[Columbia Journalism School – Masters Project – May 2011]
[Some names have been changed to protect the identities of those whose actions are in violation of the law.]
On a gray, cold day in December, Julia, wearing jeans with holes and a zip-up hoodie, and Thomas, in Timberland work boots and a light sweatshirt, walked almost 20 blocks from Allen Street in the Lower East Side of Manhattan to the Stuyvesant Town apartment complex on First Avenue and 14th Street. Neither of them had gloves, though the temperature was nearly freezing. They had been walking around the city all day, as they did most days, unable or unwilling to spend their little money on the subway or cab fare.
As the daylight faded and it started to feel as if it might snow, they stopped outside one of the tall, plain brick apartment buildings of Stuyvesant Town and waited for someone to let them in. They stood outside the metal door, bouncing on the balls of their feet to keep warm.
Julia narrowed her eyes at Thomas when he suggested things might get physical with the man they were there to see. Last time they’d visited, John and Thomas had come to blows and when Thomas accused John of stealing his television set, John had told him not to come back.
“Thomas, you can’t start any shit up there, I’m serious,” she said. “If you do, I’m leaving. I don’t wanna get arrested. We have jobs to do.”
She was anxious and tired. She was fighting a cold and, without tissues, had been leaning over to blow mucus out of her nose onto the sidewalk most of the day. Thomas snickered at her threat, but almost immediately he softened. He relaxed a bit and recited his go-to phrase, “I love my Julia,” and gave her an awkward hug. She stiffened and rolled her eyes as he bent down to wrap his long arms around her narrow shoulders.
A couple of residents – a mother and daughter, it seemed – opened the outer door, and Julia and Thomas hurried into the vestibule, where Julia squatted on the floor in the hall to make one last check of the plastic shopping bag she’d been carrying. It held two boxes of one-inch needles, one box of half-inch needles, a box of 100 medical grade syringes, cotton balls, a handful of small plastic bags full of silver and gold bottle caps and a bright red bio hazard disposal box.
John is part of the extended circle of friends Julia and Thomas have made in their years of intravenous drug use; he deals heroin out of his tiny apartment in Stuyvesant Town. On that day, Julia and Thomas were making their weekly visit to supply him with the clean needles and syringes he gives to his regular customers.
“We’re not supposed to give syringes to dealers,” Julia said, as she pushed the buzzer for John’s apartment. “But I think if they need them, they should have them.”
Julia and Thomas are the harm reduction movement’s foot soldiers in the nation’s war on drugs. It’s a controversial battle that targets not the users or the dealers, but the dangerous ways people take drugs, and the diseases, such as HIV/AIDS and hepatitis, that often result from injecting them with unclean needles. Julia and Thomas know the dangers first hand; they’re both heroin users, and Thomas has been living with Hepatitis C for twelve years. Julia says she has been diagnosed twice with acute viral hepatitis – a form of the disease that usually resolves on its own without turning into one of the chronic forms, like B and C. They both say they are trying to get clean, but their syringe exchange job, for which they are paid a stipend of $100 every two weeks, keeps them in constant contact with other users.
The more traditional generals in the drug war are skeptical of, if not morally opposed to, this focus on harm reduction over use reduction. But decades of medical research show that syringe exchange works to combat disease. Between 1992 and 2002, there was a 25 percent decrease in new cases of HIV among intravenous drug users in New York, a statistic largely attributed to access to clean needles. The research indicates that HIV infection is reduced without increasing drug use or the litter of paraphernalia near storefront exchanges. A 2010 study from San Francisco State University showed that needle exchange programs might actually reduce the amount of paraphernalia litter.
The data on efficacy are now widely considered beyond argument, but have not led to increased sources of federal funding for needle exchange programs. Opponents say funding of syringe exchange programs is tantamount to paying for users to continue doing illegal drugs. This may be closer to the truth in Vancouver, where users can exchange dirty needles for clean ones and “shoot up” in the same safe place. That’s not what harm reduction advocates in the U.S. permit. They just need funds to continue providing a place for people who use drugs (or poor people in ill health who have to inject insulin or steroids) to safely dispose of used needles and get new, clean ones for free.
