Gregory Howard found his calling in an infectious disease ward in Newark. He'd gone into detox to withdraw from a decade on drugs. Suddenly, he'd begun losing weight and his lymph nodes had swollen. His skin crawled as though infested with bugs.
Lying there, he heard the doctors talking about a new disease. It was killing men who injected drugs and who had sex with other men. Howard had done both. He called his parents and told them he was dying. When he pulled through, doctors blamed the episode simply on withdrawal.
But Howard got interested in that new disease. After 12 years on heroin and cocaine, it became something of a cause. Two years later, in 1984, he went to work for the state of New Jersey as a new breed of public health worker, educating intravenous drug users about AIDS.
These days, Howard moves lightly down the weary streets of Newark, a tall man in cowboy boots skirting the slag heaps of blackened snow. On the street corners of dilapidated neighborhoods, he talks about the deadly virus that lives in the blood in dirty needles.
The job is a kind of sword dance with Howard's fears: He has chosen not to find out whether he is infected. As for his city, studies suggest that at least 60% of its addicts are already infected. Newark may have lost the war before it was officially declared.
How does that make him feel? Howard was asked recently.
"Afraid," he answered sadly, aged 35 with a newly adopted son. He thought for a minute, about his friends and himself. Then he added, "It's like sitting on a time bomb. Waiting for it to explode."
Needle users have become a crucial front in the battle against acquired immune deficiency syndrome. They are seen as the conduit through which the disease is reaching uninfected groups: To them is traced most of the virus's seepage into the heterosexual population and the alarming increase in babies born infected.
In New York City, at least 60% of the estimated 200,000 intravenous drug users are believed already to be infected. In New Jersey, drug users account for more than half of all AIDS cases. Another 6% involve their sexual partners; another 3% are their children.
For unexplained reasons, the problem is especially devastating among blacks: A disproportionate percentage of black users are becoming infected. A recent California study found black drug users nine times more likely than white users to test positive for infection.
Yet efforts to stop the spread of AIDS among intravenous drug users have lagged--for reasons many say are logistical as well as political. They include confusion over how to tap the self-interest of the self-destructive, and society's ambivalence about drug addiction.
For example, there is little data on how best to persuade drug users to change their habits--to stop sharing needles or to clean them with bleach. And there is no conclusive data yet on whether programs to distribute needles or bleach slow the spread of AIDS.
In addition, law enforcement authorities and some public officials say such programs are immoral: To encourage needle hygiene is to condone addiction, they argue. They say the answer to needle transmission of the AIDS virus is to get addicts off drugs.
But public funding for drug treatment has plummeted. The number of treatment admissions in New Jersey dropped from 22,000 to 14,500 over the last eight years. In New York City, 2,800 people are on lists waiting to get into drug treatment programs.
Identified Too Late
So in the East, where the AIDS virus hit first and spread fastest, the problem among intravenous drug users lurched out of control before officials even identified it. As early as 1982, 30% of drug users tested in New York City already had been exposed to the virus.
In the West, it has spread more slowly among needle users--a fact attributed to a different "culture of drug use." But some experts fear the relatively low numbers may be a curse as well as a blessing because it saps the sense of urgency about addressing the problem.
"People don't seem to take this epidemic seriously until it's too late to do anything about it," said James L. Sorenson, chief of substance abuse services at San Francisco General Hospital. "By the time you get a significant number of cases, it will be too late."
One New York expert was more blunt about the situation in the East.
"Things are going to hell," he blurted recently when called by a reporter. "That really is a capital description of the situation."
It was the only point on which he asked not to be quoted by name.
Colleen Marshall started on heroin in the late 1960s. Back then, it was cool to be high, the New Jersey woman recalled recently with bitter incredulity. Who had ever heard of "Just Say No?"
"So I was just out there, you know, messing with a guy who was on coke and dope," said Marshall, a wiry, 38-year-old grandmother with a shock of rust-colored hair. "I didn't have to get out there and hustle or buy or nothing. It was easy, flowin' around me, you know?
" . . . It was the Fourth of July, at 12 or 1 o'clock in the morning. And everybody said, 'Girl, it ain't gonna hurt you.' I said, 'No, I don't want to do that. I ain't done it all this time, I won't do that.' And everybody was getting high and (stuff), so finally I said, 'Gimme a hit, gimme a hit, gimme a hit.' They skin-popped me.
