The Needle and the Damage Undone
Needle exchange Is credited with slowing the spread of AIDS in Baltimore. So how come nobody wants to talk about It?
Brown does not mince words. She does not equivocate about the work she believes needs to get done. She means to make sure a listener understands.
This rhetorical directness is an occupational strength--one of the many necessary skills in her repertoire as the director of the largest publicly funded needle-exchange program in the country. The Baltimore City program recently observed its sixth anniversary. Six years of offering clean needles to drug users so they will not rely on used and possibly disease-tainted syringes. Six years providing a politically controversial, scientifically unassailable, and at times morally rebuked service to that great bogeyman and ideological Rorschach test of the public imagination: the inner-city drug user.
"We keep a low profile," Brown says. "We're real quiet. We do what we need to do. You know, people who use drugs need an advocate. For people out here"--she points to an East Baltimore Street--"we are it. We are often the only health service they will get."
Without question, the Baltimore needle-exchange program has saved lives.
The incidence of HIV in Baltimore has decreased 35 percent since the program's inception, according to a report prepared by the Johns Hopkins School of Public Health. A July 1999 Hopkins study found a 70 percent drop in the rate at which program participants contract the virus. That means fewer infected people, which means fewer deaths. And the program provides a bridge to treatment and a drug-free life for a fortunate few city residents.
Needle exchange is a small, unassuming program--cost: $537,856 in fiscal year 1999, less than 1.7 percent of the city Health Department's $31.75 million budget that year--that works. It works with daily humanitarian acts against disease. It works by not trafficking in the moralizing clichés of "underclass" pathology, and it works by not looking for easy solutions. It works against the afflictions of post-industrial city life, and yet politicians have a hard time claiming it as their own. Even though Maryland's AIDS rate ranks fourth among states and Baltimore's seventh among major metropolitan areas; even though "the principal route of transmission for HIV in Maryland is injection-drug use," according a July report by the Maryland AIDS Administration, the state AIDS agency. To many, the needle-exchange issue begins and ends with the notion that it amounts to the state helping addicts get their fixes, that it sends the "wrong message" about drug abuse.
Such notions mean little to Michele Brown. "My thing is to help people not to die," she says flatly as she puts together a "harm-reduction kit" of clean bottle caps, small cotton balls, and alcohol swabs. "People don't need to and shouldn't have to die from their addictions." She checks the supply of containers of bleach and water she will hand out to heroin users. "People need to wake up and stop playing games."
This last comment is sighed wearily. HIV, AIDS, and intravenous-drug use are not discrete problems. They are threads in a fabric of Baltimore life, threads the politically expedient view of things doesn't take into account. The origins of needle-exchange programs in this country are a study in the limits of the politically expedient view of things.
In 1988, well into the burgeoning AIDS epidemic, activists in Tacoma, Wash., and Boston started offering injection-drug users clean needles. That same year, the New York City Health Department started the country's first publicly funded needle-exchange program, and Congress banned the use of federal funds for needle exchange. Four years later, during his first presidential campaign, Bill Clinton promised to lift the federal-funding ban--a promise he has yet to keep.
In 1994, Baltimore Mayor Kurt Schmoke made establishing needle exchange here his top legislative priority--"His number-one issue, even above education, funding issues, and crime," recalls Dr. Peter Beilenson, the city's health commissioner then and now. The city received conditional approval from the state legislature to run a pilot needle-exchange program; three years later, the program was made permanent. As of the end of summer 2000, Brown has more than 10,000 clients, drug users registered with the program to legally trade dirty needles for clean ones.
The legislation that allows needle exchange in Baltimore doesn't apply in the rest of the state. Outside of city limits, and in many states beyond Maryland, it is a prosecutable offense. "I'm from New Jersey, OK?" says Brown, who has lived in Baltimore since arriving at Morgan State University in the '70s. "New Jersey has one of the highest HIV transmission rates, and [Gov. Christie Todd Whitman] said she'd arrest anybody that gave out needles. I don't understand it. I have had a client here in Baltimore, in our program, from my hometown in New Jersey."
