Struggling to end stigmatisation in San Fransisco
Gregory Rowe Journalist, San Francisco correspondent

The homosexual activists' campaign has led the American Federal legislators to set up regional AIDS control committees, which included representatives of the most highly exposed communities. The drug abusers, who have been strongly stigmatised, are thus able to make themselves heard.

San Francisco has the sad reputation of being the city in the United States with the largest number of Emergency ward admissions due to traffic accidents: roughly 200 a year per 100,000 inhabitants. But that's nothing compared to the number of drug-related admissions to the Emergency ward. In the year 19992000 alone, there were 6,034 admissions of this kind in this city of nearly 700,000 inhabitants, which is an increase of 15% over the previous year. More than 3,000 of that number were admitted due to heroin use. The number of regular heroin users in San Francisco is estimated to range between 13,000 and 15,000 people, and only 5,000 of them are undergoing treatment. The presence of drugs is very real when you walk through the streets of downtown San Francisco. Not only do people approach you on Market Street as it crosses the Tenderloin, San Francisco's traditional drug-dealing neighbourhood, but you often see little plastic bags of white powder exchanging hands, people sleeping on the streets, and brawls and fights going on among the locals.
Although it is a relatively small city by American standards, San Francisco is at the heart of a large built-up area with more than 7 million inhabitants, which covers at least seven counties spread around the famous San Francisco Bay. The famous Silicon Valley is not far from the sprawling suburb called San Jose, which now has the largest population (800,000) and the highest incomes in the region. Across the Bay from San Francisco is the county of Alameda, which includes both hillsides inhabited by the wealthy and the more working class housing states of industrial Richmond, downtown Oakland and Fruitvale, which are mostly inhabited by black people and Latinos. This was the first municipality in the United States to declare a state of emergency because of the disproportionately large number of AIDS cases occurring among in its black population.

The first municipality in the United States to declare a state of emergency.

When asked why San Francisco seems to have more than its share of homeless people and drug-users, Steven Tierney, who is in charge of HIV Prevention at the City and County of San Francisco Department of Public Health replied, "It's the climate: it's never too hot and never too cold." However, the city is attractive for other reasons as well: "The public health and social services are particularly generous, since the waiting lists are very short. In Wisconsin you must prove 18 months of residency before having access to these services. That's not the case here." Actually, as Tierney goes on to say, "people of all kinds come here to get away from discrimination or to live in paradise. These people are relatively young and they are in transit. They stay here for only 3 years on the average. You go to New York to get a job in finance. You come to San Francisco to get away from responsibility."

A revolutionary piece of legislation: the Ryan White Care Act (1990).

During the 70s, gays began to join the hippies and other freedom-seekers and the city thus became the first ever to fly the rainbow flag above its City Hall in official recognition of the "Gay Nation". It was a long hard battle for homosexuals to win the first seat on the town council and become the first sexual minority to use the ethnic minority mode of social activism to obtain democratic representation. The first elected representative, Harvey Milk, was killed less than 12 months later by a homophobic member of the council. This tragic event is thought by many gays to be the point at which their movement crystallised, and surprisingly enough, it was to have long-term effects on health care policies.
Harvey Milk was shot in 1979. In 1981, the gay community used its extensive networks, community centers and recently acquired vocal acumen to start what would soon be known as "AIDS activism". This activism greatly helped the IV drug using community, which had never had the opportunity of setting up political structures of this kind.
The approach to drug use in the US is traditionally one of punishment, prohibition and attempts to stop drug production. Needless to say, the Federal Government did not suddenly turn into a compassionate provider of health care services for IV drug users in under the Reagan administration in the early 80's. But in 1990, the Ryan White Care Act was passed, and this was a revolutionary piece of legislation.

In this Act, which was drawn up mainly by gay, white activists who had spearheaded the AIDS movement, it was stated that regions were to be created based on the rates of HIV prevalence*. Federal funds would be allocated to these regions accordingly, and the way in which these funds were distributed would be decided and supervised by a committee consisting of patients, activists, health care providers and policy makers, based on ethnic and gender-related criteria as well as other criteria such as the mode of transmission and the patients' serological status. These committees are called Ryan White Planning Councils. They include IVDUs to ensure that they are really representative of the population as a whole. They were strongly criticised at first by the medical and pharmaceutical industries, whose members objected to taking their cues from community councils of this kind. Although most of the gay males did not have much contact with the IVDU community when putting together this proposal for legislation, the terms in which it was expressed were broad enough for any person affected by HIV to be able to join these Councils. Since it was passed under the Republican Bush administration during a period of recession, some say this legislation was voted simply because policy makers were able to convince lawmakers that it was cheaper to have people with HIV in care than out of care. Whatever the case may be, the law pioneered the participation in health care policy and funding of hitherto excluded communities, including people of various ethnic origins and IV drug users.

The inclusion of these communities was definitely needed, as they gradually began to account for a disproportionately large proportion of all those infected with HIV. In 1999, the leading cause of death among the black male inhabitants of the USA in the 25 to 44 year-old age-group was AIDS. This group and the Latino community have much higher rates of IV drug abuse than the average population.

Homeless drug addicts could at last be identified.

Stu Flavell, International Co-ordinator of the Global Network of People with HIV (GNP+), is all in favour of the Ryan White Care Act, which was re-voted last year, 10 years after it creation: "This legislation has enabled hundreds of HIV+ people, heterosexuals and members of ethnic groups to be involved in the process. I was a gay white Planning Council chairperson who was replaced by a Latino IDU... The Act brings people into care who would otherwise be falling into the broad cracks in the American health care delivery system. Our Council had to make sure not only that drug users were being cared for, but also that the health care providers were actually supplying the right kind of care. This meant that we could at last identify the homeless drug-addicts who were not being cared for and to find out why this was the case."

California, a reputedly go-ahead State, adopted needle replacement policies only in January 2001. One of the policies that the Federal Government has not supported, however, is needle exchange. Although this strategy is known to decrease the number of new HIV infections, a government so intent on punishment could not openly give money to help people participate in an illegal activity. Even under a Democrat government, federal funding was extremely limited and only to be used according to very strict criteria, although several studies were published showing that needle replacement does not encourage the use of drugs. Needle exchange programs are now being set up by local City and County authorities here and there across the country, and number around 60 so far. The State of California, the most populous and traditionally the most progressive of the 50 States, only recently officially adopted State-wide needle exchange policies on January 1, 2001. Shortly afterwards, the Oakland center providing the local Latino community with syringes was burned to the ground, probably by arsons.

So how have things changed for IV drug users since the good old days? According to Lisa O'Connor, a 36year old HIV+ who was formerly an addict and is now a project co-ordinator working with IVDUs in Oakland, things have changed: "It's a lot easier now to get sterile equipment because of all the needle exchange programs. Ten years ago, we had to buy them on the streets or make a fake diabetic ID card for the pharmacist. I would say that the rate of occurrence of HIV and Hepatitis C reached a peak among IV drug users during that time."

However despite the massive changes, Lisa O'Connor believes IVDUs still don't talk freely about HIV, even to each other: "Some people say that they always tell the person they are having a shot with if they are positive, but I don't really think many of them do so. There is still too much shame, despair and stigma attached. "