Allan Clear Letter to NIH

5/7/2004

Honorable Elias A. Zerhouni, M.D.
Director
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892

Dear Dr. Zerhouni:

As you know, the application of public health in the United States is sometimes inhibited by ideological positions that are fashioned by personal belief systems rather than science. Congressman Souder's letter of April 27th regarding the value of harm reduction programs for substance users offers a selective review and distorted interpretation of the wealth of available research on the subject. I would like to address eight inaccurate assertions by Congressman Souder about harm reduction programs and the science evaluating those programs. 

1. "…'harm reduction' is an ideological position that assumes individuals cannot or will not make healthy decisions."

The harm reduction model asserts that individuals will make healthy choices if provided with accurate information and with access to tangible resources such as injection equipment, drug treatment and other health services. Harm reduction is not a deficit model.

2.  "Advocates of this position hold that dangerous behaviors, such as drug abuse, should be accepted by society and those who choose such lifestyles - or become trapped in them - should be enabled to continue these behaviors in a less harmful manner."

Implicit in the term harm reduction is the belief that drugs can cause real harms. However, these harms are not an inevitable consequence of drug use, and can be prevented or ameliorated through a range of strategies that include but do not invariably require complete cessation from all drug use.  Indeed, history suggests that narrowly focusing health promotion and disease
prevention efforts on eliminating the use of all psychoactive substances would be neither feasible or effective.  Therefore harm reduction posits that reducing damage from consumption of drugs (including alcohol and nicotine) is a more realistic and pragmatic approach. In many cases, reducing drug-related harm entails reduction of drug consumption, through interventions that include prevention of initiating drug use, abstinence, maintenance and substitution therapies, and substance abuse treatment.  Harm reduction practice in fact encompasses the promotion of all of these interventions, tailored to meet individual needs and circumstances.  Yet the harm reduction model also recognizes that cessation of drug use can be extremely difficult and can take multiple

attempts, with recurring cycles of reduced consumption and relapse.  Therefore individuals caught in these cycles need support to stave off unnecessary death and disease and other social harms during periods of active drug use.  Congressman Souder mischaracterizes harm reduction practice by constructing a false dichotomy between harm reduction and abstinence-oriented approaches, when in fact these strategies would be more accurately described as overlapping elements within a continuum of care.

3. "These lifestyles are the result of addiction, mental illness of other conditions that should and can be treated rather than accepted as normative, healthy behaviors.  Sadly, harm reduction largely ignores these realities…"

On the contrary, harm reduction workers are perhaps the only people effectively addressing these conditions among the majority of drug users not currently receiving treatment. Indeed, harm reduction takes on all the greater urgency for this population given the limited success of alternate strategies in the United States.  The harms and risks of addiction and mental illness are too often compounded by policies that respond to drug use through incarceration, expulsion from public housing, exclusion from shelter, discrimination and structural barriers to accessing medical care and social services, permanent removal of children, and denial of public welfare and other benefits and financial assistance programs. Harm reduction practitioners recognize and respond to addiction and mental illness as critical health problems that develop and function within an array of cultural contexts and social forces that cannot be reduced or responded to solely through medical models.  Harm reduction attempts to promote and facilitate access to care for addiction and mental illness while recognizing the impact of structural impediments to effective and appropriate treatment.

4. "Sadly, harm reduction largely ignores these realities and programs driven by this ideological position have not been adequately reviewed with unbiased, scientific rigor."

Congressman Souder's contention is insupportable.  The most cursory review of research on harm reduction and syringe exchange programs cannot fail to acknowledge the impeccable reputations of leading researchers from world-renowned institutions, the rigorous peer review process of journals publishing their work, and the reviews conducted by various governmental, medical, public health, and research entities over the last fifteen years validating the design and analysis of this research and endorsing conclusions that support the efficacy of needle exchange and harm reduction approaches to disease prevention.

5. "I am concerned that harm reduction programs that sustain continued drug abuse, such as injection rooms and needle distributions, likely weaken drug abusers' defenses against infection, sustain drug abusers' long term risk for disease, and minimize the benefits of the available treatments for HIV disease."

Congressman Souder is conflating the risks and harms of drug use with the effects of participation in harm reduction programs.  Harm reduction programs do not sustain drug abuse, but rather engage drug users in a continuum of care from which they would otherwise be excluded. Harm reduction and syringe exchange programs have proven to be excellent pathways into drug treatment and medical care, and much of the work and successes of these programs lies in their unique ability to help drug users prepare for, access, benefit from, and remain in appropriate health care and substance abuse treatment.  The notion that participation in harm reduction programs can "sustain continued drug abuse" is completely unsupported by any evidence.  Contrary to Congressman Souder's assertion, harm reduction programs can help maximize the benefits of HIV treatments through education, adherence counseling, and other forms of support.

