefits for something as intangible as trauma and grief support doesn’t often go very far,” she adds.

Fifteen CTS sites were announced in late March, six of them in Toronto. The proposal accepted for South Riverdale’s Moss Park site would extend service to 12 hours a day, seven days a week. But the government has yet to hand over the funds, so in March, frontline workers were placed on month-to-month contracts.

“We don’t know if that financial agreement is going to be on a one-year basis or more long-term,” Barnett says.

There’s no indication the provincial government will act on the board of health’s request to fund trauma and grief supports, Barnett adds, so South Riverdale is moving on its own.

The community health centre has siphoned $20,000 from its other programs for a one-year pilot project to give its injection site workers access to counsellors, therapists or Indigenous elders, along with self-care courses in yoga or art, for example.

Gillian Kolla, a PhD candidate at the University of Toronto’s Dalla Lana School of Public Health, who is researching the impact of opioid-related trauma on health, believes funding struggles reflect a dismissive provincial attitude.

“I don’t think this would be happening with any other health issue,” Kolla says. “It is very much linked to the stigma around people who use drugs. It’s very much the idea that these people are disposable.”

Thomas Egdorf, director of the AIDS Bereavement and Resiliency Program, links the trauma struggles of workers in the opioid overdose crisis to social attitudes prevalent during the deadly height of HIV and AIDS in the 1980s.

“One of the challenges is disenfranchised grief, which is grief that isn’t supported, really, by society,” Egdorf says.

“Often, when workers reach out for support outside of their community, they get responses like, ‘Well, what did you expect? They inject drugs.’ It’s like you don’t have the legitimacy to grieve because ‘of course this person was going to die.’

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“So traditional places where people could go for support — grief counselling, grief groups — don’t often work in these situations because of the judgments a lot of people attach to how someone dies,” Egdorf adds.

At the entrance to the Moss Park overdose prevention site, around a wall painting of an eagle with a syringe in its claws, are the portraits of a dozen people who recently died. Some were front-line colleagues, including Angela Kokinos, who saved lives at St. Stephen’s until her death in September 2018, and Leon “Pops” Alward, a trailblazing volunteer at the Moss Park site when it began as a cluster of tents in 2017. Others are clients the workers knew well.

“Many of the people we interact with in our work have been ostracized and stigmatized and pushed away by other people,” says Marissa Martins. “We sometimes are the only safe place for people to be authentically themselves — artistic, musical, loving, funny. So you see all these beautiful things that people are finally given permission to be.

“You grow fond of them, and then you lose them,” she adds.

For Steff Pinch, the death of 45-year-old client Rodney Rizun forced the need for a break.

Rizun, a talented musician and “born storyteller,” was shot dead in an Etobicoke residence on June 5, 2018. His unsolved murder capped a terrible four-month period when almost 20 of Pinch’s clients, friends and relatives died from natural causes, violence or overdoses.

At the time, Pinch was a harm reduction worker at the LAMP Community Health Centre in Etobicoke. LAMP isn’t a supervised injection site, but it offers drop-in services for drug users.

Pinch says clients would often inject in the centre’s washrooms or around the grounds, causing Pinch and co-workers to scramble in and out of the building saving lives. “For a while, it was every single week someone I knew was dying,” Pinch says. “It was overwhelming.”

Pinch’s only self-care option was short-term medical leave under Employment Insurance. That meant navigating multiple hoops, including finding a doctor at a walk-in clinic and paying for medical forms to be filled.

Pinch ended the EI “stress leave” about halfway through the 15-week period because the doctor would only continue approving it if Pinch went on anti-depressants.

“I refused to go on psychiatric medication because I don’t have a psychiatric problem,” Pinch says. “Everyone is dying! I make sense!”

Harm reduction workers are a tightly knit group and Pinch counts Liz Merlos, who heads harm reduction efforts at Parkdale Queen West Community Health Centre, as a supportive ally.

Merlos has spent months on a waiting list for subsidized counselling to deal with anxiety attacks. She initially called the employer assistance plan but a counsellor told her she needed more help than they could offer.

“There are many times when I’m like, I can’t go to work today, I just can’t,” says Merlos, who grew up in Parkdale and helped save her younger brother from an opioid overdose two years ago at her mother’s home. “I’m struggling with a lot of the things that my peers and colleagues are struggling with.”

