A major overhaul to safeguard the country’s produce is not yet in place, confounding attempts to shut down virulent strains or prevent them altogether.
CHARLESTON, W.Va. — To its critics here, the needle exchange was an unregulated, mismanaged nightmare — a “mini-mall for junkies and drug dealers” in the words of Danny Jones, the city’s mayor — drawing crime into the city and flooding the streets with syringes. To its supporters, it was a crucial response to an escalating crisis, and the last bulwark standing between the region and a potential outbreak of hepatitis and H.I.V.
When Charleston closed the program last month after a little more than two years of operation, it was the latest casualty of a conflict playing out in a growing number of American communities. At least seven other such exchanges have closed in the past two years, even as dozens of others have opened.
Needle exchanges dispense sterile syringes to drug users and give them somewhere to discard their used syringes safely. Often, as in Charleston’s case, an exchange will offer supporting services, too: on-site medical care, hepatitis/H.I.V. screening, counseling and connections to drug treatment.
They were once a largely urban phenomenon. But the opioid crisis is changing the landscape. After an H.I.V. outbreak among injection drug users in Scott County, Ind., in 2015, health officials opened many exchanges in suburbs, rural areas and small cities in more conservative parts of the country. Some of these communities have had second thoughts.
Syringe exchanges in the United States
Sources: Centers for Disease Control and Prevention, Harm Reduction International, North American Syringe Exchange Network
Public health experts now find themselves relitigating questions that in their view were settled decades ago, while political leaders worry that harm reduction — that is, mitigating the risks from drug use — means enabling drug use.
The research is unambiguous: Needle exchanges reduce the spread of bloodborne diseases like hepatitis C and H.I.V. and do not increase drug use. They’ve been shown to reduce overdose deaths, decrease the number of needles discarded in public places and make it more likely that drug users enter treatment. They also save money: One recent study estimated that $10 million spent on needle exchanges might save more than $70 million in averted H.I.V. treatment costs alone.
Health experts say the programs create relationships between deeply addicted people and the health care system, an essential step if they are to be reintegrated into society. “It’s the most low-threshold way for people who use drugs to have contact with any kind of public health professional,” said Alex H. Kral, an epidemiologist with RTI International, a nonprofit research organization. “And that’s a powerful intervention.”
Yet needle exchanges — also called syringe exchanges or syringe services programs — have struggled to gain public acceptance in the United States, which still lags far behind many countries in their adoption. According to the North American Syringe Exchange Network, 333 such programs operate across the country, up from 204 in 2013. In Australia, a country with less than a tenth as many people, there are more than 3,000.
People who inject drugs per syringe exchange
A gateway to treatment in Charleston
When Dr. Michael Brumage began working as director of the Kanawha-Charleston Health Department in August 2015, the lessons of Scott County were on his mind: He was determined to bring a syringe exchange to Charleston. The exchange opened four months later with broad support from local government, law enforcement and the wider community.
“I was really impressed by the thoughtfulness that went into planning the program and the care that went into making it effective at all levels,” said Daniel Raymond, the deputy director of planning and policy for the Harm Reduction Coalition, a nonprofit advocacy group. He said he had considered the Charleston program “to not only be a huge success story but also a potential model for other communities.”
This might have been its downfall: It was too successful. At its busiest, 483 drug users passed through the exchange in just eight hours — in a city of 50,000 people. “Nobody expected the numbers to grow so rapidly,” said Brenda Isaac, the president of the Kanawha County Board of Health, who explained that the pace left little room for individualized, focused care.
As the health department struggled to manage the crowds, it began to hear more complaints from law enforcement about discarded needles. By the summer of 2017, the initial enthusiasm for the exchange among city officials was waning. In early 2018, news accounts of a 5-year-old girl accidentally stuck with an uncapped syringe in a McDonald’s bathroom captured public attention. A local TV segment described Charleston as buried under “Needles Everywhere.”
Weekly visitors to Charleston’s harm reduction program
Visitors to the health department exchange increased steadily since it opened.
Source: Kanawha-Charleston Health Department
For the mayor, the location of the exchange made its existence untenable. It was housed in the health department building, a squat brutalist structure across the street from the gleaming, newly renovated civic center. The civic center — a $100 million development project — was intended to be the linchpin of a revitalized city.
“We can do that,” Mr. Jones said, gesturing to pictures of needles sitting in front of him, “or we can do this,” he said, holding up a piece of paper where he’d outlined his administration’s economic development deals.
The mayor is in recovery himself — an alcoholic, he says, 24 years sober — and father to a son who has struggled with heroin addiction. He argues for prescription heroin, saying it should be provided to people where it can be used safely under supervision. He just wants those services far from Charleston, and definitely far from the new civic center. “I understand recovery,” Mr. Jones said. “I’m in it myself, and I believe in it. But I don’t believe we have to destroy a city over it.”
