International Journal of Drug Policy 12 (2001) 45 – 57

www.elsevier.com/locate/drugpo

Point Defiance: a case study of the United States’ first

public needle exchange in Tacoma, Washington
Susan G. Sherman a,*, Dave Purchase b
a
John Hopkins School of Hygiene and Public Health, Department of Epidemiology, 614 N. Wolfe Street, Baltimore,
MD 21205, USA
b
Point Defiance AIDS Projects, 535 Dock Street, c 112, Tacoma, WA 98402, USA

Abstract

The first publicly funded needle exchange program in the United States began in Tacoma, Washington, in August
1988. The exchange’s history is characterized by a series of firsts: the first American publicly funded exchange; the first
pharmacy exchange; the first American needle delivery program; and the first state Supreme Court ruling not only
supporting the existence of a needle exchange program but superseding existing drug paraphernalia laws. It is also
unique because it began outside of the public health system and was not compromised by political feasibility. This
article documents the events and personalities which led to the exchange’s establishment and its expansion over time;
the program’s local, state and legal challenges and advocates; its portrayal in the local and national media; the
research that documented its successes; and its important contribution to the fight for drug users’ unencumbered
access to sterile needles. © 2001 Elsevier Science B.V. All rights reserved.

Keywords: Needle exchange program; Harm reduction; Tacoma; Case study

Introduction Needle exchange programs (NEPs) are a cost

Injection drug use continues to be the sec-
ond leading risk factor for becoming infected
with Human Immunodeficiency Virus (HIV)
in the United States (Centers for Disease
Control and Prevention, 1999). It is directly
or indirectly the source of HIV in over half of
heterosexually transmitted Acquired Im-
munodeficiency Syndrome (AIDS) cases.
* Corresponding author. Tel: + 1-410-5025368; fax: + 1-
410-5025385.
E-mail address: ssherman@sph.jhu.edu (S.L. Sherman).
effective method of disseminating clean
needles and have been shown to be effective
in reducing the spread of HIV among injec-
tion drug users (IDUs) in the United States,
Europe, and Australia (Hartgers et al., 1992;
Watters, 1994; Des Jarlais et al., 1995; Nor-
mand et al., 1995; Vlahov et al., 1997; Dias et
al., 1998). In spite of this scientific evidence,
as well as seven US government reports that
endorse NEPs as a method of reducing the
spread of HIV, the US Federal Government
has banned the funding of needle exchanges

0955-3959/01/$ - see front matter © 2001 Elsevier Science B.V. All rights reserved.
PII: S 0 9 5 5 - 3 9 5 9 ( 0 0 ) 0 0 0 7 4 - 8
46 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
for over a decade (National Commission on
AIDS, 1991; General Accounting Office,
1993; Lurie and Reingold, 1993; Normand et
al., 1995; Office of Technology Assessment of
the US Congress, 1995). A series of federal
statutes enacted since 1988 have expressly
restricted or banned the use of federally ap-
propriated funds to finance NEPs (Needle et
al., 1998). Opponents feel that the very exis-
tence of NEPs condones drug use and alter-
natively, recommend abstinence-based drug
treatment programs as the primary solution
in abating drug abuse (Lurie and Reingold,
1993; Nadelmann et al., 1997). Although pos-
sibly theoretically appealing, there is an in-
sufficient number of treatment slots in the US
relative to the number of drug users, in addi-
tion to the fact that drug users, as any group
of individuals, have a variety of treatment
needs. Fewer than 15% of IDUs are in treat-
ment at any period of time (Wiley and Sa-
muel, 1989; Lurie and Reingold, 1993).
The US experience departs from that of
other western industrialized nations, many of
which, by the early 1990s, had made legal
access to sterile injection equipment a pri-
mary component of AIDS prevention pro-
grams targeting IDUs (Lindesmith Center,
1997). Countries such as Germany, Switzer-
land, Britain and Australia have incorporated
harm reduction principles into their treat-
ment of drug use as a public health problem.
Harm reduction, as its name implies, focuses
on minimizing the harms associated with in-
jection drug use and informs a broad spec-
trum of treatment modalities and policies
related to drug use as opposed to solely
focusing abstinence-based models and the
criminalization of drug users.
