A CLEAN START

City Limits -- New York City's urban affairs news magazine - in its
July/August issue profiles new needle-exchange programs intended to reduce
the spread of HIV among injection drug users in New York City. Tom Frieden,
the city's health commissioner, has "adopted harm reduction as the ethic"
of the city's Department of Health and Mental Hygiene, and is supporting
funding to expand needle-exchange programs into neighborhoods in Queens and
Staten Island, according to City Limits

The city's health commissioner wants New York to be a leader in preventing
drug users from getting AIDS. So why are so many people who agree with Tom
Frieden's goal so alarmed by his methods?

Robert Soto is known as "the polar bear" by folks on the block--that's the
block, at the intersection of Knickerbocker Avenue and Troutman Street in
Bushwick, where the NYPD has been trying and failing for a decade to get
rid of the drug trade.

Since 1992, when the New York Times identified the area as the city's most
brazen drug market, the cops have spared nothing trying to bring it under
control.

None if it has worked.

Rain or shine, Soto's out here three nights a week. That's why they call
him the polar bear--he never gets cold. "They got the best heroin over
here, so they keep coming back," Soto says, explaining why police can't
snuff it out. "Even people as far as Rochester know it," he laughs, shaking
his head in marvel. "Knickerbocker and Troutman!"

Sitting hunched over in the door of his van, an unlit cigarette dangling
over his graying goatee, Soto comes off like a Latin Tony Soprano. In fact,
his whole crew looks and acts like drug dealers.

They strut up and down Knickerbocker, tossing knowing head nods at
acquaintances. But they're not selling dope--they're distributing needles
and condoms and first-aid kits.

"We're all old hustlers, so we know the game," explains Fernando Soto (no
relation), who runs the program they work for, called Afterhours. If you're
going to connect with people on a block this charged, you can't just walk
up on somebody yapping about needles.

You've got to blend in, let them see you're not an undercover cop.

The group's van is parked halfway between the area's prostitution and drug
market, which puts it right in the path of sex workers coming to and fro.
"Yo, you got condoms?" asks someone in a group passing by. One of the women
wears her long hair in a swoop down the side of her face and neck. Soto
guesses she's hiding track marks; when you've been using hard for a long
time, you've got to find places to shoot where you can get a quicker,
stronger high. The women who work this stroll are using with that kind of
intensity. They choose the location for the convenience: Once they turn a
trick they can go just a few blocks and cop a bag, and repeat the process
all night.

Up the street, several regular customers are lingering in front of a
bodega. One guy's been trying to get his girlfriend into detox through Soto
for weeks, but she won't show up for the appointments. They're both waiting
for some clean needles and first-aid kits, but Soto can't get them to walk
down to the van. This kind of passiveness is why he'd prefer to park right
at Troutman and Knickerbocker--a lot of customers can't be bothered to hike
the block and a half just for a clean needle.

But the police write the rules around here, and they're gradually shoving
the van down the street.

The 83rd Precinct, like most in New York City, worries that people giving
out needles will draw users to the area.

In New York City, efforts to slow HIV's spread among and beyond drug users
has looked a lot like this block-by-block turf war between cops, users and
AIDS activists.

But now the city Department of Health is giving an unprecedented government
seal of approval to programs like this. It is, for the first time,
instigating a new needle exchange operation, the first expansion of the
city's network since outlaw activists launched sites over a decade ago.

From the first days of AIDS, injection drug use has been a favored vector
for the virus.

It still accounts for half of the epidemic, and that's without considering
the people who get the virus by having sex with infected users.

Researchers in Europe learned pretty quickly that a cheap, effective way to
break the link between drug use and HIV was to flood the market with new
syringes, and thus eliminate the needle sharing that passes the virus.

But distrust of needle exchange runs deep in New York City. Entire
communities, terrorized by the drug trade and its fallout, have been dead
set against it. In 1986, Albany joined the first wave of state legislatures
to criminalize the possession or sale of syringes.

In response, Ed Koch's health department broached the idea of exchanging
used needles for clean ones. The black community's reaction was as swift as
it was vitriolic.

The Amsterdam News called for Koch's resignation. Harlem Councilmember
Hilton Clark labeled it a "genocidal campaign," and black Police Chief
Benjamin Ward compared it to the infamous Tuskegee syphilis experiments.
Koch still eventually set up a tiny test project, but one of Mayor David
Dinkins' first acts in office was to shut it down.