In early March, the mayor began using his daily radio show to rally public sentiment against the health department, citing discarded needles and rising crime that he attributed to what he saw as a weekly influx of people using drugs.
Last month, the police chief imposed new rules on the program, loosely based on those used by a much smaller exchange run by West Virginia Health Right, a clinic nearby. Participation would be limited to people who could prove — with picture ID — that they lived in the county. Testing for hepatitis and H.I.V. would be mandatory. Needles would be dispensed only in strict one-for-one trades.
Public health experts condemned the measures. An ID requirement would be prohibitive for many people, said Mr. Raymond, particularly for the quarter of the program’s patients who are homeless. And strict one-for-one exchange goes against decades of public health research that shows greater flexibility to be a better policy. “I would rather close down the needle exchange altogether than follow those rules,” said Dr. Dan Ciccarone, a professor of family and community medicine at the University of California, San Francisco. “This is really truly backwards.”
Hours after the chief’s announcement, health department leadership suspended the syringe exchange rather than comply with the new regulations.
Drug users caught in the middle
In the middle of this dispute are the estimated 3 percent to 4 percent of Charleston’s residents who inject drugs, typically heroin or meth.
Trent Farr, 54, says he has cancer and is homeless. He has lived in Charleston almost 26 years and has multiple medical problems, many related to chronic drug use. “I go through more pain in a day than some people do in their entire lives,” he said while waiting for the Crossroads Shelter to begin meal service. “I hate — I absolutely hate — using needles,” Mr. Farr said, explaining that his drug use is the only thing he has found to mute his pain. For him, the health department’s closing “changes everything.”
Amber White, 24, agreed. “Now people have to go out and rob and steal to get points,” she said, referring to unused needles. She said that when the exchange was running, unused needles became so plentiful that people could afford to give them away. Now that they’re becoming scarce again, she said drug users would face a choice of either sharing them or resorting to crime to get money to buy unused ones.
With sterile syringes harder to find, Ms. White worries about contracting H.I.V. or hepatitis, both of which she has managed to avoid — to her surprise — despite heavy drug use. Twenty-six percent of the injection drug users looked at by the health department tested positive for hepatitis C.
Counties at risk of an H.I.V. outbreak
C.D.C. researchers identified 220 counties in the United States that are most vulnerable to an outbreak of H.I.V. associated with injection drug use. Many, including Kanawha County, are clustered along the Ohio Valley and in Appalachia.
Both Mr. Farr and Ms. White expressed frustration at what they said were the small minority of users who left discarded needles in the open. “If I see them laying on the ground, I’ll pick them up and throw them away,” Ms. White said. “Because, you know, I think it’s nasty — and I use drugs. So I can’t imagine what it looks like to somebody that doesn’t even use.”
Fears of the next H.I.V. outbreak
The harm reduction program remains active in Charleston, but is now seeing only a dozen clients each week for counseling, H.I.V. testing or medical care. The relationship between the health department and the city has become toxic, to the point that the mayor and city officials have spoken openly of dismantling the department altogether. “It’s our health department,” said Paul Ellis, the city attorney. “We created it. We can make it disappear.”
For the health department, the needle exchange was a way of getting drug users in the door, exposing them to medical care, keeping them connected to the community and giving them hope. “The only way to address the opioid epidemic is to engage the people who are using,” Dr. Brumage said. “These are modern-day lepers that no one wants to see or touch. The syringe services program was a place these people could go and be treated like real human beings.”
While the exchange was open, the health department also collected data on its patients. These records show at least eight people with H.I.V. among the injection drug users the department tested. All but one live in the city of Charleston. If they share needles in the months ahead, Charleston is at “grave risk for an H.I.V. outbreak just like the one in Scott County,” Dr. Brumage said. “We’re sitting on a powder keg.”
At least 84 people have been infected so far, according to health officials, who traced the illnesses to romaine lettuce from southwestern Arizona.
Vaccination rates across Europe are lower than in the United States. Various longstanding anti-vaccine movements persist there, and some conservative Protestant sects in Europe believe vaccination subverts God’s will.
Twenty years ago this month, a study of eight children published in The Lancet by Dr. Andrew J. Wakefield suggested that the measles-mumps-rubella vaccine triggered intestinal inflammation and autism. The journal later retracted the paper, and Dr. Wakefield lost his British medical license after it was revealed that he was a paid consultant for attorneys suing vaccine companies.
The controversy nonetheless triggered a wave of anti-vaccine hysteria. A 2016 survey of 67 countries led by the London School of Hygiene and Tropical Medicine found that skepticism about vaccine safety was highest in France. Skepticism was also high in Russia, Ukraine, Greece and Bosnia-Herzegovina.
