Needle in a haystack

(in Washington) - Donna Shalala and her scientific advisers looked distinctly uneasy. Conservatives watching her April 20 press conference might have been excused for diagnosing her discomfort as an unaccustomed bout with conscience. After all, the HHS secretary-long an advocate of giving clean needles to intravenous drug users to slow the spread of AIDS-was now passing up the opportunity to pass out more. To the consternation of AIDS activists and many public-health officials, Ms. Shalala announced that the Clinton Administration was opposed to federal funding of needle-exchange programs (NEPs).

Republican leaders on Capitol Hill were as surprised as anyone at the news. Sensing a political opening, they had prepared to blast the president for encouraging drug use in the name of AIDS prevention. "The ammunition was loaded," confided a high-ranking Republican aide. "We were ready to go with a news release essentially blasting Shalala and the administration if they were to support federal funding."

As press secretaries scurried back to their computers to fashion an updated response, AIDS activists were hastily organizing a demonstration for the following morning outside HHS headquarters. Everyone in Washington, it seemed, was taken aback by the announcement.

Including Ms. Shalala herself. The cabinet official had started her day looking forward to unveiling the administration's "progressive" new policy on needle exchanges. Huddled with her advisers at 8:30 a.m., she was going over talking points that would stress that the decision to support federal funding of NEPs was based on "science, science, science." Yet just hours later, there she was, announcing instead that states and cities would be on their own if they wanted to provide clean needles to addicts.

According to AIDS organizations, there are already over 100 needle exchange programs in existence. San Francisco, not surprisingly, has America's most active program, exchanging some 2 million needles each year since 1988. Of the estimated 17,000 injection drug users in the city, approximately 5,000 use the NEP. A private organization runs the exchange, but it has received public funds since 1993, when then-mayor Frank Jordan declared a local state of emergency, allowing him, under California law, to appropriate city funds to take whatever steps he saw as "necessary to provide for the protection of life."

Just up the coast in Seattle, the city's Department of Health runs its own NEP at a cost of about $500,000 per year. The city insists that it merely exchanges new needles for used ones on a one-to-one basis, which the state supreme court ruled was acceptable under Washington law. Five publicly funded sites are currently in operation, and this city is doing its best to get the word out: Nearly 33,000 hits have been recorded on the NEP Web site, which includes phone numbers and addresses.

But Ms. Shalala was on record as wanting more. She had said repeatedly in the past that she favored federal tax dollars in support of NEPs, so when her office contacted AIDS organizations telling them to expect good news from the press conference, there was little doubt as to what was planned.

The abrupt turnabout left friends and foes alike searching for an explanation. Was someone in the administration actually listening to that still, small voice? Not quite. Instead it was the persistent nagging of drug czar Barry McCaffrey that managed to get the president's ear. Published reports say Mr. McCaffrey tipped off Rep. Dennis Hastert (R-Ill.), chairman of an anti-drug task force in the House, that HHS officials were about to severely undermine the war on drugs. Mr. Hastert's spokesman confirmed that the drug czar and others had informed the congressman about administration plans.

Mr. Hastert, who had been chosen to accompany the president on last month's trip to South America, faced down Mr. Clinton in Chile and told him to back off his plans to fund NEPs. On the return flight from Chile, the president heard more of the same from Mr. McCaffrey, who seized the opportunity to speak his mind without immediate opposition from HHS officials. Thousands of miles away from his pro-NEP advisers, Mr. Clinton began to waver.

Back in Washington, meanwhile, the threat of political fallout from a decision to fund NEPs was becoming reality. Grassroots organizations and conservatives on Capitol Hill gave President Clinton a taste of what he might expect if he used taxpayer dollars to provide drug addicts with clean needles. "If Secretary Shalala falls for the clean-needles pitch, it would be a tragic new example of the administration's cease-fire in the 'War on Drugs,'" warned Sen. John Ashcroft (R-Mo.) in a press release. "And the casualties are our children." Meanwhile, Gary Bauer's Family Research Council called federal funding of NEPs a "national disgrace" and blasted the administration for seeking to "promote a culture of death by condemning addicts to the killing fields of heroin." Mr. Clinton, hearing political footsteps, changed his mind.

