This article was reprinted with permission from Reader's Digest, where it first appeared. The author changed the names of some of the addicts to protect their privacy.
PARKED NEXT to an abandoned lot on Baltimore's south side, the big cream-colored recreational vehicle seems out of place. So, too, do the dozen-odd men and women who gather by the RV's side door, most of them carrying brown-paper lunch sacks filled with used syringes.
One or two at a time, they step inside and dump the needles onto a table. Casually dressed public-health workers verify identification, then hand each of the men and women another bag with an equal number of brand-new needles. They will use them to inject heroin and cocaine.
Since 1994, the Baltimore City Needle Exchange Program has distributed more than 2 million syringes to some 10,000 addicts. It is the largest program of its kind operated by a local health department, though there are 167 others across the country.
Many are run by AIDS activists and nonprofit groups in violation of drug-paraphernalia laws. The Baltimore program, however, was granted an exemption from state drug laws by the legislature. Baltimore's needle exchange, like the others, is defended principally as a public-health measure. Advocates say that there is a population of addicts who will inject drugs regardless of the law.
At least with a free supply of clean needles, they won't borrow those of fellow addicts and risk infection. Peter Lurie of Public Citizen's Health Research Group, for example, argues that programs like Baltimore's "reduce new HIV and hepatitis infections for drug users, their sex partners and children without increasing drug use."
Many hotly oppose these programs. "The risk that needle exchanges might encourage a higher rate of drug use clearly outweighs any potential benefit," asserts retired Gen. Barry R. McCaffrey, director of the Office of National Drug Control Policy and the nation's No. 1 drug warrior. "The only proven answer lies in comprehensive drug treatment" getting addicts to quit.
Over the course of three months in some of Baltimore's most drug-infested neighborhoods, I talked to drug users inside and outside the needle exchange.
I also interviewed treatment specialists, researchers, public-health officials and police. Evidence that the program encourages a higher rate of drug use was hard to come by. But there was plenty of evidence that it doesn't work as it's supposed to.
The plain fact is, many addicts share their clean needles with others, and sell them to buy drugs.
I met Debra Clark (not her real name) last summer outside the needle-exchange van on Ramsay Street. The 43-year-old had frizzy, shoulder-length brown hair and smoked a cigarette, which she occasionally wedged in a gap between two teeth. Clark told me she had been an addict for several years and stole to get money to buy drugs.
Her apartment, in a run-down neighborhood, was in disarray. Little sunlight filtered through the pulled curtains of an upstairs bedroom; trash, newspapers and clothes were strewn on the floor and piled on a dresser, several of whose drawers were missing. Near the door, a baby slept in a crib. Clark said she was watching the infant for a friend. There was a machete underneath a small TV.
Clark's brother, a heavily tattooed 31-year-old, was sitting, bent over, on the edge of a soiled mattress. Sweating profusely and gagging, the man badly needed a fix. He told me that he had been in and out of jail for assault. He was not in the needle-exchange program.
Clark melted a caplet of heroin in a bottle cap, drew it into her new syringe and injected a vein on the back of her hand. Droplets of blood oozed out as she withdrew the needle, which she handed to her brother. He drew more heroin from the cap, jabbed the needle into his forearm, then put the needle on a nightstand next to an overflowing ashtray. Clark told me that she and every other addict she knew shared needles.
That very day, before we met, she'd shared a program needle with a friend. "If you find somebody who doesn't share, I'll give you $100," she bet. "Common sense tells you not to, but when you feel like you're dying, you don't care." It's a remark I heard again and again.
"The underlying assumption of needle-exchange advocates is that addicts behave rationally," notes Herbert D. Kleber, executive vice president of the National Center on Addiction and Substance Abuse at Columbia University and among those who question these programs. "But often they don't, especially when they are experiencing severe muscle cramps and vomiting, in the throes of heroin withdrawal."
Wearing an orange T-shirt, a white baseball cap and black wraparound sunglasses, Darryl Davis (not his real name) walked slowly up Greenmount Avenue in East Baltimore. "New ones, new ones," he called out. The insides of his tightly muscled forearms were scarred horribly from years of injecting heroin and cocaine.
"The best and fairest that can be said is that the case that needle exchanges work has not been made."
David Murray, director of research, Statistical Assessment Service
At an intersection, I moved away as a man in tan pants and a blue shirt approached Davis. They stepped around the corner. The man handed a dollar bill to Davis, who pulled out a brand-new needle from a small black pouch. This is how Davis, who said he is a former construction worker on disability, spends his days. Enrolled in the needle-exchange program for five years, he told me he picks up 25 fresh syringes from the van, sells some for drugs, then scrounges others to exchange.
Sitting on a stoop, he motioned up and down the street and said, "In these three blocks, there are probably 15 people selling needles. Everybody's got 'em."
And not just in this neighborhood. On another day, at the intersection of Baltimore and Monroe streets across town, drugs, needles and cash are exchanged around the clock.
A woman wanting to buy a syringe approached a needle-exchange participant I was speaking to. He did not have one. "Anybody got some new ones?" he shouted.
Immediately, a man in jeans and dark sunglasses stepped out of a rowhouse doorway and slipped the woman a needle for a folded dollar bill.
