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The conduct of the police with respect to injection and other drug users has contributed to clearing the streets and sidewalks of the Downtown Eastside of the drug users who were previously seen there in large numbers. But health service providers who spoke to Human Rights Watch and many others quoted in the local press expressed deep concern that the displacement of drug users and other aspects of the police presence and conduct would have disastrous health consequences, including fuelling transmission of HIV and hepatitis C from use of contaminated syringes and increasing the risk of overdose and of severe illness from injection or ingestion of poor-quality drugs. "I've worked here since 1978, and I haven't seen these numbers of policemen before," said Liz James, a nurse in the government-funded Street Nurse Program of Vancouver. She said the police presence has led to a state of "high anxiety and real desperation" among the city's most vulnerable persons, including injection drug users: "They're not willing to make contact with us or to engage and get the help they need."83

Article 12 of the International Covenant on Economic, Social and Cultural Rights, to which Canada is party, recognizes "the right of everyone to the enjoyment of the highest attainable standard of health."84 Below, Human Rights Watch documents several ways in which police misconduct in Vancouver threatens the health of injection drug users: by interfering with legal needle exchange, street outreach and other harm reduction programs; by increasing the risk of overdose and other complications associated with illegal drug use; and by interrupting basic health care services, including the delivery of HIV/AIDS medication. While abstaining from drugs may be the surest method of avoiding these health outcomes, harm reduction programs such as needle exchange have been conclusively demonstrated to reduce HIV risk without encouraging drug use or drug-related crime.85 Canadian courts have also found that addiction, whether to legal or illegal drugs, may be a form of handicap or disability on the basis of which individuals may not be discriminated against.86 Policies that, intentionally or not, single out drug users for police action, deprive them of health services and generally make it harder for them to protect themselves from fatal diseases run afoul of Canada's constitutional guarantee of equality under the law and its international human rights obligations.

Interference with legal needle exchange and street outreach
Needle exchange, a proven effective intervention for preventing transmission of HIV and other blood-borne infections among injection drug users, is legal in Canada and in many cases funded by the government. Yet needle exchange program staff expressed deep concern that they were unable to reach injection drug users with sterile syringes. According to the records kept by the needle exchange program of VANDU, which includes the only mobile street-based service in the Downtown Eastside, the service provided users an average of 1165 syringes per night in the two weeks before the beginning of the crackdown. In contrast, the totals for the first three days of the crackdown, the nights of April 7, 8 and 9, were 773, 816 and 719 respectively, about two-thirds the normal total.87 Dave Apsey of VANDU added that distribution of condoms, which are also provided by VANDU, had also greatly declined since the beginning of the crackdown. "Usually in a night we go through four boxes [there are 144 condoms per box], but now we're lucky if we go through one," he said.88

The legal risk assumed by needle exchange participants in Canada may not be as great as in the United States, where possession of drug paraphernalia is potentially a criminal offense. However, Canada's Controlled Drugs and Substances Act specifically defines as a controlled substance "any thing that contains or has on it a controlled substance and that is used or intended or designed for introducing the substance into the human body."89 This provision may be interpreted to include syringes containing trace amounts of drug residue, something needle exchange participants routinely transport back to needle exchange sites.90 In addition, some needle exchange volunteers told Human Rights Watch that possession of even sterile syringes may be prohibited by bail, probation or parole orders. Courts in the United States have held that stopping, arresting, punishing or in any way penalizing participants in legal needle exchanges on the basis of possession of new or used hypodermic syringes subverts the legislative intent behind permitting needle exchange in the first place.91

One of VANDU's volunteer needle exchangers, who preferred to be anonymous because he himself had been "jacked up" by the police several times during the first week of the crackdown, said he was shocked by the degree to which the police presence was keeping drug users from obtaining clean needles. "Half the people we normally have wouldn't exchange because the police were there," he said of one of the first days of the crackdown. "When I was out [offering sterile syringes in the mobile exchange service], there were cops on every corner and a couple on the sidewalk."92 A particularly dangerous sign, according to needle exchange workers, is that some of the needles being returned to them are coming back taped together with cellophane or black tape or with very dull points from repeated use.93 "When you see rigs94 with tape, you know it's bad," said one needle exchange worker. "We know people are reusing and trying to pick out the best of the old rigs. . . . People are asking for bleach95 and packs of matches to sharpen old needles."96

An additional concern of exchange volunteers was that injectors were too scared to carry the clean needles they were given, leaving them unprepared in case they had an opportunity to inject. "Last night I had someone drop seven brand new rigs into my [disposal] container," said one volunteer. "He just didn't want them on him. They were still in their wrappers."97 For the same reason, this volunteer observed, injectors were taking fewer new syringes than they normally did. "We give up to ten [as "loans" rather than strictly against exchange of used syringes], and people are only taking one or two," he said. While accompanying VANDU volunteers on their mobile needle exchange, Human Rights Watch researchers observed that many injection drug users were only asking for enough equipment for a single injection.

