When I visit a city, I like to check out people doing interesting stuff. Usually these will be individuals or organizations working in social justice advocacy or activism, or in community-building services such as health promotion, educational equity, re-entry work, etc.
Because of my own work, I often talk to people working at the intersection of health, drug policy and mass incarceration. It’s just a thing I do. Some people like to see the local sports team. Some go to the museums or catch a show. I like to talk to people about interesting things they do for the people around them.
Last month I found myself in Nashville, Tenn., for a professional conference. I’d been invited to speak on an evening panel on mass incarceration, drug policy, public health and harm reduction. Also on the panel was Ron Crowder, the executive director of Street Works, an organization focusing on HIV prevention, education and care that primarily serves African-American Nashvillians, especially those in East Nashville. I’d reached out to Crowder and scheduled a meeting with him for the following day. The conference, an annual event, was four days long, and I figured that I could afford to play hooky for an afternoon.
The conference was at the downtown Sheraton, and the cab ride was 10 bucks and 10 minutes across the Cumberland River to the James A. Cayce Homes, a public housing project in East Nashville. By habit, I like to arrive ahead of time to appointments, and I ended up waiting in the drizzling rain for a few minutes until Crowder pulled up in a white sedan.
Crowder, in his mid-60s, bounded out of the vehicle and approached me using a hand-carved walking cane. He seemed pretty spry, and I half wondered if the cane was for some kind of effect—maybe the stately senior gentleman whom you ordinarily wouldn’t imagine to have spent decades handing out condoms and clean syringes.
“You’ve been waiting long?”
“Not at all, Mr. Crowder.” I was early, and so was he. “I just got here.”
He unlocked the door and let us in. “I call this the corporate headquarters,” he announced, showing me some seven or eight desks throughout four office rooms. “Today all the staff are in the field or at one of the other locations. And we have a couple who took off today.”
I’ve visited a number of harm-reduction organizations in different parts of the country and around the world, but I’d never seen one based in a U.S. public housing project. Yet the distinctive way in which the Street Works offices were arranged was instantly familiar. The entire townhouse was arranged by the precepts of the harm reductionist’s feng shui, an improvisational architectural style born of the union of urgent necessity and human creativity.
Three-bedroom houses in Cayce are about 1,300 square feet, and here, every precious one had been arranged for maximum efficiency. Each of the three upstairs bedrooms had been turned into offices (one of these was Crowder’s, the executive office). The downstairs living room had been converted into a reception-and-administrative area of three desks. On the walls and display cases were neatly arranged and well-stocked inventories of condoms, dental dams, and a wide array of educational pamphlets and HIV-positive-life magazines.
Everything was organized according to an organizational spatial logic: well ordered yet welcoming; a bit cramped but clearly operational. In fact, the objects whose placement apparently had garnered the least attention were, in fact, the various awards that Street Works had earned over the years.
Various trophies and plaques could be found in the oddest places, even functioning as paperweights atop stacks of paper. A 2005 citation from the U.S. House of Representatives hung well below eye level in a corner of Crowder’s office, while signs proclaiming various motivational quotes from Martin Luther King Jr., Mahatmas Gandhi or Anonymous took more prominent wall space. I tried not to read too much into it, but it all seemed to speak of a certain humility, an unwillingness to bask in past achievement when one should be moving forward.
Built between 1941 and 1954 as part of the Nashville Housing Authority’s New Deal and postwar program (pdf) of state-supported residential, ethnically segregated housing, the Case apartments now comprise Nashville’s oldest public housing stock. Each of its 900-plus units is a two-story, with one, two or three bedrooms.
Many years ago, this particular apartment had been perennially vacant, and Street Works squatted here and set up its HIV-prevention center, including in its work education outreach, condom distribution and needle exchange. This was in the late 1990s, and harm reduction was controversial. However, Crowder had the backing of the Rev. Edwin Sanders of the social-justice-oriented Metropolitan Interdenominational Church. Sanders had founded the MIC with the explicit mission of being “inclusive of all and alienating to none.”
For Sanders, this had meant a particular commitment to people marginalized by their drug use, sexuality or HIV status. While it is true that most black religious leaders in the early years of the epidemic kept HIV at arm’s length—the best that many of them could do was espouse the no less stigmatizing moralism of “hate the sin but love the sinner”—Sanders, like Bishop Carl Bean (the founder of the Unity Fellowship Church Movement in Los Angeles) and the Rev. Ella Eure-Eaton (of Harlem’s Upper Room AIDS Ministry), was among a national group of black clergy who took up HIV work and harm reduction well ahead of their co-religionists. In the 1980s, Sanders had run a literal underground needle exchange in the basement of his church.
Meanwhile, Sanders and Crowder had allies in the Tennessee Department of Health to whom they and their work were pleasantly familiar. By the mid-1990s, white-dominated state and local health departments across the country had simultaneously realized the benefits of harm-reductive practices such as mass education and needle and condom distribution, while recognizing their limited success in reaching black populations. The Department of Health had recruited Crowder to serve on one of its community advisory boards to help it guide health policy in Nashville.
At the same time, viewing the various sectors arrayed in support of harm reduction, Nashville’s first black chief of police, Emmett Turner, took an enlightened view of their activities, and soon after agreed not to arrest or otherwise harass Street Works personnel. Within a matter of years, the city’s housing authority offered Crowder an outright lease to the apartment-turned-office suite in the Cayce Homes. Thus a wonderful, though imperfect, community-based public health alliance was born.
I don’t know if you could say that Crowder was born for this work, but he was made for it by his own life. Crowder himself “shot dope for 20 years” throughout the 1970s and 1980s, a dark and chaotic period during which “I was always either in jail, on my way to jail, just coming out of jail, or on probation or parole,” he said.
