This is the third analysis in the “Epidemic in a Pandemic” series that looks at what has happened to substance-use treatment access and effectiveness during COVID-19. Read the first analysis here.
Border cities are characterized by their dynamism, their vitality. There are always people here and there; there is always something to do; they are vibrant cities and, perhaps, that is why they become such exciting cities. Today, in the face of the COVID-19 epidemic, cities like Mexicali, Tijuana, and Ciudad Juárez have come to a standstill. Streets are empty, businesses are closed, and the long lines of cars trying to “get to the other side” have disappeared. The border is closed. The only people visible live on the street, wandering around looking for something to eat, something to pick up. They have nowhere to go and among those with substance dependence perhaps the only place they can go is to the syringe-exchange, that is if they are lucky enough not to be detained.
Despite the risk generated by COVID-19, and precisely for this reason, Verter, Prevencasa, Centro de Servicios Ser, Programa Compañeros, and Irapuato Vive—organizations that implement harm reduction interventions in Mexicali, Tijuana, Ciudad Juárez, Irapuato, and Guanajuato, respectively—continue to offer their services to the population of people who inject drugs. Nevertheless, the situation is becoming critical due to the shortage of supplies and the increasing police harassment targeting the population who are mostly homeless.
“We try to take care of ourselves as much as we can, but we don’t have protection supplies for us, at least not enough. We provide services with great care. We know that counting on us makes all the difference for this population, and that is why we do not close, despite the risk … I think that if we close, we leave these people to their fate, and we cannot do that. We will provide the services while we can, until we run out of the last syringe.”
Lourdes Angulo, Verter, Harm reduction provider
One of the most critical challenges facing harm reduction organizations in Mexico today is the lack of public funding. Since 2019, when a presidential decree eliminated federal public funding for civil society organizations, the ability to offer health services to the population of marginalized drug users has been at constant risk. Not only do they not have resources to pay the professionals who provide the services but the necessary supplies are increasingly scarce.
“We had a bank of syringes, but we already used all the supplies, and we don’t see from where we could have enough supplies again. We always depend on international donations and projects that come our way, but it is living in uncertainty. Now with the COVID-19, everything gets more complicated, since the borders are closed, so even if they donate to us, there is no way to get them to this side. We do not have any support from the national government or state governments.”
Alfonso Rivera, Prevencasa, Harm reduction provider
In this uncertainty, COVID-19 arrived and made more complex the work conditions of people in the field, offering health services to a population that does not otherwise have access, due to the stigma, discrimination, and criminalization of people who use drugs.
“It has happened to me that I have tried to enter the General Hospital and simply, the guard when he sees me, will not let me in, he tells me that I need identification, but I know that is because of how I look. So, I highly value the service these boys provide, because I know that I can come here and they heal my wounds, they know my name, they offer me a glass of water … They never make me feel bad for using drugs or living on the street.”
A user of harm reduction services in Tijuana
Substance-dependent people not only require information on how to prevent COVID-19, something that organizations have been providing since the beginning of this year, but they also need access to water, soap, and sterile supplies (e.g., syringes) to avoid infections. Giving information without distributing the necessary supplies is useless. It is opening demand that cannot be satisfied due to the extreme living conditions of the population that is served by harm-reduction organizations in Mexico. However, the national government remains deaf to the clamor for support.
In Monterrey, Acodemis, the only organization offering harm-reduction supplies, has been forced to suspend the distribution of kits due to lack of resources. In other words, in Monterrey the reduction activities have stopped. In Tijuana, the organization Centro de Servicios Ser has also halted operations for lack of supplies and is waiting for donations to reactivate its services.
In these conditions, organizations have had to resort to their social capital to meet the pressing needs faced by substance-dependent people, because as they explain, “we cannot just say, ‘sorry, I do not have.’ You feel the commitment to support them; you are not going to let them die while you take shelter in your house.[1] Before COVID-19, the concern was to buy supplies for safe consumption of substances. Today the need to offer water, soaps, antibacterial gel, food, face masks, and gloves has been added. For this, raffles and requests for donations have been solicited from family, friends, private companies, and international organizations. It has been this support that up to now has allowed the work to be sustained. Five years ago, there were five harm-reduction organizations in Tijuana, today there is only one left. Without government support, the fate of these organizations is death.
