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Second Generation health care puts a squeeze on space in the Downtown Eastside

The Portland Hotel Society's Coco Culbertson is concerned about changes to health-care in the Downtown Eastside coming at the expense of non-medical programs that are often preferred by clients distrustful of larger institutions. Travis Lupick photo.
The Portland Hotel Society’s Coco Culbertson is concerned about changes to health-care in the Downtown Eastside coming at the expense of non-medical programs that are often preferred by clients distrustful of larger institutions. Travis Lupick photo.

David Ogilvie has created artwork since his childhood, but it wasn’t until he was 66 years old that he sold his first drawing. At a café on Main Street, the artist gave credit to Gallery Gachet, a space on Cordova Street near Columbia.

“The modest success that I’ve gained has been at least partly due to them,” Ogilvie said. He recounted that in 2015, Gallery Gachet gave him his first proper exhibition and, soon after, the Capilano Review made an offer for a series of his work.

Ogilvie said it can be hard to explain the difference this made in his life, and similarly difficult to explain the health benefits that Gallery Gachet provides to the Downtown Eastside. But he argued that its impact on mental health in the community is significant.

“Without Gallery Gachet, I don’t think I would have gotten this far,” he said. “I might not have made it at all.”

For 22 years, the gallery has operated with support from the provincial health ministry. But in September 2015, Vancouver Coastal Health (VCH), the regional care provider in charge of that money, eliminated Gallery Gachet’s $132,000 in annual funding.

The cut was the first of many moves VCH has begun as part of its “Second Generation” strategy for health care in the Downtown Eastside. The plan is described by VCH as no less than a “system transformation”. As the name Second Generation suggests, it represents the most significant revision of health care in the Downtown Eastside since VCH’s inception in 2001.

Already five years in the making, Second Generation entered an implementation phase last February. That is scheduled to continue through to October, with an official launch planned for the following month.

What’s at stake is almost $60 million that VCH spends every year on the health of Vancouver’s most marginalized residents, those of the Downtown Eastside.

A September 3 VCH media release lists a host of new mental-health and addictions services planned as part of Second Generation. That document and related materials describe a renewed emphasis on clinical services and integrated care delivered with a low-barriers approach that is heavy on peer involvement. The release warns that programs not falling within this focus on clinical applications may be discontinued.

“VCH contracts without a clear health mandate or those offering stand-alone services without formal connections to health care services may not be renewed,” it reads.

Critics of the plan argue that such a tight focus on medical and psychiatric programs will come at the expense of services that, though less formal, are no less beneficial.

Ted Bruce was interim executive director of the Portland Hotel Society for 14 months before he retired in August 2015.

“There is a need for clinical services but there is also a need to balance the clinical services we provide with some of those other, softer, support systems, which are just as important,” he told the Straight.

Portland operates Insite, North America’s first supervised-injection facility, plus 19 social-housing projects throughout the Downtown Eastside.

“What’s important to any population—and, particularly, these folks—is social inclusion, the ability to build community amongst themselves, and the ability to support each other,” Bruce explained. “The kind of programming that has long-term vision—of not just a clinical service but services that build inclusiveness and community—it’s a very important. But that’s often what is not happening when there is an emphasis only on the clinical.”

Bruce stopped short of direct criticism of Second Generation but added: “There are some things that VCH needs to think long and hard about.”

VCH’s chief medical health officer, Dr. Patricia Daly, is quoted in the September release acknowledging that the transition may encounter resistance.

“This is just the beginning of a long-term strategy for change in the Downtown Eastside that will evolve over time,” she said. “We know not everyone will agree with the changes being made, but as health care providers we know that services in the Downtown Eastside can be improved”.

Three organizations lost in the shuffle

Gallery Gachet was the first nonprofit to lose funding.

On April 7, VCH announced that a second organization would be dropped in the shuffle: the Drug User Resource Centre (DURC), a drop-in across the street from Oppenheimer Park that the Portland Hotel Society has run since 2003. DURC previously received $634,000 a year from VCH.

On May 13, in an email to the Straight, VCH named a third: ARA Mental Health, which offers advocacy services for people with mental-health challenges in a building at Pender and Beatty streets. The organization, founded in 1996, has received about $220,000 in annual government funding the past few years.

VCH has extended support to both DURC and ARA to continue operating while they seek new sources of funding, but only through to the end of this summer.

