Philippa Jones says not all needle users are criminals. Photo / Belinda Lansley
Are you a peer?
That's the question Philippa Jones knew people were asking in their heads, if not out loud, as she met the workers at her new job. What the question meant was: do you have a history of hard drug use?
In most senior management roles, the stigma attached to an affirmative answer would be a problem. At the New Zealand Needle Exchange Programme it's more of a plus. The concept of peer support and services is central to the 34-year-old needle exchange scheme, where stigma and judgement are the enemy and the clients, injecting drug users, feel more comfortable dealing with someone who's been there too. Most of the people working in the national network of 21 exchanges are peers.
"There's nobody that knows more about this subject than the people in this organisation who understand the experience that our clients have and who have empathy for our clients," says the 58-year-old Jones, who left a director-level strategic role with Deloitte to become Needle Exchange's national operations manager last year. "But I think what I would say is, peers also need non-peers to be speaking up."
Unlike her predecessor, NGO veteran Kathryn Leafe – who, as she frankly told journalists, "went off the rails" as a young woman – Jones does not have a personal drug use story to tell. Before her two years with Deloitte, her CV is that of a high-level strategic manager. She has directed major change programmes at the Ministry of Health, ACC and Housing New Zealand. She was chief operating officer at Lincoln University and has held executive posts at Christchurch Polytechnic, Crop and Food, and Christchurch City Council. So yes, her friends and family were a little surprised.
"They'd say, 'Oh, what are you doing now?' And I said, 'Oh, I'm working for the New Zealand Needle Exchange.' And once I got through to them that it wasn't about knitting or crochet needles, they sort of went, what? So I had a a 10-to-15-minute spiel that I used to explain the role, the attraction and what we do. And by the end of that, in most cases, people go, 'Oh, that's amazing.' So a lot of people simply don't know about it."
The question might be asked, though: exactly how and why does a person go from being a director at Deloitte – and late in a career dealing with big numbers – to be the face of an important but marginalised NGO who hasn't had a pay rise in five years?
"If you look at the scheme of my career, I've tended to work in areas where there was a strong social element or health element, so for me it was a return to that sector. But it's also a unique organisation, an opportunity to really make a difference – to take a small organisation begun by a group of activists into its next phase."
She admits, however, that she didn't know much about Needle Exchange when she applied for the job. Most people don't. The stigma around injecting drug use and the need for discretion for the sake of its clients mean the programme has largely done its work under the radar.
It began in 1987 when, with a varying individual mix of practicality and fear of the gathering HIV epidemic, MPs voted to legalise the provision of needles and other injecting equipment to anyone who injected drugs, to reduce infection through sharing. The government would fund such a service, but it would actually be carried out by 20 different local trusts. Although some public health professionals were involved (professor-to-be Michael Baker was a prime mover) it was quite a different operation to the methadone programmes launched in the previous decade, where drug users were often shamed and bullied by doctors.
In 2021, a few ructions down the line, there are five trusts under the national programme, distributing more than 3.5 million needles annually via the 21 exchanges and 180 partner pharmacies – and the rate of HIV infection in the New Zealand injecting drug population is 0.2 per cent. That compares to a global average of 13 per cent, 4.5 per cent in Western Europe and nearly 25 per cent in Eastern Europe. It has not only been a matter of lives saved, but taxpayer dollars: a 2002 assessment by the Burnet Institute found that every dollar spent on Needle Exchange saved $20 in lifetime treatment.
By contrast, about half the people who inject drugs in New Zealand carry antibodies for hepatitis C, down from a peak of 70 per cent. Most of the tens of thousands of people who contracted that virus through injecting were infected before Needle Exchange began. It wasn't even established that the virus caused chronic and potentially fatal liver disease until the early 1990s.
But even here, the network of exchanges is playing a key public health role. Five years ago, the Ministry of Health's rollout of new hep C antiviral drugs, a functional miracle cure for the virus, specifically included needle exchanges. That was partly at the urging of Auckland liver specialist Professor Ed Gane, who had already recruited a nurse to run a twice-weekly clinic at Auckland Needle Exchange, scanning the livers of clients who in many cases had been stigmatised by doctors and would not set foot in a hospital. Needle Exchange is playing a pivotal role in the national goal to eliminate hepatitis C by 2030.
Yet, for all the results, the needle exchange law sometimes looks like an unrepeatable policy miracle. In 2004, when associate Health Minister Jim Anderton (himself a former doubter duly persuaded by the evidence) brought an amendment that removed any fee for a needle swap and reversed the onus of proof for possession of injecting equipment, the parliamentary debate showed what could happen. Future Health Minister Tony Ryall told the House the measures were "all part of a politically correct, liberal agenda being pushed by this Government and the health authorities under the name of harm minimisation, when what is required is leadership that says this stuff is wrong and should be stopped."
