Safe is the New Risky
Dr. Mark Tyndall thinks the national capital needs a safe injection site. But championing the cause of harm reduction is proving to be a hard sell
Do you care whether David Becker lives or dies? Perhaps that isn’t a fair question, considering you don’t even know the guy.
All right, then, let me tell you about this David Becker. He’s 57 years old. He lives in Vancouver with his 28-year-old daughter. He works several part-time jobs — mostly cleaning gigs that pay him in cash — pocketing about $60 a day. He spends it all on drugs — preferably speedballs, a mixture of cocaine and heroin. He shoots up first thing in the morning before the nausea comes, then twice more by evening, capping the day with one last fix at bedtime, which falls somewhere between midnight and dawn. He has been pumping that poison into his body for a long, long time. “I haven’t missed a day in 20 years,” says Becker.
Oh, another thing about David Becker. He’s HIV positive. Got the virus back in 1998, when fresh syringes — or “rigs,” as he calls them — were hard to come by in Vancouver. A place downtown used to hand them out, he recalls, but it closed too early — two fixes too early. He would rather have used clean needles, of course, but if none were around, a dirty one did the job. “If you have the drugs in your hand, you want it in you as fast as possible,” explains Becker. “You will do anything to get it in you. If you see a rig on the ground, you pick it up.”
So there you have it. David Becker. A drug addict with no intention of becoming a recovering drug addict.
Now let’s revisit the question we began with. Do you care whether David Becker lives or dies? He is an unrepentant drug addict, after all. Doesn’t that make him a parasite and a social leper and a burden on society? If he nods off after pushing too much junk into a vein and never wakes up, isn’t that his own damn fault? Why should you care? Why should any of us care?
Well, it just so happens that some people do care. Some people are more interested in keeping drug addicts alive than putting them in jail. Some people believe that drug addiction is a complex medical problem, most often the result of a horrible start in life, and that prevention and treatment programs, though important, aren’t going to make it go away. Some people believe that addicts who refuse treatment now might accept it later, but not if overdoses claim them first. The dead don’t detox. Some people believe a marginalized population hell-bent on self-destruction still deserves protection from HIV, from hepatitis C and, ultimately, from itself.
Fortunately for Becker, some of these people are health care professionals who live in Vancouver and run Insite, the only facility in North America where addicts can legally inject illicit drugs under medical supervision. That’s where Becker usually injects, which means that the odds of dying from an overdose are lower for him than for addicts who shoot up in the street. The 6,000 or so David Beckers in Ottawa, however, aren’t so fortunate. At least, not yet. But it appears that will soon change.
There is growing interest in Ottawa’s harm-reduction community in creating a safe injection site here in the nation’s capital. The Ottawa Police Service isn’t keen on the idea. The mayor isn’t crazy about it either. Yet local advocates for the health rights of injection drug users remain hopeful for two reasons. The first is the September 2011 ruling by the Supreme Court of Canada that forbade the federal government to close Insite — an encouraging triumph of evidence over ideology. The second is the recent arrival in the city of Dr. Mark Tyndall.
Let’s start with the credentials. Mark Tyndall has a medical degree from McMaster University in Hamilton and a Ph.D. in epidemiology from the Harvard School of Public Health in Boston. He spent four years conducting HIV research in Kenya. His name appears on numerous papers in some of the world’s top medical journals. Many of those studies, completed during his 11 years at the B.C. Centre for Excellence in HIV/AIDS in Vancouver, investigated Insite. In late 2010, ready for a new challenge, Tyndall accepted a position as head of infectious diseases at the Ottawa Hospital/University of Ottawa.
“Mark is one of the country’s top infectious disease experts. He is a medical doctor and a researcher. He’s no fool,” says Dan Small, director of the PHS Community Services Society, which operates Insite with Vancouver Coastal Health. “If he believes, based on the evidence, that there is a need to create a safe injection site in Ottawa, the only questions left are about the practical matters of doing it.”
Okay, then, enough with the resumé and the praise. Yes, Tyndall is a smart guy. Good luck finding someone in Ottawa who knows more about preventing HIV among injection drug users. He’s also an outspoken guy. And that combination — head full of data and big ideas, mouth eager to share — hasn’t earned him favour with those who don’t care much for giving the city’s junkies a nice, safe place to get high. “I’m looked upon as a know-it-all invader,” says Tyndall.
