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Brief
History of Needle Exchange in the U.S.
by
Jon Zibbell
Springfield Users' Council
Before
I start, I first want to thank the organizing committee
for asking me to speak on needle provision in the
US and also for putting together such a comprehensive
program regarding the injection question. I want
to dedicate this morning's presentation to Sharon
Mullen, a friend and long time drug user activist
who passed away last month due to the restricted
access of sterile syringes in her city.
Let
me begin with two caveats. First, I am speaking
this morning as a harm reductionist working for
an illegal safer injection service and as a social
anthropologist at the University of Massachusetts.
My talk this morning is going to focus on the actual
practice of needle provision in the US and its relation
to federal, state and local policies and laws. Although
the conditions that allow us to administer a legal
program, or cause us to implement a program illegally,
are specific to the drug war politics of the US,
I believe that you will identify with many unfortunate
parallels to the situations in your own respective
countries.
And
second, since there is an overwhelming amount of
evidence-based research which proves that access
to sterile syringes significantly lowers the spread
of blood-borne disease, my job this morning is not
to describe the positive effects of needle provision
or to re-articulate the scientific evidence which
proves that we, as harm reduction activists and
workers, are correct. Instead, I am going to describe
the complicated and unpredictable path needle exchange
has traversed since the onset of the AIDS epidemic
in the mid 1980s. The underlying thread that runs
through this entire talk is an elaboration of A.R.
Moss' polemic that "politics is the basic science
of public health." For an evidence-based fanatic
like me, especially when it comes to health policy;
I will change that to "when it comes to health
policies concerning illicit drug users, politics
is the basic science of public health implementation."
The
ostensibly small number of state sanctioned needle
exchange programs in the United States testifies
to the fact that harm reduction is not even close
to becoming a dominant philosophy and practice in
drug services. Since the onset of AIDS in the mid-1980s,
the implementation of needle exchange programs has
taken an uneven path of development. Even when government-funded
research proves that needle exchange can slow the
spread of blood-borne disease while not increasing
drug use, and even with the Center for Disease Control
claiming that 40,000 more people are diagnosed with
HIV every year, the federal government continues
to refuse funding for such programs. Here, the US
departs from that of many other industrialized nations
who, by the 1990s, had a made legal access to safer
injection equipment a primary component of AIDS
prevention targeting injecting drug users. In fact,
according to Vlahov et al., the US remains the only
country in the world to explicitly ban the use of
national government funds for syringe exchange services.
Since
1988, Congress has passed at least seven statutes
that contain provisions prohibiting or restricting
the use of federal funds for needle exchange. In
1989, the National Academy of Science produced a
600 page report calling for the government to fund
NEX as an effective strategy to reduce the spread
of AIDS. In March of that year, Dr Louis Sullivan,
then secretary of Health and Human Services, agreed
with the report, but she could not convince President
Bush who opposed needle exchange "under any
circumstances."
Under
the terms of public law, federal funds to support
NEPs are conditioned on a determination by the secretary
of health and human services that such programs
reduce the spread of HIV while not encouraging illicit
drug use. After seven federal research projects,
it was found that needle exchange programs did in
fact fulfill both those conditions. Thus, in 1998,
the secretary of health and human services, Donna
Shalaha, made the determination that, "A meticulous
review has now proven that needle exchange programs
can reduce the transmission of HIV and save lives
without losing ground in the battle against illegal
drugs. It offers communities that decide to pursue
NEX programs yet another weapon in their fight against
AIDS."
However,
even with all the evidenced-based research, the
act"s restriction on federal funding was not
lifted. After a government panel advised him of
the benefits of NEX, Former President Clinton capitulated
to his drug czar William Mcafferey that lifting
the ban on needle exchange would send the wrong
message in the nation"s fight against drugs.
Using a conservative model, Ernie Drucker estimated
that 10,000 deaths could have been avoided between
1987 and 1995 and would have saved 500 million dollars
in health care expenditures if Clinton lifted the
ban on federal funding.
In
an acknowledgement that teeters on the edge of a
guilt-laden confessional, Former President Clinton
at the fourteenth international AIDS conference
in Barcelona explained about his refusal to lift
the ban of federal funding of needle exchange programs.
ìI think I was wrong about that, we were
worried about drug use going up in Americaî
he said. A little late for apologies Bill.
In
2000, when 36% of all AIDS cases and approximately
50% of new HIV infections reported to the Center
of Disease Control had occurred among injection
drug users, their partners and their children, Mr.
