Downtown Eastside

The Downtown Eastside (DTES) is a neighbourhood in Vancouver, British Columbia, Canada. The area, one of the city's oldest, is notorious for its levels of drug use, poverty, mental illness, sex work, homelessness, and crime. It is also known for its strong community resilience and history of social activism.

Around the beginning 20th century, the DTES was the political, cultural, and retail centre of the city. Over several decades, the city centre gradually shifted westwards and the DTES became a poor, although relatively stable, neighbourhood. In the 1980s, the area began a rapid decline due to several factors including an influx of hard drugs, the de-institutionalization of mentally ill individuals, policies that pushed prostitution and drug-related activity out of nearby areas, and the cessation of federal funding for social housing. By 1997, an epidemic of HIV infection and drug overdoses in the DTES led to the declaration of a public health emergency. As of 2017, critical issues are an epidemic of opioid overdoses, especially those involving the drug fentanyl, decrepit and squalid housing and a shortage of low-cost rental housing, and a high prevalence of severe mental illness which often co-occurs with addiction.

The population of the DTES is estimated at around 6,000 to 8,000. Compared with the city as a whole, the DTES has a higher proportion of males, and of adults who live alone. It also has significantly more First Nation Canadians, who are further disproportionately affected by the neighbourhood's social problems. The neighbourhood has a history of attracting individuals with mental health and addiction issues, both from around British Columbia and across Canada, many of whom are drawn by its drug market, low-barrier services. Law enforcement policies are among the most progressive in Canada, however many vulnerable members of the community have low trust in police.

Gentrification of the area began in the 1980s, when Vancouver was preparing to host the Expo 86 world's fair, a trend that some see as a force for revitalization, but that others believe has led to displacement and homelessness. Numerous efforts have been made to improve the DTES, at an estimated cost of over $1.4 billion as of 2009. Services in the greater DTES area are estimated to cost $360 million per year. Commentators from across the political spectrum have said that little progress has been made in resolving the issues of the neighbourhood as a whole, although there are individual success stories. Proposals for addressing the issues of the area include increasing investment in social housing, increasing capacity for treating people with addictions and mental illness, making services more distributed across the city and region instead of concentrated in the DTES, and improving co-ordination of services. However, little agreement exists between the municipal, provincial, and federal governments regarding long-term plans for the area.

Geography
The term "Downtown Eastside" is most often used to refer to an area 10 to 50 blocks in size, a few blocks east of the city's central business district. The neighbourhood's issues are most visible in a stretch of Hastings Street around Main Street, which the Vancouver Sun described in 2006 as "four blocks of hell."

Some indications of the borders of the DTES, which shift and are poorly defined, are as follows:
 * A 2016 analysis of crime in the DTES by The Georgia Straight focused on an area that consisted of a six-block length of Hastings and Cordova Streets, between Cambie Street and Jackson Avenue.
 * The City of Vancouver describes a "Community-based Development Area", in which places that are important to low-income residents are concentrated. This area includes Hastings Street from Abbott Street to Heatley Avenue, and the blocks surrounding Oppenheimer Park.
 * By some definitions, the DTES extends along Main Street to beyond Terminal Avenue, and the DTES also includes a strip of land adjacent to the Vancouver's port.

For some community planning and statistical purposes, the City of Vancouver uses the term "Downtown Eastside" to refer to a much larger area with considerable social and economic diversity, including Chinatown, Gastown, Strathcona, the Victory Square area, and the light industrial area to the north. This area, referred to in this article as the greater DTES area, is bordered by Richards Street to the west, Clark Drive to the east, Waterfront Road and Water Street to the north and various streets to the south including Malkin Street/Prior Avenue. The greater DTES area includes some popular tourist areas and nearly 20% of Vancouver's heritage buildings.

Strathcona in the 1890s included the entire DTES. By 1994 Strathcona's northern boundary was generally considered to be the alley between East Pender and East Hastings Streets, though some place it at Railway Street, including DTES east of Gore Avenue.

History


The DTES forms part of the traditional territories of the Squamish, Tsleil-Waututh, and Musqueam First Nations. European settlement of the area began in the mid-19th century, and most early buildings were destroyed in the Great Vancouver Fire of 1886. Residents rebuilt their town at the edge of Burrard Inlet, between Cambie and Carrall Streets, a townsite that now forms Gastown and part of the DTES. At the turn of the century, the DTES was the heart of the city, containing city hall, the courthouse, banks, the main shopping district, and the Carnegie Library. Travellers connecting between Pacific steamships and the western terminus of the Canadian Pacific Railway used its hundreds of hotels and rooming houses. Large Japanese and Chinese communities settled in Japantown within the DTES, and in nearby Chinatown.

