Vancouver's Downtown Eastside, for years a testing ground of liberal policies that allegedly stem the damage of drug abuse and the spread of AIDS, is now reaping the tragic harvest. The drug trade's western boundary is the former Woodwards building, where drug dealers routinely accost passers-by. Closer to Main Street, slum hotels like the Brandiz, the Balmoral and the Roosevelt bulge with filth and violence.

Alleys throng with scarecrow-like figures inserting syringes into arms, necks or any other body part still harbouring an uncollapsed vein. Rather than worry that shared needles might cause them to inadvertently contract HIV, some junkies actively seek infection in order to qualify for the more generous welfare available when AIDS progresses into its deadly final stages. In the nearby police headquarters, holding cells overflow with addicts, so beat cops merely watch as the junkies shoot up, intervening only if a fight erupts.

East of Main, Hastings becomes a surreal smorgasbord of prostitutes shivering from drug withdrawal and the ravages of AIDS. The Skid Road red-light district ends nine blocks later at Glen Drive. But the drug and sex commerce soon re-erupts, as pushers and juvenile hookers ply their trade in a lower-middle-class family district. The trucks, family vans and BMWs patronizing the area demonstrate that business is brisk and knows no boundaries.

In this three-and-a-half-kilometre thoroughfare of disease and despair, death is the only peace many of its lost denizens will ever experience. Ironically, speeding the addicts towards that final rest may be the sole benefit that "harm-reduction" drug initiatives have conferred on their recipients. On September 25, the Vancouver and Richmond Health Board (VRHB) declared the HIV/AIDS infection rate in the Downtown Eastside a medical emergency. But rather than concede that harm reduction has proven a deadly failure, the VRHB is calling for even more accommodating programs.

In a unanimous motion, the 16-member board said the situation demands immediate action. Of the estimated 4,000 Downtown Eastside intravenous (IV) drug users, 8% are HIV-positive (by comparison, 5% of junkies in Miami's blighted ghettos are infected). Epidemiologists predict the infection rate will increase to 15% next year, and to 50% by January 1999.

The VRHB has asked its officials to draft an action plan by October 23 outlining how to spend an additional $3 million Victoria has allotted to IV-user treatment. "We need to try some new things and think beyond the conventional," John Blatherwick told reporters.

The VRHB chief medical officer's comment might seem to imply that harm reduction schemes like needle distribution and methadone treatment, which constitute the prevailing orthodoxy among the armada of medical professionals and social workers ministering to the Downtown Eastside, will be replaced by abstinence-oriented methods that have worked elsewhere. Instead, the VRHB appears bent on augmenting existing harm-reduction programs and creating new ones. According to Dr. Blatherwick, the initiatives will include:

• Expanding the Downtown Eastside Youth Activities (DEYAS) needle-exchange program, even though research indicates that the program, used by 7,000 addicts, has boosted HIV rates.
• Increasing the number of methadone outlets, even though methadone, a synthetic opiate that reduces the craving for heroin, is as addictive as heroin.
• Hiring more outreach workers, whose job it is to dispense free condoms and instruct addicts how to inject drugs "safely."

Further down the harm-reduction road, Dr. Blatherwick and his colleagues want "safe houses" in the Downtown Eastside where junkies can shoot up in supposedly clean and violence-free surroundings. Dr. Blatherwick would also like to see welfare expanded and decriminalization of hard drugs.

Abstinence-oriented recovery workers are appalled at the continued harm-reduction focus. Billy Weseloswki, a former Skid Road heroin and cocaine addict who now runs Coquitlam's Innervisions Recovery Centre, says that "expanding needle-exchange and methadone programs is a real tragedy. People are dying of AIDS or addiction, and civic leaders are saying to them, 'it's okay, keep on going.'"

Dr. Steffanie Strathdee, manager of epidemiology at the B.C. Centre for Excellence in HIV/AIDS, notes that B.C. addicts now have "the highest rate of HIV infection in North America and perhaps in the developed world. We need more detox centres, and responsibly managed rehabilitation programs that get people off drugs and keep them clean."

For his part, RCMP drug awareness co-ordinator Sergeant Chuck Doucette worries that the VRHB's plans could jeopardize health care in other communities. "There are over 10,000 intravenous drug users in Greater Vancouver," he warns. "This could be the beginning of chaos."

