In the United States. AIDS first struck primarily homosexual men. but today the virus appears to be spreading most rapidly among intravenous drug users. In New York City, 34 percent of all people with AIDS have been heterosexual i.v. drug users, who presumably caught the disease by sharing needles and syringes with someone infected by the virus. Nationally, about one-fifth of the more than 36.000 AIDS cases have involved i.v drugs. An accurate estimate is probably double that, since many addicts’ deaths from tuberculosis, pneumonia and other illnesses are now being recognized as AIDS-related.
The figures on the extent of the AIDS crisis reflect patterns of transmission prevalent years ago. when the people who now have the disease were exposed to the virus. Then, sexual activity among gays, particularly anal intercourse. was the primary mode of transmission. Approximately 26.000 gay men have AIDS or have died of it. But as the gay community has become increasingly aggressive in promoting "safe sex," it has to some extent contained the spread of the disease. No comparable preventive action has been taken among i.v. drug users. An estimated 50 to 60 percent of New York City’s 200,000 to 250,000 needle-drug addicts have already been infected, and AIDS was their leading cause of death by 1985. Today, as an official at the Federal Centers for Disease Control told me, "Dirty needles are the way the virus is spreading."
Infected addicts, in turn, transmit the virus to their sexual partners, a process already responsible for the overwhelming majority of non-Haitian heterosexually transmitted AIDS cases. To an unknown extent, addicted prostitutes are spreading the virus to their clients as well. According to Dr. Harold Jaffe, chair of the AIDS epidemiology division at the Centers for Disease Control, "Infected drug users are the main portal of transmission to other parts of the heterosexual community, and their newborns." Dr. André Nahmias of Emory University said that nearly all of the AIDS-infected infants born in the United States, estimated at between 2,000 and 4,000 a year, are the offspring of i.v. drug users.
One AIDS expert told me that if the disease becomes another "black plague," shared injection equipment will "unquestionably" be the cause. Yet, as The New York Times has reported. "No effective attack has been mounted on the spread of AIDS by shared needles." Worse, in eleven states, including New York, the government plays an active role in perpetuating the disease by maintaining laws against the sale of sterile hypodermic needles and syringes without a doctor’s prescription. In Boston the street price of supposedly clean "works" (needle and syringe) has reportedly doubled since the AIDS epidemic began —"capitalism at its best," in the words of one angry participant at an anti-AIDS meeting there. A woman attending the same meeting asked, logically: "Why don’t they just hand out syringes? That’s the simple solution."
Indeed, the most straightforward government response would be, at minimum, to legalize the sale and possession of works in all states and, ideally, to distribute sterile works as widely as possible, with no involvement of law-enforcement officers, no questions asked and no strings attached. Much more tentatively, the National Academy of Sciences recommended "increased availability on an experimental basis of sterile needles and syringes to reduce sharing of injection equipment, a known mode of transmission."
But such programs have not been implemented anywhere in this country. The main reason appears to be politicians’ reluctance to take any action that could be mistaken for tolerance of illegal drug use. In New York City, for example, former health commissioner Dr. David Sencer "periodically" proposed needle distribution to Mayor Edward Koch. He was rebuffed until August 1985, five years into the AIDS epidemic, when Koch told Sencer. "If you don’t mind being the fall guy, why don’t you write a memo, and I’ll circulate it." He did, and though for Sencer the proposal was "just epidemiological sense." the result was that "everybody said, Yeech," especially the district attorneys and police. Koch rejected needle distribution as an idea "whose time has not come and, based on the response, will never come." Recently, New York City’s health commissioner, Dr. Stephen Joseph, finally proposed a small experimental program involving less than 1 percent of the city’s addict population. Despite the fact that AIDS has become the city’s leading killer of young men and women. New York State rejected the plan last month, ostensibly because the experiment was scientifically unsound. Dr. Lloyd Novick, director of the state’s Center for Community Health, said it would be "exceedingly difficult" for any plan to meet New York’s scientific standards. Meanwhile, the New York State Bar Association’s Committee on Medicine and Law has urged the state to legalize the purchase of needles and syringes without a prescription.
