It's 11 o'clock on a busy Wednesday night inside 327 Carrall St. A dozen junkies nod on ragged couches and chairs lining the downtown storefront's cluttered front room, where one handwritten sign on the wall declares: "End the war on the poor." The Clash rattles through a pair of stereo speakers ancient-sounding enough to be an AM radio. The occasional flare of rubbing alcohol spikes through the haze of cigarette smoke and smell of hot coffee -- in the smaller back room, two or three junkies at a time inject heroin or cocaine into their veins using sterile swabs and fresh needles under the watchful eye of a registered nurse. In here they can also receive advice on vein care, skin infections and detox programs, or just temporarily escape the hustle of one of the bleakest city blocks in all of Canada.
"I can do my fix in here without getting jacked for it," says Shelley, a young woman with dark, tired eyes. Bruised holes dot the crooks of her arms. She wears a tight white blouse, fishnets and black boots -- one of the 80 percent of women who work in the sex trade among the neighborhood's nearly 5,000 drug addicts. "People are pretty nice to each other here," she says with a slight smile.
The 327 Carrall St. operation is illegal, but the mayor's office has looked the other way since it opened on April 7. The guerrilla safe-injection site running here every night from 10 p.m. to 2 a.m. ensures junkies have sterile gear to shoot up with, and discourages them from fixing alone -- a main contributing cause of overdose -- in the festering alleys and decrepit residency motels of the neighborhood. The site is the de facto vanguard of an evolving "harm-reduction" strategy that the city of Vancouver hopes will help clean up the streets and halt a decade-long illicit-drug catastrophe that's killed more than 2,000 via overdose and infectious disease.
Essentially, the situation here has been so bad for so long that the government is willing to help addicts plunge illegal drugs into their veins if it means stemming the greater tide of destruction. If the city's official plan stays on track, by mid-September street junkies will be able to walk into a storefront at nearby 135 East Hastings St. almost any time of day and get high in a safe, clean facility administered by the provincial Vancouver Coastal Health Authority. It's a prospect that's angered conservatives from Ottawa to Washington.
For now, this makeshift site operating in privately donated space is about all the street addicts have. The slogan "Solidarity, Resistance, Liberation" is painted on a sign above the front entrance; inside the front room I'm greeted by the revolution's unlikely leader: a 26-year-old activist wearing a baseball cap on her shaved head. Megan Oleson is a registered nurse who works in critical care at Vancouver General Hospital by day; every night she comes here to provide clean needles and advice to junkies (who must supply their own drugs), with the help of volunteers including current and ex-users. Friendly and mild-mannered, Oleson is modest about her role. She emphasizes that staffing a safe-injection site with addicts' peers is vital to promoting its use. "They really run the site," she says. But it's quickly clear from the way everyone greets her that Oleson is revered by the dozens of patrons, up to 30 per night who inject drugs and another 70 to 100 who come in just for a little sanctuary. Other activists in the neighborhood say Oleson rarely sleeps, but she looks relaxed and focused -- a petite Florence Nightingale with a pierced nose, red tank top and combat boots.
To Canadian conservatives, however -- and to an agitated Bush administration keeping a glaring eye on ever-liberalizing Canadian social policy -- Megan Oleson is more akin to Public Enemy No. 1. She's a renegade promoting criminal behavior and the decriminalization of hard drugs -- the patron saint of a policy that would nurture chronic abuse, the further decay of city neighborhoods, and capitulation in the long, hard-fought war on drugs. And Washington may have good reason to fear what's happening in Vancouver: If the new policy, planned and fought for at the local level, indeed proves effective, other North American cities troubled by throngs of drug addicts -- Seattle, San Francisco and New York -- may be eager to follow.
Vancouver's bold strategy has further provoked the Bush administration, which recently has watched Canada sanction gay marriage and close in on federal decriminalization of marijuana. The prospect of government-backed hard-drug use next door has the White House palpably unsettled: As soon as Vancouver's planned site gained Canadian federal approval in late June, U.S. drug czar John Walters went off. "It's immoral to allow people to suffer and die from a disease we know how to treat," he told the Associated Press. "There are no safe-injection sites," he added, calling the policy "a lie" and "state-sponsored personal suicide." David Murray, special assistant in the U.S. Office of National Drug Control Policy, told the Vancouver Sun on May 2 that likely "unintended consequences" of the safe-injection site could force the U.S. to tighten border controls to prevent increased drug trafficking. That could, of course, negatively impact trade of all sorts.
