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H A R MR E D U C T I O NC O M M U N I C A T I O NPrison or Treatment:A Real Choice?Interview with Bonnie VeyseyBY E L L E N M I L L E R - M ACK ,PHOTOS BY MICHAEL JACOBSON-HARDYSEPTEMBER 24, 1999E: Observation about residential drug treatmentand incarceration: both strip people oftheir identities.B: Incarceration is based on a logic of securityfirst, and the easiest way to improve security isto have equal standards of behavior—proceduresand protocols—for everyone. To keep asecure institution, you apply the same requirementsto everyone: reducing individualityis a goal regardless of whether you are maleor female. Residential drug treatment forwomen is making some progress, although itvaries quite a bit. There is a growing acknowledgmentthat women are different from men,and that a woman’s individuality and creativitycan be engaged.E: Observation: Neither residential drug treatmentor incarceration prepares people for lifein the real world. continued on page 4H A R M R E D U C T I O N C O A L I T I O N S U M M E R 2 0 0 0 N O . 1 0

H A R M R E D U C T I O NC O M M U N I C A T I O NS U M M E R 2 0 0 0 N O . 1 0This issue is dedicated to the memory of Dana Beard (aka Sheila O’Shea).Dana, we miss you!COVERPrison or Treatment: A Real Choice? AnInterview with Bonnie Veyseyby Ellen Miller-Mack3 Letter from the EditorFEATURED ARTICLES4 Letters from JailCollected by Ellen Miller-Mack8 On Paroleby Eve Rosahn10 Back in theUSSRby Drew Kramer14 Moscow Postscriptby Drew Kramer16 A Needle Exchange is a Terrible Thing to Wasteby Brian Murphy19 Bad Attitudes in the ER: It’s a Two Way Streetby Neil Flynn21 Drug User SurveyPrepared By Brent WhittekerCOLUMNS22 Witch’s Brewby Donna Odierna24 On the Groundby Delaney Ellison26 Reports From The Frontby Corinne Carey29 Global VoiceReports by Allan Clear and Graciela Touze30 Harm Reduction Books and VideosReviews by Allan ClearC0VER PHOTO: Razor and high-voltage wire at the North CentralCorrectional Center, Gardner, MA. Reprinted from Behind the Razor Wire:Portrait of a Contemporary American Prison Syatem, by Michael Jacobson-Hardy, (c) 1999 New York University.THE HARM REDUCTION COALITION (HRC)is committed to reducing drug-related harm among individualsand communities by initiating and promoting local, regional, andnational harm reduction education and training, resources andpublications, and community organizing. HRC fosters alternativemodels to conventional health and human services and drugtreatment; challenges traditional client/ provider relationships;and provides resources, educational materials, and support tohealth professionals and drug users in their communities toaddress drug-related harm.The Harm Reduction Coalition believes in every individual’sright to health and well-being as well as in their competency to protectand help themselves, their loved ones, and their communities.Editorial PolicyHarm Reduction Communication provides a forum for the exchangeof practical, “hands on” harm reduction techniques and information;promotes open discussion of theoretical and political issuesof importance to harm reduction and the movement; and informsthe community through resource listings and announcements ofrelevant events. Harm Reduction Communication is committed to presentingthe views and opinions of drug users, drug substitutiontherapy consumers, former users and people in recovery, outreachand front-line workers, and others whose voices have traditionallybeen ignored, and to exploring harm reduction issues in theunique and complicated context of American life.Since a large part of harm reduction is about casting a criticaleye toward the thoughts, feelings, and language we have learnedto have and use about drugs and drug users, Harm Reduction Communicationassumes that contributors choose their words as carefullyas we would. Therefore, we do not change ‘addict’ to ‘user’and so forth unless we feel that the author truly meant to use a differentword, and contributors always have last say.The views of contributors to Harm Reduction Communicationdo not necessarily reflect those of the editorial staff or of the HarmReduction Coalition. Any part of this publication may be freely reproducedas long as HRC is credited.Design and Layout: James PittmanPrinting: GM Printing, NY, NYPhotos on cover and pages 4 and 8 courtesy Michael Jacobson-Hardy.Photos on pages 10, 11, 12 and 15 courtesy John Ranard.Please write in your comments, feelings, responses—we want to hearfrom you. If you would like to submit an article, or photos or artwork,we would be happy to look at your material. (See our websitewww.harmreduction.org/news/submission.html for submissionguidelines.) HRC gives a voice to communities that are ignored by conventionalmedia: drug users, people of color, individuals who are HIVor Hepatitis C positive, and sexual minorities. If you have never writtensomething for publication, assistance is available: just ask for it.(You can call the editor at 212 213 6376, or include a note with yoursubmission.)Send all submissions and correspondence to:Editor, Harm Reduction Communication, Harm Reduction Coalition22 West 27th Street, 5th Floor, New York, NY 10001Or email: hrc@harmreduction.orgH A R M R E D U C T I O N C O A L I T I O NAllan Clear, Executive DirectorDanine Hodge, Director of Finance and AdministrationDonald Grove, Director of DevelopmentDon McVinney, Director of Education and TrainingAmu Ptah, National Training CoordinatorEdith Springer, Senior TrainerPaula Santiago, National Community Organizer/Conference OrganizerSuzie Ko, Assistant to the Executive Director/Conference OrganizerPaul Cherashore, Coordinator of Resources and PublicationsAlvaro Arias, NY Office ManagerOrlando Roman, Treatment AdvocateOAKLAND OFFICEMaria Quevedo, Director Of California TrainingFernando Alaniz, California Office ManagerMain Office 22 West 27 th Street, 5 th floor, New York, NY 10001, tel.212.213.6376 fax.212.213.6582, e-mail: hrc@harmreduction.orgWest Coast Office 3223 Lakeshore Avenue, Oakland, CA 94610, tel.510.444.6969 fax.510.444.6977, http://www.harmreduction.org2

LETTER FROM THE EDITOROn February 4, 1999, the NYPD gave AmadouDiallo the right to remain silent. And they did itwithout even saying a word. Firing 41 bullets in8 seconds, the police killed an unarmed, innocent man.Also wounded that night was the constitutional right ofevery American to due process of law.—ACLU ad that appearedin the NY Times shortly after the four officers chargedwith his killing were acquitted on all counts.When Amadou Diallo’s killers got off scot free last February there wasa protest in his old Bronx neighborhood. A few arrests were made;one of the arrested protesters was a 23-year-old man by the name ofMalcolm Ferguson. On March 1, less than one week after the verdict,Malcolm was shot and killed in a struggle with a NYC undercovercop. Malcolm was fleeing cops who were checking out a known drugspot, and he was unarmed. Shortly after the killing, police were sayingthat heroin had been found on his body. Within days, the NYPDwas branding Malcolm a heroin addict and dealer. Only days lateranother New Yorker was shot and killed by police, this time becausehe objected to an undercover cop’s attempts to buy pot from him. AlthoughPatrick Dorismond did not have any pot on him when he waskilled, and was actually a security guard, the Mayor let us know hehad a prior marijuana arrest—enough to earn him the designation “druguser.” Go back almost another year, to when Gideon Busch was killedby six cops. You could ask Gideon, if he was still alive, how he managedto scare 6 cops badly enough that they had to shoot him dead.Since he can’t answer, the Mayor and the NYPD answered for him:besides being “mentally unstable,” he had been smoking pot—the implicationbeing that he was in a pot induced craze! The commonthread in all three cases: authorities used the drug use of the victims asa subtle justification for their deaths at the hands of cops.This past February Time Magazine published a story in their Lawsection called “A Get Tough Policy That Failed.” Among other things,this article was a catalog of the failures of the Drug War. Included werephotos of Derrick Smith, a 19-year old New Yorker convicted of sellingcrack, who committed suicide rather than serve a long sentence,and Jedonna Young, recently released after serving 20 years for heroinpossession. Search the internet under police brutality and the drugwar will surely come up. A story in free-market.net—dated October 28,1999—touched on the police murders of Octavio Paz (a 65-year oldLos Angeles grandfather), Pedro Navarro (a Mexican immigrant late ofHouston), Amadou Diallo and Donald Scott (to prove that even richwhite Californians can’t be 100% sure of their safety). All were committedunder the guise of drug war operations, the modern version ofVietnam-era “search and destroy” missions.On May 4, I happened to pick up an issue of NY Press, a reactionaryrag that I rarely read, unless I’m in the mood to get aggravated.The cover story was “Waking Up to A Police State,” by AlexanderCockburn. (Strangely, the Press publishes a column by Cockburn, along time liberal who also has written for The Nation, The LA Times andthe Press’ arch nemesis—the Village Voice.) Cockburn reviewed someof the seminal events of the last few years that he says point to the riseof “our jackboot state.” He then went on to conclude that the “insanedrug war has been a bi-partisan affair” with “consequences etched intothe fabric of our lives.” He concludes by saying that “the swelling policestate is an expression of the War on Drugs. No politician that doesnot call for a cease-fire and rollback in that cruel, futile war—our domesticVietnam—has any standing to bewail the loss of our freedoms.”Cockburn’s article was written in response to the April INS seizureof Elian Gonzalez, as well as police actions at the world bank protestsheld in Washington, DC that same month. The reaction to the Gonzalezseizure has been by turns fascinating, sad and amusing to veteransof this war. It took a police raid into the home of a middle classCuban American family to wake up white America to the new face oflaw enforcement. African-American residents of our inner cities, whohave been dealing with a virtual state of siege for the last thirty years,responded with a collective “Tell me something I don’t already know!”Yes, the Drug War has been in the news a lot lately, generating “celebrated”cases, incidents so shocking they offend even the middleclass,the ones supposedly being protected from “criminals” like Patrick, Malcolm,Gideon...the list is endless. There are plenty of stories that don’tmake the news: Joey, who was hopelessly strung out on pills and heroin.In and out of rehab, on and off of methadone and dope, he had tosell to support his habit. Caught one last time, he killed himself ratherthan serve the stiff sentence he knew he was going to get. Or my friend,who shall remain nameless, recipient of a 1 year suspended sentencefor the residue found in a syringe. (We won’t even talk about the illegalstop and search that led to the syringe’s discovery: we gave upthose rights years ago!) Having failed to live up to her probation requirements,she now faces the threat of discovery and jail every day.Yet Patrick, Malcolm and the rest are not so different than you andI. Unfortunately, they happened to get in the way of the drug war juggernaut,and became its victims. Then the military (in this case domesticlaw enforcement) did what armies always do when civilians arekilled: justified its actions by demonizing the victims while telling us thatin war there’s always “collateral” damage. As we enter a new phaseof this war—when it becomes so important to win, to avoid another losslike Vietnam—in New York City we are also given a hint of what it willlook like should we loose: rising crime rates and falling arrest rates,supposedly fallout from the reining in of NYPD’s elite street crime unitin the Diallo killing’s aftermath.For a few days after the Elian debacle, when people realized thatno one is immune to state-sanctioned violence, it looked like maybethings would change. Maybe people would see the ugly underside ofthe beast’s belly, and just say NO. Enough! But now I don’t think so.After further reflection most of us will come to believe this isn’t our problem.(Besides, the Elian raid was yesterday’s news: now we have theprice of our Microsoft stock to worry about. And there’s those risingcrime rates...) Call me a pessimist, but I think it’s only going to getworse, before it eventually does get better. Things always get better. Itmay take ten years, but change will come. Sadly, twenty years fromnow we’ll be putting up our own memorial wall. All those needlessdeaths. For what!—PAUL CHERASHORE3

I N T E R S E C T I O N S : P R I S O N A N D T R E A T M E N TPrison or Treatment: A Real Choice? cont. from coverB: Absolutely, both of those situations aretotal environments, total communities. Whileinside, there are very few decisions thatwomen are allowed to make regarding theirday to day lives. There are few opportunitiesto try out new interpersonal or drugresistance strategies: strategies thatdeal with how to relate to family, workand all the pressures that a woman experiencesupon her release.E: How are we different from men?B: From a corrections point of viewthe most important difference is howwomen and men organize in groups. Mentend to organize hierarchically aroundpower, and women tend to organize in flatstructures around “who you know” (relationships).Increasingly, residential treatmentprograms for women are respondingto women’s needs to connect with other peoplewho have important roles in their lives,as mothers and as friends and as partners. Ina therapeutic environment, you get men todisclose and acknowledge responsibility. Butwith women, that’s never a problem.Women are always willing to accept responsibilityfor their behavior and anything elsethat they can possibly claim responsibilityfor. And they’re willing to disclose a lotmore readily in therapy than men. You haveto treat a woman in a more holistic fashion.E: Both residential drug treatment and incarceration,in most cases, rip mothers fromtheir children.B: That’s true. A couple of prisons have infantprograms, but the kids can only remainfor a few months. Residential treatment usuallyexcludes children, but more and morethey’re being brought in with the moms.But that’s an issue that we need to considercarefully. Talking to women themselves,sometimes they’re really looking for a breakfrom their social responsibilities so they canThere are very few placeswhere you can fail withoutbeing incarcerated again.take care of themselves instead of always takingcare of someone else.E: Observation: Drug treatment expects thenearly impossible. I.e. it expects people tobe able to figure out how to remain cleanand sober for the rest of their days. The consequencesof relapse, both in the residentialdrug treatment and within the criminal justicesystem, seem to have equally horrificconsequences for women, with failure resultingin incarceration.B: Assuming that drug treatment is part of acorrectional program, or some sort of diversion,yes, I think it is nearly impossible. Weknow that relapse is predictable. We hope toextend the periods of relapse, from point offailure to point of failure, so that over thecourse of a woman’s life she will come to aTop right and bottom left, prisoners at MCI, Framingham.Top left, Ten Block, MCI Cedar Junction,Walpole, Massachusetts.Reprinted from Behind the Razor Wire: Portrait of aContemporary American Prison System, by MichaelJacobson-Hardy, ©1999 by New York University.Photos ©1999 by Michael Jacobson-Hardy.point where she can remain clean and sober.Certainly, one would not expect that early inher recovery career. But there are very fewplaces where you can fail without being incarceratedagain. If a woman in a residentialdrug treatment program goes out and getshigh, and she comes back and theydiscover this, they throw her back injail. And certainly if she commits anycrimes she goes back to jail. Yes, Ithink both actions have the same result,depending again on the residentialtreatment program, and theirpolicy toward use during the program.If you break their policy of total abstinenceand it’s linked to a correctionalprogram (which is fairly common), then thewoman goes directly back to jail.L E T T E R S F R O M J A I LC O L L E C T E D BY E L L E NM I L L E R - M A C KThe following 2 letters were written by women whoare, in effect, political prisoners. They express theirfeelings and observations about the drug war,particularly how incarceration and coerced treatment haveimpacted their lives. Lisa ran away from home for the firsttime at age 5. She was in and out of foster care throughouther childhood, and took up drug use at an early age. Shewas a patient of mine while in jail. Dianna’s parents werewriters who also taught at a number of colleges around theworld. She was exposed to heroin as a teenager, whileliving in Australia. She continued on with her owneducation and has a post graduate degree. At the timeDianna wrote this letter, she was incarcerated for violatingprobation, and was negotiating with her probation officer.Dianna was eventually released to her mother’s custody.Nurse practitioners provide medical /primary care, very

