Miguel Ramos, site manager of the New York Harm Reduction Educators' needle exchange in East Harlem provides a local resident with clean syringes. (Photo by Lauren Browne/CNS)

They call him the Rubberman.

On the streets of Asheville, N.C., he is hard to miss.

Six feet tall, with long, dark hair pulled back in a Shirley Temple curl, sporting an unkempt Dick Van Dyke mustache, he is a well-known personality who walks through town distributing condoms and sex education pamphlets to locals and visitors alike.

But public health advocate Michael Harney is not only in the business of handing out rubbers, as his nickname might suggest. In an old plastic grocery bag slung across one broad shoulder, he carries a valuable commodity in this part of the country—clean syringes.

Harney currently runs the only openly active illegal needle exchange program in North Carolina, one of many U.S. states where syringe exchange is still prohibited.

“This is a small program,” says Harney in a telephone interview. “I only distribute 10,000 to 12,000 needles a year. But am I meeting all the need out there? Of course not.”

Health experts across the country celebrated victory last December when Congress voted to lift a 21-year ban on federal funding for needle exchange programs. While legal programs in states like New York and California are already applying for new funds, underground operations have little hope of any financial assistance. Antiquated state law, rather than federal funding, is still the real obstacle to needle exchange, according to grass-roots advocates.

Meanwhile, injection drug users with no access to clean syringes are acquiring fatal blood-borne diseases like HIV and hepatitis at alarming rates. Legal barriers disproportionately affect poor, minority populations, according to new research. Improperly discarded needles litter towns and endanger residents, while increased rates of disease place financial burdens on an already stressed health care system.

Every Tuesday morning, Miguel Ramos and his team from the nonprofit organization New York Harm Reduction Educators park two midsize motor homes on a corner in East Harlem. They pitch a small white tent along the sidewalk; stock it with sterile syringes, cookers, cottons and water; and wait for neighborhood addicts to drop by.

The organization, known by locals as the “Cadillac of harm reduction programs,” is one of the oldest needle exchange programs in the country. Such programs were born in the 1980s, during the early stages of the HIV/AIDS epidemic, when injection drug users were disproportionately affected by the disease.

Two decades later, New York City health workers like Ramos have helped decrease HIV infection in drug addicts by 75 percent, according to a 2005 study.

But despite multiple federally funded studies showing that access to sterile syringes makes injection drug addiction less deadly without increasing use, needle exchange has remained a political battleground.

“Simply put, needle exchange programs enable the addicted to continue down the destructive and deadly path of drug dependence,” states the Florida-based nonprofit organization Save Our Society From Drugs, in its position statement.

Florida state drug paraphernalia laws currently outlaw needle exchange.

In November 1988, Congress banned federal funding for any program that distributed sterile syringes for illicit drug use. The ban undercut initiatives providing important public health services, according to community health experts.

States were left with the power to decide whether they would permit and fund needle exchange programs via a public health exception to drug paraphernalia laws. Many decided against it.

But this past December, Congress’ decision to lift the 21-year-old federal funding ban gave legalized programs a glimmer of hope.

There have already been funding cuts at the state level, says Herbert Quinones, program director at New York Harm Reduction Educators. “We are definitely applying for federal money, but that’s not guaranteed either. The administration has just decided to freeze domestic funding. So who knows what’s going to happen? We’re hoping for the best.”

Wilfredo Rodriguez, Martha Ruiz and Miguel Ramos from the nonprofit organization New York Harm Reduction Educators set up a syringe exchange tent on the corner of 110th Street and Park Avenue. (Photo by Lauren Browne/CNS)

In states that have outlawed needle exchange, like North Carolina and Nevada, activists believe that federal funds will do nothing for the injection drug users they serve.

“We don’t have any needle exchange programs in the state of Nevada,” says Jennifer Morss, executive director of the nonprofit organization Aid for AIDS of Nevada. “So I can’t really tell you how the funding would affect our programs.”

Some 94 percent of injection drug users surveyed in Las Vegas reported that they would use a clean-needle exchange program if one were made available, according to a 2001 study.

“The health department can apply for all the federal funding it wants,” says Harney. “Even if the federal law has lifted the ban, this is still a state issue. If the state doesn’t allow us to receive those funds, we’re not going to get them. There is such a fear at the legislative level.”

As in many states, the North Carolina drug laws are tricky. Although syringe exchange programs are banned, drug injectors are legally permitted to purchase sterile needles without a prescription from local pharmacies.

But North Carolina has strict drug paraphernalia laws. Anyone caught in possession of a needle without having a prescription, even if it was just bought from a pharmacist, can be (and often is) arrested.

Pharmacists also have the right to refuse to sell a syringe if the customer does not have a prescription.  Some request identification—sorely lacking in the homeless population—or other information before they are willing to sell needles.

“One day a guy came in here looking for me to give him a clean needle,” says Harney. “But he couldn’t find me. So he goes to a pharmacy down the street. Pharmacist asks to see a prescription. He says he doesn’t have one but asks whether the pharmacist would rather be filling him a prescription for HIV or hep C meds.  The pharmacist replies, ‘If you’re a junkie, you deserve to have AIDS.’ ”

Harney started the Needle Exchange Program of Asheville in 1994.

“I was an outreach worker in western North Carolina,” says Harney. “Every day, I was tripping over needles in the streets. That’s when I decided to do something about it.”

Harney describes his operation as “illegal but tolerated” by local officials. Political support in what is considered by many to be the most liberal pocket of the state sustains his efforts.

Although there are other harm reduction organizations in North Carolina, they do not openly advertise needle exchange services. Injection drug users are often too afraid to seek out clean needles or other health services.

“We operate underground,” says said one public health activist in North Carolina who asked to remain unnamed for fear that she would be targeted by law enforcement officials. “The minute they find out that we’re passing out syringes, we get shut down. People are scared to call the police or call the ambulance when someone has OD’d. They’re afraid of the legal repercussions. They think they can’t go to the doctor because the doctor is going to see the track marks. So they never go to the emergency room.”

IV drug users account for more than 20 percent of new HIV infections in the U.S., according to 2007 data from the Centers for Disease Control and Prevention. Injection drug use is also the leading cause of hepatitis C infection.

Restrictive drug paraphernalia laws disproportionately affect minority populations. In the Raleigh-Durham, N.C., area, white injection drug users are five times as likely as black users to report pharmacies as their primary source of syringes, according to a January report by Family Health International.

Public health officials believe that individuals who do not obtain their needles from pharmacies must acquire new needles illegally or simply reuse the ones they or their friends have. An estimated 50 percent of Americans diagnosed with HIV are black, according to 2007 data from the Centers for Disease Control and Prevention.

But syringe exchange programs don’t benefit only injection drug users.

“My biggest concern is proper disposal of used needles,” says Harney. “Don’t flush ’em down the toilet. Then you’re gonna need a plumber. Don’t put ’em in the garbage can. It puts garbagemen in harm’s way. Don’t throw it over your fence and get your neighbors in trouble. This is about public health and safety for the entire community. I’ve received pizza boxes of needles, milk jugs, Pepsi bottles, you name it.”

Syringe exchange programs are also cost effective, which reduces the burden on community health care services. Using clean-needle exchange to prevent one person from acquiring HIV saves tens of thousands of dollars a year, according to a 1997 study.

Health activists across the nation who promote syringe exchange, either legally or illegally, have one common goal: to prevent injection drug users from becoming sick, so they can concentrate on what is really important—recovering from addiction.

“It’s a lot harder to get off drugs if you are sick on top of it,” says the anonymous health worker in North Carolina. “No one deserves disease.”