Springfield Users' Council - http://www.springfielduserscouncil.org
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Brief History of Needle Exchange in the U.S.
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.
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. Thank you.
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Springfield Users' Council - http://www.springfielduserscouncil.org