Children play in a street in Dar es Salaam, Tanzania, not far from house where users buy heroin and spread disease.
Photo courtesy of The Global Fund/Mia Collis.


The Street of
Blood and Smoke

By Jason Kane

This is the story of a drug dealer, a nurse and the stretch of road that lies between them.

In a busy coastal city, in a poor part of town, two women work side by side toward opposite goals—one selling heroin and cocaine to her neighbors, the other trying to save them from addiction.

From a distance, the drug dealer and the nurse appear to counterbalance each other. Their workplaces sit like weights on opposite ends of a dusty block in the slum.

Get a little closer and it becomes clear that they are, in a way, partners. Fatuma Chande sells drugs to local addicts. Rehema Mpili hands out the clean needles. Together, they make it cheap and easy to do drugs in this corner of the world.

Both admit that harm is being done, but they also take pride in the fact that the arrangement is helping make their neighborhood healthier by reducing the rates of HIV, tuberculosis and even drug addiction itself.

It's a highly controversial idea. Most public health officials say that delivering so-called "harm reduction" services directly to the populations that need them most will be key to controlling some of the world's deadliest diseases in the long-run. Opponents, including former President George W. Bush, say it encourages drug use in society while fueling the cycle of addiction for current users.

But the stakes are clear: About 16 million injecting drug users now live throughout the world, some 3 million with HIV. The World Health Organization reports that one out of 10 new HIV infections worldwide can be attributed to IV drug use.

In the part of the world where the drug dealer and nurse spend their days, the HIV rate among those who inject drugs is closer to 40 percent, and the tuberculosis count is much higher.

This story could easily take place in eastern Europe, central Asia or even parts of the United States. But the setting is the east African nation of Tanzania, in a city called Dar es Salaam and a neighborhood known as Keko Mwanga.

“Who takes?” Fatuma Chande isn’t in the mood to negotiate. Hovering over a roomful of tired-looking men, she unrolls a string of individually wrapped packages of powder and dangles it in front of their eyes. Several hands reach for the heroin. “You take? You pay.”

Paying isn’t very hard for most. At less than $2 per round, the vast majority of these men can scrape up enough money begging or doing odd jobs to make it possible for them to stop by the dimly lit back room of Chande’s house at least three times per day.

She distributes the powder and steps back to watch.

Smoking a combination of heroin, cocaine and marijuana is popular in the drug dens of Dar es Salaam. Photo courtesy of The Global Fund/Mia Collis.

On all four sides of a wooden table in the center of the room, the men set about their work, heating a mixture of marijuana, cocaine, heroin and tobacco called kokteli, or “cocktail,” on a small plate held above matchstick candles. They mix the powder, gather it into piles with sharp razor blades, roll it in paper and sit back and smoke. Several inject heroin straight into their veins.

Known commonly as a drug “hotpoint,” the place radiates chaos. A television blasts soap operas in the corner. A bed frame hangs down from the partially collapsed ceiling. Somewhere in the smoke, a three-year-old watches wide-eyed as powder roasts above the flames.

Chande surveys it all from the outermost edge, her lips pursed, fists at her hips, expression stone-cold. Standing there in her floor-length pink dress and white turban, she looks like either a shrewd businesswoman or a stern mother.

For the past decade, the 47-year-old has been overseeing this enterprise, pulling in about $120 per day. Two-thirds go to the drug distributors, with much of the rest handed to her brother, who owns the business. Making a small profit for herself requires discipline, savvy and perhaps most of all, a relatively healthy and consistent customer base—not easy in a place like this.

Aside from the smog and wall-to-wall bodies, the most distinguishing feature of Chande’s drug den is the stagnant air. It mixes with the smoke and sits in the back of the throat like a dry rag.

With all the used syringes and razor blades laying around, the drug dealer is apprehensive to hazard a guess about how many people have contracted HIV in this space.

Conditions like these are ripe for the transmission of tuberculosis. The bacteria that triggers the disease travels easily through still air—especially if it’s being propelled mouth-to-mouth through hacking coughs. At least five of Chande’s regulars were diagnosed with TB recently.

And fueling TB transmission further is the human immunodeficiency virus. By its nature, HIV breaks down the immune system, opening the body up to all kinds of diseases. But the deadliest co-infection of all is tuberculosis. In the last decade, it has become the leading cause of death among people living with HIV.

There is plenty of that in Chande’s hotpoint, too. With all the used syringes and razor blades laying around, the drug dealer is apprehensive to hazard a guess about how many people have contracted HIV in this space.

