The Harm in “Harm Reduction”

Every major city in the United States seems to have its designated opioid district, a tucked-away part of town where normal rules are suspended and the drug trade shapes the social order: Kensington in Philadelphia, the Tenderloin in San Francisco, Pioneer Square in Seattle. The scenes are sadly familiar: disheveled men and women living under blue tarpaulins, dealers doing hand-to-hand transactions between large trash receptacles, and dope fiends searching with their fingertips for the last good vein. Methadone clinics and rescue missions operate amid a steady rumble of ambulances and police cruisers, vehicles sent not to enforce public order but to manage the status quo.

Political leaders have long sought to transform these places. Among progressive policymakers, the prevailing trend is “harm reduction,” a public-health approach that accepts widespread drug use and directs resources toward mitigating its negative consequences. Harm reduction began with needle exchange and methadone clinics, which helped, respectively, to reduce the transmission of blood-borne diseases and to stabilize addicts with opioid replacements. Now, as Western nations confront the opioid crisis, cities in Canada, Australia, and Europe have adopted a new harm-reduction strategy: so-called safe-injection sites, where addicts can take drugs—predominantly heroin and methamphetamine—under the supervision of medical professionals, who intervene in case of emergency.

Public-health officials and progressive leaders often cite Vancouver, Canada, as the gold standard of harm reduction. Over the past 30 years, Vancouver has implemented the full range of harm-reduction strategies. The centerpiece of the city’s current efforts is the Insite safe-injection facility on East Hastings Street, which has drawn the attention of academics and media from around the world. Advocates argue that such facilities can prevent fatal overdoses, reduce rates of infection, connect addicts to social services, and mitigate street disorder, with few negative consequences.

What’s happening in Vancouver can hardly be categorized as a success, however. Though harm reduction has brought some benefits, such as reducing the transmission of HIV, it has also compounded the problems of addiction, homelessness, and public disorder. Vancouver’s concentration of services in its own opioid district, the Downtown Eastside, has created a veritable death trap for addicts around British Columbia, who travel there to obtain drugs, overdose, and then perish in the streets.

As cities in the United States, including San Francisco, Denver, Philadelphia, and Seattle, consider opening their own safe-injection sites, they should understand the full consequences of these practices. Beneath the narrow certainties of the academic literature runs a deeper story that reveals the hidden costs of harm reduction. As the coronavirus begins to spread in opioid districts throughout North America, policymakers must reconsider the wisdom of concentrating vulnerable, immunocompromised populations in tight quarters, where they can become vectors for a catastrophic outbreak.

On the surface, Vancouver is an unlikely location for an opioid epidemic. In popular imagination, the crisis is taking place in impoverished inner-city slums or forgotten rural communities. According to the influential “deaths of despair” hypothesis, the opioid crisis is most pronounced in communities exposed to “prolonged economic distress,” leading to a decline in life expectancy for middle-aged men. But Vancouver is neither West Baltimore nor West Virginia—it’s one of the world’s most prosperous and progressive cities, with a booming economy, liberal leadership, and universal health care. And yet, despite this affluence, the city faces one of the worst drug problems on record. Since 2008, overdose deaths in British Columbia are up 151 percent, with Vancouver’s numbers driving much of the increase. According to CTV News, Vancouver’s “paramedics and dispatchers are feeling fatigued and burnt out” by the pace of opioid overdoses, “and some are experiencing occupational stress injuries such as post-traumatic stress disorder.”

The Downtown Eastside neighborhood is ground zero for the troubles. For the past century, the area has been Vancouver’s Skid Row, home to a dense network of cheap hotels, bars, brothels, and, increasingly, homeless encampments and social-services offices. It’s here, across ten city blocks, that Vancouver has launched its experiment in harm reduction, opening Canada’s first needle exchange in 1988 and North America’s first safe-injection facility in 2003. Rather than try to disperse the Downtown Eastside’s social pathologies throughout the region, policymakers have decided to concentrate new subsidized housing construction, welfare services, and drug programs in the neighborhood. Total social spending in the Downtown Eastside now amounts to more than $1 million per day.

