Abstract
Recently, the Supreme Court of Canada delivered an important victory for the public’s health when it ruled that Insite, a harm reduction program in Vancouver, British Columbia, should be allowed to remain open (Austen, 2011).
Insite serves as a safe injection site for injection drug users (IDUs). Among its services, it provides clean supplies, including clean syringes, with which users can inject their own “preobtained” drugs in a supervised setting. Nurses and other staff are available to intervene in case of overdose or other health problems. The program also serves to connect IDUs with primary care services, mental health treatment, and addictions counseling. An affiliated program provides detoxification services for IDUs who want to stop using drugs.
Canada’s Controlled Drugs and Substances Act (CDSA) includes criminal penalties for possession of or trafficking in illegal drugs. It also allows the Minister of Health to grant an exemption for medical and scientific purposes. Insite opened its doors in 2003 under an exemption granted by Canada’s Liberal government.
Insite is located in Vancouver’s downtown eastside, an area known for widespread drug use. Opening a safe injection site there was a measured response to address some of the myriad health and social problems facing the community. The program reflects principles of harm reduction for IDUs: instead of limiting services to drug users who are ready to stop using, Insite provides a means to reduce some of their major health risks, not the least of which is the risk of acquiring and transmitting HIV and Hepatitis C through shared injection equipment. It is the same approach that has driven syringe exchange programs in the United States and elsewhere.
U.S. readers may recall that Congress had banned federal funding of such programs starting in 1998 but lifted this ban in 2009, amid mounting evidence that syringe exchange programs reduce transmission of HIV and Hepatitis C with no apparent increase in drug use or crime. Vancouver’s Insite had also amassed significant research in support of the efficacy of safe injection sites—including research on Insite as well as sites in Australia and other countries (Health Canada, 2008).
Insite’s initial exemption under the CDSA expired in 2006. It received two extensions, but its 2008 exemption application was denied by the Minister of Health in Canada’s Conservative government. Insite had won a favorable ruling in court, including a further exemption. After the federal government’s appeal of that ruling was dismissed by an appellate court, the government appealed that dismissal to the federal Supreme Court.
Section 7 of the Canadian Charter of Rights and Freedoms declares that “Everyone has the right to life, liberty and security of the person and the right not to be deprived thereof except in accordance with the principles of fundamental justice.” In its decision, rendered on September 30, the Supreme Court of Canada ruled that denying Insite an exemption from federal drug possession and trafficking laws was indeed “not in accordance with the principles of fundamental justice.”
The Court’s decision focused on a single program in one Canadian city, and it necessarily rested on interpretation and application of Canadian law—its federal Constitution and its federal drug laws. But the decision holds important implications for harm reduction efforts beyond Vancouver and beyond Canada. Insite is the first safe injection site in North America. The Court’s decision is likely to encourage programs in other parts of Canada to seek exemptions that will allow them to open safe injection sites.
But the ruling is also an important vindication of the public health principles underlying harm reduction efforts. On behalf of a unanimous Court, Chief Justice Beverley McLachlin wrote that the effect of denying Insite an exemption “would have been to prevent injection drug users from accessing the health services offered by Insite, threatening the health and indeed the lives of potential clients.” She further wrote that
the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on Insite’s premises. (Attorney General of Canada, et al. v. PHS Community Services Society, et al., 2011)
Nurses play a critical role in Insite’s services and in many other harm reduction programs. Nursing organizations in Canada provided visible support to Insite and its nurses during the program’s long and ultimately successful legal battle. The Canadian Nurses Association, the Registered Nurses Association of Ontario, and the Association of Registered Nurses of British Columbia filed as interveners in support of Insite. In their brief, they warned of the legal risk to nurses and nursing practice posed by a failure to exempt Insite from Canada’s drug laws. They also included a clear defense of harm reduction, declaring that “[t]he evidence is uncontroverted: denying users access to supervised injection increases the risk of death and infectious disease” (2011).
The Canadian Supreme Court’s decision to sustain this vital, pioneering, evidence-based program is good news for public health advocates throughout North America and the world. It should serve to encourage harm reduction efforts, which have demonstrated their success in saving lives and combatting transmission of bloodborne diseases. The fact that nursing has played such central role in this program—and such a visible role in its defense—should be a particular point of pride for nurses as well.