Differential experiences of Mexican policing by people who inject drugs residing in Tijuana and San Diego

Abstract

Background

Research among people who inject drugs (PWIDs) in the USA and Mexico has identified a range of adverse health impacts associated with policing of PWIDs. We employed a mixed methods design to investigate how PWIDs from San Diego and Mexico experienced policing in Tijuana, and how these interactions affect PWIDs behavior, stratifying by country of origin.

Methods

In 2012–2014, 575 PWIDs in San Diego, 102 of whom had used drugs in Mexico in the past six months, were enrolled in the STAHR-II study, with qualitative interviews conducted with a subsample of 20 who had recently injected drugs in Mexico. During this period, 735 PWIDs in Tijuana were also enrolled in the El Cuete-IV study, with qualitative interviews conducted with a subsample of 20 recently stopped by police. We calculated descriptive statistics for quantitative variables and conducted thematic analysis of qualitative transcripts. Integration of these data involved comparing frequencies across cohorts and using qualitative themes to explain and explore findings.

Results

Sixty-one percent of San Diego-based participants had been recently stopped by law enforcement officers (LEOs) in Mexico; 53% reported it was somewhat or very likely that they would be arrested while in Mexico because they look like a drug user. Ninety percent of Tijuana-based participants had been recently stopped by LEOs; 84% reported it was somewhat or very likely they could get arrested because they look like a drug user. Participants in both cohorts described bribery and targeting by LEOs in Mexico. However, most San Diego-based participants described compliance with bribery as a safeguard against arrest and detention, with mistreatment being rare. Tijuana-based participants described being routinely targeted by LEOs, were frequently detained, and reported instances of sexual and physical violence. Tijuana-based participants described modifying how, where, and with whom they injected drugs in response; and experienced feelings of stress, anxiety, and powerlessness. This was less common among San Diego-based participants, who mostly attempted to avoid contact with LEOs in Mexico while engaging in risky injection behavior.

Conclusion

Experiences of discrimination and stigma were reported by a larger proportion of PWIDs living in Mexico, suggesting that they may be subject to greater health harms related to policing practices compared with those residing in the USA. Our findings reinforce the importance of efforts to curb abuse and align policing practices with public health goals in both the US and Mexico.

Introduction

Tijuana is a city in the Mexican state of Baja California across the border from San Diego, California. Both cities are located on a major international drug trafficking route that runs from the Andean region in South America to the United States, making drugs such as heroin, methamphetamine, and cocaine abundant in both cities (Bucardo et al., 2005). Approximately 10,000 people who inject drugs (PWIDs) reside in Tijuana, with many more crossing the border from San Diego, reportedly to use and buy illicit drugs because of lower prices, easier access, and to avoid facing legal penalties in the United States (Morales, Lozada, Magis, & Saaverda, 2004; Volkmann et al., 2011; Wagner et al., 2012).

In 2010 Mexico decriminalized possession of small amounts of illegal drugs (e.g., heroin, cocaine, methamphetamines) for personal use (Moreno, Licea, & Rodriguez-Ajenjo, 2010). Carrying syringes is also permitted in Mexico; however, past research has shown that in Mexico “laws on the books” are not always applied by law enforcement officers on the streets, resulting in arbitrary policing (Beletsky, Lozada et al., 2013; Beletsky, Thomas et al., 2012; Miller et al., 2009). Additionally, evidence of widespread police corruption in some cities in Mexico, including instances of PWIDs being targeted and experiencing physical and sexual abuse from the police, has been recorded (Beletsky, Lozada et al., 2013; Beletsky, Wagner et al., 2015; Miller et al., 2009; Werb et al., 2015).

The risk environment framework posits that health outcomes are not only a result of individual-level behaviors and characteristics but also are influenced by the larger structure and environment within which individuals reside (Rhodes, 2002). Law enforcement practices, both official laws and enforcement of those laws, are one of the structural aspects that shape PWIDs’ risk environment (Burris et al., 2004; Rhodes, 2002), including individuals’ ability to access sterile needle/syringes and their capacity to avoid risky injection behaviors (Bluthenthal, Kral, Erringer, & Edlin, 1999; Bluthenthal, Lorvick, Kral, Erringer, & Kahn, 1999; Miller et al., 2009; Strathdee, Beletsky, & Kerr, 2015). Research among PWIDs in the Tijuana–San Diego border region has shown that individuals frequently travel between these two cities and have social relationships that transcend the international border (Volkmann et al., 2011; Wagner et al., 2010, 2012; Zúñiga et al., 2006). Given the connectedness of these two communities and the recent legal change in Mexico that has the potential to impact drug use risk environments in San Diego and Tijuana, we sought to investigate how policing practices in Tijuana may affect Mexican and American PWIDs differentially, in order to inform public health intervention and policies to reduce health and social risks associated with injection drug use.

