A Conversation with Dr Mark Tyndall
In Vancouver, British Columbia, nice restaurants, new coffee shops, and trendy boutiques are constantly popping up — the city is definitely a hip, urban environment experiencing a transition. Yet although the area has grown increasingly popular with Canadians, there exists a seedy underside, characterised by open drug use and homelessness — surrounded by high-priced condos and businesses.
This area is Downtown East Vancouver and it’s here that the city’s problems seem especially dire, because the homelessness and flagrant drug use is concentrated within just 10 city blocks. It’s for this reason that Vancouver, BC, makes for such an interesting case study. Because the city’s misery is concentrated in such a small section, a lot can be learned by studying the epidemic of opioid addiction here.
To that end, I spoke with Dr Mark Tyndall, Director of UBC Centre for Disease Control, and a vocal public health advocate for harm reduction programs.
About Dr Mark Tyndall
Mark’s long been interested in marginalised populations. He began his medical career training as an infectious disease doctor, before spending two years in Kenya, working on HIV prevention. He then completed a doctoral degree at Harvard University which included living in Kenya for an additional two years. His thesis work focused on health and human rights as it related to the AIDS epidemic.
When he returned to Canada, he wanted to continue in the same vein of work, so he took a job at McMaster University to work in the global health program. Later, he went to St. Paul’s Hospital in Vancouver to work as an infectious diseases doctor and to be the Program Director for Epidemiology at the BC Centre of Excellence for HIV, where he was co-lead investigator on the evaluation of INSITE, North America’s first supervised injection site.
From there, Mark went to work as Chief of the Division of Infectious Diseases at the University of Ottawa in 2010, before ultimately accepting his current position as the Executive Medical Director at the BC Centre for Disease Control in 2014.
As he puts it, “Within the first year I got there, this overdose [thing] started creeping up. Nobody would have ever predicted the state that we’re in now — the overdose crisis. So outside of my administrative work… where I find myself now is trying to take some leadership in the opioid crisis.”
The Origins of the Drug Crisis in Vancouver, BC
Vancouver’s colorful history may have been a contributing factor to its current drug epidemic. Mark explains, “I mean, it’s really been a community in somewhat chaos for probably 50 years or more.
“It’s right beside the port. It was built on these small hotels that cropped up. So, I think for decades, it was a place where mostly men dropped off for short periods of time and stayed over for a week in between lumber jobs or mining jobs.
“It kind of had a work feel to it and it developed a lot of bars and a lot of prostitution and a lot of alcohol and a lot of drugs. Most cities have this kind of area, but the downtown east side really had its own culture and feel and transience to it.
“Also, it’s a unique place in Canada because really, it’s the only documented ghetto — all around it is high-priced buildings and condos and businesses — but they’ve kind of allowed this area just to be left alone and everybody who goes on welfare who couldn’t afford anywhere else in the city, ended up in the famous downtown east side.”
Mark explains that initially, Vancouver, BC, had a problem with white powder heroin. It was relatively cheap and of good quality. However, the supply dried up over the years, and today, people using drugs rely on fentanyl.
“84% of people who die of overdose in Vancouver have fentanyl in their system. If you look at non-fentanyl overdoses, they’ve actually gone down a bit over the last decade and fentanyl has just skyrocketed,” says Mark.
He says, “I think it’s the same [dealers] but it must have been a business decision, that it’s too much trouble or too risky now to bring in heroin, so let’s just dump fentanyl. The supply of heroin disappeared almost overnight.
“Now they’ve got a powder that looks sort of like heroin and initially they introduced it slowly so that we found more and more bundles with heroin and fentanyl, but now it’s just all fentanyl powder.”
How Harm Reduction Programs Can Help
In Mark’s experience, he believes that harm reduction programs and safe houses can make a meaningful difference in peoples’ lives.
