Bobby Tolbert is a slender, soft-spoken man with a wide smile and an understated elegance. He remembers when he began shooting heroin as a teenager in the 1960s.
"When I was coming up," he shakes his head, "we used a medicine dropper with a spike in it and a dollar bill wrapped up around it. We didn't have these syringes."
Tolbert grew up in the Queensbridge housing projects in Long Island City. At 15 years old Tolbert began what would be a multi-decade habit of use.
Back then, he says, no one thought there was anything wrong with sharing needles. But in 1995, after suffering a series of colds that wouldn't go away, Tolbert was diagnosed as HIV positive.
Tolbert sees his situation as fortunate. "I was one of the lucky ones," he said. "Eighty percent of those guys I used with are dead of HIV or overdose."
Tolbert's case is far from unique. Many injection-drug users continue to be at elevated risk, not only for HIV, but for other communicable diseases like hepatitis C, for overdose, for violence, and for other risk factors. These are serious health issues which affect not only the user, not only other users who might share needles, but potentially anyone using a public facility, walking down a city street, watching their child play on a public playground.
Under Mayor Michael Bloomberg, New York has done a lot to reach the somewhat paradoxical goal of improving the lives of people who shoot up drugs. But some advocates say the city could do even more -- finding inspiration in a new program in Canada that gives people a safe, clean place to inject their narcotics. Critics, though, say that creating such a service here would be politically difficult and detract from efforts to help people kick their habits.
Injection in the City
Despite advances, drug use still takes a heavy toll in New York.
The New York City Department of Health and Mental Hygiene calls New York City "the epicenter of HIV/AIDS in the U.S." It states that more than 107,000 New Yorkers are living with HIV and warns, "Thousands more don't know they're infected."
The department calculates that the AIDS case rate in New York City is almost three times the U.S. average and lists HIV as the third leading cause of death for New York City residents aged 35 to 54.
The statistics for New York state indicate that since the beginning of the outbreak, more HIV infections have been introduced through injection drug use than any other means of transmission. But in recent years, public health programs such as needle exchanges have had massive success in reducing the transmission rate in New York, and in 2010 a mere 4.3 percent of new HIV diagnoses were in people with a history of injection drug use.
There is still a long way to go, however. A 2008 study in the Harm Reduction Journal found that more than half of injection drug users were not able to consistently use sterile needles. And while syringe exchange programs help reduce the spread of HIV, they do much less to prevent transmission of hepatitis C, which can live not just in the needles but in the other equipment used -- and sometimes shared -- for injection, such as cotton balls, "cookers" or water used for cooking the drug.
Sean Barry, director of Voices Of Community Activists & Leaders, or VOCAL, a statewide organization serving low-income people living with and affected by HIV/AIDS, drug use and incarceration, said the success of reducing HIV transmission should not obscure the urgency of reducing other health risks associated with drug use.
"I think we now need to look at a more comprehensive approach to health. Not just HIV, HIV, HIV, which is what has been driving policy, but at other health issues, like overdose prevention and wound care," he said.
Overdose and Public Injection
A large factor in whether or not people use safer injection practices is whether or not they have a safe place to inject. People injecting in rushed, dimly lit, unclean or unsafe facilities are less likely to take the time to set up new clean equipment, and also far less likely to test a drug before injecting a full dose.
Public health leaders notes that users can reduce their risk of overdose if they test a drug before injecting it. Overdose is common in New York City, as different batches of the same substance can be cut with different ingredients and so can vary in strength and purity.
Barry points out that the danger of overdose increases when users inject drugs in places where users may not get help quickly.
"If people are injecting somewhere like a bathroom or a park, it's less likely that someone will notice if they overdose and their life is at risk," he said.
The Harm Reduction Journal study found that nearly half -- 49 percent -- of those studied reported injecting in a public or semi-public location in the previous month. This was particularly likely among people without permanent or private housing -- a significant percent of the drug using population.
Not only are injections in public places far more likely to be more dangerous to the user, they can subject other people in the area to risk as well from used needles and other detritus.
While the law requires that VOCAL inform anyone who comes into its office that drug use is illegal and so not allowed on the premises, the group also provides sharps containers in the bathrooms.
Barry said the goal is to try to ensure that, if people do inject, they will have a safe place to dispose of their needles. He calls that approach "reality-based," adding, "The reality is, people are going to inject drugs somewhere. So we can pretend it's not happening, but we know it's going on."
New York Gets Involved
Under Mayor Michael Bloomberg, Barry says, New York has taken a lot of step to lower HIV rates and address other issues with injection drug use. The City Council funded a coalition of groups called the "Injection Drug Users Health Alliance," which has allowed syringe exchange programs to scale up overdose prevention education and distribute Naloxone, a drug that counters overdose from opiate drugs.
While Barry said that the mayor has not directly funded any syringe exchange programs or other substance use programs around overdose prevention, he credits the department of health in this administration as being a very committed partner. "I don't think this issue was ever on Giuliani's radar, at least not in terms of implementing public health approaches," Barry said.
Barry also credits Bloomberg with sticking by public health decisions even when they are controversial, such as the safer heroin use pamphlet published by the health department that provoked sharp criticism from City Councilmember and Public Safety Committee Chair Peter Vallone and other officials.
