 So, I want to start out by thanking CTN for providing this space for us to meet and for providing a record of this meeting. And I'm going to start out actually with a little quote. I apologize that we're without some slides. We all came with some PowerPoints, so we're going to have to speak to some, but on both sides we're going to have to speak to some things that we had hoped to show visually and we hope you'll bear with us on that. But I just wanted to start with a quote. This is from Mr. Rogers. And he said, it's very dramatic when two people come together to work something out. It's easy to take a gun and annihilate your opposition, but what is really exciting to me is to see people with differing views come together and finally respect each other. So that's what we're aiming to do tonight, and I'm going to go ahead and start. First of all, I want to thank everyone for coming. We are expecting a few late comers. There's a lot going on at City Hall. There's a few different meetings going on. So we do expect some stragglers, so please help them feel welcome. At first I'm going to start by introducing the folks. My name is Laura Cannon, and I'm with the Bayside Neighborhood Association, and I expect that we'll see some more folks from BNA. There's a couple here already. And from the Portland Public Health, we have Zoe Odlin-Platz, who is a community health promotion specialist. She has been the liaison to the BNA for the needle exchange thus far. We have Caroline Teschke, who's the program manager of India Street Public Health, which sort of envelops the needle exchange. And then we have Toho Soma, who is program manager of health equity and research, and is acting public health division co-director. So I'm just going to start out for those of you who may not be aware. The genesis of this gathering was concern in the Bayside Neighborhood about materials some members of the community found which were being distributed by the Portland Needle Exchange. We the Bayside Neighborhood Association sent a letter about our concerns to the needle exchange and some relevant members of city government. And around that same time there were some newspaper articles published about the program and about the correspondence that we had exchanged. We're very thankful that the needle exchange has made some changes to the execution of that particular service that they provide. And we're going to get into more details about that in the questions and answers. But in our ongoing discussion that resulted, we agreed that a meeting like this would be helpful to address some of the gaps in information and some of the gaps in communication about the services provided by the needle exchange and the problem of substance abuse in Portland and the impact that this issue has on the whole community. And so, you know, substance abuse is a big and complex challenge. It's currently faced by cities across the country and across the world. We're not going to solve the whole problem in the next 90 minutes. But our goal tonight is to share information and impressions across the two groups who are grappling this issue from different angles. So we're all better empowered to address the problem as a community. And I do want to address my husband, Sean, who's going to be keeping us to task on the timing because we end at 7.30 sharp. Did you want to make any opening comments before we start with the questions? Really just to say how delighted we are to be here. I think I could speak for all of us by saying that. And to emphasize that for the work that we do, how important our community relations are. Thank you for having us. Thank you for being here. So as I said, to start out with, and this is the start of the first Q&A for timing. The discussion we're having now came about because of concern about some Ziploc bags that some members of the neighborhood had found, which contain little smaller bags of unlabeled white powder and some instructions for mixing it with crack cocaine to shoot up. And this is the program that you've made some changes to, which we're very grateful for. So to start with, what is the purpose of that white powder, which we now understand is vitamin C, and the instructions that you provide for use to certain IV drug users? And is crack cocaine the only drug that vitamin C is used with? Sure. So vitamin C powder is used in place of vinegar or lemon juice in the process of injecting crack cocaine. Something is needed to sort of break it down into an injectable solution. Vinegar and lemon juice are very acidic and very damaging to the veins and also can carry fungus and other bacteria. Vitamin C powder is a very common tool in needle exchange programs that's used for crack cocaine injection. It's a little less damaging on the veins and it's mixed with water prior to injection. And yes, that's the only drug that it is used for. In Portland and really in Maine in general, it's a very small percentage of people that are using crack cocaine for injection. And we give a very small amount of this powder out, I'd say less than 15 percent of the people that we see say that they inject crack cocaine and we give out one to two packets of it a week. And would you like to explain, Zoe, why the instructions were put on there? Yeah. So before we had changed the packaging and it was just in a Ziploc bag, which was the way it was before I came along, the directions were there just mostly for the user just to make sure that they weren't using too much because if you use too much of the vitamin C powder, it's then just as acidic as lemon juice or vinegar and really the directions were just put on there just so that after we have that one-on-one conversation in the needle exchange, when they leave and go to use it, if they need a reminder, it's there. And so can you just describe the changes that you made to the program? Sure. It came to our attention that there were some concerns about the packaging and so once those concerns were brought to us, we changed the packaging as quickly as possible. Because we wanted to address the issue so quickly, we just sort of came up with a temporary solution which was just like a small plastic container and it just simply said vitamin C. Then you helped us sort of do some research and we found another option which was really great which were these and they're just single use packets. You obviously can't reuse the bag, it's sterile which was something that I found was really important and it's a very small amount so it's easier for us when we have that conversation with folks to really say this is all that you need, you probably don't even need this much but it is a single use packet so just throw it in the trash when you're done with it. We were really glad that it was brought to our attention because we were able to address it and really it benefited everyone in the long run. It was a perfect example, I mean it was Laura who actually came up with this and we found that the supplier is in the United Kingdom where I come from many years ago but we ordered it and got receipt of it within a week. And it was actually, I won't say the name because he's not here, I don't know if he wants credit but it was another member of BNA who pointed that source out to me and I was able to pass it on to you. And so this was really important to us because the printed instructions caused a lot of concern obviously when something is printed and it can end up beyond the population you're trying to serve and we're concerned about the message that sends. We were concerned about the white powder that was unlabeled and just kind of how that could be misinterpreted by anybody, how it was subject to tampering perhaps and so the fact that there's no more printed instructions and that it's a non-receivable, clearly labeled package is something that we as a community can feel a lot more comfortable about and worry less about some of the side effects beyond the population that you're trying to serve. So that was a real success story for me and I think we all can agree that that was a really good improvement for everyone who's impacted by this so thank you very much. Absolutely and it really helped us when we are working with people in the exchange just to have that interaction and really say I mean we always whenever we give this out we go to lengths to make sure they understand exactly what it's for, it's not used for anything else and now that it comes in these little tiny packets we know and can feel very confident about the fact that no one can use it for something else or tamper with it or you know it can't be mistaken for anything else so we're glad for that too. Great, thanks. And I think I asked you this or you already said it but you said that I think you estimate about 50 packets of that vitamin C part of will be given out in the next 12 months. Yes. So not a huge part of what you do but not at all. Since it was turning up in the neighborhood we really appreciate that you made that effort. Absolutely. And the total cost for those 50 packets is 6.5 cents. Yes. We bought. Such a deal. Yes. And we're lucky we do, we get some donations from the community, some clients of ours give us donations and our vitamin C packets were purchased with that. Great. Great. We'll talk a little bit more about funding in a few minutes. Part of the reason that that program or that service you provide caused such concern is that people weren't aware of it. It's not listed on the Needle Exchange webpage on Portland, Portland, what's the Portland City website? PortlandMain.gov, I'm on it all the time, I think I would know that. Or in any of the brochures that we had seen. Are there any other programs you run or services that you provide or materials you distribute which are not explicitly described in those sources of information? I just wanted to be clear that we never thought