Lightning in a Bottle, Photo by TheSightsAndSounds.com
March 31, 2020
By Emanuel Sferios
“If you look for truth, you may find comfort in the end; if you look for comfort, you will not get either comfort or truth.” – C.S. Lewis
As the founder of DanceSafe, I have worked in public health for over twenty years. I’ve seen firsthand how public policy decisions directly affect people’s lives. Take drug prohibition, for example: Last year approximately 70,000 Americans died as a result of prohibition and the unsafe drug supply it creates, a more than threefold increase since the year 2000. Conversely, countries like Portugal, who decriminalized all drugs, have reduced their drug-related fatality rates by half. And Switzerland, who took it a step further by implementing widespread opioid maintenance programs (including heroin maintenance) saw a 64% drop in overdose fatalities.
Proper public health policies, enforced by law, can mean the difference between life and death. This is true when it comes to drug use, and it is true for pandemics like COVID-19.
At this time (March 31st), about 20 states have implemented some form of lockdown, closing all non-essential businesses and advising or ordering people to stay home unless absolutely necessary. The US death toll is over 3,000, having doubled over the last 48 hours. (1) The exponential growth of transmissions that epidemiologists had been warning us about for over a month is now plainly visible across the country, as hospitals in New York desperately care for sick patients in hallways and the Army sets up field hospitals in Seattle.
Everything happening now is no surprise, and we know what will happen next. There is near-universal consensus among epidemiologists, given what we know about this virus, that lockdowns are the only way to prevent hospitals from being overwhelmed with sick patients in need of limited ventilators. Because community transmission has already begun, it’s too late for containment, which requires widespread testing and contact tracing. Now, everyone needs to “shelter in place.” The difference between doing nothing versus implementing a nationwide shelter in place policy could mean the difference between 1 million versus 10 million US deaths. This worst case scenario is unlikely to transpire, but it is not simply conjecture. If 75% of the US population of 330 million becomes infected (which is guaranteed if we do nothing) and if we end up with a 4% fatality rate, then ten million Americans would die. (2) In comparison, over the last 20 years, approximately 500,000 people have died in the US from all illicit drug-related causes.
It is also worth mentioning that young people are not immune to the virus, nor are they unlikely to get critically ill. Nearly 20% of COVID-19 patients needing hospitalization, according to the CDC, are between the ages of 20 and 44, with 18% of these requiring a ventilator. And while it is true that young people who are able to get on ventilation are far more likely to survive than older people, the problem is the lack of machines. The New England Journal of Medicine estimates that for every COVID-19 patient in the US who requires a machine, 31 won’t get one. People will simply be turned away, including many young people. New York is already sharing ventilators.
A Bottom Up Approach – When Our Government Fails, Individual Actions Matter
The US Federal Government just passed an economic relief package that privileges big business and the banking industry over working people. President Trump, against the advice of his own public health advisors, recently refused to issue a quarantine for New York and other hardest hit states, and has suggested “packing the churches” and lifting all social distancing measures by Easter (update: he just backtracked on that and extended social distancing recommendations until April 30th).
It is unlikely that states will follow the President’s advice. After all, the current response to the pandemic did not begin with the White House, nor with the CDC (which still hasn’t authorized the use of WHO-approved test kits, despite a massive shortage), nor any federal agency. It began in cities and towns, with epidemiologists, public health professionals and regular citizens educating others and placing upward pressure on local and state politicians.
To understand how this bottom-up approach works, consider El Paso, TX, who last week passed its own county-wide shelter in place ordinance, despite a lack of action by its state government. If the measure remains in place, it could save the lives of up to 21,000 El Paso residents. (3)
Make no mistake. The bottom-up approach begins with you—practicing social distancing, educating your friends and family, and asking your local representatives to implement and enforce shelter in place ordinances.
Here’s an example: When the AIDS crisis began in the 1980s, people who understood the pandemic began distributing clean syringes to IV drug users. They did not ask permission; they just went out and did it. Many of these public health workers went to jail, but over time local politicians watched what was happening, saw the results, and passed local laws legalizing needle exchanges. Eventually states began following suit, and today at least 35 states have some form of legal, funded needle exchange program.
Compare this to the federal government’s response, which during the peak of the AIDS pandemic in 1988 banned funding for needle exchanges. The ban wasn’t lifted until 2009, and was even reinstated in 2011.
