HOW A COMMUNITY CLINIC HAS RESPONDED TO THE WAR ON DRUGS: AN ETHNOGRAPHIC STUDY by Carolina Arredondo Sanchez Lira A thesis accepted and approved in partial fulfillment of the requirements for the degree of Master of Arts in Global Studies Thesis Committee: Kristin Yarris, Ph.D., Chair Lesley Jo Weaver, Ph.D., Member Camille Cioffi, Ph.D., Member University of Oregon Summer 2024 2 © 2024 Carolina Arredondo Sanchez Lira 3 THESIS ABSTRACT Carolina Arredondo Sanchez Lira Master of Arts in Global Studies Title: How a Community Clinic Has Responded to the War on Drugs: An Ethnographic Study This thesis explores the profound social impacts that the War on Drugs in Mexico has had on women who use drugs and reside in the border town of Tijuana, Baja California. The War on Drugs was a failed policy initiated by Felipe Calderon, Mexican president from 2006 to 2012, which has led to an increase in violence, corruption, human rights violations, and marginalization of vulnerable communities. Nonetheless, Mexican president Andres Manuel Lopez Obrador (AMLO), who promised to dismantle the War on Drugs, has instead strengthened it. From the beginning of his presidency in 2018 until 2024, AMLO deployed the National Guard to combat the insecurity in Mexico. Also, AMLO decided not only to cut all funding to organizations but also not to support harm reduction measures. The lack of resources and funding has made it challenging for people who use drugs, especially women, to receive the needed support. Through the lens of the Social Ecological Model (SEM), this research aims to investigate the multifaceted effects of the War on Drugs on women who use drugs, emphasizing gender and drug use. The project focuses on PrevenCasa, a non-profit community clinic in Tijuana. As well the study further examines the social and health outcomes of the harm reduction services provided by the clinic to women who use drugs. The research employs an ethnographic method, including observations and semi-structured interviews with focus group participants and staff members in the clinic. As well the thesis aims to understand what are the socio-effects of the services that PrevenCasa, a community health organization in the Zona Norte, has to offer to women who use drugs. Findings from this study will contribute to a better understanding of the negative impact of harmful policies on marginalized communities, such as women who use drugs. As well the project will contribute to understanding the critical role that harm reduction can have in improving the health and well-being of women who use drugs. 4 CURRICULUM VITAE NAME OF AUTHOR: Carolina Arredondo Sanchez Lira GRADUATE AND UNDERGRADUATE SCHOOLS ATTENDED: University of Oregon, Eugene DEGREES AWARDED: Master of Arts, Global Studies, 2024, University of Oregon Bachelor of Arts, Political Science and Latin American Studies, 2017, University of Oregon, Eugene. AREAS OF SPECIAL INTEREST: Public Health Harm Reduction Global Health Social Determinants of Health Structural Violence Im/migrant Communities Latino Communities Reproductive Health Drug Policy PROFESSIONAL EXPERIENCE: Representative, Youth Rise, 2024 – current Board Member, Daisy C.H.A.I.N, 2022-2024 Graduate Educator, University of Oregon, 2022-2024 Disease Intervention Specialist, Lane County Public Health, 2018-2022 Community Health Worker, Lane County Public Health, 2016-2017 Program Manager Mills International Center, University of Oregon, 2015-2017 5 GRANTS, AWARDS, AND HONORS: Graduate Teaching Fellowship, University of Oregon, 2022-2024 Center for Latino/a and Latin American Studies (CLLAS) Summer Research Grant, University of Oregon, 2023 George & Conni Slape Fellowship, University of Oregon, 2023 Thurber Award, University of Oregon, 2023 Division of Graduate Studies Dissertation Award, University of Oregon 2023 Global Engagement, University of Oregon, 2023 ICSP Scholarship, University of Oregon, 2013-2017 Board of Commissioners Recognition for COVID-19 Response, Lane County, 2020 NCSD Scholarship Policy Academy, National Coalition of STD Directors, 2019 World AIDS Day Award Recipient, HIV Alliance, 2019 NCSD DIS Scholarship, National Coalition of STD Directors, 2018 Board of Commissioners Recognition for I’m healthy! / Soy Sano!, Lane County, 2017 PUBLICATIONS: CATALYSTS FOR CHANGE: YOUTH-DRIVEN INSIGHT IN OPIOD HARM REDUCTION, Authors: Rebeca Calzada, Atika Juristia, Teresa Castro, Carolina Arredondo S.L., Vincentius Azvian, Alfonso Chávez, Susan Wambui, Walter Osigai Etepesit, Paul Sixpence. 6 ACKNOWLEDGMENTS First and foremost, I want to thank the women who were part of my focus groups. Thank them for sharing their life stories and experiences with me. This project is possible because of each one of them. I also want to thank the staff in the community organization who welcomed me and supported me throughout my two-and-a-half months in Tijuana. This project would not have been possible without the staff and clients, who are incredibly resilient despite the heavy toll that the War on Drugs has inflicted in Tijuana, Baja, California. ¡Gracias Mari, Alfonso, Steph, y Mariana! You all have taught me the importance of constantly showing up for our communities despite adversity. Furthermore, I would like to express my gratitude to my wonderful advisors, Dr. Kristin Yarris, Dr. Lesley “Jo” Weaver, and Dr. Camille Cioffi, for their support, guidance, and encouragement throughout the preparation of my project and thesis. Additionally, I would like to thank my parents and siblings, who cheered from afar throughout these last two years. Jaime, thank you for showing me that pursuing higher education is possible; I am proud of you. Ben, thank you for being a fantastic partner throughout this whole journey. Thanks to my friends in Public Health, you all motivated me to return to school. Finally, thank you to my friends Kate, Veronica, and Keri who have helped me since day one of this journey. I want to dedicate this thesis to my mom, who has devoted her life to caring for her children. Thank you for teaching me the importance of fighting injustices and helping others. Mom, thank you for putting up with this wild child; I love you. This study was made possible by the generous support of the University of Oregon Center for Latino/a and Latin American Studies (CLLAS), the George & Conni Slape Fellowship, the 7 University of Oregon Thurber Award, the University of Oregon Global Oregon Award, and the University of Oregon Division of Graduate Studies. Their funding has been crucial in the successful completion of this project. 8 TABLE OF CONTENTS CHAPTER I................................................................................................................................. 13 INTRODUCTION .......................................................................................................................... 13 Purpose of the Study ............................................................................................................. 15 CHAPTER II ............................................................................................................................... 18 REVIEW OF THE LITERATURE ..................................................................................................... 18 Social-Ecological Model....................................................................................................... 18 Mexico’s Policies .................................................................................................................. 21 Social Determinants of Health in Vulnerable Communities ................................................. 30 Violence................................................................................................................................. 34 CHAPTER III ............................................................................................................................. 40 METHODS................................................................................................................................... 40 Locality.................................................................................................................................. 40 Positionality Statement ......................................................................................................... 41 Methods ................................................................................................................................. 41 Research Population ............................................................................................................. 47 CHAPTER IV.............................................................................................................................. 49 PREVENCASA: SERVICES AND CLIENTS DEMOGRAPHICS ........................................................... 49 Overview ............................................................................................................................... 49 CHAPTER V ............................................................................................................................... 60 DATA ANALYSIS ........................................................................................................................ 60 Focus Groups ........................................................................................................................ 60 Overall Participants.............................................................................................................. 62 Staff Interviews..................................................................................................................... 62 CHAPTER VI.............................................................................................................................. 64 PREVENCASA AND WOMEN WHO USE DRUGS........................................................................... 64 HOW HAS THE WAR ON DRUGS MARGINALIZED WOMEN WHO USE DRUGS IN BAJA CALIFORNIA? ..... 64 9 Overall .................................................................................................................................. 65 CHAPTER VII ............................................................................................................................ 97 PREVENCASA: SAFETY, ADVOCACY, AND COMMUNITY FOR MARGINALIZED WOMEN.............. 97 WHAT ARE THE SOCIAL IMPACTS OF PREVENCASA'S SERVICES FOR WOMEN WHO USE DRUGS? ........ 97 Safety: Harm Reduction Services.......................................................................................... 98 Interpersonal Level: Harm Reduction Interventions .......................................................... 103 Advocacy: Empowering through Education ....................................................................... 114 Community .......................................................................................................................... 122 CHAPTER VIII ........................................................................................................................ 132 IDENTIFIED NEEDS IN PREVENCASA ........................................................................................ 132 WHAT ARE THE NEEDS TO BETTER SERVE WOMEN WHO USE DRUGS IN TIJUANA? .......................... 132 Outside of PrevenCasa........................................................................................................ 132 Within PrevenCasa ............................................................................................................. 133 Overall ................................................................................................................................ 142 CHAPTER IX............................................................................................................................ 143 CONCLUSION: PREVENCASA AND THE SOCIO ECOLOGICAL MODEL ........................................ 