reportage Health

Invisible Women

The unseen plight of Manipur’s female drug users

By S COUSINS | 1 September 2017

ON THE OUTSKIRTS OF IMPHAL, an abandoned red-brick house stands amid rice paddies, its front garden overgrown with weeds. It does not have a front door, just a chained gate, and its floors are made of concrete. The house looks like it is still being constructed, with pieces of wood, piles of garbage and other building materials lying around in it. Dirty footprints on the ground are the only signs that visitors frequent the decrepit structure.

The house is a spot where injecting drug users in the Imphal area congregate. When I visited the place on a dusty morning in late May, I encountered a group of men and women of varying ages, lying down on the floor of a back room, which was littered with needles. Some were injecting heroin. Others were smoking bright-red tablets of WY—a mixture of methamphetamine and caffeine. They were placing the tablets on a strip of aluminium foil, heating them from below, breathing in the fumes and then exhaling huge clouds of smoke. In nearby Myanmar, where WY is produced, it is called yaba, which translates literally to “mad drug.”

One of the people gathered was Jenny: a 46-year-old woman who comes to the house every day to do drugs. Jenny, who is homeless, used to be a schoolteacher. Now, she deals drugs and does sex work in order to survive, and to afford drugs for herself.

Jenny, who has a sunken face and greying hair that she ties in a low bun, was wearing a dark green long skirt. The rest of the users in the house looked like they came from varied backgrounds—a few wore button-down shirts and long pants and seemed like they were taking a quick break from work, whereas others looked completely dishevelled and lost.

Jenny and I sat on stools as she made small talk with a middle-aged woman—one of the chief drug dealers in Imphal. The woman cut a pile of white powder heroin and divided it into bags, each one priced at Rs 100—enough for one hit. A six-year-old girl—the dealer’s daughter—wandered around the building, barefoot. The child’s job was to unlock the chain at the front of the building whenever someone turned up, and to fetch water whenever people needed it. Jenny bought a few grams of heroin to deal on the streets later in the afternoon, storing it in an inner zippered pocket of her purse.

“I’m sorry you have to see this,” she told me. “Please don’t ever do drugs.”

Jenny said that, around a decade ago, she began having problems with her husband. “He would say bad words, shouting stupid, stupid words.” His abuse drove Jenny to drugs. “He is the cause of this,” she said. “He doesn’t talk to me anymore.” The pair have two children, who live in Assam. Jenny does not remember the last time she saw them.

Speaking of the high she gets from heroin, Jenny said, “At first I couldn’t stand it—it was very hard. But the next time, I felt like chasing it. It’s very good at getting rid of all the problems in my life.”

Jenny has injected so many times that the veins in her arms have collapsed, rendering them useless. Instead, she injects into the muscle in her right arm. I watched her shoot up heroin twice and smoke three WY tablets, after which she became incoherent, mumbling gibberish. Her head hung low and every few minutes someone—another drug user, who was also high—punched her in the shoulder or stomach to check that she was still conscious.

IN 2009, A STUDY BY the National Aids Control Organisation estimated there were approximately 200,000 injecting drug users in India. Other research puts the figure much higher. A 2006 study published in the journal Sexually Transmitted Infections pinned the number at 1.1 million users, most of whom are concentrated in the Northeast—primarily Manipur and Nagaland—but who are rapidly growing in Punjab and other states in north-western India.

A recent article in the British Medical Journal estimates that women make up roughly 20 percent of drug users in India. Despite this, there is a lack of scholarship related to drug use among women in India. This dearth of information contributes to female injecting drug users in India being a misunderstood and, as a consequence, a largely invisible population.

Many factors contribute to the prevalence of drug use in the Northeast. For one, Manipur, Nagaland and Mizoram share a long, porous border with Myanmar, the world’s second-largest producer of opium, after Afghanistan. Drugs flow easily and cheaply across this border.

In addition to being close to Myanmar, Manipur and Nagaland are characterised by long-standing civil insurgency. For decades, dozens of different armed groups have been fighting to either secede from those states, or from India as a whole. This has had a profound effect on the communities in the Northeast—a 2008 report from the international NGO Human Rights Watch described the region as enduring “decades of neglect, widespread corruption, and a failure by successive governments to deliver economic growth and sustainable development.”

A consequence of this stunted economic growth is that Manipur is also plagued by a widespread job shortage—as of last year, almost 750,000 of the state’s 2.7 million residents were unemployed. As one former drug user in his thirties put it to me: “The only jobs in Manipur are ones with the government.”