6. Congressman Souder levels criticism against syringe exchange programs by citing research from Montreal and Vancouver.

It is interesting to note that Congressman Souder could not find any data from the United States questioning the role of syringe exchange programs in HIV prevention. Equally disappointing Congressman Souder's misrepresentation of the findings and conclusions of the Canadian studies, even though lead investigators Strathdee and Schechter have publicly asserted that politicians from the United States have been willfully misinterpreting their research since publication of initial findings in 1997.

By now you will have received letters from prominent researchers in response to Congressman Souder's factual distortions, and these researchers are better placed to defend their field and work.

7. "Needle exchanges focus almost exclusively upon a single mode of transmission among IDUs - sharing of contaminated needles - and largely ignore other important factors such as the individual, the behaviors that cause risk taking, the impact of the substance on the individual and the substance being abused itself."

Virtually all existing syringe exchange programs also address sexual risk among injectors. Syringe exchange programs have helped reduce HIV prevalence among injectors in New York City from 60% to approximately 15% since 1990. This dramatic reduction in HIV rates could not have occurred had programs failed to address sexual transmission in tandem with injection-related risk through education, support, and individual and group counseling. These interventions do not focus solely on injection practices or sexual risk, but rather address the array of conditions jeopardizing the health of drug users, including homelessness, poverty, and lack of adequate health care and access to effective drug treatment.

8. "This scientific and anecdotal evidence appears to indicate that harm reduction programs have failed to provide a prevention panacea for drug abusers against the dangers of HIV, hepatitis and other health risks."

No one has ever suggested that harm reduction or syringe exchange is a prevention panacea for drug users against the dangers of HIV, hepatitis and other health risks. Nor would it be possible to argue that substance abuse treatment or criminal justice policies targeting drug use and drug users have provided such a panacea.  Harm reduction and syringe exchange programs provide another tool, alongside drug treatment and drug prevention, in reducing the damage that drug use causes in the lives of individuals.
Congressman Souder does not provide a plan to combat these difficult issues.  In the absence of better tools than those provided by harm reduction programs, it is vital to expand upon existing harm reduction services and service modalities.  However, I do endorse Congressman Souder's request for a summary of the available scientific data demonstrating: (1)  The impact of drug abuse on the body's immune system; (2)  Impaired decision making that increases HIV risk as a result of drug intoxication; (3) HIV risk by drug users attributable to risky sexual behavior in exchange for drugs and drug money; (4)  Cultural or normative needle sharing behaviors by drug using populations; and (5) Inferior health outcomes among those being treated for HIV infection.

In addition, I am requesting that the NIH compile an authoritative review of all US based, federally funded research demonstrating the impact of syringe exchange programs on: (1)  The spread of HIV among injection drug users; (2)  The spread of Hepatitis B and Hepatitis C among injection drug users; (3) The frequency of injection among injection drug users; (4) The reuse and sharing of injection equipment among drug injectors; (5) The disinfection of used syringes; (6) The entry into drug treatment via syringe exchange programs and associated  treatment outcomes; (7) The number of discarded contaminated syringes in the vicinity of syringe exchange programs; (8) The initiation of non-injectors into injection.  I also request that this review also include an evaluation of research examining the community consequence and public health impact upon the closing of a syringe exchange program.  This data collectively provides a crucial context for the issues raised by Congressman Souder.

I am requesting that this compilation be not only forwarded to the Subcommittee on Criminal Justice, Drug Policy and Human Resources but also to Health and Human Services Secretary Tommy G. Thompson and also to Surgeon General Richard H. Carmona. If you find the evidence compelling that syringe exchange programs have a significant role to play in reducing HIV and other viral infections among drug injectors, their sexual partners and the wider community, then I also request that you make a very strong recommendation that the current congressional ban on the Federal funding of syringe exchange programs be lifted and that harm reduction and syringe exchange programs be recognized and supported as a vital part of a comprehensive strategy to prevent disease and reduce drug-related harm.

Sound science and good public health demands that public policy be guided by the best available research, and that research be pursued free of ideological constraints.  These principles have all too often been discarded in the history of harm reduction and syringe exchange programs in the United States.  I trust that your response to Congressman Souder will help to rectify this scandal.

Sincerely,

Allan Clear
Executive Director
Harm Reduction Coalition
22 W 27th St. 5th Floor
NYC NY 10001