Letter From Dallas
The Damage Done
Texas is the only state in the country that won’t allow needle-exchange programs for drug addicts. It’s time for that to change.
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It is not hard to understand why Michael feels compassion for those still captive to drugs and wants to protect them from disease and death. But it’s also easy to understand why others regard HIV/AIDS and hepatitis C as a matter of just deserts, or at least as a regrettable effect of avoidable causes; when people use dangerous drugs, bad things happen. Those who hold such views, however, should pause in the face of the enormous costs of treating people infected with these diseases. Texas is home to more than 67,000 people living with HIV/AIDS, the fourth-largest concentration in the nation. An estimated 387,000 Texans are infected with hepatitis C, which can lead to cirrhosis, liver failure, and cancer. A major study published in the November 2006 issue of Medical Care estimates that the current cost of lifetime treatment for a person with HIV is $618,900, though that number has been projected to drop to $385,200. Even using that lower estimate, treating just those Texans who have been infected in the past five years will cost an estimated $8.2 billion, not counting the more than three thousand new cases added each year. The same report estimates that the net savings for each case prevented is $303,100. Treatment for those with hepatitis C, a population six times as large as those living with HIV and AIDS, can run to $20,000 to $30,000 per year, with lifetime costs of more than $300,000. Preventing just one case of either disease would save far more than the annual cost of a first-rate needle exchange program.
Many people infected with these diseases receive little or no medical treatment, but for those who do, Medicaid or other public funds bear a high proportion of the cost. From 2001 to 2005, Texas state Medicaid costs for HIV/AIDS services totaled $316.5 million—and that doesn’t include outlays by private payers, insurance companies, or government programs such as Medicare and Veterans Affairs. Of those whose hepatitis C progresses to end-stage liver disease later in life, Medicare picks up the $300,000 or so for the one in four fortunate enough to receive a transplant.
These costs can be dramatically cut, as carefully studied programs in other states have shown. A New Haven, Connecticut, exchange program begun in 1990 was estimated to have cut HIV transmission by 33 percent in the first two years of the program, with a similar reduction in the spread of hepatitis. A Johns Hopkins study of the Baltimore City Needle Exchange, launched in 1994 at the urging of Mayor Kurt Schmoke, concluded that, after six years in operation, the incidence of HIV in that city decreased by 35 percent overall and 70 percent among the approximately 10,000 participants in the program. In both cities, about 20 percent of participants voluntarily entered drug treatment, and in Baltimore the number of used needles collected in the trash fell by almost half, reducing the threat of injury or infection to children and others who might come in contact with them accidentally. An Australian study that examined data from 103 cities worldwide found that cities with NEPs experienced an average annual decrease in HIV cases of 18.6 percent; cities without such programs had an average 8.1 percent increase.
No one seriously disputes these findings. At least ten comprehensive studies, most funded by the federal government and conducted by such organizations as the National Academy of Science, the Centers for Disease Control and Prevention, the American Medical Association, and the National Commission on AIDS, have concluded that access to clean needles is an effective measure for reducing the incidence of blood-borne diseases and that it neither encourages people to start injecting drugs nor increases drug use by those who are already users. Dr. C. Everett Koop, who played a central role in rallying evangelical Christians to oppose abortion before Ronald Reagan appointed him surgeon general, applied his pro-life convictions to this issue as well. “When we are dealing with something as devastating as the AIDS epidemic,” he declared, “it doesn’t matter what we do to reach people that have to be reached, we have to do it.… If clean needles will do anything to contain a part of the epidemic, we should not have any foolish inhibitions about doing so.” Dr. David Satcher, who served as surgeon general from 1998 to 2002, and National Institutes of Health director Dr. Harold Varmus, both of whom were appointed by President Bill Clinton, also offered strong endorsements of NEPs.
The science is clear. What is lacking is adequate funding and political will. In the 2005 session of the Texas Legislature, Senator Jon Lindsay, a respected moderate-conservative Republican from Houston, sponsored a bill that would have made it legal for private individuals and organizations to fund and operate NEPs in Texas—not costing the state a cent but potentially saving it millions. The Health and Human Services Committee sent the bill forward with only one dissenting vote, but it never came to a final vote on the Senate floor.