Needle exchange, called into being by outspoken activists and undertaken only by the most committed professionals, is a hard sell for most politicians. Asked about Mayor Martin O'Malley's position on the issue, a mayoral spokesperson responds with practiced public-relations opacity: "I think we will just say the mayor gives his general support and leave it at that."
In office 10 months, O'Malley has shifted focus from active advocacy of so-called "harm-reduction" models like needle exchange to more aggressive policing and faith-based youth programs. Such efforts are not necessarily wrong, they're just more politically sellable, which means they are where the federal and grant money goes. Everyone at least pays lip service to the notion that, as police Commissioner Edward Norris has said, "You can't arrest your way out of the [drug] problem." Most everyone ostensibly agrees that more drug treatment is better than more prison space. Yet the gap between the rhetoric and actual resources for treatment and harm reduction in Baltimore is breathtaking.
Brown has a small three-ring binder. In it she keeps track of the 390 drug-treatment slots she has available for the more than 10,000 participants in her program. No space in the book stays blank for long.
"Today. You got any slots to-day?" a heroin user booms skeptically as he steps up into the needle-dispensing RV at the corner of Monroe Avenue and Ramsay Street in Southwest Baltimore. The van's cabin steams in the September heat. Other clients stand patiently, laconically outside the vehicle's door. It's a little after 10 in the morning. The red used-syringe bin with biohazard stickers on it is already filling up.
"No, but you can check back tomorrow," a staffer replies, his inflection making the response sound scripted. "Wait"--he checks a notebook--"be here Wednesday. Be here at 9:30 Wednesday. There will be an opening at [Johns Hopkins] Bayview [Medical Center]." Needle-exchange staff always urge early arrival; it's first-come, first-served on those 390 slots.
"Yeah. Wednesday." The user shrugs and heads back out on the street.
"Twenty, 30 times a day," says Nadir Abdullah, a needle-exchange staffer. It's how often he turns away those requesting treatment, how often he gets that shrug. "All the time, man. All the time."
This year, Beilenson asked the state for an additional $25 million a year to provide comprehensive, on-demand drug treatment. He has publicly criticized Gov. Parris Glendening for offering $8 million, not nearly enough to cover the city's needs, the health commissioner says.
Lamont Coger is a big man, built like an athlete, and like an athlete he is a model of choreographed efficiency. You have to move smoothly when your workplace is a 26-foot-long recreational vehicle with two laptop-computer work areas and storage space packed full of supplies. With three staffers and, at any given time, up to three clients inside, the mobile needle-exchange office can get a little tight.
"I was a community activist in the Sandtown-Winchester neighborhood. I was already a HIV/AIDS activist," Coger says, recalling when he joined the program he now serves as deputy director. "I saw what was going on. . . . People are still going to use. They're going to get the drugs." Coger is skeptical of law-enforcement pledges to stem the drug trade, but he adds, "The point is not to have a permanent needle-exchange program [either]. This is a bridge to treatment. This should be a bridge to something else."
Until that bridge is built, though, Coger has other plans. "I want to take needle exchange to the next level and get what I call a 'harm-reduction center.' We need an open door where users can come. We need a place to do ongoing education, have peer counseling, where people have a place to sit down. I mean, our clients don't have a place to sit down. But I don't think Baltimore is ready for state-of-the-art drug treatment."
The needle-exchange program works out of a pair of Gulf Stream "Conquest Limited Edition" RVs that Brown regularly cusses for their accumulating repair bills. In addition, the program operates at a space at Fibus Pharmacy on Garrison Boulevard in Northwest Baltimore, leased to it by proprietor Norman Levin. Fibus has been in operation since 1910; Levin's pharmacist father bought the business in 1931, and Levin started working there in 1957. It is the only pharmacy in Baltimore that is actively involved in the needle-exchange program.
"I believe in this program," Levin says. "The corporate chain pharmacies don't want to have anything to do with it. The other pharmacies, well, most just don't want to get involved."
Besides Fibus, the program does its work at eight locations. Each RV, with three staffers per, splits the day between two sites, opening for two-hour stretches in each locale. Two outreach workers round out the staff; they are pressed into service for any task that needs doing, except physically exchanging needles. Paid with federal grant money, they are prohibited by the still-extant federal-funding ban from so doing.
