The sight of the homeless people of Madrid would be familiar to New Yorkers.
Some spend the night in cardboard caves, others are buried beneath layers of blankets. The supermarket shopping carts carry around life’s possessions. In downtown Madrid, the homeless stake out their territory, staying on a particular block day after day. There are the personal touches; the man who stayed next to my hotel had a television and watched movies and soccer matches.
But the street dwellers are as trapped in socialist Spain as they are in the Republican United States. The problem of homelessness represents one facet of drug abuse. In nations all over the world, many homeless people have drug careers spanning decades. They often have no usable veins in their arms. Some need to use great dexterity to inject drugs into their groins or necks. AIDS, hepatitis C and tuberculosis are endemic to this population, for whom hope does not come easily. Nor can most medical practitioners comfortably work with these individuals.
Madrid Positivo offers an exception to this rule.
Fueled by the idealism of a Spanish doctor, Madrid Positivo provides medical services, clean needles and methadone on a daily basis. Using a van, they go to three sites a day—every day of the year. The program is devoid of the bureaucracy and rules that bedevil programs in the United States. A doctor prescribes a daily dose of methadone. Workers pour it into disposable cups and it is consumed on the spot. The flexible rules make the methadone program accessible to the homeless, the same group that is hardest to reach in the United States.
Programs in the U.S. require urine tests to determine that the patients are not using illegal drugs, and detailed regimens are in place to prevent patients from selling the methadone. Often the clients must keep appointments. Structured in this manner, the American programs are limited to middle class, or at least well-organized users, and inaccessible to the more defiant street person.
It is hard to conceive that the idealistic staff in Madrid Positivo would work in the security-conscious environment required by the U.S. rules. This is at best unfortunate because the street populations have dire needs. But American rules direct methadone to a different population.
Madrid Positivo strikes even the Spanish as a liberal advocacy venture. Spain has a punitive drug policy that levies strict jail terms or fines on people who carry more than a small weight in drugs. Between 1996 and 2004, the prison population rose from 44,312 to 58,456 with the largest number of arrests for cannabis-related offenses. The dominant drug education program and drug rehab programs are tied to the Roman Catholic Church and emphasize abstention. Madrid Positivo is an island of harm reduction in a sea of prohibition.
But the program works, for the same reason good drug programs work all over the world, because it provides medical services in a friendly and caring environment. This humane approach is crucial to a successful drug abuse reduction effort. Dr. Carlos Alvarez Vera who authorized Madrid Positivo when he was in charge of anti-drug programs for the Madrid region, sees non-governmental organizations playing a crucial role in dealing with drug abuse. According to him , these programs bring a motivation that can never be duplicated by a corporate or government bureaucracy.
Madrid Positivo has medical doctors, trained social workers and educators who work directly with the clients at the roadside locations, building up long-term rapport and familiarity. Some weekends, Dr. Jorge Gutierrez, the founder and driving force of Madrid Positivo, organizes activities for clients, and provides them with opportunities to relate with the staff outside of their street environment. On one trip, when a client got lost, and others searched for him in the dark, the homeless man took a simple practical step. He found a hunter’s shack and prepared to pass the night—hardly a new experience for him. He was touched when he found that the others were worried enough to search for him.
This man and others leave the streets to enter transitional housing provided by the program. One supposes that with more support the number of people resuming a normal life would increase.
The homeless don’t need to be told to give up drugs or to take responsibility for their lives. They have little experience with successfully sustaining steps towards improving their conditions. Small steps can be greeted with enthusiasm. A relapse can be met with a smile and encouragement to resume better habits. Harm reduction works by closely observing the individual and encouraging the development of healthy habits. Its practitioners work hard to prevent clients from becoming discouraged because of single bad incidents. It is an attitude that is unremarkable in a schoolteacher, but somehow denigrated when dealing with drug users.
All drug rehab programs have a substantial failure rate. They focus on these who take steps toward health, and recognize that each individual finds a path out of their conditions. Even after 20 years on the streets, a person who receives medical care for his ailments and has a home to live in can lead a healthy life where the change appears miraculous.
When you want to talk about drug abuse, the homeless represent the extreme, a level of self-destruction that goes beyond what the barebackers and crystal meth addicts are doing. A harm reduction approach is preferable to calling on the cops to arrest gays. It is low in cost and doesn’t threaten the liberty of self-destructive people. Harm reduction is the best public health approach, and its tenets should be applied to the barebacking problem.
