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Is the City Prepared to Help Returning Veterans?


Veterans Affairs
Photo by Alec Hamilton

At age 17, Selena Coppa enlisted in the military through the Delayed Entry Program, a program that allows people too young to enlist to promise to enter the military once they are of age. The Brooklyn native says she joined out of a strong sense of service to her community. “I wanted to give something back in exchange.” she explains.

She served for eight years in the United States Army, working as an intelligence analyst, a platoon sergeant, and an intelligence squad leader, before returning to New York City two years ago.

Shortly after she returned, Coppa began experiencing symptoms of post-traumatic stress. She began having nightmares, and would startle awake at any sound. She would hear or see something, and suddenly be immersed in forceful memories of combat. More and more often she would find herself needing to quickly leave a situation in order to calm herself down, and that began taking a toll on her work and her school.

A single mother, Coppa has struggled to find adequate healthcare for herself and her young daughter. Yet despite being aware of the services offered through the VA hospital and the city, Coppa says she avoids using them. The crowds often present at city clinics trigger her PTSD, and she has concerns about the quality of care in both city clinics and the VA. In desperation she brought her daughter to a city health clinic to get sutures once, but was so unhappy with the situation that she spent more than she could afford to take her child to a private doctor for the follow-up.

Last year Coppa fell sick with a particularly violent flu. After waiting several hours to be seen at the VA, Coppa gave up and tried to return home. On her way home she passed out on the sidewalk in Brooklyn, and dropped her purse. Strangers helped her home and no one stole her bag.

One in Eight

The greater New York City area is home to an estimated 1.3 million veterans. The highest numbers of veterans are currently in Queens, with an estimated 225,370 veterans, followed by Brooklyn, Manhattan, and then the Bronx and Staten Island.

This number is about to increase sharply as thousands of veterans return from service in Iraq and Afghanistan. A demographic analysis of recruits by the Heritage Center found that the Bronx and Brooklyn were among the ninety-nine ZCTA (zip code tabulation areas) to have sent the most recruits into the military in 2003. In addition, as of 2009, there were 26,240 people on active duty in New York State and 39.353 or reserve and National Guard.

As operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) wind down, the city will experience a surge in younger veterans. Many of these will struggle with unprecedented levels of psychological health problems as a result of extended deployment and severe violence. Yet at the same time those veterans are returning home, to a bad economy and a city that is facing budget shortfalls resulting in reduced services.

The Mayor’s Office of Veteran’s Affairs seems ill prepared to deal with the influx of new troops and their needs. MOVA currently operates on a $500,000 annual budget, $400,000 of which goes to employee salary, according to the testimony of Commissioner Terrance Holliday. And the commissioner has been unable to explain what help his office has provided to returning troops that need mental health services.

Asked by City Councilmember Dan Halloran to name what MOVA has done to address issues of mental health services, Holliday was only able to say that his department had organized an outreach event, but could site no other effort. He did say that the agency was spending a lot of “energy and personal capital” on getting people into jobs. In addition he testified that to his knowledge the veterans his organization served had all had positive interactions with the VA, though he was unable to quantify even roughly, how many veterans his agency had helped.

Yet Commissioner Holliday testified that MOVA hasn’t had a problem with lack of funding. Councilmember Halloran was astounded by that response. “The city spent four times that amount on the condom campaign.” he said. “As a veteran, you don’t have a problem with that?”

The commissioner shook his head. “As a veteran, I do not.”

Hard times in the city have made for hard times for the local agencies and nonprofits that provide services for the city’s vulnerable. Suicide prevention service The Samaritans of New York saw their twenty-year contract with the DOHMH cut completely, only to be restored by the City Council. Executive Director Alan Ross said of the cuts “We went from helping people in crisis, to being in crisis.” While Samaritans does not provide services geared specifically for veterans, their plight is indicative of that of many nonprofits in the city.

Unique Needs

Returning veterans can face a wide variety of mental and physical health challenges, and may have unique needs resulting from their service. Those physically injured during their time in the military may have challenges regarding self-care or transportation, requiring service ranging from minimal to intensive. At the same time, many veterans are returning with the less visible wounds of mental trauma, wounds which can be devastating for the individual as well as their families and communities.

