3   Needles in Nanaimo

Exclusionary Versus Inclusionary Approaches to Illicit Drug Users

Sydney Weaver

The best way out of addiction is overcoming dislocation by finding a secure place in a real community. (Alexander 2008, 340)

Policies designed to address illicit drug use are, on the whole, shaped less by concerns for the health and safety of drug users than by political and economic interests and mainstream community values, a pattern especially visible at the local level. At the same time, because no society is monolithic, the use of illicit drugs has spawned complex, controversial debates about the relative appropriateness and effectiveness of specific policy approaches and modes of intervention. In this chapter, I explore this debate as it unfolded over the first decade of this century in the small city of Nanaimo, British Columbia, which lies on the east side of Vancouver Island, roughly an hour’s drive north of Victoria. Originally a coal mining town, Nanaimo developed an economy founded on logging and commercial fishing. As income from these industries gradually waned and rates of unemployment rose, Nanaimo was obliged to reinvent itself in an effort to diversify its economic base. Already economically depressed, the city was particularly vulnerable to the cuts in funding for social services that followed the election, in 2001, of a provincial government committed to neoliberal principles of financial management—cuts that only exacerbated existing social and economic disparities.

Nanaimo’s efforts to develop a municipal policy to address illicit drug use occurred at a time when two competing approaches were available for consideration. One was the so-called war on drugs, a strategy in which drug users are implicitly viewed as enemy agents working to undermine the very moral values on which society rests. Unsurprisingly, the chief weapon in this war is law enforcement. The other was the Four Pillars approach, which combines law enforcement with three supportive measures: prevention, treatment, and harm reduction. A strategy that originated in Europe, the Four Pillars model was implemented in 2001 in Vancouver, a city located just across the Strait of Georgia from Nanaimo. The story of Nanaimo’s approach to managing illicit drug use turns on the tension between these alternatives. Clearly, the Four Pillars approach strives for greater flexibility and nuance, as well as situating addiction firmly within a public health framework. And yet, as I will argue below, it falls short of ideal.

Policy Approaches to the Management of Illicit Drug Use

In North America, efforts to regulate the consumption and distribution of narcotics date back to the years prior to World War I, when both Canada and the United States enacted laws restricting access to opiates and cocaine. The “war” on drugs was officially declared in 1971, however, when US President Richard Nixon announced that drug abuse had “assumed the dimensions of national emergency,” thereby requiring a “full-scale attack” to combat the problem.1 As a management strategy, however, the war on drugs has by most accounts been a dismal failure. Propelled by the cultivation of fear and enforced through forms of state violence, this policy approach has not only failed to reduce the incidence of problematic illicit drug use but has significantly exacerbated the health and social problems of drug users (Alexander 1990, 53–93; Boyd 2004; Boyd and Faith 1999). In addition, the war-on-drugs campaign successfully diverts public attention to the “drug addict” as criminal, thereby frustrating the recognition that habitual drug use is often an adaptive response to poverty, racism, dislocation, and trauma (Alexander 1990 and 2008; Boyd 1999, 177–182; Boyd 2004, 160–167; van Wormer and Davis 2003).

A structural analysis of the war-on-drugs policy reveals its racialized, gendered, and classist nature (Alexander 1990, 2001, 2008; Boyd 2004 and 2009; Nunn 2002). The retributive character of this approach relies on the cultivation of fear and of othering, ensuring the moral superiority of white middle-class individuals who use only licit drugs and only for legitimate medical reasons. The commitment of the public to financing the war on drugs is partially accomplished by harnessing the media in constructing marginalized people as dangerous, immoral deviants (Boyd 2004, 2009; Reinarman and Levine 2004; Taylor 2008; van Wormer and Davis 2003). As Boyd (2009, 32) observes, “Canadian and U.S. law enforcement . . . made sure that their stories and ‘construction’ of the illegal-drug user were supplied to journalists and politicians.” With the media fuelling condemnatory public opinion, criminalization strategies flourished in both the United States and Canada throughout the twentieth century. In Nanaimo, public fear of drug users has been a prominent factor in the struggle to address illicit drug use, one that has posed substantial challenges for social rights advocates, policy makers, and users.

The Four Pillars Model

Dissatisfaction with punitive approaches to illicit drug use was officially voiced in British Columbia in 1994, with the release of a report by the Office of the Coroner (British Columbia, Ministry of the Attorney General, 1994). The report, which presented the conclusions of a task force convened to investigate an upsurge in the number of deaths in the province from drug overdoses, was highly critical of the prevailing approach to illicit drug use, with its emphasis on the punishment of drug users via the criminal justice system. Arguing that the criminalization of drug use served primarily to aggravate surrounding social problems, the report recommended that addiction be understood as a health issue. Yet, despite its urging that immediate and decisive action be taken to address the inadequacies of the present approach, little came of the report (see MacPherson, Mulla, and Richardson 2006, 127–28).

The need for a more effective strategy was especially evident in Vancouver’s Downtown Eastside, which had a growing population of injection drug users. Recognizing that the war-on-drugs approach was not working, the City of Vancouver moved in 2001 to adopt a new policy, embedded in which was a more complex understanding of the nature of drug addiction and its origins. The new approach, outlined in A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver (MacPherson 2001), called for an equal focus on the four pillars of (1) prevention, aimed primarily at youth, in an effort to head off the problem; (2) treatment, including the development of various government-funded programs for users trying to abstain from drugs; (3) the enforcement of drug laws, to enhance public safety by curbing the drug trade and associated crimes; and (4) harm reduction, which involves the promotion of health practices designed to reduce health risks for users of illicit drugs, such as the transmission of HIV and hepatitis C. Among the more controversial harm reduction measures adopted in Vancouver were a needle exchange program, which would provide users with new, sterile syringes in exchange for used ones, and a safe injection site, which would offer a secure setting in which users can inject drugs under the supervision of a health care worker. In addition to preventing overdose deaths, such sites open channels of communication between drug users and support personnel, who can educate users about the health risks associated with mainlining drugs and help them connect with social and health services, including treatment programs.

The Four Pillars framework was imported to Vancouver from Europe. The first step consisted of fact-finding trips to various European cities (among them Geneva, Zurich, Frankfurt, and Amsterdam) made by a member of Vancouver’s social planning department and subsequently by local politicians, while the second entailed a similar trip by local activists, accompanied by representatives of local media. As McCann (2008, 1) points out, by adopting the Four Pillars approach, Vancouver distanced itself from the dominant ideological and legal framework that exists throughout Canada and from the entrenched American war-on-drugs perspective, ultimately earning itself a place in global discussions of drug policy. McCann (2008, 15) also describes the multi-layered complexity, fiscally and in terms of national and international contacts, that catalyzed the emergence of this policy. These are fortuitous, globalized, urban, sophisticated layers that Nanaimo, a small city off the mainland, does not possess.

Harm reduction offers substantial benefits, including significant improvements in user and community health, evident in reductions in fatal overdoses of illicit street drugs, new HIV diagnoses, and levels of street crime, as well as fewer discarded syringes (Alexander 2006, 118). Although these are noteworthy accomplishments, problems remain, chiefly in connection with the manner in which the Four Pillars framework has been implemented. Specifically, an unbalanced fiscal emphasis on enforcement has relegated the other three pillars of harm reduction, prevention, and treatment to lower-priority status. A review of Canada’s Drug Strategy as reformulated in 2003 revealed that “current federal spending on harm reduction initiatives which target HIV/AIDS and other serious harms is insignificant compared to the funds devoted to treatment and, particularly, enforcement”—even though the revised strategy promised “a balanced approach to reduce both the demand for and the supply of drugs through prevention, treatment, enforcement and harm reduction initiatives” (DeBeck et al. 2006, 10). It further appeared that “while controversial interventions supported through the Drug Strategy are being held to an extraordinary standard of proof, interventions receiving the greatest proportion of funding remain under-evaluated” (10). A similar pattern was noted following the introduction, in 2007, of the new National Anti-drug Strategy (see DeBeck et al. 2009). The net result of the federal bias towards enforcement has been to mirror the war-on-drugs policy that the Four Pillars approach was intended to replace.