For many years, death hovered. “They were all becoming sick and I didn’t know how to help them,” Chande says. “They were counting themselves as finished.”

Then came Mukikute.

Addicts prepare a mixture of marijuana, cocaine, heroin and tobacco, called kokteli, as health workers from a nearby clinic share advice on avoiding HIV and tuberculosis.
Photo courtesy of The Global Fund / Mia Collis

The light overpowers the front entrance hall of the Mukikute Keko Drop-In Center almost as much as the darkness does in Chande’s drug den. Just a few doors separate the two places, making it easy for drug users like Ramadhan Hassan to transition easily between the worlds of addiction and recovery.

Hassan comes here often to take anti-tuberculosis medication and do more basic things, like grab a few cashew nuts for breakfast, take a shower or sleep for a few hours on one of the mattresses in the back. He says he’s intent on turning his life around, and it helps that the nurse here believes that’s possible, too.

Dressed in a floral hijab that covers everything but her face, nurse Rehema Mpili listens patiently as drug users share their troubles. And Hassan’s list just got longer. He’s homeless, was recently diagnosed with tuberculosis and often goes hungry. Several days before, he stopped by an abandoned wall and started pulling out bricks, hoping to sell them for food to take with his anti-TB medication. Then a guard walked up and opened fire, he says. He holds out a hand to show Mpili the shrapnel still lodged in the flesh of his palm.

Next to him, Hamza Rashid doesn’t know where to start. He’s chronically unemployed and HIV-positive. “Life was tough on me,” he says. “I felt the only relief would probably be to get hooked on drugs to help lose my mind and ease off the hardship.”

Then there’s the scared-looking 22-year-old man named Abdul Rashid who arrived several days earlier, recently released from jail, fresh from the male prostitution circuit and addicted to cocaine. It didn’t take the staff long to diagnose him with HIV.

The nurse hears their stories and nods. Mpili and the rest of the drop-in center staff know too well that many of these drug users have no real intention of kicking the habit, though most of them vaguely express an interest in doing so.

“And I won’t ever tell them to stop,” she says. “I want to educate them so one day they will realize what they are doing maybe and want to get out.”

Staff know too well that many of these drug users have no real intention of kicking the habit, though most of them vaguely express an interest in doing so.

Instead, she shares basic facts about tuberculosis and HIV—what they are, how they spread and how to receive treatment in this part of the city. She passes out condoms and clean needles and explains that HIV passes easily between drug users who allow their blood or sexual fluids to mix.

Specifically targeting drug users with this kind of information is a growing priority for the global health community. Along with sex workers, prisoners and men who have sex with men, drug users, especially those who inject drugs, represent a disproportionate share of the population living with HIV and a “high risk” group for contracting tuberculosis.

Outside of sub-Saharan Africa, 30 percent of HIV infections—that translates to about 3 million people—are attributed to injecting drug use, according to UNAIDS. In Eastern Europe and central Asia, it’s as high as 80 percent. And in several countries in sub-Saharan Africa, “a new wave of infections due to drug injecting has emerged in recent years,” the agency reports.

In reference to a 2011 speech by former Secretary of State Hillary Clinton calling for an “AIDS-free Generation,” a group of World Bank researchers bluntly wrote in a recent report that “an AIDS-free generation will not be possible unless HIV prevention, treatment, and care are taken to scale for people who inject drugs.”

Tanzania has seen a dramatic rise in drug use in the last 10 years as its major cities—especially Dar es Salaam—have become entrenched more deeply in international drug trafficking routes. Even as the HIV prevalence rate dropped to 5.1 percent for adults in the general population, studies show that the rate among people who inject drugs remains somewhere between 35 and 42 percent. Among female drug users, it’s as high as 67 percent.

The majority of these addicts say they shoot up three times per day, with 41 percent of them sharing needles in the past 30 days, according to a 2013 report published in the journal Advances in Preventive Medicine. And those taking part in one kind of risky behavior are quite likely to be dabbling in others: When asked, only 42 percent reported using condoms during sex in the last 30 days.

After an “urgent request for help” from the French aid organization Doctors of the World, Dr. Mark Stoove of Melbourne’s Burnet Institute conducted a study of Tanzania’s injecting drug addicts. His conclusion: the HIV problem among them had become so severe it threatened to spill heavily into the general population.

"All of that work going into prevention in heterosexual populations through antiretroviral therapies can potentially be watered down by the lack of attention to particularly high-risk populations like drug users," Stoove told the press in 2012.

