On a mild February afternoon at an office in Baltimore’s Pigtown neighborhood — a racially mixed and gentrifying part of town, but still heavily working class, and a hot spot for the city’s opioid overdose epidemic — Rajani Gudlavalleti, Harriet Smith, and Lookman Mojeed were huddled over clementines and mixed nuts.
They were talking about how they would get past their latest setback in furnishing the city with so-called safe consumption sites — clean, nonjudgmental places where opioid drug users can inject while being monitored by staff so that if they start to overdose, they can be given lifesaving injections of the overdose-reversal drug naloxone, or Narcan.
The push for such sites has intensified as drug overdose deaths in the U.S. continue to soar, especially now that deadly fentanyl is showing up in so many street drugs. In a 12-month period ending in September 2017, at least 67,944 U.S. deaths were attributed to overdoses, according to the latest data from the Centers for Disease Control (CDC). That’s a 13 percent increase over the same period ending in September 2016, and far more than the estimated 43,000 who died of AIDS in 1995, the epidemic’s peak year in the U.S.
Currently, there are no such legal sites in the U.S.; the only known, active safe consumption site operates an an illegal facility in an undisclosed city where the opioid epidemic has been especially troublesome, and researchers have already found it effective in preventing overdose deaths. Those findings reflect outcomes from some of the 66 cities worldwide where safe consumption sites are legal. Research has also found that such sites help take drug users and paraphernalia off the streets and can guide willing users into substance treatment, medical and mental health services.
Such evidence has led to movements advocating for sites in opioid-plagued U.S. cities, including Philadelphia, New York, San Francisco and Seattle. San Francisco’s first site may open as soon as this summer — and may be the first to force the federal government to decide whether it will prosecute or turn a blind eye toward them.
In less famously liberal cities like Baltimore, the fight is slower-going. A week before, a Maryland Senate committee had voted to authorize such sites, in an acknowledgment that overdose deaths there had risen dramatically. But Gudlavaletti, Smith and Mojeed had just learned that over the weekend — the same one, in fact, that the New York Times opinion section had endorsed the idea of safe consumption — shadowy forces in Philadelphia had convinced the committee to rescind their vote on the sites, which remain controversial because many see them as condoning or even encouraging drug use.
“We don’t even know who convinced them to go back on their vote,” grumbled Gudlavalleti, 32, a community organizer for Baltimore’s Bridges Coalition, an advocacy collective facilitating conversations about safe consumption in various communities across the city. Alongside Smith, 34, the executive director, and Mojeed, 27, an intern earning his masters in public health at Johns Hopkins, Gudlavelleti is also part of the Baltimore Harm Reduction Coalition, a network of health, policy and social service professionals advocating that punitive state approaches to behavior like drug use and sex work be replaced with a harm-reduction model.
Harm reduction is the principle that people should not be judged or criminalized for behaviors like sex or drug use, but empowered with tools to stay as healthy and safe as possible while engaging in them. With strong roots in the needle-exchange programs that began in the 1980s and 90s to prevent the spread of HIV, harm reduction believes in meeting people where they are, rather than enforcing abstinence or complete behavior change.
The approach is based on decades of clinical observation that when people are judged or told to do something absolutely, they often shut down or do the opposite — but when they’re made to feel that their own safety and health are prioritized, they become more open to staying connected to care, which in turn leaves them open to the possibility of reducing or giving up harmful behaviors down the line.
A 2010 Journal of Clinical Psychology review of dozens of prior studies of harm reduction programs found that such interventions are “effective in recruiting a larger proportion of afflicted clients and in reaching several populations (e.g., worksite, homeless) that conventional treatment programs rarely reach.”
And when it comes to being part of a community that traditional healthcare has historically failed to reach, Gudlavalleti, Smith and Mojeed know whereof they speak. They all identify as queer. And all three are part of a vast network of queer- or LGBTQ-identifying people populating the harm-reduction movement nationwide.
At this moment, much of that movement is focused on setting up safe consumption sites in order to reverse overdoses. And it’s largely because of the legacy of AIDS that many of those working on the front lines of the safe-consumption movement are queer.
“As queer people, we come out of this AIDS activist ACT UP tradition, where we’ve been very vulnerable around healthcare and health coverage and have had to fight for our lives,” says Jennifer Flynn Walker, 46, a Brooklyn-based organizer with the progressive nonprofit Center for Popular Democracy. She is working on establishing an ACT UP-like national network of drug-user-led activism to demand comprehensive federal funding for the opioid epidemic. That idea, recently endorsed by Senator Elizabeth Warren, is modeled after the 1990 Ryan White CARE Act, which was sparked by activism and has since funded treatment and services for people with HIV/AIDS.
“Not all queer people are affected by the opioid epidemic,” she says, “but we’re particularly attuned to people who are stigmatized and need to fight for their healthcare.”
There’s another reason why queer folks are so involved in harm reduction: Their complicated relationship with drugs. “I’ve heard so many stories from queer people who’ve had positive experiences with drug use at dance parties as part of claiming their queer identity,” says Laura Thomas, 51, the queer-identifying interim California director for the national Drug Policy Alliance, which advocates for drug laws based in public health, not criminalization. “We know that drugs aren’t necessarily a universally bad thing. So how do we make sure that people aren’t harmed by them?”
That’s a question that the Baltimore folks are grappling with constantly. Soon, their Harm Reduction Coalition will open a needle-exchange site specifically for cis and trans women, who, they say, often report not feeling safe among men at the city’s only publicly-run needle exchange.
