Kole Taylor knew the Health Equity Alliance's syringe shortage was dire when, in August 2024, a client who otherwise used new supplies told him he was playing "needle roulette."
Needle roulette, Taylor said, is when a person reaches into a container of used syringes and uses whichever one they pull out to inject drugs.
It was the first time the now-former employee at the Health Equity Alliance, commonly referred to as HEAL, remembers the organization running out of supplies since he joined in February.
"As supplies dwindled down, we got anxious because we didn't know when our next supply would come in and how we could support these people," Taylor said.
HEAL's role as the largest sterile needle provider in Bangor came to a crashing halt last month when the Maine Department of Health and Human Services revoked the organization's certification as a syringe service provider on Nov. 4, due in part to HEAL's lack of supplies as noted during a site visit by DHHS on Oct. 18. HEAL then furloughed most of its staff, ended its syringe exchange program and closed its community center.
Those actions came after more than a year of financial turbulence that jeopardized the organization's ability to serve the area's most vulnerable residents, according to six current and former employees interviewed by the Bangor Daily News. Their allegations raise concerns about the organization's future amid an active HIV outbreak in Penobscot County that has so far resulted in 14 confirmed cases of the disease.
HEAL employees detailed their concerns and grievances in a 41-page letter that was sent to the organization's Board of Directors in September and to the Maine Center for Disease Control and Prevention in October. The BDN obtained a copy of the letter, in which employees describe "a lack of accountability, transparency and strategic planning" among the organization's leadership that they allege led to multiple supply outages.
HEAL employees came forward with their concerns after the organization's board of directors decided to keep executive director Josh D'Alessio in his position after conducting an internal investigation, Heath Myers, a HEAL employee since April, said.
"This organization works every day to empower marginalized communities and realize health justice," the board's spokesperson Dan Cashman said. "The board feels that the staff we have in place does that work very well for this community."
The organization's most severe syringe shortage occurred in September through November 2023, according to employees.
"This was the first time in years that we ever ran out completely," said one employee who worked in HEAL's syringe exchange for at least two years and who spoke on the condition of anonymity out of fear of retaliation by the organization's management. "There were times that we ran low, but never to this scale."
The organization's stock of harm reduction materials, such as syringes, tourniquets and alcohol wipes, dwindled as employees rationed supplies to clients. When items ran out entirely, employees said other organizations, including Wabanaki Public Health and Wellness, loaned HEAL materials.
Lisa Sockabasin, CEO of Wabanaki Public Health and Wellness, confirmed that the organization gave HEAL more than 2,000 sterile syringes in October 2023.
This was a departure for HEAL, which was considered one of the region's premiere social service organizations for decades since being founded in 1988 as the Down East AIDS Network.
The organization was one of three state-certified syringe providers in Penobscot County that distributed sterile materials to people who use drugs and also collected used needles. That work prevents people who inject drugs from reusing or sharing supplies, which can spread bloodborne diseases.
From November 2022 to October 2023, HEAL's Bangor location gave away 658,627 sterile syringes to 1,062 people enrolled in the exchange program, according to a 2023 annual report of Maine's syringe service programs, making it the largest provider of sterile syringes in the county. It collected and disposed of 591,138 used needles during the same timeframe.
HEAL has a $350,000 annual contract with the state to be a certified syringe provider, according to D'Alessio. That funding covers the cost of operating the organization's Bangor and Ellsworth locations, purchasing harm reduction supplies and paying four and a half employees.
The contract the organization has with the state requires HEAL to foot the bill for operating its syringe exchange, then send an invoice to the state to be reimbursed roughly $29,000 each month, D'Alessio said.
While this system can suffice, D'Alessio said HEAL and other small organizations that don't have good credit or an endowment can run into trouble when the state's reimbursements get delayed. HEAL usually doesn't have the extra funding to cover its expenses until the state's payments arrive.
"When we run low, there isn't another pocket of money sitting somewhere," D'Alessio said. "The first thing I do when I wake up in the morning is check the state payment website and see if the payment's been processed."
When the organization's stock of materials was depleted in the fall of 2023 and no new supplies arrived, employees said they brought concerns to management. Multiple HEAL employees told the BDN they were told by D'Alessio that the organization's shortage of syringes and other supplies was due to funding from the state not arriving when promised.
D'Alessio confirmed HEAL saw a "significant shortage" of harm reduction materials in October and November 2023 due to delayed payments from the state that the organization needs to purchase the supplies.
