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HomeMy WebLinkAboutMINUTES - 12141999 - D1 �t TO: Board of Supervisors Contra Costa County FROM: Supervisor John Gioia DATE: December 14, 1999 SUBJECT: Declaring a local Public Health Emergency for HIV/AIDS and Hepatitis C (under California Government Code section 8630) and Authorizing County Health Department Support for Needle Exchange Programs SPECIFIC REQUEST(S) OR RECOMMENDATION(S): ACKNOWLEDGE that there is a rapid and increasingly p g y epidemic rate of HIV and Hepatitis C transmission and infection among injection drug users in Contra Costa County. DECLARE a local emergency (under California Government Code section 8630) due to the existence of a critical local public health crisis based upon the increasing and epidemic number of AIDS/HIV and Hepatitis C cases in Contra Costa County, especially among linjection drug users. DIRECT the Contra Costa Health Services Department to take immediate steps to prevent the further spread of HIV and Hepatitis C by taking the following actions: 1. Provide additional supplies and staff support for needle exchange services in West County. CCHSD will collaborate closely with Exchange Works to support and strengthen existing services at the two needle exchange sites in Richmond/North Richmond. This shall include providing supplies necessary for operation or by providing funding for Exchange Works to purchase these supplies and providing one staff person to collaborate with Exchange Works volunteers at the sites in order to assist in risk reduction counseling and pre-treatment substance abuse counseling. 2. Facilitate a planning process to establish a needle exchange site in East County. 3. Participate in a long-range planning process to improve services in both East and West County. CCHSD will be one of several partners to help enact a vision of a community-based program with comprehensive services. CCHSD`s role will include helping identify additional resources and building partnerships with federal and local governments, foundations, community volunteers, social service providers and others. 4. Provide regular progress reports to local authorities, including the Board of Supervisors, on the status of the pilot needle exchange program and on the health impacts of these activities. CONTINUED ON ATTACHMENT: YES SIGNA E ACTION OF BOARD ON December 14, 1999 APPROVED AS RECOM46NDED x OTHER.x VOTE OF SUPERVISORS See Addendum for Board action I HEREBY CERTIFY THAT THIS IS A TRUE AND x UNANIMOUS (ABSENT CORRECT COPY OF AN ACTION TAKEN AND AYES: NOES: ENTERED ON THE MINUTES OF THE BOARD OF ABSENT: ABSTAIN: SUPERVISORS ON THE DATE SHOWN. Contact: Supervisor Gioia(510/374-3231) ATTESTED-- _December 14, 999 County Counsel PHIL BATCHELOR CLERK OF THE Health Services Director BOARD OF SUPERVISORS AND Count Administrator COUNTY ADMINISTRATOR BY-4 , DEPUTY 1 DIRECT all County departments (including the Sheriffs Department and the Health Services Department) to fully cooperate in the needle exchange program authorized pursuant to this Board action. ACKNOWLEDGE that the National Institute of Health has concluded that needle exchange programs prevent HIV and other communicable disease transmission (suchas Hepatitis C) among injection drug users, their partners, and the wider community, and do not result in increased injection drug use. ACKNOWLEDGE that a well run needle exchange program actually encourages drug users to seek substance abuse treatment and decreases drug use. DECLARE that the authorization of needle exchange programs pursuant to the declaration of a public health emergency is designed to prevent the transmission of HIV/AIDS and Hepatitis C and does not imply that the County supports or condones injection drug use. BACKGROUND/REASONS FOR RECOMMENDATION: A. Legislation Authorizing Needle Exchange Programs A new law (AB136, California Health and Safety Code section 11364.7) signed in October 1999 by Governor Davis decriminalizes needle exchange in those jurisdictions where local authorities have declared "a local emergency due to the existence of a critical local public health crisis." Contra Costa County can take a significant step to improve the health and well-being of residents by supporting needle exchange services in conjunction with a declaration of public health emergency. The West County AIDS Task Force (a group of representatives from the County, City of Richmond, community based organizations, AIDS patients, faith community, and health providers) which has been meeting monthly since February 1999 to address AIDS in the African-American community, endorses the declaration of a public health emergency and the support and expansion of needle exchange programs. B. The Need for Needle Exchange Programs The HIV epidemic in the United States and in Contra Costa County is increasingly associated with injection drug use. It is estimated that 50% of the more than 40,000 new HIV infections which occur each year in the U.S. are related to injection drug use. The Center for Disease Control (CDC) reports that more than 63% of all AIDS cases among women are related to injection drug use. More than 75% of babies diagnosed with HIV are infected as a result of injection drug use by a parent. Here in Contra Costa County, the proportion of AIDS cases attributable to injection drug use is significantly higher than in Alameda or San Francisco counties. Between 1982 and 1986, injection drug use was identified as the mode of transmission in 9% of the population diagnosed with AIDS in Contra Costa County. As of July 1999, 30% of all people living with AIDS in Contra Costa were infected through injection drug use. The number of AIDS cases is highest in West County. As of December 1997, Richmond had the highest cumulative incidence of AIDS (4.8 per 1,000 population) among Contra Costa cities, with at least 50 cases. On October 28, 1998, President Clinton declared HIV/AIDS to be a severe and ongoing health crisis in racial and ethnic communities. While racial and ethnic groups account for 25% of the U.S. population, they account for more than 50% of all AIDS cases. AIDS deaths in the U.S. remain nearly 10 times higher among African-Americans than whites. Furthermore, while overall AIDS deaths are down in the U.S., AIDS remains the leading killer of African-Americans age 25-44. African-Americans in Richmond comprise approximately 33% of all people living with AIDS in Contra Costa (1998 data). 67% of all people diagnosed with AIDS in Richmond from 1982-1998 are African-American. Injection drug use was estimated as the probable mode of infection among 40% of all individuals diagnosed with AIDS in Richmond from 1982-1998. Among African-Americans diagnosed with AIDS in Richmond during the same time period, 53% were most likely infected through injection drug use. Among African-Americans living with AIDS in Contra Costa, nearly half (49.8%) identified injection drug use as their probable mode of infection, according to data for the period from April 1997-March 1998. 2 C. Cost Effectiveness of Needle Exchanae Programs Of the 712 individuals receiving HIV/AIDS care through the Ryan White CARE Act in 1999, 263 or 37% were infected due to injection drug use (this figure includes injection drug use and their sexual -partners). If needle exchange had been in place in Contra Costa in the 1960"s, many of these 263 individuals may not have become infected with HIV. If needle exchange programs had reduced the rate of HIV transmission among intravenous drug users by 30%, as estimated by a 1997 National Institute of Health (NIH) consensus report, it is possible that we could have prevented 79 cases of HIV disease. By preventing 79 infections, we could have saved approximately $2.7 million in medical care costs and $1.3 million in medication costs. This monetary savings is, of course, on top of the savings in human loss and misery. The California Syringe Exchange Network estimates that the average cost to serve one person for one year in a needle exchange program is $74. In contrast, the average annual cost of providing medical care including the cost of medications for a person living with HIV or AIDS is approximately $34,000. D. The Public Health Community Supports Needle Exchange Programs Six independently conducted U.S. government-funded studies and the 1997 NIH consensus report all concluded that NEEDLE EXCHANGE PROGRAMS PREVENT HIV AND OTHER COMMUNICABLE DISEASE TRANSMISSION AMONG INJECTION DRUG USERS, THEIR PARTNERS, AND THE WIDER COMMUNITY, AND DO NOT RESULT IN INCREASED INJECTION DRUG USE. The National Institute of Health has concluded that needle exchange is an essential component of a comprehensive HIV prevention program. Other organizations which support needle exchange programs include the U.S. Conference of Mayors, the American Medical Association, the American Academy of Pediatrics, the American Public Health Association, the National Black Caucus of State Legislators, the American Bar Association, and U.S. Health and Human Services Secretary Donna Shalala. Even public opinion surveys have shown strong support for needle exchange programs as demonstrated in a 1999 Field Institute survey of Californians which found that 69% favored needle exchange programs to help stop the spread of AIDS/HIV. Over the past five years, the following cities and counties have declared local public health emergencies based on AIDS/HIV: Alameda County, Marin County, Sonoma County, Los Angeles County, Santa Cruz County, Monterey County, City and County of San Francisco, Oakland, Berkeley, Salinas, West Hollywood, and Sacramento. E. Existing HIV/AIDS Prevention and Needle Exchange Programs in Contra Costa While the Contra Costa Health Services Department (CCHSD) does not currently provide needle exchange services (since it is prohibited from doing so by law absent a declared public health state of emergency) it does provide other services targeted at injection drug users, including: (1) HIV/AIDS Outreach and Education, (2) HIV Antibody testing, (3) Substance Abuse Treatment, (4) Health on Wheels Van, and (5) Substance Abuse Counseling and Referrals for HIV-infected clients. There is one community based needle exchange service currently in operation in Contra Costa County. Exchange Works, a non-profit organization, distributes needles at two sites in Richmond (Richmond and North Richmond) on a one-to-one exchange basis -- one dirty needle for one clean needle. Its volunteer staff currently exchanges 5,000 needles per week at the two sites. Individuals from throughout Contra Costa County come to the needle exchange sites in Richmond. Exchange Works has almost exhausted its funding for an on-going supply of needles and has been struggling to secure funding to maintain its services. It has developed a very trustful relationship with the intravenous drug use community. Such trust is vital to the ongoing success of a needle exchange program. There are currently no established needle exchange programs in East or Central County, although there is an unfunded, informal exchange program in East County since there is an acknowledged need in that part of the county. FISCAL IMPACT: NONE. The CCHSD shall investigate the reallocation of existing staff and resources to implement the support and expansion of needle exchange programs as authorized in this Board action. 3 ADDENDUM TO ITEM D.1 DECEMBER 14, 1999 On this date, the Board of Supervisors considered a request from Supervisor John Gioia to declare a local public health emergency for HIV/AIDS and Hepatitis C under California Government Code Section 8630 and to authorize the County Health Department's support for needle exchange programs. Supervisor Gioia presented the report Dr. William Walker, Health Services Department Director, spoke in support of the program. Dr. Wendel Bruenner, Public Health Director, spoke in support of the program. The following persons presented testimony: Mike Arata, 589 Bobbie Drive, Danville, in opposition; Harry C. Sweet, Jr., 1330 North Broadway, Suite 200-A, Walnut Creek, in opposition; Torn Aswad, P.O. Box 31114, Walnut Creek, in support; Reverend Llewellyn Christian, 1090 Parkside Drive, Richmond, in support; Hazel Wesson, 450 36`h Street, Richmond, representing AIDS Community Network, in support; Doris Glasper, 1760 Chester Drive, Pittsburg, representing PSCC; Alberto Padilla, 304 Wildberry Drive, Brentwood, in opposition; Michael Jay, c/o General Delivery, Concord, in opposition; Bobby Lee Bowens, 515 Silver Avenue, Richmond, representing Exchange Works, in support; Francie Koehler, 3121 Sheldon Drive, Richmond, representing Exchange Works, in support; Doris Copperman, 3 Penrith Walk, Pleasant Hill, representing Public and Environmental Health Advisory Board. Following discussion of the issues,the Board took the following action: APPROVED the requests contained in the report from Supervisor Gioia; AMENDED Direction 2 to the Contra Costa Health Services Department to read "Facilitate a planning process to establish a needle exchange site in East County coordinated through the office of the District V Supervisor"; DIRECTED that County Counsel, Health Services Director, and the County Administrator calendar the matter on the Board agenda for consideration every two or three weeks, until it is determined that it is not necessary; DIRECTED the Health Services Director to report to the Board in six months on the status and results of the program, and addressing comments of speakers today. WILLIAM B. WALKER, M. D. OFFICE OF HEALTH SERVICES ✓IRECTOR THE DIRECTOR 20 AI?en Street CONTRA COSTA Martinez, 553-3'91 94753-3'.91 HEALTH S E RSI -�x GZ�I C E S �" t(925)—37370— -5098 To: Board of Supervisors Date: December 8, 1999 From: William B. Walker, MD Re: Recommendation to Declare a Director of Health Services Public Health Emergency for HIV/AIDS and to Implement a Needle s Exchange Program in