All of which bounces off Megan Oleson. "There's really nothing radical about this place," she says, once things slow down and we're able to go into the less-crowded back room to talk. "It's highly practical. Safe-injection sites are first-contact work at the ground level. I do about two or three referrals every night to shelters, to places that offer detox and prevention, and to recovery homes." At a nearby table partially curtained off with a sheet, a young woman licks her lips as she cooks a shot of heroin, her face knotted with anticipation. "The reality of it," Oleson continues, "is that for those who want to break away from the hustle of the street, and many of them do, this gives them time to think about it, and to have someone to talk to."
She keeps a nonchalant eye on the junkie, who now has a skinny rubber tube cranked around her left bicep. The woman finds the swollen vein on her forearm, slides the needle in and presses the plunger down. Oleson quietly notes her good technique; uninformed junkies often jab needles into their arms, legs or neck, causing abscesses and other skin problems. The woman tilts her head back against the wall, eyes closed, her face dropping. "Drug users and people in poverty deserve dignity and help," Oleson says.
As we exit through the front room for a quick walk to the corner store, Oleson notes that the rules at 327 -- no fighting, no dealing, no unsupervised fixing -- are set by the users themselves. "There's nothing better than people determining their own health needs, right?" she asks. Looking around at all the nodding faces tinged with easiness and pain -- many of them Asian, black or indigenous, most of them impoverished -- it's a tough question to answer.
Since 1993, greater Vancouver has seen an awful share of the needle and the damage done: an average of 147 overdose deaths annually among an estimated 12,000 injection users of heroin and cocaine. At first, the long-term drug crisis is hard to fathom amid the picturesque landscape: a prosperous city ringed by lapping bays, green forests and mountains; home to a vibrant, polyglot community of almost 2 million still riding the rush of a successful bid for the 2010 Winter Olympics.
But detour into the roughly 10 blocks of the notorious downtown Eastside and the lush environs give way to the stench of urine, piles of trash, and discarded needles. The neighborhood's boarded-up storefronts, few dingy bars and numerous flophouses give no clue that the tourist-friendly Gastown and Chinatown districts are close by. Infectious disease has swept through a desperate populace of back-alley users commonly preparing fixes with dirty needles and puddle water -- more than 30 percent have HIV and 90 percent hepatitis C. Fearful of law enforcement and street thugs, some hurried addicts use their own blood to dissolve powdered narcotics for injection. The concentration of poverty scattered around the open drug scene's epicenter at Main and Hastings -- known locally as "pain and wasting" -- was recognized by the 1996 Canadian census as the poorest neighborhood in the nation. By 1997, with hundreds of deaths on the downtown streets, city officials had declared an epidemic.
According to Dr. Evan Wood, an epidemiologist at University of British Columbia, an abundance of cheap drugs and acute poverty underwrite the ghetto of despair. Displacement due to law-enforcement patterns and "ridiculously underfunded" addiction treatment exacerbate the problem.
"The only really effective way to deal with the drug crisis is to get at the demand side," says Wood, who also conducts leading HIV/AIDS research at St. Paul Hospital in Vancouver. "But there's a five-day waiting list to get into detox, and you have to phone every morning to keep yourself on that list." It's a striking state of affairs, given Canada's reputation for providing a vast social safety net. With nowhere to turn, most addicts choose to inject -- the fastest and cheapest way to get high -- regardless of the health dangers.
The first of its kind on the North American continent, Vancouver's official safe-injection site will be a proving ground for the city's ambitious "Four Pillars" drug policy. The strategy also calls for greater treatment and prevention programs, and vigorous law enforcement targeting dealers -- but not addicts, whom the policy says should be treated as a health problem. At an annual cost of about $2 million (Canadian), the site will offer 12 injection stations, a medical emergency room, counseling offices, and a "chill-out" room where users can socialize or simply relax after their latest fix, according to Viviana Zanocco, a spokesperson for the Vancouver Coastal Health Authority.
