Through 1997, Vancouver authorities met regularly in response to an unprecedented outbreak of HIV/AIDS. The virus had killed 877 people in the city of Vancouver over the preceding five years, plus another 555 across British Columbia.
A budding Downtown Eastside activist named Ann Livingston attended many of those meetings along with her boyfriend, Bud Osborn.
“Somebody was looking at the graphs of AIDS deaths,” Livingston recounts in the 2017 book Fighting for Space: How a Group of Drug Users Transformed One City’s Struggle With Addiction.
The health official presenting the numbers turned from the charts on the wall and told the group, “If we don’t do anything, they are going to come down, because we’ll hit a saturation point.”
What the bureaucrat was suggesting, Livingston explains, is that there would soon be so many people in Vancouver killed by AIDS that there would be a smaller number at risk of catching the virus. That would translate to a smaller number of deaths.
“Bud lost his shit,” Livingston says in the book. “He jumps up, the fucking chair falls over, and he starts screaming. ‘Are you fucking serious?!’”
Interviewed for Fighting for Space in 2017, pioneering public-health physician John Blatherwick, who chaired that meeting, conceded that that official’s suggestion is likely what occurred.
“There wasn’t something that we did that helped,” Blatherwick says. “When so many people got infected, there were fewer people left to get infected. And so the number of cases went up and up and up, and then dropped.…The epidemic burned itself out.”
During the five years leading up to 2020, there were 1,349 illicit-drug overdose deaths in the city of Vancouver, plus another 4,030 across the province (up to October 2019), according to the B.C. Coroners Service.
Beginning in 2013, when the synthetic-opioid fentanyl appeared in Vancouver street drugs, the numbers went up and up and up. Then, from 2018 to 2019, there were significant declines.
Has B.C.’s overdose epidemic reached a point of saturation?
Did deaths decline in 2019 because, with so many people already gone, there were simply fewer left to die?
“I’ve been saying this for a while now,” Hawkfeather Peterson, vice-president of the B.C.-Yukon Association of Drug War Survivors, told the Straight. “Our population has been decimated. There’s just not enough of us left to die anymore.…We’ve been obliterated.”
In a telephone interview, Peterson, who does outreach work with the harm-reduction group Sunshine Coast Connections, recounted the deaths of friends and family members as a horrifying matter of routine.
“Sometimes, you don’t hear from someone and you wonder what happened,” they said. “But typically, you wake up the next day and you hear that someone has died. And it’s never anyone you ever expect, because you never expect anyone you care about to die.…It’s panic and constant heartache.”
In June 2019, the B.C. Centre for Disease Control (BCCDC) shared a research project calculating that B.C.’s harm-reduction programs—things like naloxone distribution and supervised injection—have saved a significant number of lives.
“The study estimates that without access to and rapid scale up of harm reduction and treatment strategies, the number of overdose deaths in B.C. would be 2.5 times as high,” it reads.
Since then, politicians and public-health officials have pointed to that paper to argue that the decline in overdose deaths B.C. experienced from 2018 to 2019 was, while not a victory, a reason for “cautious optimism”.
But Peterson is not the only one who fears that another factor driving that reduction in deaths was the epidemic reaching a point of saturation.
Thomas Kerr is a senior scientist at the B.C. Centre on Substance Use and professor with UBC's faculty of medicine. He’s been around long enough to remember Vancouver’s HIV/AIDS crisis of the 1990s, and said there are parallels with the opioid epidemic of today.
“The ugly reality is that the population at risk is probably reduced because so many people have died," Kerr told the Straight.
This phenomenon is a “simple epidemiological reality”, he said.
“This does not mean that [harm-reduction] interventions have not had impact,” Kerr added. “Thousands of people have been resuscitated and saved. But when you lose thousands of people, that reduces the total number of people who are at risk.”
Many more people still at risk
From December 2017 to December 2018, Dr. Patricia Daly served as executive director and clinical lead for B.C.'s Overdose Emergency Response Centre. She acknowledged the thought of a saturation point had crossed her mind.
“We do see this when we get an outbreak,” Daly, who’s also chief medical health officer of Vancouver Coastal Health, told the Straight. “Let’s say a measles virus enters a school. You would get an outbreak, and even if you did nothing, the outbreak would eventually die down, because everyone who was susceptible to measles would get it. So that was one of our questions: how are we going to know if we have any impact?”
But with the overdose crisis, Daly continued, there is additional data that suggests this is not what has occurred.
“We’re not just monitoring deaths; we’re monitoring overdoses that are reported to B.C. Ambulance [Service], and those actually went up last year,” she explained.
Statistics supplied by the Provincial Health Services Authority confirm Daly’s assertion. B.C. saw 23,700 emergency calls for a drug overdose in 2018, and is now on track for a projected 24,800 in 2019, the figures show.
“If the theory is that there are fewer people at risk, [nonfatal] overdoses should be going down, too. And that’s not happening,” Daly said.
She also pointed to the work of Bohdan Nosyk, a health-sciences researcher at Simon Fraser University who has been trying to figure out how many people in B.C. are at risk of a drug overdose.
“The number that he’s come up with, based on a point in time last year…is about 65,000,” Daly said. “So there are many, many more people at risk.” (Nosyk’s work remains under peer review, but is being shared internally among B.C. public-health officials. He could not be reached for comment by deadline.)
The BCCDC paper that’s often used to attribute B.C.’s decline in deaths to harm reduction was coauthored by Mike Irvine. In a telephone interview, the epidemiologist emphasized that that paper says that harm reduction is likely responsible for saving a specific number of lives during a specific period analyzed. It does not say that harm reduction is wholly responsible for the roughly one-third decline in deaths recorded through 2019, Irvine noted.
Moreover, he continued, the decline in 2019 might not actually be a decline. It could be a blip—a statistical anomaly amid what could later become clear is a disaster that is still only getting worse.
“In the past, we have seen potential declines [in deaths], but then it has increased again,” Irvine said. “And so we have to be cautious. We don’t necessarily know where this is coming from and nonfatal overdoses remain very high.”
Fatality numbers could rise again
On the phone from the BCCDC, Margot Kuo, an epidemiologist with the organization, noted there are key differences between the usual viral outbreak and B.C.’s increase in drug-overdose deaths.
“With disease epidemiology, people become immune and you put control measures in place to stop exposure,” she explained. “But here, in this particular situation, we don’t have any control measures on exposure. We are at the mercy of the drug supply. So people remain at risk.”
Like Irving, Kuo cautioned it’s yet to be determined whether the drop in overdose deaths observed in 2019 is where the numbers are going to stay.
“There is still a large pool of people at risk and we still have no control over exposure,” she said. “Really, everything is driven by the toxicity of the drug supply, over which we have no control.”
Peterson said something similar and emphasized they think drug-user groups like the the B.C.-Yukon Association of Drug War Survivors have the answer. If only the right people in power would listen.
“All they are doing is giving us naloxone,” Peterson said. “What they are doing is not preventing overdoses. We do have options that will do that. We have decriminalization, we have safe supply.…But the support we have for those things remains minimal. That is just so frustrating.”