A Clean Start

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Robert Soto is known as “the polar bear” by folks on the block–that’s the block, at the intersection of Knickerbocker Avenue and Troutman Street in Bushwick, where the NYPD has been trying and failing for a decade to get rid of the drug trade. Since 1992, when the New York Times identified the area as the city’s most brazen drug market, the cops have spared nothing trying to bring it under control. None if it has worked.

Rain or shine, Soto’s out here three nights a week. That’s why they call him the polar bear–he never gets cold. “They got the best heroin over here, so they keep coming back,” Soto says, explaining why police can’t snuff it out. “Even people as far as Rochester know it,” he laughs, shaking his head in marvel. “Knickerbocker and Troutman!”

Sitting hunched over in the door of his van, an unlit cigarette dangling over his graying goatee, Soto comes off like a Latin Tony Soprano. In fact, his whole crew looks and acts like drug dealers. They strut up and down Knickerbocker, tossing knowing head nods at acquaintances. But they’re not selling dope–they’re distributing needles and condoms and first-aid kits.

“We’re all old hustlers, so we know the game,” explains Fernando Soto (no relation), who runs the program they work for, called Afterhours. If you’re going to connect with people on a block this charged, you can’t just walk up on somebody yapping about needles. You’ve got to blend in, let them see you’re not an undercover cop.

The group’s van is parked halfway between the area’s prostitution and drug market, which puts it right in the path of sex workers coming to and fro. “Yo, you got condoms?” asks someone in a group passing by. One of the women wears her long hair in a swoop down the side of her face and neck. Soto guesses she’s hiding track marks; when you’ve been using hard for a long time, you’ve got to find places to shoot where you can get a quicker, stronger high. The women who work this stroll are using with that kind of intensity. They choose the location for the convenience: Once they turn a trick they can go just a few blocks and cop a bag, and repeat the process all night.

Up the street, several regular customers are lingering in front of a bodega. One guy’s been trying to get his girlfriend into detox through Soto for weeks, but she won’t show up for the appointments. They’re both waiting for some clean needles and first-aid kits, but Soto can’t get them to walk down to the van. This kind of passiveness is why he’d prefer to park right at Troutman and Knickerbocker–a lot of customers can’t be bothered to hike the block and a half just for a clean needle. But the police write the rules around here, and they’re gradually shoving the van down the street. The 83rd Precinct, like most in New York City, worries that people giving out needles will draw users to the area.

In New York City, efforts to slow HIV’s spread among and beyond drug users has looked a lot like this block-by-block turf war between cops, users and AIDS activists. But now the city Department of Health is giving an unprecedented government seal of approval to programs like this. It is, for the first time, instigating a new needle exchange operation, the first expansion of the city’s network since outlaw activists launched sites over a decade ago.

From the first days of AIDS, injection drug use has been a favored vector for the virus. It still accounts for half of the epidemic, and that’s without considering the people who get the virus by having sex with infected users. Researchers in Europe learned pretty quickly that a cheap, effective way to break the link between drug use and HIV was to flood the market with new syringes, and thus eliminate the needle sharing that passes the virus.

But distrust of needle exchange runs deep in New York City. Entire communities, terrorized by the drug trade and its fallout, have been dead set against it. In 1986, Albany joined the first wave of state legislatures to criminalize the possession or sale of syringes. In response, Ed Koch’s health department broached the idea of exchanging used needles for clean ones. The black community’s reaction was as swift as it was vitriolic. The Amsterdam News called for Koch’s resignation. Harlem Councilmember Hilton Clark labeled it a “genocidal campaign,” and black Police Chief Benjamin Ward compared it to the infamous Tuskegee syphilis experiments. Koch still eventually set up a tiny test project, but one of Mayor David Dinkins’ first acts in office was to shut it down.

Mayor Bloomberg’s confident young health commissioner is the first City Hall official to step back into this minefield. With his workplace smoking ban, Tom Frieden has already made a name for himself as a public health crusader. But with far less fanfare, Frieden has also set out to radically reshape how we treat drug users. When Frieden took office in 2002, he officially adopted harm reduction as the ethic of the health department. If someone’s using gobs of crack each day, you don’t push detox, but rather teach the person how to savor the first hit–which is the best one–and thus cut down the volume being used.

