DOING HARM BY DOING GOOD

A new study of the use of needle exchanges to restrict the spread of
HIV in Montreal, published in the American Journal of Epidemiology,
suggests that the "harm reduction" approach to AIDS does the opposite.
It found that 7.9 per cent of needleexchange users contracted HIV
between September 1988 and January 1995, as against only 3.1 per cent
of those who did not.

The theory behind needle exchanges was that since sharing needles for
intravenous drug use is the second most significant means of HIV
transmission, giving out clean needles would help limit the problem.
It hasn't. In 1996 alone, Vancouver's Downtown Eastside Youth
Activities (DEYAS) needle exchange program handed out 2.38 million
needles 2.38 million. Yet eight per cent of Vancouver's intravenous
drug users are HIV positive, as against only five per cent in Miami's
ghettos.

The American experience with AIDS is equally stark. Abandoning
traditional, proven disease control methods, U.S. policymakers
concentrated on making risky behaviour less risky instead of less
frequent. But according to the World Health Organization, in 1993 (the
last year for which it had figures) the rate of new AIDS cases per
million people per year in the U.S. was 276 (and in the American
dependency of Puerto Rico a staggering 654) while in Brazil it was 75,
in Mexico 46 and in Argentina 48.

How can this be? The answer is that "harm reduction" strategies fail
because they work. Human beings are complex, strange creatures. But
all of us have a variety of desires and limited resources for
achieving what we want, and therefore we all face the necessity of
making choices based on an assessment of costs and benefits.

So any policy that reduces the costs of certain courses of action,
however inherently unattractive, guarantees that more people will
engage in them. Some people will use drugs intravenously even when
sterile needles are not available. Making them available does not
change that fact. They would rather use clean than dirty, but will use
either. And the more they use the more likely they are to make a
mistake, especially if they feel safer than they are.

Another group, with a slightly better grip on their lives, will shoot
up when, but only when, sterile needles are available. But more use
means worse addiction. So distributing needles results in more people
engaging in risky behaviour that may become fatal when, over time,
they become so desperate and degraded they will shoot up with or
without a clean needle. Safe facilities for shooting up also seem to
increase needle sharing and infection.

Two lessons emerge: First, we must eliminate "AIDS exceptionalism" and
treat it like any other epidemic. Second, public policy must always
take a dynamic rather than a static view. What matters is not only how
changing incentives will affect those who already engage in a certain
kind of conduct, but how and whether it will encourage others to do so
as well.

Lest this analysis be seen as "further victimizing the marginalized,"
it should be noted that "harm reduction" seems to be killing the very
people it seeks to help.

Copyright 1997 The Ottawa Citizen