Ah, San Francisco in the summertime. The sun beating down on your face, the fresh air carrying a hint of sea salt with it, the friendly young woman handing you a bundle of clean syringes…
It's 6 p.m. Tuesday, neddle-exchange time on Duboce Street near the Safeway supermarket, where I'm standing alongside five volunteers from Prevention Point, an organization that – in violation of state and city law, as well as a June 7 attorney general ruling – distributes 1.5 million syringes a year to an estimated 2,500 of San Francisco's injecting drug addicts.
The point of the exchange, so the speak, is to reduce the spread of AIDS and other diseases via needle-sharing, something junkies are notorious for. Theoretically, if you give druggies clean needles in return for their dirty ones, they won't use the dirty ones again – because they can't. Neither will their friends, lovers, or spouses. Kids won't prick their fingers on Dad's used point. Fewer cases of HIV transmission, less hepatitis-B and -C transmission, a whole lot fewer abscesses and heart and blood infections.
By now, everyone knows that bleach can be used to sterilize syringes and needles, but bleach isn't a long-term solution to blood-borne infection. Bleached syringes become weathered and worn, and after repeated use the points on the Micro-Fine IV needles grow dull, making them painful to use. Sometimes the needles turn kinked ot barbed, causing more pain and infection. New needles are a must.
Needle exchange is the boldest example of “harm reduction,” a '90s public-policy idea that holds that the enforcement of drug laws should be less harmful and costly to users and bystanders than the dangers inherent in drug use itself. Harm reductionists like Arnold Trebach of the Drug Policy Foundation and the people at Prevention Point posit that drug use is a public health problem, not a criminal problem. They say imprisoning drug addicts for a habit they seem unable to curb makes as much sense as busting children for having chicken pox.
After almost a decade of vilifying heroin users, our culture seems ready to humanize junkies via outreach projects like needle exchanges. Armes with medical evidence that drug users can take better care of their health if given the chance, the harm reductionists are tilting against high political odds to bring drug users inside the medical tent. Help them help themselves, say the harm reductionists, so we can fight AIDS. So we can slow or stop drug users' self-destruction. So we can decrease the costs engendered by drug use to society – theft, illness, the warehousing of drug users in megaprisons. The message is simple: If drug users are sick, a compassionate society should attempt to minimize their suffering.
The Duboce exchange consists of a couple of small steel tables upon which a banquet of condoms, cotton balls, and alcohol wipes is displayed. But these are a sideshow. The main event is the thousands of clean Becton-Dickinson U-100 insulin syringes displayed in their bright orange boxes, waiting for a new home. There's also a “biohazard” bucket beside one of the tables for the safe caching of contaminated needles prior to their incineration.
Prevention Point currently operates nine exchange sites in the city, as regular as a bus schedule. In fact, Prevention Point has printed a schedule in English ans Spanish on a convenient 3×5 card. Each site dispenses needles and accessories one night a week, except for Sixth Street, which runs three nights a week.
The Duboce Street site is popular, garnering 60 to 90 people during each two-hour-long exchange. It's not as popular as the one on 14th Street near Mission, which regularly attracts around 200 exchangers, but businesss is so brisk that the clientele forms a line before the exchange opens.
Located behind the Safeway between Church and Market streets, the Duboce Street site is inconspicuous but not invisible to passers-by. Not inconspicuous enough, if you ask Safeway. Although the exchange is conducted on a public sidewalk, a couple of Ambassador Security guards dressed in cop drag, their radios squealing full blast, approach the exchange as it gets under way. For the fourth consecutive Tuesday, they politely ask just exactly what is going on.
The stream of clients lined up at the exchanges ripples away from the guards. Nobody wants attention. Nobody wants trouble. The clients perform the mental equation in their heads: Is this where the needle exchange finally gets busted, and what happens to people who are caught walking toward it with a bunch of highly illegall, slightly used hypodermics? No way to get out of that one, friends. They can type my DNA. I've seen the O.J. trial.