She dreads extended breaks from the job — even long weekends — because “every time you come back, someone is gone.”

Almost 900 injections were supervised at Merlos’s site in the first three months of this year. She notes the work goes much beyond reversing overdoses. She and her five co-workers often act like counsellors, listening to heartbreaking stories of childhood trauma and loss.

“You bring it home,” Merlos says. “You bring it into your relationships and your friendships. And it has a toll because it’s so overwhelming. I tell my mom things and my son things and they’re, like, traumatized and worried for me.”

Some years ago, Keren Elumir made a deal with a colleague: “Alcohol wasn’t going to be our go-to on a really bad workday.”

She began work as a street nurse in downtown Toronto in the late 1990s at a Christian charity called Sanctuary, which operates drop-in services for the homeless and marginalized.

There were moments of acute distress, like the time Elumir cut down a suicidal client she knew well from a tree in a downtown park. But she quickly developed what she describes as “this weird, beautiful intimacy” with the people she served. It felt very much like a privilege.

“We hear their stories, their fight for self-respect, their fight against shame, their fight to stay alive today,” she says. “We witness the effects of childhood trauma, of things that nobody should have ever gone through. And we’re often the receptacles of their wishes and dreams.

“So we have this beautiful, intimate relationship often with people that in a way almost become family.”

The support went both ways. Years ago, when her first child was born, serious complications kept her baby in hospital for days.

“I would come out of Mount Sinai Hospital and there was a crew of guys waiting for me to get an update on how my baby was,” she recalls.

“The ones who are still alive — a lot of them are not — feel like they have invested in my child. They’re as excited about her graduating from high school almost as much as I am.”

As clients died premature deaths — from violence, overdoses and hard lives on the streets — Elumir began a personal act of remembrance. She listed their names in a journal.

About five years ago, the number of names rapidly grew. Fentanyl was by then commonly being used by dealers to give street drugs a more powerful high, causing a sharp rise in overdoses. In 2018, almost 75 per cent of accidental opioid-related deaths in Canada involved fentanyl.

One of the people fentanyl killed was Chris, an Indigenous man Elumir knew well. He’d greet her with a big hug and minutes later Elumir would inevitably notice one of her earrings missing.

She visited Chris one day at the Leslie Street Spit, where he camped, and saw her earrings hanging from a tree like wind chimes. “He thought it was hilarious,” she says.

Chris told her of being taken from his parents and placed in a residential school. He was maybe 6 years old. School authorities shaved his head and treated it with kerosene to make sure he didn’t have bugs.

“I don’t think he ever lost that sense of shame and fear he experienced as a little kid,” Elumir says. “He really struggled with white people. He told me numerous times that he didn’t know how to deal with wanting to hate me and wanting to love me all at the same time.”

Chris asked Elumir for help one day — his long, clumped hair was infested with lice. Combing out the bugs was impossible. Chris told Elumir to shave it off.

“He sat and cried through the whole thing,” she says, holding back tears.

Chris vanished sometime later. Rumour spread on the street that he had died. So a memorial service was held for him at Sanctuary. Chris’s street friends packed the place. In the middle of the service, a tall man walked in and asked, “Whose funeral is this?” It was Chris, fresh out of jail.

“He actually showed up at his own memorial service!” Elumir says. “It was crazy. So we used to joke that there were resurrections happening on the street.”

Three years ago, on a rainy day, Elumir found Chris lying dead of an overdose in a doorway. By then she had stopped putting names on her list of the dead. “It was too many. It was too painful.

“It’s this contrast of grief and rage,” she says. “People matter! Why can’t (governments) get that it’s not as simple as, ‘go to detox,’ it’s not as simple as, ‘go get a job.’ ”

Elumir can’t seem to shake Chris’s ghost. “I see a tall, slender, Indigenous man who walks like his feet are sore, and I think it’s him and I go to yell his name and, no …”

She needed a break after 14 years as a street nurse and joined a family health team in North York, caring for pregnant women and babies. But when tents for a safe injection site were raised at Moss Park in 2017, she immediately volunteered. And when the site moved into the Sherbourne St. building, she took a job there part time, with no benefits.

“I don’t think I really have an option,” Elumir says, when asked why she continues to do the traumatic work. “This is a community of people I love. I cannot imagine walking away from that as long as there is a need.”

Correction — July 3rd, 2019: A previous version of this story misspelled Rodney Rizun’s last name.