American JailsAmerican
Jails, May/June 2000American Jails, May/June 2000
Publication of the American Jail Association
By Paula N. Rubin and Susan W. McCampbell
Introduction – The Face of the HIV/AIDS Epidemic
While the incidence of HIV/AIDS is declining
in the United States, this disease "continues to be far more prevalent among inmates
than in the total U.S. population." It is estimated that 2.2 percent of all jail
inmates are HIV positive, with the highest infection rates centered in large, urban jails.
But these statistics are not news to jail
administrators who battle the added burdens these inmates place on the jail medical costs
and the health and safety of jail staff. Jail medical costs continue to rise
notwithstanding findings that inmates with HIV, AIDS and TB are still, "seriously
under served in terms of medical care, drug treatment and psycho-social services."
While statistics on jail inmate medical costs
nationally are not specifically maintained, the U.S. Department of Justice’s Bureau
of Justice Statistics (BJS) reports this data for prisons. BJS reported for 1996 that
state corrections systems devoted, on average, 11.6 percent of annual operating budgets to
inmate medical costs. That is a staggering 2.45 billion dollars a year. In 1994, a
reported $11,011,269,000 was spent by local governments on corrections. Using the prison
data to estimate jail medical expenditures, a conservative estimate is that jails spend
1.3 billion dollars a year on inmate medical costs.
Inmates with more serious and chronic medical
conditions, requiring more medical capacity and financial resources, will continue to
enter jails. The public debate about universal health care, access to on-demand drug
treatment and insurance coverage of treatment for mental illness all impact the inmate
health care delivery system and health care costs. Jail administrators have choices. They
can wait for others to make decisions that impact their jail’s bottom line and then
react to them, or jail professionals can be proactive and work together with public health
officials to effectuate policies that ultimately improve conditions and address the costs
of inmate medical care in their jails. Since whatever happens in the community will
shortly arrive in the jail, administrators need to follow and influence the various public
health debates as they ultimately relate to jail medical service.
Anatomy of an
Issue
One issue that jail administrators can
impact is the transmission of blood-borne diseases through injection drug use (IDU).
Proposed strategies for fighting the "war on drugs" and the accompanying
incidence of blood-borne disease, have included legalization of drugs and government
control and sale of illegal drugs as a way to regulate costs and control demand.
Perhaps the most hotly debated harm reduction
strategy to the twin epidemic of HIV and drug addiction is the use of needle exchange
programs (NEPs). NEPs allow injection drug users to exchange used/dirty needles for a
clean one without fear of criminal consequences, while simultaneously having the chance to
interact with drug treatment professionals.
The AIDS epidemic had its beginnings in 1981 and
injection drug use has been a prominent contributor to the magnitude of this health
crisis. In some communities, injection drug use has accounted for 60 percent of reported
AIDS cases and nearly 40 percent of all reported AIDS cases were connected to injection
drug use. Often the new AIDS victims are the sex partners and the children of injection
drug users.
In addition to Health and Human Services (HHS)
Secretary Donna Shalala, many public health and medical organizations endorse NEPs as an
effective component of a comprehensive HIV prevention program. At the same time, some
public safety organizations, following the lead of the Director of the Office of National
Drug Control Policy, Barry McCaffrey, have rejected NEPs.
Striking a balance between "feeding an
addiction" and preventing the spread of a fatal disease seems to be at the very core
of communities’ struggle with NEPs. In addition, by turning a blind eye to the
various needle exchange laws, pharmacy regulations that restrict access to syringes and
current drug paraphernalia laws, criminal justice professionals are placed in a position
that runs contrary to their sworn duty. Hampden County (Massachusetts) District Attorney
William Bennett captured this dilemma, "I do not understand how I can support the use
of drugs by providing needles and prosecute someone who uses them."
On the other hand, enforcement of drug
paraphernalia laws impacts how some IDUs [injection drug users] make decisions about using
sterile needles, resulting in the spread of AIDS. A female heroin addict was "asked
why she did not carry sterile syringes to use when she injected drugs: ‘Because, she
answered, I would rather get AIDS than go to jail.’ "
What
Is an NEP and How Does It Operate?
While there is no single way to distribute
clean needles to IDUs, certain common traits mark this HIV prevention strategy. Typically,
NEPs offer IDUs a non-threatening, public location to bring a dirty needle and exchange it
for a sterile one. At the same time, these users can be encouraged and supported in taking
advantage of treatment options, medical care and other services. In fact, the United
States Conference of Mayors suggests that referral to treatment is perhaps the most
overlooked and most vital role NEPs play.
