At the same time, it’s hard to blame Rosenstein and the Redmond city council member for connecting the dots between the Downtown Eastside’s squalid condition and the city’s progressive drug policies. Tyndall says he’s taken other American visitors interested in harm reduction on much the same tour that he took me on and struggled to explain how, while all these lives were being saved, things were getting so much worse. “They’re like ‘This is it? You’re telling me this is progress?’” Tyndall recounts.

You can blame the fact that there haven’t been enough sites or that the drugs themselves are still illegal. But the inconvenient truth that sometimes gets lost in the conversation about harm reduction is that drugs can do a lot of harm all on their own. Yes, fentanyl may be what kills people, and yes, the criminalization of drugs may be what’s landing many of them in jail.

Opioids have devastated Vancouver’s Downtown Eastside neighborhood. Samantha Cooper The seven-block district contains one of North America’s densest populations of injection drug users. Samantha Cooper

But even if no one winds up dead or behind bars, using drugs can still torpedo a career, break up a family, and drain a bank account. Harm reduction isn’t synonymous with harm elimination, and activists pushing for supervised injection sites in the US would be wise not to hang too many hopes on what a single clinic can do.

These interventions, at the most basic level, are a last resort designed explicitly to keep people who use drugs alive. That means they may continue to live in a cycle of addiction, and it means they may continue to look like “drug-addled, glassy-eyed” masses on the streets of Vancouver or Philadelphia or San Francisco.

That’s not pretty to watch, and it’s natural to seek different results. It’s also natural to want to know how many people are getting and staying sober. And if that number isn’t charting up and to the right, it’s natural to wonder, well, what was the point?

If any one of those people were someone you loved, the point would be abundantly clear. As an oft-cited motto in harm-reduction circles goes: You can’t get sober if you’re already dead.

Twenty years after he first started treating people in the Downtown Eastside, and a year and a half after he concocted a crazy plan that could help save their lives, Tyndall is realizing he might need to start playing by the rules.

Even as he continues to advocate for his vending machines, he’s pushing the first phase of his less-ambitious pilot project through an ethics review board at the University of British Columbia, where Tyndall is also a professor of medicine. That one-year study, which will likely operate out of one of the Downtown Eastside’s overdose prevention sites, will include 50 subjects and will require a health care worker to dole out the medication.

Initially, subjects will have to inject under supervision, but Tyndall hopes most of them will be able to begin taking the pills with them within a week. To get honest feedback from his subjects, Tyndall hopes to work with peer staffers to survey participants on whether they’re diverting the drugs.

“I’ve been trying to do this for long enough that some progress is better than no progress,” he says. Whether his vending machines will ultimately collect dust or someday be effectively deployed and persuade their doubters remains unclear.

What is clear, though, is that over the last year and a half, Tyndall’s radical proposal did help shift the Overton window around a safe supply, broadening the conversation even at the highest reaches of government about what might be possible. In Vancouver, the city’s newly elected mayor, Kennedy Stewart, has thrown his full support behind the vending machine idea and says he has discussed the need for a regulated supply of safer opioids with Prime Minister Justin Trudeau.