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Dope Project Overdose Warning Flyer

Print out and distribute if you work with heroin using populations.  Spread the word to anyone who needs to know!

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The first Woman of the Week!

On Tuesdays I do street outreach with women in the 16th and Mission area of San Francisco. I’ve been doing this since the beginning of 2008 and I look forward to seeing these women every week. Lately I’ve been wanting to share these experiences with you so I’ve decided to photograph one woman a week with her permission to be published on my blog.

This is Isobel; I took this picture last week when she walked by wearing an adorable dress, carrying a stuffed bunny rabbit and putting on make-up. I thought she looked so cute I asked if I could take her picture, she readily agreed. I’ve seen her for years with varying frequency,  but lately she’s been in the same hotel and I see her almost every week. She has a great sense of fashion and a sweet personality.

Isobel

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Happy Maundy Thursday!

Howdy folks! Sorry I’ve been neglecting this site, but I swear it’s for a good cause- I’m finishing up my last few months of nursing school! I’m currently doing a preceptorship at SF General, and am between 12-hour graveyard shifts, so I’ll keep this short and sweet. I just wanted to express how grateful I am to be going into a profession where I am going to get to care for people for a living, it truly is an honor and a gift. Today is Maundy Thursday- a religious holiday that is symbolized by Jesus washing his disciples feet and sharing his last meal with them; this symbol of caring for other people and enjoying their company highlights my favorite parts of humanity. In the past few years I have been able to go out and wash the feet of homeless folks on this day with the people of Care Through Touch; this year I will be unable to make that event, but tonight when I work in the hospital I will strive to keep that sentiment in my heart as I care for my patients, and today I wish for all of you the same- care for and Love each other. Go ahead and do it selfishly, because honestly, it feels really amazing.

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Pay it Forward Revisited, Lessons Learned

Last month I told you about buying Judith McDonald’s because we had run out of bagged lunches, and she told us she was starving. I’ve been meaning to add to that post and can only blame the hectic holiday season for my tardiness, because I’ve actually been on break from school. (A break that is ending tomorrow I might add sadly.)

The next week our outreach group had a meeting to discuss a variety of things; the incident with Judith came up, and I quickly realized that it wasn’t to give me accolades. The director was concerned that A: Judith would expect us to buy her food any time we were out now, and B: other clients might hear about it and feel like we play favorites. I had considered the issue of boundaries before offering to buy Judith food, but at that instant I felt like the current need was greater. The amazing thing about this meeting was that I didn’t feel defensive; I, like many people, prefer to be told everything I am doing is awesome and perfect, and often take offense at someone suggesting otherwise, but in this case I didn’t feel bad at all. It wasn’t because I was sure that I had done the right thing, in fact, listening to her concerns I realized that I probably hadn’t, instead it was because I knew I wasn’t being chastised. Outreach work is hard, and not because we carry around heavy bags; it’s hard because navigating the group of people we do is often treacherous. You’re never sure how much to give of yourself; if you give too little it’s not enough, if you give too much you undermine your program and your ability to carry on. Everyone in that room has grappled with these concerns, and I knew that my director had done the same and just wanted to share the benefit of her experience with me. She wasn’t even saying she was right, she couldn’t, we’re working with experience, instinct, and human beings, the latter being notoriously difficult to manage. I sat in that room in a discussion where I felt like we were so desperate to do this work in the best way possible that my ego had just waited in the car. It was a really awesome feeling.

I realized the best way to perform damage control was to talk to Judith and explain that I had acted alone, and that we wouldn’t always be able to buy her food when we ran out, and that’s what I did. Her response, “That’s okay, I don’t like McDonald’s that much anyways.”

Editor’s note: Rereading this I just wanted to acknowledge the importance of having an awesome director in this situation; if she had approached this differently I might well have felt much differently. It is important to treat volunteers with respect, because it is hard to give your time to an organization if you feel they don’t appreciate you. Volunteers are a valuable resource and should be treated as such, but unfortunately not all organizations understand this. I am lucky. :)

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Happy International Day to End Violence against Sex Workers!