143 Future Directions ................................................................................................................ 148 APPENDICES ........................................................................................................................... 150 APPENDIX A............................................................................................................................. 150 APPENDIX B ............................................................................................................................. 152 APPENDIX C ............................................................................................................................. 154 APPENDIX D............................................................................................................................. 155 APPENDIX E ............................................................................................................................. 156 APPENDIX F ............................................................................................................................. 157 10 LIST OF FIGURES Figure Pages Figure 1. Socio Ecological Model Tijuana. Created by Carolina ................................................. 20 Figure 2. Demographic data from research project 2023. Place of origin. Focus group participants. ....................................................................................................................................................... 60 Figure 3. Demographic data from research project 2023. Age. Focus group participants. .......... 60 Figure 4. Demographic Data from research project 2023. Drug of Choice. Focus group participants. ................................................................................................................................... 61 Figure 5. Demographic data from research project 2023. Consumption Mode. Focus group participants. ................................................................................................................................... 61 Figure 6. Attendance research project 2023. Focus group participants per group. ...................... 62 Figure 7. Data coded during the Research Project 2023. Overall type of violence mentions. ..... 65 Figure 8. Data coded during the research project 2023. Overall type of violence. Structural violence breakdown. .................................................................................................................................... 66 Figure 9. Data coded during the research project 2023. Criminal justice system mentions. ........ 66 Figure 10. Data coded during the research project 2023. Institutional violence mentions. .......... 75 Figure 11. Data coded during the research project 2023. Overall importance of PrevenCasa. .... 97 Figure 12. Data coded during the research project 2023. Overall importance of PrevenCasa. Harm Reduction mentions breakdown.................................................................................................... 97 Figure 13. Google map marking Zona Norte (Blue) neighborhood and downtown (Red). Green lines indicate outreach route done by PrevenCasa Harm Reduction team. Created by Carolina Arredondo. .................................................................................................................................. 110 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425838 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425839 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425839 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425840 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425841 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425841 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425842 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425842 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425843 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425844 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425845 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425845 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425846 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425847 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425848 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425849 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425849 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425850 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425850 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425850 11 Figure 14. “Bloqueadores”. 2023. Created by Stephanie Yamaguchi, Mariana Gonzalez, Carolina Arredondo, and Alfonso Chavez. Picture taken by Carolina Arredondo. .................................. 118 Figure 15. “Servir y Proteger”. Picture taken by Carolina Arredondo. ...................................... 119 Figure 16. “Servir y Proteger” – “To Serve and Protect”. 2023. Created by Stephanie Yamaguchi, Mariana Gonzalez, Carolina Arredondo, and Alfonso Chavez. Picture taken by Carolina Arredondo. .................................................................................................................................. 120 Figure 17. “Servir y Proteger”. Picture taken by Carolina Arredondo. ...................................... 120 Figure 18. Data coded during the research project 2023. Overall data for identified needs. ..... 134 Figure 19. PrevenCasa Identifications. 2024 .............................................................................. 135 Figure 20. Data coded during the research project 2023. Overall data for identified needs. La Zona. ..................................................................................................................................................... 139 Figure 21. Socio Ecological Framework (SEM) using the data from the research project. ....... 144 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425851 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425851 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425852 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425853 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425853 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425853 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425854 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425855 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425856 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425857 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425857 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177425858 12 LIST OF TABLES Figure Page Table 1. PrevenCasa client demographics. Gender and Age. 2022. Source PrevenCasa ............. 49 Table 2. PrevenCasa client demographics. Living conditions 2022. Source PrevenCasa ............ 51 Table 3. PrevenCasa client demographics. Employment. 2022. Source PrevenCasa ................... 52 Table 5. Overall collected data focus group participants. Research Project 2023. ....................... 62 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177426172 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177426173 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177426174 file://///Users/carolinaarredondo/Downloads/Thesis%20CASL2024.%20Edited.docx%23_Toc177426175 13 CHAPTER I Introduction The so-called "War on Drugs," implemented by Felipe Calderon's government, created more violence than before the reform took place. The implementation of this plan is aimed at imitating the one that was enforced in the United States. The War on Drugs in México has centered on extreme militarization, which has evoked human rights violations. Even after Calderon implemented the Narcomenudeo reform, which decriminalized certain drugs in small quantities, neither drug consumption nor production decreased. As a result, there was an increase in the spread of blood diseases among drug users and a high rate of mass incarceration. While President Felipe Calderon officially declared the War on Drugs in 2006 due to its proximity to the U.S., Mexico's policies have always been influenced by the United States. In 2008, Calderon decided to implement the Merida Initiative. This initiative was a cooperative agreement between the U.S. and Mexico to combat the threat of drug trafficking. Primarily, the initiative aimed to provide more equipment and assistance in training for the military and police to break up the drug cartels. However, these previous tactics to deter drug cartels have not been effective. As of 2018, the president of Mexico from 2018 to 2024, Andres Manuel Lopez Obrador (AMLO), has continued the implementation of the War on Drugs as a security tactic to "combat" drug cartels. These failed policies have instead caused more damage. According to the Human Rights Watch (2011), the War on Drugs has spread numerous human rights abuses. Some of the violations that were determined in this report consisted of kidnapping, torture, homicides, and femicides (Human Rights Watch, 2011). The article recognizes that while drug cartels can cause some of these harms, it is also justice officials that are implicated in these violations through corruption. According to Human Rights Watch, from 2006 until 2012, the War on Drugs caused 14 the violent deaths of 60,000 people (Human Rights Watch, 2012). However, a part of the War on Drugs that has not often been talked about is how this war has affected the most vulnerable communities. One of those most vulnerable communities is people who use drugs, especially those who identify as women. Andres Manuel Lopez Obrador has not only focused on deploying the National Guard to the streets to "protect" the community. However, AMLO has also focused on creating a national campaign that focuses on the dangers of consuming drugs. As a result, AMLO's policies have also focused on cutting any funding to non-profits, especially those that provide harm reduction services. As of March 2024, the United Nations Commission on Narcotic Drugs recognized and highlighted the importance that harm reduction measures play in the prevention of drug use and overdose (United Nations, 2024). The United Nations also recognizes that harm reduction is an important strategy to reduce and prevent the spread of communicable diseases such as HIV and Help C (World Health Organization, 2022). Unfortunately, the current administration in Mexico has stated that harm reduction strategies, such as the use of naloxone to prevent an overdose, cause more harm by prolonging a person's pain (Dominguez, 2023). Since the arrival of fentanyl in Mexico in 2019, there has been a significant increase in overdose deaths. This situation has been exacerbated by the Mexican government's failure to provide essential resources such as naloxone. Needle exchange, naloxone to revert overdoses, and fentanyl testing kits are hard to obtain. Due to the global overdose epidemic, there has been a push for Safe Consumption Sites (SCS) as a harm reduction strategy to reduce and ultimately prevent sharing needles among users, rushed injections causing wound infection, and death-related overdoses. The first two unsanctioned SCS in Latin America are in Baja, California, one in Mexicali, and the other in Tijuana. Most importantly, the War on Drugs strategy has caused significant harm to people who 15 use drugs, particularly women, due to the intense stigmatization and gender-based violence they frequently endure. While drug use occurs nationwide, Tijuana is a significant drug entry and exit point. Most importantly, Tijuana is a primary repatriation site for Mexican nationals and other migrant communities. An advocacy group for human rights in the Americas studied how many migrants were in Tijuana. They estimated that at least 300,00 individuals had migrated to or through Tijuana within the past year, which counted for at least 15 percent of Tijuana's