Recent studies have indicated a high prevalence of mental health issues in returned service personnel. A recent memo from the Samaritans of New York suicide prevention organization claims that more American soldiers are dying from suicide than from warfare. The memo quotes a Rand Corporation study that found that nearly 20 percent of US service members returning from war will report symptoms of PTSD or major depression, but only 53 percent of those will seek help. The study sites both gaps in services and stigma around seeking help as factors.

Coppa’s experience backs up those findings. Many veterans with PTSD have trouble dealing with bureaucracy and complicated paperwork, and as a result are disqualified from services for which they should be entitled. Coppa said veterans who try to access city services may also encounter a barrier in the requirement by some services of proof of residency. Coppa explained that many veterans, especially those just returning from service, don’t immediately have access to housing, and may be sleeping on couches with friends and family.

While it is hard to find data on the exact numbers of veterans facing mental health issues in New York City, the enormous numbers of veterans living in the area indicate that these problems identified on a national scale are going to be particularly evident here. City Council Speaker Christine Quinn testified at an oversight hearing on the high rate of suicide among veterans that it is likely that national trends of PTSD and other mental health issues are the same or higher in New York City. “This city is not the easiest place to live,” she noted.

PTSD can stem from other things besides direct combat experience. A factsheet issued by the Service Women’s Action Network (SWAN) says that while combat trauma is the leading cause of PTSD among men, military sexual assault is the leading cause ofPTSD among women veterans.

SWAN reports that 3,158 military sexual assaults were reported for 2010, with the Department of Defense (DOD) estimating that only 13.5% of sexual assault survivors report the attack. DOD estimates that in 2010 alone, there were more than 19,000 sexual assaults in the military.

PTSD is particularly likely in those veterans who served directly in combat, and in those most likely to have received abuses at the hands of others, including their command and fellow soldiers – women, non-heterosexuals, and people perceived to be non-heterosexual. For many sufferers the symptoms are manageable but difficult, hindering their health and happiness. For some, PTSD can be even more harmful, resulting in violence or injury to themselves or others.

Adding to the already-high incidence of depression among veterans is the difficult labor market they find on return. The Department of Labor estimates unemployment amongst Iraq and Afghanistan-era veterans to have reached a record 15.2% in January of 2011. Unemployment is a large and persistent stressor on individuals and their families.

The Veterans Administration

While the Veterans Administration is charged with making services available to veterans who enroll, many of those leaving the military do not receive the care they need from the VA. Reasons include a stigma associated with asking for help, as well as daunting enrollment procedures and a expectation of sub-par care.

SWAN National Peer Support Helpline Caseworker Rebekah Havrilla testified to the City Council that sexual assault survivors treated in military medical settings can experience further victimization, sometimes resulting increased rates of depression and PTSD. “I refrain as much as possible from referring female veterans to the VA.” she told the Council. SWAN’s website states that female sexual assault survivors report a lower quality of care from the VA than from outside care, and that there are “enormous barriers” to receiving VA disability compensation for sexual trauma‐related PTSD, especially for women.

Coppa initially went to the VA for treatment for her PTSD. She said the crowds there are less of a problem than at city clinics, but long wait-times to be seen and a lack of privacy act as powerful deterrents, as does the lack of childcare accommodations. During a visit to seek help managing her flashbacks, Coppa was compelled to describe the most personal details of her trauma in a busy hospital, in front of her then-six-year-old daughter. “When we got back” Coppa recalled, “she begged me never to go to the VA again. It was such an awful experience.”

A Struggle to Stay

Asked how she will get the care she needs going forward, Selena laughs. “That’s a very good question. It’s not one I have an answer to.”

She hopes to be able to stay in Brooklyn near her family, but worries that the high cost of living and the lack of services may eventually drive her to move out of New York.

Despite her struggles, Coppa remains proud of her sacrifice for her country, and says she does not regret having enlisted.

“I still think it was the right thing, even though I don’t feel my service was valued – or is valued—by many. I still feel good about deciding to serve, whether or not I am served in return.”