In the United States, NEPs have one of
three legal statuses: legal; illegal-tolerated
(decriminalized); or illegal-underground
(Paone et al. 1997). But even legal exchanges
can be challenged by two types of law. Pre-
scription laws mandate a physician’s prescrip-
tion in order to purchase a syringe (Lurie and
Reingold, 1993). The second type of law,
drug paraphernalia laws, exist in 47 US states
and make the unauthorised manufacture,
possession, or distribution of drug parapher-
nalia a misdemeanor or felony offense. A
recent study of found that California IDUs
who reported a concern with possible arrest
due to drug paraphernalia laws were twice as
likely to report sharing syringes compared to
those who were not (Bluthenthal et al., 1999).
In spite of the predominantly hostile political
environment and lack of federal funding,
over 113 NEPs operate in the US, each of
which has a unique history based on a conflu-
ence of political and social factors. The estab-
lishment of the first US publicly funded NEP
in Tacoma, Washington was shaped by per-
sonal relationships and a strong commitment
to the Tacoma community, as well as the
foresight of public health, civic, and criminal
justice agencies. At the center of the ex-
change’s origins and continual operations is
Dave Purchase, a community activist and
internationally recognized needle exchange
advocate. This case study describes the politi-
cal alliances, barriers, and tactics used to
develop and sustain the Tacoma NEP, called
Point Defiance. In addition to cited literature
and personal interviews with several key
players, the majority of information was
derived from in-depth interviews with Dave
Purchase in October, 1998.
Point Defiance
Tacoma, Washington is a small working-
class port city with a long history of employ-
ment in the logging and fishing industry and
roughly 176 000 inhabitants. There is nothing
unique to the city of Tacoma as to why it
housed the United States’ first publicly
 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
funded NEP. In comparison to other cities it
has a relatively small number of IDUs, ap-
proximately 3000 (Hagan et al., 1993). At the
time the Tacoma NEP began, the city had
only 63 AIDS cases. The exchange’s birth
was the result of the work of three men
concerned about the health of Tacoma IDUs
and the lack of a politically hostile climate.
Dave Purchase, a former director of an
outpatient drug treatment center that offered
a methadone detoxification program, had
been working in the treatment business for
close to two decades. In 1983 Purchase had
‘time on his hands’ as a result of a major leg
injury sustained when he was hit by a drunk
driver. Two years of physical therapy,
wheelchairs, crutches, and rehabilitation gave
Purchase time to think about his career and
his increasing frustration over the monolithic
way drug treatment had come to be
practised.
During this time, Purchase’s friend and
long-term colleague, Terry Reid, informed
him about a new epidemic, Pneumocystis
carinii, that was occurring among incarcer-
ated IDUs in New York’s Ryker’s Island. In
1985, Reid received his first HIV prevention
grant to create an HIV educational video for
his methadone program. Since Purchase had
the reputation of being a gifted speaker, he
became involved in the project along with
Kevin Costello, an award winning film-
maker. The three men produced a short video
called ‘Drugs and AIDS: An Appeal to
Users’. The day the film was completed, Pur-
chase was walking down the street when a
building exploded, breaking his recently-
healed leg in three places.
During the two and a half ensuing years of
physical rehabilitation, Purchase had more
time to reflect and became increasingly an-
gered by substance abuse treatment’s re-
sponse to this new epidemic among drug
users. His discussions with state substance
47
abuse officials about targeting drug users for
HIV prevention were not successful. Their
prevailing attitude was that such programs
were not within the domain of drug treat-
ment. As Purchase’s frustration increased, he
began searching for alternatives to the absti-
nence-based treatment model to confront the
HIV epidemic among IDUs.
In 1987, Purchase began contemplating the
idea of starting a public exchange in Tacoma
after reading about Amsterdam’s NEP
started by users’ unions as well as conversa-
tions with Cathy Oliver, the Program Direc-
tor of a Portland, Oregon social service
agency. She had obtained a grant form the
American Foundation for AIDS Research to
start a NEP, but because of the prohibitive
cost of liability insurance, the program did
not begin until November, 1989. By the
spring of 1988, Dave was back on his feet
with the help of a cane and began talking to
Reid about starting an NEP. Since he was no
longer employed by any agency, he did not
have liability issues and, in his mind, he could
live with the worst case scenario of being
arrested.
