Harm Reduction Policy , Political Economy , and Insite

Abstract: This paper seeks to answer why Insite, Vancouver's safe injection facility, continues to be a controversial issue, given that empirical investigations of the facility have demonstrated that the site improves health and saves health care dollars. As Insite represented a shift to harm reduction policy, from historically dominant drug control policy, it has drawn opposition from local, national and international players.  Using a political economy framework, this paper looks at the population around Insite, examining who the clients are and whether the facility is beneficial to them.  The Downtown Eastside of Vancouver, where Insite is located, is known to be one of the poorest neighbourhoods in Canada, and as such the population is extremely marginalized (The Globe and Mail, 2008).  This paper argues that the attempts by the federal Conservative Party to shut down Insite are based on ideology rather than the effectiveness of the facility.  Using the Gramscian concept of hegemony, this paper argues that the federal Conservative Party attempted to use its hegemonic dominance to close down Insite.  This paper will also briefly discuss the legal history of Insite,  and the empirical literature, briefly summarizing the evidence researchers have found.


Introduction
Vancouver's Downtown Eastside experienced an injecting drug user (IDU) crisis in the early 1990s.In 1997, due to epidemics of both HIV/AIDS and hepatitis C, a public health emergency was declared for this area (Supreme Court of Canada, 2011).In response to the situation, community members opened a safe injection facility called the Back Alley Site in 1995, which local police shut down a year later.In 2002, Larry Campbell was elected mayor, promising to clean up the Downtown Eastside and open a safe injection facility.Insite, Vancouver's safe injection facility, was created in 2003.It operates under an exemption to the Controlled Drugs and Substances Act and is jointly funded by Health Canada and the Ministry of Health in British Columbia (Canadian Broadcasting Corporation, 2009).The facility provides a place for safer injecting, education about safer injecting, basic health care, and referral to addiction treatment for the Downtown Eastside IDU community of Vancouver.At Insite, IDUs are given a sterile needle, alcohol swab, cooking spoon, and clean water each visit.One or two nurses and a counselor are always present at the facility to supervise injections and provide onsite counseling services, respectively (Tyndall et al., 2006).The facility came into existence when the federal Liberal Party was in power, but has faced serious political and legal pressures since the Conservative Party formed the federal government.This continued until 2011, when the Supreme Court of Canada ruled to uphold Insite's exemption, instructing the Minister of Health to continue its exemption under the CDSA (SCC, 2011).
The purpose of this paper is to discuss Insite through a political economy framework.This paper will analyze the population that Insite serves asking why, considering the well documented savings and health benefits the facility offers, Insite continues to be a controversial issue.It will seek to answer who the users are, why they use Insite, and what Insite offers them?Concepts from political economy will be used; in particular the concept of hegemony.Hegemony is a useful concept to use in analyzing Insite because it considers questions of power in political and economic contexts (Fontana, 2006).

