It's just after noon in the hills of Cayey and life in this sleepy Puerto Rican mountain town continues at a predictable pace.
Old men lounge in a local park swapping stories amid the sweltering heat. Stores and diners bustle with customers, and the local church, Nuestra Señora de la Asunción, rings its bells on the hour.
Nearby, hidden behind a thicket of lush trees and tall grass, Cecilio Camacho expertly pierces his skin with a hypodermic needle. He pulls back the syringe’s plunger and clouds of blood spill into the barrel. He sighs after finding the vein. Then, with the dexterity of an addict who has injected thousands of times, he gently shoots about five dollars’ worth of heroin into his bloodstream.
For the last three decades, Puerto Rico's public health officials have unsuccessfully fought a full-scale public health crisis. Today, the island has one of the highest HIV/AIDS infection rates in the U.S. and more than 50 percent of all newly reported cases come from intravenous drug use.
Overwhelmed and chronically underfunded, the existing framework of health programs struggles to serve the island’s estimated 60,000 intravenous drug users, so a patchwork of groups tries to fill the void. In 2007, Joseph Carroll Miranda helped start El Punto en la Montaña, a group that offers medical supplies and services to addicts who live in rural areas, out of the reach of government services.
Operating on a shoestring budget of about $50,000 a year -- most of it from non-profit donors in the U.S. –Miranda and a small team of volunteers deliver clean needles, juice and snacks to addicts each week. They bring along educational pamphlets, too, with explanations of how to use syringes and warnings about reusing needles. Sometimes he puts them in detoxification programs.
“It’s not a program to glorify or condemn drug use,” Miranda explained. “There is no moral judgment. The bottom line is to teach addicts how to take care of themselves.” The pragmatic approach helps his group’s approachability in a place plagued by social stigma. Government officials, drug user, and volunteer health workers cite the culture of shame as the biggest obstacle to fixing the problem.
Programs like Miranda’s -- based on a successful philosophy used during the 1990s in New York -- remove politics and morality from the equation and focus solely on education and treatment.
“The point is to reduce the harm that comes from drug use both to the individual and community,” Miranda said. “Anything in that direction is a success.”
For Miranda, who as a teenager watched drug use skyrocket, the work is personal. A lot of his friends used, some eventually died. In a way, building the program was for them.
“Being in a position to do something about this was a blessing,” Miranda said. “I’ve lost a lot of friends to drugs and a program like this could have prevented it.”
As the government scaled back its funding, organizations like Miranda’s tried to pick up the slack.
“The government is not doing what it should be doing,” Miranda said. “So what you have is the proliferation of nonprofits doing that kind of work here in Puerto Rico.”
The government’s own survey estimates a treatment gap of 92 percent, with only a small portion of the drug using population receiving detoxification services like methadone treatment.
Today, Cecilio Camacho’s needle is new.
Voluteers from El Punto en la Montaña brought him a package of 25 sanitized syringes, something he doesn’t always have.
His heroin addiction started the same way many do on the island: with tragedy. He was 17 when his grandma died. She was the one who raised him and he spiraled into a deep depression.
"I felt like I lost everything and I felt lonely," he said. "I felt like I too wanted to die.”
Drugs hadn’t appealed to him before, even though many of his friends used. The pain of losing her made him reckless, though, and soon drinking led to harder drugs. Until finally, while struggling with a bout of depression, he bought two bags of heroin, found a needle, and shot up.
Unlike in most U.S. states, there isn’t easy access to clean needles in Puerto Rico, so many addicts reuse their needles or share them. Those who can afford it buy clean syringes from diabetes patients. And in extreme cases, addicts use rocks and coins to sharpen syringe points dull from overuse.
While aggressive public health initiatives have successfully reduced the transmission of HIV/AIDS through intravenous drug use in the U.S., Puerto Rico implemented approaches that ended up exacerbating the problem – increased policing and lengthy incarceration rates for drug addicts.
Dr. Carmen Albizu-Garcia, one of Puerto Rico’s leading public health researchers on drug addiction, said these punitive policies paved the way for the problem.
“We realized that what we had was the horrible outcome of bad drug policy,” said Albizu-Garcia, who has researched the link between public policy and drug use.
As Puerto Rico sought stricter sentences for drug dealers and more jail time for users, many publicly-funded treatment programs adopted zero tolerance policies, cutting off treatment to people who relapsed.
These factors created a snowball effect and by 2001 the number of new HIV cases were among the highest in all the Western Hemisphere.
"We are facing a situation that was totally preventable," she said.
This past January Governor Garcia Padilla picked Albizu-Garcia’s husband, Dr. Salvador Santiago Negrón, to lead Puerto Rico’s Department of Mental Health and Addiction.
The new leadership says it plans to expanded services and integrate addiction treatment into primary health care, but the battle against the persistent stigma remains. While the change could come too late for thousands of addicts, Albizu-Garcia is hopeful.
“This is not a vice,” said Albizu-Garcia, who is tasked with fighting the stigma as a researcher at a local university. “It’s a health issue, and until people see it as such, we won't see a change.”
Nearly 40 years later, Camacho still struggles with addiction. He checks in and out of rehab. During some periods he’s clean and other times he uses several times a day. A few times he almost died from shooting up too much heroin.
"I didn't know the consequences before,” Camacho said. “But knowing them now, I'd prefer death to be sick with drugs."