National Street Outreach Workers Conference Austin, TX Leo Beletsky, JD, MPH Division of Global Public Health UCSD School of Medicine

 Law enforcement practices are a known risk factor for IDUs and SWs  Deter uptake of prevention/outreach services  Deter summoning of emergency response to OD  Force injection and sex to locations that encourage risky behavior  Deter IDUs and SWs from seeking health services and reduce ability to defend against crime and abuse  Police experience actually associated with HIV

 Accepted wisdom is that police interference is a key limiting factor for SEPs, but experience on ground varies widely  Perceived frequency of police interference is associated with:  racial make-up of SEP clientele,  program visibility and footprint,  whether programs systematically document problems  Policy implementation gaps and local context help explain why NOT associated with legal environment, funding, gov’t involvement  Most programs do not systematically document police issues

Study: Police Interference Percent of programs with non-zero police incidents (12 mo)

 Typically, negative health impacts are unintended  Police are ‘just doing their job’  Police see drug use through the lens of criminality, not health; trained to treat drug users as criminals, not people  Police may be unaware of existing laws re: harm reduction practice (SEP, pharmacy sales, etc)  Police are often unaware of evidence behind HR

 Fear of needle stick injury (NSI) and other occupational risks from contact with IDUs and SWs  Poor knowledge on infectious disease transmission  Frustration with tools to address the root causes of the problems that cause social ills (poverty, substance abuse, poor education, etc.)  Competing priorities from politicians, media, and community groups

7  Conflict between two philosophies  The realists (that’s us)  The moralists (that’s them) ▪ (but luckily for us this is too simplistic..)  Political Context  Elected Judges and prosecutors  Religiosity, moralism, being seen as “soft” of vice crime Competition for limited resources ▪ Limited funds, unlimited demands ▪ Union support

 Public health professionals often fail to identify and address law enforcement concerns when planning and implementing harm reduction programs  Efforts to address public health need not conflict with law enforcement goals of reducing street crime and enhancing public order  Public health is good for everyone in the community, including law enforcement  Successful integration with law enforcement is an essential element of successful outreach operations

 Two main levels of interventions to align police practice with public health goals:  Law on the Books: through legislative advocacy or impact litigation, change the laws affecting IDUs ▪ Pros: large impact (national, state); applies to all actors: police, prosecution, health care providers, etc. ▪ Cons: time consuming; unlikely to change core drug laws (at least in the US); expensive; legislative advocacy requires building strong constituency; law enforcement may resist change imposed by liberalized laws

 Law on the Streets: Change the way the laws on the books are enforced (or not) ▪ Pros: can be done at the local level, taking advantage of local conditions; relatively inexpensive; utilizes ambiguity in existing law and LEO discretion ▪ Cons: piecemeal approach; inability to make large impact; time consuming; finding common ground and building alliances is difficult and time consuming ▪ But it’s possible! ▪ You don’t have to take our word for it ▪ Ask Phil Fiuty, Rachel McLean, Greg Denham, Basha Silverman..

 Identifying common ground  Forging institutional communication  Changing culture and perception  Providing law enforcement training  Providing training to clients, others in the community  Community outreach and relations  Infiltration: foster personal relationships  Stress common interests and goals

 Increased syringe access is good for police  Accidental needle-sticks decreased among law enforcement officers by 66% post pharmacy access legislation in Connecticut Groseclose SL et al. (1995). Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting Drug Users and Police Officers – Connecticut, JAIDS 10: ..and other public employees ▪ Needle sightings by sanitation workers decreased post implementation in New York Lawitts, S. (2002). J Am Pharm Assoc. 42(Supplement 2): S92-S93.  “The more contact they have with us, the less contact they’ll have with you”  Outreach as bridge to treatment, resources

 Prevention  Relationship-building  Education  Legal basis  Monitoring  Surveillance at service points and in community  Response  Horizontal relationships  Legal approaches  Policy approaches  Media strategy

“I strongly believe the government of the state of Delaware should not place itself in the position of enabling drug users to inject their bodies with lethal and dangerous drugs” -Wilmington Police Chief Michael Szczerba -The News Journal, 10/17/06

 Legalization brought opportunity to find common ground with and educate police – head problems off at the pass  Legislation itself set up oversight committee comprised of public health, law enforcement & community  Multifaceted approach: prevention, monitoring and response