In the spring of 1988, Purchase, Reid and
Flannigan called a small number of influen-
tial politicians and officials who Purchase
described as needing to ‘know about the im-
pending plan’. The calls were not requests for
permission, rather, courtesy calls to individu-
als whose support was vital to the existence
of an exchange. The short list was comprised
of the Tacoma mayor; the Health Depart-
ment Director, who had already placed AIDS
as a top priority; the Chief of Police; and the
County Executive1. In describing this buy-in
process, Purchase said, ‘I always found it
better to beg for forgiveness than ask for
1
The County Executive is a paid employee who runs the
County, which, in this case, is a larger geographic area than
the city of Tacoma.
48 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
permission…the last thing a public person
wants to run into is a surprise’. Additionally,
Purchase was not interested in angering offi-
cials in his hometown.
I am really a homeboy. I wasn’t some
carpetbagger from out of town. Tacoma is
my home. I’m fond of my hometown. I’ve
never registered to vote outside of Tacoma.
I’ve lived other places, but no more than
half an hour from where I live now. I’ve
traveled a lot, but I live in the house I grew
up in.
These local politicians who openly sup-
ported the exchange were not all ‘left-wing
liberals’. As Purchase said, ‘Doug [the
mayor], bless his heart, openly described him-
self as a very conservative Republican. But it
(needle exchange) made sense to him. And
the line he came up with in one of his inter-
views was, ‘we’re not giving them whiskey,
we’re giving them a clean glass. If they get
sick from dirty glasses, we’ve got to pay for
that’. Purchase’s reputation was an asset not
only with key health and city officials but
also with the injection drug using community.
He was known to be streetwise and had many
personal relationships with IDUs from 20
years of working in drug treatment.
On August 8, a second round of calls was
made to inform people that the exchange
would be beginning the next day. On August
9, Dave Purchase set up a small 1960s-era TV
tray, given to him by a local jazz musician
and friend, Ron Rustad, in downtown
Tacoma on Pacific Avenue and began ex-
changing needles. This site, a virtual retail
drug street market, came to be known as the
‘Central Exchange’ (Hagan et al., 1991). In
the beginning, Purchase had no idea how
long he would be giving out needles, and
assumed he would ‘go back to work in the
fall, probably have to go work in drug treat-
ment’. Purchase exchanged 37 needles the
first day. An employee of the Pierce County
AIDS Foundation, Patrick Rumrill, immedi-
ately began working with Purchase 20 h a
week. He and Purchase became close friends
and he volunteered for the exchange until he
died from AIDS in 1991. The exchange be-
came a formal non-profit organization sev-
eral months after it opened, and Purchase
named it Point Defiance — referring not
only to the ‘points’ or heads of needles, but
also a Tacoma city park.
Purchase attributes the early and relatively
unencumbered success of the exchange to
several factors, but primarily being the na-
tion’s first. As he said, ‘we had no precedent.
Tacoma was never saddled with a bunch of
rules’. Another key to success was the candid
support of important Tacoma officials early
in the process. Even though the NEP was set
up without official Government sponsorship
or financial backing and was in violation of
the state paraphernalia law, the Police Chief
made a conscious decision not to arrest Dave
Purchase. ‘By implication or direct order, the
police were asked not to hassle Dave’ (Flan-
nigan, 1998). As stated by a police spokesper-
son in the local newspaper, ‘Conventional
law enforcement hasn’t helped the AIDS
problem. Before you put the clamps on some-
body trying to help, you better have an alter-
native. We didn’t’ (Gross, 1989). In
discussing the support of key individuals who
could have easily closed down the exchange,
Purchase said,
The bravery, the real bravery was on the
part of Doug [the mayor], Al Allen [Health
Department Director], Joe Stortini [the
County Commissioner] and the guy who
was against us on the city council, Greg
Mykland. These people had political and
professional careers on the line. I know for
 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
a fact that some of them lost long-time
friends over it. I know that for a fact. I
mean friends. Especially Doug because he
facilitated a lot of the meetings, was
screamed at by people who used to be his
sort of business colleagues.
The exchange also had the early endorse-
ment of two other key constituencies: the
IDU community and the broader Tacoma
citizenry. The morning after the exchange
was funded by the Health Department in
January 1989, Purchase received an indica-
tion of the IDU community’s stake in the
program. ‘I’m across the street and I can
hear they’re yelling something and see them
clapping. And I open the door, and what
these people are yelling is ‘We got funded.’
Not ‘you got funded’ but ‘we got funded.’