Might be better to come back after this has blown over.
Yana Wirengard, who is ferrying Prevention Point's supplies between this site and two others tonight, knows the drill. Deftly motioning the guards away from the exchange, she patiently explains that this is public property, that she's tried – without success – to reach the store's manager for a meeting about the exchange.
After a few minutes, she persuades the guards that yes, this has all been talked about before; yes, yes, this a public property, we've been trying to meet with the manager, yes, yes, yes. The guards leave, satisfied until next Tuesday, and the needle exchange begins in earnest. The clients queue up as if a cashier has opened a new register in a busy Safeway. Orderly lines form. Most used points are bundled into groups of five or 10, and there is no limit to the number of needles you can swap. One drug user brought in 500 at the Taylor Street exchange, saying that he was exchanging for his entire household. A clipboard-wielding volunteer ticks off the points as they're deposited in the biohazard bucket and calls the total to another volunteer handling the clean syringes.
“34, huh?” a volunteer says to the client. “OK, you want longs or shorts?” in reference to half-inch or 1-inch needles. The older the client, the more likely he'll want longs – he might have to dig a little deeper to find a vein. [page]
Another volunteer dispenses accessories to the clients: Alcohol prep pads to swab the injection site; cotton balls or pellets to stanch any temporary blood flow; rubber bands for wrapping used points in a bunch; a fistful of condoms; and a bottle of bleach, should the client be a do-it-yourself cleaner. The goods are all slipped into a brown paper bag, the kind every jumior-high student has carried his lunch in. Thank you for shopping Prevention Point.
Some clients hurry away, but some stay to chat, or peruse a zine distributed by a Duboce volunteer: Fuck Yer Laws, Fuck Yer Lies. Ostensibly “by addicts, for addicts,” FYLFYL's ACT UP-ish politics clash with the quiet junkies making their way through this checkout stand. One volunteer says the zine is still put together by volunteers with increasing help from the users, with volunteers trying to involve them more. One client, fresh points in hand, asks if FYLFYL needs a desktop publishing designer and is diappointed to learn that the production is mostly cut-and-paste – but what cutting and pasting: “Handy Hints by the Australian IV League,” a Gray'a Anatomy-style diagram revealing injectable blood vessels like the subclavians, internal and external jugulars, median cubital, cephalic, dorsal venous arch…
There are also bumper stickers for distribution at the exchange: “Fuck Safe [heart symbol] Shoot Clean!
Just Don't Call Me a Junkie
The non-pejorative name in public health circles for junkies is “IDUs” (“injecting drug users”), which replaces the emergency room doc's label of “IVDAs” (“intravenous drug abusers”). IDUs include steroid, cocaine, and amphetamine injectors, and the new label is designed not to judge or stigmatize them.
“They get that elsewhere; why do it here?” asks a Duboce Street volunteer.
IDUs come in all shapes, colors – mostly white in San Francisco, by the way – and from all rungs on the socio-economic ladder. At the Prevention Point sites, I rarely encounter the Planet Eisenhower stereotype of the emaciated, twitching junkie; perhaps 10 percent of the clients I see have a waxiness of complexion, with many having sunglassed their pupils out of scrutiny's range.
I do, however, talk briefly with a 40-going-on-60 future Jane Doe at the Webster exchange. Doe started injecting speed 15 years ago, moving on the heroin. By now, scoliosis has canted her back, her complexion is shot, and her handshake is about as firm as a dying man's last breath. And speaking of breath, she is recovering from a recent pneumothorax – a hole in her lung. (You're not likely to have this malady – unless your lungs are brittle from years of crack-smoking, or you've been shot or stabbed.) Now that Doe is breathing well again, the big news is that she's gained a pound in the last week, fighting off AIDS-related wasting. That leaves her free to worry that the Safeway on Webster might close its bottle-and-can redemption facility.
