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