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Martin Schechter: fighting the politicians with science
FEATURE
Martin Schechter: fighting the politicians with science abstract presented at the 12th World esearchers must be vigilant about Conference on AIDS (Geneva, how their data are used by Switzerland; June 28–July 3). people with political agendas, warns Schechter explains that the reason Canadian epidemiologist Martin addicts who use needle exchanges Schechter. His words are based on tend to have higher rates of HIV bitter experience. Schechter believes infection than those who that there is substantial do not is because “their evidence that sterile risk-behaviour profile is needle exchange can many-fold more risky help prevent the spread than people who get of HIV among injecting their needles from drug users. But politipharmacies and other cians, particularly in sources. By analogy, the USA, have used people who attend Schechter’s work to hospitals have a higherargue against the public than-normal mortality funding of needlerate, but hospitals are exchange programmes. not generally seen as Several countries responsible for causing have included needletheir deaths”, he says. exchange programmes Now 46 years old, in their fight against the Putting the record straight Schechter is described spread of HIV/AIDS. as “an outstanding scientist” by But in the USA conservative politiInternational AIDS Society president cians continue to voice strong opposiMark Wainberg. But Schechter only tion to such programmes. In 1996, became a medical researcher after Schechter’s team reported that there realising that the abstractions of were significantly higher rates of HIV pure algebra, in which he holds a infection among injecting drug users doctorate, offer little social benefit. who had attended Vancouver’s He attended medical school at needle exchange than among those McMaster University, Ontario, and who had not visited the exchange. did a year of clinical training at This, they argued, reflected a Wellesley Hospital, Toronto, before difference in risk-taking behaviour. obtaining a master’s degree in But members of the US House of epidemiology at the University of Representatives and the Senate interToronto and the National Cancer preted the findings as evidence that Institute of Canada’s epidemiology needle exchanges might actually prounit. In 1983, he took up a faculty mote the spread of HIV. A report by position in epidemiology at the the Office of National Drug Control University of British Columbia, Policy offered up a similar interpretaVancouver. tion. And based in part on this Schechter’s involvement in AIDS report, the US government renewed dates from this time. A pathologist its ban on the use of federal funds for and a group of family physicians needle exchanges in April this year. working in the area were concerned Schechter, who co-chaired the XI about the large number of gay men International Conference on AIDS in they were seeing with lymphadenoVancouver, Canada, in 1996, is pathy, so the doctors approached shocked at how politicians have disSchechter to ask for help in putting torted his research. “I think it’s outtogether a study. “In those days”, rageous. To see scientific evidence says Schechter, “we used to speak of twisted without any thoughtfulness is a hypothetical viral agent. HIV-1 had difficult for a researcher to accept.” not yet been discovered. We had no To counter this distortion, cases of AIDS, so we used persistent Schechter and six colleagues have generalised lymphadenopathy or now done another study on 694 PGL as our clinical outcome”, he injecting drug users. In this new continues. “We did a case-control study they found no evidence that study of PGL within our cohort of Vancouver’s needle-exchange progay men and found that the risk facgramme was causally associated with tors for PGL were identical to the risk a higher risk of transmission of HIV factors for AIDS, so that they likely infection. “Opponents of needle shared the same viral cause.” Because exchange should desist from citing PGL was affecting 35% of the cohort, this association as evidence that Schechter realised that this was an needle exchange may exacerbate the epidemic of “monstrous” size. spread of HIV”, they wrote in an
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1042
Vancouver, like many port cities, has a drug problem, and the rundown inner-city district has a high concentration of drug addicts. In 1989, that district became the site of a needle-exchange programme which is now one of North America’s largest, exchanging more than two million needles annually. In 1996, the neighbourhood started to experience an explosive HIV outbreak. The following year, Schechter’s team found that the annual incidence of HIV infection among Vancouver intravenous drug users was 18·6%— an “astronomically” high rate. Schechter blames the outbreak on a series of bad public-policy decisions that reduced social housing for the poor and de-institutionalised the mentally ill without proper community support. Dingy hotel rooms turned into shooting galleries as addicts switched from injecting heroin to injecting cocaine. With this switch, the addicts needle-sharing behaviour changed—they injected more often and were less likely to worry about using sterile needles, explains Schechter. Schechter believes this publichealth problem is compounded by the “war on drugs” being waged by North American law enforcement officials. “The prohibition of drugs causes far more harm than the drugs themselves”, he argues. “All the death and disease could be prevented —and that makes me angry.” Conservative politicians may see these statements as evidence that Schechter is a dangerous liberal. But long-standing colleague, Vancouver virologist Michael O’Shaughnessy disagrees. “Schechter is a dogged researcher. He’s sound and he’s conservative. He’s always looking at both sides of the coin, so when he finally gets to a point of saying, ‘this is what I believe’, he’s done his homework.” Schechter and his team are still battling to get their work understood by the politicians. To this end, they plan to find out whether some needle-exchange programmes are more effective in halting the spread of HIV than others. And they are to take part in a multicentre North American trial of medically prescribed heroin. “Needle exchanges are only one piece of the puzzle. We have to try and do a lot of other things to reduce the harm caused by drug addiction”, concludes Schechter. Jon Ferry
