I met Henry at the Montefiore Methadone Clinic in the Bronx. He was black, in his early forties, a long term Methadonian and a gentleman. He was diagnosed HIV+ some years ago and now has AIDS.

He had heard about the unique Heroin prescribing service available to committed users in Liverpool and I wanted more information about life as a drug user in the Bronx, so he took me for a coffee in the inevitable McDonalds next to the clinic.

We immediately hit it off. We shared horror stories from the old days with nostalgic laughter and amusement as only ex-dope fiends can!

He had lost a toe from shooting Dilaudid — an old Yankee favorite, and I had lost a finger from shooting Diconal — an old Brit favorite!

Perverse some may say, but we also shared stories of the bad times as well as the fun times, sadly recalling friends who never made it — just as any 'War' veterans would!

Henry was well read in "drug history" and knew about the old British System of doctors having the option of prescribing Heroin and other drugs if they so wished. He, like many professionals also, assumed that this was no longer the case in England.

I proceeded to tell him about the 'Harm Reduction' strategy that we had implemented in Liverpool and the surrounding Districts and the subsequent benefits to users, their families and the society around them. He didn't exhibit the shock or amazement expressed by many professionals on hearing the details of our work, he nodded, smiled and asked pertinent questions that revealed an insight into drug issues that is only to be found in intelligent 'drug policy' consumers, or in his case, victims.

His main response was relief. Relief that all is not lost. There are still places where drug users are not only treated humanely, but offered the widest range of options, from traditional drug free programs to safer drug programs, which may involve the legal supply of injectable or smokable forms of heroin, cocaine, amphetamine etc.

Relief that there are services in existence where staff will not only help you stop using drugs, but will offer advice to committed users and the equipment to achieve the desired drug experience in the safest possible way.

Henry was tired of being a victim in the relentless American civil war on its drug users. He had AIDS, he was sick and he knew his time was almost up. Would it be possible for him to come to Liverpool and see all of this in operation, and maybe even sign up for some of "that fancy Heroin treatment?" He was waiting for an insurance pay out from being hit by a stray car, if the money arrived 'in time' ( his words) he was going to come to Liverpool to try to pass what little time he had left in a pharmacological retirement!

We then went walkabout in bombed out South Bronx. Henry was obviously regarded as an elder statesman in the local society of dope-fiends. We sat in what appeared to be the remains of somebody's apartment, where a few of the younger locals were shooting coke. Each had their own equipment but it was old and worn. Henry told them about Liverpool and my work there, but these younger users had no sense of their drug history and were amazed that "things could be so different!"

"Why don't they do that here?" one of the lads asked.

"Because they hate us man, they want us all dead!, was another's bitter response. At the end of the eighties in New York City, there is not much evidence to refute this statement.

Henry escorted me back to the clinic where every day a thousand people queue up to swallow a little methadone. "Don't forget man, as soon as my money comes through, I'm on the next flight to Liverpool!"

We shook hands, smiled, and went our separate ways.

A few months later, his counsellor at Montefiore rang me to tell me that Henry had died. Apparently he was determined to get to Liverpool and "sign up!". He died before the insurance paid out. Maybe he wouldn't have made it, maybe he would have, who knows?

But isn't it sad that what we regard in Mersey as simply a treatment option, should remain a dying man's dream in America?

It is experiences such as this that fuel my energy and commitment. It is the honor of meeting people like Henry that convince me that it is worthwhile.

Harm-reduction is not exactly a new concept or form of practice for many in the drugs field. However, for many organizations and even some governments it has taken the advent of HIV to promote the theory and prac-tice from a fringe activity undertaken by individual 'radical' drug workers to that of a primary strategic tool which recognizes that for the majority of drug users abstinence may or may not be achievable. But is certainly undesirable even in the face of what to non-users appears to be overwhelming deterrents such as imprisonment, illness, isolation etc. This basically was the theory of British drug policy until the early seventies when doctors in the UK decided that they did not feel comfortable in the role of State suppliers of drugs.

In Liverpool and one or two other British cities, some doctors continued to practise the 'British System' of supplying pharmaceutically pure drugs to committed users. Syringes have always been available from pharmacies, although sales were and still are at the discretion of the pharmacist.

I can remember, as a client of a drug clinic, picking up my prescription of drugs and the pharmacist asking whether I had enough syringes for the week, that was in 1972. So when HIV became an issue for drug services in Liverpool we didn't find ourselves embroiled in the battle to change the philosophical basis of abstinence-based services, our problems became those related to expansion rather than re-orientation .