Methods

Setting

This mixed methods analysis used data from two cohorts of PWIDs from Tijuana and San Diego. Between 2012 and 2014, data were collected from two independent mixed methods cohort studies among PWIDs, which were both designed to study the impact of the 2010 law through which Mexico decriminalized possession of small amounts of certain drugs (e.g., heroin) for personal use (Moreno et al., 2010). The El Cuete-IV study recruited 735 PWIDs in Tijuana, while the STAHR-II study recruited 575 PWIDs in San Diego. A detailed description of the methods is provided elsewhere (Robertson et al., 2014). Recruitment for both studies was done using targeted sampling and street-based outreach in areas frequented by PWIDs. The study protocols were approved by the Human Subjects Protection Program of the University of California, San Diego (STAHR-II and El Cuete-IV) and the Ethics Board of the Colegio de la Frontera Norte (El Cuete-IV). Written informed consent was obtained from all participants.

Quantitative measures

Quantitative data were collected via semi-annual visits in which participants were interviewed using Computer Assisted Personal Interviewing (CAPI) software. The one-on-one interviews were conducted in English or Spanish by trained bilingual interviewers, and included questions about demographics, law enforcement interactions such as arrest/stop history, bribery, and what happened during the stop. To the extent possible, the quantitative questions were aligned between the STAHR-II and El Cuete-IV surveys to allow comparisons across cohorts; however, some questions were unique to each cohort.

Qualitative interviews

Subsamples of participants from each cohort were purposively sampled based on their responses in the surveys and were invited to undergo in-depth qualitative interviews. San Diego-based participants were sampled if they used drugs in Mexico in the previous six months. Tijuana-based participants were sampled if they had been stopped or arrested by law enforcement officers in Tijuana in the past six months. Trained bilingual interviewers used cohort-specific interview guides to conduct the qualitative interviews. The interviews with San Diego-based participants focused on their experiences and rationale for buying and using drugs in Tijuana, and contained a series of questions assessing their interactions with and concerns about interacting with law enforcement officers while in Tijuana. The interviews with Tijuana-based participants focused on their history of interactions with law enforcement officers in Tijuana.

The number of qualitative interviews was determined based on the principle of conceptual saturation (Guba & Lincoln, 1989). During qualitative data collection, regular meetings were held in which investigators could evaluate saturation. New participants were interviewed when new themes were identified and warranted further exploration, and the investigators identified a priori an upper limit of 20 participants per study site (i.e., San Diego and Tijuana), for a total of 40 qualitative interviews.

Mixed methods analysis

Descriptive statistics were computed for all quantitative variables of interest. Data for both cohorts are displayed in a single table to facilitate comparisons, though statistical comparisons were not calculated due to differences in the quantitative measures used in the two surveys. Qualitative interviews were transcribed and interviews conducted in Spanish were translated into English for analysis. We analyzed a subset of the qualitative interviews, selected to ensure a diverse sample based on gender, race/ethnicity, and experiences with law enforcement in Mexico. The analytic team (authors 1 and 8) met regularly to discuss the findings and determine when conceptual saturation was achieved. Our final qualitative data set consisted of nine of the twenty interviews with San Diego-based participants (5 males, 4 females) and ten of the twenty interviews with Tijuana-based participants (6 males, 4 females). Our qualitative analysis strategy was designed to elucidate and provide context for observations made from the quantitative comparisons. First, transcripts were coded for themes that were derived from the quantitative data (e.g., experiences of bribery, reason for being stopped). Themes that emerged from the interviews were added to the codebook (e.g., corruption, behaviors resulting from interactions with the police, feelings about being targeted by the police) and transcripts were re-coded to incorporate these emerging themes. ATLAS.ti (Scientific Software Development, Berlin, Germany) was used to manage coding and analysis.