Until December 2009, federal funds were only available for the “support services” that harm reduction centers offer, such as HIV testing, outreach and prevention. New language in the Fiscal Year 2010 Consolidated Appropriations Act made it possible for some federal funding to also be used for syringe exchange. While this is a triumph of more than twenty years of legislative work, it isn’t enough. There is no additional money allocated for syringe exchange and most states still only use the funds, which come through the Centers for Disease Control (CDC), for support services.
But in New York, where the American harm reduction movement began in the 1980s, the state is working with the federal government to allow the use of federal money left over from fiscal year 2010 to fund syringe exchange. But not-for-profit service organizations like harm reduction centers usually don’t have money “left over,” and local advocates know their funding troubles are far from over.
The Lower East Side Harm Reduction Center on Allen St in Manhattan was one of the first, and it has struggled on and off with funding and stigma since it opened in 1992.
“It’s a miracle it’s still around,” said director Raquel Algarin.
Tucked among Chinese food markets, kitchen equipment suppliers and thread and fabric stores, the storefront windows are covered in flyers for group meetings and yoga classes, and a sign proclaiming that no drugs are to be sold or used on the premises. Most afternoons, men unload trucks of rice and fruit in front of the building, wheeling hand trucks back and forth on the sidewalk past the glass front door. This center is where Thomas and Julia receive their ongoing peer exchange training and where they come at least once a week to stock up on supplies.
On the day of the visit to John’s apartment, Julia had first stopped at the center, making her way straight to the alcove just inside the door, where an intern or employee checks in participants and handles exchanges. Cupboards are stocked with boxes of syringes, needles of different gauges and red hazardous waste disposal boxes.
There’s no limit to how many needles or syringes a peer exchanger can take. The center keeps track of every needle and syringe that goes through its doors on a computer. The number out and number in never match, but that isn’t the goal; the more clean supplies that go out, the less chance there is of infection.
Julia filled a wrinkled shopping bag with the “works,” for preparing and using heroin. She carefully chose cotton balls, gauze, Band-Aids and silver- and gold-colored bottle caps from clear plastic containers on a white metal shelving unit on the wall.
She saves some of the supplies she gathers at the center for herself and Thomas (they prefer to cook their drugs in the silver caps rather than the gold ones, which she says rust too quickly), but most of them she passes out to friends and other users. The Lower East Side center recruits users who regularly come in for clean needles to become part of what they call their Positive Action Peer Education Program (PAPEP).
There’s a competitive admissions process, and there are three training cycles with 11 participants each year. They go through needle-stick, overdose and outreach training and are required to attend lectures at the health department and regular debriefing meetings at the center. At the end of each cycle, the top three PAPEP participants are offered internships, and everyone gets job search assistance. But there’s no sobriety requirement.
The irony is that drug users themselves are often the most qualified outreach workers, because they know where their fellow users hang out, what they need and what they will and won’t do to get help. There’s a trust there that doesn’t always exist between well-meaning non-profit employees and their program participants. A sobriety requirement would also defeat harm reduction’s aim to promote safe practices without forcing anyone into rehab or detox.
The center is not just a hub for syringe exchange. On average, about five people enter to pick up new syringes or drop off used ones every day, but many more cycle through the door for support group meetings, outreach training and sometimes just to hang out in the day room watching TV and drinking hot tea. The ground floor of the building houses the syringe exchange storefront, check-in desk, day room and several meeting and examination rooms. The walls are brightly decorated for each holiday with the kind of cardboard snowflakes, hearts or shamrocks that are often used to decorate school classrooms. Upstairs, caseworkers and administrators work at cubicles in one big, bright room with exposed brick walls.
There’s a housing specialist to get participants into apartments, a doctor who tests for HIV and other diseases, even a room reserved especially for Reiki, a hand healing technique that Raquel Algarin, the director, has found is good for relieving stress in both employees and participants.
When Julia’s bag was nearly full of works, she asked the attendant for two boxes of one inch needles and one box of “halfs.” She said she takes more during the summer because there are a lot more people on the street and in the parks, especially teenagers who travel, like she did before settling in Brooklyn with Thomas last July. Julia is representative of the recent trend toward a younger demographic of heroin users. She is 22, and has been injecting heroin since she was 15. She has a sweet face and a polite, slightly shy, demeanor. She wears hoop rings in the two piercings under her bottom lip and she has a big head of dark brown dreadlocks, some with small puka shells tied to the ends. Her forearms are covered in tattoos, including one that resembles a train, in addition to small, faded squiggles and stars and crude, Frankenstein-like stitches.
