On Thursday, Aug. 25, the day after provincial income-assistance recipients received their support payments, the sirens started: Ambulance, police and fire engines throughout Vancouver were responding to a spike in accidental drug overdoses. Although media reports on overdoses have rightfully focused on the toll caused by fentanyl, a new and more powerful opioid, that particular Thursday is not unique.
Sirens are heard throughout Vancouver every month on the days after "cheque day," and are part of a long-standing monthly ritual that locals also refer to as "Welfare Wednesday" or "Mardi Gras." Drug dealers collect outstanding debts. The hashtag #WelfareWednesday is used to advertise drink specials. Community workers hand out fruit to people standing in line at the bank. Thanks to quick action by first responders, family members and health providers, almost all overdoses do not result in death. Some, devastatingly, do.
Amidst what has now been declared an overdose epidemic and public-health emergency, recent research conducted at the B.C. Centre for Disease Control documented a 40-per-cent increase in fatal overdoses on the days following assistance payments. Insite's subsequent decision to open its doors 24 hours a day around cheque day – and its exceptional capacity to prevent accidental overdoses from becoming lethal – will hopefully do something to stem the tide of completely preventable deaths that occur at this time every month. No one has ever died of an overdose at Insite.
However, overdose increases around cheque day do not just occur in Vancouver. They have been documented across the province, across the country and around the world. Insite's commendable efforts will do little to help someone in Surrey, Prince George or Thunder Bay.
While fatal overdose is the worst of the drug-related harms that spike around cheque day, it is not the only one. A growing list of studies document increases in everything from people leaving hospital against the advice of their doctors and clients being unable to access services that are either closed or have lineups out the door, to police being called in to assist in the ER and street-level violence. These are things Insite cannot fix.
The rise in drug use and drug-related harm around cheque day is an example of a logical administrative decision that has unintended yet severe health, social and economic consequences. Yet most jurisdictions in Canada and the United States deliver social-assistance payments in the same way: once a month, on the same day for everyone.
Academics, health-care practitioners and others have been calling for the system to be changed. It seems like an intuitive next step. But is it really that simple? The existing system already demonstrates how what might seem like a straightforward approach might not be upon closer examination.
Our researchers at the B.C. Centre for Excellence in HIV/AIDS are trying to find out whether there may be a better way. In October, 2015, we initiated an experimental study in the Downtown Eastside testing whether not paying study volunteers at the same time each month can do anything to reduce drug use and drug-related harms. We are examining what happens when people get paid at a different time than everybody else. We are also looking at what happens when they are paid – like most people in regular jobs – twice a month instead of monthly.
And while there are already ways to vary payment frequency in the province (for example, "mid-month" split payments administered by the Ministry of Social Development and Social Innovation), such setups are often mandatory conditions resulting from some previous transgression. Further, their impacts have not been evaluated. There is a serious need for research evidence that examines potential health and social policy solutions, not just health and social problems.
It is clear there are alternatives to the "once a month, all at the same time" approach to income-assistance payments. When the study is over, we hope we will have some sense of whether a change at the policy level – and finding a way to give people some choice in the matter – can help quiet the monthly chorus of sirens and keep people alive.
Lindsey Richardson is an assistant professor of sociology at the University of British Columbia and a research scientist at the B.C. Centre for Excellence in HIV/AIDS. She is also the lead investigator of the TASA Cheque Day study examining whether changing the frequency and timing of income-assistance payments can reduce drug use and related harm.