Needle exchange volunteers expressed particular concern that fear of arrest was driving drug users into unsafe injection practices.98 "I have seen people too scared to come down and get new rigs," said a board member of VANDU.99 "It's not worth going to jail for. They're scared to go; they're just scared of the cops. To be honest with you, most of them will share. If they've got no bleach, they'll use water to rinse it first." Charles Joseph Parker, president of the Vancouver Association of People on Methadone, said: "It's fear of being jacked up . . . so immediately they [drug users] stay away from it [needle exchange]. Of that 30 percent [the decline in needle exchange use], I bet you we're going to have . . . people who are going to get HIV or at least hep C, but most likely they're going to wind up with HIV-for the sake of this? We want to be killing our brothers and sisters for this?"100 Considering the crackdown's role in driving people to reuse needles, Dave Apsey, a veteran needle exchange worker, said of the police action: "This is not harm reduction-it's harm production."101

Thirty-five year-old Gerald B., who said he uses needles to inject speed, told Human Rights Watch that the first day of the crackdown was the first time in a long time he shared injection equipment. "That's when the cops came out," Gerald B. said. "It was Monday morning. And Monday night I had to come out and get some rigs, but I didn't want to come out that night because there were too many cops."102 Human Rights Watch observed a heavy police presence on and off for four days outside the two main facilities doing needle exchange near the intersection of Main Street and Hastings Avenue where drug users often had to pass police motorcycles and cars parked near the door of the facilities to get to fixed needle exchange services. Human Rights Watch researchers also accompanied mobile needle exchange providers in the neighborhood for four nights during which the police did not interfere with the work.

With a few exceptions, according to VANDU workers, the mobile needle exchange volunteers are not welcomed by owners of the single-room occupancy hotels where VANDU suspects many more drug users are injecting since the beginning of the police crackdown. "A lot of owners don't want the customers to see needle exchange, and also the tenant might be accused of a crime and doesn't want the landlord to know," said Apsey.103 The VANDU workers noted that in the few hotels where they have through their network been able to distribute clean needles to people hiding in the rooms, they found users very relieved to get needles because they had been reusing old ones and in some cases paying people several dollars for old needles.

In addition to maintaining an intimidating presence near needle exchange sites, police also obstruct legal needle exchange by confiscating syringes from needle exchange participants-even though, as noted above, possession of sterile syringes is legal across Canada. "They [two policemen] searched me for drugs, took my pipe, smashed it; took all my syringes even though they were new-I just got them at the exchange," said Martin S., fifty-five.104 Another injection drug user said that on April 15 near the Carnegie Center he witnessed confiscation by two uniformed police officers of "six syringes wrapped in a plastic bag" from a woman who is a long-time resident of the neighborhood.105 Several needle exchange workers told Human Rights Watch that not only were fewer drug users seeking out needle exchange services since the crackdown, but those who did come were requesting fewer syringes because they did not want to be caught with them on their person if they were stopped by the police.106 Jim Jones of VANDU noted that many drug users with previous arrests who may be waiting to go to court may have "red zone" bail conditions that prevent them from coming to the Downtown Eastside where they have the best access to needles.107 The VANDU workers also distribute small tubes of water suitable for injected preparations, and they feared that the lower utilization of their program meant people were injecting with water from puddles or other unclean liquid.

