In India, Illicit Pharmaceuticals Ravage Communities and Lives

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For Indians too poor to buy heroin, neighborhood pharmacists are willing dealers, further entrenching a cycle of addiction, infection, and death

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An injecting drug user (IDU) fills a syringe with buprenorphine on a roadside in Chandigarh / Reuters

NEW DELHI, India -- Dharminder was just 17 years old when his half-naked body was found one morning in an alley near Jahangirpuri station, the northern terminus of the New Delhi Metro's yellow line. The teen's body was slung onto a vegetable cart and covered with a blanket that left his bare toes exposed as he was wheeled down the main road leading from the Metro station to the morgue.

Dharminder's official autopsy from Babu Jagjivan Ram Memorial Hospital describes various external injuries to his ribs, chest, abdomen, and shoulders, caused by a "blunt" implement. On arrival, he was wearing "pants only, soiled with fecal matter." The document guesses his age incorrectly at 18 or 19, but it doesn't matter. Dharminder was a junkie, and the locals disparage junkies -- they steal, they carry disease; they're untouchable beyond caste.

No one is exactly sure how he expired, but 23-year-old Nikhil Kumar, who works in a nearby metal-cutting shop, believes Dharminder was beaten to death by three other junkies the night before his body was discovered. Whether it was for the drugs or money he may have been hoarding, no one willing to talk knows for certain.

This area in northwest Delhi is best known for the Azadpur Fruit and Vegetable Market, but across National Highway 1, Jahangirpuri is home to another roaring industry: hawking products with longer sell-by dates than the tons of bananas and tomatoes that come through Azadpur: illicit pharmaceuticals. This is not the only neighbourhood in Delhi with a drug problem -- areas like Yamuna Bazar and Silampur are also notorious for the numbers of addicts trawling their streets. What makes Jahangirpuri so dangerous is that, here, the chemists are the drug dealers. This would be easy enough to hide -- if the Jahangirpuri chemists who sell prescription pharmaceutical drugs over the counter actually felt the need for discretion. But they don't. It's as easy to obtain and shoot pharmaceuticals here as it is to get a free meal at the nearby Sikh temple and save money for another hit.

For Dharminder, like many before him and many others sure to follow, Jahangirpuri truly was the end of the line.

•       •       •       •       •


"Young people get old here very quickly," says Rajiv, a 47-year-old ex-user with a pronounced limp in his left leg, as he roots around in a hidden compartment inside his blue track pants for a match to keep his beedi going. He lights the undecided ember into a glow under his push-broom moustache and exhales. "Here, in every house you have a junkie."

Rajiv would know. After years of drug abuse, he has been staying at a centre in Saket, in South Delhi, run by Sahara, an NGO that treats and houses injecting drug users. Sahara opened a treatment centre in Jahangirpuri in 2001, and in 2006 received expanded funding as part of the United Nations Office on Drugs and Crime's (UNODC) Project H13, intended to curb the spread of HIV/AIDS in South Asian countries. But it didn't last long -- as Mike Marshall, the former director of projects at Sahara, tells me, "All UNODC projects in India lost their funding and had to close due to the global recession."

There has been no recession, however, for those who cater to the addictions of India's abject. Chemists here know what users need, and they have conveniently bundled the requisite gear into a kind of Japanese bento box: one two-milliliter ampule of diazepam, a tranquillizer better known as Valium, also used to stop seizures and aid in alcohol withdrawal; one two-millimeter ampule of buprenorphine, a synthetic opioid like methadone used to treat addiction to opiates; and one two-milliliter bottle of Avil, an antihistamine meant to be injected intramuscularly (though many users prefer a 10-milliliter bottle so they can use the larger receptacle to mix all three drugs); one syringe; and two detachable needles. Users say the antihistamine is good for preventing rash, but it's mostly to increase the volume of a shot. One Jahangirpuri chemist, to attract new customers, has begun to throw in a digestif of a Netrovet-10 tablet, a strong sedative. A set costs 50 to 60 rupees, about one dollar.

Before Sahara shut its doors here, this is where Rajiv spent most of his reclaimed time after his withdrawal period, doing the legwork he and other independent aid workers describe as crucial: knocking on doors and talking to families who have no idea how to stop this surge of over-the-counter pharmaceuticals from stealing away their loved ones.

Rajiv, like the independent aid workers who have effectively, albeit unofficially, replaced Sahara and H13, says that the door-to-door canvassing is the only thing they see making a real difference.

"Dharminder's case is very common," an aid worker whom I'll call Sita later tells me. "We find dead kids on the sides of the road here all the time."

