July 2015
#Nurse , 1551 Views
Heroin, Chains and Good Intentions

Byline: Kerry Harwin
Photographs: Sachin Pillai

Imphal’s rehabilitation centres struggle in the face of an addiction crisis.

To tell the story of heroin and rehabilitation in Manipur, to explain the vast historical antecedents that have led to a massive concentration of heroin addicts in a very small state, would require an entire book. And I’m working on that. But for now, to understand this very small slice of the story, there are a few essential facts that you need to understand:

Manipur shares a lengthy border with Burma, a country that produces a significant amount of the world’s heroin. This border is mostly jungle, and much of it is controlled not by the Indian state, but by various insurgent groups, each with their own agenda. Most of these groups, ideologically based and prone to moral policing, are not involved in the drug trade. But many of the smaller groups—little more than goonda outfits with a patina of political persuasion—are directly involved. In any case, the general state of lawlessness is such that heroin flows freely into India, with Manipur as a major transit point.

This means that heroin in Manipur is both very cheap and very pure. A single hit ranges from Rs 30 to Rs 100, spiking as high as Rs 200 during the times of political reshuffle, or when a newly hired police superintendent decides to make a show of force. The crackdowns never last long.

Cheap heroin is dangerous in combination with stark underdevelopment. Simply put, in Manipur, there is very little for one to do with their days; jobs are almost nonexistent unless you’re politically connected or able to bribe your way in. Imphal, the state capital, essentially shuts down after 7pm. After night falls, there are no restaurants, no bars, no coffee shops. Even driving at night leaves you open to police harassment if you are in Imphal and harassment from insurgent outfits should you leave the city. If you spend more than a couple of weeks in Manipur, you stop being surprised at the masses of young people who decide to give heroin a try. There is nowhere to go, nothing to do, and even finding a job can feel like a Sisyphean task.

Those who can leave often do.

Ricky, an officer in the Manipur Rifles, is telling me about how he smuggles heroin into the Manipur Rifles camp. Or, more accurately, he’s telling me that he smuggles heroin into the Manipur Rifles camp. Because there is no oversight, the how wouldn’t make for much of a story: he simply brings it in his suitcase.

I am sitting with Ricky in a narrow alley on the North side of Imphal, in the BOC, a neighbourhood and heroin hotspot named after the now defunct Burmese Oil Corporation. In the small, kachcha house across the lane, I see a mass of stacked cardboard boxes. They are small and green and inconspicuous, and it would be easy to walk past them without a glance. For those who look more closely, their contents surprise. They are boxes of tiny and cheap insulin syringes.

Down the lane, about five metres from Ricky and I, an unfinished brick building with no roof serves as a temporary squat for some of the city’s heroin addicts. A large piece of plywood has been placed in front of the empty doorframe; it gives the police and other security forces in the area the pretense of deniability, though there is no question of what happens behind the board. Just outside the squat, a pile of trash is dominated by hundreds of tiny red and white needles and the small squares of white notebook paper in which heroin is purchased. The two together give the entirely inaccurate impression of a mound of candy and candy wrappers.

Ricky continues, telling me about his struggle to manage his addiction while serving in a paramilitary police force: “[When I report for duty], they send me far, to Ukhrul. But before going, I will buy 500 or 1,000 [worth of] stuff and carry it with me. When the stuff finishes, I’ll give my gun to my friend. ‘Please look [after it] for me. I’ll be back.’”

Typically, Ricky injects heroin. When on duty, however, he makes do with secretively smoking the stuff, once in the morning and once before bed. This lasts as long as his heroin does, at which point he goes absent without leave. “And they’ll check… in roll call. They will find out that I was missing. Then they’ll give me absent.” He laughs. “They’ll cut my salary, but if the case is serious, they can give me suspension.”

Currently, he is on leave. His commanding officer has given him six months off, he tells me, to get clean. Sitting in the kind of gravitationally impossible lean that only the heroin glazed seem able to manage, it’s not that Ricky doesn’t understand the irony of making such a statement while in one of India’s most active heroin injecting hotspots, it’s just that he’s too worn and defeated to really give a shit. He went into rehab when he was first put on leave, but escaped after only a handful of days. Withdrawal seemed too difficult, and the lure of cheap, pure, and easily available heroin too strong.

“I stayed at Overcomer for ten days,” Ricky says of his most recent stint, “but then I want to run out. I escaped. It was easy, … there was no fencing. They do it with the help of God, preaching, it’s Jesus. If we leave here, we can return. In another rehab, if we return, we will be punished. But here, at Overcomer, they didn’t punish, they scold.”

Ricky’s narration stops. A group of off-duty (one hopes) Narcotics Bureau officers in civilian garb have stormed into the alley, determined to shut things down. But it is the kind of determination born not out of professional duty, but out of the bottom of a plastic bottle of local rice wine. The group of fat officers, visibly drunk, kick down the “door”, shouting angrily. A gaggle of junkies scatter in their path, clearing out of the alley.

