The Best American Essays 2017

by Leslie Jamison

  For a year, at least, you manage all right.

  I know that, in the late ’80s and ’90s, the rapid spread of HIV through needle sharing galvanized U.S. activists to challenge state laws and distribute hypodermic syringes for free, without a prescription; that the rate of new HIV cases in Vancouver among intravenous drug users persuaded even conservative politicians to consider opening a supervised-injection site; that were it not for the HIV epidemic, many drug-policy reforms in the U.S. and elsewhere might not have occurred.

  I find it curious how few articles on the emerging “epidemics”—heroin, opioid—mention the disease. I wonder whether it is because, with antiretrovirals so widely available, HIV is perceived to be less threatening than it once was. I chase the question for a time. I print out medical papers, underline findings. I call an epidemiologist at a prestigious university, who answers my questions patiently. He tells me that some of the best research is being done by an epidemiologist in Kentucky, who has been following a cohort of intravenous drug users since 2008. (Appalachia has disproportionately high rates of nonmedical prescription-opioid use and overdose-related deaths.) No one in the cohort had yet been diagnosed HIV positive, but 70 percent have hepatitis C. I ask why this matters, and he says that rising hepatitis C rates often forecast HIV outbreaks, because the viruses spread through the same behaviors—unprotected sexual intercourse and needle sharing—and both require a certain density of drug users to sustain transmission. But hep C is ten times more infectious, can live outside the body longer, and is extremely difficult to kill; it spreads more easily. A hepatitis C outbreak indicates that all the factors are present for an HIV outbreak.

  In many ways, it’s a ticking time bomb, the epidemiologist says, especially since, in rural Appalachian communities, knowledge about HIV tends to be minimal; these populations have not previously had to deal with the disease.

  I hang up the phone, look up the data set that tracks syringe-distribution programs by state. Kentucky, 0; Tennessee, 0; Georgia, 1; South Carolina, 0; North Carolina, 6; Alabama, 0; Mississippi, 0; Ohio, 2; Virginia, 0; West Virginia, 0; Pennsylvania, 2; New York, 22; Maryland, 1.

  You are weak and exhausted, have been for months. Every time we make plans, you cancel. Months pass and I don’t see you. When by routine appointment you see your hepatologist, he sends you to the emergency room. You will need a blood transfusion to give you the hemoglobin that you need. By the time I arrive, the blood has been ordered from the bank, is being warmed. We wait for hours. The transfusion itself will take hours, too. I leave you there alone.

  Before I go, the doctor tells me that what you are experiencing is a complication from hepatitis C.

  We sit at your kitchen table beside the four-drawer wooden dresser, its surface lined with pill vials and bottles of methadone. I tell you about Insite. You appear bewildered, shocked even. “How can that possibly help anyone get off drugs?”

  Your first reaction resembles most people’s, but it’s not what I want you to say. I want you to argue that getting people off drugs need not be the primary goal. I want you to be critical of the status quo—of the morass of law and policy in which you and millions of others are entangled. But you are not. You have only ever been exposed to one idea, one approach: abstinence.

  I explain it to you this way: that the most serious harms that arise from drug use—HIV, endocarditis, tetanus, septicemia, thrombosis—come not from the drugs but from external factors. Of all the ways to administer drugs, injecting carries the most risks. The drug solution bypasses the body’s natural filtering mechanisms against disease and bacteria. Access to sterile equipment and hygienic injection conditions can mean the difference between living and dying.

  I say, thinking you might relate, that policing has an especially devastating effect on people who use drugs intravenously and are entrenched in street life. When they fear the police, they don’t stop using, they just move elsewhere—to neighboring areas, where they may create new syringe-sharing networks, or to hidden or indoor locations. In such places, needle sharing is more common, because access to clean needles is cut off. When police are around, users avoid carrying clean needles, for fear of being identified as addicts and harassed. Overdoses increase. Precarious witnesses, fearful that police will follow medical personnel to the scene, fail to seek help.

  I have stats at the ready. Nearly 500,000 Americans are incarcerated on drug charges. Another 1.2 million are supervised on probation or parole. Overwhelmingly, those affected are black, and not because they use and sell drugs at higher rates—on the contrary. I say that prison is no place for people who use drugs, help does not await them there. Maintenance therapies using methadone and buprenorphine are not available for people with opioid dependencies. Often an incarcerated person will continue to use drugs throughout a prison stay, and the clandestine nature of his use means that he is now more at risk than he might otherwise have been, using unsterile needles and sharing syringes among multiple inmates. Overdose rates peak in the first few weeks after release from prison, with mortality rates higher than what would be expected in similar demographic groups in the general population.

  You begin to understand. You agree none of this is good. But still you are uneasy. You maintain it would be better to encourage people to stop using altogether.

  A year has passed since I spoke with the epidemiologist. I read in the newspaper that more than eighty people in Scott County, Indiana, have tested positive for HIV, most of them from a small town called Austin. The outbreak can be traced to intravenous use of the drug Opana, an opioid analgesic. The transmission rate has been around 80 percent.