The relative success of a Four Pillars approach depends, of course, on the social and political context in which it is implemented. The embrace of neoliberal principles of governance, both in British Columbia and in Canada as a whole, may have thwarted balanced funding of the four pillars, given the neoliberal emphasis on “small government,” which translates into an unwillingness to fund social services of the sort associated with the welfare state. In such an ideological environment, programs designed to provide support to drug users are unlikely to be high on the list of fiscal priorities. In addition, drug addiction does not accord well with the neoliberal emphasis on entrepreneurialism and productivity. As Alicia Sanderson (2011, 3) points out, the creation of North America’s first safe injection site in Vancouver’s Downtown Eastside met with “persistent and adamant resistance among high-level government officials in Canada and the United States.” Such resistance not only imposes fiscal constraints but also generates a moral climate that discourages compassion for individuals perceived as drains on the economy. Although addiction researchers in Canada have called attention to the benefits of harm reduction (see, for example, Hathaway and Tousaw 2008), as well as to the ineffectiveness of law enforcement and its potential to increase health risks among intravenous drug users (Werb et al. 2008; Wood et al. 2004), the emphasis continues to fall on punitive measures.

Despite its vulnerability to imbalances in implementation, the Four Pillars model clearly represents a more humane and more complex response to illicit drug use than does a strategy that relies primarily or entirely on law enforcement. At the same time, a deeper analysis of the Four Pillars model reveals significant limitations on its ability to effect long-term positive changes not only in the health of individual users but in the social framing of addiction. Bruce Alexander (2006, 121) argues that “social changes of the magnitude necessary to have a substantial impact on the problem of addiction are beyond the Four-Pillar Approach.” The social changes to which he refers to can be roughly summarized as the strengthening of social and community relationships, which, in his view, have eroded over time. In The Globalisation of Addiction, Alexander (2008, 3) points to “the growing domination of all aspects of modern life by free-market economics,” which has produced a society that “subjects people to unrelenting pressures towards individualism, competition, and rapid change, dislocating them from social life.” In these circumstances, community relationships that sustain the spirit are severely weakened or even destroyed, and individuals react to this sense of dislocation “by concocting the best substitutes they can for a sustaining social, cultural, and spiritual wholeness” (3). In other words, addiction is, in part, an adaptive response to an increasingly pervasive sense of loss and isolation.

This isolation of the individual from his or her social context is reinforced by the current health care framework, in which physiological good health is presumed to reflect an individual’s willingness to avoid risks and cultivate a healthy lifestyle. In this view, health is in large measure a matter of personal responsibility, and individuals are assumed to be capable of free choice. This shift towards individual accountability is problematic in many respects, but it has especially damaging consequences in the context of drug addiction. As Tim Buchanan (2004, 390) points out, such a perspective “risks pathologising problem drug users by holding them solely responsible for exercising poor choices and allowing themselves to drift into drug addiction,” tempting others “to embrace the view that problem drug use warrants no sympathy because it is a self-inflicted condition.” At the same time, an emphasis on individual agency “tends to promote pathological notions of dependence such as the addictive personality,” in an effort to account for the poor choices that culminate in this self-inflicted condition (390). What this focus on individual health neglects to acknowledge, Buchanan argues (2004), is that in many cases “problem drug use is largely a socially constructed phenomenon that has less to do with individual choice or physical dependence, and much more to do with the structural disadvantages, limited opportunities, alternatives and resources” (391).

Alexander (2008, 342) argues that, inasmuch as addiction is a response to the pain of social dislocation, drug treatment “will become more effective when it is oriented towards achieving or restoring psychosocial integration,” which he defines as the “profound interdependence between individual and society that normally grows and develops throughout each person’s lifespan” (58). To the extent that the Four Pillars framework fails to acknowledge the social embeddedness of addiction, its transformative power is severely curtailed. What is needed is a more inclusive and systemic approach that acknowledges the conditions that lie at the origins of drug addiction and, by fostering public understanding, can promote an attitude of compassion towards users. A social determinants of health model provides the theoretical basis for such an approach.

The Social Determinants of Health Model

Writing in Social Determinants of Health: The Canadian Facts, Juha Mikkonen and Dennis Raphael (2010, 7) argue that “the primary factors that shape the health of Canadians are not medical treatments or lifestyle choices but rather the living conditions they experience.” This insight is fundamental to any social determinants of health framework. According to a model developed in 2002, Canadians share fourteen basic social determinants of health: Aboriginal status, disability, early life, education, employment and working conditions, food insecurity, gender, health services, housing, income and income distribution, race, social safety net, social exclusion, and unemployment and job security (Mikkonen and Raphael 2010, 9). In other words, a person’s gender, race or ethnicity, and class, as well as presence or absence of a disability, determine that person’s relative ease of access to food, education, housing, health and social services, social capital, and a means to earn a livelihood. In turn, a person’s degree of access to these assets exerts a determining influence on the status of his or her health.

Those who become habitual users of illegal drugs could be analyzed from the standpoint of any one of these fourteen factors. I will focus here on social exclusion, however, simply because drug-addicted individuals—notably those who live in poverty and/or belong to racialized groups—tend to constitute a highly marginalized population. Social exclusion effectively denies certain citizens the opportunity to participate fully in society and thus to share equitably in its benefits. Describing the Canadian situation, Mikkonen and Raphael (2010, 32) observe that many features of our society combine to “marginalize people and limit their access to social, cultural and economic resources. Socially excluded Canadians are more likely to be unemployed and earn lower wages. They have less access to health and social services, and means of furthering their education. These groups are increasingly being segregated into specific neighborhoods.”

As Robin Peace (2001, 26) notes, social exclusion is often defined in relatively narrow economic terms, as referring to “poverty, income inequality, deprivation or lack of employment.” But such definitions fail to capture the psycho-social effects of exclusion. Citing reports on the European Union’s Poverty Programmes, Peace emphasizes that social exclusion must be recognized both as a dynamic process, rather than a static condition, and as multidimensional. Not only does it involve “a lack of resources and/or denial of social rights,” but it also frequently results “in multiple deprivations, the breaking of family ties and social relationships, and loss of identity and purpose” (26). In this respect, social exclusion contributes to the sense of dislocation that Alexander (2008) identifies.

In the case of drug users, social exclusion is often compounded by the stigma attaching to the fact of addiction, with addicts viewed as individuals lacking in self-discipline who have lost control over their lives (Room 2005). Such negative images are often compounded by other sources of stigma, such as poverty, homelessness, or a history of incarceration, which have been shown to exert an adverse impact on the health of drug users (Galea and Vlahov 2002). In addition, social processes of exclusion are fed by the media’s tendency to draw connections among illicit drug use, race, and crime, thereby fuelling public fears about the “drug problem” and serving to create and sustain an atmosphere of moral panic (Altheide 1997; Boyd 2009; Eby 2009; Chiricos, Eschholz, and Gertz 1997). Somewhat ironically, efforts to exclude certain individuals from the broader public place a significant financial burden on that public—reflected, for example, in hospitalization costs for homeless persons (Hwang et al. 2011; United Kingdom, ODPM 2004, 8) as well as in the diversion of public resources, including police, into enforcement measures that often prove ineffective (Wood et al. 2004).

