By Jacqueline Marino; photos by Susan Adcock
Ron Crowder smoked heroin for the first time while he was in Vietnam. When he came home to Nashville in the 1970s, he found the locally available heroin too weak for his needs. To satisfy his addiction, he had to start injecting the drug into his bloodstream. He continued doing so, sometimes several times a day, for the next two decades. Crowder sustained his heroin habit in local ”shooting galleries,“ sketchy apartments in South Nashville. He only needed one of two tickets for admission: money or dope.
Junkies would scoop up discarded syringes off the floor, Crowder remembers, rinse them with water (which isn’t sufficient to kill blood-borne diseases), and then resell them to other users, as if they were new. If users didn’t want to buy needles, they could always share. Even after AIDS became endemic among intravenous drug users, many didn’t start bringing their own syringes. The disease was scary, but it wasn’t scary enough to make them change their behavior.
During his last three years as a junkie, Crowder made his living in the shooting galleries. Although he had a bachelor’s degree in accounting, by the late 1980s he was no longer employable. To feed his addiction, he committed petty crimes and tested heroin for dealers.
It was in jail that Crowder found out he was HIV positive. Although he says the diagnosis was devastating, it wasn’t enough to make him change his lifestyle. He went back to the shooting galleries, back to using heroin, back to sharing needles. Most of the time, he didn’t tell other users he was HIV positive, but now, years later, he’s convinced that it wouldn’t have made a difference.
Crowder, now 45, quit using drugs in 1991. As a case manager for Project COPE, an outreach and education program based at Meharry Medical College, where he works with African American intravenous drug users and their sex partners, he has no trouble recalling his time in the shooting galleries.
”Those people would have used my needle anyway because they wanted to get high,“ he says. ”It’s the nature of being an addict. They use to live and they live to use. I’m not a Harvard graduate, but I knew the risk of being infected, and I still shared needles.
”Sometimes I’d clean them and I’d forget if it was this one that was used, or that one. People will go through $500 worth of dope and won’t buy a dollar syringe.“
From 1992 to 1996, 1,180 Davidson County residents tested positive for HIV. According to the Nashville and Davidson County Health Department, 33 percent of those people say they contracted the disease by injecting drugs. But the actual percentage may be higher, since many drug users lie and claim to have been infected by some other means. Nationally, one-third of new HIV infections occurred in intravenous drug users, their children, and sex partners.
In some East Coast cities, injected drug use has become the most common mode of HIV transmission. The Metro Health Department’s statistics indicate that, locally, the majority of HIV-positive people contracted the virus through sex. But with the reported increase in heroin usage in Nashville, intravenous transmission of HIV is thought to be on the rise.
Local AIDS service providers overwhelmingly support needle exchange programs as a bona fide method of prevention, as long as they’re administered properly. In other cities such programs allow intravenous drug users to trade their used syringes for sterile ones. Proponents say exchange programs link drug users to the health-care system. In addition to providing clean syringes, outreach workers also supply users with information about safer sex, provide access to HIV testing, and refer them to drug treatment and other services.
Joe Interrante, executive director of Nashville CARES, an agency that provides AIDS service and education for Middle Tennessee, says the implementation of a successful needle-exchange program boils down to ”a question of strategy and logistics.“ But he adds, ”The evidence is pretty clear. It works.“
Anne Maier, executive director of the Comprehensive Care Center, an outpatient treatment center for people with AIDS, says about 30 percent of the center’s patients are intravenous drug users.
”I know there’s a lot of controversy about [needle exchanges],“ she says. ”But there are reports out there now that show it stops HIV transmission. Anything we can do to stop that is worth it.“
Like other AIDS services providers, Interrante and Maier emphasize that reliable funding and widespread community support are essential to make any needle-exchange program work. And yet Nashville has no government-supervised program of needle exchange. In 1996, in fact, the Health Department withdrew a request for Metro Council to accept a $28,000 grant from the Washington, D.C.-based Drug Policy Foundation. The grant was earmarked for the implementation of an exchange program.
