Third post in a series on the First Annual Interprofessional Health Law Conference.

The harm reduction panel spoke about strategies for reducing communicable diseases.  Most of the discussion focused on the controversy over injection sites.

The first legal injection site in North America was Insite in Vancouver, B.C.  The downtown eastside area where the clinic is based was considered by the  Canadian Community
Epidemiology Network on Drug Use (CCENDU) as the center of an injection drug epidemic.

The US Office of National Drug Control Policy called it “state-sponsored suicide,” and Harper later said, “We as a government will not use taxpayers’ money to fund drug use.”

The first speaker was Shaun Hopkins, a social worker who is the manager of The Works needle exchange program in Toronto.

The Works is part of the City’s 4-pronged strategy towards drug reduction,  which requires a complex solution.  People need different parts of the strategy depending on where they are in their lives and their stage of recovery.

The program’s approach is to use a combination of tactics:

• Fixed site
• Street outreach
• Mobile component
• Contracts with community agencies
• Peer programs

Hopkins claimed that they don’t view their provision of services through a moral lense, but instead reduce it to a health issue.  Their kits are considered medical devices and therefore fall under some exemptions.

The benefits of needle exchange include:

• Decrease HIV, Hepatitis B and C and other infections
• Decrease in drug use related health problems
• Safe contact for drug users
• Increase in referrals to health services, detox, drug treatment, housing, etc.

What this does is create a humane and honest approach, and meets people where they are with their drug use.  It doesn’t require abstinence, but it doesn’t exclude it either.  Their mission is to reduce transmittable diseases, and they provide information on how to avoid transmission.

The Works gets their mandate from the Health Care Protection Act, which provides for the distribution of clean needles under the Ontario Harm Reduction Program.   But the wording of the statue of somewhat vague, and has allowed some communities in Ontario to not provide services that are desperately needed by drug users in the province.

Vocal opposition to fixed sites in Victoria contributed to it’s closure, and they relocated but eventually found themselves without a home.  This is unacceptable because of the harm that it causes.

Historically they used a 1 for 1 policy.  They only provided the equipment to people who had one to return.  The rationale was that these people would likely use the dirty needles anyways if they were not provided clean ones.  Without these programs they would be forced elsewhere.  This would be in direct contradiction with the mandate to stop the spread of disease.

The AIDS epidemic is so serious we have to do what we can, without foolish inhibitions.  Studies show that these programs are highly effective, and have a 75% reduction in transmission rate.

The controversy though has led to more research.  The findings have demonstrated that these sites do not lead to more drug use, and can be an important way for these people to access health services.

The cost of one syringe is one dollar.  The cost of Hepatitis B over a lifetime is over one million dollars.

The next speaker was Hon. Carolyn Bennett, MP, the Liberal health critic and vocal supporter of supervised injection sites.  The conference organizers were clear to indicate that other political parties were invited but refused to participate.

As a physician, Bennett was extremely interested in harm reduction.  She started by asking,

If you have never met any poor people, how can you make policy for them?

She noted that about 85% of one shelter she cited were the victims of incest.  These people did not want to become addicts.  The used drugs to numb themselves down from serious emotional trauma that was outside of their control.

The person who was supposed to be looking after them in their lives actually abused them.  The strategy is to reduce the harm they have in dying from communicable diseases, until we can help them get back into the lives they deserve.

She noted that they already have the sharp pointy instruments, it’s just that the ones that they have are dirty.

Bennett presented some harm reduction facts, and noted that harm reduction goes hand in hand with prevention and treatment.

But the current government doesn’t like supervised injection sites and has taken it off the table based on ideology.   This is about ideology over evidence, and the evidence shows it works.

She cited the Toronto Public Health needle exchange program to prevent the spread of communicable disease.  They offered harm reduction and methadone services.  But the fuss over Insite in Vancouver has held them back from doing more.

On May. 29, 2008 there was a hearing of the health committee that heard expert witnesses.  She referred the audience to check the Hansard for those seeking verification.   The experts supported the safe injection sites harm reduction strategy.

Dr. David Butler Jones, Chief Public Health Officer of Canada, who had helped develop the initiative under the Liberals, wasn’t allowed to say much.  he wasn’t allowed a press conference or release, but was reduced to saying that the science and the debate speaks for itself:^[*]

Mr. David Butler Jones (Chief Public Health Officer, Public Health Agency of Canada, Department of Health):

I think the science speaks for itself. The debate speaks for itself.

Bennett referred to the limitations placed on Jones, and the knowledge that the current health Minister had regarding the evidence supporting injection sites:

Mr. David Butler Jones:

The minister, I think, recognizes that harm reduction is part of the strategy.

Hon. Hedy Fry:

Have you asked him?

Mr. David Butler Jones:

As other ministers who have been around this table might recognize, it’s inappropriate to speak of personal advice to the minister. I’ve told you what my position is on my view of the science and my view of harm reduction as part of a public health approach, and of the respect in which I hold Parliament and others in the decisions they make and the way they move forward on those choices.

Jones’ report was then sandwiched by others to bury the information.

