Crack Cocaine and Harlem’s Health

Harlem is one of the most famous urban all-black communities in the United States. In its early years, Harlem prospered and gained international recognition as a center of African American music, art, and literature. Between 1960 and 1990, four disparate forces—suburbanization, economic decline, epidemic disease, and municipal public policy—transformed Harlem from a functional "urban habitat" to a deurbanized area with a hyper-concentration of poor people with serious health problems.

In 1990, Colin McCord and Harold Freeman published a special article in the New England Journal of Medicine that described the relative risk of death for Harlem residents in comparison with other areas of New York City. Harlem had the highest rate of age-adjusted mortality from all causes. The rate was more than double that of U.S. whites and was 50 percent higher than that of U.S. blacks living in other areas. Cardiovascular disease, cirrhosis, homicide, neoplasms, and drug dependency were the five major causes of death. Homicide, cirrhosis, and drug-related deaths accounted for 40 percent of excess mortality in Harlem, suggesting a corresponding excess burden of substance abuse-associated morbidity. They concluded, "Black men in Harlem were less likely to reach the age of 65 than men in Bangladesh.

Zip code-level data for all New York City hospital admissions, covering 1989-1990, released by the New York State Health Systems Agency (HSA), complement McCord and Freeman's analysis. HSA found that the five Harlem and East Harlem zip codes were ranked among the "top ten" (out of a total of 168 city wide) with respect to substance-abuse admissions; three of the five were ranked among the highest ten with respect to hospital admissions for psychosis (much of which was drug related); and two of the five were ranked among the top ten with respect to HIV and cirrhosis admissions.

In 1996, the unique nature of the problems of Harlem was underscored by Arline Geronimus and colleagues, who compared mortality rates for white and black Americans living in poor or more prosperous communities in four parts of the United States They found that men and women living in Harlem had the lowest likelihood of surviving to age sixty-five (37 percent for men; 65 percent for women). The authors note: "The situation in Harlem was particularly dire. Comparison of the estimates by McCord and Freeman with ours shows that in Harlem mortality among women relative to that nationwide has not improved since 1980, whereas mortality among men has deteriorated. On the other hand, groups that might have been expected to have excess mortality rates equivalent to or higher than the rates in Harlem did not." Their findings suggest that social factors in addition to race and income are needed to explain excess mortality in Harlem.

The crack cocaine epidemic of 1985-1995 significantly contributed to the decline of health in the Harlem community. Crack was both a direct and an indirect cause of excess morbidity and mortality. Lives were lost as a result of crack use and crack-related violence. In the course of crack use, many addicts contracted and died from HIV/AIDS and other illnesses. The adverse health effects of the crack epidemic included increases in rates of sexually transmitted diseases, respiratory conditions, and psychological problems. The epidemic also caused social disruption that undermined the community fabric and, in turn, further aggravated health. In order to describe the contributions of crack to ill health in Harlem, this article will review the general features of the crack epidemic and will relate stories of the epidemic as recalled by Harlem residents.

The Crack Cocaine Epidemic

Few people in the United States, other than those involved in the drug underground, recognized the emergence of a smokable form of cocaine. The first mention of crystallized cocaine occurred in an early 1970s guide to illegal drug use, entitled The Gourmet Cokebook It next appeared in 1981, as a footnote in another underground publication, David Lee's Cocaine Handbook That same year, the near-death experience of comedian-actor Richard Pryor introduced the practice of smoking cocaine, in this case "freebasing," to the general public However, the process of reconstituting cocaine for smoking was not fully understood Freebase, the base-state form of cocaine without adulterants, was not clearly distinguished from crystal cocaine, the form that contains the impurities and filler from the hydrochloride as well as from the processing products. Even among many users, particularly at the street level, the two were considered equivalents In the mid-1980s, the unadulterated smokable cocaine rock form became known as "crack" because of the crackling sound made during heating and drying once the cocaine hydrochloride is dissolved in water and sodium bicarbonate (baking soda)

Crack first received media attention in 1984. The Los Angeles Times reported that in "South Central, cocaine sales explode with $25 rocks. It would be almost a year before the term "crack" appeared in print. On November 17, 1985, while covering a story on a drug treatment center, a New York Times reporter discovered that this "new form of cocaine, known as crack, was for sale in New York City. Two weeks later a Times headline read: "A New Purified Form of Cocaine Causes Alarm as Abuse Increases. As crack moved north from Miami, west from New York and Washington, D.C., and east from Los Angeles, intense national media coverage followed

