Scott Sumner  

"Forcing" the GOP to accept needles

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Here's a revealing (and very sad) Politico article on the drug epidemic in "red states."

It wasn't supposed to happen here. Not in Austin, a one-doctor-and-an-ice-cream-shop town of 4,200 in southeastern Indiana, nestled off Interstate 65 on the road from Indianapolis to Louisville, where dusty storefronts sit vacant and many residents, lacking cars, walk to the local market. Not in rural, impoverished Scott County, which had reported fewer than five new cases of HIV infection each year, and just three cases in the past six years. Not in a state where, of the 500 new cases reported annually, only 3 percent are linked to injection drug use.

But it did. And it could happen in many more backwoods towns just as unprepared as Austin.

As the largest HIV/AIDS outbreak in Indiana's history roils this Hoosier hamlet, it reflects the changing face of the epidemic in the U.S., as a disease that once primarily afflicted gays and minorities in deep-blue cities rises in rural red states. This new evolution of HIV is also forcing a new generation of Republican policymakers to confront its orthodox opposition to remedies such as government-funded needle-exchange programs.

Over the past decade, the virus cascaded from urban cities like San Francisco, New York and Washington, D.C., into poor, rural swaths of red states in middle America--opening a new front in the national fight against the spread of HIV. "It started in the coastal states among middle-class white gay men, and then the epidemic evolved into affecting more and more minorities in the South," says Carlos del Rio, an AIDS researcher at Emory University in Atlanta. "Obviously, now the epidemic is changed. Now, what we're seeing is it impacting the rural communities."

In this Indiana burg, the virus is not spreading among networks of gay men, but in rapid, cluster-like fashion within jobless white families who inject prescription painkillers with dirty needles.

"This is an HIV outbreak in a rural setting that is linked to an injection drug use," says Jennifer Walthall, Indiana's deputy state health commissioner. "That hasn't been seen in the U.S. to date." Since November, Walthall's state health department has identified 163 cases of new HIV infections, including three preliminary positives. Eighty percent also tested positive for hepatitis C. "This was not on the radar," Walthall says.

In April, Walthall's office, along with the Centers for Disease Control and Prevention, issued a health advisory to public health departments nationwide--a preemptive salvo to stave off similar outbreaks among injection drug users. The missive targeted health departments in rural counties east of the Mississippi River, where opioid abuse and needle-borne infections are spiking, according to the CDC.

Scott County's outbreak was so severe that Indiana Gov. Mike Pence, long an opponent of funding needle exchanges as a member of Congress, issued an executive order in March that gave local health officials authority to establish a "limited and focused" 30-day needle exchange. Last Thursday, Jerome Adams, Indiana State Health Commissioner, declared a public health emergency in Scott County through May 2016, extending the needle exchange in Austin for another year. In Kentucky, where new HIV and hepatitis C infections are also skyrocketing, state lawmakers approved in March a law that would allow health departments and local governments to launch their own needle exchanges.

Such moves by Republican governors and legislators would have once been considered GOP heresy. A federal ban on funding such exchanges has deep roots. In 1988, during a debate over passage of the appropriations bill for the Departments of Labor, Health and Human Services, and Education, North Carolina Republican Sen. Jesse Helms introduced a rider that effectively banned federal funding of needle exchanges (specifically, the language applied to anything that "promote[d] or encourage[d] homosexual sexual activities"). A decade later, in 1998, President Bill Clinton's administration endorsed the idea of needle exchanges--though didn't go so far as to propose a reversal of the federal funding ban. "Well, as long as your needle is clean, what's a little heroin or cocaine among friends?" then-House Speaker Newt Gingrich responded, sarcastically. "Your government would like to give you a free needle but doesn't have the courage to do it."

In December of 2009, President Barack Obama, backed by congressional Democrats, overturned the ban. And two years later, in 2011, House Republicans reinstated it.

I don't think that I even need to comment.

Comments and Sharing

COMMENTS (20 to date)
Lorenzo from Oz writes:

Makes me very grateful for Aussie pragmatism, and Neal Blewett, Health Minister when HIV hit Australia, who involved everyone and concentrated on finding out what worked.

Scott Sumner writes:

Lorenzo, Yes, I agree about Australia. This country has some peculiar obsessions. It was the term "forcing" that sent a chill down my spine. Perhaps the harshest comment I've read on an American political party in decades.

NZ writes:

"Such moves by Republican governors and legislators would have once been considered GOP heresy."

Go back just a little further and such moves by Democrat governors and legislators would have once been considered DNP heresy instead. They invented the war on drugs, after all, and championed it for half a century before the Neocons came along and picked up the gauntlet.

Anyway, Helms was onto something, though he may not have realized it. By offering free needle exchanges, you lower the cost of an activity that happens to be dangerous and illegal. Free needle exchanges paired with drug prohibition make no sense to me for that reason.

The best combination is legal permissiveness coupled with cultural restrictiveness. The worst combination is legal restrictiveness coupled with cultural permissiveness. Needle exchanges push us further into the latter territory.