In San Francisco. Mayor Dianne Feinstein opposed her own health commissioner’s needle-distribution proposal so strongly that, according to a spokesman for Feinstein, "it’s really a dead option at this point." In New Jersey a needle-distribution plan proposed by Jack Rutledge, New Jersey’s deputy health commissioner, was to "include only proven addicts…provide education…and exchange clean needles for used ones." Yet the discussion was dropped in part "because of the fear that implementation would draw drug addicts from New York and Pennsylvania into the state." which the Health Department evidently considered a more serious problem than the rapidly rising number of AIDS fatalities. In Massachusetts an advisory panel told the Governor’s Task Force on AIDS that it had considered a free needle plan "exhaustively," but had dropped it because of expected political opposition, uncertainty about its effectiveness, and the "mixed message" it would purportedly send about drugs. Yet the panel itself conceded that 75 percent of the estimated 40,000 i.v. drug addicts in Massachusetts are not in any type of prevention or treatment program. Health Commissioner Bailus Walker Jr. said in March 1986 that such a plan "is not a proper role of government at this time,." even though an official of his own department, Dr. George Grady, had estimated that the AIDS epidemic might actually level off, at about 250 new cases annually, by the end of this year, if it were not for the spread by drug users.
The public response so far has been to urge addicts to enter treatment or use sterile works, even though neither is widely available. According to the administrator of New York City’s largest methadone center, which has a waiting list of 1,000, drug treatment programs there are reaching only "a drop in the bucket." The medical director of New Jersey’s AIDS program characterized the state’s drug-treatment operations as "overwhelmed." Prior to the Reagan Administration’s budget cuts of 1981. Methadone treatment was free in New Jersey. In 1980, 8,703 addicts enrolled in the program, but by 1984, when methadone treatment cost $50 to S170, only 3,075 became involved.
A few states, including New York and New Jersey, have hired former addicts to teach i.v. drug users how to avoid AIDS. New Jersey is distributing coupons entitling addicts to several weeks of free detoxification. In some cities, among them San Francisco and Chicago, addicts are being given bottles of bleach for sterilizing needles. Bleach can kill the AIDS virus in the laboratory, although its effectiveness in practice is unknown. Brianne Comella, of the AIDS Action Committee of Massachusetts, called bleach "a promotional gimmick," but said he hopes it will "drive the message a little better."
In Europe the situation is very different. The Netherlands began letting addicts exchange dirty needles for clean ones two years ago, initially to protect them from hepatitis B, a far less serious disease than AIDS. France recently legalized free needle exchanges in drugstores. Britain has approved a pilot program at ten to twelve centers, involving syringe exchanges tied to counseling In Switzerland, as in other Western European countries, the sale of syringes is no longer illegal. Besides Sweden, which as of mid-February reported fewer than one hundred AIDS cases, the United States is apparently the only affected Western nation to have taken no steps to make sterile works more available. As a Federal public health official told me, his European counterparts "simply cannot understand why the U.S. isn’t doing these things."
The most common argument against casing access to sterile works is that it would "encourage drug addiction," an unlikely thesis for which no evidence has been offered. As Dr. Mathilde Krim,. co-chair of the American Foundation for AIDS Research, sensibly observed, "Nobody is going to take an i.v. just because the needle is available." In the Netherlands, for example, no increase in i.v. drug use or in the number of new users has been observed since the introduction of the needle-exchange program. The public health officials and health providers I interviewed characterized the notion that clean works will stimulate drug abuse as "unlikely." "ignorant" or "ridiculous." But even if it were true, there is no comparison between the dangers of cleanly administered i.v. drugs—which, while real, are limited, can be escaped through treatment and are uncontagious—and those from AIDS , which is always fatal and can be spread to other users, sex partners and babies Where drugs are available, needles generally are; the only practical question fot public policy is whether they are to be clean or dirty. Few would openly support making intravenous use of heroin and cocaine capital offenses, but that is what withholding sterile injection equipment effectively does.
Another common objection is that there is no rigorous scientific evidence to suggest that providing fresh needles would make a big difference in the spread of the epidemic. But even a small difference, perhaps the saving of several thousand lives, would justify the effort. And, while much remains unknown, there is reason to believe that the availability of clean works could do far more, possibly saving tens of thousands of lives over the years Roger Staub, head of a private Swiss organization helping AIDS victims, said that his teams of volunteers "know that free syringes help to slow down the rate of infection," from their direct experience. "I am sure of this," he added. "Our policy is that every addict should have his own ivringe." Dr. Samuel Friedman, from Narcotic and Drug Research Inc., a private research company, told me that many Dutch addicts are using the clean works made available by their government and that the spread of AIDS to the general population in the United Slates "might be slowed down" by a similar program, "particularly if accompanied by training in how to avoid situations that might encourage sharing of injection equipment." A New York City public health official told me that people in his department familiar with addicts "say it would work, would save a significant number of people." This was confirnied by a physician’s assistant with long experience treating addicts in New York City, who said: "For the most part addicts understand the dangers of AIDS. They’re very frightened. A large percentage would not share needles if clean ones were easily available."