According to a 1988 Drug Enforcement Agency (DEA) report, the availability of crack was first noted in Los Angeles, San Diego, and Houston in 1981. Crack was localized in those areas until 1985, when crack use became a serious problem in New York City. According to the DEA, "Crack cocaine literally exploded on the drug scene during 1986 and was reported available in 28 states and the District of Columbia. The presence of crack was attested to by street surveillance, emergency-room visits, and arrest records. For example, crack arrests accounted for 72 percent of all New York Police Department (NYPD) Narcotics Division cocaine arrests during the first seven months of 1987. In 1989, lifetime prevalence reached 1.9 percent

Political Response

Fueled by the media, political campaigns, and the national elections, illicit drug use and associated crime, in particular crack-related crime, dominated public policy debate between 1986 and 1990. In the summer of 1986, Newsweek declared crack "an authentic national crisis," comparable to the civil rights movement, the Vietnam War, and Watergate Crack had become widely available in U.S. cities and was largely concentrated in inner-city areas.

On July 15, 1986, the Committee on Governmental Affairs' Permanent Subcommittee on Investigations held a hearing "to examine a frightening and dangerous new twist in the drug abuse problem — the growing availability and use of a cheap, highly addictive, and deadly form of cocaine known on the streets as crack. Senators William Roth, William Cohen, Lawton Chiles, Sam Nunn, John Glenn, and Alfonse D'Amato convened the "Crack" Cocaine Hearings. In turn, each described crack as "an egalitarian drug, attracting users of all races colors and creeds, all walks of life and income, and all degrees of dependence. The hearings clearly established that crack use had reached near-epidemic proportions and required immediate combative measures aimed at treatment, prevention research, and education

The following month, on August 4, 1986, President Ronald Reagan announced a new antidrug policy. The governmental response focused almost exclusively on interdiction and eradication of the drug supply. On September 14, 1986, in a nationally televised address, Reagan, determined to begin "a sustained, relentless effort to rid America of this scourge by mobilizing every segment of society against drug abuse, declared a 'War on Drugs.' The next day, Time magazine ran a ten-page story entitled: "Fed Up and Frightened, the Nation Mounts a Crusade Against Drugs. On October 27, 1986, the first Antidrug Abuse Act was enacted. Of the $1.7 billion allocated, approximately 86 percent went to law enforcement, prisons, and interdiction, and 14 percent went to treatment, education, and prevention In addition, an annual White House Conference for a Drug-Free America was established. Over the next two years, drug use and sales increased, and social, legal, and medical problems proliferated.

At the time, little was known about the long-term outcome of addiction to crack, but even short-term use produced important physical consequences, including cardiovascular complications (heart attack, stroke), pulmonary complications (chronic cough, aggravation of asthma), and psychiatric complications (paranoia, depression). Arnold Washton and colleagues warned, in 1986, that addiction to crack was growing at alarming rates. They noted that "during the past three years, a growing epidemic of cocaine use in the United States has resulted in widespread physical, psychiatric, and social problems that have alarmed medical experts, parents, and law enforcement officials. The brief duration of the drug effect and rapid onset of compulsive use made this drug an ideal product from the perspective of drug marketers. Crack, they argued, was a "self-marketing product" that "assures the dealer a reliable clientele and a high profit margin.

The Second War on Drugs

Drug abuse, in particular crack use, remained at the forefront of social issues during the 1988 presidential election campaign. As a result, on October 22, 1988, Congress enacted a second anti-drug abuse act. This time $2.8 billion—a $1 billion increase— was set aside to bolster antidrug efforts The focus on eradication and interdiction of the drug supply continued. However, 50 percent of the first year's budget and 60 percent of each year's thereafter were allocated to demand reduction. The 1988 legislation also created two new government offices, the White House Office of National Drug Control Policy, which was responsible for the annual National Drug Control Strategy, and the Office of Substance Abuse Prevention, which focused on treatment and prevention. This new drug policy placed an emphasis on severely penalizing crack users and dealers Steven Belenko, an antidrug policy researcher, argued that "what distinguished this anti-drug campaign was its strong emphasis on a single drug—crack cocaine. He stated that the policy was driven by four assumptions about the effects of crack: (1) Crack is rapidly and strongly addictive, (2) crack users become irrational and exhibit bizarre and violent behavior, (3) the involvement of youth in crack dealing means more chaotic and violent distribution networks, and (4) crack is linked to promiscuous sexual activity. In turn, crack "is viewed as the quintessential 'hedonistic' drug and as such is in polar opposition to the prevailing white Protestant conservative morality of America.