Contra Costa County The Health Services Department recommends the Board of Supervisors declare a Public Health Emergency for HIV/AIDS, and implement a needle exchange program in Contra Costa, as proposed by Supervisor Gioia. The attached report from the Health Services Department documents the major contribution of IV drug use to the continued spread of AIDS in Contra Costa County. As of July, 1999, 30% of all people living with AIDS in Contra Costa were infected through injection drug use. Others are infected as partners of injection drug users, or as infants born to infected mothers. In addition, we are learning more about the extensive prevalence of Hepatitis C. That disease, also spread by injection drug use, often results in liver transplant or death for the infected individual. Needle exchange programs have been demonstrated in repeated studies to be effective in reducing the transmission of HIV among IV drug users. Some of the more important studies are described in the attached report. There is every reason to believe that needle exchange will also be effective in reducing the widespread transmission of Hepatitis C. Histay of Needle Exchange Proposal 'n Contra Costa 1n 1994 and 1995 the Health Services Department conducted 19 community forums in all areas of the county to discuss the public health issues of needle exchange. The Substance Abuse Advisory Board and the Public and Environmental Health Advisory Board discussed the needle exchange issues and recommended that the Health Services Department initiate a needle exchange program in Contra Costa. In 1995 the Health Services Department recommended a needle exchange program for the County. The Department's proposed program would not promote or condone drug abuse, but rather would reach out to IV drug users and encourage them to enter into treatment. The Department's recommendation was based on the following points: • The Health Services Department should conduct a needle exchange program as part of its public health responsibility to control communicable disease in the community. fr + Contra Costa Community Substance Abuse Services + Contra Costa Emergency Medical Services + Contra Costa Environmental Health + Contra Costa Health Plan • Contra Costa Hazardous Materials Programs +Contra Costa Mental Health + Contra Costa Public Health + Contra Costa Regional Medcal Center • Contra Costa Health Centers • Any needle exchange program must include a strong component to encourage IV drug users to enter into treatment. • Needle exchange programs should be initiated in consultation with local communities. • Any needle exchange program should include an evaluation component to measure the effectiveness of the program. The Board of the Supervisors supported the Health Services Department recommendation, but Attorney General Dan Lungren sent a letter to Contra Costa and every other county in the state indicating that needle exchange is illegal in California and cannot be instituted even by public authorities. Legislation legalizing needle exchange in California was unanimously endorsed by the Board of Supervisors, but subsequently vetoed by then-Governor Wilson. This year the Board of Supervisors again unanimously endorsed AB 136 (Mazzoni), which would legalize needle exchange. That bill was signed by Governor Davis after modifications which left the legislation completely consistent with Contra Costa policy. Under this legislation, needle exchange programs can legally be implemented under the auspices of the health department upon the declaration of a local emergency by the Board of Supervisors. Needle Exchange Programs in West County An unofficial needle exchange program has been implemented in West County for several years by a community-based organization called Exchange Works. For the last six months, the West County AIDS Task Force co-chaired by Supervisor Gioia and Richmond Vice Mayor Irma Anderson has been considering needle exchange in the broader context of the HIV infection in West County, particularly among people of color. In addition to county and city representatives, the Task Force includes community-based organizations, faith community representatives, service providers, and other individuals and groups concerned about HIV/AIDS. Health Services Department staff have been working closely with the Task Force. The West County needle exchange proposal is well thought out and consistent with Health Services Department and legal guidelines. Staffing would be provided by Exchange Works and existing Health Services Department staff from the AIDS, Communicable Disease, and Substance Abuse programs. We recommend that the Health Services Department develop an MOU with Exchange Works, thereby bringing the project under the umbrella of state law. Needle Exchange in East County There are sporadic needle exchange activities in East County implemented by some community individuals or groups, but there is no systematic, organized exchange program in that region. AIDS epidemiology indicates, however, that HIV transmission by intravenous drug use is a major problem also in East County. The Health Services Department would initiate a community planning process to identify what kind of needle exchange program would be appropriate for the East County community. Conclusion HIV transmission in Contra Costa County by IV drug use is a public health emergency, and currently the source of infection of 30% of all people living with AIDS in Contra Costa. A well planned and responsibly implemented needle exchange program can be effective in slowing the transmission of HIV and Hepatitis C in our county. Needle exchange does not promote IV drug use; on the contrary, an effective needle exchange program can reduce drug abuse by encouraging users to enter treatment. Needle exchange is not a panacea nor a total solution to the problem of AIDS. Needle exchange is, however, an important too[ for local health departments in combating this devastating and persistent epidemic, and can save lives in Contra Costa. Attachments CONTRA COSTA HEALTH SERVICES DEPARTMENT PROPOSED NEEDLE EXCHANGE PROGRAM Executive Summary Needle exchange is a strategy that is proven to decrease transmission of HIV/AIDS,Hepatitis C and other blood-borne diseases among injection drug users, their partners and children, and the broader community. In October 1999, Governor Gray Davis signed into law AB 136 on needle exchange. This law decriminalizes needle exchange in local jurisdictions where local authorities have declared a public health state of emergency. AB 136 now gives local jurisdictions the authority to add this strategy to their prevention efforts. Contra Costa County can take a significant step toward improving the well-being of its residents by supporting needle exchange services pursuant to a declaration of public health emergency. Injection drug users represent the parts of our communities where poverty,homelessness,and poor health are most concentrated. Needle exchange services give an opportunity to these individuals to change their behavior in ways that protect their own health as well as the health of their needle sharing and sexual partners. This document covers the following: • Effectiveness of needle exchange programs in preventing HIV/AIDS and other infectious disease transmission, • Cost effectiveness of needle exchange programs; • Epidemiology ofH1V/AIDS and other infectious diseases in Contra Costa; • Process for declaring a public health state of emergency; • Existing health services to injection drug users in Contra Costa. This proposal outlines the Contra Costa Health Services Department's (CCHSD)needle exchange program. Needle exchange services will be centered in Richmond/North Richmond and Pittsburg/ Bay Point, the two areas of the County where injection drug use is believed to be most prevalent. The CCHSD program will involve: 1)collaboration with Exchange Works,a non-profit organization which has been providing needle exchange in West County since 1995, to operate 2 weekly needle exchange sites in Richmond and North Richmond; and 2) operation of a weekly exchange in East County. CCHSD developed the proposal in discussion with community leaders, health and human service organizations, and interested individuals. The final shape that needle exchange services take must reflect the input and concerns of community members. CCHSD invites community participation into the planning process. Therefore, this proposal represents a work in progress. "G Ae&pineaexl99nexpin" I. BACKGROUND Needle Exchanges An Effective Approach to Public Health Needle exchange uses a traditional public health approach of reducing exposure to known infectious agents, by reducing the number of contaminated needles in our environment. Over 100 needle exchange programs now operate in the United States. While opponents initially suggested that needle exchange would not work because drug users do not care about their health, existing programs prove this assumption wrong. Between 1994 and 1997, the number of clean needles exchanged for dirty ones more than doubled, according to the Centers for Disease Control and Prevention.' Needle exchange programs prevent HIV and other communicable disease transmission among injection drug users,their partners,and the wider community,and do not result in increased injection drug use. Six U.S. government-funded studies conducted independently by the National Commission of AID S (1991), the General Accounting Office(1993),the University of California for the Centers for Disease Control and Prevention (1993), the National Academy of Sciences (1995), the Congressional Office of Technology Assessment(1995), and the National Institutes ofHealth(1997) all support these conclusions. The National Institutes of Health (NIH) consensus report (1997) stated that needle exchange programs should be viewed as an essential component of a comprehensive HIV prevention program. The report estimated that needle exchange programs reduce HIV transmission by at least 30%among injection drug users and increase referrals to drug treatment programs. The report further emphasized that needle exchange programs do not encourage non-drug users to use drugs and that programs do not cause an increase in used needles discarded in public spaces. It is conservatively estimated that a national needle exchange program in the U.S., if it had been in place from the period 1987-2000, could have prevented 5150 — 11,329 HIV infections among injection drug users, their sexual partners, and their children.' A recent study by the University of California at San Francisco found significantly lower rates of syringe sharing among the clients who used the Richmond (Contra Costa) needle exchange.4 Needle exchange programs have also been found to be effective at reducing the rates of other infectious diseases, including hepatitis B and C.5 Support for Needle Exchange Programs In April of 1998, Health and Human Services Secretary Donna Shalala endorsed needle exchange programs as an effective HIV prevention measure, and encouraged local communities to provide political and financial support. Organizations which support the implementation of needle exchange programs include the U.S. Conference of Mayors,the American Medical Association,the American Academy of Pediatrics, the American Public Health Association, National Black Caucus of State Legislators and the American Bar Association. "G:1e&p\need1ex199nexp1n" 2 Public opinion surveys have also shown strong support for needle exchange programs. A 1999 Field Institute survey of California adults found that 6911/o favored needle exchange programs"to help stop the spread of AIDS and HIV infection. ,7 Support was widespread across geographic and ethnic lines. The Boards of Supervisors in Alameda,Marin, San Francisco, Sonoma, Santa Cruz,Monterey, and Los Angeles counties have declared local states of emergency due to the AIDS epidemic in order to support needle exchange programs. The Contra Costa County HIV Prevention Steering Committee, the Substance Abuse Advisory Board,and other local boards and organizations have endorsed needle exchange. The Need for Needle Exchange in Contra Costa The HIV epidemic in the United States and in Contra Costa County is increasingly associated with injection drug use. It is estimated that 50% of the more than 40,000 of the new HIV infections, which occur each year in the United States, are related to injection drug use.8 The CDC reports that more than 63%of all AIDS cases among women are related to injection drug use. More than 75%of babies diagnosed with HIV are infected as result of injection drug use by a parent. In Contra Costa, among those living with AIDS, the proportion of AIDS cases attributable to injection drug use is significantly higher than in neighboring Alameda or San Francisco counties. Between 1982 and 1986, injection drug use was identified as the mode oftransn-fission in 9%of the population diagnosed with AIDS in Contra Costa. As of July 1999, 30% of all people living with AIDS were infected through injection drug use. Of the 712 people living with HIV or AIDS and receiving services through the Ryan White CARE Act in 1999, 263 or 37% were infected due to injection drug use(this figure includes injection drug users and their sexual partners). Cost effectiveness of Needle Exchange Programs Needle exchange is a cost-effective public health strategy. It is possible to weigh the costs ofrunning needle exchange programs against the costs of treating HIV/AIDS and other infectious diseases. The cost of sterile needle is approximately ten cents($.10). The California Syringe Exchange Network (CASEN)estimates that average cost for needle exchange programs to serve one person for a year is approximately$74. In contrast,the average annual cost of medications for a person living with HIV or AIDS is approximately $15,000 - $18,000. The