Although illicit-drug use inside the site will be permitted by special federal exemption, defining a boundary for street enforcement may remain tricky. "One Catch-22 is that people will still have to purchase their illicit drugs from somebody," says Zanocco. "How does the site work if people are too scared to go in because they're afraid the police will be standing outside the door? It's a struggle, I admit it. We're working with the police department on a strategy."
"This is a health problem, not a criminal problem," says Vancouver Mayor Larry Campbell. Like many other Canadian officials, Campbell appears unfazed by Washington's rhetoric. "We have conservatives in Canada, too, and they won't look at fact or reason either," he says flatly. "I've been to Zurich [Switzerland] where they had a problem way worse than ours, and I've seen the results." The harm-reduction component of the widely endorsed plan -- Mayor Campbell was voted into office in 2002 promising to implement it -- is modeled after programs in Europe and Australia, which have dramatically reduced overdose deaths and the spread of disease.
Though Canada is tagged a firebrand of progressive social policy next to the U.S., it, too, has long fought a supply-side war on drugs. Almost 95 percent of the roughly $500 million spent annually on Canada's drug strategy goes toward efforts to reduce the illicit drug supply. But that paradigm may be cracking now, due in part to the dire situation in Vancouver, and some leading-edge research at University of British Columbia.
With an in-depth study of the city's injection drug users already in progress, Evan Wood and his colleague Dr. Martin Schechter, head of UBC's epidemiology department, were able to measure the impact in late 2000 of a seizure of 220 pounds of heroin -- the single largest drug-enforcement win in Canada's history. Following more than 120 addicts during the months before and after, the researchers reported that "the massive seizure appeared to have no impact on injection users or on the perceived availability of heroin." In fact, the study found that the median price of heroin in Vancouver dropped 20 percent following the seizure, with no change in purity, suggesting an even more saturated supply. Separate research showed the number of fatal overdoses actually ticked higher in the following months.
Wood and Schechter also cite a 2001 United Nations report indicating that only 5 percent of the global illegal drug flow is successfully thwarted by law enforcement. Still, the problem isn't on the enforcement front lines. "The responsibility lies with the politicians and policymakers who continue to direct the overwhelming majority of resources into failing supply-reduction strategies, despite the wealth of scientific evidence demonstrating their ineffectiveness," they write. "Our strong consensus [is] that curbing HIV and overdose epidemics requires a shift toward prevention, treatment and harm reduction."
The devastation visible on Vancouver's downtown streets leaves little doubt that the war on drugs has failed here. But working with an inherently unstable clientele of street junkies, there are no guarantees harm-reduction measures will succeed. Coaxing marginalized addicts to embrace an official safe-injection site could prove difficult -- let alone making the site an effective stepping stone to detox and rehabilitation.
"I used to break into cars all the time, anything to get another fix," says Robert, a jittery 37-year-old junkie in shorts and a tattered T-shirt who asks me for 15 cents at the corner of Abbot and West Pender. It's early afternoon and a couple of businessmen in suits whisk by; normal commercial activity and the hardcore street hustle blend with a strange ease on this block. Robert's fingertips are blackened, and scabby holes pock the backs of his hands, his forearms and the sides of his neck. He says he's heard about the coming safe-injection site, but quickly adds, "I don't shoot no more." We go into the McDonald's on the corner, where he pays the few extra cents he needed for his order: two strawberry sundaes, with extra peanuts. "I think that site is a foolish idea," he says, repeating unconvincingly that he's been clean for three months.
Back outside at the bus stop, Robert greets a young addict named Jasmine, then sits down to eat. He keeps glancing across the street, where a couple of prostitutes work the corner in broad daylight, a pimp-dealer type lurking close behind. "You don't think I'm going to be on heroin do you?" he says, jiggling on the bus stop seat. "I'm not ever going to be a junkie again. Never."
Angelic-faced Jasmine says the site wouldn't get her off the street. "When you have to fix, you do it wherever you want. You won't wait to go to some other place."
