Health Committee on May 29th, 2008

[The Chair, Conservative, Joy Smith]

We're looking forward to your presentation.

[Prof. Neil Boyd]

Thank you.

I'll begin by making some remarks about the context of harm reduction. I think the meaning of harm reduction is both complicated and compromised by the manner in which we have historically defined drugs as legal and illegal. The most dangerous drugs to public health are the legal ones, irrespective of rates of use. I particularly note tobacco, which kills some 35,000 Canadians annually. Even when you look at the rates of use of both legal and illegal drugs in our culture, it's very difficult to see a drug with greater morbidity and greater potential for addiction than tobacco.

So I think we need to make the point that when we consider harm reduction, we are very much influenced by the kinds of cultural blinders we have around what we think of as a “drug”. Who do we think of as a pusher, for example, a corporation that sells tobacco in a global context or a young man who sells small amounts of heroin or cocaine on the corner of Main and Hastings Streets? Both are arguably distributing legal and illegal drugs, but I think there are some open questions about harm and harm reduction.

So harm reduction initiatives can apply usefully to both legal and illegal drugs. All harm reduction programs acknowledge drug use, but they try to curb the harms of the drug and the harms of the policies that are attached to its use and distribution. In many instances, these are the harms of the law itself.

Think of designated driver programs for those using alcohol. We accept that young people will drink, and will drink to a point beyond .08, that is, to a level of impairment. Yet we bring in a designated driver program, which very few of us would oppose, but is an acknowledgement that despite what we do, some people will consume alcohol to the point of impairment, and that we need to protect young people from themselves.

Non-smokers' rights programs are arguably quite analogous to a supervised injection site, because we are protecting the public from unwanted smoke, in much the same way that one might argue that a supervised injection site protects the public from unwanted injection debris and from the risk of contracting disease from needles in their community, and so forth.

Of course, needle exchange programs for injectable drug use are another form of harm reduction. If we think about the regulation of cannabis by age and location of use, this could arguably be a harm reduction program. None of us wants grow ops in our neighbourhoods, and none of us wants the violence of the trade, so one could see regulation of that industry as a harm reduction program, it seems to me.

I'll speak specifically now about supervised injection sites. They attract what my colleague Dan Small has called “wounded individuals”—not working class, upper-middle class, and middle-class people who are injecting cocaine or heroin in a party atmosphere one might see as self-indulgent, but people with profound substance abuse and mental health problems.

The liberal notion of de-institutionalization, the liberal reality of de-institutionalization in the 1970s, has arguably given birth to many of these problems. But if supervised injection sites did not exist, these people would not stop using drugs. They would use drugs in more dangerous and unhealthy circumstances, as 95% of them continue to do today, without potential access to diagnostics, immunization, treatment, and what I think is the most important point, the beginning of a dialogue that might lead to a healthier lifestyle that avoids the possibility of HIV infection and that leads to better diagnostics and more immunization.

I won't repeat the commentaries and cite the many research reports that demonstrate the health benefits. Others have done that and will continue to do that. I will say, as a criminologist, that the supervised injection site has not promoted crime. Our detailed temporal and spatial analysis of the neighbourhood suggests that it did not work to attract drug dealers or property criminals, and in fact there was a modest reduction in public order in the neighbourhood.

Additionally, it appears to have benefits to cost ratios of between 2:1 to 8:1, depending on the model of analysis employed and the costing framework that is adopted.

In an ideal world there would not be any need for a supervised injection site, but we do not live in an ideal world. If we care about helping people who are severely disadvantaged, I think we will see quite clearly the many benefits that flow from harm reduction, with respect to both legal and illegal drugs, and in this specific context, in the form of the supervised injection site in Vancouver.

Thanks very much for your time.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Boyd. Thank you for your patience this morning and thank you for your insightful comments. I appreciate that.

We'll now go to Dr. Montaner.

I'm just going to interrupt for a minute to let you know that the Czech delegation is here today, joining us in our committee. Welcome.

We'll now go to Dr. Montaner.

[Dr. Julio Montaner, Director, British Columbia Centre for Excellence in HIV/AIDS]

My name is Julio Montaner. I am the director of the B.C. Centre for Excellence in HIV/AIDS in Vancouver. I'm the chair of AIDS research at the University of British Columbia and the director of the HIV program at St. Paul's Hospital Providence Health Care. As of two years ago, through a democratic process, I was elected president of the International AIDS Society, which is the largest body that brings together health professionals in the field of HIV and AIDS.

