Anne-Karine Dabo, a mother of a two-year-old who moved to Harlem three years ago, began avoiding the playground at Marcus Garvey Park last year. The intersection of 125th Street and Lenox Avenue came next. Soon, she was finding alternate routes around her own neighborhood.
"It was more than just seeing people who were high. It was seeing people who looked dead," she said.
At first, she regularly called 911 to help drug users in distress but stopped when it became commonplace shortly before the pandemic began. Dabo said the neighborhood has rapidly changed for the worse, and that the uneven distribution of opioid treatment programs across the city is to blame.
For decades, Harlem residents have voiced concerns that their neighborhood has been a too-convenient location to place social services, like shelters and addiction programs, that other neighborhoods fight hard to keep out. This past weekend, Rev. Al Sharpton and U.S. Rep. Adriano Espaillat led a protest against a newly installed supervised injection site in Harlem, the first facility of its kind in the nation.
Protesters made clear these sentiments are not driven by a not-in-my-backyard mentality — many of the Harlem protesters support the overall creation of overdose prevention services. But these residents have been galvanized by the fact that most of the patients attending opioid programs in Harlem do not live in Harlem. That first came to light in 2019 when a community group called the Greater Harlem Coalition requested data from the New York State Office of Addiction Services and Supports (OASAS), which is responsible for licensing clinics.
In an independent analysis of the updated data for 2019-2020, WNYC/Gothamist found that fewer than 25% of admissions — 605 people — to Harlem clinics were Harlem residents. The remaining 75% were patients — 1,841 people — who traveled from as far as Staten Island or Westchester to get to the clinics. Some patients travel upwards of two hours from areas with far fewer programs than Harlem, and long commutes are known to impede the delivery of addiction care. Mapping the city’s centers and their programs reveals a concentration in Harlem and the south Bronx.
These areas do rank among the highest in New York City when it comes to drug overdoses, particularly with opioids. But a recently released top-15 list for 2020 also includes far away neighborhoods such as Stapleton, St. George and Tottenville in Staten Island or East New York, Bed Stuy and Crown Heights in Brooklyn, and Rockaway, in Queens. The Bronx saw the biggest citywide jump in opioid death rate from 2019 to 2020, followed by Queens, Brooklyn, Staten Island and Manhattan.
That’s why Sharpton, along with a host of community groups, are pushing back. They say Harlem is overburdened by programs that are much needed by vulnerable New Yorkers, but often placed in minority communities with the least power to resist them rather than being equitably distributed throughout the city. Some advocates are also pushing for better access and looser restrictions to at-home overdose remedies.
Fighting NIMBYism And Stigma Over Opioid Services
In early October, longtime resident Tanshelle Brown attended a protest on the issue at Marcus Garvey Park with her young children, who crowded patiently around her feet.
“We want to know that when we wake up in the morning and we do our part to send our kids to school, we’re sending them to a safe environment,” she said. “We’re relying on the community, but this is the image that we get when we step outside of our doors. It’s not safe and it’s not okay.”
Dabo also worries about the impact on her two-year-old daughter.
“What she's internalizing is that it's normal to see Black and brown people passed out on the street. And then when we see them like that, we just keep walking,” Dabo said. “You know that your child is growing up in this environment that is telling them that they don't matter, and that their environment doesn't matter.”
The opioid crisis has worsened nationally during the pandemic. About 73,000 people died of an opioid overdose in the 12 months following March 2020, a 37% increase compared to the year ahead of the lockdowns. Harlem residents said they didn't have to look farther than their own streets to see the opioid crisis' impact: residents report an uptick in open drug deals and stray needles left in parks, and it’s made many longtime residents feel unsafe for the first time in decades.
Their anecdotes are supported by numbers collected by the city health department. Harlem recorded about 30 to 49 drug overdose deaths per 100,000 people from April 2018 to March 2019. During a similar period from April 2020 to March 2021, the rate jumped up to 50 to 95 deaths per 100,000 residents.
Clearly, Black and brown neighborhoods are where the government will put services that whiter and wealthier neighborhoods don't want to see.