Results

From 2012 to 2014, 575 San Diego-based participants provided data on the quantitative survey, 102 of whom (79.4% male) had used drugs in Mexico in the past six months. The majority of participants were White (58.8%) with a mean age of 40.1 years (range = 18–64 years). Most participants (64.7%) had completed high school, and 64.7% considered themselves to be homeless in the past six months. The majority of participants spoke only English; 27.5% reported being able to converse in Spanish.

Seven hundred and thirty-five Tijuana-based participants (62.1% male) participated in the quantitative survey during the same time period. Participants were mostly born in Mexico (93.1%) and had a mean age of 37.4 (range = 18–63). Participants had completed an average of eight years of education. More than half of participants (62%) made less than $2999 pesos per month (approximately $159 USD).

Experience of law enforcement stops and arrests

San Diego participants

Sixty-one percent (n = 62) of the 102 San Diego-based participants who had used drugs in Mexico in the past six months had been stopped by law enforcement in Mexico at least once in their lifetime (Table 1). Fifty-three percent (n = 53) reported that it is somewhat/very likely that they will be arrested while in Mexico just because they look like a drug user.

Table 1.

Law enforcement experiences described by San Diego-based (N=102) and Tijuana-based (N=735) participants

STAHR-II				El Cuete
Arrest/Stop History	N	n	%		N	n	%
Ever stopped by law enforcement in Mexico	102	62	61%	Ever stopped by law enforcement	734	663	90%
Of the times you were stopped by law enforcement in Mexico, did the law enforcement officer ever:				The last time you were stopped in the past six months, did the law enforcement officer
Demand money as a form of a bribe	61	43	71%	Demand money as a form of a bribe	440	62	14%
Physically beat or punch you	61	13	21%	Physically beat you*	440*	29*	7%*
Detain you	61	33	54%
How likely do think it is that you will be arrested just because you look like a drug user while in Mexico?				How likely could get arrested for drug possession because you look like a drug user?
Somewhat/Very Unlikely	100	47	47%	Somewhat/Very Unlikely	735	115	16%
Somewhat/Very Likely	100	53	53%	Somewhat/Very Likely	735	620	84%
Perceived Need to Bribe
How likely do you think it is that police would demand a bribe from you if they stop you when you are carrying new, unused syringes in Mexico?				How likely do you think it is that police would demand a bribe if stopped when carrying new syringes
Somewhat/Very Unlikely	100	23	23%	Somewhat/Very Unlikely	735	121	16%
Somewhat/Very Likely	100	64	64%	Somewhat/Very Likely	735	614	84%
How likely do you think it is that police would demand a bribe from you if they stop you when you are carrying used syringes in Mexico?				How likely do you think it is that police would demand a bribe if stopped when carrying used syringes
Somewhat/Very Unlikely	100	23	23%	Somewhat/Very Unlikely	735	123	17%
Somewhat/Very Likely	100	77	77%	Somewhat/Very Likely	735	612	83%

^*not collected

In qualitative interviews, participants explained that they believe the police not only targeted them because they looked like a drug user but also because they were perceived to be White and/or American PWIDs who were more likely to have money. Participants believed that police would target them because they thought they could make money off of them, not because they wanted to actually charge them for a drug-related offense.

If you’re American they figure you have money, I mean I’ve been stopped just for looking at a police officer, . . . ‘cause they think you’re buying drugs, and they think that they can get money off of you by finding your drugs and, you know, threatening to take you to jail . . . . I’ll see them single me out and I’ll be in a crowd of Hispanic people from Mexico and they’ll single me out, and stop me every time. [White Male, age 26, STAHR]

Tijuana participants

Ninety percent (n = 663) of the 735 Tijuana-based participants had been stopped by law enforcement in Tijuana in the past six months. Eighty-four percent reported that it is somewhat/very likely that they could get arrested for drug possession just because they look like a drug user.

In the qualitative interviews participants described how they are stopped and harassed daily by the police because they are PWIDs. Some described being stopped while going to the grocery store and conducting other daily activities, which was particularly disruptive to the lives of people who live in these high drug use areas. Tijuana-based participants also described frequently being stopped and picked up for what they believed to be no reason, or simply because the police want them to leave the area.