That’s why “harm reduction” advocates like Mpili and her colleagues at Mukikute say their work is so critically important. They believe it’s unrealistic to think that all drug users will quit cold turkey and even more so that jailing them will push down illegal drug use or prevent the transmission of HIV.

Recent analysis from the Global Commission on Drug Policy found that the same countries employing the most aggressive drug war strategies—including arresting and incarcerating drug users for drug or needle possession—saw increases of more than 25 percent in new HIV infections. Why the upswing? Health experts say such practices drive drug users so far underground that they’re almost guaranteed to share and reuse dirty needles.

Meanwhile, HIV rates among New York City’s injecting drug users dropped from 54 percent to 13 percent in the 10 years after its needle exchange programs went into effect. And harm reduction strategies in Amsterdam—one of the injecting drug capitals of the world—recently achieved a reality that many believed to be impossible. "We conclude that drug users no longer play a role in the HIV epidemic in Amsterdam," researcher Bart Francis Xavier Grady announced at the International AIDS Conference in 2012.

Patients wait to be seen by clinic health workers at the Mukikute Keko Drop-In Center, which provides sterile syringes, condoms, antiseptic wipes, free meals and counseling to the slum’s drug users. Photo courtesy of The Global Fund/Mia Collis.

At the same meeting, a researcher with Johns Hopkins calculated that expanding the needle exchange program in the U.S. by 10 percent—at a cost of roughly $64 million per year—would prevent 500 HIV infections among drug users. The savings, when HIV treatment costs are tallied: $193 million, according to the study.

For similar reasons, Tanzania became the first country in sub-Saharan Africa to implement a full-scale, government-backed harm reduction program for injecting drug users in 2011. Michel Sidibe, executive director of UNAIDS, didn’t mince words on the approach. “The evidence is clear and decisive: Sufficient provision and coverage of needle and syringe programs, opioid substitution therapy and antiretroviral therapy … work to effectively reduce HIV transmission among people who inject drugs,” he wrote in Harm Reduction International’s 2012 report.

That’s not to say opposition isn’t fierce. When he ran for president in 2000, George W. Bush - who would later achieve remarkable gains in the global fight against AIDS with the creation of the multi-billion dollar initiative known as the President’s Emergency Plan for AIDS Relief, or PEPFAR—stated explicitly, “I do not favor needle exchange programs and other so-called ‘harm reduction’ strategies to combat drug use.”

Rather, he proposed a mix of prevention, education, treatment and law enforcement efforts that would send a clear message to society—children in particular—that there are right and wrong choices. He continued throughout his presidency to advocate not for “risk reduction” but “risk elimination that offers people hope and recovery, not a dead-end approach that offers despair and addiction.”

While the ban on federal funding for needle exchanges—both domestically and in foreign assistance programming—was briefly lifted during the Obama administration, Congress reinstated it as part of a spending bill passed in 2011, and it remains in effect today. Former Kansas Rep. Todd Tiahrt, one of the chief proponents of the ban during his tenure, summed up for the press why he thought it should remain in place: "I am very concerned that we would use federal tax dollars to support the drug habits of people who desperately need help,” he said.

Others worry that needle exchanges and general harm reduction interventions could lead to a societal perception that the government encourages drug use, or even pave the way for legalization.

But that’s missing the point, said Mauro Guarinieri, a senior advisor with the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“We are not for legalizing drug use,” he said. “We're talking about having a rational approach to drug use which is not incarcerating people or pushing people underground—because that doesn’t make sense from a public health perspective.”

The Global Fund spends roughly $600 million on harm reduction services each year in 58 countries throughout the globe—more money than any other organization in the world. One of the reasons, Guarinieri said, is that many people fall between the extremes of “using drugs, taking a lot of risks, getting sick and dying” on the one hand and “quitting drugs and having a healthy life” on the other, he said. “You can reduce the risk related to drug use to a minimum and still help many people live a relatively normal life.”

Mpili can vouch for that. It’s why she gathers up fresh needles and condoms so often and makes the journey down the strip of dirt road separating the Mukikukete Drop-In Center and the strung-out regulars in Fatuma Chande’s drug den.

She remembers what it was like to be one of them.

Come Back to Life

Usually loud and confident, Mpili’s tone becomes a little softer when she remembers the past.

There was a time, not so long ago, when her options ran out. Her food business failed, her marriage dissolved and she returned home each evening to see her three small children with hunger in their eyes. So she consulted with some friends and they all advised the same thing: Sex work. Quick and easy.

“I was doing it for the children,” she says. “I did it so they could go to school. I wanted them to have better jobs than me.”

