Harm Reduction at Ground Level
Photo Courtesy of IDEA Exchange Tampa
In fifty years of volunteering, I have rarely encountered an ostensibly altruistic effort that could not be sentimentalized. From working with other teens in the 1970s at one of the first summer camps dedicated to the needs of young people suffering from muscular dystrophy, to passing out Thanksgiving turkeys at a food pantry in the 21st century, all of us with the good fortune to be able to volunteer could look wistfully in the mirror and think, “The world is better because of my efforts.” Full stop. No question. Unequivocal good work, the reward that comes from a sense of selfless engagement with those who need aid, aid that I could deliver.
At the end of 2023, my world – suffused with egotistic altruism – was shattered when I began volunteering at the needle exchange site in Tampa, Florida, a city I have called home since 1999. On Tuesday nights, I found myself passing out bags of snacks and sterile syringes to people who inject drugs, and to other users in that orbit. Having lost my son to substance abuse (alcohol), I felt a connection to the other volunteers and the staff who ran the site, similar to what I have felt with my fellow soldiers during a 20-year career in the Army. We were on the front lines, trying to save the lives of people who were engaging in the most self-destructive behavior imaginable. We were trying to give them supplies so that the users could continue their behavior and stay alive. Maybe — and only a big maybe — our efforts would keep one of these users alive long enough for them to enter a course of recovery. We did not prevent anyone from shooting up heroin or fentanyl; we made shooting up safer. Hence, the shorthand term for needle exchange programs is harm reduction.
In preparation for this harm reduction work, I did some due diligence. In the course of my research, I tripped over the numbers of opioid overdose deaths in the USA per year, something north of one hundred thousand every year since 2021. That is more people than we lost in Vietnam and all the conflicts since then, combined.
The Tampa needle exchange is a state-level effort that is part of the US government’s contribution to harm reduction services. For the sake of clarity, six states currently outlaw any harm reduction services, and several restrict it to the point of making its impact negligible at best.
I soon learned that harm reduction can be applied to any behavior, but the term arose from clandestine needle exchange efforts in the early 1990s, which organized to stem the spread of HIV infection among intravenous (IV) drug users. “Needle exchange” can be a misleading or inaccurate term, given that it suggests a person who injects drugs can exchange used syringes to get sterile ones. That exchange in itself can be an obstacle to achieving the goal of preventing the spread of infectious diseases through shared needles. Still, harm reduction includes providing all manner of supplies and education intended to keep its target population (IV drug users) alive long enough to reach a path of recovery.
The needle exchange in Tampa is called IDEA Exchange Tampa. IDEA is an acronym for Infectious Disease Elimination Act, disease elimination being the premise upon which Govenor DeSantis signed legislation allowing – not funding – the service to stop the spread of HIV and hepatitis through shared needles. Throughout my months as a volunteer, I experienced a cognitive dissonance not unlike what someone might feel upon opening the door in a house they have lived in for several years and finding, suddenly, on the other side the Atlantic Ocean. Previously, people resting on the sidewalk or under the shelters of bus stops were invisible to me. They were invisible because I willed them to be, or so I came to realize once I was face-to-face with them.
IDEA Exchange Tampa is run as a mobile site, set up for 3 to 4 hours in two locations on different days of the week. The schedule is published on the website. The people who come to avail themselves of the services (respectfully referred to as participants) know when and where to be as much by word-of-mouth as any other means, since living in the street does not come with free Wi-Fi, and the street is where many of the participants live. The night sessions bring out more sex workers than the daylight hours. In three hours of a night session, the exchange can accommodate 40 to 50 participants, with one-third to one-half comprised of sex workers, although it is impossible to know who is a sex worker by appearance alone. Some of the participants are obviously unhoused. They walk up to the site, carrying what appears to be all they own. Some have bicycles or e-bikes draped in plastic shopping bags carrying their accumulated wealth. Most of the women participants either drive or come by Uber. The paid staff who run the site know from intake interviews and conversations who all the participants are, who is doing what, who is living where, and who is living nowhere.
The intake interviews are required by the legislation authorizing the service. The state has six authorized needle exchange sites at the time of this writing. Outside these legal footprints, harm reduction can get a person in trouble, as one of the staff discovered. Attempting to provide harm reduction services to participants in a city near Tampa, the worker was arrested by local law enforcement. You don't travel around with tourniquets, syringes, and other consumption supplies without drawing suspicion.
Intake interviews are also where participants learn that they must bring their used syringes in order to get fresh ones. And bring them they do. On a typical night with forty participants, volunteers usually fill a standard hospital “sharps” container in the 13-gallon range over the course of three hours. In return, the site volunteers fill plastic bags with consumption supplies to include the lifesaving drug naloxone (a.k.a. Narcan). During any given night, 3000 syringes can go out along with dozens of boxes of Narcan.
