Clean needles. Clean spoons. And a roof over their heads.
Vancouver, the city with the highest number of drug overdose fatalities in Canada, may soon have a safe place for local addicts to use their drug of choice.
That would make it the first city in North America to open a walk-in "safe injection site." It's a controversial plan that is nonetheless being closely watched by city and health officials in the US Pacific Northwest, where heroin abuse has soared to the highest levels in the US.
Similar safe sites are already in use in several European cities.
To activists like Dean Wilson, chairman of the Harm Reduction Action Society (HRAS), the high numbers of overdose deaths - an average of 147 a year since 1993 in Vancouver - and increased rates of needle-borne infection with HIV and hepatitis warrant this radical step. He says his organization will open an injection site by Valentine's Day, with or without city hall's blessing.
Injection sites, says Mr. Wilson, "can keep addicts alive long enough to let them make the right decisions" about getting off drugs.
Mayor Philip Owen, however, calls the HRAS plan "a big mistake." He's not opposed in principle to safe injection sites. "Eventually, we'll have them," he says at one point during an interview in his office in Vancouver's Art Deco city hall. But injection sites need informed public support behind them, he insists. And they must be part of a comprehensive approach that includes four pillars: prevention, treatment, enforcement, and harm reduction.
Harm reduction is clearly the most hot-button of the proposals being considered.
Supporters call it a pragmatic approach to minimizing the consequences of drug use without requiring abstinence. Some public-health experts hail harm reduction as the equivalent in the drug field to the "safe sex" approach to combating AIDS. Similarly, harm reduction assumes that some level of addiction within the population is inevitable.
Critics see safe injection sites as "enabling" illegal drug use, attracting addicts from elsewhere, and requiring police and city officials to look the other way.
"The way to decrease the number of deaths from overdoses is to decrease the number of overdoses," says Bryce Rositch, a Vancouver architect and the head of Community Alliance, a neighborhood activist group. He accuses harm reduction advocates of putting the safety of addicts ahead of the safety of the larger community.
But at Main and Hastings, in Vancouver's downtown East Side, the larger community seems to have disappeared. In broad daylight in the middle of what might elsewhere be called the workday, young drug dealers in high-tops, baggy jeans, and down jackets, stand on corners and in doorways, hawking their wares only slightly more discreetly than sellers in a farmers' market.
A young man going into convulsions on the sidewalk is attended to by police officers and paramedics. But the dealers and users on the street are subject to surveillance, not arrest, from the police vehicles parked at the curb.
The drug crisis in Vancouver illustrates the challenge of developing a consensus among polarized elements of the community. It also leaves people feeling forced to choose among solutions that may in turn cause greater problems.
A few years ago, for instance, a spate of drug-related stabbings led to a police crackdown on dealing in bars. The traffic was forced onto the street - where it is easier for the police to monitor, but where it is also more visible to the public.
Even advocates of safe injection sites are divided on whether they might do more harm than good. At a minimum, some say, an injection site gets addicts off the street and ensures the presence of a social or healthcare worker to call an ambulance if a user overdoses.
But others say that injection sites shouldn't be introduced except as a first step in a continuum leading to detoxification and some form of long-term treatment for addiction.
"You need it all," says Mayor Owen. But there is widespread agreement that there simply aren't treatment facilities available for addicts wanting them.
Ray Baker, who chairs the addiction medicine committee of the British Columbia Medical Association, says that in the 15 years he has been practicing "I've seen degradation and decay of treatment resources.... Prevention has been neglected."
A big problem here, as Donald MacPherson, drug-policy coordinator for Vancouver, explains, is that addicts have to be off drugs, at least for a short time, to be accepted for most treatment programs. He likens the range of treatment options to a "ladder with the bottom four rungs missing."
This approach reaches only 20 percent of addicts, he says. Hence the interest in lower-rung approaches, such as safe injection sites. "The aim is to engage them in care," says Dr. Baker. "If we can engage them in care, we can improve their health."
The drug crisis here may be the result of a combination of factors unique to Vancouver: a port city with generally permissive attitudes and a climate that makes open-air dealing possible year-round. And inexpensive drugs.
But the situation here is being watched across Canada. Owen says he wants safe injection sites to develop within the context of a national drug policy. He would like to have "10 or 15 cities" across Canada open sites simultaneously. Otherwise, he suggests, Vancouver would just attract more addicts. In January, a series of public forums on the mayor's four-pillar approach will begin. Wilson, who describes himself as a heroin addict now stabilized on methadone, says HRAS is willing to give the mayor some time. "But if the discussion breaks down, we'll go ahead."
(c) Copyright 2000. The Christian Science Publishing Society