  Meanwhile a woman in Austin buys a license to carry a handgun because she fears for her young children. The woman takes pictures of “all this stuff going on” and calls the tip line. “I do nothing but,” she says. On her lawn is a sign: no loitering or prostituting is allowed in front of these premises.

  You resent me now. I am trying to help you budget your money. You are spending your entire monthly payment within the first week. When your next deposit comes, I transfer it into the account you cannot access. Every week, I allow you one quarter of your stipend, after deducting your bills and rent. But you won’t stop texting me, asking for more money. I try to reason with you, explain why you need the budget. I try putting my foot down, which amounts to ignoring your texts. You say you are buying a lot of five-dollar bootleg DVDs (Hitchcock is your favorite), but you forget that I know how to do math. And you are not interested in any of the solutions I come up with—a cheap computer, an internet connection, Netflix.

  Every time I say no, I know I am passing judgment on you, on the things you desire for yourself (your collection of Adidas sneakers is by now substantial), what you prioritize. I am measuring you against an ethic of responsibility, a conception of the good life, that I do not want to force you to share. I can recognize this, but I can’t hew my way out of the irony that accepting your irresponsibility only shifts the burden onto me, and this too seems unjust.

  You were lucky once. You and my father sold your childhood home for $300,000. You never risked going to prison to support yourself. But before long, your half was gone, and you started spending my father’s share. He cut you off, begged you to stop, but you said no, you had never felt so alive, you were having the time of your life.

  We go to the bank and close the joint account, transfer your savings. You have total control.

  I feel light.

  Your savings vanish within a month.

  You show up to an appointment with your psychiatrist, but it is the wrong day. You are confused, delirious. You travel by ambulance to the psychiatric emergency room at a nearby hospital. Your social worker calls to report what has happened. He says you may be showing signs of early-onset dementia. He says you may be abusing your methadone. I tell him about our recent conversation, the one where you told me you were taking Klonopin to sleep at night; the one where you guardedly suggested you may not be taking it as directed. />
  Two weeks later the social worker calls me again. You have terminated your services with their facility. You are within your rights to do so, and by phoning to let me know, the social worker is breaking protocol. But he is worried, thinks you lied when you said you found a psychiatrist closer to home. He believes you may no longer be fit to take care of yourself. He wants to call Adult Protective Services, would I be all right with that, and might he provide them with my phone number? He says to me, Please, you are the only person H. has.

  It takes a few days, but I reach you. I come over with pastries from the Doughnut Plant. You seem all right—lucid, lively. You want to know how I know about it all. You are annoyed that someone would call me. You tell me that you like your new facility, that you are happy not to travel to Crown Heights to see your psychiatrist. Getting around the city is hard now. Scoliosis has you bent in two. You are not lying about the existence of this new facility. But when I ask whether you have a new social worker, someone who can help manage your various appointments, who knows what services you are eligible for, who can connect you with the things you need, who you can talk to about your private thoughts, it occurs to you, for the first time, that you do not. I tell you to look into it.

  A few weeks later, I hear from my father that you have started traveling to Crown Heights again.

  I met R. through a dating app. Now I am sitting with him in a wooden booth in a dark bar drinking Campari with soda and lime. We talk, and it’s clear he knows a lot of things. He refuses to say much about it, but for years he studied Kabbalah. He also lived in India, studied Buddhism. Now he works as a professor. We share some ideas about politics, enough to make him stand out among the other dates. We seem to be getting along all right.

  Recently he has been to Vancouver. I tell him that I’ve also been there. We talk about the Downtown Eastside, and he tells me he knows and respects the work of Gabor Maté, whom I interviewed on my trip. Maté is a physician and harm-reduction advocate, a proponent of safe injection sites, who worked in the Downtown Eastside for twelve years. He’s also a proponent of the healing powers of ayahuasca, which is how R. knows of him. I enjoy this conversation, the overlaps in our knowledge. I tell him about Da Vinci’s Inquest, the Canadian television program based on Vancouver’s chief coroner turned mayor, the same mayor who was in office when Insite opened. R. tells me that he has done, still sometimes does do, heroin. A casual user.

  It’s like a test. I can recall the many times I have pointed out, in abstract conversations, that heroin’s reputation does not align with scientific evidence; that although it can be devastating for some, it is not, in itself, any more dangerous than a lot of other drugs, and people who use heroin are unduly stigmatized. But here it is no longer abstract. Will I hold it against R.?

  Later, when I mention this detail to a friend, she frowns. “I like the other guy better.”

  You are cured of your hepatitis after a course of Sovaldi, a new pill that clears the disease in 95 percent of cases. The price of this near-certain cure: $84,000. Each pill costs $1,000. You are fortunate to live in New York, the state where Medicaid coverage of the drug is the most generous. Many states pay for only the sickest patients. You are, relatively speaking, not that sick.

  For the first time I come across an article in the popular press that challenges the accepted narrative. A professor of psychology and psychiatry named Carl Hart says the heroin public-health crisis is a myth. He claims the attorney general is overstating the problem. The commonly cited metrics are insufficient and misleading: the number of people who have tried heroin doesn’t tell you how many people have dependency issues.