When asked if the Maine CDC had ever delayed funding to HEAL, Maine DHHS spokesperson Lindsay Hammes said funding was initially delayed in spring 2024 due to "invoicing that was inconsistent with contract terms."
The Maine CDC and HEAL resolved the invoicing issues and funding was restored in June 2024, Hammes said. But that delay depleted the organization's stock, multiple employees told the BDN.
D'Alessio explained that HEAL's reimbursement payments were delayed twice because an employee wrote the wrong organization identification code on the invoice documents. On other occasions, "math errors" in the invoice stymied payments, but D'Alessio couldn't remember the details of those errors.
HEAL received the last shipment of harm reduction materials on June 19 and staff were told those supplies would last for two to three months, according to the employees' letter.
Employees urged D'Alessio to order more harm reduction supplies in August 2024 because the organization was running low, according to emails obtained by the BDN.
In an Aug. 30 email, the employee told D'Alessio that the organization was entirely out of some supplies and would likely be out of more, including syringes, by the end of the week. Because of the lack of materials, the employee also reported hearing HEAL clients discuss reusing or sharing materials.
"If we have to limit or be without syringes, I am certain that people will resort to sharing, or using syringes they are finding," the employee wrote. "I am deeply worried about the impact this will have on our community and the risk that this lack of supplies is putting people in."
By Sept. 10, HEAL's syringe exchange was entirely or nearly out of various items the organization distributes to those who use drugs, the employees' letter reads.
D'Alessio alleges the organization hasn't grappled with shortages in 2024 outside of a few items getting low due to supply chain issues.
"I don't remember any significant shortages in the spring," D'Alessio said. "If there was one and someone showed me there was proof of it, super, but I don't recall it."
HEAL's financial woes aren't new.
The organization faced a $400,000 shortfall when D'Alessio became HEAL's interim director in the fall of 2022. He said keeping the organization afloat at the time was "a gargantuan leap."
"I was not handed a ship that was seaworthy, but getting us to a point where we have long-term financial stability is my goal," said D'Alessio, who was made HEAL's official executive director 18 months ago. "I'm proud that we're still here."
Employees witnessed the effects of the supply shortages firsthand.
Myers said he found someone suffering from "cotton fever" in the bathroom at HEAL's community center. Cotton fever is a series of flu-like symptoms a person can experience after mistakenly injecting bacteria into the bloodstream when using drugs, usually when re-using contaminated materials.
The HEAL employee who worked in the organization's syringe exchange for at least two years said one client who injected drugs for decades and never reused or shared syringes came into the exchange with wounds from an infection from his wrist to his elbow.
In another case, a HEAL client who was unable to receive enough sterile syringes asked a HEAL employee how they could clean needles in order to reuse them safely. That HEAL employee, who worked in the organization's harm reduction department for more than a year, spoke to the BDN on the condition of anonymity due to fear of retaliation by management.
Meanwhile, the Maine CDC issued a health advisory in February after three people in Penobscot County tested positive for HIV and hepatitis C beginning in October 2023. Two people reported injecting drugs with used or shared syringes.
Typically, Penobscot County has seen one new HIV case among people who inject drugs each year over the last five years.
HIV is a virus that attacks a person's immune system, destroying cells that fight infection and disease, according to the CDC. It can be controlled with proper medical treatment, but there is no cure.
Hepatitis C is a liver infection that can be a short-term illness in some people, but becomes a chronic condition in more than half and leads to serious and life-threatening conditions like cirrhosis and liver cancer, according to the CDC.
By August, the number of new HIV and hepatitis C cases in Penobscot County surged to 13 all among people who reported injecting drugs within the last year, the Maine CDC reported. A 14th case was diagnosed in November.
HEAL staff claim they urged D'Alessio to alert the Maine CDC to a possible connection between the supply shortages and the HIV outbreak.
"Given the severe shortages of supplies that preceded the HIV outbreak fueled primarily by intravenous [drug use], the probability a link exists between these events is significant enough to warrant further inquiry," staff wrote in the letter to the board of directors.
Despite staff's concerns, the Maine CDC and D'Alessio deny there's any connection.
The Maine CDC does not have any evidence that the disruption of HEAL services has contributed to the cluster of HIV cases in Penobscot County, according to Hammes.
While D'Alessio said he worried about the spike in HIV locally, he doesn't believe HEAL's shortages contributed to it because other local organizations continued to provide syringes.