E: Residential drug treatment and correctionalfacilities are similar in their emphasison security and control. The rules are veryarbitrary, and women are treated like children.This is where the link between treatmentand incarceration is most oppressive.B: In mental health treatment, correctionalfacilities and drug treatment, one of thefoundations of intervention is creatingdoable behavior contracts. Involving womenin creating very specific behavioral plans cangive them a sense of safety. I.e: this is whatyou can do. If you don’t do this or you dothis, this is what will happen. Really layingout the consequences of unwanted behavior.The difference is in creating a contractwith women instead of creating rules withouttheir understanding why or how it mightbenefit them. There is a nothing to gainfrom infantilizing people. And there is nogain from excluding women from their ownrecovery process. But I do think that contractsfor minute behaviors can create asense of safety for women.E: Some women’s sexuality is devastated. It’svery difficult for me to imagine how awoman can come into her powers in eitherthe setting of incarceration, or residentialdrug treatment.B: Many women will be returning to thecommunity and returning to relationshipswith male partners. In single sex places, it’svery difficult for women to reclaim their sexuality,or begin to understand their sexualityand sensuality.E: And when some women finally have anopportunity to develop emotional and sexualrelationships with other women, it is notallowed.B: That is correct. One fact we know is thatwomen who are addicted to drugs and alcoholalso have higher rates of childhoodphysical and sexual abuse. There are a lot ofproblems and issues around sexuality, andhealing needs to be accomplished. In thetherapeutic communities that have mixedpopulations, the sexual politics and the sexualexchange can be really problematic: nothealing to women but rather continuingpatterns that have hurt them in the past andcontinue to hurt them. And in American societywe don’t allow women to be their ownsexual persons, to derive pleasure safely, ontheir own terms, from their sexual activities.We don’t have a trauma recovery that isbody-based, only the kind that’s thinkingbased.E: Let’s think about sexuality in the broadcontext of self expression, sexuality as partof just being a living, breathing woman. Letme give an example of what happened to awoman that I know, in a mixed residentialprogram. She got sent back to jail for flirtingwith a man in the kitchen. She was expressingherself. And she may have been doingsomething that was intuitively part of herhealing. Yet unconditionally that is perceivedas something negative, detrimental,something to be punished for.B: What can I say? It’s not an individualissue, it’s a systems issue. It’s a programissue. Female inmates also get punished fortrading sex for cigarettes or favors from correctionalofficers. That makes no sense tome. In situations where there are power differentialsit makes no sense to me to punishthe person who has a lower power positionfor trying to improve their situation. It happensall the time. Judging women for theirbehavior by a standard that is different fromthe males is endemic in our culture. I assumethat the male recipient was pleasedwith the attentions, and if this person wasnot similarly punished, that’s really problematic.But how do you address somethingthat is so inherent in a culture? I don’t findit surprising. It’s quite predictable. The rulesare explicit: no fraternizing with the oppositesex. It flies in the face of a woman’s selfexpression as a full human being.E: Observation: Conditions of probationlink drug treatment and incarceration, unmercifully.The contracts are very explicit,including, oftentimes, completely disruptinga relationship that they may have withsomeone who also happens to have beenusing drugs or who also happens to have arecord, along with the random urine tests orthe daily urines. The absolute abstinence includesabstaining from people women haverelationships with.B: Women often use drugs in associationwith somebody. So what’s the easiest way toimprove the probability that a woman willbe able to stay clean and sober? Disrupttheir relationships with drug users and associates.That’s research based. Corrections/probationare very interested inresearch based outcomes. So they will usewhat comes out of the research communityand say, “okay, well let’s improve our probationsuccess rate, and this is the way we’regoing to do it.” It’s goes back again to theidea of probation.What is probation? If the purpose is toreintegrate the individual into a community,you’re more likely to put into place intermediatesanctions, progressive sanctions,change supervision levels for someone whois at risk of relapse. But if you believe probationis risk management and that anyoneusing drugs becomes an increased risk tothe community, then if the woman fails herdrug treatment, she will be re-incarcerated.L E T T E R S F R O M J A I Lmuch the way doctors do. In most states, we can writeprescriptions for all kinds of medications; we diagnose and treat.In some settings, we are able to spend more time with folks thandoctors. My focus is on helping each woman achieve her ownhealth goals. I am a partner, listener, facilitator, advocate andclinician. The women at the jail entrust me with the stories of theirlives, and are open to discovering how to feel better. I’ve beenlistening to these women very carefully, and a whole world ofbrazen injustice has opened up to me. Of course I can’t speak foranyone but myself, but I take what they’ve taught me and speak.And I encourage them to write. What can they really use from thevarious institutions that have intruded on their lives? What willrelieve their pain, bring them back to their kids, begin theirhealing? What would meaningful, effective, healing drugtreatment look like? What is safety, and have you ever known it?My gratitude to these women is huge. They give me clarity ofpurpose.—ELLEN MILLER-MACKApril 15, 1998Dear Ms. Jensen,Hello from Rikers. I hope you are doing well. This is DiannaKastanakis, one of your people on probation. I am ok, feelingmuch healthier and mentally much clearer. I’ll be seeing youon the 21st in court.First and foremost I would like to apologize for nothaving heeded your recommendation of going to court, but Iunfortunately was focused on my using at the time. I realizethat you were only trying to look out for my well-being andtrying to keep me out of more trouble. I wasn’t beingresponsible back then—and I’m doing my time for it. I knowmy parents have kept in close contact with you and thepolice department, and that they have expressed their opinionon, and concerns for, my future. Although their residence isprobably the safest environment for me (and what I oftenrefer to as my home), I am 28 years-old and should bejudged as an individual. And there are other places that aresafe and drug free where I could temporarily reside. I dounderstand and respect, however, all the concern my parentshave, and I regret all the suffering I have inadvertentlycaused them through my substance use.I would like it to be known that I am not interested incompleting a treatment program. Here in jail my movementmight be restricted but I at least have freedom of thought,something I would not have in the programs. I know that tosucceed in treatment one must have a desire within to bedrug free. However, I also feel that some programs areactually detrimental, and neither suited to my personal needsnor to my philosophy of recovery.If I use once I am told that I have “relapsed” when I’drather think of such an incident as “research.” I am told thatI have a disease, which I do not accept. I am told to alwaysadd the word “addict” after my name. Why not identify as adaughter, as an anthropologist, as a human being? I am toldto focus on self-defeating behavior rather than selfempoweringbehavior. I am told that as a prostitute I wasselling myself; this is a moral judgement that is verydangerous (as if people were or could be commodities!) Iwas my own boss, selling a service, never degrading myselfbecause of my occupation. On the contrary, I empoweredmyself, while growing and learning immensely about myselfand other people. This even though sex work is illegal (but5

The idea of risk management is built onmale offenders, and probation departmentpolicies are based on male offenders. Theunrecognized cost of returning a woman toincarceration has not been considered bymost probation departments.E: Love and sexuality are part of human existence.It’s very hard for me to accept thatsomething good and healthy—involvinglove in a relationship—is not permitted, asa condition of probation.B: It really supports women returning to acommunity to maintain relationships withwomen they have spent time with in jail, particularlyif those are support groups thatcontinue after their incarceration. But inmany jurisdictions, association with ex-offendersis prohibited as a general conditionof probation/parole. They’re now openingthe doors to those individuals because thereis a growing acknowledgment that peoplewho have similar experiences are in the bestposition to help each other. Regarding associationswith friends or intimate partnersWe don’t know the impactof the violence that womensustain over the course oftheir lives, especially ontheir substance abuse.who are drug users, it is more complex. Oftentimespeople can keep those relationshipspretty secret, depending on what theprobation department’s standard is forsupervision. I think women are real smartabout this. If they’ve had enough time tothink about their recovery and reflect ontheir pathways into addiction, they maketheir own choices. And they will continue tomake choices, knowing that there are consequencesfor those choices.E: Do you think that it would be a good andhealthy thing, if the range of choices forwomen includes continued use of an illegalsubstance?B: In this current culture, I don’t see thathappening. But let’s push the envelope a littlebit and go over to alcohol. Or prescribeddrugs. Because women can abuse alcohol orprescribed drugs without criminal sanction.E: What concerns do you have regardingwomen with mental illness?B: The sad state of affairs is that most womenwho have significant mental health problemsare excluded from drug treatment, period.E: Because they are not allowed to takemedication?B: No, it is because they are considered poorfits. There are exclusionary criteria based ondiagnostic category. If you have any kind ofa psychotic disorder you will be excluded outof hand. For women, this is problematic.Number one, it needs to be person based. Ifa woman who is diagnosed with schizophreniahas the ability to sit through groups, andto benefit from residential treatment, I believethat she should be allowed to. Secondly,because diagnoses are not hard and fast,and a woman’s diagnosis will shift over time,those exclusionary criteria are very damaging.If you link drug treatment and correctionaloutcomes (i.e. treatment bringsdiversion from jail into probation), andthere is an exclusionary criteria for a womanwho has a mental health condition, then youare treating women differently and it’s havingan impact on their constitutional rights.Although we don’t have the prevalence estimatesin general for women that exist formen, there are two female-based studiesavailable for mental disorders. one of jailsand one of prisons. Thereis nothing about probation.We don’t know awhole lot about the intersectionof criminal behavior,substance use andmental health symptoms,and we know less about itin terms of women. Wedon’t know the impact ofthe violence that womensustain over the course of their lives, especiallyon their substance use, (social) behaviorand mental status. And we know almostnothing about the course of recovery interms of substance use, trauma and mentalhealth. We’re sort of shooting in the darkwhen we provide drug treatment forwomen. We need a lot more research.E: You have a vision of helping women withmental illness, who have been in troublewith the law.B: First, I think the American public needsto be more aware that our national policieshave a vastly deleterious effect on womenand families. Particularly our War on Drugs.Criminal sanctions for possession and usehave increased the population of women behindbars, or women under correctional supervision,by hundreds of percent. Statisticsshow that women are incarcerated mostlyfor drug-related offenses. That has generationalimpact: it affects families, it affectschildren’s future behavior. It has costs associatedwith foster care and future treatmentfor the kids. And childhood physical andsexual abuse—long term, severe, occurringthrough at least early adolescence to youngL E T T E R S F R O M J A I Lthat is another issue altogether).In jail I can avoid contact with certain people. In aprogram I am encouraged to interact with, and confide in,people with whom I’d rather not share my vulnerabilities:many people react hatefully and meanly when threatened orjealous of an individual. In a program I am also told to notinteract with men, and overall I feel that women areencouraged to “act like ladies”—in other words, to be daintyand submissive rather than assertive and “real.” My successin the program depended on active participation in AA andNA meetings, and I was doomed to failure for having aninterest in Rational Recovery and Buddhist spirituality.At least in jail I can choose the books I read withoutfear of criticism, choose who I associate with and to whatextent, and decide whether I want to go to AA or NAmeetings—which, incidentally, I am on the waiting list for.Here I can go to the gym, read, write, have a prison job, goto art class and go to church, and I don’t feel anybody istrying to transform my way of thinking to fit someone else’smold. There is more than one path to self-improvement, andhere I feel the path I prefer is more accessible.My point is I’d rather complete my time in Rikersrather than in a program. I honestly find it more beneficialfor my situation, considering that my parents don’t seemanxious to have me at their house upon my release. I wouldalso rather wrap up my case, since probation until April (orextended probation) would be more rope to hang myselfwith, and prevent me from going to my native country,Greece.My mother did mention to me that she would bewilling to take me into her home if I was in a methadoneprogram. I consider this to be a reasonable option, since Ihave had trouble staying off heroin for the past six years.Although I would still be dependent on a substance, my lifewould have some structure and stability, and could be normaland crime-free. However, I must say that right now I feelreluctant to be released into a methadone program. I’drather wrap up my time with perhaps 30 more days inRikers. Then, upon release, deal with my addiction andconsider seriously whether methadone is what I need. (Iwould prefer heroin-distribution programs to methadone asheroin is much less harmful. I won’t get into the reasonswhy we don’t have this choice, other than to say that it’s apolitically motivated decision that’s related to the enormousamount of revenue this drug’s continued illegality generatesin the black market.)I hope this letter finds you in good health and spirits,and I hope you take my feelings and opinions intoconsideration. I believe we can come to an agreeablecompromise. I did complete almost four months of treatment,and gave only one dirty urine for marijuana. Althoughsufficient reason for discharge—which I can respect, but feelis a little severe—it was not heroin or cocaine. I did trespass,but I hope you don’t feel that this merits too severe apunishment. In any case, I know and have faith that youhave the utmost concern for my well being. I thank you foryour time and patience, and I am looking forward to seeingyou on Thursday the 21st.Sincerely,Dianna Kastanakis6

adulthood, if not starting very, very young—has direct and known mental health consequences.So the women that we’re seeing incorrections have pretty significant emotionalproblems. As long as that goes unacknowledgedand untreated, we set womenup for this continuing cycle of violence, ofsubstance use, of incarceration.Our conditions of confinement, particularlyfor women who are victims of violence,are inhumane. They directly mimic whathas happened to them as children. We need tostart thinking about those conditions of confinement.Privacy, supervision, how we managewomen in crises. Whether we have menin uniform throwing a woman to the groundor whether we have talk down strategies.How we restrain women for psychiatric purposes.All of those things need to be reconsidered,as they are being reconsidered inthe psychiatric community. I would like tosee the number of women incarcerated, particularlyfor drug related offenses, reduced.I don’t think any woman who is convicted ofa non-violent crime needs to be behind bars;I think its social cost is too high.E: What if you were designing a diversionprogram for women with mental healthissues?B: First and foremost is meeting basic needs,like housing that allows women to have childrenwith them. If you have that, you canthen find ways of giving women meaningfulroles—whether that is involvement in educationalactivities, job readiness or employment.So that women can normalize theirlives, have something that is meaningful forthem to do. Then you set up a structure inwhich women can start their recovery emotionallyand from substances. The clinicalservices that are required on top of that arefairly minimal. I don’t think it’s necessaryfor all women to have psychotherapists. I dobelieve it is important for women to havefriends and relationships, and opportunitiesto talk to each other. Women need a fullarray of services that they themselves chooseto receive.Many women do want professional assistancemore than medication. Many womenfind medication to work quite well, somewomen don’t. Some women really like tohave a professional to talk to for lots of differentreasons. A typical request may be “Idon’t want to burden my friend with this,but I really need to talk about this.” It maybe a safety issue, like “I’m afraid that I can’tcontrol myself and I need to talk to a professionalwhere I feel safe to fall apart.”E: So then really, these are all elements thatneed to be used in residential drug treatment,assuming that the majority of womenwho are in those programs have mentalhealth issues? And would they be beneficialfor women with very serious diagnoses, suchas bipolar disorders , or schizophrenia?B: Sure, those are the fundamental requirements.You’ve got to take care of basic needsfirst, and roles are very important forwomen. And then the clinical pieces are important,but if you can’t take care of thebasic needs first, nothing else really matters.E: Will it ever be possible to infuse traditionaldrug treatment with harm reductionstrategies if the criminal justice system is payingthe bill?B: I think so. If you can get the correctionsside to understand recovery, then I thinkyou have a chance of pushing harm reductionstrategies. That’s really, really difficultstuff. But hypothetically it is possible. We’vebeen pretty effective in getting harm reductionstrategies out to the general public. Ifyou can gain the acceptance of drug treatment,and have them saying harm reductionis safe and therapeutically sound and efficacious,then the department of correctionswill probably come too. ■Ellen Miller-Mack is a nurse practitioner atBrightwood Health Center in Springfield,Massachusetts, specializing in HIV primarycare and women’s health for the past 10 years.As one of several community-based clinicians,her work includes providing gynecologicaland HIV care to women held at the HampdenCounty Correctional Center. She speaks bothlocally and nationally on HIV and women,sexual health and prison issues.Bonita M. Veysey, Ph.D, has written severalarticles on the specific needs of women withsubstance abuse and mental disorders in thecriminal justice system and has consulted withcorrectional facilities regarding the need for servicesfor women in trouble with the law. Sheworked as a researcher in mental health servicesand corrections policies for 15 years priorto joining the faculty of Rutgers University.Michael Jacobson-Hardy is the author of Behindthe Razor Wire: Portrait of a ContemporaryAmerican Prison System andThe Changing Landscape of Labor:American Workers and Workplaces. Hisphotographs have been exhibited widely andare included in many public and private collections,including the Smithsonian Institution,the Henry Ford Museum, the YaleUniversity Art Gallery and the Rose Art Museumat Brandeis University.L E T T E R S F R O M J A I LLisa writes from jailIn my 23 years of existence I have seen a lot. A lot of drugabuse, a lot of crime, a lot of incarcerations and much drugtreatment. From my experiences I have formed some opinionsof my own about how drug addicts should be helped.I definitely don’t believe that locking people awayfrom society is the answer. Something like over 80% ofpeople incarcerated in county jails are there for drug-relatedcharges. These charges usually consist of minor offensessuch as violations of probation, dirty urine, simplepossession and small-scale larceny. Recidivism is very highfor addicts, meaning they go out and do the same kind ofcrimes—most of which don’t endanger anyone directly—andend up back in jail. I am aware that drugs are illegal and Iwon’t go into whether I think they should be or not; I justdon’t believe that someone who is in jail for giving a dirtyurine should get the same sentence as someone whocommits “real” crimes.Jails don’t offer much to help addicts recover. There aresome short term groups which basically educate people aboutaddiction and suggest ways to stay away from drugs. Theytell you to change just about every aspect of your life: avoid“people, places and things.” I really don’t think all of thatmatters as much as what’s in your head. I know no matterwhere I am, no matter who I’m with, if I get the thought inmy mind that I am going to get high, I do it. It’s really hardto give up everything you know and a lot of people can’t.As far as programs like halfway houses go, I havemixed feelings. I’ve been to six different programs and acouple of them twice. All of them had their own philosophiesand rules. Some were very strict and had a lot of structure:lots of groups all day and limited or no freedom to do whatyou want. I didn’t last long in those programs. The longest Imade it was about 2 weeks before I either got thrown out orleft on my own. They may work for some people but I foundthe more rules there were the more reasons I had to rebel. Ididn’t like having to be forced to talk about my feelings, orpast; if you aren’t ready to deal with all of that, it actuallycauses more harm than good. There wasn’t really anything toprepare people for the dealing with the “real world” uponrelease, where there isn’t that type of structure, or people tomake your decisions.There are programs that go to the extreme oppositeand have very little structure and a lot of freedom to dowhatever you’d like. Instead of paid staff to tell you what todo, a “social model” runs it, meaning you are supposed togo to other residents for help and support. It’s important tolean how to ask for help. But again, if you’re not ready fora lot of freedom, which can be dangerous, then it’s notgood. Out of all the programs, this is the only one Igraduated.Then there are the programs that fall somewhere inbetween. I find those to be the best to help you not onlystay away from drugs and alcohol, but to transition intosociety, too. I think that it’s important to have a middleground with structure and freedom.I’m not sure if jails or programs can make anydifference to people who aren’t ready to change. I guess itreally depends on how desperate a person is. ■7