Public Concern

Although Reagan's antidrug campaign failed to stem the growth of drug use and related illegal activity, it succeeded in generating an unprecedented level of public concern The 1989 National Drug Control Strategy contained the following statement in its introduction: "One drug—crack—has stubbornly resisted our prevention efforts. Crack's stranglehold on hundreds of thousands of young Americans is tightening. To date, the crack plague has been concentrated in our central cities, but it has begun to spread to small suburbs and small towns. The idea that crack was extending into nonurban middle-class areas terrified the public. In the mid-1980s, it was rumored that crack was so highly addictive that one-time use could cause addiction. In order to continue consumption of the drug, addicts spent their money, dispersed valuable possessions, and participated in sex-for-money-or-drugs exchanges. Concurrently, those areas affected by crack reported an increase in the rates of common sexually transmitted diseases, particularly syphilis and gonorrhea In the course of binges—episodes of incessant drug use that might last up to several days—parents neglected their children, and all users neglected basic health care needs for adequate food, clothing, and shelter. As the epidemic of crack use proceeded, the violence among drug dealers for control of territory fed into a growing epidemic of gun-related homicide, predominately among young African-American men The escalating violence was steadily transforming peaceful neighborhoods into war zones.

Media coverage reinforced the idea that crack was destroying America. The New York Times continuously ran front-page articles about crack: February 20, 1989, "After Three Years, the Crack Plague in New York Grows Worse"; May 10, 1989, "Crack Spreads Fear and Frustration, Overwhelming Hospitals"; October 1, 1989, "Crack, Bane of Inner City, Is Now Gripping Suburbs. The next day, an article entitled "The Spreading Web of Crack" appeared The Washington Post cover stories included: June 3, 1989, "Small Towns Wrestle with the 'Scourge'"; September 22, 1989, "Drug Buy Setup for Bush Speech: DEA Lured Seller to Lafayette Park"; December 18, 1989, "For Pregnant Addict, Crack Comes First"; January 6, 1990, "She Smoked Crack, Then Killed Her Children. The Wall Street Journal headlines read: May 4,1989, "Spreading Plague"; July 18,1989, "Born to Lose: Babies of Crack Users Crowd Hospitals. The Wall Street Journal's July article on crack babies was followed by two New York Times articles, one in August and another in November One of the most striking features of this coverage was the fact that with few exceptions, the faces of crack babies were black. As the nonwhite crack user/dealer became a familiar image in U.S. news reports and magazine articles, the characterization of the crack epidemic began to change.

By 1990, crack was no longer considered an egalitarian drug. Crack use and crack-related crime were largely concentrated in poor nonwhite communities, and it appeared that the pattern would continue. In 1991, the National Institute on Drug Abuse (NIDA) reported a decline in crack use among middleclass high-school and college students. Subsequently, crack lost its place on the national agenda. The 1991 National Drug Control Strategy, a 122-page document, mentioned crack only three times, once in the introduction. By contrast, a year earlier, in the ninety-page 1989 National Drug Control Strategy, crack had been mentioned twenty-nine times, ten of those times in the fourteen-page introduction Neither crack nor cocaine appeared in the 7997 National Strategy on Emerging Drug Trends

The withdrawal of public and political support for crack research and treatment left affected communities defenseless against crack and its attendant social and health problems. All the while, the actual number of people addicted to crack continued to rise In 1988, a San Francisco community leader, Shirley Gross, wrote: "Nothing in the history of substance abuse has prepared us for the devastation that is caused by the use of cocaine 'crack'... Crack has destroyed entire communities by engulfing families in the web of crack sales or use. Largely African-American sections of Oakland, San Francisco, and Los Angeles were "taken over" by drug dealers. Addiction and drug-related violence created massive alteration in the social conditions of these communities. An ethnographer, Ben Bowser, described marked changes in the Bayview-Hunter's Point community in San Francisco In particular, he signaled that drug traffickers were forming their own social systems, complete with common expectations, beliefs, values, and rules and that women, drawn into crack-related prostitution, might be far more effective transmitters of HIV infection than were women addicted to heroin.

