Southern States Outlaw Syringe Exchanges Used to Prevent Disease

In the pale light of early morning, a mobile unit sits curbside in Atlanta, Georgia’s most notorious crime zone. A woman in a tattered coat shuffles up to the vehicle. She’s diabetic and carries a bag of over 300 used syringes. The people in the mobile unit are happy to accept the needles, and they offer her clean insulin syringes in exchange. Mostly volunteers, they have braved the cold to bring public health services to the neighborhood’s residents. In doing so, they are breaking the law.

Syringe exchange, the act of exchanging a used syringe for a clean one, is an accepted practice for reducing bloodborne disease transmission in much of the northern United States. Not so in the South, which has steadfastly refused to endorse syringe exchange, and the practice is more or less prohibited in all Dixie states. But despite a legal situation that is ambiguous at best and often outright hostile, 13 syringe exchange programs exist in the South. Scattered across nine states, the programs and the people who run them are as colorful as they are unexpected. A program in New Orleans runs a clandestine exchange through volunteers on bicycles, advertising their services through a circus and the local music scene. In South Carolina, a doctor, two reverends and an atheist formed an unlikely alliance to create the first syringe exchange program in their state. In North Carolina, a former drug user living with HIV and hepatitis C distributes needles from the back of his van to help others avoid his fate.

The exchange programs are diverse in size, scope and methodology, but they share a common goal to reduce disease in their communities and to offer services to a population both stigmatized and ignored by traditional health providers. 

“Just because you suffer from the disease of addiction does not exclude you from basic medical services and equipment,” says Jeff McDowell, executive director of the Atlanta Harm Reduction Coalition, which operates an exchange. “It costs $680,000 to treat a person with HIV and 9 cents to prevent it with a clean syringe.”

AHRC runs the largest and most comprehensive syringe exchange program in the South. Three times a week, outreach workers from AHRC visit fixed locations in a mobile unit. The unit is equipped with an examination room where clients are offered nonemergency medical care, HIV and hepatitis C testing, overdose prevention education, and referral to drug treatment if the client requests. Clients may also receive brown-bagged meals and access to a shower.

Unlike most syringe exchange programs in the South, and despite Georgia law prohibiting the distribution of hypodermic needles for nonemergency purposes, AHRC operates right under the nose of the Atlanta police department.

“We have an unspoken agreement with the police because a lot of officers recognize the benefits of syringe exchange,” explains Jeff McDowell. Benefits include lower rates of HIV and hepatitis C in the community, the collection of used syringes that might otherwise be discarded in public parks or bathrooms, and fewer accidental needle-sticks to law enforcement. AHRC distributed approximately 61,000 syringes last year and collected 60,000 dirty needles off the streets. Mutual respect between Atlanta law enforcement and AHRC has allowed the syringe exchange to operate effectively for nearly two decades.

Interestingly, local law enforcement policy toward syringe exchange seems to determine program operation more than state law. AHRC’s cooperative relationship with local police is unusual in the South. Miami offers a more characteristic example of how exchanges adapt to a murky legal environment. No official exchange program exists in Miami, just one man who believes in the public health benefits of syringe access. Fernando (an alias) collects extra syringes from local diabetics and disperses them to drug users who might otherwise share dirty needles. He operates as a volunteer and is discreet in his deliveries so as not to attract the attention of a police force tough on paraphernalia laws. Similar programs operate in Little Rock, Arkansas, Jackson, Mississippi, and Nashville, Tennessee, among others. In most cases, drug users are provided a phone number to call when they need supplies, and a volunteer performs a clandestine delivery.

North Carolina, home to five different syringe programs, illustrates how police practices can differ even within the same state. In western North Carolina, Michael Harney runs the Needle Exchange Program of Asheville with full knowledge of local law enforcement. “We’re honest with officers in Asheville about our program,” Harney says. “As long as we keep a low profile in the community and neighborhoods, they don’t interfere with this component of public health strategy.”

