NOTES FROM THE DRUG WARS

Ernest Drucker, Ph.D. is Director of the Drug Treatment Program and Professor of Epidemiology and Social Medecine at Montefiore Medical Centre/Albert Einstein College of Medicine in the Bronx

Points West

You had to see it to believe it. About a dozen men and women - young, old; Latino, Black and White; well -dressed, scruffy - a cross-section of San Francisco, lined-up outside a shuttered auto supply store in the city's Mission District to pick up clean needles and syringes. This is San Francisco's needle exchange - Prevention Point, directed by George Walker and staffed by a hardy band of a dozen AIDS activists. Since starting eight months ago, Prevention Point has given out over 20,000 sterile needles and syringes - more than the total number of drug injectors in the city, 25% of whom have utilised the

'program already. By distributing clean needles and syringes to IV drug users, plus bleach kits, advice on how to use drugs safely, and help getting into overcrowded drug treatment, the program engages the group at highest risk for contracting the AIDS virus and spreading it to other drug users, to sexual partners and, during pregnancy, to their own children.

Elsewhere in the country - in Tacoma, Washington; Portland, Oregon; Boulder, Colorado and in cities up and down the East Coast - small groups of volunteers, concerned and committed local citizens, are getting the job done - and bringing public health agencies along as they go. Charles Eaton (who made a success of the New York City exchange despite overwhelming odds) reports that in Tacoma they are distributing 400 syringes a day. Last year, 350 people entered drug treatment as a result of their participation in the Tacoma exchange. The public health departments of Tacoma and Seattle, restrained by law suits brought by the State of Washington, won their recent court cases, legitimizing the public health authority to continue the program and removing the last legal obstacles to continued public funding. In Portland, when insurance was not available for a community-based organisation to run the needle exchange, the city chipped in to provide insurance; a unique and creative public/private collaboration. In Boulder, a classically structured public health intervention has proceeded, without significant objections, to provide clean injection equipment to drug users. And, in Connecticut and Hawaii, state legislators are trying to remove the legal obstacles to access to clean needles.

Why is it that so many other cities are doing what the City of New York can't seem to manage, despite the fact that its AIDS and drug problem is the biggest in the world? "What's the matter with you people back there?", one of the San Francisco ex-addicts said to me on hearing that Mayor Dinkins would close New York's needle exchange that very day - the only legal needle distribution program east of the Mississippi. No wonder drug and AIDS experts come to New York from all over the world to see how not to handle this epidemic.

But if New York can't seem to get it right, San Francisco can't seem to get it wrong. Over three years ago, San Francisco's gay communities succeeded in virtually stopping the spread of AIDS among homosexual men. And they did it long before government-sponsored prevention programs kicked in. Now, once again, San Francisco seems in the lead, preventing the spread of AIDS among its drug users. The area's AIDS activists and public health experts, knowledgeable both about the epidemic and local politics, managed to negotiate their needle exchange with city health officials, the police, and the mayor's office. They produced an arrangement under which the city itself does not give out needles, but leaves this to groups of community volunteers - many of them former drug users - who run the project in an extremely responsible and careful manner. They will not give out new needles unless people bring in old ones; they keep track of who they are serving; and work side-by-side with other outreach workers giving out bleach and condoms, and re-inforcing AIDS prevention instructions. Frequently they also help clients get into drug treatment.

San Fransisco has been doing effective AIDS outreach to drug users for a number of years now, so it is probably no coincidence that the city has one of the lowest rates of new infections among this group - about 1-2% per year according to Dr. Andrew Moss, AIDS epidemiologist at the San Francisco General Hospital. By way of comparison, Don des Jarlais, New York AIDS and drug researcher, reports an annual rate of 5-7% among drug injectors in New York City. While it is difficult to attribute San Francisco's achievement to any single intervention (needles, bleach, condoms or mass publicity campaigns), there is unquestionably a synergy of all these programs. They work together by giving the right message. Beyond that, there is a sense of community around AIDS in San Francisco - the city takes AIDS very seriously, both in word and deed. San Francisco has not allowed local politics to derail its AIDS prevention programs.

Missing The Point

Yet in New York, when the former health commissioner, Dr. Stephen C. Joseph went out on a limb to establish an extremely modest needle exchange program, buried in a municipal office building's cellar close by City Hall and Police headquarters - far from where the addicts were - he got nothing but grief. The program soon became a political football in the 1989 mayoralty race, polarizing Black and White; public health and politics. However, even New York's modest program did succeed in some important ways. (See Cherni Gilman's article in International Journal on Drug Policy Vol 1. no.5) It served as a "bridge to treatment" for several hundred injectors, getting about half of those referred into care - a first sign of interest in helping them extend their lives, rather than moralizing about a tough problem few are prepared to really treat. As Eaton reports, the program is now being closed because (officially) it "...did not draw enough participants to test its scientific premise". He goes on to remark that recent reports from Australia and New Zealand "are remarkable to the eyes of a New Yorker because they do not carry the excess baggage of untreated 'control' groups needed to 'scientifically prove' that needle exchange will stop AIDS. Instead, their objectives are modestly stated in behavioural, operational terms and include assessment of impact on the community. They are addressed to an audience which may be sceptical and worried about possible encouragement of drug abuse and other negative impact, but who substantially agree that to do nothing is unacceptable in the face of a deadly epidemic. These reports assume that harm minimisation is a shared value, resulting in support of good-faith efforts at disease prevention and responsibility in evaluation of both positive and negative outcomes". He suggests a parallel, with the disputes surrounding development of new AIDS drugs and the need for new ways of testing them - ways which do not depend on depriving people of needed care.