To be sure, VCH services in the Downtown Eastside are expanding by a number of measures. The clearest of these is funding. VCH has said it is increasing what it spends in the neighbourhood by $4 million a year, bringing the annual total to $59 million. There are also extended service hours coming to a number of existing clinics and an entirely new addictions-treatment centre tentatively planned for Powell Street.

Of course, Gallery Gachet’s take on Second Generation focuses on the money it lost to allow for those programs to expand.

“The pattern that I would say seems to be becoming clear,” said Cecily Nicholson, the organization’s financial administrator, “is that there is a lack of attention to preventative means, social, and tertiary services—services that are not directly clinical but are also completely necessary.”

She described Ogilvie’s story as typical of the gallery’s membership, many of whom struggle with mental-health challenges.

“Like the fellow who just brought in his sculpture last week,” Nicholson said. “These are people who are isolated in SROs—very poor housing conditions—but with wall-to-wall art in their rooms. And they have not been able to share it. That is a common narrative.”

She warned that as VCH moves to fill gaps in its system, it is this population that’s at risk of falling through new cracks that open up.

A state of extreme anxiety

For this article, the Straight spoke with some two dozen people employed by VCH-funded nonprofits and the clients for whom those organizations provide care.

Several people who have spoken to the Straight on a regular basis in the past refused to go on the record for an interview about Second Generation. They cited fears of placing funding in jeopardy. Some pointed to nondisclosure agreements that are now routinely built into contracts with VCH and even applications for VCH contracts.

Those and other conversations revealed a community in a state of extreme anxiety for the changes that are coming.

Coco Culbertson is in charge of housing, community, and peer development for the Portland Hotel Society, one of the few nonprofits that was willing to comment on the record for this story.

She noted that it is still early days in the rollout of Second Generation, and she stressed that service providers don’t yet fully understand how the plan will change health care in the Downtown Eastside.

“It remains to be seen,” she said. “And I think it’s important we stay in discussion with VCH.”

At the same time, Culbertson expressed concern for a focus on clinical services coming at the expense of community programs that she maintained—although perhaps not involving a psychiatrist in a lab coat—do improve people’s health.

“From the PHS Community Services Society’s perspective, nonclinical, nonmedicalized, and noninstitutional approaches to care are at the heart of what we do and why we’ve been successful in engaging thousands of people every day in the Downtown Eastside,” Culbertson said. “I would hope that VCH will continue to value those interventions.”

Marion Allaart is executive director of the Vancouver Area Network of Drug Users (Vandu), a nonprofit founded in 1998 that was instrumental in the fight for Insite. Asked about Second Generation, Allaart’s response was representative of other nonprofit employees who only spoke off the record.

“We’ve been expecting them to come for us for a long time,” Allaart told the Straight.

Service improvements throughout the community

VCH’s mental-health and addictions programs in the Downtown Eastside are overseen by Andrew MacFarlane, operations director of community health services (inner city–east). In a wide-ranging interview at VCH headquarters at West 6th Avenue and Cambie Street, he began by outlining the problems that VCH aims to address with Second Generation.

“We’ve, historically, not been great about being low-barrier and accessible for vulnerable people,” MacFarlane said. “Between 9 a.m. and 4 p.m. doesn’t work for a lot of people that have chaos in their lives.”

To that end, MacFarlane said, VCH is extending service hours and expanding programs at three existing clinics: at 59 West Pender Street, 569 Powell Street, and 330 Heatley Street.

At those locations, he said, doors will soon be open 12 hours a day, seven days a week.

A second complaint VCH heard in its consultation phase for Second Generation was of a system heavily burdened by its complicated structure, where services are isolated from one another in ways that prevent many mentally ill people from receiving care.

“We had programs that were really siloed,” MacFarlane said. “If you saw a mental-health clinician somewhere, then you had to walk somewhere else to a primary-care doctor, who may or may not be in the loop on what is happening with your mental-health treatment.”

To address that problem, new “integrated health-care teams” will deploy at those three locations and others to offer more holistic care, he continued.

“We have a model that we’re implementing that is about having one care team that is really interdisciplinary with a single care coordinator at the centre of it,” MacFarlane said. “Each client will have a designated care coordinator, which will provide a single point of contact for other care providers and agencies.”

Second Generation will also bring a whole new point of access to the Downtown Eastside: the Railtown Centre for Addictions (a working title that could change). VCH declined to reveal a location for the building but multiple sources told the Straight it will likely open on Powell Street east of Oppenheimer Park. VCH will run the centre itself (as opposed to contracting it to a nonprofit). It is scheduled to open this fall.

