The needle and the damage undone

Vancouver has halted a drug epidemic by helping street addicts shoot up in safety. Will U.S. cities -- and Bush's drug czar -- learn from the Canadians' success?

Published September 22, 2006 11:00AM (EDT)

Three years ago, Vancouver opened a bold new front in the eternal war on drugs. In a downtown neighborhood notorious for street addicts, healthcare workers began welcoming clients into a new "safe injection site," a legal facility for users of illegal narcotics such as heroin and cocaine.

Since then, 18 hours a day, seven days a week, users have been free to enter Insite, located in a renovated storefront at 135 East Hastings Street, and inject their own drugs under the supervision of healthcare professionals. Inside, there are 12 individual booths where users shoot up. They are given clean gear, including needles, spoons and tourniquets. Afterward, they are free to relax in an adjacent "chill-out" room, where they can drink coffee and watch TV. They can also get medical advice and information about rehabilitation programs.

The operation, which today remains the only one of its kind in North America, is funded and run by the provincial Canadian government. This month, the federal government was set to rule on whether to extend Insite's legal status, but has decided to delay the decision. In the meantime, Insite will be allowed to continue operating while additional studies are conducted into how the program affects treatment, prevention and crime.

For drug experts across North America, it will continue to be a closely watched experiment in curtailing drug use, and related crime and urban blight. They know that eradicating the world's supply of illicit narcotics is a statistical impossibility. According to the United Nations' 2006 World Drug Report, despite a record seizure of massive quantities of opiates -- 120 metric tons worldwide -- law enforcement managed to intercept less than one-quarter of the total produced.

But while the war can never be won, Vancouver is winning a key battle. The Insite program has saved hundreds of lives. It has wiped away much of the drug use in the surrounding streets, while increasing the number of addicts seeking treatment and rehabilitation. Some local conservatives, once fierce opponents of the injection site, are now backing it. And supporters believe the site's success will prove a beachhead for a less punitive and more humane war on drugs extending across Canada -- and even to drug-troubled cities south of the Canadian border.

By the time Insite opened in September 2003, Vancouver was reeling from a decade-long drug crisis, with an estimated 12,000 addicts in the city. That August, I spent some time in the bleak environs of the Downtown Eastside, home to one of the most desperate populations of junkies anywhere. The streets were littered with discarded needles and trash. They were also littered with bodies -- nearly three per week on average, the victims of overdoses. Infectious disease ravaged the thousands of addicts in the neighborhood, some of whom dissolved their stashes using puddle water, or even their own blood, before fixing with shared needles in the back alleys. A third had contracted HIV, and no less than nine out of 10 were infected with hepatitis C. The situation had become so grim that authorities had tacitly allowed the operation of an illegal safe injection site run by neighborhood activists, while plans for the government's own, first set in motion in 1997, crawled forward.

On a warm day in late August this year, the same neighborhood felt strikingly different. While there were still plenty of indigent people around, the streets were cleaner, and the visceral sense of foreboding and despair was gone. On the sidewalk in front of Insite, flanked by a pornography store and a Chinese barber shop with bars on the windows, I met Nathan Allen, a bespectacled 29-year-old resident of the neighborhood. A banker by trade, Allen was helping run a community campaign to secure Insite's future. "Just seeing the renewed optimism of the neighborhood has been amazing," he told me. "It's been a dramatic change over the last three years. I remember a person dying almost every day out here. One of your neighbors was always in mourning."

Those victims and neighbors were a range of people, many of whom fit the image of a typical street junkie -- homeless, broke and frail -- and others who did not. Dean Wilson, a wiry middle-aged addict and neighborhood activist I met then, expressed the outrage many felt at the time about the glacial pace of the government's response to the crisis. "Our friends are out on the streets dying," he'd told me. "We'll do what we have to do, with or without the authorities." Wilson and the activist group Vancouver Area Network of Drug Users patrolled the back alleys for medical emergencies, handing out clean needles and guiding junkies to the illegal safe injection site, which was located in a decrepit storefront just a couple blocks from where Insite now operates.

The population they were urgently trying to save included hundreds of impoverished Canadian Aboriginals, and thousands of women, many of them sex workers. But there were also young professionals and college kids buying and using. One of them, a student named Aaron, wearing a hooded sweatshirt and a backpack, had sat down next to me on a park bench at 1 a.m. He was soft-spoken, intelligent and articulate. He talked candidly of his failure to stay sober, and told of the city's then more aggressive law-enforcement approach to addicts. During a crackdown that April, "tons of cops were just jacking anybody on the street and throwing them into paddy wagons," he said. "It was like a war zone down here."

Nevertheless, disease kept spreading, and street junkies kept dropping.

By June 2003, facing down the hostility of Canadian conservatives and Bush officials in Washington, the provincial Vancouver Coastal Health authority received an exemption under Canada's Controlled Drugs and Substances Act to establish and operate Insite for three years. It was approved as a pilot project to halt the devastation, with the additional goal of gleaning data useful to public policymakers. The British Columbia Ministry of Health put up $1.2 million (Canadian) to renovate the former retail space, and has supplied approximately $2 million annually for operating costs. Modeled after successful "harm-reduction" programs in Europe begun in the 1980s, the plan to open Insite had wide political support in a city socially progressive by most measures. It was part of then Mayor Larry Campbell's "four-pillars" strategy that also emphasized prevention, treatment and law enforcement -- the latter targeting drug dealers, but not users, who were viewed as sick people in need of help rather than handcuffs.

Rising support for the policy north of the border agitated Washington. Shortly after Insite gained Canadian federal approval, President Bush's drug czar, John P. Walters, slammed the program as immoral. "There are no safe injection sites," he declared, calling Vancouver's policy "a lie" and "state-sponsored personal suicide."

