How Vancouver Smashed Prejudice Against People Who Use Drugs
Insite, a facility where people can inject drugs with medical support, is a resounding success that hasn’t been replicated anywhere else in North America. We ask one of its architects how it happened—and why it hasn’t happened again.
Insite, the only legal supervised injection facility in North America, receives over 500 visits to its injection room each day. Clients are given clean syringes, cookers, filters, water and tourniquets. Using 12 booths, they inject the illegal drugs that they bring along with them, under the supervision of nurses.
A heavily scrutinized flagship of the harm reduction movement, Insite’s success is backed by reams of evidence. A 2011 study published in The Lancet, for example, found that overdose deaths in the immediate Downtown Eastside area of Vancouver where Insite is located fell by 35% between 2001 and 2005, compared with a 9% fall in Vancouver as a whole. Add the many other proven health and social benefits to drug users and the wider community—fewer HIV and hepatitis C transmissions; less public drug consumption; more referrals to addiction treatment; reduced public costs—and it’s easy to see why drug policy reformers in the US cast envious eyes in Vancouver’s direction.
Insite opened back in 2003. But what did it take to overcome the inevitable public and political prejudices against supervised injection facilities, including the mistaken idea that such a program “promotes” drug use? And why does Insite, despite the good it does, still stand alone in North America?
Substance.com was invited to the New York headquarters of the Harm Reduction Coalition by Allan Clear, its longstanding executive director, to meet with someone perfectly placed to answer questions like these: Donald MacPherson, who was the drug policy coordinator for Vancouver from 2000 to 2009, a position which he used to help drive the positive changes there. Since 2009, he has been the executive director of the Canadian Drug Policy Coalition, an organization pushing for wider reform.
How does something as radical as Insite go from being an idea to a reality?
Donald MacPherson: If you have a big enough problem, you can get innovative stuff done. It took from the mid-‘90s to 2003 to open Insite. It came out of a public policy disaster in the middle of this beautiful city, with hundreds of people dying. In ‘88 there were like 17 overdose deaths in Vancouver. In ‘93, there were 200. So the chief coroner was going a little crazy.
During this epidemic of overdose, HIV, hep C and injection drug use, the city created the conditions for the explosion of the drug market in the Downtown Eastside. They started giving no-gos to users and dealers west of a certain street so they couldn’t go to Granville Street, the commercial strip for all the tourists. It concentrated this market in the Downtown Eastside.
Insite took an alignment of many sectors of the community over time, driven by some key people in the Downtown Eastside—by drug users, by a local poet, Bud Osborn, who was on the regional health board and was passionate about bringing the drug-using community into engagement with health people. There were meetings of drug users in parks, in hotels. VANDU [the Vancouver Area Network of Drug Users] started organizing and demonstrating—bringing coffins into city hall meetings and that sort of stuff. Have you seen the movie, Fix: The Story of an Addicted City?
Allan Clear: It’s got the most brilliant drug-user organizing scene I’ve ever seen, when they do the city hall stuff. It’s like ACT UP [AIDS Coalition to Unleash Power], except it’s all drug users doing it.
Donald MacPherson: The Portland Hotel Society people [the nonprofit that now co-runs Insite] were there, wondering what the hell to do. The mayor, Phillip Owen, was wondering what the hell to do: The woman who made Fix said that he looked like this small-town mayor with a big-city problem. He kept saying, “The judges are letting us down—they’re not putting people in prison for long enough.” That was the only line he had.
But in 1998 the mayor held an international conference and the Portland Hotel Society did too. Both conferences brought people from Europe. The notion that there were other ideas out there was swirling around, and that’s what I was pushing: This problem’s been seen in other cities and they did things. There are things you can do. The alliance of city folk came together and ‘98 was the big learning year.
The city created a drug policy position that allowed me to come into the game in a bigger way and write a drug strategy for the city. That was something the mayor wanted, because he had an election coming and he wanted to wave a plan in front of the province and the federal government.
Your plan was the Four Pillars strategy—harm reduction, treatment, prevention, enforcement—which we’ve also seen in a European context.
Donald MacPherson: Yeah, we just took this strategy and made the long words shorter. And there were many consultations with the community. We had the alignment of Liberal mayor, Liberal regional premier and Liberal prime minister, so the window for discussions around injection sites was wide open. Phillip Owen did polling for the Four Pillars plan and got 90% approval. The lowest approval was 70%—and that was for an injection site! So we knew we had this great thing going in terms of public support.
Allan Clear: After Vancouver pushed things into the Downtown Eastside, you had a more visible street presence of drug users—you had your overdose situation, you had injection in the streets. One of the ways to deal with street users was to provide an indoor space which is supervised, so you don’t have that public nuisance.
Donald Macpherson: Absolutely. The other thing about Insite is it’s actually the fourth “first injection site” in North America—there were three illegal ones beforehand. First in 1995, Ann Livingston [a nurse who co-founded VANDU] was involved in The Back Alley, a dumpy little place which was tolerated by the police for 18 months. An NGO in the neighborhood gave them money for coffee and stipends and stuff.