population (2022, WOLA). Many individuals who have either been deported to Mexico or are stuck in Tijuana face a range of reintegration challenges, such as social isolation, homelessness, unemployment, discrimination, and drug dependency. Another study done in Tijuana discovered that following their U.S. deportation, migrant women were suffering from social and physical stressors due to the lack of community support, financial security, emotional distress, physical insecurity, drug abuse, and lack of access to health care services (Robertson et al., 2011). The same study also highlights the importance of allocating more resources to women who use drugs, acknowledging their increased vulnerability to experiencing higher levels of violence. For this reason, I focus on women who use drugs for this thesis, specifically those who reside in Tijuana, Baja California. A non-profit community clinic in Tijuana, PrevenCasa, has been working with these marginalized populations. The clinic provides medical and behavioral services and harm reduction services such as needle exchange, fentanyl testing strips, and Narcan. Two years ago, they opened an unsanctioned Safe Consumption Site (SCS). I plan to focus my research on Tijuana, Baja California, at PREVENCASA. Purpose of the Study 16 The purpose of this project is to: 1) identify in which ways the War on Drugs policies have contributed to the marginalization of women who use drugs in Tijuana, Baja, California. The project also seeks to 2) understand what are the socio-effects that PrevenCasa creates based on the services it provides to women who use drugs. Lastly, the project also aims to 3) understand areas of growth for PrevenCasa and in their delivery of services for women who use drugs. Lastly, this project has used the 4) Social Ecological Model (SEM) framework to analyze the different levels that affect the well-being of women who use drugs. This research uses the Social Ecological Model (SEM) framework. The SEM focuses on the different levels (individual, relationship, community, societal) that can affect health. This project will shed light on the barrier faced by migrant users in Tijuana and show the effect of harm reduction strategies to prevent overdoses or infectious diseases. In addition, a) it will help create program recommendations to improve the physical, social, and mental health of an underserved and overlooked community on the border; b) it will produce findings and recommendations that will help assess the harm reduction services that are provided at the community clinic PREVENCASA and make recommendations for improvement. As the primary researcher, I will hold weekly semi-structured focus groups with clients. Community support, financial security, emotional distress, physical insecurity, drug abuse, and lack of access to health care services (Robertson et al., 2011). The same study also highlights the importance of allocating more resources to women who use drugs, acknowledging their increased vulnerability to experiencing higher levels of violence. For this reason, I focus on women who use drugs for this thesis, specifically those who reside in Tijuana, Baja California. 17 My thesis research questions aim to understand the social impacts that the War on Drugs has had on women who use drugs. I planned ethnographic research through observations and focus groups to explore these three research questions: 1. How have women who use drugs in Tijuana, Baja California, been marginalized by the War on Drugs? 2. What are the social impacts of PrevenCasa's services for women who use drugs? 3. What are the needs to better serve women who use drugs in Tijuana? 18 CHAPTER II Review of the Literature Social-Ecological Model For this project, I am utilizing the Social-Ecological Model to analyze further how the War on Drugs and the Services that PrevenCasa offers have impacted women who use drugs in Tijuana, Baja California. This model focuses on health promotion while addressing individuals and their environments. This model conceptualizes that to change people, you should also change their environment and how they move around the world. From the social-ecological model, we can understand why migrants and deportees in México, especially in Tijuana, are highly susceptible to not only having their rights violated but also may be more susceptible to engaging in high-risk behaviors such as using drugs. From the previous points mentioned, utilizing this framework, we can understand why migrants and deportees at the border in Tijuana have a higher risk of suffering from depression, trauma, homelessness, lack of job opportunities, drug dependency, and discrimination. We can understand that specific policies in México and structural barriers affect their overall health. Indeed, much of the public health research regarding migrants and drug use understands that harm reduction interventions carry benefits such as decreasing overdoses and communicable diseases. However, beyond these clinical benefits, it is essential to understand why harm reduction works, what they create for individuals neglected by the governing body where they reside, and why community activists keep fighting to provide these services despite governmental support. Therefore, this research aims to utilize the social-ecological model to study why the harm reduction services provided in a clinic in Tijuana, despite their lack of government support, can still provide these essential services. 19 Meanwhile, in the article "Intersections between syndemic conditions and stages along the continuum of overdose risk among women who inject drugs in Mexicali, México" by Pablo Gonzalez-Nieto et al. (2023), the article talks about how women who use drugs and suffer a combination of violence, are at risk of overdosing. This is because women either do not access harm reduction resources, tend to overdose in places where no one can assist them, and their trauma may increase their drug use (Gonzalez-Nieto et al., 2023). In the article, Gonzalez-Nieto states that "experiencing multiple types of violence, specifically sexual violence, has been shown to amplify the risk of overdose in women" (Gonzalez-Nieto et al., p.120, 2023). However, I would argue that multiple levels of violence, at individual, interpersonal, organizational, societal, and institutional, contribute to poor health outcomes. These health outcomes are increased overdoses that lead to death, not aging because of early death, depression, and isolation. The SEM allows us to understand at how many levels women can experience, especially women who use drugs, experience various challenges in their daily lives. This framework highlights the necessity of better and much more supportive integrated care for women and demonstrates how violence impacts their livelihoods. In the book "Pathologies of Power: Rethinking Health and Human Rights" by Paul Farmer (1999), he makes the important claim of rethinking health as a human right and to see it from a social and ecological standpoint. Similarly, to the social-ecological model, farmers understand that individuals will be mentally and physically healthy once they understand that health strategies should be addressed from an individual and environmental perspective. For example, in Tijuana, migrants cannot be truly healthy if they do not have access to medical services. However, most importantly, they cannot be healthy when the National Guard is persecuting them, meaning their 20 human rights are violated. Farmer also states that while human rights are universal, "the risk of having one's rights violated is not universal" (Farmer, 1999, p. 109). In some sections of this literature review, it is highlighted that Mexican citizens are afraid of the new War on Drugs that AMLO has led in México. However, it is also highlighted that migrants and deportees have a higher chance of having their rights violated at different levels. As noted before, utilizing a social-ecological model, migrants and deportees in Tijuana have their rights violated through this depiction: This paper also highlights that when adopting public health strategies for marginalized communities, we can engage them in changing or adopting risky behaviors. Harm reduction Figure 1. Socio Ecological Model Tijuana. Created by Carolina 21 strategies function with marginalized communities in Tijuana because the individuals, interpersonal, organizational, and community are addressed within the small environment they tend to engage the most. For example, in Tijuana, PrevenCasa, while not being a governmental institution, has taken an essential role in ensuring health rights are achieved in one way or another. This local clinic has become the community in which migrants/deportees who use drugs most often interact. While AMLO policies will not change soon, perhaps communities, clinics, and providers can see the positive impact PrevenCasa has made in the Zona Norte in Tijuana. Access to health and harm reduction resources such as safe-consumption sites, needle exchange, and fentanyl testing strips should be seen as a fundamental human right. Mexico’s Policies War on Drugs According to the organization "Security Assistance Monitor" (2007), the United States delivered about 1.4 billion dollars and allocated around 2.5 billion through the Merida Initiative. Most of the funding was directed towards security. After the adverse effects of the War on Drugs, in 2009, Felipe Calderon decided to pass a new drug policy called "Ley Narcomenudeo." This reform differed slightly from the previous stand on the War on Drugs. The Ley Narcomenudeo aimed to decriminalize the use of drugs in small quantities, decrease mass incarcerations due to drug possession, and provide medical rehabilitation for users. However, the main problem with this reform was that there was so much corruption in México that there was no funding for substance use disorder treatment centers. Also, both the federal police and the civilians had a lack of knowledge about what the law allowed. The reform only led to more significant mass incarceration and inefficient treatments, both rehab and medicinal, for drug users. Finally, it also led to an increase in blood illnesses such as HIV/AIDS and HCV due to the lack of resources such 22 as needle exchange for intravenous drug users. The current administration of Lopez Obrador has not decided to change this policy. Currently, AMLO has heightened the War on Drugs by sending the National Guard to "protect" civilians from drug cartels. However, these initiatives only caused more harm, especially in border towns like Tijuana. People were not only afraid of the drug cartels, but also there was fear of the legal power the military obtained. The deployment of the Mexican National Guard to border towns was not only to discourage migrants from staying in México but to "combat" drug cartels. In the news article "The Cartels Flexed Their Power in Tijuana - and Now the Battle For Influence" by Wood et al. (2022), it is noted how, after August of 2022, AMLO decided to send more National Guards to Tijuana to fight drug cartels. The authors interviewed citizens and Mexican journalists who stated that they do not feel more secure with this new strategy. Instead, they feel this is the same strategy previous governments have taken, and now they fear the National Guard will violate their rights. While there is no public record by the government and the National Guard, Mexican journalists believe Baja California has more military personnel than other Mexican states (Wood et al., 2022). Also, due to the increased presence of fentanyl in drugs, a synthetic opioid that is much stronger than heroin, AMLO has decided to launch a prohibitionist drug strategy. This "new" strategy imitates the DARE program adopted in the United States in the 90s. While police do not go to schools to teach children about the consequences of using drugs, much of his strategy