Thread by @EverettMaroon

Some person keeps lying about syringe exchange programs and saying that they don't work so here is a long thread on the evidence for harm reduction, with a bit at the end on how local public health and nonprofits function.

Syringe exchange started as a street program in the Tacoma, WA, because nobody was helping improve the health of folks who injected drugs. Dave Purchase showed people how to sterilize their equipment and told them to stop sharing needles. davepurchaseproject.org/about-us

That was 1988. It got attention almost immediately, because then as now, drug users are highly stigmatized in American society. But quickly public health folks wanted to see if this idea worked. Charles Eaton in NYC ran the first government-funded study of syringe exchange.

Quickly enough studies were showing that people using clean needles instead of dirty ones had fewer adverse health events like abscess, cellulitis, and amputations. And ending copious sharing practices cut down on HIV and hepatitis C transmission.

One landmark study comparing drug injectors who used syringe exchange vs. those who didn't in NYC was conducted by Don Des Jarlais, now on faculty at Mt. Sinai. s3.amazonaws.com/academia.edu.d…
Turns out, the syringe program made a huge difference.

Since the beginning of syringe exchange, more than 1,500 studies have been conducted on its effects. The American Foundation for AIDS Research curated many of these into helpful fact sheets. amfar.org/uploadedFiles/…

Here's another one: amfar.org/uploadedFiles/…

Turns out, people who use a syringe exchange are 5 times as likely to enter rehabilitation programs as non-participants. ncbi.nlm.nih.gov/pubmed/11027894
#harmreduction #syringeexchange #hrc

Needle stick injuries among first responders go down, because people injecting drugs hold on to them so they can return them at the exchange. Robberies and burglaries decrease in the areas around exchange sites. And yes, morbidity associated with needle use decreases.

Part of what is underlying all of this is a trust relationship between the exchanger and the staff. They feel more free to ask us questions and we supply them with referrals and resources to improve their health and their lives. Many exchanges offer first aid supplies. Toiletries

help people support their hygiene and grooming, which also cuts down on disease. Sometimes we have pantry items we can give out, supporting a better baseline of nutrition. And most syringe service programs (SSPs) do HIV and hepatitis C testing.

At our Pasco, WA SSP alone, we have identified more than 30 new cases of hep C in the last nine months. Just those 30 people knowing their status will save the region tens of thousands of dollars in future health care costs averted. Why? Because those people will get cured.

So their health will be improved, and they will not need onerous future care past their treatment. They also won't spread hep C to more people, because needles are not the only way it spreads. But for sure it is cheaper to cure hep C than to replace a liver.

There are other related outcomes that are beneficial. People can stay in work longer if they are healthier (yes, many people who use drugs have jobs), which supports community economies. It's not just about lowering infectious disease transmission, although they are great at that

and some of the benefits are detailed here: link.springer.com/article/10.100…

But let's have a broader discussion of public health, please, because the public at large continues to misunderstand what public health is trying to do. Its core functions are to promote health and prevent disease, at the human population level.

It is incumbent on public health agencies to identify threats to community health wherever they are. Influenza, Ebola, e-coli are well known threats, and they are frightening because they seem to spontaneously pop up and harm people. But we know that

any infectious disease has patterns, based on its lifespan, its preferred living environments (flu likes cold damp weather, for instance), and its biological limits. When we talk about HIV, we are talking about a retrovirus that first showed up on a mass scale among gay men.

And because the US was then governed by a known homophobe, former President Reagan, we saw open hostility to helping stem the emerging epidemic. More than 50,000 Americans had died before the federal government did ANYTHING about HIV.

We also see a lot of stigma around people who use drugs, in no small part thanks to Reagan's wife, Nancy, and her "just say no" campaign. The "war on drugs" was a war on drug users very quickly. Think of how folks talked about crack users in the 1980s. That mindset is still here.

So it is not surprising that it's deeply controversial to serve people who use drugs in an attempt to quell HIV. We work in this painful legacy. But as public health providers and partners, we know this is one of the main ways that HIV stays in our communities. If the goal is to

stem disease and improve health, we must find effective ways to support those at greatest risk no matter the political controversiality of the method.

Okay, now I have to go to an appointment, but I'll pick this up in about half an hour.

So about public health: the core mission has changed but their funding certainly has. For the last theee decades these offices have seen budget cuts in most years. They do a lot with less. The GOP mantra has been smaller govt, but this function is critical.

Most public health agencies no longer have “clinical services,” meaning no vaccinations, no STD treatments, far fewer services to even rest people for disease. This doesn’t change the need for these services however.

Much of the work transitioned over to groups like Planned Parenthood. Which then have seen their funding cut as well. Along with the pushback against the Affordable Care Act, it’s not clear where people without insurance are supposed to go. So syringe exchange stands as one

Alternative for care, at least for identifying new HIV and hep C and some STIs. But of course all of these sites of care are denigrated from the conservative right.

For sure one thing public health offices don’t do is conduct studies. It’s all they can do to deliver care, support a few initiatives like Healthy People or smoking cessation, etc. some have gotten into anti-suicide since US rates are now so high.

It’s not that nobody does studies on public health programs, it’s that public health departments themselves are generally not doing that work. Universities are. NIH is. CDC is.

So to demand that a local nonprofit or a local health jurisdiction conduct studies on its own programs—that’s not a thing.

What we do deliver is quality care, which we assess using metrics that include program participant surveys, data collection on our outputs, and comparisons between similar services and orgs.

But it is unreasonable and wrong headed to think that cash-strapped public health orgs should conduct their own studies. For one, many orgs especially rural public health agencies don’t have enough service recipients to count for a study to be scientifically valid.

Which is a big reason why what public health tries to do is follow the evidence base from legit, peer-reviewed and reproducible studies and analysis. Staff attend lectures, symposia, read up on the latest work, etc. So do reputable nonprofits like mine.

So to summarize: does syringe exchange work? Yes.
How do we know? From the enormous evidence base.
How can we trust that? Look for consistent results from separate institutions.
Why doesn’t our public health sept do it’s own research? That’s not their mission.

Oops, their core mission has NOT changed, is what I meant.