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.
“HEY, TED!” NO ANSWER. “HEY, TED!” No answer. The lack of response didn’t surprise me, since the modest house appeared to be unoccupied. The shades were drawn and there were no obvious signs of life, but my guide kept walking along the driveway. “Hey, Ted! It’s Michael.” This time, a muffled voice behind a shuttered window asked, “Who you got with you?”
“It’s okay,” Michael said, glancing at me. “He’s cool.”
“Go round back,” Ted answered after some hesitation.
The back door was unlocked, leading to a small, empty room, but the door that led from that room to the rest of the house was blocked with iron burglar bars, as were all the windows, creating the appearance of an inverted jail. DeeDee, a cigarette-thin black woman in nondescript pants and T-shirt, peered around the edge of the burglar door, then unlocked it and threw her arms around Michael Lesley, a longtime volunteer with DANSE, the Dallas Area Needle-Syringe Exchange program (he asked that his real name not be used). At DeeDee’s direction, I stepped past Ted, a cinnamon-colored man in his fifties clad only in shorts. He was sitting on the edge of a king-size bed next to a bright lamp with the shade removed, poking his left leg with a syringe as he searched for a non-collapsed vein underneath the scabrous stretch of blue-black leathery skin between his knee and his ankle.
Ted was in charge here, “working the package,” selling $5 caps of heroin and heroin-cocaine “speedballs” he’d bought from a higher-level dealer and providing users a place to shoot up in relative safety. Business seemed to be good. A sturdy young black man followed us in and went into a darkened adjoining room where a grainy TV was flickering. A few minutes later a white couple who appeared to be in their mid-forties and looked as if they might have just gotten off work at Wendy’s or Pep Boys passed through and joined him.
On the other side of the big bed lay Rosetta, her skinny forearms covered by raw abscesses at least three inches wide and six inches long. Her groggy state indicated that she had been more successful than Ted at finding a vein. The space between them was littered with cigarettes, a large ashtray, several $20 bills, an elastic band, and a few loose syringes. At the head of the bed, under Rosetta’s oversight, sat a cardboard box containing what was left of the two hundred BD brand syringes that Michael had brought on his last visit. DANSE, like an estimated 185 programs around the country, supplies sterile syringes to drug addicts in exchange for used ones and serves as an important bridge to treatment and rehabilitation. The point is not to facilitate their habit—they are going to shoot up anyway—but to keep them from getting infected with HIV/AIDS or hepatitis C and spreading it to others, ruining lives and costing taxpayers billions of dollars in medical bills.
Addicts may not be models of prudent forethought, but they recognize the value of clean needles and are jealous of their supply. I asked why they thought it important to have new needles. Without looking up, Ted said, “To keep from getting diseases, like AIDS.” Do users know that? “They know it,” DeeDee replied, “but sometimes they forget.” Since lack of funding had kept DANSE off the street for most of 2006, where had they been getting their needles? Ted explained that, because he is a diabetic, he depends on Walgreens. “They know me,” he said. “I get what I need, and I sell some to people that come in here.” If needle exchanges were legal in Texas, making it easy for users to get sterile syringes, would most do so? “Definitely. Definitely!” Rosetta said, with notable conviction.
They were obviously pleased that Michael was back in action and promised to give him some used needles when he returned the next day with a sharps container. I asked if they ever picked needles off the street to exchange for clean ones. “Yes,” said DeeDee. “And that keeps children from getting hurt.” After a few more questions, I thanked them for being so candid, and Michael and I left. For me, it was a new experience. For Michael, it was just another stop in his regular weekend rounds, operating on the edge of the law but at the heart of sound and compassionate health care.
An estimated one third of HIV infections in this country can be traced to injecting drug users (IDUs), their sexual partners, and their offspring. Hepatitis C, the most destructive variant of that disease, is present in the blood of more than 70 percent of all adult IDUs. A contaminated needle is an extremely efficient transmitter of a blood-borne disease. In the mid-eighties, as public health officials in the Netherlands and Australia realized that HIV and hepatitis were spreading at alarming rates among IDUs, they began experimenting with programs to supply addicts with clean needles in exchange for their used ones. The immediate and obvious success of these programs in reducing the incidence of both diseases—it was estimated that 25,000 cases of HIV and 21,000 cases of hepatitis C were prevented during the nineties—led authorities in Canada and numerous European, Asian, Middle Eastern, and Latin American countries to follow suit. In some locales, sterile syringes can be exchanged at pharmacies, police stations, and even specially designed vending machines. At St. Vincent’s Hospital in Sydney nuns operate the exchange.
