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The Struggle To Implement Needle Exchange In Three Cities
By Tom Cannell |
Togliatti, a city of around 750,000 people and home to the largest auto manufacturer in Russia, sits southeast of Moscow on the Volga River. You may have heard of it through the participation of some of its residents in the mail-order Russian bride business. Recently, Tim Rhodes of the University of London led a team to the city to conduct one of the first in-depth HIV surveillance studies in Russia. In 1998, though the HIV infection rate in Russia was beginning to climb, there were only two positive tests for HIV in Togliatti out of almost 100,000 tests given. In 1999, that number had still increased only to ten. One year later, in 2000, Togliatti had 3,680 new cases of HIV.
The city's epidemic, characteristic of Russia's nationwide HIV crisis, spread almost entirely through the shared use of needles by drug users. The devastating capacity of needle sharing has been proven over the years not only throughout Russian cities, but also in Edinburgh, Bangkok, and more recently in Kathmandu, Nepal. Wherever there is an entrenched community of outlawed drug users, if HIV is introduced it will be passed from vein to needle to vein, and people will start to die of AIDS. What we see in Togliatti, which is typical of an injection-based epidemic, is the horrifying swiftness with which the virus can spread.
When HIV is transmitted sexually it requires direct person-to-person contact, which, excluding the exceptional case of prostitution, tends to limit the virus's spread to a small network of people. In contrast, injection-based transmission is borne indirectly from person to person by the needle, which serves as a vector. An injection drug user will inject a certain number of times each day, depending on the intensity of his addiction and his drug of choice: a heroin addict may inject twice a day, whereas someone using cocaine may have to shoot up as many as thirty times daily. As a result, an infected drug user could introduce hundreds of contaminated needles a month into his community, depending on his injection habits. In contrast, very few people have that much sex, particularly with a different person each time. And in an injecting community where needles are scarce and safety standards are lax, infected needles can be reused repeatedly, passing HIV to an exponentially increasing number of users, and explaining how an injection epidemic can rage out of control so quickly.
Furthermore, transmission by injection is not a separate reality from transmission by sex. An outbreak that begins in a community of drug users spreads to their children and lovers and to their lovers' lovers and more. Russia faces the possibility of ten million HIV infections within the next fifteen years. What started as the concern of mostly homosexual drug users has become the fastest growing HIV epidemic in the world.
Russia's sudden descent into its current hellish state should frighten us, though we live so far away. While Russia has many disadvantages which the United States avoids in its struggle against AIDS, including higher-bore needles, widespread ignorance, and a dismal public health system, Togliatti is not the only industrial city in the world with poverty and a drug problem. Cities like this exist right here in Connecticut.
New Haven, located just off the I-95 drug corridor between Philadelphia and Baltimore, has for a long time been home to a large number of drug users with easy access to their fix. Before cell phones became standard equipment in the drug trade, there were open-air drug markets and shooting galleries on Congress, Dixwell, and Edgewood Avenues. Not surprisingly, injection over the past two decades has left New Haven with a significant HIV/AIDS problem. Currently there are around 2,200 people living with AIDS in the city of 123,000, a prevalence that far exceeds the national average. And yet New Haven is far from the point of a crisis like the one facing Togliatti. Next year is expected to bring at least several thousand new HIV cases to Togliatti, whereas New Haven is likely to see around thirty. The spread of the disease is managed in New Haven in a way that Russia will never achieve with its current policies.
What accounts for such a pronounced difference? In addition to America's far superior public health system and its work in educating citizens, one program in particular has been helping to keep American transmission in check. New Haven may have invented the Frisbee, but it is also the home of American needle exchange.
A needle exchange is a program that distributes clean syringes to drug users, usually in exchange for their used ones. The idea is that if syringes infected with blood-borne diseases are removed from circulation, then sharing needles is less likely to be harmful. Exchanges also provide users with health education, disease testing, referrals to drug treatment, and often medical care and food.
The first known needle exchange occurred in the Netherlands, but the idea surfaced in the United States when Jon Parker, a dyslexic Yale medical student and former drug user, started passing out needles from a storefront near the Yale University School of Medicine, against Connecticut law. At the time, it was illegal to buy a syringe in Connecticut without a prescription. Parker bought them in Vermont. But in 1990, with support from New Haven Mayor John Daniels and Yale scholars such as Alvin Novick, head of the Mayor's Task Force on AIDS, the Connecticut State Legislature approved a pilot needle exchange program in New Haven and allocated a small amount of money to support it. Daniels had opposed needle exchange as a member of the state legislature, but after Novick took him to visit a neonatal intensive ward where the AIDS-stricken children of infected drug users were being treated, he reversed his stance. The encounter humanized for him the desperate situation of drug-addicted people and their families. Alongside Hawaii, Connecticut became one of the first states to experiment with the idea of allowing drug users to be given clean needles in exchange for used ones. Calling themselves "the AIDS Brigade," Parker and his associates drove a brightly colored van through New Haven communities, exchanging needles.
