Oscar crouches in a small shack near a muddy embankment in the Kensington “badlands” of Philadelphia. Decorating the roof of his makeshift home are nearly a half-dozen plastic syringes, their needles embedded at sharp angles in the wood. Now 47, Oscar was born and raised in this neighborhood. He became addicted to heroin and “started this sad lifestyle,” he says, when he was 24.

Philadelphia has been walloped by the opioid epidemic, and Kensington—an impoverished neighborhood of low-slung row houses and deeply pitted streets—is its epicenter. When I ask how many people that he personally knew have died from an overdose, Oscar replies, “I lost count,” then clarifies: “I don’t say that figuratively—I did. And the sad story is that they get younger and younger.” He thinks it’s been dozens, at the least.

Kensington’s miseries, like Oscar’s, aren’t altogether new. The neighborhood has been the scene of an open-air drug market for decades, one of the more brutal legacies of the multipronged devastation of deindustrialization, wage stagnation, and racism. Yet no one here can recall anything like the current crisis. Just a few months back, The New York Times breathlessly labeled Kensington, which has some of the region’s cheapest and strongest opioids, the “Walmart of Heroin.”

In 2017, 236 people here died from overdoses, nearly one-fifth of all the overdose deaths in Philadelphia that year. The crisis is so acute that librarians at the local public library have received training in administering the overdose drug naloxone—a skill they use regularly. And while there were signs of a slight decline in 2018, the neighborhood remains a lethal outpost of the opioid crisis—which is the reason, on a chilly day last spring, that I came to find myself wandering its sidewalks and underpasses, talking to Oscar and other locals.

I’d been invited by Chris Moraff, an independent researcher and journalist, and Jeff Deeney, a social worker and writer. Both are white and in their 40s, with a history of using opioids on these streets; both have since dedicated their lives to fighting for the better understanding and care of people with addictions. They are among a number of volunteers and groups who regularly visit Kensington to help the largely homeless people who take drugs here.

Dressed in a dark-blue hoodie and a matching Phillies baseball cap, Moraff has friendly brown eyes that also hint at skepticism. In his backpack, he carries test strips that can detect the presence of fentanyl and its derivatives, which he shares with those who want to know what’s in the stuff they’ve bought and take precautions if the test is positive.

Deeney, broad-shouldered and nearly bald, has a warm smile and an open demeanor. He provides supplies like clean needles and also helps those who want shelter, addiction treatment, or other services to find their way through the system. He says he returns to these streets again and again out of a sense of obligation, as an act of karmic payback for the kindness shown to him during his own years of addiction. “I found older users who took care of me… African-American men who, for really no reason, just looked out for me,” he says. “I felt like there was some sort of cosmic debt that I owed to this community, because I had contributed to the chaos down there and I just wanted to set it right.”

Moraff has similar motivations. “The simplest answer is obviously [that] my own personal history of problematic drug use in the past makes it an issue that I have a special affinity and compassion for,” he says.

In recent months, this shared compassion has come to include a new focus: the push to help Philly become the first city in the United States to open a safe-injection facility, or SIF. SIFs, which are also called “supervised consumption” or “overdose prevention” sites, are essentially syringe exchanges that allow people to inject on-site, under the supervision of a nurse or a trained naloxone administrator. Some of these places are immaculate, medical-style facilities complete with on-site services and referrals to treatment programs; others are little more than tents. But in each case, the mission is the same: to save lives by reducing needle sharing and other unsafe practices—and by reversing overdose if it occurs.

“People don’t want to inject in public,” Deeney says. “They don’t want to have little kids see them get high or turn tricks, [but] they don’t have the power to create a space where they can get relief from these conditions.” SIFs, he explains, give drug users room to reflect, along with access to peers and others who not only know how to help, but who recognize their humanity. All of this can set the stage for many forms of recovery.

It’s a counterintuitive approach—how can it be healthy to help people shoot drugs?—but it takes on a devastating clarity as we set off into the squalor and unpredictability of Kensington, with its sidewalks dotted with crack vials and syringe caps. As we enter the area, the first thing we see is a line of police cars; the cops have blocked off the street, we learn, in order to arrest a suspected drug dealer armed with a gun. They’ve likely scared off the other dealers and customers, because we don’t see many people for a few more blocks, until we reach a series of underpasses. There, beneath the roar of unseen traffic, we find a collection of tents, with some residents peering out or walking nearby.

