On paper, Charleston, West Virginia, seemed like a prime candidate for a clean needle exchange.
In 2015, West Virginia had the highest drug overdose rate in the nation and the federal government identified Kanawha County, where Charleston is located, as one of the U.S. counties most vulnerable to an HIV outbreak among injection drug users. Most of all, Charleston’s new health department director, Dr. Michael Brumage, was dead set on avoiding a Scott County, Indiana,-style HIV outbreak in his city, where an estimated 4 percent of residents were injecting drugs.
From a public health perspective, syringe exchanges are a straightforward, evidence-based way to stop the spread of infectious disease from needle sharing. But politically and socially, they’re more complex.
Just two years after Brumage got Charleston’s exchange up and running, everything fell apart.
The health department couldn’t handle the high volume of people streaming in from surrounding counties for needles and health care. Law enforcement officers complained about used needles in the streets. After a local child pricked herself on an uncapped syringe in a McDonald’s bathroom, the local TV station ran a segment on the incident that national news outlets picked up. Perhaps worst of all, the mayor ― whose own son struggled with heroin addiction ― launched a campaign against the exchange, calling it a “mini-mall for junkies and drug dealers.”
In March, to Brumage’s chagrin, the needle exchange closed its doors to the public.
“From a public health perspective, syringe exchanges are a straightforward, evidence-based way to stop the spread of infectious disease from needle sharing. But politically and socially, they’re more complex.”
Brumage, who resigned from his health department role and now works for West Virginia University School of Public Health, worried that denying health services to the homeless and people with addiction would lead to a spike in new cases of infectious diseases.
“We’ll have to wait until after the fact to see if there’s a huge surge,” he said. “It’s truly tragic timing for the closure of a program like this.”
Daniel Raymond, policy director of the Harm Reduction Coalition, expressed concern about the potential for a chilling effect on other West Virginia communities, which now might not start needle exchanges because of the potential for controversy.
Raymond also echoed Brumage’s worries about infectious diseases.
“If you’ve been seeing hundreds of people, what happens to them?” he asked, citing possible consequences like an increased risk of spreading hepatitis C, an uptick in overdose deaths and fewer avenues for connecting people with addiction treatment.
“Those are all things that the Charleston mayor and the Charleston police chief and city council have not come up with meaningful solutions to,” Raymond said.
Structural And Social Barriers Outside Cities
Rural and suburban communities around the country are using harm reduction approaches that were built for cities. And it’s not working.
HIV and hepatitis infections are on the rise in these areas, and to effectively stem the tide of overdoses and disease transmission, public health experts will have to do more to adapt these approaches for suburban and rural residents. These communities typically contend with shakier health infrastructure and include more politically and socially conservative constitutents, making it more difficult to drum up local support for such measures.
“The problem has been that the rural and suburban areas where a lot of the epidemic is [are] so qualitatively different than those urban spaces,” explained Jon Zibbell, a senior public health analyst at the nonprofit research group RTI International.
“People have had trouble just taking an urban model and dumping it into a rural model.”
Rural communities face myriad barriers, from social to structural, when introducing harm reduction to local residents. On the social side, there’s a conservative notion that harm reduction enables drug use, even if it saves lives and stops the spread of disease. And rural residents, like their urban counterparts, don’t want to see evidence of drug use on the streets, meaning needle exchanges often spur a “not in my backyard” backlash in communities with limited public space.
The lack of anonymity in small communities can also keep people with addiction from seeking treatment or clean needles, since they’re essentially announcing their drug status to the community at large when they park at the local methadone clinic.
On the structural side, sparse population means rural residents have to travel longer distance to access health and harm reduction services, often using unreliable public transportation networks to reach under-resourced facilities during limited hours of operation.
Infectious Diseases Hit A New Population
The evidence that exchanges prevent diseases from spreading has been widely available for decades, but hasn’t always resonated with rural policymakers. In 2015, for example, then-Indiana Gov. Mike Pence (R) delayed authorizing an exchange in Scott County, where an HIV outbreak was underway, because he believed exchanges promoted drug use.
“The moralism of drug use always usurps the science around the program,” Zibbell said.
It’s also the relative newness of these diseases in rural communities, which HIV and hep C now disproportionately affect.
Rates of new cases of hepatitis C, a blood-borne viral infection that can cause liver damage and can spread through shared drug injection equipment, were declining in the United States until 2010. But in the four years that followed, new infection rates more than doubled, according to a report published in the journal Clinical Infectious Diseases in 2017.
The largest increase was among 20- to 29-year-olds in non-urban areas, who were sharing drug injection equipment. (Hepatitis C has long been associated with the Boomer generation, a much older age cohort.) The report also found that 80 percent of the nearly 30,000 young people infected with the disease lived more than 10 miles from a syringe exchange program, with the farthest distances occurring in rural parts of the South and Midwest.
“That explosion in the number of people using the program spoke to a really strong unmet need. In many ways, we were building the plane as we were flying it.”
While hep C is curable, it’s not cheap. Costs range from $55,700 to $94,800 for a 12-week treatment, and $26,400 for an eight-week treatment, according to Healthline. (States like New York, New Jersey and California have begun to include funding for hep C treatment for low-income individuals in their budgets.)
