Injecting doubt: the rhetoric of harm reduction and the fate of Insite

The debate over the future of Insite, the successful safe-injection and drug health centre in Vancouver's Downtown Eastside, grew more impassioned this month after the federal government's so-low-key-as-to-be-well-nigh-subsonic release of a report by a panel of experts tasked with assessing existing scientific research on the facility.

Perhaps the loudest squawk came from the authors of the report's most quoted studies: "This government may already have garnered a reputation for being the most antiscience government in Canadian history." In a sharply worded article published last week on Straight.com, Thomas Kerr and Evan Wood, research scientists at the British Columbia Centre for Excellence in HIV/AIDS, accuse the federal Conservatives of politicizing science in their straight-laced and passive-aggressive approach to Insite's work with injection drug users.

Doing exactly what it was set up to do
Kerr and Wood charge the government with attempting to "cloud science" and "manufacture uncertainty." In the Tories' get-tough, war-on-drugs strategy, they aver, there is no room for sound public health strategies like harm reduction — despite the wealth of scientific evidence to support these interventions, including 22 studies by the authors which appeared in major medical journals such as the New England Journal of Medicine, the Lancet, and the British Medical Journal. This plethora of research shows that Insite is doing exactly what it was set up to do:

• contributing to reductions in the number of people injecting in public and the number of discarded syringes on city streets,
• helping to reduce HIV-risk behaviour and saving lives that might otherwise have been lost to fatal overdose,
• achieving a 30% increase in the use of detoxification programs among Insite users in the year after the site opened,
• not increasing crime or leading others to take up injection-drug use.

Moreover, Insite appears to be cost-effective and is popular among the general public. Within the strict limits imposed on it, Insite just seems to work. Undeterred by mere facts, however, Prime Minister Stephen Harper, whose strong opposition to "deviant behaviour" is well known, claims to remain unconvinced. Neither the overwhelming scientific evidence nor Insite's articulate defenders — not even the largely positive conclusions of the government's own Expert Advisory Committee — seem to have swayed this staunch defender of prudence and propriety and his loyal supporters.

The most negative finding the Committee could come up with was that Insite did not show a record of addiction prevention. However, as the Canadian Medicine blog points out in an April 14 post, "it should come as no surprise that prevention hasn't improved. Perhaps the prevention of further harm and more death should be prevention enough, and we shouldn't expect one single intervention to solve the problem of drug addiction itself. After all, this is a 'harm reduction' project we are talking about — not harm prevention." However, as is the case with global warming, no amount of compounding detail is enough to disabuse the determined believer.

Ideological warfare
Given the significant disagreement on this issue, perhaps the very term "harm reduction" is the problem, as A.I. Leshner of the American Association for the Advancement of Science suggests [1]. The imprecise application of this term and its use as a euphemism for drug legalization have "sufficiently inflamed ... drug warriors that they cannot have a rational discussion of even the underlying concept, let alone how harm-reduction strategies might be implemented." Leshner advocates the avoidance of ideological intensity. "Let's get on with studying specific strategies to protect the public health and ensure social well-being and give up this term that only gets in the way, even if it does make sense." This well-meant and seemingly pragmatic dismissal of ideology, so characteristic of certain debates within American elites, is itself highly ideological. Excellent solutions are brought forward in print, and they stay securely in print. There are still no safe injection sites anywhere in the United States.

From a Canadian perspective, Bernadette Pauly of the University of Victoria reminds us that harm reduction, however well implemented, is only a partial solution [2]. Conceived within a broader social justice context, harm reduction strategies should be part of a comprehensive approach to reducing social inequities, providing accessible health care, and improving the health of those who are street-involved. Pauly is proposing to move from print to political project. All well and good, but then we confront the by-one's-own-bootstraps catechism of the dogged Harperites and their extraordinary ability to mobilize the fear and petty prejudices of Canadians in support of their retrograde policies.

The worst part of having success is trying to find someone who is happy for you, as Bette Midler once said. Insite's harm reduction achievements are being deliberately downplayed as time runs out on the facility's exemption from federal legislation that would otherwise see operators charged under federal drug laws. The current licence expires on June 30, when Health Minister Tony Clement must decide whether to grant another exemption to the Controlled Drugs and Substances Act or amend legislation that prohibits it. Battle lines are being drawn as two law suits challenging the federal government's jurisdiction over the matter head to the British Columbia Supreme Court, and experts like Thomas Kerr demand publicly that the Minister honour the findings of his own researchers and stop injecting doubt by his disingenuous questioning of Insite's raison d'être.