While Council was considering the grant, radio talk show hosts like Dave Macy of WLAC expressed their disgust over the prospect of the Health Department distributing free needles to drug addicts. ”It may save lives, but people are killing themselves every time they put drugs in their system,“ Macy says now. ”If they are using drugs and have gotten themselves into that lifestyle, they’re probably better off if they die.
”You save lives [with needle exchanges], but what are those lives like? How valuable are they?“
To this day, George Armistead, the Council member-at-large who led the charge against accepting the grant, says he still opposes giving clean needles to drug addicts because it’s ”like giving bullets to robbers.“
Sensing that public opinion might have swayed the already less-than-supportive Council, Health Department director Dr. Stephanie Bailey decided to avoid bringing the issue to a vote altogether. Bailey had become a firm believer in needle-exchange programs after a pilot program in Metro had yielded positive results. (In that program, more participants than expected had gone into drug treatment, even more than the national average.) ”I wasn’t going to let anything keep us from doing a needle-exchange program in Davidson County,“ Bailey says. ”We put all the statistics in front of them and we still had a verbal minority that made such a debacle of it.“
But Bailey also feared Council might vote to return the grant because Armistead and several other Council members were protesting that a needle-exchange program would encourage drug use. ”I didn’t want to put it to the test,“ she says.
Faced with a dilemma, Bailey transferred the needle-exchange program grant to the Metropolitan Interdenominational Church, which was already providing some services in Nashville’s housing projects and other areas where drug use is prevalent. Joyce Perkins, a long-time AIDS activist who worked in underground needle-exchange programs in New York City a decade ago, coordinates the Harm Reduction Program. The church began operating the Davidson County Harm Reduction Program last July. Since that time, the program has distributed about 10,000 syringes.
Other programs exist in the drug underground of shooting galleries, where there is a black market for needles, but the Harm Reduction Program has open support from the Metro Health Department and from some religious leaders. That makes it the most mainstream needle-exchange program in the city, and probably the state. Not only do volunteers distribute clean syringes on the street, they also provide addicts with ”home deliveries“—kits of clean syringes, cotton, cookers, and the other paraphernalia they need to get high without exposing themselves to HIV and other blood-borne illnesses.
The outreach workers also offer condoms and information to the program’s participants, if they request it. ”It’s not, åHere’s a needle. Come to treatment,’ “ Perkins says. But that’s what she hopes happens. About 40 participants have accessed drug treatment since July.
Still, needle-exchange advocates say the existing program doesn’t fill the need for clean syringes in Nashville. You won’t see this service advertised, and unless you do intravenous drugs, the organizers of this program don’t really want you to know about it. According to Metro Police Department spokesman Don Aaron, unless they are required by a medical condition, it is illegal to possess hypodermic syringes in Nashville. That is one of the main reasons Nashville’s Harm Reduction Program, like needle-exchange initiatives in many other cities, has kept a low profile. There is no advertising or promotion aside from word of mouth. Even the words ”needle exchange“ were deliberately excluded from the program’s name.
To one reporter who called the Metropolitan Interdenominational Church pretending to be a drug user, the needle-exchange program’s modus operandi bore a striking resemblance to a drug deal. Over the telephone, the church gave him a pager number to call. He was told to page an outreach worker who would meet him somewhere with clean syringes.
Most participants, it seems, do not call in. Outreach workers drive a city-supplied van, or their own vehicles, to drug-infested areas, both in the inner city and in outlying areas. They also do ”home deliveries“ and provide needles to people on an as-needed basis. Some outreach workers strike out on their own, blending into the inner-city neighborhoods and attempting to penetrate hard-to-reach groups of intravenous-drug users. Ron Crowder, serving as a volunteer, still visits the galleries. Not to shoot up, but to deliver clean needles.
One former intravenous drug user credits Crowder for helping her kick her six-year cocaine addiction. Unlike Crowder, who started out using heroin, Jan (not her real name) progressed from alcohol to marijuana to cocaine. She says she was a ”functional addict,“ who continued working as a nurse despite her drug abuse. Eventually, her habit grew so unmanageable she left the familiar circle of upscale drug abusers she frequented to hang out with the serious junkies. To satisfy her addiction, she resorted to ”selling my body, selling my clothes, selling my kids’ clothes, the washer, dryer, everything.“
Jan found out she was HIV-positive when she was in the hospital being treated for pneumonia. Because she shared needles and was having unprotected sex as well, she’s not sure how she contracted the disease. After she was diagnosed, however, she continued to inject cocaine. She met Crowder after she finally decided to quit.
