Men and women, many of them under 30, come to see Dave Purchase.
For the most part, they are thin and gaunt, some with needle tracks and sores, their young bodies wasted from drug abuse and street life. Others step out of vehicles that have pulled up for a quick stop, or get off a bus with a bag of groceries in their arms — people you would never guess are intravenous drug users.
Purchase gives them free "rigs" or "outfits" — needles and syringes — in exchange for their used ones. He also dispenses alcohol wipes, small bottles of bleach, and condoms from a van parked on the street. But mostly, he gives them dignity.
He listens to their latest hassle — a squabble with a boyfriend, a run-in with the police — and some stop by to tell him they've kicked their drug habit.
"Stay alive, now" is his parting advice to all.
Purchase runs the needle exchange program in Tacoma, Wash. — one of the first of its kind in the nation. He founded the program in August 1988 as a private effort to prevent the spread of AIDS.
"Dead people can't get into drug treatment," he said of his visitors. "You can get over being stupid, but you can't get over being dead.
"The issue is AIDS. It's as simple as that."
Besides the AIDS preventive wares, Purchase also dispenses advice: how to use bleach to sterilize a used needle, the need for condoms, and the availability of drug treatment.
But beginning such a controversial — and perhaps illegal — enterprise as the needle exchange required the support of many community leaders, including the local health department, the police, and others.
The deadly link between drug abuse and AIDS posed new challenges for those working in drug treatment and public health: How to find a way to help curb the spread of AIDS, especially among IV drug users. For some in the public sector, the question seemed easily answered. If people stopped using drugs, their risk of exposure to the virus would be lessened. For those familiar with the harsh realities of drug abuse, this was an oversimplified answer which would doom many individuals to a painful and costly death. Set against the backdrop of the complexities of drug treatment, some health officials and drug treatment counselors realized that a successful AIDS prevention program for IV drug users would require potentially controversial steps.
"It's an issue of whether we are going to choose to protect the lives of all of us, or whether we are going to choose to have a public health system which is only available for those people we like or whose behavior we approve of," said Purchase.
As former Tacoma Mayor Doug Sutherland recalls, the issues surrounding AIDS had been known for some time. As a member of the Tacoma-Pierce County board of health, he had attended study sessions about the virus. Many people, he said, continued to think of AIDS as a disease limited to gays or to IV drug users.
"Many people had the tendency to downplay it and to say 'That's their problem,'" said Sutherland. "But it became obvious that this was a health issue that needed a substantial amount of public education, that it was not just their problem, that it was our problem. I, along with some others, had educating to do.
"There was some real difficulty early on when we discussed ways to attack it. Dave Purchase had decided that our approach was taking far too long, that there were too many people being exposed (to AIDS) in the meantime. And he unilaterally decided to start the process of needle exchanging, that he would begin the distribution of free, clean needles."
Purchase contacted community leaders to inform them of his plan to begin the needle exchange, including Allen Sutherland, Terry Reid, a substance abuse section manager at the health departrnent, and Ray Fjetland, Tacoma's chief of police. Others volunteered to assist Purchase on the streets, educating clients on safe sex practices, "bleach and teach," and methadone treatment.
"Dave called me up and said 'I want to start a needle exchange,'" said Reid, who has counseled IV drug users for years. "We'd worked as counselors together for many years and knew each other well. We talked about how a needle exchange might work in Tacoma.
After operating the needle exchange as a private enterprise for five months, Purchase approached the Tacoma-Pierce County board of health with a proposal to incorporate the program into the health department's AIDS prevention efforts. Both Purchase and health officials realized that public education about drug abuse and AIDS was a necessary step in building support for such a controversial measure.
"In some parts of the country, just recommending it is an invitation to dismissal or more problems than you care to deal with," said Dr. Al Allen, director of the Tacoma-Pierce County Health Department. "I didn't really think so much that I was putting my neck on the line, but I knew that it there was considerable risk potential."
"Most of us said, 'Oh my god. We need this like a hole in the head,'" said Sutherland. "We knew that it was going to be an enormous political problem. There were several conversations among members of the health board and it became apparent that there was a majority of the board in support of the program.
"Each of us had to wrestle with questions: Was this a health problem? By endorsing the program, were we in fact endorsing the use of drugs? And were we really in violation of state and federal law?," he said. "Public hearings were held to find ways to mitigate the impact of the program, since it was not the kind of program that was going to be readily accepted. But we didn't have the luxury of taking a year's period of time to sell the program."