Sex Education in the City


pushed out
Photo by Romanna Klee

New York City will once again mandate sex education in public schools starting in the spring semester. It is not a moment too soon.

One of every four girls in the country between the ages of 15 and 19 has had a sexually transmitted infection, and 50 percent of black girls in that age group. In the city, teenagers account for one in four of all sexually transmitted infections. And while HIV diagnoses are going down in the city overall, they are going up among young men who have sex with men, especially blacks and Latinos according to Monica Sweeney, assistant commissioner at the New York City Department of Health and Mental Hygiene's Bureau of HIV/AIDS Prevention and Control. The department estimates that 4,000 people a year are becoming infected with HIV in New York.

The new mandate, announced this summer by Schools Chancellor Dennis Walcott, is part of the city's $127 million Young Men's Initiative targeting black and Latino young males through a combination of city money and private philanthropy, mostly from Mayor Michael Bloomberg himself and George Soros' Open Society Foundations.

"The chancellor and the mayor should be commended for implementing this new curriculum," said Michael A. Carrera, the dean of U.S. sex educators who began as a teacher in the Bronx in 1959 and has directed the Adolescent Sexuality and Pregnancy Prevention Programs at the Children's Aid Society since 1970.

He and other advocates, though, would like to see a program that is more comprehensive than what is being proposed.

While most city groups that work with adolescents fought for the mandate, opposition to it came swiftly from the Catholic Church. Joseph Zwilling, a spokesperson for the Archdiocese of New York, told the New York Times that the requirement "allows the public school system to substitute its beliefs and values for those of the parents." The Vatican newspaper featured an editorial condemning "useless, and even harmful, school courses."

Addressing a Need

In putting the new plan in the context of the Young Men's Initiative, the Department of Education is responding to the fact that 57 percent of new HIV diagnoses in the city in 2009 were among black and Latino men. They also saw that more than 40 percent of teens in East and Central Harlem, Bedford-Stuyvesant, Bushwick, and the South Bronx were sexually active versus a little less than 30 percent in the rest of the city.

While HIV is no longer a death sentence, those infected have to deal with a lifetime of taking medications and coping with their side effects. And sexually transmitted infections "make people who have them more likely to get HIV and more likely to infect others with HIV," Sweeney said.

While the new mandate made headlines, in the last school year 43 percent of high schools reported that they had already been using the high school version of "HealthSmart" and 38 percent "Reducing the Risk," two well-regarded and field-tested curricula. And in middle schools, 64 percent are using "HealthSmart" geared to those young people.

How We Got Here

It is not as if sex education is anything new in city schools.

A report prepared by NARAL Pro-Choice New York Foundation and the National Institute for Reproductive Health in November 2010 documents a history that began in the late 1930s. At that time, some Board of Education members, alarmed by high rates of pregnancy and sexually transmitted infections, called for "sex instruction, in the mild form of a study of mammalian reproduction." The proposal was rejected by the board, then endorsed by the United Parents Association in 1939.

It took until 1967 for the school system to offer "Family Living, Including Sex Education." Later that year, the state began requiring health education, including sex education -- though the sex education part was overturned in 1969. By the mid-1980s with the HIV/AIDS epidemic in full swing, sex education was still not reaching all students, so the state mandated AIDS education for middle and high school students in 1987.

In 1991 with AIDS raging out of control, people with AIDS dropping like flies, and no end in sight (this was before the mid-1990s advent of the drug combinations that vastly extended the lifespan of people with HIV), the New York City Board of Education enacted its own AIDS education mandate for all grades and made condoms available in high schools.

As director of education at the Hetrick-Martin Institute for LGBT youth then, I was -- full disclosure -- part of the AIDS Advisory Council to then Schools Chancellor Joseph Fernandez that wrote the 1991 plan and advocated for it. Fernandez put his chancellorship behind the plan and Mayor David Dinkins, who had two appointed two of the seven members of the board, expended significant political capital getting it passed.

After Rudy Giuliani became mayor in 1994, he gained influence over a majority of Board of Education members and encouraged them to ban condom lessons in classrooms and to enact a measure letting parents choose to have their kids opt out of the right to pick up condoms in high school resource rooms. Fernandez had resisted the latter as silly since a student barred from picking up a condom himself or herself could easily send a friend to get one.