This is not to imply that every relevant organization supports or plays an active role in the strategy but it is safe to say the majority certainly do.

In October 1986, as Director of the Regional Drug Training & Information Centre I called a conference of all the Region's Drug Services to examine the relationship between drug use and HIV. This was the first time many service staff had heard, first hand, from someone working in an area where HIV had already swept through a community of drug injectors.

Dr. Roy Robertson from Edinburgh painted a picture of what happens when the supply of syringes is severely restricted, when the Police harass drug users to the extent that users would rather meet and share equipment than risk conviction for traces of drugs in their own used syringes, and where what few drug services there are have been designed solely to help those who wished to stop using altogether.

Compared to Scotland and other areas Mersey looked good, on the surface at least. Our Health services were aware of only twelve HIV+ injectors, (less than 0.1 percent), none of whom were believed to have been infected locally. In Edinburgh at least 60 percent of their injectors are HIV positive.

It therefore appeared that we were in a very good position to implement the only possible antidote to this epidemic, preventative education and the means to avoid infection.

The main resolution which received overwhelming support was that sterile paraphernalia should be made available as soon as possible to all injectors.

However, knovving how bureaucratic drug agency management committees can be, it became obvious time would be lost if we had to wait for this 'management' process to be completed.

I therefore decided to open up a room at the Training Centre as a temporary Syringe Exchange Service [ SES1 until the other specialist Drug Services got their act together.

The Training Centre was part of the same building as the Liverpool Drug Dependency Clinic which meant that many of their clients already knew our set-up and trusted us. Also many of the Clinic clients were known to me as friends or former associates from the 'scene'.

So we were in an ideal position to very quickly win the trust of significant numbers of customers. The only space available in the Centre was a disused bathroom into which we put boxes of syringes supplied by the Clinic next door.

Within one week we were open and exchanging equipment, while the other agencies 'discussed' the issue. The Clinic staff, under Dr. John Marks, were telling all of their clients about the new SES. On the first day nearly forty clients came in to exchange their equipment.

The local Police were very supportive. The Drug Squad were already starting to see the futility of harassing individual drug users and had recently introduced a cautioning policy for possession of cannabis [this now applies to all drugs including heroin and cocaine]. This meant that anyone caught in possession of small amounts of the drug on their first or maybe second drug offence, would only receive a 'warning', the offence would not become part of their criminal record, and they would not be taken to court for prosecution.

The Police agreed to stay away from the SES and not to prosecute users for possession of used syringes. This meant that clients of the SES would not feel deterred from returning their used equipment. In fact, the Police went further in their support by offering to supply leaflets to any drug user they apprehended to advertise the new SES! Also, if they did have to confiscate used syringes they would issue a receipt for the amount seized which could then be presented at the SES for a similar amount of sterile equipment.

As a former prisoner of the Drug Squad on many occasions I never thought I would hear myself saying it, but Merseyside Police have without doubt played the most supportive role in our strategy aimed at improving the health of our drug using citizens, and protecting the wide community.

The local mass media played a similar supportive role. After negotiation, the local newspaper reported the existence of the new SES only after it had been operating without problems for a few weeks. The paper then ran what was basically an advertising campaign for the service which again attracted more clients.

To me, this process of consultation with the decision makers rather than their deputies was the key strategy in developing a new service with the minimal amount of opposition.

It became obvious very quickly that we were developing a totally new type of specialist drug service that drug users wanted rather than what professionals deemed they needed. We started to feel that it wasn't enough to just dish out clean equipment, although this would obviously reduce sharing, we were seeing people with what can only be described as third world health problems: malnutrition, untreated STD's, abscesses, ulcers etc. A lot of these health problems were related to the poor street drugs our clients were injecting. They knew these drugs were causing problems, but were still determined to carry on!

Fortunately we had a Clinician in Dr. John Marks who was prepared to prescribe injectable drugs to injectors in poor physical health. We were then able to very quickly arrange for some of our clients to receive ampoules of pharmaceutically pure drugs, such as Heroin, which would not cause them any physical problems.

Other problems were caused by poor injecting technique. Many a time clients would appear, desperate to find a vein after all their accessible sites were rendered unusable. As a former injector, armed with basic anatomical knowledge supplied by medical friends I found myself in the possibly dangerous and certainly uncomfortable role of 'vein doctor', advising clients on how to recognize arterial blood and avoid possible nerve damage.