For instance, he says that the Canadian nonprofit, Portland Hotel Society, has done a great job by offering housing to the most difficult-to-house individuals. He believes that what sets this nonprofit apart is that, “They really offered non-judgmental housing. So, it was very hard to get kicked out of a Portland Hotel because they just put up with everything.
“That model really took off — at one point there were probably ten hotels that were run by the Portland Hotel Society that were very low-threshold places where people could stay.
“Most of those people would have spent their lives in jail if they hadn’t had that housing because they were people that were often in a lot of trouble and were involved in a lot of drugs and crime. So, I think that was hugely innovative.”
Mark also says he’s seen a lot of benefit from the country’s needle exchange program. “Where once people were limited to a couple of needles a day, more liberal needle distribution means that today in the downtown eastside of Vancouver, there’s very little HIV or hepatitis C transmission.”
Additionally, there’s been a lot of progress on methadone prescribing and access in Canada. Mark says, “We worked on research to show optimum dosing of methadone — that doing urine tests was pretty useless and cutting people off methadone made no sense, those kind of things.”
Although Mark realises that harm reduction programs are controversial, he feels that they bring a realistic approach to the crisis of opioid addiction. He says that thus far, the welfare system has done a really poor job of helping people overcome the social problems that contributed to their addiction in the first place.
He explains, “We don’t give people enough money to ever get ahead or move on. There’s very little opportunity for job training or education, and you’re dealing with so many broken people. You know, your teeth have all fallen out and you have a criminal record and you’ve put tattoos all over your face and those things make it very difficult to move on.
“One of our messages is to have reasonable expectations for people, so we’ve really pushed back on this ‘everybody can recover’ type thing,” says Mark.
“People have these unrealistic expectations like, if we allow them [drug users] to go to a supervised injection site, we need to get them hooked up with care, and then we need to get them abstinent and recovered.
“That so rarely happens to people that I don’t have those expectations anymore. I want to keep people alive and relatively healthy and hope for the best.”
Stigmatising Drug Users Isn’t the Answer
Mark believes that the way we stigmatise drug users is part of the reason that society seems relatively apathetic to the opioid crisis.
In a recent TED talk he gave, he said that if thousands of people were being poisoned by food or water, we’d make changes to legislation and we’d support victims and do everything we could to help. On the other hand, when drugs are involved, we tend to be indifferent because people who use drugs aren’t viewed as blameless.
As Mark puts it, “So, the way that we treat people who die of anything drug related, it’s still really their fault. Like, you had a choice. You made this stupid decision. You inject, and you died. It’s your fault.”
Of course, that mindset translates into public policy decisions that Mark feels can cause even more harm.
“We’re asking people to go out into an alley, buy stuff that we know is very likely to be too toxic and poison them and that’s okay. It’s not like they have an alternative. The alternative is okay. You know you’re going to buy this stuff. Here’s some stuff that’s pharmaceutical grade. Use that,” he says.
“How many people have told me, ‘Don’t people know this could kill them?’ Like, yeah, actually they do know it can kill them and they still keep using it because they’re addicted. They will not stop.
“If the threat of instant death and poisoning doesn’t stop people, then nothing is going to stop people. That’s why we need to offer an alternative.”
Could Australia Experience a Similar Opioid Problem?
Of course, Vancouver’s opioid epidemic brings up the question, ‘Could it happen here?’ Mark — who’s visited Kings Cross in Sydney before — believes it’s possible.
He says, “At one point, [Canada and Australia] had very similar problems, but things here have gotten worse here and things in Australia haven’t. I don’t really understand why that happened but, you know, it could go bad [in Australia] too I think. It’s going to be fascinating to know what happens because I don’t see any reason why fentanyl couldn’t get there and cause the chaos like it has here.”
Hopefully, Australia will avoid that fate. But should anything similar occur here, Mark believes that the answer lies — at least partially — in implementing harm reduction programs. He feels that approach is the one most based on common sense.
As he explains, when you have a large number of people in the population who are at high risk of overdosing, “you have to do something different.”