Here’s one of the things this alleged know-it-all knows: safe injection sites work. Insite has probably been studied more than any other medical program in Canada’s history, says Tyndall. Those studies show a reduction in fatal overdoses and in the spread of infectious diseases. Drug users who visit Insite are also more likely to enter treatment and counselling. In short: fewer dead addicts, more former addicts. There are even public-order benefits, including a reduction in the number of addicts shooting up outside, which also means that fewer dirty needles end up discarded in the street. Safe injection sites are also cost-effective. Insite’s annual budget is nearly $3 million, an investment that has proven worthwhile from an economic standpoint. The lifetime cost of treating an injection drug user with HIV is somewhere in the neighbourhood of $200,000. Insite prevents, on average, 35 new cases of HIV a year in the Vancouver area. (This figure is based on risk-reduction modelling that analyzes rates of intravenous drug use in the area, the users’ participation at Insite, and the percentage that have HIV). So, 35 cases per year at $200,000 per addict. Do the math. Tyndall sums it up succinctly: “It’s hard to find anybody who knows anything about addiction and deals with drug addicts who thinks this is a bad idea.”
In fact, there isn’t a single piece of rock-solid, peer-reviewed evidence in any reputable scientific journal that suggests Insite didn’t meet its objectives. In handing down its decision in support of the program, the Supreme Court of Canada noted that “the decision to implement a supervised safe injection site was the result of years of research, planning, and intergovernment co-operation.” It goes on to say that Insite “was launched as an experiment. The experiment has proved successful. Insite has saved lives and improved health. And it did those things without increasing the incidence of drug use and crime in the surrounding area.” Lawyers for the federal government couldn’t find anything to support closure (and it’s a safe bet that if stats supporting closure were out there, they would have tracked them down).
But if you absolutely refuse to accept that a medically supervised injection facility could do more good than harm in a community, don’t fret. You can no doubt scrounge up, in some dark corner of the Internet, “evidence” to support your argument. Google is just a browser away. Knock yourself out.
Now, getting back to the things that Mark Tyndall knows. Let’s add this to the list: the HIV rate for injection drug users in Ottawa is among the highest in Canada. Actually, quite a few people know that, including Rob Boyd, director of the Oasis harm-reduction program at the Sandy Hill Community Centre. “HIV rates have been measured as high as 21 percent in drug users in Ottawa,” says Boyd, citing a 2006 federal government study that tracked the behaviour of drug users in major cities over two years. “That is definitely alarming. That’s the kind of number that’s comparable to populations in sub-Saharan Africa.”
Even people who don’t live here know Ottawa has a mess on its hands and is doing too little to clean it up. “Ottawa has one of the worst problems with respect to drug use and HIV. The lack of attention given to this problem is mind-boggling,” says Thomas Kerr, co-director of the Urban Health Research Initiative at the B.C. Centre for Excellence in HIV/AIDS and a professor of medicine at the University of British Columbia. “I imagine it must be very frustrating for Mark [Tyndall] to be reliving the debates about these issues.”
Yeah, about those debates. “Frustrating” probably isn’t how Tyndall would describe them. A better guess would be “futile” or, better still, “unnecessary.”
Supervised injection services in Ottawa would probably look different from those in Vancouver. Ottawa has no equivalent to the notorious Downtown Eastside, the drug haven where Insite is located, so it might be wiser to have multiple sites rather than a single facility. And though Vancouver has more injection drug users than Ottawa — with an estimated 12,000, about twice as many — the nature of addiction doesn’t change across time zones. “Every addict I see here looks exactly the same as the ones I saw in Vancouver,” says Tyndall. “They have all the same problems.”
Actually, potential users of a safe injection site in Ottawa do have one problem that addicts in Vancouver didn’t have in the lead-up to the founding of Insite: a complete lack of support from their mayor. During his 2002 mayoral campaign, former Vancouver mayor Larry Campbell, who is now a senator, promised to open a safe injection site in the Downtown Eastside if he won the election. He did. In a landslide. Insite opened the following year. Ottawa’s current mayor, Jim Watson, also made a promise about a safe injection site during his campaign. He promised not to support it.