I N T E R S E C T I O N S : P R I S O N A N D T R E A T M E N TON PAROLEBY E V E R O S A H N , P H OTO BY M I C H A E L J A C O B S O N - H A R DYOn New Year’s Day, a lockdown of NY state’s 70,000+ prisoners preventedwhat may have been the largest prison strike since the 1971 AtticaRebellion. The issue was parole—or, rather, the failure of the N.Y.State Board of Parole to grant early release to prisoners whose positiveprison records would have, in the past, entitled them to what wasthen called parole. 1 The present anti-crime climate has given us threestrikes-and-you’reout laws, longer prison sentences and harsher conditionsinside prisons. It has also caused the parole system to fall intodisfavor. We need only await the next arrest of a parolee to witness aGiuliani/Pataki press conference calling for the end of all parole.The parole system had its root in the moralideas of the Quakers. The Quakers held thatan individual should, after some time inprison reflecting and rehabilitating, be releasedinto the community at the earliestpossible time. “It’s purpose is to help individualsreintegrate into society as constructiveindividuals as soon as they are able. . .”said the United States Supreme Court inMorrissey v Brewer, a 1972 case which formalizedparole law. 2 In order to help the paroleemake the transition back into the community,the parole system mandates that they obeya series of stringent conditions designed toprevent behavior that’s seen as dangerous ordestructive, and that they report regularly toa parole officer. That officer was historicallycast in a combination role as a cop and socialworker, and the workings of parole weremore informal and collaborative than the adversarialset-up of criminal trials. The ParoleOfficer was to counsel the parolee; referthem to counseling, treatment and job trainingas appropriate and generally offer supportand a sympathetic ear to individualsattempting to adjust to life in the “freeworld.” At the same time, if the P.O. believesthat her supervisee isn’t adjusting properly,her responsibility is to impose new conditionsof parole or, as a last resort, chargethem with violating the conditions of theirparole and re-incarcerate them.As rehabilitative (change) oriented theoriesof incarceration have been replaced byan ideology of punishment, the parole officerhas become more and more a law enforcementofficer and the system of parolemore about repression than reintegration.Parole officers are under substantial pressureto re-incarcerate their parolees at theearliest opportunity rather than to workwith them over the rough spots.Whether the parole system ever lived upto its humane-sounding ideals is open toquestion. There’s no doubt, though, that paroleofficers are feeling pressure: recently,the N.Y. State Parole Officer’s Associationcirculated a petition opposing the N.Y. PoliceDepartment’s use of parole officers inlaw enforcement operations like “OperationGunslinger.” The N.Y.P.D. are taking advantageof the fact that while police need a warrantor consent to enter an individual’shome, parolees must let their parole officerscome in and search their homes, as part ofthe conditions of parole. “Gunslinger” andother recent campaigns have teamed P.O.’swith N.Y.P.D. officers, who get a free passpast your constitutional rights and into yourhome as a result.The reality of parole can be harsh. If youare granted parole, your “discharge plan” toparole may very well instruct you to reportto a homeless shelter as your “approved residence,”even if you have a history of seriousmental or physical health issues. (In thoseinstances, you may very well be releasedwithout sufficient medication or, more likely,with none at all, and directions to go to ahospital emergency room the day after yourrelease for assessment. You will be expectedto travel at your own expense to meet withyour parole officer, apply for public assistanceand attend drug treatment programsand job-training. If you fail to keep any ofthese appointments, you may very well becharged with violating your parole and sentback to prison.One of the standard conditions of paroleis that all drug use is prohibited. The parolesystem will most likely require any individualwith a substantial drug history to submit regularlyto urine tests by their P.O., and to participatein some sort of drug treatment.Though P.O.’s will look askance at continuingpositive urinalyses, their significancemay be outweighed by the individual’s continuedparticipation in treatment. Ofcourse, those of us who defend accused paroleviolators too often see situations in8

which parolees are violated before any attemptis made by the P.O. to refer them forany type of supportive programs.Tips for AgenciesIf you interact with parolees as a serviceprovider there are a variety of ways you cansupport these clients. If your client has themisfortune to be charged with a parole violation(or even if the P.O. and their supervisorare considering it) your intervention mayprove to be vital:First and foremost: if you report a client’s failureto regularly attend a program, or failureto participate appropriately, they may verywell be sent back to prison. Try to balanceyour contractual and professional responsibilitieswith the understanding that parole isa “zero tolerance” system. If you have to reporta client’s non-participation try to includein your report a recommendation that theyreturn to your program after they are againreleased from jail, if that is appropriate.Parolees are far too often charged with paroleviolations because of inaccurate informationprovided to their P.O.s by drugtreatment and other programs. If you areasked whether or not an individual is stillmaking use of your services, make sure yougive the right information. Trying to retractincorrect information after your client is incarceratedfor a parole violation is difficult,and they will still spend days if not months injail waiting for it all to get sorted out. If youhave the opportunity to make a positive assessmentof a parolee’s participation in yourprogram activities put it in writing and senda copy to both the parole officer and to theindividual.PRISON FACTS 1If You Are On ParoleYou probably already understand that the systemis more interested in your submission totheir authority than they are in what you’rereally thinking or doing. If you are on paroleand are using drugs or have a substantialdrug history, the best course of action is tofind a drug treatment program you can livewith, and build whatever relationship you canwith your counselor there. Showing that youare attending consistently may prove to bemore important than a dirty urine.If you are referred to a drug programthat you don’t find helpful, feel free to locateanother one for yourself—but makesure that your P.O. knows what you’re doing,and don’t stop your attendance at the firstprogram till your acceptance into the secondone is firmed up.There are conditions of parole that prohibitbeing involved in criminal activity, andthat require you to report every instance ofpolice contact to your parole officer as soonas you can. An arrest will not necessarily resultin a violation of your parole, but failingto tell your P.O. about it most likely will.If you are arrested or even questioned onthe street by a police officer make sure thatyour parole officer is informed as soon aspossible. If you are incarcerated and are havingtrouble making telephone calls, getsomeone else to do it: your attorney at yourarraignment, a social services worker in thejail, a chaplain or a relative. If the parole officeris difficult to get in touch with, havethat person request to speak to a supervisorand write down their name and the date andtime of the call. Your parole officer will automaticallyget an “arrest notice” informingthem of your arrest a day or two after it happens,so you’re not saving yourself by failingto notify them.You have probably had experience with alot of attorneys, some not so competent. Ifyou are arrested on a new criminal chargeor charged with violating your parole, try tolet your attorney know the truth about whathappened. They can’t tell anyone withoutyour prior approval, and it’s better if theyhear it from you than from the prosecutor.■Eve S. Rosahn is an attorney with the ParoleRevocation Defense Unit of The Legal Aid Society.If you are on parole, or if you are a serviceprovider who works with parolees, andyou need some information, please call her at718-260-4749, or send an e-mail to her aterosahn@legal-aid.org.1 Until late 1999, people convicted of seriouscrimes in New York State were given indeterminatesentences that specified a minimumand a maximum (like five years - fifteen years.)After the minimum judge-imposed sentence isserved, people appear before members of theBoard of Parole, who are mandated to reviewthe underlying crime and the individual’s activitiessince incarceration, and decide whetheror not the individual can live a “law abidinglife” if released to the community. If it was decidedthat they could, they are released to servethe rest of their sentence on parole. New sentencinglaws have altered this system, but stillprovide for a period of “post-release supervision”that is in all respects similar to parole.2 Morrissey v. Brewer, 92 S.Ct. 2593, 408 U.S. 471,33 L.Ed. 484 (Iowa 1972)■ There are about 70,000 prisoners in NY state prisons, and another 20,00 being held at Riker’s Island alone on NYC sentences or awaiting trial orparole revocation hearings.■ One-third of the people who went to jail in 1996 were parole violators, often as a result of drug use.■ 23% of all state prisoners and 60% of all federal prisoners are incarcerated for drug crimes, and we don’t know how many for drug-related crimes.■ The chances of getting a prison sentence after being arrested for a drug crime rose 447% from 1980 to 1992.■ In 1997 only 9.7% of prisoners nationally were receiving drug treatment, down from 24.5% in 1991—despite the fact that treatment is often a requirementfor parole release.■ There are profound racist disparities in who goes to prison for drug use. African-Americans represent 13% of the nation’s monthly drug users, 35%of those arrested for drug possession, and 74% of those who go to prison for drug possession.■ Number of prisoners in all US corrections facilities: 2.000,0001 The figures in this section were obtained from The Sentencing Project, a non-profit organization studying the rates and nature of incarceration in the U.S.Try their web site at www.Sentencing project.org, or write to them at The Sentencing Project, 514 10th Street, NW, Suite 1000, Washington, DC 20004.9

P U S H I N G B O U N D A R I E SBACKIN THE USSRBY D R E W K R A M E R , P H O T O S BY J O H N R A N A R DThis article was originally written for our Fall, 1999 issue, but was bumped to this issue by space limitations. Sincework on this project has continued, we’ve included a postscript, which follows this article. Where necessary, I’ve addednotations to the original piece.—EDWhat do we mean when we talk about harm reduction? This term is used and abused so often.Agencies are named, trainings are given, jeremiads are hurled, conferences are convened,all in the name of harm reduction. I was sure I knew. There might be shades of differencebetween my ideas and those of the people who sat around me at the plenary of HRC’s 2nd NationalHarm Reduction Conference, but all of us would probably agree on most of the basic issues.Secure as I was in my grasp of harm reduction, I was dispatched to bring the gospel to Moscow. On theplane on the way over, I sat next to an information systems engineer from Indiana who had a suitcase fullof religious tracts. Both of us were on a mission: he to save souls, me to save lives. Both of us were selfrighteousin the way that all true believers are.10

People come in to be tested becausethey are sick, and they want to find outif HIV is the cause of their illness.I spent twelve days in Moscow in May (1999-ed), and now I am left wondering what harmreduction is all about. My ideas about harmreduction have been informed largely by mywork at the Lower East Side Harm ReductionCenter, and my knowledge of similar programs.I see harm reduction as a set of strategiesfor working with people who use drugsso that services can be delivered in a meaningfuland appropriate way. I see harm reductionalso as the basis of a critique of manyaspects of American society, from the war ondrugs to the inequities of the healthcare systemand on and on. By nature I am suspiciousof all orthodoxies. My approach iswholly pragmatic, and I’ve always liked thefact that so many aspects of harm reductionwere self-evident and common sense approaches.Smug as I was in my belief in mypragmatic outlook, I hoped that there wasmuch good that my agency could do throughthis partnership: no vague hocus-pocus, justconcrete, replicable programs and strategies.Injection drug use is exploding inMoscow. During the Soviet era, all pharmaceuticalscame in liquid form, cheaper thanpills or capsules. At the same time, there wasno pot or crack to smoke, and very little cocaineor heroin to snort, so if you were a druguser, you were shooting up. The end of theSoviet era left an entire country in a vacuumof values and assurances. There were nolonger any guarantees. Since 1991, tankshave rolled through the streets of the capital,banks have vanished, the health care systemhas collapsed, people work for months withoutreceiving a paycheck. Many young peoplehave started using drugs. Twenty percent ofthe students at Moscow State University areshooting up. Rates of HIV are just a step behind.In 1995 there were 500 known AIDScases in Russia. As of December, 1998, therewere 20,000. Ninety percent of these are relatedto syringe sharing among injectiondrug users.Over the winter (of 1998-99, ed), I put ina proposal to partner with a Russian non-governmentalsocial services agency to providetechnical assistance in developing a programto prevent the spread of HIV among injectiondrug users. Here in New York City, syringesharing is driven by the scarcity ofOpposite Page Above: A Moscow dealer cutsheroin in a "pritone"—a place where drugs are soldand consumed. Heroin produced in the Asiaticstates has begun to flood the Russian market, replacingthe traditional liquid opium called "Chorneshka,""Chornie" or black. ©John RanardAbove: A gypsy woman on the outskirts of NizhnyNovgorod sells liquid opium. © John Ranardsterile syringes. Provide access to sterile syringesand you bring HIV transmission to astandstill. Further, you provide a gateway toservices and healthcare to people whowouldn’t otherwise have that access. All soobvious. Because syringe exchange has beenso successful in reducing the spread of HIVin communities where injection drug use isprevalent in New York City, surely the samebenefits would be seen in Moscow. Our proposalwas enthusiastically funded.We were partnered with an agency calledNAN, an acronym for Nyet Alogolismu yNarcomanii, or “No to Alcoholism and Drug11

Here in the U.S., the way we connect withdrug users is by offering syringe access.Use.” (The name alone made me suspicious.)NAN began their work providing servicesto children who were made homelessby their parents’ drug and alcohol use. Theyset up a shelter for these children in 1987.Gradually, they began to provide services,such as drug detox and counseling, to thedrug using parents. In Russia, all of theseideas were completely new. NAN was the firstto break this ground. The president of theorganization has been named a specialadvisor on youth and drug use to the Russiangovernment. NAN enjoys a sterling reputationin Russia, and provides trainings toservice providers throughout the Confederationof Independent States (CIS). The purposeof the May trip was to meet the folksfrom NAN and develop a workplan to guideour efforts over the next two years.Moscow is an intensely political city. TheRussian President, Boris Yeltsin, was the formerMoscow party boss. The current mayorof Moscow, Yuri Lushkov, will probably bethe next president. People who work in Citygovernment want to work in the regionalgovernment. People who work in the regionalgovernment want to work for the Federalgovernment. The way not to advance isto be associated with anything controversial.Above: Students of Moscow Architectural Instituteinject black-market pharmaceutical Ketamine.A 10cc bottle cost about $10.00 and is good for10 doses. ©John RanardMayor Lushkov has put billions of foreignaid dollars into beautifying Moscow. Everythinghas a fresh coat of paint. The city is thecleanest I’ve ever seen. Russia is also a largelymilitarized society as a result of thedecades of the Cold War. There are three policeforces and their duties and responsibilitiesoverlap. But basically, being a policeofficer is Moscow is all about using the threatof arrest to extort money. Police tend to onlystop BMWs and Mercedes for traffic violations.If commercial sex workers or drugusers have a few hundred dollars on them,they avoid arrest. The police are everywhere.There’s one on every corner, as stone facedas Socialist-Realist era heroic statues. Theydon’t even say hello back.NAN is committed to doing needle exchange.They have managed to get a letter ofacknowledgment from the local governmentoffice in the southwest corner of Moscowwhere they operate, as well as the local policeprecincts. They will begin by developing literature,then starting street outreach, recruitingpeer outreach workers, developingcontacts and gaining the trust of users. NextAugust, they start distributing syringes.After working for five straight days to developa workplan down to the slightest detailto accomplish this, I am frankly at a loss toclaim definitively that this will be a harm reductionprogram. It will provide access toclean needles, street outreach and supportiveservices, but it will be unlike any one ofthe dozens of organizations I’ve seen that dothat in the U.S. For one thing, the drug usersare different. They’re all young. Twentythreeis old. A conversation I had with twousers was telling in a number of respects.Valery and Ivan (not their real names) were19 and 21, respectively. They had both beenshooting up since they were about 14 yearsold. They shot white heroin, which costsabout $50 a gram. They also shot speed,which goes by the name of “vint.” Cocainewas way out of their price range. I askedabout black tar, and also about a sort ofopium poppy soup I had heard was common.They told me that tar was a pain in theass because you had to cut it with vinegar,and it was full of crud. The opium soup—boiled buds and seeds of opium poppies—ismostly used by younger kids. As Ivan put it,“I would have to inject two liters of that intomy arm to get off.” I asked them about syringeaccess: did they ever have a hard timegetting syringes? In Moscow, syringes aresold at every pharmacy. It is illegal for thepharmacist to refuse to sell you a syringe.Surely it can’t be that easy. In fact, it is. Theonly time Valery and Ivan had a problem waswhen they don’t manage to cop until one inthe morning and everything is closed, andthen it’s your own stupid fault for not thinkingahead and spending a few cents for a syringeat the pharmacy.Next I asked them about syringe sharing.Had they ever shared syringes? Both of themgave an emphatic no. Never. Stupid thing.Would never do it. Then, Valery elaborated:“When I’m shooting up with my friends, andthere’s someone there I don’t know, I won’tshare syringes with him.” Ivan agreed. Neverdo that with someone you don’t know.Then I asked if they ever knew anyonewho had HIV. They both knew of one person.They had met him in a detox program.While he was in the detox, he had been testedfor HIV and found out he had AIDS. I explainedthat a person could have HIV andfeel strong and healthy, and have no visiblesigns of having HIV. The expression on their12

