Colin Miller doesn’t want to add to the list of names tattooed on his arm.
“Nathan” committed suicide in downtown Minneapolis after a five-year struggle with heroin.
“Jason” died of an overdose in a hotel room in Montana.
They found “Denver” in a ditch down in Archdale.
There are 12 names in all, and more that could be added. They are the inky memorials for Miller’s friends who died of overdoses or another type of drug-related death. Most of them involved opioids.
Nearly 30,000 Americans die from opioid overdoses each year as a nationwide drug epidemic continues to spread throughout the country, not only in areas traditionally associated with poverty like the inner city and the Appalachian holler but in upscale suburbia as well.
In North Carolina alone, heroin deaths increased 554 percent between 2010 and 2014 and the mortality figures are expected to have risen again in 2015. Prescription opioids — synthetic medications such as Oxycontin that mimic the pain-relieving properties of opiates — are believed to be a risk factor for heroin use, according to the National Institutes of Health. Of the top 25 worst cities for opioid abuse, four of them are in North Carolina, with Wilmington ranked at No. 1.
Not content with merely adding to the list, Miller recently co-founded a syringe exchange with Erika Mishoe near downtown Winston-Salem. A syringe exchange — trading dirty or used needles that have been used to inject heroin for clean ones — is part of a set of ideas and principles called “harm reduction,” designed to mitigate the damaging effects of drug addiction.
“A lot of drug users will never see the healthcare system,” Miller said. “They’re forgotten. Syringe exchange is a point of contact where we can at least start to give people some education and show them that there are people who care and to teach them ways to care for themselves.”
The Twin City Harm Reduction Collective began operating out of Green Street United Methodist Church in early December. The Winston-Salem site is one of 19 operations created since July, when then-Gov. Pat McCrory signed NC House Bill 972 legalizing syringe exchanges.
In addition to the usual coalition around humane substance-abuse policy, the campaign to legalize syringe exchange in North Carolina has found support among law enforcement officers who realize that they can’t simply arrest their way out of the drug war. In fact, these new policies were in part the result of a strategic campaign spearheaded by the North Carolina Harm Reduction Coalition to educate and lobby law enforcement and elected officials, many of them Republican, about the public health benefits of harm reduction. The campaign has become an organizing model for other proponents throughout the South.
“The country has moved towards harm reduction in a really big way in the past few years because of the scope of the opioid epidemic,” said Tessie Castillo, the communications and advocacy coordinator at the NC Harm Reduction Coalition.
“Legislators are just looking for answers,” she said. “We’ve had them all along but no one was listening.”
With a significant number of law enforcement officers now supporting syringe exchange and Naloxone distribution, many wonder if the drug war has turned a corner by becoming more just and humane. Harm-reduction advocates remain doubtful about this optimistic perspective and believe the collateral damage of the drug war will take decades to overcome, but they view the recent wave of laws legalizing syringe exchange as a step in the right direction.
“The legalization of syringe exchange,” Miller said, “symbolizes the shift from, ‘We’re going to punish you’ to, ‘Let us help you.’”
The creation of Winston-Salem’s first legal syringe exchange is a story of pain and redemption and of a community, cautiously but optimistically, navigating the ruins of a public health epidemic.
The face of addiction
Though often regarded with the same grimy, deviant imagery stereotypically ascribed to the heroin epidemic of the 1960s which plagued mainly African Americans living in inner cities, young white men and women of all socioeconomic groups are the main abusers of heroin today, and the drug has thoroughly inundated bucolic, rural America.
A 2014 study in the Journal of the American Medical Association Psychiatry titled “The Changing Face of Heroin Use in the United States” reported that 90 percent of respondents who began using opioids in the last decade were white.
Some see discrepancies in the harsh treatment of drug addicts who used crack cocaine –- commonly associated with African Americans — during the 1980s and today’s public health resources being unleashed for white communities suffering from opiate addiction.
“Such public-health responses were not necessarily unthinkable during the crack-cocaine wave of the 1980s or the heroin epidemic of the 1960s.,” wrote Andrew Cohen in The Atlantic. “But the limited public-health measures adopted during those eras were overshadowed by more punitive responses to those crises.”