Yet, as Charleston showed, scaling up intervention and treatments can be challenging in rural areas. Charleston’s exchange was operating close to the city’s central business district on a shoestring budget. When demand for the exchange swelled and hundreds of people were streaming into the health department for services each day, the department couldn’t keep pace.
“In some way, I think they were victims of their own success,” Raymond said. “They were seeing more people, but not more dollars.”
Brumage never anticipated the volume of patients the exchange would attract.
“That explosion in the number of people using the program spoke to a really strong unmet need,” he said. “In many ways, we were building the plane as we were flying it.”
Needle Exchanges Designed For Cities
The United States’ first publicly funded clean needle exchange was founded in 1988 in Tacoma, Washington. New York City opened its own exchange the following year, and activists in the LGBTQ and drug-injecting communities demanded programs to help stop HIV from spreading.
“Needle exchanges really came out of the AIDS epidemic,” Zibbell noted. “And the AIDS epidemic disproportionately affected people in big coastal cities.”
At the same time, the government banned the use of federal funds for needle exchanges. As the chief of drug policy said at the time, government funding for clean needles “undercuts the credibility of society’s message that drug use is illegal and morally wrong.” This relegated that power to the states ― and meant that locales where drug injection or HIV weren’t prevalent never developed the robust programs that cities like New York, Chicago and San Francisco have today.
Rural areas were largely excluded from the injection heroin epidemic of the 1980s and 1990s.
“That’s different than the East Coast, that’s been dealing with heroin and narcotics for the last 150 years,” Zibbell said. “New York. Philly. D.C. Boston. Baltimore. We’re talking heroin meccas since the end of the 19th century into the 20th century.”
The rise of prescription drugs changed that narrative entirely.
Largely lacking the open-air drug markets common in cities, rural Americans picked up prescription opioids at local pharmacies, essentially creating an entirely decentralized drug culture in sparsely populated areas that lacked both networks of drug users and networks of health services.
Instead of buying and injecting drugs on the streets, people in rural areas often call a drug dealer to deliver the drugs to them and inject at home. In part, that’s how the rural market works. It’s also a privacy issue. In a small town, everyone knows everyone.
This makes it especially hard for health workers to do outreach in rural communities.
“The structure of social relations determines the drug networks, which in turn, determines how you are going to access those people,” Zibbell said. “The largest point about needle exchange [is] you have to access the population and they have to trust you.”
Building trust can be nearly impossible if urban harm reduction experts parachute into rural areas to set up programs.
Zibbell, who has visited and given talks in Appalachia, said there was skepticism toward outside experts’ attempts to guide Appalachian harm reduction initiatives.
Appalachians don’t want New Yorkers swooping in and telling them how to run a program, Zibbell explained. If anything, they’d rather hear from Scott County. He summed up their point of view. “We are not the North East. We are unique.”
“The largest point about needle exchange [is] you have to access the population and they have to trust you.”
Beyond distrust of outsiders, harm reduction programs in rural communities face other challenges.
Charleston, for example, hosted one of only two large-scale needle exchanges in West Virginia. That prompted people to travel into the city to get clean needles and utilize the exchange’s health care services, drawing the ire of the mayor in the process.
At the height of the needle exchange’s operation, more than 483 people passed through in an eight-hour span, according to The New York Times. Such high usage proved that the exchange was desperately needed. But for a city of just 50,000 people, it was also a catastrophe. The health department was inundated with patients and unable to provide them with individualized care, while law enforcement was frustrated by finding discarded needles in the streets.
Then the police chief imposed a series of rules that enraged public health experts, including limiting clean needles to a one-to-one exchange, imposing mandatory HIV and hep C testing, and barring people who weren’t residents of the county from accessing the exchange, meaning everyone had to show a picture ID to get in.
“I think that overwhelmed Charleston,” Zibbell said. “So instead of fixing [the exchange], they were reactionary and closed it.”
Racing To Develop Rural Harm Reduction Models
A few public health experts are beginning to identify how to better adapt harm reduction approaches to rural communities.
Kentucky, which now has more than 50 small needle exchanges since the state legalized the practice in 2015, might provide a valuable blueprint. The state health department also plans to start mobile needle exchange in two counties in July ― which, in addition to offering clean needles, will provide overdose reversal kits and HIV testing.
“That gets around the NIMBY issue,” Zibbell said of needle exchange mobile van programs, referring to the “not in my backyard” ethos that plagues needle exchanges from coast to coast.
Still, it’s complicated.
Vans reach people where they are, but typically offer fewer health services and connections to care, such as case managers or counselors, than centralized health centers do. And as Raymond noted, the Charleston exchange started in the health department precisely because there was no budget to rent space or buy vans.
“I don’t want that lesson to get lost, that programs like Charleston can do amazing work in a short period of time,” Raymond said.
Brumage says he wishes he’d worked harder to educate the community, and especially the mayor, the police chief and first responders, about the principles of harm reduction.
In his view, people showing up to use IV drugs in the middle of the city became an unpalatable situation for the mayor, who assailed the program with legitimate concerns ― “but also with a fair degree of misinformation,” Brumage said.
Brumage, Raymond and Zibell all see the closure of Charleston’s exchange as a step in the back-and-forth nature of harm reduction implementation, rather than an endpoint or the city. Still, Raymond worries that it could be years before a robust rural-specific blueprint develops.
“I wish we had time for trial and error, but it looks like we’re racing the clock,” he said. “There’s no obvious playbook.”