When evidence, economic arguments and the law aren’t enough: Responding to political attacks on harm reduction
Across Canada, harm reduction is under attack. Innovative and evidence-informed programs have been cut, reversed and shuttered. Politicians are retreating from progressive drug policies. Where Canadians were once global leaders in harm reduction, now governments at all levels are retreating from harm reduction principles and practices. The contrast with where Canada once was and current Canadian drug policy is striking.
Harm reduction advocates and their allies are fighting back. They are producing evidence briefs about health benefits and preventable deaths, making arguments about costs and launching legal challenges. But these efforts have not been enough to prevent shutting down harm reduction interventions. If these strategies won’t work, what should harm reduction advocates do next?
A rollback in harm reduction
Below are some examples of the broad reversal in Canada’s approach to substance use policy:
- Shutting down supervised consumption. Up until 2025, few other countries had implemented supervised consumption as widely as Canada. Now, through legal and financial pressures, governments are forcing sites to close in Ontario, Alberta and Saskatchewan.
- Retreating from prescribed alternatives. While other countries have long had programs that allowed clinicians to prescribe alternatives to the unregulated drug supply (such as prescription heroin), Canada had particularly low barriers to prescribed alternative (safer supply) programs – perhaps the lowest in the world. Now, the federal government has ended funding for these programs and Alberta and Ontario have prohibited or restricted safer supply prescribing.
- Abandoning decriminalization and extending criminalization. British Colombia has ended its decriminalization project while Toronto’s was never approved. Ontario cities are no longer allowed to apply for decriminalization initiatives. Ontario has given police greater powers against people who use drugs in encampments, in rented spaces and on transit.
- Backtracking from distributing harm reduction supplies. Many Canadian cities, including Toronto, were early adopters of needle and syringe programs. These programs are an important reason why people who inject drugs have historically had low rates of HIV infection in the city, compared with rates in other cities of Toronto’s size. Now, even needle and syringe distribution – for which there is strong evidence for efficacy – is prohibited in Ontario’s HART Hubs. Other cities have similarly experienced cuts to funding for harm reduction supplies.
- Moving toward involuntary treatment. Alberta, B.C., Manitoba and Saskatchewan have each moved to mandate drug treatment or detain individuals who use drugs.
There is much to be written about how Canada got to this point, but it’s critical to look forward as well. Why are the strategies that harm reduction advocates have relied on not working in the current political climate? Most importantly, what is the path forward to advocate for harm reduction effectively?
Evidence is not enough
The evidence for harm reduction interventions has accumulated over decades. For some strategies, such as needle and syringe programs, the evidence is robust, while for others, like prescribed alternatives, the evidence is emerging. I believe more research is both necessary and welcome.
But evidence alone is insufficient to protect harm reduction from its attackers, for three reasons:
- Decisions to roll back harm reduction interventions were not evidence-based so more evidence won’t change those decisions. The Premier of Ontario was clear that his motivation was primarily ideological when he said, “I just don’t believe safe consumption sites.”
- The evidence that has been cited to shut down harm reduction is often anecdotal or based on uncertain data. Ontario said it had evidence of increased crime near supervised injection sites but never made the data public and subsequent reports did not support this claim. In British Columbia, for example, public disorder was attributed to decriminalization, based on perception rather than data.
- Harm reduction opponents have focused disproportionately on “evidence” of harm while neglecting evidence of benefits to people who use drugs.
Perhaps harm reduction opponents are recognizing the flimsiness of basing policy decisions on whims and weak data. A recent academic article, from investigators at a centre funded by the government of Alberta, claimed to show that closing supervised consumption sites led to more opioid agonist therapy prescribing with no adverse mortality outcomes. The article has significant flaws, but politicians have cited it as evidence, even while misrepresenting the results. It’s also important to recognize that the analysis of evidence can itself be political. For all these reasons, just generating more evidence will not save harm reduction.