In January 1989, the board of health adopted the needle exchange, providing $43,000 in city and county funds for the program. Purchase is quick to credit local officials for their role in the successful implementation of the controversial project
Allen recalled how education about AIDS played a significant role in making the needle exchange possible.
"One of our board members remarked how unusual it was for a board of health in the United States to consider this," said Allen. "She attributed the attitude of the board to the study sessions. So what was originally shocking over a period of time was no longer shocking — it was still controversial, but supportable by four out of five members of the board."
"Dave Purchase was also very amenable in trying to make the program work," said Sutherland. "We started a very concentrated and reactive media campaign because this was not only the first needle exchange in the nation where we had an opportunity not only to show how it works, but also to get statistics."
They decided that a van, supplied with outreach materials such as AIDS information, methadone treatment coupons, condoms, bleach, food, and clothing — as well as hypodermic equipment — would be located in a downtown area frequented by IV users. A second needle exchange was established at the health department's drug treatment section. But even though the board of health had been convinced of the need for the needle exchange, Purchase and others found themselves in the middle of a political hurricane.
With the number of AIDS cases rising among intravenous drug users and their sexual partners and children, many health officials believe that a needle exchange program is a prudent way to try to keep the virus and other diseases in check. But some politicians and business people claimed that the program would promote drug use, and its presence downtown would serve as a mecca for criminals, prostitutes, and junkies. They cited concern that such programs legitimize drug use by providing paraphernalia for the users at a time when drugs and drug-related crime were high profile issues.
Purchase feels that many opponents of the needle exchange program choose to disregard medical data that indicates such exchanges actually reduce drug use. Such attitudes, he says, stem from ignorance about drug cultures and social prejudice toward his clients.
"Look at who we're dealing with: hookers, junkies, and dope fiends. Just imagine what it would be like if AIDS was transmitted by the steering wheel of $30,000 cars. What would America have done about AIDS years ago?" charged Purchase. "And now there are over a million Americans infected."
The Tacoma-Pierce County Health department estimates that there are 3,000 intravenous drug users in the county. About two to five percent of them already have tested positive for exposure to the AIDS virus.
Studies of the program indicate that 80 percent of people using the exchange have changed their injecting practices. On average the number of times people inject with pre-used syringes has been reduced by half, and bleach use has increased substantially. In addition, 350 individuals have signed up for methadone treatment, using coupons that Purchase and other outreach workers dispense.
Also, the Tacoma Police department reports seeing fewer needles discarded on streets, in alleys, or parking lots where they may be picked up or stepped on.
"From a modest beginning, we developed a really first-rate program, and it wasn't long after that we won a national award for the best public health program at the local level for the AIDS prevention program," said Allen. "Part of what allowed me to support the needle exchange was that I felt there was a possibility of acceptance by our community. One of the indications of tolerance was our police chief, Ray Fjetland. He could have poisoned it publicly and on the streets through his officers. But he's very progressive."
Fjetland had been approached by Purchase about the needle exchange. Though under existing law, he could have used his authority to arrest individuals who distributed needles — a misdemeanor charge — he decided to wait and see what the effects of a needle exchange would be on the streets.
"We felt that AIDS was a bigger threat," said Fjetland. "We anticipated that community leaders would be divided over it, but we knew that the prosecutor's office wasn't going to prosecute. So we felt that the right thing to do was let Dave try his program.
"From our point of view, it was better for the users to be disposing of their needles safely, rather than leaving them on the streets," added Fjetland. "And in the course of getting their needles, these people would come into contact with health workers who can give them literature and advice about getting off drugs. So we saw it as an opportunity to actually reduce some of the problems associated with drug use."
But it will be 6-10 years before the success of the program can really be determined.
"That a long time, especially for a junkie, where a week is a dozen lifetimes," said Purchase.
Purchase is also dismayed by those who have criticized the needle exchange based on the congenial atmosphere created where he sets up shop. He feels that his clients, like those of any other service-oriented business, will be more likely to respond positively to his message if treated with some dignity.
When users arrive to trade in their rigs and pick up other AIDS-preventive wares, the outreach workers are friendly, chatty, and concerned. Much of the talk is about what's happening in the clients' lives, but in the language of the streets. After working on downtown street corners for almost two years, Purchase, Garcia, and others know most of the junkies by name.
