Chamberlain described Czechoslovakia at the time of the Munich Agreement as "that far away coun-try about which we know so little." Australia often feels like that Isolation has its advantages and dis-advantages.

The strong links between the gay sister cities of San Francisco and Sydney inevitably resulted in the rapid spread of human immunodefiency virus infection to Sydney homosexual and bisexual males. As a result, 70 percent of Australia's AIDS cases are within the state of New South Wales and con-centrated in Sydney, the largest metropolis in the state. Most of these cases have occurred in Sydney's eastern suburbs, which function as a gay ghetto. The same neighborhoods are also known to have a high density of injecting drug users, and it is therefore surprising that after a decade of HIV infection in the homosexual community HIV infection is still so infrequent among injecting drug users. This may in part be due to serendipity; it is also likely that the early and vigorous implementation of HIV prevention strategies for injecting drug users has contributed.

The experiment with needle and syringe exchange in the Netherlands in the early 80s became well known in Australia soon afterward. Many prominent scientific and medical authorities publicly advocated the rapid institution of similar policies in Australia. As recognition of the critical importance of this strategy increased, more and more official bodies and commentators began pressing for needle and syringe exchange in Australia by 1985.

However, the matter remained controversial and vigorous opposition to this notion soon developed. The fact that this strategy was also supported in the United Kingdom by Sir Gerard Vaughan, the former Conservative Health Minister under Margaret Thatcher, was also thought to be significant.

The government's senior medical and scientific advisory body on AIDS at the time — the National AIDS Task Force — had some reluctance atout fully embracing the idea. The notion of "careful and scientific evaluation of pilot studies" developed. Several such pilot studies were devised and considered. Throughout 1985 and 1986, it was clear that the proposal to subject this strategy to research would inevitably delay the introduction of the policy. Some influential policy makers felt that Australian political leaders and the community were not ready for such an adventurous departure from existing drug policy. They preferred to choose policy options from among those thought to be more acceptable. The size, duration and extent of the evaluation was also discussed in some detail.

My involvement in this area had begun fairly early as I had provided gastroenterological diagnostic services to the first AIDS patients in the country who started appearing at my hospital in 1983. By 1984, we already had seen antibody positive homosexual injecting drug users, and it became obvious that Australia would also inevitably succumb to this new, frightening complication of illicit drug use.

I had prepared several research proposals and was in the habit of regularly supplying material on the subject to the media, which commendably showed great interest in this subject.

I also briefed my local member of Parliament on the subject even though he was known to have distinctly conservative leanings. I provided him with the information that the right-wing of Thatcher's Conservative Party had sponsored a bill in the British House of Commons advocating needle and syringe exchanges.

As the months passed, more and more people concerned about the spread of HIV infection in Australia became convinced that this was an important initiative and needed to be started as soon as possible. However, committee after committee referred this matter to other subcommittees or called for more data. A colleague decided to do a Ph.D. on evaluation of the strategy of making needles and syringes available and several of us attempted to devise a project whereby conclusive proof could be obtained of the effectiveness of this strategy. It was readily apparent within a few hours that it was not possible to determine the effectiveness of this policy in reducing the spread of HIV infection among injecting drug users because of the multiplicity of factors involved in HIV transmission.
 

Setting Up a Needle Exchange

On returning from yet another committee meeting on the subject in November 1986, I decided that we could wait no longer and had to go ahead without requesting permission from anybody. Therefore, my staff and I decided to personally donate money for the establishment of our own pilot project, obtain the required sterile injection equipment and place notices on the doors of our building. The next day, Nov. 13, 1986, the "Darlinghurst Pilot Needle and Syringe Exchange Programme" had begun. It was the first needle and syringe exchange program in Australia. Some days later, I received an official invitation from the state Department of Health to discontinue the project. I pointed out innocently that the pilot needle and syringe exchange project was being undertaken by private individuals, funding the exercise out of their own pockets, and making up any time lost from their employment. The project was a voluntary one, and I was therefore not able to order my staff to stop the project.

Days later, while I was attending a regular Department of Health committee meeting, I was informed that the provision of injection equipment to drug addicts was in breach of the state Drugs Misuse and Trafficking Act. I replied that I was unaware of this breach of legislation but should the department wish to proceed with police action, the rationale of the exercise would need to be explained to waiting television cameras, and that, undoubtedly, this would not reflect well on the department. I was privately advised that no police action would be instigated.