The measles outbreaks have led some European countries to crack down. Laws were passed in France, Germany and Italy requiring that parents vaccinate their children or at least consult a doctor about doing so. Italy and Germany imposed fines of $600 to $3,000 for failing to comply.
The Centers for Disease Control and Prevention currently has Level 1 travel watches in effect for Americans thinking of visiting Britain, Greece, Italy, Romania, Serbia and Ukraine. Travelers under age 60 are advised to have two doses of measles vaccine before going. (Everyone born before 1957 is assumed to have had measles as a child and therefore to be immune.)
The United States eliminated measles transmission in 2000, but since then there have been sporadic outbreaks caused by infected travelers. In 2015, the “Disneyland outbreak” ultimately led to over 150 cases in seven states. Investigators believe it began with a single theme park visitor who infected 39 others.
In the United States, measles causes pneumonia in about one of 20 cases. One to two cases of measles per 1,000 are fatal; some survivors are left blind or deaf. In countries where children are malnourished and health care is rare, the death rate is as high as 6 percent, the World Health Organization said.
Despite setbacks in Europe, measles vaccine has led to a huge drop in global deaths from the disease. In the 1980s, measles killed 2.6 million a year. In 2016, for the first time since records were kept, deaths fell below 100,000.
In the last two decades, philanthropic donors have paid for 5.5 billion doses for poor countries.
The Rio Olympics went ahead without spreading the virus, and new diagnostic tests for Zika were swiftly designed and deployed. Scientists are moving ahead with multiple vaccine candidates and new ways to fight mosquitoes without pesticides.
But the positives were counterbalanced by many negatives, experts said. They harshly criticized the partisan bickering that delayed a Zika-funding bill in Congress for months, and they decried the failure of every city in the hemisphere — other than Miami — to control mosquitoes.
Most praised the W.H.O. for declaring an emergency on Feb. 1, but also condemned as premature its decision to end it on Nov. 18.
But the greatest failure, all agreed, was that while tourists were warned away from epidemic areas, tens of millions of women living in them — many of them poor slum dwellers — were left unprotected.
As a result, a wave of brain-damaged babies is now being born. Their families are already suffering, and their medical care will eventually cost hundreds of millions of dollars.
The failure to advise women to postpone pregnancy, if they could, until the epidemic passed “was the single greatest travesty of the epidemic,” said Amir Attaran, a professor of law and medicine at the University of Ottawa.
It was “hideously racist hypocrisy,” he added. “Female American tourists were given the best and safest public health advice, while brown Puerto Rican inhabitants were told something else entirely.”
Credit Paulo Whitaker/Reuters
Politics Got in the Way
Impoverished Latin American and Caribbean women were badly served in many ways, other experts said.
Trucks sprayed pesticides that often did not work. Admonitions from on high to wear repellent and long sleeves were given with no studies proving that they could protect indefinitely.
And health authorities, fearful of offending religious conservatives, never seriously discussed abortion as an alternative to having permanently deformed babies — even in countries where abortion is legal.
That reluctance created an unusual gulf between official advice and actual practice. Many gynecologists interviewed said privately that they offered abortions to patients whose ultrasound scans showed abnormally small heads or brain damage.
But they did so without official support or guidance from the W.H.O. or the Centers for Disease Control and Prevention.
During the epidemic, when health officials were asked why they did not advise delaying pregnancy or seeking abortions, they said that to do so would interfere with women’s reproductive rights or prevent older women from conceiving in time to have children.
At the W.H.O., Dr. Bruce Aylward, head of the Zika emergency response, called pregnancy “a complicated decision that is different for each individual woman.”
Dr. Thomas R. Frieden, director of the C.D.C., said he followed the advice of Dr. Denise J. Jamieson, chief of the agency’s women’s health and fertility branch, who said it was “not a government doctor’s job to tell women what to do with their bodies.”
Dr. Gostin said he felt the agencies had been too cautious, out of fear of criticism from women’s groups.
“Public health ought to trump that,” he said. “Giving women advice is very different from controlling women.”
Michael T. Osterholm, director of the University of Minnesota’s Center for Infectious Disease Research and Policy, gave a blunter explanation for the shyness from officials.
“The C.D.C. always gets in trouble with Congress when it talks about contraception or bullets,” he said. (By the latter, he meant that it was hard for the officials to point out that gunshots are a major cause of American deaths for fear of offending the gun lobby.)
“And abortion?” he added. “You talk about third rails in politics? Abortion is the fifth rail. They can’t touch it. If the C.D.C. had pushed the envelope any farther, its funding would have been at risk.”
C.D.C. guidance on Zika was “a little coy,” agreed Dr. William Schaffner, chairman of preventive medicine at Vanderbilt University Medical School.
Credit Vanderlei Almeida/Agence France-Presse — Getty Images
“A recommendation to put off pregnancy until the risk abated should have been front and center — and much more explicit.”
