8.3 Analyses: How This Initiative Illustrates The Mobilization Of Population Health

8.3.1 How the determinants of health are addressed

The Vancouver Agreement is based on an analysis that moves the focus of the "drug problem" in the DTES toward a comprehensive range of broader economic and social determinants, and away from personal health practices and coping skills. The determinants addressed by the various initiatives under the Agreement include income and social status, social support networks, education, employment and working conditions, social environments, physical environments, health services, and to some extent, gender. This analysis was supported by reviews of current international research and experimentation related to substance misuse and HIV intervention strategies with harm reduction models as a focus. Examples of comprehensive strategies implemented in several European and Canadian cities were examined, as were existing data on the socioeconomic and health status of DTES residents, data on housing stock and conditions, illegal activity, and other related issues (1A).

The table below relates health determinants to the specific Sub-committees and initiatives of the Vancouver Agreement, to illustrate its comprehensive approach to the problems in the DTES. As the table suggests, the interaction among determinants is addressed through the cross-cutting nature of the work of several Sub-committees (1B).

DETERMINANT	SUB-COMMITTEE/INITIATIVE
Income and social status	Economic and Social Development: economic development program (PEACH) Primary Health Care and Comprehensive Substance Misuse Sub-committees: skills training
Social support networks	Community Capacity-building Sub-committee Primary Health Care and Comprehensive Substance Misuse Sub-committees: referral and support services
Education	Training, Skills Development and Employment Sub-committee Primary Health Care Sub-committee: skills training
Employment and working conditions	Training, Skills Development and Employment Sub-committee Primary Health Care and Comprehensive Substance Misuse Sub-committees: skills training
Social environments	Safety and Justice Sub-committee: policing re-orientation and redeployment Community Capacity-building Sub-committee
Physical environments	Housing Sub-committee: new housing projects Physical redesign of drug activity locations Street improvement programs
Personal health practices and coping skills	Primary Health Care and Comprehensive Substance Misuse Sub-committees: prevention, treatment and referral services
Health services	Primary Health Care and Comprehensive Substance Misuse Sub-committees: re-organization and expansion of services based on a comprehensive community health framework
Gender/culture	Primary Health Care Sub-committee: consolidation/expansion of treatment services for women Community consultations involving cultural and First Nations groups

In terms of gaps in knowledge about the determinants (IC), much remains to be learned about the effectiveness of some of these strategies in dealing with this form of urban social disintegration. Although some information is available about the effectiveness of individual strategies such as low-threshold services or needle exchanges, the comprehensive nature of this initiative puts it at the cutting edge of these types of interventions. Stakeholders in the Agreement and elsewhere will be following the results of this program and other similar ones around the world in coming years.

8.3.2 How the focus is placed on the health of populations

The population addressed in this initiative - people living or involved within the DTES geographical boundaries - is actually composed of several very heterogenous population and interest groups, including:

• street-involved people, including a large number of substance users and misusers
• residents, both homeowners and renters, notably families with children and the isolated elderly
• Gastown community residents and businesses
• Chinatown community residents and businesses
• other ethnic communities, including Vietnamese, French-speaking and Spanish-speaking groups
• urban Aboriginal people.

The overall strategy of the Vancouver Agreement is to address the health determinants as they affect all of these populations. However, many of them have competing interests and preferences. For example, low-income families want to see more social housing and greater emphasis on enforcement for community safety; the injection drug-users association would like to see the creation of safe injection sites within the community; and the business owners argue for increased market housing and economic and physical revitalization programs. The Vancouver Agreement Strategy therefore uses a multi-determinant, multi-initiative approach to address as many issues as possible, while at the same time attempting to develop strategies to reconcile competing approaches and conflicts.

8.3.3 How upstream investment has occurred

The various initiatives in the Vancouver Agreement are designed to form a continuum that can be seen as running from downstream to upstream, using multiple strategies in order to meet acute needs, while at the same time working toward changes in basic social and economic conditions. An example of this continuum approach is found in the "Comprehensive Framework for Community Health," which includes the following components:

• Long-term management and rehabilitation and other supported activities (downstream):
  range of housing options for alcohol and mental health clients.

• Treatment of urgent health problems and management of chronic health problems and disease (midstream):
  full spectrum of primary care; communicable disease treatment; substance misuse services (themselves a continuum of sobering services, withdrawal management, stabilization services, outreach and opiate replacement therapy, treatment programs).