Despite these intensive efforts, the city has failed meaningfully to reduce rates of addiction, homelessness, and criminality in the neighborhood, which remains the epicenter for all overdose deaths in the region. In 2017, the City of Vancouver logged 8,000 overdose calls, with the Downtown Eastside responsible for 5,000 of the total, even with a population of only a few thousand residents. The situation has become ever more chaotic, as Covid-19 threatens to spread among many homeless men and women who have nowhere else to go.

For the addicts caught up in the Downtown Eastside’s web of social programs, the results are not encouraging. According to a ten-year longitudinal study by Simon Fraser University professor Julian Somers, even the most service-intensive interventions failed to produce better outcomes. In his study of 433 addicts enrolled in Vancouver at Home, a program offering free housing and comprehensive services, Somers concluded that “despite the high concentration of services and supports in the [Downtown Eastside], members of the current sample experienced significant personal decline rather than recovery, as evidenced by their involvements with criminal justice, large increases in acute care and prolonged homelessness.” Over ten years, Somers writes, “participants’ use of community medical services and hospital services each tripled, while criminal convictions and welfare receipt doubled.”

Even the key claim of harm-reduction advocates—that safe-injection sites reduce overdose deaths—loses much of its rhetorical power when viewed in context. While it’s true that Insite recorded 189,837 visits last year without any fatalities on the premises, the Downtown Eastside streets saw more overdose deaths than ever. It’s not that addicts who use the safe-injection site are achieving sobriety; they’re just not dying on the floor of the Insite injection room. According to the latest numbers, more than 1,500 overdoses a year have taken place within a block of the Insite facility in the Downtown Eastside. And even the “no deaths on the premises” statistic might be misleading. As a secret recording from the Powell Street Getaway facility reveals, it’s possible for addicts to overdose at safe-injection sites, and then die en route to the hospital or after they have returned to the streets.

More broadly, if the objective is to maximize overdose reversals, safe-injection sites may not be the most efficient method of achieving this goal. According to the BC Centre for Disease Control, British Columbia currently sees between 1,000 and 2,000 overdose reversals per month. These are primarily administered in the field by paramedics, law enforcement, community members, and other drug users. The government’s decentralized Take Home Naloxone and Facility Overdose Response programs, which distribute overdose-reversal kits into the community, cover a much broader territory and deliver much greater results than brick-and-mortar safe-injection sites, with less potential for negative spillover effects.

Finally, even if one accepts the purported benefits of safe-injection sites, the solution cannot scale to serve the addict population in the Downtown Eastside. The Insite facility has a $3 million annual budget, 12-seat injection room, and averages 700 to 800 visits per day—but according to the latest data, these figures represent only 4 percent of the total number of daily injections in the Downtown Eastside. In other words, if policymakers were to scale safe-injection sites to meet the overall rate of neighborhood drug consumption, they would need to build 25 more facilities in the Downtown Eastside alone—a political, financial, and spatial impossibility.

The Downtown Eastside is one of the world’s most heavily studied neighborhoods. A cursory glance through the academic literature reveals at least 6,500 peer-reviewed papers, journal articles, and scientific reports that focus on life there. According to the National Post, the neighborhood is home to “more than 170 nonprofits clustered in an area of only a few blocks, all devoted towards supporting an increasingly dense community of addicts.” An entire social-scientific sector is devoted to solving the problems of the Downtown Eastside, to little avail.

Indeed, these efforts have contributed to a “magnet effect” that encourages opioid addicts from around British Columbia to move into the neighborhood in search of social programs, a permissive social environment, and easy access to drugs. According to the Simon Fraser University study, from 2005 to 2015, the number of homeless addicts who had migrated to the Downtown Eastside from outside the neighborhood increased from 17 percent to 52 percent of the overall population. In the name of compassion, public officials have created perverse incentives that are worsening homelessness, overdoses, and crime.