While Miller wears the scars of chaotic drug addiction on his body, Erika Mishoe’s personal experience with the drug epidemic is less apparent but still painful: Close family members died from drug overdoses only two years apart . She hesitated to give more details about drug abuse in her family because of the discomfort that it might cause among the rest of them due to the stigma of addiction.
Despite the tragedy of losing family and friends to drugs, it is a world largely unfamiliar to Mishoe and on the surface, miles away from the domestic bliss of her family life. And so her first reaction upon hearing about syringe exchange was a mixture of naivety, curiosity and shock.
At the Really Really Free Market of Winston-Salem, an event where people give away free items for those in need,a drug user approached Mishoe and asked her why the city didn’t have a syringe exchange. “What’s a syringe exchange?” she asked him. The man’s answer confounded Mishoe.
Wait a second, she thought. We’re going to give them syringes so they can inject drugs? Don’t we want them to not do that?
Like other harm-reduction advocates interviewed for this story, including former addicts, it took time for Mishoe to process the concept of putting clean needles into the hands of drug users for the sole purpose of injecting a potentially fatal and illegal substance into their veins.
Would that make drug users want to use more drugs? What was the difference between a harm reduction advocate exchanging needles and the dealer on the street corner?
Mishoe scoured the internet for the answers to these and other questions. Her research unveiled an entire subculture that offered a radically different way of addressing drug abuse, a stark alternative to the tough-on-crime mindset that underpinned the War on Drugs and continues to permeate the South.
Suffering in her own town
Beginning in the 1980s as a response to widespread drug abuse and to the AIDS epidemic, harm-reduction tactics aim to promote public health by preventing the spread of disease through sharing needles. Putting an emphasis on treating drug users with respect, advocates meet addicts “where they are” by recognizing that abstinence can only occur if and when people are ready to stop using drugs. It doesn’t come through force, but with compassion and understanding.
Harm-reduction advocates drew inspiration from civil and human rights movements and the tactics of AIDS activist groups such as Act Up, working in the streets of cities like New York to promote syringe-exchange access and agitating against the abstinence-only mindset that dominated drug treatment at that time.
During the next 20 years, lawmakers in numerous states embraced harm-reducing tactics, including the distribution of the overdose-reversal drug called Naloxone, either out of necessity or because commonly held beliefs were disproved by studies showing that syringe exchange programs actually slowed the spread of diseases like AIDS and Hepatitis C and did not increase drug use. In fact, New York deemed its syringe exchange program to be the “gold standard” of HIV prevention.
Despite evidence that it worked, harm reduction had its detractors. Leading the crusade were hardliners like US Sen. Jesse Helms of North Carolina, whose ultra-conservative rhetoric against needle exchange was imbued with moral condemnation. Already known for vitriolic remarks against homosexuals and for lobbying legislation that clamped down on AIDS funding, Helms championed a bill in 1988 prohibiting federal funding for syringe-exchange programs, implying that handing out clean needles was the moral equivalent to the state selling smack.
The result was almost no official support for harm reduction in the South, North Carolina in particular. States in the Deep South continue to lag behind the rest of the country in public health emergency preparedness while disease rates remain high.
“Eight of the 10 states with the highest rates of new cases of HIV are in the South,” according to the CDC.
The growing number of legal syringe exchange programs in states that were traditionally “tough on crime” reflects the desperation of communities ravaged by escalating opiate abuse.
Last summer, North Carolina became the latest Southern state to legalize syringe exchange and make it easier to get Naloxone. Referencing lawmakers’ longtime refusal to legalize syringe exchange, Gov. McCrory conceded at the signing ceremony that, “It’s not the politically correct thing to do, at least on my side of the aisle, but it’s the right thing to do.”
These steps represent a symbolic victory for harm-reduction advocates who envision a South unshackled from a culture of hatred for drug users propagated by Helms and others.
“I don’t work in the healthcare industry and I don’t really have a lot of friends who shoot up heroin, so I didn’t really know any of these things,” Mishoe said.
Given her firsthand experience, harm reduction provided a way for her to help others avoid the pain of losing loved ones.
“It concerns me nonetheless that people are suffering in my own town,” she said. “If there are proven results that this is an effective way to deal with this public health epidemic, then why not? Why are we not doing this here?”
Although she didn’t know it at the time, Mishoe would soon play a large role in rectifying this oversight by bringing syringe exchange to Winston-Salem.