When he became minister, Ryall did not, of course, reverse the changes. But it was an illustration of the way a kind of culture war has developed around drug harm reduction. In the US, where the opioid epidemic is worse than ever, needle exchanges are closing amid political firestorms. That war will heat up here if and when another policy miracle comes closer. As one of the raft of public health experts who signed an open letter to Health Minister Andrew Little this year, Jones would like to see personal use and possession of all drugs decriminalised.
"I mean, not just from a health-based approach but really from a human rights perspective. Not all of our clients are heavy users or have addictions but, of course, a good number do. They might also have mental health issues, might have suffered abuse and all sorts of challenges in their lives. So why are they not entitled to access healthcare like anybody else? And it's simply because they're being criminalised at the moment. That needs to change. It's failed and it's costing us a lot of money as a country."
Criminalisation presents unusual challenges for the needle exchange service itself. When, as practised change agents often do, Jones launched a project to understand the programme as it stood, she discovered there was a lot they didn't know. As she told this year's Parliamentary Drug Policy Symposium, the criminal status of drug use and subsequent need for discretion meant that Needle Exchange couldn't even say how many people used its service, let alone get an overview of who they were, including how many were Māori.
"Of course," she drily told the audience, "if our clients weren't criminalised they might feel more confident about sharing that information."
For now, only "transactions" are tracked and on that basis she estimates that the service sees between 8000 and 15,000 people a year. Some come in every day, some once or twice a year. Some inject opioids, some methamphetamine, some steroids.
"It was originally envisaged as a confidential service for a very good reason," says Jones. "I'm hoping that in the future we can get rid of criminalisation but it'll still take some energy and effort to establish an appropriate way to collect information from our clients."
A fair part of what is known has come through the work of University of Otago researcher Dr Geoff Noller, who co-ordinates the national office's research programme. Noller himself praises Jones' "steady and calm determination to make significant changes to the programme on a number of fronts. What I find most impressive about Philippa is her ability to uncomplicate difficult tasks and thereby achieve significant changes while bringing everyone with her. As someone who's spent over a decade in needle exchange, I can tell you this is an impressive achievement.
"She's fearless!" he adds.
"Well, I sort of play with a straight bat," Jones smiles when the praise is passed on. "But also, if something's not right, then you need to address it. I'm not one for sweeping things under the carpet and I always think that it's much better to be upfront and transparent when there are issues that need to be addressed. So I'm not afraid to address those. I'll try to do it in as diplomatic and appropriate way as possible but we can't really make progress if we're not prepared to have honest conversations about things. I've had plenty of scary experiences in other jobs, so I've got a few scars on my back."
Part of that job is renewing the relationship with the Ministry of Health, where she used to work. Needle Exchange doesn't do treatment but, she thinks, a real health-based response could see counselling, GP surgeries and opioid substitution services co-located with exchanges, leveraging the trust they have built up with clients.
There's also the money. The $5.1 million the programme receives annually from the ministry represents 80 per cent of its income. That number has been static for five years – and three and a half decades in, Needle Exchange still operates on one-year contracts. Jones must be frustrated looking at the $1.9 billion promised for mental health and addictions, largely unspent since it was announced in the "Wellbeing Budget" of 2019.
"Well, it will be good when we can get to the bottom of that and find out what has been spent and hasn't. Who knows what's going on there, but there's not enough money getting out to the local areas, to the communities where people can actually do real work and make a difference. Somehow it's getting tied up in the bureaucracy – and we need to somehow get the money into the services on the ground in the local areas."
As she pursues structural change, the one-time health bureaucrat has made personal changes. Around the time she took the job, Jones and her husband sold their 1.2ha property at the foot of the Port Hills and moved into an apartment in Christchurch's new city centre. She now rides an e-bike to work. She enjoys the city's French and Italian film festivals. And she's wondering whether her organisation should seek to be allowed to provide meth pipes.
As shocking as that might sound, the logic is clear enough – there are far fewer direct and acute health risks in smoking than injecting – but there's a sort of nitty-gritty at the frontlines of drug harm reduction that even Jones can sound a little surprised to hear herself voicing.
Yet, if the idea of drug use being a health issue rather than a criminal issue ever does progress from being an easy government slogan to a comprehensive reality, it won't be the last unexpected conversation to be had - for Jones or the rest of us.
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