“People just look at me and think I’m on drugs even when I’m not,” she said.
She was born in Detroit, and after attending six different high schools and being kicked out of her parents’ house, Julia moved around a lot, mostly by herself. She went to Austin, Tex., for a while and spent time in Hollywood, but never had a real place to live. She always stayed on the street or in a park, except for a short time a few years ago when her mother let her move back home while she went to cosmetology school. But she wanted to stop using, and the heroin in Detroit was “too good,” she said. But the dope in New York City is bad, she said, and that’s good for her.
As of that day in December, she claimed to be three weeks clean, but estimated that she’d slip up again within the next week.
“I think you find comfort in what you know you can find anywhere,” she said after leaving the center to make her way to Stuyvesant Town. “I’m an addict, I can’t explain it.”
But she says she is trying to quit. She and Thomas both started doing peer exchange when they entered methadone treatment in the summer, and Thomas decided to stop selling heroin. He’s 31, but looks much younger. He has a soft face with light blue eyes and makes eye contact with everyone he talks to. He has a big, thick cross tattoo on the front of his neck. He’s tall and thin, with a buzzed hair cut. In December, he said he’d been clean for three months. But when Julia met up with him outside her methadone clinic at Gramercy Park – a trek out of the way, but she said she would be ill if she didn’t go – he said he’d just been kicked out of his own clinic for using foul language. He said they had him on a “detox plan” that was making him “sick and edgy,” but addiction expert Dr. Robert Newman at Beth Israel Medical Center said this is unlikely. Detox is rarely used as treatment for heroin addiction, because relapse is the rule.
“Bottom line: opiate addiction is a chronic, relapsing medical condition for which no cure has ever been demonstrated,” he said. What’s easier to believe, and makes the most sense given Julia’s stuffy nose and Thomas’s erratic personality, is that both of them are using regularly, but trying to stop by participating in methadone maintenance. This usually entails drinking a liquid solution, with opiate properties, to curb cravings.
Newman said maintenance should “start low, go slow, aim high.” But he’s frustrated with the “counter-therapeutic” practices he sees from a lot of providers, like forcing users to accept counseling whether they want it or not. That’s the kind of practice harm reduction centers vehemently avoid, because it pushes participants away. Yet the stigma around various methods of harm reduction, methadone maintenance included, has kept programs like the Lower East Side center fighting to stay open.
When underground syringe exchange programs began cropping up in the late 1980s, fear was the rule. The AIDS virus was out of control, as was the debate surrounding how to combat it in the drug world. There were those who believed that making all drugs legal was the answer – that way users would feel more comfortable seeking out clean supplies and getting tested for diseases. At the other end of the spectrum were the religious right, politicians and some skeptics in the medical and social service industries who favored the existing tactics of rehabilitation and incarceration for dealing with drug use.
Allan Clear is the director of the Harm Reduction Coalition, a national non-profit organization that he co-founded in 1993 to support syringe exchange and other harm reduction strategies. At that time, he said, syringe exchange advocates were “lumped in” with those who wanted to legalize drugs altogether. He believes some liberal politicians are still afraid to extend their support because of the reaction they might receive from the right.
“Our attitude towards drug users is a social construct,” he said. “There are very real problems when you take chemicals and put them into your body, but all of the stigma is either legislated or propaganda.”
He was sitting comfortably in a T-shirt and jeans in his modest fifth floor office on 27th Street near Manhattan’s Flatiron District. An impressive collection of soccer trophies and semi-deflated soccer balls from his years playing the sport in England as a young man lines the shelf above his desk. Laminated posters and newspaper articles about syringe exchange decorate one wall. Clear left Britain in 1983 and moved to New York City. He worked at bars in the West and East Villages, using and selling drugs himself. He saw that the drug culture here was a seedy underground where users were stereotyped and stigmatized.
This was different from what he’d experienced in the U.K., where drug use was prevalent but users weren’t yet shunned. He had a lot of gay friends in New York, and said he was “at the center of the (AIDS) epidemic.” A few friends joined ACT UP New York, an AIDS activist organization; it appealed to him because its “in-your-face” advocacy reminded him of the punk rock scene back in England. But he didn’t feel he had much of a role in the organization as a straight man, so he decided to focus on a subset of the AIDS issue – intravenous drug use.