Here’s another example: When I started DanceSafe back in 1998, I began setting up booths at local raves in Oakland, CA, openly testing ecstasy tablets to help people avoid the counterfeit pills containing PMA (para-methoxy-amphetamine), which had begun killing people a few years earlier. Like the early needle exchange pioneers, I didn’t ask permission. Rather, I hired a lawyer and prepared to be arrested. The strategy was to win a high-profile court case using the necessity defense and set a national precedent so other people would feel safe offering pill-testing services in their own communities. (4)
Yet no arrests happened. To this day, 20 years later, not a single DanceSafe volunteer, nor any person approaching the DanceSafe booth seeking drug testing services, has ever been arrested. We still test drugs at festivals across the country, often with the support of local police or sheriff’s departments, who sometimes themselves bring us drugs they have confiscated to get them tested.
Nonetheless, the federal response to MDMA and harm reduction has been abysmal. After police raids and the formal prosecution of rave promoters back in 1999 and 2000 failed to stop the rave culture, congress passed the RAVE Act (a.k.a. The Illicit Drug Anti-proliferation Act) in 2003. Authored by then-Senator Joe Biden, this anti-public health law has led to the deaths of dozens of people, and despite a recent popular campaign calling on congress to amend the act, the law remains in effect, dissuading many promoters from implementing life-saving public health and harm reduction policies.
In short, we should not rely on the federal government when it comes to public health. Rather, we need a bottom-up approach. This is where DanceSafe’s Party In Place campaign enters the picture.
Party in Place. Stay Home. Set an Example.
It is incumbent upon each of us, as individuals, to do the right thing to protect our communities. And this means staying home and only going out when necessary (groceries, laundry, emergency medical needs). Do not throw house parties. Do not have friends or family over, even if they tell you they are also sheltering in place. Visiting other people’s homes undermines the goal of social distancing. Remember, this isn’t just about protecting yourself; it’s also about protecting others. Most cases of COVID-19 are transmitted asymptomatically by infected individuals who do not know they are infected. It happens when they cough, sneeze or even exhale in close proximity to others.
This is not panicking. This is science, and we all share a responsibility for each other.
Taking Drugs During a Pandemic – A Personal Story
It’s been more than two weeks since my partner, Ruth, and I began sheltering in place here in Southern New Mexico, and it’s already been difficult. So far, we’ve only left the house three times: once to buy groceries; and twice to check the mail and the fax machine at Ruth’s clinic. (Ruth is a nurse practitioner with a private practice, and she now sees patients only by phone or video.) Staying home and not visiting friends is stressful. Worrying about finances, and the safety of family and friends elsewhere adds to that stress. In my case, I lost 80% of my income; my sister lost all her income; and a friend just tested positive for COVID-19 and told me she isn’t doing well. I’m not sleeping well; I’ve become more irritable; and Ruth and I have had a few uncharacteristic fights.
All this led Ruth and me to take MDMA last week. It had been a while since we last rolled together. And when we do roll (or when we use any drug) we have a little ritual where we hold our pills up in the air and take turns stating our intentions for the experience. As a drug educator, as well as someone who went through a brief addiction to methamphetamine in my late twenties, I have always cautioned people about the risk of using certain drugs for stress relief. MDMA is one of them. It may not have the same addiction potential as benzos, alcohol or opioids, but it’s still easy to develop problematic use patterns if you begin relying on it to relieve your stress.
Nevertheless, this time stress relief was my conscious intention. I wanted a break. And I got one. As soon as it came on, all my stress melted away. For the next five hours Ruth and I talked about our relationship, the fight we had a few days earlier, our families and our friends, and even the coronavirus. We talked about them in ways we hadn’t before—with love and hope instead of anger and fear. We began to hear each other more, and to find some hope in this dark situation, in how this horrific pandemic might end up bringing the world closer together by teaching us what really matters—which isn’t money.
The MDMA also taught me something about myself, my relationship with Ruth, and a common social dynamic playing itself out right now between friends and family members everywhere. I woke up the next morning and made a Facebook post about it. I’d like to share it with you here in full.
I went a bit crazy yesterday. Crying, then fighting with people I love. Crying again. It was a repeat like this the entire day.
As people are figuring out what to do, there’s a lot of fear. People deal with fear differently. Some panic. Others go into denial. We then bifurcate towards opposite extremes.