The IDUs interact alertly and cheerfully with the predominately female staff at Duboce. Whether this camaraderie stems from the volunteers' low-key friendliness or the IDUs' relief at having secured clean, safe points is a tossup. Such is the case with one sweaty man who talks distractedly with the volunteers, struggling with a shoulder bag in one hand, needles in another, while a spoon and a pint of Haagen-Dazs butter pecan teeter in the balance.
I am startled by the number of department store “gimme” bags that pull double duty as syringe cases: Drakkar Noir, Banana Republic, Abercrombie & Fitch Co., Polo. I imagine predatory perfume spritzers at Macy's cornering a matronly Atherton woman: “With every $25 purchase of Lancome Apres-Bath Heroin, you get a free toilet kit for your needles.”
Although possessing a needle with this intent to inject illegal drugs is still a misdemeanor under California law, San Francisco officials began winking at an illegal needle program begun by Prevention Point in November 1988. The group, initially a mixed bag of “AIDS researchers, social scientists, HIV counselors, educators, AIDS activists, medical personnel, AIDS-affected individuals, teachers, lawyers, and people in drug and alcohol recovery,” is now composed of about 80 volunteers and four paid staff. But in 1988, it was not much more than people standing around, wondering how to deliver needles to IDUs.
Yana Wiren-gard says the earliest organized needle exchangers skulked around the Tenderloin pushing a baby carriage full of syringes. Seeking out IDUs, they'd announce their presence with this greeting: “Can I feed your baby?”
The exchangers worked in constant fear of a bust, but the politics of AIDS in San Francisco made their cause politically popular, with Supervisor Angela Alioto leading the charge. After a few initial hassles by startled police, Prevention Point set up its first regular exchange site on Eddy Street just west of Taylor on Nov. 2, 1988.
As the group gained notoriety, it sought city support and funding, hoping that San Francisco would emulate the Connecticut model, which incorporated the findings of a Yale University study on the spread of HIV in New Haven's IDUs. The Constitution State changed its laws to allow the purchase of syringes over the counter, a rarity in the Northeast. In California, AIDS activists and health officials persuaded the California legislature to legalize exchanges in three successive years – 1992, 1993, and 1994 – but each time Gov. Pete Wilson, currying the crucial punish-the-junkies vote, vetoed the bills.
“In blunt terms,” he wrote in vetoing the 1993 bill, “is it worth reducing the risk of infection to intravenous drug users at the potentially far greater cost of undermining all our other preventive anti-drug efforts? … What are [young people] to think when … we give formal sanction to a project which facilitates drug use?”
Thwarted by the governor, but encouraged by a friendly legislature, frustrated city officials took matters into their own hands 26 months ago: They place San Francisco under a legally effective semipermanent state of emergency. [page]
The city charter bestows rather sweeping powers upon the mayor and the director of public health to stop threats to the general well-being. These powers, typically used to combat cholera, typhus, and civil disorder in the wake of disasters, were enlisted to fight the AIDS epidemic after Mayor Frank Jordan and then-director of public health Dr. Raymond Baxter checked with city attorneys. On March 11, 1993, Jordan declared a state of emergency in the city and county of San Francisco, sending the declaration to the Board of Supervisors for approval, which did so four days later.
The Government Code requires the Board of Supervisors to recertify the emergency every 14 days, so with monotonous regularity the board has extended the lives of the needle exchanges at two-week intervals ever since. The city now funds just over $300,00 of Prevention Point's budget, while the San Francisco AIDS Foundation makes up another $150,000 from its fund-raising activities – the AIDS Wallk, the AIDS Dance-a-Thon, and private donors.
As early as January 1992, prior to the declaration, the San Francisco Police Department said it would not “actively look for violations” of state prescription laws. The current policy is to not harass needle exchangers; unless you're dumb enough to shoot up where a cop can see you, it's difficult to get busted for the possession of a needle. (The city's tolerant stance has made Police Chief Anthony Ribera and Mayor Frank Jordan minor heroes in harm-reduction circles. In New York, store-front needle-exchange programs receive state “waivers” for their work; in Washington, a county director of public health successfully sued the state to allow the legal existence and funding of the Tacoma exchange.)