Economic arguments aren’t convincing governments
Perhaps economic arguments for harm reduction interventions are compelling. Harm reduction interventions offer opportunities for preventive care and associated cost offsets, such as decreasing the risk of acquiring hepatitis C infection or treating wounds early. In a recent review of 16 health economics studies of actual or planned supervised consumption sites across North America, each study found that the sites represented good value for money. These findings were robust across settings and using a variety of analytical methods. The studies may even have underestimated the cost-effectiveness of supervised consumption sites since many of them were conducted before changes to the unregulated drug supply. The introduction of more toxic drugs means that preventing overdose has the potential to both save more lives and offset additional costs.
Unfortunately, making a business case for harm reduction isn’t changing harm reduction policy, for two reasons. First, while governments have cut funding for harm reduction, they have increased overall funding for drug-related services. The Ontario government is fond of pointing out that it has invested over $500 million in HART Hubs. When it comes to substance use, the government does not have an austerity objective. Second, economic evaluations in health are always about the outcome gained for money invested. Harm reduction opponents have made it clear that the outcome they care about most is the number of people who are abstinent from drug use. Recovery-oriented strategies will therefore always be prioritized over harm reduction. In summary, economic considerations reflect the government’s value priorities, they are not driving them.
Laws cannot prevent funding cuts
What about legal challenges? Harm reduction proponents have sued the Alberta, British Columbia and Ontario governments, including Charter cases that echo the landmark Supreme Court legal case about Insite, Canada’s first sanctioned supervised consumption site in Vancouver.
In Ontario, an injunction has prevented the government from forcing one site to close, although the final decision is still pending in this case, for which I was an expert witness. Yet all the other sites that relied on public funding have since shut down or soon will, not because of the court case, but because their funding was withdrawn. What governments cannot do through the courts, they seem willing to do through withdrawing resources.
Furthermore, governments have increasingly demonstrated their willingness to use Section 33 of the Canadian Charter of Rights and Freedoms (the “notwithstanding” clause) to force through legislation that is, or may be, unconstitutional. Despite legal victories for harm reduction, like the Ontario injunction, governments are finding ways to shut down services.
The Need for Political Action
Recognizing the limited role of evidence, economic considerations and legal approaches is not an argument for nihilism. Each are necessary for making the case for harm reduction, but none is sufficient on its own. Even together, they are not enough. At its core, the attack on harm reduction is political. And it must be fought politically.
Political approaches can take many forms, but I believe that all should have a core set of principles. First, efforts need to be guided by people who use drugs. “Nothing about us without us” is a fundamental principle in harm reduction politics. It ensures that the needs of people who use drugs are not neglected or diminished. For those in positions of power, like academics, lawyers, healthcare providers and other decision-makers, this means being aware of and ceding some of our power.
Second, being political necessitates being vocal. Harm reduction providers in Ontario have been sometimes skittish in publicly defending their programs because of fear that the government will be punitive when it comes to funding. Yet funding cuts affect the silent as much as the vocal. In the end, being quiet saves no one. There is a risk when people speak out about harmful government policies, especially as harm reduction opponents have targeted individuals and organizations. The solution is to form and join coalitions, both to avoid foregrounding any single entity and to support each other for what will be a long campaign.
Third, being political requires avoiding the trap of partisan politics. While Conservative governments have been particularly hard on harm reduction, the federal Liberal governments and provincial NDP governments in B.C. and Manitoba have all retreated from harm reduction.
Fourth, I believe being political requires remaining principled. The attacks on harm reduction have included spreading misinformation, disseminating stigmatizing pictures, using derogatory language, whipping up moral panics and putting pressure on high-profile harm reduction advocates. Proponents have rarely responded with similar strategies. Harm reduction proponents have, time and again, demonstrated compassion and care – for each other and for broader communities – in their arguments and their actions. That should continue.
Harm reduction will not go away, but it will continue to evolve as it is threatened. Getting political is the best way to ensure it remains grounded in maximizing the health and dignity of all members of our communities.
Dr. Ahmed Bayoumi is a general internist, HIV clinician, scientist and professor at the University of Toronto. He is an expert in health services research, with a focus on issues related to the health of people experiencing marginalization, including people who use drugs and people living with HIV.