Research paper
The establishment of North America's first state sanctioned supervised injection facility: A case study in culture change

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Abstract

The serious adverse health consequences associated with illicit drug use in Vancouver has brought international attention to the city. It is now widely recognized that innovative and bold strategies are required to confront epidemics of drug overdose, HIV and Hepatitis C infections, and injection-related bacterial infections. The establishment of North America's first supervised injection facility (SIF) required a major cultural shift in the way drug addiction is viewed. The story behind the SIF in Vancouver is a complex and interconnected series of events brought about by the activities of advocates, peers, community agencies, politicians, journalists, academics and other key players to bring about social change. The aim of this narrative is to highlight the ideas, processes and historical events that contributed to a cultural transformation that was critical to opening the SIF in Vancouver. By doing this, we hope to encourage other communities to take the bold steps necessary to reduce the devastating health and social consequences of injection drug use.

Introduction

The serious adverse health consequences associated with illicit drug use has brought international attention to the city of Vancouver and in particular to the Downtown Eastside (DTES) neighbourhood. HIV and Hepatitis C infections, fatal drug overdoses, public drug use and injection-related infections have been well documented in this community (Strathdee et al., 1997, Tyndall et al., 2001). In order to make basic healthcare contact with a group not reached elsewhere, the opening of a supervised injection facility (SIF) was planned. Similar sites were operational in numerous European cities, as well as Sydney, Australia (de Jong and Wever, 1999, Dolan et al., 2000). The aim of this paper is to provide an impressionistic account of the ideas, processes and politics that led to the opening of North America's first SIF.

This account focuses on culture change with regard to the SIF as a public initiative that exists in a cultural “zone of friction” where different meanings, identities and levels of power encounter one another (Ortner, 1997). We define culture as the process of negotiating meaning with respect to constantly changing implicit and explicit values that underpin the moral fabric of social action or inaction. The establishment of the SIF was culturally momentous, a massive undertaking, that was more like building a cultural railroad from coast to coast than establishing a local pilot project.

Aside from the importance of culture change, three theoretical concepts are useful for understanding the creation of North America's first publicly authorized SIF. The first, Bourdieu's (1999) concept of the habitus, has been adapted to refer to the underlying reflexive set of values associated with addiction that had to be altered in order to realize the culture change. The second, Gusfield's (1989) notion of the cultural construction of public problems is important for framing the discussion of the healthcare epidemic that underlined the establishment of this SIF. The third concept is the notion of the deliberate use of symbols as part of the politics of embarrassment in order to garner public and government attention to the plight of people living with addictions (Dyck, 1985, Dyck, 1991, Jhappan, 1990). All three of these theoretical concepts are useful for interpreting the way in which the SIF was established in Vancouver.

Section snippets

Cultural transformation

The story of North America's first SIF features key individuals who took a leading role over the past decade to realize social change. There were a number of supporters who worked from within and outside numerous political and institutional systems. Fig. 1 shows the major stakeholders that helped to establish the SIF. There was a villain in the story. However the villain was not a person but conventionality itself (embodied in the addiction habitus as we will argue shortly) and the fear of what

Peer movement

The peer-to-peer social movement, comprising active drug users, was key to humanizing the issue of addiction. The most notable role was played by the Vancouver Area Network of Drug Users (VANDU: http://www.vandu.org/) (Kerr et al., 2005a). VANDU attempts to provide a voice for marginalized drug users in the community. The membership is organized into a number of peer support and advocacy groups including a crack cocaine users group, a methadone maintenance treatment group, and a needle exchange

Making a statement

Much like indigenous peoples who marshal key symbols to make their case to the public, the DTES community utilized symbols to attempt to make a dramatic impact on public opinion. A few examples from Vancouver's Downtown Eastside are illustrative. Firstly, the community organized a display of 1000 crosses in a local park symbolizing those lives lost to preventable drug overdoses over a five-year period. Two years later the same organizers staged the 2000 crosses event when the death toll from

The opening

When the SIF was officially opened in September 2003, a large cast of characters including people with addictions, the media, dignitaries and community activists came together, many for the first time, at one celebratory event. They stood together in the injection room while figures from all levels of government took turns speaking. Bud Osborn read a poem (see Appendix A). When the commemorative event was over, people with addictions slowly began to use the site. In this small room, with its

Conclusion: cultural wave of kindness

We have argued that the SIF is in a busy cultural intersection where fundamental understandings of addiction have been changed. In order for this cultural change to occur, two events had to unfold. First, the dominant narratives about addiction encapsulated in what we have termed the addiction habitus, had to be confronted. Second, the issues of addiction faced by Vancouver had to be constructed into a public problem necessitating an official government response. These cultural changes were

Acknowledgments

This paper is dedicated to Bud Osborn, the social justice poet who dared to demand something better than death.

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