MacFarlane described the Railtown Centre as a low-barriers medical hub for people with addiction issues.

“This includes an interdisciplinary team, an on-site physician, pharmacist, nurses, and evidence-based psychosocial supports such as social workers, counsellors, peers, and financial workers,” he said.

He noted it will also involve a drop-in component that, crucially, will allow people to connect with addictions services without having to make an appointment or work their way up a wait list.

Through all of that, MacFarlane maintained that harm-reduction programs such as needle exchanges will continue to be a “core competency” of VCH’s work in the Downtown Eastside.

He said that Insite, the city’s only low-barrier supervised-injection facility, has already seen its hours shifted to open earlier in the morning. MacFarlane added that VCH also hopes to soon see supervised injection occur at additional locations. “We are actively pursuing approval to go ahead with that,” he said.

Feedback falling on deaf ears?

For Second Generation, VCH conducted an extensive consultation process that lasted longer than two years.

It commissioned three lengthy papers that presented Downtown Eastside residents’ views on what they want for the community. Today, VCH points to those documents as evidence the Second Generation rollout is following the advice of the people it serves.

At the daily street market on the unit block of East Hastings Street, the Straight asked one of those papers’ authors, Ann Livingston, if Second Generation’s implementation fits with the community feedback she presented in her report.

“Hell, no,” she replied. “I don’t think they’ve looked at it at all.”

Livingston, a cofounder of Vandu, argued that Gallery Gachet and DURC, though not perfect, made people feel welcome and a part of decisions related to their care.

“The things that make the most difference in people’s lives is being welcomed, having autonomy, and having power,” Livingston explained. “Trauma-informed services should be accessible. People should feel welcome. They shouldn’t have to buzz to get in; they shouldn’t have to be a client; they shouldn’t have to give their name….That’s a model for trauma-informed services. But that seems to have been dropped.”

Support for change

Livingston and other Downtown Eastside residents interviewed for this story also raised serious questions about the first big winner in the funding shuffle that’s come with Second Generation: Lookout Emergency Aid Society. She criticized the group’s record on harm reduction in Surrey, where it previously operated as Keys Housing and Health Solutions under the direction of Fraser Health Authority. Livingston took issue with restrictive hours for harm-reduction programs and a past requirement for needle exchange to happen on a one-for-one basis (since abolished).

When DURC lost $634,000 in annual funding from VCH, Lookout gained about $200,000 to allow it to extend hours and expand services at a drop-in centre called LivingRoom, located on Powell Street just east of Oppenheimer Park.

In a telephone interview, Lookout’s executive director, Shayne Williams, defended the organization’s harm-reduction services in both Surrey and Vancouver. He said harm reduction will also be a big part of expanded programs at LivingRoom, though he added it was too early to say exactly what shape those will take.

Williams did, however, note the new LivingRoom will fit with VCH’s stated emphasis on clinical applications. “It certainly won’t be hardcore clinical,” he said. “But the focus will be to be proactive. To help folks get connections to care, to VCH services, to other, more clinical services, and to be that kind of entry point for folks.”

Stephen Finlay is executive director of ARA Mental Health. Despite VCH eliminating funding for his organization, he was largely supportive of Second Generation.

“For many years, everybody has complained—and rightly so—that clients get shuffled from door to door,” he began. “Vancouver Coastal Health listened to that. And they are trying to set up this service so that there is less of that.”

Discussing cuts to his organizations and others like Gallery Gachet and DURC, Finlay alluded to an issue larger than VCH. He pointed out that the health-care provider no longer receives annual budget increases like it once did.

Budgetary constraints

A review of VCH’s annual reports shows Finlay is correct.

In 2009, the B.C. Ministry of Health gave VCH a seven-percent increase to its total operating budget. Since then, there’s been a downward trend in the amount of annual increases. In 2010 and 2011, the increase was three percent each year, then four percent in 2012, two percent in 2013, and three percent in 2014. Then, in 2015, provincial contributions to VCH were reduced by one percent from the previous year.

Since 2010, the change in ministry funding for VCH has averaged plus–two percent per year, barely keeping up with inflation, let alone costs associated with new technologies and aging baby boomers.

Asked if this situation has put a squeeze on services in the Downtown Eastside, VCH’s director of strategy deployment, Natasha Golbeck, remained upbeat.