As it turns out, much of the academic literature in support of the current harm-reduction policy is more about activism than hard science. According to a recent survey by the RAND Corporation, nearly 80 percent of the literature on safe-injection sites is made up of studies from just two facilities: Insite in Vancouver and the Medically Supervised Injection Centre, in Sydney, Australia. As the RAND scholars conclude, these studies are neither rigorous nor definitive, and they often ignore the potential for community-level harm and second-order effects. “We conducted our own assessment of the individual studies,” the report argues, “and found that the evidence base concerning the overall effects of SCSs [supervised consumption sites] is limited in quality and location.”

Even worse, as a recent investigation by the Huffington Post revealed, one activist-researcher who had lobbied for the original funding for Insite coauthored all 33 studies of the facility from 2003 to 2009. Unsurprisingly, they showed unanimously positive results. Some of these studies were even produced in collaboration with the Vancouver Area Network of Drug Users, an activist group that requires researchers to agree to their rules, including: “if researchers want to work with us they should really become allies of our movement,” “we want to see the research—in progress—to give feedback,” and “[researchers must] present us with an explanation and action plan on how the research will contribute to the empowerment and liberation of people who use drugs.” This is the language of radicalism, not science, and any study conducted under such auspices should be treated with skepticism.

Safe-injection advocates have positioned themselves as the arbiters of a morally neutral, scientific objectivity, dismissing dissenters as “deniers.” But the advocates have constructed their argument on the moral foundation of “harm reduction,” which cannot be evaluated simply as a neutral science. Though it has proved a valuable tool in some cases—for example, preventing infections and reversing overdoses—harm reduction makes profound assumptions about human nature that must be subjected to a broader public debate.

The critical question facing neighborhoods like the Downtown Eastside is: What is the desired end? Mark Tyndall, a physician and leading harm-reduction advocate in Vancouver, believes that the goal of sobriety—the traditional telos of both medicine and public policy, when it comes to drug abuse—is outdated and should be abandoned. The real objective, he argues, should not be recovery from addiction but the maintenance of addiction, possibly in perpetuity. “People have these unrealistic expectations like . . . we need to get [safe-injection users] abstinent and recovered,” Tyndall explains. “That so rarely happens to people that I don’t have those expectations anymore. I want to keep people alive and relatively healthy and hope for the best.”

The flaw of harm-reduction theory is that it contains no natural limits. Convinced that safe-injection sites are insufficient, Tyndall and his colleagues at the BC Centre for Disease Control are launching a pilot program to provide addicts with a “clean supply” of opioids through “ATM-style machines—with biometric scanners, real-time monitoring and alarm systems—that would distribute the pills to patients.” The Vancouver Mayor’s Overdose Emergency Task Force has endorsed the plan, recommending that the city “prioritize and identify space for a suitable location for a storefront service space, either in or adjacent to the Downtown Eastside.”

The vision of ATM-style opioid dispensers evokes Aldous Huxley’s Brave New World, in which an opioid-style drug, soma, is given to the lower castes. This approach threatens to reduce man into a machine. It’s no giant leap from the state-sanctioned distribution of soma to the untouchables of the World State to the administration of “clean” hydromorphone to the desperate tent-dwellers of East Hastings Street.

Huxley’s novel illustrates how the science of addiction can’t be untangled from its moral, political, and philosophical dimensions. Huxley’s fear was that, without restraint, addiction could become the dominant refuge from the difficulties of existence. “There’s always soma to calm your anger, to reconcile you to your enemies, to make you patient and long-suffering,” he wrote. “In the past you could only accomplish these things by making a great effort and after years of hard moral training. Now, you swallow two or three half-gramme tablets, and there you are. Anybody can be virtuous now. You can carry at least half your morality about in a bottle. Christianity without tears—that’s what soma is.”

Harm reduction is ultimately a pessimistic philosophy. It rests on the premise that human beings are subordinated to biological determinism, with almost no room for agency, hope, or grace, and maintains that science can lead us out of the darkness of addiction and human despair. Yet despite harm reduction’s influence over social policy for decades now, there seems no end in sight for the disorder of neighborhoods like the Downtown Eastside. As tents continue to line the streets of major cities, the addiction crisis demands an answer. Harm reduction isn’t it.