Needle Exchange Comes of Age
At the stroke of noon on a frigid late-winter Boston day, a dozen or so shivering men and women carrying a banner announcing themselves as the AIDS Brigade began to set up shop across the street from City Hospital. They intended to hand out clean needles to intravenous drug users, they said, and immediately a handful of hopeful syringe recipients lined up. "Let us save lives," the activists demanded, but immediately they were confronted by a band of noisy antagonists. What followed wasn't exactly a discussion of the public health benefits—which are well documented—of exchanging dirty needles for clean ones to reduce the spread of HIV. "Killers!" the opponents shouted. "How many AIDS deaths will your intolerance cause?" the AIDS Brigade members countered, as a single TV camera whirred and a couple of reporters scribbled notes. Some African-American community leaders from the predominantly black neighborhood of Roxbury, who have long opposed the AIDS Brigade's tactics, were also taking notes.
Just then Jon Parker, founder of the AIDS Brigade, made his entrance. Parker was carrying cardboard boxes filled with hundreds of used, and maybe HIV-contaminated, needles that he had collected from the streets of Boston. His intention was to hand these syringes over to the city in order to embarrass public officials out of their inaction. At that moment two telegenic policemen, who had been quietly standing by, made their move. The boxes of needles were seized and stowed in the trunk of the police car, and Parker was led away, unresisting. He has been arrested dozens of times since 1986, when as a public health student at Yale he began his crusade to get clean needles into the hands of addicts.
Meanwhile, more than a hundred needle-exchange advocates were convening for the North American Syringe Exchange Convention across town at the Government Center Holiday Inn. The talks were studded with street-smart colloquialisms and drug lingo, Clusters of syringes were pinned on lapels as ersatz boutonnieres; tie-dye and jeans were the sartorial order of the day. The session's organizer, Dave Purchase, who effectively launched the needle exchange movement five years ago when he set up a TV tray on the streets of Tacoma, Washington, looked like a shambling bear. Cigarette smoke hung thick in the anteroom adjacent to the meeting hall, mute testimony to the fact that addictions can be hard to beat.
Yet for all its countercultural style, the Boston gathering signaled something very mainstream: Needle exchange has come of age politically. The research to back this approach to AIDS prevention has been accumulating for some time. In the late 1980s, studies from several locales—notably Amsterdam, Sydney, Edinburgh and southern Sweden—showed markedly lower increases in HIV infection rates among addicts who exchanged dirty syringes for clean ones. In 1991, confirming research was reported in Tacoma, the first American city to adopt such a program, and in New Haven, where Yale University scientists have been conducting perhaps the most analytically sophisticated efficacy study. The research has rebutted narcotics officials' fears that such a venture would encourage people to try heroin.
Now other American communities are getting the message. Since 1990 the estimated number of I.V. needles swapped in the United States has more than tripled, to nearly 4 million annually. An impressive array of locales that operate, or at least tolerate, exchange programs sent representatives to Boston, among them New York City, the epicenter of the drugs/AIDS pandemic; New Haven; Philadelphia; Chicago; Seattle; San Francisco; Hawaii (where a statewide program is running); and smaller cities and rural outposts like Boulder, Colorado, and Wyndham, Connecticut.
There were dispirited accounts from Providence and Rochester, where activists have unsuccessfully tried to launch programs; but the feeling was that in these cities, success was just a matter of time. And although there were tales of failures from places like Indianapolis, where the one-man underground operation run by a renegade Public Health Department employee is out of funds, these were the conspicuous exceptions.
Jon Parker made an appearance at the convention the morning after his arrest, but the featured speaker was a quintessentially establishment figure, Dr. Jonathan Mann, who during the 1980s ran the World Health Organization's much-praised AIDS initiative. Mann is now the Francois-Xavier Bagnoud Professor of Public Health at Harvard.
Several legislators threw a reception for the group at Doric Hall in the Massachusetts State House. Boston Mayor Ray Flynn added his welcoming words: "As you know, Boston has been a national leader in the effort to...remove the legal barriers that prevent [drug users'] access to clean needles.... In 1987, our early efforts led Boston to become the first city in the United States to approve the development of a needle/syringe exchange program."