During the Depression, hundreds of men arrived in Vancouver in search of work. Most of them later returned to their hometowns, except workers who had been injured or those who were sick or elderly. These men remained in the DTES area – at the time known as Skid Road – which was a non-judgemental, affordable place to live. Among them, drinking was a common pastime. In addition to being a major cultural and entertainment district, Hastings Street was also a centre for beer parlours and brothels.

In 1942, the neighbourhood lost its entire ethnic Japanese population, estimated at 8,000 to 10,000, due to the Japanese-Canadian internment. Most did not return to the once-thriving Japantown community after the war. In the 1950s, the city centre continued its shift westward when the interurban rail line, whose main depot was at Carrall and Hastings, closed. Theatres and shops moved towards Granville and Robson Streets. As tourist traffic declined, the neighbourhood's hotels became run-down and were gradually converted to Single room occupancy (or SRO) housing, a use which persists to this day. By 1965, the area was known for prostitution and for having a relatively high proportion of poor single men, many of whom were alcoholic, disabled, or pensioners.

1980s


In the early 1980s, the DTES was an edgy but still relatively calm place to live. The neighbourhood began a marked shift before Expo 86, when an estimated 800 to 1,000 tenants were evicted from DTES residential hotels to make room for tourists. With Expo 86 also came an influx of high-purity cocaine and heroin. In efforts to clean up other areas of the city, police cracked down on the cocaine market and street prostitution, but these activities resurfaced in the DTES. Within the DTES, police officers gave up on arresting the huge numbers of individual drug users, and chose to focus their efforts on dealers instead.

Meanwhile, the provincial government adopted a policy of de-institutionalization of the mentally ill, leading to the mass discharge of Riverview Hospital's patients with the promise that they would be integrated into the community. Between 1985 and 1999, the number of patient-days of care provided by B.C. psychiatric hospitals declined by nearly 65%. Many of the de-institutionalized mentally ill moved to the DTES, attracted by the accepting culture and low-cost housing, but floundered without adequate treatment and support and soon became addicted to the neighbourhoods's readily available drugs.

Between 1980 and 2002, more than 60 women went missing from the DTES, most of them sex workers. Robert Pickton was charged with the murders of 26 of these women and convicted on six counts in 2007. He claimed to have murdered 49 women. As of 2009, an estimated 39 women were still missing from the Downtown Eastside.

1990s to present
In the 1990s, the situation in the DTES deteriorated further on several fronts. Woodward's, an anchor store in the 100-block of West Hastings street, closed in 1993 with devastating impact on the formerly bustling retail district. Meanwhile, a crisis in housing and homelessness was emerging.

Between 1970 and the late 1990s, the supply of low-income housing shrank in both the DTES and in other parts of the city, partly because of conversion into more expensive condominiums or hotels. In 1993, the federal government stopped funding social housing, and the rate of building social housing in B.C. dropped by two-thirds despite rising demand for it. By 1995, reports had begun to emerge of homeless people sleeping in parks, alleyways, and abandoned buildings. Cuts to the provincial welfare program in 2002 caused further hardship for the poor and homeless. Citywide, the number of homeless people climbed from 630 in 2002 to 1,300 in 2005.

Without the presence of a viable retail economy, a drug economy proliferated, with an accompanying increase in crime, while police presence actually decreased. Crack cocaine arrived in Vancouver in 1995, and crystal methamphetamine started to appear in the DTES in 2003. In 1997 the local health authority declared a public health emergency in the DTES: Rates of HIV infection, spread by needle-sharing amongst drug users, were worse than anywhere in the world outside Sub-Saharan Africa and more than 1000 people had died of drug overdoses. Efforts to reduce drug-related deaths in the DTES included the opening of a needle exchange in 1989, the opening of North America's first legal safe injection site in 2003, and treatment with anti-retroviral drugs. A shift among users from injected cocaine to crack cocaine use may have also slowed the spread of disease. Rates of HIV infection dropped from 8.1 cases per 100 person-years in 1997 to 0.37 cases per 100 person-years by 2011. By 2015, the 40-block area surrounding the safe injection site had also seen a 35% decline in overdose deaths. In the 21st century, considerable investment was made in DTES services and infrastructure, including the redevelopment of the Woodward's Building and the acquisition of 23 single room occupancy hotels by the provincial government for conversion to social housing. In 2009, The Globe and Mail estimated that governments and the private sector had spent more than $1.4 billion since 2000 on projects aimed at resolving the area's many problems.