In 1991 Crowder was in prison, four months into an eight-year sentence for burglary of the management office of a housing project—the same project, in fact, in which we sat and talked. “It’s just a few buildings over. My brother and I thought we’d rob the office, figuring that they had food stamps there that we could sell. It was stupid.” He laughed mirthlessly and slowly shook his head. “But we both needed dope. And, of course, we got caught.”
In prison he was diagnosed with HIV. The test was not routine, and he might not have found out then had it not been for an accident in the prison dental office, where a doctor dropped a device that broke her skin on its way to the floor. Though the instrument presumably had been sterilized prior to this particular procedure, the prison tested every patient she had seen that day. Crowder was one of them.
“They locked me in an isolation room, and nobody would talk to me or come near me for days,” he said. “I didn’t know what was going on, but one day they put a sign on the window of my door, you know, for people to know. The sign said, ‘Caution—human fluid.’ That’s when I knew I’d tested positive.”
In light of this new health information, Crowder and his lawyer petitioned the corrections department to have him released on a suspended sentence, betting that where the state may not be swayed by humanitarian reasons, they would be willing to take the opportunity to release a medically expensive and challenging inmate. Whichever gambit did the trick, Crowder today isn’t quite sure, but he went home and resolved to make certain changes.
One’s success in ceasing one’s problematic use of drugs is much more complicated than simple “willpower.” As human personality characteristics go, willpower is about as useful and clinically measurable as charisma, gusto or stick-to-itiveness. In reality, for all the research on this thing we call “addiction,” there is no real consensus or one generalizable theory to explain it. And we know even less precisely about how people get out of it. Some describe their own recovery as having begun at a moment of hitting “rock bottom.”
This is a particularly powerful cultural narrative, but it misses something: that people regard a point in their lives as “rock bottom” when they perceive themselves as capable of doing more and being better than where their current path is leading them. This may sound like the same thing as “willpower,” but it is importantly different because it implies motivation and opportunity to take a new path, not simply the determination not to continue on the old destructive one. It would be easy to frame Crowder’s own turnaround in “rock bottom” terms, but if one listens to him carefully, one will discern a narrative of realized purpose.
“I had been out there in the streets, shooting dope, and I never really stopped to think that I could get [HIV],” Crowder said. “And I knew that there were other people out there who weren’t thinking about it, either—people who didn’t have the knowledge or means to protect themselves.”
Fast-forward some 26 years later, and here I was speaking with an older, deeply purposeful Crowder who was still bothered by the work ahead of him.
“HIV is still a problem in Nashville,” he said. “We’re reaching a lot of people, but we’re also dealing with a lot.” Indeed, in 2015 Nashville ranked No. 22 among U.S. cities with the highest annual rates of new HIV infections. For a long time, HIV has been a problem in the largely black westernmost area of East Nashville. And, of course, it is rooted largely in the same social, political and financial precariousness found in many black economically depressed and underserved communities.
Unemployment in East Nashville is 15 points above the average for Tennessee’s Davidson County. Twenty percent of Cayce Homes residents are unemployed, and more than a third of Cayce Homes residents are stuck in low-wage jobs. Medically underserved, a large proportion of working-age adults are on disability, a particularly dangerous situation when combined with the area’s recent status as a food desert whose inadequate public transportation and comparatively low rates of automobile ownership mean, for many, a formidable distance to grocery stores.
In some East Nashville schools, according to East Nashville’s food-justice Give Me 10 organization, as many as 98 percent of students qualify for free and reduced lunch. For many children, this one meal of the day may be the most secure. Indeed, while men who have sex with men, and people who use intravenous drugs, constitute populations historically vulnerable to HIV infection, much of Crowder’s outreach is also to men and women thrown into sex work or survival sex, who themselves are often substance users.
And Tennessee itself is even more vulnerable as its prescription-opioid epidemic turns into a heroin crisis. Epidemiologically studying the recent injection-drug-related hepatitis C and HIV outbreak in Scott County, Ind., the U.S. Centers for Disease Control and Prevention correlated its causes to six indicators. These six were found in some 220 rural counties across the United States, 41 of which were in Tennessee.
Yet the concern here is not for the black and urban districts that have demanded attention for years. Just a few days before I met with Crowder, the state’s House of Representatives had passed a bill allowing for the decriminalization of needle exchanges. Its author, Rep. Patsy Hazlewood, represents Signal Mountain, a suburb of Chattanooga that is 98 percent white and has an average annual household income of nearly $80,000.
In contrast, some neighborhoods in the westernmost region of East Nashville are upward of 95 percent black (although some neighborhoods are more mixed), and the average annual household income ranges from $8,000 to less than $30,000. Hazlewood’s bill passed in the House 71-17 and will soon arrive at the Senate, and she actually touts it for its requirement that the state Department of Health directly oversee these syringe exchanges, but no actual public funds will be given to them.
This effectively means that people like Ron Crowder and organizations like Street Works that serve much more vulnerable—but black—communities will have to compete for private money with white service organizations serving better-resourced white constituencies.
It could be argued that it is questionable whether you can call the Hazlewood bill real harm reduction if it fails to address at least some of the structural inequities and economic insecurities that produce HIV and other health vulnerabilities in so many other communities. Indeed, in our anxious rush to find answers to the largely white opioid and heroin epidemic, we should slow down and make sure that we’re actually asking the right questions. This, after all, may be the moment to have that larger conversation about who else is also suffering, and what we may do for them as well.
Samuel K. Roberts, Ph.D., of Columbia University, is director of Columbia’s Institute for Research in African-American Studies, associate professor of history and associate professor of sociomedical sciences. He is the author of Infectious Fear: Politics, Disease, and the Health Effects of Segregation and is currently writing a book on America’s long and fraught history of race, rehabilitation and recovery.