faces was the one people get when they realizethat the person they’re talking to is crazy.This lack of awareness that people can beHIV positive and not have AIDS is widespreadin Moscow. I visited an HIV testingclinic run by NAN. I asked the counselorwhat made people come in to be tested.Were they worried about high-risk activitythey were involved in? Had they read abrochure? Had they found out that a formersex partner was HIV positive? It was explainedto me that people come in to betested because they are sick, and they wantto find out if HIV is the cause of their illness.Without the knowledge that someonecould be HIV positive and appear to be thepicture of robust health, there’s no perceptionof risk. The only “face of AIDS” thatmany Russians are familiar with is the devastationwrought by end-stage AIDS. Obviously,you would hesitate before sharing workswith someone so visibly afflicted.In the context of Moscow, education,rather than syringe access, becomes the crucialpoint. This is where harm reduction getstricky. Here in the U.S., the way we connectwith drug users is by offering syringe access.This radical yet simple act communicates agreat deal in and of itself. The user doesn’tneed it explained to him or her that thisperson offering them sets sees them not asjust an addict to hassle into drug treatment,but as someone who can make choices, whocan be educated and whose life is worth saving.Working in our exchange, I see it allthe time. When someone comes in for thefirst time, they’re expecting a hassle.They’re preparing themselves for a counselingsession, where they’ll have to give theirwhole life story and the theme is, “Gee, I’vetried to get off drugs again and again. I’m somiserable I hate myself. Please help me.”When they realize that to the extent that theregulations of the Department of Health ofthe State of New York permit, there’s noneof that—no questions, no copping to anidentity that isn’t real to them, and, if youdon’t have to rush off, stay and have a cup ofcoffee and relax on the sofa for a while—there is an immediate sense of ownership ofthe space. This is a place for people who usedrugs. That’s basically how I look at harm reduction.Safe space. Come in out of thedrug war outside, put your feet up and feelat home.But what will it be like for NAN? Becausesyringes are available, offering syringes isless of a radical act. What will be involved ingaining the trust of users in this context,given the fact that syringe access is not themeaningful act we New Yorkers experienceit to be? Furthermore, what if the street outreachworker doesn’t happen to be a medicaldoctor? Will the information have anyweight?Attempts made by agencies informed bythe Dutch model of harm reduction, comingout of self-organizing among communitiesof drug users, have not been successfulin Moscow. This model is seen as alien (andit doesn’t help that the people trying to introducethis model are, by and large, notRussian but American and European). Theusers I spoke to thought that the peoplerunning such programs were crazy.Russians also have a completely differentway of looking at social services. For onething, they are completely materialist intheir approach. Treatment is treatment: it isa procedure or a medication. The talkingcure, psychotherapy, and its numerous variantshave all the usefulness of bathing suitsin the Arctic. At the same time, psychiatrywas used as a means of political repressionin the past. Furthermore, there is the pervasivethinking that if you don’t have a doctorate,what you have to say can’t be of muchvalue. AIDS activism here in the U.S. hasworked to diminish this “cult of the expert.”You, and not your doctor, is the expert onwhat goes on with your body. Similarly, adrug user is the best person to speak authenticallyabout drug use, not a doctor orresearcher. Giving people a role in shapingand determining the policies and decisionsthat will affect their lives is called empowerment,and this idea seems wholly alien toevery Russian I’ve spoken to.For example, I had described to me byan Irish woman working in Moscow the horrifyingscene she witnessed at a clinic fortreatment of STDs. On a tour of the clinic,she was given a white lab coat to wear andshown into a room where about sixty menand women in white lab coats were sittingaround in a circle. One by one, women whohad syphilis were brought in and sat down inthe center of the room. They were questionedabout what symptoms they had, howthey had gotten syphilis, why they didn’t usea condom, from whom had they contractedsyphilis. At one point, an older woman wasasked to take off her tunic and walk aroundthe room so that each of the people in thelab coats could see the rash on her lowerback. The women subjected to this sat stonefacedthrough the probing questions. Thewoman who related the story told me howshe had voiced her outrage to the person givingher the tour of the clinic. He explainedthat the women agreed to take part in thestudy and it was explained to them that it wasbeing done in the interests of medical science.Many of the women had done it before.He didn’t see what the problem was.At the same time, Russians haven’t quitegotten around to criminalizing drug use theway we have. Drug use is viewed as a medicalproblem (to be addressed by doctors), notas deviant behavior. However, this may bechanging. There are new laws that makepossession of even a small amount of a controlledsubstance enough to put you inprison for several years, and there is even alaw that makes it illegal to “promote” druguse. However, these laws were viewed bymany people I talked to as attempts to addressthe threat of American cultural imperialism,rather than drug use. Lyrics of rocksongs were the real target, not people in theWhen offered free syringes, userswon’t necessarily be grateful or openor feel that they are being treated withdignity despite their drug use; rather,they’ll probably just be perplexed.harm reduction movement. Of course, it’sthe drug users who will end up suffering,and McDonald’s restaurants will continue toproliferate.One night, I went along with a group ofpeople doing outreach to commercial sexworkers. We went to several spots in downtownMoscow. We’d turn down a side streetor alley off of some main thoroughfare andthere would be thirty to eighty attractiveyoung women lined up against the wall. Thewomen were all well dressed in designerclothes. It looked like a Calvin Klein fashionspread. Cars would pull up, and men wouldtalk to the managers. The managers tendedto be women, also. The john would pick outa woman, she’d get in his car, and they’d gooff. We approached the women wheneverthere were no customers present. Thewomen enthusiastically took our brochuresabout condom use and HIV prevention. Unfortunately,that night there were no condomsto distribute. I asked one of themembers of the outreach team how many of13

and the wide expanse of the square with St. Basil’s Cathedral and the wallsof the Kremlin were surreal in their beauty. We were there to conduct an eightday training (the warm, cozy conference room kind of training) for a group ofpeople whom Sergei had identified as potential outreach workers. The curriculumincluded HIV, harm reduction, drug use, behavioral interventions, outthesewomen he thought were injection drugusers. He answered, “very few.” He explainedthat if a manager suspected one ofthe women to be injecting, the woman wouldbe fired. That would leave the woman withno money, forcing her to work on her own ata Metro station on the outskirts of the city.Strangely, everybody doing street outreachin Moscow seems to be focusing onthe downtown area. True, there is lots of actionthere, but it’s a lucky break that NANwants to work in a far-flung corner of thisimmense city. (This is where the sex workersthat get fired for being injection drug usershave to work.) We visited the neighborhood.It looked very different (large, slab architectureapartment buildings, bare streetsand sidewalks and, of course, sparklingclean), but it felt just like the Lower EastSide. It’s also far from the center of power.Mayor Lushkov probably doesn’t keep veryclose tabs on what happens out there.In October, some of the staff here at theLower East Side Harm Reduction Centerwill go back to Moscow to give a training toNAN’s staff on HIV, harm reduction, streetoutreach, the works. Then, NAN will headout into the streets, armed with literature,condoms, socks, gloves, hats, bleach kits, syringesand folks ready to do on-the-streetcounseling and referrals to services. Andthen what? When they approach a group ofpeople hanging at the Metro station waitingto cop, what will happen? I don’t thinkthere’s an answer to this question. The Russiancontext is different in so many ways, thatthe same act—giving a syringe to a personwho injects drugs—will be perceived differently.Yes it will be low-threshold, yes it willbe non-judgmental, yes it will meet peoplewhere they’re at. But when offered free syringes,users won’t necessarily be grateful oropen or feel that they are being treated withdignity despite their drug use; rather, they’llprobably just be perplexed. Since it will be adrug using peer—not an “expert” with astring of letters following his name—who isdoing the street outreach and education,any information offered might be viewedwith suspicion. Hopefully, the project willtake on a life of its own. Like any livingthing, it will adapt to its environment, butalso change its environment by the veryvirtue of the fact that it exists.MOSCOW POSTSCRIPTBY D R E W K R A M E R ,P H O T O BY J O H N R A N A R DFor a little over a year, the Lower East Side Harm Reduction Center has beenworking with Nyet Alcogolismu y Narcomanii (NAN, or No to Alcoholism andDrug Use), providing technical assistance in developing a HIV prevention programfor users. This article is a follow-up to the preceding one, which Drew originallywrote last September for our Fall, 99 issue.—ED.In May, 1999 LESNEP staff traveled to Moscow to meet their counterpartsat NAN. In August of 1999, prior to LESNEP’s October return trip toMoscow, NAN’s project coordinators—Sergei Polyatikin and NatalyaDolzhanskaya—came to New York. The ostensible reason was training. WhatI really wanted to do was give Sergei and Natalya an idea of what their projectcould look like, and also, what the whole continuum of care looked likehere in New York City. For two frantic, fast paced weeks, we shuttled themaround the city visiting other syringe exchange operations (New York HarmReduction Educators, Positive Health Project), peer educatorprograms (Exponents/Arrive), AIDS day treatmentcenters, drug treatment facilities, methadone clinics, researchers.Anyone who could make time in their schedule,we were there. Comparatively, I was amazed at thedisparity between options and services available to drugusers living with HIV here in New York City (even withall the barriers that exist) and those in Moscow. Again and again Sergei andNatalya came back to the same question: who pays for all of this? We wouldthen explain about Ryan White funding, CDC funding, funding from the Stateand City Departments of Health. (In Moscow—where things cost about as muchas they do in New York—doctors who work for the government get paid about$300 a month, and often go for months without pay because the governmentcan’t pay its bills.)There was, however, a problematic development during the trip. I noticedthat Sergei and Natalya seemed to have a fixation on training and research.This concerned me more than I let on. Although elements of training and researchare built into our collaboration, they are ancillary. The overall goal is toensure that injection drug users in Moscow get the education, tools and resourcesnecessary to stem the tide of new HIV infections. Training and researchare ways to make that happen, but not ends in themselves. However, even atour agency, the temptation is great. It is the rare individual who, in the freezingrain of February, would rather be out in the street doing sex worker outreachthan in a nice cozy conference room sipping coffee and eating a danish andlistening to a training on outreach strategies targeting sex workers. I didn’t wantthe project derailed by this trap.Although training was the primary focus during most of the first year, in settingout the work plan, I made sure that it was on-the-job training. In October,I traveled again to Moscow, this time accompanied by Van Asher, our Outreachand Volunteer Coordinator, and Steve Finkel, our Substance Use Counselor.The night we arrived, we walked up to Red Square. Snow was falling,The fledgling NAN outreach teamstarted out simple: condoms, alcoholpads, prevention literature.14

And what about NAN, the agency that’sgoing to be doing this work? My agency wasstarted at the grass roots, by a group of activistsfrom ACT UP. We were breaking thelaw for the first three years of our existence.NAN is the Russian equivalent of the UnitedWay. Their work with users to date has beenall about drug detox. And yet NAN, “No toAlcoholism and Drug Use,” is going to bedoing harm reduction work in Moscow.What is incredibly refreshing is thatSergei, the program director at NAN whowill be running the project, sees none ofthese contradictions. When he says that heis a harm reductionist, he means that he’swilling to do whatever it takes to prevent thepeople he knows through doing this workfor the past ten years from being wiped outby HIV. If that means braving the RussianWinter on a Moscow street corner to handout syringes by the fist full, then so be it.When I would try to describe for Sergei thecontroversy surrounding harm reduction,and the battles that rage even among peopleworking in harm reduction, he grows impatient.“It works. What’s to argue about?”So here I am back at the Lower East SideHarm Reduction Center, working the exchangecounter on a Monday night. I recordsyringes in, syringes out. I talk to peopleabout the recent overdoses we’ve seen in theneighborhood, asking what they’ve heard,reviewing the basics of OD prevention. Makingsure there’s milk for the coffee becauseI hate that powdered stuff and I’m sureeveryone else does, too. Saying hello andcatching up with the people I see every Mondaynight. Explaining to someone that ifthey left their ID card at home they have tostop at the desk and get a new one becausethat’s the best hope you have if you getstopped by the cops. Syringes in, syringesout. This is harm reduction, I’m sure of it. Ifonly it were possible to figure out for myselfjust what that means. As my saintly whitehairedgrandmother would say, “If you couldput that in a bottle and sell it, you’d make agoddamn fortune.” ■Drew Kramer is Executive Director of theLower East Side Harm Reduction Center.Above: Outreach workers talking to users in Moscow. ©John RanardJohn Ranard has been photographing the HIV story in Russia since 1995 whenhe discovered Moscow college students home-cooking and injecting their ownchemistry. His photo-documentary project "Inside a High-Risk Community" hasbeen supported by the International Harm Reduction Development programof the Open Society Institute and Medecins Sans Frontier - Holland. A collectionof these photographs will be exhibited at OK Harris Gallery, 383 West Broadway,New York City from November 18 to December 8, 2000.reach strategies, the works. Meeting and getting to know the trainees gaveme hope. They were young and enthusiastic, and from the first day they wereanxious to get out of the training room and into the streets. Despite their youth,they had among them years and years of experience shooting up in Moscow,and spoke with authority about the challenges that drug users in Moscow face.Afterwards, a second team arrived from New York. The plan was that whileeverything was fresh in their minds, our people and their people would hit thestreets together. Mark Gerse, our Deputy Executive Director, lead the secondteam, composed of Larry Gray, Needle Exchange Coordinator; Angela Daigle,Women’s Program Coordinator and Richard Alvarez, our Intake and ReferralsCoordinator. The fledgling NAN outreach team started out simple: condoms,alcohol pads, prevention literature. They hit Metro stations, the area aroundMoscow State University, street corners, wherever they thought that drug usersmight congregate. Immediately, they met with good results. Everyone they encounteredwanted information. They were describing safer injection practices,demonstrating bleach sterilization, showing how to clean the injection site usingthe alcohol pads. Driving home the message: always use a clean syringe.Mark, Larry, Angela and Richard were in Moscow for ten days. They wereout on the streets with Sasha, Alexi, Piotr, Ulia, Sveta and Lena and whoeverelse wanted to come along every day. And then, goodbyes and dosvedanyaswere exchanged, and our folks returned to New York, leaving the NAN teamto continue what we had started together. Over the weeks and months that followed,we exchanged e-mail. Through the miracle of the information superhighway,we offered suggestions on problems as they arose, and made surethat all the necessary supplies got to NAN’s offices and got out on the streets.There were many setbacks: “We can’t get past security to get into MoscowState University.” “We’re not meeting enough people.” “We don’t have aphone, so there’s no way to do follow-up.” With much email back and forth,we guided the NAN outreach workers through and around these obstacles.One of the trickier issues that came up was the nature of how drugs areobtained and used in Moscow. Things happen not on street corners, but inapartments, among close-knit groups of people who know each other. Recently,the NAN outreach workers have succeeded in forging alliances withthe people who live in several of the apartments, and that’s where they’redoing the work.When this last piece of news reached me, I was stopped in my tracks. Itseems that it’s working. In Moscow, drug use related harms are being reduced.Drug uses are getting the information and the tools that they need. And the heroesof the story are not the U.S. government, not the Russian government, notthe Lower East Side Harm Reduction Center and not Nyet Alcogolismu y Narcomanii,but Sasha, Alexi, Piotr, Ulia, Sveta and Lena, who are hitting the streets,working with their peers and building a movement. ■15

P U S H I N G B O U N D A R I E SA N E E D L E E X C H A N G EIS A TERRIBLE THINGT O W A S T EBY B R I A N M U R P H YNow that the U.S. government, the AMA and the World Health Organization have figured out thatneedle exchange is a good thing, we can look beyond fighting for our mere existence. Needleexchanges, occupying a unique place between the culture of providers and the culture of ourmost underserved people, are in a position to provide a host of services, like healthcare, case management,legal services, psychotherapy and so on. But to do this successfully, we have to cater to our customers.The culture of the healthcare and thedrug treatment systems—bureaucratic, ruledriven,schedule-driven—is polar oppositeto the street culture of its marginalized customers.On the street timing rather thantimeliness is valued; personal loyalty countsabove blanket rules and quick wits, courageand streetsmarts are valued above competencein filling out forms. The two culturesare so foreign to one another that whenthey meet, they are clueless about how oneanother behaves, and the customer comesout the loser. I’ll give an example. New YorkHarm Reduction Educators (NYHRE),where I work as a therapist, has a needle exchangesite on 110th Street. One time wehad a visiting case worker come out there tomeet potential clients. I came in on the tailend of a conversation between her and ahomeless guy who was HIV positive and totallyunconnected to services.Case Worker: “So, you’ll see me onThursday at four o’clock. Please don’t belate, because I have people coming beforeyou and people coming after you, and Idon’t want to waste the time slot.”Homeless Guy: “Okay, good. I’ll bethere...”Case Worker: “Anything else you want toask?”Homeless Guy: “Yes. When I come seeyou on Thursday, does it matter if I come inthe morning or the afternoon?”Was the homeless guy just being dumb?No. He was lost in a culture whose rulesmade no sense to him. Just as if the caseworker had been told to come down to 110Street and Lexington and cop a bag ofdope. She would have made a lot of elementarymistakes negotiating that system. Ofcourse, we in the mainstream culture believeour world is the “real” world. That’snatural enough. What’s not okay is when themarginalized customers get left flailing inHarm reduction wants nothing to standbetween itself and its customers.the wind because they have trouble adaptingto mainstream ways. Someone has tocross the great divide between these two islanduniverses, and the people who shoulddo that are the ones who get the paycheck.Let’s take a step back and look at privateindustry’s version of lowering barriers betweenthemselves and their customers. Backin the fifties corporate America discoveredthat if you clustered all your shops underone roof you could sell more stuff thanwhen they were separated off one by one.We call that the mall. America also started toexploit the fact that the more attractive andeasy you made the act of buying, the morepeople would buy, whether or not they reallyneeded it. And so, the advent of glamouradvertising, credit cards, extended storehours and “have a nice day.” CorporateAmerica wishes us a nice day because ithelps their bottom line.Just like corporate America, harm reductionwants nothing to stand between itselfand its customers. Harm reduction says: wewill skip across this great divide betweenproviders and clients by offering services tothe clients in ways that will make sense tothem. A needle exchange like New YorkHarm Reduction Educators meets the customersmore than half way by:■ Going to the street where they meet, atthe times that they meet there.■ Making the program anonymous.■ Making it easy to enroll.■ Being friendly and helpful.■ Offering the customers what they want,not what we, in our moral glory, have decidedthey need.Needle exchange has not just been effectivein reducing the transmission of HIV;it has also been successful in reaching out toa population of customers that no-one elseseems able to get to. It makes sense to invitea few more “shops” into the needle exchange“mall” because, as we know fromreal malls, the more hot stores you have, themore successful the whole place is going tobe. At NYHRE we have started that process.If the needle exchange is like The Gap, aflagship store attracting a core volume ofcustomers, these other services have been16

