Injecting Truth: Vancouver's Controversial Insite Facility
It would have been quite a news conference, and it very nearly happened. Last fall, the Royal Canadian Mounted Police and the British Columbia Centre for Excellence in HIV/AIDS, after months of intense, private talks, agreed to face the media together to declare their agreement that research shows the "benefits" and "positive impacts" of supervised injection sites for intravenous drug users. For the RCMP, making such a statement would have been a turning point: the Mounties would have had to distance themselves from dubious studies, commissioned by the force itself, that were critical of Insite, Vancouver's pioneering safe injection facility. And that would have been a politically awkward move for the federal police, since Prime Minister Stephen HARPER's Conservative government is firmly committed to shutting down Insite.
But senior officers seemed ready to take that dramatic step. "I can confirm we are good to go from our end," said Chief Superintendent Bob Harriman, a top RCMP drug enforcement officer in Vancouver, in an email he sent on Oct. 28, 2009, to Dr. Julio Montaner, director of the B.C. centre. Harriman's email included "proposed messaging for [a] joint media release" of the RCMP and the research centre. The RCMP would acknowledge "an extensive body of Canadian and international peer-reviewed research reporting the benefits of supervised injection sites and no objective peer-reviewed studies demonstrating harms." As well, Harriman said the RCMP would admit that "reviews" commissioned by the force, which contested the centre's research, "did not meet conventional academic standards."
The proposed joint media release was never issued. Nor did the RCMP officers and the centre's doctors appear together for their planned news conference. According to Montaner, two days before the scheduled event last December - after a venue had been booked at the University of British Columbia and "the banners were ready" - he received a telephone call from Deputy Commissioner Gary Bass, the most senior RCMP officer in British Columbia. "He said, 'Julio, can't do it,' " Montaner recalls. "I said, 'What do you mean, Gary?' He said, 'I'm really sorry, I've been ordered not to go ahead with the news conference.' " Montaner says Bass made it clear that the order came from RCMP headquarters in Ottawa.
Even after that setback, Montaner pursued his grievance further up the RCMP chain of command. He's known for his tenacity. Along with heading the research centre, Montaner is a professor of medicine at UBC, and it was announced recently that he will receive the Order of British Columbia for his groundbreaking AIDS work. A charismatic figure in the international movement to combat the disease, Montaner straddles science and advocacy. When his negotiations with Bass didn't pan out, he pressed on early this year to develop what he describes as a remarkably productive relationship with Deputy Commissioner Raf Souccar, a high-ranking RCMP officer in Ottawa, who is responsible for the force's federal and international operations, and has an extensive background in drug investigations.
Despite forging those key links, Montaner finally failed to get the RCMP to agree to publicly admit any mistakes on Insite. On June 24, his centre instead filed a complaint with the Commission for Public Complaints Against the RCMP, hoping that the watchdog body would, among other remedies, order the force to acknowledge that it had wrongly tried to discredit the centre's legitimate research demonstrating Insite's benefits. However, the commission sent him a letter late last month saying that sorting out this tangled episode went beyond its mandate. At that point, Montaner told Maclean's his story in an interview and his centre provided key documents supporting his version of events. The RCMP declined to make a senior officer available to be interviewed for this article or to answer any questions.
Insite has been controversial ever since it was established in 2003 as North America's first legal facility where drug addicts could go to inject themselves. Located in the heart of Vancouver's troubled Downtown Eastside, Insite has 12 booths where users inject the illegal drugs they bring in with them, with nurses standing by. They're given clean syringes, cookers, filters, water and tourniquets. More than 400 overdoses have occurred at the facility, but nobody has ever died there from one. Counsellors and social workers are available to help addicts who want to make a bid to change their lives.
The former Liberal government allowed Insite to open by exempting it from drug enforcement laws for three years. Health Canada provided funding to evaluate it as a sort of pilot project in harm reduction. Montaner's centre took on the bulk of that research. Although he's emerged as a forceful advocate for Insite, he denies his centre set out to produce supportive findings. "We honestly came into this without knowing if it would be all good, all bad, or somewhere in between," he says.