Opinions vary on whether the area has improved: A 2014 article in the conservative National Post said, "For all the money and attention here, there is little success at either getting the area's shattered populace back on their feet, or cleaning up the neighbourhood into something resembling a healthy community." Former NDP premier Mike Harcourt described the current reality of the neighbourhood as "100-per-cent failure." Also in 2014, B.C. housing minister Rich Coleman said, "I’ll go down for a walk in the Downtown Eastside, night time or day time, and it's dramatically different than it was. It's incredibly better than it was five, six years ago."

Demographics
There are no official population figures for the DTES. Estimates have ranged from 6,000 to 8,000; the geographic boundaries associated with these figures was not provided.

Official figures are available for the greater DTES area, which was home to an estimated 18,477 people in 2011. In comparison to the city of Vancouver overall, the greater DTES had a higher proportion of males (60% vs. 50%), more seniors (22% vs 13%), fewer children and youth (10% vs 18%), slightly fewer immigrants, and more Aboriginals (10% vs. 2%).

A 2009 demographic profile by the Globe and Mail focused on an area of just over 30 city blocks in and around the DTES: It indicated that 14% of the residents were of Aboriginal descent. The average household size was 1.3 residents; 82% of the population lived alone. Children and teenagers made up 7% of the population, compared to 25% for Canada overall.

A population that is frequently studied is tenants of single room occupancy (SRO) hotels in the greater DTES area. According to a 2013 survey, this population is 77% male, with a median age of 44. Aboriginals make up 28% of the population, and Caucasians 59%.

Addiction and mental illness
The DTES population suffers from very high rates of addiction and mental illness. In 2007, Vancouver Coastal Health estimated that 2,100 DTES residents "exhibit behaviour that is outside the norm" and require more support in the areas of health and addiction services. According to the Vancouver Police Department (VPD) in 2008, up to 500 of these individuals were "chronically mentally ill with disabling addictions, extreme behaviours, no permanent housing and regular police contact." As of 2009, the DTES was home to an estimated 1,800 to 3,600 individuals who were considered to be at "extremely high health risk" due to severe addiction and/or mental illness, equivalent to 60% of the population in this category for the 1 million people in the Vancouver Coastal Health region.

A 2013 study of SRO tenants in the greater DTES found that 95.2% had some form of substance dependence and 74.4% had a mental illness, including 47.4% with psychosis. Only one third of individuals with psychosis were receiving treatment, and among those with concurrent addiction, the proportion receiving treatment was even lower. A 2016 study of the 323 most chronic offenders in the DTES found that 99% had at least one mental disorder, and more than 80% also had substance abuse issues. Between 60% and 70% of mentally ill patients treated at St. Paul's Hospital, the hospital closest to the DTES, are estimated to have multiple addictions. Possible explanations for the high level of co-occurrence between addiction and mental illness in the DTES include the vulnerability of the mentally ill to drug dealers, and a recent rise in crystal methamphetamine use, which can cause permanent psychosis.

Substance use
A 2010 BBC article described the DTES as "home to one of the worst drug problems in North America." In 2011, crack cocaine was the most commonly used illicit hard drug in Vancouver, followed by injected prescription opioids (such as fentanyl and OxyContin), heroin, crystal methamphetamine (usually injected rather than smoked), and cocaine (also usually injected). Alcoholism, especially when it involves the use of highly toxic isopropyl alcohol, is a significant source of harm to residents of the DTES.

In 2016, a board member of the Vancouver Area Network of Drug Users said that in the previous year, Vancouver's supply of heroin had virtually disappeared and been replaced by fentanyl, which is cheaper and more potent. At the end of 2014, the DTES saw a dramatic rise in fentanyl overdoses, and in 2016 the surge in drug overdose deaths led to the declaration of a public health emergency across the province.