During the organization's severe shortage in fall 2023, for example, Needlepoint Sanctuary brought sterile supplies directly to the city's largest homeless encampment and HEAL was still able to dispose of the contaminated needles for them, D'Alessio said.
HEAL staff forwarded a copy of the letter sent to the board of directors to the Maine CDC on Oct. 15, Myers said.
Three days later on Oct. 18, the Maine CDC conducted a site visit at HEAL, in part, to resolve the organization's invoicing areas, Hammes said. The Maine CDC also conducts annual site visits with all contracted syringe service program providers.
Hammes did not respond to questions regarding whether the Maine CDC conducted any other inspections of HEAL since it became a state-certified syringe provider. Hammes didn't provide details on what was discovered during any other inspections of HEAL.
The Maine CDC suspended HEAL's license to distribute syringes on Nov. 4 due to the organization's failure to follow the state's syringe exchange policy, lacking the appropriate syringe service supplies and inaccurately collecting data, among other violations, according to a Nov. 4 letter the state sent to HEAL.
The state came to this conclusion after inspecting the organization, reviewing documents HEAL was required to submit and interviewing employees, according to the letter.
"We take these statements of deficiencies seriously and view them as opportunities to improve," D'Alessio said. "Ultimately, we're only here to serve the community and we want to do it well."
It's unclear what comes next for HEAL.
On Nov. 14, the Maine Recovery Council voted unanimously to withhold two years of funding for HEAL because the organization is not a state certified syringe service provider. Pat Kimball, chairperson of the Maine Recovery Council, said the group will reconsider the decision if HEAL becomes a state-certified syringe provider again.
The Occupational Safety and Health Administration is also investigating HEAL after an employee filed an anonymous complaint on Oct. 31, the same day the organization furloughed most of its employees.
HEAL has lost standing in the community as well. Last month, the organization surrendered its role as the financial manager of the Bangor Pride festival to the Downtown Bangor Partnership.
HEAL also lost its contract with Bangor to pick up used syringes around town, D'Alessio said. That has affected the area's other syringe service providers. Wabanaki Public Health and Wellness, for example, has seen a more than 600 percent increase in the number of people looking to it for harm reduction supplies, Sockabasin said.
The Bangor City Council may also terminate more than $307,000 in unspent pandemic recovery funding it gave to the organization because HEAL is "undergoing an organizational restructuring and paused virtually all operations."
The city gave HEAL $694,700 in 2023 to create and operate its resource center, which opened in April and was intended to be a safe place where people who are homeless, use drugs or have a mental health diagnosis, can stay warm and access services.
HEAL's syringe service provider certification suspension lasted until Dec. 16, at which time D'Alessio had to submit a remediation plan to the Maine CDC.
In his remediation plan, D'Alessio wrote the organization would perform more frequent and thorough training with staff and create a new database to track and report the services the organization offers.
He also plans to better manage HEAL's inventory of harm reduction materials. Moving forward, D'Alessio plans to slowly build a bank of supplies that holds 20 percent more than what's needed. He also plans to create a "financial back-up" for harm reduction supplies to prevent shortages in the future.
Hammes confirmed on Dec. 20 that the Maine CDC received and is reviewing D'Alessio's remediation plan, but a final decision on whether to give HEAL its certification back hasn't been made.
If the Maine CDC restores HEAL's license, D'Alessio said he plans to call back the staff who were furloughed and believes "most" will return. The organization will close for two days to train staff, regardless if they've received training before, he said.
"We have a lot of very dedicated and mission-oriented folks who have earned the trust and built relationships with the folks we serve in the community," D'Alessio said.
It's unclear, however, how many of the furloughed employees will return.
Two furloughed supervisors, one full time and one part time, have left in the past 30 days, according to D'Alessio. Abby D'Alessio, Josh D'Alessio's wife who served as HEAL's harm reduction manager, also resigned on Dec. 11, Josh D'Alessio said.
Myers said he, as well as several colleagues, are "highly doubtful" they'd return to the organization. While they still believe in the mission of HEAL and the services it provides, Myers said many aren't willing to return without a change in the organization's leadership.
"We want it to be managed in an ethical way that protects its participants and employees," Myers said. "For many people, HEAL is a lifeline."
Despite the interruption in HEAL's services, D'Alessio believes the organization still has support from the community.
"Obviously, everyone wishes we were open today, but I think people are looking forward to a HEAL version 2.0," D'Alessio said.