The potential benefits of a socially inclusive approach to problem drug use can to some extent be inferred from the positive results obtained by the adoption of a restorative justice framework in the area of corrections. Whereas incarceration isolates offenders from the society at large, restorative justice seeks to maintain social connectedness by bringing together the offender, the victim(s), and the community with a view to reparation. In this “process of coming together to restore relationships,” reconciliation becomes possible between the wrongdoer and the wronged, while “the community is also provided with an opportunity to heal through the reintegration of victims and offenders” (Latimer, Dowden, and Muise 2005, 129). Research into the outcome of restorative justice programs not only reveals reduced rates of recidivism (van Wormer 2003; Latimer, Dowden, and Muise 2005, 137) but also, and perhaps more importantly, psychological benefits to all involved, deriving above all from the strengthening of relationships. As a UK government report, Tackling Social Exclusion, notes, a restorative justice approach implemented by Bradford’s Youth Offending Team “has linked young offenders to the (often socially excluded) victims of their crimes, such as older people, in a way which has reduced some of the isolation they previously experienced” (United Kingdom, ODPM 2004, 11). Similar psychosocial benefits would almost certainly accrue from efforts to draw drug users into the community.

Situating Nanaimo

Located roughly 110 kilometres north of Victoria, Nanaimo is the second largest city on Vancouver Island. As of the 2016 census, the Nanaimo metropolitan area had a population of 104,936 people, with roughly 90,000 residents living within the city limits. By contrast, the Victoria metropolitan area was home to nearly 368,000 people, while the population of Vancouver stood at over 4 million.2 However, population in itself does not define the small city. In setting forth an agenda for research on small cities, David Bell and Mark Jayne (2009, 689) suggest that “smallness can be more productively thought of in terms of influence and reach, rather than population size, density and growth,” which points to the challenge that small cities face in developing a “competitive advantage in the global urban hierarchy.” Recognizing the need to expand its economic base, Nanaimo embarked during the 1990s on efforts to extend its influence and reach, drawing on its strategic location as a port city in reasonable proximity both to the capital of British Columbia (Victoria) and to its largest metropolitan centre (Vancouver). Central to these efforts was the development of the downtown waterfront area as a tourist destination, as well as the construction of the Port of Nanaimo Centre, which houses conference facilities. As economic planners were aware, the city’s task was to create “a positive image that communicates to outsiders that Nanaimo is an attractive and supportive place to live and invest” (Sailor 2010, 143).3

Almost inevitably, the decline of traditional industries creates a population of individuals who are not only unemployed but, in some sense, unemployable, in that their skills do not mesh with the needs of the new economy. Economic dislocation thus tends to produce not merely poverty and food insecurity but a sense of purposelessness and futility—conditions that easily give rise to social problems. In 2001, Nanaimo’s unemployment rate stood at 11.6 percent, compared to the provincial average of 8.5 percent, with male participation in the labour force having declined between 1996 and 2001 from 71.5 percent to 65.9 percent (2001 census figures, cited in NWGH 2003, 9, 8). Nanaimo’s struggle to carve itself a niche in a globalizing economy was thus complicated by an increase in visible homelessness, a trend noted by the BC Ministry of Health in its 1999 annual report (British Columbia, Office of the Provincial Health Officer 2000, 40). In Reducing Homelessness: A Community Plan for Nanaimo, BC, the Nanaimo Working Group on Homelessness (2003) argued, however, that the city’s “greater concern” lay with the degree of “relative homelessness” in Nanaimo, a problem that reflected both “generational poverty and structural and transitional problems in the local and regional economy” (NWGH 2003, 8).4

Nanaimo’s difficulties were doubtless intensified by Canada’s embrace of neoliberal principles of economic and social management. Neoliberalism holds that “human well-being can be best advanced by maximizing entrepreneurial and individual freedoms through the unrestricted flow of capital,” a proposal that “functions best under a framework characterized by free markets, free trade, and individual liberty” (Sailor 2010, 7). Among other things, this ideology translates into a reduction in government support for social services, on the theory that these can be provided more efficiently through private-sector competition (despite considerable evidence to the contrary). At the federal level, neoliberalism entails efforts to “shrink” government by offloading fiscal responsibilities onto provinces and municipalities. Lacking adequate sources of local revenue, smaller municipalities (such as Nanaimo) often have little choice but to pursue private-sector business investments and corporate partnerships and/or to attract tourist dollars.

Nanaimo’s response to the growing visibility of homelessness and drug addiction developed within this rather unforgiving neoliberal framework. Local social service providers and advocacy groups were, of course, well aware of the negative effect of funding cuts on both clients and workers. The 2003 report issued by the Nanaimo Working Group on Homelessness noted that agencies responding to the needs of drug users were under tremendous strain, with substantial waitlists for services (NWGH 2003, 19). Nor did a homeless population of drug users dovetail well with Nanaimo’s plans to gentrify its waterfront.

A Shift in Discourse: The Evolution of City Policy

Between 2003 and 2008, the City of Nanaimo commissioned a series of reports relating to social development, homelessness, and illicit drug use. These reports, which provide insight into Nanaimo’s struggle to address the social problem of drug use, were supplemented by two action plans drawn up by the Nanaimo Working Group on Homelessness. Also included in this analysis is the only report that focused specifically on developing an alcohol and drug strategy (NADAC Strategy Working Group 2006). I analyze these reports through a social determinants of health lens, with specific reference to social exclusion.

In 2003, Nanaimo’s Social Development Strategy Steering Committee commissioned a social status report for the city, as a first phase in the creation of a social development strategy. The resulting report (John Talbot and Associates 2003) describes the situation in Nanaimo at that time in terms of its economy and key social determinants such as education, health, housing, and participation. Also produced in 2003 was Reducing Homelessness: A Community Plan for Nanaimo, BC (NWGH 2003). This report, prepared by the Nanaimo Working Group on Homelessness, identifies population groups at risk of homelessness, among them “people suffering from addiction”—a population that overlaps with virtually all of the other target groups, which include “people living with or at risk of HIV/AIDS, Hepatitis C, or other communicable diseases” and “people living with mental illness” (4). Poverty and social exclusion are significant themes throughout this report, reflecting a structural analysis of homelessness, and housing is appropriately described as an important social determinant of health. The report recommends a continuum of services and a communication strategy that aims to inform the public of the social and fiscal costs of homelessness. This latter recommendation is crucial to garnering public investment; the report notes that in the past, communication strategies were recommended but “not fully implemented” (28).

In 2004, by way of a follow-up to the 2003 social status report, the city released a report that proposed a social development strategy for Nanaimo (John Talbot and Associates 2004). Intended as a response to “high rates of income assistance, increasing homelessness and poverty, persistently high unemployment levels and substance misuse issues” (ii), the report was based on consultation with approximately five hundred people, including a focus group with lone and young parents and “an alcohol and drug focus group” (4). The report calls for an “inclusive” community that facilitates “social and intergenerational interaction” and “optimizes community and family support systems” (8). These proposals reflect a social inclusion model; indeed, one of the report’s five main themes is inclusiveness. Also noted in this report is the public’s lack of understanding of illicit drug use and how this contributes to sparse funding for relevant services (23). However, this concern with public ignorance is not reflected in the report’s recommendations. Although the report emphasizes the importance of viewing illicit drug use as a health, not a criminal, issue, recommendations focus on enforcement rather than on public education and strategies to achieve social inclusion.

In 2005, the City of Nanaimo, under pressure from service providers, commissioned a study of the impact of recent zoning changes on the provision of social services (NWCI 2005). The new zoning bylaw, which had been provisionally adopted in February 2005, prohibited “social service resource centres,” such as food banks, facilities that offer free meals or used clothing, and drop-in centres, from operating within the city limits. (The one exception was a Salvation Army facility.) An equally hostile spatial exclusion effort was reflected in the outright ban on any “drug addiction treatment facilities,” such as “methadone clinics, needle exchanges, safe injection sites (of which there are none at present in Nanaimo) and any other centre that treats persons with substance abuse problems” (4). Although service providers had expressed concerns to city council prior to the passing of the new zoning bylaw, city council temporarily overrode these concerns. The bylaw was, however, adopted on the understanding that the City of Nanaimo would commission a report to evaluate whether the service providers’ concerns were legitimate.

