Fighting for Space

  Ostrow gave PHS an “important decision”: it could continue with the protests or it could “continue to be an organization that works with VCH.”

  In the meantime, Townsend was banished from dealing with the health authority.

  “VCH will no longer deal with PHS through Mr. Townsend,” the letter states. Dan Small was appointed the health authority’s sole point of contact with PHS.

  The letter ends with a warning: “We will be closely monitoring any further protest activities organized by PHS and will take all necessary steps to ensure that our staff and clients are made to feel safe and supported when they come to work or to receive the clinical care they need.”

  Ostrow declined to grant an interview. Bibby, the PHS board’s president, recalls how he and his colleagues didn’t know what to make of the document. The board was aware of the New Fountain and Rainier campaigns, he says, and they knew the government was not happy about them. But Bibby says Ostrow’s letter was over the top. He argues that more than anything, it underscored an ideological divide. “It was like, ‘How dare somebody do something different,’” he recalls.

  In spite of Ostrow’s warning, PHS did not stop.

  “It’s not like for the sake of it we wanted to deliberately cause problems, but we had made a commitment,” Townsend says. “We had made a commitment to the women at the Rainer. We had sat with them in tears. And they’d said, ‘We want to do something.’ So we promised that we would do something. And we were not going to renege on that.”

  On December 18, just five days after PHS received that letter from Ostrow, some 200 people gathered outside the Rainier Hotel for a march on VCH headquarters. They carried black coffins on their shoulders. Others dressed up like the grim reaper, wearing black robes and hoods over their heads. Most of the Rainier’s tenants themselves walked among the group of protesters that day, a powerful sight, given that some of them were in frail health. They called it a “funeral procession.” The message was obvious: cut funding for the Rainier and you are killing women.

  Upon arriving at VCH, Small, dressed in a suit, walked into the building and presented a cake and basket of cookies. “We’re not going to come into the building, there’s nothing to be worried about,” he told them. “This is an upsetting thing, but it’s about your boss.”

  Outside, the group set up on a patch of grass, playing loud music and voicing demands through a megaphone. It was a standard PHS protest, of the same sort that PHS had been holding in the Downtown Eastside for twenty years. But the location was different: this one took the fight to the health authority’s front door.

  From there, the march proceeded to the constituency office of the BC Premier, Christy Clark. “At the premier’s office, it got more out of control,” Townsend says. A parade float with a band playing on it joined the marchers to make even more noise. Leaders of Vancouver’s Indigenous community made speeches that emphasized how vulnerable women were in the Downtown Eastside and how important a place like the Rainier was for them.

  “They were completely freaked out,” Townsend remembers.

  On January 25, Jack Bibby and the board received a second letter from Vancouver Coastal Health president and CEO David Ostrow. “I made it clear that while PHS has the right to disagree with the decision and voice such opinions publicly should it choose to do so, the manner in which this has been occurring not only undermines the credibility and suitability of PHS as a service delivery partner to VCH, but is intimidating and threatening to our employees,” it begins. Ostrow took specific issue with posters that had appeared around VCH offices that referenced the Rainier protests and which were attributed to PHS.

  “The intent of my December 13 letter was to make it clear these kinds of behaviours, should they continue, could seriously jeopardize VCH’s relationship with PHS and bring into question our continued partnership,” the letter continues. “The ongoing protest activities and anti-VCH comments leave us with little choice but to examine our relationship and review options.”

  Kerstin Stuerzbecher acknowledges that PHS had initiated a shift in its relationship with authorities. “We had started to use tactics that I think the government took personal,” she says. “We didn’t just march down the street or block off Main and Hastings with a Killing Fields banner or whatever … We did things that were more direct. Our strategy did change, and I think that that had consequences.”

  Vancouver Coastal Health did not provide funding to continue in-house and non-clinical services at the Rainier Hotel. The building remained under the control of PHS, and the women who lived their got to keep their rooms. But the programs that PHS had fought for were cut.

  “I felt devastated,” Townsend says. “I felt that I’d let the women down.”

  PHS lost the battle and, though it would take a while before they realized it, it had also cost them the war.

  63Registered Charity Information Return. “PHS Community Services Society,” Canada Revenue Agency, 2013.

  64KPMG Forensic Inc. “Report to BC Housing PHS Community Services Society (“PHS”)” (Vancouver, BC, July 18, 2013), 19.

  65Joanne Bezzubetz, Roland Barrios, “Vancouver’s Rainier Hotel Will Continue to Be Served,” Vancouver Sun, November 2, 2012.

  Chapter 30

  Sacramento, California

  Somewhere in the United States, a supervised-injection facility has operated since September 2014.

  In liberal cities such as San Francisco and Seattle, staff at certain needle-exchange programs have long turned the other way to let people inject drugs in their bathrooms. But this facility, which we’ll call Othersite, is more than that. It’s not a needle exchange. It was designed and operates specifically as a supervised-injection facility.