That was a wonderful feeling’. Purchase
knew and respected the power of the inject-
ing community, ‘if people on the street
putting a bad word on us, they were one of
two groups that could have ruined the ex-
change’.
As far as the broader community, in De-
cember 1988, the local newspaper, the News
Tribune, published a Gallup poll survey
which showed the exchange had an overall
approval rating of 67%, with an 85% ap-
proval from those in the age bracket at
highest risk for HIV/AIDS. Other Tacoma
citizens illustrated their support through un-
solicited financial contributions. Although
Purchase primarily funded the exchange for
its first 6 months, he recalled,
People would drive up. They’d just shake
my hand and there would be five bucks.
Sometimes twenty. Very early on a person
who I’d known for a couple of years and is
still a good friend of mine just started
giving three hundred bucks a month. And
49
he had the money, it’s not like he was
starving to do this, but I mean, that kind
of thing and it was very affirming
Although opposition existed from the be-
ginning, the exchange’s origins were not
challenged by vitriolic or moral arguments
to the same extent as many other US NEPs.
After hearing Purchase describe the ex-
change’s history, a member of the US Na-
tional Commission on AIDS was struck by
‘the idea that a needle exchange could be
established without fanfare’ (King, 1990).
According to Purchase, there was one essen-
tial moral argument about his work, and
that was the fact that ‘we were right. I serve
the truth’.
Around the same time the Tacoma pro-
gram began, NEPs were being considered in
various forms throughout the US. The pilot
project in Portland, Oregon would have
been the nation’s first needle exchange ex-
cept for problems receiving liability in-
surance. In November 1988 an exchange,
Prevention Point, was opened in San Fran-
cisco. Although the city and County of San
Francisco tolerated the exchange, it was ille-
gal according to state law. The first New
York City exchange opened one week after
the San Francisco program, as a small pilot
project. Although New York City had some
of the US’ highest rates of HIV, hepatitis B
virus, and hepatitis C virus, advocates had a
very difficult time establishing an exchange
large enough to meet the needs of the city’s
200,000 IDUs (Des Jarlais and Stepherson,
1991). Many New York Hispanic and
African American politicians viewed the first
exchange program as a racist research ex-
periment. The New York City pilot pro-
gram had a limited number of participants,
required photo identification, and was
housed next to police headquarters, the
courthouse, and the jail, ‘…buried in a mu-
50 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
nicipal office building cellar far from where
the addicts were’ (Drucker, 1990).
In contrast, Purchase’s freedom as an inde-
pendent agent was vital in the early opera-
tions of the exchange. Unlike other cities that
had to follow the dictates of NEP skeptics,
Point Defiance’s staff were able to shape
services. The exchange’s primary goal was
straightforward: to provide IDUs with steril-
ized syringes in exchange for dirty ones.
Point Defiance did not ask for names, require
IDUs carry an ‘exchange card’, or give any
form of identification. Anonymity was an
extremely important factor in Point
Defiance’s immediate success with IDUs. Ac-
cording to Purchase, the rule of law is, ‘we
don’t ask and we don’t tell’. The Health
Department had a large role not only in the
program’s inception, but also its longevity. In
addition to his personal and professional re-
lationship with Terry Reid as well as the
Health Department Director Al Allen’s sup-
port, Purchase developed a long-standing re-
lationship with Holly Hagan, a Health
Department epidemiologist who shared his
harm reduction philosophy. In December
1988, Purchase and Hagan presented the first
of many program evaluations to the County
Health Board. On January 4 1989, the Health
Board voted on one of three levels of action,
each of which involved spending differing
degrees of money on Point Defiance. The
Board voted to fund the most expensive op-
tion, making Tacoma the first US govern-
ment-sponsored NEP and provided Purchase
with a part-time salary and outreach supplies.
The four-to-one vote provided a 6 month
personal services contract for $17 500 US
dollars (USD), paid by pooled funding: half
from the city and half from the county. At
that time, the NEP had already distributed
over 11 000 needles.
A part of the exchange’s early success was
its ability to establish trust between IDUs
and the social service system as well as de-
bunk the myth that NEPs were in direct
contradiction to abstinence-based drug treat-
ment programs. In an effort to diffuse the
tension between traditional drug treatment
supporters and the NEP, Tacoma health offi-
cials were quick to publicize the benefit the
exchange had on bringing people into drug
treatment. In a national newspaper, Terry
Reid was quoted as saying, ‘one thing that’s
conveyed through a needle exchange program
is that somebody cares about drug users.