Be gentle with people, no matter which side you are on, because this is a vicious feedback system. If you’re concerned, like me, that people aren’t taking the coronavirus seriously enough, getting angry with them is likely to just make them think you are panicking even more than they thought you were to begin with. If you think people are panicking over a situation that isn’t going to be that bad, getting angry with them is just going to make them panic even more.
As for me, I’m one of the ones who thinks most people aren’t taking this seriously enough, and last night I had a realization. While lying in bed with Ruth, she read out loud to me an article from an author trying to be hopeful, which cited a few pieces of good news (“most people recover,” “they have contained it in China and a few Asian countries,” etc), mixed with a few claims I thought were just wishful thinking. As she was reading to me, I got so upset I cut her off. I raised my voice and started telling her (once again) about all the terrible things that are likely to happen if we don’t, as a society, self-isolate, lock down cities, yada yada yada. She didn’t want to hear it anymore and told me so.
We went to sleep without resolution.
As I was lying there, I realized that for the past week I’ve been interpreting every positive or hopeful statement from anyone as a sign that they are dismissing the seriousness of what is happening, and this was making me feel both angry and hopeless. I realized that **my** feelings of hopelessness came from seeing people around me not taking **current call for action** seriously enough, while **their** feeling of hopelessness came from seeing people around them seemingly lack any hope in the **outcome**.
So… moving forward, I’m going to start pointing out to people the **positive** outcome we could achieve if we self-isolate, rather than only pointing out the negative outcomes if we don’t. I think this might be a better way.
Pointing out the positives is always more useful than pointing out the negatives. This is one of the most fundamental truisms of effective drug education, and a founding principle of DanceSafe. If you want people to use drugs more responsibly, talking only about the risks and how they might die if they do it wrong is far less effective than telling them about the amazing benefits they can have if they do it right. This is why our drug information cards always mention the benefits of each drug first. And make no mistake, this approach holds true whether you are discussing psychedelics or heroin, MDMA or meth. All drugs have benefits, and acknowledging those benefits removes shame and stigma and allows a person to better understand why they are using—or possibly misusing—drugs.
While our MDMA experience was therapeutic, neither of us has felt like tripping. The classic psychedelics are a different beast entirely, and carry more psychological risks (although MDMA also carries this risk to some degree). Of course, the biggest problem right now is that the pandemic has greatly reduced the options for set and setting. Set means mindset. And for me, in the middle of this pandemic, it just doesn’t feel right. Psychedelics are often called “non-specific psychic amplifiers,” and they carry a risk of igniting unpleasant and sometimes traumatic psychological experiences. I think I could easily spin out on negativity right now.
If you are considering tripping, or using any drugs during the pandemic, check out DanceSafe’s Party In Place campaign.
Daily Drug Users and the Opioid Markets
I could not write an article on the coronavirus and drugs without discussing opioids. Daily opioid users are some of the most vulnerable people in our communities, and they are in an even more vulnerable situation right now because of the pandemic. Most significantly, the supply is drying up. Fentanyl has largely replaced heroin in most North American cities, and the Mexican cartels who bring most of it into the country are having a hard time getting the precursors from China. Wuhan, the center of the pandemic in China, just so happens to be the center of fentanyl precursor production.
To find out what the situation is like on the ground right now, I spoke to Dennis Couchon of Harm Reduction Ohio. Ohio is one of the states currently being hit hardest by the coronavirus, and if anyone would know what impact it is having on daily opioid users, he would: “The drug supply has decreased dramatically,” he told me, “sending people into forced detox. Also, a lot of people no longer have money, or they are self-isolating and so they no longer have access to their dealers. Dealers are isolating, too. And even people who still have access [to opioids] are afraid they won’t soon.”
According to Dennis, this has resulted in large numbers of people joining methadone programs and getting Suboxone prescriptions. And so far, at least in Ohio, most people have been able to get medication. “We’ve expanded these [Medication-Assisted Treatment] programs a lot over the last two years,” he told me, “so there is a lot of untapped capacity in Ohio.” This is welcomed news.
Ohioans experiencing homelessness, however, are having a much harder time. And it’s not just because of a dwindling supply of opioids. It’s also a lack of food. Most of the food pantries have closed, and even the ones that are open don’t have much food. This is because so much of it comes from stores and restaurants that are now closed or have their own shortages. For people who rely on these charitable programs to eat, disruptions in the supply chain are a serious problem. “This is the first time I’ve ever seen real hunger,” Dennis told me.
