Syringe exchange programs have been controversial since their inception in the 1980s at the height of the AIDS epidemic. Due to their association with marginalized populations, especially drug users and HIV/AIDS patients, syringe exchange programs have also been up for debate recently. Despite their proven cost-effectiveness, syringe exchange programs (SEPs) continue to be framed as efforts that drain government resources and promote drug use. Much of the controversy surrounding SEPs, however, is grounded in politics, rather than medical science.

Syringe exchange programs provide intravenous drug users with clean, sterile syringes in exchange for their used ones. According to a 2005 Center for Disease Control Report, the first organized SEPs in the United States were founded in the late 1980s in Washington, Oregon, California, and New York City. Additionally, New Haven has played a central role in American syringe exchange policy. One of the movement’s earliest and most vocal activists was Jon Stuen-Parker, a Yale School of Public Health student and former intravenous drug user, according to an article on the Yale School of Medicine website.

According to a publication sponsored by the Kaiser Family Foundation, although a government-sponsored needle exchange program was established in the Netherlands by 1984, laws in many American states classified needles and syringes as drug paraphernalia during that time. The Yale School of Medicine article describes how early proponents of syringe exchange, Stuen-Parker included, were arrested for handing out needles in view of police officers. According to a Frontline article, over time, and despite legal roadblocks, syringe and needle exchange programs—both legal and illegal—were established in many major cities by the early 1990s. These programs adhered to the public health philosophy of “harm reduction,” an approach that the Kaiser Family Foundation’s report describes as recognizing “that many drug users fail to abstain totally.” Because the public health community has acknowledged that drug users will likely continue to inject drugs using needles furnished by SEPs, syringe exchange programs have drawn the ire of politicians for decades.

The opposition to syringe exchange programs is multifaceted and includes law enforcement, district attorneys, community organizations and, most critically, the federal government. Tension between groups advocating for and against the establishment of these programs arises largely from what a 2006 American Journal of Public Health article by Dr. Barbara Tempalski calls a “struggle[…] between law enforcement and medical providers as to whether drug users should be defined as criminals or medical patients.” This debate is rooted in the history of the United States; since President Nixon declared a “war on drugs” and drug use as America’s “public enemy number one” in a June 1971 speech, elected officials have a vested interest in appearing “tough on drugs” to voters. Subsequent presidents have instituted mandatory minimum sentences for drug possession, established the Office of National Drug Control Policy, and devoted billions of dollars to curbing the import and use of drugs. Indeed, drug policy in the United States has been formulated to punish drug users rather than focusing on the drug using population’s health or rehabilitation.

The government’s approach to drug use is the opposite of harm reduction; rather than directing resources and attention to those who currently use drugs, current policies aim to prevent drug use. Consider D.A.R.E. (Drug Abuse Resistance Education), founded in 1983 by Los Angeles Police Department Chief Daryl F. Gates, according to the D.A.R.E. website. The website explains that every president since Ronald Reagan has declared one day a year to be “D.A.R.E Day”; the DARE curriculum is taught in all 50 states to 26 million children, as estimated by the Independence County Sheriff’s Department, and the program states on its official website that it receives funding from federal sources.

A more critical look at D.A.R.E. reveals that this program is not without controversy. Founder Daryl F. Gates famously declared that casual drug users should be shot and later refused to retract his statement at an L.A.P.D. Medal of Valor banquet. Additionally, the United States General Accounting Office in 2003 found “no statistically significant differences” for drug use between groups that had undergone D.A.R.E. education and those that had not. This program, which has not been shown to meet its stated goal, continues to receive both support and funding from the federal government.

Syringe exchange programs face the opposite problem: studies have proven they are effective, yet they lack government funding. According to the Center for Strategic International Studies, Congress passed six bans between 1988 to 1993 on the usage of federal funding for needle exchange programs.

In spite of political inaction, SEPs serve an important and cost-effective public health purpose. In a 1997 report on interventions to prevent HIV risk behaviors, the National Institutes of Health stated that “an impressive body of work suggests powerful effects from needle exchange programs […] studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs [intravenous drug users].” More recently, in 2000, former Surgeon General David Satcher said, “There is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces transmission of HIV.” A 2004 World Health Organization policy brief, “Provision of Sterile Injecting Equipment to Reduce HIV Transmission,” compared an 18.6% decrease in the HIV rate in 36 cities with needle exchanges compared to an 8.1% increase in HIV rates in 67 cities without needle exchanges. Peter Lurie and Ernest Drucker in their 1997 Lancet article, “An Opportunity Lost,” estimated that a national implementation of syringe exchanges in the late 1980s would have saved 20,000 lives and $1.1 billion in healthcare costs by the year 2000. Syringe exchanges also help prevent the transmission of other diseases spread by blood, most notably hepatitis C, which as of 2007, killed more Americans than HIV, according to a post on the Scientific American blog.