focuses on teaching people, especially youth, to "Just Say No" to drugs. The government has launched a series of TV commercials that aim to depict what it looks like to use drugs. For example, the National Strategy for Drug Prevention Department in México launched a song that alludes to what it means to sell and consume drugs: 23 “Escucha bien hermano, pues el negocio de la droga termina mal, esto siempre termina mal…Si fumas o lo inhalas, te estas muriendo vivo, te olvidas de tu apellido…piensa más en tu gente, o en tus amigos” “Listen brother, this drug business ends badly, this always ends badly…If you smoke or inhale, you are dying alive, you forget your last name…think about your family, or friends…this always ends badly”. The Mexican government has launched a website called "México Sin Fentanilo" (México without Fentanyl). On this website, the main message they want to portray is that "Mexicans know how to say no to fentanyl". Meanwhile, another part of the new strategy is to have a special curriculum for elementary, middle schools, and high schools to teach children the dangers of using drugs. In one of the teaching videos, children are taught that they can die by only touching fentanyl. The video says phrases such as these ("México sin Fentanilo", 2022): “Comienzas a morir en cuanto pruebas fentanilo…Te lo pueden ofrecer, es pastillas, o aplicado en papel…también lo mezclan con gotas para los ojos o lo ponen en gomitas de dulce…Es tan adictivo, que es imposible dejarlo, por eso los traficantes lo agregan a otras drogas para engañarte. Cuando te ofrezcan cualquier droga, nunca aceptes. Si entra a tu cuerpo perderá interés en tus actividades diarias. Tus brazos, manos y cuerpo se irán deformando. Si te drogas, te dañas”. “You start to die when you try fentanyl…They can offer it to you in pills, or on a laminated paper…They also mix it with eye drops o can put it on gummy bears…Is so addictive, that it is impossible to leave it, that's why drug traffickers add it to other drugs. when they offer you any type of drugs, don't accept it. If it enters your body you will lose interest in your daily activities. Your hands, arms and body will be deformed. If you consume drugs, you damage yourself”. The new War on Drugs claimed by AMLO has only focused on more militarization of the country and spreading fear and misinformation about the consequences of using drugs. This new prohibitionist strategy disregards the fact that some people will experiment with drugs. Instead, such policies should focus on a prevention and harm reduction lens. Health Systems As stated previously, the president of Mexico, AMLO, from 2018 to 2024, has decided to defund the National Public Health System and any other organization that provides healthcare 24 services. He justified defunding public clinics, hospitals, and community health organizations. Stopping contracts with pharmaceutical companies was to end corruption. In the article "AMLO's México Leads to Drastic Cuts of Health System" by David Agren (2019), the writer explains the adverse effects of this strategy on México. Primarily, the writer comments that this cut in funding has caused many organizations that work on HIV prevention and care management to cut their staff and services in half. This means that individuals cannot access free HIV testing as before, and there is a lack of community support for HIV/AIDS-positive patients. The writer also states that due to his cut in contracts with pharmaceuticals, "shortage of antiretroviral drugs were reported in some states" (Agren, 2019, p. 2290). Instead, the government is seeking to purchase a cheaper antiretroviral regime that they claim to be as effective as others. However, from a clinical perspective, this creates the misconception that there is only one "formula" to treat HIV. This strategy focuses more on achieving a political agenda than on the community's health. Meanwhile, another part of his strategy was to cut funding for community-based organizations or NGOs. It is important to note that in México, due to the government not having a well-designed centralized public health system, many of the prevention strategies towards drug use, HIV/AIDs, HCV, and other communicable diseases fell on community clinics. This can be observed in the clinic PrevenCasa in Tijuana, Baja California. For the past 12 years, this clinic has focused on providing medical care to migrants and deportees who cannot go to public hospitals due to not having a national identification to qualify for medical care. In addition to providing primary health services, the company has also focused on providing harm reduction services for drug users. These services have been essential for the communities who reside in the Zona Norte in Tijuana, one of the most impoverished areas of Tijuana. PrevenCasa is one of the organizations 25 whose funding has been cut. Due to this, the community clinic has recently started to depend on the continuation of their work, volunteers, and donations. In the article by David Agren (2019), he interviewed a doctor who works in a public hospital in México City. In his interview, the doctor stated that excessive saving and controlling the health budget is inhumane. That control "skimps the poorest Mexicans' resources (Agren, 2019, p. 2290). In the case of Tijuana, Robertson et al. (2011) showed in their research the risks migrant men experience in Tijuana and their likelihood of acquiring HIV/AIDS due to riskier sexual practices and drug use. These health measures that AMLO has taken have led organizations like PrevenCasa to find their resources and funders to provide health services when the government is absent. For example, PrevenCasa receives harm reduction donations such as needles, fentanyl testing strips, Narcan, and medical equipment such as an ultrasound machine to keep providing essential community service. Because of the lack of proper response from the government to drug- related overdoses, this clinic started the first SCS in Tijuana. This will be the second unsanctioned SCS in Latin America since the second is in Mexicali, Baja California. Harm Reduction This terminology has been around since the 1980s. Harm reduction focuses on creating interventions to reduce high-risk behaviors. In the book, “Harm Reduction: National and International Perspectives” (1999) by Inciardi and Harrison, the authors talk about the origins of harm reduction and its evolution. According to the authors, this approach began in the 1980s, especially in Australia, the United Kingdom, and the Netherlands (Inciardi & Harrison, 1999). The primary emergence of harm reduction was due to the HIV epidemic among people who use intravenous drugs. For example, at the time of the publication in 1999, the authors state that the United States had reported that 30% of their newly diagnosed HIV cases had a previous history of 26 injection drug use (Inciardi and Harrison). The harm reduction approach focused on adopting safer strategies, such as providing sterile needles so people would not share syringes. Andrew Ball (2007), a medical doctor who conducts research in global health, explains in his article “HIV, injecting drug use and harm reduction: A public health response” how harm reduction arose as a strategy to reduce HIV transmission. Since it was possible to acquire HIV through sharing needles, harm reduction sought to provide sterile syringes to individuals instead of telling them to stop injecting drugs to prevent HIV (Ball, 2007). In another qualitative study article, “Update on harm- reduction policy and intervention research” by Marlatt and Witkiewitz, harm reduction and addiction are compared to traffic lights. The writer states that “for other active users who are considering a change in their harmful habits, the choice appears to be a dichotomous one: abstain or keep using. It’s as though on their life journeys, users approach an intersection marked by a traffic light: either the light is red (stop using) or green (keep using) (Marlatt & Witkiewitz, 2010). But traffic lights also have a yellow light that signals the driver to slow down, take caution, and notice the potential harms associated with crossing that intersection” (Marlatt & Witkiewitz, 2010, p. 590). This analogy best describes how harm reduction strategies understand that users may change their behaviors but should meet at a middle point. Throughout the years, harm reduction has begun to expand, and it now includes interventions such as naloxone and smoking pipe distribution, safe consumption sites, methadone, and buprenorphine treatment. However, harm reduction has also been now applied to a much broader range of public health issues, such as sexual health, tobacco use, and nutrition. Instead of criminalizing or shaming people for their health practices, harm reduction advocates for equitable access to health services and policies that reduce harm while respecting people’s autonomies. 27 While harm reduction has been adopted globally, some governments do not always support it. In México, the administration of President Andres Manuel Lopez Obrador has stated that these strategies prolong people’s pain. Currently, there is a humanitarian crisis due to the lack of state and federal response to the rise in death-related overdoses among migrant communities in Tijuana. In México, many of the harm reduction services that are available in the United States, such as needle exchange, fentanyl testing strips, and Narcan, are not widely available. It is up to community organizations to come up with funding and ways to access those harm-reduction resources. Also, due to the rise in overdoses due to fentanyl, it is essential to implement a new strategy to prevent death-related overdoses. SCS serves as a safety net “clinic” that allows educating clients about the importance of not sharing needles, testing their drugs, and not using them alone. As a result, these SCS can help reduce death-related drug overdoses. Most importantly, if situated within a medical clinic, individuals can receive needed medical attention such as wound cleaning, syphilis treatment, HIV testing and referral, and Hep C treatment. As mentioned before, most of the drug policies in Mexico and the United States have focused on criminalizing drug use. The reality is that people will not stop consuming substances and forbidding their use of them can only cause more harm. As a result, some organizations here in the United States and Mexico have opened SCS to prevent clients from sharing needles or overdosing. It is important to note that these sites are unsanctioned. For clarification, an unsanctioned SCS means that it operates without official approval from the government. One location is in the U.S. in New York City, while the other is in Mexicali, Baja California. In the article “Behavior Change After Fentanyl Testing at a Safe Consumption Space” for Women in Northern Mexico by David Goodman et al.., they talk about how this SCS was able to change behavior among women who use drugs. Their study focused on surveying 30 women who 28 came to inject at the SCS provided by the organization called Verter. In their survey, they wanted to understand “1) history of drug use; 2) substance use treatment experiences; 3) access to harm reduction services; 4) fentanyl knowledge and testing; 5) stigma, violence and access to health services” (Goodman at el., 2023, p. 3). After testing their drug, 15 women bought a drug contaminated with fentanyl. As a result, “7 out of those 15 subsequently used less of the intended substance, one did not use the intended dose, and 7 did not change their behavior” (Goodman et al., 2023, p. 3). Still, 7 out of the 15 women opted to consume; the other half did change their behavior (Goodman at el., 2023). By providing drug testing at the SCS, half of the people reduced their drug use. It encourages people to adopt positive prevention techniques. This SCS also seeks to