No shingle is hung out, no sandwich board placed on the sidewalk. There is no sign, no advertisement, no marketing. You only know what's up with that unmarked RV if you're in the life. You go there because you want to shoot clean. If it's busy, you wait in line out on the sidewalk.
When it's your turn, if you've already registered, you step up into the vehicle and hand a staff member your card. You put your used syringes on the table in front of you and count them out with the staff. If you're being helpful, you have all your syringes bound with rubber bands, there'll be caps on the spikes, and you are returning only needles you got from the program on your last visit. In return you get clean needles. You are offered a harm-reduction kit, condoms, an HIV test, information. If you ask, you are given an empathetic ear, direction, personal tales of getting through, getting over, getting out of the life. Needle-exchange staff members offer up the raw materials of hope.
If you're new, the staff will sit you down and register you. You answer a series of questions. You are given information about HIV, the social-services system, where to get medical attention, how not to die. You get a numbered, laminated card. The cards are important--the enabling legislation for Baltimore's program says one has to prove you are a participant to be excused from the state's drug-paraphernalia laws. If you are stopped by the police and don't have your card, or can't otherwise prove to the officer's satisfaction that your cooker and syringe came from the program, you are in violation of the law. You are a criminal.
The 1954-vintage Eastern District Health Clinic building has one of those civic-minded facades, with the names of public-health heroes such as Louis Pasteur and Edwin Chadwick carved into concrete above its entrance. Across the street, construction cranes soar above a massive building project on the sprawling campus of the Johns Hopkins Hospital. Two days a week one of the needle-exchange vans is parked at Caroline and Monument streets between the facade and the cranes, sitting out in the street like an embarrassing relative in this family of health-care institutions.
"Baby, you got your card?" Laura says as she rounds an East Baltimore corner and huddles with her boyfriend and another man after leaving the van with clean syringes and bleach. "I don't need the clean water, I can get that." Laura doesn't have her program card and neither does the other man, so they consolidate their works in a brown paper bag and give it to the boyfriend.
"The cops don't care if you're in the program," Laura's boyfriend says. "They'll get you up against the wall, they'll take your stuff, smash up your cigarettes. But if you have your card you have a better chance of not taking a charge."
"The police regularly hassle our clients. This is just the truth," Robyn Moore says. Moore, a former user, has been working for the program for almost two years. "You know, I heard the new [police] commissioner on the radio the other day and he kept referring with such disgust, such ignorance, to 'the junkies' in Baltimore. I called into the program, but it ended before I could get through. I was going to tell the commissioner that I think he needs to get educated about drug use. These are people just like you and me, just like we are." Moore gestures to the rest of the staff on the van. "He needs to get educated about addiction. I think he needs to educate his people about drug addiction in this city."
Laura and her friends are white. The needle-exchange staff will tell you, truthfully, that addiction knows no color. They will point out that at the site over by Pigtown more than 90 percent of those stepping up to the van are white. They will tell you they have had clients of every race, every color, from every station in life. They can give you an encyclopedic number of counter-examples to every stereotype you might have about who shoots drugs and why.
But at the crossroads of HIV and intravenous-drug use, the epidemiology reveals a political truth about why needle-exchange is often seen as less expedient, a more difficult sale to the citizenry. From the beginning of the AIDS epidemic in the early '80s through the end of 1998, African-Americans and Latinos together accounted for three-quarters of all injection-drug-related AIDS cases. In 1998, the rate of such AIDS cases among blacks was 14 times higher than for whites, and six times higher for Latinos than for whites.
In the 12 months ending in March 1999, 87 percent of those diagnosed with HIV in the state were African-American, according to the Maryland AIDS Administration. Eighty-two percent of people known to be living with the virus or the disease in the state are black, and more than half of them live in Baltimore City.
"Over time, the epidemic has been shifting to have larger portions of females, African-Americans, injection-drug users, and heterosexual contacts," the state agency reported in July. "The fastest growing demographic group is African-American women who acquire HIV through heterosexual contact."
While some connoisseurs like to inject their cocaine, the marriage between heroin and the syringe is a tight and long-lasting one. Heroin has a special place in the public imagination. Like the dreams spawned from its powerful opiates, heroin is often used as a public metaphor for urban pestilence, poverty, hopelessness, and social disease. To spend any time with the needle-exchange staff is to escape the exaggerated fantasy life of heroin in political discourse. It's a place to get the truth.
