|HIV/AIDS & HCV|
|Written by Ernest Drucker|
NEW YORK, Through the Eye of the Needle
Notes from THE DRUG WARS
by Ernest Drucker
Executive Director, Drug Treatment Services, The Monefiore Medical Center, New York
Dealing with addiction in the United States is a bit like disarming an explosive device - ignorance can be fatal. And, even with great skill and sophistication, one slip or clumsy move can lead to the whole thing blowing up in your face. Take, for example, New York's experience with a needle exchange pilot program aimed at restricting the spread of AIDS. The definitive research establishing the role of shared needles in spreading HIV infection among IV drug users, has been done in New York City. Here, millions of public dollars were spent to support large studies which carefully counted the number of times drug users shared their needles and syringes, where and with whom they did so, and the relation of this behavior to AIDS risk. New York is also the home of neighborhood "shooting galleries", where needles are shared by hundreds. Shooting galleries have been directly linked to the rapid spread of HIV and appear to prosper where possession of needles and syringes are most vigorously prosecuted and where the punishment for carrying such a paraphernalia" is harshest.
Yet, in one of the great ironies of America's war on drugs, every attempt to turn such research into public policy has encountered enormous hostility. And nowhere is this resistance more dramatic than in New York City where about 50% of 200,000 IV drug users are already infected with the AIDS virus - over 100,000 people - of whom at least 10,000 have already developed the full-blown disease and 5,000 have died. In the midst of such carnage, one would expect an atmosphere of alarm, and a willingness to try almost anything. But, in fact, the reverse is true, and New York seems incapable of doing anything to alter the situation. Not that the City is without resources. There are 40,000 drug treatment "slots" available in New York - 35,000 of these for long-term Methadone maintenance. Yet, even this huge clinical apparatus, in place since the early 1970's, has failed to stem the spread of the AIDS virus among the City's drug users. In large part this is because most of the infection of IV drug users occurred here between 19761984 - before there was any real public awareness of the risk. But it is also due to the widespread use of cocaine which has flooded New York since 1980. Seizures of hundreds of kilograms by United States customs and local police have now become commonplace. However, these represent only a small fraction of the total supply of the drug which becomes more readily available at ever lower prices. During this period, IV heroin users, who had always injected cocaine - usually in combination with heroin, as a speedball" - flocked to the drug. New, more lucrative markets in the professional, business and entertainment worlds, brought a significant increase in the availability of high quality cocaine for the old junkies, who had established their place in distribution networks. And cocaine itself (not generally viewed or described as addictive) took on a new upscale cachet the drug seemed almost respectable. By the mid 1980's, cocaine, once considered the "caviare" of drugs, had become a street staple from Harlem to Wall Street.
The older cohort of New York's 200,000 IV heroin users had, for the most part, greatly reduced their injecting prior to the influx of cocaine. But now, as a consequence of this change in their access to large quantities of pure cocaine, there was a sharp increase in the frequency of injecting and the sharing of needles and syringes by this group. The wide availability of Methadone had elevated heroin users' tolerance levels for opiates making it hard to get high on doses of heroin that the average street addict could afford. But Methadone has no effect on cocaine - a much shorter-acting drug usually used in "runs" or binges. This is a very different pattern from heroin where one injection will "hold" the user for 3-12 hours, depending on the size of the habit. Now, it was not uncommon for addicts to shoot cocaine scores of times in a day and for as long as their cash held out. The association of HIV infection with IV cocaine use and attendance at shooting galleries in New York became well established by early 1986. And the recognition of this pattern heightened interest in possible ways to reduce needle use and limit needle sharing among IV drug users e.g., needle exchange programs.
As early as 1985, the New York City Department of Health had attempted to institute a needle exchange program of some sort. The' initial proposal was made by the Health Commissioner at the time, Dr. David Sencer, a seasoned public health officer and epidemiologist who formerly headed the Federal Centers for Disease Control (CDC) in Atlanta. But there was an immediate chorus of protest from the law enforcement community, especially from the City's District Attorney's offices, and New York Mayor Ed Koch refused to support the plan. Dr. Sencer left the job shortly thereafter and was replaced by Dr. Stephen Joseph who began to advocate for a needle exchange in modified form - as a pilot experiment for those on a waiting list to get into New York's overcrowded drug treatment programs.
