An HIV epidemic swept through Vancouver’s Downtown Eastside in the late 1990’s, carrying off the poor, the drug addicted, the mentally ill, and other vulnerable souls

Article by Guy Saddy  
With photography by
Peter Bennett

  ANGELA MOVED THROUGH THE TENT LIKE A NEWLY FOALED COLT, a caricature of grace clearly unprepared for a life in high heels. The backs of her legs were mottled with purple bruises---from a punch-up with one of her customers, maybe, or from injection-site bruising---the legacy of a life lived with needles. Who knew? She was confident, though, even combative, as she tramped about the tent like a drill sergeant, surveying the landscape and making sure everything went according to her own internal plan. Occasionally she’d take time out to engage the media, here to cover “Out of Harm’s Way,” a day-long community-directed symposium bringing together an international panel of drug “harm-reduction” experts with residents of Vancouver’s problem plagued Downtown Eastside.


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   “I’m police Chief Bruce Chamber’s daughter,” she’d lie to the assembled reporters, some of whom dutifully took notes. “You can interview me later.” This was her day, and in her mind, she was both host and focus. Up close, you’d notice the flashing, wild eyes, the slight downward curve of her open mouth. But it was the soft pink dress, like a bridesmaid’s gown, that made her unforgettable. The bruises seemed even uglier against the contrasting swish of the pretty pink hem.
   By 4 o’clock she wanted to leave. She had been here for six hours, a long time in one place without drugs. For most of the day, she’d been genially harassing Liz Evans for money. Evans, who manages the Portland Hotel, where angle lived, kept finding little pieces of paper in her pockets: invoices from Angela for imaginary services. They started at $50, then dropped as the day wore on until her final demand came in at a very reasonable per diem rate of $5.
   “Okay, Angie,” Evans said laughing and handing her a five-dollar bill. “Thanks. You earned it.” Angela pocketed the money, leaned in, and kissed Evans on the check, then took off in the direction of Powell Street, wobbling on those unsteady high heels into the most dangerous neighbourhood in Canada. It was the last time anyone saw her.


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Cheap hotels, drugs, and a concentration of social services draws a wide variety of disaffected people to the Downtown Eastside.

People to the Downtown Eastside

  BEFORE SHE JOINED THE ROLLS OF Vancouver’s 22 mainly street involved missing women, Angela was one of 7,000 injection drug users (IDUs) who call Vancouver’s Downtown Eastside home. Many are our most disposable citizens: the sex-trade workers, the poor, the drug addicted, and often, the mentally ill. Like Angela, many are HIV positive; about 40 percent of the addicts who live in the Downtown Eastside are infected with the virus that causes AIDS---the highest rate of HIV infection among IDUs in Canada.
   It wasn’t always like this. HIV infection, while previously not unheard of among Vancouver’s drug community, had for years remained steady at extremely low levels, a fact largely attributed to the establishment in 1998 of a highly regarded needle exchange program (see sidebar, page 48). Everything, it seemed, was working the way it should: from the late 1980s, when the first studies were done, to the early 1990s, the HIV “seroprevalence” for IDUs fluctuated between 2 and 3 percent. Vancouver was a model: a city that had stemmed the tide of HIV in an extremely vulnerable population.
   In 1994, however, things began to change. Street nurses started to report more positive tests among Downtown Eastside addicts. At nearby St. Paul’s Hospital, Julio Montaner, an HIV/AIDS specialist, saw a shift in his patient profile from mainly gay men to IDUs, who quite suddenly accounted for 45 percent of his new patients.
   More than a shift, really: a sea change. The percentage of addicts testing positive for HIV had climbed from 2 percent to 7 percent in 18 months. In 1995, 38 percent of newly diagnosed HIV patients claimed IDU as their primary risk factor, up from 9 percent in 1995.