In the spring, newly appointed police Commissioner Norris requested the help of the U.S. Drug Enforcement Administration (DEA) in assessing the nature and scope of the drug trade in Baltimore. The federal agency announced its findings in late July, declaring Baltimore "the 'most heroin-plagued' city in the United States," The Sun reported in a front-page article.
After a three-month study "based on DEA intelligence and statistics," as well as unidentified "independent research," the agency found that Baltimore "has now become a center for distribution of a unique form of heroin . . . that is 'significantly higher in purity,'" according to The Sun. The paper reported that South American drug cartels have made Baltimore "one of their U.S. distribution points," in order to avoid competition with South Asian cartels that operate out of New York and Miami.
The story was based on a "summary of the agency's findings" released by Special Agent William Hocker, spokesperson for the Baltimore DEA office. A copy of the actual findings is harder to come by. "I don't really know of any report," says Sgt. Scott Rowe, a city police spokesperson. "I just know what, basically, was reported."
DEA spokesperson Laura Dicesare says there was no report per se; the agency "put together a PowerPoint presentation for the Baltimore police." The data on which the presentation was based "is all publicly available information, most it available on the Internet," she says. Hocker, for his part, says the DEA "never said [Baltimore] was a distribution center or that cartels had made it a center. I can't speak to what was reported."
According to Alfred McCoy, a University of Wisconsin history professor and author of The Politics of Heroin, "there is nothing unique, purity-wise or based on country of origin," about Baltimore's heroin. While Afghanistan and Myanmar together supply 80 percent of the heroin worldwide, South American heroin is not unique to Baltimore, according to both McCoy and the DEA statistics. "Most of the U.S. market, 60 percent or more, is coming from South America," McCoy says.
In the needle-exchange vans, among the folks who deal daily with Baltimore's user population, there is similar skepticism. "The [dealers] in Baltimore don't have the resources, the logistics, or the intelligence capabilities to be moving all these drugs in here," says Nathaniel Issac, a former user who works on outreach with the program. "This is a New York market." Issac maintains the purity of street-level smack isn't a function of some different strain of the drug, but of "straight marketing strategies. [Dealers] start with something more potent to [attract] the customers."
"I don't believe it," Lamont Coger says bluntly of claims that the heroin is different now. "You could always get pure stuff if you knew where to go."
Coger's and Issac's assessment is necessarily narrow and anecdotal, based on street-level encounters rather than the global intelligence on which the DEA professes to rely. But the "publicly available information" the agency relied on has its limitations in proving the larger, more sensational claims of a heroin pestilence particular to Baltimore.
For example, the claim that Baltimore is the nation's most heroin-wracked city is based largely on the "1999 Year End Emergency Department Data" report from the Drug Abuse Warning Network (DAWN), an arm of the federal National Clearinghouse for Alcohol and Drug Information that compiles information on drug-related emergency-room visits. According DAWN, Baltimore leads the nation in emergency hospitalizations linked to heroin. But the authors of the report explicitly warn against using it to make the kind of claims made by DEA and city officials: "It is also important to recognize that DAWN does not provide a complete picture of the problems associated with drug use, but rather focuses on the impact that these problems have on hospital [emergency departments] in the U.S. If a patient is admitted to another part of the hospital for treatment, or treated in a physician's office or at a drug-treatment center, the episode would not be included in DAWN." Because DAWN is comparing Baltimore's drug "episodes" with those of other cities, what it might be measuring, ironically, is the absence of treatment options here other than hospital emergency rooms.
"That's how I got clean," Robyn Moore says, folding her hands with poise in front of her as she speaks. "I got tired of looking the way I did. I was living in abandoned houses. I had to do it for me. I walked into the emergency room at the University of Maryland [Medical Center] and told them I'm on drugs, I use drugs, and if I don't get some help I'm going to kill myself."