Health officials recounted the chilling story of one city in Europe where drugstores had been unofficially selling works to addicts. When the practice was halted by the police, the rate of AIDS exposure among addicts skyrocketed. A public health official in Texas, where needles and syringes can be bought in drugstores, told me what happened when some state legislators risked the same consequences there, by introducing bills to restrict the sale of injection equipment: "We [the public health department] said, Please. God, don’t do this." The bills were dropped. He said that the legal access to sterile works in Texas has "unquestionably" helped to prevent AIDS; only an estimated 3 percent of i.v. addicts have been exposed to the AIDS virus. He added that giving away works, which does not happen in Texas, "would help even more."
Another rationale for inaction was provided by a New York Times editorial last August. New York City, the editorialist wrote, "cannot…well afford the vast numbers of needles required" for large-scale distribution. Two pharmacies I contacted said that a complete set of works appropriate for i.v. drug injection retails for about 25 cents and costs about 20 cents wholesale. The New York State Health Department estimates that 30,000 New Yorkers, many poor, will die of AIDS in the next five years. Each case, according to the National Academy of Sciences, costs $30,000 to $150,000 to treat, suggesting an overall cost, for direct medical services alone, of about $3 billion. Assuming that about half the new AIDS cases in New York involve dirty needles, half that sum. $1.5 billion, could easily be invested in appropriate prevention, using The Times‘s businesslike logic. This would inundate the streets with 7.5 billion fresh works, or about 30.000 sets for each of New York’s quarter-million addicts. For $10 million—about $1 per resident—New York City could buy 50 million new works, enough to give every addict 200 sets.
The much more affluent, organized and otherwise healthy homosexual community heroically helped itself when no one else would. But the addict population has been unable to mobilize against the AIDS threat, though a fledgling organization of addicts, ex-addicts and sympathizers called ADAPT is making a start in New York City. The Federal government’s "just say no" approach is as unlikely to keep addicts from shooting up as it is to stop teen-agers from having sex.
Public officials could not permit addicts of a different drug, alcohol, to die by the thousands if a promising means of prevention were available. That is because alcoholism is now generally viewed as a disease that can afflict anyone and not a result of moral insufficiency. But there is profound contempt for addicts in our society, reinforced by racism, as they are primarily black or Hispanic and poor. As New York’s former health commissioner, Dr. Sencer rhetorically asked: "Who speaks for the drug abuser in this society? Who’s in favor of them?" Dr. George Annas, professor of health law at the Boston University School of Public Health, minced fewer words: "People just hate addicts. They’d just as soon all the heroin addicts got AIDS and died. They’re not going to come out and say that, but I think that’s an undercurrent."
Eventually the i.v. drug-using population will probably become saturated with the virus, as much of the gay community already has. Then, clean works might still be able to keep new i.v. users from being infected and may slow the course of the disease in other addicts, since for unknown reasons sharing needles appears to speed up its progression. As more and more heterosexuals get AIDS this way. the disease may well become self-sustaining among them.
The blame for this aspect of the AIDS scandal rests squarely with politicians—local, state and Federal—who have consistently rejected the warnings and proposals of their own health advisers. I found widespread sentiment in favor of the legalization or distribution of sterile needles, at least on an experimental basis, at the Centers for Disease Control, the National Institute on Drug Abuse, and state and city health departments in New York, Massachusetts and elsewhere. A Federal official in charge of one program for AIDS prevention told me in confidence that "some of us, those who consider ourselves scientists, consider that clean needles should be a part of the effort," and that resistance is coming "not from Public Health Service people" but from "the Attorney General’s office" and the "political people" at Health and Human Services. Another official summed up his private views more bluntly, "It’s probably criminal that they’re not flooding the streets with needles and syringes."
The only real hope, if it can be called that, is in the fact that dirty needles and syringes are ultimately putting not just junkies but the whole population at risk of AIDS. Eventually thousands of deaths in well-to-do society may force Federal, state and city governments to do whatever is necessary to slow the menace. The danger is that the response will be repressive; mass detention camps for drug users, and conceivably for homosexuals and bisexuals as well, is one possibility nervously mentioned by some who understand the magnitude of the AIDS-drug connection. It is clear that compassion for the dying is insufficient to produce serious action. Fear may prove a more powerful motive.