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A Partial Solution: Pharmacy Access, Clean Needles and Emergency Contraception

By Maxwell Ciardullo
Editors note: This article highlights the shared obstacles to accessing two stigmatized public health toolsemergency contraception and clean syringesparticularly when they are distributed through private, for-profit channels, like pharmacies. It calls for advocates to promote pharmacy distribution, while promoting free community healthcare and opposing federal policies which block access. It makes an argument for increased cooperation between the reproductive justice, harm reduction and AIDS movements. Betsy Hartmann and Anne Hendrixson

Emergency contraception (EC) and clean syringes dont often come up in the same conversation, but these two public health tools are facing similar political and policy challenges in the US. Conservatives on both sides of the aisle have stigmatized the tools and recent federal policy decisions have made them harder to

access for most Americans. In December 2011, Congress reinstated the federal ban on funding syringe exchange programs (SEPs) as part of a spending bill after a two-year reprieve. In the same month, Health and Human Services Secretary Kathleen Sebelius overruled Food and Drug Administration (FDA) scientists in order to keep emergency contraception behind the pharmacy counter for anyone 17 years old and over, and entirely inaccessible to anyone younger than 17 years old without a prescription. Both of these policies reflect a strain of conservative political ideology, which argues that EC and SEPs encourage and enable bad behavior. Emergency contraception is birth control that can be used after unprotected sex. The antichoice movement has claimed that EClike abortion, sex education, HPV vaccines, and even mandated insurance coverage of birth control as preventative healthcareencourages promiscuity, particularly among young people.1 However, several studies suggest that access to EC does not influence young peoples sexual decisions. The Guttmacher Institute conducted

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research into the sexual practices of young women who were issued EC before sex and found that those polled did not have a higher rate of unprotected sex than young women who had to obtain it after unprotected sex.2

Syringe exchange programs and practices have been through the same political wringer. SEPs provide clean syringes and other related services to injection drug In the case of syringe exchange, the return of the users to prevent the sharing of used syringes, and thus funding ban cuts off a source of support for critical the spread of HIV and Hepatitis C. Typically, SEPs opprograms that are often struggling to keep their erate with very low barriers to access and a non-judgshelves stocked with life-saving supplies and their mental attitude about whether their participants stop doors open. In Washington, D.C., the citys oldest and using drugs. Despite conclusive research proving their largest SEP recently closed for lack of funding. The merit as an HIV and Hepatitis C prevention tool (not to District still has the highest HIV prevalence rate in the mention successes preventing injection-related infeccountry and injection drug use still accounts for 21% tions and overdoses, and connecting of all new AIDS cases.7 In Massachudrug users to treatment), conservative setts, SEPs have only been approved lawmakers and think tanks have branded in four cities: Boston, Cambridge, Like people SEPs as programs that condone and inNorthampton, and Provincetown. seeking EC, drug crease drug use.3 One of the more public In most states like Massachusetts, users are being attacks on syringe exchange programs where SEPs arent able to meet the abandoned to was conducted by former Republican need, pharmacies are allowed Governor of New Jersey, Christine Todd though not mandatedto sell meet their need Whitman, who used materials from consterile syringes to customers without for clean syringes servative think-tank the Heritage Founa prescription. Still, people who at for-profit dation to support her argument that the inject drugs (including hormones) pharmacies, programs do not work and encourage and do not live in cities with progreswhether they can drug use. Her administration even went sive drug policies are left to rely on afford to or not. so far as to use sting operations to arrest pharmacies as their only legal access staff at needle exchanges.4 point for sterile syringes.

reduced services or closed altogether in the last few years due to federal and state legislative harassment and de-funding. A recent report also found that indigenous peoples access to emergency contraceptives has been limited by the fact that many Indian Health Service clinics do not stock the drug and have inconsistent policies.6

Privatization of Access
Policy decisions like these leave the distribution of preventative healthcare measures like EC and clean needles to for-profit pharmacies and their employees, which translates into barriers to access: higher prices, lack of counseling, and in some cases, stigmatizing experiences. Teens younger than 17 years old who lack the support of a parent or guardian with health insurance will have to rely on older friends or relatives to access EC through pharmacies. Those 17 years old and older will also have to request EC from pharmacists, and in a number of states pharmacists or pharmacies are allowed to refuse to sell EC to anyone. Some states have excluded EC from Medicaid coverage, so poor and working class young people will have to find $50 in their already tight household budgets in order to access it.5 Young people who live near a Planned Parenthood or independent reproductive health clinic may find assistance there; however, many clinics have