average annual cost of providing medical care, including the cost of medications, is approximately $34,000. The costs of treating injection drug users with HIV disease may be even higher because many wait until they are seriously ill before accessing primary health care services. A majority of these patients do not have private medical insurance and will likely be treated through publicly funded medical programs. If needle exchange had been in place in Contra Costa in the 1980s, many of the 263 clients who receive Ryan White Care Act services and who were infected with HIV due to injection drug use, may not have become infected with HIV. If needle exchange programs had reduced the rate of HIV transmission among injection drug users(IDUs)by at least 30%,as estimated by the NIH consensus "G:\e&p\need1ex\99nexp1n" 3 study, it is possible that we could have prevented 79 cases of HIV disease. By preventing 79 infections,we would also have saved approximately$2,700,000 in medical care costs and$1,300,000 in medication costs. If we assume that our needle exchange would have reduced HIV infections by only 10%, it is possible that we could have prevented approximately 26 cases of HIV disease and saved approximately$884,000 in related health care costs. The savings in human loss and misery is, of course, immeasurable. Declarim a Public Health State of Emergency In October 1999, Governor Gray Davis signed into law AB 136(Mazzoni)on needle exchange. This law, which amended Section 11364.7 of the California Health and Safety Code, states: "No public entity,its agents,or employees shall be subject to criminal prosecution for distribution ofhypodermic needles or syringes to participants in clean needle and syringe exchange projects authorized by the public entity pursuant to a declaration of a local emergency due to the existence of a critical local public health crisis." California Government Code(GC)section 8550 et sea. authorizes the governing body of county or city to declare a local emergency. A local emergency, as defined in GC Section 8558, is the "duly proclaimed existence of conditions of disaster or of extreme peril to the safety of persons and property within the territorial limits of a city and county...caused by such conditions as air pollution, fire, flood, storm, epidemic...which conditions are likely to be beyond the control of the services, personnel, equipment, and facilities of that political subdivision and require the combined forces of other political subdivisions to combat..." This means that State law empowers local authorities, acting within parameters established by relevant local administrative codes and charters,to declare a public emergency to exist in connection with the AIMS epidemic,the high rate of HIV transmission in injection drug users, and the corresponding high rate of HIV/AIDS in individuals who inject drugs and in their sexual partners and children. By law, the Board of Supervisors must appoint a health officer who "...may take any preventive measure which may be necessary to protect and preserve the public health from any public health hazard during any...'local emergency,'as defined by Section 8558 of the Government Code,within his jurisdiction." The declaration of local emergency allows local authorities to direct the forces of any department in the city and county in any service deemed reasonable and suitable to meet the emergency. Thus,the rapid and continuing escalation of HIV transmission among injection drug users entitles the Board of Supervisors to direct the Department of Health Services to take immediate steps to prevent the further spread of HIV. By federal government acknowledgment,needle exchange is now known to be a suitable and effective means to reduce HIV/AIDS transmission among injection drug users, their partners and children. We recommend that Contra Costa County join with other Bay Area counties in implementing needle exchange programs as a part of comprehensive strategy to prevent HIV/AIDS and other communicable diseases and to bring underserved individuals into care and treatment. «GAe8rp\neaex\99nexp1n" 4 II. PILOT NEEDLE EXCHANGE PROGRAM IN CONTRA COSTA COUNTY Existing Services for Injection Drug Users County-Operated Services The Contra Costa Health Services Department does not currently provide needle exchange services. However, CCHSD currently provides several other types of services that are aimed at injection drug users, including: ♦ IIIVIAIDS Outreach and Education.Beginning in 1987, street-based outreach workers began reaching injection drug users and their partners to provide risk reduction counseling. Outreach workers supply HIV risk reduction information and materials; including condoms and bleach kits, as well as referrals to local drug recovery programs and other health and social services. Outreach workers also recruit and train peer educators who are recovered injection drug users; these peer educators share messages about avoiding needle sharing, cleaning needles, and using condoms. Finally, outreach workers give educational presentations to injection drug users in local detention facilities, drug recovery programs, soup kitchens and homeless shelters. Funding from the State Office of AIDS covers a portion of this activity. ♦ HIV Antibody Testing. The Neighborhood Intervention Geared to High Risk Testing (NIGHT)program,funded by a grant from the State Office of AIDS,provides HIV antibody testing and counseling to individuals at high risk for HIV, including injection drug users and their partners in community settings. ♦ Substance Abuse Treatment: The Community Substance Abuse Services(C SAS) system of care is a planned,comprehensive approach for providing alcohol and other drug treatment and prevention services. The continuum of care combines administrative and clinical services in an integrated system;the Access Unit offers screening,placement, and care coordination for substance users seeking treatment. CSAS offers assessment, detoxification, outpatient counseling, narcotic treatment via methadone maintenance and detoxification, residential recovery services, referrals to transitional housing and other ancillary services, services for pregnant and parenting women and their children, and primary prevention services. These services are funded through a variety of federal, state, and local sources. ♦ Health on Wheels(HOW) Van: The HOW van,a mobile clinic that provides basic health care for people without insurance or access to services,currently operates at needle exchange sites 3 times per month in West County. Approximately 5-6 clients,all of whom are injection drug users, receive HOW van services each time the van visits the needle exchange sites. Services include wound and abscess care, urgent care for acute illnesses, immunizations(particularly tetanus vaccination), pregnancy testing, cervical cancer screening,and HIV and STD testing and counseling. A family nurse practitioner, a registered nurse and a driver C HIV and STD counselor staff the HOW van. Funding for the van itself was provided by Chevron in collaboration with the City of Richmond,and Contra Costa County covers the cost of services "GAe&p\need1ex\99nexp1n" 5 and operation of the HOW van. ♦ Substance Abuse Counseling and Referrals far HIV-infected clients: In 1997, the CCHSD AIDS Program began funding a local community-based organization to provide substance abuse coordination services to county residents dually-diagnosed with HIV and substance abuse issues. This service includes immediate, short-term substance abuse counseling as well as referrals to and coordination of longer-term substance abuse treatment and related service. This service,funded by Ryan White CARE Act funds,has been available countywide since its inception. Community-Based Needle Exchange Services Exchange Works,a non-profit organization,began offering needle exchange services in West County in 1995. The organization initially trained a group of 6 volunteers concerned about the toll of HIV/AIDS to staff a single weekly street-based site in Richmond, and used supplies donated by other regional needle exchange programs. The organization has received small amounts of grant funding from a variety of foundations. In 1997 Exchange Works was able to expand to a second weekly street-based site in North Richmond. In September 1995,Exchange Works exchanger)355 needles to 12 individuals. In September 1997, after opening its second site, staff exchanged 8,782 needles to 241 individuals. Currently,Exchange Works exchanges approximately 5,000 needles per week at its two sites. Exchange Works currently operates under the fiscal auspices of Neighborhood House of North Richmond. Exchange Works conducts a one-to-one exchange(one dirty needle for one clean needle). Exchange Works applies principals of harm reduction,by encouraging individuals to pursue positive health care behaviors in their own time and way. Exchange Works staff remains entirely volunteer, and periodically includes contributions from exchange users who want to take a more active role in their own and their peer's health care. Since its inception, Exchange Works has struggled to secure funding for needle exchange services. As of October, 1999 the program had almost exhausted it's funding for an do-going supply of needles. Given its volunteer staff and struggles to maintain access to basic supplies,Exchange Works has not had the resources to provide in-depth support to clients around primary health care,substance abuse treatment, and other services. Nevertheless,Exchange Works has played an important role in encouraging clients to use the CCHSD's Health On Wheels (HOW) van, which provides on-site medical care for needle exchange clients approximately three times per month. Over time, Exchange Works has slowly developed a trustful relationship with injection drug users in our communities. This trust is reflected in the steady increase in number of needles exchanged since 1995. Clients, many of whom have a high level of distrust of"the system," come to the exchange knowing that they will receive friendly, non judgmental services. Currently there are no established needle exchange programs in East or Central County. An unfunded, informal exchange does operate in East County. This exchange is operated by private citizens with sporadic access to supplies of sterile needles, and the program has no ongoing oversight. "GAe&p\need1ext99nexp1n" 6 __ _ __. Pilot Contra Costa Needle Exchange Program The Health Services Department proposes to strengthen needle exchange services in Contra Costa in compliance with AB 136. CCHSD will work closely with Exchange Works,the West County AIDS Task Force, the Substance Abuse Advisory Board, the Public and Environmental Health Advisory Board(PEHAB), and other bodies to identify and implement strategies to enhance existing services countywide. Specifically, CCHSD proposes to do the following: 1. Provide additional supplies and staff support for needle exchange services in West County. CCHSD will collaborate closely with Exchange Works to support existing services at the two needle exchange sites in Richmond. 2. Facilitate a planning process to establish a needle exchange site in East County, appropriate for that community. 3. Participate in a long-range planning process to improve services in both East and West County. CCHSD will be one of several partners helping to enact a vision of a community-based program with comprehensive services. CCHSD's role will be to help identify additional resources and build partnerships with federal and local governments, foundations, community volunteers, social service providers and others. Elements of this long-range vision include: ♦ Providing on-site medical care for abscesses and other primary health care needs; ♦ Providing substance abuse counseling, pre-treatment and referrals; ♦ Providing HIV antibody testing and sexually transmitted disease screening, Providing linkages to other support services for clients. 