of using this vitamin C powder as a program by itself. The Needle Exchange is a program and giving out the packets was just part of that. So we didn't give it the significance perhaps of a program because in conjunction with the syringes that we exchange, which we'll talk about later, we also do give out certain other supplies and they're mostly loosely kind of to do with making the injection event safer and there's things like alcohol prep pads, gauze, band-aids and I don't think it would have occurred to us to have listed those on the website. We can, there's certainly no objection to doing so, but they are not the program, they're just sort of part of the exchange. Would you agree, Zoe? Yeah, I would. One source, when I was looking at harm reduction programs, I think I saw one source that said that reusing any of the works presents some risks and I think one of the things listed were that it's like little metal cups that it's mixed up in. They're called cookers. Cookers. Do you provide that sort of material to people? We do. We do. Okay. We don't want people not to reuse them, not to share them because sharing any equipment involved in injection can transmit HIV and hepatitis C, so in an ideal world, somebody would use a clean, each piece of equipment every time they inject. Okay. How are we doing on time? So I think we're going to move on to just sort of the basic services you provide and structure and stuff. So can you kind of give us some basic statistics about the number of clients you serve, the number of needles that you exchange, and what's the process that you go through with a new client and with a returning client? Sure. Well, I can start with the numbers. There's a handout off to the side of the one pager that has kind of our basic statistics, excuse me. I can tell you that so in this past fiscal year, in our year runs July to June, so from July 2013 to June 2014, we had 801 enrollees in exchange. They made 5,639 exchanges, and in total we exchanged 153,920 needles. So that's about 192 needles per enrollee over the course of the year. And the numbers have gone up, and we attribute that to a lot of the outreach that we've been doing. Some of the hours that Zoe and her colleagues set aside are to do outreach in the community to let them know that this service exists. Okay. I'm going to do some more follow-up questions regarding what causes the numbers to go up and down and so forth. And then the process, the intake process that Zoe can explain. Yeah, so the intake process, and there's also handouts over there that show both of the, there's two forms. There's an enrollment form that everyone does when they first come in. We assign everyone an anonymous number, so they get like a client ID number, so everyone gets a card, and then we go through a series of questions, basic demographics, and then risk assessment questions, when is the last time you had an HIV hepatitis C test, status of your HIV and hepatitis C test, hepatitis A and B immunizations. If you have any history or any current, you know, sharing of your needles or equipment with a partner or friends, if you have a safe place to inject, and what drugs you're using. And we collect all that information and keep it on our database, which helps for our reporting purposes. And I think importantly for questions that might come up down the line, we also record how long the individual has been injecting drugs. Correct, yes, we all, when somebody first enrolls, we always ask, you know, when was the first time that you injected, how long have you been injecting drugs? Which is an interesting thing, and it always sort of leads to a conversation, and it's almost always a similar conversation when it comes to opiate use, but by the time people come to us, they've been using usually for several years. It's rare that we see anyone come in who's been using needles for even less than a year. Most people come to us saying that they had been buying their needles at a pharmacy, but either that it was very difficult to find a pharmacy that would sell needles to them or just that they felt that they were treated so poorly, unfortunately, in some situations that they didn't feel comfortable going back. So they find out about our service and they come in, and then each time somebody comes back, there's other questions that we ask in another form, which is a daily exchange form, that we always write their card number down, the number of needles that, you know, are collected and distributed, and then, you know, any changes going on in your life? When's the last time you tested? Again, you know, the immunization question, because we're able to offer hepatitis A and B immunizations to the folks in the exchange for free, which is great, you know, what's your housing status? Are you interested in talking about treatment today? And then we usually, you know, fill it in, and then once again, all of that information is entered. So we're able, when we go into our computer system, to kind of pull up that person's record and go, you know, see the last time they were in, if there was anything that we want to bring up when they're here, and just have a really good conversation, and then that way we can talk about any service they may be interested in discussing, you know. Maybe they want to come into STD clinic on Thursday, and we can talk to them about the hours of that and what services we provide. Maybe they want to talk about treatment options in the area. Maybe they need a primary care doctor. You know, we really sit and talk and try to, if we can't offer the service at India Street ourselves, at least get them pointed in the right direction. And there is a lot of evidence that those, it's the repetition of those encounters that leads people to eventually access some sort of treatment if it's available. They build the trust, you know, with Zoe and with her colleague, Lizzie, who's also here tonight. And after a certain while, it's that consistent interaction that leads to people seeking treatment if they're ready to do so. Yeah, I mean, I've had numerous people come back to me. Maybe it's a month later or a couple years later even, and they'll walk through the door and I'll say, you know, where have you been? I've been thinking about you and, you know, they've gotten clean and they're proud to come back and tell us, which is probably the best thing about the work that we do. Yeah, I'm sure it is. You guys brought some great visual aids here. Can you tell us about these bio boxes and sort of how they're used, how your clients get them, you know, sort of what the process is, what they're for? Yeah, so when somebody first enrolls, we always give them a personal sharps box that's like this and that holds up to 10 needles. And we encourage them to hold on to it and they kind of bring their needles back in this and, you know, count them out as they're taking them out of their own box into our bigger box to let us know how many needles they're bringing back. And they can pretty, people can pretty much get a new one whenever they need to. Sometimes the top breaks or, you know, they just need another one for whatever reason. And so they're always available in the exchange. Always, always, we always have them. And then we do have the larger size for folks who tend to do what's called the secondary exchange, which is sometimes exchanging for maybe everyone who lives in their apartment or, you know, their whole household or a group of friends. And that this box holds about up to 50 needles. Okay. And that was actually one of my other questions. What's the process for counting or estimating the number of needles that people bring in when it's more than that 10? So regardless of how many they have, whether it's one or more than one, there's really no estimating. They do have to count each needle. We have a large red biohazard box in our exchange room and some smaller ones on the walls. But we sit and they count and then once they, you know, finish counting, we write down their number and go from there. If they do have a large quantity of needles, we do often encourage people not to take all of them at once. And to have, you know, a credit on their account or not. Some people just want to get rid of them and they only want to small them out back. But, you know, that piece kind of comes up after they finish counting. Okay. Thank you. And we do have a limit actually, currently, that we never give out more than 50 needles per visit. Is there a limit per day? Can someone come back more than once in a day? They can. I mean, it's rare. But that's just sort of per the state law with the syringe exchange programs throughout the state. We created the limit on our own. But we found it very helpful and, you know, we haven't had any complaints. That's good. So when you considered all the staff, all the equipment, all the materials you distribute in the programs you administer, can you explain what's funded by federal agencies, state agencies, city of Portland, private, it's it's all that's probably one of the biggest sources of confusion. And misinformation or misinformation are just I don't I still don't understand it. And I've been talking to you for a while now. It is very complicated. Partly because the federal government flip flops backwards and forwards on their position on this. We recently had a visit from Michael Botticelli, who is the White House. Drugs are no, what's his? Yes. Acting Director of National Drug Control Policy. Thank you, Julie. And we all got the opportunity to meet with him. And he said very clearly, the federal government is in favor of needle exchange is they they promote them, and they are in favor of them. However, the there has been a law in existence for a long time that any money that comes through the federal government, either by grant or any other means cannot be used to buy