A central concern over the consequences of a flawed drug-addiction policy is the potential transmission of AIDS to other groups. An estimated 10,000 to 15,000 British Columbians are infected with HIV through various means, and 1,000 more contract the virus yearly. And although AIDS remains a disease that primarily strikes homosexuals and addicts, it is spreading outside that sphere. Michael O'Shaughnessy, director of the B.C. Centre for Excellence, reports that "women are contracting the virus in increasing numbers, and they currently represent 20% of the yearly infection rate. They get it from husbands who visit prostitutes, male IV users and bisexual men."

Dr. O'Shaughnessy's centre, which operates out of St. Paul's Hospital in Vancouver, dispenses almost $22 million worth of drugs to patients annually. About 90% of patients in St. Paul's 18-bed AIDS ward are injection drug users. HIV-positive people can survive up to a dozen years before developing full-blown AIDS and five years after that. It costs B.C. $140,000 to care for a single patient throughout the disease's course.

Like the Downtown Eastside's drug programs, AIDS strategies have been heavily influenced by the foundational harm-reduction premise that society should stop "stigmatizing" the disease's victims. The biggest problems surrounding both HIV transmission and drug addiction, it is argued, arise from the refusal to accept and support those who engage in homosexuality and drug abuse. In the case of AIDS, activists have persuaded government and health officials to treat it differently than every other deadly communicable disease. The federal government's $112-million "National AIDS Strategy," inaugurated in 1990, conspicuously avoided any direct reference to male homosexuals as the group most afflicted. Ottawa also extended legislative protection against "homosexual bigotry" by classifying AIDS as a disability, thus placing it under human-rights legislation prohibiting any type of discrimination.

Consequently, AIDS sufferers could not be quarantined. Nor could com- pulsory, non-anonymous testing of likely carriers—a practice that historically has been the first line of defence when coping with a deadly plague—take place.

When it came to curbing AIDS amongst IV-drug users, the harm-reduction influence was magnified. In fact, the concept originated in Britain in the mid-1960s. "Liverpool's Merseyside Hospital developed the idea addicts should be given drugs and a safe haven to use them," Sgt. Doucette says. "The theory was that if addicts were spared criminal prosecution and other adverse social ramifications, they would be more inclined to rehabilitate."

Britain was also one of the first countries to discover that harm reduction doesn't work. "Within a few years it became obvious that the policies practised by Merseyside were creating more addicts, and the hospital abandoned them in the late 1960s," says the Mountie.

Although critics like Mr. Weselowski have long argued that only an abstinence-oriented approach will rehabilitate addicts—and by extension reduce HIV rates—not until this year did B.C. Centre for Excellence and University of B.C. researchers quantify that Vancouver's harm reduction may really have been a prescription for harm production. When DEYAS began distributing sterile needles to junkies in 1988, only 1% of addicts tested HIV-positive. Preliminary findings by the researchers published in August show that 92% of 1,006 addicts surveyed last fall have used the DEYAS program, and 23% are HIV-positive.

Furthermore, because many of the HIV-negative individuals will soon contract HIV through shared needles, the infection rate could rise to 70% by as soon as the end of 1997 among that limited group.

Observers ascribe much of the increase to cocaine's increased popularity. Vancouver police constable and Province columnist Mark Tonner describes cocaine as "instant insanity. Users become so crazy they do what is called a 'wash': when one guy shoots up and discards the needle, another guy will pick it up, stick it in his arm and draw blood to wash any coke residue that may be in the needle. He then re-injects the blood and coke back into his arm." Const. Tonner adds that before the needle exchange was created, "syringes were hard to find, and junkies jealously protected them. Not now."

DEYAS, however, has no intention of abandoning needle distribution. Judy McGuire, the exchange's program manager, says that while her staff will not hand out more than last year's 2.38 million needles, "we will expand the number of distribution sites. Currently, we only have one central site and two vans, and this has concentrated addicts in one area and helped encourage them to share syringes."

Methadone maintenance is also slated for augmentation. "We will boost the number of distribution outlets from 500 to 2,000 by the end of next year," Dr. Blatherwick promises.

And despite the fact that some addicts are known to have deliberately tried to contract HIV to get additional welfare, he wants their social assistance increased. "It's true some junkies are trying to infect themselves," he admits, "but they won't get any extra money for another decade, when they develop AIDS." Dr. Blatherwick concedes that a fortified welfare system "would compel some people to buy more drugs. But others would use the money to buy food and find better accommodations." How that would serve to slow the spread of HIV, Dr. Blatherwick does not explain.