Well here, like always, the police see us and well they go and arrest us. . . . whether we have drugs or not, they already have us like . . . like something that’s needed, they see us as, something for them, we are just used as part of their job, so then they go and present us to the judge . . . . and they hit you to . . . aside from getting you even if you don’t have anything, they make something up. They do it so that one leaves this place, the drugs. [Male, age 28, El Cuete]

Many believed that the police apply the law unfairly, and that there is little uniformity in how police enforce the laws. This creates uncertainty and unfair treatment for the participants affected by this arbitrary policing.

And now it is not, not only because they wear a plaque (badge) they do as they please and not their job; if they feel like it, they take you in. If they don’t, they don’t. If you are guilty, you just give them some money and they let you go. [Male, age 32, El Cuete]

Bribery

San Diego participants

Sixty-four percent of the 102 San Diego-based participants who had used drugs in Mexico reported that it is somewhat/very likely that police in Mexico would demand a bribe from them if they were stopped for carrying new or unused syringes and 77% reported that this is somewhat/very likely if they were carrying used syringes. Consistent with these perceptions, 71% (n = 43) of the individuals who had ever been stopped by law enforcement in Mexico reported being asked for a bribe. In the qualitative interviews, participants further explained how widespread this bribery is:

Yeah, they say, the- “What is your freedom cost?” you know, what- what- “What is your freedom worth to you?” you know, and that’s really like “Give us money and we’ll letchu go”. [White Male, age 26, STAHR]

Of the San Diego-based participants who had been stopped by law enforcement in Mexico, 54% (n = 33) reported ever being detained, though few in the qualitative interviews described having spent time in jail in Mexico. The qualitative interviews revealed that most Americans felt that officers’ willingness to take bribes was a safeguard against being arrested and detained. In addition to drugs being easier to get and less expensive in Mexico compared to San Diego, this perceived ability to pay a bribe to avoid going to jail was another reason why Americans traveled to Mexico to buy and use drugs.

If they know that you have a hundred dollars they’ll take some dollars, but they’ll let you go. It’s not like they’ll put you in jail. [Latina & Filipina Female, age 33, STAHR, emphasis added] Mexico, you could pay them to not get in trouble, I mean, that’s really like the, you know, that’s awesome. [ID 0478, White Male, age 26, STAHR]

Tijuana participants

Eighty-four percent of Tijuana-based participants reported that it is somewhat/very likely that police would demand a bribe if they were stopped for carrying new or unused syringes, and 83% said it is somewhat/very likely if they were carrying used syringes. Of the 440 Tijuana-based participants who had been stopped by law enforcement in the past six months, 14% (n = 62) reported that the officer demanded a bribe the last time they were stopped. In the qualitative interviews participants described how bribes could frequently be used to avoid going to jail but if they do not have money they often end up going to jail.

They put me in the patrol car and then we were on the way, on the way they stopped and they asked me how much money I has, that if I wanted to go home . . . that how much money did I have and I told them that I had no money so then he told me, the police told me, “You’re screwed, because you’re going to la veinte [jail]” . . . [Female, age 46, El Cuete]

San Diego participants

Of the 102 San Diego-based participants who had ever been stopped by law enforcement in Mexico, 13% (n = 13) reported that they had been physically beaten by police officers there. In the qualitative interviews very few reported interactions with the police involving harassment or physical abuse. Participants mostly described normal interactions (except for the bribery), and some even described positive interactions:

I get stopped by cops in Mexico, um, they’re always like kinda, they’re kinda nice to me no matter what, like even if I’m in their control. They’re kinda nice. [White Female. Age 21, STAHR]

Tijuana participants

In contrast, 7% (n = 29) of the 440 Tijuana-based survey participants who had been stopped in the past six months reported being beaten by the police during the last time they were stopped, and almost all of the participants in the qualitative interviews reported being physically abused by the police at some point in time, sometimes to the point of injury.