With that in mind, her next moves were as calculating as they were practical. She became a call girl in the rich part of town, making her services known to the men with flashy cars and big jobs.

Heroin, she believed, was an unavoidable hazard of the profession. “Because that work is really hard, you make it so you don’t feel much of anything,” she said.

“I had to smoke in order to do that work.”

Rehema Mpili counsels a patient at the Mukikute Keko Drop-In Center. Photo courtesy of The Global Fund/Mia Collis.

But it didn’t take long for the other hazards of the profession to catch up with her. After seven or eight years of unprotected sex, Mpili started coughing uncontrollably and sweating through the night. She quickly became too weak to travel to the rich part of town.

A double diagnosis followed—HIV and tuberculosis. It was a blow Mpili claims saved her life.

“While I was sick, my family was close to me and I could not tell them that I was smoking or that I wanted to,” she says. “So the sickness helped me to get out of that. Because I thought to myself, ‘Once I get cured, I will never go back. I will pray to God that I won’t go back to that.’”

She never did.

After recovery, Mpili became a peer educator, helping detect potential TB cases and counsel her neighbors through their own battles. And when enough of them started calling her “nurse” out of respect, she decided to get the proper training and make it official.

Rehema Mpili usually makes eye contact with Fatuma Chande as the nurse walks into the hotpoint. The piles of clean needles and stacks of condoms don’t threaten the drug dealer. In many ways, she’s grateful.

This is simply a business to Chande—“an obligation,” she calls it. When her brother started the business 10 years ago in the family home, Chande says he pressured her to the point she “didn’t really have a choice” but to become his partner.

And for most of those 10 years, she watched the men of her neighborhood deteriorate in front of her, riddled with addiction and plagued by disease. She watched tuberculosis and HIV spread, knowing conditions in her own home were contributing.

“I never had any happiness making that profit,” she says. “A lot of people have a hard time living because of these drugs. The customers just make me sad—and even my brother is addicted.”

Chande worries most of all that her grandchildren will end up going down the same path, especially three-year-old Warda, who spends most days in the hotpoint. The drug users have made a habit of sending children to buy cigarettes and paper to wrap their cocktails.

“So they are being brought up in this environment and I really think they will use or end up sick from disease,” she says. “I worry they will end up addicted to drugs.”

Much of this, Chande says she can’t control. But it’s also why she threw open her doors when the Mukikute workers approached her last September about “interventions.”

It’s why Chande steps back and watches when Mpili and her co-workers bring in the fresh needles, collect mucus samples to test for tuberculosis or conduct HIV education workshops in the middle of all the darkness and smoke.

She encourages the drug users to listen to the Mukikute workers about using a driver’s license or other flat object rather than razor blades while producing their cocktails to avoid the transmission of blood. And when one of her regular customers tests positive for tuberculosis, she bars them from the hotpoint until they’re no longer contagious and pushes them to keep steady with their medication until the treatment is complete.

Almost a year after Mukikute’s interventions began, the results are evident, she claims. “Many of them have regained their health.”

A Mukikute worker brings food to a cocaine addict who was released from jail several days before stopping by the Mukikute Keko Drop-In Center. A quick test has revealed the 22-year-old is HIV-positive. Photo courtesy of The Global Fund/Mia Collis.

It might seem difficult for a former heroin addict to walk into a place like the hotpoint. But it’s not, Mpili says.

“When I go there, I just feel pity,” she says. “I know the hardships they are facing.”

And though she now feels like a better mother to her three children and never wants them to know about her past, she’s also not embarrassed to share every grisly detail of her history with the drug users of Keko Mwanga. Just seeing her sitting there in the hotpoint—healthy, sober and prosperous—is a harm reduction strategy in itself, she said.

“I tell them straight out: When I was in their place, I didn’t expect all these sudden changes in my life,” she says. “Even my family thought I would die. They never thought I would revive and come back to life like this.”

Mpili tells the story only to those who are curious about why she comes so frequently to such a place. After all, she’s not there to preach. She laughs sheepishly when the drug users say that she looks “too good” to be HIV-positive—and a former sex worker and drug addict, at that. She’s proud to hear them say that.

And for those who will listen, she ends the story like this: “If you want to do it, you can come back to life, too. Let me help.”

Posted: August 14, 2013

EDITOR'S NOTE: Jason Kane traveled to Tanzania with the Global Fund to Fight AIDS, Tuberculosis and Malaria. The international financing institution provides funding to countries to support evidence-based programs that prevent, treat and care for people living with the three diseases. The Global Fund does not finance Mukikute's harm reduction activities in Keko Mwanga.

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