With his steel-grey hair and spectacles, he looks more like a country doctor than a troublemaker, yet here is Dr. Julio Montaner cracking open what Health Minister Rona Ambrose and indeed the entire federal Conservative government consider the very gates of hell. It is the inner door to Vancouver’s Insite safe injection facility, the only such site in all of North America. All 13 mirrored booths are in use by addicts injecting illegal street drugs into their veins. There’s an old man with a motorized scooter, a young guy with a mountain bike parked behind his chair, and all ages in between. There’s a nurse and care attendants watching over the predominantly male group. It is spotless and bright in here, there’s a ready supply of clean syringes, sterilized water, alcohol swabs and rubber tourniquets to bring drug-battered veins to the surface.
There will be 600 injections in here over the course of the day. No one will die of an overdose this day; no one has ever died of an overdose here since this opened in 2003. The hundreds of overdose deaths over the years happened outside in the streets, urine-soaked alleys and the fetid single-room occupancy hotels of Vancouver’s Downtown Eastside. Sometimes the dead are found with needles still jammed in their arms. It is sad that such a place is needed, but not as pathetic as watching someone inject in a Vancouver alley and then offer the syringe to a companion. Montaner, director of the B.C. Centre for Excellence in HIV/AIDS, watches respectfully from the door for a couple of minutes, then ushers a group of international journalists outside, through a waiting room of drug-sick addicts waiting their turn.
Over the course of the next several days more than 6,000 world-leading researchers, clinicians and public health officials will gather in Vancouver for a conference of the International AIDS Society (IAS). They will learn all there is to know about this storefront facility and its role as part of a harm reduction strategy that has made B.C. a world-beater in the fight against the deadly infection—and a pariah in the eyes of Stephen Harper’s Conservative government.
Insite was opened, following extensive consultation, after a public health emergency was declared in Vancouver in 1997 in an attempt to counter more than 1,000 overdose deaths in the preceding years and a spike in HIV and hepatitis C infections caused by shared needles. Dr. Thomas Kerr of the B.C. Centre for Excellence in HIV/AIDS called the outbreak “the most explosive epidemic of HIV infection that had been observed outside of sub-Saharan Africa.” Since then, B.C. has gone from having the highest infection rate in Canada to among the lowest. “In the immediate area around Insite, the 40-block area around the facility, there’s been a 35-per-cent decline in overdose deaths,” says Kerr. “And people who use Insite on a regular basis are 30 per cent more likely to enter addiction treatment.”
The supervised injection site, the only one of its kind in North America but one of about 90 around the world, has been a target of the federal Conservative government since it came to power in 2006. In 2008, then federal health minister Tony Clement called Insite, “a failure of public policy, indeed of ethical judgment.” Since then a succession of ministers, including current Health Minister Rona Ambrose, have been consistent in their opposition, saying it diverts finances from treatment, legitimizes illegal drug use, encourages others to inject drugs, is a magnet for crime and threatens neighbourhoods.
Kerr and Montaner are using the conference to make the case to delegates and the international media that ideology and the stigma of HIV and drug use are blinding governments, including Canada’s, to the building on the substantial advances in anti-viral therapies that have reduced HIV in B.C. to the level of a chronic disease—as well as the harm-reduction strategies that have contributed to a plunging rate of new infections.
While Insite has the full backing of the city of Vancouver, its police department, public health officials and the B.C. government, the constant federal attacks resulted in the facility becoming one of the most studied health initiatives in Canadian history. More than 40 peer-reviewed studies have been published in The Lancet, the New England Journal of Medicine, and the British Medical Journal among others, concluding that the facility and other harm-reduction strategies like free needle exchanges have slashed HIV infections and overdose death rates, and have increased the number of people seeking treatment without contributing to an increase in crime, notes Kerr, one of the lead researchers.
The federal government’s determination to close Insite by refusing to renew its exemption from existing drug laws was fought all the way to the Supreme Court of Canada, only to lose in a unanimous 2011 decision. The high court’s conclusion in ordering the federal government to allow the continued operation of the facility: “Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada.”
Plans to use the high court ruling as a precedent to add other supervised injection sites in B.C., and to open one in Montreal, however, are stymied by new federal legislation. The so-called Respect for Communities Act received royal assent this June. Ambrose said the law brings “greater clarity and transparency” to the application process. Critics say the law requires such a high level of public approval, research and consultation that it is all but impossible to open new facilities.
Any doubts about the government’s intentions were largely erased after the Supreme Court ruling by a petition and fundraising appeal the party sent to its base under the headline: “Keep heroin out of our backyards. Add your name if you demand a say before a supervised drug consumption site is opened close to your family.”
The campaign, under the signature of Jenni Byrne, national campaign manager, states “special interests are trying to open up these supervised drug consumption sites in cities and towns across Canada—over the objections of local residents and law enforcement. We’ve had enough—that’s why I am pleased the Harper government is acting to put the safety of our communities first,” she said, referencing the new legislation.
The issue of stigma and ideology trumping science is a constant theme among researchers here. Canada is hardly the worst offender. HIV infection rages out of control in eastern Europe and parts of Asia and Africa. There are also alarming new HIV outbreaks in Indiana and Appalachia among poor, white rural residents known to share needles, says Chris Beyrer, president of the IAS, and director of the Johns Hopkins Center for Public Health and Human Rights in Baltimore. In much of the U.S., and until it was largely too late to curb the outbreak in Indiana, there are laws against allowing even needle exchanges. “We are an evidence-based organization,” he says of the IAS. “The evidence is overwhelming that needle-syringe exchange and safe injection facilities work, save lives, are cost-effective, and prevent new infections. So, of course, we are vigorously working on trying to move the bar from saying this can only be done in an emergency to saying this is a part of basic public health.”
Dr. Nora Volkow, director of the U.S. National Institute on Drug Abuse, also holds open the possibility that supervised injection sites are not beyond the possibility in the conservative United States. The fact that the Republican governor of Indiana relented and allowed needle exchanges in the face of the HIV and hepatitis C outbreak is a case in point. “You should never say that it is unlikely,” she said in an interview at the conference. “If you had asked me that same question about would they approve the needle and syringe exchange programs in Indiana, I would have said ‘no, I don’t think so.’ Sometimes reality forces the issue.”
Montaner, however, is not optimistic under the current government in Canada. “Look, the only hope for us to have a constructive approach to HIV/AIDS and everything else that needs to be done in order to address the needs of this epidemic is to make this an election issue. I don’t see the Conservatives doing that.”
In fact, they already have. It’s called the Respect for Communities Act.