4. Provide regular progress reports to local authorities on the status of the pilot needle exchange program and on the health impacts of these activities. Procedures for Proposed Needle Exchanee Proeram CCHSD will use the following procedures in implementing the proposed needle exchange program: ♦ Access to needles and other supplies.Keeping an adequate stock of needles and other supplies is an acute need for an effective needle exchange program. CCHSD will explore two options: 1) purchasing additional needles and supplies for all exchange sites in Contra Costa;or 2)providing funding to a fiscal agent for the purchase of needles and other supplies. + One-to-one exchange. CCHSD will document one-to-one exchanges at all sites. Exchange Works currently practices and documents one-to-one exchange. Clients count and bundle their needles, and staff give out only as many needles as a client brings. Safety protocols. CCHSD will review policies for blood borne pathogen safety at all exchange sites, including needle disposal protocols. CCHSD will provide training as needed to support the safe operation of all exchange sites, and will offer free Hepatitis B immunization to staff and volunteers as needed. "GAe&ptneedtex199nexpin" 7 ♦ Access to medical care. CCHSD will explore expanding the hours the HOVE van is available so that services can be available every exchange evening in West County. The HOW van provides basic medical care including, but not limited to, abscess/wound treatment, HIV counseling and testing, and STD screening. Exchange staff will maintain logs tracking referrals to additional medical care. Although the HOW van is not currently funded to serge East County,CCHSD will attempt to identify other resources for auxiliary medical care at any East County sites. ♦ Access to drug treatment programs. CCHSD will identify resources to place a substance abuse outreach worker/counselor on site to facilitate pre-treatment counseling and assessment and to provide referrals to treatment programs. The substance abuse outreach worker/counselor will maintain logs tracking referrals to care and treatment programs. In West County, there are currently no resources on-site at the exchanges to facilitate client access to substance abuse care and treatment. ♦ Adequate staffing and outreach. CCHSD will provide consistent outreach staff at the exchange sites with information about community resources, risk reduction activities, case management programs, etc. CCHSD staff will maintain simple referral logs. ♦ .Monitoring and Evaluation. CCHSD will monitor the number of needles exchanged and basic demographics of the population served. Exchange Works currently tracks this type of information. To facilitate the collection of information related to outcomes, outreach workers will be equipped with simple logs to track referrals into services. West County CCHSD proposes to explore strengthening Exchange Works' existing program in West County in two ways. 1) by providing,additional supplies necessary for operation, or by providing funding for Exchange Works to purchase these supplies;z)by providing staff time to collaborate with Exchange Works volunteers at the two weekly sites. This staff person,likely a Disease Intervention Technician (DIT), will have skills in risk reduction counseling and pre-treatment substance abuse counseling. The staff person will provide a link between exchange users and County and community operated social services, and will track referrals to these services. CCHSD will monitor needle exchange services, and provide oversight information to the Board of Supervisors as necessary. However, Exchange Works will maintain responsibility for day-to day operations of the needle exchange sites in West County. East County CCHSD proposes to undertake a planning process to develop a pilot needle exchange appropriate for East County. Because an infrastructure of sites,volunteers, and auxiliary resources does not exist in East County, CCHSD will facilitate a needs assessment and community planning process before proposing further details to support an East County exchange. The Health Services Department is "GAe&pineed1ex\99nexp1n" 8 committed to a program in East County that slows the spread of HIV and Hepatitis C,and meets the needs of the East County Community, Fiscal Impact CCHSD proposes to implement this proposal by redirecting existing staff and supplies toward needle exchange services. In particular, outreach workers--both CCHSD employees and staff: of the community based organizations with which the County contracts--can integrate promotion into ongoing work. CCHSD staff'can also provide on-site risk-reduction counseling and pre-treatment substance abuse counseling at needle exchange sites. Finally, CCHSD can further direct risk- reduction supplies,which are already disseminated among at-risk populations throughout the county (condoms,bleach kits, educational materials, etc.),to needle exchange sites. There will be a need to identify resources to provide supplies for the exchange program. } Centers for Disease Control and Prevention,"Update: Syringe Exchange Programs—United States, 1997,"Morbidity and Mortality Weekly Report,August 14, 1998. 2 National Commission on Acquired Immune Deficiency Syndrome,The Twin Epidemics of Suhstance Use and HI, July 1991;U.S.General Accounting Office. Needle Exchange Programs:Research Suggests Promise as an AIDS Prevention Strategy. Report No. GAOIHRD-93-60. Washington DC:US Government Printing Office, 1993;Lurie,P. Reingold,A.L.,Bowser,B.,et al. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Prepared for the Centers for Disease Control and Prevention,September 1993;Normand,J.,Vlahov,D.,and Moses,L.E.,Eds. Preventing HIV Transmission: The Role of Sterile Needles and Bleach. Washington,DC:National Academy Press(National Research Council and Institute of Medicine), 1995;Congress of the United States,Office of Technology Assessment. The Effectiveness of AIDS Prevention Efforts,Publication No.OTA-BP-H-172. Washington DC:US Government Printing Office,September 1995;National Institutes of Health Consensus Statement. Interventions to Prevent HIV Risk Behaviors, 15(2),February I I-13, 1997. 3 Lurie,P. and Drucker,E. "An Opportunity Lost:HIV Infections Associated with Lack of a National Needle-Exchange Programme in the USA,"Lancet, 1997,Vol. 349:604-608. 4 Bluthenthal,R,et al. "Factors Associated with Syringe Sharing Among Injection Drug Users(IDUs)Following the Implementation of a Medium.-Sized Syringe Exchange Program(SEP),"Paper presented at American Public Health Association Meeting,Washington DC,November 15-19, 1998. 5 Hagan,H.,"Reduced Risk of Hepatitis B and C among Participants in a Syringe Exchange Program."American Journal of Public Health, 1995,Vol.85,pp. 1531-37. 6 Health and Human Services Department Press Release,"Research Shows Needle Exchange Programs Reduce HIV Infections Without Increasing Drug Use,"April 20, 1998. 7 "Overwhelming Majority of Californians Support Needle Exchange," San Francisco AIDS Foundation press release, Sacramento,CA,August 26, 1999. 8 Holmberg,S.D."The Estimated Prevalence and Incidence of HIV in 96 Large U.S.Metropolitan Areas."American Journal of Public Health, 1996;86:642-654. "G:\e&p\needlex199nexpin" 9 PUBLIC AND ENVIRONMENTAL CONSIDERWITH-2L HEALTH ADVISORY BOARD Wilma Blackman Doris Copperman Art Hatchett RECEIVED Mary Lou Laubscher Mar,'orie Leeds Edith Loewenstein =OF 91999 Yolanda Marquez Kimberly McClenden Bessanderson McNeil CLE8K BOARD SUPE€�U€SORS Jeffrey Ritterman CONTRA COSTA CO. Mary Rocha Nick Rodriguez Jean Sid Michele Thompson COVER LETTER Bonita Woodson cbzk: Thomas Zimmerman PX-C fficlo Mammy: bear Clerk of the Board: Joseph Hafey George Kaplan Carolyn Robinson Attached please find a letter of support for a needle exchange program in Contra Tracey Rattray Costa County, including a request to the Board of Supervisors to declare a Executive Assistant to the public health state of emergency. Public&Environmental Health Advisory Board Please add this letter to the needle exchange packet on the December 14 B©S agenda, and distribute the provided copies to Chairman Canciamilla, as well as Supervisors Uilkema, Gerber, DeSaulnier and Gioia. If you have any questions,please call me at 5-6835 (313-6835). Thank you, Tracey Rattray Executive Assistant, PEHAB Contra Costa Health Services 657 Center Avenue,Suite 200 Martinez,CA 94553-4669 PHONE:(926)313-6836 FAX.(925)313-6721 PUBLIC AND ENVIRONMENTAL HEALTH ADVISORY BOARD Wilma Blackman Doris Copperman Art Hatchett Mary Lou Laubscher Marjorie Leeds Edith Loewenstein December 7, 1999 Yolanda Marquez Kimberly McClenden Bessanderson McNeil Jeffrey Ritterman Mary Rocha Nick Rodriguez Chairman Joseph Canciamilla Jean Sin Michele Thompson Contra Costa Board of Supervisors Bonita Woodson 651 Pine Street Chak: Martinez, CA 94553 Thomas Ammerman Ex-Q i lrz embers: Dear Chairman Canciamilla: Joseph Ha€ey George Kaplan Caroiyn Robinson The Public and Environmental Health Advisory Board(PEHAB) would like to Tracey Rattray request that the Contra Costa Board of Supervisors declare a;public health state Executive Assistant to the of emergency and allocate sufficient resources to support a needle exchange Public&Environmental program in our county. Health Advisory Board More than half of new HIV infections are directly or indirectly related to injection drug use. Hepatitis C is another disease which is now primarily spread by injection drug use. We urge you to support a needle exchange program in Contra Costa and join the growing ranks of citizens who want to prevent the transmission of HIV and blood-borne hepatitis through contaminated needles. Chronic disease prevention is a priority issue for PEHAB and scientific research shows that needle exchange programs are effective in slowing the spread of HIV and hepatitis. In addition,needle exchange programs provide a means of contact with intravenous drug addicts and help facilitate their entry into drug treatment programs. Assembly Bill 518 enables county health departments to support needle exchange programs if the Board of Supervisors declares a public health state of emergency. We urge you to take this step in support of this critical public health issue. Sincerely, Thomas Zimmerman Chair, PEHAB Contra Costa Health Services 597 Center Avenue,Suite 200 Martinez,CA 54553-4559 PHONE:(925)313-5535 FAX:(525)313-6721 k fit F#JJ3L 1 C: f SHL 1 H HllM d N I S i HH 1 I UN F RX NU. ; 92t>--.51,i—b r21 Det c. ld t 113'.3`3 11'50W i'2 PUBLIC AND ENVIRONMENTAL onNsioER wiTH-�2L HEALTH ADVISORY BOARD moftom Wilms, dcrt5an 0009 Ad H9009 dory Wu Laubadw #or* "th Lo~* Ytlwwa Marquez K~y iVlc.0anden jttestt Mc;tilaif jt R1ftianW r Mary Rocha .BOARD OF Sl3f'E�?�i.€'? !dick Rix C-'."�NITRA COSV> M J"n Sid lti+llchal*Thompson COWER L.FF'rRR Bonita Woodson Chwr. Tlxz nys ZWWnafman Dear Clerk of the Board: jossph t-t"y George Kaplan Carolyn lw Attached plea find a letter of support for a needle exchange prograyn in Contra yrww ft"y Costa County, including a request to the Board of Supervisors to declares a Frew.AwaWftvt to the public hr4lth state of emetgewy. Pubilo a jerw9ronmontal t►aattrs Advisory lsoard Please add this!often to the needle exchange packet on the Dccmber 141309 agenda, said distribute the provided copies to Chairman Cowdamilla, as well as Supervisors Uilkoma,Gerber,DeSaulnior and Gioia. If you have any questions,please call me at 5-6935 (313-6835). Thank you., -TwwwjT�a" Tracey ltattray alb Executive Assistant. PEHAB Contra Costa Mftatth swvinum 507 Cef'A#tr Avra ova.Su"200 Martinez CA 84 388 PHONE,(W5)393-636 RAX:(823)393-8721 F HUM , PUHL I L HE-RL i H F-DM I N I S#lH f I UN F RX Nth. Jam—51 5 b f i Dec. U/ 11.:t>1W H's PIUSBPLIC AND ENVIRONMENTAL HEALTH ADVISORY BOARD mmatom TYi+sm&%&WW amsc^pper"M Ad Hntc*md Mary Um}„aubscher Ma*A*Loodo lac to l cewonstein December 7, 1999 Yoku-46 Marquez Kfrttb ady MCCI*nd#n sessan"Mm McNeil Jeffty Rittarrnan Mary Roeft ruck Rodno"X Chairaun Joseph Cimcimilla loan sirf Whale ThoMson Contra Costa Bow4 of Supervisors Bonita Woodson 651 Pine Street mac: Martinez,CA 44553 Thonum zkyrtan e1-QACj0-t40gear Chairman Canciamilla; J+ ph Haley George Kaplan C W*n;Wb1AW The Public and EnOronmental Health Advisory Board(PEHAl3)would like to .rte,Aettray request that the Contra Costa Burd of Supam isors declare a public health state S"outive Aselstrst to UW of emergency and allocate sufficicat resources to support a needle exchange Public a t*rivirwmettt*d progrmtt in ow county. Health Adv"(Y ward More than half of new HIV infections are directly or indirectly related to injection drug use. Hepatitis C is another disease which is now primarily spread by injection drug use. We urge you to support a needle exchange proms in Contra Coate and join the mowing,ranks of citizens who want to prevent the tranarniasion of HIV and blood-boats hepatitis tliroughf containinatod needles. Chromic discase prevention is a priority issue for P-13HAB and scientific roseamh shows that needle exchange programs are eft'ective in slowing the spread of HIV and.hepatitis, in addition, needle exchange progrAms provide a mets of eontact with intravenous drug addicts and help facilitate their entry into drug treatment proms. Assembly Bill 518 enablca county health departments to support needle exchange programs if the Board of Supervisors declares a public health state of emergency. We urge you to take this step in support of this critical public health issue. Sincemly, 0.07 Thomas Zimmerman Chair,PEHAB Contra Costa HoWtn Swvices 507 Genter Avenue,Butte Merttw,CA"663-440 PHONE.,(925)313-6036 FAX:M25)313-8721 CONSIDER WITH RECD<+.uYt" } h OO»lYWXi :._ C.`ontra.Cvsla County Bovxd of Supervisors Fax: 335 - 1913 rim BOARD OF A ICU, FAMILY TRESS Dear Supervisors, ENTER Since 1978, Family Strew Center has worked with hundreds ofCOIATA CostE.County Families to prevent vhild abuse and.neglect. Towitrds,these ef%rts.we address a variety of problerrii that of mt parenting,, including substance abuse. BOARD OF DIRF.CTORS 1.414Arrautidn' Ahficugh it is cominonly bolicved that .supplying n cclles will encourage f:rim"i"ttily l umatrrr rurth-r akl'Dusc.Quer staff's significant experience with this population has Ed brAt tau&?,t us that(x)ntatct with Needle Exchange staff will increase the well SStfttrliu f.'rWs ltAstt being of these otherwise isolated individual a and their children.In otl-er words,when clients walk. in. Needle Exchange sta Irwin have the Crstl;y lk+#rPfea oppwtunky to observe the condition of the clients and their children, and Yg , Fri, Co,�,,t,ltrxnt refer them to ether agencies that can address their myriad of needs. Not Bill ett,u•n only`.will Needle FxcbajWc save lives, but it will help bring anctition to G°ottt,+Furca child-en who are often%e verjety neglected. t:,piwa 110*r rsclo aur:t t rrr When you vote on Dectnaher 10.please think about tlx:many children in sltnr�.t ,ltt:,t�,} C'ont•a Costa County who are affected by the isolated lifestyles iuxi poter4al deaths of their parents.Thank you for your support, Slwnnon Kiibry fttlrtict Desirver lro>vt1 t, bu rl c5'1t7Ct'I ly+� hi..I.IdArr Ev..'Mfivo 1'rttQrlr)Lyon 4A� Fittzrttrurl CetatrPaarrt (:..iy S tdrr Barbffi; Bysick .