Source: New York Times (NY)
Pubdate: Tue, 21 Apr 1998
Author: Cheryl Gay Stolberg


WASHINGTON -- After a bitter internal debate, the Clinton administration on
Monday declined to lift a 9-year-old ban on federal funding for programs to
distribute clean needles to drug addicts, even as the government's top
scientists certified that such programs do not encourage drug abuse and can
save lives by reducing the spread of AIDS.

The decision, announced by Donna Shalala, the secretary of health and human
services, was immediately denounced by public-health experts and advocates
for people with AIDS, who had been told in recent days that the ban was
about to be lifted.

"At best this is hypocrisy," said Dr. Scott Hitt, chairman of the
President's Advisory Council on HIV and AIDS. "At worst, it's a lie. And no
matter what, its immoral."

The decision came after a week of negotiations between Shalala's staff and
the White House, according to two administration officials familiar with
the talks. Shalala had been pressing to rescind the ban, with some
restrictions, and was prepared to defend that decision on Capitol Hill,
knowing it was bound to be controversial.

But the president's policy advisers feared that Republicans might push
through legislation that would strip federal money from organizations that
provide free needles, even though the money was used for other purposes.
Late Sunday night, as Clinton returned from Chile, he decided to instruct
Shalala to announce that federal funds would not be released, despite the
scientific evidence that needle-exchange programs help prevent the spread
of HIV. "Any Republican could have offered a resolution, and we almost
certainly would have lost," said one of the officials, both of whom spoke
on condition they not be identified. "We don't have the votes for this in
an election year." To further complicate matters, Gen. Barry McCaffrey, the
retired Army officer who is the administration's director of national drug
policy, has been been fighting to retain the ban.

Sandra Thurman, the White House director of national AIDS policy, has
argued strenuously that it should be lifted. But McCaffrey argued that such
a move would send the wrong message to children -- a position that another
official said was "an important consideration" for Clinton.

The ban dates back to 1989, when Congress declared that no federal money
could be spent to support clean-needle programs until the government could
provide scientific evidence that such programs both reduced the spread of
HIV, the virus that causes AIDS, and did not encourage drug use. The
administration offered that scientific evidence Monday for the first time.
With the evidence in hand, the administration was free to begin drafting
guidelines for how federal money could be spent for needle-exchange
programs. Although Shalala's staff had come up with such guidelines, the
president declined to endorse them, officials said.

In effect, the decision means that state and local governments, which
receive block grants from Washington for AIDS prevention efforts, are still
barred from using that money for needle exchange.

As the debate has continued, needle-exchange programs have cropped up
across the United States. Today there are about 100 programs in 20 states,
many operating on a shoestring budget, with private or local funds. In many
states, needle exchange remains illegal, but law-enforcement officers look
the other way and allow the programs to continue. Public-health experts had
been hoping a release of federal funds would have legitimized these
programs. (In New York, officials can grant permission for certain
needle-exchange programs to operate.) "There are states that for years have
hidden behind federal opposition to needle exchange to justify their own
inaction," said Dr. Peter Lurie, who in 1993, while teaching at the
University of California at San Francisco, published the first
government-financed survey of the effectiveness of needle-exchange
programs. Monday's decision, he said, means state and local officials will
have to "push forward for needle exchange even in the face of the federal
government's cowardice."

Federal officials have estimated that every day 33 people become infected
with the AIDS virus as a result of intravenous drug use, a figure that
includes drug abusers themselves, as well as their partners and children.
Intravenous drug use is also responsible for most of the increase in AIDS,
particularly among the poor and minorities.

Dr. David Satcher, the surgeon general, said Monday that 40 percent of all
new AIDS infections in the United States are either directly or indirectly
attributed to infection by contaminated needles; among women and children,
the figure is 75 percent.

Lurie, who now works as a research associate at Public Citizen, a
Washington advocacy group specializing in public-health issues, estimated
Monday that had the government paid for needle-exchange programs, 17,000
lives could have been saved during Clinton's eight years in office. "It is
frustrating in the extreme," he said, "to see political considerations take
precedence over public-health ones, particularly when a huge cost in human
life is predictable."

The decision clearly made the government's top scientists uncomfortable. At
the press conference announcing it, Shalala was accompanied by a phalanx of
them, including Satcher and Dr. Harold Varmus, director of the National
Institutes of Health, as well as two institute directors and two officials
from the Centers for Disease Control and Prevention in Atlanta. Most
shifted uncomfortably in their seats as reporters peppered Shalala with
questions about the administration's decision, although none publicly
disagreed with it.

Shalala declined to discuss the internal debate between her office and the
White House -- or even her own recommendations to the president -but said
the administration hoped that its pronouncement would spur state and local
governments to pay for the programs on their own. In defending the decision
not to release federal funds, she said studies show that needle-exchange
programs work best when they are carefully designed within local

"We are sending the message that the senior scientists of this government,
in conjunction with a number of scientists around the world," have
concluded that "these needle-exchange programs do in fact work in reducing
HIV transmission and do not encourage drug use," she said. Indeed, while
critics have complained that the programs promote drug abuse, Varmus said
Monday that is clearly not the case. An extensive review of the scientific
literature, Varmus said, provided "increasingly strong evidence" that
needle-exchange programs can be an effective means of bringing addicts in
for treatment.

He cited a Baltimore study of nearly 3,000 addicts, which found that the
needle-exchange program dramatically reduced the sharing of tainted
needles, and that half the participants in the program entered treatment.
As expected, Monday's decision prompted a flurry of announcements from
Congress. Sen. John Ashcroft, R-Mo., called the administration's position
"an intolerable message that it's time to accept drug use as a way of
life." But Rep. Nancy Pelosi, D-Calif., complained that the administration
had missed an opportunity to save lives. "It defies logic," she said, "to
determine a program's efficacy and then not fund the program, especially in
the middle of an epidemic. The administration's decision shows a lack of
political will in the midst of a public-health emergency."