LD Bottorff writes:

I, for one, would like to be assured that reliable studies have been done that show that needle exchanges actually reduce the spread of AIDS. I don't think I understand the libertarian case for taxpayer subsidized drug paraphernalia.

_NL writes:

I saw this article at the time and I think it was coy about making the most incisive observation: it's easy to oppose a political policy that seems designed to alleviate the pains of social ills associated with others, but to support the same policy when it alleviates pains caused by ills within your own affiliated groups. Which implies that at least some conservatives were either dismissive or prejudiced when the issue was important to black and gay groups, but started becoming either attentive or sympathetic once it affected smalltown white people.

So some people oppose needle exchanges for fear that it encourages gay sex or urban drug use, then rethink the issue when it might be seen as encouraging rural and smalltown drug use.

Some people, generally a shrinking minority, frame opposition to abortion as intended to punish people (particularly women) for having sex. Even though there's a ready-made argument to be made that banning abortion could save lives, some people stake their opposition against making it too easy to have sex. This also arose from some commentators on the HPV vaccine, who were concerned that reducing the risk of cancer from sexual contact might encourage sexual contact.

I think it's wrong to want activities to be more dangerous simply to dissuade people from engaging in them. That was the thinking that led the government to spike alcohol during Prohibition, leading to needless injury and death.

LD Bottorff writes:

Apparently this 11 year old report from WHO ( sec. 3.2.11) concludes that there is no evidence that exchange programs increase illicit drug use, so my concern has been addressed.

Mr. Econotarian writes:

The National Institutes of Health Consensus Panel on HIV Prevention to stated that:

"An impressive body of evidence suggests powerful effects from needle exchange programs....Studies show reduction in risk behavior as high as 80%, with estimates of a 30% or greater reduction of HIV in IDUs."

Economic studies have concluded that SEPs (syringe exchange programs) are also cost effective. At an average cost of $0.97 per syringe distributed, SEPs can save money in all IDU (injection drug user) populations where the annual HIV seroincidence exceeds 2.1 per 100 person years. The cost per HIV infection prevented by SEPs has been calculated at $4,000 to $12,000, considerably less than the estimated $190,000 medical costs of treating a person infected with HIV.

SEPs have been shown to be an effective way to link some hard-to-reach IDUs with important public health services, including TB and STD screening and treatment. Through their referrals to substance abuse treatment, SEPs can help IDUs stop using drugs. Studies also show that SEPs do not encourage drug use among SEP participants or the recruitment of first-time drug users. In addition, a number of studies have shown that IDUs will use sterile syringes if they can obtain them.


ThomasH writes:

Like the "War on Terror" and the "War on Crime," the "War on Drugs" was invented by Republican politicians for their political benefit. If they can be persuaded that they are no longer in their benefit, the policy will change.

Edgar writes:

So Pence is an evil, evil man because he believes in federalism? Or maybe he is aware of the principle of subsidiarity and that makes him a laughingstock? Or maybe someone suffers manic mood affiliation.

BZ writes:

@LD - Don't be confused: there is nothing libertarian about this proposal, or, philosophically at least, Dr. Sumner, who seems to be a utilitarian.

NZ writes:

@ThomasH, who said:

...the "War on Drugs" was invented by Republican politicians [1] for their political benefit [2]. If they can be persuaded that they are no longer in their benefit, the policy will change [3].
Wrong on all counts, I think:

1. Federal drug prohibition was a left-wing, Progressive Democrat invention. What you see now is an artifact of the fact that the war on drugs was appropriated by Neocons, who took over the Republican party in the middle of the 20th century and then came up with the catchy name "war on drugs".

2. They liked the idea because it provided an unlimited justification for international interventionism. It doesn't have much to do, I think you'll agree, with other traditionally Republican political goals like small government, national security, and civil orderliness.

3. Plenty of persuasive arguments are already well-known, even to leading Republicans. They are ineffective because none of these well-known arguments highlight drug prohibition's connection to international interventionism, or the Progressive legacy of government overreach, or to the multi-pronged national security risk created by the war on drugs.

Instead, people are talking about individual liberty and disparate impact and so forth, and Republican politicians are yawning.

Scott Sumner writes:

I think a lot of people are missing the point; the post is not about whether needle exchanges are a good idea.

Perhaps the "point" is too horrible to contemplate.

NZ writes:

Hah! Scott, apparently you did need to comment, because I'm confused about which "point" you're trying to emphasize. There are several "angles" one could take:

  • Drug use gets treated like a viral epidemic in the press, as if drug users have no agency in their own drug use.
  • Mean old evil white Republicans don't care about people's well-being until those people are rural and white. (Of course, that hasn't stopped them on a host of other issues...)
  • Maybe you're unironically concerned about the spread of needle-borne HIV to small-town USA? I applaud you if that's true. Small-town USA is emblematic (to me at least) of a lot of what makes America such a great place to live.
  • You're shaking your head at the fact that politicans act based on what's politically feasible rather than on what works based on evidence.
  • Something about the 10th Amendment?
  • ...Something else I'm missing?
Alex writes:

@NZ @ThomasH

Consider the possibility that which party the old men (now dead or retired from politics) who started the so-called War on Drugs belonged to is utterly irrelevant, and only solutions to the problems we face today are relevant.