The entire dust-up was precipitated by an earlier congressional compromise. In 1993, Congress gave the surgeon general the authority to fund NEPs if there were scientific proof that doing so would slow the spread of the AIDS virus without contributing to increased drug use. Four years later, as David Satcher's nomination for surgeon general languished in the Senate, Ms. Shalala appeared ready to certify herself that the two criteria had been met. The House precluded that possibility by voting 266-158 to forbid the HHS secretary from beginning federal funding of NEPs. When the Senate wouldn't agree to such a total ban, the two chambers reached a compromise that placed a six-month moratorium on federal funding of NEPs.

The moratorium expired March 31, and Ms. Shalala wasted no time in pushing her pet project to the top of the agenda despite the fact that scientific opinion was deeply divided. On the question of reducing HIV infection, Ms. Shalala was prepared to call the evidence "airtight." But the studies that she relied on were merely surveys of drug users as to their HIV status. Even officials of the National Academy of Sciences admitted such surveys were methodologically flawed, since many of those surveyed might not have been aware that they were HIV positive. The only truly "airtight" study would have compared blood samples from NEP participants and nonparticipants, but such studies simply don't exist in America.

In Canada, however, thorough studies have been conducted for years. Vancouver, which has the largest NEP in the Western Hemisphere, also has one of the highest rates of HIV infection in the world. An 18-month study there tracked infection among 257 addicts who tested negative at the outset. By the end of the study, 24 of them-about 10 percent-had contracted the virus, and all but one of those said they had been regularly obtaining clean needles from the city. In addition, drug overdose deaths in the city have increased five times since 1988, when the needle exchange program was launched.

The best comparative study comes from Montreal. Some 1,600 drug users there gave blood for a scientific study lasting two years. Comparing the samples of NEP participants and nonparticipants, researchers found, to their surprise, that those who took advantage of the free needle swap were more than twice as likely to contract the AIDS virus. They concluded, in the December 1997 issue of the American Journal of Epidemiology, that distributing clean needles to drug addicts carries the risk of "possibly deleterious effects on HIV transmission."

These studies and more were available to Ms. Shalala as she pressed for a decision that she insisted should be based on "science, science, science." Besides calling into question the honesty of the HHS secretary and her advisers, the NEP debate has also raised doubts about Dr. Satcher, who was confirmed as surgeon general just two months earlier.

During the confirmation hearings, Sen. Ashcroft and a handful of other conservatives portrayed the nominee as a proponent of needle exchanges who would use his position as America's leading doctor to push for federal funding. But Dr. Satcher's defenders, including Sen. Bill Frist (R-Tenn.), insisted the nominee had given them assurances that he would never advocate such a position. Besides, they said, the position was largely ceremonial and offered little opportunity for any real harm.

Although Dr. Satcher was largely silent in the days leading up to Ms. Shalala's press conference, he mounted his bully pulpit soon afterwards to blast the administration for refusing to fund NEPs-just what he had promised never to do. Ceremonial position or no, hundreds of newspapers cited Dr. Satcher's "disappointment" with the president's decision as well as his admonition to local communities to "find the funds" for needle exchanges without the help of Uncle Sam.

Conservatives vow to see to it that Uncle Sam never offers such help. Four House leaders hurriedly introduced a bill dubbed "Needle Ban-Plus" stipulating that no federal funds "may be expended, directly or indirectly, to carry out any program of distributing sterile needles or syringes." On April 29, that proposal passed 287-140.

Sen. Ashcroft, meanwhile, says Congress must act because Ms. Shalala and her supporters won't give up so easily. "This is an agenda item that's being deferred, it's not being abandoned." The day after telling WORLD that he wanted "to just ban the distribution of needles to drug addicts by the government," he announced that he would use a parliamentary device to speed a similar bill through the Senate by short-circuiting the usual committee process.

The problem with the current ban, Mr. Ashcroft said, is that it's merely conditional, encouraging needle-exchange advocates to continue finessing the scientific evidence until they can "prove" their case. But no blessing by science or the government can alter the basic immorality of a policy that encourages drug use, he stressed. "Too often we've come to the conclusion that if the government will take a vice and embrace it, it becomes a virtue.... But it's wrong whether the government endorses it or not. We can make something legal, but it's still wrong."