George W. Bush responded to the question of lifting
the federal ban on needle exchange at the annual
meeting of the AIDS foundation of Chicago. He stated
and I quote: ìI do not favor needle exchange
programs and other so-called harm reduction strategies
to combat drug use. I support a comprehensive mix
of prevention, education, treatment, law enforcement
and supply interdiction to curb drug use and promote
a healthy drug free America, not misguided efforts
to weaken drug lawsÖand needle exchange programs
signal nothing but abdication, that these dangers
are here to stay. America needs a president who
will aim not just for risk reduction, but for risk
elimination that offers people hope and recovery,
not a dead end approach that offers despair and
addiction.î
However,
that year, Bush"s drug czar, Scott Evertz stated
the power and efficacy of needle exchange in the
fight against AIDS. But Scotty should have known
better than to agree with federal evidence, for
after that statement, Bush announced that Joseph
O"Neil would replace Evertz as his drug czar.
In another bizarre twist, the secretary of health
and human services, Tommy Thompson, said that the
Bush Administration has no plans to permit federal
funding of NEP, although when Thompson was governor
of Wisconsin he excluded syringes from the definition
of paraphernalia in his state"s law, thus making
it legal to possess syringes.
In
April of 2003, the New York Times claimed scientists
who study AIDS were warned by federal health officials
that their research may come under official scrutiny
by the Department of Health and Human Services or
by members of congress because the topics are politically
controversial. They were advised they can avoid
unfavorable attention by keeping certain keywords,
such as ìmen who have sex with men,î
anal sex, needle exchange and sex workers, out of
their application for federal grants. In other words,
the Bush administration is currently policing the
lexicon of federal grant applications and flagging
for review those grants that do not fall in line
with his abstinence-only agenda.
Due
to the on-going, bi-partisan federal ban on NEX
funding, the responsibility of reducing injection-related
harm is transferred to individual states. State
politics, however, is a complicated and unpredictable
process. States will often delegate the power to
authorize needle exchange to the actual cities and
towns where the exchange will operate. When this
occurs, local authorization is determined by the
actually form of government particular to each respective
city. In some cities, authorization for needle exchange
is dependent on a majority city council vote, whereas
in other cities, the mayor has the power to write
an executive order that unilaterally mandates needle
exchange when there is a public health emergency
such as HIV.
Since
the power to authorize NEX is relegated to individual
States and those states then delegate their authority
to individual cities and towns, the result is similar
to methadone prescribing in the UK: wherein access
to services is more dependent on what zip code you
reside rather than on the health needs of a particular
individual, group or community. However, in order
to implement a program, individual cities and towns
need to pass legislation to challenge two types
of law.
The
first are the State"s prescription laws which
prohibit persons from dispensing or possessing syringes
without a valid medical prescription for a ìlegitimate
medical purpose.î In other words, they cannot
knowingly sell a syringe to someone who intends
to inject an illicit substance. Thus, the uneven
relationship between state and local ordinances
create an inconsistent mandate regarding syringe
provision. Eight states still require a prescription
to purchase syringes and five states explicitly
prohibit the nonprescription sale of syringes. For
example, the state of Michigan does not require
prescriptions for the sale of needles, but the Michigan
cities of Warren, Westland and Detroit place certain
restrictions on the purchase and or possession of
syringes. Similarly, Florida state law does not
require a prescription for purchasing syringes,
but Dade and several other Florida counties have
prescription ordinances that regulate their sale.
The
second are State paraphernalia laws. 47 States and
DC have drug paraphernalia laws that make the unauthorized
manufacture, possession or distribution of drug
paraphernalia a misdemeanor or felony offense. Out
of those, only five states carve out exceptions
for operating syringe exchange programs and those
five states require NEP participants to carry a
certificate or other evidence of program participation.
Some states even ban the implementation of needle
exchange in their statutory laws. Of the ten states
with the highest rates of injection related AIDS,
four have laws that prevent the establishment of
needle exchange programs. And New York, Maryland,
Connecticut, Pennsylvania, Rhode Island and Massachusetts
permit injecting drug users access to sterile syringes
under some conditions, but the situation is mixed:
Maryland only permits NEP in Baltimore. In Pennsylvania
and Massachusetts, NEPs only exists on the basis
of local initiative, and in my city of Springfield,
which ranks 13th per capita in the nation with regard
to injection related AIDS, the city council consistently
votes it down.
Within
the uneven development of US syringe policy that
I just described, I will describe three main trends
outlined by the CAPS 2001 Needle Exchange Report
that characterize the struggle to implement needle
exchange programs in the US.
1.
The first trend is to publicly challenge the prescription
laws through a civil disobedience approach to
NEX, such as implementing a program without state
and local authorization; in other words, illegally.
2. The second trend are programs that started
as illegal/underground but then received state
or local authority to operate and sometimes ended
up receiving funding from local governments.
3. And the third trend is linked to the growing
institutionalization of NEP, ones that were started
by activists with the support of the department
of public health and then received either government
or foundation funding but still didn't have statutory
authority to operate.