Other local governments have followed San Francisco's lead: Sonoma County declared a state of emergency in March 1994; Richard Riordan, the Republican mayor of Los Angeles, declared one last Sept. 6; Santa Clara County did so a week later; and Santa Cruz County did the same on May 23.
San Francisco is the “volume dealer” of the bunch, moving a vastly greater number of needles, setups, and condoms than any other program in the U.S. It lacks the resources to offer other services except vitamins at its Sixth Street site. The Santa Cruz exchange adds hot soup and bagels, and a couple of times a week Odwalla drops off some fresh juice. The Lower East Side Harm Reduction Center in Manhattan features a full-time acupuncture center and women-only exchange hours one day a week.
The local “emergencies” haven't made the needle exchanges a done deal in California. In response to a hypothetical question by Assemblywoman Barbara Alby (R-Fair Oaks), Attorney General Dan Lungren issued a 10-page opinion of the subject on June 7. He concluded that needle-exchange programs violate state law, that city-declared public health emergencies like San Francisco's are void, and that the “necessity defense” – basically, esoteric cases of breaking the law in order to prevent an imminent specific threat to life – is invalid.
San Francisco public health director Dr. Sandra Hernandez dismisses Lungren's notions as political rantings, criticizing the governor and Lungren for “continuing to promote an illegality notion.”
“It's an opinion,” Hernandez says.
“Until it goes to court, it's not illegal. The attorney general is an elected official and has a certain agenda. What you have is one attorney general and one governor who are staring at all this [favorable] evidence … that it is a good public health program. It's a tragedy when good public health policy is considered illegal.” She adds that the legislature's passage of needle-exchange bills is more indicative of the people's will than the governor's vetoes.
“[Needle prescription laws] passed 50 or 150 years ago did not take into account [a] social situation” like AIDS, she says.
District Attorney Arlo Smith interprets the law differently, telling the Bay Area Reporter that “[e]nforcement is a local issue … juries have been unanimous in accepting the defense of medical necessity.” Jordan is equally adamant about preserving needle exchanges.
But Lungren has his allies, like Alameda County Sheriff Charles Plummer, a 47-year law enforcement veteran who asked Lungren for a needle-exchange opinion at about the same time as did the assembly-woman. As recently as 1994, Plummer was busting needle exchangers, in spite of the wishes of the Oakland and Berkeley city councils, both of which had issued San Francisco-style emergency declarations. Former Alameda County District Attorney Jack Meehan would then prosecute, even though many prosecutions ended in acquittals.
Mindful of his oath “to support the laws and the Constitution,” Plummer warned the police chiefs in Alameda County not to ignore needle laws, saying, “If they blatantly ignored that, than I'd send in the deputies and make the arrests.”
In conversation, Plummer is no foaming fanatic. Asked for his views on needle exhanges, he says, “What's wrong wiht it is it's against the law” and that he's “not convinced by the studies I've read that it prevents the spread of AIDS. It sends the wrong message.”
Plummer is more a legal dogmatist than he is a drug dogmatist: Ask him about pot, and he volunteers, “It's absolutely asinine to prohibit people who are in chemotherapy from having marijuana. They ought to be able to get a prescription and get what they need.”
“Laws really are like the old boxcar on the freight train,” Plummer adds. “They take awhile to catch up with the rest of the train,” adding that is the state legalized needle exchange, he would then enforce that law.
The origin of the term “harm reduction” can be traced back to 1992 in Northern Europe, where regarding drug addiction as a disease rather than a crime is more widely accepted. In Switzerland, addict populations are aggressively surveyed, treated, and counseled; at a last resort in the Netherlands, addicts are given government heroin. [page]
Stateside, harm reduction is the latest semantic tool in the war on the War on Drugs. As everyone in the abortion battle knows, it's image-enhancing to be for something, instead of against something: Pro-abortionists present themselves as “pro-choice” and anti-abortionists bill themselves as “pro-life.” Who can possibly oppose harm reduction? If you're against harm reduction, you must be for harming people, right?