That creates trust, and with such interactions
you create a window of opportunity for them
to come into treatment’ (UPI staff, 1989).
Eight months after the program began, 150
additional Tacoma IDUs had sought treat-
ment, an increase of 53% over the previous
year.
Purchase not only started Point Defiance
but has also been involved in promoting and
establishing NEPs through the US and the
world. The Tacoma program was quickly
heralded as a model for others in the US In
April, 1989, the Health Department’s govern-
ing board sent him and Al Allen to testify on
NEPs in front of a US Congressional Com-
mittee. In 1989, Purchase also founded the
North American Syringe Exchange Network
(NASEN), a grass-roots organization of
needle exchange organizers throughout
North America. The first NASEN conference
took place in Tacoma in 1991, and was at-
tended by over 60 activists, NEP employees,
and researchers and rose to 100 participants
by 1992. NASEN continues to provide a vital
role in being a forum for discussion, the
dissemination of information and research
findings, and a source of seed money to
exchanges throughout the US. It plays a key
role in the broader US harm reduction
movement.
 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
Point Defiance’s growth
Over the years, Point Defiance grew
rapidly. In April 1989 a second street-based
exchange site was added in another area with
a heavy drug scene. By July 1989, Point
Defiance was exchanging 600 syringes daily, a
sixfold increase over the previous 6 months
(Bond, 1989). By 1990, it expanded its hours
of operation from two afternoons to 6 days a
week and two Brisk County Health Depart-
ment employees were assigned to work with
Point Defiance, Quincy Walker and Anna
Maria Garcia. In June 1990, the Health De-
partment decided to add more sites in down-
town Tacoma in addition to the Central
Exchange, which was now exchanging
needles with roughly 500 different IDUs a
week. By this time a site had already been
added at the Health Department pharmacy
located across the hall from a methadone
clinic and other clinical public health services.
This was the first pharmacy-based NEP site
in the US. At that time state law allowed for
the sale of syringes, at the discretion of the
pharmacist, without a prescription (Hagan et
al., 1993).
In December, 1990, Purchase’s co-worker
Patrick Rumrill suggested they start another
first, a needle delivery service in order to
reach people who did not use the fixed ex-
change sites. The delivery quickly became a
major source of supplying clean needles to
new networks of IDUs who were not in-
volved in the downtown street scene. Most
delivery encounters occurred at major inter-
sections. This service allowed users living in
the County access to sterile syringes and, as
Purchase explained, did not necessitate ‘Point
Defiance getting approval from every munici-
pality, every sheriff deputy, and every chief of
police to exchange needles’. The geographic
expansion incurred negligible costs for the
program. In 1998, the program delivered
51
close to 45% of its syringes. The program’s
budget grew as well. By 1994, Point
Defiance’s budget was $240 000 USD and it
was estimated that the NEP had prevented
roughly 550 HIV infections, equaling $55
million USD in medical costs (Porterfield,
1995).
The program also gained notoriety because
of its founder. Dave Purchase became some-
what of a hero in Tacoma, as reflected in a
description of him in the local newspaper:
Purchase was a hero because he saw what
was needed and he acted. Because he in-
spired others to work with him, won police
co-operation and community, church, pub-
lic health, and city support for a project
that simply had to be undertaken (Craw-
ford, 1995).
Purchase and the program began receiving
numerous awards shortly after Point
Defiance was established. In July 1989, Point
Defiance was named the best new public
health program by the National Association
of County Health Officials. In 1989, Purchase
and John Parker-Stuart, the first man to dis-
tribute needles in the United States, shared
the Richard Dennis Drug Peace Award from
the Drug Policy Foundation. Purchase was
honored in June 1990 with a Tacoma City of
Destiny Award, which was chosen by a com-
mittee of Tacoma citizens in recognition of
his outstanding community service. In 1992,
the World Health Organization report cited
the Tacoma exchange as one of the most
effective and least expensive NEPs in the
world.
The political context
The issue of needle exchange was also on
the political agenda of the Washington state
52 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
government. Governor Booth Gardner, a
Tacoma native, was supportive of needle ex-
changes and understood their far-reaching
public health benefits. As early as 1988,
Gardner had appointed a State AIDS Advi-
sory Committee to stop the spread of AIDS
in the face of mounting political opposition.