"An addict will always find a way to hustle the system," Jerome Rogers (not his real name) would tell me. Rogers, a 47-year-old former heroin and cocaine addict who participated in the needle-exchange program, is in treatment. Selling needles, I learned, is not the only hustle.
Jackie Webster (not her real name) said she started injecting heroin eight years ago. Now the 26-year-old prostitute shoots up 15 times a day. When I met her, she had recently been arrested for carrying syringes containing heroin residue. Released on $1,500 bail, she figured a needle-exchange ID card would be her ticket to freedom.
When addicts are registered in the program, they are given a laminated yellow identification card with a participant number. Holders of these cards, which do not have a name or photograph, are immune from the city's drug-paraphernalia laws and cannot be arrested for carrying needles.
"I'm going to show this card to the judge, and he'll throw my charges out," Webster explained to the two health department workers in the needle-exchange van. Her words were slurred, and she was nearly falling off the bench. The workers grinned at each other while enrolling her in the program, then gave her an ID card and two "starter" needles. After she left, they commented that she wasn't as high as "some of the people we get in here."
Drug treatment or help of any kind was never mentioned. A month later Webster appeared in court, where a judge dismissed the charges against her.
City Health Commissioner Peter L. Beilenson acknowledges that Baltimore's needle exchange has flaws. "Is this a perfect system? No. There's no question it's not."
But, he says, the benefits far outweigh the abuse, which he describes as occurring among a "very, very small" percentage of participants. Officials at the needle-exchange program directed me to Durond Coats (his real name), whom they cited as a success story. Coats had been a heroin addict for 17 years when he registered with the needle-exchange program at age 34.
"Heroin had destroyed my life," he told me. His wife and daughter had left him, and he had lost his house.
Coats remained disease-free, and counselors got him into a treatment program. The former restaurant worker, who said he receives disability for a bad back, has been clean for more than three years: "The needle-exchange program changed my life. Now I get up and go to the library and spend time with my daughter." He is, indeed, a success story. And there are undoubtedly others. But Coats acknowledged that for the first six months in the program, he, too, sold his needles to buy drugs.
Personal anecdotes aside, various studies during the past several years have reported that needle exchanges led to a decline in HIV infection rates. In Baltimore, for instance, Johns Hopkins University researchers reported that the rate of new HIV infections dropped from 4.2 percent to 2.7 percent annually in the four years after the program started.
Critics have pointed to shortcomings in many of these studies, such as relying on self-reporting about disease instead of actual blood testing, small sample sizes, and high dropout rates, which make follow-up impossible.
The Baltimore study did use blood testing, though its sample size, 484, was small in relation to the total number of addicts in the city. David Vlahov, the lead researcher, believes that the program contributed to the drop of infection rates, but cautions that there were probably additional factors, and that the needle exchange was not directly responsible for the drop.
Two of the more comprehensive, rigorous studies that examined needle exchanges were conducted in Canada and published in 1997. The results were disquieting. A study of Montreal's needle-exchange program tested the blood of 1,600 addicts every six months over an average of 22 months. The researchers found a high degree of needle sharing among participants and that they were nearly three times more likely to become infected with HIV as those not in the program. "We believe that caution is warranted before accepting needle-exchange programs as uniformly beneficial in any setting," wrote Julie Bruneau, the study's lead author.
Another study of nearly 1,000 participants in Vancouver's needle-exchange program -- which distributes more than 2 million needles a year -- found that HIV rates among the city's injection-drug users soared from 2 percent in 1988 to 23 percent in 1997.
This research also found a "high level" of needle sharing, including among those infected with HIV. The researchers expressed support for needle-exchange programs. Nevertheless, their study concluded, "Despite having the largest needle-exchange program in North America, Vancouver has been experiencing an ongoing HIV epidemic."
David Murray, director of research for the Statistical Assessment Service in Washington, has reviewed the major needle-exchange studies. "The stronger the studies have been methodologically," he says, "the weaker the conclusion has been that HIV is actually being reduced. That's a real warning sign. The best and fairest that can be said is that the case that needle exchanges work has not been made."
Needle-exchange advocates maintain that these programs should be part of a larger, comprehensive strategy to reduce intravenous drug use and HIV through treatment and other measures.
When Baltimore's needle exchange was debated in early 1994, Beilenson promised that it would "serve as a direct bridge to substance-abuse treatment" and that there would be "an adequate number of treatment slots for those program participants who desire to become drug-free." Since then, despite quadrupling treatment funding over the past five years, the city has only 390 treatment spaces for hard-core users among the 10,000 enrolled in the program. (There are an estimated 40,000 injection-drug addicts in Baltimore.) Day after day, I watched drug users stream into the RVs asking for treatment, only to walk out with bags of new syringes and the news that no treatment spaces were available.
More help needed
One of them, 35-year-old Ronald Anderson (not his real name), was fidgeting nervously outside the needle-exchange RV last winter as he waited his turn. Tall and wiry, with sandy brown hair and a weathered face, Anderson said he had been using for seven years, an addiction that started with painkillers when he was hospitalized for a broken jaw and gradually grew into shooting heroin. Anderson, who is a carpenter, described his addiction as "a miserable way of life, a game of Russian roulette."
He was glad the needle exchange exists but added that what he needed was help breaking his habit, not easier access to more needles. "This program is not helping your addiction," he said. "It's just giving you an endless supply of clean needles with which to put the drugs into your veins."