educate clients on healthcare prevention, such as mental health and communicable diseases. In this study, Goodman et al. also screened women for depression and sexually transmitted infections. As a result, they found that “over three-quarters (77%) of women screened positive for PTSD…One participant tested reactive for HIV, six tested reactive for syphilis, and 87% were HCV seropositive” (Goodman at el., 2023 p. 3). After these results, women were either referred to the general hospital in Mexicali to seek treatment for syphilis or Hep C. Unfortunately, the only service they are not referred to is for mental health care. However, the staff performing these tests for depression would explain to the participants what the results meant and what they could do as follow-up steps (Goodman at el., 2023). In another research article, “Addressing the Nation’s Opioid Epidemic by Kral and Davidson (2017), they state that this SCS in NYC represents a “protected time and space for injecting; appropriate guidance and equipment to reduce harms; proper disposal of used equipment; and onsite or linkage to medical care substance use treatment, and social services” (Kral & Davidson, 2017, p. 920). This SCS acts as a safety net “clinic” for users who do not trust 29 other medical clinics since they can receive judgment from physicians. In this article, the authors state how this SCS has decreased the number of overdoses in this neighborhood in NYC. For example, according to Kral, in the two years this program has been open, “there has only been two overdoses, one overdose per 1,287” (Kral & Davidson, 2017, p. 922). This shows that people can text their drugs and make an informed decision about whether to consume and how much to consume. It also shows that in SCS, with the appropriate staff support, it is more likely for people not to overdose. Kral and Davidson mention that another benefit of SCS sites is the opportunity to offer education regarding how to “mitigate negative consequences of their drug use and allows for conversations related to entering substance use treatment programs” (Kral & Davidson, 2017, p. 920). This proves that SCS is a space to educate patients about positive health practices. Instead of condemning their drug use, this space helps the person to feel comfortable and perhaps feel more comfortable about entering a treatment center. Overall, Krall and Davidson claim that safe injection centers have more positive benefits than many of the prior drug policies that have been implemented in the United States. Migration and Deportation Much has been said about the US stance on immigration; it is also essential to understand how the Mexican government has been a partaker. In the article "Biden's 'De-Trumpization of Migration Policy: The López Obrador Response" by Mónica Verea (2023), the authors provide a timeline and explanation of the immigration reforms that took place during and after the Trump presidency. At the beginning of his presidency in 2018, President Lopez Obrador (AMLO) stated that any migrant passing through México was welcome. Verea describes this as the "open-door policy" to give migrants work permits to make a living in México (2023). However, President Trump saw this as encouraging and easing migrant arrival at the port of entry to the US. Instead, 30 Trump expected AMLO to change this welcoming policy to one that is more aggressive. A prime motive for AMLO to agree was a political-economic one: to avoid a 5% increase in tariffs. Trump pressured México to accept the Migrant Protection Protocol (MPP) (Verea, 2023, p.30). The MPP, also known as Remain-in-México, aims to keep migrants seeking asylum, to remain in México, most often in the border towns, until they can get an immigration court date on the US side. The Human Rights Watch has also stated that this migration policy has caused migrants to "face risks of kidnapping, extorsion, rape and other abuses in México" ("Mexico: Abuses Against Asylum Seekers at US Border, 2021). While it is important to note that much of this collaboration with the US and México regarding their immigration policies came from political and economic pressure on México, AMLO enforced rough policies. For one, Verea states that México opted for a heavily militarized strategy, which meant deploying the National Guard to ports of entry, both to the US and México, to restrict migrants from entering (Verea, 2023). Humans Rights Watch stated that this migration policy has caused migrants to "face risks of kidnapping, extorsion, rape and other abuses in México. Verea (2023) also noted in her article that "despite a lack of relevant training, the Mexican National Guard has taken on a significant role in immigration management…they target vulnerable migrants and asylum seekers, resulting in highly unsafe conditions with abuses and violation of human rights" (p. 32). President López Obrador, while we have pushed him to adopt harsh migration policies, has opted to militarize the Mexican borders heavily and refuses to provide a place for migrants to stay while waiting for their case to be heard. Social Determinants of Health in Vulnerable Communities In an article by Castaneda et al. (2015), "Immigration as a Social Determinant of Health," the authors highlight that broadening our understanding of how multiple variants can affect health 31 outcomes is essential. Castaneda et al. importantly state that immigration can be a social determinant of health since it can affect someone's health outcomes (2015). While this is not only due to the resources one can lack (such as health care coverage), but it can also only be due to trauma, stigma, lacking community, and structural barriers. The writers state that "being an immigrant limits behavioral choices and, indeed, often directly impacts and significantly alters the effects of another social positioning…because it places individuals in ambiguous and often hostile relationships to the state and its institutions, including health services" (Castaneda et al., 2015, p. 378). While the authors in this article focus on the instances of Latines in the United States, I compare this similarity to migrants and deportees in México. This is due to Tijuana being a primary repatriation site for Mexican nationals and other migrant communities. An advocacy group for human rights in the Americas studied how many migrants were in Tijuana. They estimated that at least 300,00 individuals had migrated to or through Tijuana within 2022, which counted for at least 15 percent of Tijuana's population (WOLA, 2022). Many individuals who have either been deported to Mexico or are in Tijuana waiting to gain asylum in the United States face a range of reintegration challenges, such as social isolation, homelessness, unemployment, discrimination, and drug dependency. A study done in Tijuana, México, focused on the correlation between injection drug users (IDUs) trying new drugs and increasing their risk of acquiring HIV following their deportation to México (Robertson et al., 2011). The researchers found that, indeed, after being deported, migrant individuals were not only trying new drugs but were suffering from social and physical stressors due to the lack of community support, financial security, emotional distress, physical insecurity, drug abuse, and lack of access to health care services (Robertson et al., 2011). Another exploratory qualitative study, done by Robertson et al. (2011) titled "Deportation experiences of women who inject drugs in Tijuana, Mexico," focuses on the relation of deportation 32 experiences among IDU women in Tijuana and found that women reported heightened stressors that affected their overall health and aim to stop using drugs (2011, Robertson et al.). From these articles and research, we can understand that immigration, as well as deportation, can be a social determinant of health. Trauma While Castaneda et al. do not explicitly talk about deportation, they highlight how deportation can significantly impact social determinants of health. Specifically, deportation can cause severe trauma, not only by assuming individuals belong to the "home countries" they have been repatriated or deported to but also due to the multiple challenges they must face when arriving in a hostile and unknown location. In the book "Voices of the Border: Testimonios Migratorios" by Tobin Hansen et al. (2021), the authors provide testimonies highlighting the struggles after being deported. For example, the authors include a testimonial from Santiago in their book. This individual tells how he crossed the desert from Sonora to the US. Samuel was not only extorted by the cartel but witnessed a traumatic event when Immigration Enforcement started to shoot at them. Samuel also stated that the hardest was when he was detained. In his testimonio, he stated, "the toughest thing about detention is your self-esteem; they take you down to rock bottom…it is humiliating" (Hansen et al., 2021, p. 32). Later, Santiago also explains that after he was deported and immigration would not give him his things back, he became worried about being unable to eat if he could not access the food at the local migrant shelter in Sonora (Hansen et al., 2021). In another testimony by an individual named Ramon, he stated that after his deportation and being diagnosed with cancer, he could not get medical care in Sonora and could not let himself think about his current reality of being alone since it would make him depressed (Hansen et al., 2021). 33 Similarly, in the research article "Deportation Experiences of Women Who Inject Drugs in Tijuana, México" by Robertson et al. (2011), it was discovered that "nine women described feeling lonely and sad following their most recent deportation, often because they were separated from children and other family members in the United States and elsewhere in México. Several women discussed losing everything" (Robertson et al., 2011). In these testimonies and research articles, Hansen et al., Robertson et al., and Castaneda et al. highlight the trauma that immigration and deportation can cause to an individual. These are emotional distress health outcomes that can negatively impact someone's mental health. Belonging Hansen et al. (2021) mention in their chapters "Wealth Inequality and Migration" and "Deported from Home," from his book, that there are assumptions that when people are being deported to México, they are being deported to their "homes." This is troublesome because individuals who have left their country for an extended period may not have a sense of belonging to their initial birth countries. For example, the assumption is that Mexican nationals who have lived in the US for an extended period still call home and have family ties in México. However, the reality is that many individuals left at a young age, and most of their upbringing was in the United States. Some individuals have formed family ties in the US after living there for more than ten years. Hansen states that "belonging has interpersonal, cultural, and linguistic dimensions and is tied to individual and collective memory… Deep social and cultural ties are interwoven over the long periods that people live in the country" (Hansen et al., 2021, p.144). With this, he states that someone belonging is formed throughout the years. In Robertson et al. research articles it is noted that female participants "lacking social networks in Tijuana described feelings of fear, isolation, disorientation with the neighborhoods or street culture of Tijuana and other border cities in which 34 they were released" (Robertson et al., 2011, p. 502). This lack of social network or belonging made participants feel stressed and depressed. Robertson et al. found that following their deportation, women who reported a high level of stress due to physical and social environments prevented women from decreasing their drug consumption and perhaps increasing it (2011). The