"So I went around skin-popping for about six months. Next thing I know, I wake up one morning, I feel bad. My nose is running. I say, 'I think I'm coming down with a cold.' Right? So the guy I was going with, his sister, she said, 'Oh, you think you got a cold, huh?' She said, 'You know, you is dumb. I used to think you knew so much. You ain't got no cold. You got a habit!'
"I said, 'No I don't!'
" 'Yes you do. You got a habit.' "
Last September, Marshall was hospitalized with "a touch of pneumonia." It turned out to be pneumocystis carinii pneumonia, one of the sure signs of AIDS. It had never occurred to Marshall that she was even infected. And it took a long time to accept that she was sick.
"It took me almost three months to let it come from the back of my head to the front," recalled Marshall, bathed in the naked, fluorescent glow of a methadone maintenance clinic in Newark. "This is it. Now you gotta get yourself together."
No one knows how many intravenous drug users there are in the United States. One government estimate puts the number at 1.1 million to 1.3 million. In New York City alone, officials figure there are 200,000; in Los Angeles County, estimates range from 80,000 to 130,000.
So far, intravenous drug users account for 17% of the approximately 52,000 AIDS cases nationwide, according to the federal Centers for Disease Control. Another 7% of the cases involve users who are also homosexual. But blood samples from addicts in treatment suggest many more are infected and eventually will come down with AIDS.
According to those studies, 50% of addicts tested in Jersey City had been exposed to the virus by 1984. The rate had risen to 60% by last year. In New York City, some drug program workers speculate that the level in some areas may be as high as 80%.
In California, the figures are significantly lower. Studies in San Francisco have found that 15% of drug users studied had been exposed. In Los Angeles, studies put the level somewhere between 2% and 5%.
Different Users, Practices
The key to those geographic differences lies in what some call "the ecology of drug use"--who uses, what they use and how they go about it. The practice and conditions of needle sharing in particular, treatment officials say, differ from coast to coast.
In New York City, addicts congregate in large, commercial "shooting galleries"--often abandoned, multistory buildings in lower Manhattan or the South Bronx. There they can buy drugs, rent syringes, even enlist someone to find them an accessible vein.
Hundreds of drug users may frequent a shooting gallery in a day. And in a dense, vertical city, there may be other galleries within walking distance. Drug users move easily from one gallery to another. Needles become shared resources, like drinking fountains in public parks.
"It's a very effective mechanism for spreading disease," said Dr. Richard Chaisson, an AIDS researcher in San Francisco. "It's similar to the (gay) bathhouse scene that used to exist in San Francisco, where hundreds of people a day would be exposed to the virus."
On the West Coast, needle sharing occurs on a more intimate scale, researchers say. Users meet in residential hotel rooms, homes or abandoned cars. Los Angeles' sprawl reduces the concentration of users and inhibits movement from one gallery to another.
In addition, homosexual and heterosexual drug users may interact more in the East, where researchers say both groups tend to use heroin. Homosexual men on the West Coast may tend to shoot cocaine and speed and have less contact with heterosexuals shooting heroin, one researcher speculated.
Habits may also help explain the high infection rate among blacks.
Chaisson, who has found that 27% of black addicts tested in San Francisco had been exposed to the AIDS virus compared to 10% of Hispanics and 7% of whites, said some studies indicate blacks may frequent shooting galleries and share needles slightly more often.
But he said black addicts also appear to engage more often in a practice called "booting," drawing blood into a syringe and mixing it with the drug before injection. That technique prolongs the rush from the drug. But it also heightens the risk of contaminated equipment.
"We really don't have an answer to why the rate among blacks is so much greater than among whites," said Chaisson, who works extensively with addicts in the AIDS clinic at San Francisco General Hospital. ". . . It's an unanswered question."
So far, attempts to stop the spread of AIDS among intravenous drug users have been slow in coming.
Many drug users exist on society's periphery. They have little contact with public health agencies, doctors, even newspapers and television. Because their habit is illegal and many commit crimes to support it, many are wary of traditional authority.
In addition, changing a drug user's behavior is a complex task. Addiction thrives on denying reality and on self-destructive impulses. Although experts insist it is possible to appeal to a drug user's self-interest, many users say it is hard to be cautious when you are sick.
"You go into a shooting gallery and you see all those needles around," said Floyd Bailey, a former Marine Corps staff sergeant from San Diego County who shot drugs for 15 years. "You ain't going to think where that needle's been; you only think about where it's going to go."
