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R.R.
Frerichs Posting
Earlier this week Dr. Tim France distributed a message to SEA-AIDS sent
out by the American Foundation for AIDS Research (AMFAR) on the Clinton
Administration's stance (or better, "non-stance") on government funding
of needle exchange programs. Dr. France concluded with a question if the
AMFAR posting "might present a valuable advocacy opportunity for statements
in Asian countries?"
Before advocacy groups throughout Asia start moving forward to endorse
needle-exchange programs, they might want to consider an interesting commentary
which appeared in yesterday's Wall Street Journal (see below). The author
suggests that more study would be useful. Likely the scientific debate
on this contentious issue will continue until additional investigations
are completed and methodological issues are resolved.
It seems logical
for advocacy groups in Asia to await the findings of local investigations
and small demonstration projects in their own countries, before recommending
widespread implementation of a controversial, and possibly harmful policy
that is still being actively debated in the United States.
Commentary: "Clean Needles May Be Bad Medicine"
By DAVID MURRAY (Wall Street Journal, April 22, 1998)
The Clinton administration on Monday endorsed the practice of giving
clean needles to drug addicts in order to prevent transmission of the AIDS
virus. "A meticulous scientific review has now proven that needle-exchange
programs can reduce the transmission of HIV and save lives without losing
ground on the battle against illegal drugs," Secretary of Health and Human
Services Donna Shalala announced.
The administration is not unanimous, however; the drug czar, Gen. Barry
McCaffrey, who opposes needle exchange, was out of the country Monday.
Who's right? As recently as a month ago, HHS had resisted needle-exchange
programs. "We have not yet concluded that needle exchange programs do not
encourage drug use," spokeswoman Melissa Skolfield told the Washington
Post March 17. By Monday the department had reached that conclusion, though
the scientific evidence that needle exchanges don't encourage drug use
is as weak today as it was a month ago. In fact, the evidence is far from
clear that needle-exchange programs protect against HIV infection.
Most studies have had serious methodological limitations, and new studies
in Montreal and Vancouver have revealed a troubling patternIn general,
the better the study design, the less convincing the evidence that clean-needle
giveaways protect against HIV.
The Montreal study, the most sophisticated yet, found that those who
attended needle-exchange programs had a substantially higher risk of HIV
infection than intravenous drug addicts who did not. In a much-discussed
New York Times op-ed article two weeks ago, Julie Bruneau and Martin T.
Schechter, authors of the Montreal and Vancouver studies respectively,
explained the higher risk this way." Because these programs are in inner-city
neighborhoods, they serve users who are at greatest risk of infection.
Those who didn't accept free needles . . . were less likely to engage
in the riskiest activities."
Dr. Bruneau is apparently rejecting her own research. For her study
had statistical controls to correct for precisely this factor. In the American
Journal of Epidemiology, Dr. Bruneau wrote "These findings cannot be explained
solely on the basis of the concentration around needle-exchange programs
of a higher risk intravenous drug user population with a greater baseline
HIV prevalence."
Even more troubling, Dr. Bruneau reported that addicts who were initially
HIV-negative were more likely to become positive after participation in
the needle exchange.
Dr. Bruneau speculated that needle-exchange programs "may have facilitated
formation of new sharing networks, with the programs becoming the gathering
places for isolated [addicts]."
Janet Lapey of Drug Watch International says needle-exchange programs
often become "buyer's clubs" for addicts, attracting not only scattered
users but opportunistic dealers. Not everyone agrees. Dr. Schechter says
that when he asked his study's heroin users, they reported meeting elsewhere.
But a delegation from Gen. McCaffrey's office returned from Vancouver in
early April with some startling news.
Although more than 2.5 million clean needles were given out last year,
the death rate from illegal drugs has skyrocketed. "Vancouver is literally
swamped with drugs," the delegation concluded. "With an at-risk population,
without access to drug treatment, needle exchange appears to be nothing
more than a facilitator for drug use."
The problem for science is that no study has used the most effective
method for settling such issues--a randomized control trial. Moreover,
needle-exchange programs are usually embedded in complex programs of outreach,
education and treatment, which themselves affect HIV risk.
A 1996 study showed that through outreach and education alone, HIV incidence
in Chicago-area intravenous drug users was reduced 71% in the absence of
a needle exchange.
Peter Lurie of the University of Michigan argues that "to defer public
health action on those grounds [awaiting better research] is to surrender
the science of epidemiology to thoughtless empiricism and to endanger the
lives of thousands of intravenous drug users." But Dr. Lurie's reasoning
appears circular.
Only someone already convinced that needle-exchange programs are effective
at preventing HIV can claim that addicts are jeopardized by further testing.
And drug use carries risks besides HIV infection. A recent article in the
Journal of the American Medical Association warned that the arrival of
a new drug from Mexico called "black-tar heroin," cut with dirt and shoe
polish, is spreading "wound botulism." This potent toxin leads to paralysis
and agonizing death, even when injected by a clean needle.
Thus, dispensing needles to the addicted could produce a public health
tragedy if this policy does indeed place them at greater risk for HIV or
enhances the legitimacy of hard drug use. Simply put, the administration's
case is not proven. Mr. Murray is director of research for the Statistical
Assessment Service, a nonprofit group in Washington.
After reading this I wondered more about David Murray and the organization
he represents. I searched on the world wide web and found his organization
address at [site is no longer applicable].
They list in the "about Stats" section their affiliation status (i.e.,
"nonpartisan, non-profit research organization") and present their board
of advisors, one of whom is Dr. James Q. Wilson, a distinguished Professor
Emeritus of political science at UCLA. I sent a brief note to the Statistical
Assessment Service last night and asked about David Murray. Here is part
of what they wrote back this morning.
Brief Academic Bio for David Murray, M.A., Ph.D. University of Chicago
(Social Anthropology).
Taught at Connecticut College, Brown University, Brandeis University
(total of 16 years). Interests include social theory and research method,
the philosophy and ethnography of scientific practice, cognition and linguistics.
Currently Director of Research for STATS, a non-profit group concerned
with the role of scientific research in media and public policy, and Adjunct
Professor in the Graduate School of Public Policy at Georgetown University.
I also read some of their other postings and found them to be very insightful.
But don't trust me, judge for yourself by going to their web site. Likely
the above posting on the needle exchange controversy will join their many
others at the http://www.stats.org/ site
in the coming weeks.
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