lack of community is a common theme among deportees. For example, in the testimonios from Hansen's chapters, many of them alluded to not having family in México that could help them or that it is not easy to communicate with loved ones back in the US. Through these testimonies, we can observe how deportees who are sent "back" to México, lacking a tight connection to their initial homes, may find it extremely hard to cope with their current situation, which has a more significant impact on their overall health. Violence Violence: Structural Barriers and Vulnerability In the article "Structural Vulnerability and Health: Latino Migrant Laborers in the United States" by Quesada et al. (2012), the writers focus on explaining how migrants experience structural vulnerability and structural violence. The writers alluded to Galtung's definition of structural violence as "the structures set by institutions that can cause harm" (Quesada et al., 2012, p. 340). Galtung is specific that institutions exercise this violence, and while it cannot be tracked directly, it abstractly presents itself. For Castaneda et al. and Galtung, this violence and vulnerability can be observed in the lack of health care coverage for undocumented migrants. For Hansen et al., this violence can be observed at the moment individuals are deported and lack access not only to health but to community resources. For example, in Hansen's chapters, they shared the testimony from Ramon, who, while in the US, was diagnosed with cancer and cannot continue his medical treatment in México once he has been deported. In other testimonies, the man shared how 35 the immigration officers stole their money and lost their belongings. Therefore, when they were deported, they could not have access to health care services due to their lack of identification. Another form in which migrants and deportees in México suffer from structural violence is through the handling of migrant centers. On March 27th, 2023, 40 migrants who were detained at a Mexican immigration center in Ciudad Juarez (a border town) were killed during a fire. In the New York Times article "As Migrants' Desperation Mounts at the Border, a Fire Kills Dozens" by Rocio Gallegos et al. (2023), the writers describe how 38 migrants died, while the other 28 migrants were injured in a fire. The article shows a harrowing video in which one can observe the security camera recording the voices of migrants pleading for help while the room is filled with smoke. Most shocking, the video also shows the security guards leaving the migrants inside while they exit. In this article, and in the many more that came after this horrendous situation, it was pointed out that the Mexican government initially justified their abandonment of migrants by saying that since they started the fire, they were at fault. Later, after two security guards were found guilty, they also found a migrant guilty of starting it and convicted for it (Rocio Gallegos et al., 2023). In another news article by VICE News, "Migrants Died In Detention Fire Because They Couldn't Pay $200 Bribe to Be Released" by Luis Chaparro (2023), it was noted that although it is unknown who started the fire, some of the migrants were affected by it because they could not leave the detention center after failing to pay a $200 bribe. In the article, the writer noted that this center "operates as an 'extortion center' according to three survivors and two guards who spoke to VICE World News" (Chaparro, 2023). Meanwhile, in the border town of Mexicali, in February of this current year, a harm reduction organization, Verter AC, opened a civil case against the local government due to arbitrary arrests of migrants and unhoused individuals. The organization 36 recorded more than 600 arbitrary arrests from October 2019 to September 2020. A news article from a local newspaper in México noted that while there is not a current number, some individuals were taken to a treatment center against their own will instead of being taken to the local jail. In Ramon's testimony, he also shared that even though he had not done anything wrong, he was assaulted by the Mexican police (Hansen et al., 2022). In the testimonies from Hansen and in the news articles, there is the critical observation that migrants and deportees are affected in multiple forms and that the social, economic, cultural, and health are interconnected. Migrants suffer from structural violence by the migration centers they end up in México and by local policies that cause arbitrary arrests. However, migrants also face huge vulnerabilities by not having their rights violated. In the article by Quesada, the authors refer to structural vulnerability as a "more neutral and inclusive term …to extend the economic, material, and political insights of structural violence to encompass more explicitly (and to project to a wider audience) not only political-economic but also cultural and idiosyncratic sources of physical and psychodynamic distress" (Quesada et al., 2011, p. 341). Using this focus, we can understand that a broader system can have an inherited impact on immigrants' lives. Hence, these testimonies and acts of human rights violation of migrants show us their vulnerability. Gender-Based Violence Gender-based violence (GVB) refers to harmful actions that are directed towards an individual based on their gender. This violence is rooted in gender inequality, societal norms, and stigma. It is important to note that gender-based violence can be perpetuated through physical, emotional, economic, institutional, sexual, and psychological abuse. This type of violence is not linear and is often interconnected. 37 The United Nations passed in 1993 the Elimination of Violence Against Women. However, according to Wilson, while many countries decided to endorse this act, some governments were either not adequately equipped or were unwilling to take any action (Wilson, 2014, p. 3). While there was a global recognition that gender-based violence does occur, there were no actual actions taken. Violence against women can include structural violence and intimate violence. For example, México, a leading country in femicides, passed laws in 1996 that addressed domestic violence and femicide (Wilson, 2014, p.3). Unfortunately, still up to this day, there are no real consequences for when a woman or someone within the LGBTQ+ community is killed. According to an article by the Wilson Center, ten women are murdered every day in México (Wilson Center, 2023). As well, in 2022, approximately "3,754 women and girls were murdered…Of this total, only 947 were investigated as femicides. However, some civil organizations suggest that stated authorities classify femicides as homicides to lower the statistics'' (Wilson Center, 2023). Besides not taking proper actions to prevent women from being killed, harassed, or disappeared, the Mexican government is also not reporting accurate numbers regarding gender-based violence. While some cases are solved in México, the majority go unresolved. It is often that community members rally and demand justice for those who have disappeared. Moreover, through that community, families can find some relief. In the chapter "Violence Against Women in Latin America" by Tamar Wilson (2014), the writer describes how gender-based violence (GBV) has occurred throughout Latin America. Most importantly, the writer describes how community groups have worked towards dismantling those systems that create violence and oppression. For example, Wilson mentions that women in the Southern area of Oaxaca, indigenous women "have organized in reaction to the structural violence caused by neoliberal policies" (Wilson, 2014, p. 13). First, the writer identifies that institutions and policies can inflict violence. In this context, 38 neoliberal policies promoted by the Mexican government have oppressed women, particularly those of color, and created harmful situations. However, the group referenced by the writer has actively challenged these policies, refusing to conform to neoliberal ideals. It has pressured the government to take steps toward ensuring the livelihood of indigenous women in Oaxaca. It is crucial to note that it is not the government recognizing and taking direct action; instead, it is the women who have been directly impacted and have suffered violence who are driving the change (Wilson, 2014). For example, in 2022, a young woman, Debanhi Escobar, went missing in Monterrey, Nuevo Leon. Debanhi's friends called her an Uber after attending a night party. According to the news in México, Debanhi had gotten into Uber and jumped out of the car after the driver harassed her. A video proved that Debanhi had been walking alone on the highway seeking help. In a moment of need, Debanhi entered a motel to ask for a phone so she could call her parents. Unfortunately, she was never able to do so. Up until now, it is unknown who killed Debanhi and what transpired throughout the night. Initially, she was declared as a missing person. The Mexican government tried to justify her disappearance by saying that it was a teenager who had run away from home. However, thanks to her family and other community organizations that advocate for gender-based violence, they started to demand justice. Due to the community labor that was done, the government was pressured to investigate the case. It took two weeks to find her body inside the cistern at the motel. In the beginning, the government stated that she had probably drowned and that this was not a femicide. However, after the forensic revision, it was determined that she had been suffocated prior to being dumped into the cistern. To this day, no one has been arrested for her disappearance. Unfortunately, Debanhi's case is not isolated. Women and LGBTQ+ 39 communities suffer from GVB every day. Debanhi's story highlights the vulnerabilities that women face in México. 40 CHAPTER III Methods Locality I, the principal investigator, have a personal connection with the community and the non- profit health clinic. In 2017, I volunteered with this non-profit clinic for two months. After that first visit, I have consistently traveled to Tijuana and volunteered with this clinic for one to two weeks. My volunteering involved assembling harm reduction kits and distributing them to clients and nearby neighborhoods. As such, I am known within the community and have an excellent professional relationship with staff members at this local non-profit clinic. I rely on these connections between staff members and clients to recruit people to participate in my study. The non-profit clinic has been instrumental in creating an initial focus group to engage clients and gather feedback on the need for an unsanctioned safe-consumption site. While my research does not primarily focus on safe consumption sites, it does aim to understand the essential services within the clinic, why patients seek services in PrevenCasa, and the challenges faced by women who use drugs and live on the border. The insights from this research could enhance the clinic's services and bring about positive changes. The previous participants in the focus group are a valuable resource and could be recruited for this semi-structured group. I have completed all translations of the interviews and data gathered through the research, and I am optimistic about the potential impact of this study. Overall, the clinic has nine paid staff members. PrevenCasa has numerous volunteers and interns, but this tends to fluctuate. Hence, the project aimed to interview 3 to 10 staff members. I aimed to recruit 10 to 30 participants for the four focus groups. The majority of PrevenCasa 41 clientele are individuals who self-identify as male, so recruiting 30 participants could be a challenge. Positionality Statement As the principal investigator, I bring personal and professional connections to the community and the PrevenCasa organization. After