"You had so many more transactions and it was such a busy market," he says. "There was more crime, disorder and violence."

Whereas an addicted heroin user might need a few fixes a day, a cocaine high comes and goes quickly. This meant more frequent buying and using. The public health implications were grim. Anyone injecting the stuff -- either as powder or, as became more frequent in the 1990s, as crack -- might be slamming cocaine into their veins 20 times a day.

The Downtown Eastside Youth Activities Society (DEYAS) was one of the first community groups to respond to the surge in injection drug-use. Under the direction of John Turvey, DEYAS secured $100,000 from mayor Gordon Campbell to operate Canada's first needle exchange in 1989.

Sadly, clean needles would do nothing to curb the rising trend of overdose fatalities across B.C. The most common culprit: a new grade of heroin, generically coined "China White." Ten times purer than anything that had been on the street a few years earlier, it began flooding into Vancouver in the early '90s.

Raising Cain

With the physical evidence of a crisis passing through his office everyday, B.C. chief coroner Vince Cain spent the summer of 1994 compiling a report. The previous year, there had been 331 fatal drug overdoses in the province. Ann Livingston, who had recently moved to Main and Powell, recalls going to the final public hearing of the coroner's commission that June. She brought her kids along, towing them in a wagon to keep them quiet.

"So I kept going back and forth with the wagon at the back of the Carnegie Centre, listening to what all the people were saying," she says. "I think that must have been one of the first times that drug users were asked what they actually thought about anything."

The Cain Report was published that September. With recommendations reminiscent of the 1952 Community Chest, Cain dismissed the war on drugs as "an expensive failure" and recommended, most controversially, the establishment of supervised injection sites.

While city hall was only beginning to mull over the implications of Cain's recommendations, some in the Downtown Eastside were already beginning to act. In 1995, Livingston created the group IV Feed. Using funding from DEYAS, she rented a storefront at 356 Powell St. to set up a "drop-in centre" for addicts. In reality, the Back Alley Drop-In was an injection site.

With no medical personnel, the underfunded and undersupplied facility "had every kind of problem you can imagine," says Livingston. "It was like fear and loathing on Powell Street."

But it was still preferable to an alley, she says. This was a place where addicts could escape, to access clean syringes and to fix in a safe environment. The police, recognizing the benefits of having junkies off the street, mostly turned a blind eye to the operation.

The Back Alley lost its funding the next year. Livingston would go on to operate two more illegal injection sites -- in 2000 and again in 2003 -- before Insite opened.

A growing epidemic

Along with the overdose crisis, it was also becoming clear that intravenous drug users were being ravaged by communicable disease. Dr. Steffanie Strathdee at the B.C. Centre for Excellence in HIV/AIDS began to investigate. In 1996, she helped set up the Vancouver Injection Drug Users Study (VIDUS), an ongoing health survey of over 1,000 local drug users. The 1997 results confirmed what many in the community already knew: the neighbourhood was facing a severe epidemic. Nearly 90 per cent of those surveyed had Hepatitis C, while more than one in five was HIV positive.

Within the Downtown Eastside specifically, HIV rates hovered closer to one in three. The neighbourhood, it was declared, had the highest HIV/AIDS rate in the developed world. In September of that year, Vancouver's chief medical health officer, John Blatherwick, declared a public health emergency in the Downtown Eastside. The reminder was hardly necessary for many in the neighbourhood.

In July of 1997, activist and health board member Bud Osborn planted 1,000 crosses in Oppenheimer Park for the drug users who had died across B.C. in the previous four years. A few months later, he and Livingston held the first public meeting of what would become the Vancouver Action Network of Drug Users (VANDU). An organization principally made up of current and former drug-users, it was legally incorporated and granted health authority funding the following year. VANDU would later play an instrumental role in organizing unrestrictive needle exchanges and lobbying city hall for more action.

Out of harm's way

On a rainy November day in 1998, the Portland Hotel Society (PHS) organized a public conference in Oppenheimer Park. Called "Out of Harm's Way," organizers had invited an international panel of drug squad cops, public health wonks and legal experts to speak authoritatively on the wisdom of supervised injection sites.

"I remember standing on the corner of Hastings and all these drug users coming up to tell me that this was just a terrible thing," says Mark Townsend, PHS executive director. "That this was like giving candy to a baby."

It was a familiar argument. When Townsend and his partner Liz Evans founded the society in 1993, they were one of the first housing providers in the neighbourhood to encourage safe drug use.

"That was seen as a devilish, evil thing to do," Townsend recalls. "Now most housing providers are more than happy to provide rigs."

Like that debate, the call for a supervised injection site seemed to Townsend and his colleagues to be the logical step in addressing a health crisis. But if something so unfamiliar was to be opened in the neighbourhood, Townsend knew he would need the community's support. About city hall, Victoria or Ottawa, he was not so concerned.