Toward Community Empowerment: The Puerto Rican Ganchero

Abstract

People who inject drugs (PWID) who migrate from Puerto Rico (PR) to New York City (NYC) are at elevated risk for hepatitis C (HCV), HIV and drug overdose. There is an urgent need to identify a sustainable path toward improving the health outcomes of this population. Peer-driven HIV/HCV prevention interventions for PWID are effective in reducing risk behaviors. Additionally, the concept of intravention—naturally occurring disease prevention activities among PWID (Friedman, 2004)—is a suitable theoretical framework to cast and bolster PWID-indigenous risk reduction norms and practices to achieve positive health outcomes. From 2017–2019, we conducted an ethnographic study in the Bronx, NYC to identify the injection risks of migrant Puerto Rican PWID, institutional barriers to risk reduction and solutions to these barriers. Study components included a longitudinal ethnography with 40 migrant PWID (e.g., baseline and exit interviews and monthly face-to-face follow-ups for 12 months), two institutional ethnographies (IEs) with 10 migrants and six service providers, and three focus groups (FGs) with another 15 migrant PWID. Data were analyzed using a grounded theory approach. In this article, we present findings from the IEs and FGs, specifically regarding a promising intravention pathway to promote health empowerment among these migrants that leverages an existing social role within their networks: the PR-indigenous ganchero. A ganchero is a vein-finding expert who is paid with drugs or cash for providing injection services. Ethnographic evidence from this study suggests that gancheros can occupy harm reduction leadership roles among migrant Puerto Rican PWID, adapting standard overdose and HIV/HCV prevention education to the specific experiences of their community. We conclude by noting the culturally appropriate risk reduction service delivery improvements needed to mitigate the health vulnerabilities of migrants and provide a roadmap for improving service delivery and identifying future research avenues.

Introduction

People who inject drugs (PWID) who migrate from Puerto Rico (PR) to New York City (NYC) are a highly vulnerable group at elevated risk for hepatitis C (HCV), HIV and overdose (Deren et al., 2014, 2007a, 2007b; Gelpí-Acosta et al., 2016, 2011; Greer et al., 2017, Nolan et al., 2019). Although reliable prevalence and incidence figures for migrant Puerto Rican PWID in NYC do not exist, research suggests that this group bears a disproportionately high burden of HIV and HCV relative to other PWID in NYC (Gelpí-Acosta et al., 2011, 2016). A recent longitudinal ethnography found 22.5% and 90% of a cohort of 40 migrants were HIV and HCV positive, respectively, and that regardless of access to syringe services programs (SSPs), at least 60% injected drugs with syringes used by others, after rinsing them with water and blowing air through the barrel (“water-rinsing and air-blowing”) (Gelpí-Acosta et al., 2019). Additionally, NYC’s borough of the Bronx in 2018 had the highest rate (34.1 per 100,000 residents) and number (391) of overdose fatalities in NYC (Nolan et al., 2019). There, more fatalities occurred among Latinx (n = 206) than among non-Latinx Blacks (n = 125) and non-Latinx Whites (n = 49) combined (Office of the Chief Medical Examiner, 2019). A sizable group of Puerto Rican migrant PWID live in the Bronx (Gelpí-Acosta et al., 2011, 2016), and contribute to these ominous overdose statistics. In light of these threats, identifying a feasible and sustainable path toward improving the health outcomes of this population is urgently needed. In this article, we assess the prospects of a migrant-led disease and overdose prevention intervention in NYC, and probe the feasibility of using gancheros (Puerto Rican migrant PWID who provide expert and usually safe injection services to their peers, Gelpí-Acosta et al., 2019) as health promoters.

Peer-driven HIV/HCV prevention interventions for PWID have been shown to be effective in reducing risk norms and behaviors (Broadhead, 1998; Latkin, 1998; Latkin & Knowlton, 2005, 2015; Weeks et al., 2006, 2009). Using a social network diffusion model, Latkin (1998) and Weeks and colleagues (2006, 2009) demonstrated the efficacy of interventions that harness peer influence by relying on PWID to disseminate risk-reduction education to their network members. Because our previous research has shown that Puerto Rican migrants in the Bronx are highly networked (Gelpí-Acosta et al., 2011, 2016), peer-driven interventions that rely on social network ties may be particularly effective in reaching this population. In addition, by training community members to function as front-line interventionists/educators, peer-driven interventions may be perceived as more credible than interventions delivered by professionals. In fact, in the Bienvenidos study, after training Puerto Rican PWID enrolled in methadone maintenance treatment to conduct street outreach to PWID in their community, Deren and colleagues showed that peer-driven HIV/HCV prevention education models are not only welcomed by Puerto Rican PWID in NYC but can have empowerment and vocational benefits for those trained as peers (Deren et al., 2011; Guarino et al., 2010).

Sociologist Marie Jauffret-Roustide (2009) expands on this notion of drug user empowerment. In describing the efficacy of drug user-led “self-support groups” in France, she powerfully advocates that people who use drugs empower themselves by reclaiming from service providers (or professionals) their “right to speak.” She argues that, although criminalization has led to the demonization of drug users, and the associated “spoiling” of their identities (in Goffman’s sense, 1963), there are aspects of their identities as drug users that people can use as tools for changing the very social tenets that position them as outcasts. That is, drug users’ identities are fluid and can be sources of pride. The task at hand is to tap into the elements of their identities as drug users they already possess—and are proud of—to help improve quality of life for people who use drugs more broadly.