This unemployment, and the boredom that comes with it, pushes thousands in the region towards drug use. “Unemployment is one of the biggest issues in Manipur,” RK Nalinikanta, a former drug user, and president of the Community Network for Empowerment in Manipur, told me. “People who inject drugs are treated as second-class citizens. We are the victims, and the government needs to take responsibility.”

However, the reasons why men and women fall into drug use differ starkly, a global health expert who has extensively researched female injecting drug users in Manipur said. “My anecdotal impression is that guys are more likely to get into drug use because of boredom and wanting to have some fun, but become addicted over time,” the expert, who did not want to use her name for fear it could jeopardise her work in the region, said. “Whereas women tend to drift into drug use because they are socioeconomically vulnerable and the drugs help them to deal with their pain.” Women, she added, “often enter drug use with a history of losing their family or dysfunctional family relationships, and even if they had family before drug use, they’re very unlikely to have an ongoing relationship with them now.”

In fact, a study by the United Nations Office on Drugs and Crime in 2015 found that Manipur has the highest ratio of female to male users in all north-eastern states—28.2 percent of injecting users in the state are women. It found that half of Manipur’s female drug addicts rely on drug dealing and sex work as their primary sources of income, just like Jenny does.

THE DAY AFTER I FIRST MET JENNY, I travelled by car for about two hours down a potholed road from Imphal to Churachandpur district, in south-west Manipur. The surrounding terrain was dotted with bamboo shacks, electric-green rice paddies and mountains.

Over the last few years Churachandpur had seen violence, driven by concerns over land-reform bills passed in parliament. That violence had prevented some international NGOs from operating in the area, or caused them to institute restrictions, such as a 5 pm curfew.

I went to Churachandpur to visit a centre that provides opiate substitution therapy, or OST—a form of treating opiate addiction by replacing illicit drugs, such as heroin, with medically prescribed ones, such as buprenorphine or methadone. These legal alternatives are longer-acting than their illegal cousins, but they produce less of a euphoric high, which in turn helps reduce the user’s cravings and withdrawal symptoms.

Research illustrates wide-ranging benefits of OST, including reduced drug use, reduced criminal behaviour, reduced risk of contracting HIV and improved retention in treatment for HIV and other blood-borne diseases. But according to research by the World Health Organisation, despite these benefits, only three percent of injecting drug users in India—and only 8 percent of them worldwide—have access to OST.

On paper, India has embraced OST. The country licensed buprenorphine for the treatment of opioid dependence in drug treatment centres in 1999. In 2008, OST was incorporated into the National AIDS Control Programme’s harm-reduction efforts. Then in 2011, international NGOs hailed India for its introduction of methadone-maintenance treatment—a more powerful opiate than buprenorphine, for users with more serious addiction.

But the realities on the ground are different. In Manipur, I saw many people, especially women, struggle to access OST because the few services and centres that were, in theory, available to them were inadequate.

Once we reached Churachandpur, a local health worker led me down a narrow, dark alleyway and up a steep staircase, to a two-storey building. The place housed Shalom—an NGO that was one of the first in India to begin programmes in clean needle exchange and OST. On the first floor of the building was a sparse room, in which about a dozen male drug users laid around on couches.

The men visit Shalom regularly, treating it as a safe space in which they can relax. Before commencing their treatment, users consult with a drug counsellor before being passed on to an OST doctor who can administer the liquid every morning. “When people want to stop using heroin, when they’re ready to give up, they come upstairs,” Khamzamuan Muana, a drug counsellor at Shalom, told me.
Even people who are not receiving OST are free to use the space. They are especially encouraged to come pick up sterile needles to use so that they do not share needles with other users, and can inject without fear of contracting blood-borne diseases. Such services, called needle-exchange programmes, are a mainstay of drug-treatment initiatives across India and the world.

I met the director of Shalom, Puii Pachuau—a woman with short jet-black hair and a serious face. She spoke to me about the general patterns she had observed among drug users in the area. “For a while we thought it”—drug use—“was on the decline, but I don’t know if it’s decreasing as much as we think it is,” she said. “We’re noticing a lot of new injectors. There’s not a whole lot of opportunities for people here.”

Shalom currently has 200 patients on OST, and a long waiting list. The vast majority of its clients, however are male. “Female drug users are treated differently,” Pachuau said. “Their families don’t accept them, so they have to live on the street, and many become sex workers.”