In January 1989, the Washington State
Board of Pharmacy had requested the state’s
House Health Care Committee eliminate the
state law restricting pharmacies’ sale of sy-
ringes to those with medical problems. This
brought the issue of the Tacoma exchange to
a state level and in March 1989, the Republi-
can-controlled Washington Senate proposed
a ban on needle exchanges. At the time,
Tacoma and Seattle were the only two cities
in the state with exchanges. Governor Gard-
ner publicly spoke against the ban and once
it passed in the Senate, vetoed the legislation
in an effort to ‘give the NEPs a chance to
work’ (McDaniel, 1989).
A vocal NEP opponent was the state At-
torney General, Ken Eikenberry, who in re-
sponse to the Governor’s veto, issued a
formal, non-binding, legal opinion in July
1989. This brief stated that under Washing-
ton’s Uniform Control Substances Act (the
state’s drug paraphernalia law), it was unlaw-
ful to deliver drug paraphernalia knowing
that it will be used to inject a controlled
substance (Bond, 1989). Eikenberry’s opinion
effectively created a conflict between the state
attorney and local health officials, in that he
believed state drug paraphernalia laws could
not be violated even in the face of a public
health crisis.
This state debate spurred challenges within
the city of Tacoma. The Tacoma City Attor-
ney filed a similar legal opinion to Eikenber-
ry’s and proposed withholding the city’s half
of the exchange’s funding. In October, 1989,
the Health Department Director Al Allen
responded by filing a suit in the Pierce
County Superior Court against Pierce
County and the city of Tacoma over the
city’s threat to cut off funds to the exchange2.
This was the first case in the US to test the
legality of a publicly funded needle exchange
(Shatzkin, 1990). Such a case mandated judi-
cial opinion as to the balance of power be-
tween the state’s existing drug paraphernalia
laws and the public health authority in light
of a public health emergency. On February
17, 1990, Tacoma won its first legal battle.
Superior Court Judge Robert Peterson ruled
that although it was illegal to distribute hy-
podermic needles, Health Department work-
ers were exempt from such a rule because
they were carrying out their ‘lawful duty to
prevent the spread of disease among the pub-
lic’. The Tacoma program’s existence was
further insured by a Washington State
Supreme Court ruling in November, 19923.
The decision was in reference to a case
brought forth by the Spokane County Health
District Board in its fight to establish a NEP
in Spokane4. The Supreme Court unani-
mously decided that the state’s exchange pro-
grams were lawful HIV prevention measures.
The Supreme Court ruled that the Health
Department Director had the authority to
decide needle exchange was necessary in light
of the public health emergency at hand and
that the Drug Paraphernalia Act was not
written with the foreknowledge of
AIDS.Throughout all of these legal proce-
dures, the exchange never closed its doors. As
Purchase said, ‘I made a foolish promise
around that time. It (the 1990 case) started a
rumor on the street that we were going to
close, and one day there were people standing
2
Allen 6. City of Tacoma, 1990.
3
Spokane County Health District and Beare 6. Brocket,
1992.
4
RCW 70.24.
 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
around wanting to know if I was going to
leave. I told them I wasn’t leaving until HIV
did’.
The Media
As a seasoned political activist, Purchase
knew the value of a good relationship with
the media – he viewed it as one of the
exchange’s best friends. Purchase’s gift with
words as well as his visual presence benefited
his cause greatly. Early on, he was described
as a bearded, burly Mother Theresa, which
‘‘infuriated the conservative opposition and
gave us a good laugh.’’ His quotes and pho-
tographs have appeared in numerous local,
state, and national newspapers. On January
23 1989, the New York Times ran its first of
many articles about the program. In stark
contrast to the New York City experience,
the article called attention to the fact that
Point Defiance was born with far less con-
tention than other programs. The article
stated, ‘Tacoma’s effort is extraordinary be-
cause it took shape with virtually no civic
upheaval. In part, this was credited to the
enlightened attitudes of the Pacific Northwest
as well Purchase’s personal crusade with
gradual government participation’ (Gross,
1989).
