The long fight for safe injecting rooms
Last Saturday, the second medically supervised injecting centre (MSIC) in Australia opened its doors in Melbourne’s North Richmond. It was a long time coming. Nearly two decades ago, I met with a group of nurses, doctors, drug users and their parents in the basement of the Wayside Chapel in Sydney to launch the “Tolerance Room” – a safe injecting space, and small act of civil disobedience, that we hoped would push the then premier, Bob Carr, forward on opening the country’s first MSIC in Kings Cross. This was the height of Australia’s heroin epidemic, 1999, a year when about 1116 people would die from heroin overdoses – many of them in the Cross. We felt the risk of prosecution was worth it if we could slow the rate of people – particularly young people – dying all around us.
Medically supervised injecting centres, also known as drug consumption rooms, are specialised facilities where people who use illicit drugs can self-administer without fear of legal consequences. They are staffed by professionals who are trained and equipped to prevent drug overdose deaths and offer other help and support. Of those established around the world, most are in Western Europe, although Canada and the United States are increasingly looking to MSICs to cope with their own opioid crises.
The opening of Australia’s second MSIC marks the end of more than two decades of relentless struggle and advocacy. To trace its origins, you need to go back even before the Tolerance Room, through the work of countless people. As President John F. Kennedy and others have said, “Success has many fathers, while failure is an orphan.”
David Stanley, who runs a Melbourne advertising agency specialising in public health, began quietly working with others on an MSIC for Melbourne in the 1990s. His group visited facilities in the Netherlands and Switzerland and organised for two leading European researchers in the space to visit Australia to assist local advocacy efforts. And a Melbourne MSIC came awfully close to getting across the line when Steve Bracks unexpectedly won the Victorian state elections in 1999, after promising to establish five centres in Melbourne. But in government Bracks abandoned his commitment in the face of vociferous local opposition. About the same time, the ACT government also dropped a commitment to open a MSIC in Canberra.
Stanley kept pushing, though, in this Sisyphean task. He was one of the people responsible for the elegant “You Talk We Die” mural that popped up in Richmond in 2017. The names of those who’d died from heroin overdoses in the area were painted onto the wall, and mothers from around the state came to see their children’s names and to pay tribute. It helped highlight the issue at a time when the MSIC campaign was in a slump.
Fiona Patten, leader of the Reason Party – previously known as the Australian Sex Party – and a member of the Victorian Legislative Council, built a critical coalition of supporters in state parliament. Richmond local Judy Ryan rallied a group of residents, who came to be known by the campaign as its “military wing”. Well-known and highly respected Melbourne barrister Robert Richter, QC, was a long-time advocate. Former Victorian Liberal premier Jeff Kennett visited the Sydney MSIC and became a critical ally, spurred on by his strong commitment to improving mental health and his knowledge of the often-dreadful mental health of people who inject drugs.
But to try to tie the MSIC to any one person, or any one event, is nearly impossible. Having worked in drug law reform in Australia for much of my professional life, I can safely say that making any progress often feels like alchemy.
The first watershed moment came in December 2016, during a coronial inquest into the drug overdose death of Ms A, a young mother with small children, in the toilet of a Hungry Jack’s in North Richmond, a suburb that had seen 34 drug overdose deaths already that year. At the inquest, Richter cross-examined a staff member of the Victorian Department of Health who was responsible for drug policy. Asked what international evidence ministers had been given about the efficacy of MSICs, she was forced to admit that none had been provided, despite the fact the department’s role was to offer whole, unbiased and complete evidence to ministers.
The next year came another premature death, this time to cancer of Fiona Richardson, a well-regarded state Labor politician, which prompted a byelection for the inner-city seat of Northcote. A fierce battle between the ALP and the Greens erupted. When elected in 2014, the Victorian premier, Daniel Andrews, had vowed to stick strictly to his election commitments – in stark contrast to the then prime minister Tony Abbott – but unfortunately this included a promise to not establish an MSIC during his first term of government.
