All levels of government and the private sector need to mount a serious and sustained attack on the social problems that promote licit and illicit drug use in American society.
The combined epidemic of HIV and substance use has hit hardest the individuals in our society who are least equipped to deal with it – the poor. The poor of this nation, especially within communities of color, lack access to medical care, housing, food, and other basic needs. Substance use treatment and HIV education may often seem like luxuries to people who do not know where they will sleep at night or where their next meal will come from. As Sandra Vining-Bethea of the Bridgeport Women's Project told the Commission, "It's hard to educate a woman who is homeless and hungry."(37)
Those who live in poverty are also subject to extremes of social neglect which can add to the likelihood of substance use and risk practices. As Dr. Robert Fullilove of the Psychiatric Institute in New York told the Commission:
The one thing we know about poverty in this country in the last 20 years is that it has really altered the structure of many of the neighborhoods in the United States. Blacks and Latins are increasingly concentrated in areas that are becoming poorer and poorer, and with that concentration has come a tremendous increase, not just in HIV infection, not just in the prevalence of drug abuse, but a whole host of other serious social problems ranging from crime to just about anything that you can possibly describe. (38)
If the nation is to provide treatment and education which will move people away from substance use problems and the risk of HIV infection, it must recognize the role which poverty plays in this dilemma.
As Dr. Fullilove went on to tell the Commission:
. . .the most common feature of drug abuse is relapse. And we think relapse is related to environmental factors, the degree to which people live in neighborhoods where the neighborhood itself is a toxic agent that promotes addiction. . . . Unless we are able to stabilize the communities in which drug abuse, (particularly non-white communities), unless we're able to stabilize these neighborhoods and provide them with some kind of economic base, the underground economy which pushes and promotes crack cocaine addiction is going to do far more to damage our efforts to reach individuals. . . . (39)
While attacking the problems of HIV and substance use in the short-term with the methods discussed above, the federal government must lead the way in simultaneously addressing the larger social issues of poverty, homelessness and lack of medical care. We must work cooperatively with both the public and private sectors to remove these barriers to prevention and treatment.