Vancouver's Safe-Injection Sites Controversy

It's Tuesday morning in the subterranean public toilets at the corner of Vancouver's Main and Hastings streets and things have changed. No one is jamming heroin into a vein. No one is fumbling to light a crack pipe. No one is trying to turn a trick.

It's Tuesday morning in the subterranean public toilets at the corner of Vancouver's Main and Hastings streets and things have changed. No one is jamming heroin into a vein. No one is fumbling to light a crack pipe. No one is trying to turn a trick. When people walk down the stairs, often a bit warily, it is to use these city-owned facilities for their intended purpose. For more than eight years now, the formidable husband-wife team of Jim and Julie Scott have run this "comfort station." They've seen it all, here at the intersection of Pain and Wasting, as it's often called. But this recent, relative calm is a rare and wonderful development.

Until a year ago, the Scotts were overwhelmed by relentless, pounding waves of the addicted, who considered the toilets the closest they had to a safe drug consumption site. "It was getting really, really bad," says Julie, who saw runaways as young as 11 or 12 being swept into the drug culture. Today, they may find one person a week instead of dozens a day trying to fix in the toilets. They credit two initiatives, both started by the previous municipal administration. Renovations last fall by the city made the 80-year-old facilities less intimidating to the general public. And an extensive police presence on the corner scared off the dealers.

It's three months since activist Mayor Larry Campbell took office with a mandate to end the Downtown Eastside district's drug-fuelled spiral, which has claimed more than 2,000 deaths by overdose in the past decade. But sweeping the dealers off Canada's most notorious corner, while a welcome example of political will, is more illusory than substantial. The drug trade has merely scattered a few blocks at most. Now comes the hard part.

Soon, likely by July or August, the neighbourhood will have the first sanctioned and supervised injection sites in North America for users of heroin and other illicit drugs. A community housing and advocacy group, the Portland Hotel Society, has already built a prototype, with a comfy waiting room and six injection booths. For the moment, it stands unused. Society CEO Dan Small is confident the facility will be included in a trial of safe-injection sites that Ottawa plans to launch soon. Health Canada, in drafting criteria for the study, calls such sites "a protected space in which injection drug users can use their drugs more safely, cleanly and under less stress, and thus reduce the risk of overdose fatality or the transmission of infectious diseases." But the Portland group won't wait forever for the federal green light. Getting started soon, says Small, looking at several frail addicts on the street outside, "would be the morally and epidemiologically right thing to do."

The problem is not unique to Vancouver. Toronto has some 10,000 to 15,000 injection drug users, Montreal and Vancouver about 12,000 each, according to estimates cited in the final report in December of the House of Commons special committee on the non-medical use of drugs. Cities considering similar sites - including Montreal, Quebec City, Winnipeg and Victoria - as well as a disapproving U.S. administration, will be closely monitoring the Vancouver trial. Toronto has no similar plans - Ontario Health Minister Tony Clement has vowed to fight injection sites "every step of the way," saying there is no evidence they're effective. There are 40 or 50 such sites in the world, in Switzerland, Germany, the Netherlands and Australia. Their effectiveness, the federal guidelines acknowledge, "remains to be demonstrated in terms of hard indicators and rigorous evaluation methods."

Few will watch more critically than veterans of the neighbourhood's drug wars. John Turvey, executive director of the Downtown Eastside Youth Activities Society, which began Canada's first needle exchange in 1988, isn't jumping on the injection-site bandwagon. He worries the initiative will focus resources on just one localized part of what must be a broad-based solution. "I don't want to belabour injection sites," he says. "Do the bloody thing, get on with it, but how about some treatment and detox while we're at it?" That treatment, he says, should be far from the ready supply of drugs in the Downtown Eastside. Will Vancouver-only injection sites draw even more drug activity to the area, Turvey asks. "That potential would be radically reduced if we had adequate regional services that would stabilize people in their own community."

Injection sites are the attention-grabbing part of Vancouver's so-called Four Pillars drug strategy. But prevention, treatment and enforcement are just as essential. The plan, with its underlying philosophy that addiction is an illness rather than a crime, was first championed, at the cost of his political career, by former mayor Philip Owen. But it was Campbell, as a former chief coroner of B.C. (and inspiration for the popular Da Vinci's Inquest TV series), who had the credibility to sell the strategy to voters in last November's municipal elections.

The idea has gained converts on a national scale. The Commons committee on the non-medical use of drugs made harm-reduction measures a key part of its December report. Among its recommendations: needle exchanges (already in place in many cities) to reduce the transmission of disease through sharing needles; a proposal to treat the most intractable addicts in Canada's largest cities with prescription heroin; and the "safe" injection trials. The prevailing theory of the Liberal-dominated committee is that, to rehabilitate addicts, you must first keep them alive. But Canadian Alliance MP Randy White, a vice-chair of the committee, has a different take, warning that the drug trials will amount to "de facto legalization of heroin" in Canada's major cities.

In Vancouver, Campbell's executive assistant, Geoff Meggs, concedes that the safe-injection trial "is a pretty modest program." Detoxification, rehabilitation and enforcement, though, are much more expensive. The plan, submitted to Ottawa by the Vancouver Coastal Health Authority, includes two injection facilities: the Portland Hotel Society site, and one at the Dr. Peter Centre for people with HIV/AIDS at the downtown St. Paul's Hospital, which has, in fact, operated an injection room for almost a year without waiting for federal approval. The plan would include counselling, but not key programs to wean addicts off drugs. "We've recognized we need to have the other components in place," says health authority spokesman Clay Adams, "but there's such a desire to move urgently that we're simply going ahead with it. The clinical trial will be over a three-year period and we'll see how the other pieces fall into place."

That piecemeal approach worries many cash-starved agencies already on the neighbourhood's front lines. Lou Demerais, the wise and cranky executive director of the Vancouver Native Health Society, fires up a cigarette and walks west from the society's storefront operation on Hastings. With Aboriginal needle junkies being infected by HIV at twice the rate of non-Aboriginals, a supervised site would seem to be made to order. And Demerais isn't opposed, just leery of a half-baked approach. If the trial is to help, it can't be limited to drug injection, he says. "What do you do with the other 85 per cent who are using any number of substances, or multi-using them: crack, injectable cocaine, methamphetamines, all of it?" he asks. "And they pour a lot of booze on top of all that." Will the sites be open 24 hours a day, he asks. Will they test the quality of street drugs before they're injected? "Who's going to pay for all that?"

A block away from the becalmed corner of Main and Hastings, the atmosphere changes. Demerais weaves among the displaced dealers and users, strung in a skittish, twitchy line along a row of derelict storefronts. His message is implicit in the route he's chosen. The danger is that addicts and politicians are chasing the same thing: a quick fix.

Maclean's March 17, 2003