For example, in Ciudad Juárez, Programa Compañeros installed portable water stations in the consumption spaces, where they also provide safe supplies for injection, food, and Naloxone to prevent deaths from overdoses, thanks to donations from fraternal organizations in El Paso, Texas. It seems somewhat minor, but have you ever wondered how you wash your hands if you live on the street? In Tijuana, the people who live in the canal wash their bodies, their clothes, and prepare their drugs with the dirty water from the drain. In the absence of public drinking fountains or water sources, people on the street sometimes use the bathrooms of commercial establishments. Still, now that most of these businesses are closed, there is no way to access clean water sources, so that portable water stations become a life or death resource.
In Mexico, there are only two public clinics that offer methadone and around ten private clinics. However, fieldworkers have noticed that due to COVID-19, they are not receiving new “patients” and have limited the service hours.
In Tijuana, Prevencasa delivers soap, antibacterial gel, and washable cloth face masks, thanks to donations from the United Nation’s High Commission for Refugees (UNHCR)/La Agencia de la ONU para los Refugiados (ACNUR). Prevencasa has also managed to establish a working group in coordination with Sanitary Jurisdiction Number Two, Municipal Medical Services, and merchants in the northern area. Through this coordination, Prevencasa is offering COVID-19 screening tests to people who use injected drugs and who have any symptoms. People who test positive are offered shelter in a space adjacent to the organization, which was adapted to receive them, where they will be provided with food, medical care, and methadone until the end of the recommended period of isolation. To date, no cases have been detected, but they can offer shelter to 60 people who inject drugs, who live on the street, and who are positive for COVID-19. This is a unique strategy in the country that should be replicated in each city of the Republic, if the public were interested in serving this population.
But much more is required. For example, there is an urgent need for access to opioid replacement therapy. In Mexico, there are only two public clinics that offer methadone and around ten private clinics. However, fieldworkers have noticed that due to COVID-19, they are not receiving new “patients” and have limited the service hours. Policies have not been relaxed so that people can take more doses home and prices have not been reduced. In Estado de Mexico, the most important public institution that delivers treatment for problematic drug use (Centros de Integración Juvenil (CIJ)), are also not receiving new patients. Some of these CIJ are not even providing services for their established clients. Under these conditions, people who use drugs in Mexico are called upon by the National Commissioner on Addictions (Conadic) to practice “temperance” or to “reduce our consumption” but neither the resources nor the conditions are offered so that dependent people can effectively do so. Public institutions seem to live in a different reality, so they do not even have sufficient empathy to assess the challenges faced by people with dependency and who live on the margins.
“The situation is tough here in Juárez. The shiva [heroin] is very cut [mixed with other substances to make it work]. So the doses are not enough now to even remove the malilla [withdrawal syndrome], so what the users are doing is stuffing themselves with pills and alcohol… It is despair. To top it off, there is no methadone. Today one of the clinics closed and the other only provides services for a few hours but does not receive new people. That’s why overdoses have increased, last week I learned of two who overdosed; they did not have Naloxone.”[2]
Gisela Zambrano, Co-President of the Mexican Harm Reduction Network (Redumex)
According to Alfonso Rivera, who works for Prevencasa, in Tijuana, the Red Cross is no longer attending to overdoses because they are overwhelmed transporting people with COVID-19, which is the priority of all health units, in addition to the daily emergencies of the city. In Juarez, the network of public hospitals are not receiving people who use drugs and present any COVID-19 symptoms, the argument is that they only receive COVID cases. The substance-dependent population is left to die, and there is not even a record of what the figures for these deaths are. These lives do not matter to authorities and therefore are deaths that do not even merit being counted.
