The COVID-19 crisis has taken so much away from people who use drugs in New York. An historic number of lives have been lost to skyrocketing, preventable fatal overdoses; New York City subways, one of the few warm spaces to ride out the cold weather while maintaining social distancing, now ban rough sleepers; more barriers have emerged to already-inaccessible addiction medications.
Across the state, access to safer use supplies and harm reduction organizations—especially those outside of New York City—is at risk of joining the list.
Frontline workers and an advocate informed Filter of an emerging shortage in supplies designed to prevent skin and vein damage, burns and the transmission of infectious diseases, like HIV, hepatitis C and now COVID-19—all while syringe service program (SSP) participants’ demand for safer use supplies has risen.
Other care providers have also seen medical supply shortages. But the difference between well-resourced hospitals and shoestring SSPs is funding—and in this case, New York State’s AIDS Institute has delayed full reimbursements to contractors.
Some SSPs haven’t been paid for their services by the State since April—the start of the 2021 fiscal year and about two weeks into New York’s COVID-19 response. And if they do receive payment while the crisis is still ongoing, it will only be 80 percent of the budgeted amount.
To spell that out: Harm reduction organizations are providing uncompensated labor for state interests, fronting the money themselves. They hope that adequate safer use supplies will soon arrive and that they’ll be compensated in the future—but their work continues out of an obligation to people who use drugs.
The Looming Syringe Shortage
With the start of the HIV/AIDS epidemic 35 years in the past, the looming crisis of scarce safer use supplies in one of the states with the most public health funding might have been unthinkable for harm reductionists a year ago.
But in October 2020, at least three syringe service programs in New York State have not been able to fully stock up on safer use equipment. Their supplier, Foundation for AIDS Research (amfAR), provides them with fewer materials than requested, with little-to-no explanation, according to two of the SSPs’ leaders.
Numbers of available syringes, needles, sterile water tubes, alcohol prep pads or crack pipe stems have all dwindled, according to the three workers.
“I’ve been in harm reduction since 2012 and this is the first time so consistently that there is not enough syringes.”
“This [month’s, or October’s, order] was the first number where we saw a decrease in supply,” Mary Brewster, managing director of harm reduction services at Harlem United, told Filter.
For Max Sepulveda, managing director of harm reduction services at Housing Works, the shortage he’s seeing is unprecedented. “I’ve been in harm reduction since 2012 and this is the first time so consistently that there is not enough [syringes] to provide,” he said.
As a result, SSP workers are beginning to ration supplies. Usually, SSP participants can request as many works as they want—a policy promoting secondary exchange and thereby the saturation of drug-user networks with safer use equipment. But now, “we are going to have to squeeze out every syringe,” Brewster said. “We are going to have to count every syringe we give out.”
Rationing safer use supplies summons harm reductionists’ worst fears. Reusing dulled needles or jagged crack pipes; injecting before first sterilizing the skin; sharing used works with one another—all of these behaviors further jeopardize the health of drug users amid a pandemic that has killed Black and Latinx people at far higher rates than whites. As fatal overdoses surge, multiple harm reduction leaders interviewed by Filter expressed fears of HIV outbreaks resulting from the crumbling harm reduction infrastructure.
All three SSP leaders say their organizations are having what Brewster described as, “tougher conversations” with participants about transitioning to different needle gauges and syringe volumes as popular sizes run out.
They all expressed to Filter that their participants are resilient and adaptable. Nonetheless, Stephanie Lao, executive director of Catholic Charities, fears that some may be alienated from the programs. “I’m afraid telling people we don’t have syringes, and they’ll stop coming. We’ve had that happen, [like when they’re] asking for a specific gauge and CC [a unit of measure for syringe volume].”
“They are getting ready to make their own alcohol prep pads. It’s that dire.”
Jasmine Budnella, drug policy coordinator at VOCAL-NY, is even aware of one program that’s considering making its own supplies. “They are getting ready to make their own alcohol prep pads. It’s that dire,” she said.
While the programs are not yet seeing absolute shortages, the workers are concerned about how they can support people in need of safer injection equipment. Lao is considering referring participants to pharmacies—a non-ideal alternative that limits purchases to 10 syringes and often harbors hostility to people who use drugs.
The thought of returning to the outdated practice of distributing cleaning solutions for sterilizing used works has even crossed her mind. “We’ve made so much progress,” said Lao, and yet, “here we are: bleach and water.”
Harm Reductionists’ Unpaid Labor
The cause of the safer use equipment shortage is uncertain. Neither the contracting agency nor the contractor involved in supplying syringes to SSPs—the Department of Health (DoH) and amfAR, respectively—responded to Filter’s request for comment.
But it’s been suggested that amfAR, like many other harm reduction contractors, is not being paid.