•31to+ury Executive Director BO Rn OF ADVISORS Ehrr.q.md A?Balogh i-lizabt rt«11.r Williwn F'Broh? ji:.;Iir&Pker Card and the'Nil ft i.80rt IVILLW MAE AND JOHN MARSHALL TYLE a SUILDINQ7 2086 C.C)MMEACE q%(ENUE (ONC0,11D, CA 94520 e925) 827-0219 FAX(9PS)8PT) 19?2 a�"d V69 :/-O 66—Z-0—Z>"C3 Aprjl 24, 1998- DRUG CZAR.STATEME... EXCHANGE AND MINORh'ft .k)k**AM1W"fif SedrugpoIicy.gov/news/press/1998/042498.htmi FOR IMMEDIATE RELEASE Contact: Bob Weiner, 202-395-6618 April 24, 1998 DRUG CZAR STATEMENT ON NEEDLE EXCHANGE AND MINORITY COMMUNITIES Washington, D.C. -- Director of the Office of National Drug ' Control Policy Barry McCaffrey released this statement on needle exchange and minority communities in response to a press conference held by certain Congressional members held today: Il "Needle exchange programs are almost exclusively located in disadvantaged, predominantly minority, low income neighborhoods. You find needle exchanges in Compton,not on Rodeo Drive. These programs are magnets for all social ills--pulling in N: crime, violence, addicts, prostitution, dealers, and t gangs and driving out hope and opportunity. The overwhelming likelihood is that the burdens of any expansion in needle exchange programs will ! continue to fall upon those already struggling to get by. Minority communities and their representatives 1;s F should exercise great care before issuing a blanket endorsement of these programs. If you're a parent already fighting to bring your children up right and protect them from drugs,you have to ask: "Do I want one of these programs on my corner or near my child's school?" If you're a minister, trying to administer moral guidance and keep faith alive against real odds,you have to question:, "Do my parishioners need to face greater temptations and evils?" If you're a businesswoman, you have to think: "Do I want my clients to have to run the gauntlet of drugs and crime to get into my shop?" For me the right answer is: "I'm fighting to get drugs off my streets." Search ( Site Map I Contact ONDCP I Related Links Flash (Other ONDCP-Sponsored Sites j Horne CTAC I Drug-Free Communities I HIDTA Privacy Policy I of 1 12/10/1999 10:23 AM Statistical Assessment Service(a Washington,D.C.based think tank that inte"pmts sfatistical and scientific data for journalists),the Montreal study is one of the"Mon sophisticated yt+t" Dr.Murray has also opined that"tete better the study design,the less convincing the evidence that clears needle giveaways protect against HIV," Dr.Murray's tudst recent column on the subject Brom the Wall Street Journal is also attached. Needle-exchange programi,to the extent they involve injection of so-called"black-tar', heroin", may exacerbate other public health problems as well. According to Dr,Murray, a recent article in Journal of the American Medical Association(JAMA)warned that "black-tar heroin",which is cut with dirt and shoe polish,is spreading"wound botulisd, a potent toxin that leads to paralysis and a particularly agonizing death,evert when in.ice(cd with a clears needle. If(lie public health value of"needle-exchange"is murky,the public Way of nv4uences of needle distribution programs are unhappily very,very clear. Needle-exchange programs tactually encourage and enhance dmg trafticking by adding value to that illegal , commerce. In other words,if one person has five needles from the needle-exchange program,and no dope;while the mood person has dope but no needles,a btttiiness- tr nsacction is in the offing. Dr.James Curtis,professor of psychiatry at Columbia( University,and director of psychiatry at Harlem Hospital has alluded to this issue its a New York Times article, which is also attached for your review. Needle-exchange programs adversely affect communities that are themselves in a ftgile public safety status. As Dr.Curtin has painted out,needle-exchange programs become the magnet for not only addicts,but for dealers as well. Used needles literally litter the sidewalks and allays in neighborhoods that are the sites of needle-exchange.programs, These programs,of course,take place in precisely the neighborhoods that don't:feed yet 3 an additional inftWon of addicts and drug dealers—and whose children don't need to be cxposed to an additional infusion of needles into their daily lives(the prospect of a child v irking themselves with one of many abandoned needles is truly horrifying). At a time ti+hen law enfarceamett is foCus#ng on quality of life issues in those fragile neighborhoo4 the injection of a needle-exchange program into one of arose communities Is.bad public Safely policy. Needle-exchange programs place government in a very ambiguous position. On one hand, government is engaging in drag enforcement efforts,focusing on drug education progratrts to keep children off illegal drugs, using screening mechanisms to discover past iIlcgtel drug use among government and judicial applicants;while on the other hand,AB 18 would put local governments in the business of distributing the very instrumentality or illegal drag use! Can n o e spell"mixed message"? '. Ilrc public safety Issues have profound implications for law enforcement and for neighborhood safety. Additionally, the Montreal and Vancouver studies suggest the possibility of a very bard public health result. It is axiomatic that if the results of the Montreal and Vancouver studies are;replicated anywhere in California.the rascal and !social costs of needle:exchange could be staggering. The California Narcotic Officers'Association opposes needle exchange and respecUUlly roquests your veto of Ala S 18. .S.tuCexe Jahn Lovell Legislative Counsel Cxlitorala Narcotic Officers' Association Cattf ornta Parcotic ictre Zlzoriattoa 28245 AVENUE C.AWKER DTPs 230-4ALENCIA,CALIFORINIA 91355-1201 (idle)"S 0080•FAX(161)MAW W President nt CHRISTY MaCAMP►PlEU SNE Son k" i at Vice Pretatetsnt WALT ALLEN August 24, 1999 ONE Granges vera President G taltl?Est}} GARY Honorable;Gray Kavas G Soft JQaQuen D.A. Governor of the State of California 3rd vise Ptasidont Sacramento, CA 95814 EC MANAVIAN 004 L.A,C1401191t0uae Dear Governor Davis; 4th W4 Praaicint FLICK OULE# 'nit California Narcotic Officers' Association,which represents over 7,000 law DOPCRACNIT Sergaantlit AM$ Ctiforcenlent professionals throughout California,is strongly opposed to Assembly Bill MICHAEL KENNEDY 't)X, Assembly Sill 518 would permit so-called"needle-exchange"programs, Joining Bars tire:OWipo D.A,'a Office CNOA in opposition to this bill are the Association for Los Angeles Deputy Sheriff's,the Isxacu#rka oirattao C'ailirornia State Sheriffs' Association,the California Peace Officers' Association,and the ROBERT Ang " ,M(tit) California Police Chiefs' Association, T'he phrase"iiteae-exchange"is really a Lisa Angara,S.D.trot) General Counsel mi nomcr,since these programs typically involve needle dladbuti,not exchange. BRUCE WOLFt Van Nuys Historically,the debate on"needle-exchange"has been presented ass question of Director of Training wlicther public health policy will trump public safety policy;or whether the policy JAMES AUMOND OND determinations will be reversed. t MV4 Co.D.A.(rat) Airs Chsirvmn Emerging data suggests that this is a false debate. A recent paper published its the 371ng SLOi( AMERICAN JOURNAL Of EPIDEMIOLOGY(attached for our review)dealing with Los Angasea s.Cr.{sett �' +� conference chairperson needle-oxchange programs in Montreal suggests that nadlc-exchango programs are not a MICHAEL GUY freestanding strategy in combating IRV. According to the author of thesis study, lir, Julia Los Angel"P.M(rei) llruiwau,of the University of Montrtarl Department of Psychiatry, "ride elevations for Legislative Chairperson HIV infection associated with NEIL'attendance were substantial and consistent In all three ROBERT ANISo a smcisw risk tassessmont scenarios in[the]Cohort of Injection drug hers,despite extensive teNe Son�ra�c+tip R&y.a. 1, ari_iustmem for cofounders, In summary, in Montreal NXP users appear to have higher THOMAS GALLA13MER seroconversion rates than NEP nonusers"(emphasis added), fan trte:tsK,S.tJ, Region It Chatrperacn I Iinvi spoken personally with Dr.lsrutwau about her study,since it tars been the subject TONY SIDLEY of so match controversy. She indicated that the success or failure of needle-exchange aLEDNET programs(fttxl a public health perspective)is dependent on the supporting variables that Region tit Ghalrpsrson arc constructed uouitd the ro asst, 71du Ili Ill its one of the problems with AA 518 WILLIAM GARVkY p � � ,� DONINe Los Angles Ala �IS is reit open-ended authorization for local governments to embark on necdlew Rion Iv chalrperaen c\ch ng,e programs, As such,it is devoid of any language mandating whatever supporting JOSEPH KENNEY i ar+,iblos that could help pruvult a public health failure of a program—'w happcnod its DOJ113NE San Diego Monirctll, In other words,there is no gW'xt`anwe that a needle-exchange program Rergian v Chatrpe+ron a ti i torized pursuant to AB 518 won't result in the type of public health disaster than was JoBEI'H 1tH l+ ood in tho Montreal study there is a second stud of the needle-exchange program in 1=sit♦rtGn P.D.P.o. �'( y 8 �' S Resgron yr chairImmon Vancouver which showed similar unfortunate results,so,it is clear than the Montreal BLUR SUMMEY o.xorivtice was not an aberration). Sirni Vedley P.D, Region vii chatrtiersois FN cn allowing for the caveats of the.Montreal study, it raises disturbing questions about JOHN VALA Fraanv S.D. 1130 public health efficacy of needle excliatige programs as a strategy to combat HIV.V. At Region Vile cheirperaon the very least,it suggests that the proponents of needle-exchanges have not met their ERIC NP49R Nndezi of proof. Further,according to David Murray,Director of Research for the Shasta S.D, Imt"Mta%Past Praadent OMAN Pr1CAULEY Riva*"R 0,(Pied) "FOR BET'MA NARCOTc ENFORcFww r DWI N>edie Exchange Update 4/I9/98 http://www.DrugWatch.arg/Documents/JLNeedles498.htmi 26. The Boston Globe, May 22, 1997. 27. Edlin BR et al, The New England Journal of Medicine 331:1422-7, 1994.28. The Hartford Courant, March 11, 1997. 29. Standard Times, November 6, 1996. 30. Satel, Sally, Wall Street Journal, January 6, 1998. 31. Letter from Dr. Curtis to Reverend Edgar L. Vann, April 11, 1996. Curtis JL, National Press Club,' August 20, 1997. Curtis JL, The Black Leadership Commission on AIDS, June 4, 1997. of 5 12/07/1999 1:49 PM DWI Needle Exchange Update 4/19/98 http://www.DrugWatch.org/Documents/JLNeedles498.htmI discontinued since they are not safe or effective and since they result in increased drug use and HIV/AIDS. References References 1. Weibel WW et al,J. AIDS and Human Retrovirology 12:282-289, 1996. 2. Bruneau J et al, American J Epidemiology 146:1007-1010, 1997. 3. Hurley SF et al, The Lancet 349:1797-1800, 1997. 4. Strathdee SA et al, AIDS 11159-1765, 1997. 5.The Public Health Impact of Needle Exchange Programs in the United States and Abroad,U. Cal,1993. 6. National Research Council/Institute of Medicine, Preventing HIV Transmission the Role of Sterile Needles and Bleach,National Academy Press, Washington DC,p. 302-304, 1995. 7. Bruneau J et al,American J Epidemiology, 146:994-1002,1997. 8. DesJarlais D et al,Lancet348:987-991, 1996. 9. Heimer K et al,American Journal of Medicine 95:214-220, 1993. 10.BBruneau J et al, American Journal of Epidemiology 146:1007-1010, 1997. 11. Grove D, The Harm Reduction Coalition„NYC, Harm Reduction Communication, Spring 1996. 12, Ehrenfeld, Rachel, Insight, December 29, 1997. 13. The New York Times Magazine, October 15, 1997. 14. British Columbia Report,August 1997. 15. USA Today 5/21/97. 16. Watters JK et al, Journal of the American Medical Association 271:115-120, 1994. 17. The Boston Globe "Overdoses swamp San Francisco ERs" February 1, 1998. 18. The Washington Post 4/24/97. 19. The New York Times 8/18/96.20. Boston Globe 1/10/90. 21. The Boston Globe 8/5/93. 22. The Boston Globe 8/2/33:23 The Boston Globe Magazine 6/8/37. 24 Final Report: First Year of Pilot NEP in MA, The Medical Foundation, .Boston, October 1995.25 Epiderniologic Trends in Drug Abuse, Community Epidemiology Work Group,National Institute on Drug Abuse, .Tune 1997, p.21-23. 4 of 5 12/07/1999 1:49 PM .......... . ... ..... DWI Needle Exchange Update 4/19/98 http://www.DrugWatch.org/Documents/JLNeedles498.ht since 1988 when the NEP started. Now Vancouver has the highest heroin death rate in North America, and is referred to as Canada's "drug and crime capital."xviii(18) The 1997 National Institutes of Health Consensus Panel Report on HIV Prevention praised the NEP in Glasgow, Scotland, but the report ignored Glasgow's massive resultant heroin epidemic. Currently,as revealed in an article entitled "Rethinking 'harm reduction' for Glasgow addicts," Glasgow leads the United Kingdom in deaths from heroin overdose, and the incidence of AIDS is rising.xix(19) In Boston, illegal NEPs were encouraged after the well-known, long-time needle provider Jon Stuen-Parker was acquitted in 1990 amidst much media publicity.xx(20) Then in July 1993,NEPs were legalized, and the city became a magnet for heroin. Logan Airport has been branded the country's "heroin port;"xxi(2 1) Boston leads the nation in heroin purity(average 81%); and heroin samples of 99.9%are found on Boston streets.xxii(22)Boston now has the cheapest,purest heroin in the world and a serious heroin epidemic among the youth.xxiii(23)The Boston NEP was supposed to be a "pilot study" but there was no evaluation of seroconversion rates in the addicts nor of the rising level of heroin use in the Boston area.xxiv(24) Similarly, the.Baltimore NEP is praised by those who run it, but the massive drug epidemic in the city is overlooked. For instance, the National Institutes of Health reports that heroin treatment and ER admission rates in Baltimore have increased steadily from 1991 to 1995. "At one open-air drug supermarket(open 9 a.m. to 9 p.m.)customers were herded into lines sometimes 20 or 30 people deep. Guarded by persons armed with guns and baseball bats, customers are frisked for weapons, and then allowed to purchase$10 capsules of heroin."xxv(25)Baltimore's mayor Kurt Scchmoke is a pro-drug legalizer on the Board of the Drug Policy Foundation. He favors not only NEPs but also heroin distribution.xxvi(26) Any societal intervention which encourages drug use will also result in increased AIDS rates.It is important to note that needle sharing is