NEW HAVEN -- Four times a week a van rolls away from the city health department's outreach office here loaded with hope, charity and good intentions.
And needles. Lots of needles.
Aboard the van are three or four social workers. They are bound for the city's worst parts, determined to get these needles into the proper hands -- the shaky grasp of New Haven's heroin and cocaine addicts.
About 2,500 are so afflicted here, about 2 percent of the city's population, probably a lower rate than in Baltimore. Baltimore doesn't have a needle exchange program but, with political support from City Hall and, more recently, from Gov. William Donald Schaefer, seems headed in that direction.
In addition to the needles, the van carries little bottles of antiseptic bleach, pure water, condoms, alcohol wipes, cookers (little caps to heat heroin in), cotton -- just about everything an injecting drug addict might need to protect himself or herself from the HIV virus that opens the door of the body to AIDS.
These supplies are liberally dispensed -- free. Everything, that is, but the needles, which are very carefully dispensed -- but still are free.
Needles are bar-coded and numbered. An addict who brings in three old needles gets three new ones. One addict, an unhappy-looking man named Felix, thin as a stick figure, brought in 24 needles and left the van with 24 new ones.
"He's lost a lot of weight," community health worker Mark Kinzly observed of Felix, who has been exchanging needles at every opportunity for almost three years, though he doesn't appear likely to be doing it much longer.
"Every week we pick up the papers and see our own clients in the obituaries," said Dominick Maldonado, also a community health worker, "Last week, we lost two."
The van also carries literature, a library of pamphlets on the self-protective strategies against acquired immune deficiency syndrome.
Taken together, the van and its contents constitute the New Haven Needle Exchange Program.
This is what Mayor Kurt L. Schmoke wants to set up in Baltimore, or some variation of it. Now that Governor Schaefer has acquiesced, it is likely to come into being.
And it's none too soon, according to one of Mr. Maldonado's clients, who boarded the van in a neighborhood called The Hill and declared:
"Baltimore needs this program. When I lived in Baltimore near Erdman Avenue, I saw they got a lot of IV [intravenous] drug abusers there. It could save lives."
His name was Beep. Or at least that's the name he was registered under. Most addicts use code names and are encouraged to do so. One calls himself George Bush.
When Beep went to Baltimore with his girlfriend, he carried a little travel kit of clean needles and other necessities, because such things -- "works," the addicts call them -- are illegal in Maryland.
Sale of syringes legal
Not here. A year ago, encouraged by the success of the needle program in reducing the incidence of AIDS among addicts, the Connecticut Legislature legalized the sale of syringes without prescription by pharmacies. Now addicts have a choice: They can pay for their needles (about 50 cents each), or continue to get them free from the needle exchange.
The legalized sale of needles has reduced the traffic through the van by about half, said Mr. Maldonado. He is the soft-spoken boss on the van; he refers to the addicts as "clients" even as they call themselves "dope fiends."
Mr. Maldonado has been with the program since it began in November 1990, on a $25,000 grant from the Connecticut Legislature.
The start-up money was not surrendered readily. In fact, in 1988 when the New Haven Health Department asked the state for funds to set up the program, it got the same answer the Maryland General Assembly gave Mayor Schmoke.
"I was told flat out, don't come back," recalled William P. Quinn, head of the New Haven Health Department.
After about 1 1/2 years of hard lobbying by Mayor John C. Daniels, Police Chief Nick Pastore and the medical community, including doctors at Yale University's hospital, the legislature finally came across.
More positive choices
"From November 1990 to November 1991, 900 people enrolled in the program," said Mr. Quinn. "We expected 300."
To date, about 1,600 have registered. The monthly average of clients is about 300. Some have died; some have dropped out; others have made more positive choices.
"The number that is most pleasing to us is that one out of four of them have gotten into treatment," Mr. Quinn said. "People actually come to our needle-exchange vans and ask us to get them into treatment programs."