Mayor Bloomberg's confident young health commissioner is the first City
Hall official to step back into this minefield.

With his workplace smoking ban, Tom Frieden has already made a name for
himself as a public health crusader. But with far less fanfare, Frieden has
also set out to radically reshape how we treat drug users.

When Frieden took office in 2002, he officially adopted harm reduction as
the ethic of the health department. If someone's using gobs of crack each
day, you don't push detox, but rather teach the person how to savor the
first hit--which is the best one--and thus cut down the volume being used.

Frieden has launched a plan to expand needle exchange into three Queens
neighborhoods--Long Island City, Jamaica and Far Rockaway--and he intends
to move into Staten Island once that's done. He has also worked with the
City Council over the past two years to funnel city tax dollars into the
programs for the first time. And he's not stopping with needle exchange:
Frieden wants to use public money to hand out overdose-prevention medicine
to addicts.

He's cajoling local doctors to start prescribing a new treatment for opiate
addiction.

And he's working closely with gay activists to slow the spread of crystal
meth in Chelsea.

New York has never seen this stuff before.

With some notable exceptions, like San Francisco and Baltimore, neither has
the rest of the country.

By focusing strictly on producing results, Frieden is giving AIDS activists
exactly what they have spent the last 20 years begging government for: He's
taking the politics out of public health.

The problem is that may not be as good an idea as it sounds.

Frieden's critics say that his focus on research and results is refreshing
but leaves him unwilling to engage in community dialogue.

Without that, even the best ideas struggle to move from proposals to policies.

And Frieden's closest allies in the fight against AIDS fear his radical
harm reduction ideas will wither if he doesn't become an expert not just in
public health, but in politics, too.

You don't walk into a senior center in Queens and have a casual
conversation about giving out needles to addicts.

But here's Frieden doing exactly that. And why not? He's armed, after all,
with data. He likes to answer questions by beginning "the data show...,"
the way a pastor might call up his favorite Bible verse when put on the spot.

There are the 80,000 New Yorkers living with HIV--a "terrible blight," he
reminds everyone at the Long Island City community board meeting.

There's the fact that we've got the largest number of injection drug users
in the country, and thus more infected with the AIDS virus than anywhere else.

Pushing the other way, New York City is home to nine privately run needle
exchange programs, which in the last decade have helped cut the HIV
infection rate among drug users by half. And don't forget the savings.
"They are actually by far the most cost-effective means of preventing HIV,"
Frieden points out, sounding like a high school science teacher unveiling
the ta-da! conclusion of a chemistry experiment. "For whatever reason," he
shrugs in conclusion, "there has never been a program in Queens." Frieden
is wise to gloss over the reason why: The last time anyone tried to open a
needle exchange in Queens, Borough President Claire Shulman stopped the
conversation cold.

In Manhattan and Brooklyn, AIDS activists prevailed--between 1992 and 1995,
they set up those nine programs, with permission from the state health
department and their local community boards.

But not a single new needle exchange has opened since then, and some
places--including all of Queens and Staten Island, as well as much of the
Bronx--have never had one.

To expand into those realms, Frieden needs the approval of each
neighborhood's community board.

That's why he's in Long Island City tonight, advocating a plan that would
allow the AIDS Center of Queens County to distribute needles from a van
parked next door to the Queensbridge Houses, the massive public housing
complex on the northern edge of Long Island City. But when he finishes his
calm, deliberate presentation of the public health facts, the commissioner
faces hostility strong enough to take you back to 1986. "The health
department has used and abused the entire community board process," rails
one minister from the Center of Hope International, the neighborhood's most
influential black church.

Another reads a letter from the church's pastor, who is tired of seeing his
community used as "a dumping ground for people who do not think we know
what's best for our neighborhood." One by one, a group of black ministers
rise to vent rage at the otherwise all-white room, and urge the board to
halt its proceedings--"I just don't think this is right!" All this from a
ministry that supports the idea of needle exchange.

The ministers were at the meeting because Long Island City's council
member, Eric Gioia, had brought them there specifically to create this
scene. It was the first time Frieden or anyone from the health department
had spoken to the church or to anyone from Queensbridge Houses. For that
matter, the department had done little to take advantage of Gioia, who is
both politically progressive and enormously popular in Queensbridge, to
help sell its ideas to his constituents. Data, Frieden and his staff seemed
to believe, would provide all the persuasion necessary.