Then came the Dr. Peter Centre, our other injection room in Vancouver—it often gets left out of the story, too. It’s very low-volume because it’s part of a day program for people with HIV. Their nurses asked the ethicist at the College of Registered Nurses whether supervising injections was within the scope of nursing practice, and the decision was, yes. As long as you don’t do the injection or handle the drugs, helping—showing how, finding veins—is all within the scope of nursing practice. At that point the Dr. Peter Centre board decided to open a supervised injection site. It wasn’t public—just for maybe 30 people in that program who were injectors.
Nurses on AIDS wards in New York and San Francisco changed actual medical practice.
Donald MacPherson: The Canadian nurses are our secret weapon. The Canadian Association of Nurses in AIDS Care has a campaign going on about how nursing is harm reduction.
The third injection site was opened by another nurse in the Downtown Eastside, Megan Olsen. Insite was going to happen, and the police decided since they’d lost that battle, they hammered this very active, visible drug market on a corner of Main Street in the spring of 2003. That’s when Human Rights Watch came to write a report: VANDU called them and said, “You’ve got to get here, the police are doing horrible things to drug users.” They dispersed this drug market, after tolerating it for 13 years across the street from the police station. Their logic was that they were helping to prepare for when Insite opens, so that it’s not a big free-for-all. But they really clamped down. Insite still wasn’t going to open for another six months, so Megan opened another injection site.
My job at that time was to make sure that Insite was going to happen. I had to try to convince Megan to shut it down, because the cops were really upset: “You got the official, high-volume site—we want this one closed.” They did shut it down, but it was an important part of the story—a way to keep the pressure on.
This was the pattern in Europe, too: They were not legal before they were legal. The whole problem with our plan was that we started down the road but didn’t scale it up. Zürich has five injection or consumption rooms. Frankfurt has five. We got stuck.
For political reasons?
Donald MacPherson: Yeah. The current mayor has been totally supportive but he’s not gonna push anything, he’s an environmental guy. People come to visit Vancouver to visit the bike paths now.
But Insite must be one of the most scrutinized drug programs in the world. Over 30 studies have been done on it?
Donald MacPherson: Over 40, I think. And they’re still going.
And the good outcomes keep showing up and the bad outcomes keep not showing up. Yet after all this time, it’s still the only facility of its kind in North America. What’s with that?
Donald MacPherson: In Canada, what’s with that is that the federal government changed, and it’s working to push back the so-called liberalized discussion on harm reduction and drug policy. They’re using a lot of fear-mongering, running a campaign to keep injection sites out. They brought legislation in called the “Respect for Communities Act.” Respect for some in communities. They’re going to protect communities, not from drugs but from services like Insite! It’s bizarre.
The day that legislation was tabled, the Conservative party launched a not-in-my-backyard digital campaign, saying, “There are groups across the country wanting to bring injection sites to your backyard.” It’s really bad, nasty stuff, using all sort of pejorative words for people who use drugs. So that’s put a chill on the municipal and provincial authorities who are trying to move things forward. Had we scaled it up, had the Liberal government stayed in, there was broad acceptance of this as a concept.
Vancouver’s innovations have an impact way beyond the immediate community they serve, don’t they? Not long ago we saw your crack-pipe vending machines spark a lot of discussion.
Donald MacPherson: Right. They got on CNN—these two little forlorn machines!
Allan Clear: There’s also heroin maintenance programs, which generate a certain amount of interest. But when I went up to Vancouver, the thing that struck me was, you’ve got Insite on one floor of this building. Then you have two more floors, where you have Onsite, the drug treatment program, and an aftercare program. And that’s all linked into housing for active drug users, medical care for active drug users. It isn’t just this one center—it’s a whole system built around care and support for drug users. That gets lost.
Donald MacPherson: Housing is critical. Insite is like the wedge into the criminalization of the people who use drugs. But the people who use Insite have a lot of problems—it’s not a well population. And the housing situation is still bad in Vancouver—there’s still a couple of thousand homeless people.
Just as we were getting our heads around spreading harm reduction across the city, decentralizing needle exchange from one site to 30 different types of site, they were cutting social housing. We thought we were making progress, but we were being sabotaged by this other social policy. That’s partly why I say Vancouver’s stuck. We really needed to scale things up. Everyone’s attention wandered, so we’re left with what’s really a tiny intervention into a big problem.
Drug policy in North America has a very long way to go. How optimistic are you?
Donald MacPherson: Certainly around cannabis, change is in the wind. I think the legal regulation discussion around other drugs is still really hard. And I think the Insite discussion is still really hard. Unfortunately a lot of people had to die and get HIV and hep. C before Canada did anything. There’s a certain level of tolerance for this ridiculous situation, with people with severe addictions having to scramble around to find dealers every day. Is that just ok?
You’re not going to treat your way out of this situation. You’re not going to harm-reduce your way out of it. It’s a structural problem here, called drug prohibition. That’s what I find frustrating: You still have this monolithic elephant in the room.
Will Godfrey is the editor-in-chief of Substance.com.
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