Photo: AP / DARRYL DYCK

This month, as the Trump administration implements its long-promised agenda to combat opioid addiction by physically boxing out and then probably executing its sources, local legislatures are more quietly parsing the question of who should inject, and where. Safe injection sites—typically, clean and professionally staffed spaces where drug users can get sterilized needles and shoot up—are some of the most controversial of the harm-reduction tactics being floated in the United States today, though they have existed in other countries for decades. Canada has been operating them since 2003.

The first above-board safe injection site in America may open in San Francisco in July, but the fear of condoning “lawless” activity has prevented many municipalities from moving forward. In Philadelphia this week, angry neighbors shouted down their council members, having heard a false rumor that a safe injection site had already broken ground. A handful of state counties have introduced pre-emptive bans to keep the question from even being posed.

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Many police departments, as well as nervous neighbors, say supervised drug use will “normalize” illegal behavior and keep drugs in circulation, as if the nearly 200 deaths a day from opioid overdoses isn’t indicative of a normalized problem. “The people living through it aren’t deviants,” the conflict zone photojournalist James Nachtwey wrote in a widely read TIME magazine photo essay this month, which showed images of Americans shooting up on San Francisco streets, in Boston-area restrooms, under bridges, and in their own suburban homes.

In almost every story you read about safe injection sites, you’ll see a quick aside about the first couple of experiments in this vein. The first experiment was in a church in the Netherlands in the ‘70s, which provided a safe place to do drugs as part of its alternative youth program. But the second, in Switzerland nearly 40 years ago, became the first state-sanctioned site, and its model was exported across Europe and eventually to Canada. Centers based on its model are still running today.

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They called it the “Fixerstuebli.” Literally, the word translates into “little junkie room” in English, but with an additional inflection of warmth: “Stuebli,” a Swiss diminutive, connotes coziness. But the project didn’t come out of a country that was particularly sympathetic to its drug users at the time.

Nearly 40 years ago, when the street-corner drug scene in Switzerland’s major cities was the stuff of legend and the country was not yet an international model for harm-reduction policy, the homeless and drug-addicted were handled punitively by the local police. Dealers and users were dealt harsh prison sentences in a zero-tolerance environment. But the problem continued through the ‘80s and the public health crisis only deepened as high-risk users lived on the street (or in the famous “Needle Parks”) and shared paraphernalia. By 1986 the country had 500 HIV cases per million people, the highest in Western Europe at the time, and a vast and visible drug epidemic. In Bern, the preferred center of the street-level drug culture was in the vicinity of the federal building.

The Fixerstuebli in Bern was originally conceptualized as a basic cafe setting for people who weren’t welcome in the city’s other, more reputable establishments; its staffers, advocates trying to curb the spread of HIV supported in part by the Contract Foundation of Bern, planned to provide hot food and a place to rest as an entrance point into various “self-help” programs. At first there was no shooting up allowed in the building, though social workers were stationed to provide support and counseling for whomever came by.

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Robert B. Haemming, a psychologist and harm-reduction advocate, was active with the center at the time; he wrote anecdotal case studies about the site starting the the ’90s. In his essay, “The Street Corner Agency with the Shooting Room,” he writes that unemployed drug users were contracted to build the first home for the cafe in a place where users already hung out—but by the time construction was finished, the center of the drug scene had moved on to another location.

However, “the news about this place quickly spread” Haemmig writes. “The uptake of this project was tremendous; despite the fact that most drug users gathered at another location, they moved during the opening hours to our place.” Open hours were during the day at first, until a neighbor complained and they moved closing time from 7 in the evening until 10.

Over time, Haemmig and his colleagues expanded the program, providing clean needles and condoms, as well as information about safe sex and drug use. When users started to inject there on their own, social workers allowed them a room in which to do so, safely and covertly; that cover was soon blown, as the demand for a safe space to shoot up skyrocketed and Swiss lawmakers accused Fixerstuebli employees of “assisting others to commit offense.”

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The charges were later dropped, thanks in part to a group of judges and prosecutors who successfully argued the services provided at the center were medical in nature, rather than based on providing banned substances. Once the Fixerstuebli assured the city they were turning away minors and that no drug deals were happening on the premises, police allowed them to continue their work. The legal precedent allowed other Swiss cities to open their own centers, as well.

But as the Bern site became more popular and both TV cameras and opportunistic drug dealers arrived, Haemmig noted the small cafe became overcrowded, the effort to “prevent [clients] from becoming exhibits in a human zoo” too much to handle in such a small cafe. In 1990, the landlord gave up and booted the Fixerstuebli from the building. Less than a year later, they were reinstalled in two locations: a temporary structure near the open drug scene and a street-level basement that belonged to the city. The leases were the result of long discussions between the advocates and the state; unsurprisingly, “it was mainly the director of police who opposed the project,” Haemmig writes.

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In the five years since they’d introduced the safe injection site to Bern, there had been no reported overdoses in the vicinity of the buildings. In the early 1990s, a primary health care center was added to address the poor health many drug users were in. Twenty-six years later, there are 98 safe injection sites in 10 countries, and harm reduction is one of the central pillars of Swiss drug policy. It’s estimated that around 70 percent of the 30,000 opiate and cocaine users in the country get treatment, and the number of intravenous drug users with HIV has gone down by about half in the last ten years.

We don’t have that kind of evidence here yet: There is only one safe injection site in the United State that’s been studied as a harm reduction model, and it is both covert and illegal. It’s staffed by local volunteers six hours a day, five days a week. Like the early Fixerstuebli, workers operate underground.

Recently, two researchers from UC-Davis were invited to study it as long as they did not disclose its location. The researchers estimated the center prevented 2,300 public injections over a two-year period, and considered it a major, if illegal, success. “We really applaud the work they’re doing,” one told the Washington Post. “It’s extremely courageous to operate a lifesaving service like this.”

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They said it took the volunteers who set the site up a year to decide to take the risky step—and only about a month to start providing care.