In the resulting report, Neilson-Welch Consulting provides a window onto the highly contested issue of illicit drug use in Nanaimo. The report describes a web of fear, experienced by all stakeholders, as both prominent and problematic: “In NWCI’s view, the environment in which the zoning changes affecting service providers were conceived and adopted can be characterized as one of fear. Each of the key players in Downtown Nanaimo—business, the City, residents, social service providers—sees the signs of stress in VCAND and experiences a sense of fear” (NWCI 2005, 7–8).5 The report describes how this pervasive fear fostered mistrust, negatively affected relationships among key players, and perpetuated a divisive “us and them” dynamic among stakeholders (9). The consultants argue that the zoning changes “divide rather than strengthen the community” (13) and that “proponents of the zoning changes are attempting to control a factor that they will be unable to control” (12)—namely, the physical location of people in need of social services. The insights revealed in this report highlight the importance—to city council, to the public, and to business interests—of the control and ownership of public space. These territorial efforts to spatially exclude service providers signify the intensity of fear and hostility related to illicit drug use.

The NWCI report goes on to argue that supporters of the zoning bylaw overlook two important considerations. The first concerns the capacity of service providers to manage their operations in a way that minimizes any negative impact on the area in which they are located (NWCI 2005, 12). The report thus redirects the gaze from where service providers are located to how they deliver services. As the authors further observe, “the other issue that is lost under zoning is the importance of collective action in dealing with the signs of stress” (12). The report then calls on social service providers in the area to “initiate a process of building community acceptance,” to “educate clients,” and to “support and hold each other accountable” (22–23). While the authors recognize the strain on service providers’ already scarce resources, they argue that “providers that are unable or unwilling to commit such resources should not expect to operate in Nanaimo” (23). In addition, the report encourages client groups to recognize the need for a “balance of rights and responsibilities,” with the former defined as “the rights of clients to access important services” and the latter as “respecting the needs and recognizing the concerns of the neighbourhood in which the services are located” (31).

The rights and responsibilities framework was taken up by the city, if perhaps in a somewhat lopsided fashion. As a local government official commented in an interview: “We think that there’s dignity in reciprocity. In other words, if you’re going to provide someone with those services, then what we ask you to do is be clear with them that when they go into the public realm, there’s certain expectations about how they conduct themselves. So it’s not a free lunch.” If it were applied across the board, a rights and responsibility framework might have potential to guide policy founded on principles of social inclusion, but, as conceived in the report, it extends only to service users and providers. The NWCI report does discourage the city from adopting an enforcement approach to the new requirements for service providers, noting that enforcement is not “consistent with the cooperative approach being promoted” (NWCI 2005, 26). At the same time, “targeted enforcement” and an increased police presence focused on illicit drug users form part of the report’s recommended strategy (29).

In naming fear and divisive sentiments among stakeholders, emphasizing a spirit of cooperation, providing some strategies to facilitate cooperation, and including a few service users in planning decisions, the NWCI report differs to some extent from others. However, while the report recommends dialogue and cooperation, urging both businesses and residents to communicate with service providers, the bulk of the responsibility is assigned to service providers. Instead, the report might also have proposed increased responsibility for the city government, including recommendations that the city address the public fear that seemed to drive city council’s decision to adopt the new zoning bylaw prior to its review and that it also identify and attempt to overcome obstacles to communication among all stakeholders.

In 2006, the NADAC Strategy Working Group, in collaboration with various local agencies, prepared a report titled Process for Developing an Alcohol and Drug Strategy for Nanaimo. Describing itself as a “coalition of community, government and non-government agencies concerned with the alcohol and drug problem in Nanaimo and committed to action that will reduce the harm within our community,” NADAC—the Nanaimo Alcohol and Drug Action Committee—resided within the Nanaimo Youth Services Association and was chaired by the association’s director.6 As would be expected, this resulted in the strategy’s emphasis on youth, an emphasis also visible in NADAC’s source of funding, the Nanaimo Addiction Foundation. Although young people are the standard target of measures aimed at prevention, an analysis of the homeless population in Nanaimo revealed that, at the time, middle-aged men formed the majority of the homeless, drug-using population: “Males outnumbered females by a wide margin: 59 males (61%) to 38 females (39%)” (Tubbs 2008, 5). The median age of Nanaimo’s homeless rose from 35.6 years in 2005 to 41.39 years in 2008; of 302 homeless counted in Nanaimo in 2008, “only ten clients report that they do not use alcohol or drugs” (4). Thus, the majority of Nanaimo’s homeless, illicit-drug-using population, adult men, were excluded from the city’s only official alcohol and drug strategy.

Evidently, “action that will reduce the harm within our community” did not extend to reducing harm to drug users—perhaps on the unspoken assumption that they are not part of “our community.” Indeed, the NADAC report (2006, 7) cites numerous American government resources that promote a punitive war-on-drugs discourse, resources that have already been demonstrated to be marked by racism, classism, and sexism (Boyd and Faith 1999; Nunn 2002; Reinarman and Levine 2004). Rather than emphasizing how certain social determinants negatively affect health, the NADAC report simply notes that marginalization on the basis of “race, Aboriginal status, class background, disability, homelessness and addiction or fetal alcohol effects” has been shown to correlate with the risk of being “involved in crime” (7).

Had a structural analysis been undertaken in this report, the discussion could have been moved towards a social determinants of health model, one in which the vulnerabilities of marginalized youth would be addressed through social inclusion measures such as family counselling, employment opportunities, and supported housing (see March, Oviedo-Joekes, and Romero 2006). Although the report calls for a “paradigm shift in political will and public acknowledgment” and underscores the need “for all citizens to become healthy and productive” (NADAC Strategy Working Group 2006, 18), the strategy itself reflects a less than inclusive approach. The report recommends a “community consultation process,” but the homeless and/or users of illicit drug users are not listed as target groups for consultation (27). Consultation with these citizens could have helped NADAC’s working group better understand the impact of social exclusion on health and thus develop a more comprehensive and effective strategy. Given that no follow-up reports were issued, it is unclear how far city policy was influenced by NADAC’s recommendations.

In 2008, the City of Nanaimo commissioned CitySpaces Consulting to develop a Harm Reduction and Housing Action Plan that would address “the increasing problems of homelessness and the related challenges of mental illness and drug addiction” (CSC 2008b, 1). The result was a series of three reports. The first, A Response to Homelessness in Nanaimo: A Housing First Approach—Relevant Best Practices, documents the need for low-barrier housing in Nanaimo and describes a series of best practices illustrated by initiatives in other cities that have proved effective. The Housing First model is based on the premise that “stable housing enables individuals to better address their barriers to employment, addictions, and poor health” (3) and stipulates that the provision of housing should not be contingent upon certain preconditions, such as abstinence from illicit drug use. Noting that municipalities have often been reluctant to take the lead in initiatives to address homelessness, the report significantly assigns a number of key roles to municipal government, including advocacy, problem solving, and the building of partnerships (CSC 2008a, 9). As the authors point out, “While many communities have made strides towards adopting housing first approaches and introducing significant initiatives to respond to homelessness, there continues to be opposition. Community leadership is essential to raise awareness and foster cooperation among major stakeholders” (9–10).

The second report builds on the first, detailing the need for harm reduction and Housing First services in Nanaimo (CSC 2008b). Two focus groups informed this second document, one made up of business owners and the other of service providers. Also consulted were health authority representatives, the RCMP, and presidents of neighbourhood associations—and, perhaps most important, five homeless persons were interviewed. The report identifies “balancing enforcement and service delivery” as one of the challenges faced by the city (17). CitySpaces also noted continuing problematic public attitudes, apparent in “community reluctance to reward bad behaviour” and a belief that “addicts choose their lifestyle and therefore are not deserving of help until they clean themselves up” (18; emphasis in the original).