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  By 1997, about 25 percent of Vancouver’s drug addicts were HIV positive, and that same year, the transmission rate soared to 18.6 percent, which meant that for every 100 disease-free drug users, by the end of the year, 19 would be infected with HIV. A public health emergency was declared. Unbelievably, Vancouver’s addicts had registered the highest HIV transmission rate in North America, possibly in the entire Western world.
   “We seemed to be doing the right things,” reflects Steffanie Strathdee, who, before moving on to Baltimore’s John Hopkins School of Public Health in 1998, was director of the epidemiology program for the B.C. Centre for Excellence in HIV/AIDs, the province’s foremost HIV research center. “What is unusual about Vancouver is that things stayed stable and low for a long time and looked under control---and then we had an explosion.”
   In 1990, Angela Jardine, said by her mother to have the intellectual abilities of an 11 year old moved to the Downtown Eastside and landed right in the middle of that explosion. The elder of two daughters, she was born in Sudbury, Ontario, in 1971, and at the age of 9 moved with her family to Sparwood, British Columbia, where the coal industry beckoned with the promise of jobs and a better life. Long before the move, however, there had been signs that Angela was different. She was slow to walk and talk. In kindergarten, she was prone to off-the-wall, emotional outbursts, leading to her first psychological assessment at the age of 5. While no definitive diagnosis was ever forthcoming, over the years the usual catch phrases, clinical and otherwise, were tossed around: hyperactive, sever behavioral problems, cognitively impaired, and extensive supervision required.
   She liked school but didn’t fit in. The other kids made fun of the way she talked and tormented her about her noticeably imperfect coordination. “Angela was like some sort of beacon that kept blinking ‘I’m different,’” her mother, Deborah Jardine, remembers. “It was like an aura that was around her. People who came close to her, right away it made them angry, and they didn’t want anything to do with her, which was unfortunate.”
   Unable to control her any longer, Jardine allowed Angela, then 16, to be moved into “respite care” in nearby Castelgar. Then, in 1990, Angela left rural British Columbia forever and moved to Vancouver’s Downtown Eastside. Her timing couldn’t have been worse.

At the WISH drop-in centre, above, street sex workers can find a brief respite from the hardships outside. The Portland lobby serves as an impromptu clinic where residents can receive cocktails of HIV-fighting drugs.

AT THIS OFFICE IN ST. PAUL’S HOSPITAL, the largest HIV treatment facility in Canada, Martin Schechter leans forward in his chair, eyes locked on his computer screen. He does this a lot. For Schechter, the computer is his weapon in the fight against the Vancouver outbreak. Largely through mathematical modeling, he is changing the way people think about how this epidemic progressed.
   Previously it was thought that if 10 percent of an IDU community became HIV positive, that would set the stage for an explosive outbreak that would see seroprevalence rise to 40 to 50 percent within one to four years. “People would talk as though an area could go along with a relatively stable prevalence---3, 4, or 5 percent---but once it crept up to 10 percent, things would really explode,” says Schechter. “Over that last couple of years, I’ve come to think that’s probably wrong.”
    Instead, Schechter argues, the key to understanding the explosion is primary infection---the immediate period after a person, “seroconverts,” or initially comes into contact with HIV. “In the early 1980s, people were thought to be very infectious in the later stages of the disease,” says Schechter. “But nobody really talked about what happened immediately after you were first exposed to HIV, the reason being, it’s really only a short period of time. Why would you worry about a period of two or three months compared to years, right?”


  Established in 1998, Vancouver’s Needle Exchange Program (NEP) is arguably the longest-running and largest-volume needle exchange in North America, exchanging more than 2.5 million syringes annually. It was supposed to do what other exchanges had seemingly done: keep HIV infection rates down.  
   So when a new 1996 B.C. Centre for Excellence in HIV/AIDS study that reported rocketing transmission rates also stated that “frequent NEP attendees” were, in fact, more likely to have been infected, it caused a huge stir---mainly in the United States, where the very concept of needle exchange is a hot political potato. Could Vancouver’s NEP actually be contributing to the outbreak?  
   The data showed that regular NEP users were engaging in higher-risk activities, and the paper mused that NEP sites may be spawning “new social networks” where new attendees met sharing partners. “A lot of the ideological opponents [of NEPs] took the Vancouver data and seized on it,” says Martin Schechter, one of the study’s authors. “We became the poster children for the anti-needle-exchange crowd.”  
   But a subsequent 1999 study of almost 700 IDUs showed that during 15 months, only 0.7 percent reported meeting new people through the NEP, while only one person met a “sharing partner” there. And the study confirmed what NEP opponents had chosen to ignore in the earlier report: the reason frequent NEP users were more likely to be HIV positive was that the NEP regularly attracted the highest-risk IDUs. As for whether the NEP has had a beneficial effect, “I would hate to think of the level of HIV infection without it,” says John Turvey. “You know, I think it would be staggering.”  --G.S