Harm reduction marks the convergence of AIDS activism and the drug legalization movements. The closest the movement has to a leader is Arnold Trebach, president of the anti-drug-war Drug Policy Foundation in Washington, D.C., who says harm reduction starts with the assumption that a drug-free society is “impossible … [and] of you accept the presence of drugs [in] normal people, using drugs in a decent way, you blow apart the assumption of current policy.”
Trebach espouses the idea that if drug users are treated humanely. with counseling, contact with the medical system, and education, addiction-driven theft can be reduced, as well as emergency room admissions, jail populations, blood-borne disease, and overdose deaths. Harm reductionists advocate, for instance, that the medical establishment train drug users to do their dope after a welfare appointment, not before, so as not to be kicked off welfare. Once that habit is established, maybe you can talk about easing users into a methadone program.
Trebach wants addiction handled in a British fashion, with heroin addiction considered a medical matter between doctor and patient. He thinks injectable methadone for junkies would be a great idea, saying the dispensing of that heroin substitute “would be such a major step forward, the logical next step,” which sounds reasonable. But in the next breath, he says, things like, “Heroin is a perfectly good drug,” which to a drug warrior is the screech of nails on a chalkboard.
IDUs by the Numbers
Public health director Hernandez believes “unequivocally” that needle exchange and condom availability have lowered the infection rates for HIV, hepatitis B, and hepatitis C, and, anecdotally at least, the incidence of endocarditis (heart-valve infection).
Because IDUs live furtively in a criminal underground, measuring anything about their lives is a tricky business. But as best as anyone can determine, the rate of HIV infection in IDUs in San Francisco has hovered around 13 percent to 14 percent since the exchanges snuck into operation in 1988. This figure is substantially better than surrouding communitites that lack needle exchanges, especially heavily African-American cities like Richmond (26.4 percent) and East Palo Alto (31.9 percent).
A UCSF research team that studied the San Francisco needle exchanges put hard numbers to the question of the efficacy of needle exchanges and found that increases availability of clean needles reduced needle sharing “and the high rate of infectious disease transmission that accompanies this practice.” The findings, “Syringe and Needle Exchange as HIV/AIDS Prevention for Injection Drug Users,” was published in the January 1994 Journal of the American Medical Association.
The paper's primary author, John Watters, is a pyschologist whose interest in harm reduction came after years of working in the Massachusetts penal system, where he got to know a lot of cons and ex-cons. Listening to their stories, he says he gradually learned that two-thirds of the people behind bars were there for drug crimes – usually simple possession – and practically none had committed a crime against a person. These users were guilty of what Watters calls “utilitarian crimes” against property – i.e., stealing a car to finance their habit. Otherwise, they appeared to be normal people warped by a lack of access to heroin, needles, and health care.
Watters became convinced that imprisoning addicts was “cruel to these people, destructive to their lives” and those of their spouses and children.
“It struck me that this [imprisonment] was not only unnecessary and tremendously expensive to the Commonwealth [of Massachusetts], but ultimately self-defeating,” since it created a permanently or serially incarcerated population. This led Watters to harm reduction, and to an associate professorship at UCSF, where he teaches epidemiology and surveys addict populations to determine risk behaviors for hepatitis and AIDS.
The Watters paper is based on 5,644 surveys of needle-exchange clients conducted over a five-and-a-half -year period by the Urban Health Study (UHS), a San Francisco group that he chairs. UHS reports as estimated 13,000 to 16,000 IDUs in San Francisco, and has dedicated itself to surveying addict populations since 1985. Conducting what Watters calls “very open-ended, freewheeling interviews,” the researchers ask IDUs about their AIDS knowledge and HIV/AIDS risk behaviors, and get them to confide their medical histories and their drug-use histories, as well as their sexual histories.
One myth obliterated by the interviews: the notion of a needle-sharing “ritual,” as Bill Clinton's drug czar Lee Brown calls it.
