Harm Reduction: Will it Snowball?

[Editor's note: This is the second of a three-part series published by Megaphone Magazine on drugs and the evolution of harm reduction in Vancouver. The first in the series, an article detailing the history of the city's drug wars, can be found here. See this story's sidebar for more information about Megaphone, Vancouver's street paper, and how you can support it.]

When I meet Peter Ferentzy in the lobby of Vancouver's Georgian Court hotel downtown, the 52-year-old Torontonian leaps up to greet me with a firm handshake. Throughout our morning together, he speaks enthusiastically about his academic and recreational pursuits in equal measure, jumping wildly from his love of philosopher Michel Foucault to his enjoyment of boxing, B-movies and mixed martial arts.

Ferentzy was the kind of teenager who didn't care much for high school, but read university-level academic texts in his spare time. His mix of barely-contained kinetic energy and intellectual fervour has led him through numerous jobs, in addition to a high-functioning alcohol addiction that was later interrupted by a crack cocaine addiction.

"Crack really screwed up my alcohol," he says. Eventually, on the road to recovery, he enroled at York University, where he earned a PhD in social and political thought.

Ferentzy prides himself on bringing knowledge "from the gutter up to the halls of academe." He's trying to bridge the gap, he says, between traditional, tough-love approaches to addiction and what really works.

Rather than punishing addicts and idealizing abstinence as the goal for people with addictions, Ferentzy is a passionate supporter of harm reduction approaches that do not punish drug users and instead provide them with positive social supports to improve their lives on their own terms. For all his tough-guy posturing, "treating people kindly is better than all this tough talk," he says. Recovery, he says, must be seen as a social issue.

"Instead of talking about treatment and prevention, we should be talking about social infrastructure and social support. And housing. More education," Ferentzy says. "(If) you teach somebody how to use a computer and give that person a job opportunity, that person's chances of beating their addiction is way higher than if you were to spend the same effort at a treatment institution.

"I'm not against treatment, but it's overrated."

Ferentzy's perspectives may not seem novel here in drug-policy-obsessed Vancouver, where the Downtown Eastside's HIV crisis in the 1990s led to the creation of the Four Pillars Drug Strategy in 2000. That strategy holds harm reduction as a central tenet, along with prevention, treatment and enforcement.

But health measures to mitigate harm to illicit drug users, otherwise known as harm reduction activities, continue to meet resistance across Canada despite overwhelming evidence that abstinence-based approaches to drug addiction don't help everyone. Robust local, national and international scientific evidence shows that models for harm reduction like Insite, Vancouver's safe injection site, save lives and connect people to care they wouldn't otherwise receive.

Tilting the scales

While the historic September 2011 Supreme Court of Canada ruling that allowed Insite to stay open under an exemption from drug laws was seen as a victory to drug users and health advocates, the federal Conservative government has opposed the safe-injection site all along.

In a January 2012 article in the Canadian Medical Association Journal, journalist Paul Christopher Webster writes, "harm reduction programs are anathema to Stephen Harper's governing Conservative party." The situation will only get worse, Webster predicts, once Harper's infamous omnibus crime legislation is passed. Called the Safe Streets and Communities Act, Bill C-10 is currently sitting before the Senate. [Note: Since this story was first published, Bill C-10 has passed and is now law.] The new prisons built under the legislation will only see more people in Canadian jails, Webster continues, which are already hotbeds for drug-related Hepatitis C and HIV.

Meanwhile, harm reduction, despite an overwhelming volume of national and international scientific research that speaks to its success, has become an increasingly polarized term since the Conservative government launched its $64-million National Anti-Drug Strategy in 2007. Under that strategy, 70 per cent of funding was to go to law enforcement initiatives. Prevention, treatment and, crucially, harm reduction received the least amount of funding. An informal audit of the strategy from the International Journal of Drug Policy found harm reduction would receive only two per cent of overall National Anti-Drug Strategy funding.