The obvious approach, many say, is to try to get drug users into treatment.
But opportunities for drug treatment have shrunk steadily since 1981 when the federal government shifted the program to the states and cut funding by one-quarter. Some programs in large cities now report waiting lists as long as seven months.
In Los Angeles County, where the cuts were made harsher by Proposition 13, the number of publicly funded treatment "slots" dropped from 7,022 in 1982 to 4,548 in 1987. The county's outreach program, a mainstay of prevention, was abolished in 1983.
In New Jersey, the state began requiring addicts to share the cost of treatment and make an initial down payment. As a result, state officials say, the number of people admitted to treatment in that state dropped by one-third.
In recent months, Los Angeles and other cities have increased funding for methadone maintenance. San Francisco is giving preference to infected drug users. New Jersey has begun distributing coupons for a 21-day detoxification, paid for by the state.
Of the first 1,000 coupons, 84% were redeemed--a rate one state official called "phenomenal" considering the program involves addicts. Twenty-eight percent of those who took up the offer remained in treatment beyond the 21 days, he said.
"What it tells me is that one of the major disincentives to drug treatment is that people can't pay for it," said Bob Baxter, a public health consultant with New Jersey Department of Health Services. "And if you provide treatment and make it affordable or free, they come."
But there is little likelihood of dramatic increases in drug funding, experts say.
"I just don't think the leadership is there," said Karst J. Besteman, executive director of the Alcohol and Drug Problems Assn. of North America and a former deputy director at the federal National Institute on Drug Abuse.
"It doesn't help that the people we're concerned about are a non-constituency in any kind of political sense," Besteman said. "I mean, who do you know that was elected by the drug addicts in their district?"
More Than Treatment Needed
Even if it were available, many say treatment is not the entire answer.
Less than one-fifth of all intravenous drug users are in treatment at any time, experts estimate. Many simply are not interested. A recent San Francisco survey found that more than half the drug users polled would not enter treatment even if it were immediately available.
For that reason, some researchers say the most realistic approach to slowing the spread of AIDS among drug users is to make it possible for them to use clean needles. One way of doing that, they say, is to put an end to needle sharing.
But needle sharing is often an economic necessity. Because possession of syringes without a prescription is a crime, addicts buy them on the black market. They say they risk sharing because bootleg syringes are expensive, risky to carry and often unavailable.
As a result, some advocates have called for decriminalizing needle possession. Others have proposed government sponsored "needle exchanges"--an approach used widely in Europe under which addicts may exchange dirty needles for clean ones.
One analysis of the British needle exchanges begun in 1986 found that while their impact on the spread of AIDS remains unclear, the programs have succeeded in getting AIDS information to drug users who are outside the treatment system.
But the idea has proved impossibly controversial in the United States. Law enforcement officials have fought it, saying it would encourage addiction. Three years after it was first proposed in the United States, only one program is nearing implementation.
New York state officials intend later this year to begin the nation's first pilot needle-exchange program on a limited basis, exchanging needles for several hundred addicts already on waiting lists for treatment programs who agree to be counseled in return.
On Wednesday, Boston officials began discussing a proposal by Mayor Raymond Flynn that the city set up an experimental sterile needle exchange. In Los Angeles County, the Board of Supervisors flatly rejected a proposal that it consider such an option.
"It seems that within the political rhetoric of the United States, our preferred solution for drug problems has been to declare a war on drugs and try to get rid of the whole drug problem," said Donald C. Des Jarlais, coordinator of AIDS research for the New York state division of substance abuse services. " . . . Anything that doesn't appear to be getting rid of the whole problem is suspect."
Even efforts to teach users how to clean their equipment are controversial.
Under political pressure, the Los Angeles County Department of Health Services withdrew from circulation a pamphlet telling addicts how to disinfect needles. They replaced it with a new version urging addicts to stop using drugs. It made no mention of cleaning needles.
"It's contradictory that you can encourage a person to be a 'healthy' drug user," said Los Angeles County Supervisor Mike Antonovich, who contends the county should not appear to condone drug use. " . . . I think the educational campaign has to be aimed at getting people off drugs, becoming self-reliant and responsible."
Gregory Howard stepped out of the car into the gutter of Pennsylvania Avenue in Newark. Nearby, there were some leafless elms, a small park and a few stray dogs. The street had a toothless look about it: a row of dilapidated houses punctuated by vacant lots.