Clearly, data was not enough.

Gioia and the Queensbridge leaders were furious they hadn't been consulted
on the proposal that the board was poised to approve.

As a result, would-be allies in Frieden's effort became staunch foes, and
the board was forced to discard the AIDS Center's ambitious proposal.

Weeks later a new one would emerge, but to many of those who have been
doing this work for the last 10 years, that compromise was hardly a move
forward in the fight against AIDS.

With some 15,000 residents, Queensbridge is the largest public housing
complex in the nation.

But it owes its worldwide notoriety to the songs of hip-hop artist Nas, who
grew up there and performed chart-topping odes to the wide-open drug trade
it hosted in the 1980s and 1990s. They call me Nas, I'm not your legal type
of fella/ Moet-drinkin', marijuana-smokin' street dweller.

It's the image that Nas invokes--of shootouts and purse snatchings, of dope
fiends roaming the streets and pissing in elevators--that older
Queensbridge residents think of when they hear about drugs. Near as they
can tell, the cops have finally run that sort of thing out of their world.

"When the crack epidemic was here, I used to find crack vials and all
that," recalls Rita Normandeau, who has lived with her husband, Raymond, in
Queensbridge since the early 1970s. She twists up her face in disgust at
the memory.

The Normandeaus realize some people still use drugs, but nothing like in
those days. "The biggest contraband at Queensbridge now is cigarettes--$5 a
pack," Raymond jokes.

Hardly enough, they think, to justify putting in a needle exchange, which
they worry would pull drug users back to the neighborhood.

It's a few weeks after the Long Island City community board encounter, and
the Normandeaus and other residents at the monthly Queensbridge tenants
association meeting are revisiting the episode--but they're not so much
focused on AIDS or drugs as they are on how much they resent Frieden. Gioia
reminds them why. The boyish Queens native is giving a typically rapid-fire
soliloquy on the way bureaucrats sequestered in lower Manhattan abuse the
boroughs, and in the process he's slinging a load of carpetbagger mud at
the commissioner. "He's not from here," Gioia tells the group, one of the
city's more politically engaged tenants organizations. "You can't do things
from on high. You can't do things from City Hall. Think about how much I'm
around."

Indeed, the young, progressive white guy is loved by Queensbridge's aging,
largely conservative and black civic gatekeepers precisely because of his
hands-on political style.

He knows the first name of almost every audience member who asks him a
question but also knows enough to instead use Mr. or Mrs. when he's
noticeably younger than that person. "He comes around," testifies Rita
Normandeau. "He's not a phony."

As has been the case since Koch's beleaguered proposal, the fire Frieden
took at the community board meeting was not so much about drugs as it was
race. Standing on the street in Queensbridge, you can look south over the
Queensboro bridge, just past the Dharma & Greg billboard, into the rapidly
gentrifying and increasingly white central Long Island City. The folks on
the north side are starting to feel put out. What's more, the two sections
of Long Island City are represented by two different community boards.

In this context, the needle exchange proposal on the table that night
couldn't have been more explosive: The site proposed for the van straddled
the border between the two boards and the two worlds they represent.

The health department and AIDS Center of Queens County say they approached
both boards, but only the one south of the bridge responded--that's why the
Queensbridge residents weren't in the loop about the plan. People in
Queensbridge say a bunch of shifty bureaucrats conspired with the Long
Island City crowd to put a needle exchange on their doorstep without having
to get permission. When asked about charges that he and the AIDS Center
avoided consulting Queensbridge, Frieden shrugs it off as political
pandering. "That's what one politician would have you believe," he
concludes. Frieden sees the dispute as merely one over where the needle
exchange should be located--near Queensbridge Houses, or further into Long
Island City proper--and says that's heartening. "This time last year," he
notes, "you had, at best, people not talking about it at all."

When he took over the health department, Frieden conducted a review of the
city's AIDS programs, identified the needle exchange network as a cheap and
effective prevention strategy, and zeroed in on its clear gaps. The
department contacted AIDS Center of Queens County and offered support for
the grueling process of getting permission to expand into those places.
"The department felt, and the commissioner certainly was in the lead on
this, that if we really were invested in this we needed to not just be
providing the fiscal support, but we should be visible in Queens," explains
Marjorie Hill, Frieden's associate commissioner for HIV/AIDS.