Crack and Health

The crack epidemic undermined health in the affected communities, most of which were poor. Crack's disastrous impact on health could be measured in the spread of sexually transmitted diseases, including HIV, and the rapid escalation of violence (handgun violence related to drug sales). In 1988, the U.S. Centers for Disease Control (CDC) cited crack use, coupled with the practice of bartering sexual services in exchange for the drug, as a factor in the increase in STDs (sex tied to drugs) An association between crack use and HIV infection, noted among women with pelvic inflammatory disease in New York City, was the first indication that crack use might become an important factor in the spread of HIV infection Several lines of evidence have since substantiated the fact that levels of risk behavior and infection with STDs, including HIV, are high among crack users Mary Ann Chiasson and colleagues at the New York City Department of Health (NYCDOH) examined the link between HIV infection and crack use The overall seroprevalence rate among the 201 crack users, who denied traditional HTV-associated risk behaviors, was 12 percent. The Centers for Disease Control conducted a multiyear, multisite study designed to assess HTV seroprevalence among crack users interviewed at three sites in the United States— New York, Miami, and San Francisco Women with a history of engaging in sex work associated with crack cocaine use were found to be particularly at risk The prevalence of HIV infection among crack-smoking women in the sample was reported to be 29.6 percent in New York City and 23.0 percent in Miami

The association of crack with violence was acknowledged by criminologists and other researchers throughout the country A NIDA monograph pointed out that "structural violence," that is, violence related to the control of markets, was a major cause of all violence linked to drug use An increase in use of guns appears to follow the emergence of crack in selected cities in the United States The presence of guns leads to an increase in the risk for firearm-related homicide Guns played a critical role in the rise in the number of homicides in the United States. Although firearm-related homicide had been the leading cause of death among African-American male teenagers since 1969, a marked increase was noted beginning in 1987. Lois Fingerhut and colleagues reported that "from 1987 through 1989, the firearm homicide rate among black males 15 to 19 years of age increased 71 percent to 85.3 deaths per 100,000 population, while the death rate from motor vehicle crashes (the second leading cause of death among black teenage males) fell 3 percent to 26.5 per 100,000. It was also found that firearm-related deaths were concentrated in core metropolitan areas

Individual Life Stories: Crack’s Impact on Harlem

As the epidemic progressed, it became clear that compulsive crack use would have a tremendous impact on users, their families, and the larger communities within which the epidemic was embedded. Harlem, like so many other poor, inner-city communities, lacked the economic and social resources necessary to ward off crack's destructive forces. Harlem's hollowed-out landscape of abandoned and deteriorating buildings provided an optimal setting for the crack trade. Dealers quickly converted vacant structures into crack houses—twenty-four-hour centers for crack consumption, sale, and distribution Absentee landlords made it easy for crack dealers to set up shop in occupied dilapidated buildings. Residents recalled how buildings and entire blocks became overrun with crack dealers and users, leaving many frightened, isolated, and disillusioned. The social effects of crack were related to three factors: the growth of the drug culture, drug-related prostitution, and the collapse of family and community functioning. The dramatic social changes that Harlem underwent as result of crack-related activity contributed to a significant health decline. Unfortunately, the Harlem community has not been able to fully recover from the disastrous effects of the epidemic. Interviews with Harlem residents provide a glimpse into the ways crack-related crime and violence have disrupted personal, domestic, and community social networks.