not the only way drug users are infected with AIDS since they are at high risk for acquiring AIDS sexually through promiscuity or prostitution. For instance,a study of non-needle using NYC crack addicts showed a high incidence of HIV/AIDS.xxvii(27)Addicts often fund their addiction through prostitution and trading sex for drugs. Furthermore, addicts commonly support their habit by selling drugs to other addicts, and by recruiting new addicts. They target the youth, often providing free samples and free needles to hook their clients.By enabling addicts to stay addicted,NEPs serve to increase the numbers of new young addicts. Recently, many communities have been attempting to defeat these NEPs before they start or to close them once they have started, In Willimantic, Connecticut, community opposition to its NEP arose as many discarded needles were observed along with increased open drug use. One man,having received needles from NEP, fatally overdosed after his friend unsuccessfully tried to get help from the exchange. Also, a toddler was stuck by a needle discarded near the NEP which was finally shut down.xxviii(28) In New Bedford, Massachusetts,there was a referendum, and the people voted down NEPs by a margin of over 2-1.xxix(29)A 1997 survey done by the Family Research Council found that Americans overwhelmingly oppose NEPs,and believe giving an endless supply of needles to drug addicts is irresponsible, representing an official endorsement of illegal drug use which encourages teenage drug use. Rather Than Encourage Drug Use,Treatment Should Be Mandated By providing needles to addicts,NEPs enable the addict to continue self-destructive illegal behavior. With regard to treatment outcomes,NEPs should be compared to mandatory treatment programs,such as drug courts, which serve to force addicts into treatment whether they are "ready" or not. An addict under the influence of a mind-altering drug does not think clearly and may overdose before he/she ever concludes that treatment is the best choice.Indeed,most persons in treatment are there because of an encounter with the criminal justice system,and studies show that involuntary treatment works as well as voluntary treatment. Thus addiction specialist Dr. Sally Satel writes that"For Addicts, Force is the Best Medicine."xxx(30) Even worse is the fact that,as pointed out by addiction expert Dr. James L. Curtis, NEPs often serve to lure recovering addicts back into injecting drug use.xxxi(3 1) Since outreach/education programs and mandatory treatment programs are safe and effective in preventing both drug use and HIV/AIDS, these programs should be encouraged and funded. NEPs should be 3 of 5 ......:.............................................:::.1,7.../..l}.7..1toQ9 7 df P7..« I>tiV1 Needle Exchange Update 4119/98 http://www.DrugWatch.org/Documents/JLNeedles498.htmi in different populationsviii(8) or the New Haven study which was based on a mathematical model of anonymous needles,ix(9) Some authors have suggested that the increase in HIV in NEP users in Vancouver and Montreal is because NEPs attract high-risk IVDUs. If this is true, then most IVDUs are at high risk, since 92% of Vancouver IVDUs used the NEP. However, an alternative hypothesis was posed by the authors of the Montreal study who postulated that NEPs may serve to facilitate the formation of"new [needle] sharing groups gathering together isolated IVDUs."x(10)This evidence is supported by information that NEPs serve as buyers' clubs and facilitate drug use. Pro-needle activist Donald Grove has written, "Most needle exchange programs actually provide a valuable service to users beyond sterile injection equipment. They serve as sites of informal (and increasingly formal) organizing and corning together. A user might be able to do the networking needed to find good drags in the half an hour he spends at the street-based needle exchange site--networking that might otherwise have taken half day."xi(11) By cutting down on the search time, i.e. the time necessary to find drugs, an addict again is able to inject more frequently, resulting in increased drug use, dependency, and exposure to HIV/AIDS through needle sharing or sexual behavior. Facilitation of Drug Use Leads To Rise In Cocaine and Heroin This facilitation of drug use, coupled with the provision of needles in large quantities, may also explain the rapid rise in binge cocaine injection which may be is injected up to 40 times a day. Some NEPs are actually encouraging cocaine and crack injection by providing so-called "safe crack kits" with instructions on how to inject crack intravenously.xii(12) This increases the addict's drug dependency and: irrational behavior, including prostitution and needle sharing. In some NEPs, needles are provided in huge batches of 1000, and although there is supposed to be a one-for-one exchange,the reality is that more needles are put out on the street than are taken in. For instance,on March 8, 1997,Nancy Sosman of the Coalition for a Better Community, NYC, accompanied by a reporter from the New York Times visited the Manhattan Lower East Side NEP requesting needles.xiii(13)Even though they had no needles to exchange and were not drug-users, they were promptly given 60 syringes and needles, little pans for cooking the heroin,instructions on how to properly inject drugs into their veins, and a card exempting thein from arrest for possession of drug paraphernalia. They were told that they did not need to return the needles. This community has requested that the NEP be closed. NEPs also facilitate drug use because police are instructed not to "harass" addicts in areas surrounding these needle programs. Addicts are exempted from arrest because they are given an anonymous identification code number. Since police in these areas must ignore drug use, as they are instructed not to "harass" these program participants, it is no wonder drug addiction is increasing. In Vancouver, Lynne Bryson, a Downtown Eastside resident, notes that large numbers of addicts visit the exchange,pick up needles, and "shoot up" nearby. She has watched addicts buy heroin outside the NEP building "and inject it while huddled against buildings in nearby alleys."xiv(I 4)As the presence of law enforcement declines in these areas, it is not surprising that the supply of drugs also rises,with increased purity and lower prices. This also serves to hook new young users. With addictive drugs, increased supply,creates increased demand. Surprisingly,the response in both Vancouver and Montreal to the above-mentioned reports was to increase the amount of needles provided. Many drug prevention experts have long feared that the proliferation of NEPs,now numbering over 100 in the US, would result in a rise in heroin use, and indeed,this has come to pass.This rise in drug use was ignored by all the federally-funded studies which recommended federally funding NEPs. The National Center on Addiction and Substance Abuse at Columbia University reported August 14, 1997 that heroin use by American teens doubled from 1991 to 1996. In the past decade, experts estimate that the number of US heroin addicts has risen from 550,000 to 700,000.xv(15) A 1994 San Francisco study falsely concluded that there was no increase in community heroin use because there was no increase in young users frequenting the NEP.xvi(16) The rising rate of heroin use in the community was not measured, and the lead author,needle provider Jahn Watters, was found dead of an IV heroin overdose in November 1995. According to the Public Statistics Institute,hospital admissions for heroin in San Francisco increased 66%from 1986 to 1995.xvii(17) In Vancouver,heroin use has risen sharply: deaths from drug overdoses have increased over five-fold 2 of 12/07/1999 1:48 PM ............ DWI Needle Exchange Update 4/19/98 http://www.DrugWatch -org/Documents/JLNeedles498.htmI DRUG WATCH INTERNATIONAL P.O. Box 45218 Omaha,Nebraska 68145-0218 (402) 384-9212 (402) 397-9924 Fax NEEDLE EXCHANGE PROGRAMS: 1998 REPORT By Janet D. Lapey, MD April 1998 Needle Exchange Programs Have Not Been Proven To Prevent HIV/AIDS Outreach/education programs have been shown to be very effective in preventing HIV/AIDS. For instance, a Chicago study showed that HIV seroconversion rates fell from 8.4 to 2.4 per 100 person-years, a drop of 71%, in IV drug addicts through outreach/education alone without provision of needles.i(1)Needle exchange programs (NEPs) add needle provision to such programs. Therefore,in order to prove that the needle component of a program is beneficial,NEPs must be compared to outreach/education programs which do not dispense needles. This point was made in a Montreal study, which stated, "We caution against trying to prove directly the causal relation between NEP use and reduction in HIV incidence. Evaluating the effect of NEPs per se without accounting for other interventions and changes over time in the dynamics of the epidemic may prove to be a perilous exercise."ii (2)The authors conclude, "Observational epidemiological studies.....are yet to provide unequivocal evidence of benefit for NEPs." An example of this failure to control for variables is a NEP study in The Lancet which compared HIV prevalence in different cities but did not compare differences in outreach/education and/or treatment facilities.iii(3) Furthermore, recent studies of NEPs show a marked increase in AIDS. A 1997 Vancouver study reported that when their NEP started in 1988, HIV prevalence in IV drug addicts was only 1-2%,now it is 23%.iv(4) HIV seroconversion rate in addicts(92%of whom have used the NEP)is now 18.6 per 100 person-years. Vancouver, with a population of 450,000, has the largest NEP in North America, providing over 2 million needles per year. However, a very high rate of needle sharing still occurs. The study found that 40% of HIV-positive addicts had lent their used syringe in the previous 6 months, and 39% of HIV-negative addicts had borrowed mused syringe in the previous 6 months. Heroin use has also risen as will be described below. Ironically, the Vancouver NEP was highly praised in a 1993 study sponsored by the Centers for Disease Control.v(5) The Vancouver study corroborates a previous Chicago study which also demonstrated that their NEP did not reduce needle-sharing and other risky injecting behavior among participants.vi(6)The Chicago study found that 39%of program participants shared syringes vs 38%of non-participants; 39%of program participants "handed off' dirty needles vs 38%0 of non-participants; and 68% of program participants displayed injecting risks vs 66% of non-participants. A Montreal study showed that IV addicts who used the NEP were more than twice as likely to become infected with HIV as IV addicts who did not use the NEP.vii(7)There was an HIV seroconversion rate of 7.9 per 100 person years among those who attended the needle program,and a rate of 3.1 per 100 person-years among those who did nota The data was collected from 1988-1995 with 974 subjects involved in the seroconversion analysis. There was a cumulative probability of 33%HIV seroconversion for NEP participants compared to 13% for non-users. It is important to note that the Chicago, Montreal, and Vancouver studies followed the same group of addicts over an extended period of time, measuring their seroconversion from HIV negative to HIV positive. This has not been the case in previous studies which have purported to show the success of NEPs, such as a New York study which combined results lof5 �­........ .........I............. ... ....... It is to be hoped that the Board of Supervisors will arrange for more comprehensive discussion of a life-and-death mater like needle exchange than can be provided by assigning the matter as a Tuesday meeting agenda Item on just the prior Thursday and permitting only a single day's brief response before acting—and all of this as most citizens are preoccupied with the Christmas season rush of shopping, social engagements, and religious functions. It is further to be hoped that Supervisors will refrain from turning their response to these comments into a personal attack, or a silly and misdirected class-warfare lecture, as was my experience when I spoke in 1995 on the needle-exchange issue—and as has recently been the experience of Ernie Scherer when he came to speak about library-tax issues. Finally, I request that the local press, instead of trumpeting misleading and outright false interpretations of the available data and research in a he said/she said format, instead report the facts: AIDS cases in Contra Costa County are sharply down in all categories, including cases among injection drug users--- and significant research indicates that needle-exchange programs will make things worse, not better. QUESTIONS 1. Q. What about dirty needles left lying around in parks where kids can get to them. Won't needle- exchange programs diminish that problem? A. No. Go back and read Nancy Sosman's letter on p. 5. Needle exchange programs merely exacerbate the overall problem. Z. Q. What about HIV infection of spouses? Won't a needle-exchange program diminish such problems? A. Again, no. The question assumes that needle exchange is in fact an effective means of reducing HIV infection rates. Available data does not support that conclusion. In fact, needle exchange is clearly iatrogenic. That's a physician's four-bit term for a "cure"that's worse than the disease. 3. Q. You say that MEPs facilitate illegal behavior. But in a figurative analogy, isn't it reasonable to jaywalk in order to push someone out of the way of an onrushing truck? A. On several levels, the analogy doesn't apply to needle exchange. The rescuing jaywalker isn't tax supported. His intervention doesn't enable, facilitate, or subsidize destructive behavior. The injection drug user assumes two metaphorical roles in the analogy: he/she is both the individual in the middle of the road and the truck driver. Finally, when an individual engages in a pattern of systematically self- destructive behavior, he/she should be restrained, not assisted in continuing the destructive behavior. 