added over the course of time to take advantageof that flow:■ Acupuncture■ Referrals to drug treatment, housing,food pantries, etc.■ Outreach and special services to femalesex workers■ Legal services■ Special outreach to HIV positive clients■ Medical help■ Volunteer program■ Transitional case management■ An 800 number to call when the exchangeis not out there■ Safer injection supplies, condoms, vitamins,antibiotic cream, coffee, cool water■ Street-based support groups■ Sidewalk psychotherapy.And our experience has been just like atthe mall. Our customers come for the basicservice, make an impulse buy of another servicelike acupuncture or case managementand start to get hooked up in the system.Here is the heart of the matter: the successfulstores have re-engineered themselvesto suit—indeed ensnare—the customer. Servicesbased on a harm reduction model dothe self-same thing, and I’ll give sidewalkpsychotherapy as an example, because it isthe service I offer. Let’s look first at therapyin a conventional, clinic-based setting. Itdoes the following:■ An intake, either by phone or in person,where a person’s level of need and eligibilityare evaluated.■ If the person is eligible for therapy an appointmentis scheduled.■ The first session or two are spent on afairly exhaustive psychosocial profile,reaching a formal diagnosis and in creatinga treatment plan.■ Then therapy proper begins. The clientmay be subjected to long waits in an anemicwaiting room before the session(waiting to see the therapist) and after(waiting to have their next appointmentprocessed.)■ Clients who consistently miss appointmentswill be denied service.■ Clients who come to sessions high will bedenied service.■ Therapy continues for as long as the insuranceholds.■ If the client reveals a significant drugproblem, he or she will likely be referredout to substance abuse counseling andthe relationship with the therapist willcease.■ If the therapy takes place in a substanceabuse, rather than a mental health setting,there will probably be a cat-andmousegame between client andtherapist where the therapist sees theclient as an untrustworthy “addict.”Most of these elements represent barriersto service, and the customers whochoose not to shop at the mental healthclinic or the outpatient substance abuse programare considered “unready for treatment,”“in denial” or “recidivist.” Thetherapy at NYHRE, on the other hand,works on the low threshold approach of theneedle exchange. The exchange itself takesplace at tables on the sidewalk under arather festive blue-and-white striped canopy.Acupuncture is given inside the van, workersfor the various outreach initiatives combthe local streets and service providers likethe lawyer and the referral person “work theline” of participants waiting to exchange syringes.Sidewalk psychotherapy takes placea few yards away from the hubbub of theneedle exchange tables. The “office” comprisesof two folding chairs and a card tableto hold my files. A little like the lawyer andthe referral workers, I mill around collectingclients by chatting with people who aremaking exchanges; and sometimes otherworkers at the site refer people to me. Wethen sit in the “office” and conduct a therapysession which is remarkably similar towhat you might find in any other therapist’soffice. But here are some of the ways inwhich sidewalk psychotherapy, being a lowthresholdservice, differs from the indoor variety:■ Service is immediate and, if necessary,anonymous.■ Intake takes two minutes; if it seems likeit might discourage a customer, we skip it.■ There is no psychosocial assessment, noformal diagnosis, no formal treatmentplan.■ There are no insurance requirements.■ There are no appointments.■ The client determines how long the sessionwill be.■ The client determines the course of treatment.■ People who are high are as welcome asanyone else.■ To the client it be may like chatting; Iknow it’s therapy.Street people, whose homelessness ordrug use may have put them the wrong sideof the law, are not always happy to reveal theiridentity to someone who could be connectedto “the system.” But they live incredibly stressfullives and often have a pressing need fortherapy. So we don’t ask for information thatmight compromise them. And unlike the rigmaroleof appointments, intakes and assessmentsthat takes place at a clinic, the clientwill have a session immediately—or as soonas I have finished with the person beforethem. Since we don’t ask for insurance, wedon’t discourage people who have lost theircards, been thrown off Medicaid or whoOur customers come for the basicservice, make an impulse buy ofanother service like acupuncture orcase management, and start to gethooked up in the system.don’t want to endure waiting to have theircard processed. Appointments may be kingin the world of watches and calendar books,but they don’t carry much weight on thestreet. So the service is purely drop-in.We don’t even respect the 50 minutehour (or is it 30 minutes these days?) Theclient sets the length of the session, which inturn depends on the client’s interest in stayingin the chair. Some people can only bearto sit down for five minutes, others may goover the hour. Those who sit down (or standup) and counsel for a brief amount of timemay eventually be coaxed deeper into theprocess—or they may get their needs met asis. Since the client is in charge of theprocess, the course of treatment is not definedby the therapist or the insurance company,but by whether or not the client wantsto come back. And like the FBI, no case isever completely closed.Diagnosis can invite a labeling mentality,so I don’t do it. In my notes, however, I dorecord the length of the session and its mainthemes, which might be something like,“Depression/Housing,” “Legal/Anxiety” or“Family/Drug Use.” Interestingly, over thecourse of any given month, the subject ofdrugs comes up less often than emotionalconcerns or the need for concrete services.For the customers then, drugs are not theparamount issue—even though providersdivide up their whole service provision accordingto whether or not these customersare using.Of course I see clients while they are17

Co-sponsored by the American Foundationfor AIDS Research ● Advocates for Recoverythrough Medicine ● AIDS Action Council ●Broadway Cares/Equity Fights AIDS ● Centerfor Health Policy Development ●Center on Crime, Communities and Culture ●DanceSafe ● Florida AIDS Action ● HCVGlobal Foundation ● International Womenand Drugs Network ● Latino Commission onAIDS ● NAMA ● National Association forPeople With AIDS ● National Minority AIDSCouncil ● North American Syringe ExchangeNetwork ● North American Users Union ●Red Latino Americana De Reducción DeDaños ● Palm Beach InstituteHRC GRATEFULLY ACKNOWLEDGES THEFINANCIAL SUPPORT OF THESECORPORATE AND NON-PROFIT SPONSORSamfAR, Agouron, Broadway Cares/EquityFights AIDS, Drug Policy Foundation, Dupont,Glaxo-Wellcome, Roche , Schering-PloughOctober 22–25, 2000Wyndham Hotel Miami-Biscayne BayMiami-Dade County, FLExhibitors:If you would like to exhibit call: Paula Santiago @ 212 213-6376 ext. 15KeynotesCarmen Vazquez, Lesbian and Gay Community Services Center, NYLynn Paltrow, National Advocates for Pregnant Women.Augustin Loya IIIPotential speakersRaquel Algarin (Lower East Side Harm Reduction Center, NY), Paola Barahona (Prevention Works, DC),Scott Burris (Temple University, PA), Patt Denning (Addiction Treatment Alternatives, CA), Karen Dodge(Palm Beach County HIV Care Council, Fl), Delaney Ellison (CARES, MI), Heather Meschery, (Santa CruzNeedle Exchange Program), Ethan Nadelmann, (Lindesmith Center, NY), Richard Needle (Office ofHIV/AIDS Policy), Denise Paone (Beth-Israel Chemical Dependency Institute, NY), Dave Purchase (NorthAmerican Syringe Exchange Network, WA), Emanuel Sferios (DanceSafe, CA), Carol Shapiro (La Bodega dela Familia, NY), Susan Sherman (Johns Hopkins School of Public Health, MD), Harry Simpson (AgouronPharmaceuticals, MI), and Evelyn Ullah (Miami-Dade County Department of Health, Fl) presenting the results ofthe Crisis Intervention Teams in Miami.Confirmed Caucus Meetings:International Women and Drugs Network/Women’s Network Meeting 10:00 a.m. Sunday October 22 Allwomen welcome. Contact hrcconf@harmreduction.org for more information. NEX Youth Caucus Tentativemeeting time Monday October 23 7:00 p.m. Contact Ro Guiliano 415 436-9005 for more info. MethadoneConsumers meeting time Monday, October 23, 7:00 p.m. Contact hrcconf@harmreduction.org for moreinformation. CaSEN meeting day/time TBA. Contact Brent Whitteker 619 602 2763 for more info. MentalHealth Professionals in Harm Reduction, meeting day/time TBA. Contact Andrew Tatarsky212-633-8157.Free Pre-Conference InstituteSaturday October 21 9:00 a.m. to 4:30 p.m. Club Drugsand Harm Reduction: In conjunction with the 3rd NationalHarm Reduction Conference, DanceSafe will host a one-dayevent at the Wyndham Miami Biscayne Bay Hotel, October 21,2000. DanceSafe provides harm reduction information andservices within the rave and nightclub community, and islaunching a national "safe settings" campaign in conjunction withthe Right To Dance Coalition, to reduce dance-related medicalemergencies and demonstrate a practical alternative to the zerotolerance approach: "Zero deaths! Zero arrests!". For more info.contact DanceSafe @ 510-834-4654, or surfhttp://www.dancesafe.org/ and http://www.righttodance.org/.Rapid AssessmentIn response to the HIV emergency mandate of the CongressionalBlack Caucus, the Federal government has launched a RapidAssessment tool. This tool allows cities and communities toquickly create an epidemiological profile of HIV in their area, andis vital in creating an effective response to the spread of HIVamong drug injectors and their partners. So far, projects havebeen completed in Miami, Philadelphia and Detroit. HRC’sconference will feature a training on Rapid Assessmentimplementation presented by Drs. Richard Needle, Eric Goosbyand Chris Bates of the US Department of Health and HumanServices. The conference will also feature reports from Miamiand Detroit on Rapid Assessment.18

P U S H I N G B O U N D A R I E SBad Attitudes in the ER:It’s a Two-Way Street!BY N E I L F LY N N , I L L U S T R AT I O N BY S U N J E N S E NThis article is a presentation made by the author to Emergency Room physicians, residents, and interns at the Universityof California, Davis Medical Center and at the Heroin Overdose Prevention Conference in Seattle, January2000. The ideas presented in this article are more conceptual and come from personal observation rather than empiricdata. The ideas evolved naturally from Knowledge, Attitude, and Behavior (KAB) work with drug users and 25years of experience as a health care provider.The Problem—Health Care ProvidersHealth care providers often hold negative, stereotyped beliefs about drug users, beliefs whichinfluence attitude as well as care. Drug war rhetoric has had a significant affect on health careproviders, in spite of mounting scientific, medical and public health evidence to the contrary.There is widespread ignorance of the data supporting harm reduction approaches to care, and an absenceof harm reduction curriculum in medical training and Continuing Medical Education (CME) programs.Often these beliefs are based on bad experiences with individual drug users, and on personal useof drugs, rather than on medical/scientific knowledge; the better health care providers personally knowtheir drug-using patients, the more positive their attitudes toward drug users are.The Problem—Drug UsersDrug users, who often expect to be treatedpoorly by emergency medical technicians(EMT) or emergency room (ER)staff, frequently appear to have “a chip ontheir shoulder.” These attitudes resultfrom prior negative experiences withhealth care providers. Users are often in agreat deal of pain when they seek treatment,and are irritable. In addition, thereis a fear of exposure of their drug use tofamily, friends and employers—not tomention their health insurance provider.There is also the possibility that they willbe turned over to the police by hospitalworkers (and arrested and prosecuted),should they have any drugs in their possession.Drug users are estranged and marginalizedfrom the non-drug-using society,and frequently have un-addressed mentalhealth issues. All of these issues contributeto the poor patient-provider relationshipthat develops.The SurveyWe conducted a brief, rather informal surveyof 22 ER health care providers in Fall, 1999regarding their KAB about drug users. Theywere presented with several statements, priorto a harm reduction talk, and asked to agreeor disagree. The percent of those whoagreed with each statement is in bold textfollowing the sentence. The results follow:Drug use (other than alcohol) per se isbad. This includes marijuana, opiates, cocaine,methamphetamines and hallucinogens—36%affirmative. This responsesuggests to me that harm reduction is a conceptthat might find fertile soil among emergencycare providers.People who use drugs other than alcoholdeserve to go to jail—0% agreed. This responseis even more heartening.Sending people to jail for drug use ismore effective in dealing with the problemsof drug use than is any other use of taxpayers’money—0% agreed. Once again we seethat ER staff may be potential converts tothe harm reduction philosophy.Most of the resources the U.S. devotes toaddressing drug use are used for law enforcement—14%affirmative. We can introducea little cognitive dissonance here byeducating these providers that, despite theempiric evidence which supports alternativeuses of our tax dollars, most of the moneythrown at the problem lands in the law enforcementpocket—not the treatment pocket.Public money would, in general, be betterspent if a public health (disease prevention,health promotion) and medical model(drug treatment) rather than a criminalizationmodel were to inform U.S. drug policy—68%agreed. If they only knew!When drug users are difficult to workwith in the ER, and on the hospital wards,the “blame” for it is mostly theirs—45%agreed. Over half recognize their own contributionto the problem. The great majorityof these health care providers are people19

of high intelligence and big hearts. Theyneed training and tools!Most drug users couldn’t control theirdrug use and be productive citizens if theyhad unlimited access to their drug of choice(sterile, known potency), at reasonablecost—36% agreed. Here again we see thatalmost 2/3 of these health care providershave somehow heard, processed and agreedto some extent that drug users can be responsiblefor themselves, given opportunity.Possible Solutions—Health CareProviders■ Improve health care providers knowledgeof the various drug use cultures anddrug use itself.■ Put a human face on drug users.■ Appeal to health care providers innatecompassion and humanity—nothing hitsus harder than to be accused of insensitivityand lack of compassion. It is ourAchilles’ heel!■ All levels of medical and nursing educationshould include more training onthese issues. A concentrated effort to includeprinciples of harm reduction inCME and basic training will pay dividendsfor harm reduction.Health care providers need a better understandingof psychosocial aspects of druguse. Often times, mental health issues probablypreceded drug use. In fact, drug usemay be ameliorating symptoms. Many drugusers were abused as children. Health careproviders should call loudly for policy makersto provide for comprehensive treatmenton demand.Health care providers should also have abetter knowledge of the pharmacology andeffects of opiates, cocaine, methamphetaminesand hallucinogens (most have triedmarijuana). It wouldn’t hurt to comparethese drugs to alcohol and tobacco productsfor safety, potential for injury, abuse, etc.They need better guidelines for judginganalgesic needs of drug users as well as a betterunderstanding of abstinence syndromes(withdrawal)—and proper alleviation ofthese symptoms.Training should demystify drug usersand debunk the myths surrounding them.Drug users are not asking to get or stay highin the hospital. Heroin users want to be ascomfortable and free from pain as the personin the next bed, but this often requires asignificantly higher opiate dose than for thenon-habituated, and health care providersdon’t fully understand this.Health care providers should examinetheir attitudes and “attitudes.” Health careproviders should be more hospitable andfeel free to use humor—“I’m sorry, butheroin isn’t on the menu yet, may I offeryou sustained release morphine or perhapsmethadone?”We must continue to point out the crueltyof the present system. We can give healthcare providers an alternate vision of drugusers, with much of the violence, hostility,anger and self-loathing removed: we can callit “decriminalization.” Shame on us for buyinginto and supporting the drug war—we(health care providers) should know better,leading the way to harm reduction.After the session, the participants wereasked, “Has this discussion changed youropinion of drug users in the ER in a significantway? Four out of 22 (14%) said yes. Wewill revisit these issues with ER staff in sixmonths.Possible Solution—Drug UsersExpose drug users to drug user-centeredprimary and secondary healthcare. Assertivenesstraining should be provided duringdrug user-centered healthcare, and inpeer advocacy programs. Because everyhealth care provider’s contact with a drugusing-patient is an opportunity to changeminds, we need to get drug users on a missionto teach health care providers. At leasthalf, or more, of drug users can become patient(double entendre) teachers of healthcare providers. After all, it is a two way street.SummaryAlthough this was a small survey, and needsto be repeated on a larger scale, its resultswere not surprising. Health care providershave bought into the drug war as ordinarycitizens and haven’t applied their professionalexpertise to the problem. When theydo they will think differently. More trainingis needed: make it the CME topic du jour.Drug users psychological reintegration intosociety will also go a long way toward improvingprofessional and private lives ofboth drug users and health care providers.Acknowledgements: I am indebted tothe personnel of Harm Reduction Services,Sacramento, the talented group of researchpersonnel with whom I work: (especially Ms.Rachel Anderson, Ms. Lynell Clancy and Mr.Jim Britton), and the many drug users whohave, and will, undoubtedly, continue toteach me of our common humanity. ■Neil Flynn, M.D., M.P.H., is Professor ofClinical Medicine, University of California,Davis and Director of research, Center forAIDS Research, Education, & Services. Neilhas conducted research on the epidemiology ofHIV among IDUs for the past 13 years, andhas provided medical care to HIV-infected individualsin the Sacramento region for thepast 17 years.WE WANT YHRC MBecoming a member of the Harm Reduction Coalition is one of the most significant ways youcan support our organization’s work and mission. As a coalition of harm reduction practitioners,providers, and consumers, HRC draws its strength, diversity, and expertise from the nationwidenetwork—people and organizations like you—that is HRC. As a member, you will receive regularreports about HRC activities and events; a one-year subscription to Harm Reduction Communication;and discounts on HRC conferences, trainings, publications, and merchandise. Sodemonstrate your support of harm reduction and the Harm Reduction Coalition by becominga member today._____ $35 Individual_____ $100 Organizational_____ $150 Senior Member_____ $500 Core Member_____ $1000 Harm Reduction PartnerName: _________________________________________________________________Organization: ____________________________________________________________Address: _______________________________________________________________City: _______________________________ State: _________ Zip Code: ______________Phone: ( ) _______________ Fax: ( ) _______________E-mail: ________________________________________________________________Send all membership subscriptions to: Membership, Harm Reduction Coalition,22 West 27th Street, 5th floor, NY, NY 10001☛20