Though some were surprised that Lindsay would sponsor the bill, he called it “a no-brainer.” “I talked to doctors and medical people, people who worked at clinics,” he explained. “They convinced me that it made sense to get dirty needles off the street. It wasn’t a hard sell at all. And of course, there is the side benefit of getting users in contact with clinics and medical professionals.” As for why the bill failed in 2005, he said that too many socially conservative legislators “are afraid of their shadow. They’re afraid they’ll be branded as catering to druggies and don’t want that to be a potential campaign issue. That’s the bottom line that is causing the hang-up. A large number of them don’t understand the issue. It’s more of a knee-jerk reaction.”
Randall Ellis, the director of government relations with Legacy Community Health Services, a nonprofit organization in Houston, goes even further. While acknowledging that some legislators honestly feel that giving needles to addicts may somehow affect their own children, he also suspects that the fact that most IDUs are minorities or otherwise powerless people makes it easy to ignore their plight. “The people who would benefit from this,” he said, “are some of the most disenfranchised members of our society. Some people in the Legislature truly don’t care about those folks.”
Lindsay recalled that progress on his bill had been helped by the support of two Republican physicians in the Senate, Robert Deuell, of Greenville, and Kyle Janek, of Houston. That voice should be even stronger in the current session, since Deuell is sponsoring the bill this time. “There is absolutely no reason to oppose a needle exchange program,” Deuell said. “The research is there. People who oppose it think it will encourage drug use. Research has shown it does not. It serves to prevent transmission of HIV and other blood-borne diseases such as hepatitis B and C, and it actually brings addicts to treatment, if they so desire.” Deuell also stressed that allowing greater access to sterile syringes “is going to cost the state less money. It costs us a fortune to treat HIV and hepatitis C. It’s breaking the budget.”
Even though passage of Deuell’s bill would not call for state funding of NEPs, private funding should be much easier to obtain once the programs are able to move out of the shadows. Although NASEN was the earliest significant funder of NEPs and is still active in the field, the major money today comes from the Syringe Access Fund, a multimillion-dollar collaboration by the Levi Strauss Foundation, the Tides Foundation, the National AIDS Fund, and several other private foundations with an interest in AIDS prevention and research. The Levi Strauss Foundation, which initiated the fund, has been involved with AIDS education and treatment since the early days of the epidemic, in the eighties, but in 2001 foundation officials determined they could have the greatest impact by facilitating access to sterile syringes. “We didn’t pull this out of thin air,” said Stuart Burden, director of Community Affairs-Americas, who was a key player in that decision. “The evidence is very clear, very strong, and incredibly consistent. When we looked at what was driving the pandemic, at least thirty-three percent of it was being driven by contact with dirty syringes. The cost-benefit is extraordinary—providing a clean needle that costs seven cents can save thousands of dollars in care and treatment. With a small amount of money you can make a real difference.”
Deuell noted that saving money is not his only motive for sponsoring the bill. “There’s also the compassion factor. These are human beings. I don’t want people to get these diseases. Some people say, ‘Punish them. Let them suffer. Let them die.’ I look at it from a Christian viewpoint: What would Jesus do? We need to show compassion and try to help. They are God’s children too. When they need new needles, this puts them in touch with someone who might reach them. The very act of handing them clean needles says, ‘Your life has value to me. I want you to know that we care about you. When you want to get off, we’re here to help you.’ If they’re in a back alley, using a dirty needle, there’s no chance of that. Do I wish we didn’t have to do things like this? Absolutely. I’m a conservative Republican. I don’t like drug use, but reality is reality. Some people are going to use drugs.”
Deuell’s strategy will be to provide his colleagues and constituents with accurate information. “At one time,” he acknowledged, “I was opposed, but I looked at the data. As Churchill said, ‘You can’t argue with arithmetic.’ When people have disagreed with my vote, I’ve shown them the data and asked them, ‘How could I argue with that?’ Some people, some legislators, don’t want to be confused with facts. We’ve got to get them to look at the data and information and say, ‘This saves human suffering. It saves the state money.’ This is not just win-win. It’s win-win-win-win-win-win. I hope we can pass it with education, facts, and reason and not kill it with emotion.”
This time, the Legislature needs to let Texas achieve these multiple victories, and it can do so in good conscience. No responsible person wants to encourage drug abuse. No fiscally prudent person wants to waste money simply to satisfy a sense of righteous indignation. No compassionate person wants to consign people unnecessarily to death or a living hell. Fortunately, providing injecting drug users with access to sterile syringes allows us to be responsible, prudent, and compassionate—admirable criteria for good public policy.
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