     The arc of HIV infection resembles a U-shaped curved. In the first three or four months after infection, the typical seroconverter is afflicted with extremely high viral loads. As the body begins to fight off the disease, the loads drops drop and eventually stabilize at relatively low levels, marking the beginning of the infection’s latent stage. Loads remain down until the late stages of the disease, when, as the body loses it’s fight against AIDS, they rise to extremely high levels once again. During the short-lived initial stage, the newly infected can carry about 1,000,000 HIV particles per millimeter of blood, on average about 100 times more virus than a latent stage sufferer.
   “Assuming they were sharing with a continuous number of partners through their lifetime, in that three-month period after initial infection, they could infect as many other people as they would during 300 months of latent infection. Three hundred months is twenty-five years,” says Schechter, “So when you think of it like that, this short period takes on a whole new meaning.”

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     Especially since Vancouver was full of new and potential addicts, who largely gravitated to the city’s Downtown Eastside. It was here, in an area of maybe 20 square blocks, that the environment itself played a part in an epidemic that would draw the attention of HIV experts throughout the world.
   Downstairs, in the Portland Hotel’s office, Theresa, a 44-year-old HIV-positive resident, sits slumped in a chair while a visiting nurse cuts away the bandages that cover her ankles.
   “It’s not from fixin’,” she assures us, as the bandages covering one leg fall away. In front of her is her antiretroviral AIDS medication, 22 pills that she takes daily.
   Beyond the office door is the hotel lobby, dominated by a pop machine, a television set, and a few ratty, cast-off couches---a singularly grey place that serves as the only common area for the hotel’s 70 hard-to-house residents, many of whom have been diagnosed with multiple problems: chronic mental health conditions combined with an addiction, for example. Publicly funded by provincial and civic coffers, the Portland provides housing for those who, like Angela and Theresa, can’t find anywhere else to live.
   Theresa slowly peels away the bandages. “I’m feeling sick. I think it’s from the medication.” She has endocarditis and methicillin-resistant Staphylococcus aureus, one of the superbug bacteria, a surprisingly common affliction in the Downtown Eastside. Theresa was diagnosed with HIV about four years ago, just as the epidemic started to pick up steam, and health problems have dogged her since. “I’m not used to bein’sick,” she says, dropping her gaze. “And I lost my figure too.” She’s on a methadone maintenance program administered through the Portland.


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At the Portland, hope comes in the form of a creative-writing workshop, offering a change from the day to day demands of Carrall Street, just outside. 

   “Angela? We knew each other, yeah,” says Theresa, peeling off the last of the bandages to reveal a yellowing would. “But we weren’t friends, you know? Angela had a hard time keeping friends.”
   Upstairs, Angela’s belongings fill six small boxes. One of them contains a drawstring purse, a few shirts. In another, a pair of sensible white shoes, the kind nurses wear. Next to these are two carved doves, one of which is missing a wing. A workbook falls open to a completed page: “The REATH is an organ,” it reads, and next to it, in Angela’s childlike hand, the carefully filled-in blanks: HEART.
   There’s also a collection of photographs, and Mark Townsend, who with Liz Evans co-manages the Portland, starts laying them down, one by one, as though dealing from a deck of cards. Angela with her sister Amber at Christmas. Angela was 16.
   “It’s quite amazing,” says Townsend, lingering over the last shot. “Her face has hardly changed.”
   He’s right. Even then, however, it’s clear there was something wrong with the little girl in the photo. She seems jumpy and wired, barely in control. Next, Townsend turns over a plasticized ID from a neighbourhood cheque-cashing store. On it is a birth date: June 23, 1971. Angela was 27 when she disappeared on November 20, 1998. Even Townsend is surprised. She looked much older.
   The Downtown Eastside has been victimized by the rest of the city’s overall success. Since Expo 86, when local real estate prices began to soar, Vancouver’s stock of cheap hotels and rooming houses outside the Eastside has been steadily eroding, with many being converted to mid-priced backpacker lodgings or “boutique” hotels. In 1994, the federal government slashed social-housing spending, prompting a migration of new residents---many of them drug users and deinstitutionalized mentally ill---into the Downtown Eastside searching for what services and affordable accommodation remained. At the same time, the area itself was becoming smaller as developers eyed the elegant turn-of-the-century architecture on the edges of nearby Gastown. The result was an area unlike any other in Canada or, indeed, in the U.S. Pacific Northwest: a dense concentration of poverty-stricken users compressed into an ever-constricting space.
   Within that environment was a smaller ecosystem dominated by single room occupancy (SRO) hotels.