Purchase's response to the notion that those people are not worth public concern is a cry of disbelief.
"Fascism is not a small current in 20th century history — and we're probably not over it yet," he said. "But it's real clear that we're all the same. We all have a bellybutton, and we can all get AIDS."
Tacoma's precedent-setting needle exchange program has been widely lauded as a national model. Its supporters include a host of national, state and local health officials.
Despite the support for such programs, some politicians continued to feel that the needle exchange tacitly endorsed drug use. In the spring of 1989, the Washington state legislature passed a comprehensive drug bill which outlawed needle exchanges. Though Governor Booth Gardner vetoed that portion of the bill, further clouding the issue were conflicting state laws. Some argued that the exchange was prohibited by an anti-drug measure adopted by the legislature years ago, while others contended that it was authorized by the AIDS Omnibus Bill of 1988 which allows health departments to use any necessary means to combat AIDS.
A conservative state legislator asked the Washington state attorney general to issue a legal opinion on the needle exchange. His opinion found the exchange to be illegal — specifically that an AIDS prevention bill passed by the legislature in 1988 did not preempt an earlier law that prohibited the sale of hypodermic needles for illicit purposes.
Purchase, who worked as a drug counselor for almost 20 years and who served on the Washington state substance abuse advisory board, found himself accused of promoting drug use. He calls the political wrangling about the issue "scary."
"This isn't the kind of question where the classic compromise in government tends to find some middle ground," he said. "This is life and death. There isn't room for political jostling.
"If the legislature, or any govemment body, were to specifically make needle exchange programs illegal, the direct result would be the death of people in this state. It's just that those people will not die the day after the law is passed, they'll die in 7-10 years."
Following the attorney general's opinion, Tacoma City Attorney Bill Barker advised city finance officials in September 1989 to withhold funds from the program until its legal status was more firmly established. The county, under its funding guidelines, also had to withhold its payment to the program. This left the health department with enough money to continue the needle exchange program in Tacoma until the end of the year.
The Tacoma-Pierce County Health Department filed suit against both the city and Pierce County to restore funding, which also put the question of legality in the hands of the court
In Seattle, where the Seattle-King County Health Department operates a needle exchange, city attorneys also reviewed the legality of rieedle exchanges. Randy Gainer, assistant attorney for the City of Seattle said that under the AIDS Omnibus Bill, his departrnent concluded the needle exchange is legal.
"Though it's not perfectly spelled out, there is sufficient latitude in the wording of the AIDS Omnibus Bill to argue in favor of the legality of the needle exchange. Tacoma's city attorneys had an arguable case," he said, "however, because of health implications, we advised the Seattle City Council to continue support of the needle exchange."
"It boiled down to a test of whether the attorney general's opinion was supportable," said Allen. "After a lot of jawboning, the decision was to arrange a friendly suit"
"I engineered the lawsuit using the issue of nonpayment," said Sutherland. "We got the parties together and set up a civil suit The question of legality was dicey, but it had to be answered. So here again, we took a chance."
Though some argue that the legal maneuvering on the part of the city was unnecessary, the issue was later settled, at least temporarily, by the historic decision on April 9, 1990, by Superior Judge Robert H. Peterson that declared needle exchanges legal in Washington State. And in the meantime, the program earned more accolades in the medical community, including the 1989 national achievement award by the National Association of County Health Officers.
But the needle exchange has also drawn criticism from members of the Bush administration's anti-drug team.
In late September 1989, Reggie Walton, assistant to drug czar William Bennett, who was in Tacoma to address a conference of drug treatment program directors, criticized needle exchanges for sending a message that condones drug use.
Walton, who did not visit the site of the needle exchange where many people go to receive clean needles, said at a news conference later that he doubted that the needle exchange reduces needle-sharing. He postulated that most drug users will use any needle immediately available to them.
"I doubt that they are going to say want to get high, so I will go down to the local distribution center, collect my needle, and then go back and shoot up drugs,'" he said.
But health department statistics confirm an earlier study that showed the needle exchange is effective in curtailing needle-sharing among drug users.
"Some days I come home and I'm just beat," said Purchase. "On those days, I say to myself 'Today, one. One person didn't get AIDS.'"
Dulcey Consuelo Davidson, Institute for Citizen Education in the Law, Puget Sound School of Law, Tacoma, WA.