Tuesday, February 8, 2011

Some Lessons from a Needle Injection Pilot

Excellent article (and some must see accompanying photographs in the linked page) on a drug injection site project in Vancouver.  Articles on these places always interest me, the evidence is overwhelming that they bring multiple benefits and no one has been able to show significant downsides to them (assuming they are put up in already rough areas, I can see why people wouldn't want them in an area with little existing crime or illicit drug use).  Yet, in most places, the public and the government hates them.  While I haven't read anything to confirm this, there are two reasons for this that seem intuitive.  First, they make problems more visible that people prefer to ignore and have left to back alleys and dingy rooms rather than publicly funded clinics.  Second, they are very challenging ideologically to anyone that takes a tough on crime stance.   That these things work and have a growing body of literature to support this is tough when the tough on crime stance and incarceration enjoys little data to support its effectiveness.  If more data continues to come in showing these things work, especially if they affect drug usage rates as well (which this article doesn't go into), it brings a lot more into question than needle injection site.

A second observation from the article is that it illustrates a theme I keep coming back to with my health care posts.  That theme is the idea that the fractured nature of payments in the US is one of the key drivers of health care costs.  Since in Canada all health care is paid for by the government these problems don't exist.  AIDS patients are very expensive to treat and can have high externalities for the rest of society.  From the government's perspective almost the entire externality is captured, it bears the costs of treatments, the lost taxes due to illness, costs imposed by new infections, public order costs from drug use outside the clinics, political pressure from fears of a rising AIDS rate, etc.  In the US, no single actor feels the effects of all of these externalities.  A private company may bear the cost of treatment, but it doesn't see a decline in revenues nor does it feel public pressure by a rising AIDS rate and likely does not bear the cost of an additional infection, it certainly doesn't feel any responsibility for the public order issues of drug injection.  The same can be said for the US government, it doesn't necessarily bear the full cost for each infection since the private sector is responsible for some of the payments.  While AIDS and drug injections are an unusually clear case of this, it's illustrative of why I think only the government is positioned to fully bear both the costs and benefits of health issues and is the only economically efficient actor to bear these costs, due to the number of costs and benefits that cannot be internalized by other economic actors.

The article contains some striking information on the public health issues involved, one striking number given was this:
Even $50 million spent on drugs, he said, ultimately saves $300 million because roughly 400 people a year avoid infection. (The estimated lifetime cost of treating a Canadian with AIDS is $750,000.)
 A very powerful argument in favor of these treatments, if they can be backed up, but one that only partially applies in the US, where in many cases the government won't be baring the costs, assuming that the drug addicts will rarely receive retrovirals and the people getting treated are those infected when it spreads into the wider community (through many channels, including prostitution, but also other channels as well).

Another striking statistic specific to HIV infections:
A 1997 study in The Lancet found that in 29 cities worldwide with needle exchange, H.I.V. infection dropped 6 percent a year among drug injectors, while in 51 cities without, it rose by about 6 percent.


  1. Great post! I was very disappointed that during the recession one of the first public health programs to be cut was AIDS prevention. These programs are incredibly efficient and have a great ROI. I believe infectious disease prevention and drug addiction treatment is often placed on the back-burner because of the false belief that they are problems of the disadvantaged (people we like to ignore in this country, because of some sort of deeply engrained Social Darwinism in our culture). AIDS is a huge issue for the gay community and class offers no immunity to drug addiction.

  2. The main problem that the US has with respect to health care (and addiction is necessarily part of it) is the moral issue. Americans have decided that morally it is not necessary to provide health care for every single citizen. Thus health care in the US is a profit making business with its look on the Medical Loss Ratio. So the discussion on the needle exchange and injection clinics in the US are just a wrinkle on this moral issue. Harping about economics and ROI is putting the cart before the horses. If Obama would have charged from the beginning with this idea of morality in a presumably Christian nation, US could have had a public option, or a very regulated private insurance sector, non-profit, a la Switzerland, or Netherlands, Germany, France, Japan, etc...