As the report notes at the outset, harm reduction aims to “ensure that the most vulnerable and the most street-entrenched individuals have access to a range of services that will minimize harm and enable them to pursue their goals towards recovery and stability” (CSC 2008b, ES-2). This approach is an improvement on the war-on-drugs approach, but strategies are still needed to counter public opposition to harm reduction practices and to incorporate these practices into a broader framework that promotes social inclusion. As noted above, public preconceptions, which give rise to a process of othering, present an obstacle for current and former drug users who are attempting to achieve social integration. Julian Buchanan (2004, 395) explains: “For many problem drug users relapse is not simply the result of physical craving or a lack in motivation, but it is a direct consequence of a frustration and inability to secure a position in normal community life and establish everyday routines.” In other words, the spatial and moral exclusion of drug users only makes it that much more difficult for them to work towards recovery. Although Housing First initiatives are a step towards social inclusion, disparaging attitudes on the part of the public may compromise the benefits of such initiatives, effectively sabotaging positive outcomes.

The final report by CitySpaces Consulting lays out an eight-point action plan to reduce homelessness in Nanaimo and improve the quality of life for the city’s most vulnerable citizens (CSC 2008c). Noting that earlier efforts to tackle homelessness have tended to be “disjointed and under-resourced,” the report emphasizes the need to mobilize broad support for a “comprehensive and cohesive response” to a continuing problem (13). Indeed, noteworthy among the eight points is “Facilitate community acceptance.” The plan described in the report focuses on harm reduction strategies under the broader umbrella of a Housing First approach, which was to be implemented in Nanaimo through collaboration with the Vancouver Island Health Authority and BC Housing. The Action Plan developed by CitySpaces was adopted by Nanaimo City Council in 2008. According to one city official, approval of the plan “led to the signing of a Memorandum of Understanding with BC Housing in November of 2008 and funding commitments in 2009 and 2010 to construct 160 units of low-barrier housing on five sites throughout the City” (pers. comm., 2011).7

As is evident from these three reports, a shift towards a discourse of inclusion—however clumsy and piecemeal, and however contested by the business community and the public—did occur. This important shift could be sustained and enhanced if Nanaimo were to adopt a social determinants of health framework. This framework would support the public education needed to foster social inclusion. For instance, the city could provide information distributed by the Vancouver Island Health Authority (VIHA) about the social factors that contribute to illicit drug use. In 2006, VIHA released a discussion paper on the social determinants of health, which describes Nanaimo as “among the worst-performing areas in the province,” as measured by a composite socioeconomic index based on “economic hardship, crime, health, education, children-at-risk and youth-at-risk” (VIHA 2006, 3). Nanaimo was also identified as one of the three areas with the highest level of income inequality (17). Greater public awareness of this situation could precipitate a shift in public perceptions of drug users and increased support for Housing First initiatives.

The VIHA report (2006, 23) notes the existence in BC of high levels of social exclusion among people who are unable to work or are unemployed, as well as among recipients of social assistance (23). In addition, people with physical or mental disabilities often struggle with social exclusion, and the report further recommends that action be taken to enable such people to “participate more fully in the opportunities afforded by their communities” (26). Nanaimo’s challenge lies in translating observations about the importance of social inclusion into policy. Harm reduction services, such as those offered in Nanaimo by NARSF Programs Ltd., make a significant contribution towards social inclusion and health promotion for citizens struggling with addiction.8 But shifts in the direction of policy and the allocation of resources must be accompanied by educational initiatives that emphasize the social context of illicit drug use and the costs of social exclusion to taxpayers, the individual, and the economy.9 Such educational efforts would help to foster public support for harm reduction practices and for programs designed to promote social inclusion measures, which would increase the likelihood of improved funding of such initiatives.

Analysis of the Nanaimo Strategy

Spatial Exclusion

Nanaimo’s attempts to resuscitate its economy by attracting both business investments and a tourist trade gave rise to a range of legal sanctions and bylaws that aimed to “disappear” the already marginalized from potentially revenue-generating public spaces. In 2005, the RCMP introduced a “multi-pronged approach” to the management of Nanaimo’s growing street population (see CSC 2008b, 6–7). This approach combined surveillance and law enforcement with modifications to the built environment (in accordance with a strategy known as Crime Prevention Through Environmental Design) and with the spatial exclusion of the homeless in the form of two red zones. Although the creation of red zones led to a “marked reduction in visible homelessness and open drug use” in the red-zoned areas, it did so with the predictable result: “Many of the visible homeless and street-entrenched population were pushed out of downtown and into neighbouring areas” (7). As is well recognized, such tactics of dispersal merely move a problem around: as the report noted, no evidence existed to suggest any actual reduction in the number of homeless. In fact, as service providers pointed out, the use of red zoning increased health and safety risks for the homeless, in part by preventing access to crucial social services located in the downtown, and also contributed to “further criminalization of problems like addiction and mental illness” (7; emphasis in the original).10

The red zones were intended to support the revitalization of Nanaimo’s downtown by sparing the relatively affluent the sight of citizens deemed undesirable. Ultimately, the goal was to remove unsightly bodies and replace them with more “sightly” ones symbolic of health and prosperity. As the city official I interviewed put it, “You need young, talented, ambitious people from outside to come here,” adding that this is “the thing that appeals” to members of city council. The same official also spoke approvingly of the role of the RCMP (“God bless ’em”) in “busting up” groups of homeless drug users: “They’ll drag them around, so to speak, in small subgroups around the city, not allowing them to roost anywhere and to claim possession of a territory.” The metaphor is one of warfare, with society’s marginalized citizens cast in the role of enemy invaders who have no right to a home—not even on the street.

Public Perceptions of Drug Users

As we have seen, the report prepared in 2005 by Neilson-Welch Consulting called attention to the fears that fed into discussions of Nanaimo’s population of homeless drug users (see NWCI 2005, 7–9). Research has explored how fear can propel policy (see, for example, Allen 2000; Brinegar 2000; and Kingfisher 2007), a mechanism perhaps visible in the decision of Nanaimo City Council to implement its zoning bylaw prior to undertaking a review of the possible consequences (NWCI 2005, 1). Fears about the visible presence of “derelicts”—panhandlers, drug addicts, hookers, and so on—are often driven in part by concerns about property values or business investments, but they also reflect an equation of such individuals with potentially violent criminals, with the result that the marginalized are assumed to pose a threat to personal security. “They might choose your business next to do their crack in front of,” the city official I interviewed remarked of drug users, “and you’re not safe—no one is safe in this community from these people.”

Punitive public attitudes towards illicit drug users continue to plague Nanaimo (see, for example, Sterritt 2018). Although Nanaimo has taken concrete, visible action towards supporting a harm reduction, Housing First approach to drug addiction, these initiatives must be sustained by community education directed towards transforming public views of drug users, which is a critical first step in fostering social inclusion. As Room (2005, 152) points out, “psychoactive substance use occurs in a highly charged field of moral forces,” within which the processes of marginalization and stigmatization operate. Educating the public about such processes and the moral judgments that underlie them might help to shift community perceptions of drug users. If, for example, community members were informed about life events common to many users of illicit drugs—including domestic violence and abuse, trauma, and the experience of racism (see, for example, Bungay et al. 2010; Maté 2008; Shannon, Spittal, and Thomas 2007)—their fears might give way to a more sympathetic perspective. Advocacy groups and progressive city officials have a crucial part to play in promoting an understanding of addiction as a public health issue, in educating the public about the effects of social exclusion, and in evolving and supporting policies aimed at incorporating drug users into the community.

