A New York Needle Exchange in Action
The Fix reports from the Washington Heights Corner Project, where participants and staff members share some surprising truths about how harm reduction works on the ground.
Around 6 pm on a spring evening, I walk with Hector Mata through an area of northern Manhattan known as “the Zig-Zag," sculpted by the off-ramps of the George Washington Bridge. We pass a playground, go down through a woodsy area, slip through a hole in a fence, and step into a clearing next to a highway. We see cushions, blankets, a makeshift tent and a near-human-sized doll. A real woman is sitting against a stone wall.
"That's Chris," says Mata. As she hears us approaching, she looks up, startled. "It's just me, Hector; you don't have to be scared," he calls out. She relaxes. A man pokes his head out of the tent. "You guys need needles?" Mata asks.
"Yeah," Chris replies. She’s a young white woman, her face badly burnt. Mata later explains that the burns are from the crack pipe getting too hot. Because ruptures in the skin are common, particularly on the lips, sharing paraphernalia can spread HIV and Hep C. He gives them clean needles, as well as cookers for crack, “chore boys” (copper wool used for smoking crack—the cheap stuff from the store can release carcinogens), and stem tips (the pieces for the end of the pipe). “Do you mind if...?” Chris asks, trailing off.
“Hey, we’re in your space,” Mata replies. Chris pulls a torn sweater over her head to form an expedient shelter, takes a hit of crack and walks away a little to exhale. The air takes on a sharp, plasticky smell.
Hector Mata is doing outreach work for the Washington Heights Corner Project (WHCP), a needle exchange, harm reduction and community program. He grew up in the neighborhood; his father was a "big-time drug dealer." For the past two and a half years, he's been working to help drug users. As we walk away, he makes a sound of disappointment. "I forgot to ask if they needed condoms. Did you see the way they were lying down together? A lot of sex gets exchanged for drugs. I'll get them to them next time."
"Someone may want to stop crack, but not heroin. That's still a step. We believe in 'any positive change.'"
Mata's comment to Chris—"We're in your space"—captures WHCP’s attitude. Taeko Frost, the program's executive director, says they try to embody the concept of "meeting a person where they are." WHCP provides sterile syringes and injection supplies, safer sex and safer smoking supplies both on the streets and at its center on West 181st Street. The program also offers a wealth of services on site: case management, counseling, nurses, hepatitis testing (over 50% of participants test positive), STI screenings, pap smears, volunteer med students and doctors and more. Everything is free, and participants are never asked for ID or Medicaid. And there's no limit on the number of clean needles they can obtain: Some take up to 500, Mata says, "and we have a really high return rate"—cutting the chances of someone else handling a used needle.
The CDC estimates that 1.1 million people in the US are living with HIV. Around 50,000 people become infected each year, and drug users’ sharing of contaminated needles accounts for 7–14% of that total. Syringe exchange programs have been shown to substantially reduce the chances of this form of transmission. Yet almost continually since 1988, there has been a ban on federal funding for such programs. WCHP is funded primarily by the New York State Department of Health, with additional support from NYC Department of Health and other grants and donations.
The sun begins to set over the Zig-Zag. "We'd better get back," Mata tells me. "It's not such a good idea to be walking around after dark for you." Back at the center, he shows me around. An altar at the front commemorates participants who have passed away. "OD is a huge thing here," he comments. The office is filled with harm-reduction items: flavored condoms, dildos, a map of pharmacies that sell syringes for when WHCP is closed, fliers about injection procedure (like this one) and homemade posters. One, entitled "This Damn Dirty Needle," reads: "I don't approve of drug use, but I know clean needles will help keep my daughter alive while she's using drugs."
Drop-in center coordinator Hector Mata
A drop-off for used needles stands alongside a veritable store of free goods available to participants: toothbrushes, lube, tourniquets, more chore boys, water to mix with heroin, saline, cotton, gauze, multivitamins, deodorant. There's also chocolate and soup, thanks to the advocacy of the Participant Advisory Board—a group of participants who meet weekly to discuss program issues, formed with the idea that the people who are being helped have insight into what will help the most.
This mindset is evident in one of the most important strands of WHCP's mission: Peer-delivered syringe exchange. The pilot program trains injection drug users to give out syringes among their own social networks. Initiated in 2006, it’s regulated by New York State Department of Health. All of New York State’s 13 syringe exchange outreach organizations have some form of program for peers, utilizing their ability to deliver resources to isolated communities.
WHCP peers are generally paid $150 per two weeks, plus up to $25 for cell phone use and monthly unlimited MetroCards. WHCP selects participants to become peers through an application system, and Frost says the positions are coveted. The most important criterion is "very good listening skills." But if an applicant writes that they want to get "clean," or go to detox or rehab, it's usually a deal-breaker—as a peer, they'd have to be around drugs and drug users constantly, so WHCP will turn them down for the peer job, and help them to achieve their stated goal instead. Still, both Frost and Mata say that many people who become peers stop using anyway, even if that wasn't their original intention. The role has that effect.