Tyndall once bumped into the mayor — at a gala for the Ottawa Hospital — and brought up the topic again. As Tyndall remembers it, Watson told him that he had promised to withhold support and that he was a man of his word. Tyndall asked Watson if he would reconsider, given all the evidence supporting the benefits of supervised injection sites. Again, Tyndall recalls, the mayor robotically spouted the bit about being a man of his word.
When contacted with an interview request for this article, the mayor’s office responded by saying he was too busy. But the office did provide, by email, a quote from Mayor Watson that started with “I do not support locating a safe injection site in Ottawa and was very clear about that in the last election” and ended with a sentence about how using “scarce public health dollars” for prevention programs and youth drug treatment centres would “be my focus when it comes to helping young people addicted to drugs.” If those words seem familiar, it might be because it’s the exact statement that appeared in an Ottawa Citizen article on October 1, 2011. Perhaps someone should reboot the mayor. His automated response button appears stuck on repeat.
Former Ottawa police chief Vern White, who recently left the force to join the Senate, also went on the record with his opposition to a supervised injection site, claiming in the same Citizen article that it would have “an extreme negative impact” on people who live nearby. But to paraphrase addiction experts: Who cares what the police think? And to quote Thomas Kerr directly: “With all due respect to the chief of police, I am not sure he is qualified to determine what public health programs should or should not be implemented.”
Even Tyndall, who would prefer to have the mayor and police on board, says that he doesn’t require their support. “We don’t need permission from the mayor or the police. If this was a prostate cancer clinic, we wouldn’t be asking the mayor what he thinks.” What Tyndall does need is permission from the Ministry of Health, which appears to be open to the idea. Tyndall points to three projects currently in the planning stages in Quebec — none of which have the vocal support of the police or mayor. “It’s about getting a really committed group of people energized, getting some funding, getting volunteers to staff it. I think, in the next year, I’d like to get a dozen people together to get it going.”
Police officers and politicians aren’t the only ones, however, who are leery of the role of harm reduction in fighting drug addiction. Harm-reduction experts lament the fact that misconceptions abound in the general public as well. Some people see medically supervised injection as enabling an illegal activity, nothing more. In other words, to borrow the tone of a typical Internet comment on this topic, why the expletive are we buying expletive crack pipes and needles to help expletive junkies do expletive drugs?
Shouldn’t we take that harm-reduction money and instead invest it in prevention and treatment and law enforcement to make the problem disappear? Then there wouldn’t be a need to medically supervise drug addicts, because there wouldn’t be any drug addicts. Uh, sure. That’s going to happen. “Human beings use drugs. This is a reality. The opposition will often create a utopia situation, but there’s never been a society on the planet that has eliminated drug use. Why do we think we can?” Rob Boyd says simply. “We have to deal with it. The consequences of not dealing with it are too extreme.”
If there were two other commonly held beliefs that Tyndall could magically dispel, they would be that drug addiction can be swiftly overcome and that drug addicts deserve scorn rather than sympathy. People with no expertise but plenty of opinions tend to overestimate a person’s ability to kick an addiction, says Tyndall. But it can take years, even decades. A recovering addict may relapse five times, 10 times, 20 times. Tyndall says he has seen thousands of people addicted to drugs, and few have been able to transform themselves completely.
Many drug addicts simply aren’t equipped to remain dedicated to treatment. They have no coping skills, no self-esteem, no support network. Most have terrible histories, says Tyndall. Drug-addicted parents. Poverty. Mental illness. Sexual abuse. Odds are, they were neglected as infants or abandoned as children or incarcerated as youths. Yes, they still have a choice. Lots of people have difficult lives, and not all turn to drugs. But the temptation can be awfully strong when you’ve lived five lifetimes’ worth of pain before your 20th birthday. Like many people who have experienced severe trauma, they feel the only thing they can turn to is a substance to treat the pain, whether it’s social or physical or emotional pain. They get so entrenched in that lifestyle that they can’t get out of it, explains Tyndall. “At the end of the day, the push to provide a safe drug injection site is about common sense and decency. We should treat the most marginalized and disadvantaged people better than we do.”
This feature was the cover story in the April 2012 edition.