In March 1997, Joan Viteri died of overwhelming septicemia, a complication of an operation for an abscess in her hip caused by injection drug use. Joan came from a middle-class family and was well educated, but she had become a heroin user at the age of 16. Although Joan had access to medical care, the possibility of undergoing a surgical procedure without sufficient postoperative narcotic pain control—a practice illicit drug users often encounter—scared her. This, in addition to the contemptuous attitude providers often hold toward injection drug users, made using medical treatment an appalling option for Joan. She therefore delayed obtaining treatment for a simple abscess until it became fatal.
Joan's story is not unique. As a society we have elected to declare a "war on drugs." In reality, the war on drugs is a war on people. Drug use can clearly be harmful: heroin can cause respiratory collapse, alcohol can cause cirrhosis, and methamphetamines can cause psychosis. However, no known drug causes hepatitis C, wound botulism, necrotizing fasciitis, or HIV infection. Every day these infections disseminate among drug users, causing disease, disability, and death. The illegal, marginalized social context in which drug users are forced to exist sustains and perpetuates these infectious diseases.
The combination of a lack of primary prevention strategies and deferred use of secondary care increases morbidity and mortality among injection drug users (IDUs). Although contaminated needles facilitate the spread of infectious diseases,1- 3 primary prevention through needle exchange remains illegal. Lack of secondary care permits treatable bacterial and fungal infections to grow unchecked, leading to serious or fatal diseases.4- 6
In 1995, 35% of all AIDS cases reported in the United States were directly or indirectly associated with injection drug use.7 Hepatitis B and C infections are prevalent in the IDU population.3,8,9 In some user populations, transmission of hepatitis C occurs so rapidly that within 6 months of beginning drug use one third of users are infected, and within 2 years, 90% have contracted hepatitis C.10 These diseases affect the community at large. Perinatal transmission, coupled with high-risk behaviors, such as exchanging sex for money and/or drugs and multiple sexual partners, make IDUs a vector for infectious disease transmission into non–drug-using, noninfected populations.11- 13
Most IDUs are familiar with injection-related diseases and are able to diagnose their illnesses as accurately as clinicians.14 Ironically, only a fraction of IDUs seek out prophylactic or necessary medical treatment. Some IDUs fear being arrested for involvement in illegal activities. According to Dr Neil Flynn (verbal communication, July 1998), professor of infectious diseases at the UC Davis School of Medicine, many IDUs are indigent and do not qualify for disability or state Medicaid. Therefore, they are unable to pay for medical services. However, Dr Flynn believes that for many IDUs the primary deterrent to seeking medical care is indignation stemming from prior dismissive treatment from health care professionals. Few people would subject themselves to the treatment that some health care providers reserve for the drug user unless, as Joan, they have no other choice.15
Harm reduction is an alternative approach to the "war on drugs."16,17 The primary tenet of harm reduction is that any step to reduce the negative effects of drug use is valuable. Rather than placing an emphasis on sending "right and wrong messages," harm reduction pragmatically addresses drug use from a public health and medical perspective, without moralizing. Transdermal nicotine patches for addicted smokers,18 needle exchange,1,2 and sex education coupled with the distribution of free condoms to sexually active teens19 are all examples of harm reduction practices that have been effective. Anecdotally we know that the harm reduction practice of providing free taxi rides for the intoxicated has reduced alcohol-related traffic fatalities. Harm reduction encompasses abstinence as a desirable goal, but recognizes that when abstinence is not possible, it is not ethical to ignore the other available means of reducing human suffering.
There are 14000 IDUs who inject on a daily basis in Sacramento, Calif.20 As students at UC Davis School of Medicine working in the Sacramento area, we recognized a need for primary health care services specifically directed toward the IDU population. Toward this end, we created a primary care clinic, the Joan Viteri Memorial Clinic, based on the philosophy of harm reduction. The mission of this clinic is to diagnose, treat, and prevent diseases associated with injection drug use without judgment and free of charge. The clinic does not mandate abstinence.
Supported by donations from public and private sources, the clinic opened August 1, 1998. UC Davis has donated equipment, certain laboratory services, and malpractice liability coverage for medical students and physicians. Additionally, Harm Reduction Services, a Sacramento social outreach program for IDUs, has donated clinic space. Every Saturday afternoon, 5 medical students provide patient care overseen by a volunteer attending physician. In the first month alone, the students treated more than 40 patients with needs ranging from wound care and abscess drainage to hepatitis C management.
By exposing medical students to the impact of drugs and drug policy on the local community and the user, this clinic serves as a unique adjunct to our clinical and political education. By engendering understanding and mutual respect between providers and IDUs, we hope to change provider and user attitudes toward each other. We believe that lifestyle choices do not preclude a person from deserving compassion and care. We hope that our clinic will serve as a positive model for other clinics wishing to provide drug users with primary health care.
Gunn N, White C, Srinivasan R. Primary Care as Harm Reduction for Injection Drug Users. JAMA. 1998;280(13):1191–1195. doi:10.1001/jama.280.13.1191-JMS1007-3-1
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