In a 2008 survey of SRO residents in the greater DTES, 32% self-reported as being addicted to drugs, 20% were addicted to alcohol, 52% smoked cigarettes regularly, and 51% smoked marijuana. In 2003, the DTES was home to an estimated 4,700 injection drug users. Most live in unstable housing or are homelesss, and approximately 20% are sex workers. In 2006, DTES residents incurred half of the deaths from illegal drug overdoses in the entire province. Between 1996 and 2011, there have been large fluctuations in drug usage, with the most recent trend being an overall decline in illicit drug use between 2007 and 2011. However, between 2010 and 2014, hospitalizations related to addictions increased by 89% at St. Paul's Hospital.

According to a 2008 survey of greater DTES area SROs, tenants who used drugs estimated the cost of their habits at $30 per day, on average. Some addicts spend hundreds of dollars per day on drugs. Police attribute much of the property crime in Vancouver to chronic repeat offenders who steal to support their drug habits.

Mental illness
The VPD reported in 2008 that in its district that includes the Downtown Eastside, mental health was a factor in 42% of all incidents in which police were involved. The police department says its officers are often forced to act as front-line mental health workers, due to the lack of more appropriate supports for this population.

In 2013, the city and police department reported that in the previous three years, there had been a 43% increase in people with severe mental illness and/or addiction in the emergency department of St. Paul's Hospital. In Vancouver, apprehensions under the Mental Health Act rose by 16% between 2010 and 2012, and there was also an increase in the number of violent incidents involving mentally ill people. Mayor Gregor Robertson described the mental health crisis as "on par with, if not more serious than" the DTES HIV/AIDS epidemic that had led to a declaration of a public health emergency in 1997.

Prostitution
Vancouver has an estimated 1,000 street sex workers and according to police, most of them work in the DTES. They call the neighbourhood, and contiguous industrial areas near Vancouver's port, the "low track", where they typically earn $5 to $20 for a date. Most are survival sex workers who use prostitution to support their drug addictions; up to two thirds say they have been physically or sexually assaulted while working. Sex workers, particularly women with children, find it difficult to find housing that they can afford, and often have difficulty leaving prostitution because of criminal records or addictions that make it harder to find jobs.

Although Aboriginals make up only 2% of Vancouver's population, approximately 40% of Vancouver's street sex workers are Aboriginal. In one 2005 study, 52% of the prostitutes surveyed in Vancouver were Aboriginal, 96% reported having been sexually abused in childhood, and 81% reported childhood physical abuse. Some researchers and Aboriginal advocacy groups have attributed the over-representation of Aboriginals in Vancouver's sex trade to transgenerational trauma, linking it to Canada's colonial history, and in particular to the residential schools that previous generations of indigenous Canadians were forced to attend.

Crime and public disorder
Reported crime rates in the DTES are higher than in the rest of the city, due mostly to assaults, robberies and public intoxication. Although the DTES is home to 3% of Vancouver's population, it was the location of 16% of the city's reported sexual assaults in 2012. In 2008, it was the location of 34.5% of all reported serious assaults and 22.6% of all robberies in the city.

These figures may be an underestimate, as marginalized populations such as DTES residents tend to be less likely to report crime. The figures do not indicate how many of the reported crimes were actually committed by DTES residents; some residents and business owners believe that visitors from other neighbourhoods are responsible for a significant proportion of serious crimes. According to police, DTES women say that what they fear most are "predatory drug dealers who conduct their business with violence, torture and terror."

In addition to reported crime, the DTES has highly visible street disorder, that the New York Times described as "a shock even to someone familiar with the Lower East Side of Manhattan in the 1980s or the Tenderloin in San Francisco." Some government social workers have refused to enter certain SROs out of concern for their own safety, despite being mandated to monitor children who live there. Tourists are often encouraged to avoid the DTES, although they are seldom actually victims of crime. High crime rates and difficulties in obtaining affordable property insurance deter legitimate businesses from opening or staying in the area, resulting in many vacant storefronts.

Poverty
The greater DTES area is significantly poorer than the rest of Vancouver, with a median income of $13,691 versus $47,229 for the city as a whole. 53% of the greater DTES population is low-income, compared to 13.6% of the population of Metro Vancouver. In the V6A postal area, whose boundaries are similar to the greater DTES area, 6,339 residents received some form of social assistance in 2013. Of these, 3,193 were considered disabled and 1,461 were considered "employable". The base welfare rate for single adults who are considered employable is $610 per month: $375 per month for shelter and $235 per month for all other expenses. Advocates for low-income DTES residents say this amount, which has not increased since 2007, is not enough to live on. In 1981, the base welfare rate was equivalent to $970 per month after adjustment for inflation.