The following day, I visited the site of a methadone-maintenance-treatment programme in Imphal, and encountered a very similar situation to the one I saw at Shalom. The programme, which is supported by the National Aids Control Organisation, is at the Regional Institute of Medical Sciences, or RIMS—a one-level white building at the back of the main hospital in western Imphal. Here, men—mostly young and tattooed—filed into a small room, one after another, and each drank a small dose of bright orange liquid: methadone.

Thokchom Indira Devi, the regional coordinator of RIMS, told me that of the 88 clients who were currently on OST treatment at the centre, only three were female. During the multiple visits I made, over the course of a few weeks, I never spotted a single woman coming in for treatment. In anti-drug programmes in Manipur, Devi said, women are “left behind.”

“If a male drug user is suffering, there’s some level of acceptance, but females, there’s no acceptance at all,” Devi’s research assistant, who goes by the name Loli, said. “They are forced to leave their family and manage on their own.” He also pointed at the effects of societal censure of female drug users. “When you look at the set up here, because of the taboo and stigma, it’s very difficult for a woman to come here,” he said. “It’s a male-dominated society where men are supported and women are neglected.”

Loli also said that women face “more structural barriers in accessing services” for drug treatment than men do. One of these barriers is that, in order for users to be eligible for methadone-maintenance treatment at RIMS, Devi and Loli told me, the programme must be one’s last resort. This means that patients must prove that they have tried, and failed, at programmes for drug rehabilitation and detoxification. The former usually involves medication, counselling and sharing experiences with other addicts, and the latter is usually an in-patient programme that involves quitting drugs with no replacement chemical treatment. But this rule poses an especially difficult challenge for women, since the vast majority of drug rehabilitation and detoxification programmes are designed for males, by males, and have a male staff. Negative attitudes towards female users, coupled with the lack of facilities that allow children inside, are huge obstacles for women, many of whom are single parents.

A 2012 study published in the journal BMC Public Health found that female drug users “frequently emphasised the desperate need for women-only and women-friendly drug and alcohol detoxification and rehabilitation centres that are low cost and can accommodate children.” The paper also found that a major barrier for women seeking services, even at NGOs, was that doing so “could result in the woman being identified as HIV positive, a drug user or a sex worker (whether or not she was)”—outcomes that could bring deep societal prejudice and discriminatory consequences to women.

Such prejudice means that women users also face disproportionate difficulty in reintegrating into their communities after completing treatment. Unlike men, who are more likely to receive help from their families once they recover, women are not so easily reconciled with or supported by their relatives, and therefore face a more acute risk of relapsing.

Another eligibility criterion for RIMS’s methadone programme is that patients must live within a five-kilometre radius of the centre. This ends up disproportionately excluding female users—many of whom are homeless, and so have no fixed address. While there are no figures on female drug users’ homelessness in Manipur, drug users and NGO workers with whom I spoke stressed a desperate need for women’s shelters in the state.

THE NIRVANA FOUNDATION is one of the few organisations that work exclusively with female injecting drug users in Imphal. It is easy to miss the narrow building just off the main road in town, as a dark curtain shrouds the entryway.

The women visit the Nirvana Foundation’s drop-in centre to shower, rest, pick up condoms and receive medical assistance—a doctor visits three times a week. I visited the centre multiple times, usually in the early afternoon, when users were more likely to be there resting. One day, in early May, about a dozen women laid spread out on mats, in a room on the top floor. Most had bloodshot eyes, scruffy hair and tattered clothing. Their bruised and scarred arms reminded me of connect-the-dot puzzles.

Despite the heat, one woman wore a beanie cap—the previous night, a group of men had shaved her head to “insult her and to embarrass her,” she said.

All of the women I spoke with at the drop-in-centre had been shunned by their families, and are now forced to live on the streets and resort to sex work. One woman told me she started taking drugs two years earlier, because of family problems. Another told me she recently tried to start OST, but could not continue, because the services were not catered towards women. “I started taking OST one week ago, but it was a male-centric clinic. I had to ask the drop-in-centre to have OST where it’s friendly,” she told me.

Jenny, who also visits the centre, told me that all the women there are homeless. “It’s very tough,” she said. “We are all struggling because we were chased out by our families. Drug use doesn’t look good for ladies.”

These realities stand in stark contrast to Manipur’s general reputation for being a state that excels in the realm of women’s rights. In fact, compared to most other Indian states, a girl born in Manipur is more likely to be educated, to survive childbirth and to work as an adult. But, as Sobhana Sorokhaibam, the general secretary and founder of the Nirvana Foundation, told me: “It’s still India after all.” Female injecting drug users, she said, are particularly “vulnerable to torture” and abuse, both emotional and physical. “Their chances of exploitation are high.”