No one disputes that Baltimore faces a crisis with drugs in general, and heroin in particular, and that drugs have a profound impact on life in the city. But the DEA/police narratives of plague and pestilence, reported without question or context by the mainstream media, reinforce the caricature of the city's heroin problem as some disembodied, inexorable force. The bromides of policy-makers and the slumming clichés of journalists trade all too easily on stereotypes of some spiritually enervated "inner-city life." The caveats in the DAWN report get lost in the rush to declare, "Baltimore Crowned Heroin Capital," as CBSNews.com did in the headline of its version of the DEA story. "Baltimore's situation is worse than other cities because of an entrenched drug culture that runs through entire families and spans generations," the TV network reported. CNN followed the same lead in a Sept. 22 story, conjuring up images of a forsaken place "succumbing to heroin."
Even city Health Commissioner Beilenson, discussing the selection of sites for needle exchange, describes some of them as "out there, like the wild, wild West." He points to the now-famous junction of Fayette and Monroe streets as a particularly woolly outpost of the program, inserting air quotes around the words "the corner" in recognition of the book and TV miniseries set there. What's interesting about Beilenson's emphasis is that the needle-exchange doesn't operate at Fayette and Monroe. It does operate at other West Baltimore locations, probably serving folks who live or cop around the fabled intersection. But the blurring between reality and representation is telling. Whatever one thinks about the quality of the David Simon/Ed Burns book or the subsequent HBO miniseries, "the corner" has become a stand-in, shorthand for a dramatic dysfunction neatly packaged for the public.
The reality is, of course, much more complex. The development of Baltimore's heroin market over the last three-plus decades is the result of several factors, not the least of which is the failure of government to devote resources to treatment and harm-reduction proportional to those devoted to law enforcement. The disparity runs smack into what Arnold Trebach, founder of the pro-decriminalization Drug Policy Foundation, calls in his book The Heroin Solution "the iron law of the opium trade." "Wherever there is persistent demand, in time a supply appears," Trebach writes. "And whenever a supply is cut off, another soon replaces it in sufficient volume to satisfy the demand." Decades of drug policy have focused on cutting off the supply rather than reducing the demand. We may succeed in breaking up the South American cartels, but if South American poppies can no longer supplying Baltimore users, Burmese or Afghan poppies eventually will.
In July, President Clinton flew to Cartagena, Colombia, to ritually sign off on a $1.3 billion military-aid package to that South American country. According to DEA, more than 50 percent of heroin that will fill the barrels of Baltimore's syringes is either grown, processed, or will pass through Columbia. The bill passed Congress shorn of an amendment that would have provided $225 million for drug-treatment and -prevention programs in the United States. The amendment received only 11 votes in the Senate. The rest of the senators might have been surprised to learn that Colombia's national chief of police, Gen. Rosso Jose Serrano, disagreed with their priorities. "We'd rather see drug consumption drop [in the United States] than get any of this aid," he told The New York Times.
Michele Brown doesn't have time to linger over questions of U.S. foreign policy. She has a job to do. In really bad weather, when it snows, she'll call up local radio and TV stations so that she can get the needle-exchange program included in announcements of school and government-office closings. She wants to let clients know the program is open for business. (When the weather is so bad that driving the RVs isn't safe, staffers load up their own vehicles and open up shop.) "Some of the stations have run the announcements," she says. "Sometimes I get, 'Needle exchange? What's that?'"
John Harris has been working for the needle-exchange program just six months. He's 44, but still youthfully handsome, only some gray in his closely cropped goatee betraying his age. He is a man with a mission.
"I believe in the power of example," he says, leaning in close as he speaks. Like Brown, he doesn't waste words in helping a listener understand what the needle-exchange program is all about. "My life is an example."
Harris grew up in West Baltimore--went to high school there, played football, was a young man to be reckoned with. At the age of 19, though, he got caught up in the life, and stayed there until he was 34. He got off drugs a decade ago and has stayed off.
"Addiction destroys you from the inside first," he reflects. "It's a disease of the thinking. The last four years of my time using was a nightmare. I don't know if 'hell' is even capable of describing it." John works full-time for the program, goes to school full-time at night, and is a phone call away from five recovering addicts he is guiding through the process of staying clean.
"I believe that no one is hopeless. Anyone can change given the right circumstances," he says. "You know, they didn't have this [needle-exchange program] when I was out here running. . . .
"I really do believe that no one is hopeless. That's why I'm out here now."
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