Guest Editorial - Can We Talk?

Jeffrey L. Goldhagen, M.D., Director, Duval County Health Department

This month, it is my pleasure to have Dr. Jeff Goldhagen contribute a guest editorial. Dr. Goldhagen has helped bring the issue of a needle sharing program to the forefront of our conciousness. The spread of the HIV virus has brought the issue to the frontburner. It has been estimated that approximately 10,000 Americans will become infected with the HIV virus due to innoculation with shared, contaminated needles. This is a preventable tragedy. Perhaps the broader discussion should not just be limited to needle sharing, but should be expanded to include our entire cultural response to the drug problem. Perhaps we should consider if the drug problem should be transferred from the enforcement segment of our society, with arrest and incarceration as individual outcomes, to the public health sector, with education for prevention and methadone treatment as individual outcomes. Nadelman¹in the January/February issue of Foreign Affairs reported that the cost of the war on drugs has gone from 1 billion dollars annually in 1980 to 16 billion dollars in 1997. Unfortunately, drugs have not gone away. Should our approach be the creation of needle sharing programs with concomitant "safe houses" for users to gather and then trade in the spent needle and syringe as is done in Europe and Australia? Will this lead to greater drug usage and dependency with increased suffering? Should drug distribution be altered to take desperation to obtain out of the equation? Would this take the narco states and bandit states with the associated underground economy out of the equation? Would we send a person to prison today for having in their possession, in the privacy of their own homes, a fifth of Jack Daniels? Today no, but during the 1920's we would have. Perhaps, just perhaps, our cultural attitude towards the drug abuse problem, while well intentioned, is equally archaic.

This is a large question, with huge ramifications that has no quick fix to it. We at the journal are delighted to give Dr. Goldhagen an editorial forum. I encourage reader response, both positive and negative.

Michael J. Bernhardt, M.D., Editor

1. Nadelman E. Experimenting with drugs. Foreign Affairs. 1998; 77; (1): 111-127.

The decision was made at the last Medical Society Board meeting for the Society to assume a leadership role in the discussion about Syringe Exchange programs in Jacksonville. The critical issue was, however, not really syringe exchange, but rather dialogue. The same can be said about indigent health care, gun control, managed care, school health, child health insurance, sex education in the schools, children's rights, disaster response, HIV prevention, adolescent pregnancy prevention, welfare reform, access to health care, inequities in minority health and a host of other issues that impact health in this community.

The voice of physicians and the leadership of the Medical Society has been conspicuously absent with regard to these and other important community health and social issues. The vacuum created by this absence has all too often been consumed by bias, partisanship, anecdote, anger and ignorance.

Jacksonville needs the expertise, professionalism and leadership that can only be provided by physicians and the Medical Society.

The spectrum of perspective on issues within the Society will be as diverse as the members themselves. This is an asset that the Society can offer the community. The concern for consensus should not preclude a leadership role in convening community dialogue. An understanding of science and the scientific method—its rigor and limitations—is an important contribution that can be made by physicians. The intersection of science with interpretation and perspective is a conceptual framework that physicians can provide the community to frame dialog and discussion.

There are critical Assessment, Policy Development and Assurance roles to be played by physicians and organized medicine—not just on the national and state levels—but most importantly in local communities where voices are best heard and understood. Identification and solutions for community health problems, informing the public about important health issues, participation in community partnerships, contributing to community health policies and health service endeavors; the linkage of patients to health services, and assuring the competency and effectiveness of the health care system are core health service functions that must be embraced by physicians. These go beyond the traditional role of the practitioner to be sure—but are nevertheless important to the health and well being of individuals and the community as a whole.

Syringe or Needle Exchange is just one, but a good example of a community health issue in which science intersects anecdote, ignorance, bias, prejudice and politics. There is no doubt that providing clean needles and syringes to addicts in exchange for used syringes and needles interrupts the transmission of HIV. There is no more basic a medical principle than the effect of interrupting a vector on the transmission of an infectious agent that is dependent on the vector for transmission. The data related to the impact of SEP's on drug use is less intuitive, but no less rigorous than the transmission data. After 14 years of experience in more than 100 communities in the U.S. no increase or spread of drug use has been documented in any communities in which SEP's have operated.

Should a Jacksonville community implement a syringe exchange program? This is a question that must be addressed and decided by a well informed community. Should the Medical Society play a leadership role in organizing the dialog? Our Board has said Yes. Could this serve as a precedent for future endeavors of the Medical Society? This is a question for the Society to consider. It is my sense that the credibility and accountability of medicine in general, and physicians in particular, depend on the leadership we play in these roles.

A future issue of our Journal will feature an article that details the science of Syringe Exchange and a chronicle of the experience of other communities. In the meantime, with the commitment and courage demonstrated by our Board and with the support of the Society, we will move forward with convening and facilitating a community dialogue on this issue. Your involvement in this and future discussions concerning critical community health issues will be necessary to ensure improvement in our community's health and the primacy of the role medicine and physicians play in our society.

Editor's Note: On 4/20/98, the Clinton administration refused funding for nationwide needle exchange program.

May, 1998/ Jacksonville Medicine

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