This was certainly an unsatisfactory situation. It was now clear we needed a specialist Health Centre for these people. Within twelve months the Maryland Centre was opened. This was the first time the National Health Service had made full medical services available to drug users and prostitutes. Since then the centre has been used by over 2500 local clients

Since the Liverpool exchange program opened, 13 local syringe exchange programs have also started up in the Mersey Region, with at least one program operating in each of the ten districts. In addition, many pharmacies throughout the region make syringes available to drug users, though most make a small charge and only a small number take back used syringes. But one of the most effective innovations has been the development of an HIV prevention outreach program, in which drugs/HIV workers are trained to deliver a health care service to drug injec-tors and prostitutes, based on giving advice on safer drug use and safer sex, providing free condoms, exchanging syringes, and referring contacts to agencies.

The outreach workers operate within the community in such arenas as the street, cafes, public houses, clubs, public transport and drug users' homes. The three pioneering outreach workers, one working with female prostitutes, one vvith male prostitutes, and one with drug injectors, started in September 1987 on a part-time basis. In the first six months of 1989, they made contact with 130 female prostitutes, 50 male prostitutes and 70 drug injectors.

The recent British central government increase in resources for HIV prevention among drug users is being used by our Health Authority to expand their HIV prevention services, including increased resources for building-based syringe exchange programs, the appointment of a pharmacy syringe distribution coordinator, a confidential telephone service, a publicity campaign and expansion of the outreach program. The latter involves the appointment of two more outreach workers to deal with prostitutes (one with female prostitutes and one with male prostitutes), and ten additional outreach workers to work with drug injectors in five of the districts of the Mersey Region. By 1990, there were 26 outreach workers.

In addition, other districts have been funded to set up mobile clinics, which will provide a level of service between building-based programs. In the Liverpool and Wirral districts these large vans, each staffed by at least two health workers, stop at a number of set locations every day, and offer a health care and syringe exchange service to drug injectors and prostitutes within their own residential areas.

Finally, we established a Drugs & HIV Monitoring Unit, staffed by four researchers, to monitor and evaluate the effectiveness of the new HIV prevention services, and to develop a routine monitoring system for all drug services in the region.

Four years on, the evidence of the success of this strategy remains very encouraging. Mersey Health Region has the lowest number and rate of HIV+ injectors in England. It also has the highest rate of drug users in treatment which reveals that 'Harm reduction' services actually serve, for many, as gateways into drug treatment rather than as deterrents, as was initially postulated by opponents of the concept. The data also reveals that over 70 percent of clients of these new SES services were not previously in contact with any other drug service! Also, two studies at Liverpool University have found that drug users in treatment commit significantly less acquisitive crime than most not in treatment.

Only fifteen injectors in Mersey are known to be HIV+ at March 1990. Again, none are believed to have been infected locally. Our HIV prevalence estimate among our drug injectors is believed to be about 0.1 percent.

One of the most fascinating developments in the local drug politics has been the opposition to our harm reduction strategy by the local City Council. Liverpool has always been a Socialist stronghold and has been 'at war' with Conservative central government over a number of issues. The city came to be regarded as having the most left-wing Council in the UK, and whenever visitors come to study our programs they are usually shocked by the bitter opposition from our 'radical' socialist City Council!

A strange, puritanical streak runs through the Trotskyist activists who control the Council's 'Drug Strategy'. The 'War On Drugs' rhetoric is exploited in a cynical attempt to undermine the Health Authority's Harm Reduction Strategy.

The establishment of our first SES was undertaken in a cloak and dagger way, so as to avoid pickets of Trotskyists determined to prevent the opening of any service which they regarded as 'condoning' drug use. Over the last few years I have visited the US on a regular basis and find it quite sad to realize that when it comes to consideration of drug policy our intelligent, Socialist City Council ideologues can make William Bennett sound like Norman Zinberg!

I can actually remember the exact phrase thrown at me in an argument with an outraged Councillor at a Trade Union conference on drugs. He regarded the prescribing of Heroin to committed users as "Sedating the potential revolutionary fervor of working class youth, who might otherwise rise up and smash Thatcherism, which, as we all know comrades, is the root cause of the drug epidemic we've got now."!

It would appear that, when it comes to drug issues, there is no 'Opposition' Party! The right and left are united in their respective position on the wars on drugs.

However, we are fortunate working in Public Health at a Regional and Local level in England. Local Health services are not departments of the local Council, as in the US, but the District and Regional Health Au-thorities which constitute Britain's National Health Service, managed by the governments Department of Health.

