Pristine, progressive Vancouver has a dirty little secret: one of the highest rates of HIV infection in the developed world. Has needle exchange failed this town?
Nestled between snowcapped mountains and the Pacific Ocean, and blanketed with evergreens, Vancouver, the third-largest metropolis in Canada, is one of the pearl cities of the Pacific Rim. Pocket-sized and postcard-pretty, it's no wonder the city is a popular location for film shoots. With its affluent, cosmopolitan air, it could stand in for Manhattan or San Francisco if it didn't also boast miles of walkable seawall and sandy beaches as well as Canada's largest urban park.
But there's a fatal flaw in the gem. Back in 1996, as the international AIDS elite crowded uptown at Canada Place for the hope-filled, history-making International AIDS Conference, a mile south, in the 10 squalid blocks that make up the Downtown Eastside, it was business as usual -- despair, addiction and a boom in HIV infections among needle users. The Vancouver Injection Drug Users Study (VIDUS), launched that year, would show that 18 of every 100 of its IV-drug users had seroconverted within the past 12 months -- seven years after the city boldly unveiled needle exchanges -- conferring on Vancouver the dubious distinction of having one of the highest rates of HIV infection in the developed world.
The finding was cannon fodder for needle-exchange opponents. The VIDUS study had its most explosive impact south of the border, where its results were successfully invoked during Clinton-era congressional hearings to squelch proposals to lift the ban on federal funding for needle exchange. But five years after, far from folding up its needle exchanges, Vancouver is pioneering the most controversial step yet in the uphill battle to help HIV negative drug users stay that way: safe-injection sites. From Capitol Hill to Russia, Thailand and other drug capitals, partisan eyes are sure to be watching.
It's the end of the month -- Welfare Wednesday, when government checks unwittingly fund a binge of drug abuse -- and at the corner of Hastings and Main, in Vancouver's Downtown Eastside, scores of dealers are working the sidewalk outside the Carnegie Community Center. Heroin ("down") and injectable coke ("up") are for sale at $10 a pop. A young woman dressed in a bra-top and cutoff jeans squats against a wall in open view, cooks up, searches her arm for a piece of skin not covered in sores and injects herself. Her eyes glaze over and she floats to junkie heaven.
Women bear the brunt of it in this district. In fact, last year VIDUS data revealed that female Downtown Eastsiders were the first group in the developed world to have a 50 percent higher rate of HIV infection than their male counterparts. "Most women here are sexual-abuse survivors with low self-esteem," says Cara Moody, an outreach worker with Positive Women's Network, whose clients are mostly sex workers. Aboriginal people are also over-represented here. "Many have gone through the residential school system," explains Doreen Littlejohn, director of Positive Outlook, the HIV-outreach arm of the Vancouver Native Health Society. "They've basically had their childhood, families, culture ripped away."
While Toronto or Montreal, Seattle or San Francisco may have as many IV-drug users, no city has had anything like the rate of IV drug-transmitted HIV in Vancouver, home to North America's largest needle exchange program. The outbreak in the late '90s, Vancouver's second wave of HIV, has proved to be as devastating as the first among gay men a decade earlier, but it came about for different reasons. In the mid-'80s, Vancouver city officials, headed by a gentrification-mad mayor, Jack Volrich, organized a citywide makeover in preparation for Expo '86, the World's Fair that made the city's international reputation. Prostitutes were driven out of the newly gussied-up West End -- now home to middle-class gay men, hip couples and seniors -- by a shame-the-johns campaign backed up by a court injunction. Drug dealers soon followed as police swept all the down-and-outs into the traditionally rowdy, poverty-stricken Downtown Eastside. Then a prolonged early '90s recession led to cuts in health and social-service spending, shuttering mental-health residences and detox clinics and leaving many vulnerable people to fall through the safety net and land in single-room occupancies in the Downtown Eastside -- the only neighborhood with rents low enough to be covered by welfare.
But injectable cocaine -- the drug of choice in these parts -- was the match that sparked the HIV epidemic in this socio-economic tinderbox. Vancouver's huge port and its proximity to British Columbia's sparsely populated, difficult-to-patrol coastline made it particularly attractive to Asian and Central American drug-smuggling rings, and the city had become a major center of North American drug trafficking. Coke flowed cheaply and freely on the Downtown streets. "You can do one shot and it lasts a couple of hours," says Trish, 48, who is HIV positive and in recovery. Because the high is so addictive, it's not uncommon to inject 50 times a day if you have the money. Once on a coke high, using a clean rig is less of a priority than getting the next fix.