And even when you do not do a thing to them and you speak well to them and all, they do not like you because they resent us a lot and they beat you, they have beaten me. They have pulled me with their hand and almost broken it. [Female, age 36, El Cuete]

It was where I got my spine disc hurt. Here the disc where I cannot get up if I bend down because I got beaten by three officers with the riffles and kicks. [Male, age 45, El Cuete]

Participants also described being verbally abused: . . . they humiliate you verbally as well; not only do they beat you alright. If not with what they tell you. [Female, age 36, El Cuete]

A number of female participants reported sexual abuse by the police.

Because a lot of times they rape you. They do it and they don’t pay you, and what are you going to do? They’re the police, you can’t go against them. [Female, age 46, El Cuete]

Many participants reported being disrespected or dehumanized by the police, which they often attributed to law enforcement officers’ dislike of PWIDs. Furthermore, participants recognized that being a person who injects drugs “marks” them and results in them being devalued by law enforcement and society. This suggests that Tijuana-based PWIDs perceive that they are stigmatized by law enforcement, which results in being targeted on the basis of their drug use.

I personally am a drug addict right . . . And because of that I do not have any value, people start thinking and reaching conclusions and they mark you and give you a label . . . [Male, age 32, El Cuete]

Like if I was a dog. Here they do not treat us drug addicts like human beings having a problem, they treat us like undesirables, do you understand me? Like something negative against your health, right? [Male, age 38, El Cuete]

Effects of law enforcement on PWIDs behavior

San Diego participants

Three themes emerged regarding how San Diego-based participants modified their behavior in response to law enforcement in Mexico. Participants reported that they would try not to draw attention to themselves. This included the way they dressed and how they acted. Participants also described being very vigilant by watching for law enforcement officers and hiding their drugs. Finally, participants described avoiding the police to minimize their encounters.

It’s out in the open, but we’re very careful. I mean, you know we’re watching for cops. At least I am, I mean we usually have a routine, where you look this way, I look that way. stuff like that. [Asian Male, age 38, STAHR]

Tijuana participants

Tijuana-based participants also described ways that they modified their behavior in response to the police. Similar to the San Diego-based participants, Tijuana-based participants would try to be discreet and always keep a lookout for the police. Participants also described avoiding the police whenever possible, even if this meant altering where they used and bought drugs. In contrast to San Diego-based participants, some described how they used to use drugs in shooting galleries or with other people, but because of their fear of the police they now go home and use alone. This suggests that targeting of Tijuana-based PWIDs by law enforcement is likely incentivizing riskier forms of drug use.

I go home and cure [inject] myself. Before I fixed [injected] myself by the border or in other spots; in shooting galleries, and not now because I am telling you one gets fearful that the police might come. [Female, age 36, El Cuete]

Some described how the stress and mistreatment from the police caused them to use more drugs, which was not reported by San Diego-based participants:

Because they make me feel bad. They make me feel like if we are worse than a dog; so I use that as a reason to drug myself. If they were really at the service of society and they treat us like that, can you imagine if they were not serving civilians? They kill us, they are like killers with a license. [Male, age 38, El Cuete]

After encounters with law enforcement that resulted in incarceration, most reported the first thing that they did when they got out was to use drugs. Many reported experiencing withdrawal symptoms and, as a result, sharing needles because of their desperation to get high. In the qualitative interviews with San Diego-based PWIDs no participants reported going to jail; thus, they did not report these same experiences.

Discussion

The findings presented herein indicate that San Diego and Tijuana-based PWIDs experienced differential treatment by law enforcement in Tijuana. According to PWIDs, this disparity in treatment stems, in large part, from the perceived higher economic status of PWIDs who reside in the United States. While it should be acknowledged that not all encounters with law enforcement officers described by our participants were negative, our findings suggest that Tijuana-based PWIDs experienced more negative treatment from law enforcement officers, which impacted their behavior and potentially increases their risk for more negative outcomes compared to San Diego-based PWIDs. Our findings are consistent with others that show how policing and the enforcement of law interact with individual level determinants to structure the risk environment for PWIDs (Rhodes et al., 2005). Critical to the current research is the finding that the experience of arbitrary policing appears to differ based on individuals' national origin. A greater percentage of Tijuana-based PWIDs reported that they believed they would be arbitrarily arrested just for looking like a drug user compared to San Diego-based PWIDs. In other research, anticipation of being targeted by the police, higher perceived consequences of being arrested, and receiving tickets or citations have been shown to inhibit protective health behaviors such as carrying clean syringes (Beletsky, Wagner et al., 2015), impede access sterile injection equipment (Bluthenthal, Kral, Lorvick, & Watters,1997), and increase the risk for sharing syringes (Wagner, Simon-Freeman, & Bluthenthal, 2013).