• Prevention, health promotion and community capacity building (upstream):
  prevention and education; communicable disease control; peer supports and user mobilization.

It is the aim of the initiative that all parts on this continuum will be available and accessible in the DTES by the end of the Agreement. It is interesting to note that the Primary Care and Comprehensive Substance Misuse Strategy Sub-committees considered becoming fused in March 2000 as they became convinced of the need for an integrative model along this continuum. This recommendation was not at first accepted by the Management Committee.

The housing initiatives are working with a similar continuum notion, aiming to work from downstream to upstream. In this instance, the Agreement is expected to put housing into place beginning with crisis housing - moving people through this to temporary housing, then social/subsidized housing, to market housing. The actions outlined in the Agreement can be viewed as trying to break bottlenecks in this continuum.

8.3.4 What accomplishments are anticipated in the short, medium and long term

In the short term, the expected accomplishments of the Vancouver Agreement are to create mechanisms for better intergovernmental collaboration, so that the levels of government are less likely to play one against the other. This may have spin-off benefits for other types of initiatives as well, outside the DTES. In the medium to long term, the Agreement is expected to produce gains in health service provision in the areas of drug addiction and mental health, that some feel have been seriously under-funded until now.

In the medium to long term, among the residents of the DTES, expected impacts include a decrease in HIV and hepatitis rates, decreases in overdose deaths and emergency room overdose consultations, and increased utilization of primary health services by those who are currently not accessing the system: "Dealing with marginalized groups in ways to stop marginalizing them, helping them get back on track." In addition, decreases in homelessness and income-security dependency are also expected. At the community level, a safer and gentler community is expected, with a less open drug scene, greater safety for residents and a more vibrant economic and social life.

8.3.5 How multiple strategies are applied

The Vancouver Agreement includes the entire spectrum of population health strategies, all variously interwoven: "It is trying to connect with marginalized people in a comprehensive manner." The emphasis is on breaking down the barriers and bridging the gaps among service providers to strengthen the community's resources and assets. Focussing on the drug-involved population, some examples of interconnections are:

• Health promotion and disease prevention connecting with health services re-orientation:
  integrating education, referral and harm-reduction strategies into primary care; providing outreach services to addicted individuals.

• Public policy development and coordination interconnecting with health services re-orientation and connecting with risk management:
  providing a safe contact environment available 24/7 where intoxicated individuals can spend detox time off the street; policy coordination with police for a Saferide program without arrests.

• Creation of supportive environments connected with re-orientation of health services:
  creation of new crisis and medium-term housing units for people at risk of homelessness, with provision of health and social supports.

• Capacity building connected with creation of supportive physical and social environments:
  economic development grants made available to residents, coupled with neighbourhood clean-up and support to community development activities.

• Citizen engagement connected with capacity building and environmental actions:
  outreach education, peer training and counselling, mobile needle exchange, needle sweeps and street cleanup involving a 300-member association of drug users as workers.

The various interventions are situated in multiple settings, including public spaces, living spaces (for example, hotels, social housing, shelters), commercial centres and health and social service agencies.

It should be noted that many of these strategies have complex implications. For example, the relocation and expansion of health service locations required extended efforts on the part of the City of Vancouver and the Vancouver Richmond Health Board, with public hearing processes and various legal and zoning steps to be dealt with (not to mention parking spaces). All of these steps take time, and most of them require educating other bodies and officials, as well as the public, about the value of the approach and its place in the overall determinants picture.

8.3.6 How collaboration across levels and sectors has occurred

8.3.6.1 Nature and implications of collaboration

This initiative involves a very large number of departments, agencies and other bodies in all three levels of government. Each level of government is represented in the Committees at each level, so that each level of discussion and decision making reflects the perspectives and mandates of all three main partners and governance is shared. This collaboration is challenging because of the stovepipe relationships that have existed in the past, and because each set of partners feels that it has strong rights and legitimacy to work on behalf of the DTES community. On the other hand, all partners come to the table with a sense of frustration over the lack of progress in the DTES over the decade, but also with a willingness to work together in order to deal with the problems in the community.