Officially, New York state agencies—like DoH’s AIDS Institute (AI), which oversees SSPs—are withholding one-fifth of contract payments from contractors submitting monthly “vouchers” below $500,000, according to an email sent from AI staff to contractors in August and obtained by Filter. All SSPs’ vouchers—like those of Albany-based Project Safe Point, the SSP of Catholic Charities Care Coordination Services, which relies on them as a major funding source—fall within that range. AI stated that the amount “being withheld […] will be reviewed for payment at a later date” and “advance payments are currently on hold.”
“My biggest concern was not making payroll.”
But according to Lao of Catholic Charities, Project Safe Point hasn’t received any payment since the start of the state’s 2021 fiscal year on April 1. The effects were felt almost immediately. “I was concerned about having a potential cash flow issue. My biggest concern was not making payroll,” Lao said. By June, her organization ended up drawing on bank-lent funds to pay employees.
ACR Health, a far-Upstate SSP located just on the border with Canada, is facing similar state funding challenges, according to a September news report. “Eventually we won’t have the money to support the program and eventually will have to furlough those people until they find the money to bring them back on and have the program continue,” said its executive director, Wil Murtaugh.
In New York City, Housing Works’ Sepulveda is seeing a similar lapse in payment, although it doesn’t yet pose a mortal threat to the organization. Brewster of Harlem United doesn’t oversee finances, but said she was not aware of the SSP’s last reimbursement, noting that their state contract pales in comparison to their city contract, which has continued to pay out.
The COVID-19 economic crisis is only exacerbating state agencies’ preexisting tendency to not properly abide by contracts. In 2019, 50 percent of state contracts with nonprofits were paid late—a three percentage point rise from 2018. It’s “simply unacceptable,” “harms” service providers and “erodes service delivery to vulnerable populations,” wrote State Comptroller Thomas DiNapoli in his June 2020 report.
One of the harm reduction leaders from the two relatively financially-stable NYC organizations understands the state’s tricky financial position. “We are in the middle of a crisis,” said Sepulveda. “In a normal setting, it would make me concerned and very angry. But these are unusual times, and unusual situations happen.”
But for Lao, without the funding force of New York City behind her, the future is shaky at best. “How do we plan appropriately? If I spend, I may never recoup that. A 20 percent hold may become a 20 percent cut,” she said. “It’s hard to appropriately plan programmatically when you don’t know what’s going to happen when we finally get paid or the budget gets approved.”
A Path Forward
If New York harm reduction organizations are to survive COVID-19 austerity, they will likely need to confront both bureaucratic challenges and the longstanding political apathy of the state’s executive branch.
Other than vital supplies and funds being withheld, a key issue seems to be the state failing to keep harm reductionists apprised of the situation. Sepulveda of Housing Works called that a lack of “transparency” regarding the increasingly unavailable safer use equipment. For example, he said amfAR has only informed him simply that they do “not have enough supplies.” This opacity, he said, “can put any kind of scenario in our head,” sparking anxiety about what the future holds. “There doesn’t seem to be a straightforward plan.”
The AIDS Institute’s brief August email does not seem to have assuaged financial anxiety. When Lao of Catholic Charities inquired about a potential payout timeline, the AI representative, she said, dodged the question, and instead “asked all these questions” about her access to credit and funding from other contracts—questions she called “irrelevant” and “none of their business.”
The two didn’t suggest a fix to the communication problems, other than simply increasing transparency. Although Sepulveda identified institutional issues, he’s focused on continuing to deliver services. “Our clients need us right now. It’s a financial burden and an emotional toll on the staff, but our clients are in a much more vulnerable position.”
“The real issue is they don’t want to pay,” Lao suspects.
But the miscommunications may just be symptoms of a problem that runs far deeper. “The real issue is they don’t want to pay,” Lao suspects. “Or they don’t have the money.”
The likelihood of the former over the latter is supported by the whopping $4 billion remaining from the support received by the state through the federal Coronavirus Relief Fund, as of July 31. In a September letter, State Assembly members and social service organizations demanded that Governor Andrew Cuomo make use of the idle funds to “to pay for [social and health] services that have already been provided to sustain these services during the pandemic.”
Budnella of VOCAL-NY, which signed onto the letter, locates Governor Cuomo’s failure to support services within his seasoned track record of stalling on approving life-saving interventions like safe consumption sites, gutting state Medicaid and public hospitals, and expressing explicit carceral hostility towards people who inject drugs.
On October 20, VOCAL-NY and other harm reductionists publicly revealed that Governor Cuomo willfully misled activists about a negotiated deal from earlier this year to enhance Medicaid recipients’ access to opioid use disorder medication. The coalition discovered that it will not in fact eliminate the barrier of prior authorization for the life-saving treatments.
Without immediate intervention by the state, Budnella fears the worst for people who use drugs and the organizations committed to supporting them.
“How are we going to stretch the supplies [and funds]” she posed, “and what if we can’t?”
Photograph of safer injection equipment by Todd Huffman via Wikimedia Commons/Creative Commons