I'm coming in front of you today not really to talk about the results of our research, which I believe has been clearly and emphatically demonstrated to you earlier today by my colleague Dr. Thomas Kerr. He is abundantly familiar with the research evidence, the cost-benefit of this intervention, which has been alluded to by the previous speaker in quite clear terms. I would like to give you a sense of why we are investing in this kind of research, this kind of program, and where this fits in the continuum of our struggle and fight against HIV and AIDS in this country and at the international level.

Our group has been fighting HIV and AIDS through research. I should mention that our group has collected a total of over 350 peer- reviewed publications on various aspects of HIV and AIDS and over 150 in the field of HIV and drug addiction.

We had made some substantial progress fighting HIV by the mid-1990s. In 1996, we were instrumental in the discovery and distribution of the so-called modern HIV treatment, a highly active antiretroviral therapy. It goes by the acronym of HAART. HAART, the so-called cocktail, changed the lives of people affected with HIV in that it basically turned the disease into a chronic, manageable disease. It not only allowed us to control and prevent HIV from becoming AIDS, but also, as we have published recently, it prevented transmission of HIV from infected individuals to their partners or to those involved in close relationships with them.

In 1996, in view of this overwhelming evidence, already we felt there was a moral imperative to do something to expand the benefit of antiretroviral therapy to those who needed it but had difficulty accessing the programs. Working together with my colleague Michael O’Shaughnessy, we had previously identified a new upswing in HIV infections emerging from the downtown eastside in Vancouver. For that reason, working with other members of the B.C. centre, we put together a number of studies, including the Vancouver intravenous drug usage study, a cohort that taught us a great deal regarding the needs of individuals living in that very impoverished area of our city.

As a result of that research, we became critically aware that something needed to be done to facilitate entry into the health care system of this very marginalized group of individuals. We were similarly concerned that the status quo, business as usual, was not acceptable in view of the fact that the rates of acquisition of hepatitis C, HIV, and other infectious diseases, including subcutaneous infections and heart disease, were going up and we could not find any way to stop it. Suffice it to say that the rates of hepatitis C surpassed 90% in this population, with HIV rates in excess of 30% in some subgroups. This is as high as you have seen in the worst affected areas of the world, Botswana and the like.

For this reason, we felt compelled to mobilize our resources to try to do something to bring some form of order and health care to these people's lives, assuming they wished to avail themselves of this proposition.

Needle exchanges, and later on the supervised injection site, emerged out of this. The evidence is quite clear. Through engagement in the supervised injection site, through the good work of Vancouver Coastal Health and the Portland Hotel Society, these addicts have now been able to engage in appropriate health care in increasing numbers. In some instances, they have been able to reduce their consumption. They have been able to better manage episodes of overdose, decrease hospital admissions, and so on--

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Montaner. I'm sorry to interrupt you, but I did give you more time. I want to thank you for your video presentation. We need to go to questions now.

Could we begin, please, with Dr. Bennett?

[Carolyn Bennett, Liberal, St. Paul's, ON]

Thank you very much, Madam Chair.

I'm pleased to be joined on our side today by two of my colleagues who are also physicians. I think they feel as strongly as most of the medical community in Canada that there seems to be a change in Canada's policy, preferring ideologies over science and evidence.

We have seen young patients who suffered from incest or from some other condition who ended up with an addiction. Personally, we know stories of patients who have died before they had the chance to turn their lives around. We know of many patients who, because of their addiction, now are living with HIV/AIDS and hepatitis C.

It's very sad to have had to ask for this special hearing today. We thought Canada would be a leader on this. I think to have some of the witnesses who are with us today who were there, particularly Mayor Owen and the committee you put together on your framework for action on the four pillars in 2004.... I would ask if you would table that framework for action for us.

I'm also upset at the difficulty in our country at this time...that the Chief Public Health Officer for Canada has remained particularly silent on this. Mr. Kerr, I understood you met with the public health officers for Canada. What was the reception of this idea?

Could all of you tell me what consultation took place in order to remove the fourth pillar of the drug strategy for Canada, and were you consulted?

I would also like to bring to you from my city of Toronto a plea from the public health department there, that they would like to be able to do supervised injections in their needle exchange programs in a decentralized way, like cities like Barcelona, like all of that.