Fernandez also stood behind multicultural curricula inclusive of sexual orientation issues, an issue that became a tabloid controversy when conservative Community School District 24 in Queens refused to implement such programs. When the board dumped Fernandez in 1993, the mainstream press often cited his role in these culture wars. In fact, his fractious relationship with the politicized board in the days before mayoral control was probably a more decisive factor. Nevertheless, for a decade city leaders were reluctant to stick their necks out on sex.

By 2003, Scott Stringer, then a member of the State Assembly, issued a report giving health education in the city schools a "failing grade." A push by a coalition of advocates got the city AIDS education curricula updated in 2005, revisions that I reviewed in Gay City News as light on dealing with the isolation of the young people most affected by HIV -- males having sex with males.

The election of a new mayor – Michael Bloomberg – with an interest in public health in charge, led in 2007 to the creation of the Office of Fitness and Health Education that recommended two curricula – "HealthSmart" for middle schools and "Reducing the Risk" for high schools. Until now, these were not mandated, but many principals opted to use them.

A poll sponsored by Family Planning Advocates in 2009 found that 85 percent of the New York State electorate supported comprehensive sex education in the schools and 77 percent believed – mistakenly -- that it was already mandated.

A diverse coalition of 30 groups cited that poll and a wealth of evidence on the need for a system-wide program in a May 2010 letter to then Chancellor Joel Klein. Earlier last year, the New York Civil Liberties Unions, a member of the coalition says it obtained "a previously unreleased evaluation of a Department of Education-approved, evidence-based sexuality education program that was piloted in 10 South Bronx middle and high schools during the spring semester of the 2007-2008 school year. According to the evaluation ... the pilot program was widely supported by teachers, principals, parents and students in the seven schools that completed it."

The New Plan

In introducing the Young Men's Initiative in an Aug. 9 letter to his colleagues, Walcott wrote, "We have students who are having sex before the age of 13; students who have had multiple sexual partners; and students who aren't protecting themselves against sexually transmitted diseases and HIV/AIDS. As a parent and a grandparent -- and as the person responsible for ensuring that all of our public school students receive a high-quality education -- that is very concerning."

All that is being required under the new plan is that schools offer "sex education lessons during one semester in both middle and high school." Teachers and principals have lots of flexibility about how to incorporate those lessons into the health curriculum and in which grade to offer the lessons. As with HIV prevention lessons, a parental opt out is being offered. Health educators will once again be permitted to demonstrate the proper use of a condom -- an exercise that teaches also opens a dialogue around how to negotiate for safer sex.

The city also is working on enhancing lessons relating to sexual orientation and gender identity and expression in the sex education curricula. This comes partly because the federal Centers for Disease Control is now pushing for such instruction in programs that it funds such as a five-year teen pregnancy reduction program in two Bronx community districts. And after decades of resistance to stepped up efforts to counter bullying, the Department of Education is spreading its "Respect for All" program throughout the schools. Under a new state anti-bullying law that soon kicks in, the schools will have to do even more in terms of tracking, addressing and preventing the problem.

The recommended sex education curricula are posted online for anyone to review: http://schools.nyc.gov/Academics/FitnessandHealth/StandardsCurriculum/default.htm.

The Next Steps

Alison Yager, supervising attorney for HIV Policy at HIV Law Project, is part of the Sex Education Alliance of New York City, a broad coalition that has long pushed for comprehensive sexual health education in New York City. She appreciates the city's move but think more needs to be done. She recently wrote wrote about the key role that HIV-positive women played in advocating for comprehensive sex education in New York City.

"We're thrilled that the city has taken this step," Yager said. "The question is: Will schools implement it, and if so, how? And further, how will the DOE and the public know what's happening in the classrooms?" Yager said that there needs to be "an enforcement mechanism and adequate oversight" of the mandate.

"The tremendous diversity among students in city schools creates another imperative,” Yager said. These lessons "need to be sensitive to students from varied cultural backgrounds, to both male and female students, and to be inclusive of LGBT students."