Parker's work alone might have resulted in New Haven being recognized for its role in the fight against HIV. However, the real import of New Haven comes from the work of Robert Heimer, a disease transmission specialist, and Edward Kaplan, an expert on mathematically modeling HIV prevention. As researchers involved with the exchange, they were concerned about the lack of hard evidence supporting the common-sense hypothesis that needle exchange should reduce HIV transmission. Most of the studies that had been done on needle exchange relied on interviews with clients, whom many suspected of telling researchers exactly what they wanted to hear. Heimer and Kaplan hit upon an innovative strategy to demonstrate that needle exchange was succeeding. Rather than working with clients, Heimer and Kaplan tested the needles that were turned in to the exchange and assigned tracking numbers to the needles that were handed out. Between 1990 and 1992, using a model developed by Kaplan, the pair found that the percentage of HIV-infected needles returned to the exchange dropped from 65% to around 35%. Before 1990, when the exchange began, the average needle circulated for seven days before being disposed; after only two years of the aboveboard exchange, circulation time was cut to two days. According to Kaplan's model, new HIV infections among exchange clients had been cut by 33%.
These results were published in the journal AIDS in 1994 to enormous acclaim. The appearance of convincing evidence in favor of exchange programs moved the intervention to the forefront of debate over HIV policy, not only in the United States but worldwide, and led to several other equally supportive studies. Although needle exchanges remain extremely controversial in public debate, Heimer and Kaplan's work has led to their general acceptance in the public health community.
Considering its dismal failure in preventing injection-based HIV transmission, one might suspect that Togliatti lacks a needle exchange. In fact, an exchange supported by private money does exist, but nobody uses it. Any user who ventures toward the exchange is likely to fall into the hands of the policemen who often wait nearby. The needle exchange movement in Russia is utterly crippled by stiff opposition from the police, even though it is legal to distribute syringes. Police often shut down exchanges without giving just cause. In St. Petersburg, one of the syringe exchange vans was firebombed; police involvement is suspected.
Users know that if they are caught carrying a syringe, even though anyone can legally carry them in Russia, they can expect to be harassed and arrested, perhaps for something like "swearing in public" or "petty hooliganism," pay fines, and spend days or weeks in jail isolated from their drug supply. The result, not surprisingly, is that users are afraid to carry clean needles on their way to buy drugs and instead use the needles that are left with their dealers by other buyers. Tim Rhodes, who interviewed users in Togliatti, found that one out of three users had shared injection equipment in the last month and almost a tenth had shared with someone whom they knew to be HIV positive. Addicts are simply more frightened of the police than they are of AIDS.
The importance of what has happened in New Haven, therefore, is not just that there has been needle exchange operating for the past decade, but also that from the moment the exchange emerged as a legal entity in 1990, the New Haven Police Department has not only refrained from being obstructive, but has actually supported its work. Under Chief Nicholas Pastore, the department developed a training seminar for the New Haven Police Academy which specifically addressed police interaction with needle exchange. Officers stayed away from the van when it was operating, and users got the message that it was safe for them to accept its services. For the most part this relationship is intact under current chief Francisco Ortiz. According to Dominic Maldonado, the exchange program's current director, there have been incidents of harassment by New Haven police officers, but in every case a meeting with the chief has cleared up the trouble.
When the Connecticut legislature concluded that the New Haven experiment was a success, it expanded exchange programs into Bridgeport and Hartford. All three of these programs are still in operation and studies have shown them to have reduced injection transmission: New Haven's success is well documented in Heimer and Kaplan's work, and in Bridgeport, injection-associated cases of AIDS have dropped from around half of all cases to just over 30% since the exchange began its work.
There is, however, continuing friction. In January 2001, a federal judge ruled that Bridgeport police were contravening the Connecticut needle exchange law by arresting and harassing needle exchange clients. The anonymous plaintiffs, in a case brought by the ACLU against local police, testified to having been harassed, pushed around, humiliated, and arrested by Bridgeport officers. One user was forced to reach his hand into a dirty public toilet to pull out a drug cooker. The other plaintiff, when he gave his needle exchange ID card to the officer, was told bluntly, "We don't give a fuck." Both plaintiffs had needles on them, but no drugs. The message being sent to users was clear: don't carry syringes around with you.