4. Q. Isn't it better that some people wind up in jail or sued so that others don't wind up in a morgue? A. Again, a false dichotomy is assumed. The question posits the incorrect notion that needle exchange programs provide effective prophylaxis in battling AIDS. They do not. 5. Q. Doesn't methadone treatment as a substitute for heroin suggest the benefit to be derived from using needle-exchange as a means of contacting injection drug users and enticing them into treatment? A. Methadone is hardly a panacea. There are serious questions about its long-term effectiveness. And let us not forget that methadone is a hopeful means of interrupting the cycle of dependency. It does not enable, facilitate, or subsidize the very behavior we hope to suppress. Methadone doesn't help advance a hidden agenda, i.e. drug legalization. By the way, an even more effective substitute drug, levo-alpha acetylmethadol (LAAM) is sometimes used in place of methadone. 6. Q. So haw should we deal with the problem of drug abuse and AIDS transmission? A. The answer, in part: full reporting and contact tracing,teaching clear standards of right and wrong, re-stigmatizing self-destructive and societally harmful behaviors; changing the incentives back to a common-sense approach that rewards responsible behavior and punishes irresponsible behavior. The "manual" insists that"drug use" should not be stigmatized as"addiction," and that instead of identifying the"client" as "impaired, ill, in denial, nor/-compliant," he/she should be regarded as "sovereign,competent, functional." Instead of drug abstinence,the goal of the "client" should be "harm reduction." The'proper role of the"provider" is to offer"holistic understanding" "provide alternatives and assist client in uncovering authentic self and in identifying new d'irections'." Another important objective is "humanizing and `normalizing' drug users." Among the organizational objectives: "Work with existing community groups to establish credibility, "Pressure city officials to declare a state of emergency"; "Do exchange as a civil disobedience"; "Support Drug Policy Foundation and others in support of NSE [needle-syringe exchange].n5 In other words, behind all the psychobabble lies a tunnel-visioned determination to push drug legalization upon society at large. An illustration of the attitude was a'comment made by one of the addicts attending a Pittsburg community meeting on NEP'I visited in 1995: "We have a right to keep our habit clean." Endnotes, This Section Only: 1. School of Public Health, University of California at Berkeley and Institute for Health Policy Studies,University of California at San Francisco: The Public Health Impact of Needle Exchange Programs in the United States, Prepared for the Centers for Disease Control,issued October 1993. 2. "About the Drug Policy Foundation,"A Statement of Policy on the Organization's Letterhead,undated. 3. Otto Moulton, ©rug Watch fntemational,An Update. 4. The Drug Policy Letter(Washington,D.C.:The Drug Policy Foundation),22 Spring 1994. 5. "Harm Reduction Working Group"(San Francisco, CA 94107: P.O.Box 77248), undated paper. Vlll. Reductio Ad Absurdum After all, if the ostensible objective is public health, and clean needles for addicts is supposedly a well- documented approach, why not go all the way? Since improper use of syringes--even clean ones--can result in septicemia and other dangerous conditions, how about providing professional injection training, and a nurse or physician to perform intravenous injections for those unable to"shoot up"'properly themselves? And isn't it true that permanent disabilities, even fatalities, occur rather commonly because of impurities found in street-grade psychoactive substances? Why not brew up the pure stuff in county health laboratories, and trade reagent-grade material for the adulterated junk that victimizes local addicts now? With any luck at all, we can begin to approach the statistical performance levels of the needle-exchange program begun in Zurich's Platzspitz Garden in 1987. Initially serving "only"a few hundred"clients"a day, the program eventually drew almost 20,000 regular users (including an estimated 5,000 foreign nationals) to Zurich's very own Needle Park. Platzspitz also became a mecca for international drug marketers and common thieves. And Zurich's chief medical officer reported that his staff was resuscitating an average of 12 people a day in the park-- just before Zurich's city fathers voted to move the drug bazaar up the street to the abandoned Letten Train Station, early in 1992. The entire scandalous,mess was finally closed in February, 1995. IX, In Conclusion Isn't it obvious? We should not be enabling, facilitating, or subsidizing ILLEGAL behavior we say want to suppress. County supervisors should forget"harm reduction" and follow the prime directive of physicians instead: FIRST, DO NO HARM. Needle-exchange programs violate that directive, insult common sense, and overlook or ignore a significant body of research and anecdotal experience. V. Public Funding and Facilitation of Needle-Exchange Programs Leaves the County Exposed to Civil Liability for Harm That Develop from NEPs. It is my understanding that the California Narcotics Officers'Association is developing or has already developed a letter giving examples of the numerous instances in which local jurisdictions are likely to be held civilly liable for NEP-connected problems, ranging from needle sticks by children who find County-provided needles to overdose and A€DSdeaths among addicts Who congregate at NEP sites for the false reassurance they provide. . Vl. At Least Some Organizations Cited in Today's Proposal as Favoring NEPs Are Compromised An example is the American Public Health Association(APHA), cited by some as source of objective information on needle-exchange programs, is itself a compromised entity. The April, 1995 edition of its newsletter reported on a March briefing it co-sponsored with the Drug Policy Foundation, an organization which supports generalized drug legalization. V11. The Endgame is Drug Legalization A report compiled for the federal Centers for Disease Control', repeatedly cited by needle-exchange proponents, was not been officially released by the CDC, but rather by the Drug'Policy Foundation, a well-funded Washington lobbying group allied with ACLU, the National Organization for the Reform of Marijuana Laws(NORML), and other entities which seek to overturn U.S. restrictions on possession and use of controlled harmful substances. Participants in DPF's November, 1992 Media Strategies Workshop were told, "Never take an open legalization position. Change the image and build credibility. After you do this, you can say whatever you want and people will believe you." DPF's Spring, 1994 newsletter advised readers to "Emphasize the refreshing sanity of Cir. Elders as contrasted with the insanity of the drug warriors."4 The euphemism of choice for needle distribution and related schemes is "harm reduction." In October 1993, a so-ca#led "National Harm Reduction Working Group" met to"examine the relationship of harm reduction to needle-syringe exchange." Discussion included whether to include the organization as "a body of the North American Syringe Exchange Network (NASEN), a body of the Drug Policy Foundation (DPF), or as a separate entity." The third option was chosen. Listed "contributors" to the working paper that emerged from the 1993 meeting included the following: Dan Bigg Chicago Recovery Alliance George Kenney AIDS Action Coalition, Boston Ricky Blumenthal, Alameda County Exchange, Oakland Sara Kershar S.F.Harm'Reduction Working Group George Clark Harm Reduction Working Group, S.F Lisa Moore San Francisco Renee Edgington Clean Needles Now, Los Angeles Dave Purchase Point Defiance AIDS Project,Tacoma Heather Edney Santa Cruz Needle Exchange I Joyce Rivera-Beckman St.Ana's Harm Reduction, Bronx Delia Garcia S.F. Public Health Dept., AIDS Office Edith Springer Harm Reduction, Manhattan & N.J. Mark Girse Lower East Side, New York Imani Woods Street Outreach Services, Seattle Jon Hammond Prevention Point, Philadelphia Kevin Zeese Drug Policy Foundation, Wash. D.C. The working paper was proposed as "a manual to assist communities and programs in implementing and expanding needle-syringe exchange and other harm reduction programs." in a section entitled "Larger Issues," the real objective of needle exchange schemes was articulated: "Harm reduction can and must occur at all levels of society,if the representation and criminalization of drugs and drug use is to be addressed.'' `Chose working in harm reduction can and do lobby against the criminalization and incarceration of users and for the legalization of drug paraphernalia." 4 .......... IV. Noodle Exchange Programs Wreck Communities The real-world experience of Zurich (and other communities) suggests that needle-exchange and the winking, laissez-faire outlook at drug-use that tends to develop in conjunction or as a direct result of such programs is harmful to law and order: ZURICH --.,.The unraveling first began in February 1992 when the city elders sent squads of police officers to close down the central Platzspftz public park,where thousands of addicts and dealers congregated to transact their business for at least two years. The action, however, merely moved the market a half-mile up the road to a disused railway station called Letten,where the drug market thrived on Europe's most liberal drug laws, on the alienation of the young, and on the very affluence that makes the city so beloved of its bankers.... In the effort to prevent the spread of AIDS the authorities readily provided new clean syringes in exchange for used ones, as they still do at many shelters for addicts in the city.... [O]nly about one-fifth of the addicts came from Zurich while the rest came mainly from among the 30,000 addicts elsewhere in Switzerland. (Cowell,A: "Zurich's Open Drug Policy Goes Into Withdrawal," New York Times international, March 12, 1995) CBS News reported the closing of Platzspitz on January 29, 1992: "When the city fathers took a picturesque park in the heart of Zurich and turned it into a free-fire zone for shooting up drugs, they thought they had contained a relatively small problem. Instead,they created a nightmare. In the past two years, Zurich's Needle Park has become a magnet for addicts and pushers from all over Europe. Drug use has exploded....Zurich now has the worst AIDS problem in Europe. "Fenton/Haiderman/Needle Park—Evening News,"CBS News Transcript,January 29, 1992 Needle exchange programs are beginning to destroy neighborhoods in the U. S. as well. Nancy Sosman said as much in a letter to the New York Times (appeared Dec. 6, 1994): Needle Exchanges You can receive your government. sponsored clean noW161 (there is no Destroy Neighborhoods limit to the number),rob and Aes)to get money for drugs (or sell Your To the Editor: clean needles),buy cocaine In store, Ro your Nov.20 front-page articla fronts or heroin on any corner,then on the decrease In human Immuno, -leave, behind a pool of blood. dirty deficiency virus infection among ad- syringes. glassine bags, alcohat dints in New York's noodle exchange swabs and battle caps, the debris of programs: deprived indifference. Ever tine* the Lower East Side The needle exchange piogram has Harm Reduction Cantor, a noodif legitimized drug use on the Lower exchange program,began operating East Side and by Its tacit approval In an storefront In a residential popes has invited a population of predators lation of working poor,<ourvommu,- into our community.statistics on the pity has witnessed drug abuse not spread of AIDS cannot be the only seen since Operation Pressure Point criteria for measuring the success of cleared the area of drugs In the the program. NANCY SOSMAN 19901L Now York,Dec. 1.119.4 Needle exchange Is a link In a The writer is a member at Commu- chain called "ono-stop shopping." nfty Board 3, And Director of the Office of National Drug Control Policy Barry McCaffery has observed that "Needle exchange programs are almost exclusively located in disadvantaged, predominantly minority, low income neighborhoods. You find needle exchanges in Compton, not on Rodeo Drive. These programs are magnets for all social ills—pulling in crime, violence, addicts, prostitution, dealers and gangs and driving out hope and opportunity," (statement attached to this packet) Air ......... These findings are not surprising to those who have paid attention to the details of needle-exchange research, without a predispositive bias in favor of NEPs. In 1995,when taxpayer-funded needle exchange was last proposed to the Board of Supervisors, I celled attention to some of the information buried in the volume then cited as a principal source of support for needle-exchange programs. Entitled The public Health Impact of Needle Exchange Programs in the United States and Abroad, the book included these findings : Page 349: 21 of 99 drug users who were not regular injectors stated they would start injecting if sterile equipment were readily available. Page 44: Needle sharing remains a ritualistic behavior among injection drug-users. Page 233: Deborah Frazier-Mowze of the Black Leadership Commission on AIDS observes that needle-exchange programs do not get clients into drug abuse treatment; further, says David Fleming, injection drug users are not in treatment because their do not want to be there. Page 387: Santa Cruz Police Chief Jack Bassett reported that the number of discarded needles near the needle-exchange program has increased substantially since its opening, even though the program is a "one