syringes in a needle exchange. And there have been various attempts over the years to have that changed. And, you know, sometimes the Democrat or somebody will bring up the initiative to add it to a bill. But unfortunately, it almost always gets knocked off the bill at the time of passage to make it easier to pass. And currently, that stands. No federal monies can be used to buy syringes for needle exchanges. And we abide by that 100%. We get some federal funding for some of the other programs that we have at our clinic in India Street. But we do not use any federal money. Similarly, we do not use any state money, because the state of Maine wishes to be in compliance with the federal government ruling, and has not written separate legislature surrounding that. So we do get state funding for some of our programs. None of that money, none of it not one cent is used to buy syringes. So what we're left with is applying for money from private foundations, and using private donations from the community and other people. And that is the money that is used to buy the syringes for the exchange exclusively. It sits in a separate account in the operations department of the Health and Human Services and Public Health Division. It's only used for that purpose to buy those supplies. And it comes from predominantly from one small foundation called the Coma Foundation. And just to give you a sense, it costs about $15,000 a year to buy all the syringes we need, we can buy them in bulk and we can buy them very inexpensively. And it's actually very difficult to raise that money. We have sort of work on the bake sale model almost, you know, we're constantly anxious about about it running, running down. But we stick meticulously to the law regarding the funding. The city of Portland does not fund us to buy syringes either. So all that money comes from private foundations and or donations. And is that with what you said about the funding for the syringes, does that apply to the cookers as well? That's a little less clear. But most of the supplies we buy with that separate account, there are certain things like alcohol pads and gauzes, which come under the more general medical supply model that we are able to use other funding for. But for anything that directly relates to syringes, particularly, we have to use that money. That's the law. Okay. And if anybody questions it, we can pay for salaries, with state funding. But Zoe, for example, I mean, doing supervising the exchanges is a very, is only a part of what she does. She does outreach. She works in the STD clinic. She does a lot of testing. She coordinates referral to care and linkage to care, and does many, many other things. And just to kind of round it out, the needle exchange itself is licensed by the state, you know, law was passed by the state back in 97 to allow what they call hypodermic apparatus exchanges. And that law is also on the table for reference. And so ours started in 98 right after that law was passed. Okay. And given the complexity of where the funding comes from and the sort of the different levels of oversight and so forth, what entity holds the legal liability for the needle exchange in the event of any injury resulting from the services you provide or the perception of that? Well, we are covered by main statute to do our work. In terms of specific liability, we anybody in the public health division is in the city of Portland. And we are covered by a blanket liability taught for the city. But in terms of specific liability, I don't really, I think we'd have to ask our legal department. Are you talking about someone in the community? Yeah. Okay, yeah. No, we definitely would consult with legal. Yeah. Yeah, I don't have the answer, the exact answer. And I don't want to speak on the behalf all right. I'm just kind of doing a time check. Can you have you had any just I know you've obviously had recent discussions with us, but in terms of your regular internal discussions, do you talk about how to handle potential harm to the community from discarded needles? Do you have developed policy on that issue? Is that set by you? Is that set by the city? That's a complex question. We've actually had had a recent initiative to promote the safe disposal of sharps that needles that are found in public places. And there was a committee convened, which involved the acting city manager, representation from the police department, the fire department, public works, the med queue, the paramedics and the med queue, and ourselves in public health from several different divisions. And that meeting was convened over a period of about nine months, which was it Zoe, I think. And Zoe and I both sat on that. And what we came up with was a strategy for the disposal of needles that were found on public property. And we have a brochure which we distribute widely, which gives people instructions as to who to call if they find needles on public places. And there is a number for the public works department who will come out and collect those needles. In terms of needles that are found on people's private property, that is a bit more complicated. So our initiative there was to inform people how to dispose safely of needles that you might find or have in your possession. And this doesn't just apply to people who use the needle exchange. There are a lot of diabetics in the city who have absolutely no idea what to do with their needles. And you would think that there would be very structured programs from medical providers and so on around that. But in fact, they're not. And at a recent city council meeting, one of our counselors actually said that they are a diabetic and they have no idea what to do with their needles. And we get calls on a daily basis about this. And it's part of the service that we provide to either advise about that or, you know, talk about that. And we try not to advertise it too fully because we would be overwhelmed. But we will take needles from diabetics from time to time. Yeah. And we also we worked or I contacted the Department of Environmental Protection in Augusta and they provided us with a great brochure, which is a state of Maine brochure on proper disposal of sharps in your home. So we let people know about that website, which is really helpful. And there's brochures on the table here. And CTN, we've done some public service announcements through CTN and also around safe disposal of needles. And just through the outreach work that we do in the needle exchange, you know, on the street level, with our folks, you know, we talk to them about encouraging their friends to come in and sign up in the exchange because unfortunately, you know, there are still people out there who don't access our program, because they don't know about it yet. And so we're always talking to people about safe disposal options, you know, and encouraging other people to come in because more people we have coming into the exchange who are using injection drugs, you know, at least we know all of those needles are being disposed of with us and being disposed of properly and safely. Thank you. Sorry, I'm just having to prioritize for time here. That's all right. I am going to go ahead and move on to the next section, which is about harm reduction. And this is from the Needle Exchanges Facebook page. We work upon the harm reduction model and believe strongly that reducing the number of shared needles and educating high risk populations reduces the transmission of HIV. These statements have been proven and show that areas with needle exchange programs have reduced HIV transmission, reduced drug use and crime, and increased public awareness and increased instance of people going into treatment for drug abuse. You also provided some reference materials to me supporting the harm reduction model. And some of these upcoming questions are going to refer to those. I apologize that we don't have slides. I did have a slide that had the URLs of some of these documents. But if you signed the sign up sheet that's going along, I can send those use URLs out to you. So basically, you know, I'm sort of getting educated about what harm reduction means. Can you, you know, is the harm reduction model proven in Portland? And do you have statistics that those services reduce HIV transmission, reduce drug use, increase the number of people going into Portland and reduce crime here in Portland? I think we can, most of the studies around harm reduction have been done on a large scale. They've been done on a national level, on an international level, they've been done in many countries. And it's a very firmly established position, the harm reduction. To take it down specifically to Portland is something that certainly we don't have the resources to do those kind of studies. We record our data, but to do a kind of very specific targeted study like that would take money and resources and staff that we just aren't available to us. But what I can say is that over the last three years, we've done well over 1000 HIV tests in our needle exchange and amongst our needle exchange users. And we have identified only two cases of HIV in that period of time, which shows certainly that people who are accessing our our exchange are very much less likely than they were 15 or 20 years ago, to be contracting HIV, which as you know, is a disease which is serious, it can be treated, but it puts a very big pressure and burden on the healthcare system. And as we like to say, if you use one 10 cent clean needle and save one case of HIV, you are probably saving up to $500,000 worth of lifetime medical costs on average. And often it's a lot higher. So it's a, you know, harm reduction is something that that we we practice and are committed to. But it's also very pragmatic in terms of health care, and promoting and protecting the health of people and preventing