Bloomberg, Barry said, "has really tried to remove politics from the equation, at least with drug user health."
Some policies predate this administration. Syringe exchange programs have operated legally in New York for 20 years, and the department of health publishes a needle exchange schedule on its website.
Barry says drug users want the tools to care for themselves and others. "There's a stereotype of drug users as selfish people, who don't care about the people around them or even about their own health, but it's not true. When people have access, they use it and take advantage of it. They don’t want to put themselves and others at risk," he said.
But needle exchange programs still face hurdles. Until recently it was illegal to possess a syringe with heroin residue in it, making people with dirty syringes to exchange vulnerable to arrest as they tried to do the safer thing.
Advocates were successful in changing the law so that people cannot be charged with possession for returning used syringes with a trace amount of heroin to a needle-exchange program. Yet many report that harassment continues. Tolbert says that it is not uncommon for overzealous police to tear up or confiscate the cards that identify people as participants in an exchange program, or to arrest people for loitering or trespassing now that they cannot make an arrest for syringe possession. He recalls one officer who described making arrests at a needle exchange program as "like shooting fish in a barrel."
Many syringe exchange programs do more than offer clean syringes. They clean up needle litter, maintain drop-in centers, and offer wrap around services and support such as housing, domestic abuse, medical, educational, or other help.
Safe Injection Sites
The program in Vancouver, British Columbia, though, goes a step further. Seven years ago, the city opened North America's only "safe injection site."
In an area once known to have the fastest growing HIV rate on the continent, drug users can now access medical testing and treatment, clean needles, counseling and security. The experiment seems to be working -- infection rates have fallen dramatically, overdose deaths have been prevented, needle litter has decreased, and advocates even claim that sexual extortion of addicts and overall neighborhood violence has diminished. Yet Insite remains the only such center in North America.
In New York, syringe exchange sites offer as part of their services judgement-free support for users in all parts of their lives, not just their drug use. At many programs, workers talk with recipients to identify and support their goals, and help user identify concrete steps towards accomplishing those goals.
Advocates say a safe injection site could provide these services and more. It could offer a safe, private place for people with addictions to engage in injection. This would be a tremendous benefit for the drug users, who can inject more safely in a clean facility with adequate light, medical professionals and sterile needles.
The benefit might be even greater to non-users in the neighborhood. Residents would be much less likely to witness -- or have their children witness -- injection. It would relieve non-professionals from the trauma and burden of trying to deal with people having bad reactions from drugs, and sharply minimize the risk of accidental contact with discarded needles. For users, a safe injection facility could be a place to seek counseling, treatment, or even just safety and understanding.
The Harm Reduction Journal concludes similarly. "Safe injecting facilities might resolve the syringe gap by attracting higher-risk injecting drug users, while reducing the public disorder caused by public injecting and relieving law enforcement of the effort required to address this problem."
"Is this another tool in the tool box to reach more people and save lives? Without a doubt, yes," Barry said.
Barry says safe injection sites cannot even be discussed in New York without immediate controversy, but he believes that could change. He points to a history of support on the state level for public health measures. Gov. Andrew Cuomo recently signed the Good Samaritan law to prevent arrest of people who call emergency services to report an overdose, and his predecessor, Gov. David Paterson signed a law to prevent the arrests of people participating in a syringe program.
"I can see Bloomberg and his administration finding some way to explore this," Barry says, referring to a safe injection site, "But I don't think he is going to do it without a strong push from advocates."
Some, though, think such an effort would detract from what should be the primary goal: getting people off drugs. City Councilmember Charles Barron of Brooklyn agrees with VOCAL that drug response policy should change from a criminal approach to one of public health, but he calls the philosophy behind safe injection sites "defeatist" and says he would oppose such sites opening.
"That's just maintaining them shooting death in their veins instead of helping them to get off the drugs," Barron said. "That doesn't make any sense."
Barron said, personal opposition aside, he does not think such an effort would survive politically. "I don’t see it taking off," he said.
Sites identified as potential locations for such a service include parts of the Bronx, East New York in Brooklyn, Harlem in Manhattan and parts of Queens. Caseworker Christina Ann with the East Harlem Neighborhood Alliance says she believes some of these communities might be open to a safe injection site. "I'm sure it would be welcome in the neighborhood," she said.
However not everybody is so sure. Matthew Washington, chairman of East Harlem's Community Board 11, takes issue with the idea of that neighborhood becoming a possible location for a service for drug users. "Dealing with injection drug use is something that everybody needs to deal with, and something the city needs to address collectively," he said. "But the city is unequally dumping these sorts of facilities in our community."
'There But For the Grace of God'
The HIV diagnosis changed life for Tolbert. Today, he works as a peer educator, teaching other injection drug users about the importance of safer injecting. He is a tireless advocate, working on issues like affordable housing for HIV positive people, and serves on the board of VOCAL.
He volunteers at needle exchange programs, and spends time going into SROs to talk to people living in poor conditions like the ones he used to live in.
"I try to educate people on how to get out of that situation, because there but for the grace of god go I," he explained.
In May Tolbert will be the keynote speaker at the Harm Reduction Coalition conference in Washington D.C.
"Now that's all I do," he laughs. "All I do is educate."