With few exceptions, American medical and public health personnel also support making sterile syringes available to IDUs. Regardless of this near unanimity, Congress continues to prohibit federal funding of any such effort. State laws vary widely, but it appears that, after both Delaware and New Jersey passed legislation authorizing needle exchange programs (NEPs) in 2006, Texas stands alone in its refusal to legitimize any method for providing sterile syringes to IDUs, despite their proven utility in preventing disease (some states without NEPs at least allow for sales or exchanges at pharmacies). Programs like DANSE operate in some of the state’s major cities, almost always under a “don’t ask, don’t tell” cover, but paraphernalia laws that criminalize supplying or possessing needles for illegal drug use make it difficult to persuade addicts to participate in a program sure to be known to the police and leaves NEP staff members and volunteers subject to arrest. (Because of that risk, workers in the state’s largest and most successful program declined to be interviewed for this article.)
DANSE traces its origins to the early nineties, when Dr. Martin Krepcho, an assistant program manager in the STD/HIV section of the Dallas County Department of Health and Human Services, became aware that HIV was spreading among IDUs in the area and that facilitating access to sterile syringes could slow the epidemic. “Since we could identify the pathways,” he told me, “we had an ethical responsibility to try to do intervention.” The administration at the health department wanted nothing to do with such an effort, so Krepcho and two colleagues dropped the subject but not their commitment. In 1993 they founded DANSE and obtained a grant from the North American Syringe Exchange Network (NASEN).
Krepcho then spoke with several police department and precinct officials, explaining what he and his associates wanted to do and where and when they’d be operating. They agreed and provided access to key officers who saw to it that DANSE workers were not hassled as they exchanged needles from the back of a pickup in areas rife with drug users. I asked Krepcho if any of their clients had shown interest in treatment to help break their habit. “Oh, Lord, yes!” he said. “We would take them to facilities for assessment and treatment and medical care.” Echoing NEP workers around the country, however, he noted that available treatment slots fell far short of the need. “If they asked for help, we weren’t sure we could get them in, so it was imperative to keep them safe and clean until they could get in, to try to preserve lives as much as we could until we could link them up with a treatment program.”
Shortly after Krepcho launched DANSE, a Dallas TV news station aired a brief report that caught the attention of Jack Taylor, an active Episcopal layman. “It was one of those things that my wife and I immediately snapped on,” Taylor recalled. “So we looked up Marty, and we’ve been involved ever since.” He explained the simple approach the DANSE volunteers used. “We’d go to a site, open the door, and put a red sharps container on the sidewalk. That was our ad. We’d go at a specific time; they would know. We’d exchange anywhere from a few hundred to the low thousands. At one time, we were exchanging so many that we had a contract with a company to pick up and dispose of the used ones.” Having lost a son to a cocaine overdose, Taylor admitted it was hard for him to give needles to people he suspected were dealers, who would use them in their shooting galleries. “But Marty helped me focus on the task,” he said. “Serve the IDU population, get needles off the street, stop the sharing, stop the spread of diseases.”
DANSE never had more than a handful of volunteers, and since Krepcho moved away in 2004, Taylor has served as managing director, raising funds, buying supplies, and keeping records. He leaves most of the actual exchange work to Michael Lesley, who knows the streets and operates exchanges in several neighborhoods on weekends. A fifty-year-old former addict, Michael got involved with DANSE in 1996 as a volunteer, and he is clearly disappointed at the recent funding drought. “We had four sites in the nineties and gave out over one hundred fifty thousand needles some years. We had thirty thousand to forty thousand dollars a year to work with. I had hot spots I had developed. I might collect one to two thousand needles at a time. We had it going real, real well. Then the funding went short. In 2005 I didn’t have but maybe ten thousand needles to give out all year. And last year, none. Now we got a small grant, and I have to start from scratch to get my clientele back.”
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.