“Smack in the Middle”: Urban Governance and the Spatialization of Overdose Epidemics

In recent years, cities in North America have declared public health emergencies in response to opioid–related overdoses and fatalities. Municipalities are reacting with various interventions and degrees of urgency, whereas harm reduction organizations coordinate the street–level fight against death. Though drug use has long been concentrated in urbanized and downtown areas, these neighborhoods are being addressed with new national attention. This article draws on qualitative interviews with participants in the Downtown Eastside (DTES) in Vancouver and the Tenderloin in San Francisco. I highlight two interconnected themes: (1) the legacy of distrust between municipal officials and drug users and (2) the disconnection between “epidemics” as narrowly constructed public health emergencies and the needs of communities. Findings show ongoing struggles with “progressive” urban agendas. San Francisco minimized fatalities thanks to the early introduction of unregulated naloxone; however, new anti–homelessness legislation and police–led initiatives continue to create social upheaval for drug users. In comparison, the rollout of Vancouver's naloxone program arrived 10 years too late. Organizations are attempting to amplify access to safe injection and overdose prevention sites in the DTES. Using interurban analysis, overdose epidemics can be conceptualized as sociospatial fields of power, providing greater insight into urban marginality and health inequalities.