disease. So that's our position. So specifically in Portland, we know that we're seeing very, very few cases of HIV disease. In our needle exchange, we're not seeing a big increase in hepatitis C, as people who are not groups that are not in needle exchanges maybe. In terms of crime, that would be something that the police department would have to monitor. And you know, maybe they could, maybe they could look at people who access our exchange and look if they're more or likely to commit drug related crimes, I wouldn't know. And that will be something that we couldn't answer. So I don't know if that's very satisfactory, but I think the hard facts are we were seeing very few cases of HIV. We know on a national level that the number of people who contract HIV through intravenous drug use has gone down dramatically over the last 20 years. I do think that this is the lack of data is a major source of frustration where we kind of get stuck on both sides of this conversation because I hear so many anecdotal stories about, oh, the instances of needles that we're finding on the streets is really, really increased. I've also heard anecdotal stories from people who said, you know, the needle exchange services saved my life. And all we have is anecdotes. And these sort of anecdotes are going back and forth. And it's very frustrating to kind of compare anecdote against anecdote and, you know, make a objective judgment call about the benefit you're providing with the added risks to, you know, be on the community you serve. And that's just kind of a comment to just an observation of a source where I find the conversation stalls and where there is more opportunity to glean some data that's relevant for Portland for Maine. I think that would really help move this conversation forward wherever we can find that. Let's see. You did mention Hepatitis C, and I know this is a source where there have been a lot of questions from the community about it. One question I had from someone was, since 2011, the needle exchange has more than doubled the needles, number of needles it distributes. And I believe that was taken from a radio program you guys did. During that same time, Portland's rate of recorded Hepatitis C infections increased over 300%. Can you explain that? Sure, I can take that. So first, I kind of want to clarify that statistic about Portland's Hep C rate rising by 300%. So I'm not quite sure on the source of that because we've never really had Portland level data. I've seen state level data and, you know, as well as preparing for this meeting, I was able to contact Maine CDC and get some county level data. So I think what they're referring to is around acute Hep C and chronic Hep C. So acute Hep C, so I know that Maine, for instance, in 2009 there were two cases of acute Hep C diagnosed. And then in 2012 it went up to 13. So that is a 550% increase. But if you look at the absolute numbers, it's going from 2 to 12. So it's not large numbers. Meanwhile, chronic Hep C cases in 2010, that's the last data I have, there were 1,142 cases in Maine. And then that went up to 1,214. So not nearly, it's not a 500% increase. So I think that is one thing we have to look at in terms of what is the statistic we're actually looking at. So, you know, I'm going to kind of turn to Caroline as well because she's a trained physician in terms of the difference between acute Hep C and chronic Hep C if you want to explain that. Well, I think Toa was making the point, this is, with all due respect, very flawed data. And it's not our data. When the way the distinction is made between chronic and acute Hep C is by self-reporting from the person who has it. And the symptoms are very vague, acute Hep C, it's being tired, you know, lethargic, just feeling generally unwell. Sometimes people do actually get jaundice and get yellow coloration, but that's by no means happens all the time. So if somebody fills out a questionnaire and they're asked when they thought they got infected and they remember feeling very unwell a couple of weeks ago, they might attribute that to having contracted acute Hep C. But there's no real objective way of judging that. So I'm not sure why the state decided to try and make this distinction, but without full medical backup, it's almost impossible to make. So the other factor involved here is that we are testing much more. You know, ten years ago we were doing very little testing of Hep C. And because we have these well-developed programs in the Division of Public Health down here, we are doing 75% of the overall testing in the state of Maine. So that's a factor too, which sort of biases some of our figures and numbers. But I think the really important statistic is the one that I mentioned, and Toho, you might like to give the precise numbers, that for people in the needle exchange, the incidence and prevalence of Hepatitis C has not changed over the last three years. It's remained completely steady. Now we'd like to see it start to go down and we do anticipate that it may. But right now we're not part of this escalating problem. This population is not part of that. It's held steady at around 18%. But of course that's a very targeted population. That's a high-risk population, so you'd imagine to see it higher. You know, it's not the general population that's 18% Hep C positive. The other thing I would say when I was talking to the Maine CDC is that, you know, I was asking, so 2 to 12 still is a bit of an increase. You know, what are some of the reasons you think it might be behind that? And one of the reasons they cited was more public education to mandated reporters like physicians and laboratories and things like that. So, you know, I think I would just hesitate to maybe attribute that huge increase necessarily to the needles that we give out. Okay, thank you. One concern that I've discussed with other people is that, you know, there's a general understanding that harm reduction is intended to be part of a spectrum of services. And for instance, from the article that you sent me, it's got a long title. I'm sorry, it's not up there. Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases and Tuberculosis for persons who use drugs illicitly. Summary guidance from CDC and US Department of Health and Human Services. In their introductory summary, they said, an integrated approach to service delivery for persons who use drugs incorporates recommended science-based public health strategies, including, and they listed 12 different things, and it's prevention and treatment of substance abuse and mental disorders, outreach programs, risk assessment for illicit use of drugs, risk assessment for infectious diseases, screening, diagnosis, and counseling for infectious diseases, vaccination, prevention of mother-to-child transmissions of infectious diseases, interventions for reduction of risk behaviors, partner services and contact follow-up, referrals to linkage and care, medical treatment for infectious diseases, and delivery of integrated prevention services. We've been dying from you to ask this question, because we can say that at 103 India Street, we provide all 12 of those strategies. Really? All 12, yes, and I can go into detail with that, but you might want to stop me talking, because we've not got all that much time. But just for an example, should somebody be diagnosed with an HIV infection in the needle exchange, we have a federally funded Ryan White program in that building, which offers primary care, HIV specialist care, substance abuse and mental health services to people with HIV. And we have physicians, nurse practitioners and nurses working in that program. We can enroll somebody in the same day that they're diagnosed if they wish to be enrolled. And all the other services listed, we have partner notification services around our STD clinic. We have STD services on the spot. I can literally go through every single one of those and explain to you that we have all those services right there. We also have extensive links with partners in the community, with the virology treatment center, which offers treatment to our patients who have hepatitis C and are willing to engage in treatment. We have connections with the Franny P body center for social support around anybody who has HIV. And we obviously have links with places like milestone who offer detoxification services. We offer suboxone services for people with HIV within the context of the practice and clinic that I described. Unfortunately, we don't, we can't offer them on a wider scale. We don't have the capacity. And yet again, over and over again, the single weakness of it all is having treatment facilities to refer people to who want to change their drug habit and get off drugs. We just have so few paces that we can send people to that will do that. Because we, you know, we always ask people in the needle exchange program if they want to talk about treatment. And there's a good number of people who do. And there's just, there are so few options because there's such a large amount of people who need treatment and very few places to send them. And I'd say that's probably unfortunately the biggest weakness. It really is the biggest weakness. And that's something that we, you know, is not is beyond our scope. We're public health, you know, we can't set up lots of treatment facilities. And for our particular clientele who don't have, who typically are not well off or don't have health insurance, it's it's an even bigger amount into crime. There are some limited facilities for young pregnant women. And that in fact is a little unfortunate because that's not something that we want to encourage. But one of the ways that you can get pregnant or get treatment is to be a young pre pregnant female. And that's sort of an ironic tragedy in a way. But for most people, the treatment is expensive and