In particular, efforts must be made to offset the negative images that abound in the popular media, which in turn shape public perceptions. With regard to addiction, Alexander (2008, 367) emphasizes the need to produce and circulate information that can counter the existing “propaganda apparatus,” with the goal of “replacing the indoctrination system with communications media that foster psychosocial integration” (367). The Nanaimo Working Group on Homelessness was well aware of the need for an effective communications strategy. As the group noted in its Nanaimo Homelessness Partnering Strategy Action Plan (2007, 15), “past efforts, such as the Homelessness Action Week that broadened participation and public relations efforts, provided opportunities for improved sharing of information on activities, and strengthened relationships with policy makers and the media.”

Social Inclusion: A Way Forward

Drug users have historically experienced all four of the key components of social exclusion described by Mikkonen and Raphael (2010, 32): denial of participation in civil affairs, as a result of various legal and institutional mechanisms; access to social goods, such as housing, health care, and education; exclusion from social production, that is, from opportunities to participate in and contribute to social and cultural activities; and economic exclusion, in the form of the inability to access a means to livelihood. In Nanaimo, as elsewhere, these processes of exclusion have been reinforced by openly condemnatory public attitudes, against which advocates of harm reduction strategies must struggle. The efforts of advocacy groups and service providers such as the Nanaimo Working Group on Homelessness and Nanaimo and Area Resource Services for Families, combined with a commitment by social planners and city council members to effect change, have resulted in substantive movement towards social inclusion. These foundational steps are commendable, but Nanaimo needs to build on them.

As Alexander (2008, 58) argues, psychosocial integration—the antithesis of social dislocation—“reconciles people’s vital needs for social belonging with their equally vital needs for autonomy and achievement.” Efforts that aim at the social inclusion of drug users must attend to both sets of needs. In this connection, Alexander proposes that ways be found “to draw land out of the control of the market” (371)—in other words, to reclaim public space. Other steps towards achieving social integration include a revival of the local arts, which, as Alexander points out, are “a necessary part of the imagery that holds communities together, contributing to people’s sense of identity and shared meaning” (372), as well as activities that create a sense of community solidarity based not on uniformity but on “cultural fusion” (376–77). Municipalities can foster social integration by organizing and funding inclusive community events held in public spaces, by linking Housing First sites to community social and recreational activities, and by supporting creative, artistic initiatives that showcase the talents of marginalized citizens (such as Vancouver’s Hope in Shadows project, which highlights the photographic skills of residents of the city’s Downtown Eastside).

Buchanan (2004, 394) also recommends services for drug users that focus on “reorientation and reintegration,” including “befriending schemes, buddying programmes, mentoring schemes, structured day programmes, sheltered work programmes, voluntary work, and basic adult education.” As he points out, initiatives focused on the drugs themselves and/or on the individual user are doomed to fail; these must be accompanied by fundamental changes in both social conditions and public attitudes towards those trapped in addiction. Drug users, whether active or abstinent, require support in their endeavours to engage in active citizenship, whether through employment readiness programs, life skills training, or other opportunities to invest in meaningful lives. Nanaimo could bolster Housing First initiatives with additional strategies aimed at social inclusion, such as providing incentives to businesses to hire recovering addicts who are attempting to join the workforce, ensuring that low-income citizens can afford access to public recreational facilities, and creating opportunities for socially marginalized groups to participate in community events.

As Mikkonen and Raphael (2010, 32) remind us, socially excluded citizens are frequently denied access to participation in civic affairs. This mechanism of exclusion is visible in the formulation of social policy, which often occurs in the absence of any input from those at whom the policy is directed. Instead, drug users must be given a voice in the creation and shaping of policies and services that directly affect their lives. Not only must their contributions be actively sought, but their ability to contribute must be practically supported by the removal of obstacles that prevent them from participating in consultations and attending meetings. Research indicates that face-to-face personal contact between members of ostracized groups and dominant, nonstigmatized groups reduces prejudicial attitudes towards the homeless (Lee, Farrell, and Link 2004), towards persons with AIDS (Herek and Capitanio 1997), and towards persons living with mental illness (Reinke et al. 2004). In community and policy-making settings, face-to-face contact between users, former users, and other members of the community could prove extremely valuable in reshaping public attitudes and in revising drug users’ own self-image.

Efforts to undo social exclusion perhaps focus overmuch on fostering a sense of social belonging, at the expense of strengthening personal autonomy and the capacity for accomplishment—two qualities that are essential to our sense of self-worth and that addiction almost inevitably undermines. In developing future strategies, Nanaimo would do well to look for ways not only to help drug users become part of the community but also to grant them their right to autonomy and to present them with opportunities to achieve.

Conclusion

This review of Nanaimo’s efforts to manage illicit drug use reveals a lengthy and complex debate, one that speaks to both the challenges and the importance of reconciling a multiplicity of conflicting perspectives through a process of education and collaboration. I have argued that adopting a social determinants of health framework, in support of the goal of social inclusion, would allow for a more sustainable solution to the coexisting problems of homelessness and drug addiction in this small city. Central to achieving both spatial and social inclusion is education, a priority identified by the Nanaimo Working Group on Homelessness. Images of the “dangerous homeless drug addict” that have historically permeated public and political discourse must continue to be challenged and subverted. Writing about resistance to Vancouver’s safe injection site, Andrew Hathaway and Kirk Tousaw (2008, 13) emphasize the power of arguments founded on human rights. While acknowledging that “popular perceptions of addiction and drug use have slowly been destabilised by evidence-based knowledge,” they go on to point out that, in Vancouver, “social activists bridged chasms that research evidence could not in forcing recognition that ‘addicts’ are sons and daughters, brothers, sisters, parents” (13).

Efforts aimed at reducing fear and positioning drug addiction as a health issue forms the basis for increased public tolerance, paving the way for the introduction of socially inclusive policies and practice. Fostering public understanding of drug addiction could take a variety of innovative forms, including posters in public places, community “town hall” events featuring speakers and short plays, radio spots, and interviews with drug users focusing on life circumstances—such as poverty, domestic violence, sexual abuse, or systemic discrimination—that contributed to their addiction. With this foundation of education aimed at engendering public acceptance, subsequent efforts to develop “user-friendly” public spaces, to encourage drug users to participate in community activities, and to provide these marginalized citizens with opportunities for work or education would be better supported.

More than a decade ago, in the discussion paper in which it recommended the adoption of a social determinants of health framework, the Vancouver Island Health Authority observed: “The kind of communities that we develop is a more important determinant of the health status of the population than the kind of health care system we construct” (VIHA 2006, 27). It added that whether “we are willing to act on this knowledge” is something that “remains to be seen” (27). By taking such action, Nanaimo could position itself as an innovative leader in managing drug addiction and provide an example of hope to other small cities struggling with poverty, homelessness, and drug use in a political and economic climate hostile to those disadvantaged by neoliberal policies. Enlightened health leadership and progressive civic leadership can certainly contribute to building more compassionate and inclusive communities. Ultimately, however, the impetus to change must come from the people who live in those communities.

References

Alexander, Bruce K. 1990. Peaceful Measures: Canada’s Way Out of the “War on Drugs.” Toronto: University of Toronto Press.

———. 2001. The Roots of Addiction in Free Market Society. Vancouver, BC: Canadian Centre for Policy Alternatives.

———. 2006. “Beyond Vancouver’s ‘Four Pillars.’” International Journal of Drug Policy 17 (2): 118–23.

———. 2008. The Globalisation of Addiction: A Study in Poverty of the Spirit. Oxford: Oxford University Press.

Allen, Tom C. 2000. Someone to Talk to: Care and Control of the Homeless. Halifax: Fernwood Publishing.

Altheide, David L. 1997. “The News Media, the Problem Frame, and the Production of Fear.” Sociological Quarterly 38 (4): 647–68.

