AN OLD CITY SEEKS A NEW MODEL

Baltimore Moves Toward 'Medicalization'

In early December 1984, an undercover police officer named Marcellus Ward
met with a pair of heroin dealers above a candy store in southwest
Baltimore. Ward had planned to make a buy, then an arrest. But when Drug
Enforcement Administration agents stormed into the building, one of the
dealers panicked and shot Ward to death. The next day, Kurt Schmoke
listened to the recording from Ward's body wire. A friend of the slain
detective, Schmoke was then Baltimore's 35-year-old chief prosecutor. The
incident, he would say later, prompted him to rethink the drug laws he had
spent six years enforcing: Setups and stings and jail terms hadn't curbed
the violence associated with the drug trade, let alone reduced drug use.

In 1988, soon after his election as Baltimore's mayor, Schmoke proposed
easing many drug laws and repealing others--in part to undercut the black
market, in part to focus resources on reducing demand. It was startling
talk from a big-city mayor, and Schmoke's call for decriminalization got
him on Nightline and on the front page of the New York Times. But of course
no mayor can decriminalize drugs. Schmoke was soon overshadowed by national
drug czar William Bennett, who preferred escalation of the drug war, not
reform.

In 1992 Schmoke returned to the drug issue--this time with a strategy that
went beyond rhetoric. That year he appointed Peter Beilenson, then 32, a
young and relatively inexperienced doctor, as health commissioner. The two
officials then set about increasing capacity for drug treatment, pledging
to continue until they reached "treatment on demand." In the past three
years, the city's treatment slots have doubled, making Baltimore a case
study for the promise--and problems--of universal drug treatment.

Aside from Baltimore, San Francisco is the only locality to even set a goal
of guaranteed, immediate treatment for any drug user who wants it. But San
Francisco has the luxury of booming tax rolls, while Baltimore is
characteristic of declining cities with the most pressing drug problems,
the most need for change and the least resources. With an estimated 60,000
addicts, the city regularly ranks first on lists of drug-related
emergency-room visits and per capita violent crime. The city has lost at
least 200,000 people since 1970, and its population drops by another 1,000
each month. Boarded up or burned-out homes scar most blocks--in total,
40,000 are abandoned. When I accompanied police Lieut. Michael Kundrat on
his evening shift through the Western District, he pointed out each of the
area's fifteen active streetcorner drug markets, which he largely blames
for forty-five murders (out of 314 citywide) last year. "If you ask what is
one of this city's biggest problems," he says, "there's no question that
it's drugs."

When Beilenson went over the budget in 1995, he found that the city was
missing its best opportunity to ameliorate that problem. Of $15 million
spent annually on treatment, only $350,000 was coming from the city. And
the city's 4,000 slots could serve only 12,000 people a year--a pittance
compared with the total addict population. Last year Schmoke ordered city
departments--including police, housing, social services and health--to come
up with budget cuts totaling $10 million over three years. That, plus new
state money and grants from the local Abell Foundation ($1 million a year
for three years) and George Soros's Open Society Institute ($2 million),
pushed the total drug-treatment budget to $32 million and the number of
slots to 7,500. At the end of this year, the slots are expected to number
8,100.

Critics note that it's taken Schmoke more than a decade to reach these
goals. Others say that if he deserves credit for the drug-treatment plan,
it is for hiring Beilenson and giving him wide latitude. Beilenson grew up
in West Los Angeles the son of a state legislator (later congressman). His
interest in drug policy--as with his other focus, universal healthcare--is
that of the pragmatic liberal, not an experienced user. (Beilenson says
he's never tried illegal drugs. When he notes, "I know what a speedball is.
I know what a cooker is. I know what ice is," he sounds like a proud student.)

The soft-spoken Beilenson quickly shook up a system that had grown
lethargic. Two years ago he spent an afternoon calling the city's public
treatment centers, telling them he was "Todd Jackson," a three-times-a-day
heroin user for four years, and asking "When can I start treatment?" Only
one of the twenty-three programs he called would even put him on the
waiting list; the others insisted he call later or come in person. He
visited three other treatment centers but none would let him through the
doors--telling him, via intercom, to come back when they were open for
intake. So Beilenson ordered the programs to coordinate their intake, and
he created a citywide referral line.

Far more important is the added treatment capacity. The waiting list for
outpatient counseling--which is least in demand--has dropped to zero. Waits
for methadone and inpatient programs, which account for two-thirds of
slots, still range from about a week for some clinics to as much as a month
for others. (Despite the citywide referral line, many people still contact
programs directly.) When Beilenson makes the case for more slots, he always
returns to the bottom line: The cost of treatment ranges from $3,500 a year
for a methadone slot to about $35,000 a year for an inpatient slot (with a
twenty-eight-day program, this would serve twelve people). Meanwhile, a
drug user supporting a $50 habit might easily need to steal $300 worth of
property each day. (Baltimore police estimate that fenced goods sell for
one-sixth of their retail value.) That, plus the costs ranging from broken
car windows to security guards to AIDS treatment to prison cells, adds up.
In a finding that has been repeated elsewhere, the California Department of
Health under Governor Pete Wilson followed addicts before, during and after
treatment and found that every dollar spent on treatment yielded seven
dollars in savings.