The
ability to claim where the first needle exchange
project developed is constrained by the numerous
ways syringe provision can occur within State and
Local laws. According to Robert Heimer, the first
NEP began operating in 1986 when Jon Parker was
conducting an illegal exchange in New Haven and
Boston. This program followed the first model wherein
drug user activists implemented their own programs
without waiting for state authorization or while
the State deliberated over future possible authorization.
According
to Dave Purchase, the first US publicly funded NEP
was in Tacoma, Washington. The birth of this program
followed model three wherein drugs workers and activists
started a program with funding and support from
the Department of Public Health. Lawrence Goslin,
however, argues that the Tacoma program was operating
in violation of state law but it had support of
the chief of police. Even with these backers, the
State district attorney argued that the program
violated the state"s drug paraphernalia act,
thus making the county public health commissioner
file a suit seeking a judgment that the exchange
was lawful. In this scenario, the health department
and the chief of police allowed the program to run,
but it still came under attack from the state prosecutor.
In November of 1988, Prevention Point, an exchange
in San Francisco, was initially started by activists
and then received support from the local health
department. In a similar scenario to the Tacoma
exchange, the city tolerated the exchange but it
was still illegal according to statutory law.
Around
the same time the Tacoma program began, NEPs were
being considered in various forms throughout the
US. Purchase argues that a pilot program in Portland,
Oregon would have been the nation"s first publicly
funded program but it had problems receiving liability
insurance. According to the 1989 Mersey Drug Journal,
the first US syringe exchange scheme began operating
in NYC on the 7th of November in 1989. However,
the NYC exchange actually opened a week after the
San Francisco exchange Prevention Point. In fact,
the first actual state-endorsed NEP in the US was
in Hawaii in 1990. This program was authorized by
the state and privately funded and operated by the
Life Foundation, a non profit AIDS group. And then
later that year, Connecticut enacted a pilot program
in New Haven.
As
a result of the risk undertaken by drug activists
and rogue health workers, these initial programs
spurred a national movement to implement NEX. However,
as a result of the failure of federal, state and
local governments to take the lead in initiating
evidence-based prevention efforts, the North American
Syringe Exchange Network reported in 2002 that there
were only approximately176 programs operating in
36 states, the district of Columbia and Puerto Rico,
and according to the Lindesmith Center, only about
10% of injectors have access to sterile syringes.
Dave
Purchase argues that NEPs have one of three legal
statuses: legal, illegal-underground and illegal
tolerated, which he labels decriminalized. I will
argue that Dave"s assertion places too much
credence in state and local prosecutors. How and
why a needle exchange program is tolerated or not
criminally prosecuted is dependent on many factors,
such as its relationship to the health department,
the race and class of the participants, its relationship
with city politicians and its adherence to the normative
outcomes dictated by the State health department.
In other words, just because a program is tolerated
for whatever reasons, doesn"t mean that it
is legal; and the bottom line is that the illegal/tolerated
status of a program does not give the needle exchange
workers protection under the law.
To
illustrate the reality of my argument, in 1998,
there were ten arrests of NEP staff and volunteers
operating ìillegal/toleratedî exchanges
in five different states. In her article, ìSad
Termination of a Life Saving Project,î Dawn
Day argues that ìin the worst case, arrest
and successful prosecution can shut down a NEP entirely,
which is what she described happened in New Jersey.
Furthermore, Goslin argues that from 1986 until
1993 more than 20 prosecutions were brought against
illegal programs for violating state drug paraphernalia
laws and needle prescription laws. And Human Rights
Watch reported that even with local approval, six
prosecutions of syringe exchange personal occurred
in California between 1991 and 2000. And last, in
a 2000 survey of syringe exchange programs in North
America, over 20% of 134 programs said they had
problems with their legal status and over 30% described
police harassment as a regular occurrence
Therefore,
even with local approval, NEX programs are continuously
being threatened by drug war ideology and conservative
interpretations of the law, meaning that just because
a program is state-sanctioned does not guarantee
its participants safe protection. For example, in
NYC, police where arresting drug users for syringe
residue and state prosecutors were attempting to
charge them with possession of narcotics. It was
not until the Harm Reduction Law Project took the
case to court, charging that the practice violated
drug users" rights under the legal protection
of a State approved program, that the possession
of syringe residue was deemed not a prosecutable
offense.
Moreover,
state prosecutors in Massachusetts were trying to
make it illegal to possess syringes in a city or
town that did not have local approval for needle
exchange, even if you received them from a state-authorized
program. In other words, they were trying to make
it illegal to possess syringes received from a legal
program if they possessed those same syringes in
any city in Massachusetts that did not have local
approval for NEX. This case went all the way to
the Massachusetts Supreme Court where the court
ruled against the state prosecutors, thus making
it legal to possess syringes anywhere in the state
if you were registered in any locally approved program.