This is a community that is broken and wounded. “You can just see the pain—it’s all over every face down there,” says Deeney (although, as we walk, we can also see signs of resilience peeking through, in various acts of kindness and in the found art that people have decorated their tents with to make them more homelike).

One man we pass has clearly just injected: Dressed in dark sweatpants and a hoodie, he is nodding out, barely able to stand, his body hunched so far over that it seems miraculous that he doesn’t smash his head on the sidewalk. Not far away, I see what at first looks like a man shaving, using the side mirror of a parked car to guide his hand. It’s only as I get closer that I realize he’s injecting into his neck, presumably having damaged the more easily accessible veins.

While all drug crises have their trademark horrors—the turf-driven gunfights of the crack years, the drawn-out agony of AIDS pre-1995—these differences mask an important truth: Addiction is always with us, and it always hits hardest among those made vulnerable by poverty, racism, downward mobility, dislocation, trauma, and mental illness. The drugs and their associated harms may change, but the vulnerabilities remain mostly the same.

At the same time, today’s opioid crisis is unique in its lethality, killing people at a pace that was previously unimaginable. Thanks to the rise of fentanyl and similar synthetic opioids, overdose is now the leading cause of death for adults under 50 in the United States—a reality that has driven down American life expectancy in recent years. In 2017 alone, more than 28,000 people died from drugs laced with fentanyl or similar synthetics, a ninefold jump from the roughly 3,000 who died in 2013. In Philadelphia, that number surpassed 1,000 people in 2017.

“For comparison,” says Philadelphia Health Commissioner Tom Farley, “at the peak of the AIDS epidemic in 1994, we had 935 deaths from AIDS.”

The analogy is an apt one. In the 1990s, the rising death toll from HIV/AIDS—which was spread increasingly through intravenous drug use—pushed advocates to take matters into their own hands. Tired of waiting while the government did nothing, activists like Jon Parker, founder of the National AIDS Brigade, and members of ACT UP began distributing clean needles and deliberately getting arrested to challenge and ultimately eliminate most of the state laws prohibiting needles as “drug paraphernalia.”

These activists, many of whom were current or former drug users, called themselves “harm reductionists” because their emphasis was, and still is, on saving lives and protecting health, rather than on trying to stop people from getting high. As they set about trying to keep people safe, they were shocked by the callous disregard among policy-makers and the public toward the people who take illegal drugs, and disturbed by a clear hypocrisy: If people seek pleasure or relief from approved drugs like alcohol, caffeine, and tobacco, they have human rights—and their drugs are regulated for purity and dosage and aren’t even seen as drugs. But if people take anything else, they are criminalized—and if they die from using black-market drugs, they, unlike almost all other consumers, are thought to have deserved it.

Harm reductionists also recognized that the basis of the system that makes legal distinctions between drugs has little to do with their comparative dangers: There’s no risk-based or scientific way, for example, to justify illegal marijuana in the context of legal alcohol and cigarettes. Indeed, anti-drug laws—including alcohol prohibition in the 1920s—have almost always been powered as much by racist and anti-immigrant panic as by genuine public-health considerations.

So these activists began to fight for their lives. They provided clean needles to reduce the spread of HIV; they argued for policies based on preserving life rather than trying to “send the right message”—a message, moreover, that certainly didn’t seem to be having the intended effect.

Nearly three decades later, the seemingly ineluctable death toll from a different epidemic has galvanized a new generation of harm reductionists like Deeney and Moraff, whose work rests on the foundation of their forerunners. Their current focus is on securing safe places for people to inject drugs under medical supervision as a means of minimizing the overdose risk. Such places exist in nearly 100 sites across 10 countries, including Australia, Canada, Denmark, France, Germany, and Switzerland. There are none, however, in the United States.

The absence of US-based safe-injection facilities isn’t surprising, given this country’s long, puritanical, “just say no” approach to drug use and addiction. But it goes against decades of evidence supporting not only the safety of these sites but also their health and treatment benefits. Over the course of several decades, millions of injections by thousands of people have taken place in SIFs—the first, in Bern, Switzerland, was founded in 1986—but there has never been a single death. Indeed, a literature review of 75 published papers shows that these facilities reduce overdose-death rates, the spread of disease, public injecting, and needle litter, as well as decrease neighborhood disorder and improve health. Moreover, SIFs have been found to make people more likely to reduce drug use, cease injecting, get treatment, and recover.

