The needle and the damage undone

From a public-health perspective, Vancouver's policy stands as a courageous risk and an unmistakable success. While 453 overdose emergencies averted is the official number cited in peer-reviewed studies of the program, there have been closer to 1,000 people in serious physical jeopardy who have been saved by Insite, according to West. "We also do a lot of other medical interventions," he said. "We see serious infections of organs and bones, lots of abscesses and skin wounds. The other day a nurse here treated a patient with a skin wound neglected for so long there were maggots in it." Such patients often have mental health issues as well. "A lot of people coming here are marginalized street addicts who wouldn't otherwise seek healthcare. Some of them are basically at death's door."

The injection site has been subject to rigorous, independent evaluation by the B.C. Centre for Excellence in HIV/AIDS, a world-renowned research organization. For the period of the legal exemption, the federal government has funded the Centre's research with a half-million dollars annually. Its findings, drawn from a two-year period ending in March 2006, have appeared in an array of leading publications, from the Canadian Medical Association Journal to the New England Journal of Medicine to the Lancet.

Insite has made a powerful impact on the drug crisis, beyond the lives saved. The sharing of needles among junkies -- like putting a match to gasoline in terms of spreading disease -- dropped 70 percent. Counsel available from professionals inside the facility has increased entry into detoxification programs and addiction treatment, with more than 4,000 referrals made, and one in five regular visitors beginning a detox program.

At the same time, fears initially raised by conservative opponents have not been realized. According to the research, the injection site has not led to an increased rate of relapse among former addicts. Nor has it proven a negative influence on those seeking to stop using, or resulted in a "honeypot effect" -- the supposition that a free, government-sanctioned drug den would attract a swarm of users from beyond Vancouver.

And far fewer people are shooting up in public. "It used to churn my stomach -- you would see four or five people lined up right there along the wall, injecting," Allen told me, pointing up the block to the Carnegie Community Center, a 100-year-old stone building whose grandeur was obscured by the street hustle. Centered on the corner of Main and Hastings, the drug scene has long been known as "pain and wasting." But while there is still a throng of addicts around, almost all injection drug use in the immediate area now takes place behind Insite's doors.

It's anything but a scene inside. The front reception area is clean and spare, with finished wood floors, contemporary light fixtures and a few chairs in a waiting area. It felt a universe apart from the shabby storefront that housed the illegal site at nearby 327 Carrall Street three years ago. (That site closed down a few months after Insite opened.) The day I visited, I was greeted by a friendly volunteer behind the desk, one of several user "peers" who help staff a government operation that might otherwise scare off street junkies.

Dealing on the premises is strictly forbidden. The users share in "a culture of responsibility," according to West -- they understand that the program's benefits, and its future, depend on upholding the government-mandated rules, and they help by reporting any wrongdoing to the staff.

"There's nothing glamorous or rock 'n' roll about using here," Allen noted, as we talked out front. "You're cared for as a sick patient." He also described one fortuitous side effect. The site's 12 injection booths are outfitted with mirrors to help the clinical staff keep watch over users -- but they've also been a catalyst for vital self-reflection. "I've talked to several users who've told me that when they saw themselves in the mirror shooting up it really shook them," Allen said. "There was a moment of realization that couldn't have happened on the street. And now those people are in treatment, or they're clean."

Halfway up the block, a weathered-looking addict with stringy hair named Dan, on his way to fix, told me he felt Insite was "a lot safer" than using on the streets. For one thing, he said, "you don't have to worry about bad rigs no more." Initially he'd been wary of talking with a journalist. Two police cars parked within 20 yards of us, however, did not appear to bother him.

The Vancouver police department is among several agencies partnered in the city's harm-reduction strategy. That's led to some intriguing circumstances, given that Insite's users purchase and possess illegal substances, often nearby. Directly across the street from where I spoke with Dan, in an open alley behind the Carnegie Center, I observed two drug sales go down in less than 15 minutes. A parked patrol car sat across the street, directly facing the alley.

I approached the car and asked the young officer with close-cropped hair sitting behind the wheel about the dealing that had just taken place in plain sight of his car. Given the city's effort to decriminalize users, did officers sometimes look the other way? He agreed to speak to me only if he was not identified. "I guess you see what you see," he said. I mentioned how different the area appeared to be since my prior visit, which elicited a sliver of a polite smile. "It's a lot better out here now," he said.

"I think the police often feel like they're shoveling water in terms of street-level dealers," said West, the Insite coordinator. He suggested the police were more interested in focusing on bigger drug traffickers operating in the city. In the neighborhood around Main and Hastings, more critical to the police department's role in the harm-reduction strategy is maintaining public order and safety. "They're really quite supportive of the site," West added. "They know it's another tool that helps them do their job."

"If somebody's dealing drugs right in front of an officer, I can assure you they'd be dealt with," said Constable Howard Chow, speaking by phone from the public affairs office of the Vancouver P.D. He noted that the squad assigned to the Downtown Eastside, one of the city's most volatile sectors, regularly conducts surveillance and sweeps to bust dealers. But he acknowledged there were priorities. "Is simple possession as harshly looked upon as trafficking, for example? No. Those officers are often inundated with calls down there. We use the resources where they're most needed." He added, "We support the site in terms of the medical research, and helping see that through for its potential benefits. We don't comment on the right or wrong of it -- that's not up to us."

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