We met Sarah Evans as an exceptional, activist-driven individual spreading positive energy and inspiring people from her surroundings to work more actively and enthusiastically on the advancement of society. Sarah is a senior program officer with the Open Society Public Health Program in New York, USA. She is in charge of advancement of the health and rights of marginalized people who use drugs throughout the world. Previously, she worked on development of the harm reduction programs in British Columbia, Canada. However, the reason for our conversation was her experience with the opening of the first legal supervised drug injection facility in North America. We had the interview on 7 February, 2013, during her visit to Macedonia and we share it further bellow, convinced that it is high time to open the discussion on safe injection facilities in our country as well.
Interviewed by Vanja Dimitrevski
Dear Sarah, we are happy to have you here, in Skopje, Macedonia. You are an expert, actually have experience with safe injecting spots, in Vancouver, Canada, and we would like to ask you, if you can share some experience with us about safe injecting spots?
Sure I can, first of all thank you very much. I am very happy to be here and speak with you about this today. I did work at the injection site as the manager, from the time that it opened, in 2003 until shortly before I moved to New York to work for Soros, in 2011. But the struggle to get the injection site open, started a long time before that, probably even before my time. The first main event I was involved in, that I was aware of, was in 1998, when we put on a large conference under a circus tent, in a public park, to talk about harm reduction. This was a new idea, that none of us had ever heard of, that we thought would help in our city. And we had invited some experts from Europe, where they already had some injection sites, to come and speak to us about their experience, and we also invited some other people who could talk about some other aspects of harm reduction.
And because it was in a tent, in the park, we could also have the community there, so drug users were there as well as policy makers, as well as politicians. And what we essentially were able to do about this was establish a community dialogue about harm reduction and supervised injection, and it put the idea on the map, mentally, for people. That was in 1998, and from then until 2003, when the site opened, we still had many struggles, basically it was like building a wall, one brick at a time. It took people working on the inside with the government, people fighting on the outside, drug user organizations, it took non-profit societies, parents’ groups, church groups, journalists, researches to create this kind of critical mass, where what had been a private problem, which is somebody suffering from an addiction, to become a public problem, that needed public solution. It took several years, as I said, from 1998, to 2003, to be finally able to open the injection site.
Who was the barrier of this initiative? Organizations or informal groups?
Well, I have to tell you, there were many barriers. Drug users themselves were not initially for the notion of supervised injection site. And it took some discussion with the drug users groups, to get people on board with the concept. I think that at first even drug users felt that if you gave them supervised injection sites, they would never go to treatment. As well, all levels of government were originally against it. There was a time when it was political suicide to support the idea. And they were opposed to it, and it took a lot of discussion and a lot of demystifying the idea, and bringing in people to talk about the fact that this had happened in other countries and the world did not come to an end, before we could finally get the buy in from all levels of government we needed.
All these efforts took place on provincial, or on national level?
Three levels: Municipal, the city, provincial, the province, and federal, the country.
And when you finally succeeded to establish the first safe injecting site, was it municipal or higher level?
What we required by law in Canada, was an exemption from the federal controlled drugs and substances act, and this was the act that governs illicit drugs or controlled substances in Canada. And in order for people to be in possession of illegal drugs and to be using illegal drugs in front of a nurse, at the injection site, in order to for both the drug user and the staff to not be breaking the law, we needed what is called exemption. Many drugs have an exemption for pilot research project, or for other purposes, and we were able to get one for a scientific pilot research project. We got that one in 2003 and it was at the decision of the federal minister of health.
Thank you, would you be kind to explain the model according to which this safe injecting spots operate?
Sure, there’s only one. I should say, only one.
In all of the Americas, North and South America.
Only one Safe injecting spot?
Yes, and it is in Vancouver, Canada. There’s only one that is open in the public. There’s actually another one smaller one that occurs in a small residential facility for people with AIDS. But the only one that is open in the public, is the one I am speaking of today. There are however, many in the world. Something like 70. One in Australia, and all the rest in Europe. They run on different models. Some of them are very low threshold, and run essentially by the community, some of them are very high threshold, and run essentially by the doctors. We wanted ours to be accessible.
So here is what happens, I’ll just walk you through it. A drug user comes in off the street, on their first visit we ask them very few questions. Not a big form to fill out, you don’t even have to give out your real name, because it is an anonymous service, we give you, or you select, an identifying name that we will use, it could be your initials or a nickname. We have a brief conversation with you, just to ascertain that you are in fact a drug user, that you are aware of some options that are available for you in terms of treatment, that you do intend to use drugs today. And then we register you and let you into the site. It’s very fast, it’s meant to be very accessible, and very easy. The person brings their own drugs, we do not give them any kind of drugs on the premises, but they bring their own drugs, that would otherwise be using on the street, and in Insite we give them all of the equipment that you could get at a needle and syringe program, to ensure a clean and safe injection. So, clean needles, cookers, alcohol slobs, actually a sink to wash their hands, which is probably the number one thing that prevents people from many kinds of infections, that they would otherwise acquire from the back alley; sterile water, as well, so you don’t have to inject using water from the puddle, or from the toilet, so everything is as clean as it can be, you inject your own drugs, nobody can inject them for you, but we can provide you with some education to show you how to minimize the harm on your vein, how to find your vein in your arm, which is better than the vain in your groin, how to use a needle without damaging your veins, etc.
And so, in and of itself, that is the main thing that the injection site offers. It’s like a safe needle exchange program that happens within four walls. In a way it’s really not complicated. It is amazing that it was such a struggle to get it open.
