[This is part one of a series about the health impacts of homelessness. – Editor]

Maria*, a recovering heroin addict, still shivers when she thinks about the agony of the infections she used to get from the wounds where she had punctured her skin to get high.

“It’s the worst pain—the worst, worst, pain. I told everyone I would rather go through childbirth again a million times. It’s an open wound,” she says.

That first under-the-skin infection—or abscess—Maria got was on her leg. A doctor had to puncture the wound, drain it, and scrape the dead skin off. She quickly learned that she had probably given herself the infection by reusing her own needles. She soon discovered the value of using a clean syringe for each use, but the pain didn’t make kicking her habit any easier. Maria says she continued to get abscesses over the next year and a half, sometimes because she didn’t properly clean the skin before or after using a syringe, and she learned the value of proper disinfection.

The same ideas are behind the concept of “harm reduction”—even when someone is engaging in potentially dangerous behavior, they can still take steps to minimize the risk they pose to their own health and the health of others. Harm reduction is most often used in relation to the distribution of syringes and overdose-reducing substances. But similar principles apply to other forms of harm reduction, like a longtime smoker chewing on nicotine gum to avoid cigarettes, or a bartender calling a taxi for a heavy drinker at the bar, or even a high school teacher telling teenagers about the virtues of safe sex. The common thread is that they all reduce the problems posed by potentially risky behavior.

There’s one important difference, however, when it comes to syringes: Dirty needles are a public health hazard when they end up in parks, at beaches and on sidewalks. An argument has been simmering for more than seven years about where the needles come from, how big the problem is and what to do about it.

POINTING FINGERS

Before Maria got clean, she felt stigmatized for her drug use and developed a sense of shame that made it more difficult to take care of herself, she says.

The two Santa Cruz County-run Syringe Services Program locations, which distribute syringes, had limited hours. So in order to get clean needles, she tried going to a Walgreens, but she says they sold her the wrong kinds of syringes, leading to more abscesses. When she went back a second time, she says, the staff made loud, embarrassing comments about her purchases, prompting her to walk out of the store.

Eventually, she learned that the local volunteer-run group called the Harm Reduction Coalition of Santa Cruz County would deliver needles to her home. She says using disinfectants and clean syringes was an initial step toward her taking her health more seriously and her first step toward recovery. Volunteers with the Harm Reduction Coalition say it isn’t an uncommon story; harm reduction, they say, is often the first step.

Maria, who works in local government, still feels the stigma following her around as a recovering addict. She catches colleagues who know her past staring at her few visible scars. And she overhears those who don’t know it making disparaging comments about drug addicts.

Intense public scrutiny has swarmed around needle exchange practices, and it appeared to first pick up in 2013, when the nonprofit Street Outreach Services was running the local needle exchange. The program handed out clean needles on Barson Street, and took used ones back. But amid pressure from public safety groups like Take Back Santa Cruz, the Santa Cruz City Council shut down the long-time program later that same year, arguing that it operated in violation of local zoning ordinances. That decision essentially punted the matter to the county, prompting the Health Services Agency (HSA) to create its own Syringe Services Program.

Health experts in Santa Cruz County and around the nation tout syringe exchanges as the preferred way to reduce costly hospital bills associated with abscesses, endocarditis and other ailments, as well as stopping dangerous diseases like Hepatitis C and HIV from spreading through the community. The Harm Reduction Coalition and the county’s Syringe Services Program also hand out other supplies like bandages, condoms, lubricants, tourniquets, water, bleach, cotton, and the overdose-reversing drug naloxone. But it’s the syringes that attract the most attention.

Although there’s no evidence that managed exchanges contribute to litter, many of the reasons opponents give for their concerns about needle exchanges have to do with the littered syringes that show up in public spaces, like parks.

In recent years, the Santa Cruz County Board of Supervisors has tightened its rules on the Syringe Services Program—at times, over the reservations of leaders of the county HSA. The program is now a one-for-one exchange, meaning that each user can only leave with the same number of syringes they came in with.

The program is actually more conservative than many exchanges in the state. The California Department of Public Health (CDPH) favors more liberal needs-based programs that provide users additional syringes when they request them.

Now the Harm Reduction Coalition of Santa Cruz County, a chapter within a national organization, has applied to the CDPH to allow the coalition to do sanctioned home deliveries of syringes around the county, running what’s known as a secondary exchange. Kate Garrett, a volunteer with the group, says the Syringe Services Program has limited hours and remote locations, making it less accessible to the community. “There’s a lot of accessibility issues, and our program is seeking to fill in some of those gaps,” Garrett says.

This is the second application from the coalition. The group pulled its previous application and scaled back its proposed operation in response to community concerns, including its decision to eliminate proposed distribution sites in Felton and Watsonville. According to its application to become a certified syringe exchange program, the Harm Reduction Coalition would be a needs-based exchange, instead of a one-for-one program, and it would operate only by delivery.

The coalition already runs an informal secondary exchange. Volunteers sign up to be clients through the Syringe Services Program, bring in dirty needles from users, swap them out with the county and share the clean ones with users. The group’s volunteers say they bring back in more syringes than they give out.

Those harm reduction practices are not without high-profile support. Santa Cruz Mayor Justin Cummings wrote a letter in support of the coalition’s application, as did Santa Cruz County Public Health Officer Dr. Gail Newel, who affirmed the evidence behind harm reduction and explained the accessibility limitations of the current Syringe Services Program. Former county Public Health Officer Dr. Arnold Leff wrote a letter of support as well, as did many activists.