John Parker, the first person to distribute
clean needles in the United States, estimates that he has been "arrested 27 times in
seven states." This approach brought NEPs into the forefront and underscored the
connection between injection drug use and the spread of AIDS. Ultimately, some NEPs were
established after much community coalition-building. Still other NEPs that were once
illegal have been legitimized and actually receive funding from local governments. Yet, in
1992, less than half of new NEPs were legal. Today, several NEPs receive government or
foundation funding while some, (Boulder, Colorado’s NEP, for example) are operated by
the local Department of Health.
There have been five different bans on the use
of federal dollars to fund NEPs. Most recently, Health and Human Services Secretary
Shalala supported lifting the ban while Drug Czar, Barry McCaffrey, opposed it.
Ultimately, the Clinton administration decided to continue the ban reasoning that it was
best to have local communities that implement NEPs use their own dollars to support them.
Although the federal ban on funding NEPs remains, federal money may be used to conduct
studies of NEPs. These funds are used by researchers to summarize current information and
collect new data "so that communities can construct the most successful programs
possible to reduce the transmission of HIV, while not encouraging illegal drug use."
The Science of
NEPs
Much research has been conducted about NEPs
and their impact on illegal drug use. These studies suggest three public health benefits:
"reduction in risk behavior; reduction in the incidence of HIV and other blood-borne
infections; and greater access to drug treatment and other HIV prevention services."
Indeed, after reviewing all of the research, HHS determined "that there is conclusive
evidence that needle exchange programs, as part of a comprehensive HIV prevention
strategy, are an effective public health intervention that reduces the transmission of HIV
and does not encourage the use of illegal drugs."
Risk reduction. Behaviors of IDUs before
and after participation in a NEP have been compared. Studies reveal a significant drop in
high risk behavior. There is less sharing of drug paraphernalia and more use of sterile
needles. In Baltimore, when comparing behaviors over a two week period following
enrollment in the NEP, self reported lending of used needles decreased from 34 percent to
15.5 percent. So did borrowing syringes (down from 23.2 percent to 11.1 percent).
Incidence reduction. Recent studies
described in the National Research Council’s review of NEPs found direct evidence of
substantially lower rates of new HIV infection among New York City IDUs. Researchers
credited the New Haven NEP with a 33 percent reduction in HIV incidence. The connection
between NEPs and reduced infection is not limited to HIV. In Pierce County, Washington,
research indicates that Hepatitis B and C cases attributable to injection use declined by
more than 75 percent within two years after a NEP was established. After eight years of
follow-up in the ALIVE study of IDUs, HIV incidence decreased 35 percent after the opening
of the NEP in Baltimore City. These findings suggest a community-wide effect of the NEP in
Baltimore.
The bigger picture. NEPs serve as
conduits to drug treatment and other HIV and drug prevention services. They have become a
"necessary component of a broader, more comprehensive HIV prevention plan." In
Baltimore, for example, the number of IDUs participating in drug treatment went up from 8
percent to 18.8 percent.
NEPs: the ultimate enabler? Opponents to
NEPs maintain that exchanges of syringes only serves to encourage illegal drug use. That
in "feeding the addiction" NEPs are feeding the epidemic. However, scientific
data now available has established the utility of needle exchange programs in reducing new
HIV infections with no evidence of increasing injection drug use." One explanation
for this phenomenon rests with the psychology of addiction. "Drug use is driven by
physiological and psychological dependency, as well as the availability of the drug
itself, rather than the means to administer it." In fact, studies in New York,
Portland and San Francisco where NEPs operate, report level or decreased injection drug
use. And in Baltimore, when comparing crime trends in NEP areas to non-NEP neighborhoods,
no significant differences were found in any drug-related arrest categories such as drug
possession, economically motivated crimes, resisting arrest or violence. In fact, no
differences in the incidence of crime were found at all.
The Bottom Line for Jail Administrators
Until cures are found for blood-borne
diseases like HIV and Hepatitis B, prevention is the only way to fight them. There is no
magic bullet in this effort and NEPs are but one harm reduction strategy in a mosaic of
methods. To be sure, NEPs are not appropriate for every community. A case-by-case analysis
should be made by the community, public health officials and criminal justice
professionals as this option is considered.
Jail administrators can influence debates on
public policy in their community. Regardless of which side of this issue jail
administrators finds themselves, it is important to understand both sides of the debate
and be armed with current and accurate information. As the de facto "other public
health facility" in most communities, jails must take a leadership role in shaping an
effective harm reduction strategy to battle the spread of blood borne diseases. |