✁DRUG USER SURVEYThank you for filling out this survey. The information collected here is to better understand drug users experiences and interests. The results will be presented atan upcoming 3rd National Harm Reduction Conference. This survey is supported by the North American Users Union.Contact Brent from the North American Users Union (NAUU) at 619-602-2763 or wbrent@ix.netcom.com with all questions and comments. Fax completed surveyto HRC @ 212 213 6582, or Utah Harm Reduction Coalition @ 801 364 0161.PLEASE USE A BLACK PEN Shade circles like this: ● Not like this: ✓ ✗What drug treatment options would you liketo see more available?o Methadoneo LAAMo lbogaine,o Buprenorphineo Inpatient Detoxo Outpatient Detoxo Acupuncture/ Herbal remedieso Rapid Opiate Detoxo 21/28 Day Detoxo Othero None/ Not ApplicableWhat drug treatment options would you liketo know more about?o Methadoneo LAAMo lbogaineo Buprenorphineo Inpatient Detox,o Outpatient Detox,o Acupuncture/ Herbal remedieso Rapid Opiate Detoxo 21/28 Day Detoxo Othero None/ Not ApplicableWhat incentives would motivate you to receivingtreatment?o High likelihood of successo Moneyo Non-judgmental staffo Easily accessibleo More personal careo Nothing/ Not ApplicableHow difficult is it for you to get treatment?o Very difficulto Somewhat difficulto Not that difficulto Not at all difficulto Don’t know/ Not ApplicableWhat is the most important drug-relatedhealth problem to you?o HIVo HCVo Overdoseo Abscesso Trackso Endocarditiso Othero NoneWhat is the most important reason for NOTreceiving help for a drug-related problem?o Financial costo Incarceration or arresto Others finding out you useo Losing your jobo Losing custody of a childo Feeling like a failureo Being judged by peopleo None/nothingHow much harassment or abuse have you experiencedfrom the police?o A loto A littleo Very littleo Noneo Don’t know/ Not ApplicableHave you ever been stopped by the police forcarrying syringes, or arrested or charged forsyringe possession?o Yes, but not arrested.o Yes, but not arrested because I was a participantin a needle exchange program (NEP).o Yes, arrested but later released because I wasa participant in a NEP.o Yes, arrested and kept in custody for more thanan hour even though I was a participant in a NEP.o Noo Don’t know/ Not ApplicableThe following questions are optional. We askthis information so we can determine whichusers have specific interests and experiences.(mark only ONE choice for each question)Sexo Maleo FemaleEthnicityo African-Americano Caucasiano Asiano Native-Americano Hispanico OtherHow often do you currently use drugs?o (More than I x/day)o (1x/day)o (1-4 x/week)o (1 x/week)o (less than I x/week)AgeBubble in left column is for tens, right column for ones.Example: For age 27 mark the left column bubble by 2 andthe right column bubble by 7.0 oo1 oo2 oo3 oo4 oo5 oo6 oo7 oo8 oo9 ooWhat is your drug of choice?o Speedo Powder Cocaineo Crack Cocaineo Heroino Speedballo Other_________________What Is the drug you use most often?o Speedo Powder Cocaineo Crack Cocaineo Heroino Speedballo Other _________________Do you use more than one drug at the sametime?o Yeso NoHow do you use most often?o Injecto Snorto Smokeo Other21

BY DONNA ODIERNAThis month we’re going to focus on herbs that are good medicine when picked and eaten raw orcooked simply, and herbs that can be made into medicinal tea without using hot water. Many ofthese herbs grow wild in city spaces, so depending on where you live, you may find that you havea whole medicine chest just waiting for the picking.As winter turns to spring, many folks who stay in shelters or doubled and tripled up with friendsfind places to sleep outdoors. Other folks live in squats with no electricity or hot water. So whilethese herbs and recipes are of clear benefit to folks who don’t have housing with all the facilities,they have an added advantage. When we use just-picked or recently-dried herbs, we are usingthe plants when they are still full of living energy. The herbs smell fresh, and they are at their mostpotent. When we prepare our teas using cold water instead of boiling water, we activate theplant’s enzymes instead of killing them, so the nutrients are easily absorbed and digested.Most of these herbs can also be bought at the herb store or the natural food store. Some harmreduction programs may have herbs for program participants. But if you decide to pick your ownherbs, please remember these points:■ Never pick and use a plant unless you are absolutely, 100%, positively surethat you know what you are picking. The best way to know is to be introducedto the plant by someone who knows it.These days, most cities have several herb identification walks (also known asweed walks) every month. Check in the alternative press or health food storebulletin boards for notices. These walks are usually inexpensive, and often havea sliding scale. If you can’t afford the price, it’s worth turning up anyway andasking if you can go along.■ Some plants are protected by law, and most parkland doesn’t allow foraging.If you get caught, you can be fined. Best to pick on private land, withpermission.■ Don’t pick in sprayed areas, too close to busy roads or where dogs congregate.■ Only pick plants where they grow abundantly, and don’t pick more than afew plants in one place. Leave most of them to reproduce so there will be plentynext year. When you leave a stand of plants, it should be impossible to tellthat you were picking there.Common Weeds/Super HealersYou can find these plants in most places where you find people. It’s as if theyare saying “Here I am! I can help you—use me!”Yarrow (Achillea millefolium)Yarrow grows in city and country, east and west. This green ally is a good oneto know. It is used in first aid to stop bleeding (chew up a leaf or use powdered,dry leaf, and put it on a scrape or shallow wound; the bleeding willslow right down). It’s also antimicrobial, so it helps to keep the wound clean.A leaf of yarrow (or sniffing some powder or tea) will stop a nosebleed. Theroots can be chewed to ease the pain of a toothache. Traditionally, the rootswere put in a jar with whiskey, whether to preserve them, to increase the effector to make them taste good—who knows? But for IDUs, one of the bestthings about yarrow is this: Yarrow improves circulation and supports good veinhealth. The tea is drunk in small quantities throughout the day, or can be usedas a skin wash before and after shooting up.WITCHEBREWS’Dandelion (Taraxacum officinale)Dandelion is a goodie. The leaves and root can be eaten as a bitter tonic,perfect after a long cold winter. Bitters stimulate the digestion and the liver,clearing and detoxifying. Having a dandelion leaf or two and a nibble of rootbefore meals while increasing fiber will stimulate the appetite and get sluggishbowels moving. It may take a while for the full effect to be seen, but over timeit is extremely effective. As a salad green or cold infusion, the leaves detoxifyby increasing urine output, so drink plenty of water when you call on this greenally. The leaves are rich in vitamin A, vitamin C and minerals. The white sapcan be used to dissolve warts and soften calluses. Try not to get it on otherskin, though: it can cause a rash.Violet (Viola odorata)This lovely little plant is deceptively pretty, hiding her strong medicine underpurple flowers and green leaves. Violet leaf relieves pain and heals. Somecrushed (or chewed) violet leaf can be placed on the temples, forehead, or theback of the neck to relieve headaches. A chewed leaf, placed over a soregum speeds healing and reduces pain. Violet tea, made with fresh or driedleaves and hot water, can be used as a herbal wash, or drunk. Violet is a naturalsource of salicylic acid, the active ingredient in aspirin. Ladies, a poulticeof the leaves (wilt the leaves in a little hot water, let cool) is heavenly for sorebreasts, especially before that time of month. And don’t forget to put a few violetleaves in your wild salad: they are brimming with vitamin C. Leaves andflowers only, please! (The roots are poisonous.)Mugwort (Artemesia vulgaris)This magical plant is at home in the city. In New York, by summer’s end, mugwortcovers the old tires, broken fences and vacant lots all over town. Sleepwith a sprig of this plant if you want to have vivid, easily remembered dreams.Otherwise, use it early in the day and keep it away from the place you sleep.Mugwort opens the third eye and lets psychic energy flow. On a more basiclevel, the cold infusion of the leaves helps when you have problems digestingfats, but crave the donuts that leave you feeling awful after you eat them. Puta few spoonfuls of leaf into a pint jar, cover with cold water, and steepovernight, then strain off the water and drink it before meals.22

Burdock (Arctium spp.)Burdock grows in many cities. The low-growing leaves are huge (up to 2-3feet long), and the thistle-like flowers form seed pods that look and act like Velcro.Burdock root is good for the liver, skin and lungs, and helps the body eliminatetoxins. It’s delicious when it’s cooked and eaten, or dry it and make thetea using either cold or hot water.Cleavers (Gallium aparine)This plant grows in cool, moist places from city to country. Look for it in a shadyspots before the weather gets too hot. Once you know cleavers, you will seeit everywhere. Its leaves circle the stem like daisy petals, and the whole stemfeels rough and sticks to clothing, hair, other stems; everything. Cleavers is oneof the best plants for the skin and lymph, and assists in cleansing and removingwastes from the body. Pick it on a dry day, let it dry and make tea from hotor cold water.Chamomile Flowers (Matricaria spp.)This one does it all—stimulates digestion, aids sleep, calms frazzled nerves andfights off bacterial infections. Make it into tea with hot or cold water, and sipit for stomach cramps or drink it before bed. It also makes a great skin wash,before or after shooting up, or any old time.Pine Needles (Pinus spp.)Pine trees grow everywhere. The needles, twigs and bark support the formationand strength of veins and capillaries. The new growth (young needles) isespecially rich in Vitamin C, which is found in all parts of the plant. Pine needles,fresh or dried, make a delicious tea (use boiling water) that clears the lungsand lifts the spirit. The very young needles can be eaten raw.Plantain (Plantago major, P. lancoleta)Here’s nature’s Band-Aid! Chew up a plantain leaf and use it to soothe insectbites, scrapes and skin rashes. The tea can be used externally as a wash, andinternally to clear the lungs during acute infection or persistent dry cough. (N.B.:This is not the banana-like plantain. It’s a low-growing plant that loves lawnsand likes to keep dandelions company.)Rose Hips (Rosa rugosa)Rose hips form after the roses have blossomed, faded and blown away. Thehips are rich in Vitamin C and flavonoids. They support the immune system, andthey are yet another herb that helps maintain good circulation and feeds theveins. Pick the hips from unsprayed rose bushes, in the fall, winter or spring.Or ask your favorite gardener to save the hips for you after she prunes unsprayedrose gardens. Rose hip tea is easy to find in natural foods stores andmarkets.Stinging Nettles (Urticaria dioicia)Anyone who has brushed into a nettle plant can show you this one. Ouch! Thewhole plant is covered with tiny hairs that sting like the dickens when they aretouched. Nettle plants let you know when you’ve found them! They like to grownear running water, so watch for pollution. The tiny nettles of early spring aredelicious. Even the little ones sting when they are fresh, so use gloves to pickthem (dried or cooked nettles don’t sting at all). Nettles are a storehouse of vitaminsand minerals, and here’s yet another plant that removes toxins from thebody. Nettle tea (hot or cold infusion) gives deep energy; it’s a great choicefor times when you’re exhausted from too much stress or to help rebound aftera speed run or a detox.(REAL) WITCH’S BREWGOOD TEA FOR GREAT VEINS1 Part Pine Needles1 Part Rose Hips1/2 Part YarrowYou can make any amount of the herb mix. Use dried herbs in the proportionsabove. (If you use 2 ounces of pine needles, use the same amountof rose hips, and 1 ounce of yarrow. Make as much or as little as you like.)Store the herbs in a clean, dry jar or a paper bag.Place 1 ounce of the herb mix into a quart jar. (One ounce is a good fullhandful for most people.) Fill the jar with boiling water, cover tightly. Letsteep for 20 minutes. Strain, and drink throughout the day for strong, flexibleveins and improved circulation. Throw away any leftover tea. Startagain with a fresh batch of herbs every day.GIMME STRENGTH SUN (OR MOON) TEA1 Part Burdock Root1 Part Nettles Leaf1 Part Cleavers HerbCombine the herbs, and store in a clean dry jar or a paper bag. Placeone ounce of herb mix in a quart jar. Fill the jar with cold water, cover tightly,and let steep all day or overnight. Shake it up every now and then. Strain,and drink the tea throughout the day, and throw away any leftover tea. Thisworks best over time, and will assist the body with deep cleansing and willimprove energy.SOME BOOKS THAT CAN HELP YOU LEARN ABOUT PLANT USE ANDIDENTIFICATION:Medicinal Plants of the Pacific West, 1993. by Michael Moore, (Also MP ofthe Desert and Canyon West, MP of the Mountain West)The Complete Medicinal Herbal, 1993, by Penelopy OdyA City Herbal, 1977, 1998, by Maida SilvermanForaging for Plants in Wild and Not-So-Wild Places, 1995, by “Wild Man”Steve BrillPeterson’s Field Guide to Eastern/Central Medicinal Plants by Steven Fosterand James A, DukeSOME WEBSITES TO CHECK OUT:http://www.herbs.org/ (Michael Moore’s site-see above booklist.)http://www.egregore.com (A general site with a large herb glossary-ed.)http://altmedicine.about.com/health/altmedicine/msub7.htm (A goodlinks page-ed.)http://herbsforhealth.about.com/health/herbsforhealth (One ofabout.com’s sites-a little on the commercial side but lots of info-ed.)http://www.allexperts.com/getExpert.asp?Category=991 (Interesting,an online q & a site. I can’t vouch for it-ed.)http://www.realtime.net/anr/herbs.html (An on-line reference guide forherbs-ed.)Donna Odierna is a herbalist, nutritionist, and health educator. She is inprivate practice and also works with IDUs at Casa Segura in Oakland, CA.23

BY DELANEY ELLISONON THEGROUNDI’ve been watching the primaries. Absent from the debate isany conversation about the drug war and it’s ramifications.No one at a town hall meeting has talked about this failedintervention’s cost in dollars or human suffering. “Junior” Bush.can’t admit (or deny) cocaine use! Is this related to Texas’drug laws that target the poor? (There are some poor, poorpeople in deep Texas!)Black leaders are out of touch with the truly marginalized in this country—sometimes, it seems, by choice. Black leadershave been forced into inaction by the old carrot/stick approach: a promise of middle class status vs. the threat ofeconomic decimation. Even though these leaders can’t be blamed for their inaction (what good would it do?), they aresorely lacking in challenging amerika’s current drug policy.I’m old enough to remember the 60’s. I know Martin Luther King would not be silent when faced with a failed policythat continues to destroy young Blacks through incarceration and violence. Malcolm, even after the enlightening tripto Mecca, would have picked up a rifle! And Rap....well, since I first wrote this, Rap has done just that!)Historically, in this country, Black leaders have challenged white privileged ideas and policy. Black leaders have devisedhumane and effective ways to address social and political issues that white politicians couldn’t or wouldn’t face.Black men and women have shown this country the way out of hunger, segregation and disparities in education andhealth care. The involvement of morally outraged black people hastened the end of an obscene, illegal war in SoutheastAsia. Today, however, after assassinations, political condemnation and dismissals, the leadership has discardedcompassion and it’s all about the money. The most insidious threat tocivil rights, constitutional protections and even foreign policy (considerColumbia) is our current drug policy.Let’s be real clear about one thing: The War on Drugs is a RaceWar! This is illustrated by the recent murders of innocent, unarmedblack men by police in New York, and the corruption and brutality ofthe LAPD’s Rampart Division. Police are warped by the soldier vs. protectormentality of the drug policy in this country. According to the FB&I,Let’s be real clear about one thing.The War on drugs is a Race War.since 1981 roughly 100,000 people have died in the drug war crossfire.Half of them were innocent bystanders. Ninety percent were blackand brown.In Michigan the drug war, through it’s main weapon, the criminal justicesystem, continues to decimate the black community. On September24, 1999, a “drug court” judge sentenced Letisha “TT” Bennett to fivedays in the Kalamazoo County Jail for giving a cocaine-contaminatedurine sample. Ms. Bennett was married, employed, had two school agechildren and was pregnant! (She was originally arrested and chargedwith manufacturing and sales of a controlled substance, and in Summer,1995 sentenced to lifetime probation. TT was assigned to drug court byher probation officer because of the enormous probation caseload.) Thisjudge, in his infinite wisdom, sentenced her to an overcrowded countyjail. A jail where there is a guarantee of no pre-natal care, nutrition orstress reduction. A jail where there is a concentration of peoplewho are likely to have a variety of communicable diseasesand infections. Felons were released that weekendwhile TT sat there! Are we missing something?It should be noted that TT is black, as are 71% of the peoplein this country who are convicted for non-violent, drugcrimes (while whites make up roughly 80% of arrests andonly 15% of convictions). The rate of incarceration for African Americanwomen is eight times higher than that of white women (Amnesty International,“Not Part of My Sentence.” Violations of the Human Rights ofWomen in Custody, Washington D.C. 1999, March, p. 19).No minister protested in TT’s behalf. No civil rights activist wrote anopinion. When TT came home she had an upper respiratory infection24