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    According to the Vancouver Injection Drug Users Survey, an ongoing study of 1,300 addicts from the Vancouver area, about half end up living in the approximately 6,500 SRO hotel rooms that make up the bulk of the region’s cheap housing. For many, these rooms are their only option. To local AIDS researchers, however, they are the hot zone. Michael O’Shaughnessey, director of the Centre for Excellence, calls them vertical shooting galleries, a term that rankles Tom Laviolette, who coordinates the Community Action Project, a neighbourhood housing advocacy initiative administered through the Carnegie Community Association. “I’ve talked to O’Shaughnessey about that,” says Laviolette wearily. “So what’s better? Having them on the street?
   A typical SRO hotel room is nine square metres of living space, generally without bathroom facilities, refrigerator, or stove. If they are classed as housekeeping rooms, linens are changed, usually weekly, while those classified as sleeping rooms are little more than places to fit a bed and usually, although not always, a sink.
   Some SRO hotels are like the Portland, clean and well run, but others are hellish, as Laviolette readily admits. “The North Star just got shut down,” he says. “Out of 30 rooms, there were maybe 6 legitimate monthly renters. The rest were dailies and hourlies. And in that case, the rooms were being used for fixing. The Roosevelt was run by a bunch of dealers, and some of the rooms were being used for tricks and rented hourly. No doors on some rooms, no maintenance. There was sewer water from a leaky toilet running down the stairs.”
   A 1995 study headed by Steffanie Strathdee found that living in unstable housing---on the streets or in a shelter, having no fixed address or in an SRO hotel---doubles the risk of contracting HIV. Within many SROs, there is a “climate for needle sharing” where many newly infected addicts, their viral loads soaring, casually engage in needle sharing. These informal sharing networks constitute another critical piece of Vancouver’s HIV puzzle.
   Again, Martin Schechter does the math. On his computer, he shows two groups, each consisting of five people. “If you just measured things like links and partnerships, both groups would look roughly equal,” he says. “But this one,” pointing to the second group, “is far more dangerous.”
   The first group is a “monogamous model”---five people in a row. For the infection to pass from the initial infectee through the entire chain, four separate infections would have to take place. The second group is a wheel of four people with a fifth person at its center. “Suppose he gets infected,” says Schechter, pointing to one of the peripheral people and tracing a path through the center to one of the other spokes. “He’s only two relationships away from everybody else in the cluster. So it just spreads, like a fireball.”
   When the fireball explodes, it burns from the middle. Those who engage in the highest-risk behaviors---indiscriminate needle sharing, working the sex trade, frequent injectors---are the first to be infected. Angela, a drug-addicted prostitute whose life was chaotic at best, was living at ground zero.


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Recently one of the 23 missing was found, but 22 women are still unaccounted for since 1995. People wonder: Are we doing enough? 