Ricky eager to avoid further trouble, follows. One of his addict brethren, an older head less intimidated by tippling officers, immediately comes closer to me, intent on correcting Ricky’s story; he’s not on suspension, I’m told, Ricky’s been fired. I have no way of knowing the truth, but it also clearly doesn’t matter. His junkie lean seems to have settled into permanent state, his clothes don’t change from one day to the next. If he is actually on leave, it is clear he will be fired should he ever again report for duty.

The most common tale of rehabilitation facilities in Manipur is one of escape. Most heroin users with whom I speak have been to rehab multiple times. Five or six is a common reply, but for many, the visits number in the tens. Some of those visits end with a temporary success; having completed the course of the program, they are released, only—if they’re talking to me on Imphal’s skid row—to eventually start using again. But more often than not, their return to the heroin gali is a product not of release, but escape.

Manipur’s rehabilitation centres are not, typically, high security facilities. The treatment rooms in which addicts detox for their first week or so in residence are often locked from the outside at night, but otherwise, there’s little keeping the addicts from leaving the premises. All the same, I’m never told “I left rehab.” Rather, it’s always high drama; it was a dark and stormy night, we were fed up with rehab, we organized a team, we made a run for it. Rehab is supposed to offer a kind of support system, and indeed, the group ethos often seems to be successfully instilled; my addict friends are unable to walk out of facilities without a team of co-conspirators.

Sanjit, my oldest and closest friend among the habitués of the BOC , had only recently run away from a rehab facility when I finally caught up with him on my latest trip to Imphal. Though it is self evident to say that it’s difficult to be friends with junkies, some logistical challenges may be less evident. There will almost always be a point in a heroin addict’s life when he’d rather have a few hits of heroin than a mobile phone. This makes meeting difficult. But rain or shine, you know they’ll be in the BOC the instant they’ve been able to put together a couple hundred rupees every morning. And so, after many mornings of hoping to show up at the right time, I finally crossed paths with Sanjit.

Thirty-three, English speaking, and well travelled within India, Sanjit doesn’t conform to your typical image of a heroin addict. Blessed and cursed by a family with the financial wherewithal to support him and his habit, he eats well and sleeps in comfort every night. Sanjit apologized for the quality of his house before inviting me over; I was surprised to find accommodation that was not only far superior to my own in Manipur, but a grade above my hastily finished New Delhi flat. Sitting on the marble floor under a lazy fan, afternoon sunlight streaming in through massive windows, Sanjit hurriedly chased a hit of heroin from the foil wrapper of a twenty rupee packet of smuggled Chinese WIN cigarettes before recounting a lackadaisical escape from his most recent rehab sting.

Cheap heroin is dangerous in combination with stark underdevelopment. Simply put, in Manipur, there is very little for one to do with their days

In Manipur, rehabilitation—or “deaddiction”, as the locals often prefer—comes in many flavours. A tour through the outskirts of Imphal reveals a quantity of centres that is shocking to the uninitiated. Most offer Narcotics Anonymous courses, but for those who prefer a less structured approach, yoga based deaddiction is a popular choice. Many centres are secular, but a large number are faith based, predominantly Christian. Nomenclature, however, can be confusing. “New Life” and “Divine Light” might be imagined to stick to strict evangelical doctrine. In fact, both are secular. Many rehab facilities—both the fanciest and the most dire—are privately run. A handful receive government support. Some offer two year programs, others enforce maximum stays of 45 days.

There are, however, a few notable exceptions in the world of Manipur drug rehabilitation. It was these exceptions that first prompted my explorations. These centres are mostly located in Churuchandpur, Manipur’s second city, located 60 kilometres from Imphal, where the predominantly Hindu and Meitei Imphal valley begins the climb into the mainly tribal and Christian hills. Their courses often run for two years. Their method is known as “chaining.”

Rakesh, 38, is something of an expert on these centres. In addition to being a patient in several centres, he was, until recently, the manager of another, Rainbow. Rainbow sits in the hills of Langol, an outlying area of Imphal that is overrun with treatment options. When Rakesh relapsed recently after six clean years, he stepped down from his position at Rainbow. He continues to work as a peer educator for Manipur Network for Positive Persons, an HIV NGO that primarily serves injecting drug users.

“Staying in the rehab is like jail,” Rakesh told me. “Actually, it’s very hard to adjust to the rules and the regulations of the rehab since we are no more kids. … [But] I don’t want to say this is bad. This good. From an economical point of view, and for health also. If there is no rehab, I [was] supposed to be in heaven a long time back. For the drug users, only three destinations is there. One is jail. One is death, and another one is institution, [which] means rehab.”