The New Haven needle exchange is not the first in the country, but it is the first legal one in the Northeast and the most thoroughly evaluated. Most of that was done by Professor Edward Kaplan of Yale's School of Organization and Management.
He showed that since the program started, the incidence of human immune deficiency virus infection among the participating addicts has dropped 33 percent as shown by testing of needles returned.
"We are taking contaminated needles out of circulation," said Mr. Quinn. "We are putting clean needles into circulation."
The New Haven program has changed a few minds previously averse to needle exchange as a method of combating AIDS. Mayor David Dinkins of New York came around; Mayor Sharon Pratt Kelly of Washington endorsed it.
Which is not to say opposition does not continue strong. Many people believe that handing out drug paraphernalia does not square with the law enforcement approach to drug abuse.
Many others believe that such "cooperative" policies might even encourage substance abuse.
New York's Rep. Charles B. Rangel is quoted in The Atlantic magazine as saying the "evidence simply does not support a wide-scale expansion of needle programs. . . ."
Also, the University of Maryland's Dr. Stephen Thomas, director of the Minority Health Research Laboratory at College Park, reports widespread resistance to needle exchange from "some of the front-line leaders in the black community." He and his colleague, Dr. Sandra Crouse Quinn, will publish an article in The Journal of Public Health Policy detailing the nature of this opposition.
Confronting that resistance are the statistics. One, contained in the Atlantic article, is that "a third of the 253,000 AIDS cases in the United States have been linked directly or indirectly to drug injection, and intravenous drug users are the fastest-growing at-risk group."
Of about 830 people in New Haven with "full-blown AIDS, 57 percent are intravenous drug users," Mr. Maldonado said.
In New York, the HIV infection rate among needle-using addicts is about 60 percent. In Baltimore, it's close to 40 percent, Mayor Schmoke says.
Needle exchange programs are proliferating, if slowly, across the country. Last year, about 2 million needles were exchanged, a fourfold increase in two years.
In needle exchange, rapid turnaround of the needles is everything. They have to turn around fast if the program's purpose is to be served.
"What you want," said Dr. Kaplan, "is for the time when the needle is put out to when it is returned to be as short as possible."
The shorter the time, the fewer the addicts who might use the needle -- and the lower the chance of HIV infection.
This was the assumption, but how to test it?
"By interviewing the needles," Dr. Kaplan answered. This, he explained, is done by bar-coding and numbering every needle turned over to an addict, then testing it for HIV when it is returned.
The turnaround time in the New Haven program has been reduced from about a week per needle to two to three days.
"Our idea was that as the circulation time goes down, the level of infection on the needles goes down," Dr. Kaplan said. "And here's the punch line: It does."
L Meanwhile, out on the street, life goes on, after a fashion.
Not long after Beep departed, Donel appeared.
"I use my own name," he said. "I been a dope fiend too long. I ain't trying to hide it."
He's 51, a former Black Panther member who has been on drugs for 34 years. This day he's sick from going without heroin for three days.
Then Gee appears, a middle-aged addict who looks as if he has never seen the sun. He said he has been on methadone for 15 years, and "sometimes it don't work for me."
Gee is followed by Bob, a talkative addict who rejected free condoms.
"I can't get no girlfriend anymore," he said. "Drugs is my woman now."
Then came Spitfire, who kept wiping the sweat from his face with his balled-up T-shirt and speaking in machine-gun bursts. He was high, but not too high to count out his old needles and the replacements.
By the end of the morning, 58 clean needles had been exchanged for 58 used ones. Nine addicts had come into the van within 90 minutes, some HIV-positive, some not.
Some appeared undernourished, some did not; some were chatty, some were sullen; some were sick, some were not. But all were moved to do this much to keep themselves alive.
These are the hardest of the hard-core addicts, the kind who were not expected to have that kind of motivation.
"I happen to think the addicts are motivated," Mr. Maldonado said. "They are used to being treated like the scum of the earth. If you treat them like human beings, with dignity, they will respond. And they are responding."