Other cities are suffering even worse. I spoke to John Torsche of the DCT Foundation in Baltimore, who provides peer support, naloxone training, and other harm reduction services to people who use drugs. “As dealers go out of business,” he told me, “the open-air drug markets are getting smaller and more concentrated, which is resulting in more violence.” An increase in drug-related shootings is adding even more strain to hospitals that now also have to deal with an influx of COVID-19 patients. Baltimore’s mayor, Jack Young, recently put out a desperate plea to people to stop shooting each other.
The challenges for people who use drugs daily and those who serve them are likely to increase. But there is some good news. For one, overdoses are declining. Nobody will complain about that, even though much of it is a result of forced abstinence. A big worry among harm reduction workers, however, is the potential for a rebound effect when the pandemic subsides and people have lost their tolerance. “When things get back to normal,” Dennis told me, “we may see a lot of people overdosing.”
Another positive side is that the pandemic appears to be getting a lot of people, including the authorities, to rethink their priorities around the drug war. Many police departments around the country have stopped enforcing drug crimes, and jails and prisons are starting to release short-term and nonviolent offenders. Similarly, methadone clinics are allowing people to take home a month’s supply at a time, and Vancouver has even started giving opioid prescriptions to people so they don’t have to buy on the street. Whether this will result in a permanent shift from policing and prisons to harm reduction and public health is unknown, and will depend on all of us and what we do after the pandemic subsides.
There Will Likely be No Festivals for a Long Time
It’s only been two weeks since Ultra music festival in Miami cancelled due to coronavirus concerns. A few days later Austin’s South by Southwest cancelled. And today there are no festivals happening anywhere in the US or Europe (and perhaps the world). But will there be any festivals this summer? To get another insider’s perspective, I called Richard Gotltlieb of RGX Medical, who provides medical services for more than 40 festivals each year in the US and abroad. “I don’t think there are going to be any festivals this summer,” he told me. “Many promoters are rescheduling rather than canceling. I think this optimism is important, but it seems unlikely.”
Richard is also a Medical Supervisor for the Black Rock City Emergency Services Department. When I asked him whether he thought Burning Man would take place (end of August/early September) he replied, “I don’t want to be the person who makes that prediction.”
I will go on record saying I do not believe Burning Man will happen this year. This isn’t pessimism. It’s realism. When mass gatherings will happen again will be decided by the virus itself—and how we respond to it. And I just can’t see any scenario where festivals or large concerts will happen sooner than the fall of 2021. That’s eighteen months from now. I’ll explain why I think this:
Essentially, epidemiologists have laid out only three possible scenarios for the course of the pandemic. Here they are:
1) The entire world manages to contain the virus by shutting down borders, engaging in mass testing and enforced quarantines, until it is totally eradicated.
2) At least 75% of the population becomes infected over the next three to six months. Perhaps up to million people in the US die, and we develop herd immunity quickly.
3) We shelter in place for the next two to three months, then again a few months later in multiple, successive waves of social distancing. We do this until a vaccine is developed in order to save lives by not overwhelming hospitals all at once.
The first scenario is exceedingly unlikely (if not outright impossible) given how widespread the pandemic already is, how easily the virus spreads, and the impossibility of shutting down all the world’s borders.
The second scenario is also unlikely (thank goodness) since many US states and much of the world have already begun to implement live-saving social distancing measures. UK Prime Minister Boris Johnson, who has now tested positive for COVID-19, backtracked on his early advocacy for option #2 after meeting with intense backlash from all sectors of society. And even though President Trump is still suggesting #2 may be an option, it is highly unlikely that cities and states would follow such a plan.
I believe only the third scenario is likely to play out. But why multiple, successive infection waves? Why not one long period of social distancing to get it all over with? The reason, according to epidemiologists, is that nobody knows how long it will take to develop a vaccine. Unlike the flu, there has never been a vaccine developed for a coronavirus. We will likely get one eventually, but even in a best case scenario this will take a minimum of eighteen months, and possibly likely much longer. Clinical trials assessing efficacy and safety are long, involving animal studies and large-scale human testing. Then we will still need many more months to mass produce enough vaccine for eight billion people.
Are we able to shut down our economy and shelter in place for two years straight? No. This is simply not possible for both economic as well as psychological reasons. And this is why the proper and most likely scenario is repeated, temporary periods of social distancing to channel the spread of the virus into smaller and smaller “infection waves,” so as not to overwhelm our healthcare capacity and keep the number of fatalities to a minimum.