Which is not to say that treatment yields permanent abstinence--from either
drugs or crime. University of Maryland studies have found that people in
outpatient treatment programs commit crimes, on average, forty-one days a
year, which seems high until it's compared with the addict population not
in treatment--for whom the average is 248 days.

Schmoke says he now prefers the word "medicalization" to
"decriminalization" but that his goal is still to treat "drug abuse
primarily as a public health problem and not primarily as a criminal
justice problem." And the refrain of the city's police commissioner, Thomas
Frazier, is that "we can't arrest our way out of this problem." Still,
Baltimore police have hardly laid down their arms. From 1988 to 1998,
Maryland's prison population climbed from about 13,000 to more than 22,000;
a significant percentage of the increase was the result of drug arrests in
Baltimore. Last year city police made 90,000 arrests, 85 percent of which
were for drug possession, sales or some offshoot of the drug trade.

Hundreds of those arrests came near the corner of Monroe and Fayette in
West Baltimore--a corner made infamous by the recent book The Corner by
David Simon and Edward Burns. A city-run needle-exchange van comes to
Monroe and Fayette each week. When Beilenson took me to visit the program,
we met a woman who embodied his wish for drug treatment--and his
frustration. Wearing a vacant look and moving in jerk-steps, she pushed a
handful of needles into a canister and picked up a package of new ones. I
followed her onto the street, where Beilenson joined us. Jackie, who wanted
to be known only by her first name, is 37 years old and looks twenty years
older. She has five children and uses between $50 and $200 worth of heroin
and cocaine a day. She's been in jail five times, for soliciting
prostitution and for "boosting" (shoplifting). She spoke with evident
anguish about this--about the jobs she had lost, about "what I put my
parents through."

"Have you thought about getting into treatment?" I asked.

"Oh yes," she said. "If I could right this minute, yes I would. Yes I
would. Next time I get the chance to get into treatment..." She trailed
off. The meaning of "right this minute" was clear enough. At that moment,
Jackie was in withdrawal--the low point of the addiction cycle and a time
when treatment referrals can be most successful. Beilenson gave her a phone
number to call, but her interest in treatment seemed unlikely to last
beyond the next score.

As we drove away, Beilenson made his diagnosis: "This is the typical addict
in Baltimore. In and out of jobs. Boosting. Prostituting. Did you see the
yellow in her eyes? She has serious liver issues--and if she doesn't get
taken care of she's going to end up very sick. What I would have liked to
do is say, 'Look, we've got treatment for you. Right now. This afternoon.
Here's where to go, and here's a token for a cab.'" But Baltimore can't
even offer immediate care to people who are begging for treatment. Despite
shorter wait lists, psychiatric hospitals report that addicts regularly
feign threats of suicide or violence to gain entry. When the city added a
twenty-four-hour staff to its treatment hotline, it turned out that 80
percent of after-hours calls came between 7:30 and 8 am. The morning's
slots are dispensed beginning at 8 am, and the callers were trying to be
first in line.

People who already want treatment, Beilenson argues, shouldn't have to
compete for slots. Everyone benefits if they get off the streets as quickly
as possible. But the real advantage with immediate treatment would apply to
people like Jackie--people who struggle with an addiction but, in the five
or ten or thirty days it takes for a slot to open, are likely to have a
change of heart, switch addresses, lose their phone or even land in jail.
And an ideal treatment system would go even further, cajoling people who
might be amenable to treatment but who would never seek it out.

Just how much will Beilenson need to make treatment-on-request a reality?
He suggests $30 million to $35 million, on top of the current budget of $32
million. But a precise figure is impossible because no one knows how many
people would seek treatment if it were easily, immediately available. Even
the total number of addicts is unknown--60,000 is just the best guess.
Finally, adding capacity to the existing system is only the beginning. At
the Glenwood Life Counseling Center, which offers methadone and therapy for
addicts, three positions went unfilled for months. The reason, says
executive director Frank Satterfield, is that the starting salary for a job
that requires a bachelor's degree and offers a slim chance of raises is
only $21,000. Satterfield says he would need to pay $27,000 to be minimally
competitive. Applied to treatment programs across the city, such salary
increases would require $2.4 million. Even fully staffed, Glenwood can
barely stay on top of administering 340 patients, soon to increase to about
500. With rare exceptions, therapy is done in groups. Vocational training,
family counseling, good psychiatric care--these services, which Satterfield
says he took for granted when he first entered the field in the early
seventies, are not possible with his budget.