Yet the Mayor added that needle exchange remains illegal in Boston, since the Massachusetts law that prohibits the possession of hypodermic needles without a prescription is still on the books. When legalization was first proposed, in the midst of Michael Dukakis's run for the presidency, the Governor wasn't about to endorse this kind of social experimentation, so the idea died. Half a decade later, it's only at Parker-orchestrated performances—and in the far more effective efforts quietly being made by a group that calls itself the I.V. League—that syringes are being swapped in Boston.
But 1993 looks like a watershed year for needle exchange. With new political backers, including Republican Governor William Weld and black community leaders, syringe exchange will probably be authorized in the Bay State. Elsewhere, notably in California and Pennsylvania, conservative governors are coming under renewed pressure to legalize needle exchange. The Mayor of San Francisco, himself a former police chief, is defying the Governor's edicts; he has just announced a public health state of emergency and is backing up his words wlth city money for syringes. Within the Clinton Administration there is support for this public health initiative, and that too represents a major shift.
During the late 1980s, when almost no American politician would take needle exchange seriously—and when many powerful black leaders were savaging the idea as a genocidal plot aimed at African-Americans—confrontation seemed the only way to get anyone to pay attention. But that time has passed. Parker's public performances convince no one anymore; they just stiffen the opposition's resolve. The real reason change is occurring is that, both in government offices and in the trenches, the parties involved are talking to, rather than past, one another.
This shift in mood was evident at the Boston convention, where one remarkable session brought together the leading players in that city's drama. "I remember that In the 1970s we were going to be saved by methadone," said Ellarwa Gadsen from Women, Inc., which helps addicts kick the habit. Gadsen was one of those taking notes at Parker's street scene. "We were going to rescue addicts and the inner city. But when the money was withdrawn, the methadone stayed but the help was gone." Gadsen acknowledged that needle exchange was likely to occur, but she was pushing for a program that guaranteed not just a syringe but drug treatment to anyone who wanted it. "In the year 2000, I don't want to see a dispensing machine for condoms and needles."
Pedro Muñoz, an AIDS activist on the other side of the issue, had his own memories to recite. "I remember going to pediatric AIDS wards and seeing all those children. I remember going to too many funerals of people who have died from AIDS." Blacks and Latinos had to help themselves, Muñoz added, making a point that drew general concurrence. "When Jon Parker walked into our community and told us, 'This is what you need,' he totally disrespected people of color."
Such a public give-and-take could never have happened a year earlier. Then, Boston's ethnic leaders seemed hopelessly dlvided, and the splits played into the hands of opponents. But many of these convention panelists had been quietly meeting for months to hammer out a compromise on needle exchange. Initially, advocates of exchange like the I.V. League insisted that the only "community" they acknowledged was the community of drug users. For their part, treatment proponents like Ellarwee Gadsen and Lawrence Robinson were fearful that needle exchanges would be boosted as a quick, cheap fix. "AIDS groups don't realize that in the minority community, AIDS is not the blggest concern; drugs and crime are the real focus," says Robinson. Yet over time, these opponents began to be swayed by the data from New Haven—and by the frank recognition that, since something was likely to happen, they were better off having a role in the new venture than merely nay-saying. Recently they signed off on a set of guiding principles, among them that drug treatment had to be part of the package and that any affected neighborhood was entltled to participate in deciding how the exchange program would be run.
The core principle is as profound as it is obvious. As Dr. Alonzo Plough, the city Health Department official who has patiently kept the old antagonists talking to one another, said, "The point is to save lives." Rhoda Creamer from Project Trust, which does HIV testing, made the same point more graphically: "We're all talking up here. I see a casket down there.'' In most of the industrialized world, clean needles are as readily available as aspirin—part of a broader public health initiative to lessen the harm done by AIDS and drugs. By not endorsing needle exchange, the United States has fallen behind in this aspect of the international war on AIDS.
The events in Boston, both at the convention and in the behind-the-scenes political negotlations, suggest that it is time for a new strategy. It's the right moment, as a matter of policy and politics, for the United States to pronounce this syringe-exchange experiment a success and get on with implementing a program of delivering clean needles—and treatment—on demand.