Normally such strong evidence documenting the many successes of such a pilot program, and the medical and public health significance of its very positive outcomes, would be the basis for celebration and lead to moves to expand the model and provide similar services elsewhere in Canada. Instead, there is a distinct possibility that InSite will be closed by the newly elected Canadian Prime Minister Paul Harper – a conservative who has traveled to the US to visit George W. Bush and come back to Ottawa hostile to harm reduction in all its forms – a sentiment that originates in Washington DC and appears to function as a loyalty test for international drug policies worldwide.
The InSite program operates under a waiver of Canadian Federal health rules that allow it to provide its services as a research project. Because InSites federal waiver is expiring in September, many fear that Mr. Harper will not renew its approval and that the program will be forced to close down. The risks associated with any potential closure of InSite need to be fully understood.
In addition to abandoning the care of so many of Vancouver's drug users and the needless pain and suffering this will inflict on them and their loved ones, it is possible to project a number of very specific consequences of any failure to continue it. By utilizing the data from the InSite studies that have been published in the peer review literature, we can predict a set of adverse outcomes and their related economic costs – all now prevented by InSite. These include:
Failure to Prevent 22 overdose deaths: based on a 5% mortality rate among 453 overdoses treated at In Site, if these had occurred in the community. [1]
Failure to Prevent 112 hospitalizations for non – lethal overdose deaths: based on a 25% hospitalization rate (including psychiatric) among 453 overdoses treated at In Site, if these overdoses occurred in the community. At a 2–5 day average length of stay for each such admission, this yields 224–560 extra hospital bed days and estimated costs (at $ 500/day) would total $112,000 to $280,000 [2]
Failure to Prevent 2000 Emergency medical visits for injection mishaps: Emergency room treatment of abscesses and other bacterial infections associated with unsafe injecting cost $1000 – $3000 per incident – annual savings $2 – 6, 000,000) [3]
Failure to Prevent 100 Hospitalizations due to bacterial infections: Based on 5% rate of hospitalization for the 2000 bacterial infections seen at Insite. Each such admission has an average length of stay of 15 – 20 days with a cost (at $500 per day) of $7500 – 15,000 per admission and a cost per year of $ 750,000 – 1 million [4]
Failure to make 100 referrals to Methadone treatment: with savings of $10,000/year/client in criminal justice and medical costs = $ 1 million [5]
The economic cost of closing InSite will far exceed the cost of operating it – by millions of dollars per year. The available data on the economic impact of Insite (in addition to the preventable deaths and disease that the programs closure will cause) indicate that the end of the program will cost Vancouver and British Columbia between $ 3,862,000 and $8,780,000 in additional health care expenses over the next two years. In addition to the increased demands that InSites closure would place on already scarce health care resources, Insites termination would also lead to thousands of additional arrests (which cost more than $10,000 apiece) court adjudications (another $10,000) and all the jail and probation time (not to mention public displeasure) associated with a return to public drug use by this large group.
As AIDS associated with injecting drug use continues to spread and ignites new regional epidemics of HIV – most dramatically evident today in the former Soviet Union – we need more InSites, not fewer ones. Vancouver's and Canada's struggle to develop and maintain innovative public health programs that more effectively deal with drugs and AIDS are ones we in the international public health community all share. But the end of InSite would be a setback not only for Vancouver and Canada – it would be a great loss for all of our efforts to build effective and sustainable public health initiatives for dealing with addiction and AIDS prevention everywhere in the world.
By granting renewal of InSite's federal approval, the Canadian federal government will be acting in the best interest not only of the citizens of Vancouver, but also in the best interests of all Canadians struggling to find effective responses to the nations daunting problems of AIDS and addictions. And, because of the high esteem in which Canadian public health is held worldwide, the actions of the Canadian government in regard to InSite will have a strong effect elsewhere. If negative they will embolden the opponents of harm reduction globally – reinforcing a dangerous trend to put some short term perceived political advantage ahead of public health evidence.
As the research on InSite makes so readily apparent, the failure to sustain InSite will most certainly condemn scores of Canadians to premature deaths (from drug overdose and AIDS) and thousands more to lives of increased disease, degradation, and criminal activity – all at inordinate public expense. The choice seems clear.