In recent years, the promise of all this evidence has begun to filter up to elected officials in some of the cities hardest hit by the opioid epidemic. Now, a race is on between Philadelphia, Seattle, San Francisco, Denver, New York City, and Ithaca, New York, to become the first to open a legal SIF in the United States. (Underground programs are already operating in some cities.) Their most immediate model: a collection of safe-injection sites that have popped up in dozens of places across our neighbor to the north, Canada.

But these cities face profound obstacles in a country that still isn’t quite sure whether it sees addiction as a sin or a disease. Last summer, shortly before Jeff Sessions lost his perch as US attorney general, the Justice Department threatened to arrest and prosecute anyone who opened such a site. And on February 5, the Justice Department sued Safehouse, the Philadelphia nonprofit that was founded last year to set up and operate the city’s SIF. The suit asks the court to preemptively declare the facility illegal, based on a section of the Controlled Substances Act commonly referred to as the “crack house” statute. Passed in 1986, the statute makes it a felony for an organization to “knowingly and intentionally…make available for use, with or without compensation, [premises] for the purpose of unlawfully…using a controlled substance.”

Still, Safehouse isn’t giving up, and if the history of litigation over syringe exchange is anything to go by, it might have a decent chance at prevailing. “We respectfully disagree with the Department of Justice’s view of the ‘crack house’ statute,” Ilana Eisenstein, a lawyer for Safehouse, told The Washington Post. “We are committed to defending Safehouse’s effort to provide lifesaving care to those at risk of overdose through the creation of safe injection facilities.”

A few months after my visit to Philadelphia, I walked down Hastings Street, the bustling main drag—or mainline, really—of Vancouver’s Downtown Eastside. With its streets buzzing with people who are either hustling to get high or trying to sustain their intoxication, it could almost be mistaken for a corner of Kensington, but for the luxury condos and hip restaurants that sprout from the asphalt.

There is another essential difference between here and Kensington: Vancouver, unlike Philadelphia, is home to more than half a dozen safe-injection sites, most of which have set up shop in this neighborhood. These include Insite, the first SIF opened in North America, and seven pop-up SIFs—in some instances, little more than tents where people with naloxone can monitor people who are using—which have been authorized by the government to deal with the current overdose crisis.

Insite (a contraction of the words “injection site”) is one of my first stops on this rainy fall morning. Set inside a scuffed three-story building, it announces its presence with the cheerful words “Welcome to Insite” etched on the door, its logo—a white hypodermic needle—engraved below them.

Inside, the injecting room has a sterile, medical feel, with its clean metal surfaces, needles, wipes, and yellow plastic containers for used syringes. Nurses will soon monitor people unobtrusively as they inject in mirrored booths that could almost be mistaken for stylist stations at a beauty salon—which they were designed to resemble. “The hair-salon aesthetic was meant to push back against what services for drug users can look like,” says Darwin Fisher, Insite’s program coordinator. Around the world, he explains, most such facilities are either shabby or carceral, or both. They look like institutions of control, not welcome.

This morning, the facility looks more clinical than comforting, but Fisher and people who have used the site say that’s only because journalists aren’t allowed to visit when people are injecting, to protect their privacy. It would feel very different, Fisher adds, “if you were here while we were open, and these booths are filled, and people have their dogs in the room and there are bikes in here, and there’s music playing and there’s cross talk.”

On average, 1,000 people a month inject at Insite, taking as long as they need and then retiring to the “chill-out” room, which is more homey and has cushioned seating and a large purple mural by a member of the community. Upstairs, a sister outfit, playfully labeled “Onsite,” provides immediate access to short-term, inpatient care to treat withdrawal as well as connections to longer-term programs for those who want them—as many do.

In 2017, the last year for which full numbers are available, there were 175,464 visits to the site by 7,301 individuals, and 2,151 overdoses treated. More than 400 people stayed at Onsite, and many others were referred to outside treatment services last year. Since Insite opened in 2003, more than 3 million injections have taken place at the facility, but there hasn’t been a single death.

None of this materialized out of the ether. Insite and its offshoot injection sites are the hard-won handiwork of Vancouver’s justly famous harm-reduction activists—most notably the Vancouver Area Network of Drug Users. VANDU was founded in 1997 by people who use drugs, and it’s still led by drug users today.