In the absence of any clear evidence (at the time) of the effectiveness of needle distribution and exchange schemes in Europe, a pilot project seemed both scientifically and politically more palatable. In the proposed experiment, 200 addicts awaiting entry to treatment would receive specially marked syringes and an ID card (to insulate them from arrest and prosecution for possession of injecting apparatus) as well as AIDS education and referral to drug treatment programs. A control group would receive AIDS education but no works. Outcomes to be measured would include: enrolment and retention in the pilot; AIDS knowledge and changes in risk behavior; self-report of sharing practices; the appearance of multiple blood types in the returned syringes; and the success of this approach in holding onto addicts till they could be placed in treatment.
This "experiment" was instantly assailed by all of its former critics in law enforcement. But now, in addition and more strongly than ever, by some of the leading Black political figures of the City who called the scheme "genocidal". Charles Rangel, U.S. Congressman from Harlem and the powerful head of the House Select Committee on Narcotics, joined a dozen other Black political leaders in calling the plan "a recklessly dangerous experiment" that would legalize, condone, and encourage intravenous drug abuse". In an apparent reference to the infamous Tuskeegee studies" of the 1930's and 40's, (in which treatment of Syphilis was withheld from poor Southern Blacks by public health officials in Alabama), Benjamin Ward, the Black Police Commissioner of New York City, objected to a needle exchange experiment where doctors (would be) conducting experiments against Blacks". Hilton Clark, a prominent City Councilman from Harlem (and son of Professor Kenneth Clark - the psychologist who had framed the psychological argument for the Supreme Court case which ended legal segregation of U.S. schools), said Health Commissioner Joseph should be arrested for murder and drug distribution". And Sterling Johnson, the City's Special Narcotics Prosecutor (also Black) vowed to fight the plan with "every breath I take" .
The political timing and context of New York's experience with a needle exchange program is important to understanding this reaction. New York City's eleven year incumbent Mayor Koch, faces a hard re-election struggle as he reaches for an unprecedented fourth-term in 1989 in the midst of disclosures of widespread corruption in his administration. The hottest political issues in New York City are drugs and increased crime (which are seen as closely related), and in a city with 50,000 highly visible homeless people, the growing disparity between the City's rich and poor- a disparity that is highly correlated with race and ethnicity.
Sensing the lines of the battle, the City's newspapers began to take sides. The elite New York Times supported the "experiment" and Mayor Koch's view that this was "a medical matter, not a law enforcement matter". But the more proletarian Daily News opposed the plan, saying it would be San act of surrender in the war on drugs" and called for the Health Commissioner's removal if he refused to back off. The needle exchange experiment would never work, said the Daily News, because it relies on the reports of unsworn, untreated, and unreliable dope addicts". The Amsterdam News, a weekly from Harlem, called instead for increased law enforcement to prevent a breakdown of law and order in minority communities" from journalism to political advocacy (or incitement to riot) by providing the street addresses of the two proposed needle distribution sites in Manhattan (heretofore undisclosed) so that the people in the vicinity would not sit quietly by while addicts waltz or slither in to pick up free needles". The Mayor ordered the Health Commissioner to abandon his plan to distribute needles in these two community sites, both of which, critics argued disingenuously, would have been within 1000 yards of school (as would almost any location in a residential community of New York).
Instead, the pilot program was drawn into the bosom of the Health Department's headquarters at 125 Worth Street - close to City Hall, Police Headquarters and the main criminal courts. Despite this accommodation to critics, the New York City Council voted 31 to 0 (in a nonbinding resolution) to cancel the needle exchange program, declaring that the City was sending the "wrong message when it distributes free needles to drug addicts while we are trying to convince our children to Say No to Drugs".