Don't tell me what the other person proposed yesterday; tell me what you're proposing today.

@Scott Sumner

I understand why you think that's horrible, and I agree (and want to throw this in the face of every 80's politician who blocked action on HIV prevention, esp. for religious reasons), but on the bright side at least everyone has skin in the game now, which is apparently necessary (that's my version of the "point" too horrible to contemplate).

NZ writes:


The party aspect is important because people act largely out of tribal loyalties, and political leaders have to be especially mindful of this. If you tell a person from the Red Team that he should do something he knows a lot of people on the Blue Team also want to do, he will be more likely to resist. But if you tell him he should oppose something the Blue Team originally invented and championed and convince him he only now agrees with it because he was duped by infiltrators, he will be more likely to be supportive.

Please don't think I'm being cynical. I also like this approach because 1) it's realistic in terms of accepting our evolved nature, and 2) it preserves logical historical consistency. Why should the party of national security and limited government support drug prohibition??

NZ writes:


By the way, rereading your above comment, it's a bit presumptuous to say the war on drugs was started by old men. The so-called "temperance" movement, which was mainly led by Progressive women, played a huge role in starting the war on drugs as well.

Also, some of the most important actors in the war on drugs are not only not dead or retired from politics, but hold very high positions. Joe Biden, for example, was instrumental in turning civil asset forfeiture into an everyday thing for law enforcement.

Alex writes:

@NZ If the logic you present in response to me #1 is true, then why were attempting to convince ThomasH, who displayed an anti-Republican bias (and thus implicitly, in my mind, a pro-Democratic bias) that "Federal drug prohibition was a left-wing, Progressive Democrat invention." Unless your goal is to push him further into a pro-War on Drugs position? Whose side are you on here, the Drug Warriors or the Liberalizers?

"The so-called "temperance" movement, which was mainly led by Progressive women"

You seem very concerned about taking the things you dislike and assigning them to the other side's ideology. As I stated before, I don't care who did what yesterday.

Joe Biden is so very unlikely to have a continued voice in government after 2016 that I feel confident in saying that Joe Biden is irrelevant. I might end up being wrong, but I think the odds are in my favor on this one.

NZ writes:


I'm confused by your question. I wasn't trying to "convince" ThomasH that federal drug prohibition was a Progressive Democrat invention, I was telling him so as a matter of plain historical fact.

Similarly, I'm not trying to "assign" the Temperance movement to Progressive women; as a matter of plain historical fact, this is who was largely responsible for it.

These facts are important and useful if there are to be practical measures taken to repeal federal drug prohibition.

I hope you're right about Joe Biden.

Alex writes:

I read your note about "Progressive Democrat", which itself has a distinct modern connotation which would not have existed at the point in time in question, as unnecessary point=scoring attempting to say to ThomasH that, "Well, your team bears responsibility".

The temperance movement may indeed have been progressive, but given a full summation of what progressive meant to them vs. what progressive would mean to a self-identifying progressive in 2015 would show that there are massive gaps. Simply stating, "The Drug War was started by progressives, The Temperance Movement (which is best understood in the context of being regarded as one of the largest failures of public policy in American history) was started by progressives" while adding no context and acknowledging no context is needless point-scoring. You wouldn't have convinced ThomasH, merely scored a point for yourself in your own head.

"These facts are important and useful if there are to be practical measures taken to repeal federal drug prohibition"

I do not agree. I see no way in which making sure people label the Drug War and the Temperance movement as "progressive inventions" would lead to a repeal of federal drug prohibition.

NZ writes:

I didn't assume ThomasH was a progressive Democrat, a liberal, a leftist, or anything like that. Since this is roughly a libertarian site, my default assumption of commenters on here is that they're some species of libertarian, unless they say something that clearly indicates otherwise.

Members of the Temperance movement were often part of or affiliated with the Progressive movement and the Democratic party, though there were a few notable exceptions. So, I don't think my use of those labels was erroneous or misleading.

You're right that there are some gaps between what progressive meant a century ago and what it means now, but I think there are fewer of these gaps than you apparently do, plus a lot of the existing gaps do not necessarily indicate any change in foundational beliefs, only migrations on specific issues. For example, while a progressive of 1915 wanted to ban alcohol, a progressive of 2015 wants to ban cigarettes, but their arguments and the impetuses (stated and unstated) behind them are for the most part interchangeable.

Today's progressives are the ideological descendants of yesterday's. They are not like the LA Dodgers or something, acquiring their name from another totally different franchise.

I know many people would call me crazy for saying this, but I don't think that Democrats/liberals/etc. will ever fully sanction the repeal of drug prohibition. The core required beliefs (limited government with limited foreign engagement, civil orderliness, national security and sovereignty) just aren't there. Therefore the push has to come from the people who have those beliefs, and they happen to be on the other side--just as they were a century ago.

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