In the 1990s, HIV/AIDS was devastating their community. By 1997, around half of all local injection-drug users had become infected, a total as bad as the epidemic had likely seen in North America. VANDU’s hundreds of active members demonstrated, blocked traffic, shouted in the streets—at one point, they installed 1,000 wooden crosses in a park to represent the death toll—and stormed meetings at City Hall until they eventually persuaded local politicians to allow and support a safe-injection site.

Still, the battle wasn’t over when Insite debuted: VANDU and its supporters had to fight all the way to Canada’s Supreme Court for the right to keep it open, which it won in 2011.

In the years since, HIV-infection rates have plummeted. Every injection taken at any one SIF is a chance to avoid a round of Russian roulette with street drugs—and Insite and the pop-up sites nearby have reported hundreds of overdose reversals. But that doesn’t mean SIFs have solved every problem of the opioid epidemic. Although overdose-death rates stabilized after Insite opened, once fentanyl hit the streets, its lethal force far outstripped the ability of a handful of SIFs to shift the broader dynamic in Vancouver.

Still, their success in the desperate game of saving lives is beyond dispute—so much so that there’s now a terrible irony. The risk from using street opioids unsupervised has become so great that in the Downtown Eastside, being homeless has become a protective factor: Since homeless people either inject in SIFs or in public, in a neighborhood where virtually everyone carries naloxone, they are much more likely to be revived than someone using the same drugs by themselves at home.

Until some 18 months ago, Philadelphia didn’t seem a likely contender for a Vancouver-style SIF. But in late 2017, as the city’s overdose rate soared so high that four times as many people were dying from opioid use as homicide, Mayor Jim Kenney assembled a task force co-chaired by Health Commissioner Tom Farley, who had previously served as the health commissioner of New York—a city with a long tradition of harm reduction.

Task-force members and others, including Police Chief Richard Ross, visited Vancouver. Afterward, Ross told The Philadelphia Inquirer that the trip had changed his position from “being adamantly against [the sites], to having an open mind”—albeit with some concerns. A study commissioned by the mayor found that just one SIF could save 25 to 75 lives per year as well as millions of dollars in hospital and ambulance costs. In Philadelphia, the sites will be given yet another name: comprehensive user-engagement sites, or CUES.

With the election of a progressive district attorney, Larry Krasner, in 2017, the city has all the key elements in place to move forward. But some community leaders remain fiercely opposed. They fear that providing more services for drug users in an area already coping with people openly selling and injecting just adds insult to injury for those who are trying to work or raise a family in the area. These critics don’t want to support the people they see as destroying their neighborhood—many of whom come from the rich, white suburbs to buy their drugs—and they certainly don’t want to attract more of them.

Solomon Jones, an African-American columnist for The Philadelphia Inquirer who is in recovery himself, is a leading critic of CUES, which he calls “bad policy.” In a 2018 column, he wrote: “People of color must not support safe injection sites, especially if those sites are not accompanied by a comprehensive plan to right the wrongs of the crack era. Blacks were criminalized for the same thing that our city now proposes supporting for mostly white heroin addicts. And if others are to be treated with compassion, we want our prisoners released, we want our records expunged, we want our property returned, and we want our communities made whole.”

At a community meeting organized by Jones at the Mount Tabor AME Church, Devin Reaves, a bespectacled, black harm-reduction leader who is also in recovery, challenged Jones and the City Council members who oppose CUES, asking them to suggest another equally proven method for reducing overdose deaths quickly. “If there’s something else we can do that can lower overdose deaths…let’s do that,” Reaves said. No response could be heard over the noise of the crowd.

When I visited Kensington with Moraff and Deeney, I asked Oscar what he thought about the idea of safe-injection sites. His answer was unequivocal: “It’ll save lives,” he said. “It’ll help the onslaught and stop the spread of [hepatitis] C and HIV.”

We stopped at an encampment, since cleared, under a bridge. This was not the kind of place that anyone would choose as home. The tents were surrounded by discarded needles, a half-eaten roast turkey, and other debris.

I spoke with one couple who lived in a tent there: Ashley, 32, a white woman with hair dyed a deliberately unnatural shade of red, is from an exclusive suburb, and she was buzzing with the uneven energy that sometimes comes from an opioid high. Her boyfriend, Salvador, who has warm brown eyes, is Latino and from this neighborhood. Both tell me that their families attribute their addictions to their relationship. “Her family blames me, and my family blames her,” Salvador says, before adding: “It’s not like that. I’m responsible for my decisions.”

