INSITE: VANCOUVER'S DRUG DILEMMA

When I was 12 years old, my dad took me for a walk through the
Downtown Eastside of Vancouver. I think he was trying to scare me
away from ever taking hard drugs - as if the Tamagotchi-toting
preteen me needed any such urging - by showing me the worst examples
of addiction. It worked - I was horrified.

The Downtown Eastside is brutal. Take a five-minute walk east from
the steam clock (a popular tourist trap in the chic Gastown district)
and the patio dining and designer boutiques of the city The Economist
called "the most livable in the world" give way to an open drug
market where alleys double as public restrooms and thousands of the
city's homeless wander the streets.

More than 5,000 drug users (about one-third of the 10-block area's
population) reside in the Downtown Eastside - Canada's poorest postal
code. The prevalence of HIV in the neighborhood is the highest in the
industrialized world, and an estimated seven out of 10 Downtown
Eastside residents have Hepatitis C. In 2007 the United Nations
Population Fund called the area a "crisis zone" with UN spokesperson
Patricia Leidl saying "It's one of the worst areas of urban blight
that I've ever seen."

Insite, a clean modern facility, looks somewhat out of place amongst
this despair. While the Downtown Eastside looks better than it has in
past years - efforts to "clean up" the area have intensified as the
2010 Winter Olympics draw closer - the neighbourhood is still mostly
made up of rundown businesses, boarded storefronts covered in posters
and bills, and narrow alleyways in which dealers surreptitiously
sling product to anyone in need of a fix. With its heavy glass door
and modern minimalist interior design, Insite stands out from its
surroundings, and with good reason - the facility is perhaps the most
important and controversial project in the country.

Launched in 2003 by the B.C. Ministry of Health and the Vancouver
Coastal Health Authority under an exemption from federal drug laws,
Insite is a supervised injection site. It's a place for drug users to
obtain sterile needles and to inject their drugs under the watchful
eye of a team of nurses - free from worry that they'll be arrested.

It's an odd situation: heroin and cocaine (the two most common drugs
injected at Insite) remain illegal in Canada, yet users are urged to
bring them to Insite and given clemency within the walls of the facility.

"There is no silver bullet to deal with the scourge of addiction,"
says Mark Townsend, executive director of the Portland Hotel Society,
which operates Insite. "If drug enforcement really worked then we
wouldn't have situations like we do in the Downtown Eastside . Insite
is about working in the reality of the situation, and most
importantly about preventing overdose deaths."

According to Townsend, the 12-seat supervised injection room is just
one part of the facility. After injecting, the 600 drug users who
visit Insite on an average day are asked to move to a post-injection
room where they can rest and rehydrate before going back onto the
street. Townsend says that this time is used to make contact with the
users, to educate them about safe injection practices, and to refer
them to medical care for treatment of wounds or to detox facilities
if the addict expresses interest in getting clean. In fact, staff can
refer addicts directly to Onsite - a 30-bed detox facility located
above Insite.

"We have a detox right above our heads, so people know that they can
always ask to be admitted there - it's really about making things as
easy as possible," says Townsend. "But the first step is just making
contact with people who have traditionally been alone in the alleys
or in hotel rooms injecting drugs on their own. These people don't
usually have any contact with health services, so that's why we've
seen that going to Insite makes users 30 per cent more likely to seek
treatment for drug addiction."

As the first project of its kind in North America, Insite is also a
subject of constant research. The B.C. Centre of Excellence in
HIV/AIDS has conducted over a dozen studies on Insite and has yet to
uncover any detrimental effects caused by the facility. Furthermore,
some of the positive effects revealed by their peer-reviewed research
are extremely encouraging: Insite has reduced the overall rate of
needle sharing in the area, led to increased enrolment in detox
programs, and has not led to an increase in intravenous drug usage.

"The scientific evidence in favour of Insite is overwhelming," says
Dr. Mark Wainberg, director of the McGill University AIDS Centre at
the Montreal Jewish General Hospital. "All indications are that this
approach towards harm reduction works."

The critical view

Some critics, however, remain unconvinced. Most prominent among them
is former federal Health Minister Tony Clement, who at the 2008
International Conference on AIDS called Insite an "abomination."
(Correction appended)

"Allowing and/or encouraging people to inject heroin into their veins
is not harm reduction . we believe it is a form of harm addition,"
said Clement, according to the Vancouver Sun.

While serving as health minister, Clement had granted Insite two
extensions - in 2006 and late 2007 - on its original three-year
exemption from Section 56 of the Controlled Drugs and Substances Act,
but the federal government is now is in the unusual position of
having no power over Insite. In May 2008, the Vancouver Area Network
of Drug Users and the Portland Hotel Society won a constitutional
challenge of the federal government's power to close the facility by
arguing that the site addresses a public health crisis. Justice Ian
Pitfield of the B.C. Supreme Court found that sections of the federal
Controlled Drugs and Substances Act are inconsistent with Section 7
of the Charter of Rights and Freedoms, and granted Insite a
constitutional exemption until the government remedies the Act.

"While there is nothing to be said in favour of the injection of
controlled substances that leads to addiction, there is much to be
said against denying addicts health care services that will
ameliorate the effects of their condition," Pitfield wrote in his
decision. "I cannot agree with the submission that an addict must
feed his addiction in an unsafe environment when a safe environment
that may lead to rehabilitation is the alternative."