Since Insite opened, there has not been a single death inside or connected to the facility among the more than 7,200 individuals who have used it -- including at least 453 people who have overdosed. Preventing overdoses from ending in fatalities is a primary objective of the program. "Those were all overdose events that could have been life-threatening without immediate medical intervention," said Jeff West, a coordinator for Vancouver Coastal Health who has been on staff at Insite since its launch. "These are people who stop breathing, or who suffer seizures or aneurisms. If they pass out in an alley and nobody sees them, they are at risk of death."

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."

The research on Insite also shows that it has not led to an increase in assaults, robberies or other drug-related crime -- another fear that was played up by conservatives. Rates of vehicle break-ins and theft in the neighborhood "declined significantly," the research found. (When I visited in 2003, it was a big enough problem that one addict offered to keep watch over my car for me.) Still, according to West, there is a patrol car within a block at most hours of the night and day. The beat cops aren't just there for Insite -- the immediate neighborhood keeps them busy in numerous ways, according to Chow -- but without them, Insite would be more vulnerable to criminal drug activity and violence on or near the premises. In this respect, conservative critics say that securing a safe injection site with police resources is an additional cost to taxpayers in the tens of thousands of dollars.

Yet supporters of the program say the costs are more than made up for in the savings to the healthcare system. "The site encourages people to pay more attention to their own health issues -- more of them get regular doctors rather than just using the emergency wards when their problems become acute," said West. "We know from area hospitals that it has relieved the burden significantly on local emergency rooms." The long view looks the same. As Fiona Gold, a nurse with the B.C. Center for Disease Control, told me in 2003, 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 a dozen such patients would cover Insite's operating expenses for a year.

There are other, less tangible considerations that can stand in the way of opening a safe injection site. "Plenty of people are going to feel like it sends the wrong message about a neighborhood," said Mark Kleiman, a former policy director in the U.S. Department of Justice who now heads the Drug Policy Analysis Program at UCLA. "Would you want one of these next door to you?"

Still, Kleiman says the potential benefits are undeniable. "Nobody's going to start using heroin because you've opened a safe injection site. Assuming you can keep crime in control, I don't see much downside," he said. "But there is a big upside in terms of public health and public order -- I'm not surprised this has worked well in Vancouver. So is it a good idea for us to try this? Certainly."

There are certainly some U.S. cities in need of solutions, including in Washington's own backyard. Since the early 1990s, Baltimore has faced a drug crisis marked by rampant crime, the spread of HIV and hundreds of overdose deaths per year. (Indeed, HBO's gritty hit drama "The Wire," which orbits around Baltimore's drug-plagued housing projects, is all too real.) According to Baltimore Health Commissioner Josh Sharfstein, authorities there believe the city is home to at least 40,000 heroin addicts -- more than three times the number in Vancouver. Data from the Centers for Disease Control shows that thousands of them have contracted HIV through injection drug use.

Amid hot debate in 1994, Baltimore implemented a needle-exchange program, along with free condom distribution and medical screening services, to stop the spread of disease. Over the following decade that helped cut HIV transmission among users by 20 percent. Activists and advocacy groups in other urban drug centers such as New York, Chicago and San Francisco have for years experimented with harm-reduction measures at the grass-roots level. But unlike Europe, and now Canada, the U.S. has never seen political will at the national level to help introduce harm-reduction measures -- let alone a sanctioned injection site -- to deal with the nation's hundreds of thousands of heroin addicts or other abundant populations of hard-drug abusers.

The Bush administration has often spoken of a "compassionate conservative" approach to social crises, but has emphasized only so-called faith-based and abstinence programs. Might they look at the results in Vancouver and consider exemption from federal drug laws for city governments under siege from drug-related disease and urban blight?

"Don't be ridiculous," Kleiman said flatly. "They're completely unserious about drug policy. It's an issue that's all about liberal-bashing to them, and playing to their base. I haven't seen them do anything counter to their own prejudices just because the science says they should."

Despite multiple calls seeking comment on Insite's results and legal status, Walters and the White House Office of National Drug Control Policy did not provide any response.

Over the past three years, Insite has built a compelling case for more places of its kind, say a range of advocates. As plans to launch it were gaining momentum in 2002, local leader George Chow was one of the program's most vocal opponents. President of the city's Chinese Benevolent Association and now a Vancouver city councilor, Chow ran as an independent that year, campaigning against the safe injection site and winning a seat on the council with strong support from the Chinese community. Chow had grown up in the Downtown Eastside, which includes the Chinatown district, and he shared the fears that many Chinatown merchants had about the harm-reduction plan.

That's all since changed. "It was a fear of the unknown -- people were afraid such a facility would bring in more chaos," Chow said, speaking by phone from his office at City Hall. "After three years that has not happened, even with an increase in the homeless. Without this facility the drug problem would have been far more out of control. There would be an even bigger problem with HIV transmission and other issues."

Chow spoke with measured but unambiguous praise of the program. Insite has had a huge impact on the neighborhood, he said, though it certainly hasn't solved all its problems. "There is no easy solution," he said. "I think a lot of people still look at this as a moral issue, and it's challenging -- but as a councilor, I believe we have to do all we can to deal with these health and social issues. This is most important, to work toward practical solutions."

And what of other drug hubs such as Toronto and Montreal? "I would advocate for a national plan, with more facilities like this in other cities," Chow said. "Not just an injection site, but also including treatment and education programs. This, of course, requires more money and resources."

Vancouver's experience, he said, shows they would be money and resources wisely spent. "Most of the original fear and controversy over this has gone away here," he continued. "I would think this would also be a good idea in U.S. cities that need it, too."

By Mark Follman

Mark Follman is Salon's deputy news editor. Read his other articles here.

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