Like people seeking EC, drug users are being abandoned to meet their need for clean syringes at forprofit pharmacies, whether they can afford to or not. I recently spent a year working at a Massachusetts SEP and decided to talk to the participants about bypassing local restrictions on SEPs by creating access points at pharmacies. In particular, I was concerned with their experiences at pharmacies in comparison to their experiences at harm reduction programs that provide syringe exchange. Of the 28 participants I talked to, 16 told stories of dirty looks and general attitudes of contempt from pharmacists.8 One participant shared that she had been hassled when she first started using pharmacies to purchase syringes, but that she learned that if she could pass as a person with diabetes, buying syringes for insulin, she would be treated much better. She has since memorized the size, gauge, and serial number of the syringes she uses to avoid questioning or suspicion when she buys from pharmacies.

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Most participants preferred to use the local SEP, but occasionally used pharmacies as a back-up when it was closed. I also talked to a number of participants who did not have regular access to the syringe exchange, but lived relatively close to a pharmacy. Many of them still bypassed the pharmacy altogether, choosing instead to use underground means to access syringesbuying them from bodegas or from people with diabetes who have prescriptions for syringes.9 This is not surprising, given that of the 62 experiences participants reported at for-profit pharmacies, 48% were described as negative, 32% as neutral, and only 19% as positive. Even when drug users encounter a friendly pharmacist, they still have to show a state-issued photo ID because it is only legal for people 18 years old and over to purchase syringes. This continues to impede or deny access to young people and people without documentation. When they can produce the ID and the $3.00-$5.00 for a pack of 10 syringes, a number of participants still expressed anxiety about being seen purchasing syringes in their neighborhood or small town. This survey suggests that for-profit pharmacies are not providing a high level of service to individuals who inject drugs. Many people have similarly reported being shamed by pharmacists when trying to purchase EC. The National Womens Law Center has been gathering these stories since 2004 and has catalogued instances in at least 24 different states. One woman in Milwaukee, WI was shouted at by her pharmacist: Youre a murderer! I will not help you kill this baby. I will not have the blood on my hands.10 Others described being laughed at, being told that the drug was too dangerous to dispense, or being denied a referral to a pharmacy that would dispense the EC. This is also not a thing of the past, as the ACLU heard from a man in Texas in January 2012 who was denied EC he was purchasing for his wife at a CVS pharmacy.11 Whether EC or sterile syringes, the barriers to access at pharmacies fall heaviest on marginalized groups: young people, poor people, and people without ID. Its not surprising that private companies do not serve public health interests well. Pharmacy corporations, like health insurance companies, are not in business to provide non-judgmental, free or low-cost healthcare services to the people who need them most. When pharmacists perceive the person at their counter to be a drug user, our cultural stigma around drug use

provides them a convenient incentive to shame or rush the customer out in order to satisfy other patrons who likely share this disrespect for people who use drugs. The same may be true for persons perceived to be engaged in non-marital sex. The pharmacys goal is profit and that is often synonymous with steering clear of controversy and replicating these stigmas and oppressions that exist everywhere.

Solutions to increase Access

One potential solution to this problem is to try to reduce barriers to access at pharmacies. In many cases, small changes could drastically increase access at these pharmacies. In New York, a Long Island AIDS organization runs a program that provides vouchers to drug users who can then trade them in at participating pharmacies for a pack of ten syringes.12 Another example is a non-profit pharmacy attached to a health clinic, which reveals that it is possible to incorporate some harm reduction practices into a pharmacy setting. This pharmacy sold individual syringes for $0.25 each rather than in packs of ten for $3.00-$5.00, like for-profit pharmacies. The price per syringe is not much different, but participants explained that being able to obtain one or two syringes at a time was one of the main reasons they patronized the non-profit pharmacy or local bodegas. The difference between hustling $0.25 and $5.00 on the street could be a number of hours and for people experiencing the painful symptoms of opiate withdrawal, speed is of the utmost importance. The non-profit pharmacy employees tended to treat participants with respect. Participants reported only one negative experience out of eleven at the non-profit pharmacy and described convenient and accessible service from the employees. Like staff at SEPs, the employees likely understood that accessing clean syringes was a way that drug users were taking care of themselves and their community. While advocates of EC and SEPs certainly support pharmacy distribution as a way to increase access even with the current restrictions and limitationsit should be understood as a stopgap measure that will never fully meet the needs of those most marginalized. What is actually needed is free, low threshold, community-based healthcare that works to understand and address peoples needs. At the very least advocates should continue to push for ending the federal syringe exchange funding ban and making EC easily accessible.