Eva Chan is a member of Community Board 11, and feels the placement of the programs in Harlem is intentional. “Clearly, Black and brown neighborhoods are where the government will put services that whiter and wealthier neighborhoods don't want to see,” she said.
Chan is aware that residents’ concerns might be lumped in with not-in-my-backyard sentiments, which crop up in response to other social programs. “Some people might think we're being NIMBY, but we're actually victims of NIMBY,” she said. When others successfully fight against building opioid programs in their neighborhoods, it causes existing programs, like the ones in Harlem, to increase their capacity. That brings an influx of vulnerable patients.
Facilities and programs like the safe injection site are also praised as lifesaving by those in the harm reduction movement. The supervised injection site in Harlem, along with another that opened in Washington Heights, reported 17 overdoses were prevented in their first week. Health care workers like Mary Brewster, who works with a syringe exchange program at Harlem United, feel caught in the middle of protesters and their patients.
"Our ultimate goal as harm reductionists is to ensure that people remain alive. That's really all we're concerned with," Brewster said. "There is continued stigma against those individuals who use substance, so this is not any surprise to us that the community is completely misinformed."
Even though overdose rates are higher in Harlem than other neighborhoods, according to the New York City Department of Health and Mental Hygiene, it still appears to handle a disproportionate number of opioid patients. Clinics in Harlem received over 21% of all of New York City’s opioid admissions, even though just 9% of the city's patients live in the northern Manhattan neighborhood, according to the OASAS data.
Fentanyl test strips in New York.
Dabo has formed a new nonprofit called Parents Raising Harlem to pressure local leaders on the saturation of opioid services. They’re starting small, with Zoom calls for parents to voice concerns and plan community outreach events, but she said that the effort has united parents who were typically divided by race, class or generation.
“As a parent, I have to say that it's a unique experience to have to face these issues, and see your child face these issues, and feel like you're not equipped to deal with them,” she said. “You want to be able to have a positive influence on your child's development, and the environment that they live in is probably the most influential.”
Shawn Hill, co-founder of Greater Harlem Coalition, said that the influx is not just of patients seeking care. “Every single day, we have three communities who come in,” he said. “We have men and women struggling to get better through treatment programs. We have dealers who attempt to prey upon them. And then we have the users who come in, because that's where the drugs are located.”
Noa Krawczyk is an assistant professor in the Department of Population Health at NYU Grossman School of Medicine and a member of the Center for Opioid Epidemiology and Policy. She said the concentration of programs in Harlem mimics a larger trend.
"What we're seeing in Harlem isn't really surprising in any way, and it does look like a lot of the rest of the country," she said. "Unfortunately, many of these programs end up concentrated in neighborhoods that also have historically disenfranchised or marginalized populations."
Krawczyk points out that the sheer number of opioid programs in New York (127 programs, according to the Substance Abuse and Mental Health Services Administration) make it an anomaly. Many states have far fewer — and that can correlate with worse patient outcomes. Both Connecticut and New Jersey suffer from a higher abundance of fatal opioid overdoses — with death rates twice as high as New York. But they also have half as many opioid programs. Florida, which has a similar sized population as the Empire State, also has a higher opioid death rate but 33% fewer programs.
The Push For At-Home Opioid Treatment
Even with a high number of programs, New York's treatment facilities still must play by federal and state rules. Methadone, in either tablet or liquid form, is a common medication used to thwart addiction. But because it is an opioid, albeit with lower potency, it must be distributed on-site by licensed clinics rather than by your cornerside pharmacies. That means many patients have to physically go to a clinic every morning to receive treatment. Because it tends to be a lifelong remedy, most programs get larger and larger over time.
Lengthy commutes to Harlem can also harm patient outcomes. Addiction research shows that impediments to receiving care, such as long commute times, can lead to worse recovery rates. As obstacles go up, patients are more likely to drop out of treatment, which presents serious risks.
“You do want to make it as easy and as convenient as possible for someone to get to their treatment program, especially when folks are often traveling most days or very often,” said Krawczyk. “There's actually a high risk of overdose when people stop taking these medications.”