out of their range and not freely available. And I think that is another real high point of concern from the community is that is that that more treatment isn't available. And how does that lack of treatment shift the meaning of the services you provide? You know, this I'll just put this into my own words. I can I can I can come to terms with the services you provide to someone, you know, so that they don't do more harm to themselves so that so that they don't increase their problems beyond substance abuse into having HIV or hepatitis C or ruining their veins or you know, whatever, if they can get on a path toward recovery, when that path toward recovery just doesn't exist or is extremely inaccessible. I just wonder and I've had other conversations with others about this, you know, does it kind of shift the meaning of what you do? And is it what what should be sort of a okay, let's keep people healthy until they're ready to get out to there's nowhere for them to go. And this is sort of they're just stuck. I think that, you know, that is something that we struggle with every day because it's really hard. And there isn't an answer and we don't have it, you know, it's really hard to sit and say to somebody, I'm sorry, you know, you don't have health insurance, you're not probably going to get health, you know, I mean, it's there's only so much you can do. And I don't have an option for you. But I feel like it is our responsibility to be there and to make sure that they're as safe as they can be today so that we can keep our community as safe as we can while we're having these struggles that are beyond us. You know, yes, we're dealing with drug issues in Portland and it's hard. But that, you know, we're we have to be here as a safety net service. And I was just talking back to what Caroline said at the outset about building that trust and how you guys build that trust over years. So we kind of need to maintain that because you don't want to drop them, you know, because say beds do open up, you know, you want to have that preexisting trust already. Absolutely. And for some people, you know, we are the only place that they come and they get any eyes on them for anything health related. You know, these are people who have struggled with and struggle with mental health issues, years of trauma, neglect. I mean, kids that grew up in situations we can't even fathom, you know, and for them to come in and see us and have us acknowledge them as a human being and ask, how are you feeling today? You know, that that's huge for some people. And that that's a big part of why we do the work we do. And we have hope that there will be treatment programs that become available. And I hope that there will be in the future so that exactly we have those relationships. And we can say to this person that we've been talking to for five years, Hey, I know your history, I know your struggles, and I've found a place for you to go. And we have to live in a certain amount of hope and optimism here. I mean, the system is, you know, has so many flaws that I think those of us inside it feel that we're reaching a point where it's going to bubble over and we have to do something about this. You know, no, no body dangles a baby on their knee and thinks they're going to grow up to be a drug addict. They think they're going to be a ballerina or a baseball player. And these are lives that, you know, we feel deserve to be healthy just like any other life. And I suppose it does come down to that to some extent. But we're hoping that the system will, if we can just maintain, if you like, build the trust, as Zoe described, so that, you know, when it's ready, we will be there. And that's actually a great segue to my next question regarding Staying Hopeful. That same paper you sent me described how coordinated programs and cooperative relationships contribute to the efficiency and effectiveness of service and treatment. What agencies or programs, government units, businesses or other groups do you consider to be collaborative partners? And are there any relationships that you feel are especially productive? We have a long list, which we're all just now trying. I can start with the ones that Caroline already mentioned, the Borough Treatment Center, which is part of Maine Med, a huge partner, Franny Peabody, who, you know, especially for the people diagnosed with HIV are two huge partners. Milestone, homeless shelters, I mean, I think, you know, the Portland Recovery Community Center is a great place that, you know, in this time of lack of services, it's a wonderful place for people who need support and need to be around other people who are clean and sober and they can go and there's meetings, there's all kinds of activities and events and wonderful people who are there, who can kind of help keep them on the right track, who've been through it, who understand. I feel like that's a huge, you know, I recommend that place to a lot of people that we see, but also, yeah, you know, Oxford Street Shelter, Preble Street, you know, I go Cumberland County Jail, I'm just in the Cumberland County Jail, Grace Street. Yeah, Suboxone Program. We have a lot of clients. Yeah. And then governmentally, you know, as we talked about before, we partner with public services and police and FireMed too, around the Sharps disposal. And then we certainly partner with Main CDC. You know, as I said, I got the data from there. And of course, they fund. And aside from recovery options and treatment options for substance abuse, are there any other major gaps that you see where you wish you had better partnerships and relationships? Laura, you have three minutes in the section. Thank you. I think we come back over and over again. We try and get, you know, we did consider that question about gaps really seriously and we couldn't get beyond the fact that we've kind of got everything else in place. It's that one piece, the lack of options for people who want to be in treatment, should be in treatment and are ready for treatment. So I think I think that's the real take home message there. And I know it's always money to raise to buy the syringes, but yeah. And also, you know, I mean, I don't see it as a gap, but I think it's constant work to do things just like this to make sure that we are very present in our community, letting people know that we're here and why we're here and, you know, just really trying to make sure we're seen as an asset to our community because that's one of our biggest goals is, you know, we want to be seen in a positive way in Portland. I think we just always have to just work on that, you know, there's always more that we can be doing and we're always trying to do it. We can have a long conversation on this, the question of just about harm reduction, because I know it's a new concept to a lot of people. And there's a little bit of frustration about the meaning of harm reduction and that who is harm reduction really for? Is the larger community considered, you know, what about the harmful sort of side effects of needle disposal or, you know, the perpetuation of drug abuse? So it's, I know I have learned a lot about the philosophy of harm reduction. I haven't come down on one side or the other. I'm still on a journey, but it's certainly... I would just say, excuse for interrupting, but harm reduction is not exclusive to just substance abuse services. You know, harm reduction is kind of a central cornerstone of public health. You know, we talk about, you know, harm reduction when you're including smoking or eating healthier, things like that. There's stages of change for any health-related behavior, not just substance abuse. So, yeah. And smoking is a very good example of that, you know, which is why the Tobacco Helpline will not give up on you because they know that people stop and start. They need support at different times. And that's a perfect example is how someone can smoke for 22 years and then suddenly they're ready to quit and they do. So I think that's an excellent analogy to her. Right. I am going to go ahead and move on to the next section and we'll talk a little bit more segue about the community, impacts on the community and the role of the community. And this is a section where we're going to try to do a little bit of rumor control, I guess, maybe, and address some of the conceptions that exist. There is a persistent perception that I have heard by some members of the community, including some social service workers and members of law enforcement, that many drug users in Portland switch to IV drug use because of the availability of free needles from the needle exchange. What's your response to that? I think we can be pretty definite that that is not an important factor in why people start to use intravenous drugs. Far more important is the drying up of the supply of oral opiates, which were available and over prescribed in our state for a long period of time. And when that supply dried up, the substitute was there. It was inexpensive, freely available heroin. And as Zoe mentioned earlier tonight, when people get to us, they don't come in and say, oh, I hear you have a needle exchange. I was thinking of using intravenous drugs. So I'd like to enroll. People come to us when they've already been using and injecting for several periods, long periods of time. Because along with asking people how long they've been using, we ask, you know, where were you getting your needles before? And like I had said earlier, people do often tell us that they went to the pharmacy and usually have a story to go along with it. But I mean, it's true. I mean, the number of people that we have seen and they span so many different types of people. But the story is so similar. A car accident or some sort of injury was prescribed pain medication. And either loss or health insurance wasn't properly