”I love him to death,“ she says. ”If it hadn’t been for him, I might not have stopped.“
Crowder has been able to draw drug users into treatment programs because he can relate to addicts on their own level. ”We’re meeting people where they’re at,“ he says. ”They’re on the street and destitute. And they’re grateful.“
On the street, Perkins says, it takes a long time to gain that kind of trust. That’s one reason she doesn’t let reporters accompany the outreach workers.
”In some places, people still think I’m a cop,“ she says.
Needle-exchange programs have had a long, slow ascent toward the mainstream, and they still aren’t quite there. Intravenous HIV transmission has reached record highs nationwide, and existing underground programs, which are mostly privately funded, can’t keep pace with the epidemic. Advocates, health-care workers, and researchers have pleaded with the federal government to fund such programs. But instead of receiving more funding, they’ve been shackled by a temporary federal ban imposed by Congress, and they’ve faced a fiery backlash from anti-drug, pro-family groups.
For opponents of needle-exchange programs, only one thing is more unsavory than giving needles to junkies. And that’s using tax dollars to buy needles to give to junkies. Despite the Clinton administration’s vow to declare an all-out war on the growing AIDS epidemic, it has yet to lift the ban on federal funding for needle-exchange programs. That roadblock makes such programs largely inaccessible in Tennessee and in many other parts of the country.
Needle-exchange programs are having a hard time gaining acceptance, but it’s not for lack of advocates. Needle exchanges have been endorsed by celebrities like Elizabeth Taylor and Miss America Kate Shindle and respected organizations like the American Medical Association and the U.S. Conference of Mayors. It’s not for lack of proof that needle-exchange programs work either. Researchers from the Centers for Disease Control, the National Academy of Sciences, and others have found that needle exchanges can reduce HIV transmission without increasing drug use.
Those opposed to needle-exchange programs, including the national Family Research Council and some sectors of the religious community, contend such programs are part of a larger effort to legalize drugs. They have questioned the scientific findings and have produced studies that suggest the life-saving potential of such programs is grossly overstated.
”Although AIDS will kill some [drug users], most will die from drug overdoses or other high-risk behaviors,“ writes Robert L. Maginnis, a policy analyst for the Family Research Council.
But there may be other reasons why needle-exchange programs have not gained widespread acceptance. Perhaps it’s because, as one AIDS activist put it, we are reluctant to face the reality of intravenous drug use in our communities and because we don’t want to indulge it. Needle-exchange programs require us to do both.
While the federal government has boosted funding for most AIDS-related programs, Congress has upheld its temporary ban on using federal funding for needle-exchange programs until March 31. After that date, Donna Shalala, secretary of the U.S. Department of Health and Human Services, can lift the ban if she determines the programs effectively prevent the spread of HIV and do not increase drug use.
Despite compelling statistical evidence that needle exchanges save lives, the state of Tennessee will not actively pursue or support them until Washington does.
”As long as federal law prevents the expenditure of federal dollars on needle-exchange programs, there are not going to be enough needle-exchange programs to determine the cost-effectiveness nor the effectiveness of needle-exchange programs reducing the spread of HIV,“ says state epidemiologist William Moore, who has been working in the AIDS field since the mid-’80s and supports comprehensive needle-exchange programs. ”It would be difficult to get general assemblies to allocate funds for these programs that many people believe are unproven.“
AIDS advocates say lukewarm attitudes on the part of national public health officials reflect a disregard for the facts and a reluctance to institute a proven strategy of preventing AIDS. According to a 1996 study published in the British medical journal, The Lancet, a national needle-exchange strategy could have prevented 4,394 to 9,666 new HIV infections in the United States between 1987 and 1995. Researchers also predicted that an additional 5,150 to 11,329 preventable infections could occur by the year 2000 if needle-exchange policies do not change.