So we were very fortunate in not having to watch thousands ofyoung people become infected with HIV while politicians oppose giving out needles, intent on promoting themselves as "the Anti-Drug warrior YOU should vote for!"

I have watched this happen in the States so often. In 1988 I was invited to give evidence at Boston City Council hearings on whether it should support the call for allowing its drug injecting citizens access to sterile equipment as a means of avoiding and passing on HIV.

It was at these hearings that I finally realized the extent to which the American 'war on drugs' ideology had pronounced that the AIDS issue was being exploited by liberals in a cynical attempt to undermine their 'War!'

I was invited by the Mayor, Ray Flynn, who along with Dr. George Lamb the Deputy Health Commissioner for Boston were putting their political lives on the line by daring to suggest that the prevention of HIV was so important that an experimental SES should be established and the results monitored.

Questions from the councillors revealed a particu-lar hostility to the idea:

Why do we need free needles? Only 20 percent of our junkies are infected. It's not like we're New York.

If they come from out of town, who pays? I don't want to pay for needles for someone else's junkies.

There was one positive note at the hearing. Standing before the Council to give my presentation I was aware of the Black Community leaders, particularly one who initially, glowered at me as though I was personally responsible for the City's drug problem.

However, as I answered their questions, some seemed to be reconsidering their position. One angry Councillor demanded to know whether I would give clean needles to a pregnant woman? I threw the question back by asking whether he would wish a pregnant woman to use infected needles? He remained silent while his comrades looked on. After the hearing finished, an unholy row broke out between the Black Councillors, with some apparently rethinking their position, much to the chagrin of their 'hard line' colleagues.

Later I visited an in-patient unit for AIDS patients, many of whom were people who had become infected by sharing needles. I was horrified to hear from two of the doctors on the ward that they too opposed the establishment of a Boston SES.

'With our drug problem we cannot afford to be sending 'mixed' messages to our young people,' was the doctors position.

At that Council Hearing was a young man named Jon Parker who approached me afterwards to thank me for the information I had given about our SES programs. He said that he had changed his position after hearing my testimony and would now be pushing for the establish-ment of a similar service in Boston. I thanked him, not realizing the court-room drama we would both find our-selves in two years later in Boston.

Frustrated by the inability of the establishment to respond to their drugs/HIV issue, he formed the 'National AIDS Brigade', a small group of ex-users who had decided to give out clean needles and risk imprisonment.

In Massachusetts, as in another ten States in the US the possession of hypodermic needles without a pre-scription is illegal and inevitably Jon was arrested one day distributing equipment to users.

When the case finally came to court, I was asked by his lawyers to give evidence in his defence. Jon was worried. He had already spent time in prison on drug related offences when he was using drugs. He was now a third year medical student and realized that his attempt at HIV prevention could land him back in jail!

Fortunately, the prosecution lawyer didn't exactly enamor himself with the female judge by challenging her impartiality as a member of Boston's Judicial AIDS Committee, which is simply a professional structure used to update judges on the latest legal developments related to AIDS.

The prosecution called no expert witnesses and almost seemed resigned to losing the case. Numerous expert witnesses were called in Jon's defence. The judge was genuinely shocked when I revealed that our estimated HIV prevalence amongst injectors was 0.1 percent.

After hearing all of the evidence the trial was adjourned and we retired with Jon to ponder his fate. Jon's defence was that he was not giving out needles to encour-age drug use, but to prevent people becoming infected with a deadly virus and that the law prohibiting possession of needles was outdated in the face of AIDS. However, he had technically broken the law and for this reason we did not feel confident that he would be found not guilty. I thought that even though the judge appeared sympathetic, Jon would be found guilty with a token penalty.

The judge returned and proceeded to give the reasons for her ruling. She accepted that Jon's intention was not to promote drug use and that as yet the State Legislature had not yet had the opportunity to reconsider the 'needle' laws in the light of the AIDS epidemic. Faced with what she regarded as good evidence about the effi-cacy of exchanging needles and the lack of any other effective intervention she felt that in this particular case she had to find Jon Parker not guilty.

It was just like a scene from American television. The court-room was packed with Jon's supporters who immediately erupted in joyous relief as Jon was engulfed by TV crews and journalists.

Harassed by journalists on the steps of the court-house, Jon was asked whether he would do it again bear-ing in mind that the judge had only found him innocent in this particular case.

`Yes, I would', was his clear reply. (And he has been charged with the same offence again in New York this year).

But sadly not an awful lot seems to have changed in the American cities most affected by HIV amongst its injectors.