The Department of Education did not provide data on how well the existing mandates on HIV/AIDS lessons were being implemented, their effectiveness, the numbers of condoms distributed in high schools, or the numbers of parents who opt out of prevention lessons, though opt out rates for programs of this type in New York typically are below 2 percent of parents.

Edward Meachem, an attorney for the Catholic Archdiocese of New York, told the Times that he encouraged parents to opt out of any lessons involving contraception and to "inspect the materials to make sure there's nothing really offensive or inaccurate being put in there."

Margie Feinberg, a spokesperson for the Department of Education, said that the schools work with the Department of Health and other city agencies to "gauge how well we're doing" and is trying to pull together answers to the questions posed by Gotham Gazette.

Carrera wants to see more comprehensiveness and more integration in the city program, calling the new mandate "well-intentioned but strategically off."

"The focus of the initiative should not be pregnancy prevention, how to use a condom, HIV -- which are all important public health issues," he said. Instead, he said, classes should offer a more complete look at issues related to sexuality.

"The department," Carrera said, “missed an opportunity to comfort parents by telling them that this would be done in a more age- and stage-appropriate fashion that characterizes comprehensive sexuality programs in middle schools beginning with giving people information about puberty, their bodies, the bodies of others, gender roles, communication with parents, and essential messages about abstinence. The absence of that kind of presentation creates anxiety, causing parents to see it as having mainly to do with genital sexual contact."

Sexuality, according to Carrera said, should be taught weekly in middle and high schools. "It is as valuable as any academic subject. We are doing young people in public school a disservice by presenting this as short-term, fragmented exposure," he said. "It needs to be done in a thoughtful way."

Carrera said the experiences of the Children's Aid Society make it clear school can teach sexuality without alarming parents. Over the last five years, he said, the organization's programs have reached 1,500 students in a wide array of city regular public and charter schools, and no parent has opted out. His classes involve parents and provide instruction on sexuality in the context of an integrated program that also helps children get "no-cost medical and dental care in their neighborhood, on-site mental health services, and daily academic support. ... When we talk about comprehensive family living/sex education in that context it makes perfect sense to parents in the overall development of their child."

Carrera put forth his vision for Family Living Educator in 1993, and it has not changed. "The many fibers which comprise the fabric of an adolescent's sexuality suggest a holistic, dynamic definition of sexuality and sexual expression. If there is to be a new paradigm of adolescent sexual health, let it move from fragmentation to wholeness," he wrote then.

Melissa Goodman, the New York Civil Liberties Union's senior counsel for LGBT and reproductive rights emphasized that the city's Department of Education has to take steps to "ensure accountability and compliance" with the new mandate. "DOE should require regular reporting by schools and then publicly release evaluations of whether schools are complying with the mandate and how," she said. Her group hopes to "meet and work with DOE officials to discuss the new mandate and compliance with the HIV/AIDS education mandate."

Beyond that, Goodman said, the new program "needs to have explicit and clear requirements that schools teach a comprehensive range of topics that give students the information and skills they need to make healthy decisions throughout their lives" and "should address sexual orientation and gender myths and stereotypes."

Sweeney at the health department echoed the need for "multiple prevention strategies" to combat teen pregnancy and sexually transmitted infections, including HIV. "There is not one answer, one intervention. Parents need to talk about it with their children, religious leaders need to talk about it." Her department is funding peers – "youth ambassadors" -- who "talk to people in their own age group."

She also said we need to address the "structural issues" in the lives of young people, explaining "Kids who drop out are much more likely to engage" in risky activity. "We need all hands on deck," Sweeney said.

After Hurricane Irene blew through New York, the mayor was able to boast, "We didn't lose a single life." The city mobilized in an unprecedented way, shutting down the subway system for the first time and evacuating low-lying areas. It will take no less of a coordinated, comprehensive effort to bring teen pregnancy and sexually transmitted infection rates below the epidemic levels that they have reached. The quality and length of thousands of young lives are at stake.

Beyond Needle Exchange: Some Say Addicts Need a Safe Place to Inject


pushed out
Photo by Todd Huffman

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."



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