The Lancet editorialized last month that ”given the weight of the scientific evidence supporting the efficacy of needle-exchange schemes, it is hard to attribute the reluctance to back such programmes to anything other than political considerations.“
Needle-exchange programs now exist in half the states. But funding is scarce, skeptics abound, and organizers go to great lengths to keep their programs out of the public eye.
Rudy Smith, an alcohol and drug treatment specialist with Nashville CARES, says harm-reduction programs often work because they help addicts feel empowered enough to confront their addictions and overcome them.
”Distributing needles would make them think, åSomebody cares about us junkies,’ “ Smith says. ”The outreach workers would get to know the people and help them feel some sort of community.“
Smith was addicted to cocaine for 15 years before becoming a drug counselor. She says she associated with intravenous drug users but did not inject drugs herself because she’s diabetic. In the last three years of working with the drug-addicted, HIV-infected community, Smith says, she’s met many people who could have benefited from a needle-exchange program. The following are among them:
♦ One man who knowingly injected into his bloodstream an HIV-tainted syringe-full of drugs because he didn’t have a clean needle.
♦ Four brothers, all of whom were HIV-positive. They all did intravenous drugs and shared needles.
♦ Many women who have told Smith they’ve lost entire days in crack houses sharing pipes, needles, and having unprotected sex.
♦ Countless addicts who have come to treatment with infected abscesses caused by repeated injections with dirty needles.
Despite Smith’s advocacy for harm reduction programs, she doesn’t believe simply distributing needles to drug users is going to solve the problem. She doesn’t know how many of her clients have used the existing needle exchanges, only that Nashville needs a larger, more comprehensive program.
”If we’re going to do it, we need to do it. But half-doing it isn’t going to help anybody,“ Smith says. ”Here in the Bible Belt, I don’t know how we’re going to do it unless the government helps.“
As the March deadline for lifting the ban on federal funding for needle-exchange programs approaches, supporters nervously await some word about what Shalala plans to do. Even though needle exchanges are favored by an impressive list of advocates, there’s a comparatively small but vocal group of adversaries, including some members of Congress and the Clinton administration’s ”drug czar,“ Barry McCaffrey, who seem to pose a serious threat.
[Needle exchange is] not an effective way to reduce the spread of AIDS or the use of drugs,“ maintains Kristin Hansen, press secretary for the Family Research Council. ”It only drives up crime and drugs and sends a mixed message to teenagers.“
By contrast, Ron Crowder is the recovered junkie of yesterday who is convinced it’s time to worry about the junkies of today and tomorrow. Needle exchange, he says is ”way underfunded. If we had funding we could do more. If we could do it more above ground, rather than underneath, we could help kids who are going to be the next HIV-infected generation.“
When Crowder talks about the merits of the harm reduction program where he volunteers, his voice steadies and becomes more serious. His train of thought is often interrupted by an urgent question—“Do you understand what I’m saying?“ But Crowder knows he must proceed with caution. ”We’ve got to be careful,“ he says. ”Do you understand what I’m saying? We can’t advertise or put this on a billboard.“
Shalala has remained mum on the topic of needle exchange. But advocates of harm reduction programs can look to the polls for encouragement. Several recent surveys indicate that public sentiment is shifting in favor of needle-exchange programs. That’s a change from the late 1980s, when at least two different polls found that roughly half or less than half of respondents supported giving sterile needles to addicts in order to slow down the spread of AIDS. Last year, a Kaiser Family Foundation poll found that 66 percent were in favor of clean-needle programs.
Such figures suggest that more of the general public is becoming convinced by AIDS advocates, medical professionals, and others whose argument, for years, has been a simple one: A needle is a small trade-off for saving a life.
For his own part, Ron Crowder is convinced that he would have used a needle-exchange program if one had existed when he was shooting heroin with soiled syringes. After Crowder became a case manager, he says, he learned that some of the people he used to share needles with were also HIV-positive. Some had known for years.
Jacqueline Marino is a staff writer at The Memphis Flyer.
Jacqueline Marino is a staff writer at The Memphis Flyer.