  Alex Kral is an epidemiologist with the University of California Berkeley’s School of Public Health. He’s evaluated injection services at Othersite and drafted a research paper about the facility that’s scheduled for publication in a forthcoming issue of the American Journal of Preventative Medicine. Kral, who has studied intravenous drug use for twenty-five years, declined to reveal the site’s location, but there are hints it is somewhere in an urban area of northern California.

  A draft copy of Kral’s paper describes the facility: “The unsanctioned supervised injection site has one large room dedicated solely to injection and an adjoining room which provides post-injection monitoring/supervision,” it begins.

  The injection room is simple. There are five steel desks. A lamp sits on each one, and white chairs are tucked beneath them. Attached to the wall in front of each desk is a small mirror. Each injection station also has its own sharps box for the safe disposal of used needles. Most users spend between ten and twenty minutes in the injection room. They can stay longer and remain under observation in an adjacent lounge, if they wish.

  “Before … a program participant injects drugs at the site, the staff person asks twelve questions, and the answers are recorded into an encrypted survey software package via a tablet computer,” Kral’s paper reads. “A staff person is stationed in the injection room at all times. Ancillary sterile injection equipment is provided by the agency, which also safely disposes of all used equipment. The staff person observing the injections has been trained in overdose prevention, resuscitation using naloxone and rescue breathing, injecting technique, and harm reduction principles.”66

  Othersite is open between four and six hours each day, five days a week. A drug user must be a member to inject there and membership is by invitation only. “There are no formal exclusion criteria,” the paper says. “Once a person comes to the agency a few times, and appears to need supervised injection services, they are invited to use the supervised injection room.”

  According to Kral’s evaluation, Othersite is a resounding success. During the first two years it was open, there were 2,574 injections by more than 100 people (the study’s method of anonymizing data obscures the exact number of participants). Based on the quick interviews that users grant upon e
ntering Othersite, Kral reports that over ninety percent of those who came to the facility would otherwise have injected drugs in a public place—a restaurant bathroom or a park, for example. “As such, this site has averted over 2,300 instances of public injection in the neighborhood during a two-year period,” the paper states. In addition, sixty-seven percent of participants admitted they discard used needles on the street. Because every needle at Othersite is dropped in a safe-disposal box as soon as it is used, Kral calculates the facility has saved the neighbourhood from 1,725 dirty needles.

  During the first two years that Othersite was open, there were only two overdoses. Such a low number is likely the result of two factors. The first is that users there can take a minute to properly measure each dose. The second reason is that when someone who has injected drugs at a supervised site shows signs of distress, staff are trained to intervene before an actual overdose renders them unconscious. Sometimes that means providing them with an oxygen tank, but other times an overdose can be kept at bay simply by keeping a drug user upright and talking. Both of the overdoses that staff responded to at Othersite were reversed with naloxone.

  “Being able to inject in a clean, well-lit space equipped with sterile equipment, where there is no need to rush due to fear of detection, may also reduce injection-related injury and disease,” Kral concludes.

  On the phone from San Francisco, Kral says that for another research paper, he calculated that if a city like San Francisco established a sanctioned injection facility, it would not only pay for itself but actually save taxpayers $3.5 million a year.

  He says his forthcoming paper about Othersite will describe the facility “as a proof of concept.”

  “An unsanctioned injection site somewhere in the United States has been operating now for two and a half years,” Kral says, “and it’s basically shown that the sky has not fallen.”

  The first time that Kral sat down with a politician to talk about bringing a supervised-injection site to San Francisco was 2007. He recalls that the media coverage was not positive, to put it mildly. But the occasional politician continued to seek his expertise. In May 2017, Kral took a seat on a San Francisco task force convened to assess the potential impacts of opening an injection site. The year before, he provided expert testimony for a bill that could bring injection sites to San Francisco plus seven other cities across California.

  Assembly Bill 186 would make it legal for local governments to open supervised-injection sites in Alameda, Fresno, Humboldt, Los Angeles, Mendocino, San Francisco, San Joaquin, and Santa Cruz. (Legal as far as state law is concerned; federal law remains another question.)

  On June 1, 2017, the California state assembly voted forty-one to thirty-three in favour of the bill, sending it on to the senate. The bill’s sponsor is Susan Talamantes Eggman, assemblywoman for California’s thirteenth district. “Generally, the assembly is where things that are controversial go to die,” she says cheerfully. “So I have very high hopes as we go into the senate that we will be successful.”

  Eggman says the idea came from San Francisco. Bay Area lawyers with a group called the Drug Policy Alliance made the three-hour drive to her office in Sacramento and asked if she’d be willing to take on something controversial. They’d targeted the right assemblywoman.

  Eggman is a licensed clinical social worker. Through the 1980s and ’90s, she worked in several positions on the frontline of the state’s response to substance abuse. She remembers the crack cocaine epidemic of the 1980s, the arrival of black tar heroin in the ’90s, and the methamphetamine craze of the 2000s. Now she says the challenge is the opioid crisis, driven by prescription painkillers and made worse by fentanyl and other synthetic analogues.

  “I already know about working with harm reduction,” Eggman says. She recounts how she first came to understand the concept years earlier, as a social worker for women who were victims of domestic abuse. “To tell people just to leave that situation, to simply get away—it is not that easy,” Eggman explains. “Instead, we ask, ‘How are you going to stay safe until the next day?’” With a drug addiction, she continues, part of the answer is harm reduction.