Not only HIV and hepatitis C but a growing syphilis epidemic is at risk of being exacerbated by the fears surrounding the heavy police presence. Street nurse Liz James told Human Rights Watch that on April 15, she met a client whom she had advised to be tested for syphilis, and she was going to administer the test on the sidewalk near the city's Oppenheimer Park. "I lost him because someone came along and said `The sixes108 are coming' and everyone scattered. I finally found him a few hours later, but people are not forthcoming anymore with information and contacts."109 "We can hardly do contact tracing for syphilis and gonorrhea,"110 said Tuan Luu, also a nurse in the Street Nurse Program. "In the last week it's been difficult to find the people we want to find; everybody is hiding in the hotels."111

Overdose, "fake" drugs and other complications
Having to inject drugs in isolated places not only leads to sharing and reusing of injection equipment, said some health providers, but to a higher risk of complications, including death, from overdose. Health service providers and drug users alike told Human Rights Watch that they feared the police crackdown was driving drug users to inject in places where they would be less likely to find help if they needed it-not only in the hotels but in more isolated and hidden parts of town.112 Service providers said it was too soon to see the impact of the crackdown on overdose deaths and illness. One expressed the concern that "after a while, we'll start finding the bodies."113 One injection drug user summed up the fears expressed by several health service providers who spoke to Human Rights Watch:

People are dying, and it's harder for people to find them when they are OD-ing [overdosing]. Just down over here, when people are OD-ing in a back alley, you find them and boom. But nobody's there [where the users are now]. Everybody's spilled all over...and they start getting high in the back, by the tracks over here and stuff like that. That's when the bodies are going to start popping up. I have seen people getting high around there, but not OD-ing yet. But it's just a matter of time.114

Drug users and service providers said that the crackdown had made it more likely that drug users would purchase and inject poor-quality or "fake" drugs with potentially lethal consequences. Linus Malik, forty-five, a long-time resident of the Downtown Eastside who said he is a non-injecting drug user, noted: "Before you knew who was who [among the dealers]; now there are a lot more strangers selling dope. The regular Hispanic dealers are not coming around because the police know them. It opens the market for new sellers and more stuff that's not real drugs," he said.115

George C., forty-two, said: "Now we have people who sell `bonk'-fake dope. With the police out there, we call it a bonker's paradise. The dealers don't care if they rip you off [with fake drugs] with a cop standing two blocks away, and the police won't arrest you for bonking."116 He added that drug users don't take the time to verify the quality of what they are sold when the police are nearby. Ajax scouring powder and Dr. Scholl's foot powder were among the substances that drug users said were being sold as drugs on the street. In other interviews, observers noted that since the crackdown, more users are having to inject hurriedly with possible adverse consequences. "Within two minutes they want that stuff in them, so they'll do it anywhere they can," said Gerald B., who also noted that users "don't worry about how much is there" and are therefore at high risk of drug overdose.117

Several drug users and service providers suggested that the significant entry of doctored or "fake" drugs into the market and the generally greater difficulty of getting drugs since the crackdown would lead to crime and violence among users and dealers. "It's gonna get violent-these crimes come out of desperation when they make it impossible to get dope. Someone who's junk-sick will do anything," said one drug user.118 Ann Livingston, executive director of VANDU and a long-time resident of the Downtown Eastside, echoed this idea, noting that when access to drugs and to services is disrupted, violence among the most marginalized drug users in the neighborhood increases.119

Adding to the potential for increased crime is the police crackdown on informal commerce among Downtown Eastside sidewalk vendors and sellers of scavenged goods. Four informal vendors interviewed by Human Rights Watch, including Arnold L. and Robert B. cited above, said that their sales of used goods or food enabled them to make a living without resorting to theft but that with the crackdown, they might face a situation where they would resort to stealing.120 The crackdown has coincided with a time of cuts in the budgets of social and health services supported by the province of British Columbia, which some service providers said would add to the risk of higher crime as a result of the crackdown.121

Interruption of health services
A number of health service providers raised the concern of interruption of medication for people with HIV/AIDS, tuberculosis and other medical conditions requiring intensive care and follow-up. Mark W. Tyndall, director of the Epidemiology Program at the British Columbia Centre for Excellence on HIV/AIDS and a practicing physician in the Downtown Eastside, told the Canadian Broadcasting Company on April 17 that the police crackdown in the neighborhood was making it more difficult to ensure follow-up in these cases. "We have some pretty crystal clear examples from yesterday where people weren't showing up for their regular ARV [antiretroviral] therapy. It's important that they take [these medicines] daily and consistently. This is jeopardizing their long-term treatment," he said.122 Tyndall said the trust built up over years with stigmatized and marginalized people can, in the face of a police crackdown, "in a day be thrown out the window." Tyndall also echoed the unanimous view of service providers who spoke to Human Rights Watch that the police crackdown would have been less disruptive to health services if it had taken place after the opening of the proposed safe injection site.