Opponents’ and public’s reaction
Over the years, there has remained a steady
opposition to Point Defiance, stronger and
more threatening at some points in time com-
pared to others. In the beginning, the most
outspoken opponent was city council member
Greg Mykland. Although he was the only
council member to vote against the Health
Department’s initial funding of the exchange,
Purchase respected him because ‘‘he asked
reasonable questions.’’ His primary argument
against the NEP was that the money could be
53
better used for drug treatment programs and
not for a program that sends out the wrong
message about drug use. A group consistently
opposed to the exchange was that of the
Downtown Business Association, whose in-
terests were represented by city council mem-
ber Mike Crowly. But the businessmen’s
opposition softened by 1995 when it was
obvious Point Defiance was not going away,
and the issue became where the exchange
should be located rather than if the exchange
should exist. At this time, the downtown was
undergoing a major renewal and in July 1995
the Board of Health unanimously voted to
have outreach workers distribute needles
downtown with the van parked several blocks
from the heart of downtown (Albert, 1995).
As downtown was no longer a major drug
epicenter and the second exchange site and
delivery program were exchanging a large
number of needles, this did not greatly affect
Point Defiance’s ability to exchange syringes.
The other group Purchase felt powerful
enough to shut down Point Defiance was the
African American ministry. In the early days,
their Ministerial Alliance sent a letter to the
Health Department stating that they ‘could
find no justification in the Bible for needle
exchange’. But they also wrote that ‘the man
who started the exchange had good inten-
tions even though he was wrong’. Although
they let their opposition be known for the
record, Purchase appreciated the fact that
they never took the issue to the pulpit. He
felt that ‘if they had done that, they would
have stopped us. We would have lost the
support of their community, and that would
have been the end of our program’.
The only time Purchase truly feared for the
exchange’s existence was due to ‘a simple
mistake’. There had been a series of meetings
every six months between the Health Depart-
ment and the Downtown Business Associa-
tion. Not long after Frederico Cruz-Urube
54 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
became the Health Department Director in
1995, the Health Department went through a
reorganization and the planning for these
meetings slipped through the cracks. The
businessmen were angered by this and ac-
cording to Purchase, ‘that was the most dan-
gerous time and it was because somebody
just forgot to do something. It was not be-
cause anything happened on the street, but it
took another year for that to calm down’.
Research
From the very beginning, Point Defiance
had a strong research component. Over the
years, this not only served to solidify the
program’s existence but also supported the
important role of NEPs in abating the spread
of blood-borne diseases. The program has
been evaluated in numerous academic jour-
nals and reported on at conferences through-
out the world (Hagan et al., 1991, 1993, 1995;
Des Jarlais et al., 1995). Tacoma has been
cited as one of five cities in the world that has
a stable low HIV seroprevalence rate, below
5%, among its IDUs (Des Jarlais et al.,
1995)5. This is directly attributable to early
intervention, the large-scale provision of ster-
ile injection equipment.
Early reports of Point Defiance’s success
occurred in a larger context of the growing
national debate on the merits of needle ex-
change. George Bush’s administration was
vocally opposed to needle exchange, noting
that more science was needed to prove that
exchanges did not in fact increase drug use.
Unfortunately, the growing number of early
studies from San Francisco, California, New
Haven, Connecticut and New York City, as
well as the Netherlands, England and Ger-
many, did not suffice the federal govern-
5
The other four cities are: Glasgow, Scotland; Lund, Swe-
den; Sydney, Australia; and Toronto, Ontario.
ment’s need for proof (Des Jarlais et al.,
1994; Kaplan and Heimer, 1994; Watters,
1994).
Federal reports, written as early as 1989,
recommended syringe exchanges as important
components of HIV prevention. In February
1989, the National Academy of Science re-
leased a 600-page report compiled by a panel
of 20 scientists and public health authorities
that found needle exchanges as a potentially
effective strategy ‘urgently needed to slow the
alarming spread of HIV among drug users,
their sexual partners, and their children’. In
March 1989, Dr Louis Sullivan became Sec-
retary of Health and Human Services and
stated that he did not ‘subscribe to the view
that it (needle exchange) condones drug
abuse’, but was unable to influence President
Bush who opposed NEPs ‘under any circum-
stances’. In 1995, a second National
Academy of Science report encouraged drug
users to exchange needles to ‘greatly reduce
the spread of the virus that causes AIDS’
(Leary, 1995). The report cited Point
Defiance’s role in the eight-fold drop in hep-
atitis among IDUs. The panel’s recommenda-
tions were a strong invitation for the Clinton
administration to lift the federal ban on fund-
ing needle exchange programs.