Although I’d prefer it if we didn’t need to have such a day, unfortunately, we do, we very very much do. Why? Because of this. The link takes you to a very long list of sex workers who were killed in 2011.

There will always be violence, and there will always be violence perpetrated against women because they are seen as easy targets, but violence against sex workers can be drastically reduced. We continue to support and enforce laws that deny people the agency to use their bodies however they see fit. We do not do this consistently: you can have sex for money as long as the person paying you isn’t the one having sex with you, as in pornography. Gold digging is perfectly legal, so is modeling and private cam shows where you can pay someone to to act out your secret fantasies live via webcam. As a society we allow the human body to be used as a commodity in almost every way imaginable, except the most simple: a straight forward exchange. This means that a sex worker has to use circuitous routes to sell their wares; this situation fosters violence in several ways.

For street workers this means being pushed into the black market where violence is already common. However, as criminals, they cannot turn to the police when they have been the victims of violence, or are in danger of becoming so. This means that violent Johns or pimps are rarely prosecuted for their crimes, leaving little deterrence against abuse.

Criminalizing sex work also leaves a mark on society’s psyche. Consumers of sex work are left feeling guilty for their actions, which can lead to feelings of resentment against the person providing the service. Furthermore, the sex workers themselves feel the stigma of criminality, which can lead to feeling that they deserve whatever abuse they receive. Prohibiting a simple exchange means that a straightforward aboveboard contract is difficult to impossible, leaving room for unhappiness on both sides of the exchange, a situation which engenders violence.

As political and moral as people want to make it, it’s still simple; if we want to reduce violence against sex workers we need to decriminalize sex work. The fact that we choose not to shows where our priorities lie.

For more information about The International Day to End Violence Against Sex Workers, and how you can participate, click here.

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Pay it Forward

I have known Judith for years, but last night was the first time I saw her cry. Her tears caused little dirty streaks to run down her cheeks and we tried to comfort her. But she didn’t want comfort, she wanted food.

Last night was my first night back on street outreach after a two month hiatus caused by nursing school conflicts. I brought out a friend who’s been really interested in coming out and helping. After packing our bags at the clinic we headed over to the Mission to hit up our usual SRO hotels. The street was hopping, our clients were out in force, and we provided some supplies to women on the street before heading into a hotel. Inside I greeted women I have known for years. This long term relationship has developed a lot of trust on both ends, they whisper what they need in my ear, and l go into their rooms alone to chat, something I would never consider with a new client. They thank us profusely and one of the women hands me a folded bill telling me, “I know you guys take donations, you have taken care of me so much over the years, take this to buy more food to give out.” I am deeply touched and take her money without looking at the amount, I thank her heartily and think about how amazing these women are.

Leaving the hotel I see she gave us a twenty, a large amount for someone on a completely fixed income. Going into the next hotel we are out of food, when we see Judith. I have known her longer than any of the other women on the street, she is sweet and childlike, and very emotionally labile. Her hands and face are usually dirty and she rocks back and forth as she talks to us. We pack her a bag with toiletries, bandaids, and condoms. She asks about a snack pack and we tell her we’ve run out. She’s incredulous, “You’ve run out? How am I supposed to eat?” We tell her we’re sorry, we’ve seen a lot of women already, we’ll try to bring out more next week. Then she starts crying, “What am I going to do? I haven’t eaten in three days? I’m going to get more sick and end up in the hospital.” She’s sobbing now, we hug her and feel impotent. But we aren’t, “Dorothy do you like McDonalds? Come on, we’ll go get you some.” But she’s in no state to leave, this is one of the major problems many of our clients have that make it so difficult for them to access services; they have emotional or psychological issues that often make leaving their rooms difficult to impossible. This is why bringing the services into the hotels is so important. It’s the heart of harm reduction: we’re literally meeting them where they are at.