weaned. Whatever the situation was, still had this addiction that had been created and turned to street drugs from it. And typically, they start either just taking them orally if it was pills and then maybe snorting and then eventually moving on to injecting. But there's so much shame associated with it. I mean, even when people come in to see us, they're embarrassed to come in and see us. And we say, hey, we do this all day long. You don't have to feel bad about being here. We're glad that you're here. You're doing it. You're making a positive step, at least in some healthy direction. But people are not proud to be injecting and doing that to their bodies. So I think I've never spoken to somebody who has come in to sign up and has never injected before, ever. Thank you. And just for the record, I did reach out to the Portland Police Chief, Michael Sosciak, about both about that perception and about just needle possession laws and the relationship that police department has with the needle exchange. He provided a document that explains the needle portion of main law. And there are a couple of copies of that on the table. Sort of a quickie is that anyone over 18 years of age is allowed to have possession of up to 10 hypodermic needles on their person. And I basically asked him, along with the perception issue, I asked him, do you enforce these laws or are you more like looking for actual drugs? And in response, he wrote, these laws about hypodermic needles are seldom utilized, but I do believe that they still have a place in our community. And then he continued, I was at the table with staff from Portland Needle Exchange and our city manager while we discussed the needle response protocols that the city currently uses. So I think we're working together to address this issue. So just for the record. So I just said what, you know, sort of basic of the main state law is, and given the prevalence of needles that we are seeing in our communities in the street, I spoke to a pharmacist at Hannaford, who told me that they sell needles, 10 needles for about $5. They require an ID, but no prescription. Their policy is 10 per person, but they do not enforce a daily limit. I didn't have time to go to Rite Aid, Walgreen, CVS, or Walmart, so I don't want to single out Hannaford. I expect that I would hear something very similar at those other places. We can fill you in on that. Yes, so it's... Yeah, so not to interrupt, but so Walgreens and CVS just as a policy across the board, they do not sell any syringes to anyone for any purpose. Rite Aid does, you need an ID and they're a similar price and Walmart does. They're less expensive. They're about $2 for 10 of them. But we try to check in with the pharmacies fairly often just to make sure, because some people ask us when we're closed, where can we go? So we try to be up to date on that just so we can refer people to pharmacies if they need to go there. Have you... I'm sort of jumping ahead here. Is there any requirement that the distributors, the sellers of hypodermic needles provide for safe disposal of them? No. No, it's just as there isn't a requirement for pharmacies to take back medication. Yeah, to take back medication. To empty grandma's medicine cabinet. There is no none. In fact, the city organizes medicine take back days. They had one just recently where people can come and bring and dispose of their meds. And I think that is why we get so many calls from people who have diabetes or use syringes in their home because they're not informed, whether in their doctor's office or at the pharmacy, there's no discussion on what to do when you need to get rid of them. Which is an issue and something that we would like to at least support that education piece. Yeah. Do you... Hold on, I gotta find my place again. Sorry. Given what you were saying before about some sort of the shame or the way people are treated when they buy needles, why would someone go and buy them at a drugstore when they can get them from you for free? I mean, I know you do the one for one exchange, but if someone else would buy them for them that one time and they never have to go in there again, who's buying them? Who's exchanging them? I mean, I think... Just how do those work together? Yeah, I mean, I think some people prefer to go to the pharmacy. They don't mind spending the money and it's just as convenient for them. They don't get Zoe asking them lots of questions and asking them if they're ready to go into treatment. That was my question, actually, yeah. Yeah, I mean, I think some people... I think people who don't know about our program might just be concerned about what's entailed. People come in and they sort of have their ID ready and they're a little nervous and what kind of information do you need? So I think there is some concern about that. We try to make sure that we have posters up in the community and we're always out doing outreach and talking about our program, but there's certainly plenty of people who don't know about us. When people come into Enroll, we always ask how they heard about us. A lot of it's word of mouth or our website, but it's amazing people will say, oh, I never knew you were here, which is something that we hear about all of our services sometimes. And you're like, really? I feel like I'm always out telling people. But I think it's just different. I mean, some people choose to go to the pharmacy and buy them and they don't want to access our program, because yeah, maybe they don't want to talk about it. I mean, it could also be something as simple as when they're going, if they need something over the weekend, we're not open on the weekend. Right, yeah, some people definitely do both, I'd say. Okay. They might buy them at the pharmacy and come dispose of them at the exchange, right? Have you, I mean, it's tough because, well, let's just quickly, do you sometimes work with people exchanging needles who just need them for their diabetes medicine or is it pretty much, you know, funding-wise we can't really afford, you know, I feel like that would open a whole door that we have such limited funding to buy syringes. So I'll sort of, you know, if somebody comes in off the street and has a bunch of used needles, I'll take them and kind of offer education, say, you know, in the future, this is what you can do, but I'm not gonna make you walk around with a bunch of dirty needles. But no, as a rule, we can't really, I mean, we're fortunate that we have other programs at India Street that we can kind of, you know, like we have the free clinic and, you know, or we can refer people across the street to main med if they need primary care, you know, so we can kind of like work around it. But we have to pay for the disposal of our needle. Yeah, okay. And it's quite expensive. Right. Is that like a main garbage rule? It's called stereocycle. Okay. And they come and they collect every month. And, you know, we have big, big red bins that the needles go into and they collect them, but it isn't an insignificant expense. So I don't think we could just open our doors. Right. So we do, but we're very responsive and always have been. You know, we sometimes get people where there's been a death in the family and the person was a diabetic and they just don't know what to do with all these needles and we'll take those. And if it's an old person who's really in a difficult situation, but we can't, we could not be the needle- Disposal state. And so in your discussions with some of the pharmacies, have you talked to them at all about, I can understand if it's not sort of in their wheelhouse to provide the kind of level of counseling you do, but to, for them to provide disposal education, for them to provide information about the services you provide, has there been? We could have our brochures available in a pharmacy. That would not be an issue. We could have them on the, you know, on the counter. We haven't actually, that's another good idea. Yeah, I mean, yeah, we have talked to pharmacies about that, you know, and I have encouraged pharmacies to get the state brochure on proper disposal at home, you know, in their home. But that's something I think that we probably will try to do more often and more regularly in the future, just due to, you know, this and you bringing it up and just the concerns in the community. I think it's an important piece of the work we do. So do we. So thank you for what you do there. The, this is kind of getting back to the overall funding we were talking about of you before, that the National and State Centers for Disease Control and the World Health Organization endorse safe and liberal access to clean hypodermic needles as a way to address the spread of HIV and hepatitis C. However, there are, as you were saying, considerable restrictions on the funding for these programs. Do you know of any, if these agencies or other agencies or organizations consider the negative side effects of liberal needle distribution such as improper disposal, do you know who in Portland or who in Maine? I know you talked about that, that sort of cross agency work you've done. But what about sort of at the state level or even at the national level, who is considering this side effect of improperly disposed needles that, I mean, it's a, the generous distribution policy is trying to solve a problem of HIV and hepatitis C, but there is a creating a problem on the other end. Do you know, are there any organizations looking at this and trying to, looking at it on sort of bigger other than you and your city colleagues and so forth trying to piece together a solution? Well, I think that the burden of the studies have all been on the positive benefits of it because needles wouldn't go away if we stopped distributing them. People would, it wouldn't make, I don't think there's any evidence that taking away the