The international community has also reacted to Canada’s shift in policies.  During the Aug. 13-18 2006 International AIDS Conference in Toronto, Health Min. Tony Clement was protested by injection site supporters who rejected the government’s backwards move.  This reaction was an embarrassment for Canada on the world stage – to speak of ideology instead of science.

Min. Clement then gave a speech to the Canadian Medical Association (CMA), and tried to confuse Canadians.  Ethical and palliative care was mixed up with recovery and the ethics of diversion, that the $3 million from the Insite program could be used elsewhere in direct costs.

Bennett’s response was that,

This guy is insulting the physicians and nurses on the frontlines… There is a refusal by this guy to acknowledge that the CMA knows more about this than he does.

Experts  did speak out though in support of Bennett, including outgoing CMA President Brian Day and incoming CMA President Robert Oullette,  as well as Paul Garfinkel of the Centre for Addiction and Mental Health (CAMH).

Bennett said that there are individual and social barriers towards harm reduction strategies.  But there are also legal barriers as well.

They have to be careful not the contravene the Criminal Code for paraphernalia law, and an exception needs to be provided.  In the U.S. it is illegal to even hand out paraphernalia, and law enforcement has engaged in crackdowns.

The political barriers, aside from censorship of senior government officials and ideology trumping evidence, is that there is insufficient funding.  To overcome these barriers and demonstrate that Canada needs harm reduction we need to separate the issue from the agenda to legalize drugs and focus on the evidence showing it works.  If you muddle the issues it becomes too easy to resist it.

Between research and policy there is communication.  But between policy and practice you need political will.

To get from practice to research and determine whether harm reduction is working you have to ask the right questions.  This is what citizen engagement about, and this is the role we can all play.

Richard Elliot, legal counsel for the Canadian HIV/AIDS Legal Network, explained his interest in things affecting people who are inject drugs given their HIV vulnerability.

He emphasized that this is not a public health issue, but a human rights issue.

Injection based transmission is one of the key drivers behind the HIV epidemic.  This includes Canada, where we started to see a decrease in new HIV from injection drug use a few years ago in part due to harm reduction programs, all of which have strong evidence-based principles behind them.

The legal implications of harm reduction is defining what it is, and the language around it is often deliberately obscured.  There is deliberate  misuse of the term – law enforcement is not harm reduction.  In some ways it is production, it actually creates drug use.

The current legal framework in Canada and the world is due to an emphasis on prohibition that leads to the harms of drug use.  Mandatory minimum drug sentences have resulted in highly racialized policies, as in the U.S.

The evidence shows that when the police have a crackdown near harm reduction services, people are reluctant to access them afterwards.

There is a link between prohibition of possession and the lack of carrying needles.  It is illegal for police to seize and destroy people’s personal property, but they do it anyways.

The public policy implications are that if a needle will escalate charges or be destroyed, people are less likely to carry clean ones or dispose of used ones properly.

A recent prison statement said that even if there is no safe site, people will do injection drugs anyways, they will just do it in an unsafe manner.  In one instance, 10 needles were being shared by 500 prisoners, with at least 70 actively using.

Political will is determining public policy in conflict with mounting evidence.

One study has an upcoming pilot project on tattooing by correctional services through freedom of information requests.  Although the findings have not been released yet, a draft evaluation shows they are cost effective and result in reduced risk behaviours.

But the government’s response to this was to cancel the program, despite the public health recommendations to the contrary.

Similarly, Elliot reminded us that Clement called the Insite program an “abomination.”

The final speaker was Eugene Oscapella from the Canadian Foundation for Drug Policy.

Oscapella said that the criminal law was not an appropriate way to deal with drug problems.

He quoted Jean Chrétien when he was the Minister of Justice,

The criminal law was an instrument of last resort, to be used only when other means of social control were inadequate or inappropriate.

The criminal law approach takes a social and health problem, and makes it a disasterous law problem.  Drugs are really a political problem in this country.

The criminal law stigmatizes and throws them in prison, but it doesn’t address the source of the issue.  He pointed out that a prison environment is not a nice place, and most people would want to use drugs more when there.

The problem is that it is treated as a moral failing instead of a health problem.  We wouldn’t, for example, treat a diabetic in the same manner.

The criminal law has created a moral panic.  And that is not the way the law is supposed to work.

We may use the law to reflect a moral element, but we do not create morality.  Created morality stigmatizes people and makes them worthless.  It uses resources on incarcerating rather than helping them.

When we criminalize people, we don’t get at the reasons why people use drugs.  Why do they want to alter their state of consciousness to get away from their situation?  This approach fosters death through overdose.

Nor do we need to criminalize something to reduce consumption.  When dealing with tobacco, the Federal government does not talk about legalization but about heavy regulation.  A complete prohibition maximizes harm reduction and allows unsafe use of drugs which often have unknown contents.

Bennett added that even when it comes to tobacco Clement is wrong.  He has said that when we tell people to quite smoking, we don’t tell them to smoke mild, or slims, or don’t inhale, etc.

She said, speaking as a physician, that in fact that’s exactly what they do.