He worked with underground needle exchange programs beginning in 1990, when it was illegal in New York to possess needles or syringes for the purposes of drug use, whether or not the person in possession was using. In 1992 when that law changed, Clear started one of the first syringe exchange programs in the city: the Lower East Side Harm Reduction Center.
New York had seen more cases of HIV resulting from intravenous drug use than any city in the country. According to research conducted by Don Des Jarlais of Beth Israel Medical Center, from 1992 to 2002, the number of clean syringes distributed in New York City grew each year from 250,000 to three million. But because of a statute that had been part of the annual Health and Human Services appropriations bills since 1988, syringe exchange programs could not get federal funding unless these research results convinced the Secretary that there was a real connection between those numbers. Further, the research had to show that providing free and accessible drug paraphernalia didn’t increase drug use. So physicians, researchers and AIDS advocates, led by Des Jarlais and David Purchase, a harm reduction pioneer, set out to find proof.
Among the most convincing studies was Purchase’s survey of intravenous drug users at his Tacoma, Washington syringe exchange program in 1995 that showed a definite correlation between access to the program and a decrease in the amount of new hepatitis cases. In an appeal to those concerned about spending money to keep drug users safe, Purchase emphasized the positive economic impact syringe exchange could have.
“There is no more cost effective AIDS prevention effort than providing the ability for sterile injection,” he said, explaining that every HIV infection treated at public expense costs the government $400,000 over the life of the patient.
He also sees it as a moral issue. In his view, the federal government is obligated to make syringe exchange a priority for AIDS prevention.
“It’s crazy to withhold the ability for a citizen to be healthy. It’s one thing not to be able to talk them into doing healthy things; it’s another to withhold very inexpensive tools. A syringe costs 8 to 10 cents.”
In 1989, President George H. W. Bush’s Secretary of Health and Human Services, Dr. Louis Sullivan, supported a report from the National Academy of Science that provided evidence that government funding of syringe exchange programs would help prevent disease without increasing drug use. But Bush opposed any funding changes. Des Jarlais began another study in 1994 that produced data “inconsistent” with the worry that syringe exchange programs led to an increase in intravenous drug use. According to his findings, published most recently by the National Development and Research Institutes and supported by a grant from the National Institutes of Health, injecting drug use decreased during the time that the number of syringe exchange programs increased.
In 1998, President Bill Clinton’s Secretary of Health and Human Services, Donna Shalala, announced that syringe exchange programs could help prevent disease without increasing drug use. But Clinton did not support lifting the ban on federal funding because it didn’t fit in with national policy on the “war on drugs.” In 2000, new President George W. Bush vowed not to support needle exchange, calling such advocacy “misguided efforts to weaken drug laws.”
Presidential candidates have taken stances on AIDS strategy in every race, and in 2008, then-candidate Barack Obama promised to repeal the ban on federal funding for syringe exchange if elected. It’s listed as a priority for AIDS prevention in the Obama- Biden plan to combat global HIV/AIDS on Change.gov, the website created for the office of the president-elect in 2008. But according to Clear, the ban on federal funding wouldn’t have been lifted without the work of AIDS advocates.
“We actually never received any help from the White House as far as we can tell,” he said. “(Obama) had opportunities to help us and he didn’t, and that shows the political fear around syringe exchange.”
On December 16, 2009, Obama did sign an appropriations bill that lifted the ban. The language in the Fiscal Year 2010 Consolidated Appropriations Act was changed to say that no federal funds could be used “in any location that has been determined by the local public health or local law enforcement authorities to be inappropriate,” emphasis added, because the guidance from the Centers for Disease Control quotes the bill as saying that both public health officials and local law enforcement have to approve.
“That’s a real problem because law enforcement is not gonna go on the public record saying they support syringe exchange activities,” Clear said.
Yet in New York, police chiefs are actually working with syringe exchange programs. In a 2009 study, Des Jarlais of Beth Israel Medical Center found that 45 percent of the syringe exchange programs surveyed reported a “somewhat good” relationship with the police, compared to 37 percent the previous year. Another 45 percent claimed a “neutral” relationship.
