It is hard to believe that there is so much resistance against the distribution of this inexpensive collection of items—the contents of "kits" distributed by Needle or Syringe Exchange Programs (NEPs and SEPs). Public health officials, AIDS researchers and activists involved in harm reduction are all in accord—NEPs save lives, reduce the transmission of HIV and Hepatitis C, and save millions of dollars in health care costs (from the NEPs and SEPs website):

In order to understand the challenges faced in confronting this resistance, we need to explore recent legislative reversals as well as public attitudes about drug use, and the specific stigma attached to IDUs.

Des Jarlais, who is a coauthor of that report, says needle exchange programs in New York City have reduced HIV infections to about 150 a year out of 150,000 injection drug users. "That is very, very close to zero," DesJarlais says, pointing out that most of the remaining infections may be due to sexual transmission, not needle drug use. At the peak of its drug-related HIV epidemic, New York City had about 13,000 new infections a year among injection drug users. There are about 200 needle exchange programs in the United States, he says. Congress has barred federal support of needle exchange, largely in the belief (never proved) that providing clean needles increases illicit drug use. This spring there was an attempt by some in Congress to prevent the District of Columbia from using nonfederal funds for needle exchanges. Washington has the worst HIV epidemic in the nation, and much of it is driven by injection drug use.

A study at the Washington AIDS conference shows HIV incidence among injection drug users in Amsterdam has fallen to almost zero. "We conclude that drug users no longer play a role in the HIV epidemic in Amsterdam," researcher Bart Francis Xavier Grady told an audience at the AIDS conference. Another study, presented by Trang Nguyen of Johns Hopkins, calculated the costs and benefits of expanding needle exchange programs in the United States. She says a 10 percent expansion — at a cost of $64 million a year — would prevent 500 HIV infections among U.S. drug users. The savings, from not having to provide HIV treatment for that relatively small number of people, would be $193 million.

I worked at a research agency with Don Des Jarlais who is cited in this NPR report :

I have lived in communities with high injection drug use, have lost close friends and former partners to AIDS which they contracted via unsterile syringe and paraphernalia sharing.

Harm reduction programmes aim to reduce the negative consequences of drug use, by reducing the harm self-inflicted by the user through unsafe practices and the harm inflicted upon society. The provision of needle exchanges and other harm reduction measures, however, is generally poor, and opposition to them is impairing the fight against HIV.

Needle exchange programmes are one of the main harm reduction measures that aim to curb the spread of blood-borne viruses such as HIV and Hepatitis C among injecting drug users (IDUs). With an estimated 1 in 5 injecting drug users worldwide infected with HIV and 30 percent of HIV infections outside sub-Saharan Africa resulting from injecting drug use, such programmes are key to bringing the global epidemic under control.

Kaiser (2011) data lists 221 NEPs operating in 33 states plus the District of Columbia.

Groups like the Harm Reduction Coalition have been successful in getting these states to allow needle exchange, but the major obstacle currently is at the federal level.

SEP Federal policy history:

In 1989, a policy rider added to the Labor Health

and Human Services Appropriations Bill banned the use of federal

funds for SEPs, stating that “No funds…shall be used to carry out any

program of distributing sterile needles or syringes for the hypodermic

injection of any illegal drug.” In 2009, Congress ended the ban by

allowing local communities to use federal funds for syringe exchange

provided that local law enforcement and health authorities did not deem

a site “inadmissible.” In December, 2011, the Labor, Health and Human Services

Appropriations bill reinstated the obsolete pre-2009 ban on use

of federal funds for SEPs without any scientific basis.

Statue of Sherlock Holmes in Edinburgh

In order to understand legislative roadblocks, we first have to confront societal attitudes surrounding drug use and addiction, which may be changing toward marijuana, but have not lessened toward IDUs—who are labelled "junkies."

Ironically, the famous literary character created by Sir Arthur Conan Doyle, "Sherlock Holmes," was an addict andinjected cocaine and morphine.

Sherlock Holmes took his bottle from the corner of the mantel-piece and his hypodermic syringe from its neat morocco case. With his long, white, nervous fingers he adjusted the delicate needle, and rolled back his left shirt-cuff. For some little time his eyes rested thoughtfully upon the sinewy forearm and wrist all dotted and scarred with innumerable puncture-marks. Finally he thrust the sharp point home, pressed down the tiny piston, and sank back into the velvet-lined arm-chair with a long sigh of satisfaction. "It is cocaine," he said, "a seven-per-cent solution. Would you care to try it?"

– Arthur Conan Doyle, The Sign of Four (1890)

The fictional Holmes character—aristocratic, intellectual, white and a force for justice, is the antithesis of what is now the stigmatized, criminalized, sinful (and often racialized) "junkie."

Novel by American beat generation writer

William S. Burroughs, published initially under the pseudonym

William Lee in 1953

In his case for legalizing heroin Jeffrey Rogers Hummel details the historical background in the shift to criminalization.

What group of currently illegal drugs did affluent, middle-age women in 19th century America widely favor? What drugs were also used in teething syrups for babies and as a cure for alcoholism? And what drugs were banned, not because of any demonstrated health hazard, but because of a congruence of special interests and anti-Chinese racism? And what drugs were first banned by the national government, not as a result of any conditions in this country, but in response to obscure international events occurring half way around the globe nearly a century ago? The answer is the opiates: heroin, morphine, and opium.

Over time, heroin and cocaine use and injection became associated with deviant, anti-social behavior, beatniks (William Burroughs), jazz musicians (see Shirley Clarke's "The Connection") and blacks, and criminalization began the process of the war on drugs becoming a war on people, particularly those in communities of color.

Hollywood played a role in the junkie stereotyping, with films like The Man with the Golden Arm and The Panic in Needle Park. International films followed, like Trainspotting.

Conservative religious groups contribute to the shaming and definition of drug use as sinful. They are self-righteous in the casting of stones. From my perspective, if anything is "immoral," it is our current drug laws.

Today's abscess riddled, track-marked, petty-thieving, walking skeletons seen emerging from shooting galleries, or wandering the streets looking to "cop," are a far cry from Sherlock Holmes. As a society we have created the problem, and as long as drug use and addiction are viewed and treated as sinful, shameful, immoral and criminal, the toll on users and society will be weighty.

Syringe exchange is only one segment of a broader harm reduction strategy, which I will explore at a later date.

If you have an hour to spare at some point, I encourage you to watch the following documentary. It will give you a better picture of what we face in the battle for harm reduction, from the perspective of all of those concerned with this issue.

To Do No Harm

"To Do No Harm" deftly examines and uncovers the personal, racial and sociologic bias against addicts. Resistance to the concept of Injection Drug Use (IDU) as a disease or public health issue that continues to color the perception of many American citizens. The documentary gives viewers an inside look at the four legal state-mandated Needle exchange sites in Boston, Cambridge, Northampton and Provincetown. Since their inception, the Department of Public Health of the State of Massachusetts has been unable to acquire the necessary permissions from local governments to open a fifth site anywhere in the state. This has been at least partly due to a lack of education surrounding the merits of harm reduction techniques when employed to combat the strong connection between drug addiction and the spread of HIV. "To Do No Harm offers a harrowing and sobering journey into the lives of intravenous drug users, needle exchange activists, and political and civic leaders working to promote harm reduction philosophies here in America," said Mark W. Baker, ASGCC Executive Director. "Aside from highlighting Needle Exchange Programs, this work provides insight into the relationship between the employment of Harm Reduction strategies in reducing the risk for several other public health problems like Hepatitis C and HIV."

To Do No Harm – Part 2







To Do No Harm – Part 3







To Do No Harm – Part 4