The experience of bribery was widespread in both samples, though Tijuana-based PWIDs were not always able to pay bribes because they did not have money. As a result, they were taken into custody more often and spent more time in jail resulting in unsafe drug use when they were released (e.g., sharing needles). San Diego-based PWIDs were almost always able to pay a bribe to avoid going to jail and, thus, rarely experienced the elevated risk for syringe sharing and/or overdose that were reported among the Tijuana-based participants. Mexico’s Narcomenudeo laws are designed to steer arrestees into drug treatment rather than jail; however if police are accepting bribes in exchange for avoiding arrest they are likely not directing PWIDs to treatment. Thus, bribery could also restrict PWIDs access to substance abuse treatment, which could perpetuate drug related harms (Mazhnaya et al., 2016; Werb et al., 2015).

Additionally, Tijuana-based PWIDs reported more widespread abuse and instances of dehumanization compared to San Diego-based PWIDs. The findings from the qualitative interviews suggest that the police discriminate against and mistreat Tijuana-based PWIDs due to drug use-related stigma. Stigma is a socially driven process of constructing and devaluing particular characteristics or “marks” (Goffman, 2009). Injection drug use is considered a stigmatizing behavior (Ahern, Stuber, & Galea, 2007; Kallen, 1989). Longstanding and widespread criminalization of drug use, as well as punitive and—at times—extrajudicial policing practices targeting PWIDs perpetuate the stigma associated with injecting drugs (Beletsky, Lozada et al., 2013; Beletsky, Wagner et al., 2015; Pryor & Bos, 2015). Individuals who possess a stigmatizing characteristic are often stereotyped and can be the victims of prejudice and discrimination enacted by non-stigmatized groups in an effort to create social distance and maintain inequalities (Earnshaw & Chaudoir, 2009; Jones et al., 1984; Major & Eccleston, 2004). Some descriptions of interactions with the police from Tijuana-based PWIDs indicated that they experienced prejudice and discrimination because of their stigmatizing characteristic (i.e., drug use). Tijuana-based PWIDs also indicated that they anticipated negative interactions with the police because of law enforcements’ dislike of drug users. Anticipated and internalized stigmas are pathways through which the experience of stigma impacts health outcomes among the stigmatized group (Earnshaw & Chaudoir, 2009). The experience of being discriminated against due to drug-related stigma was not reported by San Diego-based PWIDs, perhaps explaining some of the differences in interactions between police and Tijuana and San Diego-based PWIDs.

The finding that Tijuana and San Diego-based PWIDs experience drastically different treatment from law enforcement in Tijuana is counterintuitive, given that both groups possess the same stigmatizing characteristic – injection drug use – and are likely both seen as outgroup members relative to the police. This differential treatment might occur because San Diego-based PWIDs’ perceived identity as injection drug users, which would lead the police to treat them poorly, is less salient in this context compared to their perceived identity as Americans who have money. Police in Tijuana may perceive that they have something to gain (i.e., money) from American PWIDs; thus, they will be less likely to mistreat and incarcerate this group. This disparity indicates that the experience of possessing a stigmatizing characteristic is not uniform across all PWIDs, but instead manifests differently among PWIDs based on their country of residence and perceived economic status, among other attributes. This highlights one micro-level example of how income inequalities and differences in social position perpetuate health disparities worldwide (Friedman et al., 2016; Marmot, 2006).

Implications for Tijuana-based PWID

The results from this study revealed that, during the period under study (2012–2014), Tijuana-based PWIDs were experiencing institutional structural violence in Tijuana that had both direct (e.g., spending time in jail, physical abuse) and indirect effects (e.g., sharing needles, experiencing perceived prejudice and discrimination) on their behaviors and wellbeing.