As for a Baltimore site that would not only let people access clean needles but use them to inject there, that’s a tougher fight. The mayor, Catherine Pugh, has infamously said that she would rather see local drug users “put on a plane to Timbuktu” to be treated, and the health commissioner, Leana Wen, has expressed support for safe consumption sites but wants clarity from the U.S. Department of Justice whether such sites would be breaking federal law.
Still, Gudlavalleti thinks Maryland will have a state bill authorizing safe consumption within a few years. However, it’s important to make sure that sites are not “just thrown into poor black neighborhoods to be tested out or then removed, with no accountability,” she says. “Black people here have said adamantly that they will not be guinea pigs on this. I want safe injection sites to be truly safe. That means no police standing outside.”
The fact that nearby Philadelphia, whose population is about 44 percent black, is deep in community discussions about opening such sites is a good sign for the movement in Baltimore, Gudlavalleti added. “People here say, ‘Don’t tell me what they’re doing in Vancouver or Seattle,’” the former of which has had a large safe-injection site since 2003 that has served as a model for other North American cities considering opening their own.
“When you say ‘Vancouver’ or ‘Seattle’ around here,” says Gudlavalleti, noting how white those cities are, “you may as well be saying ‘Holland.’”
If Philadelphia is close to opening at least one site, it’s partly because of the activism of Jose de Marco, a self-described openly HIV-positive queer Afro-Latinx who for more than two decades has been a member of the city’s longstanding ACT UP chapter and a volunteer at its Prevention Point needle exchange. He remembers the Sunday in 1996 when then-HHS secretary Donna Shalala — who had just announced that the Clinton administration would rescind its promise to provide federal funding for needle exchanges — spoke at an area church.
“A bunch of local drug users got on a bus to the church and sat quietly,” he recalls. “One by one, we stood and whispered, ‘Donna Shalala, you killed my brother, you killed my sister.’” (The ban on federal funding for needle exchange was finally lifted from 2009 to 2011, then again in 2016, with the odd stipulation that funding could be used for anything but the actual needles.)
Today, de Marco is part of the SOL (Saving Our Lives) Collective pushing for safe consumption sites in Philly, which recorded over 1,200 overdose deaths last year — as frequently as 70 in 30 days. He says they still have their work cut out for them. “We pushed the health department until they approved this, but they haven’t offered to put up a dime,” he says. “And we’re getting a lot of pushback from City Council members who say they don’t want this in their districts.”
Explaining safe consumption sites to the uninitiated takes patience, he adds. “I was in an Uber and the driver said, ‘Can you imagine they want to give junkies a place to get high? They gave them needles, what else do they want?’ So you have to explain that safe consumption sites are going to not only save lives but also take users and syringes off the streets and hopefully also provide access to treatment for people who want it.”
He says it’s a no-brainer that queer folks are disproportionately involved. “As queer people, especially queer people of color, we understand injustice more intensely than most people do,” he says. “We’re often in the forefront of social justice movements. That goes all the way back to Bayard Rustin in the civil rights movement.”
Over in San Francisco, it’s hard to walk the streets without seeing people openly shooting up. “Today’s San Francisco is one big unsafe injection site,” wrote The San Francisco Chronicle last year, nothing that tens of thousands of needles are discarded in subway stations, parks and beaches there each month — and a proliferation of drug users nodding dangerously close to death. Bay Area overdose deaths have surged the past few years because of fentanyl.
That’s why it was a long-awaited victory for many when the city recently announced that it aims to open safe consumption sites as soon as July 1. “We’ve been working on this for the last ten years,” says Thomas of the Drug Policy Alliance. “I want to be optimistic” that sites will open by July, she says, “but that might be overly ambitious.”
She estimates that a third to half of California harm-reduction activists are queer. “We’ve learned that our community response to substance use has to come from a place of connection and love,” she says. Queer folks need multiple options for dealing with drug use when it gets out of hand, she says, “whether it’s total-abstinence-style recovery or something else. How do you make sure that if you’re going to be using meth all weekend that you take your PrEP?”
She points to the city’s Stonewall Project, which serves gay and bi men (both trans and cis) who use drugs, particularly crystal meth, which has long been a part of the local gay scene. “They provide everything from counseling and peer support to outreach groups, activities, needle exchange and clinical-trial enrollment. It’s a fantastic program.”
In Baltimore, Gudlavalleti and Smith continue to try to get that kind of community buy-in for harm reduction programs. Hours after lamenting about their safe-injection setback, they attended a community town hall in which about 50 people, many in recovery or the loved ones or survivors of drug users, told personal stories about how harm reduction had impacted their lives.
“One thing that stuck with me,” says Gudlavalleti, “was an older black woman in recovery, now a peer counselor, talking to a young white woman also in recovery about how to find personal forgiveness for survivor's remorse and sharing experiences with having to make sure they were safe. That really resonated with me.”
But at the town hall, Gudlavalleti and Smith did not push safe consumption sites. “Stigma reduction was our focus,” she says. “Many folks in that space may not be ready for safe consumption sites yet — or, if they were, they were quiet about it.”
She acknowledges that, even with an overdose crisis raging in Baltimore as it is in so many other cities, sites where people can shoot up safely and legally are simply not going to emerge overnight. But she sees such community forums as a necessary step. “They build the movement toward safe consumption sites because they humanize the experiences of addiction and safety.”
Then, the next morning, she got back to work — just one among countless queer folks nationwide trying to get the public to see both LGBTQ people and drug users as human beings who need compassion and safety, not judgment and punishment.
Tim Murphy is a queer HIV-positive New Yorker of half-Arab descent who has written for more than two decades on HIV/AIDS and LGBTQ+ issues for outlets including The New York Times, New York Magazine, The Nation, T Magazine, and Out and Poz. He is the author of the novel Christodora, a 40-year saga of AIDS, art, and activism in New York City.