In addition we are also able to offer overdose intervention, so you need to know that the injection site has over 1000 visits a day, so it’s very busy. And many ODs occur there, and to date nobody has died, not from a stimulant OD, nor from a heroin OD, because we have staff who are available who can intervene in an OD.
And, then because now you are comfortable and you trust us, maybe you want to talk to a nurse, and get your abscess dealt with, or talk about your pregnancy alternatives. Or maybe you want to go to the waiting room and talk to an intake worker, to get access to our detox, because we have a residential detoxification facility located right above the injection site. So immediately when somebody is ready to go to the detox facility, whether for two weeks or two days, we can let them up.
Who operates with this site? Is it some institution or NGO?
It is operated by an NGO in collaboration with the Government. The NGO hires the staff who know the clients and know the community and know how to make the project work within the community. They are called the PHS Community Services Society, a very effective NGO in Vancouver. The professional staff, the nurses, are hired by the Vancouver Health Authority, which is essentially in the public health domain, a branch of the government.
And there are also peers who work there, so drug users or ex drug users, who work in the house to help provide some peer counseling, a cup of coffee, somebody who understands, the situation at the level of the drug users themselves.
So it’s a kind of a joint program, a cooperation between the government and an NGO?
An NGO. It’s kind of like if you can imagine HOPS and Kisela Voda (Center for Drug Dependances in Skopje) getting together and deciding to create a program that had the best of both. I don’t know if you can imagine. The truth is, that’s the model that worked in Vancouver. There are many different models, there’s not one suit that is going to fit everybody. We felt that we wanted to have a lot of community staff, and a few professional clinical staff, as well, so that’s the model we chose.
Who provides the financial support for this one spot?
In Canada we still have public health care, so all aspects of health care can be paid for by the government. Of course, it’s a struggle, and part of the struggle to get Insite open is of course a struggle to get the government to allocate the funds for this kind of a program, even you can show, as we did, that it saves money in the long run, less death, less HIV, less HEP C, less hospital admissions do for severe abscesses, and other infections. So even if you can show that it saves money, it’s still a struggle to get the money from the government.
Ok, so you are still not in heaven. You still have to struggle.
Of course J. I don’t know if you are going to ask me about this but I think I should say it. After Insite opened even though we showed tremendous success in all ways in which we were evaluated and measured, saving lives, all the indicators, were tremendously successful, and the site is tremendously popular, people who come to Insite are twice as likely to go to detox, as people who do not. So we were able to show that access to this harm reduction service helps people access treatment. It can be for some people an end in itself, because it saves lives and prevents the spread of disease, but for other it can be a stepping stone to treatment. But despite all this, our federal government changed its mind (we changed governments) and we’ve been having a fight with the federal government since 2006 to keep the injection site open, and to keep the exemption, and I am happy to say that last year, after going to court for three times, we won the right to keep the injection site open.
Where do you see that problems come from? Is it because of corrupt politicians?
No we don’t have those in Canada J. I feel that in all the years I worked at Insite and fought to keep Insite open, we produced many peer reviewed papers in scientific journals, produced by the BC Center for Excellence in HIV/AIDS which is run by doctor Julio Montana. A very famous and credible group of scientific researchers, proved again and again, that the injection site was a success in saving lives. And keeping the community safer. Published these papers, in the British Medical Journal, you know, many papers that are high profile. And despite all this, our current federal government, which is a conservative government, opposes the injection site, enough to take us to court, and to take us to appeal the verdict twice, to the Supreme Court of Canada, to try and close it down. And the only reason that I can think that they did this is ideological. It’s not based on fact or evidence, I think they simply are opposed to the idea on ideological grounds.
You’ve come to Macedonia and visited some of the drug treatment and harm reduction programs. So, what is your opinion, do you think drug treatment in Macedonia should be improved?
Well, yes, but I think drug treatment everywhere in the world should be improved, including Vancouver, Canada.
Ok, if you think so, what should be improved?
First of all, the reason we are here is because you have good treatment, relative to other places in the world, and relative to other places in Europe. And that’s why we are here, it’s not because something you are doing something wrong, but because something very interesting and existing is happening in Macedonia and we are supportive of it. Having said that, I think you have lots of people here who are on methadone, but you have even more people who are waiting to get on methadone. And those waiting lists are a problem. People die on waiting lists. So it would be great if somebody in government could make a commitment to scale up methadone, so anybody who wants to access to it could get it. I think that would be of great benefit to the country of Macedonia. I think also see that there could be more collaboration between needle syringe programs and methadone programs. It’s not that this program is for people on Methadone, and that other program for people who are injecting. Even more so, because many of them are actually injecting methadone, so we are talking about the same people and even the same drugs. It would be great if the programs could collaborate in some way, so that if today a person is going to inject, we can provide them with the best help and the best service to inject safely and without harm, and tomorrow if the person wants to go to treatment, they can easily get into treatment.
What is your opinion about the needle and syringe programs?
The same answer really applies. We went into a number of drop in centers. The staff there are really nice. I think they are good programs. I think it would be even better if instead of being siloed off quietly and discretely, it would be more of what a seamless kind of, we call in Canada, a continuity of care. Today you want to inject, we give you the best service, because not everyone is ready to quit injecting. Tomorrow you would like to quit injecting and go on methadone, by that I mean all methadone, then we can give you the best service there. And that kind of collaboration would improve both services and would provide a case where you could meet the patient wherever they are at, and not create a gap in which people can fall and where harm can happen to them and to the community.