Harm reduction versus drug control policy
Harm reduction policy focuses on preventing negative consequences associated with risky activity.It is realistic, in the sense that it views incremental change as better than utopian beliefs that are unlikely to be realized (Wodak & McLeod, 2008).It is often juxtaposed with drug control policy, which is a demand and supply control policy approach consisting primarily of restricting access to illicit drugs.One of the rationales for creating Insite was the limitations associated with the drug control policy approach (Wood, Kerr, Montaner, et al., 2004).Drug control policy makes intuitive sense, since those who distribute illicit drugs face being arrested, having their assets confiscated, and being imprisoned.This makes the illicit drug trade riskier, which should cause the prices of illicit drugs to rise, thus making them harder to consistently obtain and consume (Weatherburn et al., 2003).Demand and supply drug policy, however, has been criticized for various reasons.It has been noted that intensifying the drug control approach through further criminalization may push IDUs further underground.This could lead to reduced opportunities to provide health care services, addiction treatment, and risks increasing the spread of HIV/AIDS and hepatitis C among IDUs (Wodak & McLeod, 2008).A study found that, during the heroin drought in the year 2000 in Sydney, Australia, consumption of heroin decreased; however, it was found that this was associated with an increase in the use of cocaine.The researchers also found an increase in robbery and breaking and entering, though the rates of other crimes typically associated with drug addiction remained the same (Weatherburn et al., 2003).
Another rationale for a harm reduction approach, as exemplified by Insite, is the growing number of people incarcerated for illicit drug crimes, and the high rate of HIV infection in prisons (Wood, Kerr, Montaner et al., 2004).A pure drug control approach risks further exacerbating the rates of infection rather than helping IDUs prevent blood borne infections and cease injecting.Incarceration results in exposure to an environment with a high prevalence of HIV.There is not, however, an inherent contradiction between these two paradigms.Minimizing harm from taking illicit drugs does not necessarily impede the attempt to eliminate the illicit drug trade.There are even cases where law enforcement has been used to further the goals of harm reduction by providing drug educational services, and preventing human rights abuses against IDUs (Ball, 2007).

Harm reduction and Insite
In the context of IDUs and HIV/AIDS, harm reduction can be seen as a comprehensive package consisting of needle exchange programs, addiction treatment, and the development of the local community around the IDUs (Wodak & McLeod, 2008).Insite fits within the commonly understood definitions of harm reduction policy.The stated goals of the facility are to improve access to health care services for IDUs, reduce the use of illicit injection drugs publicly, reduce litter associated with public drug use (such as syringes, packaging), and reduce exposure to infectious diseases commonplace among IDUs (Wood, Kerr, Lloyd-Smith et al., 2004).Insite represents a different approach to the problem of IDUs, emphasizing harm reduction rather than criminalization.

The Insite population
Insite provides services to Vancouver's Downtown Eastside.This area is characterized by a high prevalence of IDUs, as well as extreme poverty.Males are overrepresented in this area.Aboriginals are also over represented in the Downtown Eastside: 8.4 percent of the Downtown Eastside population reports Aboriginal heritage, compared to 2.02 percent for Vancouver and 4.39 percent for British Columbia as a whole (Buxton, 2005).
According to a 2008 study, HIV prevalence was found to be much higher among Aboriginals than non-Aboriginals living in the Downtown Eastside.The differences were found to be statistically significant (P<0.05).An interesting finding from this study is that, when compared to non-Aboriginal participants, Aboriginals were more likely to be women, younger, and involved in the sex trade (Wood, Montaner et al., 2008).This is interesting since, as mentioned earlier, males are over represented in the Downtown Eastside population (Buxton, 2005).This seems to indicate that there is something about the circumstances female Aboriginals find themselves in that makes them more vulnerable to becoming IDUs.Their living circumstances push an already marginalized population towards higher levels of marginalization.
There has also been research on the lived experience of people who live and visit the Downtown Eastside.One study, using interviews with IDUs to collect qualitative data, found that the location was associated with perceived danger due to the reputation of the neighbourhood, intensive drug use, risk of contracting HIV from contaminated needles, and involvement with the sex trade.Part of what makes this extremely problematic is that the Downtown Eastside is the only location where some people can obtain health services.One of the male participants in the study noted that, while he can get free dental care in the Downtown Eastside, he worried that he would buy an excessive amount of drugs if he went to the Downtown Eastside in order to get dental care, effectively producing a barrier between him and a needed health service (Fast et al., 2010).This is an avenue of research that should be continued, since it is known that getting IDUs to use basic health care services can be extremely problematic as IDUs tend to avoid contact with public institutions.This problem is partially remedied by safe injection facilities, since they offer a point of contact between IDUs and the health care system that would not exist otherwise (Amirkhanian et al., 2005).The barriers not remedied by safe injection facilities, such as the previously mentioned avoidance of public institutions, need to be examined more closely in order to further improve the health of people who use illicit injection drugs.