needles would lead to a reduction in the incidence of drug addiction. I don't, I just know of nothing that has shown that, that sort of, it would just make it a more dangerous practice not just for the people who inject drugs but for the whole community. I mean, diseases don't know boundaries. And you know, young school girls and Kate Elizabeth sometimes are attracted to not such good boys who do other things. You know, it's a, it's a law of consequences once you start limiting the harm reduction sort of piece of it. So I don't know, I mean, obviously the fact that we all deplore the fact that people find needles in their communities. That's a dreadful thing to be happening. And I think we're all very motivated to find strategies to stop that happening but actually studying the harm that they do, I think we all know the harm that they do. They're a potential risk. People can get stuck with them. They can pick them up at the pointed end and you know, run the risk of contracting serious diseases. So I think everybody's pushed and motivated to try and solve that problem as we are and as we've been working to do. Thank you. This question is a long one for me. It's referring to some comments that were made in the Big Talk radio show interview that was with Suzanne Murphy on MPG in February, 2012. And I think that was you, Zoe, when you had the last game. It was me, Caroline, and our former colleague. Yeah, okay. I'm a regular, true disclosure. I'm a regular part of Big Talk and watch your language on WMPG. All right. So in response to a question about negative perceptions of the needle exchange, Zoe, your answer was, everybody deserves to be healthy and I think you said that earlier tonight. You know, obviously it's not healthy to have needles in the streets where people walk and parks where children play. So there's a sense of sort of, does everybody still include us? And then elsewhere there in the program, there was discussion about some IV users who are injecting Suboxone, which originally was intended as a treatment for opiate addiction. And that led to discussion about, this was totally new to me, but addiction to the needle and to shooting up itself to the preparation to the act of injecting regardless of the drug. And that people who engage in these behaviors, specifically the Suboxone particularly, may consider themselves to actually be in recovery. And then another section of story was related about a user who's calls his visits to the needle exchange, his weekly trip to hell, despite the kindness of you and the other staff, because it's something he needs due to his addiction. All of this seems like it's really going into a gray area of not reducing harm, perhaps. What's the tipping point in your opinion, in terms of in your work, where harm reduction is sometimes not living up to its intended goals or the negative side effects are outweighing the perceived benefit? I mean, and I wanna acknowledge what you were saying before about people coming back and telling you that they're clean and you haven't seen them, that's terrific. What's the flip side of that? I think we're scientists and social scientists here. And we look at the evidence for our practices. We like to say everything we do is evidence-based to some degree or another, that's very important to us. And we evaluate our own work. I think the whole tide and philosophy would have to turn against the harm reduction movement for us to sort of change our position on that. I know that's probably not a very unsatisfactory answer, but it's hard for us to see without real evidence that says that you're doing more harm than good by your harm reduction, that we would look to change our position on that. Would you agree with that, Toho? I concur, yeah. As we said before in terms of the resources needed to conduct a really formal research study to show the positive benefits. It's specifically in Portland, kind of the conversation holds true as well. It would take a huge kind of study to look at what might be some of the negative consequences. So they do continue education, they go to national conferences, they get journal articles, and they keep up on the literature of the people who do have those resources who are tackling those questions. Laura, you're at two minutes in this section. And if I could just say, sort of on the street level of things, you know, from the conversations that I have with folks every day, like I am constantly reminded why we do this work and how important it is by the people who come back and they say, you know, this helps me stay safe. My partner is hepatitis C positive and I've stayed negative all of these years or the people that I use drugs with are HIV positive and I'm consistently testing this person negative. I mean, that to me, that shows it. Now I can't show any numbers and I don't have anything that really says that, but those are the stories that I hear every day that to me, it does live up to its goals and I haven't had an experience where I feel like, ugh, you know, I mean, do I like, you know, I live in Bayside, do I like seeing discarded needles in my neighborhood when I'm walking my baby to the playground? No, of course not, but that means, you know, that I just need to be getting our outreach workers out there and doing more education and making sure we're getting more people enrolled because I trust that this program does the work and I see it and we hear it. I mean, we hear the stories every day and that's what I think just keeps us going. And we would certainly stand by our data. I mean, our data is very meticulously monitored by someone who's very good at data, including Toho. And, you know, we know, we keep it tally. It's not our needles that are littering the neighborhood. I think we can be as confident as anybody can. Now, people might suspect our data, but it's pretty solid. We count them, we record them, we give them out in equal measure. Yeah, I mean, we consistently have more needles coming in that are going out by a significant number. Yeah, we do. So that, you know, that helps too. Right. And the last question for me before we open it up to the audience. With the upcoming elections and possible changes coming in several governmental roles, what would you ask of those holding office at the city, state and national levels on behalf of the clients you serve? Well, in terms of answering that, you know, as city employees, you know, we have to, we're kind of restricted in terms of what we can do in terms of formal advocacy and lobbying. So I kind of hesitate to answer that. I honestly, you know, I might have personal feelings, but I don't feel it's necessarily appropriate in this form or in the city to share. Really? You can't say we, you wouldn't even want to say, you know, we need more recovery programs. We need more. Well, we did identify the lack of beds for recovery as a gap, you know. Yeah, in terms of how that would be funded, that's kind of not my role. Okay. I was hoping that would be sort of a, something we could offer support on. So maybe we can talk offline about it. Sure. So I am gonna open it up to the floor. I'm sorry, we don't have mics for the floor, but whoever has a question. Anyone, Sean? I was heartened to hear you say that you do track your metrics pretty closely. And I respect what you were saying that you don't have the resources to do a comprehensive study on the Portland market with that. So I guess my question is, if a graduate student in a public health program at university or something wanted access to that data to do that kind of a study, would they be able to gain that? Yes. Actually, we have one here. Right. Who would absolutely love to do such a study. She came to us, this is Lizzie Garnat. She's came to us as a master's student from USM as an intern. And actually has done some work with our data. And it was your dissertation, right? You used our data. And we're hoping that she will do more. But we are very resource poor. And not just in terms of what we, that we can't pay people, actually finding a desk for them in a computer. You know, all those things are a struggle for us. She is your intern? She was. And she's now. They're paying me now. They're paying. That's wonderful. But I guess what I'm getting at is not, I'm not saying someone that's necessarily opposed to your point of view, but somebody that's completely divorced from being wanted access to your information to do such a study. Would that be something they would have access to? I think when they're associated with a university and we work a lot with the U.N. and USM, that's the thing I've written down is to see if we can approach partners who we know very well and see if we can go after a grant together to do that. I think someone off the street, we obviously have restrictions, blah, blah, blah that you would guess about. But I think we have long standing in relation to more universities and could probably look something together to be pretty interesting. And a generous history of data sharing too. I mean, we're not, we want our data to be used because we do feel that we can stand by it. Okay, thank you. Anyone else? No question. Who do you guys offer services to besides the at-risk population? And this is a loaded question we get about from a student at USM, chemistry student third year, last year I received services, free services from your clinic in terms of just a journal checkup from a physician and it was all volunteer stuff. But can you guys speak to the services provided to not just the at-risk population, not just the needle exchange, all the other services? We'd love to. Sure. This is a funny little building at 103 India Street in the base of the Old North School where we're housed, the public health clinic at 103 India Street. And it houses the needle exchange, but it also houses six other programs. I mentioned the