so severe she was hospitalized for three days. That same week blackleaders in this country spoke out loudly protesting television network’slack of minority faces in prime time! Well fuck it!It is paternalistic and condescending to assume that any single intervention,solution or paradigm will work to the benefit of the massesof people in this country. I don’t think I am a paranoid, but in Michigan,the Engler administration has quadrupled the bed space to accommodatedrug arrests and still 5000 people—mostly young, blackmen—are farmed out to prison systems in West Virginia every fiscalquarter—on trains! What does this bring to mind?I always hear from the drug warriors: “What message would wesend to children if we were not hard on drugs?” I think the kids havesaving interventions. If national Black leaders took the stand of ReverendEdwin Sanders II, that of inclusion and ethical treatment of drug users inthe midst of HIV/hepatitis epidemics, we could effectively change thecourse of infection and incarceration rates with the same blade of thesword. Harry Simpson lobbying Clinton for needle exchange needsmaximum support (maybe Jesse Jackson at his side!) Efficacy’s CliffThornton has it right, as do Joycelyn Elders and Maxine Waters, but weneed many, many more who will take the necessary political risks. ReickiWaiss and Dana Beard were eloquent, loving spokespersons. Thereare Black heroes in this war, just as there have always been in this country’sconflicts.People used to say a lot of shit to me. And I even used to listen: IIt is a challenge of conscious black people to re-locate thisconversation to a public health paradigm.gotten the message. Children are sensitive to fair play and peer pressure.The message is: “If you don’t look or sound like the white privilegedculture you are doomed to stigmatization and death. See, itisn’t cost effective to take care of the sick or the old or the weak. Andif you can’t solve your problems any other way, violent confrontationworks.” To prove it drugs and guns are readily available to anyonewho wants them!I don’t wish to sound insensitive, but 13 children died in Columbine,and the media and nation were paralyzed. How many black childrendied in the streets of our cities that day? I wonder if anyone talked tothose kids at Columbine about race and class? One more child diedin Flint. Their kids are murdering each other in school, the violent cauldronof the drug war froths over and the beat goes on.Where are black leaders when it comes to this failed, ineffectiveDrug Policy? The problem is that there is no conversation surroundingthis class/privilege paradigm. This must be addressed. As the industrializationof amerika has wound down from the late 1960s and theinformation and technological advances have driven a new economics,I have observed a decimation of the black community. At the sametime I have observed absorption of the black leader class into the ubermiddleclass.Black leaders have been leaders, first, in the black church. Drug useis framed as a moral issue. Therefore, black leaders are hobbled inany conversation considering any tolerance of drug use and drugusers. Herein is the reason why so few have condemned the currentdrug policy in amerika. It is the challenge of conscious black people tore-locate this conversation to a public health paradigm. Anyone whoopposes this shift, is by default supporting the current unregulated criminalblack market in drugs—or their job depends on it!While there is no bigger threat to civil rights, no more insidiousenemy to the health and well being of black and brown communities,minority leaders who consistently speak out against the War on Drugsare few and far between. Chris Rock said, “We don’t have black leaders,we got substitute teachers!”Australia has the right, common sense and compassionate approach.Families and Friends for Drug Law Reform, who worked to get sterileshooting rooms in Australia, are people who have lost loved ones andhave committed themselves to a controversial heroin trial and other lifewas very confused and not too secure, either. Today I hear a lot of shitand I marvel at people’s abilities to absorb it and think they are not affectedby it. It is easy to say I am suffering sub-culture solidarity anddismiss me when I speak with any compassion toward drug users. Butit would not be so easy to dismiss thousands of Blacks and whites andLatino(a)s lobbying close together at local, state and federal levels.Nor would it be easy to dismiss these same people supporting compassionate,ongoing interventions like harm reduction with needle exchange,barrier free services and universal health care.You know, my grandmother practiced Harm Reduction when I wasarrested. When my father was refusing or slow about getting me out ofjail, I can remember my mother recounting my grandmother’s conversationswith my father. They went something like this:Grandma: OK, them white folks have had him long enough. I want youto go over there and get him out.My Father: Shit!Grandma: Yeah, you going to get him out, and bring him to me. Sellwhatever it is you got to sell, cause that shit is mine anyway!My Father: I am tired of this shit!Grandma: Well then, bring him here to my house. You ain’t got to bebothered with him no more!My Father: Yeah, you deal with him...Grandma: That’s OK, I will!And when I would show up, covered with holding cell filth, she’d giveme $20, swearing that that is all she had.She’d say: “Now, go do what you do and come back here so youcan clean up after them white folks have dogged you...and get somereal food in you. You look a mess!”My Grandmother, uneducated, black, from the South, by way ofChicago’s Southside in the 20’s and 30’s, arrested for bootlegging,could teach us all something. We have been practicing a commonsense, compassionate, non-judgmental approach to handling drug-relatedharm. No need for McCaffrey or Guiliani or Keyes input, or theirdrug war. We know what to do, here, on the ground.Delaney Ellison is the Harm Reduction Coordinator at Community AIDSResource and Education Services, Kalamazoo, Michigan.25

BY CORINNE CAREYIf the primary goal of welfare reform in New York State is to move people off of the welfarerolls, then reform in New York is working. If its goal is to assist people in improving their livesand moving them towards healthy, housed and employed self-sufficiency, then it has beena dismal failure. The City government periodically announces with greatfanfare the number of New Yorkers no longer receiving public assistancebecause of welfare reform. The Commissioner of the State Officeof Temporary and Disability Assistance, Brian Wing, has given an actualfigure: in New York State, over 671,000 fewer people are on thewelfare rolls today than in 1995. According to the Mayor of NewYork City, Rudolph W. Giuliani, 500,000 people have left the welfarerolls since 1995. The Mayor proudly proclaims that this number is“more than the whole population of Cleveland.” Giuliani has managedto reduce the welfare rolls by nearly 45%.These statistics are dangerously misleading. While some havemoved from welfare to work, a significant number of people have beencut from the rolls for failure to comply with some requirement or other,or because they’ve simply given up trying. Many of these people arenot employed, they are not housed and they are not doing well—byanyone’s standards.Thousands of New Yorkers on public assistance have lost their benefitsfor such offenses as arriving late to a meeting with a caseworker or adoctor. Still others have simply given up what often feels like a daily fightto retain seriously inadequate benefits. (In New York City, where a onebedroomapartment is difficult to find for under $1,000, the monthly rentalallowance for a single person is $215.)In New York City, one of the most serious threats to this already vulnerablepopulation trying to retain benefits is the State’s drug and alcoholscreening and treatment scheme. Nearly everyone receivingpublic assistance in New York City 1 (in the form of rent, cash benefits,Medicaid and food stamps) has gone through the City’s screeningprocess for alcohol and substance abuse since the regulations implementingthe screening system went into effect. Heralded by treatmentprofessionals as an innovative way to open the doors to people whohaven’t had access to treatment in the past, the screening process,which consists of an initial 9-question form followed by a more formalinterview with a Certified Alcohol and Substance Abuse Counselor(CASAC), has instead become an insurmountable obstacle for thosewhose addictions are the hardest to treat.While some people who might not otherwise have access to treatmentbenefit from a referral, others are deterred from seeking food stampsand other subsistence benefits for fear of eventually losing the assistancebecause of unwillingness or inability to participate in or complete a rehabilitationprogram. Still others are cruelly set up to fail in a system thatis not equipped to deal with the complex issues facing substance users. 2It is common to say that if someone leaves a treatment program beforecompleting it, he or she has “failed” in drug treatment. However, addictionis the only disease where society attributes blame to the individual iftreatment is ineffective. And it is the only disease where those afflictedare penalized for exhibiting the symptoms of their disorder.But it is not only those who are seriously debilitated by their addictionsthat have been put in jeopardy by the new screening and treatmentrequirements. Advocates working on behalf of public assistancerecipients with alcohol and drug problems have noted several structuraland practical barriers that have made it difficult for even the mostdiligent recipient to retain his or herbenefits.ReportsfromtheFrontCLINICAL PRACTICEGUIDELINESNew “Clinical Practice Guidelines”went into effect in October1999. They remove thediscretion—granted to treatment providers by law—to determine when someone is “in compliance” with a treatmentplan. Many treatment providers expect a majority of their patients to“fail” by welfare standards and lose Medicaid and other benefits. TheGuidelines, issued by the welfare department itself, place stricter standardsof “compliance” on welfare recipients than treatment providersthemselves do. Under the Guidelines, it is conceivable that a single relapseafter only 30 days in mandatory treatment (or even a marijuanapositivemandatory urine screen) could cost a long-time user his or herbenefits. What would look to a clinician like entirely appropriateprogress in treatment spells failure to the welfare department, and requiresa loss of benefits.NAVIGATING THE SYSTEMA large number of applicants for and recipients of public assistance inNew York City risk the loss of their benefits because of the way these requirementsare being implemented. Both clients and their advocateshave found it nearly impossible to navigate the bureaucracy of the citywelfare department, its Office of Employment Services, its “job centers,”its Substance Abuse Case Control Program and the many other officesand systems that they are sent to and through.INAPPROPRIATE REFERRALSOnce someone on welfare is found to be “in need of treatment,” heor she is referred to a program approved by the State Office of Alcoholand Substance Abuse Services (OASAS). As with coerced treatmentin other forums, such as the criminal justice system, almost anytreatment program that has a bed or a space available is considered“appropriate treatment.”Certified Alcohol and Substance Abuse Counselors (CASACs) spendan average of 45 minutes conducting “in depth” interviews with applicantsand recipients, assessing the level and severity of their addictions, determiningan appropriate level of care and finding a treatment program to‘match their needs.’ Unfortunately, little attention is paid to whether the recipientshould be in an inpatient as opposed to an outpatient treatmentprogram; whether simple groups, or talk therapy, is appropriate as opposedto more rigid Therapeutic Communities (TCs); or whether an assignedtreatment program is far from the recipient’s home.Neither the regulations governing this process, nor the city welfareagency itself make any provision for those individuals who suffer fromthe dual diagnosis of “mentally ill-chemically dependent” (MICA). Mentalhealth issues are rarely identified by CASACs, and even less frequentlyprioritized. Therefore, people with a MICA diagnosis are often26

sent to treatment programs that are ill-equipped to deal with theirspecial needs. Untreated mental health issues can also contributeto a person’s inability to successfully adhere to and complete asubstance abuse treatment plan.Additionally, because referrals must only be made to thoseprograms approved by OASAS, recipients cannot be referredto effective harm reduction programs which provide low-thresholdcounseling and other services to active drug users. Sometimeswith components called “treatment readiness” programs,harm reduction programs work to sustain engagement with active drugusers who are often profoundly disconnected from other services andwho cycle in and out of treatment, the criminal justice system, and thehospital. Not surprisingly, many people have been sent to programsthat are not appropriate to their needs.INABILITY TO COMPLYIf someone has been assessed as being unable to work because of adrug or alcohol addiction, is it so surprising that the same person maybe unable to comply with a program that requires his or her attendancebeginning promptly at 8:30 every morning, six days a week? Manypeople are unable to comply with the strict requirements of drug treatmentprograms, and when they falter, instead of offering additional support,or reassessing the level of care they have been given, their casesare closed, and their benefits terminated. Recently, in a ruling againsta homeless welfare recipient who couldn’t keep up with his treatmentprogram’s schedule, a judge found that it was the recipient’s responsibilityto recognize the inadequacy of his program, where the CASACtrainedaddictions specialist had not.EVERYDAY MISTAKESBoth recipients and the system are bound to make mistakes. Mistakesthat may be an inconvenience in the life of someone not dependent onthe state for subsistence benefits have many more severe consequencesin the lives of public assistance recipients. As if the loss of rental assistance,food stamps and cash assistance for necessities were not punishmentenough for failing to submit proper documentation of a change intreatment plan, those found to be impaired by drug or alcohol addictionare the only public assistance recipients who are sanctioned with the lossof medical benefits. Thus, they are not only shut out of the very treatmentthey need, they are also prevented from accessing routine medical treatment,exacerbating existing health problems and placing these individuals,their families and their communities at risk.Welfare recipients have been sanctioned for transferring fromone drug treatment program to another, for failure to consult withcity welfare personnel before making a change in treatment planswithin the assigned treatment program, because treatment programssubmitted the wrong code to the city welfare agency to characterizea patient’s status in treatment and even for failing to attend programsto which they’d never been assigned. Treatment programs have notreceived adequate training to report the status of their patients to thecity welfare agency; therefore, it is common for an inadvertent mistakein paperwork to result in a sanction.A SYSTEM UNEQUIPPED TO DEAL WITHTREATMENT-RELATED ISSUESAlthough it is well noted by drug and alcohol treatment professionalsthat relapse is a part of treatment, there is little tolerance in a systemThousands of New Yorkers onpublic assistance have lost theirbenefits for such offenses asarriving late to a meeting with acaseworker or doctor.that punishes recipients who do relapse by cutting off their food stamps,cash benefits, rental assistance and Medicaid. While abstinence-basedprograms prove extremely effective for some, dismal drop-out and recidivismrates among those in treatment point to the general inadequacyof drug treatment as we know it. People struggling with problemdrug use continue to be the only people punished for exhibiting symptomsof what the system terms a “disease”—drug addiction.The traditional remedies provided for applicants and recipients to redressthese mistakes and grievances are wholly inadequate to addressdue process rights. Case conferences and conciliations are held withwelfare caseworkers who are untrained in the area of addiction treatment,and are thus rarely resolved in favor of a recipient—even whereevidence in favor of the recipient may be clear. For example, in a recentconciliation, a recipient who was mandated to one methadonetreatment program was sanctioned for failing to report to an entirelydifferent program (a clinic at the Veteran’s Administration) to which hehad never been sent. Although he brought proof that he was attendingthe program he was mandated to attend, because he didn’t bringproof that he was never referred to the VA, he lost at the conciliationlevel. This, despite the fact that the welfare caseworker’s file on himclearly indicated that he had never been referred to the VA.Administrative Law Judges charged with determining the merits of a recipient’scase are likewise untrained, and yet are called upon to judgethe merits of treatment decisions. Treatment professionals are rarely presentat these hearings, nor are welfare’s own CASACs. It is left up tothe recipient to explain his treatment plan, and his difficulty in meetinghis treatment goals. The recipient’s testimony is then weighed againstseveral sheets of data printouts, and, often unrepresented, the recipientloses. While there are as yet no statistics reporting the success rates27

