Jeff West, one of the coordinators of the safe injection site known as Insight, walks me through the doorway. There’s track lighting in here and the floors are clean. In the twelve mirrored booths that line the wall, almost every one of them is being used. He tells me the users like listening to Johnny Cash, Slayer and Neil Young. It looks more like a backstage dressing room for actors than a health facility. It’s exactly the kind of environment they want to create here so people feel comfortable walking in.
West thinks that harm reduction should be the underlying philosophy behind the entire approach behind all the strategies dealing with drug addiction.
139 East Hastings used to be a boxing joint. Jimi Hendrix used to live not too far from here. It is now the site of one of the only legally sanctioned safe injection sites in North America where users can bring in the drug of their choice and use it with health professionals nearby. Next door is a "Chill Out" room where users can have coffee, watch tv and meet with counsellors to get referrals to detox and other health facilities.
4,700 different people have used the site since it opened in September 2003 and has 2,500 regular users. They average 500 people a day during their operating hours from 10am to 4pm. There are medical staff on site where users can pick up a tourniquet, water, mini cookers imported from France, needles, alcohol swabs, gauze, a filter for ascorbic acid and cardboard french fry trays to carry their materials. The site is a professional health facility jointly operated by the Vancouver Coastal Health Authority and the Portland Hotel Society and costs about $2 million a year to operate.
Users bring in drugs from the street including heroin, cocaine, morphine, crack, methadone, crystal meth and talwin and ritalin (speed balls). From March 10, 2004 to the end of August 2004, 107 overdoses occurred among 72 clients but no deaths resulted. The safe injection site still requires users to bring in drugs from the black market which can enhance the risk of getting poor quality drugs which effect health outcomes includes overdoses. They are also working to make the site more comfortable for women to use.
There is a clinic adjoining the room where addicts can get treatment for abcesses, foot care to deal with "street feet" that happens with the rain, for some people to deal with mental health issues and for others to get referrals to other agencies. There are many who still believe that there needs to be more low threshold methadone maintenance available for addicts.
There are plans for a nearby site where prescription grade heroin and methadone will be available as part of the NAOMI project (North American Opium Maintenance Initiative) for users willing to be part of the study. The effects on population health will determine the effectiveness of these programs.
46% of businesses which were randomly surveyed supported the site while 34% opposed it. 63% of users rated the overall quality of Insite as excellent and a further 32% rated it as good.
In the context of the great neighbourhood wars in North America, the drug debate in Vancouver was a classic. The drug issue had not only ravaged Vancouver’s Downtown Eastside, but other neighbourhoods of the city. The users included the homeless, those with mental health issues, but also a great number of young people from across the city. Nearby businesses and neighbourhoods like Chinatown were suffering directly as a result of the drug trade. In the 1990’s a wholesale cultural change was about to happen in determining how Vancouver was to address the drug issue.
Protests and counter-protests were all the rage. As protesters from the Community Alliance including from Chinatown arrived at Canada with boxes of petitions, waving flags and singing the national anthem, the counter-protestors supporting the expansion of services were hauled away a few blocks away in paddy wagons with their signs and face paint.
Neighbourhood leaders, business improvement associations, neighbourhood groups, non-profit associations, private security, policing, health and bureaucratic intransigence at all three levels of government were all contributing factors in one of the most protracted civic altercations in recent memory. It pitted neighbour against neighbour, friend against friend and tore political parties to their very foundations.
What it left in its wake as the ten years wore on was a great human tragedy that British Columbians, Canadians and political leaders have yet to acknowledge in any real sense.
When 2,000 people die in a province from drug overdoses since 1990, should the state not have some obligation to look back and assess what happened, what went wrong, what should change and that there must have been a better way to avert these deaths?
In the glow of the upcoming Olympic Games which will bring in their wake pieces of legislation to deal with security concerns that will no doubt effect people in the downtown peninsula, there has not been ample political space directed towards a public inquiry which would look at the systemic failures which contributed to this large scale human tragedy. In fact, it is very possible, that these security related measures enacted by government could once again create the conditions where overdoses could increase.