After close to a decade of research, the
1998 US Department of Health and Human
Services Appropriation Act (FY98) stated
that the Secretary of Health and Human
Services could lift the ban if it is determined
that exchange projects effectively prevent the
spread of HIV. On April 20 1998, Health and
Human Services Secretary Donna E. Shalala
announced that although she determined
NEPs were an effective component of HIV
prevention, the act’s restriction of federal
funding would not be lifted (Needle et al.,
1998). This decision, prompted by President
Clinton’s capitulation to the US drug czar
Barry McCaffrey’s vocal opposition to NEPs,
 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
continued the ten year ban on use of federal
funds for needle exchanges.
Numerous scientific studies have demon-
strated that NEPs are effective in not only
reducing HIV transmission, but also dissemi-
nating information about HIV/AIDS, dis-
posing used syringes, and connecting
otherwise marginalized IDUs into the social
services system (Des Jarlais et al. 1994;
Groseclose et al. 1995; Nadelmann et al.,
1997). As of 1997, all but two of the 16
seroincidence6 studies on NEPs have shown
reduced incidence of HIV among partici-
pants (Paone, 1997). A study of New York
City IDUs concluded that ‘regular participa-
tion in syringe exchange programs would re-
duce the risk of HIV infection by
approximately half’ (des Jarlais et al., 1996).
Using a very conservative model, Lurie and
Drucker (1997) estimated that 4400 to
10,000 HIV infections among US IDUs
could have been avoided between 1987 and
1995 if the US Government had imple-
mented syringe exchange nationally and
would have saved $500 million USD in
health care expenditures.
Despite the federal ban and conflicting
needle exchange policies through the US,
NEPs offer a broad range of health and
referral services and are located in 30 states
and 82 cities (Centers for Disease Control
and Prevention, 1998). The exchanges are
financed by a combination of local govern-
ment funds and private donations, and the
programs distributed more than 17.5 million
syringes in 1996 (Paone, 1997). But due to
the ever-present challenges of funding as well
laws prohibiting the exchange of needles, it
is estimated that only 10% of IDUs have
access to NEPs (Nadelmann et al., 1997).
The individuals most affected by the lack
6
Seroincidence is the number of newly diagnosed HIV cases
among a given population in a specific period of time.
55
of access to sterile syringes are IDUs, their
partners and their children. In 1989, it was
estimated that injection drug users accounted
for 25% of AIDS cases nationally (Centers
for Disease Control and Prevention, 1989).
By 1997, this had increased to 36%, while
49% of AIDS cases among Latinos and
African Americans are injection-related
(Day, 1997). As of June 1997, 53% of all
children born with AIDS were the children
of IDUs or their sexual partners (Centers for
Disease Control and Prevention, 1997). Le-
gally, IDUs also continue to be threatened
or arrested under state paraphernalia laws.
This can include the offense of carrying
needles to or from an NEP.
Conclusion
This case exemplifies how policies can be
shaped and implemented by those working in
and out of ‘‘the system’’ and the importance
of buy-in from multiple players in sustaining
a successful NEP. The Tacoma experience
was shaped by a broad coalition of individu-
als who had the foresight to support an ex-
change because it seemed like a good harm
reduction option, in addition to others in
place. The fact that Point Defiance was not
born ‘in the system’ but had the support of
the Police Chief, the Mayor, and the Health
Department Director were major reasons for
its success and longevity. Unfortunately, it is
one of the few US exchanges that started in
such a supportive environment; many others
have been shut down by the police, or their
employees have been hassled or arrested. The
Tacoma story is not only an important part
of history in the harm reduction movement,
but can be instructive in the establishment of
future NEPs in its implementation and
demonstrated success. In talking about les-
sons learned over the years, Purchase said,
56 S.L. Sherman, D. Purchase / International Journal of Drug Policy 12 (2001) 45–57
If we had to do it all over again, and I
don’t mean to sound immodest, but I don’t
think there’s much that we would have
done differently. I mean if I were to do it
now, I would ask who did needle exchange,
you know. And we have — I mean we
having no precedent. We had some advan-
tages, and people really hold a standard up
to us
Acknowledgements
This study was supported by a predoctoral
training grant, c 1F31MH11806, from the
National Institute of Mental Health AIDS’
Office. Thanks to Dennis Flannigan and
Terry Reid for informative interviews. This
article is dedicated to the memory of Patrick
Rumrill.
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