Roots of resistance
John K. Watters
No modern public health issue has aroused more political ardour, fear, and public imagination than AIDS. The emergence of the AIDS epidemic has significantly changed clinical and biomedical research priorities on a global scale. The growing numbers of injection drug users (IDUs) caught in the epidemic has focused additional attention on both the drug users and the health and social policies which affect them. In the United States, injection drug use accounted for 25 per cent of the 401,749 AIDS cases diagnosed up to June, 1994, and was the second largest risk category for AIDS, following gay/bisexual males (US Centers for Disease Control and Prevention, 1994). An additional 4 per cent were reported as cases involving heterosexual contact with known IDUs. Gay and bisexual men with drug injection histories accounted for another 6 per cent of AIDS cases. Just under 1 per cent of AIDS cases were classified as paediatric exposure due to injection drug use or sex with an IDU. Thus, at least 36 per cent of AIDS cases diagnosed in the United States through June 1994 were associated with injection drug use. This estimate is conservative, as there are another 35,103 adult and paediatric cases that are of unknown relation to injection drug use or IDUs. Nevertheless, the heightened attention health care policy and research have received as a result have had little impact on the direction or content of substance abuse policy in the United States.
Nowhere are the reasons for this intransigence in substance abuse policy better illustrated than in the ongoing debate surrounding the acceptability of syringe exchange as a prevention measure to slow the spread of HIV among IDUs. Many other industrialised countries have chosen to include increased access to sterile injection equipment, including needle exchange programmes, in their AIDS prevention portfolios, including Australia, Canada, Great Britain, Holland, and Sweden (see Chapter 2). Yet with a handful of exceptions, health policy in the United States remains locked in a protracted debate over the safety, efficacy, and morality of syringe exchange. What is it about America and the American mind that have so constrained public health policy with respect to confronting the HIV epidemic among IDUs? Why are