My friend and I head out to grab McDonalds while our compatriots wait with Judith. As we walk my friend grabs my hand, I ask her if she’s okay, “Just hold my hand.” I look over and she’s crying, “I’m sorry, I don’t know why I’m having such an emotional reaction.” I tell her, “You’ve just seen a woman crying because she is hungry and hasn’t eaten in three days, this is the reaction you should have.”

I use the money I was given earlier to pay for the food, and marvel that the need presented itself so immediately. Almost like magic.

When we got back Judith was chatting happily about the Holiday party the Mission Neighborhood Resource Center is throwing for the women this Thursday. She takes the food gratefully and starts eating. At least one of the many hungry bellies in this city will be satisfied tonight.

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Will throwing a bag of clean needles into an SRO reduce HIV incidence?

This month I’ve been working on a research paper looking at needle syringe exchange (NSE) programs and whether or not they were cost effective. I finished the paper last week, and have been meaning to write to you all about it, but have been busy finishing up psych rotation in nursing school. Today however, some exciting news has come out, Governor Jerry Brown has signed into law two pieces of legislation: SB 41 and AB 604. Both bills work to move the power of regulating syringe exchange from the municipal level to the state level, thereby making the way California approaches syringe exchange more uniform. SB 41 will make it legal for pharmacies to sell syringes to people without a prescription anywhere in California; and AB 604 will move the power to establish NSE from local jurisdiction to the California Department of Public Health.

This is especially exciting for me because I worked on a project to gather signatures in support of these bills for a class on hepatitis. People are understandably reticent to remove power from local governments, but in this case it makes a lot of sense, because it’s hard for any local official to come out on the side of NSE and not get attacked for it. Public health issues should be taken out of the political arena where getting reelected matters more than the health and safety of the electorate.

However, I’m not popping open a bottle of bubbly just yet. When I started researching the issue of the cost-effectiveness of NSE I could only find scholarly articles that supported the thesis that they are indeed cost effective; it seemed like an open and shut case. I was elated. I love being right, I especially love being super duper right. I kept looking though, because my paper required at least one article that refuted my stance. I tried finding the sources the people who were squarely against NSE were quoting. It was a circular goose chase with no one reputable leading. I read over the papers I had in favor of NSE and realized that the evidence for the cost-effectiveness of NSEs all depended on them preventing transmission of HIV. The idea is that the money saved in not having to pay for a person’s HIV care will more than cover the cost of the NSE program. All of the papers I read showed this to be the case, however they also all acknowledged that they were unable to know for certain how many cases of HIV these programs were preventing. The problem is you can’t do a randomized controlled study to determine the efficacy of NSE; what are you going to do- withhold clean needles from a given population? If there is an NSE in an area the influx of needles related to it will affect users who don’t use the program just by nature of there being more clean needles in circulation.

With this new understanding I looked for papers that judged the efficacy of the programs at preventing HIV transmission instead of cost-effectiveness. I found an article that reviewed the reviews of NSE programs. What they found was that researchers tended to explain away data that didn’t support the effectiveness of NSE. I understand this, it comes from the mental pain caused by data not supporting common sense. Sharing needles is the main mode of transmission among IV drug users (IDUs), ergo, if you give them clean needles transmission rates will go down. It’s not rocket science; unfortunately, as with most things dealing with human behavior, it’s actually more complicated than rocket science. The review found that there was evidence to support the efficacy of NSE in preventing HIV transmission, but it was tentative. They also found that there was insufficient evidence to support the efficacy of NSE in preventing HCV, which isn’t surprising if you consider how much easier  it is to transmit HCV than HIV.

