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From condoms for teens to needles for addicts, doctors try to lead a divided public
By Anne Barnard, Globe Staff, 2/13/2001
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 Northampton.
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 shack like 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 Worcester 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.''
This story ran on page E1 of the Boston Globe
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