Welcome to Insite

At the corner of East Hastings and Carrall Streets in Vancouver, Canada, a raucous crowd milled around the sidewalk. Goods were on offer from a dozen sellers: hand tools, electronics, clothing, toiletries, all of uncertain provenance. There was a frenzy to make deals. A man opened a backpack filled with new tubes of toothpaste, smiling with stumps of teeth. Another sold cartons of orange juice out of a baby carriage. A shiny new mountain bike was on sale for $20. Below it all, a hushed chorus: “Powder. Powder.” “Rock. Got rock.” “Down. Need down?” This last is the local term for heroin, and there were capped syringes, tourniquets, and empty ampoules of sterile water scattered on the ground. In a shuttered doorway, a pale blonde girl in a dirty pink miniskirt, her thumb bruised black from constantly flicking her lighter, drew sunken-cheeked at a crack stem and looked up for a moment to ask, “You hooking?” A police car rolled slowly by but didn’t stop.

The Downtown Eastside of Vancouver is a short walk and a world away from the glittering skyline of its business district, where a new billion-dollar convention center will soon welcome 400,000 visitors to the winter Olympics. Last year, the Economist magazine ranked Vancouver as the “world’s most livable city.” With a temperate climate and progressive mores, it has long been a destination for Canada’s lost and dislocated. The Downtown Eastside, a dozen square blocks of dilapidated tenements and boarded storefronts, is home to one of the highest concentrations of drug addicts in the world. Scenes of open drug use recall the depths of the crack epidemic in New York City or the failed drug zone of Zurich’s “Needle Park” in the early 1990’s. An estimated 5,000 injection heroin and cocaine users live in the neighborhood, and the addict population suffers from HIV rates that are 30 times higher than the national average. Seventy percent have hepatitis C. Much of Vancouver’s homelessness is concentrated in the neighborhood, as is 40 percent of the city’s violent crime. The HIV incidence rate—the increase in new cases—hit 19 percent in 1996, the highest ever observed in the developed world. That’s comparable to the situation in Botswana.

In the face of the developing crisis, the city turned to an unlikely coalition of politicians, scientists, activists, and addicts. In 2001, Vancouver’s Mayor Philip Owen created a drug policy for the city that aimed to mitigate the risks of drug use through practical, evidence-based strategies. These “harm reduction” measures, as they’re known among public-health wonks, include safety-first programs like condom distribution and needle exchange—relatively modest interventions that have been tested in a number of North American cities. But Vancouver has gone one step further and embraced harm reduction as both a pillar of its drug policy and a moral imperative. For the past six years, Vancouver’s health authorities have been conducting a radical experiment in the way they approach and treat drug addicts. And the whole thing is centered in a nondescript three-story brick building in the heart of the Downtown Eastside.

A few blocks beyond the sidewalk market, I met up with Darwin Fisher. He is a tall, slim 43-year-old with slick black hair and a booming voice, and he stood in front of a glass-windowed storefront, hosing the previous evening’s residue off the sidewalk. A sign in the window showed a cartoon syringe, and printed above were the words Welcome to Insite. It was 9:50 a.m., and already a dozen people were milling near the entrance, pacing and smoking. Some were in wheelchairs; other pushed shopping carts loaded with their worldly possessions. Fisher smiled and chatted with them, then unlocked the door and stepped inside. Several other staff members arrived, as Fisher booted up a computer in the waiting room. The crowd outside vibrated with pent-up energy. At 10 sharp, the doors opened, and they filed in, each giving a code name to the staffer at the reception desk: Bubba63, Cosmo, Tattoorick. They were buzzed through a second door, into a large, high-ceilinged room with track lighting. A dozen stainless steel booths lined three walls, each with a large mirror. As people entered, Fisher cheerfully checked them in on another computer. “Hey there, what are you doing today?” he asked. “Down? How about number seven? Powder? Three’s open.” Within moments the booths were fully occupied. Pink Floyd’s “Another Brick in the Wall” was piped in through the sound system. Under the watchful eyes of Insite’s nurses and staff, a dozen of Vancouver’s addicts began their morning ritual of cooking up, tying off, and trying to find a usable vein to inject themselves with illegal drugs.

In this one room, however, the drugs are legal. Insite is the only government-sanctioned supervised injection site in North America. Opened in 2003 with money from Vancouver’s health authority and federal grants, Insite was initially given a three-year exemption to Canada’s Controlled Substances Act. (The facility is operated by a nonprofit social services organization called the Portland Hotel Society.) Addicts arrive with drugs scored on the streets and inject them in a supervised environment, 18 hours a day, 365 days a year. A counter was laden with clean needles, sterile water, cookers, filters, tourniquets, alcohol swabs, condoms. The database includes more than 2,000 users, identified only by code names, and an average day will see 645 injections. There are always two staffers and two nurses on duty, standing by with oxygen masks and syringes of the overdose drug naloxone. To date they have intervened in more than a thousand overdoses without a single death.

