Oversight in Plain Sight: Understanding the challenge and building the case for action

South Africa cannot fix what it cannot see. On International Overdose Awareness Day, peers, clinicians, researchers, and community leaders faced a hard truth: non-fatal overdoses are mostly invisible in formal systems, while fatal overdoses are undercounted. The poll we ran during the webinar gives us a clear compass. Community voices set the priorities, and the speakers showed how to act on them.

 What should we prioritise to improve overdose response?

​The poll was decisive. Most participants (68%) chose expanding community naloxone access and peer-led training; 32% prioritised strengthening surveillance (n=22). This is not a choice between values. It defines a sequence: save lives now while building the systems that sustain impact.
Reginald Kgoedi, Deputy Chairperson of the PWUD sector, showed what immediate action looks like. Peers are training lay responders to recognise overdose, act quickly, and administer naloxone before medical help arrives. Mobile outreach teams work in the places where overdoses happen most often, including streets, abandoned buildings, shebeens, hostels, and other informal spaces. Training links to harm reduction services such as needle and syringe services, opioid agonist therapy, and safe consumption sites.
Kalvanya Padayachee’s NACOSA survey backs this up. Overdoses happen in public spaces (73%). Many occur when services are limited: 56% during the day, 25% early morning, 19% at night. Almost half of those who experienced or witnessed an overdose reported that help was not available (45%). Where help did arrive, it came first from community members (172) and ambulances (109).

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What best describes your experience with overdose surveillance tools?

​​The poll showed a clear capacity gap. Forty-one percent have never used overdose surveillance tools and 27% have only limited experience. A smaller group relies on these tools regularly (27%), with 5% using them occasionally but facing barriers (n=22).
Associate Professor Nadine Harker of the SA MRC MAST-RU explained why surveillance often feels far from reality. Cause of death coding redistributes accidental poisonings into broad categories, which hides the details that matter for prevention. Non-fatal overdoses do not appear in most institutional datasets. Stigma and criminalisation block reporting. Harm reduction services are not well linked to national data systems. The result is predictable: we are undercounting harm and missing chances to act.
Dr Andrew Scheibe, Technical Advisor for TB HIV Care and SANPUD, grounded the science. Our brains produce endorphins and enkephalins that bind to opioid receptors and regulate pain, reward, and emotion. Heroin uses the same receptor system. Most people smoke it; some inject it. Route of use shapes risk and the support required. Clear, humane explanations like this reduce stigma and open the door to practical conversations about safety, treatment, and response.

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What best describes your community’s response to overdose?

​The poll shows a fragmented picture. Many respondents report no structured community response (36%). Many others rely on formal medical or emergency services (36%). Fewer report access to peer-distributed naloxone and training (18%) or informal networks without naloxone (9%) (n=22).
Kalvanya’s data adds texture. Two in three respondents use multiple substances (66%). Overdose risk rises when opioids mix with alcohol or benzodiazepines. Stimulant toxicity presents differently. People recognise breathing problems, choking, and loss of consciousness in opioid overdose, and rapid heart rate and high temperature with stimulants. Knowledge matters. More than half did not know how to prevent an overdose (55%). Most had never heard of naloxone (81%). Yet willingness is strong: 72% would carry naloxone if available; only 3% have used it.
Regie’s examples show how to move from fragmentation to structure. Youth RISE and SANPUD boosted awareness and preparedness. TB HIV Care’s Western Cape drop-in centre trained community champions. In Gauteng, community-led monitors practised with naloxone kits. In eThekwini, more than 150 participants helped establish a Community Action Group, with similar groups taking shape in other provinces. These are building blocks for local protocols, contact trees, and rapid referrals.

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From data to decisions

​Across eight districts in July 2024, 1,037 respondents shared a consistent picture. Most were men (84%), many were aged 25 to 35 (63%), and most faced unstable housing (64%). Polysubstance use was common (66%). Most had never overdosed (72%), but among the 256 who had, opioid-related overdoses dominated (96%) and a third reported stimulant-related overdose (33%). More than half had witnessed or knew someone who overdosed (55%), and of those cases, many were believed to be fatal (72%). These perceptions are signals. They push us to train more bystanders, carry more naloxone, and shorten the time to response.
The poll adds urgency. People want naloxone access and peer-led training now. Many have little or no experience with surveillance. Communities either have no structured response or lean on formal services that arrive late or not at all. The strategy is clear: act where harm is concentrated, document what happens, and use those data to push policy and scale what works.

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From rapid response to lasting change

​We will equip peers and families with short trainings and naloxone kits in hotspots and during off-hours, then keep the momentum by making reporting simple with a standard overdose form and feedback to improve it. We will connect the chain of care by building referral pathways between peers, facilities, EMS, and mortuaries so responses are faster and records are complete. We will keep communities informed with regular, plain-language summaries that show impact and gaps, and we will push for policy that allows over the counter naloxone while expanding harm reduction services to districts without coverage. Report every suspected overdose using SANPUD’s form and share feedback. Join a peer-led training and pick up a kit. Partner with us to pilot mobile response units and build Community Action Groups in high-risk areas. Community voices set the course. We have the tools to act. Let us use them.