Walking through Vancouver’s Downtown Eastside, it’s horrifyingly clear that decades of efforts to help the residents of the impoverished neighbourhood, however well meaning, have been a failure.
All along East Hastings Street, people line the sidewalk clutching hazardous butane torches used to smoke opioids. Many lie in a stupor or stand awkwardly folded over at the waist, a position typical of fentanyl users.
Theft and violence against retail workers have pushed out many businesses. They have been replaced by social service providers and stores catering to drug users, selling glass pipes, bags of candy and cereal by the bowl.
A man walks past the sprawling homeless encampment on East Hastings Street in Vancouver, in August, 2022. Though cities across the country are confronting the related problems of addiction, the Downtown Eastside stands out for the severity of its problems.DARRYL DYCK/The Canadian Press
One man lying on the sidewalk has a massive open wound on his leg. A few blocks away, on East Pender Street, a woman sprawled on the sidewalk screams as a man jumps on her; the police quickly run over and pull him off.
Imagine you are a resident of this neighbourhood (one lucky enough to live indoors) wanting to break your addiction and restart your life. You live in a run-down hotel room without a private kitchen or bathroom, your friends and neighbours are drug users, and your dealer is a fixture outside your building. What chance do you have to beat your addiction?
Vancouverites are numb to the crisis, given the long history of problems in the neighbourhood, but the truth is, the Downtown Eastside is much worse now than it was in previous decades. A homeless encampment along East Hastings Street was removed two years ago, but the Downtown Eastside remains a magnet for people around the province who arrive with problems, and then are sucked into a vortex of despair.
Police officers enforce a removal order at the homeless encampment along East Hastings Street in April, 2023. Years later, the area remains a magnet for those experiencing homelessness and addiction.DARRYL DYCK/The Canadian Press
Deaths from opioids have soared all across North America in the last decade, with numbers dropping somewhat last year. B.C.’s stats mirror these trends, yet it remains the worst province per capita for opioid deaths. Across the province, more than 18,000 people have died due to what the province calls “toxic drugs” in the past 10 years. High overall rates of death in the Downtown Eastside are caused not just by drugs, but treatable health conditions such as hepatitis C.
Cities all across North America are grappling with the related problems of addiction, mental illness and homelessness, particularly since fentanyl took hold, but the Downtown Eastside is a standout due to the severity of its problems. It’s an epicentre of human misery, one made worse by bad policy choices.
Poverty advocates say the Downtown Eastside is a community, which is true, but it’s not a healthy one. It’s time for an honest discussion about what can be done to move residents into better living conditions in different neighbourhoods – ideally their home communities – to break up the cluster of addiction and harm.
The people living in the Downtown Eastside, and suffering from addiction, deserve better than to be left there to die, quickly or slowly.
East Hastings Street in the Downtown Eastside in June, 2024. B.C. has instituted a 'housing first' approach to addressing addiction and homelessness, which is designed to get people into subsidized housing without any preconditions.DARRYL DYCK/The Canadian Press
Doubling down on despair
The purchase of downtown residential hotels by the B.C. and Vancouver governments over the last two decades was seen as a welcome relief measure by advocates. Previously, many such buildings were being bought by private companies and converted into new uses, leaving the residents at risk of homelessness. The thinking was that publicly run housing could be renovated and managed better, giving residents safer and more stable housing. As a result, the residents are stuck in small rooms, with shared bathrooms and without proper kitchens.
Neighbourhood zoning rules that limit new residential projects to rentals with social housing have made it difficult for projects to get built, freezing the Downtown Eastside in time. More social services and supportive housing were set up in the neighbourhood, in part because residents in other neighbourhoods didn’t want them.
Advocates and policy makers wanted to avoid what they called “gentrification.” But by creating barriers to allowing more middle and upper class people from moving in, a chance was lost to create a more balanced community that could have stabilized the neighbourhood. Instead, poverty and addiction intensified.