The belief that addicts would somehow be inspired to kick drugs if they are better provided for underscores Dr. Blatherwick's long-term goal to "buy the hotels on Skid Road and renovate them." The bid to create a bank of state-owned housing for practising junkies is also backed by Vancouver Mayor Philip Owen and Vancouver East NDP MP Libby Davies. However, the provincial New Democrats remain unconvinced. Health Minister Joy MacPhail said last week that safe houses "are unacceptable" and "will not happen while I am health minister."

As for drug legalization, Dr. Blatherwick argues that "providing addicts with free drugs would at least lessen the burden on police and the courts and reduce property crime. We have to start lobbying hard for these things. If we're able to pursue all routes, and they fail, only then can we say society has done everything it can do."

Dr. Blatherwick and other harm-reduction proponents cite European jurisdictions like Switzerland as proof that harm reduction minimizes the consequences of addiction. Closer examination of the Swiss experience suggests the opposite. Switzerland became a harm-reduction mecca in the late 1980s, when Zurich's "Needle Park" opened. There, junkies could buy and consume drugs without being harassed by police.

"Needle Park" quickly became a killing field. Addicts flooded in from across Europe, as did gangs of violent drug-dealers from countries as distant as Lebanon, Russia and South America. Dealers openly marketed their wares at tables, helping junkies to inject their drug of choice amid harried paramedics who rushed to revive overdosed customers. The park was closed in 1992, but another public shooting gallery, "Letten Station," opened in Zurich that same year. All the while, HIV rates escalated. "Letten Station" closed in 1994.

The closing merely signalled an intensification and refinement of harm reduction. Decriminalization lobbyists insisted the parks had reduced crime rates, so later that year, the Swiss government authorized prescribing heroin to addicts; some now have their drugs injected by doctors at government-run "treatment" facilities.

Those who obtain their drugs illegally find injection little more difficult. Zurich has installed needle-vending machines at a number of intersections and operates state-run safe houses where junkies can shoot up without police interference. The city also maintains apartment blocks similar to those envisioned by Mayor Owen and Ms. Libby, packed with addicts housed at state expense and visited regularly by sympathetic social workers who endeavour to meet their every need.

In a speech delivered in March 1996 to a European drug policy conference in Holland, Zurich-based Franziska Haller debunked the assertion that Needle Park and Letten Station reduced crime. Police, she explained, merely agreed not to arrest addicts or dealers when the parks were operating, even though criminal acts were occurring constantly. The consequences of this laissez-faire regime were predictable, Dr. Haller reported: "Dealer gangs from Lebanon and Nigeria took over entire parts of Zurich."

As for the state-run addict hotels, they quickly became as rife with filth and violence as any Vancouver flophouse. Meanwhile, HIV infection rates continue to rise; 1,630 Zurich junkies out of the country's estimated 30,000 addicts now have full-blown AIDS.

Drug use among youth has also escalated dramatically. Last year, 50% of Zurich's 19-year-old male students admitted to using drugs, up from less than 10% in the 1970s.

Moreover, claims that Switzerland's harm-reduction policies have prompted junkies to quit or reduce their intake have no scientific basis. Dr. Haller pointed out these findings were obtained not by objective research, but rather from health workers questioning addicts, who "know the future of the legal distribution of narcotics depends on their answers."

Nevertheless, in a national referendum earlier this month, Swiss citizens voted 70% in favour of retaining harm-reduction programs. "I suspect the government is making too much money off safe houses and vending machines to ever get rid of the system," comments Sgt. Doucette.

Others ascribe continued support to widespread ignorance of the addictive mentality. Harm reduction presupposes that addicts are rational individuals who engage in destructive behaviours only when forced to by legal and social sanctions. But in his 1993 book Reckoning: Drugs, the Cities, and the American Future, author Elliott Currie reports that abusers are instead "astonishingly committed not only to using drugs in the face of the AIDS threat, but to using them in ways that maximize the danger of infection, meanwhile refusing to alter their similarly risky sexual practices."