Some DTES residents supplement their incomes through the informal economy, through volunteer work which can yield stipends, or through criminal activity or sex work. A 2008 survey of SRO residents found that the average tenant income from all sources, including the informal economy, was $1,109 per month.

In addition to issues with addiction and mental illness, DTES residents often have difficulty finding employment due to mental and physical disabilities and lack of education and skills. According to a 2009 survey of the 30 blocks in and around the DTES, 62% of the residents over the age of 15 were not considered participants in the labour force, compared to 33% in Vancouver as a whole.

The DTES is often referred to as "Canada's poorest postal code", although this is not the case.

Housing
Both homelessness and substandard housing are major issues in the DTES, that confound the neighbourhood's problems with addiction and mental illness. In 2012, there were 846 homeless people in the greater DTES area, including 171 who were not in some form of shelter. The DTES homeless made up approximately half of the city's total homeless population, over a third of whom are Aboriginal.

Thousands of DTES residents live in SROs, which provide low-cost rooms without private kitchens or bathrooms, Although conditions in SROs vary considerably, they have become notorious for their squalor and chaos. Many are over 100 years old and in extreme disrepair with shortages of basic necessities such as heat and functioning plumbing. In 2007, it was reported that four out of five rooms had bed bugs, cockroaches, and fire code violations. Even at their best, the lack of living space in SROs leads to tenants spending more time in the public spaces of the DTES, including its street-based drug scene.

SRO landlords have often been called "slumlords" for failing to fix problems, and illegally evicting tenants. The city has often been slow to force SRO owners to make major repairs, saying that owners could not afford to make them without raising rents.

Health and well-being
A 2013 study of SRO residents in the greater DTES area found that 18.4% were HIV positive and 70.3% were positive for hepatitis C. Very few of those infected with hepatits-C receive treatment. The DTES also has higher rates of tuberculosis and syphilis than the rest of the province, and injection drug users are susceptible to other infections such as endocarditis. Aboriginals are at the greatest risk from disease.

Amongst the most vulnerable DTES residents, common issues with psychosocial well-being include low self-worth, lack of personal safety, lack of respect from others, social isolation, and low education levels. Many have lost custody of their children. A 2000 report from the Vancouver Native Health Society Medical Clinic said, "Many individuals are survivors of severe childhood trauma. Negative experiences such as family violence, parental substance abuse, sexual and emotional abuse, suicide, divorce, and residential school atrocities are the norm." Many DTES residents are too unstable to keep appointments or reliably take medication.

Life expectancy in the greater DTES area is 79.9 years, a significant improvement since the mid-1990s. Some of the increase may, however, be explained by the migration of healthier residents to the neighbourhoods surrounding the DTES. A 2015 study of DTES SRO residents found that they were eight times more likely to die than the national average, mostly due to psychosis and hepatitis-C-related liver dysfunction.

Culture
Although many outsiders fear the DTES, its residents take pride in their neighbourhood and describe it as having multiple positive assets. DTES residents say the area has a strong sense of community and cultural heritage. They describe their neighbours as being accepting and having empathy for people with addictions and health issues. According to the City, Hastings Street is valued by SRO residents as "a place to meet friends, get support, access services and feel like they belong."

The area has had a robust tradition of advocacy for its marginalized residents since at least the 1970s, when the Downtown Eastside Residents Association (DERA) was formed. Over the years, the DTES community has consistently resisted many attempts to "clean up" the neighbourhood by dispersing its close-knit residents. Successful resident-led initiatives to improve conditions in the DTES include the transformation of the then-closed Carnegie Library into a community centre in 1980, the opening of an unlicensed supervised injection site in 2003 that eventually led to the creation of Insite, improvements to Oppenheimer Park, and the creation of CRAB Park.