Opponents of syringe exchange programs are largely concerned with the lack of zero-tolerance drug policies. Providing needles to use drugs can be seen an implicit endorsement of drug use, even though many syringe exchanges offer referrals to drug rehabilitation and treatment facilities. Communities may also worry that syringe exchanges will draw drug users to their neighborhoods and increase crime. However, a 2001 report by the San Diego Clean Syringe Exchange Task Force reported that intravenous drug users mostly leave neighborhoods after receiving their clean needles and cause no significant increase in crime.

The contentious nature of federal support for syringe exchanges demonstrates the highly political nature of the issue and highlights the importance of governance and public opinion in health interventions. Despite recommendations from numerous health organizations, SEPs have failed to secure long term federal support due to conflict with the government’s zero tolerance drug policy. When public health programs request federal funding, they necessarily become a political issue. However, there is still hope for syringe exchange programs: the FY 2013 budget has not yet been finalized, meaning that funding bans for syringe exchange have not yet been made into law.

References:

1. Centers for Disease Control, “Syringe Exchange Programs”, December 2005, http://www.cdc.gov/idu/facts/aed_idu_syr.pdf
2. John Curtis, “What the Needles Said” , Yale Medicine Magazine, Summer 2001, Vol. 35, No. 3
3. Sandra D. Lane et al, “Needle Exchange: A Brief History,” http://hpcpsdi.rutgers.edu/facilitator/SAP/downloads/articles%20and%20data/History+of+Needle+Exchange.pdf
4. “Needle Exchange: A Primer”, May 30, 2006, http://www.pbs.org/wgbh/pages/frontline/aids/past/needle.html
5. Open Societies Institute, “What is Harm Reduction?”, January 1, 2001, http://www.soros.org/initiatives/health/focus/ihrd/articles_publications/articles/what_20010101
6. Barbara Tempalski et al, “Social and Political Factors Predating the Presence of Syringe Exchange Programs in 96 US Metropolitan Areas,” American Journal of Public Health, March 2007: 97 (3), 437-447. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1805016/
7. “Timeline: America’s War on Drugs”, April 2, 2007, http://www.npr.org/templates/story/story.php?storyId=9252490
8. “D.A.R.E. Keeps Good Company”, http://www.dare.com/eNewsletters.asp
9. “About D.A.R.E.”, http://www.independenceso.org/dare/
10. “About D.A.R.E.”, http://www.dare.com/home/InsideDAREAmerica/Story43fd.asp?N=InsideDAREAmerica&S=13&S=28
11. Eric Malnic and Elaine Woo, “Controversial LAPD Chief,” April 17, 2010, The Los Angeles Times, http://articles.latimes.com/2010/apr/17/local/la-me-daryl-gates17-2010apr17
12. “LAPD Chief Gates Speech on Casual Drug Users (private investigator)” , http://www.youtube.com/watch?v=ihvEgkn5BUc
13. United States General Accounting Office, “Youth Illicit Drug Use Prevention : DARE Long-Term Evaluations and Federal Effots to Identify Effective Programs,” January 15, 2003, http://www.gao.gov/new.items/d03172r.pdf
14. Matt Fisher, “A History of the Ban on Federal Funding for Syringe Exchange Programs”,  February 6, 2012, http://www.smartglobalhealth.org/blog/entry/a-history-of-the-ban-on-federal-funding-for-syringe-exchange-programs/
15. “US Surgeon General’s Latest Research Review Supports Needle Exchange Programs,” http://stopthedrugwar.org/chronicle-old/142/satcher.shtml
16. World Health Organization, “Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug Users,” 2004, http://www.who.int/hiv/pub/prev_care/effectivenesssterileneedle.pdf
17. Ernest Drucker and Peter Lurie, “An Opportunity Lost: HIV infections associated with a lack of national needle-exchange programme in the US” , The Lancet, Volume 349, Issue 9052, pp 604-608, March 1, 1997, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(96)05439-6/fulltext
18. Katherine Harmon, “Hepatitis C Now Killing More Americans than HIV”, The Scientific American Blog, February 20, 2012, http://blogs.scientificamerican.com/observations/2012/02/20/hepatitis-c-now-killing-more-americans-than-hiv/
19. San Diego Clean Syringe Task Force, “Clean Syringe Exchange Program,” 2001, www.sandiego.gov/communityservices/cleansyringe/taskfreport.pdf