Vicki Bright, a community counselor in a program of the Vancouver Coastal Health Authority that provides intensive follow-up for people living with AIDS, said the overnight incarcerations that have been common under the crackdown can impede the ability of people with HIV/AIDS to get their medications. "One of my female clients was recently picked up [by the police] and missed her methadone and her meds for a night and had no chance to contact us," she noted.123 A recent study of 238 injection drug users in Vancouver by the British Columbia Centre for Excellence on HIV/AIDS identified incarceration as one of the strongest determinants of antiretroviral treatment interruption in this population.124

Some of the health risks faced by drug users in the crackdown are also faced by sex workers in the neighborhood. Press reports indicated that sex workers were being driven by fear of police harassment to conduct business in dangerous and hidden parts of the city and that the "buddy system" some sex workers use to protect themselves was being disrupted by the crackdown.125 "On the Downtown Eastside these women are being targeted by police, thrown up against walls and harassed; we are worried that at the end of this, we'll only have more missing women," said Wanda Villanueva, a counselor at the Downtown Eastside Women's Centre.126 Her mention of missing women refers to a case that drew international attention involving the disappearance and murder over the last several years of sixty-one women sex workers, of whom over half were from the Downtown Eastside.127

83 Human Rights Watch interview, Downtown Eastside, April 14, 2003.

84 International Covenant on Economic, Social and Cultural Rights, G.A. res. 2200A (XXI), 21 U.N. GAOR Supp. (No. 16) at 49, U.N. Doc. A/6316 (1966), 993 U.N.T.S. 3,entered into force Jan. 3, 1976. Canada became a party to the ICESCR in 1976. The Committee on Economic, Social and Cultural Rights, in its general comment on article 12, states:

Violations of the obligation to respect [the right to the highest attainable standard of health] are those State actions, policies or laws that contravene the standards set out in article 12 of the Covenant and are likely to result in bodily harm, unnecessary morbidity and preventable mortality. Examples include the denial of access to health facilities, goods and services to particular individuals or groups as a result of de jure or de facto discrimination; the deliberate withholding or misrepresentation of information vital to health protection or treatment; the suspension of legislation or the adoption of laws or policies that interfere with the enjoyment of any of the components of the right to health....

Committee on Economic, Social and Cultural Rights, The right to the highest attainable standard of health, E/C.12/2000/4, CESCR General comment 14 (Aug. 11, 2000), para. 50.

85 There is a wealth of literature on this subject, much of which is reviewed in Peter Lurie and Ernest Drucker, "An opportunity lost: HIV infections associated with a lack of a national needle-exchange program in the USA," The Lancet, March 1, 1997, pp. 604-608.

86 See Entrop v. Imperial Oil Ltd. (2000) 50 O.R. (3d) 18, holding that drug addiction and alcohol abuse are a handicap for the purposes of the Ontario Human Rights Code. Drug dependency is also included as a prohibited ground of discrimination in s. 10 of the Canadian Human Rights Act, R.S.C. 1985, c. H-6.

87 Human Rights Watch interview with Jim Jones, VANDU needle exchange program, Washington Hotel, Downtown Eastside, April 13, 2003.

88 Human Rights Watch interview with David Apsey, VANDU needle exchange program, Washington Hotel, Downtown Eastside, April 13, 2003.

89 Controlled Drugs and Substances Act, s. 2(b)(ii)(B).

90 It could be argued that unless an individual intends to inject the drug residue into his or her body, the syringe containing it does not qualify as a "controlled substance" under the Act.

91 See Com. v. Landry, 779 N.E.2d 638 (Mass, 2002), Roe v. City of New York, 232 F.Supp.2d 240 (S.D.N.Y. 2002), Doe v. Bridgeport Police Dept., 198 F.R.D. 325 (D.Conn 2001).

92 Human Rights Watch interview with Dirk T., forty-two, volunteer worker in the VANDU needle exchange program, April 13, 2003.

93 Human Rights Watch interview with Jim Jones and Dave Apsey of VANDU, Washington Hotel, April 13, 2003.

94 "Rigs" is a common way to refer to needles or needles and plungers used for injecting drugs.