completing my bachelor's degree from the University of Oregon, I began working at the local health department in Eugene, OR. I initially worked on the county's implementation of what is now known as OHP Plus. This work focused on providing medical coverage and primary care for children without legal status in the United States to reduce emergency room visits. After a year, I began working in the Communicable Disease department, where I focused on HIV and STI prevention. In addition to my professional experience, I have a longstanding volunteer relationship with PrevenCasa. In 2017, I volunteered with this non-profit clinic for two months and have continued to do so during vacations and school breaks. I assemble harm reduction kits and distribute them to clients and nearby neighborhoods. This hands-on work has allowed me to build strong professional relationships with the staff and to be recognized within the community, strengthening our collective ability to make a difference. My close ties to the community and PrevenCasa provide me with invaluable insights. However, these connections may influence my research perspective. I am committed to maintaining a reflexive approach throughout the research process to mitigate this. This will ensure that my interpretations are firmly rooted in the participants' experiences rather than my own preconceptions. Methods In this research project, I used three qualitative methods. For the project, I conducted focus groups with clients, individual interviews with staff members, and participant observations, all of 42 which took place in 2023. Primarily, the project aimed to understand the lived experiences of women who use drugs in Tijuana. While it could be preferred to conduct personal interviews, staff at the clinic have had this tendency to burn out staff and clients due to the constant research projects they are constantly working on. Therefore, PrevenCasa's directors required a focus group to be conducted. As well this would serve as a continuation of the initial focus group they conducted before opening their safe consumption site for women who use drugs. Therefore, for this project, I conducted four focus groups. These four focus groups were designed to be semi-structured interviews. Primarily because this allows the interviewer to adapt the questions based on the direction in which the conversation is going. It also allows for more flexibility for participants to drop in and out during the discussion. The project also involved interviewing staff members to understand the services they provide and the challenges they face due to the War on Drugs. Therefore, the project aimed to interview between 3 to 10 staff members. The methodological approach for the staff interviews was planned to be semi-structured. Primarily, I planned this because semi-structured interviews are typically open-ended and flexible. This allows the interviewee to express their thoughts, experiences, perceptions, and reactions without being constrained. I was also interested in understanding why staff members chose to work at PrevenCasa. After a few weeks of my arrival at PrevenCasa, a new group of medical interns arrived. A few interns had stated they wanted to change their placement at PrevenCasa. This is primarily because the Zona Norte is known to have a high crime rate. This is not an uncommon feeling. A volunteer nurse shared with me that when she was initially placed to do her internship at PrevenCasa, she was nervous about it. However, the nurse also mentioned that her internship there helped transform her negative perception of the Zona Norte neighborhood and motivated her to continue volunteering her time even after 43 completing her internship. Therefore, semi-structured interviews allowed me to understand the unique background of each interviewed staff member. My project consisted of three phases: 1) community-based data collection, 1) thematic data analysis, 3) and a presentation to the community health clinic. It is important to note that I decided to conduct focus groups rather than individual interviews because the patients who come to this clinic have commented how overwhelmed they are with ongoing projects that consist of interviews. Hence, deciding to do the focus groups was a community-based data collection that sought to bring together a group of women who are drug users to share their lived experiences while also creating a safe space of support. My project consisted of three phases. During Phase 1, following the approval of my IRB in mid-June, I relocated to Tijuana and began volunteering daily at the community health organization. This continued until early September 2023, allowing clients and staff to become familiar with me. At the beginning of my project, I had planned to hold four focus groups. The nine semi-structured focus group interviews were scheduled to cover the following topics: structural barriers to services (health, food, housing), lived experiences as drug users, critical successes and common challenges to harm reduction services, use of services at PrevenCasa, community support, and area of improvement. However, after my first couple of weeks volunteering at the clinic, it is evident that the situation of the War on Drugs in México was more complex than I began to recognize the overwhelming support needs of PrevenCasa. During weeks in Tijuana, I witnessed how staff members were responding to daily overdoses within the neighborhood. Therefore, I recognized that supporting in any way possible during my time there was significant. Hence, I focused on helping cover shifts during the needle exchange and street outreach and assisted during overdose responses. As a result of this delay, in mid-June, I started to conduct my ethnographic research and observe the everyday interactions in 44 the clinic and around the neighborhood. Part of my ethnographic research also consisted of assisting the needle exchange program, accompanying the nurse at the safe consumption site whenever a patient came to use it, doing street outreach, and accompanying the harm reduction team whenever they responded to overdoses. It is also important to note that I was to be accompanied by a staff member during every activity. Therefore, I decided to conduct only four focus groups. This decision also allowed me to properly dedicate time to recruiting participants and not overwhelm the organization with help or assistance. The first focus group was planned to focus on lived experiences and structural barriers faced by women who use drugs. The second group continued with the structural obstacles, but we also discussed the services women seek when coming to PrevenCasa. During the third group, we continued to talk about the services provided by PrevenCasa and their importance amidst the criminalization of drug use. However, in this group, we also started to talk about the socio-effects that these services provide to women who use drugs. Lastly, the fourth group focused on talking about the current needs of women who use drugs and asking for other organizations that they may use. Each focus group was designed to last an hour and a half with a break in between. However, due to the depth in which participants were engaging, these groups often lasted an hour and forty- five minutes. Due to the delay in holding the first focus group, all groups were initiated at the beginning of August. These groups were conducted each Friday. On Thursdays, the outreach team would distribute harm reduction kits to clients and invite them to my focus group. Participants were offered food as an incentive to participate in these groups. This was also a request from the staff at PrevenCasa. At the project's beginning, I considered offering a small monetary incentive. Still, staff members at PrevenCasa requested this not be done to avoid potential miscommunication or fights among patients. Therefore, it was agreed that food would 45 serve as a good incentive. However, to ensure this project had a community-based approach, I asked participants what type of food they wanted to have in the following groups after the first focus group. Most of the food that was bought for these groups was purchased from local businesses. These interviews aimed to have participants that worked in different areas across the organization. The individual interviews aimed to cover topics regarding structural barriers that PrevenCasa faces, barriers to access services for women who use drugs, the motivation behind providing services and working there, and the socio-effects that the War on Drugs has had on their services. Due to the staff's limited time, three out of the five interviews I did were collected during my initial research phase. For the second phase of the research project, from October to the beginning of December of 2023, I conducted part of my content analysis from my observation notes, three interviews, and four focus groups. Using all the collected information, I identified themes through thematic coding. To begin my thematic analysis, I transcribed all staff interviews and focus group recordings and uploaded the transcriptions onto the program Dedoose. I then conducted an initial round of open coding, marking significant phrases, sentences, or paragraphs that seemed relevant to the three research questions. These codes were then grouped into three categories based on patterns or recurring ideas, which helped me identify broader subthemes. For instance, one of my main research questions was to understand the lived experiences of women who use drugs in Tijuana, Baja California. Also, during my interviews and focus groups, I asked participants to describe common challenges and experiences regarding women who use drugs. As a result, the more prominent theme consistent throughout the project was violence. However, three sub-themes arose from 46 within the overall central theme of violence. My second question explored the social impact of PrevenCasa's services on women. The interviews and focus groups also asked questions regarding the most essential services, what they represented for them, and the importance of prioritizing women in these services. As a result, the three themes that arose were safety, advocacy, and community. Lastly, my third question aimed to understand where the current needs to serve better women who use drugs. Throughout the study, participants mentioned five areas that are needed. However, most of the identified regions were within the organization and not outside of it. Throughout this process, I continually refined the themes by comparing them across different interviews to ensure they accurately reflected the participants' experiences and the overarching narrative of the data. As well, I began compiling the number of total focus group participants. Meanwhile, during winter break, I returned to Tijuana to finalize the last round of interviews and observations. In December of 2023, I volunteered at PrevenCasa for two weeks. Throughout these two weeks, I was able to interview two more staff members and gather more observations. At the end of this phase, I could guarantee that I interviewed staff members from each section of PrevenCasa. Therefore, I interviewed medical, harm reduction, and administrative staff members. During stage four of my research project, I dedicated myself to transcribing the rest of the staff interviews and my observations. I also continued to identify consistent themes throughout the focus groups and interviews. All interviews and focus groups were recorded with the participant's permission, and I took handwritten notes to make additional observations. As mentioned, audio recordings were used to gather complete information and analyze critical themes. Due to the activism and current 47 controversy surrounding harm reduction strategies in Mexico, individuals were given pseudonyms. However, PrevenCasa has stated they want to be named. Research