"Yeah, you just go around the corner," Robert exclaims.
"Think about it, people that fix coke get so retarded," Jasmine chimes. "You think they'll really stay inside there? They're gonna boogie straight out the door all jacked up!" she laughs.
"Yeah, tear up ... start ripping the carpets up!" laughs Robert. His face goes flat again. "It's like a stupid joke," he says, shaking his head.
But the site is a grave matter for Ann Livingston of Vancouver Area Network of Drug Users, an activist group working out of a ragtag office just down the block at 50 East Hastings St. The city's harm-reduction plan has wound through six years of study and debate, with the new safe-injection site promised over a year ago. "Just what really is a public health emergency?" implores Livingston, who helped set up the guerilla site at 327 Carrall. "It's a really vicious, violent thing to leave in place, while people diddle around and argue about protocols and funding. It verges on criminal negligence to stand by and watch a group of people year after year when you can predict extremely accurately how many will get HIV/AIDS, and how many will die."
The activist group, made up of hundreds of current and former addicts (Livingston herself is not a drug user), hasn't waited around. It runs nightly "alley patrols," and now distributes 1.5 million clean needles per year, according to Livingston -- that's roughly half the 3 million given out annually in Vancouver, which has the largest needle exchange in North America.
"We have a really long way to go," agrees Fiona Gold, a "street" nurse at the nearby office of the B.C. Center for Disease Control. Gold oversees CDC outreach in the Eastside. "I've told far too many people here they've tested positive for HIV. It's just nuts. We really have to do something different." According to the latest Vancouver drug use epidemiology report, injection drug use was the predominant mode of HIV transmission in B.C. from 1994 to 2000. A 1997 study of more than 1,400 Vancouver needle users revealed an HIV infection rate of 18 percent -- the highest level anywhere in the developed world. Since 1997 the number of new cases in the city has dropped significantly, but the report suggests that decline may be due to a "near saturation" of the addict population considered most prone to infection.
Conservatives, Gold also points out, should be equally invested in the harm-reduction strategy -- especially those who are fiscally conservative. Every HIV-infected addict dropped into the healthcare system costs the Canadian government an average of $150,000 in long-term care; the cost of 12 such patients would pay for the new site to run for a year, she says.
Gold introduces me to Earl Crow, a middle-aged ex-rocker from southern California with stringy blonde hair, dark brown eyes and a humble smile. He tells me how he came to Vancouver four years ago hooked on speedballs, a potent mixture of heroin and cocaine. "I was really wired, I was shooting a gram a day," he says. But he made the decision to clean up, joined Vancouver Area Network of Drug Users in 2000 and became its president for the next year and a half. He now works outreach for the CDC in the Eastside, giving out information and clean needles, and watching for medical emergencies in the back alleys -- sometimes putting in 12-hour days.
But he also knows the daunting odds harm-reduction tactics must overcome. "When I was using there wasn't a fucking person in the world who was going to come and save my life," he says. "It had to come from my own heart and head."
Crow agrees to take me around with him, and we head up Powell Street to nearby Oppenheimer Park. The mild afternoon and oasis of grass belie the park's reputation as a drug-dealing hub; at night, Crow says, it's one of the city's most dangerous spots. We run into a young addict named Michelle who says she's been in the neighborhood for 15 years, and we talk as she hurries us down the block. We reach the local welfare office and she darts inside. "She's all jumpy like that because she's been up for a few days," says Crow. "The beginning of the month is tough. It gets busy for us out here because people binge." He adds that some healthcare workers are worried the new safe-injection site could become a "revolving door" for addicts who inject coke, a much more fleeting fix than heroin. "Some of them whack 20 or 30 times a day," he says.
Michelle comes back out, check in hand, and as we hustle back toward Oppenheimer Park, I ask her what she thinks about the coming site.
"Maybe it'll work, but not if you have to go through all the nurses and a bunch of forms and shit. You'll be withdrawn by the time you can get a fix," she says, skipping along. "And it won't work if it's all super-clean and they're gonna freak out if there's one little drop of blood on the floor." At the corner of Jackson Street, she spots who she's looking for and flits off across the block.