Undeterred, supporters of a Melbourne MSIC continued their advocacy and recruitment. Enough was enough. Surely an election promise could be reconsidered in the face of so many deaths? Three years later, in October 2017, Andrews announced that his government would establish a two-year trial of an MSIC in North Richmond. A “backflip”, according to the media. Many wondered whether this decision had mostly been prompted by the effort to retain Northcote, rather than by the growing body of evidence that MSICs help keep communities and drug users safe. At the byelection, the Greens ending up winning the seat from Labor anyway.
When the world’s first official MSIC opened in Bern, Switzerland, in 1986, Australia was a world leader in pragmatic public health interventions. Faced with the serious threat of an HIV epidemic beginning among people who inject drugs then spreading to the general population, policymakers took action and introduced programs such as the needle and syringe exchange.
But in the decades since, as almost 100 MSICs have been opened around the world, Australia has dragged its feet. In 1997, the Howard government rejected a trial of prescription heroin, after six years of internationally significant scientific research. It marked a shift towards using the criminal justice system – rather than the health system – to try to deal with drug use.
That was the same year Justice James Wood found pervasive corruption linked to illicit drugs, especially in Kings Cross, during the New South Wales royal commission into police corruption. “It is fanciful to think that drug addicts can be prevented from obtaining and using prohibited drugs,” he declared, recommending government consideration of an MSIC in Sydney. The parliamentary committee established by the Carr government to investigate the issue approved a very positive report only to, mysteriously, vote against it.
Meanwhile advocates were still risking jail time by running the Tolerance Room.
Things came to a head at the 1999 Drug Summit, an event that sought to tackle the growing issue of illicit drugs in NSW, where a majority of politicians from around the state voted for an MSIC. At this time, Kings Cross had the highest concentration of heroin deaths in the country.
On July 27, 1999, I took part in a press conference to announce that the Religious Sisters of Charity, a group of Catholic nuns, had accepted a NSW government invitation to open the country’s first MSIC. I remember standing around at the reception afterwards listening to an elderly nun recount the dilemma she and her sisters felt over the MSIC. They were compelled to accept, she said, because they believed it was what the founder of their order, Mary Aikenhead, and Jesus would have done. Even this battle-worn atheist had to fight back tears hearing her describe their journey.
The nuns were stopped in their tracks, however, when Cardinal Ratzinger, then head of the Congregation for the Doctrine of the Faith in the Vatican, later to become Pope Benedict XVI, strongly warned them to desist. Facing destitution if blacklisted by the Vatican, the sisters had no choice but to relent.
Another two years passed before the Sydney MSIC finally opened in May 2001, under the Uniting Church, with Dr Ingrid van Beek as its foundation director. It has been a spectacular success. Almost a dozen major evaluations have been carried out, all with extremely positive findings. In fact, it was a Liberal state government that removed the centre’s temporary status.
MSICs around the world have been found to reduce the number of both fatal and non-fatal drug overdoses and the spread of blood-borne viral infections including HIV and hepatitis C. The centres save more money than they cost, with substantial savings from reduced ambulance callouts and health care. No increase in crime has occurred. No “honey-pot effect” has been demonstrated, with drug users attracted to the area.
Once again, Australia is experiencing rapidly increasing drug overdose deaths. Why when the need for MSICs is so great and the evidence is so compelling has it had to be such an uphill battle to establish a network of such centres in drug hotspots across the country?
The answer is inescapable. As long as Australia remains wedded to a failed and futile drug policy reliant on law enforcement to curtail drug availability, pragmatic interventions will be fiercely resisted. This has been the history of harm reduction in Australia, from methadone treatment for heroin dependence, to needle syringe programs and condom promotion to limit the spread of HIV.
Harm reduction and drug law reform eventually win these battles, but while drug abstinence remains the paramount objective, advocating pragmatism and evidence and human rights-based interventions will always be a Sisyphean task.
This article was first published in the print edition of The Saturday Paper on Jul 7, 2018 as "A hit of pragmatism". Subscribe here.