Why has a public inquiry not happened? Should there not be interim measures that health authorities can take in the context of public health emergencies unburdened by political gridlock?
In the end, these are very basic, but fundamental questions about how our state is run. In a country that prides itself in its public health care system, it was that very system that failed because other levels of government put it in a straitjacket. It was a failure at both the political and bureaucratic levels and highlighted the jurisdictional turf warfare between governments that created the kind of gridlock that led to years passing by without significant changes on the ground. All this was happening as the health indicators of injection drug users continued to deteriorate.
Perhaps the greatest failure in this whole process was that everything happened that was supposed to happen – that we were all collectively willing to look the other way as people died from addiction because they were from the wrong side of the city. In the process, because the governments of the day were unwilling to respond to a health care crisis, we saw drug addicts in the Downtown Eastside reach HIV/AIDS rates of 25%, Hep C reach 80% and TB rates that were amongst the highest in North America.
In 1993, then provincial coroner Vince Cain released a report on drug overdoses which included a recommendation to open a safe injection site. It was a controversial recommendation which garnered little media attention at the time.
As overdose deaths approached one a day in BC, the capacity to control the drug supply on the street was limited. Vancouver, as a port city, was always susceptible to a cheap supply of heroin from Asia. On the front lines, an earlier decision had been made to police the drug trade inside the bars which eventually led to public consumption by drug users along Hastings Street and the area around Oppenheimer Park. Even the suburban commuters were starting to notice. Cars, homes and small businesses were being broken in to largely by addicts. Parents on the West Side were seeing their kids effected by drug use and overdose deaths. Everybody acknowledged that something had to be done.
In the background, Asian and Indo-Canadian gang members were being killed off, victims of gangland shootings and casualties of the drug trade, where the real money was being made.
There are times in the running of governments that leaders have to ignore the polls and move ahead with legislation and policies because it means the difference between life and death for some people. The fundamental question of why it took ten years to open up a safe injection sife as the front end of a comprehensive continuum of care which health experts advocated and the Cain Report recommended needs to have a full public airing.
As people complained about the lack of policing, what people saw in front of them every day was an unsafe injection site in the alley ways and on the street. As the police cracked down, the drug trade only moved into other neighbourhoods drawing further criticism. Whether it was done by design or by a backhanded agreement, everyone in the city knew that a certain level of drug activity in the Downtown Eastside was going to be allowed. Yet even at that level, many of the dealers that were actually selling on the street were addicts themselves feeding their addiction.
On the front lines, people were working under a culture of fear, afraid to speak out about the changes that were necessary to provide health care including the more controversial measures like safe injection sites where many of the front line health workers viewed as necessary to having access to the most addicted and dual diagnosis cases. From the drug users perspective, it was important not to shoot up alone or in the alley ways where many people were overdosing. Being inside around health professionals and having access to other services was necessary – they needed a low-barrier facility if they were actually going to use it.
With the benefit of hindsight, the overdose deaths can be seen as nothing short of the largest preventable human catastrophe in BC in the past decade. At the heart of the issue, was the fact that our public agencies were not looking at the right to health care as a human rights issue – the idea that it didn’t matter whether you were on welfare, addicted to drugs or that you were poor, but that you had the same right to health care as everybody else. The reports all sounded great and expressed the need for more services, but little changed on the front lines.
What was to be defined as health care also was limited. The public dialogue and media at the time couldn’t get beyond the use of terms like "junkie" and "shooting galleries," instead of "drug addict" and "safe injection sites." It was dehumanizing to the people who were going through deep afflictions and were medicating themselves through drugs, to deal with pain, to feed their addiction or selling to make money on the street. The idea of a safe injection site couldn’t get beyond the public uproar of the philosophical and moral position of why an addict should be given a legal place to use drugs. In other words, the civic elite weren’t ready to buy in to the program, still largely uncomfortable with the idea of a public health facility that allowed drug use.