People march in support of safe supply drug programs in Vancouver in 2023. More than 18,000 people have died in B.C. from toxic drugs over the past decade.ETHAN CAIRNS/The Canadian Press
B.C.’s “housing first” approach, which is designed to get homeless people into subsidized housing without any preconditions so they can stabilize before addressing addictions, makes sense, on paper. But Julian Somers, a psychologist and professor at Simon Fraser University says, in reality, little is done after to get people into treatment to break their addictions. He’s a controversial figure due to his criticism of B.C. drug policy – but his ideas are worth listening to.
His research with Simon Fraser University’s Centre for Applied Research in Mental Health and Addiction shows people who experience homelessness alongside mental illness and addiction do best in recovery-oriented housing, where treatment is provided and staying off substances is required. That doesn’t mean that people are thrown on the street for one misstep, and pharmaceuticals can be used to ease the transition, but the emphasis is on social reintegration, and pressure is applied to keep them off drugs.
Dr. Somers says that private addictions treatment programs used by middle and upper class people ban drugs, enforcing the measure through urine tests, at least for an initial period of time. For successful results, long-term support is needed to help people reorient their lives to more meaningful pursuits and connect with loved ones and employment. Many were raised in foster care or by people other than their parents, he says, and have unresolved trauma that requires addressing. His research shows this type of treatment reduces crime incidents and medical emergencies.
Instead of putting all people in congregate housing, Dr. Somers’ research shows people do better when helped to rent independent units, where they aren’t housed with other drug users, although they still require strong supports to manage their addictions and rebuild their lives. Surveys show that people who experience homelessness and mental illness largely prefer this type of housing.
That housing should not be in the Downtown Eastside, whenever possible. Poverty activists have fought to keep the community together and prevent displacement, but Dr. Somer’s research shows that 80 per cent of the people who experience long-term homelessness, mental illness, and addiction in Vancouver’s Downtown Eastside have moved there from outside the Vancouver area. As part of a randomized controlled trial conducted by Dr. Somers, 500 such people were offered housing in various areas. Not a single person chose to stay in the Downtown Eastside.
Vancouver Mayor Ken Sim speaks during a news conference in September, 2024. Mr. Sim has vowed to 'revitalize' the Downtown Eastside through various housing and police initiatives.ETHAN CAIRNS/The Canadian Press
Mayor Ken Sim has vowed to “revitalize” the Downtown Eastside. His boosting of police resources in the area is a sensible measure, but the city’s overall approach lacks vision. In December, city council lowered the requirement for social housing units in new residential developments in the neighbourhood to 20 per cent, from 60 per cent, while boosting height allowances. This couples with a 30-year plan, launched by the city in 2017, to replace the residential hotels with affordable apartments for their residents.
Why should this one neighbourhood continue to house a disproportionate share of the city’s low-income residents? There’s no automatic requirement to build deeply affordable rental housing when a building goes up in wealthy Kitsilano or Kerrisdale. The truth of the matter is, there is a nasty unspoken social compact in Vancouver: the residents of the Downtown Eastside are allowed to deteriorate openly on the streets, so long as they stick to their own neighbourhood.
Instead of tinkering, the city needs to work with the province to find better housing for Downtown Eastside residents in their home communities or new neighbourhoods of their choosing. Most will do better when not confronted with an open air drug market every time they open their door.
Mr. Sim has a point that Vancouver has a disproportionate share of B.C.’s supportive housing and shelters, but his move to freeze the construction of net-new supportive housing in the city isn’t helpful. Making a dent in homelessness and addiction will require new projects and rental subsidies both in Vancouver and in other parts of the province. A shift toward independent rental units would help get around the typical objections from local residents to supportive housing projects in their neighbourhoods.