In 2010, the V6A postal area, which includes most of the DTES, had the second-highest concentration of artists in the city. Artists made up 4.4% of the labour force, compared to 2.3% in the city as a whole. The greater DTES area is the location of several art galleries, artist-run centres and studios. Notable annual events include the Downtown Eastside Heart of the City Festival, which showcases the art, culture, and history of the neighbourhood, and the Powell Street Festival in Oppenheimer Park, which celebrates Japanese Canadian arts and culture. City Opera of Vancouver, the Dancing on the Edge Festival, and other artists regularly perform in DTES venues such as the Carnegie Centre, the Firehall Arts Centre, and the Goldcorp Centre for the Arts at the Woodward's site. In 2010, Sam Sullivan, former mayor of Vancouver, said that in the DTES, "Behind the visible people who clearly have a lot of troubles, there's a community. Some very intelligent people say this is the cultural heart of the city."

Law enforcement
In comparison to other Canadian cities, the VPD is generally progressive in dealing with drugs and sex work, emphasizing harm reduction over law enforcement. Since the 1980s, the VPD has generally ignored drug use in the DTES, as the sheer volume of users makes it unfeasible to arrest all of them. A large-scale police crackdown on DTES drug users in 2003 made no difference except to displace drug use to adjacent neighbourhoods. To encourage people to call for help when a drug user is overdosing, paramedics rather than police respond to 911 calls about overdose deaths, except in cases where public safety is at risk.

Nationwide efforts to reduce the supply of drugs through law enforcement have had minimal impact on the easy availability or low prices of illicit drugs in Vancouver. By former mayor Mike Harcourt's estimate, police intercept only 2% of the drugs that enter the city. Vancouver police guidelines on dealing with sex workers emphasize focusing on addressing violence, human trafficking, and involvement of youth or gangs in prostitution, whereas sex involving consenting adults is not an enforcement priority.

Relations between police and DTES women were strained by police shortcomings that allowed serial killer Robert Pickton to prey on the community for years before he was arrested in 2002; the VPD apologized for its failures in 2010. In 2003, the Pivot Legal Society filed 50 complaints from DTES residents alleging police misconduct. An investigation by the RCMP, in which several VPD officers and the police chief failed to co-operate, found that 14 of those allegations were substantiated. In 2007, Pivot agreed to withdraw its remaining complaints, following apologies and changes to VPD policies and procedures.

In 2008, the VPD implemented a crackdown on minor offences such as illegal vending on sidewalks and jaywalking. The ticketing blitz was stopped after objections from community groups, so that residents with unpaid tickets – particularly women and sex workers – would be less afraid to approach police to report serious safety concerns.

In 2010, police launched an initiative to combat violence against DTES women, that resulted in the convictions of several violent offenders. However, the level of trust towards police remains low. According to some DTES activists, "gentrification/condos and police brutality", rather than drugs, are the two worst problems in the neighbourhood.

Housing availability and affordability
The City refers to the housing and homelessness situation in the DTES as a "crisis". There is wide support amongst governments, experts, and community groups on a Housing First model, which prioritizes stable, quality housing as a precursor to other interventions for the homeless, addicted, or mentally ill. Many people with severe addiction and/or mental illness require supportive housing.

As the DTES has many low-income adults who live alone and are at risk of homelessness, trends in housing options for low-income adults are of central importance to the neighbourhood. Although SROs have well-known problems, each SRO resident who loses their home and ends up on the street is estimated to cost the provincial government approximately $30,000 to $40,000 per year in additional services. In recent years, the number of units designed for low-income singles has increased slightly: In the downtown area (Burrard Street to Clark Drive) there were 11,371 units in 1993 and 12,126 units in 2013. The number of privately owned SROs declined during this time by 3283 units, while the number of social housing units increased by 4038 units. In 2014, a further 300 privately owned SRO units were lost.

However, rents in many of those units have risen. Rents in social housing units for low-income singles are fixed at the shelter component of welfare rates, but rents in privately owned SROs can vary. In 2013, 24% of privately owned SROs rented at the base welfare shelter rate of $375 per month, down from 60% in 2007. According to one advocacy group, the average lowest rent in privately owned hotels in the greater DTES area was $517 per month in 2015, and there were no vacant rooms renting at less than $425 per month.

The city has implemented a bylaw to discourage the redevelopment of SROs. Advocates for SRO tenants argue that the city's bylaw does not go far enough, as it does not prevent rent increases. The city says that only the province, not the city, has the jurisdiction to control rents, and that the province should raise welfare rates.

Since 2007, the provincial government has acquired 23 privately owned SRO hotels in the greater DTES area, containing 1,500 units. It undertook extensive renovations in 13 of those buildings at a cost of $143.3 million, of which $29.1 million was paid by the federal government. Due to rising rents and often-decrepit conditions in the area's remaining 4,484 privately owned SROs, DTES activists have called for governments to replace them with a further 5,000 social housing units for low-income singles.