What anti-drug politicos in Washington, DC, have found so potent about Vancouver's Downtown Eastside is that its HIV explosion took place against a national backdrop of liberal drug policies and aggressive needle exchange. Canada has never waged a "war on drugs," and most Canadians don't consider tough laws, mandatory sentencing and zero-tolerance policies to be effective or pragmatic methods of dealing with drug use. A Leger Marketing poll last June, for instance, found that 47 percent of Canadians were in favor of cannabis legalization. In the provinces of Quebec and British Columbia, more than 50 percent were pro-pot. Many Canadians consider it a given that marijuana will eventually be decriminalized -- last July medical marijuana was legalized -- and Canada is making steady progress in reforming its narcotics laws. In sharp contrast, the U.S. Supreme Court voted unanimously last May that there is "no accepted medical use" for pot.
Last November, Alan Rock, Canada's former Minister of Justice and now Minister of Health, said flatly, "Injection-drug use is not a law-enforcement issue." Rather, he said, addicts "have lost control of their lives and they have secondary illnesses," such as AIDS and hepatitis. "It does no good to round them up and jail them," he argued, without also "doing something about the underlying illness of addiction."
The world's first needle exchange program was established in Amsterdam in 1984. Canada's own exchanges, launched a few years later, were inspired in part by data at the 1988 International AIDS Conference about the very high rates of HIV infection among drug users in Edinburgh, Scotland, and New York City. Public health leaders believed that the comparatively low rates of HIV among Canada's drug-injectors at the time offered a rare opportunity for a pre-emptive strike, and in 1989, the Canadian government stepped up to the plate with money for pilot programs. Five of Canada's then-dozen provinces -- Ontario, British Columbia, Quebec, Alberta and Manitoba -- accepted the federal matching funds. By February 1993, a total of 28 Canadian cities had active needle exchanges. Advocates in the U.S., who were routinely arrested as they handed out clean needles at token exchanges, hailed it as a victory of science over politics.
But the data, when it arrived, didn't exactly fit the rhetoric. In 1995, a small study called The Point Project documented evidence of a higher HIV prevalence in Vancouver compared with other U.S. and Canadian cities. The study caught the attention of the U.S. National Institutes of Health, which provided the funds for VIDUS, the most ambitious needle exchange study ever. VIDUS researchers entitled its first-year summary report "Needle Exchange Is Not Enough," and they concluded -- despite their alarming finding that 18 of every 100 drug users had been infected in the past year -- that while needle exchanges were a sound first step, social, legal and moral reforms were needed to prevent further infection and overdoses. Martin Schechter, MD, a University of British Columbia epidemiologist who cowrote the study with six other leading local researchers, was horrified to discover that needle exchange opponents in the United States -- like Drug Czar Barry McCaffrey and Rep. Todd Tiahrt (R-Kansas) -- seized upon the VIDUS data for their own ends. "People were quoting our study in Congress, using it to suggest that the needle exchange in Vancouver made things worse," said Schechter. "I felt that my data had been misinterpreted. I was disappointed and a bit outraged that our findings were being used for ideological reasons."
In September 1997, Vancouver's health authority declared an emergency -- although an independent review conducted 18 months later concluded that the agency more or less ignored its own alarm. While politicians blundered, the drug crisis worsened -- not because Canadians were convinced that syringe swaps had failed, but because of a lack of organization and political will.
Grassroots organizations like Vancouver Area Network of Drug Users (VANDU) and Vancouver Native Health Society stepped in to fill the government-agency gap, and the Downtown Eastside Youth Activities Society (DEYAS) stepped up its government-funded exchanges and added vans to target hard-to-reach shooting galleries. But within months, Vancouver's main AIDS service organizations, AIDS Vancouver and BCPWA (British Columbia Persons With AIDS Society), were beleaguered by major growing pains as the new generation of IV drug-using HIVers competed for space and services at the Pacific AIDS Resources Center (PARC), situated midway between Downtown and the West End. "When you bring a bunch of HIV positive gay men who generally are middle class and comfortable in their lives under the same roof as people who are living with addiction and poverty and who often support their habits through crime, that often presents a very challenging dynamic," says BCPWA chair, Glen Hillson, who claims that much progress has been made at integrating the needs of the two diverse groups. Still, he admits, the situation could improve.
Today, some five years after the first results of the study were used to inflate needle exchanges into a congressional punching bag, the NIH-funded VIDUS continues to monitor needle users in the Downtown Eastside and currently has a cohort of 1,425 participants. From this hole-in-the-wall storefront, where a team of community-oriented researchers compensate participants with $20 every six months in exchange for their blood and lifestyle information, VIDUS is providing all kinds of data about HIV, needle giveaways and addiction.