A little while later, I was invited to meet the senior members of the New South Wales Drug Squad to explain my actions. I summarized to these police officers the existing global knowledge on HIV infection in injecting drug users and also summarized the experience thus far with needle and syringe exchange. I was advised that the meeting had been arranged to obtain information for the Minister for Police who would be advised that prosecution was unwise. It seemed perfectly evident at the time that if our action was in breach of the Drugs Misuse and Trafficking Act, the law would have to be revised or repealed. I made no secret of these views.

The government started its own scheme of sterile needle and syringe availability through retail pharmacists in the state of New South Wales just one month after our own pilot exchange program. However, the pharmacy scheme made little provision, if any, for the possibility of exchanging used equipment, and it was apparent that the dangers of a pure distribution scheme were considerable. Not only could this inadvertently increase the supply of used injection equipment and thus lead to increased sharing, but it could also lead to the discarding of used injection equipment in public places such as streets, parks or beaches.

The pilot needle and syringe exchange programs were emulated by a number of other colleagues throughout New South Wales and other parts of the country within a matter of weeks. It was clearly an idea whose time had come. Within a short period of time, it was apparent that the desire to increase the availability of sterile needles and syringes (and reduce the availability of used injection equipment) conflicted with the Drugs Misuse and Trafficking Act In particular, sections on the supply, possession and self-administration were problematic. A decision was made to repeal the sections on supply and possession of injection equipment while keeping self-administration illegal. It was thought that the government could not move too far in advance of public opinion since the act was passed only two years earlier. However, the effect of retaining the section on self administration was that drug users were soon aware that responsible behavior involving the proper disposal of used injection equipment at needle and syringe exchanges carried the risk of apprehension and prosecution. That is, used injection equipment was defined as possible evidence of self-administration of illicit drugs under the law.

Drug users began to discard used injection equipment in the streets, parks and beaches rather than risk the possibility of apprehension. Predictably, this resulted in a public outcry at the fouling of the environment with potentially dangerous materials which threatened the survival, let alone expansion, of this important HIV prevention strategy. At the time of writing, this matter has still not been satisfactorily resolved.

Effect on Overall Drug Policy

One further matter of interest is the attitude of policy makers toward the possibility of liberalizing drug policy by repealing restrictions on supply and possession of injection equipment. In order to ensure that this change did not result in increased vulnerability of the government to criticism, a new piece of legislation was introduced to outlaw equipment used for the consumption of cannabis. This legislation made it an offense to be in possession of a "bong," despite the fact that legislators had particular difficulty in defining precisely what was entailed by a bong. Bongs can be constructed from a variety of ready-made materials, including a milk carton and two straws. No prosecutions have been initiated under this legislation.

There are many lessons from this particular saga. The specter of AIDS has highlighted a new approach to drug policy in many parts of the world and speeded up a process of change so that rapid changes of policy can occur in months rather than decades. Second, the development of policy in this area highlights the difficulties of medical and scientific policy advisors operating in fields of major political tension where advisors are often tempted to "second guess" their political masters. Clearly this is a temptation to be avoided at all costs.

Third, the initiation of this policy at a time when implementation was in breach of existing legislation, was in large part possible because the act was carried out by a physician. Quite possibly, prosecution would have followed if an identical action had been undertaken by other health professionals. This should not be construed as a defense of an inegalitarian hierarchy of professions, but rather as an opportunity for physicians in countries where needle and syringe exchange is still not available to consider direct action.

Fourth, the development of this policy evolution also demonstrates the real possibility for research to be used as a weapon against change and for scientifically minded health professionals to fall into a trap. Again, this is not to decry the value of meticulous scientific research, but to emphasize the importance of differentiating slow and careful for chronic and unchanging conditions as against the need for more qualitative and speedier evaluation at times of a public health crisis.

During the evolution of this debate, many supporters of needle and syringe exchange were criticized by their opponents for opening the door to provision of illicit substances. It was argued that if one provides the syringe and needle, one may as well provide the rest of the materials. In retrospect, this argument used by the opponents of change was correct. In Australia, as in many other countries, we now provide sterile needles and syringes, swabs, spoons, and sterile water. We also provide specially prepared paper with HIV prevention slogans printed on it knowing (and intending) that it be used for wrapping illicit drugs. There does seem little point in providing all of these materials and yet not providing, under carefully controlled conditions, a safer formulation of the same drugs that can be bought illegally around the corner with unknown contaminants and at unknown concentrations.

Alex Wodak, M.D., "Bravery in Australia — Breaking the Impasse in the War on AIDS," The Drug Policy Leiter, January/ February 1990, p.3.