Brazil, by far the hardest-hit country in the epidemic, really let its women down, said Dr. Artur Timerman, president of the medical society for dengue and arbovirus specialists there.
“For religious concerns, we have a lot of restrictions regarding advising women on birth control, so we were very far from giving them correct information,” he said. “I think we will have a lot of women infected yet, as we see lower levels of awareness.”
Experts praised the C.D.C. for its work on developing new Zika tests and getting them to state laboratories quickly. Better antibody tests that identify past infections are still needed.
Most countries did not focus enough on preventing sexual transmission, experts said. Even New York City, which has a respected health department, filled its subways with posters showing big mosquitoes.
Yet not one of the nearly 1,000 cases diagnosed there by year’s end was transmitted by a local mosquito; all were either picked up elsewhere or transmitted sexually.
The number of children damaged by the epidemic is still unknown, but is likely to ultimately run into the tens of thousands across the hemisphere. As of the end of 2016, the W.H.O. had recorded more than 2,500 cases of Zika-related microcephaly in 29 countries.
Studies suggest that microcephaly — which results in an abnormally small head — represents only a small fraction of the damage done. Babies are being born blind, deaf or with rigid limbs or frequent seizures, and it seems likely that many more will eventually have learning and emotional problems.
The epidemic also showed that most nations remain inept at mosquito control.
“Miami is the one place that responded effectively,” said Duane J. Gubler, an expert in mosquito-borne diseases at the Duke-NUS Medical School in Singapore. “Others were mediocre or poor.”
Miami used both aerial and ground spraying of insecticide and larvicide, along with teams going house-to-house looking for breeding sites.
The Zika scare made pest-control officials and local residents more willing to test new technologies, including releasing male mosquitoes that pass on a life-shortening gene and female mosquitoes carrying bacteria that suppress their ability to transmit viruses.
A Dangerous Disconnect
Experts in Brazil, where the epidemic started, said doctors there acted quickly but were often thwarted by the country’s political and economic chaos — President Dilma Rousseff was ousted in August — or by hesitant foreign scientists.
“Brazil reacted with seriousness and foresight,” said Dr. Albert I. Ko, a Yale epidemiologist who has also worked in Salvador, Brazil, for many years. “The people in the trenches, the city and state public health officials, should be regarded as heroes.”
Why scientists are worried about the growing epidemic and its effects on pregnant women, and how to avoid the infection.
Both he and Dr. Ernesto T. A. Marques Jr., an infectious disease specialist at the University of Pittsburgh and at the Oswaldo Cruz Foundation in Brazil, said Brazilian scientists felt let down when they looked for outside help — at first from European donors and health agencies.
“The local researchers’ role was mainly to collect samples,” Dr. Marques said bitterly.
The C.D.C.’s initial reluctance to accept Brazilian scientists’ work also slowed the international response, said Dr. Peter J. Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine.
Even when the Brazilians found Zika virus in two women’s amniotic fluid and in the brain of a microcephalic fetus, “The C.D.C. would not accept it until they had done it themselves,” he said. “I saw that as hubris.”
The news media, for once, got relatively high marks from the experts — or at least higher marks than it did in the 2014 Ebola epidemic or the 2009 swine flu pandemic.
Three years ago, pictures from Africa showing men in spacesuits carrying dead bodies exaggerated the risk of Ebola to America, they said. By contrast, pictures of tiny-headed babies made Americans take Zika seriously but sensibly.
“In Brazil, the press was the first to sense that something was going on,” said Dr. Karin Nielsen, a pediatrician at the David Geffen Medical School at the University of California, Los Angeles, who also works in Rio. “It was pushing it even before the medical specialists were.”
The North American media, several experts said, did a good job debunking various myths that arose early in the epidemic, such as rumors blaming microcephaly on genetically modified mosquitoes, larvicide in drinking water or vaccines.
In Brazil, those rumors diverted attention for precious weeks, even prompting some cities to stop fighting mosquitoes temporarily.
Experts also felt scientific collaboration often faltered. For example, plans announced in February to gather 5,000 Zika-infected women into one study never materialized.
One big question remains: Will the virus return?
That is unknowable, most experts said, because no studies show how many people are now immune through previous infection.
Some Brazilian cities, including São Paulo, have not had big outbreaks and may be due for one, said Dr. Scott C. Weaver, a virologist at the University of Texas Medical Branch in Galveston who was one of the first to predict that Zika was likely to strike the Americas. So might Bolivia, Paraguay and Uruguay.
More than half of Puerto Rico’s population is probably still vulnerable, so Zika may flare up again, as it might anywhere along the Gulf Coast outside Miami.
“And even if Zika’s not bad next year,” Dr. Weaver said, “without a vaccine, these viruses are going to come and go.”