In Bridgeport, there has never been the concord between exchange and city police that exists in New Haven. Mark Kinzly, who ran the exchange in Bridgeport for years before returning to New Haven, and who is currently a research associate at Yale's School of Epidemiology and Public Health, remembers there always being a level of harassment. He remembers unmarked police cars pulling up next to the exchange van and shouting, "We're going to make sure you can't do shit!" Nevertheless, as the numbers indicate, the exchange in Bridgeport has been able to do good work. Even some officers who were violently hostile to the program eventually changed their minds and would sometimes bring users in to receive care and clean needles. Still, as the ACLU case indicates, police behavior over the past few years has become dangerously Ð and illegally Ð aggressive, despite a court injunction requiring officers to stop "searching, stopping, arresting, punishing or penalizing in any way any person based solely on that person's possession of injection equipment." The court ruled in January 2001. And yet, at a meeting at the Center for Interdisciplinary Research on AIDS in February of this year, officials from the Bridgeport exchange reported that police had increased their harassment even further, picking up users in sweeps and even harassing recovering addicts going into methadone clinics.
Robin Clark-Smith, the director of the AIDS program at the exchange, recounted that one user had been thrown through a glass window by police.
The natural effect of police abuse is a reduction in the number of users who are willing to accept clean needles from the exchange. Bridgeport users have for some time preferred to come to the office of the needle exchange rather than risk harassment at the van, but now the police have taken to parking their cars outside the exchange headquarters.
This is a situation too close to Togliatti for comfort. Russia has demonstrated that an exchange without police cooperation has essentially the same effect as no exchange at all, greatly increasing the risk of epidemic.
Still, to many police officers in Bridgeport and Togliatti, needle exchange makes very little sense. Certainly, this is a view expressed by many politicians, who often fear the political consequences of being considered "soft on drugs." Opposition comes not only from political conservatives, but also from within the African-American community, which has been disproportionately affected by AIDS. One of the staunchest opponents of needle exchange in Congress is Charles Rangel, a liberal Democrat from Harlem. When David Dinkins, the first black mayor of New York City and another liberal Democrat, entered office, he immediately cancelled all of the city's needle exchanges (although he later reversed himself on the strength of Heimer and Kaplan's work). The federal government has been forbidden to fund needle exchanges throughout both Democratic and Republican administrations. Despite endorsement by the Institute of Medicine, the American Public Health Association, the American Medical Association, and the U.S. Conference of Mayors, among many other groups, there is still widespread opposition to providing drug users with the means to inject themselves.
To this way of thinking, infectious disease is simply one of many destructive consequences that drugs visit upon the user and his community. Relief must come from an end to drug abuse, not from compromise. David Murray, a research analyst at the Office of National Drug Control Policy, has articulated the widely-held concern that needle exchange undermines efforts against illicit drug use by "normalizing the process." He and many others are worried that by providing clean needles, the government would implicitly endorse drug use in the minds of users and perpetuate the national problem of abuse. One reason for police aggression toward needle exchange participants seems to be to assure that none of them forms this impression.
Both law enforcement officers and public health workers are concerned with the safety of society, but a difference in priorities between the two communities leads to conflicting views on needle exchange. While an exchange worker seeks to prevent the injecting community from terminal illness, many police see drug use as a greater threat, not only to addicts, but to society as a whole. Some view users as chronic criminals whose rights are largely void and whose health is of little importance. As one drug user that Rhodes interviewed in Togliatti said, "The police always say, ÔYou drug addict, stand up, hands on the wall.' To them you aren't a human being.'" Or, as former Los Angeles Police Chief Daryl Gates said, "We should take users and shoot them." But rather than preventing drug abuse, harassment by police officers who block access to clean needles may reinforce in addicts a vision of their own worthlessness that perpetuates their problem.
Police officers are a critical part of any functioning needle exchange, and they must be convinced of the importance of programs' benefits not only to public health, but also to the fight against drug abuse itself. Peter Moskos, a Harvard sociologist and former Baltimore police officer, found that his fellow officers had little interest in HIV and viewed needle exchange as a "coddling liberal program." Unfortunately, the opposition between law enforcement and needle exchange is natural: most needle exchange operations have their roots in illegal syringe distribution and about a quarter of the needle exchanges in the country still operate against the law. Even in a place like New Haven, where there is a legal exchange, there also exists an illegal operation that provides a greater number of needles than the state allows for. Circumstances like these are hardly ideal for cooperation with law enforcement.
Dave Purchase, chairman of the North American Syringe Exchange Network, has told the author that most cities stand somewhere between New Haven's tolerance and Bridgeport's aggression: police and exchange exist in a tense, but ultimately functional, relationship. Officers have begun to understand not only that poor health among users exacerbates addiction, but also that HIV in a community of injectors threatens the health of the American public as a whole. Exchanges, for their part, will help their cause if they make a good faith effort to encourage their clients to abide by the law. It is not an easy partnership. Still, the numbers in Togliatti call out to what is at stake if police cooperation is lacking, and the history of exchange in New Haven points to solutions that can be achieved.
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