COVID-19 Harm Reduction in Tijuana: an "All Hands on Deck" Type Situation
Source: Hans-Maximo Musielik
In this interview, carried out at the DPA Reform Conference in St Louis, MO in November 2019, harm reduction workers in Tijuana, Mexico, discuss the urgency of their work and the lack of government support for protecting the lives of people who use drugs. Between a desperate need for greater access to resources and medical supplies, and the overwhelming violence of state surveillance, the need for a cultural and political shift in attitudes towards people who use drugs had never felt so urgent. Until now.
Amidst the current COVID-19 crisis, harm reduction workers are continuing to work at reduced capacity, concerned about the possibility of forced closure mandated by the government or due to lack of resources. At present, there is unclear advice regarding whether all harm reduction activities are being suspended in the region, but with the border closed it is now much harder to bring donated supplies, such as syringes, from the US into Mexico. Only goods deemed ‘essential’ are allowed through.
As of 27th March 2020, staff at Prevencasa, a harm reduction NGO at the US Mexico border, have only enough naloxone, a drug used to reverse opioid overdoses and save lives, to last a couple of weeks.
Who are you? What do you do?
Alfonso: My name is Alfonso and I’m a harm reduction worker in an NGO in the red light area of the city, which has a lot of drugs.
Rebecca: And I am from PrevenCasa and I’m a Physician – I take care of the medical part of our work.
Jaime: And I’m Jaime. I’m Professor of Drug Policy at CIDE and I work for PrevenCasa and work on harm reduction projects at the border.
What does your day-to-day life look like?
Rebecca: We see on average 100-150 people a day who come in for the needle exchange and for medical services. A large proportion of them are homeless or have been deported, so a lot of them don’t have healthcare and insurance. So we support them to get that. There are many risk factors that come together: homelessness, injecting drug use, and other high risk activities. We see a lot of infectious diseases, HIV, Hep C, TB, skin abscesses – all that comes with the territory in terms of risk factors.
Right now, one of our biggest issues is that our funding was cut this year, so we rely on a small grant from OSF. We are a small staff, the others are pretty much donations, cash, supplies… right now needles, Narcan, all our supplies are pretty much donated. We’re on pause for a minute, but we are back on track to starting our HIV clinic so we are operating a satellite clinic to the main clinic in Tijuana. So most of the people we see are entitled to Seguro Popular (popular insurance), which is a type of public insurance. There is only one type of clinic available in the city that offers specialised HIV care, so around 3000 patients are seen at the main clinic.
But one of the highest risk factors for HIV is poverty – the nearest clinic is over 2 hours away, and it’s unreasonable to ask people who inject drugs at the border to travel if you are going through withdrawal – which you probably will, given the time it takes to get there and see a doctor and get your meds, all the stuff that you need to get through, so most people just don’t go, right. Even now when we are on pause we provide rides to the clinic for people who tend to not show up because you know it’s too much to ask for people in this situation, to go over there. So what we try to do is try to run as many of those services as possible as we can inside, including diagnosis, treatment, counselling etc.
Jaime: In recent years we have been receiving funding through the ministry, who give national grants to provide harm reduction related to HIV and Hep C too. This last year the new Government decided to cancel all funds for NGOs in the country, including harm reduction NGOs such as ours.
We used to have an outreach programme also, that would move from outside bars in downtown Tijuana, who were far away but still injecting, and to try to divert them to services but we had to stop that outreach service because we didn’t have the staff or the money to carry out these tasks. Right now we’re thinking that there is syringe exchange left for one month. And we are just trying to survive on short term grants, like Rebecca said, from OSF, or some other research grants that we’re able to get through university contacts that we have in the US.
So right now for example, Alfonso delivers one syringe per client, per day.
Are the syringes single use (which can minimise risk of BBVs and other infections)?
Jaime: No, we don’t have those in Mexico.
If you had unlimited funding how many syringes would you use / give out?
Alfonso: At least 10 per day per person. Dreaming! You know. The ideal would be to have one syringe used per injection. But we are down to one per day. We’ve been emphasising a lot, now that there is more information about the dangers of sharing syringes, to remind people not to share syringes. But also now we have to educate people on how to clean their syringes and minimise the risk of infection.
What is needed in the immediate future for you to be able to continue doing your work?
Alfonso: For the government to stop criminalising drug use and people who use drugs! It’s ironic that the Mexican government have created this Fentanyl Crisis campaign, about how Fentanyl kills on a national level, but when we are the ones helping people on the street who are at risk of a problem, they’re not giving services to them.
Rebecca: The irony is that we have this campaign, but they care so little that we don’t even have any statistics about how many people die from overdoses in Mexico. They’re non-existent – they are invisible. And the criminalisation and stigmatisation of this community is not only amongst policymakers. The perception of the public is very important because, you know, these are the voters and the people who we also need on board, I think it’s an uphill battle. It’s not moving, it’s not changing really. People are dying from communicable diseases all the time that shouldn’t – in theory they have access to treatment but they have to get to the call centre to get treatment for tuberculosis, but they can’t get there, because they get stopped by the police, you know, they are criminalised just because they are carrying a syringe, or an unopened syringe. It’s terrible to see people die from not only preventable but curable diseases - they deserve access to care.
Jaime: I think they both make great points. One is the criminalisation of people who use drugs, right? We have a president that hasn’t really moved forward on the changes that he said he was gonna be doing. And then on the contrary he’s doing this public dialogue where he’s saying we should stigmatise people, we should point our fingers at them so there is shame with what they are doing. And that makes it even more difficult to try to convince the general population that this is a problem, right?