It is well established that law enforcement shapes PWIDs’ risk environment (Burris et al., 2004; Rhodes, 2002). Our results build upon this knowledge by demonstrating how this aspect of the micro level risk environment impacts behaviors, which past research has shown, are related to negative health outcomes. The results from this research found that some Tijuana-based PWIDs engaged in risky behaviors such as sharing needles, rushed injections, and altering where and with whom they inject drugs to avoid the police. For example, some PWIDs reported using drugs alone, which is a critical risk factor for fatal overdose (Davidson et al., 2003). This is consistent with past research in the US and Mexico that demonstrates that PWIDs are likely to engage in risky behaviors in order to avoid the police (Beletsky, Wagner et al., 2015; Bluthenthal, Kral et al., 1999; Philbin et al., 2008; Pollini et al., 2008; Wagner et al., 2010). These behaviors increase the risk of acquiring and spreading blood borne viruses (Beletsky, Lozada et al., 2013; Bluthenthal, Kral et al., 1999; Bluthenthal, Lorvick et al., 1999).

Many Tijuana-based PWIDs reported being incarcerated as a result of their interactions with law enforcement because they could not pay a bribe to avoid going to jail like San Diego-based PWIDs could. Past research has shown that spending time in jails has a number of implications related to negative health outcomes. Incarceration of PWIDs in overcrowded and poorly-serviced prisons can result in the transmission of HIV and tuberculosis (Burris et al., 2004). Although the sentences might be brief, opioid-dependent detainees are unlikely to receive appropriate opioid management while incarcerated, and can experience painful opioid withdrawal symptoms as a result, and upon release, they may also experience a greater likelihood of overdose death (Binswanger, Blatchford, Mueller, & Stern, 2013). Similarly, both during and directly after incarceration, individuals face elevated odds of high-risk injection behaviors, such as sharing needles (Werb et al., 2008). Additionally, incarceration can disrupt regular injecting networks, which might contribute to the spread of HIV and other blood borne pathogens (Costenbader, Astone, & Latkin, 2006).

Tijuana-based PWIDs interactions with law enforcement also have implications for their psychological well-being. Many PWIDs reported being abused, targeted, disrespected, and dehumanized because they possessed a stigmatizing characteristic. Individuals who perceive that they are the target of prejudice and discrimination are more likely to experience increased stress as well as poor psychological and physical health (Araújo & Borrell, 2006; Karlsen & Nazroo, 2002; Williams, Neighbors, & Jackson, 2003). Stress can also result in increased or continued drug use as a coping mechanism, as was described by some of our participants (Shiffman, 1982; Wills & Shiffman, 1985). Exposure to physical, verbal, and sexual mistreatment from the police resulted in PWIDs feeling a sense of hopelessness and low self-worth. Additionally, some Tijuana-based PWIDs felt as though they were considered less than human because of treatment from law enforcement, which could contribute to more internalization of negative self-perceptions, emotional distress, and poor behavioral health (Earnshaw, Smith, Chaudoir, Amico, & Copenhaver, 2013).

Implications for San Diego-based PWIDs

Our research revealed that some San Diego-based PWIDs perceived that by buying or using drugs in Mexico they could avoid harsh criminal penalties that they would face in the US, and that San Diego-based PWIDs overwhelmingly believed that they were immune to the law in Mexico because of the ability to pay the police. This perceived immunity could contribute to discrediting the Mexican criminal justice system as well as potentially harmful unintended consequences for US-based PWIDs.

Harsh US drug laws may serve as a “push” factor for PWIDs to cross the border into Mexico to buy and use drugs where they perceive a lower risk of legal consequences. This could have the unintended consequence of removing San Diegan PWIDs from their social networks, distancing them from social support, and making it more difficult to access services. PWIDs from San Diego who cross the border into Mexico may also be integrating into drug using networks with a higher baseline prevalence of hepatitis C virus and tuberculosis (Garfein et al., 2010). This could impact their risk for acquiring these infectious diseases (Rothenberg et al., 2000, 1998). PWIDs’ travel to Mexico because of a perception that it is easier to evade criminal penalties in the US, as demonstrated in the current study, or to obtain lower-cost or more available drug supplies, as shown in previous work (Wagner et al., 2012), demonstrates the continued need for laws in the US that provide alternatives to incarceration and that connect people to services (e.g., evidence based drug treatment) while keeping them connected to their support networks.

