Inter Press Service - December 22, 2004
Am Johal

Twelve mirrored booths line the wall, making the place look more like a backstage dressing room than a health facility. Almost all of them are occupied. With music playing (users prefer the dark country sounds of Johnny Cash, thrash metal band Slayer or Canada's own Neil Young) West says Insite has created exactly the kind of comfortable environment it set out to establish.

"Harm reduction is the underlying philosophy behind the site," he says. "We wanted to create a low threshold environment where users could access health care services."

The regulars, who bring in street drugs that include heroin, cocaine, morphine, crack, methadone, crystal meth, Talwin and Ritalin ("speed balls"), are mostly male. Many have a dual diagnosis of both drug addiction and mental health issues and have been living in the gritty Vancouver neighbourhood known as the Downtown Eastside for years.

Nearly 5,000 different people have used Insite to inject various drugs since it opened in September 2003. The centre has 2,500 regular users and averages 500 people a day during its operating hours from 10 am to 4 pm.

Nurses and other medical staff are on site to assist users, who also have access to a full range of equipment to prepare their drugs for consumption: tourniquets, mini cookers for crack and other drugs, needles, alcohol swabs, gauze, a filter for ascorbic acid (used to dissolve heroin, among other substances) and cardboard French fry trays to hold these materials.

But behind this professional setting are years of struggle to establish Canada's first safe injection site, as a pilot project.

Over 2,000 people have died from overdoses in the west coast province of British Columbia (BC) since 1990.

In response to that growing catastrophe, in 1993 then provincial coroner Vince Cain released a report that included a recommendation to open a safe injection site in Vancouver, BC's largest city. A controversial suggestion, it garnered little media attention at the time.

Cain's successor as coroner, Larry Campbell, raised the issue publicly as the number of deaths by overdose climbed to almost one a day in the province. Even some members of the Vancouver Police Department began speaking out, saying their ability to control the drug supply on the street was limited. In their view, as a port city Vancouver would always be susceptible to a cheap supply of heroin from Asia.

On the front lines, an earlier decision had been made to police the drug trade inside the bars, which eventually led to users consuming drugs publicly in the Downtown Eastside. That generated more petty crime, as addicts broke into cars, homes and small businesses to support their habits.

Despite those voices of authority backing the idea, many members of the public could not accept that the state should supply addicts with a legal place to use drugs.

Many still do not. Reader Karen Spier wrote to the 'Vancouver Sun' on Nov. 3: "Instead of recognising chronic, hard-core drug users as incapacitated people in desperate need of help and coming up with a way to force them into treatment," she said, "we engage in stopgap measures (like the safe injection site) that do little more than condemn people who are sick to remain locked in a cycle of degradation."

By 1997, 25 percent of drug addicts in the Downtown Eastside were found to be living with HIV/AIDS; 80 percent had hepatitis C and tuberculosis rates in the area were among the highest in North America.

When the federal government's Health Canada in 1997 called the situation a public health emergency, it opened a window to expand the public dialogue on possible ways to address the deteriorating situation.

Guest speakers were flown to Vancouver from places like Frankfurt, Amsterdam and Sydney, and public opinion slowly began to shift in favour of an injection site. The local health board slowly began increasing services as new funding arrived from the federal and provincial governments to deal with the unfolding disaster.

City planners and councillors started developing plans to move ahead with a four-pillar approach -- prevention, enforcement, treatment and harm reduction -- similar to programmes in Switzerland and Germany.

With the support of then Mayor Philip Owen, the plan moved ahead and later regulatory approvals such as an exemption to a section of Canada's Controlled Drug and Substance Act ended up being a minor move, despite criticism from the U.S. Drug Enforcement Agency (DEA) and the International Narcotics Control Board, an independent body funded through the United Nations.

John Walters, director of U.S. drug policy, called the new facility "state-sponsored personal suicide." The DEA has since opened an office in Vancouver that focuses on studying marijuana and heroin distribution.

The INCB released a report in March 2004 that said Insite violates world agreements on the control of drug abuse, and that any country that intends to implement harm reduction measures must thoroughly research their impacts first.

Former Vancouver coroner Campbell, by then the city's mayor, publicly dismissed the report, saying, "I have virtually no faith in this agency whatsoever. It's funded almost entirely by the United States. It has no concept of harm reduction. It's typical (of the attitude): 'let's fight a war on drugs'."

Insite is jointly operated by the Vancouver Coastal Health Authority, which falls under BC's Ministry of Health, and the non-profit Portland Hotel Society for about two million dollars (1.6 million U.S. dollars) a year.

From Mar. 10, 2004 to the end of August 2004, 107 overdoses occurred there among 72 clients but no one died.

So after one year, how is the site performing?

Forty-six percent of nearby businesses randomly surveyed during the past year supported Insite while 34 percent opposed it. Sixty-three percent of users rated the centre's overall quality as excellent and a further 32 percent rated it as good, according to a study conducted by the BC Centre for Excellence in HIV/AIDS.

Dr Thomas Kerr, research associate and co-principal investigator of Evaluation of the Supervised Injection Site (ESIS) with the centre, told IPS, "It is tempting to offer conclusions, but that would misinform the public before it is evaluated and is given time to be scrutinised regarding its impact on population health."

But in a report published in the Canadian Medical Association Journal on Sep. 28, 2004, based on data before and after Insite opened, Kerr and colleagues concluded in part that "public disorder" -- such as injecting drugs on the streets and discarding syringes and other injection-related litter -- had declined.

West says that anecdotal evidence supports those conclusions but that Insite will also wait the full three years of the study before making an official determination on the site's impact.

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+Vancouver Coastal Health Authority (http://www.vch.ca/sis/)

+Canadian Medical Association Journal (http://www.cmaj.ca/cgi/content/full/171/7/731)

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