“We’re always challenged in health care to do more with less and to be increasingly efficient and thoughtful about where we spend resources,” she said. “We are not doing more with less; we’re doing more with more.”

Pressed on whether or not VCH is preparing to eliminate funding for other programs beyond Gallery Gachet, DURC, and ARA Mental Health, Golbeck responded: “The things that are going to be lost have already been lost. At this point, we have made the reallocations that we’ve needed to make.”

The Ministry of Health did not make a representative available for an interview. Quoted in a VCH media release, minister Terry Lake threw his weight behind the Second Generation.

“Change is never easy, but we know it’s desperately needed in the Downtown Eastside,” he said. “Many residents increasingly struggle with chronic conditions and changing addiction issues, but a lack of integration between health services creates barriers to accessing treatment. I applaud Vancouver Coastal Health for making the changes needed to improve patient care in this neighbourhood.”

Losing space

DURC, expected to close by the end of the summer, is a low-barriers community centre that serves as a safe space for alcoholics and people addicted to hard drugs, including stimulants such as methamphetamine and crack cocaine. It offers laundry and showers plus harm-reduction services such as a crack-pipe vending machine and a managed-alcohol program that lets severe alcoholics brew their own beer.

Each Friday afternoon, the managed-alcohol program convenes at DURC for a regular meeting called the “Drinkers Lounge”. What’s said there is usually confidential (as with Alcoholics Anonymous meetings), but the group permitted the Straight to attend on April 29 on the condition that names be withheld.

Participants explained how the program saves people from drinking Listerine and hand sanitizer across the street in Oppenheimer Park. The homebrew they make at DURC is safer, and the Friday meetings allow DURC to connect members to health services, including detox and rehab.

The April 29 meeting began with a roll call of the 35 people in attendance. Next there was a round of happy birthdays, followed by a reading of the group’s rules and mandate. To conclude the meeting’s opening, people were asked to stand for a moment of silence and invited to recite the names of friends or family who had recently passed away or gone missing. One by one, 16 names were called out.

Moving to an open discussion, the topic of the day was DURC’s pending closure and VCH’s reallocation of funds to the Lookout drop-in centre called LivingRoom.

“Where are we going to go?” asked a man in the back. “The City of Vancouver doesn’t want us on the streets around here. They don’t want us in the park. They’re doing this to get rid of us.”

Liz Evans founded the Portland Hotel Society in 1993 and served on the organization’s executive management team for 20 years before she resigned in 2014. She declined to speak specifically on Second Generation, but expressed concern for marginalized people losing the spaces where they feel comfortable.

“If you’re living in a tiny SRO room, 120 square feet, where all you have that’s yours is a sink and a fridge, then having a café to sit in is meaningful,” she said. “And it just feels like space is being lost.”

On May 6, the Portland Hotel Society’s interim executive director abruptly stepped down. Pending the appointment of a new leader, Coco Culbertson is acting as a spokesperson for the organization.

She voiced concerns about the pace with which the Downtown Eastside is changing but maintained that it has learned to take care of itself.

“This community has always had a strong voice when it gets together,” Culbertson said.

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This article originally appeared in print and online at Straight.com on May 21, 2016.

Metro Vancouver hospitals refer hundreds of immigration cases to border police

Byron Cruz of Sanctuary Health warns undocumented immigrants that if they go to a hospital, they might be reported to the Canadian Border Services Agency. Travis Lupick photo.
Byron Cruz of Sanctuary Health warns undocumented immigrants that if they go to a hospital, they might be reported to the Canadian Border Services Agency. Travis Lupick photo.

Byron Cruz has encountered the sorts of situations that arise when someone is afraid a trip to a hospital could end with them being deported from the country.

He once helped a man injured on a construction site connect with a veterinarian who stitched closed a deep cut, for example. And Cruz says it’s common for pregnant women to seek his network’s help for deliveries.

“My number works as a 911 number for undocumented people,” he said, interviewed at his office in the Downtown Eastside. “We never announced our services, but my number has been given to people as the number they can call. That is very scary, because 911 is for emergencies.”

Cruz is an organizer with Sanctuary Health, a group that promises people can access care without fear of any complication that might arise from their immigration status.

He said that recent months have seen Metro Vancouver’s community of undocumented immigrants—which he estimated numbers between 3,000 and 5,000—grow increasingly reliant on such services that exist outside the province’s health-care system. A troubling statistic obtained from Fraser Health, which operates 12 hospitals throughout the Lower Mainland, may reveal why.