Mark Spawn, director of research at the New York State Association of Chiefs of Police, said there has been a “culture change” in law enforcement regarding syringe exchange. He credits a July 2010 state law that decriminalized the possession of residual amounts of a controlled substance inside a syringe or needle if the syringe or needle came from, or is going to, a syringe exchange program. Spawn created a kit for law enforcement officers to carry after they had completed a training program about the changes in syringe exchange laws. It includes a “cheat sheet” listing the most recent law changes, and a matrix that explains the different kinds of syringe exchange programs, any restrictions placed on them and which programs provide identification cards to participants and volunteers.
Algarin, the Lower East Side Harm Reduction Center’s executive director, said the New York Police Department has a positive relationship with the center, based on minimal interference. Syringe exchange advocates worry the new Republican majority in the House of Representatives may already be planning to undo their progress. That’s why the Harm Reduction Coalition is redirecting its efforts to the Senate, although Clear hopes Congress will let the language that lifted the ban slide through untouched in the next appropriations bill. Purchase, the syringe exchange innovator in Seattle, isn’t so optimistic.
“The whole issue could come up for another vote here this session and we’re getting prepared for that,” he said. “(This) Congress, on the face of it, doesn’t look to be as receptive to science and fact as it is to morality and propaganda.”
Algarin is also concerned, but far less accusatory. She’s a short, round woman in her early sixties with mocha colored skin. Usually dressed in track pants and a hooded sweatshirt, she smiles widely and gives hugs liberally. But often she looks worried. She started working in harm reduction in the 1990s after working in AIDS prevention at the New York State Department of Health and helped Clear found the Lower East Side center just after syringe exchange became legal in New York. She’s pleased the ban on federal funding is now lifted, but is quick to note that it isn’t enough. She can now use federal money to help pay peer exchangers and buy supplies, but that doesn’t mean there’s suddenly more of it to go around. She’s working with the same budget she had before, it’s just that now the federal money will be spread more thinly.
A holistic nurse, Algarin started working in AIDS education for the city health department after her brother, Ruben, died of the virus in 1987. She used her experience with AIDS and her knowledge of holistic healing to bring different kinds of therapy to the Lower East Side Harm Reduction Center. She eventually became director, but still occasionally finds time to practice Reiki on participants. She also helps organize the Positive Action Peer Education Program. She’s well aware that peer exchangers sometimes put themselves in questionable situations that no rules and regulations could prevent. The bottom line, she said, is that it doesn’t matter how or where the peer exchangers deliver the syringes, as long as the job gets done.
“It’s phenomenal, given the risks,” she said. “I think people appreciate being trusted to do this. It’s not just a job, they’re creating change.”
While statistics show that they have created change when it comes to HIV transmission, it’s hard to ignore the fact that chronic drug use is hard to shake, even among peer exchangers who see what it does to themselves and their friends. Algarin speaks particularly fondly of one former syringe exchange participant who is now part of PAPEP.
When Julius Oakley, a tall, thin black man, first started coming to the center, he was quiet and reserved. One day he told Algarin that he played piano, but his keyboard had recently broken. Algarin’s late brother Ruben had also played, and she still had an old Casio keyboard of his in her closet. She brought it to Oakley in the day room one day, and said he opened up immediately. Now Oakley can usually be found on the second and fourth Tuesdays of the month, sitting in the day room waiting for his stipend check. He is 59 years old, yet not ready, he says, to live anywhere but on the subway or the street. He began using heroin at age 14 and continued to use, he says, until December 2009, when doctors told him he had kidney failure.
He claims that throughout his 44 years of heroin addiction he managed to maintain a fairly normal life. After serving with the Red Cross in Vietnam, he says he worked as a carpenter and raised four kids, including two sons who are now carpenters themselves. He believes they never knew until recently that their whole life he was high. While struggling with his addiction, he saw harm reduction and syringe exchange programs at their conception.
“In the ’70s and ’80s it was commonplace to use someone else’s set of needles, and to use them more than once, because it was hard to come by new syringes,” Julius says. They were only available by prescription at a pharmacy, and no doctor would write a prescription for syringes to shoot up drugs. “If I had a place like this in my 20’s it might have changed my life.”
That’s part of the reason Julia and Thomas think it’s important to bring clean syringes to John, the heroin dealer. But not everything they do is in the name of harm reduction.