For more than a decade, harm-reduction programs in Europe have produced compelling results. In Zurich, Switzerland, many streets that were once needle-littered and crime-ridden are no longer so forbidding. And since the country's first safe-injection site opened in 1986, there hasn't been a single fatal overdose at any of the 13 sites operating across three Swiss cities, according to the U.S.-based advocacy group Drug Policy Alliance. Frankfurt, Germany, a city with population and drug-user demographics similar to those of Vancouver, opened five sites beginning in 1994; fatal overdoses there declined from 147 in 1991 to 26 in 1997, and the spread of HIV among drug users declined dramatically as well.
Studies of the European programs show less clear results, however, in battling long-term addiction. Though conservatives often denounce harm-reduction policy in strictly moral terms, such mixed results may be enough to arm the policy's opponents with a more practical argument: that chronic junkies pose a greater criminal threat than a public health one.
"To many harm-reduction advocates, heroin use is a practical [health] problem, but that's not a plausible view if you live in a neighborhood where drug addicts steal your television set," says Mark Kleiman, a drug policy expert and professor of public policy at University of California Los Angeles. "Ask people living in those neighborhoods if they want a safe-injection site next door, and they will say -- perfectly reasonably -- no." In fact, notes Kleiman, many harm-reduction supporters themselves get caught up in an ideological battle against the conservative crusade. "As a result," he says, "I don't think they take into account all the possible consequences of harm-reduction measures."
But the Canadian federal government appears convinced of the potential benefits; it's promised $1.5 million to fund research at the pilot site, and if the site proves effective, several more could follow in the Vancouver area and in other cities facing illicit-drug problems, including Winnipeg and Toronto.
Urban hard-drug havens in the U.S. could be next. According to a New York Times report on Aug. 11, New York City is estimated to host a staggering 200,000 heroin addicts -- more than 16 times the number in Vancouver, and 20 percent of the nearly 1 million addicts living in the U.S.
"It's certainly reasonable to expect that if this is successful in Canada, that some people will want to imitate it here," says UCLA's Kleiman. The prospect of entering uncharted legal waters may be another reason Washington conservatives are sounding a defiant note. "It's unclear to me whether or not current federal law would forbid a safe-injection site," says Kleiman. "It's not at all obvious to me that it would, because the site does not provide illicit drugs. There's no doubt that those who want to keep U.S. drug policy very supply-reduction focused feel threatened by this."
Mayor Larry Campbell, who first saw the Vancouver drug crisis blooming while working as a narcotics officer three decades ago, says that becoming B.C. chief coroner in 1996 galvanized his view of harm-reduction policy. "When you're going into a room every day and there are two people dead with needles still in their arms, you know the status quo isn't working," he says. "I went from being an enforcement officer to one whose major job was to prevent death. Hopefully this policy will do that, and prevent disease, and will give us back the heart of our city."
But conservatives also argue that the positive results of harm-reduction programs overseas may not translate across different cultures or cityscapes. "I think there are far more serious difficulties with the Swiss model than have been acknowledged," David Murray of the U.S. Office of National Drug Control Policy, a social anthropologist by training, told the Vancouver Sun in May. "My impression is that the presumed benefits will turn out to be illusory." Enabling addicts to pursue their habit, conservatives say, will inevitably boost neighborhood crime and deepen urban decay.
"It is possible safe-injection sites are a good idea," says UCLA's Kleiman. He points to the success of needle exchange programs in promoting drug use abstinence, though he stops short of the controversial heroin distribution plans that the U.K. and others have tried, with mixed success, in the past. "But purely from an economist's point of view," he says, "a safe-injection site makes being a drug user easier, and one would expect that to lead to more people becoming drug users and staying drug users."