Supplies are seen on a table at an outdoor supervised consumption site in the Downtown Eastside in May, 2021. Despite the death toll dropping slightly last year, B.C. remains the worst province per capita for opioid deaths.DARRYL DYCK/The Canadian Press
A real path to recovery
Many of Canada’s harm reduction strategies, which aim to reduce negative impacts on drug users without requiring them to stop using substances, were pioneered in Vancouver’s Downtown Eastside. The Four Pillars drug addiction strategy, launched in 2001, emphasized prevention, treatment, enforcement and harm reduction, but over the years, the balance has been lost. The expansion of harm reduction may have reached its limit, but a return to the failed “War on Drugs” also isn’t the answer.
Early advocates promoted harm reduction measures, such as methadone and safe injection sites, as a way to save lives from overdose and disease, and create a bridge to connect people to treatment and housing. But newer approaches, such as offering patients “safer supply”– uncontaminated prescription opioids as an alternative to illegal drugs – don’t require a treatment plan.
During the early days of the pandemic, the B.C. government began allowing patients to take prescription opioids off site, rather than consume them in front of a medical professional. The policy continued until last year, when it became clear that a significant portion of the opioids were ending up on the black market, in some cases triggering new addictions. Likewise, a provincial pilot to decriminalize personal possession of illicit drugs ended in January after mounting concerns about public drug use and street disorder.
B.C. Health Minister Josie Osborne announces the end of the province's personal use drug possession decriminalization pilot project in January.CHAD HIPOLITO/The Canadian Press
For harm reduction measures to work, the benefits to users must be balanced with the needs of other community members. Harm reduction measures should be a bridge to escaping addiction, not an end goal. There needs to be more of a drive, and more resources, to get people into recovery programs.
Treatment in B.C. has been difficult to access, with uncoordinated services and long waits for beds. A new “Road to Recovery” model being piloted by St. Paul’s Hospital in Vancouver is a huge improvement. People seeking recovery can visit the clinic or call a phone line and immediately get assessed by a medical professional. High risk individuals, which include people living on the street or who have experienced recent overdoses – can get into detox in 48 hours, and stay in that facility until their bed-based treatment begins.
St. Paul’s aims to add a residential option for people after they have completed the program, so they don’t end up back on the streets or in a hotel room, where they could easily fall back into drug use. B.C. is expanding the Road to Recovery model across the province. Given the right resources, this program could make a difference.
Right now, there’s little consistency or accountability for provincially funded treatment programs. Results should be tracked so it’s clear which methods are working. More regional and early intervention programs are needed across the province to prevent people from gravitating toward the Downtown Eastside.
Outreach workers prepare overdose response medical kits at a supervised drug consumption site in the Downtown Eastside in 2023. Beyond shorter term harm reduction resources, B.C. has recently made it easier to use involuntary care for those suffering from coinciding mental-health and addiction challenges.Jesse Winter/Reuters
Involuntary care as a kindness
Involuntary care is part of the puzzle. Concerns about drug users’ rights are often raised, but some people who use fentanyl, a substance that can lead to brain damage, are unable to make proper decisions about their own safety.
Imagine it was your brother or sister or child on the street, being destroyed by addiction. Would you want someone to intervene and help? Or leave them to slowly succumb to their addiction, in the name of personal autonomy?
B.C. recently made it easier to use involuntary care. Before its use is expanded, the province should develop a robust and effective system of treatment for both voluntary and involuntary patients.
It’s true that treatment followed by ongoing housing, addiction and mental health support is expensive. But the cost of the status quo is even pricier. According to Dr. Somers’ research, the annual average cost of public services, such as hospitalization and policing, for those who fall into prolonged homelessness is more than $50,000 in B.C.
The residents of the Downtown Eastside need more than just short-term solutions to help them survive another day – they need an exit path to a better life. Some will need multiple rounds of treatment, and not every person will be successful in quitting drugs. But we can’t assume that everyone will fail. By moving people into healthier environments, and providing proper supports, they will have a chance.
Governments and health officials must be brave enough to give them that chance, so yet another generation doesn’t end up living – and dying – on the sidewalks of East Hastings Street.