You get your flu shots and wonder how dirty needles transmit AIDS. Our own health compels those of us who have never been pricked by a hypodermic needle outside a medical facility to cast off our naivete. Self-injection of drugs foments a looming public health emergency.
Users inject drugs directly into veins. To assure they achieved penetration, they first draw back on the syringe until they see blood. Often after injecting they draw blood back into the syringe and reinject it, thus assuring they have received the full measure of the drug.
A microscopic component of the user's blood suffices to transmit to the next injector human immunovirus (HIV, the scientifically accepted cause of AIDS), hepatitis B and lesser blood borne diseases. Not surprisingly, HIV has spread through the needle-using population much as it spread through the gay male community.
So who cares if the dregs of society kills itself by its own misbehavior? A growing and consistent body of medical knowledge informs us we all must care, not as a matter of charity but as a matter of survival.
San Diego County is a good place to learn to care. Federal law enforcement identifies our home as both manufacturing and consuming the most methamphetamine per capita in the country. One in five San Diego meth users prefer to inject; elsewhere, users virtually all ingest by snorting. The county also ranks in the national top three for heroin use and first for "polydrug" (smorgasbord) abuse.
The HIV-infected population of the county grows steadily. Drug injectors cause much of this growth, both by exchanging contaminated needles and by having unsafe sex with people who do not inject.
Injection drug use results in hospital emergency room and hospital admissions for which the public foots the bill. Users not only overdose, they seek treatment for acute hepatitis and other communicable diseases. Police and emergency room contacts also result from domestic violence and other fights.
Pathetically, users give birth to addicted and infected babies who start their lives as wards of the state. As custodial parents, they often neglect or abuse their children.
Drug use drives two forms of crime. Users commit crimes to acquire wealth to obtain drugs. Sellers by definition are criminals. Drug sales provide the economic base for criminal syndicates ranging in size from localized gangs to international cartels.
Immune-suppressed drug users are becoming a reservoir of contagious diseases that pose grave risks to the general population. Drug-resistant strains of tuberculosis, for example, transmit without sexual contact.
Why didn't somebody do something about this?
When a previous administration announced its war on drugs, one justification was to end the suffering drugs caused their users. Although it did not admit the full extent of the public health risk, it applied a simple and reasonable logic to the concept of prevention. If there are virtually no drugs, there will be virtually no drug problems.
At the beginning of the war on drugs, I predicted we would lose and drugs would win. This has proved correct, and not for any lack of fighting effort. Two simple economic facts explain the loss. First, this nation has too much disposable wealth to spend on self-medication, even if much of it must be wrongfully appropriated. Second, people in other nations make too much wealth by supplying us, and we fuel this economic engine by making drugs illegal.
Interdiction of supply will not solve or even salve the problems resulting from drug injection. Neither can we afford, economically or morally, to create concentration camps for everyone who shoots up. We must deal with the users as we find them, abroad in society.
Confronting drug use challenges much in the American psyche. Users fall to the bottom of every social ladder. For example, gay drug injectors tend to be pariahs in the gay community. Not only are drug users the American untouchables, what they do is illegal. The American instinct is to prosecute and jail them. These two factors make it extremely difficult for them to communicate with us; they know we despise them and we would lock them up if we could.
One point of contact exists between us and them - the needle. They can't shoot up without the syringes made by legitimate businesses. Traditional efforts to prevent drug use have included criminalizing possession of a hypodermic syringe without a license or prescription. The resulting scarcity requires reuse and sharing of needles. Thus the law becomes a vector of disease.
Clean needles provide an opportunity to have impact on people who inject drugs. Users are not ignorant of the risks of sharing needles. Those risks have lower priority than food, shelter and their drug disease. The users will, however, capitalize on a risk-free opportunity to obtain a new needle.
By declaring a state of health emergency, communities may suspend enforcement of needle-possession laws. Then, service organizations can provide needle-exchange programs. The core of these programs is the trade of a used syringe for a clean one.
Does needle exchange promote drug use? This is the first question almost any American asks about needle exchange programs. The answer, so far, is no. Studies of programs in such diverse cities as San Francisco, Portland, Tacoma, New Haven and New York City show that needle exchange does not recruit injecting drug users, nor does it add to the number of injections per user or the incidence of discarded needles on the street.
Needle exchange programs begin with the syringe transaction but comprise much more. They create contact between the world of users and the society at large. They provide multiple health services, especially the base, encouragement and opportunity to begin the lifelong process of being sober.
In June of 1994, the San Diego County Grand Jury recommended acceptance of needle exchange programs here. Neither the county nor the city of San Diego has acted. In August of 1994, the mayor of Los Angeles, Richard Riordan, declared the AIDS epidemic a state of emergency and told law enforcement to refrain from interference with legitimate needle exchange programs.
Perhaps nothing happened here because drug users have no constituency. Local media have decidedly underplayed the story of the growing costs and risks to the general population arising from HIV-related diseases. There is legitimate concern about local government willfully refusing to enforce statewide law. It would be better to create statutory authorization in Sacramento first, but must San Diego wait for permission to address its epidemic?
Certainly electoral politics played a role in the local do-nothing approach. It remains popular to understand drug abuse as neither more nor less than a moral problem. At the extreme, some people believe AIDs, hepatitis, tuberculosis, poverty and lice are God's earthly punishment for sin.
November's results suggest the moral approach to the AIDS epidemic and its hypodermic vector may hold sway for several years. It will be as effective as a pocket full of posies was in warding off plague.
At the bottom, the moral approach is irrelevant. God has an eternity to punish sinners. The job of government is to promote the public health in its tangible and temporal jurisdiction. Both the Board of Supervisors and the San Diego City Council should get on with the job.