"This isn't a game I'm playing where we win or lose, it's peoples' lives," says Mayor Campbell. "If it doesn't work, we'll try something else, but we know that pure enforcement doesn't work. Remember, I'm an ex-narc and I have many friends in the DEA and FBI. The fact of the matter is, the most compelling reason to do this is the U.S. system -- just take a look at your jails. Prisons are a growth industry in the United States, and a vast majority are in there for drugs, of some form or another." Indeed, more than 70,000 inmates, or roughly 55 percent of the U.S. federal prison population, are currently locked up for drug offenses, according to the Federal Bureau of Prisons. "People don't come out rehabilitated, and the drug and health problems aren't dealt with," says Campbell. "We're simply trying to move beyond outdated laws."
Evan Wood of University of British Columbia further points to a study published by his colleague Dr. Mark Tyndall in the April 2003 scientific journal of the International AIDS Society, which concludes that jailing addicts actually worsens the HIV epidemic. Tyndall's study shows that Vancouver injection drug users incarcerated over the prior six months faced nearly triple the risk of HIV infection. "We know HIV spreads very rapidly among addicts in prison, where they're sharing rigs," says Wood, affirming that illicit drug use on the inside is indeed commonplace. "I go to many [international] public health conferences ... and my understanding is it's no different in the U.S."
Standing in the pleasant salt breeze of the city's trendy Yaletown neighborhood, former Vancouver Mayor Philip Owen explains why he defied all expectations and made harm-reduction policy an emblem of his nine-year career in office. Owen served from 1993 with the backing of the conservative Non-Partisan Association until the party dumped him from its 2002 election ticket. He was instrumental in setting the four-pillar drug strategy in motion in 1997. Owen says his perspective began to shift when a wave of crack cocaine hit the streets in 1996, and he made several trips to the Eastside to observe the growing problem. "I got to know some of the people there. It was quickly obvious: The user is sick and the dealer is evil," he says. "What are you going to do? Lock up a 16-year-old girl who's selling her body because she needs dope? You have to lock up the dealers and treat the addicts."
Dressed in a crisp button-down shirt and khakis, the now-retired Owen is more diplomatic than polemical -- until the discussion shifts to Washington. "In the State of the Union address, George W. said his approach to the narcotics problem is to prevent importation, and to treat those who are addicted." Owen claps boisterously. "Wonderful! Then do it! The problem is, the U.S. hasn't done it for 30 years and it's just bullshit to cloud over a serious issue like this. They haven't stopped the importation -- they can't -- and the consumption is rampant as can be. So that's just fine: Keep flying your planes over Colombia, Turkey and Afghanistan, and burning crops and blowing planes out of the sky," he fumes. "It isn't working and we can't wait at the city level because we've got destruction here. And it's in Seattle and Portland and San Francisco and New York. We have to deal with this at the street level, so don't come here and criticize us."
UCLA's Kleiman offers a bit more tempered advice for a displeased Bush administration.
"A really sensible U.S. government might say to Canada, 'We think this is a really dangerous experiment, but if you're crazy enough to try it in your neighborhood, God bless you, and we'll watch,'" he says. "A scientific view of drug policy would say, 'Here's an opportunity for us to learn something.' Of course, that's not what I expect to see from Washington."
For Megan Oleson, such debate is almost beside the point. A little before 1 a.m., Oleson and I are sitting on a bench in Pigeon Park, a dreary cement strip on the corner a half block from 327 Carrall. The street hustle is going strong: people dealing, smoking, drinking and using, several homeless people sleeping on the pavement. "A lot of institutions and healthcare workers claim they understand harm reduction," Oleson says, "but in the end you're challenging a lot of stigmas. You get these people parachuting into ghettos, who don't really care what people's health needs are."
Still, it seems dubious to assume all these despairing people could rescue themselves.
When we walk back inside 327 Carrall the relative calm is striking, though it's still plenty busy an hour before closing time. Some addicts sit drinking coffee, some nod off. A couple of others are pacing, anxious to get through the door into the back room.
It's not hard to imagine the look on John Ashcroft's face, were he to walk inside this place. Yet, not one person has died here since the site opened over four months ago -- even as a couple of people per week are pulled off the nearby streets in body bags.
"I'm here because I hate seeing my friends inject in the alley," Oleson says. "I hate going to fucking memorial services because people go to their hotel room and OD because they're alone."
She heads for the fixing room, pausing to greet a couple of familiar faces before she gets back to work.