Building Relationships and Support  Community outreach  Community meetings: ▪ churches ▪ community boards, ▪ civic associations, etc.  Public defender training  Networking

Client training through program-based workshops  Info on law, policies  How to react to police stop, including defusing the situation  “Street law”  Informational materials

 Standard operating procedures on SEP operations and syringe handling  Training  Syringe disposal at the department

 Occupational Safety  Basic infectious disease info  NSI Prevention tips  Glove and sharps containers distribution  Law relating to outreach efforts  Explanation of regulations  Emphasis on value of harm reduction efforts to police and community  Highlight of collaborative efforts

 Service provider has a system to ask clients about police issues  Another system tracks possible staff problems with police  Routine screening  incident report  Examples of client screening questions:  “Have your condoms been confiscated by police in the last 6 mo?”  “Have you been physically abused by police in the last 6 mo?”  “Have you had any problems with police in the last 6 months?”

 Triggers “horizontal” response, using connections with managers rather than a more slow and less effective “vertical” channel  Other strategies can involve use of the courts, media  Most problems best addressed without going through legal or media channels, because usually involve a few “bad apples”  When horizontal approaches fail, systematic abuse can be addressed through alternative channels  Systematic and accurate documentation is key  Have strategy to protect complainants

“My opinion of the program is no longer relevant, but the success of this program is…I'm committed to providing leadership and cooperation from the law-enforcement end.” Wilmington Police Chief Michael Szczerba The News Journal 8/18/08

Police willing to listen to information that comes from other police: peer-to-peer Police responsive to information that affects them directly (ie NSI) Police are generally pragmatic Positive relationships are key: use official connections to establish credibility Don’t forget Fire/EMS – they’re generally more responsive and people like them

 Harm Reduction is an effective, evidence based framework  Police adopt this too (e.g. no high-speed chases)  Law enforcement barriers do not generally disappear if you ignore them  Sometimes it serves everyone’s interests to “stay under the radar,” but have a contingency plan  Prevention, Monitoring and Response Strategy

 Drug Policy Alliance/Tides  ACLU Foundation of Delaware  Rhode Island Foundation  Wilmington, DE Police Dept.  Basha Silverman  Corey Davis  Dr. Robert Heimer, Dr. Lauretta Grau, Dr. Ted White, and Sarah Bowman, MPH  T32 MH from the National Institute of Mental Health  Rhode Island Foundation  Tides Foundation  Dr. Des Jarlais and Beth Israel staff  Harm Reduction Coalition

References 1. Beletsky L., et al. Can Police Training Help Align Law Enforcement and HIV Prevention? Preliminary Evidence from the Field. American Journal of Public Health (In press). 2. Beletsky L., et al. (2011). The Roles of Law, Client Race, and Program Visibility in Shaping Police Interference with the Operation of US Syringe Exchange Programs Addiction 106(2):357– Beletsky L, Macalino GE, and Burris S. (2005). Attitudes of Police Officers towards Syringe Access, Occupational Needle-Sticks, and Drug Use: A Qualitative Study of One City Police Department in the United States. International Journal of Drug Policy, 16(4), Blankenship K, Koester S. Criminal law, policing policy, and HIV risk in female street sex workers and injection drug users. J Law Med Ethics 2002;30: Burris S, Blankenship KM, Donoghoe M, Sherman S, Vernick JS, Case P, Lazzarini Z, Koester S. Addressing the "risk environment" for injection drug users: the mysterious case of the missing cop. Millbank Q 2004;82(1): Davis C, Burris S, Metzger D, Becher J, Lynch K. Effects of an Intensive Street-Level Police Intervention on Syringe Exchange Program Utilization: Philadelphia, Pennsylvania. Am J Public Health 2005;95(2) Kerr T, Small W, Wood E. The public health and social impacts of drug market enforcement: A review of the evidence. Int J Drug Policy. 2005;16:210– Pollini RA et al, Syringe possession arrests are associated with receptive syringe sharing in two Mexico-US border cities. Addiction 2008;103(1): Strathdee, SA et al, HIV and the Risk Environment among People Who Inject Drugs: Past, Present, and Projections for the Future, Lancet In press

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