Donald MacPherson authored the Four Pillars Drug Strategy while serving in his former role as the City of Vancouver's first drug policy coordinator. As the current executive director of the Canadian Drug Policy Coalition, he describes Canada as a paradoxically drug-loving society and drug-hating society.

"We're totally fucked up," he says.

While scientific research suggests that harm reduction strategies work, harm reduction activity continues to encounter political and ideological barriers to implementation because of the criminality and criminalization of illicit drug users.

"If we had a totally different attitude towards these drugs, we'd still have addiction problems, but they might be more manageable addiction problems," MacPherson says. "We're not there yet. We're still chasing people around -- users, dealers, importers, exporters. We're still playing the cat-and-mouse game. Which means it's hard for the official institution to respond to problems."

MacPherson's newly formed Canadian Drug Policy Coalition calls on people across the country to build a movement to change drug policy in Canada, with the understanding that the federal government's current approach to drug use isn't working.

"Harm reduction's been studied since the '70s and '80s. And there's lots of evidence to show that needle exchanges work, and injection sites work, and methadone works. Crack kits help. So let's just do it. Why is it so spotty across the country?" MacPherson asks.

"It's not as if drug users are going to just disappear. They're always going to be around. There's always going to be a small percentage of people who use drugs in a problematic way and take risks and all that sort of stuff. So let's just put those services in place, and pre-empt a lot of the really serious harms that happen, like disease transmission and death and deterioration. People deteriorate way beyond where they have to."

MacPherson warns of a popular misconception about harm reduction. "We think we can solve the addiction problem with these interventions that don't work to solve the addiction problem," he says. "Harm reduction really doesn't try to solve the addiction problem, it tries to solve the 'how do I stay healthy' problem."

Drug problems in cities, he says, are to be managed, not solved.

Public health and personal rights

Seated at the kitchen table in the Vancouver Area Network of Drug Users (VANDU) headquarters, Ann Livingston can't hide her frustration. For years, the VANDU co-founder has been leading harm reduction initiatives for and by drug users with little or no social and financial supports.

She's working on the fringe, she acknowledges, and is critical of organizations like the well-funded Portland Hotel Society, which approaches drug use from a public health perspective. Drug use, in Livingston's view, is a civil rights issue that can't be adequately addressed solely as a health issue.

Framing drug use as a health issue is hardly a step up from looking at it as an issue of criminality, she says. Singular focus on health service delivery for drug users ignores the social needs of drug users.

"It needs to go from a criminal matter to a health matter, and then it needs to go to a human rights matter," she says. "People have the right to ingest substances in their body, and they should retain that right for all substances."

Most importantly, people using drugs need autonomy after a long history of oppression, Livingston says. "The main thing would be to get them in a position where they can save their own lives. And they will."

John McKnight, a Northwestern University academic whose extensive work in education and social policy explores building communities by including marginalized people, informs Livingston's perspectives. She was an activist on birthing issues and children with disabilities -- her oldest son has cerebral palsy -- before she became involved with working with drug users in the early 1990s. She recalls attending a talk by McKnight on people with disabilities.

"He said, 'People who are disabled don't want services. They want to have a life,' " she says. " 'They want friends. They want autonomy.' "

The same can be said for drug users, Livingston says. VANDU, a 2,000-member organization of current and former illicit drug users, exists to stand up for the rights of drug users. Formed in 1997, it is the first drug user group of its kind in Canada.

The voices and knowledge of drug users is crucial for any public health progress related to illicit drug use or harm reduction, Livingston says. "If you do not have a drug user group, you will get nowhere," she emphasizes. She has been attempting to establish drug users groups across B.C. and initiate harm reduction activities for intravenous drug users in the Fraser Valley.

Needle exchanges exist in Surrey and Abbotsford, but some services operate on an outdated one-for-one needle exchange model that proved ineffective in Vancouver in the 1990s, she says.