From January 2014 to October 2015, Fraser Health referred approximately 500 patients to the Canadian Border Services Agency (CBSA), the federal police force tasked with immigration enforcement.

“When we learned this, we were very shocked,” Cruz said. “This has to be taken very seriously.”

The issue of CBSA referrals gained widespread attention in 2014 when it was reported that the previous year transit police forwarded 328 incidents to CBSA. Those calls resulted in 62 investigations and at least one death: in December 2013, Lucia Vega Jiménez committed suicide while in CBSA custody after transit police arrested her for fare evasion.

Since then, the City of Vancouver has worked to designate itself a “sanctuary city”, where undocumented immigrants can access municipal services regardless of their status. But the rest of the region has not shown the same enthusiasm for such policies.

In a telephone interview, Fraser Health spokesperson Tasleem Juma confirmed that 500 calls to CBSA was an “approximation” for the period January 1, 2015, to October 7, 2015.

Juma claimed that Fraser Health does not know how many of those referrals resulted in CBSA launching an investigation, nor could she say how many ended in deportation. “Once the information goes to CBSA, what they do with it they don’t report back to us,” she said.

CBSA refused repeated requests for an interview. A spokesperson for the B.C. Ministry of Health told the Straight the province does not have a policy on immigration referrals and leaves those decisions to each service provider.

According to Juma, Fraser Health primarily contacts CBSA for billing purposes. She explained that nonresidents are charged different rates from residents and sometimes a call to CBSA is required to confirm a patient’s status. However, a Fraser Health policy document obtained by the Straight states that both physicians and nurses have “responsibilities” to attempt to see a nonresident discharged back to their home country.

Juma maintained that those sections are written to mean staff should ensure a nonresident will have access to health services after they leave Canada.

“We are not in the business of dealing with immigration issues,” she said. “When somebody needs emergency care and they come to us, we will take care of them.”

Juma added Fraser Health is open to revising guidelines for dealings with CBSA to harmonize its policies with providers across the region. “I think that would go a long way in relieving people’s concerns about coming to get health-care services,” she said.

Vancouver Coastal Health (VCH) and Providence Health Care, which operate Vancouver General and St. Paul’s hospitals, said they could not supply numbers for CBSA referrals by deadline.

Juan Solorzano, VCH executive director of population health, told the Straight VCH now requires that a patient give their permission before a call is made to CBSA. He noted they can refuse, in which case, if residency status cannot be confirmed for billing purposes, the patient will be charged the higher rates of a nonresident.

“That policy was updated in August 2015,” Solorzano said. “We will no longer call the border services agency without consent from the client.”

Regarding the 328 cases transit police sent CBSA in 2013, Anne Drennan, a spokesperson for the force, told the Straight her organization has implemented similar reforms. She revealed that in 2014, there were only 48 referrals. And so far in 2015, transit police have called CBSA just 18 times.

“We had no interaction with CBSA in November,” she said. “What changed was the policy. We no longer ask people about their status in the country.”

City councillor Geoff Meggs delivered an update on Vancouver’s efforts to become a sanctuary city. He reported that a draft document is essentially finished and expected to begin circulating among advisory councils before the end of the year. From there, he said, he hopes it will go before city council during the first half of 2016.

Meggs acknowledged that immigration is primarily a federal issue and so the city’s authority on such policies is limited. But he added that Vancouver is acting where it can.

“Immigration and residency status is not relevant to us,” he said. “So you are safe to do business with us.”

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This article originally appeared in print and online at Straight.com on December 9, 2015.

Downtown Eastside hotel tenants dying at a rate eight times Canada’s average, UBC study finds

Despite sometimes-shoddy conditions, residents of Downtown Eastside hotels have protested the gentrification of their neighbourhood and called for the city to protect that kind of affordable housing stock. Travis Lupick photo.
Despite sometimes-shoddy conditions, residents of Downtown Eastside hotels have protested the gentrification of their neighbourhood and called for the city to protect that kind of affordable housing stock. Travis Lupick photo.

Downtown Eastside residents living in the city’s derelict hotels are dying at a rate more than eight times the national average, a UBC study has found. The risk is especially great for people living with a mental illness, even when that group is compared to people similarly living in poverty.