Hearts and minds… and needles
Like many other parents, Mishoe makes the early-morning commute across town to drop her kids off at school. It’s 6:48 a.m. when the text pops up on her phone.
“Hi Ms. Erika. I know it’s early but I really need a few kits and an exchange as soon as possible. Thank you.”
The person at the other end of the message is a drug user. The “kits” are sealed packages of Naloxone and the “exchange” means they either need clean needles or they want to give her their dirty ones. It’s a good time for Mishoe to meet. Although she works from home and has a fairly flexible schedule, she prefers to meet people during the day before it gets dark.
Most of the people with whom Mishoe exchanges needles with are young and white. Some of them want to meet up quickly and leave, but it’s obvious to her that others are looking to connect with someone who won’t shame them for using drugs.
“I’m not there to judge them or tell them they need to get treatment,” Mishoe said. “If they bring it up, I am happy to talk to them about it but I don’t try to give them advice. I am just there to give them supplies and resources.”
Before syringe exchanges were legalized last summer, Mishoe was one of many volunteers throughout the state who organized or ran underground syringe exchanges and Naloxone distribution programs. Many harm-reduction advocates are former or current drug users, or witnessed the traumatic effects of drug use, having lost loved ones to dope. Risking arrest and, in the case of recovering addicts, possible relapse, these volunteers worked outside of the law with few resources in sometimes dangerous environments.
Since the NC Harm Reduction Coalition began distributing Naloxone kits in 2013, more than 6,000 overdoses have been reversed statewide with 737 in Greensboro and 252 in Winston-Salem These amazing figures do not include overdoses reversed by law enforcement officers or healthcare workers.
It is not unusual for volunteers like Mishoe to literally save the lives of drug users by delivering shots of Naloxone to reverse overdoses. But more often, lives are saved because the harm-reduction volunteers deliver syringes and Naloxone to drug users who then pass the supplies along to their peers in the drug community. These peer exchanges amount to a vast, amorphous public-health network of people who care for one another’s wellbeing.
Often the work is about more than a simple exchange of supplies. In this way, harm-reduction advocates are the “medics” of the drug war, the ones who see the carnage upfront, and continue to focus on the humanity of those they serve. In the film Bringing Out the Dead, Frank — a paramedic whose work is nothing but pain and suffering — put it best when he reflected that his job is sometimes, “less about saving lives than bearing witness.”
Take for instance the young couple that reached out to Mishoe nearly every week to swap needles. At some point during the meet-ups, an unlikely friendship arose — the couple even invited Mishoe and her family to their home for a get-together. Still, the genuinely warm encounters remain tinged with an underlying sadness since the clean needles, hermetically sealed in sterile packaging, will be plunged into their veins, each to deliver a bolus of heroin to the brain.
“They always tell me that this is going to be the last time I hear from them,” Mishoe said wistfully. “I always hope that it is but so far, we’re still regularly in contact.”
Mishoe always makes sure to meet people in safe, well-lit locations and before taking the dirty syringes to be incinerated, she stored them on a high shelf in the basement where her kids rarely ventured.
What about arrest? Mishoe called it a “noble consequence.”
She brushed aside questions about personal risk. Her answer was simply the pain of a mother, a woman petrified at the prospect of finding her son dead from an overdose. The mother asked Mishoe for a Naloxone kit so she could reverse her son’s overdose.
“I brought her one and she got very emotional,” Mishoe remembered. “It made her feel so much better knowing that she had it. She was going to keep it in her car. Wherever she was, she was going to keep it with her.”
At the end of the story, Mishoe reminded herself to deliver a new automatic Naloxone injector to the mother.
Maybe it will save her son’s life.
Dopesick
Colin Miller was homeless.
It was winter in Minneapolis, where the average temperature in January is just above 15 degrees; he escaped the cold days by hanging out at the local library, found respite from the frigid nights by sleeping in a homeless shelter.
Miller and 300 other unfortunates slept on the floor on thin mats about an inch thick. No pillows. His roommates screamed during the night or vomited from withdrawal. Others smoked crack in the bathroom.
By 6:30 a.m. each morning, Miller — sweaty and nauseous from dope withdrawal — stumbled back in the street to hustle for heroin. Off to the races again.