Community Decline

Survival in poor urban communities depends heavily on informal social ties When the network of social relationships and corresponding social controls that permit large numbers of people to live together is greatly disrupted, behaviors that would not normally be tolerated—like crime—increase. The presence of undesirable and illicit activity limits the movements of residents and thus decreases the frequency of social exchanges. Subsequently, neighbors become estranged from one another and feelings of togetherness and security are replaced by fear and suspicion. Trust, which had been the basis for cooperation among Harlem residents, began to erode as people struggled to protect themselves and their families against a multitude of crack-related social ills. One long-term resident described Harlem in the latter half of the 1980s as follows: "Back then [1985 to 1990] Harlem was a war zone and nobody, not even the police, they wasn't doing a damn thing about it. When you're fighting for your life, and children, and home, for one thing, you don't have time to say hello. You don't want to say hello or have your children say hello. Trust no one. Fear everyone. That's a military mentality." Residents uniformly held that isolation, fear, and mistrust caused Harlem's social fabric to unravel. A long-term resident recalled:

Everybody in Harlem, including the police, knew where to get drugs. That's why nobody, unless that wanted to buy or sell drugs, ever went down those blocks. The problem was that it happened so fast. It seemed like most of the blocks had drugs. And the saddest thing were the young ladies, disrespecting themselves. Crack was something else. And I don't mean the drug itself. Or at least I don't think so. I never tried it myself, you know. Anyway, what I mean is what it did to the community, to the family. People couldn't trust their own kids. It was like [pause] prison. Nobody wanted to let their children leave the house because you never knew what was gonna be waiting outside. You see, it's one thing if a stranger gets mixed up in, but now it was the man next door or the woman upstairs, or his son or daughter. People your children had been told to respect; they grew up around; they were friends with; you knew the family for years

An elderly resident recounted how crack confined her to her apartment:

The crack was the worse. It really did, that was the end. Those that could git [leave], well, the rest, peoples like me, we just had to stay inside. Crackheads would steal everything. You wouldn't even go outside soon as it got dark. It was worse than dope [heroin] . . . seemed like every other person, or the[ir] children, or somebody they know was on crack .. . you couldn't even go to the elevator. Matter a fact, things got so bad I had to wait on my son to bring me my groceries. He lives out there in Brooklyn. Comes to see me every weekend. He wants me to go out there with him, to live you know, out there ... But I been in this here four by four since 1949. My husband died right here and I reckon I will too. I never lived nowhere [in New York] but Harlem. Well, it was real bad like that for a good while ... I'd say two or three years

Violence

Violence was closely associated with crack, and violent incidents grew dramatically as the epidemic spread. A March 1989 issue of the Crisis, the official organ of the NAACP, focused on the crack epidemic In an article entitled "Cocaine and Violence: A Marriage Made in Hell," Patricia A. Jones noted that in New York City, young children were murdered because they were in the cross fire of drug-related violence She called this violence "drug terrorism" and noted, "Innocents killed in drug terrorism incidents are basically by-products of fights for market share in the drug business.

When asked how crack affected everyday life in Harlem, one resident responded:

There were periods when every week you heard about somebody getting shot, shootings every week. Do you know what that is? We all knew what was going on, so the police had to know. Why would you let a bunch of drug lords take over a community? If they tried to do it in a white neighborhood, the police would have done something. But this was a bunch of niggers killing each other. Little black kids were getting killed .. . We couldn't even walk down many of the streets in our own neighborhood. Can you imagine streets on the Upper East Side being controlled by drug dealers? White kids getting killed in the cross fire? Would people in that community take their lives and their children's lives into their hands every time they walked down the street

An elderly resident from the Harlem Senior Citizens Center remembered an incident of violence that resulted in several deaths:

Right over here in the playground, up the street from the center, they was selling drugs. Stuff [crack vials] everywhere. We cleaned that park up, you know. I believe it, '91, yes, [in] '91. After some kids got killed. There was a big fight. Bullets flying everywhere, it was terrible. The candy store on the corner. They ran in there, too. Police was everywhere. After that we cleaned it up

Family Dysfunction

The nature of crack use has important implications for the communities that it affected. Crack use typically occurs during binges that may last for days at a time, that is, until the user is forced to stop because of exhaustion or lack of the financial wherewithal to continue. During the binge, the need to procure and use crack overwhelms all other demands that might face the user. By necessity, kinship, work, and social duties are neglected. In pursuit of the drug, many women were forced to perform degrading sexual acts in sex-for-drug exchanges. As one woman told an interviewer in describing the ways in which she had failed her children, "It hurts, it really hurts because you really want to do it. You really want to take care of your children and everything, but the drug is just constantly, it's like a monkey on your back. I want it, I want it, I want it, I want it.