What would be your advice to the Minister of Health about granting exemptions to other public health agencies and departments across the country?

Then I would like your advice on the minister's May 14 announcement that says the $10 million for new treatment services has to be for abstinence-based treatment. This sounds remotely like a Bushism, in that clinical research shows that methadone maintenance plus counselling outperforms abstinence. And who is the Minister of Health to dictate to you in clinical settings the only possible way of receiving federal government funding?

If you could just start there....

[The Chair, Conservative, Joy Smith]

Who would like to address that question?

Mr. Kerr.

[Thomas Kerr]

I believe there was at least one question directed to me, pertaining to my presentation and consultation with the Health Council of Canada. I was invited to make a 45-minute presentation detailing the findings, the peer-reviewed literature, from the scientific evaluation of Insite.

I believe I was asked to characterize the response. It was overwhelmingly positive. Our team was congratulated for producing such a large body of evidence in a short period of time. The medical health officers from different areas of Canada expressed an interest in expressing some kind of support for this initiative. I wasn't privy to exactly what form that would take, but I think it's well known that several medical health officers, including the provincial medical health officer of the province of British Columbia, have been very vocal in their support of this initiative based on the scientific evidence to date.

With regard to the question of the removal of harm reduction from the drug strategy and the release of the anti-drug strategy, no, our group was not consulted on this matter.

[Carolyn Bennett, Liberal, St. Paul's, ON]

Were any of the others consulted?

[Donald MacPherson]

The removal of the harm reduction pillar from Canada's drug strategy was met with quite a bit of concern in Vancouver. We spent a considerable amount of time and energy under Mayor Owen's leadership in developing the harm reduction approach in the four pillars, getting the acknowledgement and getting the community to come along and realize, which they have, that harm reduction is an absolutely critical component of any comprehensive strategy.

In my earlier talk, I was trying to say that the rest of the world, including the UN Office on Drugs and Crime, which is a very conservative UN body, is acknowledging that harm reduction is absolutely essential, from both a human rights perspective and a public health perspective, and more and more countries are bringing harm reduction into their public policy frameworks. So I urge the committee--and the federal government--to consider how important harm reduction is...the removal of that from the framework.

[The Chair, Conservative, Joy Smith]

Thank you very much, Mr. MacPherson.

We'll now go to Madame Gagnon.

[Christiane Gagnon, Bloc, Québec, QC]

Good morning. Thank you for being with us today.

This isn't the first time the Insite site has been threatened with closing. I remember going to Toronto at the time of the HIV-AIDS meeting. There was a demonstration in Vancouver. I had joined the group to support funding for the Insite site.

Mr. Mangham, I felt somewhat concerned by what you said. You say you are a researcher and are able to say you aren't satisfied with the scientific research on harm reduction and addiction control, and that it has produced no results. However, we sense that there are different ideologies. Other people in the field and other researchers have come to utterly different conclusions. Two witnesses told us by videoconference that, for them, this is a health issue. Not only are we thinking about the reduction of effects, but you also have to consider other objectives that are being pursued by one of the pillars of harm reduction, the Insite site.

What does it offer to that population, which in any case would use drugs in conditions that are perhaps harder and more dangerous for the public? You said that you didn't approve of the research, but that you were explaining your point of view by citing your figures and the type of research that you've conducted to contradict the scientific research, which was objective with respect to the objective pursued.

[Dr. Colin Mangham]

Thank you for the question.

As a point of clarification, I have never said—or not corrected when asked—that what I wrote or either of the other two articles or papers that were done was primary research. They're critiques of research, which are quite appropriate. You look at published research and at the interpretation and you make commentary.

In my case, the Royal Canadian Mounted Police had asked for a second opinion, because frankly, as I understood it, in some cases they were being told they didn't really have an opinion or shouldn't have one. I don't agree with that.

So I looked at the research. I've taught graduate classes. You can have a first-year graduate student read research and just critique it from the viewpoint of whether what is being said fits here. What I saw—and I would invite anyone to read those papers—is that there were many non-findings.

For example, to not have a drug overdose death at Insite is what I would call a “straw horse” finding. My goodness, I hope nobody dies at Insite of an overdose, with a nurse sitting there. That doesn't translate to saving lives. To make the statement that you've saved their lives.... You can't make that. And 2% to 5% of injections in the downtown eastside taking place—I believe I'm right here—at Insite is not going to reduce disease.