Mr. Currie cites numerous U.S. harm-reduction failures, such as a San Francisco outreach program that began distributing free condoms to IV users in 1986. "One year later, 80% of a sample of male IV users reported having multiple sex partners, and 73% said they never used condoms." The author explains that not only are drugs disinhibiting, "pressures for sex in exchange for drugs are often immediate and compelling."

Mr. Currie concurs with abstinence advocates that only an extensive network of residential treatment centres will reduce drug addiction and HIV rates significantly, and that these centres must be linked to extensive aftercare services. One country implementing that approach is Sweden, which has 20% more people than Switzerland but far fewer addicts and HIV cases. "Sweden maintains that junkies are responsible for their condition, and society will not tolerate anything less than them getting clean and staying clean," says Sgt. Doucette.

According to A Restrictive Drug Policy: The Swedish Experience, released by the Swedish National Institute of Public Health in 1995, Sweden's tough stance was adopted after trying harm reduction. A two-year pilot project inaugurated in 1965 allowed addicts to choose their own drugs and doses from clinics. The number of junkies under the program quickly swelled from 10 to 150, and officials discovered participants were supplying drugs to friends.

Other harm-reduction strategies such as needle exchanges, coupled with the courts waiving charges for minor drug offences, continued throughout the 1970s. A study published towards the end of the decade showed that not only did this cause an explosion of heroin use, it increased all crimes associated with drugs.

In 1980, politicians implemented restrictive policies instead. All criminal charges regarding possession were prosecuted except for small quantities of cannabis. Legislation passed in 1982 allowed abusers to be committed to care against their wishes if their condition was deemed life-threatening.

Since 1986, extended-care facilities have sprung up across Sweden. Today, it has about 60 residential treatment centres with a combined admission capacity of 1,300. High priority has also been given to community-care outlets and anti-drug education programs.

The results are striking. Between 1988 and 1993, the monthly number of newly infected syringe-users fell from four to two. In Stockholm, the number of new cases fell from 83 to 16 between 1987 and 1992. The total number of infected IV-drug abusers in 1993 was 633, and the number in whom AIDS had been diagnosed was only 56. As well, only 3% of pupils in the terminal grade of compulsory school said they had tried drugs in 1992, compared to 13% in the early 1970s.

These figures do not surprise Mr. Weselowski. "It's common sense to detox junkies, get them into a tightly-run recovery centre for several months, and maintain a strong bond with them after they re-enter society." Of the 1,300 people who have completed Mr. Weselowski's Innervisions recovery program over the past six years, 75% remain sober, productive citizens.

Despite Sweden's spectacular turnaround, Sgt. Doucette says that "the propaganda surrounding the Swiss model is so intense that other countries are opting for harm reduction. And we're falling into the same trap."

Indeed, a September 28 Province editorial called on the VRHB, Victoria and Ottawa to seriously consider a recommendation made by former B.C. chief coroner Vince Cain in 1995 that hard drugs be decriminalized. Had this been implemented two years ago, the newspaper claimed, the Downtown Eastside's medical emergency "might have been avoided."

The Province advanced that claim at a time when even harm-reduction advocates admit their earlier policies failed. Dr. Blatherwick and Ms. McGuire concede the needle exchange has boosted HIV rates. "The exchange just doesn't seem to work for cocaine addicts," admits Dr. Blatherwick.

Perhaps the most surprising admission from the harm-reduction camp comes from its most prominent spokesman, DEYAS founder John Turvey. Commenting on V6A 1N6, a documentary about the downtown eastside's HIV crisis that aired on VTV on September 22, Mr. Turvey said, "The dynamics of addiction isn't where you sit in your front room and make good judgement calls. They're obsessive-compulsive, they're not thinking ahead to paying the rent or eating everyday."

"What an amazing thing to say," responds Sgt. Doucette. "He instinctively reiterated the essential flaw of harm reduction. Why then are we even contemplating it?"

That question may defy easy explanation, but there's no disputing that B.C. authorities continue to promote harm reduction even as the spectre of addict-transmitted AIDS expands beyond Skid Road. Health units in New Westminster and Surrey are reporting record rates of HIV infection; 40 people in New Westminster and 41 in Surrey tested positive last year, 60% of them syringe users. "We've missed an opportunity to prevent an epidemic," laments Dr. Strathdee. "Now we'll be lucky if we can avert a medical catastrophe of unprecedented proportions."

—Robin Brunet

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