The main conclusions of more than 30 articles published in peer-reviewed journals, including the New England Journal of Medicine in the U.S. and The Lancet in Britain, were overwhelmingly positive. For instance, addicts who used Insite were found to be more likely to go into detox than those who didn't. The amount of drug-related litter, like used needles, in the neighbourhood around the site decreased measurably. Insite's nurses treated a lot of injection-related infections.
From the outset, though, Conservative politicians were uncomfortable with Insite. Tony Clement, who is now industry minister but was health minister from 2006 to 2008 - the key period when the government's position against the facility hardened from skeptical to staunchly opposed - once called it an "abomination." Active RCMP officers also occasionally voiced skepticism, but the extent of opposition to Insite inside the force wasn't clear. However, the documents assembled by Montaner's centre for its filing to the RCMP complaints commission suggests at least some Mounties were actively seeking to raise doubts about the centre's research, without drawing attention to the force's involvement.
According to the centre, the RCMP commissioned four studies reviewing the stack of articles published in medical and scientific journals. The first two, delivered in 2006 by consultants Raymond Corrado and Irwin Cohen, didn't offer much ammunition to criticize the mainstream research into Insite. Corrado found that the researchers' methodology was "appropriate" and that the "policy inferences made were generally carefully presented." Cohen uncovered no serious problems, but stressed the need for "further empirically sound evaluations."
The RCMP asked for two more reports, by Garth Davies, a criminology professor at Simon Fraser University, and Colin Mangham, research director of the Drug Prevention Network of Canada, a group opposed to Insite's harm-reduction model, founded by former Conservative MP Randy White. Both were sharply critical of the academic literature. Mangham faulted the research into Insite for failing to discuss the fact that "only a small percentage of IV drug users use Insite for even a majority of their injections." Davies cast doubt on the statistical validity of the whole body of research into safe injection facilities, including those in Europe. But neither review was published in a peer-reviewed journal, the usual sign that an academic paper stands up to expert scrutiny. Instead, they appeared in 2007 on a website called Journal of Global Drug Policy and Practice, a site supported by U.S. groups that advocate a strict line on illicit drugs.
The RCMP's involvement in commissioning the Mangham and Davies reports was subjected to a burst of publicity in the fall of 2008, when the Pivot Legal Society, a non-profit lawyers' group based in the Downtown Eastside, released emails it obtained under the Access to Information Act. In them, police officers discuss strategy surrounding the studies. "Dr. Mangham's report has now been published," reads one email from an RCMP drug enforcement officer. "As per our request, the report has no reference to the RCMP."
Pressing the RCMP to come clean on its role in generating these reports was one goal of Montaner's protracted talks with senior officers. Their conversations started soon after Pivot went public with the incriminating emails on Oct. 8, 2008. Montaner said he was stunned. He called Deputy Commissioner Bass's office, but couldn't reach him until a Saturday. They met that day at Montaner's home. "To his credit," Montaner says, "he showed up at my place not knowing what to expect." That first two-hour meeting ended, he says, with Bass agreeing to look into RCMP involvement in the studies. Many more meetings followed, bringing Bass and his officers together with Montaner and his AIDS researchers.
By last October, the RCMP seemed ready to fess up to the shortcomings of its bid to generate critiques of the centre's research. "Soon after Insite was opened, the RCMP commissioned several reviews on the impact of supervised injecting facilities, including Insite," Harriman said in his email proposing "messaging" for a joint media release. "These reviews, conducted by Cohen and Corrado, concluded that supervised injecting facilities, including Insite, were associated with positive impacts. Subsequent reviews were commissioned by the RCMP or one of its affiliates (i.e. the Addictive Drug Information Council) to provide an alternative analysis of the existing [supervised injection facility] research. The RCMP recognizes that these reviews did not meet conventional academic standards." Harriman's email admits the police should never have waded into the debate: "The RCMP is not qualified to comment or engage in discussion over the merits of this research."
After the stage seemed set for a coordinated public event to clear the air, Montaner says he was shocked when Bass called to tell him the RCMP wouldn't be issuing that mea culpa or participating in any news conference. Unwilling to give up, Montaner arranged a meeting with an even more senior Mountie, Deputy Commissioner Souccar from the force's Ottawa headquarters, early this year. Montaner again laid out his case against the RCMP's covert actions. At their first meeting, Souccar repeatedly said he couldn't accept that version of events. But, according to Montaner, Bass, who also attended, repeatedly interjected on points of dispute, saying, "Dr. Montaner is right."