For the women at the Nirvana Foundation, threats of gender violence lurk just outside the drop-in centre. When I visited, male drug users and sex-work clients hung around just outside the building, waiting for the women to leave at 4 pm, when the centre shuts each day. Some were even brazen enough to enter the Nirvana Foundation premises, only to be screamed at by the staff and chased out.
At night, the women split into groups of two or three, to be safe. Sometimes, they have sex with clients at one of the cheap hotels in the centre of town. There are a few public toilets around the city where some go to rest. On other nights, they may sleep, huddled together, in a nearby forest.

“The big problem is the night time,” Jenny told me. “We need a shelter home, a proper safe place.” In Imphal, there are no shelter homes specifically for drug users—only one for destitute women, Sorokhaibam told me.

Yumnam Tomba is a former drug user who now works with female drug users, at the Nirvana Foundation. When he was using, he said, “At least I had a home to go to.” The women he works with now, he said, face many more hardships, because their homelessness often pushes them to sex work.

Tomba said that female drug users often delay or avoid seeking treatment because they know they will be mistreated in programmes that mainly serve men. “If you’re providing OST in the same place”—as men—“people are not friendly,” he said, explaining that the negative attitudes of health care workers and male drug users towards female users often deterred women from seeking treatment in mixed-gender programmes. “Women need a separate place so they openly come and seek treatment,” he said.

Of the women I spoke to at the drop-in-centre, all agreed that they wanted to quit drug use. “We want to quit drugs, but where do we go?” Jenny asked. “There are no services for us.”

EVEN WOMEN WHO ARE not addicts themselves, but who are affected by diseases commonly associated with drug use, often face immense stigma. At the end of my first trip to Manipur, I attended a gathering of widows who had lost their husbands to drugs. They met at the office of the Community Network for Empowerment, or CoNE—an organisation that works to expand treatment for those affected by drug use.

There, I met a woman in her forties, who told me about how she had faced discrimination after learning she had contracted HIV from her husband, an injecting drug user. She found out she had the virus in 2005, and her husband passed away in 2008. Just last year, the woman found out she also has hepatitis C, which, like HIV, is closely associated with injecting drug use, since it can be transmitted by blood. If left untreated, hepatitis C can cause liver cirrhosis, cancer and ultimately death. “The way my in-laws treat me is very different to how they treat everyone else,” she told me. “They don’t want to eat with me. They have a demeaning attitude towards me.”

The other widows at the gathering reported similar ordeals. One of them was Benn Benn, a woman whose husband was also a drug user and died in 2008, of acute liver cirrhosis. He had hepatitis C and HIV, and passed both on to Benn Benn. “I was so scared about hepatitis C,” she said. “If I died, what would happen to my children?”

These days, new, highly effective treatment for hepatitis C is available. While patients can apply to have the cost of treatment reimbursed at public health facilities in Manipur, they still must pay up front, making the drugs inaccesible to many people. The standard three-month course of treatment costs approximately Rs 30,000. In this respect, Manipur lags behind several other Indian states, some of which offer hepatitis C drugs for free. For example, in Tamil Nadu, the medicines are provided free of cost at public hospitals for people living under the poverty line, and in Punjab, which has a high prevalence of the virus, treatment is free.

According to the World Health Organisation, as of the end of 2015, 42,000 people in India had been treated for hepatitis C. But, as the organisation Lawyers Collective noted in a 2016 report, there is no data available on the number of people living with hepatitis C in India or the number of people who require treatment.

Both Benn Benn and the woman in her forties, however, were able to receive treatment for free through CoNE. The organisation’s efforts so far have focussed on widows who have been ostracised from their communities because their husbands were injecting drug users. It also works to lower the cost of medicines by directly negotiating with pharmaceutical companies for drug users, along with increasing access to HIV medication and scaling up OST across the state.

According to Sorokhaibam, female injecting drug users in the Northeast are more prone to contracting blood-borne viruses such as hepatitis C and HIV than male drug users are. The previously cited UN report on drug use among women in the Northeast said that, given this disparity, it was surprising “that much of the evidence and responses on drug users do not distinguish between men and women when discussing prevalence, needs, risks and outcomes of illicit drug use.” This lack of literature on gender disparities, the report added, “has led to a possible under representation of the specific issues that women who use drugs face and a gap in appropriate policy development and understanding around their specific needs.”