8.3.6.2 Involvement and financial contribution of partners (5A, 5B, 5C, 5D)

Federal government including Health Canada
Federal departments involved include Health Canada, Western Economic Diversification, Corrections Canada, Human Resources Development Canada, Industry Canada, Status of Women Canada, Canada Mortgage and Housing Corporation, Citizenship and Immigration and the Royal Canadian Mounted Police. The federal contribution is coordinated by a federal interdepartmental committee, with representation from all of the above departments and chaired by Western Economic Diversification. This latter department has taken the federal lead throughout the negotiation and implementation of the Urban Development Agreement; indeed it was Western Economic Diversification that suggested the urban development agreement framework as the model for the Vancouver Agreement. Health Canada's role has been to provide support and expertise at all levels, including in the Sub-committees.

The total federal contribution to the Agreement is $1.5 million, of which $1 million was announced by the Minister of Health in response to the initial crisis.

Provincial government
The province of British Columbia is contributing a total of $10.1 million, of which a large portion ($7.5 million) is dedicated to the provision of new housing developments and the renovation of existing social housing in and close to the DTES. One of the new units will provide housing for DTES seniors, with supportive services offered through the Vancouver Richmond Health Board. Another will provide shelter and second-stage housing for women and children in crisis and at risk of becoming homeless. As well, the province is contributing $1.7 million to the expansion of front-line services and $1 million to the Economic Development Program.

Regional Health Board
The Vancouver Richmond Health Board is a key partner in the execution of the initiative and is represented on the Management Committee as well as on the Health and Safety Committee. Its role is delegated from the province, which has an arm's-length relationship with the province's Health Boards. With an annual budget of $1.8 billion ($400 million in Community Services), its mandate is to provide health services in its jurisdiction. Its staff and resources will be directly responsible for the management and delivery of services in the new continuum. These will include:

• Contact Centre. First point of contact (24/7) for individuals requiring basic health and safety supports; expected number of clients is 200 clients per day.

• Downtown Community Health Centre. Central health care facility in the region, expanding services and changing locations, offering care to all; expected number of clients is 200 to 300 per day.

• Pender Community Health Clinic. Primary medical and addictions treatment; expected number of clients is 80 to 100 per day.

• Lifeskills Centre. Non-drug-using facility aimed at improving health and quality of life; expected number of clients is 100 per day.

City of Vancouver
For the City of Vancouver, the Vancouver Agreement constitutes one of four components of its overall Downtown Eastside Revitalization Program. The other main components are:

• Vancouver's Coalition for Crime Prevention and Drug Treatment Initiatives (public education and discussion fora, with the Mayor as chair of the Steering Committee)

• Crime Prevention Community Development and Mobilization Project, with $1.025 million in funding from the National Crime Prevention Fund over five years (funds contributed by Department of Justice, Status of Women Canada, Canadian Heritage, Human Resources Development Canada and the British Columbia Attorney General)

• City of Vancouver Strategic Actions, continued intervention and improvement efforts that are within the City's mandate.

The City's total contribution to the Vancouver Agreement initiatives as of September 2000 is $2.3 million, of which $1.95 million was already approved by Council for initiatives in the Downtown Eastside Revitalization Program.

8.3.6.3 Gains and challenges from intersectoral collaboration

The ongoing development and implementation of the Vancouver Agreement initiatives are extremely complex, and the inter-governmental collaboration involved has not always been smooth. In the interviews, some partners noted that there were some basic disagreements among the partners about each others' strategies, and some frustration with the pace of certain developments. These difficulties are painfully open to public view because the controversial nature of some initiatives has attracted negative media attention around community response. The pain is felt most acutely by those who work closest to the community, i.e., the Vancouver Richmond Health Board and the City of Vancouver. However, all concerned are committed to advancing the cause and still see the Agreement as an unprecedented opportunity to work together of behalf of the community.

8.3.6.4 Sustainability (5E)

Those interviewed were unsure about the sustainability of the Vancouver Agreement. The Agreement is highly visible and politically volatile, and implementation of its major initiatives has been slower than hoped. In one sense, however, the Agreement seems robust: "Getting the three levels of government to talk together about their own initiatives has been a major plus, because there has been an ongoing problem of fragmentation and divisiveness." It is expected that all partners are committed to resolving the problems in the DTES, and are likely to retain their population health focus even if the partnership itself does not extend beyond the original five-year period.