Further east, in Winston Salem, Steve, who gives only his first name, operates an exchange out of the back of his van. His operational mode is much like Michael Harney’s, only Steve doesn’t have a cozy relationship with the police. “I give the police their respect, but if I see them in the community, I keep walking,” he says. He believes some officers know about his exchange, but haven’t bothered him yet. That makes him luckier than the nearby Greensboro exchange, where police raided the site and jailed the organizer for possession of a used syringe in a biohazard container. A program in Charlotte, North Carolina, was similarly raided and closed.

For most people who run syringe exchange, the risk of arrest comes with the territory. Some, like George, whose alliance with Southern reverends is launching South Carolina’s first exchange, see humor in the situation. “If the police tried to arrest me, they wouldn’t arrest much,” says the retired physician with a laugh.  

For others, fear of arrest is a serious impediment not only to people operating the exchange, but also to clients. “Some people are afraid to take syringes from us because they don’t want to get arrested,” explains Sharon Williams (an alias), organizer of an underground exchange for transgender people in Jackson, Mississippi. “They are afraid of police coming and searching their homes.”

Syringe exchange programs throughout the South share other challenges besides dealing with local police. Programs struggle with little to no funding, reliance on volunteers, limited supplies, and unfavorable public opinion.

“Public perception of syringe exchange is not always on your side in the Deep South,” says Laura Pegram, harm reduction coordinator for Women With a Vision of New Orleans. “Injection drug use and syringe exchange stir strong emotional, and often negative, reactions even in progressive groups. Combating this and trying to spread accurate and unbiased information is elemental to successful programming.”

Southerners who operate or support syringe exchange frequently confront accusations that they are enabling or endorsing drug use. “We need to get past the Bible Belt mentality and accusations about enabling drug use,” says Jeff McDowell of Atlanta. “Many of our former clients write us letters to say they are clean today and to thank us for keeping them safe and disease-free.”

Empirical evidence and numerous scientific studies demonstrate that syringe exchange programs reduce the incidence of needle sharing among drug users, who make up 19% of current HIV cases, and do not increase drug use. A 2006 investigation by the Institute of Medicine reported that syringe exchange programs actually reduce community drug use, as well as crime and the incidence of HIV and hepatitis infections. A Seattle study reported that syringe exchange participants were five times more likely to enter drug treatment programs than nonparticipants. Even the conservative American Medical Association endorses the practice, yet stigma and hostility towards drug users still abound. Despite this, most exchange operators remain cautiously optimistic.

“I feel as though you often run into situations where no good or practical solution to a problem exists and people feel disempowered,” explains Laura Pegram of New Orleans. “In light of this, it seems nearly impossible to ignore a situation [like HIV prevalence among injection drug users] that has such a clear, simple, proven, and readily available solution.  I suppose part of my job is trying to get the community and law enforcement to see such solutions as productive as opposed to problematic.”

Given the numerous challenges, legal dangers, and lack of public support, one might wonder what motivates people to continue to operate underground exchanges. Joyce (alias) in Little Rock, Arkansas, captures the spirit of the movement with a simple answer, “We do it because somebody’s got to do it.”

Versions of this phrase are repeated over and over among groups that support syringe exchange. Proponents point out that nine out of 10 states with the highest rates of HIV/AIDS transmission and death are in the South and that syringe exchange can help reverse that trend.

 “A lot of my friends have died [from HIV and hepatitis],” says Steve of Winston-Salem, North Carolina. “I do [syringe exchange] because I don’t want anybody else to go through the stuff that I went through. I do more than pass out syringes; I educate people about risks. I have taken people to drug treatment and some of them are still clean today.”

Southern syringe exchange programs will likely continue to face obstacles and difficult legal terrain in the coming years. Politicians won’t talk about them, public health departments won’t touch them, and the myths persist against an increasing body of facts. But that won’t stop the people who run syringe exchange in the South from doing what they believe is right.

Says Louise, who has served jail time for operating a syringe exchange in Greensboro, “Once you get involved in [the exchanges] and see the good you can do, you have to keep going, not matter what the cost. We have to kill this epidemic before it kills us.”


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