  Weeks later, I underline a sentence in Drug War Heresies, a book that attempts to project and evaluate the consequences of various legalization regimes and drug-policy reforms: “One million occasional drug users may pose fewer crime and health problems than 100,000 frequent users.”

  There are more interviews to transcribe. I’ve been procrastinating. Today I am listening to my conversation with Gabor Maté. My friends have been trying ayahuasca, going on retreats, and they all seem to know of him, to hold him in high regard.

  I know the quote I want, am waiting for him to say it, fast-forward through my own voice.

  He says: “Abstinence is just not a model you can force on everybody. There’s nothing wrong with it for those for whom it works. But when it comes to drug treatment there’s an assumption that one size fits all. And if you’re going to wash your hands of people who can’t go the abstinence route, then you’re giving up.”

  He says: “Harm reduction means you give out clean needles, you give out sterile water, you resuscitate people if they overdose. You help people inject more safely. You’re not treating the addiction. You’re not intending to. You’re just reducing the harm.”

  We decide to see a movie in Williamsburg. In the back of a livery car, you tell me that one thing you really miss, one thing you think you should try to do, is find a female companion. I agree that this would be ideal, but I’m not sure how to help. I say that maybe you should go online. I show you the dating app on my phone and we laugh at its absurdity. I say there must be sites for older people. But you don’t have a computer, and you don’t have a smartphone. I’m certain you could count the times you’ve used the internet on one hand.

  You tell me about the woman in the apartment below you. Whenever you try to shower, she immediately turns on all her faucets and uses up the hot water before you even have time to undress.

  I explain the unlikelihood of this—hot-water distribution in a multiunit building just doesn’t work that way. You seem reassured, but the next time we speak, you complain that the problem continues.

  Weeks later, you call in a panic. Con Edison is threatening to cut off your service, and you can’t afford to pay. The bill is several hundred dollars, despite the subsidy you receive. You tell me you had been running your space heater all day, every day, for weeks—the building had kept the heat on low. You either underestimate my intelligence or the shame is too great.

  I call Con Edison, take care of your bill. You haven’t sent a payment in six months. When I confront you with this, you insist on your version of the story.

  You call a car and ride over to my place because you don’t have money to get you through the month. My father says that if I lend it to you, he’ll pay me back.

  “You know what happened?”

  You are sitting at my dining table. You are smiling, and you tell me that when you finally met the hot-water villain, you found her beautiful and fell in love.

  You gave her a holiday gift: a note and $30. You stuffed it under her door. She kept the money, of course, but she never acknowledged you.

  When you leave I give you extra cash for your car ride home.

  A week later, you call to apologize for lying to me about the Con Ed bill. This is a first.

  The Canadian government releases details of a damning audit. The audit alleges that PHS Services, which runs Insite and in 2013 received provincial-government funding worth approximately $18 million, misused corporate credit cards and reimbursed improper expenses:

  $8,600 for limousine rides in 2013

  almost $900 per night for a stay in a British hotel

  more than $2,600 for a stay in a Disneyland resort for two adults and two children

  $5,832 for a Danube cruise

  The article reveals many other missteps.

  I wince. I know how hard these people have worked, how much they’ve done for the hard-to-house in Vancouver. I know this scandal will taint them forever. To open a facility like Insite, to set up crack-pipe vending machines (as they have also done)—to challenge the status quo in this way—you can’t make mistakes. It’s like being a politician. Someone will always want to drag you down.

  Even as the media narrative continues to focus on heroin use among middle-class youth in suburban neighborhoods and rural towns, I know that other populations are in need of resources and services. A s
tudy by the Centers for Disease Control and Prevention shows that rates of heroin use remain highest among males, eighteen- to twenty-five-year-olds, people with household incomes below $20,000, people living in urban areas, and people with no health insurance or on Medicaid.

  I take the subway up to the Bronx to BOOM!Health, a peer-run harm-reduction organization. With a small grant from the Drug Policy Alliance, BOOM! is trying to open the first legal supervised-injection facility in the U.S. They’ve even set up a model site, a single injection booth fashioned after those at Insite. I meet with the organization’s president and chief programming officer. He tells me that they want to create a pilot study, much like the one in Vancouver. I know that when advocates in San Francisco tried to set up a facility, the opposition was too great. But BOOM! is optimistic; having Bill de Blasio in the mayor’s office presents an opportunity.

  I speak with a lawyer specializing in public-health law who argues that a pilot study is not the best strategy. “The people who are moved by evidence are not necessarily legislators. Insite was evaluated every which way. There were so many papers. Most of them are some variation on the theme that it did pretty much what we thought it would do, and it didn’t do anything that its detractors thought it might do. Has that proven very persuasive, either in Canada or the U.S.? Not really!”

  Framing the facility as an incremental extension of services already available, he suggests, could prove more effective. “Almost do it under the radar.” He is not sure that he is correct, but claims that, at least to his knowledge, the federal government never busted a single syringe-exchange program; it was always the local cops and sheriffs.