The idea of supervised injection sites is not original to Vancouver. There are approximately 90 worldwide, in eight countries: The first was opened in Bern, Switzerland, in 1986, and when Zurich closed “Needle Park,” the Swiss launched supervised injection sites nationwide. The Netherlands, Spain, Germany, and several other European countries followed suit, and a site in Sydney, Australia, opened its doors in 2001. The operating principle is simple: If injection drug use is going to occur regardless, why not create a space that mitigates its dangers? That way, say its proponents, lives will be saved and the spread of disease will be checked. The risks of unsupervised injection are manifold; public drug users are often rushed and are less likely to have sterile equipment and practices. In Vancouver, researchers described addicts drawing up puddle water to mix their drugs, or doing “shake and bake,” mixing the drugs in the syringe without first cooking out their impurities. Such techniques can cause gangrenous abscesses and endocarditis, a bacterial infection of the heart valves. Public users are also less apt to test their drugs for potency. “What’s really difficult on this job is finding out that people use elsewhere, because the site’s not open 24 hours a day, and they die of an overdose,” says Fisher. “If people aren’t using here, they’re using behind a dumpster.”

The raw numbers are encouraging: In 2008 Vancouver’s overdose deaths were the lowest in 30 years, and the rate of new HIV infection among injection drug users was the lowest since recordkeeping began. Historically, one of the chief difficulties of scientifically studying the behavior of illegal drug users has been gathering meaningful data: Addicts aren’t very forthcoming with personal information. But beginning in 1996, Vancouver’s Urban Health Research Initiative canvassed the Downtown Eastside and recruited more than 1,500 participants for a study. That group, known as the Vancouver Injection Drug Users Study, participated in the longest and largest cohort study of injection drug users in the world. Combined with data from more than a thousand users in the database at Insite, researchers have had plenty to work with. Since 2003, dozens of peer-reviewed articles have been published in scientific journals like the Lancet, the American Journal of Public Health,and the New England Journal of Medicine, demonstrating the injection site’s efficacy.

Thomas Kerr, a research scientist at the British Columbia Center for Excellence in HIV/AIDS, is the principal investigator of the studies. His research found that Insite’s users tended to be from the most at-risk groups: the homeless, women, and Canadian aboriginals. As a result of the program, they were less likely to share needles and more likely to seek addiction treatment. The data clearly showed lives were being saved, its advocates insisted. “The international scientific community has basically endorsed our findings,” said Kerr. “We thought that would be enough.”

Despite a body of published research and broad local support—70 percent of Vancouverites are in favor of Insite—its existence has at times pitted police against social-service providers, scientists against politicians, and has polarized opinions at the highest levels of Canadian government. When the Conservative Party gained power in 2006, the new government targeted the center for closure. The three-year legal exemption had ended, and Kerr’s application to extend his study of Insite was denied by the Health Minister, Tony Clement. Clement called it an “abomination,” and told the Vancouver Sun that “allowing and/or encouraging people to inject heroin into their veins is not harm reduction. … [W]e believe it is a form of harm addition.” review article by Colin Mangham, which asserted that the science on Insite was inconclusive. It turned out that Mangham’s paper had appeared in the little-known, online-only Journal of Global Drug Policy and Practice. The Web site for that publication is run by the Drug Free America Foundation, an advocacy group based in St. Petersburg, Fla., with the stated aim of “opposing efforts that would legalize, decriminalize or promote illicit drugs or promote illicit drug use.” The journal was created in 2005 with a $1.5 million grant from the Office of Juvenile Justice and Delinquency Prevention, a Justice Department agency currently under investigation for its grant-making policies during the administration of George W. Bush. (The agency has been accused of cherry-picking unqualified grant proposals based on ideology and cronyism. Most notably, it made a $500,000 grant to the World Golf Association, an organization chaired by George H.W. Bush that promotes golf for at-risk youth.”>  To its critics, Insite enabled addicts, sanctioned criminality and sent the wrong message to the public about drug abuse.

The Portland Hotel Society filed suit to force the federal government to keep the site open, on the grounds that addicts have a constitutional right to health care. The courts ruled in their favor, and a government appeal of the case was thrown out  Jan. 15. Now the feds are weighing whether to take their argument to Canada’s Supreme Court, and the organizers behind Insite are pondering how to expand their reach: 24-hour service, perhaps, or an “inhalation room” for crack smokers. They would also like to bring supervised injection to other Canadian cities.

So can it work? In Vancouver, a mere hour north of the U.S. border, drug policies that would be political suicide in America have become the status quo, supported by the populace and championed by a succession of progressive mayors. While the U.S. spends billions incarcerating 350,000 nonviolent drug offenders, Vancouver offers a window into an alternate reality. They’ve discarded the most punitive excesses of the “war on drugs” and started to re-examine the way society thinks about addicts and addiction. Here in Canada, at least, it all seems very reasonable.

Click here to view a slide show on Downtown Eastside Vancouver.