“The probability that an individual with psychosis would survive to age 50 is 68% compared with 94% for those without the diagnosis among marginally housed individuals,” reads an August 2015 paper published in the British Medical Journal Open. “Individuals with psychosis may face a greater than eightfold increase in mortality risk compared with those without psychosis.”

While those grim statistics may not come as a shock to those familiar with the impoverished neighbourhood, what’s causing many of these early deaths did surprise researchers.

The paper presents findings based on a sample of 290 men and 81 women who were recruited through Downtown Eastside single-room occupancy hotels (SROs) and Vancouver’s Downtown Community Court. The group was monitored from November 2008 to August 2012 and, during that time, 31 participants died. That’s a rate of eight times the national average. And for those aged 20 to 59, the mortality rate was 10 times the Canadian average.

Contrary to popular assumptions, researchers “did not find any link with HIV or substance addiction”, a UBC media release states. In cases where participants passed away, psychosis and hepatitis C-related liver dysfunction was “significantly associated with increased mortality”.

For younger participants under the age of 59, the situation is even worse. For that group of Downtown Eastside residents, the mortality rate was found to be 10 times Canada’s average.

“We were somewhat surprised because most people thinking about the Downtown Eastside think about HIV/AIDS or the possibility of overdosing on opioids like heroin,” said William Honer, one of the study’s co-authors and head of UBC’s department of psychiatry, quoted in the release. “Our system is not doing as well in getting treatments out there for psychosis and hepatitis C in this group, and it’s interesting that those two illnesses are causing risk for early mortality.”

It was discovered only one-third of the 173 participants diagnosed with psychosis were receiving treatment for that mental-health condition. And for the 57 people with an active hepatitis C infection and related liver dysfunction, not one of them was receiving treatment for that illness.

“Psychosis is an extremely prevalent issue among inner city populations and we need to address this,” said Andrea Jones, another of the study’s authors and an MD/PhD candidate in mental health and addictions research at UBC, quoted in the release. “We need to be ready to detect and treat mental illness in an integrated way that really meets the patients where they’re at. We need to improve the detection and treatment of psychosis and hepatitis C in marginalized people across Canada.”

The study was funded by the Canadian Institutes of Health Research and by B.C. Mental Health and Substance Use Services.

It states there are some 3,800 people living in SROs in the Downtown Eastside.

There are an estimated 2,000 “severely ill” SRO tenants not receiving the care they require for mental-health and addiction challenges, according to a September 2014 report of the Mayor’s Task Force on Mental Health and Addictions.

Vancouver Coastal Health (VCH) is the regional authority the province tasks with delivering the bulk of health-care services provided to the Downtown Eastside. It spends roughly $55 million a year in the neighbourhood. A February 2015 policy paper lays out strategies and specific recommendations for a “second generation” of health-care designed for the Downtown Eastside. It acknowledges that VCH has largely failed to keep pace with changing needs, and promises the health authority will adapt and improve.

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The article was originally published in print and online at Straight.com on September 10, 2015.

SFU study finds illegal drug-injection sites are saving Vancouver taxpayers money

SFU researcher Ehsan Jozaghi looked at the numbers and found that unsanctioned supervised-injection facilities that run similar to Insite can save lives and save the city money.
SFU researcher Ehsan Jozaghi looked at the numbers and found that unsanctioned supervised-injection facilities that run similar to Insite can save lives and save the city money.

It has long been an open secret in certain health-care circles that the Vancouver Area Network of Drug Users (VANDU) will, from time to time, operate an unsanctioned drug-consumption site.

Unlike Insite, North America’s only government-approved supervised-injection facility (SIF), the VANDU sites run illegally. Usually occupying a spare room somewhere in the Downtown Eastside, these locations serve as relatively safe places for crack cocaine and heroin users to access clean equipment and consume drugs. They will sometimes remain open for months before shutting down.

Now an August 2015 paper authored by SFU researcher Ehsan Jozaghi has examined one such site and found that the illegal operations have been a good deal for Vancouver taxpayers.

“VANDU’s unsanctioned SIF establishment in the DTES saves taxpayers’ money,” reads the paper published in the academic journal Health & Justice. It explains that significant cost savings occur because consumption sites lower the transmission rates of diseases such as HIV and hepatitis C, thus saving health-care expenditures on treatment. For example, researchers estimated that one additional SIF site can run on $97,203 per year to avert 30 new HIV cases and 81 new incidents of hepatitis C.

The paper notes that Insite is operating at its maximum capacity and that efforts to establish additional SIFs have long stalled in Ottawa on account of opposition from the federal Conservative government.