Research on Insite
Part of what makes Insite interesting from a political economy perspective is the overwhelming empirical support for its cost savings and improved health outcomes.Concerns over negative consequences were initially expressed by citizens and businesses regarding Insite, such as increased HIV rates among IDUs and increasing numbers of IDUs moving to Vancouver.Neither of these predictions, however, have come to fruition (Wood, Kerr, Montaner et al., 2004).The literature, which will be discussed below, is overwhelmingly clear that the facility saves health care dollars in a time of ever increasing anxiety over the size of health care expenditures.With the exception of one study, the health benefits for the IDUs in Vancouver's Downtown Eastside have been found to be substantial.
Both cost-benefit and cost-effectiveness analyses have been performed on Insite.A costeffectiveness study simulated the population of Vancouver and analyzed variables over a ten year time span.The variables examined were rates of hepatitis C and HIV virus infection, referral to maintenance treatment and associated costs, and survival.The study only included direct medical costs, and as such it is a conservative estimate since the potential societal benefits from Insite could be quite substantial.According to the results, the existence of the safe injection facility was associated with savings of about $14 million, with 920 life years saved over 10 years (Bayoumi & Zaric, 2008).Another study, this time using mathematical modeling, also found improved health outcomes and increased societal benefit.It found that Insite, on average, prevents 35 new cases of HIV and about 3 deaths per year, which provides a social benefit valued at over $6 million per year after the costs of Insite are taken into account.This results in a cost-benefit ratio of $1:$5.12, on average (Andresen & Boyd, 2010).This means that, for every dollar spent on Insite, $5.12 worth of benefit are created.
Additionally, an analysis of Insite over a 14 month period found that over 2,000 referrals were made to other services by the facility's staff.The majority of these referrals were for addiction counseling.Other referrals, in descending order of frequency, were for medical services, emergency services, detoxification beds, other community services, housing services, methadone treatment, and recovery houses (Tyndall et al., 2006).The importance of referrals to basic health care cannot be overstated.Insite may offer the only opportunity for this population to access such care, since IDUs are typically marginalized and avoid accessing health care services (Amirkhanian et al., 2005).
There has been only one study to date that has found fault with Insite.It was published in The Journal of Global Drug Control Policy and Practice, and attempts to refute much of the empirical and theoretical literature supportive of Insite.This study also provides a critique of harm reduction policy.In disagreement with most definitions of harm reduction policy, it is defined by Mangham as "...an ideology viewing drug use as not only as inevitable, but as simply a lifestyle option, a pleasure to be pursued, even a human right (Mangham, 2007, p.2 [mistake in original])."This article was specifically mentioned by then Minister of Health Tony Clement during a meeting with the Canadian Medical Association where he stated that the evidence of the effectiveness of Insite was still unclear.The independence of this journal, however, has been disputed since the journal receives funding from the United States Department of Justice (Solomon, 2007).The legitimacy of the journal has also been questioned since it lacks submission guidelines on its website for prospective authors (Collier, 2009).The definition of harm reduction policy presented in the paper greatly contradicts the definitions that can be found elsewhere.Kerr and Wood (2008) have noted that this is just one instance of a trend in which websites pose as open access peer-reviewed journals.
Thus, the empirical literature regarding Insite is largely positive.The facility appears to reduce costs as well as provide consistent health benefits to the IDUs in Vancouver's Downtown Eastside.It allows for a rare opportunity to provide basic health care to a marginalized population that frequently avoids the health care system (Petrar et al., 2007;Amirkhanian et al., 2005).This indicates that the federal Conservative's attempts to close Insite down are based on ideological reasons, rather than concerns over cost-efficiency.