Montaner says Souccar soon came around to sounding more sympathetic to the centre's viewpoint. But on Feb. 12, Souccar dashed the physician's hopes again with a letter. "After considerable reflection, I must respectfully decline any further involvement of the RCMP in any joint media release with your organization relating to supervised injection sites," Souccar wrote to Montaner. He did, however, seem to acknowledge in the letter that the RCMP should never have sought out anti-Insite research in the first place. "I sincerely regret," Souccar wrote, "that the RCMP's best intentions to participate in finding solutions to such an important social issue, unwittingly took us down a path outside our mandate."
Even though Souccar pulled the plug, once and for all, on the idea of a joint news event, he didn't sever ties with Montaner. In fact, Souccar invited Montaner to address a meeting last winter in Vancouver of the leadership of major North American drug enforcement agencies. And Souccar went even further - asking Montaner to set up guided tours of the Insite facility for the same skeptical law enforcement leaders. "It was a great experience," Montaner says.
His respect for Souccar and Bass leaves Montaner suspecting others are to blame for the ultimate failure of his centre and the RCMP to come to terms. "The [centre] draws a very strong distinction between the co-operative response provided by the RCMP leadership in B.C. and Raf Souccar, and the cancellation of the media conference by Ottawa," the centre declared in its statement filed on June 24 with the complaints commission. But exactly who in Ottawa made the decision to cancel is far from clear. A spokesman for Public Safety Minister Vic Toews, the minister responsible for the federal police force, said his office doesn't know anything about the matter.
Closing down Insite, though, remains a fixed priority for the Conservative government. Senior RCMP officers might have been ready back in 2008 to acknowledge the "extensive body" of studies on the benefits of supervised injection sites, but federal cabinet ministers have never accepted anything of the sort. A key figure in the saga is Clement. At the 2007 annual meeting of the Canadian Medical Association, he took the doctors to task over the CMA's support for Insite. Clement claimed there was "academic debate going on" over the research into supervised injection, and alluded to new studies "questioning of the research that has already taken place."
It's likely he was referring to the critique of Insite produced for the RCMP, given that his remarks came a few months after Mangham's review was posted on the Internet. Still, Clement appointed his own expert advisory committee to review the research, too. That committee's April 2008 report found that Insite encourages drug users to seek counselling and treatment, and that its public image is positive. On the facility's local impact, the committee concluded that Insite cuts down on shooting up in the surrounding neighbourhood, without increasing petty crime. However, Clement zeroed in on certain of its findings about Insite's limited impact, such as mathematical modelling that shows the facility probably only saves one addict a year from death by overdose, and an estimate that only five per cent of Downtown Eastside drug injections take place at Insite.
Clement wouldn't renew Insite's exemption from the federal Controlled Drugs and Substances Act beyond summer 2008, which would have forced the facility to close. But the group that manages Insite took the issue to court and won a reprieve. That complex legal battle continues. Early this year, the B.C. Court of Appeal upheld the initial decision of a lower court that allowed Insite to stay open. The court ruled, in part, that Insite provides a health service, which brings it under the province's power over health, although there are overlapping federal jurisdictions, including criminal justice. The federal government appealed that ruling to the SUPREME COURT OF CANADA, which agreed in late June to hear the jurisdictional arguments. (The RCMP cited this ongoing case, along with the centre's application to the complaints commission, as reasons for not answering questions from Maclean's.)
There's a striking contrast between the government's waging of a public campaign against Insite, while top RCMP officers simultaneously engaged in private bridge-building sessions with Montaner. As the politicians sought the power to close Insite, senior Mounties quietly learned about the research into supervised injection. They seemed - based on Harriman's email to Montaner on Oct. 28, 2008 - to accept the centre's findings supporting Insite. And they appeared - based on Souccar's letter to him on Feb. 12, 2010 - to regret the RCMP's attempts to cast doubt on that research. The question now is whether these revelations about the undisclosed evolution in the RCMP's perspective on the Insite experiment will have any impact on the government's determination to end it.
See alsoDRUG USE, NONMEDICAL.
Maclean's August 30, 2010