The irony is that these deeper needs will only become apparent once the
first steps are taken. In other words, the further Baltimore moves down the
path to "medicalization," the longer the path seems. And though political
obstacles have so far been few--there is no Republican Party to speak of in
Baltimore--that may change.

A hint of future conflict came last summer, when Beilenson expressed
interest in a plan by Johns Hopkins researchers to conduct a trial in
heroin maintenance. The idea was to replicate a now-legendary Switzerland
study in which heroin addicts who had failed in repeated treatments were
given injections of the drug in a clinical setting. The results were
impressive (though not necessarily definitive): Many in the test group
found housing and employment, and the percentage committing crimes went
from 59 percent to 10 percent. In casual conversation about such a study in
Baltimore, Beilenson told a Sun reporter--while they watched their kids
play soccer--"It will be politically difficult, but I think it's going to
happen." The Sun printed these remarks, and sharp criticism came
quickly--from Governor Parris Glendening, City Council members and even the
Mayor. "This administration has no intention of initiating a heroin
maintenance program," Schmoke told the Sun. But in a recent interview,
Schmoke struck a different tone. He had to rebuke Beilenson, he explained,
because the commissioner floated a radical idea without building consensus.
But, Schmoke continued, "if you ask me what should be a part of a good
public health system to combat substance abuse, many different treatment
options should be part of that system--plus this last one, medical
distribution of certain drugs."

This puts Schmoke and Beilenson on a collision course with state officials,
most notably Lieut. Gov. Kathleen Kennedy Townsend, who said such an idea
"undermines [the] whole effort" of convincing young people that "heroin is
bad."

Indeed, while city officials try to build a model program of treatment on
demand, Townsend is staking her reputation on a different model: coerced
treatment. Last year the legislature approved Townsend's proposal to
administer twice-a-week drug tests to 25,000 people on probation or parole.
Under the $2.9 million program, positive tests for cocaine, heroin or
marijuana would trigger a series of escalating sanctions--for a midlevel
offender, for example, the first failed test would lead to two days in
jail, then five, ten, thirty, forty-five and finally a return to court for
parole violation. "You don't have to want treatment for it to work," says
Adam Gelb, Townsend's policy director.

Researchers and treatment providers have mixed opinions on coerced
treatment. "If you have leverage, you ought to use it," says Dr. Robert
Schwartz, who directs the University of Maryland School of Medicine's
division of alcohol and drug abuse, and who consults with the Open Society
Institute in Baltimore. Still, Schwartz urges that coerced treatment not
squeeze out voluntary programs--which seems a real possibility were
Townsend to get her way. Beilenson urges the state to spend more on both
forms of treatment, arguing that the big savings will come from keeping
people out of the criminal justice system in the first place.

The idea that drug users belong in prison has in the past few decades been
carved deeply into US politics and won't be easy to change. In New York,
for example, a recent study found that the state spends $680 million a year
to lock up nonviolent drug offenders, and yet the legislature has stalled
on even modest reforms of its draconian Rockefeller drug laws. Those laws,
adopted in the early seventies, were quickly adopted by other states and by
federal officials. Now, the damage is apparent even to many hawks. "We have
a failed social policy, and it has to be re-evaluated," national drug
policy director Gen. Barry McCaffrey said this year. "Otherwise, we're
going to bankrupt ourselves."

Of course McCaffrey won't propose the next logical step, which would be to
eliminate mandatory minimums and other harsh measures and redirect that
money into treatment. During his 1992 campaign, Bill Clinton pledged to
enact "treatment on demand." He quickly abandoned the promise, not just
because it would be expensive but because it runs contrary to a winning
political formula: more arrests, longer sentences, more jails.

The experiment in Baltimore challenges that formula. Officials there are
driven by the basic instinct that drug users need help, not punishment. But
they also believe the policy makes fiscal sense. And they know they'll have
to support that view with hard numbers. That's why Beilenson contracted
with a team of independent social scientists (from Johns Hopkins and two
other universities) to measure the crime, health and income of three groups
of addicts in Baltimore: those who get treatment immediately, those who
have to wait and those who get no treatment at all. The results of the $2.8
million study are expected in 2001. If it confirms Beilenson's argument
that "treatment saves money and treatment on request will save more," the
study could turn an iconoclastic experiment into a model for other cities
and states. Today, the idea of universal, immediate treatment on a national
scale is hard to imagine. But then, so was Governor Nelson Rockefeller's
idea that possession of two grams of cocaine deserved fifteen years in prison.

Note:
Joshua Wolf Shenk has written for Harper's, GQ, The Economist and
other publications. He lives in New York City.