On one corner stood a run-down, three-story house. A fire escape zigzagged down its front and the door was reinforced with battered steel. Out front, a small group of men and women loitered, breathing small ghosts into the cold air.
Two women were working the intersection nearby. They wore dancers' warm-up socks over skin-tight jeans. As cars glided past, they would veer closer and stroll alongside. Occasionally the front window would descend and negotiations would begin.
They were prostitutes, Howard explained as he walked. They work the traffic passing through. They spend their money in the shooting gallery behind the reinforced front door, he said. Then they return to the intersection to work another shift.
Howard approached the men and women in front of the house. While they talked, he handed out leaflets listing the new litany: To avoid AIDS, stop doing drugs; if you can't stop, don't use needles; if you must use needles, don't share; if you must share, clean them first.
He told them he would be bringing by coupons for 21 days of free treatment. The group nodded and pondered the leaflets, which they had seen before. A woman wrapped in grimy shearling ambled up. A handbag dangled, like something dead, from her wrist.
"I'm doing what you said, Greg," she volunteered gamely. She was no longer injecting drugs, she announced. Overstating her case, she added ingratiatingly, "If I'm going to die like that, I might as well run out in front of a bus and get it over with fast."
Walking away, Howard shrugged glumly.
"Some people are stopping," he said. "But you can tell she's still running."
Researchers, nevertheless, say people like Howard are making a dent.
In San Francisco, where outreach workers distribute pocket-sized bottles of bleach, as much as a vehicle for discussing needle use as a supply of disinfectant, researchers have been interviewing drug users to find out whether they are changing their habits.
In 1986, the year the outreach program started, only 3% of the drug users questioned said they had used bleach or knew it could kill the virus. The following year, more than 70% reported that they had used bleach, according to researchers involved in the study.
"Just the increase in knowledge alone is highly significant," said John Watters, director of the Urban Health Study in San Francisco, who helped conduct the survey. "I'm convinced that use of bleach is becoming increasingly a common practice."
Efforts to stop needle sharing and unsafe sex, however, have had less success.
In San Francisco, Chaisson said 71% of the addicts tested in the last year reported that they still share needles regularly--a discouraging indication, he said, that sharing remains an "integral part of drug use and nothing has happened to make it go away."
Similarly, researchers in New York City and San Francisco have found few signs of significant changes in users' sexual practices. Only 14% of San Francisco intravenous drug users studied in 1987 reported using condoms even half the time.
"It's easier to get drug users to change their injection behavior than it is to get them to change their sexual and child-bearing behavior," said Des Jarlais of New York.
"In the Northeast, if we got every drug user to completely stop injecting tomorrow, we still would have 150,000 intravenous drug users who are already infected and who would have to change their sexual behavior in order to control the virus," Des Jarlais added.
Floyd Bailey remembers vividly how he learned he was infected. He was in the Marine Corps in 1986 in Okinawa. All the front-line units, including his, had been tested for exposure to the AIDS virus. One day, he was summoned to see the commanding officer.
The officer was curiously diplomatic. He started out asking about Bailey's son, who had been taken to the hospital with a problem with his eye. How strange, Bailey was thinking. Suddenly, it clicked.
"I just held my head down and he told me," said Bailey, now 33 and living in San Diego County. "I didn't know what to do. . . . I was thinking, 'Damn . . . there was a possibility that I could have infected my wife and kids."
Bailey's wife, it turned out, tested negative. But Bailey's terrible knowledge turned his life upside down. He was shipped back to California, his wife asked for a divorce, he retreated deeper into drugs. Finally, he left the military.
Bailey turned to stealing and shoplifting to support his deepening drug habit. "A halfway good thief," he got busted on some misdemeanors. He was living in a hotel in San Diego when a fierce bout of paranoia last July drove him finally to enter drug treatment.
Now Bailey is an AIDS outreach worker in San Diego County, distributing condoms and pamphlets to drug users. He says he is struck by how many people who seem to think they're immune to the disease, by how many people who don't seem to care.
A lot of drug users are going to die before others take notice, predicts Bailey, who still has his health. A lot of children are going to be born only to die. In jails and honor camps, Bailey tells audiences he's not trying to make them do anything. He just wants them to think.
"I tell people, 'Hey, my name is Floyd,' " Bailey explained quietly one afternoon recently. " 'I don't have no 'Doctor' before my names or letters after. I'm a dope fiend. I know this stuff because I'm infected.' "