“In our ethnographic studies, we didn't find evidence of a ritualized practice,” says Watters. “What people consistently told us was … they had to [share], they couldn't carry a syringe with them because they'd be arrested by the police. And it's a pretty big hassle to be sick in prison.”
Watter's group gathered enough baseline information on San Francisco's IDU population to examine the effectiveness of needle exchange. Additional questions were added to the interviews with IDUs through a fairly random process: Some would be proposed in formal meetings, some over a cup of coffee.
“We did realize that because we had studied IDUs before needle exchange started in S.F., we were in a really unique position to be able to look at some of the effects, whether positive or negative,” says Jennifer Lorvick, another of the paper's authors.
Watters' effort required intense, interminable data-crunching. The 5,600-odd UHS records were transferred to a data base and crunched by a mainframe at UC Berkeley, says Lorvick.
“It's a huge data set, and every step is time-intensive,” she says. “You have to create a clean set of data to work with.” [page]
The operation is analogous to weeding an overgrown meadow until it's bare of everything but ragweed, then asking questions like, “Do all ragweed plants grow near rocks of that size? Is that because of the rock, or something about the plant? And what's the sun got to do with all this?” This is the way scientists work – you can't assume the sun has anything to do with plant growth – and they've got to be skeptical about the questions they ask and the answers they get.
Watters, Lorvick says, “wanted to be very conservative [and] stick to the data. If [researchers] don't do that, they have no credibility.”
After months of statistical weeding, Watters and company's data showed that by fall 1990, survey respondents were reporting that they used the needle exchange more frequently than the black market or other sources. Those numbers held through spring 1992, at the end of the survey, when 45 percent of the respondents were “usually” obtaining their syringes from an exchange (32 percent relied on the black market and 23 percent used other sources like pharmacies, diabetic acquaintances, or friends).
“I think that probably the most important finding of the paper,” Lorvick says, “was the relationship between using the needle exchange and not sharing needles. That was the thing that just kind of popped out, like, Bang! There's our finding.”
The data-crunch also indicated that needle exchanges weren't “recruiting” new drug users, noting that the mean age of IDUs increased from 35.8 to 41.6 over the five-and-a-half years of Watters' study, and that the percentage of those saying they'd started injecting druges within the previous year dropped from 3 percent to 1.1 percent.
In one sample of exchanged needles, UCSF researchers found that 7 percent were HIV-contaminated. Extrapolating the data, the authors calculated that 3,600 infected syringes were removed from circulation in a single month in 1992, when Prevention Point was still unfunded by the city and operating illegally. The numbers have surely risen since then, though no one has the resources to conduct another survey.
It's anybody's guess how many infections were staved off by the needle exchange. What's clear is the dynamic and dangerous link between IDUs and the transmission of AIDS. In San Francisco, 9 percent of those diagnosed with AIDS were IDUs who engaged in same-sex sex, according to May 1995 statistics from the Department of Public Health. Through the middle of 1993, the federal Centers for Disease Control found that 24 percent of all diagnosed AIDS cases were among heterosexual IDUs. In 3 percent of adult AIDS diagnoses, the sole risk factor was having an IDU as a sex partner. And better than half of all pediatric AIDS cases were traced to IDU mothers or mothers whoh ad sex with IDUs.
The epidemiological moral is that a little needle exchange now saves a huge amount of money later. The lifetime cost to treat an adult San Franciscan with AIDS can reach $250,000, says Sara Kershnar of the San Francisco-based Harm Reduction Coalition group. Prevention Point's budget for distributing needles at nine sites was just $450,000 kast year. If needle exchange prevents as few as two cases of AIDS a year, the program has paid for itself – not to mention the other infections that it can help prevent. Complications caused by hepatitis B can require a lover transplant, which costs about $300,000.
It's clear by now that the smart money should be placed on preventing incurable infectious diseases. Without needle exchange, says John Watters, “Your tax bill goes up and your daughter gets sick, or your cousin or your nephew or your nephew's cousin.”