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This article was originally published in print and online at Straight.com on September 9, 2015.

Mental-health advocates say past death reviews like Abbotsford inquest haven’t prevented tragedies

In June 2015, B.C. Health Minister Terry Lake (middle) joined Vancouver health researchers for a walk through the Downtown Eastside, a neighbourhood that accounts for a disproportionate number of emergency mental-health visits seen by nearby St. Paul's Hospital. Travis Lupick photo.
In June 2015, B.C. Health Minister Terry Lake (middle) joined Vancouver health researchers for a walk through the Downtown Eastside, a neighbourhood that accounts for a disproportionate number of emergency mental-health visits seen by nearby St. Paul’s Hospital. Travis Lupick photo.

The B.C. Schizophrenia Society (BCSS) has said it has low expectations for a coroner’s inquest that will examine three deaths linked to mental-health issues that occurred over a four-month period beginning in December 2014.

According to the B.C. Coroners Service, all three individuals died shortly after leaving Abbotsford Regional Hospital, which is run by the Fraser Health Authority. The inquest is scheduled for May 16, 2016.

BCSS program and development coordinator Ana Novakoviccalled attention to a number of previous government reviews of similar deaths. She emphasized those were followed by recommendations that failed to prevent the three being examined next year.

“Since 2008, there have been three other coroner’s inquests into deaths involving improper monitoring and discharge of mentally ill patients in hospitals under Fraser Health Authority’s jurisdiction,” Novakovic told the Straight. “A number of improvements were recommended as a result of these inquests, but it seems that they are either inadequate or have not been implemented.”

According to a BCSS analysis, those earlier cases concerned Ross Allan, who died in April 2008, Jasdeep Sandhu, who died in October 2008, and Patricia Reed, who died in February 2011. According to their respective inquest verdicts, all three were admitted to Fraser Health hospitals for mental-health reasons and died while in the care of those facilities or shortly after discharge.

BCSS executive director Deborah Conner said she’s worried the review scheduled for May 2016 will find the three people who are the subjects of that inquest—Brian Geisheimer, Sebastien Abdi, and Sarah Charles—died under similar circumstances.

“My question would be: was there a treatment plan when these people were released?” Conner said.

In a phone interview, Stan Kuperis, director of mental health and substance use for Fraser Health, listed a number of mental-health-care reforms implemented in recent years. These include improved patient-transfer protocols, for example, and revised policies for discharging patients. In addition, Kuperis emphasized that Fraser Health pays close attention to coroners’ investigations.

“We have responded to all those recommendations within previous coroner’s inquests and have put changes into place in response,” he said.

According to Conner, the most troubling aspect of this series of events is that when it comes to mental health, Fraser Health is actually among the best B.C. service providers.

“There are similar problems everywhere,” she said. “It could very easily be happening in all the other regions.”

According to Fraser Health, during the 2013–14 fiscal year, its 12 hospitals throughout the Lower Mainland saw 30,305 emergency mental-health visits.

On August 19, the Straight reported that the number of emergency mental-health visits Vancouver General Hospital and St. Paul’s Hospital see together in one year is projected to surpass 10,000 before the end of 2015. That’s up from 6,520 in 2009.

Those hospitals—operated by Vancouver Coastal Health and Providence Health Care, respectively—have also dealt with high-profile incidents that followed patients leaving a facility after they were admitted for a mental-health issue.

In December 2012, for example, Nicholas Osuteye attacked three women two days after he was discharged from St. Paul’s Hospital. In February 2012, Mohamed Amer stabbed an elderly man the same day he was released from St. Paul’s. And in January 2012, Jerome Bonneric was charged with assault shortly after St. Paul’s let him go. (An external reviewof the Amer case resulted in 22 recommendations for service improvements.)

In a telephone interview, Dr. Bill MacEwan, head of psychiatry at St. Paul’s Hospital, explained how staff work to try to ensure nobody admitted for mental-health reasons leaves on their own or without a support system in place.

“The three key things for any individual that we always try for is a place to live, follow-up care, and support, where support can be a variety of things, from family to a mental-health team,” he said. “To get those three variables covered, that’s the general approach that we take.”

MacEwan stressed that’s not always easy, especially when an individual has no fixed address.

“It’s harder to track somebody and find somebody and follow up with care if you don’t know where they live,” he said. “For those individuals, to have them go into care, that becomes more difficult. Sometimes it’s a shelter.”