The situation had briefly been called a public health emergency by Health Canada and a window had been created to expand the public dialogue on what was possible to address the increasingly deterioriating sitation. Guest speakers were flying in from out of the country from places like Frankfurt, Amsterdam and Sydney, while public opinion was slowly shifting. The Vancouver/Richmond Health Board at the time slowly began increasing services as new dollars came in from the federal and provincial governments to deal with the disaster that was unfolding.
In this environment, the user run Vancouver Area Network of Drug Users was initiated to get a better sense from the users themselves on what was needed to be done to reduce overdose deaths and disease that was wrapped up in issues like housing, poverty and mental health. Led by Ann Livingston and Bud Osborn, VANDU did more to visibly agitate the powers that be to push for change where many of them bent the ears of the health board, the Mayor and Cabinet Ministers. They took coffins to city hall, planted crosses in Oppenheimer Park, protested on the steps of the legislature and handed out flowers at the development permit meetings. In the process, they outflanked the powerful groups that were lined up to oppose them. The underlying public interest was not being met by continuing to stall.
The plans for a drug resource center were immediately met with an increasingly hostile group of Strathcona homeowners, business improvement associations and groups in Chinatown who viewed the expansion of services in the Downtown Eastside as a threat to business, property values and a genuine belief that it would exacerbate the situation. They wanted more policing, enforcement, detox and to have an expansion of services available in the entire region, rather than in the Downtown Eastside. Like the needle exchange debate, other facilities like Triage before, it pitted similar interests against each other. The NPA led city council remained divided on the issue. It was a tense interplay of power relations in full public view – something that should have happened a long time before that.
As city planners and city councillors postponed approval, they started developing plans to move ahead with the four pillar approach which included prevention, enforcement, treatment and harm reduction, similar to programs in Switzerland and Germany. They created the post of Drug Policy Coordinator which was filled by Donald MacPherson and began the process of implementing a plan.
The groundwork was being laid by the Vancouver Agreement, an urban development agreement that brought together the federal, provincial, municipal governments, including the police and health board. The development permit process for health care expansion in 2000, which included the redevelopment of four facilities, passed easily as community interests mobilized on both sides.
With the support of then Mayor Philip Owen, the plan moved ahead and later regulatory approvals such as receiving an exemption to Section 56 of the Controlled Drug and Substance Act ended up being a minor change despite criticism from the Drug Enforcement Agency in the United States and International Narcotics Control Board, a heavily US influenced independent body funded through the UN. The last civic election brought in a majority that was supportive of the drug plan and had a willingness to move forward on it.
Opening a safe injection site does not in any way deal with drug trafficking, so further projects including heroin maintenance programs which supply the drug are also about to be initiated while enforcement continues to be a key pillar in the plan. The changes to the welfare system which set term limits on welfare recipients will undoubtedly effect Vancouver’s drug strategy.
Dr. Thomas Kerr, research associate and co-principal investigator of ESIS (Evaluation of the Supervised Injection Site) with the BC Center for Excellence in HIV/AIDS says, "It is tempting to offer conclusions, but that would misinform the public before it is evaluated and is given time to be scrutinized regarding its impact on population health."
Kerr also criticizes statements from the police union president who has recently made statements the safe injection site has been ineffective in reducing overdose deaths. In his view, although overdoses have gone up this year, it is not a fair comparison to annual figures which tend to fluctuate but do not take into account those users which are currently accessing the site and could otherwise be opening themself up to more harms related to drug use. Kerr also sees the safe injection site as the initial step in providing a comprehensive continuum of care and that it was never intended to be the panacea in the first place. The Safe Injection Site is part of a three year pilot project designed to study its effectiveness on population health.
In the study report published by Kerr and others at the BC Center for Excellence in HIV/AIDS in the Canadian Medical Association Journal in September 2004, data was collected prior to the opening of the facility and after. Part of its conclusion is that ‘public disorder’ as defined in the study related to drug use has gone down including public injection drug use, publicly discarded syringes and injection related litter (syringe wrappers, syringe caps, sterile water containers and ‘cookers’). The study also counted the number of suspected drug dealers and total number of police patrols. This is only the beginning of many studies that will happen over the next few years as services expand throughout the region.
With the Olympics only a few years away, the drug debate in Vancouver is only just beginning again.