Frieden has launched a plan to expand needle exchange into three Queens neighborhoods–Long Island City, Jamaica and Far Rockaway–and he intends to move into Staten Island once that’s done. He has also worked with the City Council over the past two years to funnel city tax dollars into the programs for the first time. And he’s not stopping with needle exchange: Frieden wants to use public money to hand out overdose-prevention medicine to addicts. He’s cajoling local doctors to start prescribing a new treatment for opiate addiction. And he’s working closely with gay activists to slow the spread of crystal meth in Chelsea.

New York has never seen this stuff before. With some notable exceptions, like San Francisco and Baltimore, neither has the rest of the country. By focusing strictly on producing results, Frieden is giving AIDS activists exactly what they have spent the last 20 years begging government for: He’s taking the politics out of public health.

The problem is that may not be as good an idea as it sounds. Frieden’s critics say that his focus on research and results is refreshing but leaves him unwilling to engage in community dialogue. Without that, even the best ideas struggle to move from proposals to policies. And Frieden’s closest allies in the fight against AIDS fear his radical harm reduction ideas will wither if he doesn’t become an expert not just in public health, but in politics, too.

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You don’t walk into a senior center in Queens and have a casual conversation about giving out needles to addicts. But here’s Frieden doing exactly that. And why not? He’s armed, after all, with data. He likes to answer questions by beginning “the data show…,” the way a pastor might call up his favorite Bible verse when put on the spot.

There are the 80,000 New Yorkers living with HIV–a “terrible blight,” he reminds everyone at the Long Island City community board meeting. There’s the fact that we’ve got the largest number of injection drug users in the country, and thus more infected with the AIDS virus than anywhere else.

Pushing the other way, New York City is home to nine privately run needle exchange programs, which in the last decade have helped cut the HIV infection rate among drug users by half. And don’t forget the savings. “They are actually by far the most cost-effective means of preventing HIV,” Frieden points out, sounding like a high school science teacher unveiling the ta-da! conclusion of a chemistry experiment. “For whatever reason,” he shrugs in conclusion, “there has never been a program in Queens.” Frieden is wise to gloss over the reason why: The last time anyone tried to open a needle exchange in Queens, Borough President Claire Shulman stopped the conversation cold.

In Manhattan and Brooklyn, AIDS activists prevailed–between 1992 and 1995, they set up those nine programs, with permission from the state health department and their local community boards. But not a single new needle exchange has opened since then, and some places–including all of Queens and Staten Island, as well as much of the Bronx–have never had one.

To expand into those realms, Frieden needs the approval of each neighborhood’s community board. That’s why he’s in Long Island City tonight, advocating a plan that would allow the AIDS Center of Queens County to distribute needles from a van parked next door to the Queensbridge Houses, the massive public housing complex on the northern edge of Long Island City. But when he finishes his calm, deliberate presentation of the public health facts, the commissioner faces hostility strong enough to take you back to 1986. “The health department has used and abused the entire community board process,” rails one minister from the Center of Hope International, the neighborhood’s most influential black church. Another reads a letter from the church’s pastor, who is tired of seeing his community used as “a dumping ground for people who do not think we know what’s best for our neighborhood.” One by one, a group of black ministers rise to vent rage at the otherwise all-white room, and urge the board to halt its proceedings–“I just don’t think this is right!” All this from a ministry that supports the idea of needle exchange.

The ministers were at the meeting because Long Island City’s council member, Eric Gioia, had brought them there specifically to create this scene. It was the first time Frieden or anyone from the health department had spoken to the church or to anyone from Queensbridge Houses. For that matter, the department had done little to take advantage of Gioia, who is both politically progressive and enormously popular in Queensbridge, to help sell its ideas to his constituents. Data, Frieden and his staff seemed to believe, would provide all the persuasion necessary.