Conner said the problem is not insurmountable and primarily persists on account of a lack of political will.

“It’s not like we don’t know what has to happen,” she said. “Programs have been around for a long time. They have proven to be effective, and they have academic rigour. They just needed funding and consistency.”

In 2010 (the last year for which statistics are available), hospitals only fully implemented 26.3 percent of coroners’ recommendations, according to a department annual report.

The B.C. Ministry of Health did not make a representative available for an interview.

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The article was originally published in print and online at Straight.com on August 26, 2015.

Vancouver hospitals predict 2015 will see emergency mental-health visits surpass 10,000

St. Paul’s has gained only nine new long-term mental-health care beds since the City of Vancouver made a call for 300. Charlie Smith photo.
St. Paul’s has gained only nine new long-term mental-health care beds since the City of Vancouver made a call for 300. Charlie Smith photo.

Vancouver is experiencing a crisis in mental-health care that continues unchecked. That’s the conclusion Vision Vancouver councillor Kerry Jang draws from data covering 2009 to the end of June 2015, which show emergency mental-health and substance-misuse hospital visits have increased every year and are on track to hit a record high come December.

“We clearly need more long-term mental-health care,” Jang said in a phone interview. “We know that there are so many people in the Downtown Eastside who don’t see or have any contact with mental-health professionals at all. So the emergency ward is very much becoming primary care. That is something that has to change.”

Jang was responding to information provided at the Straight’s request by Providence Health Care, which operates St. Paul’s Hospital, and Vancouver Coastal Health, which runs Vancouver General Hospital. The statistics show that during the first six months of this year, the two hospitals together saw 5,110 people experiencing a mental-health crisis admitted and 3,703 visits for substance-misuse problems such as a drug overdose. The comparable numbers for 2014 are 4,895 mental-health emergencies and 2,830 cases of substance-misuse issues.

By the end of 2015, these numbers are projected to surpass 10,220 mental-health emergencies and 6,146 substance-misuse incidents. Taken together, that translates to an increase of 76 percent compared to 2009.

Over the last five years, the Vancouver Police Department has observed a similar rise in the number of apprehensions its officers make under the B.C. Mental Health Act. In 2014, officers detained 3,010 people under Section 28 of the act, which allows police to take into custody an individual deemed mentally unfit and a threat to themselves or others. That’s up from 2,278 in 2009. During the first six months of 2015, the VPD made 1,510 Section 28 apprehensions.

Jang, who sits on the Mayor’s Task Force on Mental Health and Addictions, said what’s needed to reverse these trends is greater involvement by the province. He reiterated a call for more long-term-care beds that Mayor Gregor Robertson has made repeatedly since declaring a “mental-health crisis” in September 2013.

The B.C. Ministry of Health declined to make a representative available for an interview.

In recent years, the province has allocated money for mental-health-care infrastructure. For example, in January 2015, it announced that an addition to VGH will open in 2017 as the largest facility for mental-health and addiction services in British Columbia. However, the city has said what’s required to address the problem in Vancouver is 300 “long-term and secure mental health treatment beds” and, in September 2014, warned that the province was falling short of that number by 250. (The province has made small numbers of new beds available—nine at St. Paul’s Hospital, for example, and 14 on the Riverview grounds in Coquitlam. But the majority of funding is going to replacing outdated facilities.)

Mark Levy is the medical manager of the VGH psychiatric-assessment unit. He told theStraight the statistics match what he’s observed on the ground.

“It does put a strain on resources,” Levy said in a phone interview. “There really hasn’t been an increase in in-patient beds to any significant degree. We do run into situations where we are in a crisis mode and we have to accommodate patients that are in the emergency room.”

Levy emphasized the numbers make clear there is a problem. But he also said they include good news, explaining that they’re at least partly the result of changing attitudes and a shift away from the justice system in favour of health care.

“People who might have been taken to cells in the past are seen by an arresting officer as suffering from a mental-health issue,” Levy said. “Now, rather than charge them—as long as it’s not a serious offence—they will bring them to hospital.”

He suggested the next step should be making more mental-health care available in communities where people live, so they receive treatment before their mental health declines to a point where they end up in an emergency room.

“These are chronic problems,” Levy said. “Are people best treated in a hospital or should we try to do whatever we can to help them deal with their problems while they are residing in the community?”

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This article was originally published in print and online at Straight.com on August 19, 2015.