In India, Illicit Pharmaceuticals Ravage Communities and Lives

A look at any survey by either a government or non-government agency shows that HIV/AIDS transmission in India involves three primary cohorts: sex workers, truckers, and injecting drug users (IDUs). Jahangirpuri's concentration of all three high-risk groups makes it a locus of India's HIV problem. The truckers who may contract the disease here will soon be on the road to all corners of the country, while many Jahangirpuri-area prostitutes -- by one count, almost 600 have tested HIV-positive -- will return home to their families, and be back in Azadpur market the next day for the night shift, and the next round of truckers.

A Project H13 survey from 2008 and 2009 found that 98 percent of all IDUs in Jahangirpuri were men, who by virtue of proximity to Azadpur and its free flow of drugs have had easy access to heroin, a party favor for many in the 1980s. It was the chemists providing pharmaceuticals over the counter to men with expensive heroin addictions that created the IDU epidemic in the mid-1990s. Rajiv, along with every recovering addict in Sita's care, tells a similar story. They'd drink with friends, then someone would suggest they smoke some heroin, which would soon become regular beyond the point of weekend recreation. That would get too expensive, and so pharmaceuticals were the next logical step. Even after business hours, a couple of pharmacists would sell the drugs from their homes, providing 24-hour access. Some still do.

Rajiv tells me that the only time you'll see dealers on the streets is when there's a shortage in the pharmacies. That hasn't happened "in quite a while", says Urdip, a 45-year-old autorickshaw driver, as he sits in Sita's centre with one leg tucked under the other, leaning against the wall, his shoulders in line with the ring of accumulated filth that demarcates the sitting area. "It feels good to get away from drugs," he leans in to tell me, though he knows that at this stage, just going out on the street would be too great a temptation to shoot up again.

According to the World Health Organization, an IDU's full physical recovery can take up to three years. But "the craving never dies in the mind", Rajiv admits, squinting one eye from the smoke of another beedi.

"These people come from the lowest castes," Rajiv explains, "so the women don't have the social freedom to go to the wine shop or to the chemist like the men. A lot of them still have to stay inside with their heads covered. ... The husband doesn't give a fuck about the house, kids, but a woman will be more sensitive to the needs of the children, to taking care of the children. She may whore to make money, but she won't inject."

Either way, HIV/AIDS is here, whether it comes from the area's drug use or prostitution or whether it's transferred from one partner to another as a result of the drug use or prostitution. I accompany Sita to the nearby hospital, Babu Jagjivan Ram, to pick up the results of her HIV test. She's negative, but most women in the area, she tells me, have to sneak away to avail themselves of the free HIV testing at the hospital. Should they test positive, Sita says, they are rarely able to undergo the continued treatment required because they keep the results hidden from their families. Locals and aid workers say street junkies are not welcome at the hospital, unless, of course, it's to the separate building at the back where their corpses are incinerated.

The National AIDS Control Organization estimates the number of HIV-positive IDUs in India at eight percent of the population, but most involved feel the number in Delhi, especially in Jahangirpuri, will turn out to be much higher. As the first group to gather specific numbers, Sahara, in conjunction with other groups, has begun a two-year research project in five Delhi neighbourhoods suffering from endemic drug use, but until they're done, there are still no hard figures on how many IDUs there are in Jahangirpuri, or how many are HIV positive.

When I return to Sita's new centre, three more addicts, along with Urdip, have sought her out. They all sit against the concrete, their varying shoulder heights contributing to the wall's dark stripe. Like the boy whose mother approached Rajiv, these men now detoxing had the advantage of a home and relative nutrition, but they're getting old. They look dejected. They look ill. Their stories vary, but they overlap more. These men want to get clean for their families. They want to start working again.

•       •       •       •       •

Moti, one of the homeless addicts, squats under one of the pillars of the Metro line that runs down the middle of National Highway 1, wearing a once-black-and-white shirt, now all grey, once-grey pants now mostly black. He scratches at his left shoulder with a bloated right hand. No veins are visible, just a rough, scaly surface, like a series of closed scabs. He wobbles to his feet and crosses the southbound lanes into an alley adjacent to Mahendra Park. From a distance, the scene is typical of urban India, rubbish collected into little multicolored ghats between the pavement and the brick walls on either side, but here, among the candy wrappers and empty pouches of PassPass, are an equal number of plastic syringe wrappers, more empty bottles with syringe-friendly caps, and even more broken glass ampules. Clumps of human turds bake in the sun and the ammonia smell of piss is overpowering. There are no syringes, however, Moti determines. He's been rustling around trying to find one hidden in the detritus to use for his afternoon fix.

He is joined almost immediately, as if telepathically, by Rajinder, another homeless man in his mid-40s. Rajinder is wearing only plastic sandals and beige trousers, barely held up by his pelvis, the skin of his stomach sagging like an old shirt on the hanger of his hip bones. He has also been scavenging through the macaroons of shit and the tumbleweeds of garbage, and confirms that there are no syringes lying around. Rajinder reaches into the secret compartment inside his trousers, pulls out a few moist 10-rupee notes and disappears.

Moti describes himself as a ragpicker and says he needs a shot in the morning to be able to do the work, then this lunchtime dose before the next round of scavenging -- the nimble digits required for pick-pocketing in Azadpur long swollen and atrophied -- and then another shot in the evening to complete his circuit. It's a short one.

Rajinder returns from the chemist, sits down, breaks open an ampule of buprenorphine and extracts the liquid with his acquired syringe. He pushes the needle through the opening in the cap of the Avil bottle and the two drugs are mixed.

For a new addict, the arms are the usual starting point; then it's on to the legs, the buttocks, the neck. Rajinder, who has mostly destroyed his circulation in these areas, loosens his pants and pulls them down to the hilt of his penis, leans against the wall and sticks the needle into his groin. The skin resists a little before snapping around the needle's tip. As the out-flowing blood fills the syringe salmon pink, his breathing slows and he becomes visibly relaxed the instant his thumb can't push any further on the plunger.

Moti has no choice now, unable to find a shootable vein anywhere after years of abuse, but to go intramuscular. And yet, the two addicts have been relatively smart. They're not using the oil-based diazepam, which quickly causes abscesses. Moti's already got a nasty one on his leg. But going intramuscular is very risky. "You know when you go to the doctor," says Rajiv, "and he puts a needle in your upper butt, your hip or your bicep? That's because those muscles are always in use. Shooting into a secondary muscle like the triceps could easily cause another abscess."

Rajinder takes a few pokes and prods into Moti's upheld triceps before finding satisfactory purchase and injecting him.

When I speak later with Dr. Rajat Ray, chief of the All India Institute of Medical Sciences' National Drug Dependence Treatment Centre, he tells me that Moti's is a severe case. The way in which Moti has been shooting up all this time is what burns out the veins to the point of sepsis: the repeated, unskilled and unsanitary injections that render advanced-stage users' limbs vascularly barren.

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Dave Besseling has been employed as a graphic designer, language teacher, visual artist, tattoo designer, travel writer, and journalist. His first book will be published in 2012.

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