So for example we have this campaign about Fentanyl, but we don’t have numbers to back it up or to explain why people are dying of overdose in terms of the exact causes. The government is just registering that people are dying - the rhetoric is that if they die they deserve it because either they were using drugs, or they were involved in organised crime.
Rebecca: So they are using fear-mongering to say to people: if you use drugs you are going to die.
Jaime: So we talk about it and it’s like having to go back to Just Say No, you know, about scaring people about drug use, instead of educating people about drugs, right? I mean I think we have all learned that it’s not the substance itself, but the conditions of marginality and health that affects the people we work with. It’s difficult to try to help a population if we don’t have anywhere to house them. They don’t have access to ID, the police, many times, will take it from them.
Alfonso: The rhetoric of criminalisation comes from the politicians and it gets reflected onto the police officers on the streets, then it gets reflected by the broader institutions of the state, for example the medical institutions that criminalise, or hound people that use drugs, that insist on asking for ID, that get stigmatised throughout all these services that you should be entitled to have access to. And that makes it hard for us, because it generates fear in the community of people who use drugs.
Rebecca: There is money being spent on anti-drug campaigns, and families against drug addiction, and there is money from the national guard supposedly to take care of this problem, but the government is doing nothing to take care of the social determinants of health and issues that actually lead people into problematic drug use, because they also see drug use as a blanket “this is wrong, we need to combat drug use”. But it's more, you know, the misery in which most of our clients and the people that we see live in. I mean if you were to spend a day in their shoes you would also want to do drugs, these types of drugs. But that’s not being addressed.
Alfonso: In addition to the population we already have, we have a growing population at the border. Migrant caravans who arrive in these communities put an additional burden on organisations such as ours to provide services. And I have seen Haitian communities, Central American communities, who have started consuming drugs for the first time here at the border. And that makes it twice or three times as hard to resolve the problem, because it is always growing.
Rebecca: Nearly 70% of people who we see have been deported, so we see people who are fleeing violence, trauma, horrible conditions already and they are not integrated into society, they are not allowed to be from either country – they are just stuck there waiting to go to the US, to see their family... and you know they already have so many issues, so much pain to carry with them. The government is not doing enough to support them to be integrated and find jobs and get access to social healthcare. So, we, as a nation, are perpetuating and creating these conditions!
Jaime: In Mexico, well, all around the world, people don’t care about people who use drugs. There are so many things happening in Mexico. So much violence, so much pain, so much fear that when we talk about people who use rugs they’re like, well, we don’t care about them. We still hear people who say you know, let them die. We have to get rid of the problem. We are trying to explain that drug use never stops. Drug users are – you cannot wish them away, they are your community.
We are there because the community needs us – we aren’t promoting drug use or anything like that like they say. We are there because there is a problem and we are trying to help solve that problem. I think we all have a desire to help the community, we just have to do it together. We need to do it, the government needs to do it – we all need to help because this is a really big problem. People who use drugs should not be seen as the enemy. We should be working hand in hand with the community to help their health.
How can people support or amplify your work? What do you need from the wider community?
Alfonso: The most urgent things are the supplies.
Jaime: The problem is that with the money that we were getting from the government, more than 60% of it was used for supplies, syringes, cookers, water, and we don’t have that right now. We cannot be a needle exchange programme without needles! We’ve been really grateful to hear from organisations internationally who are willing to donate materials for us.
But the current policies of the Mexican government make it hard or sometimes even impossible to even get these international donations. For example – we don’t have naloxone in Mexico – well, we have it, but it is for private pharmaceuticals and costs $25 per vial. So people are willing to donate it – but we can’t afford to pay the taxes on it to get it across the border. Same with syringes. People have offered 1000s of syringes but we need to find a way that the Mexican government, if they’re not going to give us money, at least they don’t make it harder for us – do no harm! Right?
Ideally, we could receive donations of supplies and bring them freely into our country. So one way people can support us would be to raise awareness and amplify just how big of a problem this is. We’re in one of those moments where if we stop doing this work, HIV rates will go up. And then we’ll be here in one year saying – well what happened? Well what happened is, you didn’t give syringes to people who were using drugs, and then the rates are just going to go up, overdoses are just going to happen more, and we should be utilising preventative harm reduction strategies before that happens – otherwise we are just in a situation where we have to figure out how to fix something after we’ve already broken it.
Rebecca: Donating, keeping up with our social media, getting involved, giving us feedback, we want to hear from the international community and the people who are doing this already in different contexts so that we can work on solutions, if you have any ideas, grants we can apply to, anything helps.
Anything else you’d like to say?
Jaime: I just want to raise one thing: people who use drugs and harm reduction workers are the people on the frontlines. And then we hear these politicians giving a speech on an international level, the UN ambassador for Mexico saying that we are going to do things differently, we are going to stop criminalisation, we are going to legalise, and stop the war on drugs. But what do we see in the community? The police are heavily armed, the army patrols the streets, people who use drugs are the first victims of this.
And it’s frustrating to hear people on an international level saying wow you have such a nice president who’s going to change these things, (as TalkingDrugs previously reported), and to have to tell them – well, guess what?! No. It’s even more chaotic, there is more violence, more stigma; there are less resources and more problems.
This is an all hands on deck type of situation, because it’s extremely grave what is happening in our country. Alfonso has seen people die – being shot just outside the organisation, as well as overdose situations. But we only hear the politicians say that everything will be better. Whilst at exactly the same time they are taking life saving resources away from us.