But New York's newly elected black mayor, David Dinkins, came into office with a pledge to many of his supporters, including the powerful Harlem Congressman and House Drug Committee Chair Charles Rangel, that he would close down the needle exchange program because it gave the "wrong message". Most drug treatment public health experts disagree, feeling that providing sterile needles to drug users gives exactly the right message. It underscores the reality of AIDS and helps bring more users into drug treatment. While, in some way, it may have been necessary for candidate Dinkins to make this Faustian bargain, Mayor Dinkins' new bargain is with all the people of New York, not just some portion of constituents who supported him early on. And the rest of New York deserves better.

Point Of Law

Fortunately, while American politicians and health officials debate about needles, other people in the United States are taking the issue to the streets. Within two weeks of New York closing its "official" needle exchange, Jon Parker's AIDS Brigade and a contingent of the AIDS Coalition to Unleash Power (Act-Up) were on Delancey Street in Manhattan's Lower East Side, distributing bleach and needles - as they had (in the tradition of civil disobedience) publicly announced that they would. The Guardian Angels even staged a counter-protest while the cops arrested Parker and ten others for possession of "drug paraphernalia". This sets the stage for a legal struggle in New York that echoes Parker's trial in Boston this last January - a trial which exonerated him and may prove an important precedent for the New York case (see Notes From The Drug Wars, IJDP no.5). And while that case moves towards trial, another guerilla needle distribution effort (already working in the South Bronx) will go public this Spring.

Other American cities facing an AIDS and drug problem have sought to avoid a frank confrontation between public health and local politics. But not New York, which now has a new Health Commissioner, Dr Woodrow Myers, whose appointment was strongly opposed by many gay activists because he was said to favour widespread testing for HIV, registry of those found positive, and aggressive contact tracing. The New York Times now quotes Myers as being "ideologically opposed" to government distribution of needles. Astonishingly, he adds that "he could not conceive of any evidence that would persuade him of the worth of such programs". Myers also took the opportunity to state his opposition to attempts to rescind the New York State law that requires a prescription to buy sterile needles and syringes - the very laws that Parker and Act-Up are now charged with violating

Other legal encounters are brewing around U.S. federal government attempts to apply pressure to methadone maintenance programs - pressure aimed at making them even more restrictive in their prescribing practices. The Drug Enforcement Agency is threatening to close down two well established clinics which, a DEA spokesman says "have become part of the problem rather than part of the solution", citing "diversion" (i.e. street sales) of take home methadone. Of course a black market in prescribed methadone will exist as long as demand greatly exceeds supply - as it does in New York City by about 6 to 1. Definitely a sellers' market at $7 per bottle for 601 00mg.

Clearly the lines are being drawn for a pitched battle in New York's courts - a prospect that the public health community should welcome. Such a court test provides the best (and perhaps the only) opportunity for airing the growing body of evidence on the value of harm reduction approaches. At issue here are not only the specific questions of drug treatment and AIDS programs, but also the entire issue of who makes drug policy - especially the legitimacy of medical and public health models. The Harrison Narcotics Act of 1914 set the US on the course in which it is foundering today - criminalization based on drug prohibition. But the US approach also served as the foundation for international treaty agreements going back to 1909 and embodied today in the Single Convention, which binds signatory nations to follow this same course. The US has played a leading role in promoting this approach but support is now eroding at the fringes as other nations begin to form their own judgements about the best way to minimise the potential damage associated both with drug use and with misdirected drugs policies. Russell Fox, QC, a prominent Australian juror, says his country is beginning a serious debate about ratification of the 1988 version of the Single Convention, and may well demur. And another whole new dimension of efforts aimed at critically evaluating international drug policy is shaping up around the Single Convention's probable contradiction of several UN statutes - e.g. on human rights and the recent Declaration of the Rights of Children.

Meanwhile in the US, the American Civil Liberties Union is entering several key cases related to drug use, civil rights and medical practice, e.g. the Jennifer Johnson case in Florida (see IJDP no.4) and, probably, the New York case involving Jon Parker and Act-Up. Another group in New York is also planning a test case and court challenge of the restrictions on physicians' prescribing practices as they are applied both to sterile needles and syringes, and to prescribing maintenance drugs other than methadone - including their injectable forms. While prohibitionist sentiment is still powerful in the US, there is also great weariness with the apparent futility and high cost of the current approach. Hopefully, these court cases will provide a mechanism for an orderly transition to new policies based on medical and public health objectives, and scientific evidence, instead of old prejudices and the failed policies they engender.