Bell, David, and Mark Jayne. 2009. “Small Cities? Towards a Research Agenda.” International Journal of Urban and Regional Research 33 (3): 683–99.

Boyd, Susan C. 1999. Mothers and Illicit Drugs: Transcending the Myths. Toronto: University of Toronto Press.

———. 2004. From Witches to Crack Moms: Women, Drug Law, and Policy. Durham, NC: Carolina Academic Press.

———. 2009. Hooked: Drug War Films in Britain, Canada, and the United States. Toronto: University of Toronto Press.

Boyd, Susan C., and Karlene Faith. 1999. “Women, Illegal Drugs, and Prison: Views from Canada.” International Journal of Drug Policy 10 (3): 195–207.

Brinegar, Sarah J. 2000. “Response to Homelessness in Tempe, Arizona: Public Opinion and Government Policy.” Urban Geography 21 (6): 497–513.

British Columbia. Ministry of the Attorney General. 1994. Report on the Task Force into Illicit Narcotic Overdose Deaths in British Columbia. Burnaby, BC: Office of the Coroner, Ministry of the Attorney General.

British Columbia. Office of the Provincial Health Officer. 2000. A Report on the Health of British Columbians: Provincial Health Officer’s Annual Report, 1999. Victoria, BC: Ministry of Health and Ministry Responsible for Seniors.

Buchanan, Julian. 2004. “Missing Links? Problem Drug Use and Social Exclusion.” Probation Journal 51 (4): 387–97.

Bungay, Vicky, Joy L. Johnson, Colleen Varcoe, and Susan C. Boyd. 2010. “Women’s Health and Use of Crack Cocaine in Context: Structural and ‘Everyday’ Violence.” International Journal of Drug Policy 21 (4): 321–29.

Chiricos, Ted, Sarah Eschholz, and Marc Gertz. 1997. “Crime, News and Fear of Crime: Toward an Indentification of Audience Effects.” Social Problems 44 (3): 342–57.

CSC (CitySpaces Consulting). 2008a (January). A Response to Homelessness in Nanaimo: A Housing First Approach—Relevant Best Practices. Prepared for the City of Nanaimo. Victoria, BC: CitySpaces Consulting. https://www.nanaimo.ca/assets/Departments/Community~Planning/Social~Planning/Nanaimos~Response~to~Homelessness~Action~Plan/080107_Nanaimo_BP_Research_MG.pdf.

———. 2008b (May). A Response to Homelessness in Nanaimo: A Housing First Approach—Situational Analysis. Prepared for the City of Nanaimo. Victoria, BC: CitySpaces Consulting. https://www.nanaimo.ca/assets/Departments/Community~Planning/Social~Planning/Nanaimos~Response~to~Homelessness~Action~Plan/080507_Nanaimo_Situational.pdf.

———. 2008c (July). Nanaimo’s Response to Homelessness: Action Plan. Prepared for the City of Nanaimo. Victoria, BC: CitySpaces Consulting. http://www.nanaimo.ca/assets/Departments/Community~Planning/Social~Planning/Nanaimos~Response~to~Homelessness~Action~Plan/080707_Nan_Strategy.pdf.

DeBeck, Kora, Evan Wood, Julio Montaner, and Thomas Kerr. 2006. “Canada’s 2003 Renewed Drug Strategy: An Evidence-Based Review.” HIV/AIDS Policy and Law Review 11 (2): 1, 5–12.

———. 2009. “Canada’s New Federal ‘National Anti-drug Strategy’: An Informal Audit of Reported Funding Allocation.” International Journal of Drug Policy 20 (2): 188–91.

Eby, David. 2009. “Closing Ceremonies: How Law, Policy and the Winter Olympics are Displacing an Inconveniently Located Low-Income Community in Vancouver.” Planning Theory and Practice 10 (3): 395–418.

Galea, Sandro, and David Vlahov. 2002. “Social Determinants and the Health of Drug Users: Socioeconomic Status, Homelessness, and Incarceration.” Public Health Reports 117 (Suppl. 1): S135–45.

Hathaway, Andrew D., and Kirk I. Tousaw. 2008. “Harm Reduction Headway and Continuing Resistance: Insights from Safe Injection in the City of Vancouver.” International Journal of Drug Policy 19 (1): 11–16.

Herek, Gregory M., and John P. Capitanio. 1997. “AIDS Stigma and Contact with Persons with AIDS: Effects of Direct and Vicarious Contact.” Journal of Applied Social Psychology 27 (1): 1–36.

Hwang, Stephen Wesley, James Weaver, Tim Aubry, and Jeffrey S. Hoch. 2011. “Hospital Costs and Length of Stay Among Homeless Patients Admitted to Medical, Surgical, and Psychiatric Services.” Medical Care 49 (4): 350–54.

John Talbot and Associates. 2003. Social Development Strategy for Nanaimo—Phase 1: Social Status Report. Prepared for the Social Development Strategy Steering Committee, City of Nanaimo. Burnaby, BC: John Talbot and Associates. https://www.nanaimo.ca/assets/Departments/Community~Planning/Social~Planning/Social~Development~Strategy/Soc_Status_Rpt.pdf.

———. 2004. Social Development Strategy for Nanaimo. Prepared for the Social Development Strategy Steering Committee, City of Nanaimo. Burnaby, BC: John Talbot and Associates. https://www.nanaimo.ca/assets/Departments/Community~Planning/Social~Planning/Social~Development~Strategy/Soc_Dev_Strategy.pdf.

Kingfisher, Catherine. 2007. “Discursive Constructions of Homelessness in a Small City in the Canadian Prairies: Notes on Destructuration, Individualization, and the Production of (Raced and Gendered) Unmarked Categories.” American Ethnologist 34 (1): 91–107.

Latimer, Jeff, Craig Dowden, and Danielle Muise. 2005. “The Effectiveness of Restorative Justice Practices: A Meta-analysis.” Prison Journal 85 (2): 127–44.

Lee, Barrett A., Chad R. Farrell, and Bruce G. Link. 2004. “Revisiting the Contact Hypothesis: The Case of Public Exposure to Homelessness.” American Sociological Reivew 69 (1): 40–63.

MacPherson, Donald. 2001. A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver. Vancouver: City of Vancouver. http://www.communityinsite.ca/pdf/frameworkforaction.pdf.

MacPherson, Donald, Zarina Mulla, and Lindsey Richardson. 2006. “The Evolution of Drug Policy in Vancouver, Canada: Strategies for Preventing Harm from Psychoactive Substance Use.” International Journal of Drug Policy 17 (2): 127–32.

Mair, Andrew. 1986. “The Homeless and the Post-industrial City.” Political Geography Quarterly 5 (4): 351–68.

March, Joan Carles, Eugenia Oviedo-Joekes, and Manuel Romero. 2006. “Drugs and Social Exclusion in Ten European Cities.” European Addiction Research 12 (1): 33–41.

Maté, Gabor. 2008. In the Realm of Hungry Ghosts: Close Encounters with Addiction. Toronto: Vintage Canada.

McCann, Eugene J. 2008. “Expertise, Truth, and Urban Policy Mobilities: Global Circuits of Knowledge in the Development of Vancouver, Canada’s ‘Four Pillar’ Drug Strategy.” Environment and Planning A 40 (4): 885–904.

Mikkonen, Juha, and Dennis Raphael. 2010. Social Determinants of Health: The Canadian Facts. Toronto: School of Health Policy and Management, York University.

NADAC Strategy Working Group. 2006. Process for Developing an Alcohol and Drug Strategy for Nanaimo. Nanaimo, BC: Nanaimo Alcohol and Drug Action Committee.

Nunn, Kenneth B. 2002. “Race, Crime and the Pool of Surplus Criminality: Or Why the ‘War on Drugs’ Was a ‘War on Blacks.’” Journal of Gender, Race, and Justice 6: 381–445.