Migration patterns
The DTES has a history of attracting migrants with mental health and addiction issues from across B.C. and Canada, with many drawn by its drug market, affordable housing, and services. Between 1991 and 2007, the DTES population increased by 140%.

A 2016 study found that 52% of DTES residents who experience chronic homelessness and serious mental-health issues had migrated from outside Vancouver in the previous 10 years, a proportion that has tripled in the last decade. The same study found that once in the DTES, the conditions of the migrants worsened. A 2013 study of tenants of DTES SROs found that while 93% of those surveyed were born in Canada, only 13% were born in Vancouver. Vancouver Coastal Health estimates that half of the population that uses its health services in the DTES are long-term residents, and that there is a population turnover of 15 to 20% each year.

Concentration of services controversy
The DTES is the site of many service offerings including social housing, health care, free meals and clothing, harm reduction for drug users, housing assistance, employment preparation, adult education, children's programs, emergency housing, arts and recreation, and legal advocacy. In 2014, the Vancouver Sun reported that there were 260 social services and housing sites in the greater DTES area, spending $360 million per year. No other Canadian city has concentrated services to this degree in one small area.

Proponents of the high level of services say that it is necessary to meet the complex needs of the DTES population. For some residents, the sense of community and acceptance that they find in the DTES makes it a unique place of healing for them.

The practice of locating a large number of services in the DTES has also been criticized for attracting vulnerable people to an area where drugs, crime, and disorder are entrenched. Some advocates for vulnerable populations believe that many DTES residents would have a better quality of life and improved chances of health if they could separate from the neighbourhood's predatory drug pushers and pimps.

During the City's planning process for the greater DTES, two-thirds of those who participated said they wanted to stay in the area. However, a 2008 survey of SRO tenants indicated that 70% wanted to leave the DTES. The City's 30-year plan is for two-thirds of the city's future social housing to be located in the greater DTES area.

Views on services in other neighbourhoods
Vancouver Coastal Health says that the lack of appropriate care for complex social and health issues outside of the DTES often does not allow people "the choice to remain in their home community where their natural support systems exist... A common barrier that prevents mentally ill and addicted people from living outside of the DTES is a lack of appropriate services and supports, and too often clients who do secure housing outside the neighbourhood return to the DTES regularly because of the lack of supports found in other communities."

Proposals to add social housing and services for the addicted and/or mentally ill to other Metro Vancouver neighbourhoods are often met with Nimbyism, even when residents selected for such projects would be low-risk individuals. A 2012 poll of Metro Vancouver residents found that although nine out of 10 of those surveyed wanted the homeless to have access to services they need, 54% believed that "housing in their community should be there for the people who can afford it." Some commentators have suggested that Vancouver residents tacitly agree to have the DTES act as a de facto ghetto for the most troubled individuals in the city.

Gentrification controversy
The DTES lies a few blocks east of the most expensive commercial real estate in the city. Since the mid-2000s, new development in the DTES has brought a mixture of market-rate housing (primarily condominiums), social housing, office spaces, restaurants, and shops. Property values in the DTES area increased by 303% between 2001 and 2013. Prices at the newer retail establishments are often far higher than low-income residents can afford.

The city promotes mixed-income housing, and requires new large housing developments in the DTES to set aside 20% of their units for social housing. As of 2014, in a section of Hastings Street from Carrall Street to Heatley Avenue, at least 60% of units must be dedicated to social housing and the rest must be rental units. Rents in at least one third of new social housing units are not permitted to exceed the shelter component of welfare rates.

Proponents say that new developments revitalize the area, improve the quality of life, provide new social housing, and encourage a stronger retail environment and a stabilizing street presence. They emphasize that their goal is for the DTES to include a mixture of income levels and avoid the problems associated with concentrated poverty, not to become an expensive yuppie-oriented neighbourhood like nearby Yaletown.

Others oppose the addition of market housing and upscale businesses to the DTES, in the belief that these changes will drive up prices, displace low-income residents, and make poor people feel less at home. Protests against new businesses and housing developments have occasionally turned violent.