His heroin habit had reached a point where he couldn’t keep money in his pocket long enough to afford a place of his own. It hadn’t always been like that. Before living on the streets for five months, Miller worked a steady job and had a girlfriend. He used and sold drugs, yes, but like so many spinning plates, he was still able to keep up with his obligations.
When Miller’s drug use was at its worst, personal health and hygiene weren’t high on his list of concerns. His friends regularly shared needles to shoot up when clean ones weren’t available and after repeated use, the needles became dull or barbed like the end of a fish hook. On top of the pain and discomfort, sharing needles increases the propensity for blood infections like Hepatitis C.
“Maybe I might rinse it out with some bleach but sometimes the drive to use the drug is just such that you don’t give a s***,” Miller said. “It’s not that I didn’t know about the risk, it was because it was too difficult for me to figure out how to get a clean needle at 3 in the morning.”
While he was living on the streets, Miller regularly popped into Access Works, a local harm-reduction clinic, to pick up syringes. One of the volunteers at the clinic named Eric happily gave him whatever he needed to get through the day.
“While they were handing me syringes,” Miller said, “they would be like, ‘Well, have we told you how Hepatitis C is transmitted?’”
“‘Did you know that you can get it from sharing water? Sharing cotton? It’s not just from syringe to syringe. A contaminated syringe could go in the water and then you draw from that water as well with your syringe and it could contaminate it.’”
Eric frequently shared these little nuggets of knowledge alongside the handfuls of plastic syringes and heroin cookers. That was the whole point of the harm reduction clinic. Miller could never have predicted it at the time, but Eric the volunteer would play an important role in jumpstarting Miller’s journey to becoming drug abstinent.
“You thinking about getting clean yet?” Eric asked Miller one day.
“No,” Miller countered. Just the syringes.
“You thinking about getting clean yet?” inquired Eric the next time Miller stopped in for supplies.
“No,” Miller shot back.
“You thinking about getting clean yet?”
“No, no, no.”
Worn down from living on the streets and suffering from perpetual dope sickness, Miller finally relented and with Eric’s help, checked himself into detox.
The day that he got out of detox, he used the last $20 in his pocket to buy heroin. He spent the latter half of his twenties in and out of treatment centers, swapped heroin for alcohol abuse and eventually relocated to Philadelphia to cop dope once more.
After moving to Winston-Salem, Miller worked for various local non-profit organizations. Although he currently works at Positive Wellness Alliance, an AIDS service organization, Miller never lost hope that syringe exchange would one day become legal in North Carolina so he could bring the same principles of harm reduction that saved his own life to addicts in his hometown.
“I see it as a big part of my recovery to help other people who are still suffering,” Miller said.
“It’s one thing that keeps me sober. That keeps me clean.”
“Use smart — Keep healthy — Stay alive”
A printed sign points the way toward the Twin City Harm Reduction Collective at Green Street United Methodist Church.
The syringe exchange is little more than a room with a locked cabinet full of supplies: Naloxone, syringes, cookers, cotton and sterile water.
Mishoe unlocks the cabinet doors and the exchange is open for business.
Although she still travels regularly to distribute clean needles and Naloxone to drug users, Mishoe hopes that having a fixed location allows more people to access their services. As remarkable as it is that more than 5,500 overdoses have been reversed through small circles of people, Miller believes that only a small percentage of the state’s IV drug users are being reached using a mobile strategy.
“We have to give resources for treatment per regulation which is something we were already doing,” Mishoe said.
“Colin has a lot of connections there through his work where he can get people into treatment and detox in the same day. That’s not part of the rule, that’s just something we were able to offer.”
State regulations governing syringe exchange require sites to register with the state Department of Health and Human Services and to draft and submit a security plan to the Winston-Salem Police Department and the Forsyth County Sheriff’s Office describing how it will keep the needles under lock and key.
Miller must also record basic demographic information about the people who visit the site, including their age and race, and the number of needles and Naloxone kits they distribute. Though still in its infancy, the exchange has served mainly white males between the ages of 20 and 50.
A stack of glossy business cards sit in the metal cabinet imprinted with a tagline that sums up the outfit’s raison d’être: “Use smart — Keep healthy — Stay alive.” Legalization allowed Mishoe and Miller to bring their work out of the shadows. They are now free to advertise the syringe exchange on social media, something that previously would have been unthinkable before but imperative to attract people to the site.