But the local elected officials had no idea the site approval process was
up and running.

Borough President Helen Marshall learned of the plan while reading a Queens
newspaper--not exactly how you build good will in a town where turf means
everything. When Frieden finally did call together the electeds, "she
actually brought that article to the meeting," says a Marshall
spokesperson. "And she said, 'We've got to know more about this.'"

After what an attendee characterized as an "acrimonious meeting," the
politicians agreed it was time to bring needle exchange to the borough, and
that they would work together with the health department on it in the
coming months.

But later that day, Gioia found out that the health committee of Long
Island City's community board was voting on a proposed site that night.

Gioia wanted the program to open, he says, but didn't have a chance to have
a meaningful conversation with his constituents, never mind persuade them
that a needle exchange would be an asset to their neighborhood. "It's been
my experience that when you're respectful to people, you can actually get
them to agree to things they may not have originally agreed to," Gioia says
now.

In the end, the health department met with the tenants' association and the
church.

Everyone kissed and made up, and the Center of Hope's pastor has even
joined the advisory committee for the new needle exchange.

But the original plan would have cleared the AIDS Center of Queens County
to dispatch a mobile crew, much like Afterhours does, to work its way into
the local drug scene.

In the compromise, brokered by Marshall, the program will instead be housed
in the AIDS Center of Queens County's office on Hunter Street in central
Long Island City, once the state signs off on the plan later this year.
That's nowhere near the epicenter of the area's drug trade, and many needle
exchange veterans fear the program has thus been set up for failure.

Afterhours is run by a very different set of rules than the new Long Island
City program will operate under.

Three years ago, state lawmakers cleared pharmacies to begin selling
syringes without a prescription and allowed medical institutions to give
out up to 10 needles to anyone asking. Fernando Soto convinced Wyckoff
Heights Hospital to let his group work under its license in Brooklyn and
Queens, and Afterhours was born. Because it's not a needle exchange, they
don't need community approval to enter a neighborhood, but neither do they
qualify for public funding.

The research that anthropologist Ric Curtis has done on the city's changing
drug markets led Afterhours to launch a mobile operation. Aggressive
policing of drug-heavy neighborhoods hasn't done much to stop the trade,
but it has dramatically changed its structure. "Many of the businesses had
been modeled on the McDonald's or Wal-Mart style of operation," says
Curtis, a professor at John Jay College of Criminal Justice, who helps fund
Afterhours and studied Long Island City's drug market for the health
department. "They had all these street-level functionaries that were just
interchangeable cogs for them, but they were getting arrested in
extraordinary numbers." That meant hassle and cost--constantly replacing
old trusted workers with new ones that needed to be more closely monitored;
regularly losing product to cops. "So eventually they said, 'You know what?
Fuck this. It's too much of a pain in the ass. We're gonna downsize.

We'll retain management and lop off labor. And management is gonna go to a
new style of business.'"

That new style employs beepers, cell phones and delivery boys, not kids
conspicuously hanging out. Now the only people on the streets are the
users, carrying around lists of phone numbers for the area dealers and
frantically trying to arrange meetings.

Gone too are the shooting galleries that once thrived in abandoned
buildings and vacant lots.

More typical is a house near Knickerbocker and Troutman. It's a private
residence, owned and occupied by an older man who has lived in the
neighborhood for some time, but he lets a number of the prostitutes who
work the stroll crash and hang out there.

After they get a bag, they go by the house and shoot up; the guy takes a share.

Only people the owner knows can come in. "At first I thought the old man
was the pimp, but he's not," says Fernando Soto. "He gets his. But he looks
out for them--or that's how they see it, anyway." Soto's Afterhours crew
connected with the house after a couple of years of stalking the
neighborhood and networking, operating like dealers.

Now the owner lets them come in, too.

The Afterhours group is slowly working through the Bushwick area, trying to
unearth these hiding spots.

So far, the team has found about 200 clients there.

What Curtis and Soto have demonstrated is that coming to users, instead of
counting on them to show up at a clinic, is the way to ensure results.

But their mobile operation remains unique.