More support needed in mid-sized communities

New harm reduction activity in Canada has continued in fits and starts in the five years since the federal Conservatives launched its Anti-Drug Strategy that effectively removed harm reduction from its mandate.

While a needle exchange in Victoria, B.C. was shut down in 2008, the Vancouver Island Health Authority (VIHA) is now moving forward with harm reduction activities in the central island. The health authority plans to add new distribution points for harm reduction supplies, such as condoms, syringes and crack pipe mouthpieces. The new distribution points take shape in the wake of Nanaimo community outrage at a mobile crack pipe distribution program in 2007.

The specific location of the sites are still to be determined, but VIHA medical health officer Dr. Paul Hasselback says local need for such services is undeniable. "Do we have a sufficiently spread-out net of services available, and healthcare services in terms of harm reduction? I have no problem with saying, 'Not at this point,' " he says.

"This isn't just about those that have a particular disease," Hasselback continues. "This is about preventing others who don't have this disease in another community." The federal Conservative mentality around drug users puts blinders on the fact that every member of the community, regardless of whether they use drugs or not, is a community member deserving of health care.

"The enlightened cities are moving forward," he says, but there's a need for more harm reduction services in mid-sized communities.

In Ottawa, Dr. Mark Tyndall shares Hasselback's sentiments. The chief and chair of Ottawa Hospital's infectious services division worked until 2010 in Vancouver at the BC Centre for Excellence in HIV/AIDS. Tyndall says more harm reduction services are needed in cities like Saskatoon, Regina, Winnipeg, Edmonton and Calgary. But each city shouldn't need to engage in the uphill battle for harm reduction activity on its own. "It should just be policy," he says.

"Vancouver's led the way, and now I think it should just snowball after that. We shouldn't have to have these battles in every city."

To his chagrin, Tyndall is currently embroiled in yet another harm reduction debate in Ottawa, where he is advocating for opening a safe-injection site in the city. Local media immediately went to Ottawa's chief of police and mayor in search of their opinions on the issue, and neither supported the initiative. Tyndall is frustrated with the déjà-vu.

"The time for debating whether a supervised injection site is a valuable tool in harm reduction is passed," he says. "I get annoyed arguing this again. And the evidence is just so overwhelming, the efficacy of this. Trying to defend why a supervised injection site is a positive addition to harm reduction has pretty much been settled already with the Vancouver experience and with the Supreme Court decision."

The municipal police force and city government in the nation's capital seem to reflect the sentiments of the federal government based in the same city.

"They just think drugs are bad and people shouldn't use them and how could we have a place where people use drugs," Tyndall says of the Ottawa mayor and police chief. "But I don't really think the police or the mayor can stop it if we place it as a necessary health initiative. I'm not naive that I can just walk up and open the doors. But at the same time, I don't think that we should take the police chief's concerns as the final word, or the mayor's concerns as the final word."

Tyndall, like other harm reduction advocates, will be keeping a close watch on Montreal and Quebec City this year, after Quebec Health Minister Yves Bolduc publicly supported the Supreme Court ruling on Insite. He has given the green light on opening sites in the province. Montreal public health director Dr. Richard Lessard came forward with a report in December that recommended Montreal open three safe injection sites and one mobile facility.

Progress like Quebec's is promising to drug policy pioneers like MacPherson, who will also be tracking progress in Montreal this year. A change in drug policy requires long-term vision, he says.

Considering the decade it took for a safe-injection site to become legal in Vancouver, "we know it's going to take 10 years to move these issues across the country."

For his part, Ferentzy remains optimistic that societal attitudes will shift in giving more autonomy to drug users, but he, like other advocates, knows change happens slowly, often frustratingly so.

"Your life span and my life span (are) a heartbeat in the life of a culture," he says. "It'll take time. Even if we haven't changed everything, the fact that the official line has changed, that's important. It's a huge victory."

[Tags: Rights + Justice, Health.]