“We’ve been pretty slow,” Miller admitted, “because the word is still getting out and a lot of people down here don’t understand that this is legal. They’re sketched out about showing up somewhere to exchange needles. They think the cops are going to be watching.”
To combat these fears, state law grants limited immunity to drug users who receive needles and supplies from certified syringe exchanges, even for used needles containing residual amounts of heroin. Participants leave the Twin City exchange armed with special cards identifying that the paraphernalia is legal just in case they get stopped by police.
Despite these gains, harm reduction in North Carolina remains a labor of love. All of the supplies at the Twin City Collective were donated by the NC Harm Reduction Coalition because state lawmakers refused to allocate public funds to pay for “needles, hypodermic syringes, or other injection supplies.” The action effectively ensures that individuals and organizations continue to carry the heavy load of trying to halt the spread of disease and simultaneously bring relief to addicts.
The Twin City syringe exchange opened its doors to little fanfare but sparked debate among some West Salem residents, revealing the deep-rooted fears that people continue to have about drug users.
Out in the open
Tegan Rae moved to the West Salem neighborhood when she was still an infant. At the time, the area suffered under the perception of being rundown and crime-ridden, and she recalled having difficulty organizing sleepovers at her house on Montgomery Street because the parents of some of her friends refused to let their kids stay overnight in the neighborhood.
Rae currently rents a house on Green Street where she and her fiancé are raising a child of their own. Although she complains that suspicious activity continues in the neighborhood, conditions overall in the area have improved since she was child.
When she first learned about the Twin City Collective on Facebook, her initial reaction was shock and concern. She shared the information on the West Salem Neighborhood Association Facebook page and asked if other residents had heard about the syringe exchange. Many had not.
“It’s scary,” Rae said. “A lot of the neighbors were angry about not being told ahead of time and about what the exchange would mean for our neighborhood.”
As a new parent, her primary concern is that the syringe exchange will increase crime in the neighborhood. She is particularly worried that increased foot traffic puts children getting on and off the school bus or playing at nearby Granville Park at risk.
Negative encounters with drug addicts fuel Rae’s fears about the type of people the syringe exchange might attract to the neighborhood.
“A junkie is a junkie,” she said.
“I have known drug users in the past and they didn’t wait to start shooting up. I am afraid that they would just go in the park and start using. Going into people’s houses to rob.”
In order to address residents’ concerns about the exchange, Miller and Mishoe agreed to speak to a special meeting of the West Salem Neighborhood Association. The meeting was a heated discussion, according to various attendants, precipitated by concerns about the syringe exchange.
Kate McFarland, who lives directly next to Green Street Church, also worries about increased foot traffic in the neighborhood and the potential for more crime.
She, too, recalled souring experiences with drug users who stole items from her or roommates who used drugs and refused to pay their share of the rent.
“I don’t want to have more users in my neighborhood,” McFarland said. “I think that was perceived by several people as me saying, ‘I don’t want poor users in my neighborhood or I don’t want those people in my neighborhood.’ That’s not the case. It’s a general level of comfort that I have with these experiences and I don’t want to have it again.”
Like other residents, McFarland was unfamiliar with the concept of harm reduction. She believes much of the pushback from residents occurred because they weren’t notified beforehand about the syringe exchange until it had already began operating.
Melissa Vickers, the former secretary of the neighborhood association, credits the group with decreasing crime in the area through the use of good communication among residents and with the police. In 2015, association members helped close the Royal Inn, a nearby hotel that they claimed was a breeding ground for drug dealing and prostitution. Discovering on Facebook that a syringe exchange had opened up down the street was an affront to the neighborhood association’s efforts being made for greater communication, Vickers said.
“There have been great improvements to this area the last 10 years,” Vickers said. “We’re all about communication. When there was no communication given and we found out on Facebook, there was a lack of general respect shown to our community.”
While she is not active within the neighborhood association, Akwete McAlister is a member of Green Street church and she had not heard about the exchange in advance either. She supports the work of the exchange and sees how it complements the progressive social programs that the church is already known for, like its dinner service, food pantry and free health clinic.
She wants a clean, safe community like everyone else in West Salem, she said, but she worries that efforts to curb crime could also have the effect of driving people out of the neighborhood.
Of the 19 syringe exchanges founded in North Carolina since July, the Winston-Salem exchange is the only one that has encountered neighborhood resistance, said Tessie Castillo of the NC Harm Reduction Coalition.