Dharminder left the town of Harpalpur in Uttar Pradesh when he was 12, already sniffing away his pick-pocketing profits in glue and solvents. In Jahangirpuri, he scavenged for scrap metal and took advantage of the tight-packed transience in the sprawling Azadpur market to reappropriate carelessly placed wallets. Before he died, Dharminder told me he made 50 to 100 rupees, about one to two U.S. dollars, a day.

Rajiv takes shelter from the afternoon sun near the alley where Dharminder's body was found. National Highway 1 and its last run of elevated Metro line are a few hundred feet away, just after a stretch of houses that look as if something has bitten their fronts off; just past where the truckers park and bring local, often casual, prostitutes to assuage the loneliness of the road. A little further east are the various recyclers who buy the materials from scavengers, who often then circle back to an alley adjacent to Mahendra Park to shoot up. Then it's back across the road to scour Azadpur for enough money to complete the circuit again.

Before long, an elderly woman nearby recognizes Rajiv and hurries over with a frantic tale, pointing to her son, who is rocking on his haunches in front of a nearby door. Rajiv explains something quietly to the child -- he can't be more than 13 or 14 tops -- who plants his forehead on his knee-hugging arms and begins to cry. Laying out the consequences that await users, Rajiv proffers himself as an example, pointing to his leg with the limp.

Neju, a junkie from an older generation, scampers over and squats, opening the buttons of his grease-sheened shirt to show Rajiv how his shoulder has healed. Most of the cap's muscle, where an abscess had been successfully removed, looks like an old shark bite. Sita tells me that abscess management is a big part of their work -- much more than detoxification. According to a UNODC report from April 2009, Sahara treated abscesses in up to 30 people per month in Jahangirpuri. This cauterized circuitry is Neju's good news to share. As he shows off his healed shoulder, a long knife falls from the left pocket of his pants.

"Put that away," Rajiv scolds him.

"It's for cutting fruit," replies Neju, who credits his longevity to his moderate pharmaceutical intake. He files the blade back into his pocket.

"Probably true," whispers Rajiv. "For real fights, they keep a surgical blade that'll cut you to the bone hidden in their mouths."

The woman thanks Rajiv for his counsel and takes his card as she leads her son away. This boy is one of the more fortunate addicts. He has a home: access to regular meals means his rate of decay will be slower than those who sleep on these streets. For him, there's no competition with fellow scavengers at the end of a hard day's work to divvy up the remains of a pharma cocktail and be tempted to take that little bit more than he should. Maybe that's what killed Dharminder.

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.

The two addicts sit for a few minutes, before getting up and stumbling out of the alley, back across the road and into the shade under the Metro line. They say it's more comfortable there, with the passing cars and trucks for their air-conditioning.

Left in the alley, Rajiv begins to pick up some of the drug packaging, some of which appears to have travelled from as far as the truckers who pass through the area -- Uttar Pradesh, Uttarakhand, Maharashtra. One receptacle is from fairly close to home: an empty bottle of Avil, made by Paksons Pharmaceuticals in Haryana.

Founded over 20 years ago by Sushil Aggarwal, Paksons produces just about every kind of prescription drug outside of those employed in cancer treatment. The company's injectable drugs plant is in Bahadurgarh, a 30-km drive west of Delhi, and Aggarwal is willing to provide a guided tour. Behind the gates painted with Hindu swastikas and past the garlanded images of Hindu gods, a series of rooms runs clockwise around the ground floor of the building, where the drugs are produced, tested, sterilely packaged, and shipped.

Aggarwal points out that the factory is constantly being visited by incognito representatives of government ministries. "They come every month, sometimes every two weeks, to inspect," he says. "They come so often I don't know which ministries they are from anymore."

Aggarwal says he has little control over his drugs ending up in the veins of junkies. For producers like him, there's another problem, one that he tells me has kept him in court for seven years.

"One day in 2003," he begins, standing in the quality control room, raising his voice over the tingling of ampules like thousands of tiny wind-blown chandeliers, "my distributor called me and asked why I was selling a certain drug in a market in Uttar Pradesh. I told him I didn't sell to that market, and that the drug was not even being produced anymore."

Aggarwal says he went to Bareilly, a city of just under a million people, to investigate. With the local police, he found the seller using the Paksons name to sell knock-offs of his drugs. The man was arrested and a copyright infringement case was filed. It is still pending.

"Why does it take seven years?" he asks, lifting his hands off the steering wheel and opening them to the ceiling, as if asking Krishna to intervene on the drive back to Delhi. "Because I don't pay money," he answers himself. "But police, they take money. ... It's a big problem."

•       •       •       •       •


Rajiv looks out across the roofs of passing buildings as the Metro's yellow line recedes from the end of its route, back south towards another Delhi -- Azadpur market on one side, Mahendra Park on the other, Moti and Rajinder underneath.