Discussion:
Politics, political economy and hegemony What this paper is arguing is that, rather than disputing the cost-effectiveness of Insite, the federal Conservative Party opposes Insite on moral and ideological grounds.Their opposition can be found in the distinction between neo-liberalism and neo-conservatism.Neoliberalism is an ideology that consists of free market economies and more progressive social positions.Neo-conservatism, on the other hand, tends to stress social and moral concerns in addition to free market economies (Johnston, 2002).The federal Liberal Party in the last few decades could be considered neo-liberal, whereas the federal Conservative Party could be considered neo-conservative.The shift from reform liberalism to neo-liberalism developed in the 1990s in most places, including when the federal Liberal Party enjoyed a majority in the House of Commons (Johnston, 2002).Insite, as it has the capacity to save public expenditures on health care, can be seen as fitting well within a neo-liberal ideology.One of the goals of neoliberalism is to reduce government expenditures so that the market can operate more freely (Johnston, 2002).The federal Conservatives tend to hold a law and order approach, much in line with traditional drug control policy (Collier, 2009).An argument made by the federal Minister of Health, likely influenced by such sentiments, stated that allowing Insite to continue operating would undermine the rule of law.On the matter of Insite upsetting the rule of law the Supreme Court of Canada found the claim baseless (SCC, 2011).
The concept of hegemony is useful to this analysis of Insite.Both the federal Liberal and federal Conservative parties could be considered hegemonic.Gramscian hegemony refers to supremacy of one group over another through non-violent means (Fontana, 2006).Since the federal government has been formed by either the Liberal or Conservative Party since Confederation, as well as the large sums of money given to the two parties as campaign donations, it would not be a stretch to say that both of these groups are hegemonic.According to Joseph, a group has to have economic, political and cultural conditions that create the environment for it to become leading.Hegemonic power is not purely about the construction of power, but is also about the social structures that allow for the reproduction of power (Joseph, 2002).As the only two federal parties that form government, these parties are typically capable of mustering political and economic support for themselves.This allows both of them to exercise their power, as well as create the foundation for future political and economic power.This supremacy, however, is not absolute.The two hegemonic political parties frequently disagree over various issues, and also have their supremacy questioned by less powerful parties.Insite is one of the issues over which the two hegemonic federal parties hold different stances.
Gramsci stated that hegemony is never static, but is constantly changing (Brodie & Rein, 2009).The very nature of power makes it continually questioned.Before the creation of safe injection facilities around the world, drug control policy was the dominant approach to dealing with IDUs in most countries (Ball, 2007).The creation of Insite can be seen as a questioning of this hegemonic policy, as it represented a shift, even if only a minor one, to harm reduction policy in Canada.This has resulted in opposition to the facility from the hegemonic federal Conservatives.As mentioned previously, the only paper critical of Insite has come from a website disguised as a peer-reviewed journal that is highly critical of harm reduction approaches and highly supportive of traditional drug control policy (Mangham, 2007;Solomon, 2007).What this article represents is an attempt for the hegemonic approach to IDUs to discredit a less established approach.Critics of The Journal of Global Drug Policy and Practice have claimed that the only purpose of the journal is to refute claims supportive of harm reduction approaches to drug policy.The president of the Canadian Health Libraries Association expressed further concerns: "[t]hat journal, which looks legitimate, which is being used by the Canadian government to back up various decisions, is supported by groups that believe enforcement is the route to reducing drug use (Collier, 2009, pp.E83-E84)."

Conclusion
In sum, this paper has attempted to answer why Insite remains a controversial issue despite the overwhelming support that the empirical literature offers for the facility's cost savings and positive health effects.It also attempted to answer who Insite serves, the characteristics of this population, and whether the facility has been beneficial to them.This paper has attempted to answer these questions through a political economy framework, looking at the role of ideology and hegemony in the context of Insite.It examined the empirical literature, demonstrating that research to date is profoundly supportive of Insite.This paper argued that this was another area in which hegemonic powers attempted to exercise their influence.They attempted to do this by creating literature that was misleading and funded through a conflict of interest.This paper also briefly discussed the legal history of the facility, attempting to provide a snapshot of the complex legal processes that have occurred in the last few years.