THE LANCET • Vol 352 • September 26, 1998
Martin Schechter: fighting the politicians with science abstract presented at the 12th World esearchers must be vigilant about Conference on AIDS (Geneva, how their data are used by Switzerland; June 28–July 3). people with political agendas, warns Schechter explains that the reason Canadian epidemiologist Martin addicts who use needle exchanges Schechter. His words are based on tend to have higher rates of HIV bitter experience. Schechter believes infection than those who that there is substantial do not is because “their evidence that sterile risk-behaviour profile is needle exchange can many-fold more risky help prevent the spread than people who get of HIV among injecting their needles from drug users. But politipharmacies and other cians, particularly in sources. By analogy, the USA, have used people who attend Schechter’s work to hospitals have a higherargue against the public than-normal mortality funding of needlerate, but hospitals are exchange programmes. not generally seen as Several countries responsible for causing have included needletheir deaths”, he says. exchange programmes Now 46 years old, in their fight against the Putting the record straight Schechter is described spread of HIV/AIDS. as “an outstanding scientist” by But in the USA conservative politiInternational AIDS Society president cians continue to voice strong opposiMark Wainberg. But Schechter only tion to such programmes. In 1996, became a medical researcher after Schechter’s team reported that there realising that the abstractions of were significantly higher rates of HIV pure algebra, in which he holds a infection among injecting drug users doctorate, offer little social benefit. who had attended Vancouver’s He attended medical school at needle exchange than among those McMaster University, Ontario, and who had not visited the exchange. did a year of clinical training at This, they argued, reflected a Wellesley Hospital, Toronto, before difference in risk-taking behaviour. obtaining a master’s degree in But members of the US House of epidemiology at the University of Representatives and the Senate interToronto and the National Cancer preted the findings as evidence that Institute of Canada’s epidemiology needle exchanges might actually prounit. In 1983, he took up a faculty mote the spread of HIV. A report by position in epidemiology at the the Office of National Drug Control University of British Columbia, Policy offered up a similar interpretaVancouver. tion. And based in part on this Schechter’s involvement in AIDS report, the US government renewed dates from this time. A pathologist its ban on the use of federal funds for and a group of family physicians needle exchanges in April this year. working in the area were concerned Schechter, who co-chaired the XI about the large number of gay men International Conference on AIDS in they were seeing with lymphadenoVancouver, Canada, in 1996, is pathy, so the doctors approached shocked at how politicians have disSchechter to ask for help in putting torted his research. “I think it’s outtogether a study. “In those days”, rageous. To see scientific evidence says Schechter, “we used to speak of twisted without any thoughtfulness is a hypothetical viral agent. HIV-1 had difficult for a researcher to accept.” not yet been discovered. We had no To counter this distortion, cases of AIDS, so we used persistent Schechter and six colleagues have generalised lymphadenopathy or now done another study on 694 PGL as our clinical outcome”, he injecting drug users. In this new continues. “We did a case-control study they found no evidence that study of PGL within our cohort of Vancouver’s needle-exchange progay men and found that the risk facgramme was causally associated with tors for PGL were identical to the risk a higher risk of transmission of HIV factors for AIDS, so that they likely infection. “Opponents of needle shared the same viral cause.” Because exchange should desist from citing PGL was affecting 35% of the cohort, this association as evidence that Schechter realised that this was an needle exchange may exacerbate the epidemic of “monstrous” size. spread of HIV”, they wrote in an
R
1042
Vancouver, like many port cities, has a drug problem, and the rundown inner-city district has a high concentration of drug addicts. In 1989, that district became the site of a needle-exchange programme which is now one of North America’s largest, exchanging more than two million needles annually. In 1996, the neighbourhood started to experience an explosive HIV outbreak. The following year, Schechter’s team found that the annual incidence of HIV infection among Vancouver intravenous drug users was 18·6%— an “astronomically” high rate. Schechter blames the outbreak on a series of bad public-policy decisions that reduced social housing for the poor and de-institutionalised the mentally ill without proper community support. Dingy hotel rooms turned into shooting galleries as addicts switched from injecting heroin to injecting cocaine. With this switch, the addicts needle-sharing behaviour changed—they injected more often and were less likely to worry about using sterile needles, explains Schechter. Schechter believes this publichealth problem is compounded by the “war on drugs” being waged by North American law enforcement officials. “The prohibition of drugs causes far more harm than the drugs themselves”, he argues. “All the death and disease could be prevented —and that makes me angry.” Conservative politicians may see these statements as evidence that Schechter is a dangerous liberal. But long-standing colleague, Vancouver virologist Michael O’Shaughnessy disagrees. “Schechter is a dogged researcher. He’s sound and he’s conservative. He’s always looking at both sides of the coin, so when he finally gets to a point of saying, ‘this is what I believe’, he’s done his homework.” Schechter and his team are still battling to get their work understood by the politicians. To this end, they plan to find out whether some needle-exchange programmes are more effective in halting the spread of HIV than others. And they are to take part in a multicentre North American trial of medically prescribed heroin. “Needle exchanges are only one piece of the puzzle. We have to try and do a lot of other things to reduce the harm caused by drug addiction”, concludes Schechter. Jon Ferry
THE LANCET • Vol 352 • September 26, 1998