“In general, people are afraid that having people who use drugs gather around will lead to increases in crime and drug use,” Castillo said. “This is not actually true, but the perception is there. Most people prefer for the drug use in their neighborhoods to be hidden, but syringe exchanges bring the issues more out in the open and a lot of people feel uncomfortable about that.”
Syringes exchanges do not increase crime, whether they operate in residential or commercial areas, according to one research study conducted in Baltimore and published in the American Journal of Public Health.
Though stats assuaged McFarland’s fears, she wants to see for herself whether Winston-Salem will follow the same trend
A part of the community
While some West Salem residents wonder why the exchange couldn’t have been located somewhere else in the city, the widespread opiate epidemic has blown holes in commonly held stereotypes that place drug abuse mainly among the poor and in communities of color.
“We might be doing pretty good if we were over in Buena Vista,” Miller said. “We’re not talking about people who live on the east side. We’re talking about suburban kids and kids from ‘good’ families. This is the face of the modern opioid epidemic.”
To effectively combat the problem, syringe exchange needs to happen where there is addiction.
Locating the syringe exchange at Green Street Church was an obvious choice for Miller. The church is located minutes from downtown and it is located on a bus route. Miller also lives in the neighborhood and wanted to set up the syringe exchange for drug users who reside in the area.
Miller hoped that the symbolism of locating the exchange at a church could chip away at the persistent belief that drug use is a moral failing, one that is particularly prevalent within Southern Christian communities.
He recalled Matthew 25:40 when Jesus told his righteous followers, “Truly, I say to you, as you did it to one of the least of these my brothers, you did it to me.”
“The way that we treat addicts, prostitutes, the least of these if you will, of which I count myself one, is horrible,” Miller said. “Things can get very nihilistic in drug culture. To then tell that person that they’re a bad person and they need to go to prison and be punished for their behavior, I feel like most addicts have been through enough punishment even without all of that.”
Rae hopes that the exchange is successful but she and her young family are looking to move out of West Salem not only because she fears the rise of crime in the neighborhood but also rising rent prices.
Vickers believes that the complicated issues that diverse neighborhoods like West Salem face will be overcome
“I hope that there’s a success story of people going into rehab and saving lives,” Vickers said. “I hope that there are no negative consequences to our community at large.”
McFarland, who owns her home, says she will remain in the neighborhood for the long haul. She cites Miller’s commitment and the dearth of research about syringe exchange for giving her cautious optimism about the Twin City site, despite lingering fears about increasing crime and lowering property values.
“Do I think that will be the situation with the needle clinic?” McFarland wondered. “I don’t think so. I hope not. Until people begin to fully understand the disease of addiction and the way that it harms people and the ways that we can still treat the addicts like humans, it’s going to be a hard sell for some people.”
After a rocky start, Miller believes that even the most vocal opponents of the Twin City Collective have come around to the idea of it remaining in the neighborhood.
“They’re still weary but they’re willing to work with us and they see that we’re trying to put their concerns to rest and be a part of the community,” Miller said.
At the West Salem Neighborhood Association meeting, Mishoe and Miller apologized for not notifying residents about the syringe exchange sooner. Mishoe told the residents that they were so excited to open the Twin City Collective in the wake of syringe-exchange legalization that they went forward with their plans without thinking to tell their neighbors.
Mostly though, it came down to saving lives. In the midst of an opiate epidemic with no end in sight and deaths from overdoses rivaling those at the height of the AIDS epidemic, Mishoe and Miller are keenly aware that time is life.
“I would rather ask for forgiveness and be available,” Miller said.
At the peak of the neighborhood debate when she feared that the purpose of the syringe exchange would be overcome by misunderstanding, Miller urged Mishoe not to take her “eyes off the prize.” invoking the Civil Rights-era folk song “Keep Your Eyes On the Prize.”
“The prize is for everyone to get off of drugs because they felt valued as a human because of this program,” Mishoe said. “Even if it’s one person, that’s why we’re here.”
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The pros of needle exchanges likely outweigh the risks associated with the programs. Public health experts have recommended needle exchanges to combat disease outbreaks for decades.
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The pros of needle exchanges likely outweigh the risks associated with the programs. Public health experts have recommended needle exchanges to combat disease outbreaks for decades.