Some participants feel that the intersectoral work has already initiated lasting change in other departments, and that this is the long-term key to sustainability. The changes in the way police forces are interacting with the community and other agencies are cited as an exemplary case of paradigm shift. Others mentioned that the community also has come to a better understanding of the importance of the health determinants.

See Table 6 in section 10 for a summary of the contribution of each sector/partner to the Vancouver Agreement.

8.3.7 How mechanisms for citizen engagement have been employed

Citizen engagement has been a major preoccupation for the Vancouver Agreement in a number of ways. The issues surrounding the management of the health and social problems in the DTES are highly sensitive, and throughout the process of developing the Agreement and its component initiatives, there has been vigorous debate in the local media; community mobilization against the initiatives by local residents' groups; and denouncements made by groups representing community segments, such as Chinese merchants, injection drug users, etc. The atmosphere has been conflictual, reflecting fundamental differences in orientation (for example, between harm reduction and repression), at times involving demonstrations.

Within this sometimes tense atmosphere, the Agreement development process has devoted considerable resources and energies to citizen-engagement issues through community consultation and community-development/conflict-resolution actions. Prior to the announcement, community consultations were held in the form of six public meetings held in five languages, and meetings with five groups of community representatives (representatives of the low-income community; Gastown business and homeowners; Chinatown community (business owners, cultural, heritage and community organizations); Vancouver Aboriginal Council; and service providers to women in the DTES). At that time, concerns were expressed about aspects of the initiative and a perceived lack of public consultation.

Since that time, a Community Consultation Working Group has been created to coordinate consultation efforts associated with specific initiatives and to develop a framework for problem solving and dispute resolution and action, based upon experiences in Winnipeg and elsewhere. This has successfully addressed some of the problems, notably with a community-based group that had issued a court challenge against creation of the Lifeskills Centre. But as one interviewee noted: "The residents of the DTES are extremely divided, vulnerable and at risk, and we always need to beware of people speaking on their behalf - especially service providers."

It was also noted by interviewees in three different partner organizations that the role of the community in the mobilization process is not yet clear. While community involvement is built into the Agreement, there is structural and operational ambiguity about how to manage it. Clarity of direction is hampered by the tensions and divisions within the community. This area remains a challenge for the initiative.

8.3.8 How accountability for health outcomes has been increased

All through the Vancouver Agreement documents, both process and outcomes evaluations are mentioned as priorities for all parties. It was decided that overall evaluation be coordinated inter-governmentally, and some preliminary work has begun. Preliminary funding has been sought from the Canadian Institutes for Health Research. However, many of those interviewed stated that evaluation now needs to move forward more rapidly and that this is a challenge for the coming months.

8.3.9 How knowledge development has occurred

One of the major learnings for some of the players in this initiative is the need to balance risk taking and prudence when working inter-governmentally on sensitive and visible issues. It is necessary to develop trust among the partners, in this case within all the various committees, but especially within the Working Group, so that work can proceed without becoming snagged on jurisdictional or mandate issues. The creation of trust, according to respondents in the case, was aided by the frequent, even constant and frank communication among committee members, and their ability to sort out their different definitions of the same terms (for example, harm reduction) in order to continue dialogue.

Some additional support from partners to the infra-structure of collaboration would have been helpful in moving the process along: "Intersectoral action requires strong and sustained support!" All of the organizing, coordinating, negotiating and mobilizing work of the Management Committee, Working Group and various Sub-committees was accomplished with no formal secretariat or other administrative support. A need for such support is now being addressed through the creation of an office for the Agreement, which partners will jointly fund. This same issue found itself expressed at some other levels as well: for example, voluntary and ad hoc mechanisms such as the Federal Interdepartmental Committee can languish if not enough attention is paid to supporting the relationships.

One of the key learnings mentioned by some of those interviewed is that having people from the highest levels within their respective governments present during the discussion went a long way to ensuring that progress could be made - even though this tended to increase the visibility and therefore the risk of volatility in the political and social context.

The complexity of issues in the Vancouver Agreement is astounding. This initiative clearly illustrates that the adoption of a population health approach can lead to major re-structuring, re-orientation and re-negotiation of policies, structures and services at all levels. But, when the issues involved are subject to intense public scrutiny, the process becomes increasingly vulnerable, and expectations are best adjusted accordingly.

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