for one" exchange. He believes the needle-exchange program drew dry- users from all over the city. - - - Page 324: "Several African-American community leaders described needle- exchange programs as`genocide.,,' Dr. Janet Lapey of Drug Watch International summarizes NEP research concisely and accurately. I have included one of her recent papers in this packet. iii. Needle Exchange Pro rams Send a Mixed Message Needle exchange programs, often euphemized as "harm reduction„ and hypothecated as a weapon in fighting AIDS transmission, are reminiscent of a former Surgeon General's impassioned call for"safer buffets." That same Surgeon General also wanted to outlaw tobacco but legalize cocaine. Contra Costa County's public health apparatus now once again proposes a parallel course -- implementing billboard regulations to limit tobacco and liquor advertising, a so-called "zero-tolerance" policy for tiring use in schools, a crackdown on liquor stores which sell to minors, and an aggressive campaign to encourage local municipal jurisdictions to enact ordinances which mandate smoke-free restaurants and workplaces -- even as the same health-care apparatus proposes to facilitate ILLEGAL and self-destructive injection drug use with a taxpayer-funded needle-exchange,program. Denying the fact, as this proposal does, will not change reality. As the California Narcotics Officers'Association observed in a letter to Governor Davis,copy attached: Needle-exchange programs place government in a very ambiguous position. One one hand,government is engaging in drug enforcement efforts, focusing on drug education programs to keep children off illegal drugs, using screening mechanism to discover past illegal drug use among government and judicial applicants;while on the other hared,AS 618 would put local governments in the business of distributing the very instrumentality of illegal drug use. Can anyone spell `mixed message'? Hepatitis Incidence by Count _Re ion, Januarythrough June, 1999 DISEASE Central County East County West County Hepatitis A 24 8 10 Hepatitis B, Acute 8 7 Hepatitis B, Carrier 66 30 75 Hepatitis C, Acute 0 0 1 Hepatitis C, Carrier 276 221 296 The incidence of Hepatitis,C Carrier status seems to have increased markedly after the introduction of needle exchanges in the County (1995), and now is distributed fairly equally throughout Its population centers. We may already be seeing a replication of Vancouver's results. (See below.) AGAIN, THE AVAILABLE DATA ARGUES AGAINST ANY EXPANSION OR FORMALIZATION OF NEEDLE EXCHANGE—IN FACT, FOR THE ENDING OF BOTH FORMAL AND"INFORMAL" NEP PROGRAMS. EXPENDITURE OF TAX DOLLARS FOR NEPs IS ESPECIALLY UNJUSTIFIED. it. Imi2ortant Research Results Argue Powerfully Against Needle-Exchange Programs Needle exchange is counterintuitive as an alleged remedy for injection drug use. And since 1995, when formai, taxpayer-funded needle exchanges were last proposed in Contra Costa County, research findings have become far more definitive in implicatingneedle-exchange programs as an apparent factor in INCREASING the rate of HIV and Hepatitis-C infection. An honest, comprehensive review would have included these facts: A. In an extensive Montreal study, infection drug users(IDUs)participating in a needl"xchana program PNEP)were mare than twice as likely to seroconvert — i.e., become HIV-infected as IDUs not participating in NEPs. There was a seroconversion rate of 7.9 per 100 person-years among individuals attending the NEP,versus a rate of 3.1 seroconversions per 100 person-years among NEP non-attendees. "Risk elevations for HIV infection associated`with NEP attendance were substantial and consistent"(Bruneau,J et al.,American Joumal of Eprdernic>logy 1997, 146:994-1002) B. When Vancouver initiated its needle-exchange program in 1988, HIV incidence among IDUs was only 1-2%. Now HIV prevalence is 23%,and Hepatitis-C prevalence is an astonishing 88%. The HIV seroconversion rate among the 92% of Vancouver IDUs who attend NE Is now estimated at 18.6 per 100 person years. Vancouver, population 46O,000,operates the largest NEP In Notch America. Additionally,there was little or not change in needle-sharing. 40% of HIV-positive IDUs had tent used syringes in the previous 6 months, and 39%of HIV-negative IDUs had borrowed used syringes in the previous'6 months. ( trathdee, S et al.,AILS 1997; 11 F59-F65) C. Not only do IDUs involved in NEPs continue their needle-sharing behaviors(above);the NEPs may In fact attract or develop new needle sharing networks.(Bruneau,J et al.,American Joumal of Epidemiology 1997; 146: 1007-1010) D. In contrast,outreach and education programs without NEPs are extremely effective In preventing HIV/AIDS. A Chicago study In volving outreach and education but NOT NEPs, demonstrated a reduction in HIV seroconversion rates from 8.4 to 2.4 per 100 person-ream,a drop of 71°!0.(Weibel, WW of a/., AIDS and Human Retrovirology 1996; 12:282-289) E. San Francisco hospital admissions for heroin addiction and/or overdose Increased 66% from 186 to 1995 after NEP introduction(Boston Globe, Feb. 1, 1998,citing the Public Statistics Institute); and NEP promoter John Watters, originally the lead on research often cited by the Contra Costa Health Services Department, died in San Francisco at age 47—of an overdose, not AIDS(Washington Blade, Dec. 81995). ............. . Here; then, is a summary of the available data for reported Contra Costa HIV infections. So far,the data is indeterminate regarding whatever affect the existing"Exchange Warps" needle-exchange program may,ice.having--- but it certainly does NOT validate the notion that there Is a "rapid an confitriri +Icat fign of HI1l'transmission among in ection drug users." A'Summary of"Recently'Detected HIV Infections" from County Health Services Reports Year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 ' HIV Positive Hetero IDUs 16 16 16 16 16 16 13 6 11 6 Hetero IDUs Tested 863 863 863 863 863 63 723 7610 379 318 Calculated, gives. . . . Note. Richmond Needle Exchange Initiated in 9995 Year1.9 1.9 1.9 1.9 1.9 1.9 1.8' 0.9 2.9 1.9 HIV} Hetero IDUs/100 Tested 1. 1.9 L 1.9 1.9 1 1.9 1.9 1.9 1,8; 0.8 2.9 1.9 NOTES: 1. For 1990096,the Identical numbers represent an annualized average--because Health Services' HIVIAIDS Epidemiology Reports combined the numbers for those years,and only the totals were available on short notice for this report. As is presently the County's practice,a given year's HIV test results are retorted from July of the 2Myious year throu,r, h June Xthe year shown in the chart. 2. The final row summarizes the available data In terms of HIV-Positive Heterosexual injection Drug Users among 100 heterosexual because other factors may be Involved among homosexual IDUs,and per 100 individuals tested because of varying numbers of tests conducted In succeeding years. 3. N Ing Dere -and nothing in the Heal rvices De rtment's re rt accom an in M 's proposal .- ustif9es the x na raced formalin anon of exlstin needle-axchar a ra s In Richm nd or piEtksbd And other factors,Including the already sharply diminished numbers of AIDS-case diagnoses summarized above,and the research mentioned below,argue strongly against even a continuationof the existing programs. 4. Data for 1999 is extrapolated from the mid year report. The drop-off in numbers tested during the last two years Is an interesting and perhaps alarming phenomenon,as is the possible Increase In presentations of an HIV-positive condition. See the comments on the developing Vancouver situation,Part It below. So far as I can tell from the available data any-postulated local relationship between lole(Alon-drun use and Hepatitis-C infections has not beer# quantified. The County's hepatitis data I've had time to locate can be found at the County's epidemiology website.[The site is hosted not by the usual county server but by the "Institute for Global Communications" at www.igc.ape.or-q/ccchdatalotherepLothcom.htmI In tura, IGC links to causes ranging from normalization of relations with Cuba to drug legalization(including the"Tides Foundation," distributor of s$1 million George Soros grant in 1997 to fund needle exchanges across the United States)]. Hepatitis Incidence in Contra Costa County(per www.igc.apc.org/ccchdatalotherep/0thcom.htmi) DISEASE 1993 1994 1996 1996 1997 1998 1999* '/ ear Hepatitis A 92 72 80 106 81 68 42 Hepatitis B Acute 4 17 6 12 24 18 19 Hepatitis B, Carrier 121 ' 113' 247 308 244 266 171 Hepatitis C,Acute 0' 0 O 6 4 6 1 Hepatitis C, Carrier 371 260 207 361 461 744 782 RECEIVED Contra Costa Supervisors Should Reject the Latest Needle cbgnge4Mg ' s t by Michael Arata — 12114199 CLExx A OFSitP Co, CE1hlTRA COSTA 1. The Contra Costa Health Services Department's awn Data Ar ues Against Needle Exchancle Today's needle-exchange proposal claims that "there is a rapid and rrtcreasin Iger epidemic rate of HIV and Hepatitis C transmission and infection among injection drug users in Contra Costa County"(p. 1) and that "the rapid and continuing escalation of HIV transmission among injection drug users"validates the declaration of a'°Public Health State of Emergency" (Health Services Dept., p. 4 ----emphasis added): But the Health Service Department's own published data does not support its contentions. The following two pages (respectively, pages 5 and 13)are reprinted from the Department's most recently published HIV/AIDS Epidemiology Report(August 1999). Annotative comments have been added for emphasis: a Conba Coffa Cdsmtr MWAIDS EskFMtbbBYJ7apM( {3 COMra Coate CcunH H1VIAIDS EAr±ftmWfoOv f2e,pM Total AIDS Cases Reported In Contra Costa through 7112199 Recal thnic)ty Distribution Heterosexual,Gay,and Female Injection Dr Diagnosed,AftAIDS Note sharp decline ftW*ftW AdalUatiofasGarttCates- ) PtalWtaoaaet(%) Tap((%?. Since,Ifre first years of the, - of AIDS diagnoses estate tial(31.3) 4 0&3) 11"(am AIDS s{udomlc in the county ea- 14.1erou.u.me 1 l•fou erf masingnumberofAIDSamong all categories Attim aAaan 596(29.!) 4(33.3) #00(w) cases are ffi*londrug users se,- —`o o.vmu.wsrmsr•0u ofinjection drug.users Laws 272(14.1) 4 M.3) ata(tad) (IDUs).nraunHy,IDUs make ibu ..... i+m.b up 27.1%(n-&W)of all the w- AsWVPtGftedsionear 3T(t.a) o(6) n(id) A10S cases dle,gnosed In Ina a ttOM Atnatiaanl Alaskan .9(0.4) o{0y... .919.) comb. The Lata aspnsaable se, In this ehtF and int table Tout. 1lW(m) #z(1C0) 29ad(l9H d"ity bet"felfaat AIDS Issas sa0n4aadMroughJvry+ �+; 12,1995. ,o_. V -This ranter 6N. ftrud•a geyfiuenlatlfwa{n+f{0)es of o. Age Distribution Year of Diagnosis 7n2'ae to a, to se, .t as At 00 of se, t: $4 as to sr es car (se.a au.NaaY�) a&-dar—) c'offaa MAO Data Ape Total I%) But this ea ac as .ae car as at 'ao si 42, e3 as 9e, riroapa Reached a high dropped t0 yleteretaaaeit29T) + .A f , a u. ,t ,f » nr ss se, e,3 ;ta. m t z .a a ta.41 62 cases is of 250 CC County se, o.r atau�(iiai o ,; x a. a s A z :e •se, t .'tr a r,a A a o 1-13 a(U.2) 1938,22 , AIDS !Vases pt.n w se, a a o o a 4 r is ,t ~ta 2+ is, w ",a is '1)' s 1f•<a T M-3) AIDSe,5 of ze•211 248(110) diagnosed in 9992 7/12 in 1999 85 total AIDS cases among IDUs in 9992(and 24 female in 1993) 3048 467(42.4) down to 21 total in 1998(9 female)and 7 as ol`7112 in 1999 f5 female) 4x+11 tb5ecst,� Race/Ethnicity of Injection Drug Users Diagnosed with AIDS Dost *12(x.3) (as of VIM) a4ia 71(3.{). Ractlethnicky Matt mus Fematt mu. Total 1%) r#t 2e,{1.31 Whitt 750 30 1110(32.2) Total 2060{S00) Rtacar Amtrican. 209.: t15 lsana 42; a 4e,fa:.a). - AaiadIP201C Wender. 4 0 t (0.T). Nauw American 2 0 2 (0.4) Tdttl i 407 152 1 "t(110) IDR DN Iasi tW YM YST Yfi YM tIN tIN Yea IW 7fa{IIID 1111 IMf awe Yw AIDS case diagnoses in Contra Costa County have 85 AIDS cases attributable to injection drug use dropped sharply,from 250 in 1992 to 62 in 1998 and were diagnosed in 1992,15 of these among 22 reported as of July 12 during 1999. . . . female IDUs (24 female IDU cases In 1993): (And from chart at right: 34.0%of cases were due AIDS cases among IDUs declined to 21 In 1998 to inlection drusr use in 1992, 33.9% in 1998) (9 female)and 7 as of July 12 in 1999(5 female) AIDS case diagnoses, of course, do not equate with HIV infections----for which the data is less defined, both locally and nationally. Contra Costa County does report"Recently Detected HIV Infections"among "Clients tested for HIV at County `Anonymous Test Sites'without prior positive test." The three test sites are located (one each) in Concord, Pittsburg, and Richmond. Health Services Department reporting now typically summarizes results from July of one year through June of the next. Results available for 1990 through mid=1995 were provided as a combined total in County HIV/AIDS Epidemiology Reports{ however. I REQUEST TO SPEAK FORM (THREE(3)MINUTE LIMIT) Complete this form,and place it in the box near the speakers' rostrum before addressing the Board. Name: k-,J V t Phone: Y4 'FAT C.*`l 16 7,f— Address: ,Address: 13-4° City: czaidi �2 2xF�. I am speaking for myself or organization: A.)L tJ Cz aA.A t 1- "�" �(..,+ (name of crrvaizetion) CHECK ONE: I wish to speak on Agenda Item# Date: l " 144 ' 4'5 My comments will be: general for X- asst I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to Consider: REQUEST TO SPEAK. FORM � (TMME(3)MINUTE LIMIT) Complete this form and place it in the box near the speakers'rostrum before addressing the Board. : GubyIA, 7C, Name: r ws �a .. ; p{ Phone: 4-) Address: t. `f�S" by rt City: CAo^CO3+- I am speaking for myself or organization: (tame of orpaization) CHECK ONE: I wish td spear on Agenda Item# -- Date My comments will be: general for ,�' against I wish to speak on the subject of I do not wish to speak but leave these comments for the Board to Consider: rttE'_�1` ,r^c c '+�...s '�•hc+v:,`-#�r� �r t'j+l r$`� �'a„rw...'ccs �+,,..a-o��.-+�-«�' ��...�� �t+� 4 e s'.,, 4,.. c,.. 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