The coalition’s application has also been met with high-profile opposition, including from local law enforcement. Santa Cruz County Sheriff Jim Hart, Santa Cruz Police Chief Andy Mills and Watsonville Police Chief David Honda have all challenged the program. Their critiques included a perceived lack of transparency and outreach on the part of the Harm Reduction Coalition. They felt that the group would not operate with enough oversight.

Former Santa Cruz Mayor David Terrazas, a lawyer with Santa Cruz-based Brereton Law Office, wrote letters expressing concerns, including that there could be environmental concerns that need to be studied and perhaps mitigated.

Third District County Supervisor Ryan Coonerty and 5th District Supervisor Bruce McPherson submitted a joint letter opposing the program, with the blessing of the Santa Cruz County Board of Supervisors. In addition to the risks posed to injection drug users, Coonerty has said that Santa Cruz has a separate health crisis—one of parents afraid to take their children out to the parks and afraid to get exercise. The Syringe Services Program has seen a drop in visits, and Coonerty attributes that to the Harm Reduction Coalition.

Meanwhile, Coonerty—who helped lead the push for a new Syringe Services Program Advisory Commission, which has yet to meet—says the Syringe Services Program is better equipped than a volunteer group to refer addicts seeking treatment in the direction of services. “This is a complex problem that we need to look at from a community-wide perspective,” Coonerty said in a board meeting this past December.

At that meeting, Coonerty presented data that three of Santa Cruz County’s neighboring counties give out a very small fraction of the syringes per capita that Santa Cruz County does.

Jen Herrera, Santa Cruz County’s chief of public health, says it is tricky, however, to try and compare one county to another—or one county program to another, for that matter—as there are many variables at play, and she says there wasn’t time to address them all at the December meeting.

Additionally, syringe exchanges aren’t the only places where users get needles. They can be purchased at pharmacies, and Herrera hasn’t seen any reason to believe managed exchanges are the source of any litter problem. “The data doesn’t show a correlation between increased syringe use and increased litter in a community,” Herrera says. “In fact, what we see is, when you don’t have a syringe program in a community, some data have shown that correlates with increased syringe litter.”

At the moment, though, Santa Cruz County is in something of a holding pattern when it comes to harm reduction.

The local Harm Reduction Coalition initially expected to hear back from the state months ago about whether its application would be accepted or not, but everything has been on hold due to the Covid-19 pandemic. A CDPH spokesperson did not answer questions about whether or not any other factors are contributing to the delay.

The pandemic response has been the HSA’s number-one priority, Herrera says.

NEEDLESS TO SAY

While needle exchanges aren’t specifically designed for the homeless, one survey showed that most local participants in the Syringe Services Program were homeless. It makes sense, given that housed addicts can purchase their syringes online. Also, according to a 2019 homeless count, 30% of local homeless grapple with substance abuse. (Those who don’t lose their housing and become homeless because of their addiction may pick up the habit on the street as a coping mechanism.)

Although the Harm Reduction Coalition is still waiting to hear back about its application, the prospect of its approval has shifted the discussion around exchanges. Hearing concerns about lack of accessibility at the Syringe Services Program, the Board of Supervisors expanded the county program’s hours.

The board also limited the amount of needles that people can exchange at one time down to 300 as part of an effort to try and curb secondary exchanges.

But the new limit hasn’t stopped the local Harm Reduction Coalition from doing secondary exchanges, or swapping out dirty needles for clean ones and distributing them to injection drug users. It has just prompted the group’s volunteers to go back to exchange needles with the county more often.

Denise Elerick, the coalition’s founder, says cracking down on exchanges has not been working. Dissatisfaction with the program and with litter is as high now as it was in 2013, after years of tweaks and limits.

She’s been broadly disappointed by local leaders who say they support health initiatives but don’t put any energy into getting behind harm reduction best practices. She says she loves popular initiatives like First Five Santa Cruz County that aim to improve the health outcomes for young children and give them a sense of equality of opportunity. But she says those dealing with drug addiction also deserve compassion, even if their life stories appear different on the surface. 

“The people that we see are somebody’s cute little babies, and they’re somebody’s children, and they’re somebody’s brother or sister, and they’re somebody’s loved one,” she says.

Elerick feels harm reduction often gets short shrift when it comes to health policy. Elerick followed Councilmember Martine Watkins’ push last year during her term as mayor to promote Health in All Policies, and Elerick was disappointed that harm reduction was not a major component of those conversations.

Watkins tells GT she sees the value of needle exchanges and other forms of harm reduction, but she says she has concerns about how they’re disposed of, and she says she prefers to look at the topic more holistically. “How do we create systems that are supportive of these people who are suffering from addiction, while also trying to get them off those substances,” she asks, “while also being mindful of those who recreate in parks and everyone else?”

More recently, Elerick has watched the county supervisors show broad support for the way leaders of Santa Cruz County’s HSA have handled the response to the Covid-19 pandemic. That has left her curious if the supervisors are going to show a similar level of support for local health leaders’ recommendations on harm reduction.

Coonerty says he still has questions that he doesn’t feel county health leaders have fully answered. He says he supports the needle exchange, and he doesn’t want to see it go anywhere. The question remains how to run it, he explains.

Coonerty would like to see HSA officials assuage his concerns before he agrees to a larger expansion of services. “If they came back and said, ‘Yes, absolutely, and we have the data to support that,’ I would listen to that,” Coonerty says. “I’m always open to listening to data-based arguments.”

* Name changed to protect source’s identity.

This story was reported with support from the California Fellowship through the USC Annenberg Center for Health Journalism.