One woman told of a mother's crack-induced neglect of her children and bartering of sex for drugs:

There was a girl up on the third floor. Well, I knowed her since she was a baby. Her Momma died and then she got the apartment, you see. Well, she was living there with her childrens, one of each; they was twins. And well, they was just as sweet and clean. Then she got messed up, you see. And well, them childrens would cry all the time and be dirty. She was out doing drugs [crack], you see. Sometime she was gone all night. After a while the marshal come and put her out... she came and rang the bell a few times but I didn't answer ... I don't know if I should be saying this. 'Cause, well, I didn't see for myself. But well, they say she started staying over by 140th. She was one of them girls that goes with mens for drugs. Well, they would be right on the street in the day and they look sickly. Used to have a name for them, my grandbaby told me about it, you see. Some kind of fruit [strawberries] ... I wonder what came a those childrens

Health

When asked to explain crack's impact on health in Harlem, residents pointed out the critical connection between the loss of community integrity and the rising rates of ill health. 

One elderly lifetime resident responded:

When I think of health, I think first of mental health and then physical. And obviously they're both being affected adversely ... In the 1980s the critical problem was stagnation, S-T-A-G-N-A-T-I-O-N; remember the word. The economy was stagnate, then came the ... Reaganomics you see and then the cocaine, crack cocaine, as you call it. Then the mental attitude was stagnate. We had the ghetto mentality ... The health problem in Harlem and the other Harlems has to do with a lack of preventive care. With crack you had the deterioration and breakdown of the community and the breakdown of the community leads to other things. Crack was the straw that broke the camel's back, so to speak

Another resident agreed:

Crack was not the problem. It was what came with crack, the crime, the gunfights, AIDS. You have to understand one of the special things about Harlem. One of the reasons people stay in Harlem is people out on the street; everyone knows one another. That's not to say that you come to my house but on a casual basis. "Good morning," "afternoon." Everyone thinks of Harlem in the way the media portrays Harlem, hoodlums, gangsters, and the like. But Harlem has a stable middle class and working class and an upper class. Just go to any subway station in the morning and you'll see the people going to work. At that time [during the epidemic], the streets were empty

The 1985-1995 crack cocaine epidemic was largely concentrated in poor, inner-city areas like Harlem. Initial fears that crack would sweep across the nation unsettled policymakers and the public. Unfortunately, ensuing public policy was shaped by a vision of the epidemic not as a health crisis but as a crime crisis. In response, an internal war was initiated, directed at controlling drug use and sales. The unacknowledged health crisis proceeded in Harlem and elsewhere. The toll of death and disease has not yet been fully assessed, and the emotional and social cost of the epidemic remains to be evaluated. But it is clear, even from a preliminary reading of the data, that drug addiction and its side effects—sexually transmitted diseases, respiratory ailments, psychological disorder, and violent trauma—all escalated as a result of the crack epidemic. Profound damage was done to family and neighborhood social networks.

As the epidemic recedes, it leaves behind a large number of addicted people who have little access to treatment or any established remedies for their problems. Crack has fallen from epidemic to endemic levels in Harlem's drug repertoire, but it has not disappeared. New cases of addiction continue to present for treatment. Other health and social sequelae continue to haunt the community: thousands of children in foster care, thousands of young men and women in the criminal justice system. The misguided policies that failed to recognize the health threats of the crack epidemic have not been rewritten.

The Harlem community bears a burden of ill health that is, in part, a result of a national failure to treat drug epidemics as health problems. The recovery of Harlem depends on correcting that failure. Prevention, in the classic models of public health, includes attention to problems that arise in the aftermath of illness. Rehabilitating victims of accidents is but one example of tertiary preventive care. In the case of Harlem, it is too late to prevent the epidemic, but it is not too late to prevent the consequences of illnesses spawned from the epidemic. A new, more health-conscious public policy is desperately needed as Harlem prepares for the future

Notes

This work is part of a pilot study supported by NIH grant #IP30AG15294-01 to Rafael Lantigua, M.D., Columbia University, College of Physicians and Surgeons, Division of General Medicine, CALME. Funding was also provided by the SOROS Foundation, Open Society Institute. The authors wish to thank Robert Lehr Goodman, M.D., for his assistance in preparing the manuscript.