The review wasn’t able to take into account comparisons of different programs, it was looking at general efficacy, and in NSE all programs are not equal. They learned this in Vancouver, Canada, home of North America’s first supervised injection facility, and home to an epic battle against high rates of HIV among IDUs. Looking at Vancouver over the past 13 years or so you can see that just starting NSE wasn’t enough, they were not able to significantly reduce dangerous behavior, such as needle sharing, until they they made clean needles readily available and easily accessible. They did away with the one for one policy (a literal exchange) and just gave people how many needles they said they needed and made collection a separate event. In effect, they had to saturate Vancouver in order to significantly affect behavior.

So this is why I’m not popping the bubbly just yet. I’m afraid that when the state comes in they either won’t do enough, or the local governments will undermine the programs where they are not wanted. This will lead to insufficient programs that will add more evidence to the idea that NSE is ineffective.

However, a bright (?) spot in all of this is that HIV related costs are so incredibly high that you only need NSE to be minimally effective in order to render the programs cost-effective, and that is why all the articles come to the conclusion that NSE is cost-effective.

(Un-cited (sorry it’s not graded and I’m not adding citations) References:

Belani, H. K., Muennig, P. A. (2008) Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New York City. Journal of HIV/AIDS &Social Services, 7(3), 229-240.

Buchner, C., Kerr, T., Montaner, J., Small, W., Wood, E., Zhang, R. (2010) Syringe sharing and HIV incidence among injection drug users and incresed access to sterile syringes. American Journal of Public Health, 100(8), 1449-1454.

Goldberg, D., Hickman, M., Hutchinson, S., Kimber, J., Palmateer, N., Rhodes, T. (2009) Evidence for the effectiveness of sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus transmission among injecting drug users: a review of reviews. Addiction, 105, 844-859.

Pinkerton, S. (2010) Is Vancouver Canada’s supervised injection facility cost-saving? Addiction, 105, 1429-1436.

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Out of the mouths of the elite

I just read the op-ed piece Warren Buffett did for the NY times this week after seeing it past around Facebook and Twitter like wildfire. I don’t have much to say about it other than- wow. It’s amazing in its honesty and succinctness. The same way we look to victims to give us insight into suffering, we should see this as a personal insight into a debate fraught with misunderstandings and outright falsehoods. The current economic debate is crucial to the people I help because many of the programs they depend on depend on government aid. It is crucial to me personally because I aspire to be a nurse at a county hospital.

The Warren Buffett editorial featured in the New York Times:

Stop Coddling the Super-Rich

OUR leaders have asked for “shared sacrifice.” But when they did the asking, they spared me. I checked with my mega-rich friends to learn what pain they were expecting. They, too, were left untouched.

While the poor and middle class fight for us in Afghanistan, and while most Americans struggle to make ends meet, we mega-rich continue to get our extraordinary tax breaks. Some of us are investment managers who earn billions from our daily labors but are allowed to classify our income as “carried interest,” thereby getting a bargain 15 percent tax rate. Others own stock index futures for 10 minutes and have 60 percent of their gain taxed at 15 percent, as if they’d been long-term investors.

These and other blessings are showered upon us by legislators in Washington who feel compelled to protect us, much as if we were spotted owls or some other endangered species. It’s nice to have friends in high places.

Last year my federal tax bill – the income tax I paid, as well as payroll taxes paid by me and on my behalf – was $6,938,744. That sounds like a lot of money. But what I paid was only 17.4 percent of my taxable income – and that’s actually a lower percentage than was paid by any of the other 20 people in our office. Their tax burdens ranged from 33 percent to 41 percent and averaged 36 percent.

If you make money with money, as some of my super-rich friends do, your percentage may be a bit lower than mine. But if you earn money from a job, your percentage will surely exceed mine – most likely by a lot.

To understand why, you need to examine the sources of government revenue. Last year about 80 percent of these revenues came from personal income taxes and payroll taxes. The mega-rich pay income taxes at a rate of 15 percent on most of their earnings but pay practically nothing in payroll taxes. It’s a different story for the middle class: typically, they fall into the 15 percent and 25 percent income tax brackets, and then are hit with heavy payroll taxes to boot.