Clearly, data was not enough. Gioia and the Queensbridge leaders were furious they hadn’t been consulted on the proposal that the board was poised to approve. As a result, would-be allies in Frieden’s effort became staunch foes, and the board was forced to discard the AIDS Center’s ambitious proposal. Weeks later a new one would emerge, but to many of those who have been doing this work for the last 10 years, that compromise was hardly a move forward in the fight against AIDS.

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With some 15,000 residents, Queensbridge is the largest public housing complex in the nation. But it owes its worldwide notoriety to the songs of hip-hop artist Nas, who grew up there and performed chart-topping odes to the wide-open drug trade it hosted in the 1980s and 1990s. They call me Nas, I’m not your legal type of fella/ Moet-drinkin’, marijuana-smokin’ street dweller. It’s the image that Nas invokes–of shootouts and purse snatchings, of dope fiends roaming the streets and pissing in elevators–that older Queensbridge residents think of when they hear about drugs. Near as they can tell, the cops have finally run that sort of thing out of their world.

“When the crack epidemic was here, I used to find crack vials and all that,” recalls Rita Normandeau, who has lived with her husband, Raymond, in Queensbridge since the early 1970s. She twists up her face in disgust at the memory. The Normandeaus realize some people still use drugs, but nothing like in those days. “The biggest contraband at Queensbridge now is cigarettes–$5 a pack,” Raymond jokes. Hardly enough, they think, to justify putting in a needle exchange, which they worry would pull drug users back to the neighborhood.

It’s a few weeks after the Long Island City community board encounter, and the Normandeaus and other residents at the monthly Queensbridge tenants association meeting are revisiting the episode–but they’re not so much focused on AIDS or drugs as they are on how much they resent Frieden. Gioia reminds them why. The boyish Queens native is giving a typically rapid-fire soliloquy on the way bureaucrats sequestered in lower Manhattan abuse the boroughs, and in the process he’s slinging a load of carpetbagger mud at the commissioner. “He’s not from here,” Gioia tells the group, one of the city’s more politically engaged tenants organizations. “You can’t do things from on high. You can’t do things from City Hall. Think about how much I’m around.”

Indeed, the young, progressive white guy is loved by Queensbridge’s aging, largely conservative and black civic gatekeepers precisely because of his hands-on political style. He knows the first name of almost every audience member who asks him a question but also knows enough to instead use Mr. or Mrs. when he’s noticeably younger than that person. “He comes around,” testifies Rita Normandeau. “He’s not a phony.”

As has been the case since Koch’s beleaguered proposal, the fire Frieden took at the community board meeting was not so much about drugs as it was race. Standing on the street in Queensbridge, you can look south over the Queensboro bridge, just past the Dharma & Greg billboard, into the rapidly gentrifying and increasingly white central Long Island City. The folks on the north side are starting to feel put out. What’s more, the two sections of Long Island City are represented by two different community boards. In this context, the needle exchange proposal on the table that night couldn’t have been more explosive: The site proposed for the van straddled the border between the two boards and the two worlds they represent.

The health department and AIDS Center of Queens County say they approached both boards, but only the one south of the bridge responded–that’s why the Queensbridge residents weren’t in the loop about the plan. People in Queensbridge say a bunch of shifty bureaucrats conspired with the Long Island City crowd to put a needle exchange on their doorstep without having to get permission. When asked about charges that he and the AIDS Center avoided consulting Queensbridge, Frieden shrugs it off as political pandering. “That’s what one politician would have you believe,” he concludes. Frieden sees the dispute as merely one over where the needle exchange should be located–near Queensbridge Houses, or further into Long Island City proper–and says that’s heartening. “This time last year,” he notes, “you had, at best, people not talking about it at all.”

When he took over the health department, Frieden conducted a review of the city’s AIDS programs, identified the needle exchange network as a cheap and effective prevention strategy, and zeroed in on its clear gaps. The department contacted AIDS Center of Queens County and offered support for the grueling process of getting permission to expand into those places. “The department felt, and the commissioner certainly was in the lead on this, that if we really were invested in this we needed to not just be providing the fiscal support, but we should be visible in Queens,” explains Marjorie Hill, Frieden’s associate commissioner for HIV/AIDS.