The pilot SES in New York City has been closed down by the incoming Mayor and Health Commissioner. That a Health Commissioner should close an SES in a City with so many of its drug using community already infected defies belief to so many in this country. That is because unless one spends time in the US it is difficult to appreci-ate the scale of the Orwellian nightmare that the War On Drugs' has created for drug users in the US. A country where so many professionals and politicians are scared to raise their voices in protest at the barbaric treatment of their fellow citizens lest they be labelled 'Traitors' in what to many outsiders looks increasingly like a fiindamental-ist, genocidal "Holy Wail

Back in Liverpool, Terry has returned home after picking up his prescription for Heroin cigarettes. He is part of an experiment to find whether we can offer a satisfying drug experience to users without them having to inject at all.

Clients of two of our drug clinics receiving mainte-nance doses of injectable heroin or methadone were offered cigarettes laced with 60 mg. of pharmaceutical Heroin or methadone. After experimenting with them, they are given the choice of cigarettes or ampoules. Significant numbers have opted for the cigarettes as they have found that smoking the drug can give them the 'rush' they desire, which only injecting previously gave them.

Terry is one of those satisfied customers. Formerly a major regional distributor of illicit heroin, he has been maintained on heroin for the last five years and now has a good job and a family.

He had caused so much damage to his venous system that even five years on it was still painful and time consuming trying to locate a suitable vein. The cigarettes were therefore a godsend to him. He could now get the desired effect without having to mutilate himself.

So, once a week, he takes his favorite brand of cigarettes to his local Pharmacist who then injects each cigarette with 60 mg. of Diamorphine and he picks his supply up three times a week. Understandably, many Pharmacists do not like having to do this as Tobacco is so damaging to health! Alternative herbal tobaccos are now being investigated.

Terry is in his thirties and is an old friend of mine. He is starting to think about giving up his drug using career and feels that the availability of the cigarettes has allowed him to think incrementally about stopping alto-gether, rather than having to fit into what for him may be an inappropriate withdrawal regime.

As I stated earlier in this essay, we have endeavor to provide the widest range of treatment options in the Region, recognizing that no two people who use drugs are alike and that 'treatment' regimes must reflect this if we are genuine about our desire to assist our citizens who are encountering problems related to their drug use.

I can remember an eminent 'drug' psychiatrist now based in London arguing for a 'Supermarket' style of service for drug users where clients could negotiate an individually tailored treatment program for themselves. Having said that he proceeded to indicate that he would not personally prescribe maintenance doses of even oral Methadone!

Some of these so called supermarket services are looking distinctly East European in content.

So the 'Mersey Harm Reduction Strategy' contin-ues, not without opposition, from both within and without. But what cannot be undone is the degree to which this humanitarian philosophy has filtered down, not only in specialist drug services, but into the generic Social Ser-vices as well.

Terry jokingly offered me one of his heroin cigarettes.

'No thanks', I replied, I'm trying to give them up!' We both laughed.

Conclusion

If there is a message in this paper for drug policy-makers and service-providers in other countries, it is that preventing the spread of HIV infection must take priority over all other interventions with drug users, and that this objective can only be achieved by attracting drug users into contact and empowering them to change their behav-ior away from HIV related practices.

Syringe exchange programs and prescribing clinics are undoubtedly some of the best bets for tackling this major task, though how the Mersey model of Harm Reduc-tion could be transported into different cultures around the world is a difficult question. In cities like Edinburgh and New York, it is a question that should have been addressed some years ago, though these cities clearly have very different stories to tell.

Allan Parry is a drug I HIV prevention consultant in Liverpool, England. His address is 20 Fir Road, Waterloo, Liverpool, England L22 4DL U.K 44 (51) 928-2234.

References

Fazey, C. (1988). An Evaluation of Liverpool Drug Depen-dency Clinic. Liverpool. Research, Evaluation and Data Analysis.

Marks, J. & Parry, A. (1987) "Syringe Exchange Programme for Drug Addicts." The Lancet, March 21, 1987.

Newcombe, R. & Parry, A. (1988). The Mersey Model of Harm Reduction: A Strategy for Dealing with Drug Users. Paper presented at the International Conference on Drug Policy Reform (Bethesda, Md., U.S.A.), October 1988.

Stimson, G. et al. (1988). Injecting Equipment Exchange Schemes: Final Report. London: Monitoring Research Group, Goldsmiths College.

Newcombe, R. (1989). "Preventing the Spread of HIV Infection." The International Journal on Drug Policy.