The only dope worth shooting is ...
On the other side of the ideological divide, the Vancouver Police Union issued a recent statement criticizing Insite, which operates near capacity, for serving only a tiny minority. That's like denouncing underfunded and understaffed day care centres in this country for serving only a small number of Canadian children. According to the Canadian Press, Chief Superintendent Derek Ogden, the RCMP's director general of drugs and organized crime, echoed his masters by stating he would like to see further research. "I absolutely cringe when I hear people talk of a safe injection site," he said in an interview from Ottawa. How about that for informed comment. The Chief Superintendent probably also cringes at the thought of certain sexual practices, religious rituals, or undergraduate film studies courses. It's comforting to know that federal law enforcement policies are being planned based on the cringe factor. Health Canada spokespersons ran for cover and would only respond to emailed questions from the media. Predictably, they intoned the mantra that the Minister was "examining" the Expert Advisory Committee's report.

Perhaps Ottawa's balmy spring weather is distracting Mr. Clement. But the question needs to be asked. What further research is really needed, and how much more examining must he do? The money spent on this lengthy and redundant investigation (no cost figures for the Committee's efforts seem to be readily available) could probably finance the start-up of another harm reduction program in, say, Toronto or Montreal. Insite remains the only safe injection site in North America.

The strange timing of the report's appearance has not gone unnoticed. The surreptitious nature of its release late on a Friday afternoon seemed designed to minimize media coverage. The ideological reasons for the health minster's coy and constrained behaviour are obvious. As David Eaves so aptly comments on his blog, "for what must be the first time in Health Canada’s history the department is trying to bury a study that highlights how one of its programs improves healthcare outcomes to Canada’s most marginalized citizens."

Scientific arguments are insufficient in themselves
In a brilliant commentary on the ideological warfare behind the war on drugs, two Canadian sociologists take on the sententious rhetoric that labels harm reduction advocates as "legalizers" in the guise of scientists and public health professionals [3]. Because the right-wing attack comes from either the intractably convinced or cleverly hypocritical stance that abstinence, prevention, and enforcement are the only acceptable and morally legitimate solutions, harm reduction's muted stance on morals, rights and values prevents proponents from engaging criticisms of this nature in terms other than the evidence or science.The case of Insite, the authors argue, demonstrates the value of asserting human rights claims that do not rest on evidence per se. Scientific arguments are insufficient in themselves to move beyond the status quo on drugs.

They conclude, "Without commitment to 'strong rights' and the sovereignty of users, harm reduction sentiments are easily subverted to a technocratic governance agenda. Against the accusation that we are really 'legalizers' harm reduction advocates need not dispute the label but rather the suggestion that opposition to the drug war is somehow irresponsible, dishonest, or immoral. Respect for human rights moves harm reduction past the confines of a scientific project — which has not been well respected outside academic circles — toward a generative programme for replacing prohibition with policies reflecting the costs and benefits of drug use and the costs and benefits of formal intervention."

Here, surely, is the way to proceed. Palaver and posturing should not get in the way of real progress, which will be measured in terms of real lives and the difference that intelligent and compassionate social programs can make. Noam Chomsky once said, "The sign of a truly totalitarian culture is that important truths simply lack cognitive meaning and are interpretable only at the level of 'Fuck You', so they can then elicit a perfectly predictable torrent of abuse in response." Let's hope that the continuing controversy over harm reduction and safe injection sites will not sink to that level.

References:

1. Leshner AI. By now, "harm reduction" harms both science and the public health. Clin Pharmacol Ther. 2008 Apr;83(4):513-14.

2. Pauly B. Harm reduction through a social justice lens. Int J Drug Policy. 2008 Feb;19(1):4-10.

3. Hathaway AD, Tousaw KI. Harm reduction headway and continuing resistance: insights from safe injection in the city of Vancouver. Int J Drug Policy. 2008 Feb;19(1):11-16.

A PDF version of the Expert Advisory Committee's report has been created by David Eaves (www.eaves.ca) and is available here.

And here are the reports from the independent researchers as provided by the Vancouver Sun: http://www.canada.com/vancouversun/pdf/FinalCost-BenefitAnalysis_.pdf http://www.canada.com/vancouversun/pdf/finalEnvironmentalScan-IDU.DOC http://www.canada.com/vancouversun/pdf/boydetalfinalsis.pdf