Peers go through the same training as staff to learn about safer sex, laws around drug use and harm reduction. There can be challenges in employing drug users: The peers usually work about 10 hours a week, but "we don't assign shifts," says Frost. Like all participants, peers "may or may not be open about what they're using" and "may or may not be homeless." The advantage is that "a peer may be the only person the participant will accept." The original intention was to train drug users in syringe disposal and safe injection, so they could show their own friends and partners. But it’s turned into much more: "They are seen as leaders," Frost says.
So why does opposition to programs like WHCP mean that the ban on federal funding for syringe exchanges—Obama overturned it in 2009, before Congress reinstated it in 2011—remains in place, despite the pleas of AIDS activists?
"We're opposed to needle exchange programs in general because the goal is abstinence,” David Evans, a special adviser to the Drug Free America Foundation, tells me. “Abstaining is the only way to prevent the harm to the individual. Giving needles is enabling drug addicts to continue their drug addiction. We're opposed to anything that would enable people to continue their addiction. These people don't die from HIV, they die from other things related to their drug use... Needle Exchange programs make it easy to be a drug addict."
A video on WHCP's website states, "Research has shown that syringe exchange does not encourage drug use. In fact, NIH found that syringe exchanges reduced risky or harmful behavior by as much as 80% in injecting drug users, reduced HIV transmission rates by 30% or more, and removed nearly 25 million used syringes from US communities."
The Drug Free America Foundation is based in Florida, but in New York, too, there are skeptics. In 2010, the state passed a bill to reduce sentences for people carrying syringes with drug "residue." Thomas W. Libous, one of the senators who voted against, says he's "never been keen on exchange programs."
Taeko Frost responds to critics by saying that she thinks it's "a natural reaction—harm reduction can be counter-intuitive." She says the broader argument is about human rights: "Who are we to say what is the right thing for someone?" And she stresses that "syringe exchange is a stepping stone to other services... Realistically, many people who get housing, medical treatment and mental health treatment have gotten those things because this is not an abstinence-based program."
"If you are a homeless active drug user with a criminal record, you may not feel comfortable walking into a place to get services,” Frost continues. “Here, they will be more honest about what their goals are, what they are using, and thus be more successful. Someone may want to stop crack, but not heroin. That's still a step. We believe in 'any positive change'—positive being defined by the participant, not the service provider."
Samantha Olivares, or "Sassy," became a WHCP staff member after first being a peer. Now 42, she never imagined she would become homeless. "I'm kind of a riches to rags story," she tells me. Her rebellious nature earned her her nickname as a child, from her grandmother saying, "Don't sass me." When she married "out of my race," her wealthy Long Island family disowned her. Eventually, she wound up on the streets, with a $400-a-day crack habit. She came to WHCP, like all peers, as a participant, having used and dealt drugs for 13 years. The center gave her "a new life," and helped her to “get my face back.”
Outreach worker Samantha "Sassy" Olivares
Becoming a peer boosted her self-esteem, and she eventually managed to quit drugs, detoxing on her own with friends looking out for her. Hired by WHCP as an outreach worker last September, she feels proud, though it can be hard: "Addicts don't always like other addicts to be clean. But I'm not snooty. I'm helping others who were my family. I may be inactive now, but I'll always be an addict." I ask how being around drug users and drugs affects her sobriety. "When participants come in smelling like crack," she smiles, "it's like a chocolate bar." To resist the temptation, "I see myself starving under a bridge. And think of my kids."
Robert, a WHCP peer, is one of the center's heroes. Last year, he personally gave out more needles than the whole of the rest of the office combined. Originally from Puerto Rico, he's 57 and grew up in the Bronx. He wears glasses and a Yankees hat, and speaks in a slow, hoarse voice.
"It all started with being homeless," he says. He worked as a printer for 25 years and as a maintenance worker for 12, but then lost his job. He wound up "here in the Heights, and met some guys I'd hang out with. All addicts." Robert himself had first used heroin at the age of 14. But one of the men he met was a peer at WHCP. He told Robert, "This place can help you." At the center, they got him an ID, examined and treated him at the clinic—"They found a whole mess of stuff wrong with me: Diabetic, high blood pressure, kidney stones, aneurism in the abdomen"— and helped him get Medicaid. They also put him on the road to finding housing.
Meanwhile, Robert noticed that a lot of the addicts he knew would pick up dirty needles and use them. He told them, "I don't understand; you can easily get boxes of needles, yet you don't. At 3 am I see you hunting for dirty needles. I'm gonna start carrying needles for you so you won't have to use dirty ones." Little by little, Robert says, people started to come to him for needles. When a peer job was posted, Robert's case manager encouraged him to apply. "I don't know anything about harm reduction," Robert said. "You're already doing it," the case manager replied.
That was two years ago. Robert still uses heroin: "I don't use as much as I used to but I'm not gonna sit here and lie to you. But I don't drink and don't smoke crack." He now has an apartment, but homeless participants trust him because he was out there with them and knows what it's like. "A lot of people think we're homeless because we don't want to work," he says. "I worked all my life; never in my life did I think I would be homeless. I used to see homeless people and say, ‘Why would I give that person money when they are going to spend it on drugs?’ I never thought, were they maybe really, really hungry?"