But the local elected officials had no idea the site approval process was up and running. Borough President Helen Marshall learned of the plan while reading a Queens newspaper–not exactly how you build good will in a town where turf means everything. When Frieden finally did call together the electeds, “she actually brought that article to the meeting,” says a Marshall spokesperson. “And she said, ‘We’ve got to know more about this.'”

After what an attendee characterized as an “acrimonious meeting,” the politicians agreed it was time to bring needle exchange to the borough, and that they would work together with the health department on it in the coming months. But later that day, Gioia found out that the health committee of Long Island City’s community board was voting on a proposed site that night. Gioia wanted the program to open, he says, but didn’t have a chance to have a meaningful conversation with his constituents, never mind persuade them that a needle exchange would be an asset to their neighborhood. “It’s been my experience that when you’re respectful to people, you can actually get them to agree to things they may not have originally agreed to,” Gioia says now.

In the end, the health department met with the tenants’ association and the church. Everyone kissed and made up, and the Center of Hope’s pastor has even joined the advisory committee for the new needle exchange. But the original plan would have cleared the AIDS Center of Queens County to dispatch a mobile crew, much like Afterhours does, to work its way into the local drug scene. In the compromise, brokered by Marshall, the program will instead be housed in the AIDS Center of Queens County’s office on Hunter Street in central Long Island City, once the state signs off on the plan later this year. That’s nowhere near the epicenter of the area’s drug trade, and many needle exchange veterans fear the program has thus been set up for failure.

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Afterhours is run by a very different set of rules than the new Long Island City program will operate under. Three years ago, state lawmakers cleared pharmacies to begin selling syringes without a prescription and allowed medical institutions to give out up to 10 needles to anyone asking. Fernando Soto convinced Wyckoff Heights Hospital to let his group work under its license in Brooklyn and Queens, and Afterhours was born. Because it’s not a needle exchange, they don’t need community approval to enter a neighborhood, but neither do they qualify for public funding.

The research that anthropologist Ric Curtis has done on the city’s changing drug markets led Afterhours to launch a mobile operation. Aggressive policing of drug-heavy neighborhoods hasn’t done much to stop the trade, but it has dramatically changed its structure. “Many of the businesses had been modeled on the McDonald’s or Wal-Mart style of operation,” says Curtis, a professor at John Jay College of Criminal Justice, who helps fund Afterhours and studied Long Island City’s drug market for the health department. “They had all these street-level functionaries that were just interchangeable cogs for them, but they were getting arrested in extraordinary numbers.” That meant hassle and cost–constantly replacing old trusted workers with new ones that needed to be more closely monitored; regularly losing product to cops. “So eventually they said, ‘You know what? Fuck this. It’s too much of a pain in the ass. We’re gonna downsize. We’ll retain management and lop off labor. And management is gonna go to a new style of business.'”

That new style employs beepers, cell phones and delivery boys, not kids conspicuously hanging out. Now the only people on the streets are the users, carrying around lists of phone numbers for the area dealers and frantically trying to arrange meetings. Gone too are the shooting galleries that once thrived in abandoned buildings and vacant lots.

More typical is a house near Knickerbocker and Troutman. It’s a private residence, owned and occupied by an older man who has lived in the neighborhood for some time, but he lets a number of the prostitutes who work the stroll crash and hang out there. After they get a bag, they go by the house and shoot up; the guy takes a share. Only people the owner knows can come in. “At first I thought the old man was the pimp, but he’s not,” says Fernando Soto. “He gets his. But he looks out for them–or that’s how they see it, anyway.” Soto’s Afterhours crew connected with the house after a couple of years of stalking the neighborhood and networking, operating like dealers. Now the owner lets them come in, too.

The Afterhours group is slowly working through the Bushwick area, trying to unearth these hiding spots. So far, the team has found about 200 clients there.

What Curtis and Soto have demonstrated is that coming to users, instead of counting on them to show up at a clinic, is the way to ensure results. But their mobile operation remains unique. Few other needle exchanges can trawl the streets like this, because their community boards have permitted them only to operate out of a fixed location, and usually only during the day. According to Curtis and several others who monitor needle exchanges, operating with these constraints is becoming less and less effective, and several programs report reaching fewer clients each year. The state health department refused to allow an interview with the office that collects and analyzes that data. But the city health department and AIDS center of Queens County say the difficulty getting users to make a special trip to a fixed location is precisely why they sought to get a mobile van in Long Island City: According to the data, it made public health sense. Politics, damn them, got in the way.