Back in the 1980s and 1990s, tax rates for the rich were far higher, and my percentage rate was in the middle of the pack. According to a theory I sometimes hear, I should have thrown a fit and refused to invest because of the elevated tax rates on capital gains and dividends.

I didn’t refuse, nor did others. I have worked with investors for 60 years and I have yet to see anyone – not even when capital gains rates were 39.9 percent in 1976-77 – shy away from a sensible investment because of the tax rate on the potential gain. People invest to make money, and potential taxes have never scared them off. And to those who argue that higher rates hurt job creation, I would note that a net of nearly 40 million jobs were added between 1980 and 2000. You know what’s happened since then: lower tax rates and far lower job creation.

Since 1992, the I.R.S. has compiled data from the returns of the 400 Americans reporting the largest income. In 1992, the top 400 had aggregate taxable income of $16.9 billion and paid federal taxes of 29.2 percent on that sum. In 2008, the aggregate income of the highest 400 had soared to $90.9 billion – a staggering $227.4 million on average – but the rate paid had fallen to 21.5 percent.

The taxes I refer to here include only federal income tax, but you can be sure that any payroll tax for the 400 was inconsequential compared to income. In fact, 88 of the 400 in 2008 reported no wages at all, though every one of them reported capital gains. Some of my brethren may shun work but they all like to invest. (I can relate to that.)

I know well many of the mega-rich and, by and large, they are very decent people. They love America and appreciate the opportunity this country has given them. Many have joined the Giving Pledge, promising to give most of their wealth to philanthropy. Most wouldn’t mind being told to pay more in taxes as well, particularly when so many of their fellow citizens are truly suffering.

Twelve members of Congress will soon take on the crucial job of rearranging our country’s finances. They’ve been instructed to devise a plan that reduces the 10-year deficit by at least $1.5 trillion. It’s vital, however, that they achieve far more than that. Americans are rapidly losing faith in the ability of Congress to deal with our country’s fiscal problems. Only action that is immediate, real and very substantial will prevent that doubt from morphing into hopelessness. That feeling can create its own reality.

Job one for the 12 is to pare down some future promises that even a rich America can’t fulfill. Big money must be saved here. The 12 should then turn to the issue of revenues. I would leave rates for 99.7 percent of taxpayers unchanged and continue the current 2-percentage-point reduction in the employee contribution to the payroll tax. This cut helps the poor and the middle class, who need every break they can get.

But for those making more than $1 million – there were 236,883 such households in 2009 – I would raise rates immediately on taxable income in excess of $1 million, including, of course, dividends and capital gains. And for those who make $10 million or more – there were 8,274 in 2009 – I would suggest an additional increase in rate.

My friends and I have been coddled long enough by a billionaire-friendly Congress. It’s time for our government to get serious about shared sacrifice.

Warren E. Buffett is the chairman and chief executive of Berkshire Hathaway.

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Crackheads need not apply- for entrance.

Walking down Market St. yesterday and saw this sign. Somehow the cheery lettering and the Giants colors don’t make the sentiment any less dehumanizing.

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Ghosts of the Present: Images of Streetwalkers From the 40′s

Too Good To Be True; Streetwalkers of San Francisco

I just came across this video essay by Kol Marshall, depicting mugshots of women who were arrested for prostitution in the forties. Several of the women have black eyes, all of them look like they have suffered from frequent physical abuse. What really struck me was how easily I could imagine the images of many of the women I work with slipped in to the rotation.

People like to use the fact that many street prostitutes are in abusive situations as a reason for why prostitution should be illegal. The problem is that it is that very illegality that makes their lives so dangerous. How can a woman go to the cops for help if she is afraid she will be arrested? None of the women I know would- they tell me the cops wouldn’t help them anyways. Trust me, the Johns know this.

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