Brian Murphy, CSW, is Director of ClinicalServices at New York Harm Reduction Educators,in New York City, where he leads counselinggroups, does individual therapy and‘sidewalk psychotherapy’ on the street inNYHRE’s mobile East Harlem needle exofrecipients challenging sanctions at fair hearings, anecdotal evidencepoints to the fact that unrepresented recipients sanctioned for drug andalcohol screening and treatment violations lose their cases in largernumbers than recipients sanctioned for other reasons.WHAT PROVIDERS CAN DOTreatment providers can have a tremendous impact on the way thatthe new screening and treatment regulations affect their patients.Providers can learn how to correctly fill out reporting forms used by thecity welfare agency to monitor the progress of public assistance recipients.Entering certain codes, or failing to attach appropriate documentation,can result in the loss of benefits for patients, and the loss ofMedicaid coverage as well. Providers can advise patients of their rightsto challenge welfare decisions to terminate their benefits, including requestinga fair hearing. Continuing aid pending an administrative decisionis available to those who challenge benefits within 10 days ofreceiving a notice from the city welfare agency.Providers can also assist patients unable to request fair hearingsthemselves due to their disability. Some patients are so impaired bysubstance use that they are unable to navigate the welfare system themselves.Providers should know that if they are transferring a patient to anotherfacility or another modality of treatment that these decisions mustbe made with the knowledge and consent of the city welfare agency.If welfare is not consulted on these treatment decisions, the patient willbe sanctioned and will lose his or her benefits. Providers can also resistpressure to adopt policies that run counter to sound clinical principles,such as implementing punitive internal sanctions or reporting patientswho experience periodic relapses to welfare.We are in an era of welfare reform in New York State where collaborationis the catch-word, and criminal justice agencies, social serviceofficials and medical and substance abuse treatment providers areall examining ways to work with one another to streamline service provision.State and local welfare officials can ameliorate the devastatingeffect these policies are having by exploring the concept of collaboratingwith the client, instead of seeing the client as an adversary, andby understanding that treatment decisions should be made by cliniciansand treatment professionals—in collaboration with their patients.If you, or someone you know, is being sanctioned for failure to participate in orcomplete a drug or alcohol treatment program in New York City, and you'd likelegal assistance but can't find a lawyer to represent you, please contact CorinneCarey at the Legal Harm Reduction Project, (212) 533-0540, extension 323,or by e-mail: ccarey@urbanjustice.org. Corinne Carey is a Criminal Justice Fellowwith the Open Society Institute’s (OSI) Center on Crime, Communities & Culture.She is currently a staff attorney with the Urban Justice Center, and is workingat the Lower East Side Harm Reduction Center/Needle Exchange Program.1 Except for those individuals receiving assistance under the Division of AIDS Servicesand Income Support (DASIS). DASIS clients are HIV+ and symptomatic, or with a T-cellcount of 200 or less. DASIS has recently been reoganized into a new department calledHASA, the HIV and AIDS Services Administration, serving both HIV+ asymptomatic andsymptomatic individuals in two separate divisions. It is likely that HASA clients will besubject to the screening, assessment, and referral process.2 This is especially true for women with children, who, as they are assessed and referredfor treatment, will be faced with the harsh realities that such they have already encounteredwhen seeking treatment on their own: too few programs, a scarcity ofchildcare and male-centered treatment approaches.Contiued from page 17continued on page 28high—we’re a needle exchange. One of themost successful people in our program, forwhatever reason, would only do therapywhen he was high. Perhaps when he wasstraight he wanted to assert his autonomy.What I do know is that with a combinationof individual therapy, group work, volunteering,work with the legal system and casemanagement, he is in a far more productivespace now than he was a year ago. And if hehad had to go about town for each serviceseparately, I don’t think for one momentthat he would have done it.My version of an “office” may not seemvery intimidating, and you might say that itis barrier-free, but that’s not true. Quite afew people at the exchange feel trappedwhen they put their bums in that foldingchair, though they would stand and chat forever.So we stand and chat. A recent conversationmade this progression: a) generalcomments on the shitty, hot the weather, b)broader observations on the topic of globalwarming, c) the client expresses a sense ofover-all impending doom, d) disclosure bythe client that his fear of contracting theHIV virus has led him to give up sex and gettested every few months even though hecannot identify any risky behaviors and e) aquestion/answer session in which the clientgets a better understanding of the virus. Didthe client see himself as “client?” Whoknows? He’s now joined a site-based group,and we’ll see where he goes from there. I believehe was a client because what I call a“therapeutic intervention” took place.Do people mind the lack of privacy? Actually,sidewalk psychotherapy is much moreprivate than it seems, since passers-by do notstop to listen, and usually do not know thattherapy is going on. People may in fact be alot more comfortable counseling on theirown turf than in the clinic, where thin walls,crowded waiting rooms and inefficient littlenoise-maker machines only give an illusionof privacy.Are the methods of sidewalk psychotherapydifferent from other therapies? Not really.I work indoors as well, and my methodsare the same in both cases. I sometimes usethe reflective listening approach of Millerand Rollnick in Motivational Interviewing;while clients who just want to be heard by anotherhuman being demand supportive therapy.And others again are best helped, in myestimation, by the cognitive approach of rationalemotive therapy. And when peopleare highly “stressed” I do a little very simplebiofeedback. My one unchangeable maximis to remain respectful and non-judgmentaltowards the client, and to remember thatthey are where they are not because they arebad or weak, or genetically conditioned, butbecause our Western culture, with its insatiableappetite for scapegoats, has identifieddrug users as top-notch scary scapegoats.So, the needle exchange holds a uniqueposition at the juncture of the provider cultureand the drug-using culture. It was onlythe AIDS crisis and the need for some sortof desperate action that created such a hybridform. But now we are there, the therapists,the case managers, the welfareworkers, the housing specialists, the jobtraining counselors, the doctors and so on,can collect at places like ours and work tomake the “whole” of clustered treatment alot larger than the sum of its parts. But forthis to work, each service must be re-tooledalong harm reduction lines, so that the customerscan manage through the barriersthat will undoubtedly still exist. If you offera high threshold service in a low thresholdsetting, you’re wasting a wonderful opportunityto reach a population that some peoplesay can’t even be reached.That’s why a needle exchange is a terriblething to waste.■28

REPORTED BY ALLAN CLEARGlobal VoiceGlobal VoiceThe U.S. Government finally funds a harm reduction manual! (However, it’s for Asia!) The Manual for Reducing Drug RelatedHarm in Asia has been produced by the Centre for Harm Reduction, Macfarlane Burnet Centre for Medical Researchin Australia and by the Asian Harm Reduction Network and is available for free ($15.00 P&P). For more info.check out their website at www.ahrn.net. Congratulations to everyone involved, especially to the towering man amongmen Nick Crofts. And yes USAID partially paid for the manual and then bought some. Crafty buggers, these Australians.At the tail end of 1999 the African Harm Reduction Network was formed in Lagos, Nigeria. Representatives fromGhana, Gambia, South Africa, Kenya, Tanzania and Nigeria were present, as was Pat O’Hare of the InternationalHarm Reduction Association. Again congratulations, and upwards and onwards.LATIN AMERICAN HARM REDUCTION NETWORK (RELARD)REPORTED BY GRACIELA TOUZEIn January 1998 representatives of Brazil, Argentina, Uruguay,Chile, Paraguay and Colombia met in São Paulo, Brazil, to found theLatin American Harm Reduction Network (RELARD). These past twoyears other countries such as Bolivia and Mexico have been involved,too. This entire process has been supported by UNAIDS and IHRAand has allowed Latin American issues to be present in the globalagenda.The main objective of RELARD is to promote actions towards the reductionof drug related harm, with priority in the prevention ofHIV/AIDS transmission, within the boundaries of public health, humanrights and citizenship in Latin America.Since its founding, RELARD has encouraged links between researchand intervention efforts and has improved co-operation within the regionand with other regions as part of the Global Voice. RELARD enhancesnational networks and discussion on harm reduction strategies.It also contributes to capacity-building and to the dissemination of informationand experiences through its newsletter and its website.Some initiatives seek to consolidate the development of alternativepolicies and programs. The Latin American Travelling Seminar (LATS)is an initiative of a group of drug experts from Latin America and Europe.We had the first LATS in Curitiba, Brazil last March and will havethe next ones in Santiago, Chile and Recife, Brazil. RELARD is also planningtwo Parliamentary Seminars for this year, in Medellin, Colombiaand in Mexico with the partnership of Fundación Universitaria LuisAmigó and Programa Compañeros.Together with the Brazilian National Coordination on STD/AIDS,the State of Rio Grande do Sul and the Municipal government of PortoAlegre, RELARD is organizing the South American Seminar on the Reductionof Drug Related Harm, which will be held in Porto Alegre, Brazilon May 15th to 19th, 2000.RELARD has also established and maintains strong links with theAIDS networks in the region. A permanent consulting group has beenformed with the participation of:■ RELARD,■ Latin American People Living with HIV/AIDS Network (REDLA+),RED LATINOAMERICANA DE REDUCCION DE DAÑOS (RELARD)En enero de 1998, representantes de Brasil, Argentina, Uruguay,Chile, Paraguay y Colombia se reunieron en São Paulo, Brasil, parafundar la Red Latinoamericana de Reducción de Daños (RELARD). Enestos dos años, otros países como Bolivia y México se han unido. Esteproceso ha sido apoyado por el ONUSIDA y la IHRA y ha permitidoque las cuestiones latinoamericanas estén presentes en la agendaglobal.El principal objetivo de la RELARD es promover acciones de Reducciónde los Daños Asociados a las Drogas, con prioridad en laprevención de la transmisión del Vih/Sida, en el marco de la SaludPública, los Derechos Humanos y de Ciudadanía en América Latina.Desde su fundación, la RELARD ha alentado los vínculos entre investigacióne intervención y ha mejorado la cooperación en la regióny con otras regiones como parte de la Voz Global. RELARD promuevelas redes nacionales y la discusión sobre las estrategias de Reducciónde Daños. También contribuye a la construcción de capacidades y ala diseminación de información y de experiencias mediante su boletíny su Página Web.Algunas iniciativas buscan consolidar el desarrollo de políticas yprogramas alternativos. El Seminario Itinerante Latinoamericano (LATS)es una iniciativa de un grupo de expertos de Latinoamérica y Europa.Tuvimos el primer LATS en Curitiba (Brasil) el pasado marzo y tendremoslos próximos en Santiago (Chile) y Recife (Brasil). RELARD tambiénestá planificando dos Seminarios Parlamentarios para este año,en Medellín (Colombia) y en México, en asociación con la FundaciónUniversitaria Luis Amigó y el Programa Compañeros.Junto con la Coordinación Nacional de ETS/SIDA del Brasil, elEstado de Rio Grande do Sul y el Gobierno municipal de Porto Alegre,la RELARD está organizando el Seminario Sudamericano de Reducciónde los Daños Asociados a las Drogas, que tendrá lugar enPorto Alegre (Brasil) del 15 al 19 de mayo.RELARD también ha establecido y mantiene sólidos lazos con lasredes de Sida de la región. Se ha conformado un grupo de consultapermanente con la participación de:■ RELARD,continued on page 30 continued on page 3029

REVIEWSHarm Reduction Books and Videos,BY ALLAN CLEARHEPATITIS C HANDBOOKBy Matthew DolanWe used to talk about harm reduction beingabout options more frequently than we seemto now. The harm reduction approach takesinto account the totality of an individual.Matthew Dolan’s third edition of the HepatitisC Handbook provides options and subjectmatter covering the whole person with a balancedemphasis on western treatments andtraditional eastern approaches to illness. It’s a terrific educationalresource. And how this book has grown from the first edition. This isprobably the most authoritative book on HCV—and also the best fordrug users. Although Matthew pulls no punches in saying that druguse is generally bad for someone with HCV he’ll also recommendprescription of diamorphine over methadone or eating hash oversmoking it. One of the joys of this book is that it will be reassuring topeople living with HCV who find themselves “feeling ill” but havingtheir symptoms dismissed by their medical provider. Armed with informationfrom this book, patients can more capably advocate fortheir own needs or take independent, positive steps that can improvethe quality of their lives. This book should be available at any goodbookstore and can always be ordered from any of the online companies.The Hepatitis C Handbook Matthew Dolan published byNorth Atlantic Books, Berkeley, California 1999.SAFER INJECTION, BETTER VEIN CARE VIDEO, @ 20 minutesProduced by Maureen Rule, Health Care for theHomeless Harm Reduction Outreach ProgramBy the time you read this theOscar’s will have been longgone. Michael Caine will havehis achievement award tuckedaway in his bedroom closet.American Beauty will havebeen christened film of the yearand Kevin Spacey will be safely tucked away in his closet. However,the film most deserving for best documentary won’t have beenmentioned at all. “Safer Injection, Better Vein Care,” based on thepost card series that the Chicago Recovery Alliance produced a coupleof years ago is an excellent short (20 minutes) presentation.None of the very picky HRC staff who has watched the tape hasquibbled at all with the content except for the lack of information onbooting. Principally geared towards empowering injectors, this videois also an amazing instructional tool for agency workers. It runs thegamut in content from improving injection techniques, tying off,preparing crack for injection, scarring prevention, and emphasizingthe need for sterile surfaces and sterile equipment. It covers overdoseprevention and response, safe disposal of syringes, needlestick preventionand much, much more. There’s no redundancy and no waste.All of this for $35.00 incl. P&P from Maureen Rule, Health Care forthe Homeless, Harm Reduction Outreach Program, PO Box 25445Albuquerque, NM 87125-0445. Phone: (505) 266-4188 Fax:(505) 266-3199. All proceeds go to the agency although it’s beingsold at close to cost. The video is also available in Spanish. And thewinner is....anyone who buys the tape.Global Voice continued from page 29■ International Community of Women (ICW),■ Latin American and the Caribbean Council of AIDS Service Organizations(LACCASO),■ International Gay and Lesbian Association (ILGA),■ Latin American Sex Workers Network.In this way, we are building a coordinated community response toHIV/AIDS challenges. A good example of this co-ordination is theHIV/AIDS Forum 2000, which will be held in Rio de Janeiro next November.Latin American networks are the co-organizers together withthe Group on Horizontal Technical Co-operation on HIV/AIDS, formedby AIDS National Programs.Drug-related problems in Latin America are increasing and the prevailingpolicies usually encourage prejudice and misinformation. Criticaldiscourses and practices are often isolated. We are conscious that aspart of harm reduction global community, we are involved in a movementfor social change, where solidarity and respect are needed. RE-LARD has boldly decided to play its role to face this global challenge.You can contact Graciela Touze by email: gratouze@cvtci.com.ar. You can visitGlobal Voice at http://www.global-voice.org, and from there go to RELARD’s site.■ Red Latinoamericana de Personas Viviendo con Vih/Sida (REDLA+),■ Comunidad Internacional de Mujeres (ICW),■ Consejo Latinoamericano y del Caribe de Organizaciones conServicios en Sida (LACCASO),■ Asociación Internacional de Gays y Lesbianas (ILGA),■ Red Latinoamericana de Trabajadores Sexuales.De esta forma, estamos construyendo una respuesta comunitariacoordinada para responder a los desafíos del Vih/Sida. Un buenejemplo de esta coordinación es el Foro 2000 sobre Vih/Sida, quese celebrará en Rio de Janeiro el próximo noviembre. Las redes latinoamericanasson co-organizadoras junto con el Grupo de CooperaciónTécnica Horizontal en Vih/Sida, formado por los ProgramasNacionales de Sida.Los problemas relacionados con las drogas en Latinoamérica estánaumentando y las políticas dominantes, la mayoría de las veces, alientanlos prejuicios y la desinformación. Los discursos y las prácticas críticosa menudo están aislados. Somos concientes de que, como partede la comunidad global de Reducción de Daños, estamos comprometidosen un movimiento por el cambio social, donde se necesitansolidaridad y respeto. La RELARD está fuertemente decidida a jugarsu papel para afrontar este desafío global.30

HRC’s THE STRAIGHT DOPE education series meets your need for accurate, practicaland non-judgmental information in straightforward language on drugs and drug use.H is for Heroin, C is for Cocaine, and S is for Speed each describe their respectivedrug and the forms in which it comes; how it is used; its physiological and subjective effectson the body and the mind; tolerance, addiction, and withdrawal; detoxification; overdoseprevention and management; legal issues; and stigma. Written by users themselves,each gives an honest account of the benefits that users report as well as the risks, dangers, and negative effects of their use.Overdose: Prevention and Survival Often the difference between life and death depends on what actions someonetakes to care for a person who has overdosed. Step by step “what to do’s” and “what not to do’s” are specifically outlined inthis brochure. Tips on how to prevent an overdose are also included.Hepatitis ABC Hepatitis is a disease that causes inflammation, swelling and sometimes permanent damage to the liver. Forpeople who inject drugs it is especially serious. This brochure was created for people who inject drugs and want more information.It is also appropriate for anyone who wants clear, general information on Hepatitis A, B and C.Hepatitis ABC (en Espanõl) La hepatitis es una enfermedad que causa inflamación, hinchazón y aveces daño permanenteal hígado. En las personas que se inyectan drogas es especialmente peligrosa. Este folleto fue creado por personas que seinyectan y quieren más información acerca de la hepatitis ABC.Getting Off Right is a plain-speaking, how-to survival guide for injection drug users. Written by drug users and serviceproviders, it is a compilation of medical facts, injection techniques, junky wisdom and common sense that aims to provide thenecessary information to keep users and their communities healthier and safer.STRAIGHT DOPE brochures can be purchased in bulk at 20 cents each. Getting Off Right is available at $5.00 per copyfor 1-10 copies, $4.00 per copy for 11-50 copies, and $3.50 per copy for more than 50 copies. Package deals (with freeshipping!) are also available—see the price list below for complete descriptions. Shipping charges: For orders in the ContinentalUS: up to 200 brochures or 10 manuals, add $4.00. For 201-1000 brochures, or 11-50 manuals, add $6.50. Allother orders, call HRC first.Please send me:Description No. copies Price each TotalC is for Cocaine _______ $0.20 _______H is for Heroin _______ $0.20 _______S is for Speed _______ $0.20 _______Overdose Prevention & Survival (Revised!) _______ $0.20 _______Hepatitis ABC _______ $0.20 _______Hepatitis ABC (en Espanol) _______ $0.20 _______Getting Off Right (1-10 copies) _______ $5.00 _______Getting Off Right (11-50 copies) _______ $4.00 _______Getting Off Right (50+ copies) _______ $3.50 _______The Starter Kit (Set of any 5 brochures—50 each + 5 Getting Off Right) $75.00 _______The Complete Set (Set of any 5 brochures—200 each + 10 Getting Off Right) $225.00 _______Getting Off Right Package (30 Getting Off Right manuals) $110.00 _______Shipping (Continental US, up to 200 brochures or 10 manuals) $4.00 _______Shipping (Continental US, 201-1000 brochures or 11-50 manuals) $6.50 _______Total Enclosed_______NAMEORGANIZATIONADDRESSCITY STATE ZIP CODECOUNTRYPHONESend orders to: Brochures, Harm Reduction Coalition,22 West 27th St., 5th fl., NY, NY 1000131

NON-PROFIT ORG.U.S. POSTAGEP A I DPERMIT NO. 569NEW YORK, NYHarm Reduction Coalition22 West 27th Street5th FloorNew York, NY 10001HARM REDUCTION COALITION22 West 27 th Street, 5 th FloorNew York, NY 10001Phone: 212-213-6376Fax: 212-213-65823223 Lakeshore AvenueOakland, CA 94610Phone: 510-444-6969Fax: 510-444-6977HARM REDUCTION COALITION