When I spoke to Rakesh about his time in rehab, the most vivid memories were of a Churuchandpur centre that is now known as Alpha and Omega. Their method of treatment involves neither Narcotics Anonymous, nor prayer, nor yoga. Rather, their theory is simple: if you keep addicts chained to their bed for two years, they can’t do heroin.

“[We were] tied with the chains,” Rakesh recalled. “Their course is around three years. Every three months they cut off one [link in the] chain. After going to seven months or something like that, I was getting a bit free. Then they put off my chain and I escaped from the Churuchandpur [rehab].”

Not only are the rules regulating patients—or inmates—at Alpha and Omega draconian, some seem to lack any purpose whatsoever other than immiseration: “They are providing only one bucket, Rakesh explained. “In that bucket, you have to urinate. And you have to do the toilet also. And you have to wash it very cleanly, and after that for drinking water also, you also have to use that bucket.” If inmates were caught teaming up—using one bucket for waste and another for drinking water—they would be beaten by rehab authorities. Beatings were also regularly doled out to inmates who had the impudence to speak during the fist six months of their stay, a period during which they were told to maintain absolute silence.

There is, perhaps, no need to mention that places like Alpha and Omega are not keen to let journalists inside their doors; my knowledge is entirely second hand and unverified. But even was his entire story fabricated, and I don’t believe that it is, these centres are no secret; anybody who knows anything about addiction in Manipur is familiar with them.

Rakesh’s story of restraint, beating, and escape at Alpha and Omega prompts me to pull back the journalistic curtain to consider the inherently parasitic nature of documenting human suffering. The more I learn about substance rehabilitation in Manipur, the more clear it becomes that although many facilities lack amenities that might be considered standard elsewhere, the practice of chaining and beating is on its way out. Only older users reported any experience with such centres.

But this is where the journalistic conflict lies. You (as a reader) and I (as a writer) share a dark secret. We don’t like to admit it, but we both know that you love suffering. It’s okay. Don’t feel bad. I do, too. For we know this much to be true: You are more likely to read, from start to end, an article about the dark corners of Manipur in which desperate heroin addicts are chained and beaten for years on end than one about the lovely living conditions at a happy and well functioning rehabilitation centre.

And I only want to make you happy. This impulse, to chase human suffering, prompts a sort of cognitive dissonance. Or, more similarly put, it makes me not like myself very much. For in every conversation that I have with a heroin addict, and I have spoken to so, so many heroin addicts over the past six months, there is a moment when I yearn for their suffering. Because after all of the preliminaries, my inevitable question—have you ever been to rehab—is followed by their inevitable affirmative answer. And then, eager to restrain my anticipation, I carefully phrase my follow-up: “Have you had any bad experiences in rehab?”

This is where my self-censure takes hold, because I am confronted with two contradictory impulses. My interview subjects tend to be sympathetic characters, and I don’t want them to have suffered. But also, I really, really want them to have suffered. Because that’s how I write the kind of story that breaks your heart. And so, when a younger addict says to me, “yes, they would punish us sometimes”, I am overcome by a nauseating cocktail of excitement and shame.

“What kind of punishment?” I ask. Inevitably, the punishment is something mundane, like washing dishes, and I am simultaneously disappointed and relieved. But the truth is, I am more disappointed than relieved.

In most of Manipur’s rehabs, doctors, nurses, and indeed, the entire field of medicine is notable largely though its absence. I visit three rehab facilities, and although conditions vary wildly, not one has any employee with a medical or nursing degree on staff. All recognize that addiction ought to be dealt with as a public health issue rather than a criminal justice problem, but are equipped only with enthusiasm.

Rainbow, where Rakesh used to work before his relapse, is both the most dire and the most inspiring of the facilities I visit. It is inspiring because it is run by a trio of former addicts who started the centre because they genuinely wished to help others through the same struggle they had successfully bested. The men work long hours and treat their clients with dignity and respect. They struggle to keep admission rates (recently raised to Rs 4,500 per month all inclusive) from slipping ever higher. And, unlike many facilities in the state that receive support from either the Church or the State, they do so with no outside funding.

In most of Manipur’s Rehabs, Doctors, Nurses, and indeed, the entire field of medicine is notable largely through its absence.

Khorazim Dhanbir Singh, the director of New Light, looks at heroin addiction in terms of its economics and the opportunity cost of addiction as a driver of underdevelopment:

“If an addict used 1,000 a day, and there are a hundred addicts…. that’s one lakh. And one lakh into thirty is equal to three crores, [which] a hundred users will spend for month. That’s 36 crores for a year. For every year, there could be a dam, or a small hospital, or a college, or an institution.”

The economics of rehab work out for the user as well. “Nowadays,” Rakesh tells me, “4,500 is nothing. If the user is outside [or rehab], he’ll consume more than 10,000 to 12,000 [rupees worth of heroin] per month. … He can spend up to 50,000 or 60,000 per month. But if he stays in rehab, he’ll spend only 4,500.”