  “The best predictor for a person to make positive changes in their life is when they have a positive therapeutic relationship with a caring person and they don’t feel judged,” Eggman adds. “That’s when they are more likely to take the next step into sobriety.”

  And so when the Drug Policy Alliance’s lawyers from San Francisco asked her if she would help with a bill to legalize supervised injection, it didn’t take much before she was willing to give it a try. “Much to the chagrin of my political advisors,” Eggman says with a laugh.

  In March 2017, Eggman held a meeting for activists and other stakeholders in her office in the California State Capitol building. “I have a good-sized office, but there were so many people that some were sitting on the floor,” she recounts. There were a number of long-time addicts and active drug users in the room, and Eggman listened to their stories. She remembers one middle-aged man in particular. “He talked about his struggle with addiction and was very compelling,” she says. The man recounted years on the street addicted to heroin. He finally got clean and told Eggman he wanted an injection site to save other people from going through what he had.

  Later, Eggman continues, a few months after that meeting, the man relapsed. “By the time we actually passed that bill, he had died from a drug overdose,” she says. “But he told me that many people were still out there suffering who could benefit from something like this.”

  66Alex Kral, Peter Davidson, “Addressing the Nation’s Opioid Epidemic: Lessons from an Unsanctioned Supervised Injection Site in the United States,” unpublished draft (2017).

  Chapter 31

  Prescription Heroin

  David Murray was driving back to Vancouver on his way home from a harm-reduction meeting out in Abbotsford, one of the city’s more distant suburbs. Ann Livingston was in the passenger seat next to him. A large kitchen knife she’d brought with them to serve snacks had slipped down in between their seats and Murray reached to look for it. When his fingers finally found the knife, he pulled it up quickly and raised it in a stabbing motion toward Livingston. He was obviously joking but made a fairly convincing show of it. Livingston laughed and they continued driving toward the Downtown Eastside.

  “The next thing I know, we’re cruising through Burnaby and there are police cars everywhere,” Murray says. Four squad cars with lights flashing and sirens blaring forced him over to the side of the highway. With guns raised, officers surrounded their vehicle and moved in. “Get out of the car!” they shouted at him.

  Murray was placed in handcuffs and questioned separately while another officer checked Livingston for injuries and ensured she wasn’t being kidnapped.

  “We had to stop ourselves from laughing,” Livingston says. “I was worried we were going to get killed.”

  Livingston and Murray had been friends for a while, but after that afternoon they grew thick as thieves.

  David Murray was in his late fifties, living in the Downtown Eastside and addicted to drugs, when he received an offer that sounded too good to be true: free heroin, three times a day, every day, paid for by Canadian taxpayers.

  He’d used heroin since his late teens, and it had stopped being any fun decades ago. Court documents reveal a list of petty crimes that Murray says were related to his addiction. In the 1970s, he spent three years in a US prison for his role in a bank robbery. “I’m not proud of those days,” he says. “I don’t like to talk about it.” Murray subsequently moved to Vancouver and held a job in the film industry for a time, but heroin got the best of him. “It led to homelessness and all the rest that goes along with everything falling apart,” he says.

  In February 2005, Murray walked by a clinic at the corner of East Hastings and Abbott streets where a younger guy sat behind a table he’d set up on the sidewalk. Kurt Lock, an employee of the Portland Hotel Society, stopped Murray
and asked him if he was interested in participating in a study, the North American Opiate Medication Initiative, or NAOMI. “I was broke and homeless at the time,” Murray recalls. “So I jumped at the idea.”

  NAOMI sought to test the health outcomes of methadone against diacetylmorphine, a medical term for heroin. Three times a day, Murray visited the clinic and received a free dose of pharmaceutical-grade opioids. The drugs were imported from Europe and regulated, which meant they were relatively safe and free from the uncertain qualities of street drugs and the poisons with which dealers cut them.

  The experiment worked like this: At a set time, a patient knocked on the clinic’s outer door. Identification was confirmed, the door was unlocked, and then, for security reasons, the patient waited for that first door to close before a second opened to let them inside. They proceeded to the injection room, which is similar to Insite’s: a series of simple booths, each one with a mirror and a chair. Inside the injection room, a patient spoke to a nurse who was positioned on the opposite side of a sheet of thick glass. Identification was confirmed for a second time. Then the patient received a set dose of diacetylmorphine that was earlier prescribed by a doctor employed by the clinic. The patient took a seat at one of the booths and injected. Finally, at the end of each visit, they spent a few minutes in the clinic’s chill room, where staff casually monitored them for adverse side effects. Because the drugs were pure and of a fixed dose, there was very seldom an overdose. Then the patient left the clinic and continued on with their day.

  NAOMI wasn’t giving out free heroin to just anyone. The eligibility criteria was steep, designed to test the effectiveness of diacetylmorphine for the treatment of long-term addicts who had repeatedly failed with traditional therapies such as methadone. Among the 251 participants, the average number of years they had used injection drugs was 16.5.