Rajiv seems all the more fragile once the train reaches busier stops and people crowd in around him, not aware of how easily he could be injured. "I can't walk around for too long," he says, crossing his left leg over his right. "All the blood goes to my foot and my leg doesn't really have a way to bring it back up. I'll have to lay down for a while when I get back to the centre."

As a manager in a garment company, Rajiv had gotten into heroin during his late 20s and early 30s, smoking "brown sugar" with friends at parties. To save money, he downgraded to morphine and eventually to the same vein-sizzling sets sold in Jahangirpuri. He was forced to stop after he spiked his femoral artery on his inner-left thigh and ruptured it -- short-circuiting the blood flow to his left leg. "Before the CT Scan at LNJP Hospital, the nurses had to call the senior doctor in because they couldn't find a vein," says Rajiv calmly. "He eventually found one in my neck."

He pulls up his left pant leg and exposes dry scales and whorls of would-be abscesses that he has to monitor carefully. "If I get a cut, it won't heal. There's no blood flow. If I break a bone, I'll have to amputate it."

•       •       •       •       •


You'd think that chemists selling illicit substances directly over the counter to obvious addicts would be cagey and nervous in their work. Not so for 50-year-old Vijay Ramesh, the owner of Dumpak Medicals, a nearby chemist's. (Both his name and that of his shop have been changed.) He arrives in Mahendra Park, adjacent to Moti and Rajinder's squalid alley, accompanied by Birendra, who does not want to give his real name because he works in Delhi's municipal corporation. From a distance, Birendra looks like any average Delhiite -- moustache, side-parted hair, slacks -- but as he gets closer, the telltale signs of light scar tissue inside his forearm and a bloated hand give it away. He's an addict, too.

The pair sits in the shade of a tree, their backs to the highway. "The addicts who live on the street buy from me," Ramesh, the chemist shop owner, tells me. "The area is such that I sell more IDU drugs than I do cough medicine." He takes off his shades and twirls one of the arms between his thumb and index finger. "Sure, addiction to anything is bad, but it's a business."

Ramesh, who resembles a subcontinental Steve Buscemi, says he operates with total confidence. Chemists are required by law to keep records of all their sales of controlled substances, but Ramesh says nobody does. Even if licensed drugs were accounted for, there are many grades of suppliers to round out the stock. "Suppliers make drugs in their homes, you don't know if it's legitimate. People make it in huts, the demand is so high."

At the Mahendra Park Police Station, Kaptaan Singh, the investigating officer in 17-year-old Dharminder's case, admits that drugs are being sold to junkies by the area's chemists. "Obviously," he says. "Where else can they buy them?"

Rajiv could have told you that, but to prove it, he sits behind a chemist in one of the local shops and observes, "99.9 percent of the customers are junkies."

Ramesh says he makes monthly payments to the police that go "all the way up. No cop has the guts to [raid] my shop. They all get their money."

Ramesh says there was a bit of a clampdown three years ago, but he hasn't had any trouble from the police since then. And he can afford the monthly kickbacks. "I charge 50 rupees for a set, and I sell between 100 and 300 sets a day," he says.

Officer Kaptaan Singh claims it's not his job to bust the dealers and pins the responsibility on government drug inspectors. It is not clear if they're from the same departments that pay frequent visits to Paksons, and Dr. Surinder Singh, the Drugs Controller General of India, declined to respond to multiple emails and phone calls. His joint and deputy commissioners were equally unwilling to talk.

•       •       •       •       •


Outside Mahendra Park, as cars and trucks pass noisily and Metro trains slice by overhead, a boy of about 12 or 13 spots Vijay Ramesh. The boy is disheveled to the point of falling apart. There are lattices of slash marks on his arms, and a stream of snot drips from his nose, over his mouth to his chin. He's carrying an empty can of Godfather beer, and it is in the manner of a mafia don that Ramesh accepts the boy's supplications. "Uncle, uncle," the urchin pleads, touching his feet, "I haven't had anything since morning."

Ramesh pats him on the head. "Go wait over there, I'll bring you something."

The boy's loyalty is important in a business where many long-term users, 40- to 50-year-olds like Rajinder and Moti, are dying, and men like Urdip are trying to get clean.

Ramesh waves at another passing local as he turns into the lane to Dumpak Medicals, with Birendra, the drug-addicted municipal employee, following close behind. The boy, meanwhile, fidgets in the dust on the side of the road, scratching at various parts of his body, waiting for Ramesh to get him through the afternoon.

"See?" Ramesh says, his black shades back on, hiding his eyes. "Old people are dying, but young people are coming."

Aside from Rajiv, names of all Jahangirpuri locals have been changed

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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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