I have never said that I or anyone else—because we don't have the data; we haven't been given the data to go off and run it or to conduct primary research.... But to critique research is very appropriate.

I will say that a graduate student in statistics could have read what I read and, I sincerely believe, have come to the same conclusions. I have done research for the government wherein there was incredible pressure to succeed. I don't know; that's one possibility, but I can't get inside people's heads.

I don't have any personal disrespect. My own and the other two pieces question what's been made of the research, question whether to do no harm justifies the expenditure. I went the furthest of them and suggested that there is a strong.... One of the things I resent is this idea that somehow opponents are ideological, but those for Insite are not. No intelligent person could read what's been said and examine the tenor of the defences of Insite and not see very clear ideology there.

I would like to say also, in answer to the question about harm reduction—why the pillar has been taken out—I think what happened had to do with the way it came about. As a practitioner in the field, I saw very quickly that what was going to be four pillars was becoming one pillar. In other words, harm reduction was the guiding philosophy and was changing treatment, prevention, and enforcement into its own image, so that prevention was no longer prevention but was talking about problematic use.

I think the government reacted to that: “Wait a minute here. Canada's going to philosophically change to a softer, more liberal view of drugs”--one that I would hope most parents, grandparents, and others wouldn't really want to see. And that's what I think they did.

By the way, I wasn't consulted either.

There's your answer.

[The Chair, Conservative, Joy Smith]

Thank you, Dr. Mangham.

We'll now go to Ms. Davies.

[Libby Davies, NDP, Vancouver East, BC]

Thank you.

How long do we have for questions and responses?

[The Chair, Conservative, Joy Smith]

It's seven minutes.

[Libby Davies, NDP, Vancouver East, BC]

First of all, my thanks to the witnesses for coming today. It's been good to hear both your expert experience and the experience from the community that was presented by the Portland Hotel.

In some ways, it's surprising that we're here in 2008, debating and studying harm reduction. As I believe Donald pointed out, 82 countries around the world support harm reduction. I think many of us had assumed and thought that the programs we have here in Canada were working. They're well received, they work at the community level, so why the heck are we here today still debating this issue? I think we know why. We'll have an opportunity to hear the minister later.

Insite is in my riding in East Vancouver, and I can tell you that I'm very glad it's there. I remember when it began. It was very controversial. Many of you were involved in the struggles that took place within the community. Now, without a shadow of a doubt, Insite has the support of the local business community, the Chinatown business community, the police, the board of trade, the premier of the province, the health minister--the list goes on. In fact, I can't find anybody who doesn't agree with Insite, other than Mr. Mangham and the minister.

So I think one of the issues we are dealing with is that people get hung up on the terminology, this term “harm reduction”.

Heather, you made a reference to low-threshold services. Mr. MacPherson, you mentioned that the city had talked a lot about the importance of low-threshold services. Neil Boyd mentions Mr. Small from the Portland Hotel Society, saying that Insite serves wounded individuals. We're talking about getting people in the door, off the street and in the door.

I wonder if Heather and Donald and maybe Liz could talk a little bit more about what low-threshold services are, to try to get across the idea that we're talking about things that actually work. We have more than enough evidence of it. But what are low-threshold services, and how do you describe them?

[Heather Hay]

Low-threshold services are based on putting out health care services and wrapping them around the client where they're at. Access to primary health care and to some of our clinics—we implemented five new sites in the downtown eastside in 18 months—is oftentimes still a barrier for people coming through the door. So it's really about bringing health care to where the people are at.

At Insite, we have provided services to over 7,000 people. We saw over 14,000 nursing interventions last year. That means that in walking through the front door, that client can get nursing support, wound and skin care, immunization, access to addiction treatment, and cures for their flu. Also, they can talk to somebody if they want to move to a place of recovery and change their life. If we weren't there, that client would be in an alleyway, a hotel room; they would be in a variety of other places in the neighbourhood, living in chaos and not accessing treatment services.

We have a contact centre, which is a low-threshold service. It contacts people from the street, gives them the skills they need to transfer from low-threshold services to higher treatment regimes. We also have peer-to-peer workers, and that's also low-threshold services, because oftentimes professionals themselves are barriers to enabling people to access treatment. We also carry a stigma towards this client population. It's very important for us to work in partnership with the community and peers in a low-threshold way.