Beneath the give-and-take of syringes, an ongoing study tracks participants diagnosed with HIV. An uninformed observer could reasonably surmise that the staff and volunteers were a group of do-gooders who chipped in and raised money for a van, laptops, and mobile Wi-Fi equipment, for sunshades, tables, chairs, drinks, snacks, and all the accouterment to safely inject oneself with heroin, and brought it to the street for easy access. The staff often do use their own money for things like drinks and snacks, but the funding for almost everything, including staff salaries, flows through a local university and hospital. What looks ad hoc is actually as deliberate as any medical clinic in an urban setting. Blood drawing is a routine occurrence, and there is a phlebotomist present. The staff includes a psychologist specifically trained in motivational interviewing techniques, anthropologists, third and fourth-year medical students, social workers who can advise on how to find medical insurance, and a wound care specialist who treats the ulcers of those who unknowingly inject themselves with xylazine, a horse tranquilizer that works great on horses but kills the skin around the injection site of humans unfortunate enough to use it.
There was no question of a transactional dimension to the behaviors observed on the nights I volunteered. The participants brought used needles and got sterile ones in return. However, free sterile needles are not what keeps bringing these participants back every week. If the needle exchange went away, most people would likely keep using and probably die sooner. What brought the participants back were the hugs.
On the Tuesdays I volunteered, I would arrive at the appointed place and time. A friendly woman in scrubs would tell me where I was needed, usually at the snacks table. She was the director of the volunteers. The site was located at a downtown street corner in a part of Tampa that would be generously described as a “low-rent district,” a spot where stores have bars over the windows. Tampa police cars cruised by every few minutes.
The needle exchange site sat in a parking lot ringed by a black wrought-iron fence. The parking lot was about the size of a football field with a gate at one end that served to control access. The needle exchange proper was set at the far end from the entrance, allowing staff and volunteers to see participants as they made their way down the sunbaked asphalt.
A large panel van emblazoned with the logo for the needle exchange sat near the fence opposite the entrance. A group of young men and women unloaded the van. They set out folding tables, chairs, collapsable pavilions, and the red sharps container. The sharps container would be the first thing participants in the program encountered, as they would dump their used syringes before proceeding.
One night, several participants were waiting for the needle exchange crew to finish setting up. The participants were each holding a container full of their used syringes. Some carried a thermos-sized sharps container like you would see in a hospital. Others had repurposed containers, such as the cardboard cylinder for oatmeal. A staff member with gloved hands took each container, popped the top off, and emptied the used syringes into the big red trashcan, removing any of the syringes that were stuck with a pair of metal tongs. As these participants were being tested for hepatitis and HIV, a young woman who appeared to me to be in her teens, walked up barefoot, in shorts and a sleeveless top, while the rest of us were in heavy coats and sock hats. She was in the company of a man who looked closer to my age (late 50s, earlier sixties) and by his appearance did not appear to be a blood relative. He walked up to the intake table while she stood back, not coming closer than 30 feet of anyone. Her companion approached the table designated for the intake interviews and appeared to explain her situation to one of the staff. After a brief exchange, another staff member disappeared into the van and emerged holding a bundle of clothes. Like one taught the necessity of great caution lest catastrophe follow, the young woman tried everything on standing in the middle of the parking lot. Not everything fit, and some articles were exchanged. In the end, the woman left in socks, shoes, pants, and a jacket. Three months later, I saw her again. She had a new companion, and she no longer had the appearance or demeanor of a young teen. The softness of a youthful glow had been replaced with a hardness defined by a deeply tanned face, cheekbones lifting from what had been a rounder face. To me, she appeared to have traveled a long distance in three months.
Still, compared to that first night, her behavior said she felt safe in the perimeter of the needle exchange. The staff and volunteers had convinced her that the war was outside the wrought iron fence. I never saw her deposit used syringes or take sterile ones. She had come back for something else, the same something else that all the participants came back for: hugs, patience, small acts of material kindness in a relatively secure setting.
The participants feel safe for the minutes they spend at the Tampa exchange. No one tells the participants that they are killing themselves. (They know that.) No one begs them to give up their self-destructive behavior. (They would if they could.) No one tries to use shame or stigma as a behavior modification device. (IV drug users are often seen as occupying the lowest rung on the ladder of people who use drugs, and they always have.) The participants come every week to be looked after for a few minutes, to have a snack, and to hear someone ask how they are doing. They come to be hugged without worrying about being arrested.
I realized in my months as a volunteer that, while needle exchange does not prevent or save people from dying of an overdose, the broader harm reduction programs can save lives. They put information and Narcan in the hands of those most likely to need it. More importantly, as a volunteer with five decades of experience, I have come to believe every person in need, regardless of their status, should be able to reasonably hope that all the do-gooders in the world will do something good for them.
And for all those do-gooders who have fought on the front lines of our country’s opioid overdose crisis, a piece of good news. Provisional data from CDC’s National Center for Health Statistics indicate a decrease of 3% in overdose deaths in 2023. This is the first annual decrease in drug overdose deaths since 2018.
Originally from Macon, Georgia, Tony Schwalm spent much of his adult life as an Army officer, serving as a tank company commander in the First Gulf War in 1991 and leading Green Berets during the Haiti invasion in 1994. Retiring from the Army in 2004, he works as a consultant to the Department of Defense and lectures to business students at the University of South Florida on the merits of improvisation as learned in the world of guerrilla warfare. In 2009, his essay, Trek, won first prize at the Mayborn Literary Non-fiction Conference at the University of North Texas and was the basis for the book The Guerrilla Factory: the Making of Special Force Officers, the Green Berets published by Simon and Schuster in 2012. He makes his home in Tampa, Florida.