NWCI (Neilson-Welch Consulting Inc.). 2005. City of Nanaimo Social Services Study: Report. Prepared for the City of Nanaimo. Kelowna, BC: Neilson-Welch Consulting Inc. https://www.nanaimo.ca/assets/Departments/Community~Planning/Publications~and~Forms/Soc_Serv_Study.pdf.

NWGH (Nanaimo Working Group on Homelessness). 2003. Reducing Homelessness: A Community Plan for Nanaimo, BC. Nanaimo: City of Nanaimo.

———. 2007. Nanaimo Homelessness Partnering Strategy Action Plan, 2007–2009. Nanaimo: City of Nanaimo.

Peace, Robin. 2001. “Social Exclusion: A Concept in Need of Definition?” Social Policy Journal of New Zealand 16: 17–35.

Reinarman, Craig, and Harry G. Levine. 2004. “Crack in the Rearview Mirror: Deconstructing Drug War Mythology.” Social Justice 31 (1–2): 182–199.

Reinke, Rebecca R., Patrick W. Corrigan, Christoph Leonhard, Robert K. Lundin, and Mary Anne Kubiak. 2004. “Examining Two Aspects of Contact on the Stigma of Mental Illness.” Journal of Social and Clinical Psychology 23 (3): 377–89.

Room, Robin. 2005. “Stigma, Social Inequality, and Alcohol and Drug Use.” Drug and Alcohol Review 24 (2): 143–55.

Sailor, Lisa E. 2010. “Conditioning Community: Power and Decision-Making in Transitioning an Industry-Based Community.” PhD diss., Department of Recreation and Leisure Studies, University of Waterloo, Waterloo, Ontario.

Sanderson, Alicia. 2011. “Insite as Representation and Regulation: A Discursively-Informed Analysis of the Implementation and Implications of Canada’s First Safe Injection Site.” Master’s thesis, Department of Criminology, University of Ottawa, Ottawa.

Shannon, Kate, Patricia Spittal, and Vicky Thomas. 2007. “Intersections of Trauma, Substance Use, and HIV Vulnerability Among Aboriginal Girls and Young Women Who Use Drugs.” In Highs and Lows: Canadian Perspectives on Women and Substance Use, edited by Nancy Poole and Lorraine Greaves, 169–75. Toronto: Centre for Addiction and Mental Health.

Sterritt, Spencer. 2018. “City of Nanaimo Rejects Chase River Location for $7 Million Supportive Housing Project.” Nanaimo News NOW, 19 February. http://nanaimonewsnow.com/article/569426/city-nanaimo-rejects-chase-river-location-7-million-supportive-housing-initiative.

Taylor, Stuart. 2008. “Outside the Outsiders: Media Representations of Drug Use.” Probation Journal 55 (4): 369–87.

Tubbs, Rebecca. 2008. Continuing and Shifting Patterns in Nanaimo’s Homeless Population: Based on the September 2008 Homeless Count. Nanaimo, BC: Nanaimo Working Group on Homelessness. http://www.nanaimo.ca/assets/Departments/Community~Planning/Social~Planning/Social~Geography/Census08ReportHomeless.pdf.

United Kingdom. ODPM (Office of the Deputy Prime Minister). 2004. Tackling Social Exclusion: Taking Stock and Looking to the Future—Emerging Findings. London: Office of the Deputy Prime Minister, Social Exclusion Unit.

van Wormer, Katherine. 2003. “Restorative Justice: A Model for Social Work Practice with Families.” Families in Society 84 (3): 441–48.

van Wormer, Katherine, and Diane Rae Davis. 2003. Addiction Treatment: A Strengths Perspective. Pacific Grove, CA: Brooks/Cole-Thomson Learning.

VIHA (Vancouver Island Health Authority). 2006. Understanding the Social Determinants of Health: A Discussion Paper from the Office of the Chief Medical Health Officer. Victoria: Vancouver Island Health Authority.

Werb, Daniel, Evan Wood, Will Small, Steffanie Strathdee, Kathy Li, Julio Montaner, and Thomas Kerr. 2008. “Effects of Police Confiscation of Illicit Drugs and Syringes Among Injection Drug Users in Vancouver.” International Journal of Drug Policy 19 (4): 332–38.

Wood, Evan, Patricia M. Spittal, Will Small, Thomas Kerr, Kathy Li, Robert S. Hogg, Mark W. Tyndall, Julio Montaner, and Martin T. Schechter. 2004. “Displacement of Canada’s Largest Public Illicit Drug Market in Response to a Police Crackdown.” Canadian Medical Association Journal / Journal de l’Association médicale canadienne 170 (10): 1551–56.

__________
1 Richard Nixon, “Special Message to the Congress on Drug Abuse Prevention and Control,” 17 June 1971, in Public Papers of the Presidents of the United States, Office of the Federal Register, National Archives and Records Service (Washington, DC: Government Printing Office, 1972). The text is available on the website of The American Presidency Project, http://www.presidency.ucsb.edu/ws/?pid=3048.

2 “Census Agglomeration of Nanaimo, British Columbia,” Focus on Geography Series, 2016 Census, Statistics Canada, 2017, https://www12.statcan.gc.ca/census-recensement/2016/as-sa/fogs-spg/Facts-cma-eng.cfm?GC=938&GK=CMA&LANG=Eng&TOPIC=1.

3 In “Conditioning Community: Power and Decision-Making in Transitioning an Industry-Based Community” (2010), Lisa Sailor presents an insightful account of Nanaimo’s quest to attract both tourists and investment (see esp. chaps. 4 and 5). She is referring here to the recommendations of the city’s Economic Development Group in Working Together to Build a Prosperous Future, a report first presented in 1999 to the Nanaimo Chamber of Commerce.

4 A term used by the United Nations, “relative homelessness” refers to people who are at risk of becoming homeless. As defined by the Nanaimo Working Group on Homelessness, the term designates “people living in spaces that do not meet basic health and safety standards, including protection from the elements, access to safe water and sanitation, security of tenure, personal safety and affordability” (NWGH 2003, 6).

5 “VCAND” is an acronym, formed from street names, used in the report to designate an area of downtown Nanaimo deemed to be “at risk”: it refers to “properties along Victoria Road, Victoria Crescent, Cavan, Dunsmuir (up to City Hall), Abbott and Nicol (including the New Hope Centre and the area behind it)” (NWCI 2005, 6).

6 “NADAC,” Prevention Hub, 2016, http://preventionhub.org/en/who-is-who/nadac-nanaimo-alcohol-and-drug-action-committee. This description originally appeared on NADAC’s own web page (http://www.nysa.bc.ca/NADAC.html).

7 See “Memorandum of Understanding Between BC Housing Management Commission (BC Housing) and the City of Nanaimo Regarding the Development of Sites for Supportive Housing,” 12 November 2008, http://www.bchousing.org/resources/Housing_Initiatives/MOU/MOU_Nanaimo.pdf.

8 Created in 1990 under the name Nanaimo and Area Resource Services for Families, NARSF Programs Ltd. offers a number of programs oriented towards harm reduction, including a needle exchange available through its Mobile Health Outreach program, as well as the Linked to Treatment (L2T) Program and the Harris House Health Clinic. For more information, see “Philosophy of Harm Reduction Programs,” NARSF Programs Ltd., 2012–14, http://www.narsf.org/harm-reduction-programs/philosophy/.

9 On these costs, see United Kingdom, ODPM (2004, 7–8).

10 See Austin (this volume) for an analysis of the RCMP’s use of red zones in Kamloops. Drawing on a case study of homeless shelters in Columbus, Ohio, Andrew Mair (1986) argues that the homeless threaten systems of meaning essential to production and consumption in the postindustrial city.