Despite the progressive policy toward drug users -- and the 3.5 million needles exchanged in 2000 -- HIV infection rates among the 1,425 current or former IV-drug users in VIDUS has grown to 35 percent, according to lead researcher Mark Tyndall, MD, compared with 0.01 percent of the general population of British Columbia. Dismayed, city officials have now come up with a "Framework for Action: A Four Pillar Approach to Vancouver's Drug Problems," which is slowly making its way from theory to practice and could be up-and-running by year's end. The plan, a typical compromise measure that has "something for everybody," calls for more aggressive prevention and education, treatment and law enforcement.
But the city proposal most likely to provoke controversy is one for safe-injection sites, run by trained professionals capable of responding to overdoses. There, users would be given sterile injection equipment and clean water. They would also have access to primary health care and counseling, which would aim at steering users off drugs and into rehab. While on paper this looks like the cutting-edge of compassion, the experience drawn from European cities has been largely disappointing, with dealers and crime springing up around the sites.
The prospect of safe-injection sites has stirred NIMBY -- Not In My Backyard -- protests from neighbors. Grant Longhurst, of the Community Alliance, which represents residents and businesses in the Downtown Eastside, echoes his neighbors when he says, "We are asking that all three levels of government cease to support or fund resources for anything that facilitates or maintains use and dealing of illegal drugs, such as needle exchange, resource centers, safe-fixing sites and quality-of-life counseling." Then, raising the rhetorical ante, he adds, "These approaches are futile." But Tyndall, a practical researcher with hands-on experience in the Downtown Eastside, backs the Four Pillar Approach as at least a start. "Safe-injection sites, heroin maintenance, dispersing the epidemic, reworking the criminal justice system -- they are very practical things that can make an immediate difference," he says. "But they're not happening quickly enough."
Facing off with hard-edged business and go-slow bureaucrats are, of course, the no-compromise activists. Cara Moody from Positive Women's Network, wants to see the powers-that-be tackle the root causes of addiction -- poverty, violence, unemployment. And she argues that to "clean up" the Downtown Eastside is to punish the most vulnerable among us -- people with a disease. "There are going to be people that need to use drugs and we should allow them to do that as safely and healthily as possible," she says. "I totally support safe-injection sites. But I also support more recovery houses, more detox centers, more social housing and increasing welfare rates so that people have more choices."
The issue of safe-injection sites may have turned up the volume of the debate, but even opponents allow that needle exchange is here to stay -- as imperfect a prevention measure as it may be. "We have been saying for years that we are not a silver bullet," says Judy McGuire, manager of the Eastside needle exchange operated by DEYAS.
The same is likely to be said of safe-injection sites if advocates win this round. Rotterdam and Zurich have already closed their sites, considered failures -- no matter how many infections and overdoses they may have prevented -- because crime infested the neighborhoods. And more than two dozen major European cities, including Berlin, Stockholm, London, Paris, Moscow and Oslo, signed the 1994 European Cities Against Drugs declaration opposing safe-injection sites and free distribution of drugs, claiming that "the answer does not lie in making harmful drugs more accessible, cheaper and socially acceptable. Attempts to do this have not proved successful." Such initiatives, officials argued, "increase our problems."
But Vancouver is still going against the grain, with some surprising backers. Positive findings from safe-injection holdout Frankfurt, where five city-operated sites have served addicts since 1994, and from Sydney, where a recently opened city-funded initiative also appears to be reducing open drug use, overdoses, crime and the possibility of
infection, have compelled former fence-sitters, including Vancouver's conservative mayor, Philip Owen, and Canada's health minister, Alan Rock, to lend their not insignificant support. "Doing nothing is not an option," Owen said recently. "What we've been doing so far is not working."
But nationally, more friendly persuasion is necessary. "I know of no mother or father in Canada who would think the minister or the government are on the right track when they offer money for safe-injection sites instead of detox centers that can help their children with a drug addiction," says Randy White, Canadian Alliance MP and vice-chair of the committee on the non-medical use of drugs.
A true "compassionate conservative," Mayor Owen is aiming soon to assemble a consortium of Canadian cities to approach Rock for pilot funding. To be sure, U.S. policy-makers will be following developments in Vancouver like hawks. Will safe-injection sites be more effective than needle exchanges in turning the tide of new infections? Whether the experiment is judged a success will hinge, as always, on who does the judging -- the Randy Whites or the Cara Moodys. Still, for as long as they last, the sites are certain to save some addicts from HIV, at least for another day.