Life at the Outpost
Journalist specialised in questions relating to drug abuse
The Sharan association in India has created a drop-in center in New Delhi that provides syringes, care, and substitution treatment.
Just a stone's throw away from the Red Fort, by the holy waters of the Yemuna River, lies the Yemuna Bazaar. There are two parks and a huge slum consisting of shacks built with odds and ends, which are mostly roofed over with tarpaulin. Add to that a labyrinth of alleyways, heaps of refuse, stagnant pools of murky water, a perpetual cloud of flies, the dust, and the odour. Thousands of people live here crammed together, including most of the city's drug addicts. This is where Sharan set up its Drop-In Center (DIC). The objective of this centre is to make basic care, counselling, needle and syringe exchange programmes, drug substitution treatment and condoms available to the drug users who live in the Yamuna Bazar parks under deplorable hygienic conditions.
A PRAGMATIC RESPONSE
This is the only DIC and the only Syringe Exchange Programme (SEP) in New Delhi, where 45% of the users inject themselves with buprenorphine and various pharmaceutical cocktails. The price is 15 rupees ($0.30) for a shot of buprenorphine, as compared to 60 rupees for shot of heroin (plus 4 rupees for syringes that can be purchased over the counter at chemists' shops or from street vendors). Only 3 % of the users are injecting "brown sugar"*. In India, most medicine can be purchased at chemists' shops without a medical prescription -in exchange for a little bonus, that is. Injectable buprenorphine (0.3 or 0.6 mg) is widely used by the population for analgesic purposes and is prescribed as a matter of routine. A number of local pharmaceutical companies manufacture it in the injectable form, but only two of them produce tablets. David is an ex-user, like all those working for the association. After spending 14 months in a rehabilitation center, he joined the Sharan team in 1995. David was born in the mountains of Darjeeling to Nepali parents and came to New Delhi at the age of seventeen. After falling in with bad company at school, he plunged into the world of drugs for 14 years, four of which he spent in one of the Yamuna Bazar parks. "I wound up living completely on the streets. I though I was going to die, just like that, without a penny to my name." These days, he is the one who takes people round the Drop-In Center, which opened two years ago.
"At first, 130 to 150 people a day were coming to exchange syringes, and 35 to get buprenorphine," he says. "Nowadays, 115 come to get oral substitution drugs, and only 30-35 to exchange syringes. The reason why the numbers have gone down from 150 customers for the SEP to 30-35 today is that they have switched to the oral substitution drug and aren't injecting any longer. They have become rehabilitated, are working, and have gone back to their families." The Drop-In Center can count that as one of its success stories.
At Sharan, they like to call the DIC "the Outpost". The first of its three small rooms built of masonry (none of which are any larger than 2 x 4 metres) is set a bit apart and is used to dispense basic care (antibiotics, paracetamol, oral rehydration salts, anti-diarrhoea medication, etc.). A table, a chair, a washbasin, and an examining table are the only furniture it contains.
CASE BY CASE
A bit farther away at the Bupre Counter, Kush is waiting for the next "customers". The only furniture there is a table, on which there is a fan and boxes of Addnok© (buprenorphine)*, in 0.2, 0.4, and 2 mg doses. "The dose depends on the individual," explains Kush. "When someone new arrives, we explain how the programme works, making it very clear that we're not an abstinence center, and that we do only harm reduction. Then we send the visitors to the doctor, who helps them to assess their needs and prescribes a dose: 2 to 4 mg on the average." Each patient has a green card marked with a two-week prescription. At the end of that period, the patient must return to see the doctor. "There are no specific dosage or time limits, but we do try to get them to cut down..." -or even to kick the habit.
Dinesh arrives with his green card. Kush counts out the tablets, places them in a bag, and crushes them up. He hands bag and its contents to Dinesh, who immediately swallows the powder. Dinesh must stay in the room at least five minutes so that Kush can check that he doesn't spit the powder out to be injected later. Kush explains, "They used to carry off the tablets to shoot them up, and we had big problems with abscesses." For a long time, the only dose available was 0.2 mg, and that meant handing over 10 to 20 tablets at once.
A SUCCESS STORY FROM THE PUBLIC HEALTH POINT OF VIEW
"Two years ago, we were treating up to 80 abscesses a day," remembers David. By now the number has dropped to 20-25 a day: another achievement for the association, which receives no aid from the government. "The only aid we get is from the European Community to finance the purchase of buprenorphine."
Aren't the patients being underdosed? The only argument Kush has to explain the difference in comparison with the average daily dose of 8 mg prescribed in France is this: "You come from a country with national health insurance, where there is plenty of treatment and medicinal products. Here we have nothing. So nobody is complaining about underdosing. When some customers leave, they always wind up coming back, because apart from the Rehab Centers, it's the best we can do for them in this part of the world."
In the SEP room directly opposite, exchange is on a voluntary basis, and some do bring back their used syringes. The receptacle, a metal box with a hole cut in the top, sits by the table. In one corner, a gloved nurse dispenses topical treatment and hands out antibiotics to those with abscesses, which are lanced by the doctor when he calls in at the centre three times a week. "Some users shoot directly into the abscess."
The five minutes required for his buprenorphine to be swallowed down are hardly up before Dinesh crosses the narrow alley to pick up his syringes (no comment). A few steps away, a group of twenty or so "customers" are chatting and whiling away the time. This is quite a gathering-place, and Sharan is beginning to organise regular meetings. "We give them information about safer shooting practices," says David, "and about STMs, HIV and basic hygiene."
Not far from the centre, the funeral pyres where the Hindi come to burn their dead (an average 50 to 60 a day) line the riverbanks. The bodies of drug users are thrown directly into the water, however, because there is no money to pay for the wood required to incinerate them.
THE SHARAN ASSOCIATION
Sharan has set up HIV and STD prevention and treatment programmes for drug users and their partners in five Indian towns. The objective of these programmes are four-fold: reducing the spread of HIV and hepatitis B and C; inducing users to change their behaviour in order to reduce the harm they are exposed to; reducing the rate of criminality and improving the quality of life; and providing substitution treatment. The New Delhi Drop-In Centeris open from 9:30 am to 4:00 pm and receives 140-160 visitors a day. The team working at the Centre consists of 21 members (only two or three of whom are not ex-users), including two doctors and 8 nurses.
In all, 350 people from 14 to 40 years of age have joined the programme. 45% of the 200 "customers" tested were HIV-positive and 40% were HCVpositive.