But the low cost facility comes with a price. The closest thing Rainbow has to an in-house medical expert was Rakesh, who once worked as a pharmaceutical representative in Navi Mumbai. Distribution of analgesics, anxiolytics, and even substitution therapies, designed to treat withdrawal symptoms without addressing the underlying addiction, are dosed out without complete medical histories, or any thought to adverse interactions. But this is not a case of irresponsible care. It is simply what happens when well meaning individuals offer the best care they can given the knowledge and funding they possess. Their overall impact is almost unarguably good. And yet, slipping into a dormitory where clients sleep, the immediate reaction of the privileged is one of disgust: about a dozen men crowd into a room that could comfortably sleep half that, their thin mattresses pushed against one another, the room overwhelmed by the ammoniac odour emitted from the bucket full of urine that sits in the corner.

Many government supported facilities are no better than these make-do, addict-supported operations. Because I have no proof and am weary of treading into libelous territory, I will not name the more suspect government funded facility that I visited. Nestled in the hills of the Senapati District, about thirty kilometres from central Imphal, one travels for fifteen minutes down a nearly impassible dirt track before reaching the facility. Unlike every other rehab or drug user NGO that visited, its staff are highly suspicious. They are unwilling to answer many questions, and especially resistant to any photos or videos.

The reason for this suspicion seems clear. Though their facilities are no better than those found at Rainbow, and though they charge clients the same monthly fee, they also take in nearly Rs one lakh per month in government support according to public records of the Ministry of Social Justice and Empowerment, the main government venue for tackling addiction. That may not sound like much, but it has to be put in Manipur perspective. The extremely rustic room that I rented for a month cost 1,500. A friend’s much more modern one bedroom apartment cost 4,000 per month. A teacher at a local private school might expect to earn 2,000 monthly. In Manipur, a million rupees a year is not small potatoes.

This knowledge, in combination with a tour of the centre’s roughshod construction, complete with overcrowded kachacha buildings, leads me, and all of the locals with whom I discuss the matter, to suspect that much of the government funding might be improving the lives of someone other than its intended beneficiaries. Corruption is difficult to prove, but a Peer Educator at a less reputable NGO that caters primarily to heroin addicts confirmed that he was routinely paid (though at the time he hadn’t received a cheque for four months) to sit in their offices and fill forms documenting falsified client interactions instead of actually going into the field to make those interactions happen. He claimed the practice was widespread among government funded NGOs.

But not all facilities can or should be painted with the brush of corruption. Many are composed of devoted staff, often drug affected individuals themselves, who work long hours for meagre pay. Shortly before leaving Manipur, Sanjit had informed me that he’d be heading back to the rehab facilities where, in any case, he had left most of his belongings. We headed to his house the next morning to see him off but, as is often the case in Manipur, he didn’t get around to leaving until the next day. Just enough time for one last run through the BOC.

When we next caught up with Sanjit, he had been at Divine Light Rehabilitation Centre for about two days. Divine Light shares a campus with a sister facility for addicts less than 25 years old and has a capacity of about 60 beds across both facilities. Though its annual funding, at 17 lakhs, is higher than that of the questionable facility we had previously visited, the funding disparity cannot account for the vast gap in quality between the two facilities. Admission fees are comparable, and not only does Divine Light host double the number of clients, it does so in a large campus that resembles an exceptionally well maintained government school. Rows of neat rooms for treatment, Narcotics Anonymous meetings, and counseling sessions sit next to a spacious dormitory with rows of well made beds. Rain splashes in a small pond in the centre of the courtyard in which we sit. Clients tend to recently planted seedlings growing around the pond. Again, I find myself thinking that Sanjit has found a nicer place to stay than my own Imphal home.

In Divine Light, I find the most professional and trained staff yet. They all have a long history of working in the sector, and though the Director is not a former user, most of the counselors are. But although experience and training abound, the ubiquitous lacuna in treatment preparedness looms again; there are no trained medical personnel on staff. Counselors make due with the knowledge they have, administering medications, such as alprazolam, that they lack the legal authority to prescribe. But it would be foolish to fault them. They have done a great deal with very little. And so I come to these pages not with a story of doctors and nurses, but of the place where there are none.

Sanjit is five days into rehab on my final visit before leaving Manipur, and has made it through the worst of his withdrawal. He is adamant that this time he will keep his promises: to me, to his counselor, and to his mother.

Eight months ago, I told Sanjit that if he got himself to Delhi after staying clean for some time, I’d take him up to Kashmir to see the snow. I meant it. This time, as he reiterates his own promise, he smiles broadly and reminds me of the snow. I think ahead, to a longed for day when I will watch him look down to the fields of white below the Gulmarg gondola. It is a promise that I desperately hope to have the opportunity to keep.