ANGELA’S ARRIVAL IN VANCOUVER coincided roughly with the first wave of cheap injection cocaine, perhaps the most critical event in the natural history of the Vancouver epidemic. Since becoming both inexpensive and plentiful in the early 1990’s cocaine is now cited as the drug of choice by 64 percent of Vancouver’s IDUs. Studies indicate that addicts who frequently inject cocaine tend to take more irrational chances---sharing needles or preparation solutions, for instance, or letting someone else inject them---thereby significantly increasing their risk of HIV infection.
   Cocaine’s main impact was both simple and chemical: while a heroin high lasts for hours, a cocaine high lasts only 20 to 30 minutes. A heroin user might inject once or twice a day, but a cocaine addict often will shoot up 4 or 5 times daily---or, when on an exceptional binge, as often as 40 times, according to street-level studies conducted by the Centre for Excellence. Needless to say, cocaine use sent the rate of needle sharing through the roof.
To Martin Schechter, the results were predictable and easily illustrated. Schechter starts with two conservative assumptions: one, that newly infected addicts had 50 times more virus in their blood than latent users, and two, that the contact rate between addicts---the number of times they would share their “rigs,” or syringes---was 2.5 times a month. “You get a kind of smoldering epidemic,” he says, “with relatively low incidence rates: a slowly rising prevalence, okay? Now, we said to ourselves, let’s simulate the change when people switched to cocaine.”
   Starting in 1994, Schechter increases the contact rate from 2.5 to 4.5 times a month---again, a moderate figure. The result is a massive spike in new infections, exactly imitating what happened in the Downtown Eastside. “Now,” says Schechter, “you can see what drives this epidemic.”
   In Angela’s case, cocaine was only one of several culprits. Like the Downtown Eastside itself, she wasn’t easily solved or understood. Or, for that matter, helped. “Angie was a very demanding person in a lot of ways,” says John Turvey, a former addict and now executive director of the Downtown Eastside Youth Activities Society, which operates the needle exchange. “She was sweet and could be compassionate when she got outside herself long enough. Very childlike….I’m absolutely dismayed she went missing. But ask me if I’m surprised, and I’m not.”
   Outside the Portland, Andrea, a pretty, young, flame-haired girl and a recent arrival at the hotel, offers a less sympathetic appraisal. “I don’t mean to be mean,” she says, “but Angela was very mentally ill, and she was ‘dope simple.’ That’s why she would, you know, put herself in stupid situations.”
   There is a pecking order on the streets, and Angela was firmly ensconced at the bottom, turning tricks behind the Astoria Hotel, perhaps defiantly under the “No Intercourse” warning painted nearby on an alley wall. Today, there are a few women working the adjacent avenues. Not many want to talk about Angela---or talk at all.
   “Yeah, I knew her. She was that retarded girl, right?” says Rebecca, tossing long, curly, dark hair. “Well, we used to chase her away from here. She was weird, you know? She’d pull up her top or raise up her skirt and show, you know, anybody who was driving by. She’d run after cars---I mean, I’m serious, she’d actually chase them down the street and shout, ‘Five bucks! Five bucks!’ She was pretty whacked.” Rebecca pauses as passing cars, invariably driven by respectable-looking middle-aged men, crawl by. “You sure you don’t have a cigarette?”


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  ANGELA IS A DIFFICULT METAPHOR, but the problem with real-life metaphors is that they lead real lives. In a way, she was much like the Downtown Eastside itself: a cauldron of seemingly unfixable problems, in your face and full of bruises. And the area’s problems continue, even though by late 1998 the transmission rate among IDUs had dropped to approximately 3.5 percent---still uncomfortably high. The transmission rates are lower not because of intervention or changing behaviors or even the increasing street presence of crack cocaine, which is smoked and not injected. Rather, they are lower because of a stark epidemiological equation: those who were most likely to become infected already have.
   Nothing much has changed. Needle sharing continues, cocaine is abundant, and living in an SRO hotel is still often the only viable alternative to being on the street. And that means for the next influx of  “new susceptibles”---let’s call them people---the conditions are still ripe for another outbreak. “The street kids of today are going to be the injection drug users of tomorrow,” warns Steffanie Strathdee. “What frightens me is that a lot of the conditions that created the epidemic are still there. If we were to wipe the slate clean and introduce a new population of injection drug users, I think we’d have another epidemic.”
   Back in the second-floor laundry room of the Portland, Jill Pleskach, a hotel worker, shows off a small toy she received as a gift: For Jill From Angie, reads the makeshift card.
   “Oh, yeah, a little thing from Angie,” she says, smiling. “You can say what you want about Angie. But I liked her. I liked her. She was a pistol, that kid.”
   Townsend misses her too. He misses the woman who had no choice but to live life with the volume turned up to 10, a self-destructive child lost to the Downtown Eastside but lose somewhere else a long time before.
   He dreams about her sometimes. Not the violent, terrible dreams some of his coworkers have. Good dreams. “I’m walking down the street, and I see the back of her, and I run up---and she’s there,” says Townsend, his voice trailing off. “She looks just the same. Funny enough, she’s wearing that pink dress.”
   Townsend looks out the window, his gaze turning westward, beyond the concrete horizon toward the postcard Vancouver of tourist brochures and travel guidebooks. There, the cherry trees are in full bloom. The city is awash in pink.

Long-time EQUINOX contributors, Guy
Saddy and Peter Bennett are based in  
Vancouver, British Columbia.  

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Updated: August 21, 2016