SAVING THE SINNER

From Condoms For Teens To Needles For Addicts, Doctors Try To Lead A Divided
Public

WORCESTER - Jessie was blond and pretty at 23, except for the pus-filled
abscesses that dotted her arms. She told the doctor she was shooting 20 bags
of heroin a day. She was also sharing needles and prostituting herself to
buy drugs - in other words, practically courting the HIV virus.

Dr. Erik Garcia didn't order her to quit. He didn't lecture, didn't tell her
she was killing herself. Instead, he took Jessie's arm and showed her one of
the first things he learned in medical school: How to inject drugs without
infecting the skin and causing an abscess.

The picture is jarring, but it's something Garcia does every day. He tells
addicts they'd be better off if they quit, but he makes it clear they're
welcome in his office either way. That infuriates William Breault, who lives
near the shelter for the homeless and clinic where Garcia works. He has
worked hard to block Garcia's dream of bringing a needle-exchange program to
town to curb needle-sharing, which spreads HIV and hepatitis C. It's wrong,
he says, to hand an addict a needle.

''First, do no harm!'' Breault said, quoting the Hippocratic oath.

Garcia is outraged, too, for other reasons: Once a heroin addict gets
hepatitis C, he or she gets a prescription for syringes as part of
treatment, but the same person can't get them to prevent the disease. ''It's
crazy!'' he said.

Their fight - between two people who plainly care deeply about Worcester -
illustrates a larger rift between physicians and the general public.
Garcia's approach is known as harm reduction or risk reduction; in his
words, ''helping people engage more safely in potentially risky behaviors,
while they work toward the goal of stopping.'' In the last decade, it has
gained wide acceptance among doctors.

But whether the topic is teenage sex or drug use, the nation seems split on
whether to emphasize public health over morality; to accept the sin, some
might put it, to protect the sinner.

''It's a place where doctors are separated from a lot, if not all, of the
rest of American society,'' said Dr. Tony Robbins, a professor of public
health at Tufts University School of Medicine.

For example, a recent survey in Rhode Island found that 95 percent of
doctors who work with addicts have no moral qualms about offering needles to
prevent disease. At the same time, more than half of Americans believe
giving out needles sends a ''pro-drug'' message, according to the Family
Research Council.

But harm reduction isn't just about needles. It's Dr. Paul Stringham at the
East Boston Neighborhood Health Center telling teenagers he'd rather they
waited until their 20s for sex, but also handing them an unlimited supply of
playfully colored condoms - red, blue and yellow.

It's the Massachusetts Medical Society endorsing emergency contraception,
even as some worry it will undermine safer sex.

And it's Dr. Stephen Boswell changing the way he counsels gay male patients
at Fenway Community Health. He still says condoms are best, but lately he
adds that if they insist on going without, oral sex is safer than anal sex.

Needle exchange, however, has prompted perhaps the most visceral debate.
Propelling the change in physician attitudes is the growing share of new HIV
infections that are found in injecting drug users, their sex partners and
their children - half of all new cases nationwide, and an even higher
percentage in Massachusetts, according to state and federal health
officials.

The American Medical Association, the Centers for Disease Control and
Prevention and the Institute of Medicine all endorse needle exchange - when
combined with efforts to get people into treatment - saying it reduces HIV
infections without increasing drug use. So did US Health and Human Services
Secretary Donna Shalala. Yet, the Clinton administration, under pressure
from conservatives, banned federal funding for the exchange programs.

And while Surgeon General David E. Satcher endorsed the programs in a letter
to Shalala, his Web site doesn't mention them - perhaps because his
predecessor, Jocelyn Elders, was drummed out of office after suggesting
another harm-reduction concept - teaching teens masturbation as an
alternative to sex.

In some states, public policy is changing. New York decriminalized syringe
possession last month, following New Hampshire, Rhode Island, Connecticut,
Maine and many others - but not Massachusetts.

In 1994, the state Legislature endorsed a pilot program allowing the
establishment of up to 10 needle exchanges. But because of resistance from
local governments, only four have been set up - in Boston, Cambridge,
Provincetown and Northamption.

Now state Health Commissioner Howard Koh has set out to convince the public
of what health officials have long believed. The state Department of Public
Health is providing $10,000 to each of nine communities - Worcester, Lowell,
New Bedford and others - for public education on the benefits of needle
exchange.

That endeavor has a long way to go in Worcester, where Garcia - a father of
two with an Elvis fetish he calls ''more of a style thing than a music
thing'' - has become a symbol of community angst.

''He is not going to be allowed to do it!'' sputters Breault, 54, a leader
of the Main South Coalition, which has twice pushed the Worcester City
Council to defeat Garcia's needle exchange. If Garcia tries to prescribe
needles to addicts, Breault vowed, he will have the district attorney and
the police after him.

Main South is a densely packed neighborhood not far from the scene of the
warehouse fire that killed six firefighters last year. Along Main Street,
every business seems to thrive on addicts, a scene that inspires both Garcia
and his opponents.

The liquor store doubles as a check-cashing place. Graham, O'Brien and
Maloney, the funeral home, buries scores of AIDS and overdose victims a
year. Two of the tallest apartment buildings contain short-term housing and
halfway houses. So many letters have fallen off Beacon Pharmacy's marquis
that its sign now makes a bad pun, saying only, ON ARM.

Down the street is Gilrein's House of the Blues, a shacklike bar and
Garcia's hangout since he started residency nine years ago at the nearby
University of Massachusetts Medical Center. The owner, Barbara Haller, 52,
likes Garcia, but not his philosophy.

''He's talking about harm reduction for the addicts. I'm talking about harm
reduction for the community,'' she said. She worries there will be more
needles underfoot, and more addicts coming to the neighborhood. She worries
that needle exchange, by decriminalizing syringe possession, will undermine
the ''zero-tolerance'' message she's been working on for years. She wants to
see measures short of needle exchange tried first.

''To ask a society to change its norms' without trying alternatives, she
said, ''is unconscionable.''

Garcia, 38, said he understands his neighbors. He holds up a needle: ''These
are what they find on their streets, in their backyards. They're afraid
their children will get stuck with them. It's a legitimate concern.''

Further along Main street is the People In Peril shelter, the only one in
Worcetser County where people don't have to be sober to get in. To get to
his office there, Garcia, compact and boisterous in a gray wool overcoat,
nubby sweater and chinos, has to pass a crowd of young men in flannel and
baggy pants. They're dealing drugs, he said. They greet him affectionately:
''Hey, Doc!'' He smiles back, shakes hands, asks what's up. Judging them, he
said, would kill any chance of persuading them to seek detoxification
treatment, or any medical care.

Jessie, he said, went back to his clinic for treatment after she was raped,
then went back again to ask him to commit her to a drug-treatment program,
as doctors can do under state law.

''She would never have come to us ... if she had not known we would help her
without judgment - and without asking for anything in return, frankly,'' he
said.

Garcia talks a lot about harm reduction with the University of Massachusetts
medical students who visit his clinic. But he is an exception, said former
state Health Commissioner David Mulligan. Medical schools and mainstream
physicians need to take a more prominent stance, he said, because they will
win over people who are not convinced by the former addicts and social
workers who have been most vocal.

''Their opinion would be so important and valued by people,'' he said, but
some have been squeamish.

Michael Stone, a fourth-year medical student at New York University, said
some older physicians questioned his focus on needle exchange. ''There's so
much stigma attached to injection drug use that some of it crosses over to
the people who care about the people who inject drugs,'' he said.

But he said his research has won approval in his job interviews for
residencies, adding, ''That sentiment wouldn't have existed pre-HIV.''