HIV program for people who have HIV disease. We have a twice-weekly walk-in STD clinic. If you can get your toe in the door between three o'clock and 5.45, we will see you. And we typically see anywhere from 15 to 22 patients at each of those clinics. And we offer services around sexually transmitted diseases, treatment, diagnosis. You're seen by an intake worker and biomedical provider and you will be given treatment and advice appropriately. So we have an HIV program. We have the STD clinic. We do adult immunization for regular vaccines. We do a travel clinic twice weekly for people who are leaving the country. We have a free clinic, which has been going for 22 years and is comprised of over 100 physicians, nurse practitioners, nurses, therapists, acupuncturists, a whole range of medical providers who donate their time to see adults who are stably housed and have no insurance and fall below certain income level. So we have, sorry. I was gonna add, because you're asking about the whole public health division, correct? I believe not just industry, because that's industry is one of seven programs that the city has. Right, so that's, but it's like peeling an onion. There's layers within layers. So, and I like to, I'm not trying to dominate her to her, but I like to tell people because the commonest response we get when people come to India Street is we didn't know you did that. You know, it's with the sort of world's biggest undiscovered secret. So we do offer a range of services, which is why we're so well positioned to execute the strategies that you asked about in that very interesting question. So I'm just one cog in the wheel, and Toho will tell you about it. Yeah, it's one of seven of the other six. So I can start with my own health equity and research, which kind of combines, as we know, there's a burgeoning refugee and immigrant community in the Portland area. So we provide services in terms of interpreting, getting people hooked up to services, because it's obviously a new healthcare system for them. The research part is kind of more my background where we do some research and evaluation of data. There's a chronic disease prevention program, which focuses mostly on physical activity, nutrition and tobacco cessation. They also do some substance abuse prevention, but it's more kind of general education through the schools and addressing underage drinking. Our environmental health and safety program, those are the guys that help keep you safe when you go out to eat in one of our great restaurants and you can find those reports online now to see their last inspection. And we also do some emergency preparedness through that. Recently, as we know with Ebola, we've been kind of using their skills to kind of prepare should something awful happen, that you think it hasn't. There is our healthcare for the homeless program down in 20 Portland street. And then our family health services includes kind of a mix of both clinical and kind of more general public health. We run four school-based clinics that are three high schools and King Middle School. There's visiting nurses for new mothers and new babies. There's a children's rural health program that serves all Portland public schools. And there is a violence prevention, what's called Portland Defending Childhood, and that's an initiative that addresses the issue of children exposed to violence. And then there's finally, on top of all that, is our operations program, which kind of does the HR and admin. So it's a pretty sizable division as part of the city. Steve? Yeah, I'm sure you mentioned you do a lot of good work in a lot of different areas. I have a number of concerns though. I think just seeing what I see in as recently as Sunday, I found a needle lying in front of the family shelter. And I found needles in my yard. And I know we have a neighbor who found people shooting up on her doorstep. And it just seems to me that for all you're talking about the work that you do and the harm reduction you do, there's little to no acknowledgement that you are exposing people who did not sign up for any of this to risk that they shouldn't have to take or that they shouldn't be exposed to. And second of all, I think it's a little disingenuous for you to say, well, we know for a fact those aren't our needles, do you stamp your needles? We do use a certain make of needle which has certain characteristics. Right, I mean, okay, so certain brands you can say that's not my needle. Yes. I understand that, but I would be surprised to think that you could say that across the board. Well, I'm sure we can't be 100%, but we can be 100% certain that we take in more needles than we give out. So in the bigger scheme of things, we are hopefully improving the situation. And I'd like to say that I'm really sorry that you find needles in your neighborhood. I think it would be very distressing. It is very distressing. I would have to say that I think I would speak for anyone in public health, that I don't think that the problem would go away if we did. I'm not saying that, I think, though, that there are probably steps that you can take to make sure that there's a little tighter reign on how your products are distributed and how you go about doing what you do. Giving cut kits and cooking kits to people is like buying a big box of candy at the store as opposed to just picking up a little bite-sized one. And I'm sorry, I appreciate the work you do, but I just see far too much exposure in far too small a confined area to have a very high comfort level with the work that you're doing. Well, thank you. You're not protecting the general public. You're protecting a specific population, which may be all well and good, but there are other people who are exposed to risks, rather needless ones. Well, thank you. I mean, I hope we are protecting. I hope we're protecting people from diseases by our work. We obviously believe that we are, but I'm really sorry that, as I say, it's so disturbing to you as it will be to anybody. Anybody. The recent initiative, again, that we are pursuing with other city departments around sharp disposals, a response to some of these community concerns. So I'm excited and I would love to see data as that program goes along. And we are open to suggestions, as I think we've proved from you. Yeah, absolutely. I mean, I would love to know some better ways that people in the community think that we could make positive changes, because we're definitely open to that. And I think that's a very constructive way to work with the community. We have like a minute and a half real hard stop, so I'll give to Sheila. I'm just gonna say quickly that we are gathering data about where we're finding sharp. So that's why we really encourage people to report that number. Because we wanna see where the hotspots are, if there are places where we're having more trouble than others. We talked about initially during this program about providing more access in certain areas, but we didn't wanna do that because there was some concern that it would drive traffic to places that you didn't want in your neighborhood. So we tried the approach of we'll come to get it, but we did talk about making safe disposal more accessible, but that created a whole host of other issues, and we're gonna wait until we get the data, see what it looks like, and then have the conversation again. So if there's some suggestions around that, we'd appreciate it. That's not gonna solve all the problems, but we are talking about it and wanna hear what you have to say. Yeah. I just have a real quick question. Yeah, I'm just curious what the alternatives are. If they can bring their needles to you, otherwise, what do they do with those? Good question. It seems to be the root of the problem, and that seems to be, if there's a lack of funding in disposing them, because it's expensive, it seems like pharmacies or... There are some needle boxes placed around the community. We're talking about perhaps at the firehouses because the firemen know how to handle or deal with the issue, and there was some concern that those who are improperly disposing might not want to be near where someone's in a uniform when they're disposing. That's all part of the conversation. And so maybe they're not everywhere, but if we find that there's a concentration, we might just consider putting more safe disposal access in other places other than having us come and pick up or having people bring it to the exchange. And we do have a brochure that offers, and the state has published a brochure, that offers advice about what, say, somebody in their own home who is a diabetic and doesn't know what to do with needles, how to dispose of them safely in sturdy plastic containers, sealing them, marking them as hazardous, and putting them in the trash so that they're clear to the people who collect them that this is what they are. So I am just going to encourage that we all continue this conversation beyond either through email, phone, maybe more meetings like this. I want to thank everyone for coming, especially coming out on such a nasty night when there's lots of other meetings going on. I just want to say a little something in conclusion, which I hope you'll indulge me in just as a result of the amount of time I've been spending on this. Substance abuse is a public health crisis. It and the behaviors that accompany it impact different people differently. As we all look for solutions, let's agree to put aside the us versus them mentality, which I feel wastes all of our time and energy in a pretty irrelevant battle. And instead, let's consider our different viewpoints as parallel challenges, not opposing ones, and keep the flow of information open so that we can establish policies that are safe and effective for every member of the community. Thank you all very much. Thank you. Thank you.