How Will This Work?
Very likely, when this current wave subsides to the point where the number of infected patients is lower than the number of hospital ventilators, social distancing measures will be lifted. Epidemiologists predict this will happen around the end of May in most states. (Search for your state here.) That’s two months from now. At that time, people will likely start going out again. Restaurants will reopen. Small house parties may even happen, and life will become a bit more bearable for everyone.
But the virus will still be around, and at some point the second wave will start. Community spread will begin again, and we will once again have to start social distancing in order to reduce the strain on hospitals and limit the number of fatalities.
It is possible that each successive infection wave will be smaller than the previous, with fewer overall cases and fewer fatalities. But this depends on whether we implement widespread testing and contact tracing that can stall the onset of community spread, and whether we can increase our healthcare capacity, particularly more nurses, more ICU beds and more ventilators. (5) This might make each successive lockdown shorter and each wave less deadly than the previous. But any way you cut it, social distancing will continue until we achieve “herd immunity,” defined as the point when approximately 85% of the population is immune—either from having contracted the virus and survived, or from having been vaccinated.
By now most people have seen the above chart from the CDC, or a similar one, visually demonstrating how social distancing measures can “flatten the curve” in order not to overwhelm our healthcare capacity. This chart, however, is deceptive for a number of reasons. First, it is simply not possible to accomplish this. Our healthcare capacity is far lower than the predicted infection rates, and hospitals are already being overwhelmed. Second, it shows only a single wave, as if a single period of social distancing will contain (i.e. eradicate) the virus. It won’t. This is global pandemic. The virus has already spread to almost every country in the world, and it will be with us, silently infecting people until the world develops herd immunity.
But back to festivals… Given that the end of the first infection wave is predicted by June, doesn’t that mean summer festivals can happen during the in-between phase, before the second outbreak? I doubt it. Even if mass gatherings are allowed in some states this summer, the psychological impact of this pandemic on the population will likely result in extreme prudence. Smaller gatherings of under a few hundred people might take place (with lots of hand washing stations), but I just do not believe that enough people will choose to attend mass gatherings this summer once the scope of death and suffering becomes obvious a few weeks from now.
So what does this mean for the festival community, for all the artists, musicians, organizers, and vendors? How do we keep our culture alive? I wish I knew the answer to that. When I attended my first rave in Oakland in 1998, I was behind a DanceSafe booth. I had never been to a rave prior to starting DanceSafe (I was a punk in Florida in the ’80s), and I feel so blessed to have become a part of the rave/festival culture, with all its love and community. And like many others, my life and career revolve around festivals. So to be completely honest, I’m worried about the future. But I won’t lose hope.
At the end of my interview with Richard Gottlieb from RGX Medical, I asked him if there was anything he wanted to say specifically to readers of this article. He replied, “My life’s work is providing medical services for mass gatherings. Two weeks ago, all mass gatherings cancelled for the foreseeable future. Now it has become clear that we are all in this together. My stress levels have gone way down. The personal growth that we will all go through during this time will be a benefit to ourselves and the community. There will be much sadness and loss but we will come out stronger than ever.”
I hope he’s right. And as usual, it will be up to us.
2. The current world fatality rate stands at 4.7%. The fatality rate right now in Italy stands at 11%. Spain and France are around 9% each, and although these numbers are certain to end up lower—because most people have not been tested and many people are asymptomatic—it is also the case that most infected persons have not yet recovered. In the end, fatality rates will depend on the strength of each country’s response, as well as their healthcare capacity—particularly the number of nurses, ICU beds and ventilators per capita. The US is unprepared in many of these areas, but if we take strong action now, we may be able to lower the fatality rate substantially.
3. El Paso has a population of 700,000. 75% of 700,000 is 525,000. 4% of 525,000 is 21,000. (See the interactive epidemic calculator.)
4. Today the term “pill testing” has changed to “drug checking” as more people now consume drugs in the form of loose, white powder rather than pressed tablets or pills. The new terminology also more easily distinguishes the harm reduction service from the testing of bodily fluids in order to “catch” people who are using drugs.
5. As the virus awakens us to the folly of a for-profit healthcare system where excess capacity is seen as wasteful, we may finally begin a transition towards a universal healthcare system like an improved Medicare for all.
This is an op-ed by Emanuel Sferios, the founder of DanceSafe and the Drug Positive podcast.