95 Cleaning syringes thoroughly with chlorine bleach can reduce the risk of HIV transmission, but bleach is ineffective against hepatitis C contamination of syringes.

96 Human Rights Watch interview with Dirk T., April 13, 2003.

97 Human Rights Watch interview with Dave Apsey, VANDU, April 13, 2003.

98 Similar findings have been made in other jurisdictions. See, e.g., Ricky Bluthenthal et al., "Collateral damage in the war on drugs: HIV risk behaviors among injection drug users," International Journal of Drug Policy 10, 1999, pp. 25-38; Lisa Maher and David Dixon, "Policing and public health: Law enforcement and harm minimization in a street-level drug market," British Journal of Criminology, Autumn 1999, pp. 488-512.

99 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

100 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

101 Human Rights Watch interview, Downtown Eastside, April 13, 2003.

102 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

103 Ibid.

104 Human Rights Watch interview, Downtown Eastside, April 14, 2003.

105 Human Rights Watch interview with Daniel R., thirty-five, Downtown Eastside, April 15, 2003.

106 Human Rights Watch interviews with VANDU needle exchange workers and mobile teams, Downtown Eastside, April 13 and April 14, 2003.

107 Human Rights Watch interview, Downtown Eastside April 13, 2003.

108 "Sixes" is a local reference to the police.

109 Human Rights Watch interview, Downtown Eastside, April 15, 2003.

110 Asking persons who test positive for syphilis and gonorrhea for the names of their sexual partners and seeking those persons out for testing and treatment are standard public health practices.

111 Human Rights Watch interview, Downtown Eastside, April 14, 2003.

112 For example, Human Rights Watch interview with Charles Joseph Parker, Downtown Eastside, April 12, 2003. This sentiment has been echoed in numerous press reports, for example, Frances Bula and Petti Fong, "Police drug plan was six months in the making: Embarrassment over city's image drove force to act," Vancouver Sun, April 11, 2003.

113 Human Rights Watch interview with Dave Apsey, April 13, 2003.

114 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

115 Human Rights Watch interview, Downtown Eastside, April 15, 2003.

116 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

117 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

118 Human Rights Watch interview with Winston R., age forty, Downtown Eastside, April 12, 2003.

119 Human Rights Watch interview, Downtown Eastside, April 12, 2003.

120 Human Rights Watch interviews, Downtown Eastside, April 12, 13 and 14, 2003.

121 The British Columbia Employment and Assistance Act of September 30, 2002 overhauled the social assistance system of the province, establishing lower rates of income assistance for low-income persons and changing eligibility rules. The Coalition of Progressive Electors with which the current majority of the Vancouver city councillors is affiliated criticized the provincial cuts strongly during the election campaign, echoing the views of many community and antipoverty groups across the province. See COPE statement on the economy [online] at and the positions of Campaign BC, a coalition of community groups that opposed the cuts [online] at (retrieved April 19, 2003).

122 Canadian Broadcasting Company British Columbia, Radio One, The Afternoon Show, interview with Dr. Mark W. Tyndall, April 17, 2003, available online at Heard April 19, 2003.

123 Human Rights Watch interview, Downtown Eastside, April 15, 2003.

124 A. Palepu, M.W. Tyndall, K. Li, B. Yip, R.S. Hogg., M.S. O'Shaughnessy, J.S.G. Montaner, and M.T. Schechter. Access and sustainability of antiretroviral therapy among injection drug users in Vancouver. Canadian Journal of Infectious Disease, volume 12(Supp. B), number 32B, 2001.

125 See, e.g., Amy Carmichael, "Crackdown in Vancouver slum before addiction centre opens angers social workers," Canadian Press, April 11, 2003.

126 Ibid; see also Peg Fong and Frances Bula, "90 arrested in drug sweep...," Vancouver Sun, April 12, 2003.

127 Philip Saunders, "Missing Women of Vancouver: Backgrounder," February 14, 2003, Canadian Broadcasting Company [online], at (Retrieved April 11, 2003.) At this writing, the case against a suspect in these murders is being heard in pretrial proceedings. The Vancouver Police Department was widely criticized for the handling of this investigation, including by family members of victims who alleged that the police neglected the case because the victims were sex workers. The Royal Canadian Mounted Police joined the investigation in 2001 in response to this dissatisfaction.

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