OASAS, the New York state office responsible for regulating and licensing the treatment programs, agrees that patients should be commuting as little as possible for care and admits that local opposition can determine where treatment programs are placed.
"Ideally, people would not have to commute long distances for care. However, due to a variety of factors, in particular opposition to the siting of these facilities in many neighborhoods, some people may have to travel to receive treatment," said Edison Alban, director of public information and communications at OASAS.
U.S. Rep. Adriano Espaillat, a Democrat representing parts of Harlem, Washington Heights and the Bronx, spoke at a rally against a new overdose prevention center in Harlem on December 11th. He said he supported the program but that too many substance use services were placed in Black and brown communities.
Kristin Richardson Jordan, who was recently elected to the New York City Council representing Harlem, said the solution is to build more of a new kind of clinic.
"Let's move towards more humane, holistic treatment and small scale models citywide, instead of having megacenters concentrated in one neighborhood like ours," said Jordan.
But another solution might mean getting rid of the commute-for-methadone model entirely, and distributing the medication more like other prescription drugs inside of pharmacies.
David Frank, a medical sociologist at NYU's Center for Drug Use and HIV/HCV Research, is not only a researcher of opioid treatment programs, but a patient. After using heroin daily for years, Frank found safety and relief with methadone programs but was painfully aware of their shortcomings. He earned his Ph.D. and now makes recommendations to improve access to treatment and reduce harm.
He said the concentration of high-capacity programs in Harlem is partially a failure of policy.
"Whatever anyone thinks about drugs, or people that use them, any program in the world that's going to make people come every single morning is doomed to failure," Frank said.
He supports expanding the number of patients who can receive take-home doses, which would make commutes to opioid clinics in Harlem far less frequent.Take-home treatments are not unprecedented. Buprenorphine, another successful opioid treatment, is available through prescriptions but is more common in whiter and wealthier communities and less accessible in minority neighborhoods.
Take-home doses of methadone come with risks. Dr. Nora Volkow, director of the National Institute on Drug Abuse, said patients can overdose on the medication, especially if patients inject it rather than take it orally as instructed. She added that clinics offer an extra layer of support.
There are patients for whom being in a methadone clinic may be necessary because they need the extra oversight of someone else.
"There are patients for whom being in a methadone clinic may be necessary because they need the extra oversight of someone else," she said. "Diversion" is another top concern: unsupervised patients might sell their methadone rather than use it as medication.
Currently, clinics are allowed to give take-home doses of up to 28 days. But state and federal guidelines put restrictions on which patients qualify. Just being late to meetings can mean a patient is denied their methadone.
“I can't count the amount of times I've seen someone in tears because of just some stupid thing: they were five minutes late to something,” Frank said.
In addition to these top-down guidelines, individual clinics have enormous leeway to determine which patients can receive take-home medication, and which must come every day. Some require complete abstinence even from alcohol, monitored urine testing or group counseling to get doses at all, let alone take-homes.
In a move that might ultimately reduce the influx of patients in Harlem, New York City loosened some restrictions during the pandemic. To allow social distancing at its opioid programs, OASAS followed federal guidelines and encouraged clinics to give longer take-home doses to certain patients they deemed “stable.” They also organized methadone deliveries and set up treatment vans in neighborhoods across the city.
Whether or not these programs expand after the pandemic will depend on their impact on patient outcomes, but Noa Krawczyk from NYU said the system needs to be less punitive for patients regardless. “Substance use continues to be something that's highly criminalized, something that's seen as a moral problem versus a health problem,” she said. Shifting that will take time.
In Harlem, residents like Maria Granville feel patients and non-patients alike are losing in the current system. She wants to reverse the destruction left in Harlem by the opioid crisis in this generation, not the next one. She brought both her son and her granddaughter to the recent protest in Marcus Garvey Park that she helped organize.
While the impact of the opioid concentration has spiked recently, she said Harlem residents fighting for fair treatment isn’t new. It’s a cycle. Granville pointed to her granddaughter at the edge of the crowded protest.
"I don't want her to have this same conversation 30 years from now," Granville said, shaking her head. "It's got to stop."
Caroline Lewis and Jaclyn Jeffrey-Wilensky contributed to reporting.