In effect, Pitfield found that addiction is an illness, and that if
they were to close Insite, the federal government would be denying
users the right to treatment and to the right of "life, liberty and
security of the person" guaranteed by Section 7. The federal
government is currently appealing Pitfield's decision.

Among the supporters of the appeal is the Canadian Police Association
- - a union representing over 54,000 Canadian police officers - which
has called for Insite to be closed, citing the facility as a
"well-intended but failed experiment."

"Supervised injection sites were supposed to be a starting point for
users to get rid of their drug addiction," says CPA President Tony
Cannavino. "The fact that [there] has not [been] an improvement in
the rate of addictions [in the Downtown Eastside] shows that the $3
million operating cost for Insite would be better spent on treatment
that will have more meaningful results and save more lives."

The Drug Prevention Network of Canada - a right-wing organization
opposed to drug legalization and harm reduction - has also been a
vocal opponent of Insite, with formerpresident Randy White claiming
in The Globe and Mail that "the objective [of programs that deal with
drug addiction] must be prevention and treatment. An injection site
does neither, as treatment must have the objective of abstinence."
The DPNC has also claimed that research into the benefits of Insite
has been biased and has uncovered insufficient proof to justify the facility.

"When you have about $3.5 million of research on your side saying
that Insite is generally a good thing, you think everyone would
listen," says Townsend. "Unfortunately, you can always find people
that will tell you that the world is flat. But science tells us the
world is not flat and that Insite is a success."

The "Four Pillars" Approach

In the media much has been made of the so-called "Four Pillars"
approach to drug addiction - prevention, treatment, harm reduction,
and enforcement - but in actuality the current approach is very much
one-dimensional. Seventy per cent of the federal government's
spending on drug addiction is earmarked for enforcement, with 17 per
cent going to treatment, four per cent for prevention, and two per
cent for harm reduction. The remaining seven per cent of national
anti-drug money is spent on coordination and research.

"All evidence is that harm reduction is a successful strategy for
dealing with drug addiction, but the government is more interested in
focussing on enforcing drug laws," says Wainberg. "Instead of feeling
pressured by the United States or other people that have backwards
approaches on these issues, we should embrace harm reduction. When
you use it in concert with the other [Four Pillars] it can be
extremely helpful for dealing with drug addiction."

One of the biggest initial concerns expressed over Insite was that it
would adversely impact the "enforcement" pillar by acting as a magnet
for drug users and crime - attracting even more unsavory characters
to the neighborhood. However, a 2008 study commissioned by the
federal government and conducted by Neil Boyd, a professor of
criminology at Simon Fraser University, found no such negative effects.

"Insite has had no impact on crime rates," says Boyd. "Furthermore,
we found that we are only just scratching the surface of the benefits
that Insite can provide."

Cost-effectiveness was among the benefits that Boyd's study
uncovered. Using conservative estimates of Insite's benefits, Boyd
found that Insite produces an annual return on investment between one
and four times its cost.

"The most significant savings for the public come through preventing
the spread of HIV infection . but it's important to note as well that
our evaluation of cost-effectiveness clearly underestimates the
benefits of Insite," says Boyd. "We were limited to just data on HIV
infection and the prevention of overdose deaths, and yet we still
found Insite was extremely cost-effective for taxpayers."

Boyd's study also gauged community support for Insite and found that
80 per cent of respondents from the Downtown Eastside thought Insite
should be "expanded, retained, or modified." A similar study by Angus
Reid Strategies in May 2008 found that 65 per cent of Vancouver
residents support Insite.

"I haven't noticed a big difference [since Insite opened]," says
'Mark,' a storeowner in the Downtown Eastside who requested his real
name not be used. "But if it stops people from [overdosing] in my
alley then that's great . It's not like [allowing drug-users to
inject themselves at Insite] is a big deal anyways. You can't stop
them from taking drugs - they're either going to do it there or
they're going to do it somewhere else - you can't police that."

The future of Insite

The future of Insite is still very much up in the air. Although
Insite has support from the vast majority of the medical community,
the mayor of Vancouver, Gregor Robertson, and B.C. Premier Gordon
Campbell, among others, the federal government seems intent on
shutting Insite down, or at the very least, ensuring that similar
projects will not be launched in other Canadian cities.

"It's consistent with their ideology which is to punish people who do
things that they don't agree with - that do things that don't fit
with their view of how the world should operate," says Boyd. "But the
line between legal and illegal drugs has no logic to it . If we were
going to criminalize the drugs that were most likely to kill you we
should probably start with tobacco, seeing as that causes over 35,000
deaths per year."

Clement and Prime Minister Stephen Harper appear to view Insite as an
ideological issue - in their opinion, drugs are immoral and by giving
addicts a safe space to inject intravenous drugs, Insite is condoning
immorality. It's likely that no amount of scientific evidence in
favour of Insite could change their minds.

"[The government is] not prepared to allow people to die . I believe
I'm on the side of compassion and on the side of the angels," says Clement.

But for Townsend - questions of morality aside - the most compelling
argument in favor of Insite is simple.

"The most important aspect [of Insite] for me is that people aren't
just going to overdose and die for no reason - all the other things
are a bonus," he said. "It just seems really unnecessary and brutal
that, with all the resources we have available to us in this day and
age, people should die because they have an addiction."

Correction: The article "Insite: Vancouver's drug dilemma" originally
referred to Tony Clement as the current federal health minister, when
in fact he was transfered out of that position in late 2008. He is
now the Minister of Industry.