However, there is a way in which the state does become very present in the day-to-day lives of people with substance dependence and who live in conditions of marginality: it is in the constant police harassment, which has intensified. Detentions for 72 hours and forced internment in nongovernmental treatment facilities called “anexos” have increased. The mass detention of people, in addition to being illegal, unnecessarily exposes them to COVID-19 due to the overcrowding or lack of water that many of these establishments face. These measures end up causing substance dependents to hide and isolate themselves, growing their probability of sharing syringes, and reduces the possibility of accessing sterile equipment.
“Police harassment is experienced here daily and intensely. Users cannot stick their heads out, because they are immediately jumped on by the police, either to commit them to an ‘anexo’ or to take them to the preventive unit. In any case, they are depriving them of their freedom and that, during this moment of COVID-19, puts at risk, not only them but the entire population, because by locking them up, without adequate hygiene measures and in overcrowding, they make the perfect mixture to sky-rocket the pandemic.”
Rosario Padilla, Centro de Servicio Ser, Harm reduction provider
“You can’t go out; everyone is scared within their tapias [shooting galleries] walls, because the police are hanging around, and as soon as they see a user, they are beaten and taken to the preventive unit. That is why everyone here is getting very high [using drugs intensely].”
Gisela Zambrano, Redumex
In addition to police violence, substance-dependent people face violence from organized crime. In Guanajuato, for example, the levels of violence have risen to such an extent that it was not possible for the harm-reduction organization, Irapuato Vive, to continue maintaining its community outreach strategies. People who require safe consumption equipment in Guanajuato now have to travel to the organization’s offices, which exposes them to arbitrary arrests by the police, as they are violating mobility restrictions.
To this, we must add the increase in economic distress and the uncertainty of not knowing when everything “will return to normal.” As Julián Rojas, from Programa Compañeros, and Alfonso Rivera, from Prevencasa, said, “there are no patios to sweep, gardens to clean, cars to clean, the sentry boxes remain closed, the shops, restaurants, bars are closed, so there is nowhere to go for money. The only way to survive is to collect the favors they have done, which generates new tensions among the population.” This overriding need for a dose, for a few pesos, exposes people to an increased risk of recruitment by organized crime organizations, which always have a task to offer.
The pandemic has made evident the institutional helplessness experienced by the substance-dependent and vulnerable populations. In the first place, due to the indifference with which federal health authorities treat this population. and secondly, due to criminalization by local authorities. The epidemic reveals wiping out as the de facto policy towards this “surplus,” “annoying,” and “dirty” population.
In this scenario, concrete actions by the federal government are necessary to guarantee the right-to-life and health of all, regardless of the condition as users or nonusers of substances, dependency or nondependency. Today more than ever, Mexico needs a public harm-reduction policy that is an integral component of the national plan against addictions. It is not enough to tell users not to share their consumer supplies. They need more supplies, so that they are not driven to share. It is time to move from discourses to adequate support for the population experiencing situations of dependency on substances, beyond stigmatization and confinement.
NOTES
[1] Lourdes Angulo, Verter, Harm Reduction provider
[2] Naloxone is a medication that reverses the effect of opioids. In Mexico this medicine is not available because the General Health Law has classified it as a narcotic and therefore a prescription is required, and a doctor applies it. For this reason, even ambulances do not carry Naloxone and it is not available in pharmacies. Some civil organizations that provide harm reduction services have community distribution strategies for Naloxone thanks to the support of international donors.
ABOUT THE AUTHOR
Angélica Ospina-Escobar is a CONACYT assistant professor in the Drug Policy Program at Centro de Investigación y Docencia Económicas (CIDE), Región Centro and a founding member of the Mexican Harm Reduction Network (Redumex).
READ THE SERIES
In “Epidemic in a Pandemic” the Rockefeller Institute’s Stories from Sullivan team examines what has happened to substance-use treatment access and effectiveness during COVID-19. Follow along here and on social media with the hashtag #StoriesfromSullivan.