One vital element of training is overdose prevention. Staff, peers and participants are all trained in administering Naloxone, which reverses opioid OD. Part of outreach includes handing out Narcan (the brand name for Naloxone) rescue kits, which WHCP is licensed to do. In 2006, New York State made it legal for a non-medical person to administer Naloxone to another to save their life. “It doesn't do any damage if the person is not overdosing on heroin,” says Frost, “so there's really no downside." Sometimes participants carry around the kits with notes attached: If I'm blue, spray this in my nose.
Though safe injection sites are illegal in the US, needle exchange programs end up providing de facto "oversight" that is otherwise lacking.
Frost says her team has reversed many overdoses—20 or 30 at the center alone. After administering Narcan, they call 911. But Mata says he often tells participants that if they’re in that situation, they shouldn’t mention overdose: In spite of New York's 911 Good Samaritan law, ensuring that the caller won't get arrested, discrimination means that ambulances tend to take longer to respond to OD calls. Mata tells participants just to say that someone "stopped breathing."
Besides discrimination from medical workers, there's the police to worry about. Although state law says anyone with a Syringe Exchange Program (SEP) card can legally carry syringes—even, as of 2010, syringes with "drug residue" on them—the laws are often not known or ignored. Mata says that sometimes police even throw away the SEP cards and arrest participants anyway. WHCP works to strengthen its relationship with the police; staff attend morning roll call at the precinct, to show SEP cards to cops and explain how they work. "We're not telling them how to do their job," says Frost. "We're just saying, 'Don't tack on a syringe charge to an arrest.'"
WHCP doesn’t only supply clean syringes to heroin and crack users. There’s a big need in the transgender community: "Some people use needles for hormones, or for silicone injections," Frost says. Syringes are also delivered to several gyms, because "men are injecting steroids there." These deliveries are made by bike, though Frost says she'd love to have the money for a truck. While most participants are local, plenty come in from New Jersey; drug users from across the river report that needle exchange spots there are always out of syringes.
If the federal funding ban were lifted, programs like WHCP would have far more potential for expansion, such as the ability to stay open 24 hours. Ideally, Frost says, US drug policy would also allow supervised injection facilities, like Insite in Vancouver. "People are overdosing and dying because they don't have a safe place to use," she says. "People need to not be in a rush when they inject drugs, and they need appropriate oversight."
Though safe injection sites are illegal in the US, needle exchange programs end up providing de facto "oversight" that is otherwise lacking. The Harm Reduction Coalition, a national advocacy organization, has a weekly podcast, with one installment entitled "Bathroom Etiquette: Injecting at the Exchange." The host explains that "A lot has been written about…supervised injection sites, and yet not very much has been done around bathrooms in needle exchange programs... We don't want to think about staff injecting in bathrooms, we don't want neighbors to think that's what’s happening. But how are organizations actually making needle exchange bathrooms safer?”
All the interviewees on the podcast—staff from needle exchange programs around the country— are anonymous because of how controversial the subject is. One woman who works at a needle exchange program in "Wichita, Kansas" says that there they line up participants and have them do push-ups and drink water. This makes injecting easier and faster, so there’s less of a hold-up for everyone waiting for the bathroom. The interviewer comments that there are, in effect, "injection facilities throughout the program that no one talks about." How did this happen? The woman explains that when her program started, "we did not allow bathroom access, then we'd get complaints from neighbors saying that people were injecting near the site. So…the thing to do is say, ‘We have had fatal overdoses in public restrooms in our neighborhood, so it would be negligent not to have safety precautions at our own location.’"
At WHCP, many participants are homeless—and New York, as Frost notes, "has a severe shortage of public bathrooms." So what’s their policy about injecting drugs in their bathroom? "People will do what they're going to do,” says Frost. “There are no cameras in the bathroom... It is not a supervised injection site, but it is meeting an important need that is being ignored. People are using in public bathrooms anyway, and ours is a better option than Starbucks or a public library." Of the numerous overdoses that have occurred on site, not one has been fatal: “We have a system in place to prepare for overdose and administer Naloxone."
Executive director Taeko Frost
As we're talking, Frost points at a plaque on the wall. It says we’re in the "Michael Carden Memorial Conference Room." Michael Carden was a WHCP board member who was also a project director at SUNY Downstate Medical Center in Brooklyn, and held a position at the Center for the Study of Hepatitis C at Weill Cornell Medical College. He recently died from a heroin overdose. Frost says that many people were surprised that someone so successful was a drug user—and that people often have the same reaction when they visit WHCP. “Med students, volunteers always say about participants, 'I would have never guessed he was a heroin user,'” she says. “Drug use comes in many forms, just like mental illness. For anyone critical of what we do here, I'd really urge them to come check it out."
Sarah Beller is a writer and social work intern who lives in Brooklyn. Her work has appeared in The Hairpin, xoJane, Lilith Magazine and Thought Catalog and frequently in The Fix, where she recently reported on drug courts.