Few other needle exchanges can trawl the streets like this, because their
community boards have permitted them only to operate out of a fixed
location, and usually only during the day. According to Curtis and several
others who monitor needle exchanges, operating with these constraints is
becoming less and less effective, and several programs report reaching
fewer clients each year. The state health department refused to allow an
interview with the office that collects and analyzes that data. But the
city health department and AIDS center of Queens County say the difficulty
getting users to make a special trip to a fixed location is precisely why
they sought to get a mobile van in Long Island City: According to the data,
it made public health sense.

Politics, damn them, got in the way.

At just 43, Frieden has already picked and won an impressive set of public
health battles.

Those victories have been the result not of slow, deliberative
consultations, but rather of his willingness to make unpopular decisions
driven by one thing above all else: the data.

Frieden began his career as an officer in the Centers for Disease Control
and Prevention's Epidemiological Intelligence Service. If Clint Eastwood
worked in health, this is the job he'd have. Agents are deployed around the
country as public health's forward defense, sniffing out new threats like
West Nile and SARS. Frieden served in New York City, where he unearthed the
spread of a drug-resistant form of tuberculosis. Since he found it, he got
the job of getting rid of it, and in 1992 became the city's director of TB
control.

He quickly proved himself impatient with bureaucracy and politics.

Facing complaints from civil liberties advocates, he pressed ahead with a
plan to detain and forcibly treat people who weren't adhering to their
regimens, thereby heading off the proliferation of new drug-resistant strains.

At the same time, he dismissed the popular notion that people who are on
drugs can't be trusted to stay in treatment.

He instead sought the counsel of the early needle exchange programs, and
learned that the real problem wasn't drug use itself but the chaotic
lifestyle it fosters.

So he got addicts with TB into stable housing and, voila, they followed
their treatment.

After four years, Frieden had cut the number of drug-resistant TB cases in
the city by a whopping 80 percent and had developed a reputation as one of
the world's brightest minds on tuberculosis control.

He left New York for India in 1996, where he did the same job for the World
Health Organization, again slashing the disease's prevalence. When
Bloomberg tried to recruit him back as the city's health commissioner,
Frieden reportedly said he'd only accept the job if he was allowed to take
on big tobacco.

Now the commissioner is cavorting with the likes of Alan Clear, head of the
Harm Reduction Coalition and a national leader on needle exchange.

A shaggy-haired Brit who was among the outlaw activists handing out needles
on the Lower East Side before it became legal, he's not exactly a City Hall
insider. "I don't even know who the last health commissioner was," he
admits. But a few months ago, Frieden brought him into the Department of
Health to school the entire staff on the principles of harm reduction.

"They get it," says Positive Health Project executive director Jason
Farrell, who is another in the burgeoning group of consummate outsiders who
praise Frieden. "The city is in a tight budget crisis--you know that and I
know that. They're looking at trimming the fat. So they put the money where
it works." Indeed, with 13 employees and an annual budget of less than $1.2
million, Farrell's needle exchange in Hell's Kitchen reaches 100 people a day.

At one point, Frieden wanted to spend half a million dollars to hand out
overdose prevention medication through the needle exchanges.

People usually shoot up with at least one other partner, so Frieden figures
if we have each of them carry around a dose of nalaxone--which EMTs use to
jolt people out of drug comas--we'll cut the city's nation-leading rate of
drug overdoses. The general counsel's office nixed the idea of using tax
dollars because of liability concerns, but Frieden's now helping needle
exchange programs glad-hand from private sources to pay for it. "It's
definitely amazing," says Daliah Keller, executive director of the
Bronx-based CitiWide Harm Reduction, which is raising money to lead the
overdose-prevention initiative. "I think we're really fortunate."

But even the commissioner's loudest cheerleaders in the AIDS world cringe
at his style.

He may be apolitical, but he's also reluctant to take advice from the
communities his radical ideas affect.

Descriptive labels like "arrogant," "forceful," and "healthy ego"
invariably come up. When he's making decisions you like, its great; when
he's not, you don't feel like you've got much choice but to swallow them.
"We like him now because he's doing what we want," says Clear. "But maybe
he'll piss us off, too."

From Frieden on down, the health department has drawn a striking amount of
hostility from AIDS activists.

In one meeting of a community panel that Washington has empowered to
oversee how the city spends federal AIDS dollars, a member lashed out at
Hill by saying her mother must not have been very good at teaching how to
tell the truth.