Population My research is with self-identified females (migrant, in-transient, deported, or Mexican nationals) who use drugs and who have used at least one of the services provided by the non-profit organization PREVENCASA. Tijuana is an appropriate location for this research as it is estimated that at least 300,00 individuals had migrated to or through Tijuana within the past year, which counted for at least 15 percent of Tijuana's population (2022, WOLA). Due to the nature of the research, all the participants in these phases of this research – interview and focus groups – were over 18. Focus Groups and Individual Interviews The participants for the focus groups and individual interviews were recruited based on my knowledge from volunteering and personal connections in the community, using a convenience sampling method, and done voluntarily. The inclusion criterion for the focus groups was as follows: 1) a person who identifies as femme 2) must be accessing any of the harm reduction services at PREVENCASA (needle exchange, Narcan, testing strips, safe-consumption-overdose center, medical care, wound clinic, condoms, mental health care services, medical care), 3) they should identify as a person who has been deported from the United States (no matter nationality), migrant, or Mexican national, 4) participants must be native Spanish-speakers or highly proficient in the language, 5) most importantly, individuals in this study should self-identify as individuals who are currently using a substance, either injecting or smoking. No specific timeline of livelihood in Tijuana should be established since this study studies the social and physical effects of accessing harm reduction 48 services at PREVENCASA. Meanwhile, for the staff interviews, the only qualifications were that the organization employed them and that they had worked there for at least six months. This study provided no direct compensation due to the clinic's policies. The non-profit stated that monetary incentives, such as money, create community problems, which should be avoided. Instead, the semi-structured focus groups were incentivized by providing harm reduction kits (smoking pipes, syringes, tourniquets, cotton balls, and lip balms). The provision of free food also incentivized the groups. The purpose of this study was explained to the participants. 49 CHAPTER IV PrevenCasa: Services and Clients Demographics Overview PrevenCasa is a non-profit organization in the Zona Norte neighborhood of Tijuana, Baja California. Since it was founded in 1992, PrevenCasa dedicated its work to the prevention of STIs, HIV, Hep C, and other infectious diseases. Their goal has always been to promote health education to vulnerable communities. At the core of their work, PrevenCasa recognizes the importance of centering their care around the patient's needs. PrevenCasa was founded on the belief that everyone's medical access is a human right. Still, their work philosophy focuses on approaching a patient's care from a harm-reductionist perspective. This mission has been critical in their delivery of services to marginalized communities such as migrants, deportees, and people who use drugs. While PrevenCasa has focused on providing free healthcare assistance, the organization has continuously grown to adapt to the specific needs of its community. The following information has been obtained and provided by PrevenCasa. Clients’ Demographics According to data obtained by PrevenCasa within the last two years, many of their patients are male (82%). On the other hand, women only account for 18% of the population they serve. One limitation of this dataset is that it only includes two genders and does not encompass others. The age average of their clientele is 29 years old and younger. In previous conversations with staff members and administration, it was observed that fewer people make it to later ages, Table 1. PrevenCasa client demographics. Gender and Age. 2022. Source PrevenCasa 50 which is linked to their health and living conditions. In conversations, some staff members provided specific examples of why this is the case in the Zona Norte. Staff pointed out that structural barriers such as lack of access to overdose prevention tools, safe drug supply, HIV and diabetes medications, secure housing, nutritious food, and comprehensive primary health care contribute to people not aging adequately, highlighting the urgent need to address these issues to improve the health and well-being of the patient population. Meanwhile, 91% of the patients have stated that their birthplace is México. Unfortunately, no data is available to understand where other patients come from. However, in conversations with staff, it was mentioned that they serve a significant population of migrants coming through Tijuana. As noted, Tijuana is a big border city since it is a port of entry where individuals can claim asylum. A few years ago, PrevenCasa was not located near any significant migrant shelters. Casa del Migrante, a shelter for migrants, is in Zona Rio, 12 minutes away from driving and walking, which is 1 hour and 17 minutes. However, Mosque Taybah has been open in the Zona Norte for two years. The mosque is 12 minutes (walking) away from PrevenCasa. Indeed, throughout my time volunteering at the organization, I observed multiple migrants who came from Turkey, Ukraine, and Russia. Another significant migrant population is Haitian. In 2016, following Haitians arriving in Tijuana with aspirations of seeking asylum in the United States, some remained in the city. Just two blocks from PrevenCasa, there are mobile carts, also known as “sobreruedas,” owned by Haitians who sell food and thrifted goods and offer haircuts. For some locals, this street is now known as Little Haiti. Central Americans are a significant portion of the clients they serve at PrevenCasa. Meanwhile, according to data from PrevenCasa, 66% of their clients have had at least one previous deportation. However, this data does not detail if clients have had more than one 51 deportation, indicating a need for more comprehensive data collection. As well it would be interesting to know the percentage of deportations among women and men, as this could provide valuable insights into gender disparities in deportation rates. Lastly, since Baja California is a deportation hub, it would also be essential to know the origins of those deportees, highlighting the need for more detailed data to understand the patient population and their unique challenges fully. Living Conditions Per PrevenCasa, 35% of their patients rent a room, 13% are staying at a shelter, and 35% are unhoused. Renting a room in Tijuana may not seem as expensive compared to the United States. Renting a room can vary from 20 to 250 pesos a day, equating to $1.50 to $13. However, it is essential to note that the size of these rooms can be tiny, and for some, these rooms are in unsafe neighborhoods or houses. For example, throughout my focus groups, numerous participants shared experiences of hazardous situations in which the women had been assaulted by the person who managed the house in which they were renting a room. Conversely, 13% of their patients are staying at a shelter. Meanwhile, it was noted that 35% of unhoused patients live under a bridge, in alleyways, at “El Bordo,” parks, or “picaderos.” For better reference, El Bordo is a sewage stream just a few yards from the US-México border. Inside El Bordo, people have built underground dirt houses, also known as ñongos. My first introduction to El Bordo was in 2015 when I volunteered at a street Wound Clinic. At that time, multiple individuals were living at El Bordo under the bridge that crosses from it. Some of them also built underground homes made from dirt and cardboard. Table 2. PrevenCasa client demographics. Living conditions 2022. Source PrevenCasa 52 However, living inside El Bordo can be extremely dangerous. For instance, during heavy rain, El Bordo can overflow, and police have intentionally set fire to the cardboard houses. On the other hand, “picaderos” refers to houses where people go to use drugs. Picaderos can be dangerous because people can overdose or poke themselves with used needles. As well, women had reported getting assaulted at some picaderos. Type of Employment As reported by PrevenCasa, 35% of their patients stated they have an informal job. Some patients said they get money by recycling cans, and others clean cars. I also witnessed this during my time there. At least two patients consistently showed up to ask staff members if they needed their cars washed. Meanwhile, other patients stated that they make money by selling thrifted goods. Per my observations during my time in Tijuana, patients will set a tent on the side of the road and sell thrifted clothes. Some of them sell electronics or furniture. Some patients stated they made money by helping small businesses. This means patients would run errands for small businesses. However, there needs to be a specification for what type of small businesses they work for. Meanwhile, other patients stated they were “taloneando” to make ends meet. Taloneando refers to working as anything to make money. Furthermore, 13% of their patients stated they had no employment. Finally, 35% of their patients said they work as sewers. As previously mentioned, the red district is in the Zona Norte. As well, sex work in the Calle Primera is legally permitted. The Hong Kong Club, a well-known strip club, is in Zona Norte. This club has been a popular destination for locals and tourists. Table 3. PrevenCasa client demographics. Employment. 2022. Source PrevenCasa 53 However, due to its location and the nature of the business, it has been involved in controversies regarding human trafficking. While none of my focus group participants stated they have worked in Hong Kong, at least four of them are sex workers who work in the Zona Norte. Services During my interview with a staff member named Ana, who has been at PrevenCasa the longest, she stated that PrevenCasa focuses on responding to the HIV epidemic. Ana noted that, at that time, HIV treatment was not provided to people in Mexico. However, PrevenCasa's founders vigorously advocated for sex workers, migrants, and people who use drugs to gain access to HIV treatment. Therefore, PrevenCasa started offering free rapid HIV testing while connecting patients to the HIV clinic in Tijuana. However, throughout the years, PrevenCasa began to partner with local and foreign universities to work on HIV/AIDS projects. For example, when I initially went to volunteer in 2015, PrevenCasa partnered with the University of California San Diego (UCSD) and Colegio de la Frontera Norte (COLEF). At the time, UCSD and PrevenCasa were working on a project that focused on testing for HIV women who used drugs. Some of my focus group participants recounted times in which this project, "El Cuete," would routinely test them for HIV and give them money for their blood samples. During my interview with Ana, she shared that PrevenCasa has contributed to organizations such as the World Fund and Open Society Foundation. Ana worked on a World Fund project focusing on HIV, Tuberculosis (TB), and Malaria prevention. However, Ana also mentioned that, at that time, they had partnered with the Mexican governmental organization CENSIDA for this project. As PrevenCasa continued to grow in its HIV prevention strategies, it also implemented telemedicine. Around eight years ago, PrevenCasa partnered with UCSD and the local government to provide in-house HIV testing and treatment. This meant that the organizations would take the 54 patients to the Centro Ambulatorio para la Prevencion y Atencion en SIDA e Infecciones de Transmisión Sexual (CAPASITS) to get their tests and viral loads for HIV. After that, patients would be able to receive their HIV medications at PrevenCasa. This was due to some patients' limitations in going t