Vancouver Follows Harm Reduction Model

Jeff West, one of the coordinators of the safe injection site known as Insite, leads the way through the entrance. There’s track lighting on the ceiling, and the floors are clean, giving the room a sanitary, clinical feel. Twelve mirrored booths line the wall, almost every one of which is being used. The regulars are mostly male, many have a dual diagnosis of drug addiction and mental health issues and have been living in the Downtown Eastside neighborhood of Vancouver for many years.

“Harm reduction is the underlying philosophy behind the site,” says West. “We wanted to create a low threshold environment where users could access health care services.” Insite is a professional health facility jointly operated by the non-profit Portland Hotel Society and the Vancouver office of the provincial government’s Ministry of Health. It costs about $2 million a year to operate.

Since it opened in September 2003, 4,700 different people have used the site to inject different drugs including heroin, crystal meth and cocaine. There are 2,500 regular users. The site averages 500 people a day during their operating hours from 10 am to 4 am.

There are medical staff on site, including nurses, where users can pick up a tourniquet, water, mini cookers imported from France, needles, alcohol swabs, gauze and cardboard french fry trays to carry their materials. All of these items are used to prepare the various drugs for consumption. From March 10, 2004 to the end of August 2004, 107 overdoses occurred among 72 clients, but no deaths resulted.

The Roots of the Crisis

The Downtown Eastside of Vancouver has been called the “poorest zip code in Canada,” and it’s obvious from the health issues its residents face. Over 2000 people have died from drug overdoses in British Columbia since 1990. HIV/AIDS rates among drug addicts in the Downtown Eastside of Vancouver reached 25%, with Hepatitis C levels reaching 80% among addicts and tuberculosis rates amongst the highest in North America, according to the Canadian Public Health Agency in 2003.

Allen Garr, a reporter for the Vancouver Courier, recounted that the move to a safe injection site began with activists lobbying city government to create a needle exchange program in Vancouver. “They were motivated by the devastating spread of disease caused by shared needles...If for no other reason, needle exchanges made sense on economic grounds; sick and dying junkies were a burden on the health care system,” wrote Garr. (Vancouver Courier, March 16, 2005)

In 1996, British Columbia’s Chief Coroner, Larry Campbell, publicly raised the issue of overdose deaths as they approached a rate of one per day.

Aggressive policing ended the drug trade inside bars but eventually led to public consumption by drug users. Even suburban commuters were starting to notice as cars, homes and small businesses were being broken into, largely by addicts.

The situation was declared a public health emergency by Health Canada in 1997, creating a public dialogue on ways to address the deteriorating situation. Guest speakers flew in from locations like Frankfurt, Amsterdam and Sydney, Australia while public opinion was slowly shifting.

“Four Pillars” Established

City planners started developing a blueprint for a Four Pillar Drug Strategy (see box) which, according to the City of Vancouver’s website, is “a coordinated, comprehensive approach that balances public order and public health in order to create a safer, healthier community.”

In 2000, Vancouver’s Mayor, Philip Owen, released a document outlining a new approach to address Vancouver’s open drug scene. In May 2001, the Four Pillar Drug Strategy was adopted as policy by the City of Vancouver.

Vancouver’s former coroner, Larry Campbell, was elected the Mayor of Vancouver in 2002 and promised to open safe injection sites. He said, “every day that we wait, somebody dies.”

“We...believe this is a health problem and not a criminal problem,” said Campbell in an interview with Vancouver Magazine’s JB McKinnon in June 2003. “We knew what a supervised injection site would look like, we knew what we wanted from treatment, and we had an idea of prevention. It will never be all enforcement - because it won’t work. It can never work. Because these people, these addicted people, are not criminals.”

The result was the opening of Insite in September 2003.

Vancouver’s strategy has provoked a strong response, especially from those south of the US/Canada border. John Walters, head of the White House’s Office of National Drug Control Policy (ONDCP) told the Associated Press that harm reduction is a “lie” and “there are no safe injection sites.” He added, “Drug abuse is a deadly disease. It’s immoral to allow people to suffer and die from a disease we know how to treat.” In 2003, the DEA opened an office in Vancouver, and some speculate it will focus on studying marijuana and heroin distribution.

The International Narcotics Control Board, an independent body funded through the United Nations, released a report in March 2004. The report stated that Vancouver’s safe injection site violates world agreements on the control of drug abuse and any country intending to use harm reduction measures must thoroughly research their impacts.

A “One Pillar” Approach?

The Four Pillar Drug Strategy has been criticized in Vancouver as being unbalanced. “Our current approach to the epidemic has been an utter failure,” wrote Dr. Evan Wood in the BC Medical Association journal (http://www.bcma.org). He emphasized the need for prevention. “Prevention is the most cost-effective intervention and should provide the framework for a comprehensive approach to minimizing the drug problem.”

Peter Ladner, a member of the Vancouver city government, is concerned that prevention and treatment have been ignored in favor of harm reduction. “[The Mayor] should review Vancouver Agreement textbook to understand he has to be the champion of all Four Pillars.”

Mayor Campbell admits that Vancouver’s prevention and treatment strategies are still under development. He said to the Drug War Chronicle (http://stopthedrugwar.org) “[W]e will be asking for a catalog of treatment programs within the province. There is a widespread sense that we don’t have enough treatment facilities, but we don’t know if that is really true - no one has a real handle on it... With prevention, we need to move forward.”

Marliss Taylor, Executive Director of the Streetworks needle exchange program, agrees with a broad strategy for drug use problems. “We need to rethink a lot of things. Drug use is a complicated issue ... it’s about helping people address their issues, past issues, mental health issues. They started drug use for a reason. A lot of times, they are self-medicating.”

In a study published by Dr. Thomas Kerr in the Canadian Medical Association Journal in September 2004, data was collected prior to and after the opening of the Insite facility. Part of its conclusion was “public disorder” related to drug use - including public drug use, discarded syringes and injection related litter - has decreased.

Dr. Dan Small of the PHS Community Services Society, administrators of the Insite safe injection site, says “No one supports addiction under the Four Pillars approach, but it is a recognition that no one should die by themselves in an alleyway. If we can prevent people from becoming addicted in the first place, there is less of a chance for the spread of infectious diseases.”

Vancouver’s Four Pillars drug strategy is contentious and still in the early stages of assessment. For this radical, European-style experiment to succeed, prevention and treatment need to be emphasized as strongly as harm reduction and police enforcement.

Am Johal is a Vancouver writer who has worked on inner-city issues and just completed a human rights exchange in Israel.

Donovan Kuehn is the Director of Outreach and Marketing for NAADAC, the National Association of Alcohol and Drug Abuse Councilors (http://naadac.org) based in Alexandria, Virginia.