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San Francisco Is Needle City

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In 1997, I went to a "needle exchange" in San Francisco to see firsthand how the "harm reduction program" prevented the spread of HIV among addicts. Exchange staff offered vitamins, treatment for sores and referrals to kick the habit; addicts handed over carefully bundled needles in a one-dirty-for-one-clean exchange. Users' participation demonstrated that they had not given up on themselves.


The needle program began with good intentions. In the 1990s, addicts often shared needles -- and HIV. The pioneer program promised to save lives and make users responsible for syringe disposal. Little did I know that over the next two decades, in San Francisco and other U.S. cities, "needle exchange" would morph into "syringe access."

Under the new order, San Francisco Department of Public Health spokeswoman Rachael Kagan explained, "you don't need a needle to get a needle." Users who show up at a "syringe access" center can get a "starter kit" of 20 needles. If they want more than 20 needles, they have to present used needles. I walked into a nearby facility and walked away with my own starter kit in a discreet plain brown bag.

San Francisco now asks users to leave their discarded syringes in drop boxes at public toilets, pharmacies and clinics. I got a "sharps" disposal box with my 20-needle kit. Alas, there's another oft-used disposal venue -- city streets and sidewalks. If you walk around the city, then you've seen the used needles.

Exchange staffers across the country concluded over the years the one-for-one component didn't work for users who could only scrounge up one or two syringes, Daniel Raymond -- policy director of the Harm Reduction Coalition, based in New York -- told me. It "ended up being counterproductive for the public health goal" of stopping the spread of HIV. Some centers stopped requiring a one-for-one trade. Even without the requirement, Raymond said, users bring in dirty needles -- at a rate of 80 percent, 90 percent, even more than 100 percent at some centers. Access, not exchange, is now considered a "best practice."


San Francisco gave away 2.4 million syringes last year. It's not clear that the "access" program is responsible for the record number of resident complaints about needle litter. But then, the switch from "exchange" to "access" occurred without public debate or an airing of possible consequences. Having sold the public on needle exchange, advocates unilaterally moved to a model that doesn't ask junkies to do something as basic as pick up after themselves.

With its goal of making self-destructive behavior less destructive, "harm reduction" always has been a dicey proposition. To work, programs must not enable more risky behavior than they prevent. In the 1990s, research found that needle exchanges increased the number of needles used without increasing drug use itself.

With record complaints about dirty needles, it seems as if, in a bid to protect the most self-destructive elements in society, San Francisco has put everyone else's health at risk by eliminating the exchange half of the bargain. Mayor Ed Lee's office sent me a statement that noted the mayor "is relying on the public health experts about how to best distribute needles to prevent the transmission of fatal diseases." Lee knows needle litter is a problem and has staff working on how to pick up used needles faster. In short, taxpayers get to fund needle giveaways for habitual offenders, pay to clean up after them, and learn to navigate in a landscape with needle litter -- in the cause of public health.



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