Clearly, this "debate" is not just about needles or even about AIDS. Rather, it reflects the City's growing impatience with its drug problem and a new and ominous hostility to the drug user and his condition. There is a sense that New York is held hostage. The drug user is blamed for the City's soaring crime rate and the escalation of violent crimes - up 20% - 30% in the last year.
The year 1988 set a new record for murder in New York City- 1,850 murders by Christmas Day, five per day - one every 4.5 hours. Forty two percent of these are reported to be "drug- related" by New York City police. The cocaine trade seems central to this massive escalation of mayhem. This drug, especially in the form of Crack, seems to be an agent for provoking individual acts of violence in the user. In addition, because of the huge new street markets it has created, Crack stimulates increased territorial warfare among drug user-dealers and their networks of local suppliers.
The prevalence of cocaine use in New York is phenomenal. A three year study sponsored by the National Institute of Justice found that 84% of all those arraigned for felony crimes in New York City tested positive for cocaine, even after excluding those cases with directly drug-related offences - e.g., possession and sales. These figures, double since 1985-86, are echoed (albeit at lower levels) in a dozen other U.S. cities and have attracted wide comment as evidence of the pervasiveness of cocaine (especially Crack) and its close ties to violence and patterns of criminality.
Coupled with disappointment in current approaches to drug treatment, especially Methadone, and its inadequacies in dealing with cocaine, the mood has turned ugly. While there is talk of expanded drug treatment, no additional funds are forthcoming and most communities oppose the establishment of treatment programs - especially on their block. Although New York City is facing a budget deficit of hundreds of millions of dollars, Mayor Ed Koch said we will spend whatever it takes to win the war on drugs and asked for $120 million more for narcotics police. The problem of AIDS has only fanned these flames and increased antipathy towards the addict.
In this highly charged atmosphere, the attempt to conduct a modest public health experiment in AIDS risk reduction by instituting a pilot needle exchange program is probably doomed to failure.
Elsewhere in the United States, a small needle exchange project has successfully begun in Tacoma, Washington and another is close to starting in Portland, Oregon. But these are cities with small numbers of drug users, very low prevalence levels for HIV among them, and none of the super-heated drug war climate of today's New York. Indeed, these pre-AIDS zones may be the only areas in the United States in which such schemes can function. But in New York, five months into the needle experiment, the pilot has, so far, attracted only about 90 participants - not surprising when addicts have to find their way to the main office of the City Health Department in downtown Manhattan - a site all-but- inaccessible to most of the addict population in Brooklyn and the Bronx, and formidable in it's bureaucratic trappings.
Its a lot easier to buy clean works on the street for $2-3 dollars - a market fed by the recent theft of 250,000 needles and syringes from the City's Bellevue Hospital.
In a final irony, exactly seventy years ago this month (April), this same location on Worth Street was the site of an earlier confrontation between law enforcement and a public health approach to addiction. Beginning on April 10, 1919, New York City's Department of Health was home to the City's first drug treatment program in which over 7,000 addicts received heroin or morphine in daily doses to be tapered off over several weeks or months. It is estimated there were about 20,000 addicts in New York City at the time. The law enforcement apparatus of that day, supported by the restrictive Harrison Narcotics Act of 1915, managed to close down that program within two years and, in New York and elsewhere in the United States, to imprison some doctors who tried to treat addicts. It was almost 40 year before American medicine would again show any serious interest in addiction, an 50 years before another public health program to treat addiction - Methadone maintenance - would again be inaugurated in New York City.
Drug addiction is, among other things, a chronic disease. But it is still not seen that way in the United States or in most of the world. The story of New York's needle exchange is simply another version of the enduring denial of this perspective. This time however, the long war on drugs has a new combatant AIDS - a global power with little regard for the local politics of the moment. By withholding needles from drug users in the midst of the AIDS epidemic, we still withhold acknowledgement of the disease status of addiction.
But now, in a particularly perverse tactic of New York's war on drugs, we also delay effective intervention long enough for AIDS to finish the job it has already begun here with such devastating efficiency.