Getting The Point In New Haven

By DICK THOMPSON NEW HAVEN

THE VAN, PAINTED WITH VIVID stripes and a rising sun, plies the drearier streets of New Haven, Conn., drawing eager throngs like some dark version of the Good Humor truck. Four times a week, the "dope fiends," as they call themselves, line up to enter the vehicle. They identify themselves to city workers by their code names ("Carol Burnett," "Streetcat," "Wizard") and, in exchange for used needles, receive survival kits: bottles of bleach, bottles of water, clean needles, and condoms. They do this because they are terrified of the epidemic that is raging through their city. "Just because I shoot drugs doesn't mean I don't care about AIDS. I care a lot," says a petite white woman, 45, who works as an executive assistant. That's right, says a dope dealer known as "Philip Morris": "Heroin don't make you retarded."

No, it doesn't, but for years the acrimonious debate over how to protect heroin users has impeded efforts by health authorities to control the spread of AIDS. Civic leaders have been caught up in moralistic arguments over whether providing clean needles to addicts would only accelerate inner-city drug abuse. In minority communities, opponents insisted that needle handouts were akin to genocide. Meanwhile, AIDS raced through intravenous-drug-using populations. Today one-third of the nation's AIDS cases originate from IV drug use. More specifically, 71% of all females with AIDS are linked directly or indirectly to IV drug use, as are 70% of all pediatric AIDS cases. Still, health experts wrangled over what to do.

Suddenly that has changed. In a dramatic turnabout, New York City last week announced that it would support a needle-exchange effort, two years after Mayor David Dinkins halted such a program. The mayor of Washington also called last week for needle exchange for addicts, as well as the distribution of free condoms in city schools and jails. Rhode Island, New Hampshire and Connecticut will probably soon take the even more dramatic step of decriminalizing the possession of hypodermics. Movements are under way in New Jersey, California and Massachusetts to remove legal barriers and begin officially sanctioned needle programs. Even in the U.S. Congress, Charles Rangel, who has led opposition to needle exchange on the ground that it threatens blacks, has asked the General Accounting Office to reevaluate the effects of such programs.

The most important catalyst for this change has been the experiment conducted in New Haven. The two-year-old program has demonstrated that needle exchange dramatically slows the rate of infection without encouraging new IV drug use. Some indicators even suggest that the program has been responsible for a decrease in both crime and the amount of drugs used illegally. The city's new police chief, Nicholas Pastore, claims that crime actually dropped 20% over the past two years, perhaps because of the improved relationship between city workers and the community. Meanwhile, referrals to drug-treatment centers increased. These results have enabled policymakers elsewhere to break the logjam. Says New York City's health commissioner Margaret Hamburg: "It all came together in the New Haven experiment."

New Haven, unfortunately, had all the right ingredients. The city of 130,000 surrounding Yale University is the seventh poorest in America. The community is 45% black, 15% Hispanic and 40% white, and with 2,000 heroin addicts, it has roughly the same proportion of addicts as New York City.

But unlike New York and most other urban centers, New Haven had a group of public-health workers who, when faced with the AIDS epidemic, pulled together to confront a politically dicey issue. "It was a very methodical process," says Elaine O'Keefe, director of the AIDS division for New Haven's health department. The New Haven workers spoke out about the value of needle exchange at civic meetings, classrooms and churches. Then, after building support from the ground up, they forced the issue into local elections. A special act of the state legislature was required to lift the ban on possession of hypodermics. After lobbying by health workers, the measure passed easily. Their efforts also helped defuse the race issue. "One thing was surely true," says black state representative William Dyson. "To do nothing was to ensure genocide."

One of the last converts to the cause was John Daniels, the city's first black mayor. Concerned at first that the program would promote drug abuse, Daniels changed his mind after seeing AIDS-infected newborns in the city's hospitals. Today he says he was wrong to impose his own moral standards on a community so desperately in need of help: "If giving needles saves a life, I support it. If giving a youngster a condom prevents AIDS or a baby with AIDS, I support it."

Support from the police has also been essential to the success of the experiment. Police chief Pastore, who has worked hard to reduce friction between cops and city residents, sees to it that his officers cooperate with the needle-exchange van. If, for instance, a police car patrols too close to an exchange site, a quick call to the chief will trigger a radioed instruction sending the car in another direction. Ultimately, Pastore hopes to restore trust between police and addicts who may need their help.

Gaining trust was a major hurdle for workers manning the needle van. Robert, a 36-year-old convicted armed robber, remembers thinking the van was part of a police sting operation. "You're not used to nobody helping you and wanting nothing in return," he says. Eventually, outreach workers in the van helped him apply to a treatment program to end his 16-year addiction to heroin. To date, more than 200 addicts have been funneled through the van and into drug- treatment programs. Nonaddicts have also turned to the van for help. Teenagers flag it down and ask for condoms. It has, in a sense, become one of the few visible expressions of the city's desire to help poor residents. "The people here are so used to being treated bad, they internalize that and think they're bad," says outreach worker Dominick Maldonado.

A major goal of the program has been to get contaminated needles out of heroin shooting galleries, where, according to one New Haven study, more than 90% of needles are contaminated with the AIDS virus. Addicts in these galleries can "rent" recycled needles either for money or for an exchange of drugs. After each use, addicts clean the needles in a pail of water set out every morning by the operator. The water starts out clear, but it is bloodred by afternoon. "We don't know who all got the virus," admits the proprietor . of one such establishment. By exchanging needles, the project also reduces the number of contaminated needles that find their way into the city's parks, playgrounds and schools. "We used to find needles scattered throughout the building," says Edith Rawls, resident director of the downtown Y.M.C.A., which houses 131 men and women (75% are addicts). "There were dirty needles in the hallways and the bathrooms. Children would see them outside and pick them up."

What has made the New Haven experiment so compelling is that researchers independent of the program did the analysis. In fact, since the state provided no money for the evaluation of the program, Yale scientists donated their time and equipment. Using the advanced techniques of molecular biology, they were able to "interview the needles" to track the spread of the virus. All needles provided by the van are coded. When the needles are distributed to addicts, the numbers and participants' code names are fed into a computer along with the date and location. When the numbered needles are returned, they are tested for HIV, and the results are run through the computer. Such studies confirm that the program has shortened the length of time needles are in circulation. "This means the number of sharing opportunities is going down," says Yale's Edward Kaplan.

The researchers were also able to put to rest the concern that free needles would entice youngsters into IV drug use. The average participant in the program is 35 and has been shooting drugs for seven years. "We are not encouraging kids from the local high school," says Kaplan. Most important, researchers established that within six months of the program's start, the rate of new infections had dropped one-third.

While these lessons have impressed lawmakers from New York to California, they have failed to budge the Bush Administration, which continues to maintain that needle programs promote drug abuse. "When you use drugs intravenously, that clearly shows you're not concerned about your health," says Bob Martinez, the nation's "drug czar." The lines snaking out of New Haven's van would seem to prove him wrong.