[Liz Evans]

Thanks for the question.

Low threshold really, to me.... Heather has explained it, but ultimately I visualize it in my mind as like a triangle. If you think of the bottom of the triangle as the base in which we collect people into the system and the peak of the triangle as where we exit them in terms of treatment, the bottom of the triangle has to be broad and it has to be on the street. We have thousands of people in our community who are addicted and homeless and suffer from social problems, and a traditional mechanism of health care delivery just doesn't reach them.

The bottom of the triangle is a way of engaging people such that they will receive and accept the service. If we raise the threshold and say, “These are the conditions by which you need to receive your health care”, we automatically have excluded hundreds and sometimes thousands of folks.

So the argument and clearly the evidence that shows that low-threshold programs engage people is really, I think, treatment. Without the injection site, we would not be engaging a whole ton of people into treatment. We know that's a fact, because we know now, since we've built the Insite/Onsite program above it, that just since the fall we've had over 250 people through the detox and treatment centre right above the injection site. Again, that's a low-threshold form of treatment, because we know that without that detox and treatment program being attached to the injection site, they would never come through the door. We've had over 50 folks, just since the end of September, go into long-term treatment as a result of walking in the door of the injection site.

And the 5% reference to the number of addicts who use the site regularly as being the ones we are attempting to target, who are the folks who are the most marginalized and the ones who are the least likely to use traditional medical services—

[The Chair, Conservative, Joy Smith]

Thank you.

[Liz Evans]

Can I just mention one quick thing? If the percentage of drug addicts in the community who have access to the site is low, it's because the site itself is at absolute maximum, full operating capacity.

[The Chair, Conservative, Joy Smith]

Thank you, Ms. Evans.

Mr. Fletcher.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

Thank you, Madam Chair. I'll be splitting my time with Mr. Tilson.

I think it's important to be clear on what the exemption actually entails. There seems to be some misunderstanding here.

All the activities Ms. Evans and Ms. Hay raised—wound protection, needle exchange, psychological help, nursing care, all those things—will occur regardless of whether the exemption is extended or not. That's clearly something that Insite does, and I think everyone supports people getting treatment. And as you say, it's important to have treatment close to where these people reside. The issue of the exemption only deals with the illegal use of narcotics, and I think that is a very serious issue.

My question is to Mr. Mangham.

You mentioned the percentage of drug injections. I have the study here, and your memory served you well: it is less than 5% of all injections that occur at Insite. I wonder, if it's only 5%, whether that doesn't undermine a lot of the harm reduction. If 95% of injections are occurring outside of Insite, I assume a lot of harm is occurring away from Insite.

[Dr. Colin Mangham]

If 5% are happening there, then that goes to say that 95% aren't, but I think the problem is that this is not surprising. Probably there needs to be more discussion and objectivity than there was. For quite a few years—and I'll say this from personal experience, and it's the truth—if you didn't agree with harm reduction, you weren't at the table, especially in British Columbia.

That pre-buying into the philosophy makes one defensive of anything it has. That's human nature. I like Chevrolets and I'll defend them even if they're junk. Likewise, I suppose, on a more serious level, I'll defend prevention, and some people may not like primary prevention. I love it.

Likewise, I don't have anything against that, but when it's unilateral and you exclude and put down and even threaten the people who disagree with you, then you're not interested, I don't think, in that 95% and whether we can do better.

One thing I want to say is that the sad status quo we're talking about—and by the way, nobody here thinks anyone in the downtown eastside or anywhere should.... I would love to help them; we're not talking about letting people die. I think there are better ways that haven't been looked at.

There was no control group, there was no other intervention, and the status quo was created by years of not doing anything about treatment. So it's a little bit hypocritical to trash the status quo that was set, because for years you've been talking about harm reduction and were not really interested in treatment. That's what's happened.

[Steven Fletcher, Conservative, Charleswood—St. James—Assiniboia, MB]

Thank you. I'm running out of time already.

I think that's why the government is investing tens of millions of dollars in Insite.

By the way, I empathize with those people who were threatened. I got a little taste of what you're maybe alluding to when my constituency office was visited by some Insite activists and it was vandalized, which is not very helpful in the public debate.

Anyway, Mr. Thompson, has the police presence increased around the Insite facility?