We
cannot fully understand the illegality of NEX in
the US without situating that illegality in the
context of America"s war on drugs and the disproportional
and devastating health consequences it places on
poor communities and communities of color. According
to Freidman et al, income inequality in the US is
associated with more drug injection and with HIV
prevalence and incidence among drug injectors. They
suggest that socioeconomic policies which affect
poverty rates and income distribution might also
affect rates of drug injection and rates of HIV
transmission among drug injectors. In other words,
they suggest that poverty as a social inequality
contributes to the spread of HIV among drug injectors.
If
we combine Friedman"s thesis with the claim
from the Illinois Based Coalition for Responsible
Syringe Policy that people of color in America make
up the majority of injection drug users with AIDS,
then what we have is a health policy that discriminates
against poor people of color. According to the Dogwood
Center"s 1999 report, from the beginning of
the epidemic through the end of 1998, African American
and Latinos together accounted for three quarters
of all injection-related AIDS cases. In addition,
the report also claimed that injection related AIDS
among blacks was 14 times higher than whites. Moreover,
in 2001, the Dogwood center reported that 10,000
African Americans and 4500 Latinos are infected
with HIV through needle sharing each year and in
1998, AIDS was the second leading cause of death
among blacks between the ages of 25 to 44 with half
of those cases due to needle sharing. Although the
negligence of state and local politicians to implement
NEX programs affect all injectors, Drucker argues
that the data show the most negative health consequences
of drug use are not evenly distributed and they
fall most heavily on those who experience the highest
rates of drug law enforcement, African Americans.
For
example, in Massachusetts, out of the four locally
approved programs, three are located in white, middle
to upper class neighborhoods. This is largely due
to the way local approval is structured in each
city. In my city of Springfield, local approval
needs to be decided by the city council through
a majority vote. However, the city council has nine
at-large representatives who reside in just three
of the eight city wards (wards 5, 6, and 7). Wards
1 and 4, whose residents are disproportionately
contracting HIV and HCV, and who voted 61% in favor
of A NEP, and who are predominantly African American
and Latino, are not even represented on the city
council. By having no representation on the council,
these residents have been denied the right to have
their needs represented in the city government,
which has therefore prevented them from equal access
to a state-approved NEP.
Due
to the fact that people of color are disproportionately
affected by the lack of needle provision in the
US, and due to the fact that politics and abstinence
fundamentalism are getting in the way of saving
lives, I will suggest here that NGOs and state-sanctioned
NEX programs need to fund and support illegal needle
exchanges in order to provide evidenced-based strategies
in cities where city councilors (and not the health
experts) determine health policies while ignoring
the scientific evidence.
Although
operating an independent program is dangerous, and
at times often volatile, there are many benefits
that derive from not being under the panoptic gaze
of the state. Since independents are not constrained
by state rules and regulations, they can implement
progressive harm reduction practices that are often
deemed inappropriate or ìnot proven to workî
by health officials or other state authorities.
For example, they can hire active drug users and
be actually user-run (and not just user friendly)
without going against state hiring policies that
prevent drug users and former incarcerated people
from receiving state employment and most importantly,
they can provide services to injection drug users
whose access to sterile syringes is limited by the
race and class bias of US syringe laws.
We
can call these practices, following Alain Bodiou,
ìprescriptions against the state,î
meaning that independent programs remain outside
of state laws but they include the state in their
political field. In other words, independents can
administer a program without the authority of the
state but they are not exterior to it with regards
to the possibility of arrest, in terms of the demand
for recognition and funding, by proving the necessity
of their program to local politicians and by confronting
draconian and racist state drug policies.
The
contradictions here are that independent programs
often do not have enough money to make real structural
changes, they often lack the institutional space
to set up a home base and they are constantly in
fear of being arrested. Whereas state funded programs
on the other hand have plenty of money to implement
new and progressive programs but they are often
limited to make real structural change outside of
the normative public health model (such as compulsory
141 exchange or hiring active drug users) and because
of their relationship to state laws, state funding
and their political bedfellows.
In
this talk I have tried to demonstrate that in order
to understand needle provision in America, we need
to recognize two main processes: (1) the complicated
and unpredictable politics of drug use and public
health within a republican democracy and (2) that
needle exchange and injection drug use cannot be
explained outside of the social and political field
where they are practiced. By understanding the social
and political underpinnings of syringe laws in America,
we can start to dismantle the practice of zip code
syringe provision by addressing not only the obvious
inconsistencies, but also by understanding the actual
material conditions that lead to discriminatory
health policies. This way, groups who are being
affected by these policies, such as drug users,
their families and their neighborhoods, can confront
politicians and health departments with the evidenced-based
knowledge to mobilize those groups. If politics
is the basic science of public health, as A.R. Moss
so polemically claims, then political organizing
and direct action are a necessary component of its
implementation and efficacy.
Presented at the 1st National
Injection Conference at the Royal Institute of British
Architects, London. October 2003
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