Costs
Several overlapping sets of data exist on costs related to the DTES:


 * DTES-specific costs: Of the estimated $360 million per year to operate 260 social services and housing sites in the greater DTES area, three quarters of the spending is funded by governments, and the rest by private donors. This figure includes operating costs of a range of organizations including neighbourhood health care services, but does not include standard city operations, the capital costs of building social housing or other infrastructure, or hospital costs.
 * Wider-area costs related to issues that are concentrated in the DTES: In the closest hospital to the DTES, Saint Paul's, injection drug use leads to approximately 15% of admissions. The annual cost of ambulances responding to overdoses in Vancouver is $500,000, and the cost of police response to calls involving mental health problems is estimated to be $9 million per year.
 * Costs per individual: For each untreated drug addict, the costs to society, including crime, judicial costs, and health care, are estimated to be at least $45,000 per year. The government-paid lifetime healthcare cost per HIV-infected injection drug user is estimated at $150,000. A 2008 study estimated that each homeless person in B.C. costs $55,000 per year in government-paid costs related to healthcare, corrections, and social services, whereas providing housing and support would cost $37,000 per year. Costs per individual vary widely: A 2016 study found that 107 chronic offenders in the DTES incur public service costs of $247,000 per person per year.

Housing strategies
Although housing and homelessness are often perceived as being municipal issues, social housing is traditionally funded primarily by senior levels of government, which receive 92% of tax revenue in Canada. Libby Davies, a former DTES activist and Member of Parliament, called for a National Housing Strategy in 2009, saying that Canada is the world's only industrialized country with no national housing plan.

In 2014, the City of Vancouver approved a 30-year plan for the greater DTES area. It sets out a goal of having 4,400 units of social housing added to the greater DTES area, 3,350 units of social housing added elsewhere in the city, and 1,900 units of new supportive housing scattered throughout the city. The cost of implementing the plan is estimated at $1 billion, of which $220-million would be paid by the city, $300-million by developers, and more than $500-million from the provincial and/or national governments. The provincial government, which recently invested $300 million in social housing in Vancouver, said that it will not be funding the proposed housing expansion, and that its housing strategy had shifted towards other models such as rent assistance rather than construction.

Addiction and mental illness strategies
In 2001, the city adopted a Four Pillars drug strategy consisting of four equally important "pillars": prevention, treatment, enforcement, and harm reduction. Advocates of the Four Pillars strategy say that the 36 recommendations associated with the policy have only been partly implemented, with prevention, treatment, and harm reduction all being underfunded. Across Canada, 94% of drug strategy dollars are spent on enforcement. The city's 2014 Local Area Plan for the DTES does not propose solutions to the neighbourhood's drug problems; an article in the National Post described it as a "221-page document that expertly skirted around any mention of the Downtown Eastside as a failed community in need of a drastic turnaround."

The VPD, B.C. Medical Association, and City of Vancouver have asked the province to urgently increase capacity for treating addiction and mental illness. In 2009, the BCMA asked that detoxification be available on demand, with no waiting period, by 2012. A 2016 study of youth who used illicit drugs in Vancouver indicated that 28% had tried unsuccessfully to access addiction treatment in the previous 6 months, with the lack of success mostly due to being placed on waiting lists.

After the city and police department described an emerging mental health crisis in Vancouver in 2013, the province implemented three of their five recommendations within a year, including new Assertive Community Treatment teams and a nine-bed urgent care facility at St. Paul's Hospital. In response to a recommendation that the province add 300 new long-term health care beds for the most severely mentally ill, provincial Health Minister Terry Lake said that more research was needed to determine whether these beds were urgently needed. As of 2015, the province had opened or committed to only 50 new beds.

Co-ordination of services
Although DTES residents often have a complex combination of needs, services are typically delivered from the perspective of a single discipline (such as police or medical), or a particular agency's mandate, with little communication between the service providers who are working with a given individual. Despite widespread agreement in principle that a co-ordinated approach is necessary to improve conditions for DTES residents, the three levels of government have not agreed on any overall long-term plan for the DTES, and there is no overall co-ordination of services for the area.

In 2009, the VPD proposed the creation of a steering committee made up of senior city and provincial stakeholders, which would be mandated to improve collaboration between service providers to enable a client-centric rather than discipline-centric model. The report recommends prioritizing the needs of the most vulnerable individuals in the neighbourhood, saying that having them get the assistance they require is "a necessary condition for other neighbourhood improvement initiatives to succeed."