Legal reforms are one tool that can be used to align public health and criminal justice priorities (Burris et al., 2004; Davis, Webb, & Burris, 2013). For example, Mexico’s 2010 “narcomenudeo” law described herein was a public health-minded reform designed to decriminalize small-scale drug possession and institute mandatory treatment for habitual users. Similarly, in the US state of California, Proposition 47 reclassified drug possession as a misdemeanor instead of a felony, reducing the number of PWIDs who spend time in jail and who acquire a serious criminal record. Yet evidence of gaps in the implementation of such a progressive reform in Mexico highlights the challenges in translating drug policy reforms into street-level practice, especially in settings characterized by a weak rule of law.

Limitations

This study has several limitations. First, all of the same questions were not asked of both samples; therefore, direct statistical comparisons of the quantitative data could not be made. Additionally, some questions were not asked of the same time frame (ever vs. past six months), further limiting comparability. Second, generalizability may be limited as this study only investigated interactions with the police in one border city. Qualitative interview participants were sampled based on particular characteristics to provide breadth of experience and context, therefore their experiences may not be representative of the broader sample of survey participants. Finally, this study only investigated interactions with law enforcement from the perspective of PWIDs and did not include data from law enforcement officers. Despite these limitations, our findings have highlighted how two groups of PWIDs experience policing differently in Tijuana and how interactions with law enforcement affect behavior and could contribute to poor health outcomes for PWIDs.

To more fully explore this phenomenon, future research should investigate interactions with PWIDs from the perspective of law enforcement. We propose that the concept of “intergroup bias” may inform an understanding of how and why prejudice against PWIDs is manifested in the criminal justice context, and could be used to guide intervention efforts. Intergroup bias refers to the tendency to categorize people into members of ingroups and outgroups, which creates an “us” verses “them” mentality (Hewstone, Rubin, & Willis, 2002). Sometimes outgroup members are dehumanized by ingroup members, which can lead to justifications of cruelty, violence, discrimination, and abuse (Haslam, 2006; Mackie & Smith,1998). Viewing PWIDs as outgroup members, coupled with dehumanization that inhibits moral restraint, might help explain why Tijuana-based PWIDs experience negative treatment from the police.

Examining law enforcement officerns’ iteractions with PWIDs through an intergroup bias perspective might provide important insights that can inform law enforcement training. Training that incorporates intergroup approaches, such as increased quality and quantity of intergroup contact (Allport, 1954; Hewstone et al., 2002; Pettigrew, 1998), can reduce stigma and prejudice and promote positive intergroup contact. Positive contact between law enforcement and PWIDs might include more respectful interactions as well as referral to treatment and services (Beletsky, Agarwal et al., 2011; Beletsky, Thomas et al., 2013; Silverman et al., 2012; Wagner et al., 2015). This type of positive contact reduces negative affect (e.g., disgust, threat) and promotes positive affect (e.g., empathy), which is important for conflict resolution (Pettigrew & Tropp, 2008; Tausch & Hewstone, 2010). Increased positive intergroup contact between the police and PWIDs might decrease dehumanization of PWIDs, facilitate mutual cooperation, and promote law enforcement practices that align with harm reducing public health initiatives. A training intervention-evaluation study with Tijuana Police Department is employing peer education, sensitization, multimedia, and interactive role-playing tools designed to reduce drug user stigmatization and harmonize police practice with public health; initial results are promising (Beletsky et al., 2016; Strathdee, Arredondo et al., 2015).

Conclusion

Although Mexico has made great strides in enacting public health-minded laws that decriminalize possession of paraphernalia and small amounts of drugs, some law enforcement practices in Tijuana have continued to perpetuate the stigma associated with injection drug use and aggravate the structural risk environment for PWIDs. Our research suggests that, for some PWIDs, negative interactions with law enforcement in Tijuana during the study period may have caused increased drug use and risky behaviors, which can indirectly contribute to poor psychological and physical health outcomes. Furthermore, the nature of these interactions and the related health outcomes appeared to differ for San Diego-and Tijuana-based PWIDs, highlighting how inequalities in income and social position can perpetuate health disparities. Recognizing the impact that law enforcement has on the lives and health outcomes of PWIDs also illuminates the potential for law enforcement to facilitate risk reduction and health promotion among these individuals. Our findings support the effort to broadly address the stigma associated with drug use, since widespread cultural change must underpin these efforts.