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At just 43, Frieden has already picked and won an impressive set of public health battles. Those victories have been the result not of slow, deliberative consultations, but rather of his willingness to make unpopular decisions driven by one thing above all else: the data.

Frieden began his career as an officer in the Centers for Disease Control and Prevention’s Epidemiological Intelligence Service. If Clint Eastwood worked in health, this is the job he’d have. Agents are deployed around the country as public health’s forward defense, sniffing out new threats like West Nile and SARS. Frieden served in New York City, where he unearthed the spread of a drug-resistant form of tuberculosis. Since he found it, he got the job of getting rid of it, and in 1992 became the city’s director of TB control.

He quickly proved himself impatient with bureaucracy and politics. Facing complaints from civil liberties advocates, he pressed ahead with a plan to detain and forcibly treat people who weren’t adhering to their regimens, thereby heading off the proliferation of new drug-resistant strains. At the same time, he dismissed the popular notion that people who are on drugs can’t be trusted to stay in treatment. He instead sought the counsel of the early needle exchange programs, and learned that the real problem wasn’t drug use itself but the chaotic lifestyle it fosters. So he got addicts with TB into stable housing and, voilà, they followed their treatment.

After four years, Frieden had cut the number of drug-resistant TB cases in the city by a whopping 80 percent and had developed a reputation as one of the world’s brightest minds on tuberculosis control. He left New York for India in 1996, where he did the same job for the World Health Organization, again slashing the disease’s prevalence. When Bloomberg tried to recruit him back as the city’s health commissioner, Frieden reportedly said he’d only accept the job if he was allowed to take on big tobacco.

Now the commissioner is cavorting with the likes of Alan Clear, head of the Harm Reduction Coalition and a national leader on needle exchange. A shaggy-haired Brit who was among the outlaw activists handing out needles on the Lower East Side before it became legal, he’s not exactly a City Hall insider. “I don’t even know who the last health commissioner was,” he admits. But a few months ago, Frieden brought him into the Department of Health to school the entire staff on the principles of harm reduction.

“They get it,” says Positive Health Project executive director Jason Farrell, who is another in the burgeoning group of consummate outsiders who praise Frieden. “The city is in a tight budget crisis–you know that and I know that. They’re looking at trimming the fat. So they put the money where it works.” Indeed, with 13 employees and an annual budget of less than $1.2 million, Farrell’s needle exchange in Hell’s Kitchen reaches 100 people a day.

At one point, Frieden wanted to spend half a million dollars to hand out overdose prevention medication through the needle exchanges. People usually shoot up with at least one other partner, so Frieden figures if we have each of them carry around a dose of nalaxone–which EMTs use to jolt people out of drug comas–we’ll cut the city’s nation-leading rate of drug overdoses. The general counsel’s office nixed the idea of using tax dollars because of liability concerns, but Frieden’s now helping needle exchange programs glad-hand from private sources to pay for it. “It’s definitely amazing,” says Daliah Keller, executive director of the Bronx-based CitiWide Harm Reduction, which is raising money to lead the overdose-prevention initiative. “I think we’re really fortunate.”

But even the commissioner’s loudest cheerleaders in the AIDS world cringe at his style. He may be apolitical, but he’s also reluctant to take advice from the communities his radical ideas affect. Descriptive labels like “arrogant,” “forceful,” and “healthy ego” invariably come up. When he’s making decisions you like, its great; when he’s not, you don’t feel like you’ve got much choice but to swallow them. “We like him now because he’s doing what we want,” says Clear. “But maybe he’ll piss us off, too.”

From Frieden on down, the health department has drawn a striking amount of hostility from AIDS activists. In one meeting of a community panel that Washington has empowered to oversee how the city spends federal AIDS dollars, a member lashed out at Hill by saying her mother must not have been very good at teaching how to tell the truth. People with as much establishment cred as New York AIDS Coalition Executive Director Joe Pressley have been arrested on the steps of City Hall in demonstrations–he, too, called Frieden a liar.