According to the Manipur State AIDS Control Society, a state offshoot of NACO, Manipur is the state with the highest HIV incidence in India. It has almost 8 percent of India’s recorded HIV cases, despite only being home to 0.2 percent of the national population.

But while HIV treatment—antiretroviral treatment—is available for free at public hospitals in Manipur, Sorokhaibam explained that female drug users often struggle to access the life-saving drugs, sometimes because they lack the required identification documents. “They are human beings without any ID,” she said. When women’s relatives learn that they are using drugs, she said, “their families have erased their identity,” which means that many women seeking treatment “have no proof of who they are.” As a result, Tomba explained, female users with HIV often cannot access free drugs at health facilities, and instead, either go without the treatment or rely on NGOs to supply them with free medicines. Or, if they have enough money, they buy the drugs from private facilities.

While no widespread prevalence studies on hepatitis C have been completed in Manipur, those with whom I spoke who work in harm reduction estimated that up to 80 percent of injecting drug users have hepatitis C. Jenny told me she had not contracted any diseases, but the other female users I spoke with were less open about their health, often shying away from my questions.

One reason that women are more prone to contracting blood-borne diseases may be because women tend to share needles more often than men. A 2008 paper on female drug use in Manipur by the Population Council found that 96.5 percent of participants had shared needles. In contrast, a 2014 study found that 13 percent of male drug users in Manipur claimed to have shared needles in the last month.
According to Sorokhaibam, women are more likely to lack access to needle-exchange programmes, leading to them often sharing with others. While the National AIDS Control Program provides one clean needle per day through its Needle Syringe Exchange Program, Tomba said women inject more frequently than men.

Purchasing brand new needles from pharmacies is often impossible because of its cost. Jenny told me that female users are often forced to choose between two risky options: sleeping with more clients in order to be able to afford new needles or deciding to share needles with others.

Sex work, of course, also puts women at great risk of contracting sexually transmitted diseases and blood-borne viruses, often because they lack negotiating power in client dealings. The Population Council study found that fewer than 10 percent of female drug users who had engaged in sex work reported regular condom use. “Clients always want to have sex without condoms,” Jenny said. “Sometimes I have 20 customers per night. The more customers we get, the more we inject.”

When I saw Jenny again, a few weeks after I had first met her, she told me that she had lately been struggling with a decline in clients. There were rumours, she said, that police had begun to crack down on sex work, which might have caused the decline.

“Where are they?” she asked me, wondering at the missing clients, shaking her head. “Where can I find them?”
one evening in imphal, I received a call late at night, from an unknown number. It was Jenny. Her voice was barely understandable, and she asked me to meet her the following morning, at 10 am, at the Nirvana Foundation drop-in centre.

When I went to meet her, however, she was not there. I tried calling the number from which she had called me the previous night, but no one picked up. She does not own a mobile phone, so had likely called me from someone else’s.

I saw her the next morning, though—at the bottom of the steps of the drop-in centre, peeling the small shells off of pumpkin seeds. She looked dishevelled and it seemed like she had had a difficult night.
Jenny invited me to go with her to sell heroin. I agreed, though I was initially reluctant, worried that it might attract too much attention. But she knows the streets of the city very well and she navigated them discreetly, with ease.
Near the bus station in central Imphal, Jenny was approached, individually, by more than ten men. She casually handed them small bags of drugs in exchange for cash. The transactions took only a few seconds, just enough for a nod of acknowledgment and a hello.

We continued walking after that, and every few minutes, someone on a scooter pulled up alongside us, swapped drugs for money and continued driving. Jenny had sold all her heroin within about half an hour, and it was time to go back, on a micro-bus, to the decrepit house on the outskirts of the city.

Once there, she sat on the floor on a mat, injected twice and fell asleep. Jenny woke up a few hours later, and it was time to hit the streets again to deal more heroin—she needed money to buy her evening hit. She told me she did not know where she would sleep that night: perhaps in the public toilets in town, the jungle near the edge of the city, or with a client at one of the cheap hotels in central Imphal.

We walked to the nearest major road to ride the bus back into town. On the way, Jenny stopped to buy an ice cream. The coldness of the treat briefly brought her out of her drug-induced haze. “I really want to quit drug use. Will you help me?” she asked me on the bus, before falling back asleep.

S Cousins is a health journalist and writer based in Nepal. Her work focusses on the systems that perpetuate inequality and the impact this has on women’s and girls’ health.

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