People with as much establishment cred as New York AIDS Coalition Executive
Director Joe Pressley have been arrested on the steps of City Hall in
demonstrations--he, too, called Frieden a liar.

Much of the anger stems from Frieden's original sin in the AIDS
community--his decision to move the city's Office of AIDS Policy, which had
been an independent agency that administered the community oversight panel,
into his own Department of Health. Frieden was convinced it was inefficient
to have separate AIDS bureaucracies. Activists disagreed, arguing to anyone
who would listen that the office served as an essential check on the Health
Department. Rather than attempt to sell his idea, Frieden did it on the
down low. "There were direct questions posed to the commissioner and Deputy
Mayor Dennis Walcott," says Pressley, "and they said, 'No, it won't
happen.' It happened." Frieden then created his own panel of community
members to advise the health department on AIDS--which he handpicked and
which meets behind closed doors. (Clear sits on the panel.)

Frieden apologizes for none of this. Activists may be concerned about the
Office of AIDS Policy's oversight role, but he's focused on its
responsibility for preparing the city's annual application for federal
funding. With that process under the health department's control, he points
out, the city got an $18 million boost this year. "I kind of wish people
would focus on the substance," he says, "rather than the symbolism."

Moreover, even Frieden's critics agree that he has been more visible and
accessible than any health commissioner in memory.

He's met with every HIV community planning body in the city--usually
nodding respectfully as they light into him. But critics say he's not much
of a listener. "It's refreshing to have a very smart guy who doesn't feel
like a politician," says Keller. "But the problem is that the way he comes
off is, 'I know best. I'm the expert.

And I don't care what you think.'"

Frieden sees this all as a diversionary conversation about style rather
than what matters: lowering HIV infection. "I'm really blunt about things,"
he shrugs, "and you have groups that have created large organizations that
are very wedded to one model of doing things."

The lingering question is whether Frieden's impatience with the
give-and-take of community politics is actually preventing him from
achieving the bottom-line results he seeks.

In the end, can you really take the politics out of public health--and
should you? Harm-reduction veterans say the final plan for the Long Island
City needle exchange is a shadow of what it could have been if the
department had started by building support within the community it planned
to target. "It's wonderful to have a commissioner that's so supportive of
syringe exchange and wants to put himself out so far," says Keller. "But I
think what's missing is, you need bottom-up as much as you need top-down."

Keller's speaking from experience. Like Afterhours, her group is one of a
few that are mobile.

CitiWide works in apartment buildings that contract with the city to house
poor people living with HIV. But when buildings leave the program, CitiWide
finds itself stuck, because going into a new building means first getting
community board approval in that neighborhood. Over the years, the group
has lost all four of the buildings it once served in the Bronx, and to make
up for that gap it decided to add an exchange at its office near The Hub.

CitiWide began reaching out to the surrounding community in the fall of
2001, and spent the next year and a half locked in a punishing political
campaign. They took the fight directly to their most obvious foes, like the
police precinct and the parents' groups--meeting individually with the most
hostile board members--and hashed out all the usual questions.

They rounded up local users and had them meet with those in opposition, to
explain for themselves why the program was needed.

And, in the end, they got one of the city's most expansive exchange sites.

It operates five days a week, 12 hours a day. "We managed to turn it on its
head," Keller brags. "Now we're like the darling of the community."

This is the sort of process AIDS activists would like to have seen Frieden
and AIDS Center of Queens County engage in Queensbridge and Long Island
City. The battle that ensued in those neighborhoods was nothing compared to
the controversy needle exchange is likely to stir in Jamaica and Far
Rockaway. Marshall has taken on a more prominent role in the community
outreach process, and meetings have already begun in Jamaica. But the
stakes go up there, too: Jamaica boasts more people diagnosed with AIDS
than do 19 states.

AIDS activists are waiting on edge to see if Frieden learned something in
Queensbridge about how to play the community game.

Gioia just wants the health commissioner to see a broader point about
policymaking, and the politics that inevitably accompany it. "I hope the
lesson they learned from this is that you can't take people for granted,"
he says. "A flawed process is a flawed result." This article was produced
under the George Washington Williams Fellowship for Journalists of Color, a
project sponsored by the Independent Press Association.