On the way to Stuyvesant Town, when Julia called John to let him know they were coming with the needles and syringes, she also mentioned Suboxone, a drug administered by treatment facilities to assist in beating heroin addiction. Dr. Newman at the Beth Israel addiction center says it’s a federal rule that for the first 90 days of methadone treatment, the participant must come to the clinic at least six days a week. After that, they have the option of using a “take home” method, like Suboxone. Juila knows a lot of users and dealers who don’t have access to it, so she sells the ones she doesn’t need. She said the usual street price for the pink-orange hexagonal tablets is $5 per pill, but she sells them to John and his girlfriend Nikki for $4.
“It’s totally illegal, but I gotta pay my phone bill, so fuck it,” she said, after hanging up the phone. “I’m trying to live totally honest and clean, trying to work, but I don’t get paid until the 24th so…” she trailed off.
She needs money for transportation, rent and food. She isn’t ready for a full-time job, and in her eyes, this is the easiest way to make extra money. And she justified it as helping others get clean while helping herself.
The door of John’s apartment opened slowly, and a doughy guy who looked about Julia’s age stood there with a glazed look on his face. Julia and Thomas entered the apartment and a small shaggy dog with kinky brown curls hanging over its eyes ran up and started sniffing their shoes. The apartment was tiny, made smaller by the piles of furniture, books and crates full of craft kits and dog toys. A book titled Clear Your Clutter with Feng Shui teetered on a pile of other books in a plastic crate. A Buddhist shrine complete with bowls overflowing with oranges was on display at the back of the room. A tiny bird, a finch or a swallow, was perched on a cookie tin on the top of a bookshelf, its head darting back and forth periodically.
The guy who had opened the door, named Dustin, now sat very still on a futon, staring straight ahead while Julia and Thomas waited for John and Nikki to come out of a back room. The dog started to hump a stuffed animal on the floor and everyone watched for a minute, no one saying anything, until Nikki came out to discuss the Suboxone. She had dreadlocks like Julia’s, but a lighter shade of brown, and was wearing ripped jeans with what looked like a fox’s tail hanging out of the right front pocket. She wasn’t sure how many pills she wanted or how much John would be willing to pay for them. She retreated to the back room – John never came out himself – and talked to him for about ten minutes. There was no door to the room, but three huge rolls of paper, rigged by a pulley system were suspended from the ceiling just above the door frame.
When Nikki finally emerged from the back room, she asked for 15 pills, and Julia fumbled in her pocket for the bottle and counted them out.
“52.50,” she said.
Nikki gave her $53 and said in a thick, nasal voice, “I greatly appreciate it.” It was barely enough, Julia said, to cover her phone bill.
She counted the money and a few syringes, and she and Thomas left. Disappointed and even more annoyed than before, Julia led Thomas back down First Avenue toward Tompkins Square Park. She hoped they would be able to give a few syringes to the “home bums,” the older men who live in the park and don’t travel around the city the way many young users do. But now it was nearly dark and bitterly cold. There were a few men milling around on a path in the middle of the park. A pair of shoes hung by their laces from a nearby tree. One thin white man in a battered leather jacket, under the influence of some substance, rambled and occasionally yelled at one of the others, who simply ignored him.
A heavy black man wearing a college letter-style jacket like you’d see on a football player was the most coherent of the group. He came over to the bench where Julia and Thomas were sitting, the bag of syringes between them, still half full. He said he would take a few and tucked them into his shirt pocket. Julia took a form out of the bag and began writing numbers down to make it look like she’d given out more syringes than she had.
Julia and Thomas hurried out of the park and took refuge from the cold in the subway. The got on the F train to go back to Brooklyn to get some rest before reporting to their second job – keeping overnight watch over a Christmas tree stand in the Bronx for the season to help make ends meet.
It was hard to tell if Julia had fudged the numbers because she thought she might get in trouble for not giving out more syringes and lose her job, or if she was just used to breaking the rules and found some kind of satisfaction in doing it. The truth is, despite the risks, Algarin and her colleagues don’t set formal guidelines for what peer exchangers can and cannot do. Algarin is concerned for their safety, and she gives suggestions – don’t go to parks because they are saturated with peer exchangers; don’t argue with the police – but she is under no illusions that the behavior of her peer exchangers will change.
She and her colleagues are focused on ending the use of dirty needles and syringes, and in that, they are succeeding. But it’s a mixed success. While the spread of disease has been reduced, the foot soldiers struggle with their own addictions and new responsibilities, sometimes with counterproductive results. In this world where needles and syringes float easily between people and exchange storefronts and drug use is an accepted norm, the difference between right and wrong isn’t always clear.