Years ago, San Francisco made a commitment to reducing harms for residents who take drugs. In 1996, the Board of Supervisors committed to a policy of treatment on demand (TOD) to ensure that San Franciscans requesting help for alcohol and other drug use received it without delay.
The TOD Planning Council advocated a harm reduction approach to helping folks who do drugs (including alcohol) even if they were not ready or willing to endorse abstinence as their goal. A harm reduction approach views any step toward improved health as a positive step.
In 2000, the Health Commission endorsed harm reduction and made it the policy of the Department of Public Health and a guiding principle for all DPH contractors.
Fast forward to 2014 and we find Mayor Ed Lee and Health Director Barbara Garcia balking at a recommendation by the HIV Prevention Planning Council that DPH consider the evidence supporting the distribution of crack pipes, a harm reduction approach with aims similar to those of needle exchange.
The suggestion that DPH should investigate and evaluate the research supporting this public health intervention seems to have caused a moral panic at the highest levels. Despite the oft-heard commitment to "evidence-based practices," both the mayor and the director of health outright refused to even evaluate the evidence. They both flatly said, "No, we will not even consider this."
All this was prompted by a unanimous resolution of the HPPC recommending that DPH evaluate the available research on the health and other impacts of distributing crack pipes and investigate the legal options for doing so. The HPPC is the city's official community planning body charged with developing plans to reduce new HIV infections.
Community activists had made a presentation to the HPPC showing the effectiveness of crack pipe distribution in other places. Results include more effective outreach to people who smoke crack, reductions in crack use, and improved health including a drop in the acquisition and transmission of HIV. Thus, the unanimous approval of a rather mildly worded resolution that merely recommended that DPH consider the evidence and possibilities.
In fact, the DPH's own 2010 HIV Prevention Plan lists crack use is an independent driver of HIV in San Francisco. Yet DPH has neither developed nor funded any programs specifically for crack smokers.
Ironically, while the mayor and the director of health were refusing to even contemplate the evidence, the San Francisco Police Department, district attorney, and city attorney have recently become advocates of harm reduction.
The police department stated that it would be happy to support the distribution of crack pipes if the health department did. The city attorney has gone on record supporting supervised injection facilities. And the district attorney recently joined the San Diego police chief in calling for a statewide reduction of drug possession charges from felonies to misdemeanors.
These positions result from research on effective methods of reducing the harms caused by alcohol and other drug use. Yet the mayor and the director of health seem to be operating on moralism and political expediency rather than reason and evidence.
Despite the knee-jerk reaction moral outrage by the mayor and health director, there is ample evidence supporting the effectiveness of harm reduction approaches. Crack use has gone down in Vancouver, B.C. and other cities throughout Canada and the world since the introduction of crack pipe distribution programs. Activists in Seattle have recently begun distribution of crack pipes and the initial data on its effectiveness is good.
Another irony is that this all occurred shortly after the 25th anniversary of Prevention Point, the needle exchange program started by activists in San Francisco to halt the spread of HIV among people who inject drugs.
In 1988, in an act of civil disobedience, these activists started exchanging used needles for sterile ones. These brave women and men, many of whom were members of the LGBT communities, risked arrest since needle exchange was then illegal in California.
Five years later, Mayor Frank Jordan declared a State of Public Health Emergency to justify ignoring state laws outlawing needle exchange. Until 2006, the Board of Supervisors had to pass a resolution every two weeks reiterating the State of Public Health Emergency to allow needle exchange to continue without legal repercussions.
Needle exchange programs are now well established in San Francisco and have been credited with keeping HIV infection rates in people who inject drugs among the lowest in the nation.
Hopefully, the mayor and the director of health will reassess the situation, be willing to evaluate the evidence from other localities, and take a brave stand similar to what the city did 20 years ago with needle exchange.
For many years, San Francisco was a model for the nation, a source of cutting-edge public health interventions. We can regain that role in the nation and the world by once again taking enlightened, forward-thinking positions on public health policies.
These are not merely theoretical policy debates – these are decisions that have real life consequences – think of how many lives have been saved by and the health and wellness impact of needle exchange programs, equally controversial at its beginning.
Michael Siever, Ph.D., is a psychologist with over 30 years of specializing in addictive behaviors and harm reduction. He founded the Stonewall Project and Magnet.