An Island Called Insite

"The most explosive outbreak of HIV infection in the Western world." That is how Dr. Thomas Kerr, a research scientist with the B.C. Centre for Excellence in HIV/AIDS, describes the 19 per cent incidence rate that happened in Vancouver's Downtown Eastside in 1996-1997. The Vancouver Richmond Health Board declared the surge a public health emergency.

Today, of the 12,000 people living in the area, approximately 5,000 inject or inhale drugs daily. Estimates are that 90 per cent of drug users have hepatitis C and 35 per cent are HIV positive.

"Seventy per cent of the women who access our services are aboriginal¸" says Marcie Summers, director of the Positive Women's Network. "This is an epidemic. Recently the health officer for Northern B.C. declared it a health crisis. Only a small percentage of women with HIV are on meds."

Summers adds that domestic violence and a lack of stable housing are the two biggest barriers for women seeking treatment. Funding from the province has remained flat though the disease is spreading to many parts of B.C. There are long waiting lists and few places where women can go for treatment with their children.

Further frontiers

Vancouver Area Drug Users director Ann Livingston credits Insite, North America's only safe injection clinic for drug users, with reducing harm. But she would like to see the facility open up an inhalation room for crack smokers and do something about the problem of assisted injections. Many older users have badly scarred veins or injured limbs, and have a great deal of trouble injecting themselves. Present policy at Insite is for self-injection only. Many of the most vulnerable users, who are physically unable to inject themselves, cannot take advantage of the safer, more congenial atmosphere of Insite. And using in the alleys makes them easy prey for robbers and thugs.

Insite has saved lives. Because the drugs brought into the facility are obtained on the illegal market, they can be toxic and sometimes deadly. This past February Wayne almost died when he injected speed that he thought was cocaine. "I wouldn't be here today if it wasn't for Insite," he says. "Thank God they had the medical staff to supply oxygen and keep me breathing. I came close to dying. I had nine seizures in 20 minutes."

Compounding matters, prejudice abounds. As Marcie Summers puts it, "We see people with HIV/AIDS as marginal people, disposable people." Kerr's view is that from an ethical, legal and human-rights perspective, society has to do something.

Apart from offering a safe injection site, Insite refers on a daily basis about four clients to addiction treatment and an average of two clients to methadone treatment. But most of the assistance the facility gives to people involves essentials such as housing and food. "You can't even talk about detox until you have a home," says Sarah Evans, Insite co-ordinator.

Fear of arrest

The number of homeless on Vancouver streets has doubled in the past year, according to The Vancouver Regional District. And many are inhalation or injection drug users.

In an attempt to restore "public order," Vancouver's Police Chief Jamie Graham announced on February 22 that there would be a crackdown on open drug use in the Downtown Eastside.

David Eby, a lawyer with the Pivot Legal Society, whose mandate is to advance the interests of marginalized persons, calls this a step back to police practices of the past. "Since the big HIV outbreak in the area 10 years ago, the police backed off and quit arresting people for simple possession of narcotics," he says. "This seems to be part of a strategy to clean up the area before the 2010 Olympics...Everyone knows it's a joke because there is no way the police could arrest everyone using drugs openly and ever have a chance of processing them. The courts couldn't handle it, the judges couldn't handle it. It would bring the system to a standstill.

"But what is happening is that users are hiding themselves away in a little nook or cranny in the alley where they won't be found for hours if they overdose." Since people are afraid of having needles and rigs on them, Eby continues, they toss them away instead of bringing them into the needle exchange, increasing disposal problems and the risk of accidental infection.

Jail and stigma

Incarceration in the wake of crackdowns leads to additional serious problems for people with HIV/AIDS.

According to Kerr, "Being in jail is one reason people stop taking their meds. Appointments with physicians are posted in public places and everybody will know that you're HIV positive...Also, in jail a syringe is shared between 20 and 30 people. If you declare, you won't get access to the syringe that's going around."

Of course there are other reasons that half of those who are HIV positive and injection drug users discontinue treatment prematurely -- reasons such as side effects. "Injection drug users have so many health issues," Kerr says, "that adding antivirals can be too difficult to tolerate."

Still, the crackdown has got a lot of people worried, since police co-operation is fundamental to effective harm reduction. With the exception of the NAOMI project, a trial heroin prescription program in the area, the only place to inject besides Insite is in the alleys.

And the violence that accompanies the street drug trade is a daily occurrence in this part of town. In March, a 44-year-old aboriginal man was knifed to death on the corner of Hastings and Main over a $5 crack transaction. As well, the criminal nature of the global drug trade is a growing issue in Europe, the U.S., Australia, Canada and in many Third World countries where the drugs are produced.

Yet, in 2001, the auditor general's report on the problem of street drugs in Canada concluded that 94 per cent of all federal resources directed toward the drug problem were spent on enforcement and incarceration -- with no measurable benefits. Society can't afford "no measurable benefits" -- the costs are staggering: property crime, criminal gangs and the spread of bloodborne diseases like HIV and hepatitis C.

Million dollars a week for drugs

With an eye to combating all these costs, the Health Officers' Council of British Columbia and the City of Vancouver Prevention Report produced papers recommending experimenting with a regulated market for illegal drugs. This wouldn't be unprecedented. The countries most progressive in drug reform, such as Holland, Switzerland, Britain and Spain, are advancing harm reduction to include things like the sale and regulation of certain narcotics and soft drugs.

Mark Haden, an addictions expert who works for the Pacific Spirit Community Health Centre in upscale Kerrisdale, agrees. "If these drugs are available only on the black market, people become enormously engaged in the criminal system. They do a lot of crime to pay for the drugs...I think it is immoral of society to allow the existence of a black market that creates so many pathologies, criminalizes our youth and creates so many problems for society."

VANDU's Ann Livingston estimates that at least $150,000 a day is spent on illegal drugs in the 10-block area of the Downtown Eastside. The resulting expenses for society involve the police force, ambulances, medics and the like, she says. "The public needs to understand the cost to them, the risk that your children will get involved in injecting drugs. This risk is very high if you don't have a regulated market."

'You might make that change'

But it takes time for people to adjust their attitudes around prescription narcotics, particularly when Hollywood and the media reinforce the notion that abstinence is the only goal. And, as Livingston says, the public has to go at its own pace. "Harm reduction is a new idea that people often have to warm up to."

Still, it may well be an idea whose time has come. "I think that Vancouver is so ready for someone to do something really radical to deal with the problems of the Downtown Eastside, up to and including the legalizing of prescription heroin and cocaine," David Eby says. "To treat this as a health and social problem and not as a criminal problem."

Wayne and his partner Carla, like many other drug addicts, would both like to see more safe injection sites as well as market control and regulation of the drugs they use.

"Crime would decrease," Wayne says. "Death would decrease. A lot of people would get their humanity back, their self-respect...People wouldn't look down on you and you would have a little bit more self-esteem so you might make that change to go over to the other side of the room, to recovery."

The couple is thinking of going into detox through Insite.

"I don't want my legacy to be on a billboard with a body count in an alley," Carla says. "I'd like to change that."

This is the second of two parts. Read the first, 'Where Carla and Wayne Shoot Up,' here.

Elaine Brière is a Vancouver writer, documentary photographer and filmmaker. She was the last photographer to visit East Timor before the Indonesian invasion of 1975. Her book East Timor: Testimony was published by Between the Lines, Toronto, in 2004.

A treatment guide for HIV-positive injection drug users and their caregivers is available at www.catie.ca/pdf/Prefix/enprefix.pdf or by calling 1.800.263.1638. For more info on harm reduction, visit www.canadianharmreduction.com.