Much of the anger stems from Frieden’s original sin in the AIDS community–his decision to move the city’s Office of AIDS Policy, which had been an independent agency that administered the community oversight panel, into his own Department of Health. Frieden was convinced it was inefficient to have separate AIDS bureaucracies. Activists disagreed, arguing to anyone who would listen that the office served as an essential check on the Health Department. Rather than attempt to sell his idea, Frieden did it on the down low. “There were direct questions posed to the commissioner and Deputy Mayor Dennis Walcott,” says Pressley, “and they said, ‘No, it won’t happen.’ It happened.” Frieden then created his own panel of community members to advise the health department on AIDS–which he handpicked and which meets behind closed doors. (Clear sits on the panel.)

Frieden apologizes for none of this. Activists may be concerned about the Office of AIDS Policy’s oversight role, but he’s focused on its responsibility for preparing the city’s annual application for federal funding. With that process under the health department’s control, he points out, the city got an $18 million boost this year. “I kind of wish people would focus on the substance,” he says, “rather than the symbolism.”

Moreover, even Frieden’s critics agree that he has been more visible and accessible than any health commissioner in memory. He’s met with every HIV community planning body in the city–usually nodding respectfully as they light into him. But critics say he’s not much of a listener. “It’s refreshing to have a very smart guy who doesn’t feel like a politician,” says Keller. “But the problem is that the way he comes off is, ‘I know best. I’m the expert. And I don’t care what you think.'”

Frieden sees this all as a diversionary conversation about style rather than what matters: lowering HIV infection. “I’m really blunt about things,” he shrugs, “and you have groups that have created large organizations that are very wedded to one model of doing things.”

The lingering question is whether Frieden’s impatience with the give-and-take of community politics is actually preventing him from achieving the bottom-line results he seeks. In the end, can you really take the politics out of public health–and should you? Harm-reduction veterans say the final plan for the Long Island City needle exchange is a shadow of what it could have been if the department had started by building support within the community it planned to target. “It’s wonderful to have a commissioner that’s so supportive of syringe exchange and wants to put himself out so far,” says Keller. “But I think what’s missing is, you need bottom-up as much as you need top-down.”

Keller’s speaking from experience. Like Afterhours, her group is one of a few that are mobile. CitiWide works in apartment buildings that contract with the city to house poor people living with HIV. But when buildings leave the program, CitiWide finds itself stuck, because going into a new building means first getting community board approval in that neighborhood. Over the years, the group has lost all four of the buildings it once served in the Bronx, and to make up for that gap it decided to add an exchange at its office near The Hub.

CitiWide began reaching out to the surrounding community in the fall of 2001, and spent the next year and a half locked in a punishing political campaign. They took the fight directly to their most obvious foes, like the police precinct and the parents’ groups–meeting individually with the most hostile board members–and hashed out all the usual questions. They rounded up local users and had them meet with those in opposition, to explain for themselves why the program was needed. And, in the end, they got one of the city’s most expansive exchange sites. It operates five days a week, 12 hours a day. “We managed to turn it on its head,” Keller brags. “Now we’re like the darling of the community.”

This is the sort of process AIDS activists would like to have seen Frieden and AIDS Center of Queens County engage in Queensbridge and Long Island City. The battle that ensued in those neighborhoods was nothing compared to the controversy needle exchange is likely to stir in Jamaica and Far Rockaway. Marshall has taken on a more prominent role in the community outreach process, and meetings have already begun in Jamaica. But the stakes go up there, too: Jamaica boasts more people diagnosed with AIDS than do 19 states. AIDS activists are waiting on edge to see if Frieden learned something in Queensbridge about how to play the community game.

Gioia just wants the health commissioner to see a broader point about policymaking, and the politics that inevitably accompany it. “I hope the lesson they learned from this is that you can’t take people for granted,” he says. “A flawed process is a flawed result.”

This article was produced under the George Washington Williams Fellowship for Journalists of Color, a project sponsored by the Independent Press Association.