Good Soldier By Herbert S. Sacks, M.D. APA President

On April 14 and 15 I participated in a symposium at Dickinson College in Carlisle, Pa., on the uses of medication in our society. Dickinson, a superb regional college, was founded by the father of American psychiatry, Benjamin Rush, in 1743. He served as a member of its Board of Trustees until his demise in 1813.

Secretary of Health and Human Services Donna Shalala, a symposium participant, spoke brilliantly about health care policy, tobacco usage, and the expected lifting of the nine-year-old ban on federal donations to programs existent in more than 20 states that reduce the spread of AIDS by providing clean needles to drug addicts. Her talk had all the hallmarks of a Shalala delivery-lucid, upbeat, showing her mastery of the text by only occasionally referring to the printed word. Her convincing rhetorical skills flourished in her response to searching questions from students, faculty, and informed physicians.

Secretary Shalala, in honing in on needle exchange programs, emphasized the recommendation of the Surgeon General, Dr. David Satcher, last year's APA's Solomon Carter Fuller Award winner. He and Dr. Harold Varmus, head of the National Institutes of Health, cited studies showing that the provision of free syringes and needles to addicts saves 33 people a day from contracting HIV. Dr. Satcher observed that 40 percent of all new AIDS cases are due to contaminated needles.

APA has strongly supported needle exchange programs on Capitol Hill and in the executive branch of government.

From April 16 through April 20 a battle ensued among Clinton's advisers. Secretary Shalala, domestic policy adviser Bruce Reed, and Vice President Al Gore were on the pro-needle side, with drug czar General Barry McCaffrey and political adviser Rahm Emmanuel leading the anti-needle camp. (Emmanuel's brother, Dr. Ezekiel Emmanuel, and sister-in-law, Dr. Linda Emmanuel, are well respected medical ethicists.)

McCaffrey's argument, highlighted by the approach of midterm elections, was that supporting needle exchange was wrong in principle and politically dangerous. He defended his views on needle exchange programs before the American Bar Association. There he noted that our judicial system holds 1.7 million Americans in prison at any one time, half for drug-related offenses, bearing disproportionately upon African Americans. He supported drug-treatment programs rather than long prison stretches. He agreed that it is unfair that a trafficker of 5 grams of crack cocaine (caricatured as a black street hustler) should face a mandatory minimum prison sentence of five years, while the threshold quantity of powder cocaine (preferred by middle- and upper-class whites) for such a sentence is 500 grams.

The central question is whether any public message, right or wrong, is being heard. McCaffrey's goal, pursued with better drug education and better high-tech border surveillance, is to halve the use and availability of narcotics in our nation by 2007. Should he be successful, illegal drugs will still be a problem for 6.5 million Americans, down from the peak of 25 million in 1979.

The general claims that the use of illegal drugs has fallen by half over the past decade and that use by young people has stopped growing. That still leaves us with 3.6 million people with a cocaine habit and more than 800,000 chronic users of heroin. In addition, among 14-year-old Americans, 10 percent smoke marijuana and 4 percent use methamphetamines and other stimulants.

Are these figures valid? Many believe that the survey methodology is rife with error and prone to distortions in interpretation. But others note that the decline in crime in Americans over the age of 18 is parallel to the decline in hard drug usage. In my last column, "Our Medicated Society," I called attention to the burgeoning sales of prescription, over-the-counter, and health food store remedies as part of our need for a quick fix for any problem, however complex or deeply rooted.

On April 20, six days after the Secretary's Dickinson College speech, White House Chief of Staff Erskine Bowles called the Secretary with the President's decision made en route home from Chile. Mr. Clinton decided that the political risks to other important programs opposed by conservative Republicans outweighed the practical benefits of a needle exchange program. Further, the opposition would claim, with loud demagoguery, that needle exchange was a government endorsement of heroin use.

Thus, Good Soldier Shalala, three hours later, faced the press, flanked by Drs. Satcher and Varmus, and actually endorsed the new research indicating that needle exchange reduces HIV infection, without encouraging drug abuse: "Another life-saving intervention." But simultaneously, she offered no funds for federal interventions.

The Washington Post revealed Secretary Shalala's leaked "talking points" memo for the press conference where she argued that "science, science, science" had driven the Administration to take action by funding the needle exchange initiative. But as Frank Rich wrote in the New York Times, "It was politics, politics, politics that in the end persuaded the Administration to do nothing." Now she is asking the states and the cities to initiate needle exchange programs without federal support.

The President's favorite book is not a work of fiction or policy, but of ancient philosophy, the Meditations of Marcus Aurelius, written 1,800 years ago. One of Aurelius's epigrams addressed the needle exchange fiasco: "If it is not right, don't do it; if it is not true, don't say it."