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These are important first steps, but its also necessary to understand HIV prevention and reproductive health issues as connected and related to larger forces that oppress communities. It is these larger forces that put people in situations where they dont have enough money for EC or reliable public transportation to the SEP. If our goal is to assist people in controlling their health and liveswhether that involves their drug use

or their fertilitythen we need to be open to directing our advocacy efforts against the racist War on Drugs, the lack of sex education in schools and detention centers, or homophobia and transphobia in the foster care and shelter systems. Whatever people identify as the greatest obstacle to their well-beingthats where we can start.

Maxwell Ciardullo is a Strong Cities, Strong Communities fellow of the German Marshall Fund of the United

States working on healthcare access in New Orleans. He recently finished a masters degree in regional planning at the University of Massachusetts while working part time for the Tapestry Health Needle Exchange Program. Previous to graduate school, he spent six years working for HIV-prevention, harm reduction, and reproductive health non-profits in Washington D.C. and New York City. The views expressed in this piece are those of the author and should not be attributed to the staff, officers, or trustees of The German Marshall Fund of the United States.

Notes
1. Heather Boonstra, Emergency Contraception: Steps Being Taken to Improve Access, The Guttmacher Report on Public Policy, Vol. 5, No. 5, (December 2002), http://www.guttmacher.org/pubs/tgr/05/5/gr050510.html. 2. R. Maclean, Teenagers Given Advance Emergency Contraception Still Use Pill and Condoms, Perspectives on Sexual and Reproductive Health, Vol. 36, No.3, (May/June 2004), http://www.guttmacher.org/pubs/journals/3613404.html. 3. Sarah Barr, Needle-Exchange Programs Face New Federal Funding Ban, Kaiser Health News, (December 21, 2011), http://www. kaiserhealthnews.org/Stories/2011/December/21/needle-exchange-federal-funding.aspx; Harm Reduction Coalition, Syringe Exchange Fact Sheets, (2010), http://harmreduction.org/issues/syringe-access/tools-best-practices/fact-sheets-syringe-access/. 4. David Kocieniewski, Hard Line on Needle Exchanges; Whitman Says AIDS Program Encourages Drug Use, New York Times, (February 2, 1999), http://www.nytimes.com/1999/02/02/nyregion/hard-line-on-needle-exchanges-whitman-says-aids-programencourages-drug-use.html?pagewanted=all&src=pm. 5. Guttmacher Institute, State Policies In Brief: Emergency Contraception, State Policies in Brief, (June 1, 2012), http://www.guttmacher.org/statecenter/spibs/spib_EC.pdf. 6. Pamela Kingfisher, Charon Asetoyer, Rolene Provost, Roundtable Report on the Accessibility of Plan B as an Over the Counter (OTC) within the Indian Health Service, Native American Womens Health Education Resource Center, (February 2012), http://www.nativeshop.org/images/stories/media/pdfs/Plan-B-Report.pdf. 7. DC Appleseed Center, HIV/AIDS in the Nations Capital, Report Card No. 6, (March 8, 2011), http://www.dcappleseed.org/project/hiv-aids. 8. Interviews were conducted in July and August of 2011 at the SEP and at one other location where exchange was not legal. Participants included all currently or recently active injection drug users who consented to the 10-minute survey. 9. Bodegas are not legally allowed to sell syringes, but some do regardless and respondents find them convenient because of their close location to dealers, anonymity, willingness to sell single needles, and willingness to sell without checking an ID. For the convenience, needles at syringes usually sell for $1.00 $2.00 each. 10. National Womens Law Center, Pharmacy Refusals 101, (April 24, 2012), www.nwlc.org/resource/pharmacy-refusals-101. 11. Brigitte Amiri and Lisa Graybill, Another Pharmacy Refuses to Sell Emergency Contraception to a Man, ACLU Blog of Rights, (January 6, 2012), http://www.aclu.org/blog/reproductive-freedom/another-pharmacy-refuses-sell-emergencycontraception-man. 12. ARCS, Expanded Syringe Access Program, (2012), http://www.arcs.org/esap.php.

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