Ashley had been homeless for two months, following a relapse after more than four years of abstinence. They had been living together in a tent under the bridge for a week. Ashley had lost at least 15 friends in the past year alone to overdose, she told me, so she recently got trained in administering naloxone, which she now carries.

She thinks that CUES would make a real difference. “A lot less people would be dying,” she says. “Ninety percent of people out here have no clue what they’re doing when someone ODs, because for so many years an OD meant jail time [just] for being there. Now it’s not that way, [but] people aren’t trained, so people are still fucking dying.”

“People are going to shoot regardless,” Salvador adds. “But if they want there to be less ODs and less disease, [CUES] is a great idea.”

As we’re talking, a police car drives up and an officer from the Special Victims Unit rolls down her window. First, she emphasizes that she’s not there to arrest anyone for drugs or open warrants. She displays pictures of two young women, who look significantly healthier than anyone around here. They are missing and believed to have been kidnapped. (The body of one has since been found, an apparent murder victim.)

In these areas rendered lawless by the criminalization of drugs, predators thrive. Most of the people here are harmless—prey made vulnerable by the trauma that leads to a large percentage of addictions, the mental illness that is often caused or exacerbated by that trauma, and the resulting drug use. Still, some come to take advantage of those who can’t defend themselves.

“This is what happens when you take a whole class of people and place them outside the boundaries of the law,” Deeney says. “They will go to these places where there essentially is no law, and that is just incredibly risky for people who can be exploited—women in particular.”

The same arguments now made against SIFS were heard more than three decades ago against needle-exchange programs. Critics argued that they would set a poor example for children and would increase drug use, community disorder, and general lawlessness, all while reducing the chances that addicted people would recover.

None of those fears proved valid. Instead, research found the opposite: that people who participate in needle-exchange programs are more likely to get into treatment than those who don’t. Nor do these programs increase the rate of drug use among young people. And they clearly fight the spread of AIDS: New York State labeled needle exchange the “gold standard” for HIV prevention in a 2014 report, which included statistics showing that, as access to clean needles increased dramatically over the last 30 years, the HIV-infection rate among New Yorkers who injected drugs plummeted, from 54 percent in 1990 to just 3 percent in 2012.

Thanks to the hard, patient work of harm-reduction activists, policy-makers in a growing number of cities understand this. Indeed, the battle over where to put safe-injection facilities may initially be solved simply by locating them inside existing needle exchanges, which have already won the NIMBY fight and which, in many cases, are eager to offer supervised-consumption rooms. To avoid stirring up opposition, many program officials didn’t want to speak on the record, but every needle-exchange worker I met with was eager to provide such spaces as soon as legally possible. Some are already doing so informally by not policing their bathrooms.

Should SIFs come aboveground, it would be a victory for harm-reduction advocates and the thousands at risk for overdose in New York, Philadelphia, Denver, and the other cities looking to open safe-injection sites. It would mean fewer deaths and an easier path to treatment. “You take somebody who’s injecting under a bridge in the rain with a dirty needle, versus somebody who can go into a clean, dry environment with some health-care workers—it’s pretty obvious what’s a better scenario,” says Mark Tyndall, who until recently was executive director of the British Columbia Centre for Disease Control.

Still, there’s a long battle ahead. And even if the SIF advocates prevail, it will be only the beginning of what needs to be a much broader, stronger push for harm reduction in the United States. Indeed, while the ferocity of the fentanyl crisis has convinced a handful of US cities of the need for safe injection, other cities in other countries have responded by experimenting with even more radical action. Vancouver, for instance, has decided to expand a program that provides pharmaceutical-grade heroin to a hard core of people addicted to the drug. The idea follows vintage harm-reduction strategies and has produced significant outcomes, according to many peer-reviewed publications, including reduced crime and drug use and increased health and employment.

It’s hard to imagine the idea catching on in Trump’s America, but it’s instructive to consider the history of harm reduction. Needle-exchange programs were considered anathema in the early 1990s; however, as the data rolled in, they were ultimately accepted and then championed by the public-health establishment, including the National Institutes of Health and the Centers for Disease Control. Before 1986, needle exchange wasn’t considered a viable possibility in the United States; now, thanks to harm-reduction activists, there are more than 300 such programs. And the story is much the same for marijuana legalization and the shift away, in fits and starts, from a punitive approach to addiction.

The momentum is on the side of harm reduction. Says Jeff Deeney: “It’s just a matter of getting from point A to point B.”