Friedman and colleagues (2007) go further by asserting that drug users can organize (a la labor unions) to reclaim their right to use drugs (not just to speak for themselves about their service needs) and their right to health, for these are not mutually exclusive categories. Indeed, there is evidence of marginalized populations, such as sex workers (Kempadoo, 2003), organizing along these lines. As Friedman et al. (2007) point out, while harm reduction services such as SSPs provide tools to facilitate health, it is the actions of drug users themselves that are essential to achieving the positive health outcomes, such as reduction in HIV transmission, that are the goal of such services. For example, to be effective, access to sterile injection equipment requires action on the part of people who use drugs; the fact that HIV prevalence among PWID in NYC dropped sharply soon after SSPs became available (Des Jarlais et al., 2005, 2011) demonstrates not only the efficacy of this specific public health intervention, but also the ability of people who use drugs to take decisive and positive health-focused action within their injection networks. They call for harm reduction programs to build upon these “micro-social” responses in order to improve the effectiveness of services.

It is within this theoretical framework that Friedman et al. coined the term “intravention,” defined as “prevention activities that are conducted by and sustained through ongoing actions of members of communities-at-risk of HIV” (Friedman et al., 2004, p. 251). An intravention seeks to enhance indigenous harm reduction norms and practices that exist within a targeted community. Building on existing risk reduction practices within drug users’ everyday contexts promotes sustainability. We find this intravention concept to be particularly appropriate for migrant Puerto Rican PWID in NYC, for they are not only a close-knit enclave of drug users but they are also a profoundly culturally distinct network of PWID: most are Spanish-monolingual males whose injection risk norms and behaviors in the diaspora remain closely connected to their experiences as PWID in PR.

For instance, they have a shared history in Puerto Rican prisons and the respective prison power groups with which they associated (i.e., Ñetas and Los 25). As we have reported elsewhere (Gelpí-Acosta et al., 2019), the overwhelming majority of migrants who participated in the longitudinal ethnographic component of the present study were imprisoned in PR prior to their migration event. Across Puerto Rican prisons, affiliating with a power group is standard procedure for incarcerated men. Originating in the 1970s with a heavy prisoner-advocacy narrative, groups such as Ñetas became pillars within PR’s correctional facilities. These prison power groups conduct prisoners’ rights advocacy, control illicit drug markets and protect their members from violence perpetrated by competing prison power groups and correctional officers alike, while securing heroin availability across the entire prison system. The importance of these groups as caring, yet authoritative informal sources of social control for the migrants in this study cannot be overstated. When they were in prison in PR, their lives depended on these groups, and migration to NYC has not diminished the existential importance of this personal history (Gelpí-Acosta et al., 2019).

Regardless of the municipality where they resided in PR, migrants in NYC also have a shared history with “bichotes,” a common label for drug lords. Similar to prison power groups, bichotes are caring insofar as they provide their clients with a morning dose of heroin to alleviate withdrawal symptoms, oversee the establishment and maintenance of “shootings” (e.g., abandoned venues where PWID congregate to inject drugs), and also compensate handsomely for not “snitching” (Gelpí-Acosta et al., 2019). Like prison power groups, bichotes are also authoritative and often violent enforcers of their rules. For instance, PWID who disrespect children and the elderly by injecting drugs in front of them are often violently assaulted, and snitches are killed (Gelpí-Acosta et al., 2019). Across PR, PWID’s behavior is strongly influenced by these unofficial agents of social control. This remains true even years after an individual has migrated to NYC, and the absence of these respected sources of social control in the diaspora influences the emergence of behaviors forbidden in PR, such as public injection and syringe littering (Gelpí-Acosta et al., 2019).

In addition to prison power groups and bichotes, there is a third Puerto Rican indigenous figure that is highly influential among migrants: the “ganchero” (Gelpí-Acosta et al., 2019). Rooted in the word “gancho,” a colloquial term in PR for “syringe,” ganchero literally means “syringe person.” Gancheros often secure sterile syringes and are also vein-finding experts who are paid with drugs or cash for providing injection services. A product of the Puerto Rican prison system, the ganchero is pivotal in the everyday lives of PWID in PR, as vein deterioration (due to cocaine injection) is common and over time makes it increasingly difficult to find accessible veins in which to inject. Gancheros therefore symbolize relief (from vein-finding anxieties) and also health (as they are often equipped with sterile syringes). The ganchero is in high demand in PR and also in NYC, for unlike bichotes and prison power groups, gancheros migrate and provide their services to migrants in the Bronx. When asked about effective ways to reduce injection risks, migrants in the longitudinal ethnographic component of this study identified the ganchero as a plausible pathway (Gelpí-Acosta et al., 2019).

Enhanced by our grounded theory approach (Glaser & Strauss, 1967), this ganchero-specific datum prompted the research question we seek to answer in this article: What would an HIV/HCV and overdose prevention intervention with gancheros look like for migrants in NYC? Because these migrants’ deeply-embedded history matters, we contend that an intravention may be the most effective means to address known migrants’ risk norms such as the belief that “air and water kill HIV,” and the associated high-risk behavior of sharing syringes after “water-rinsing and air-blowing” them (Gelpí-Acosta et al., 2019). Changing risk norms and behaviors in a population so fundamentally distinct from other PWID in NYC may require carving paths toward positive health behavior change from within. An intervention approach that aims to promote intravention by assisting in the development of a migrant-driven, self-sustaining culture of support for harm reduction may be effective in helping minimize the very significant vulnerabilities of this population (Gelpí-Acosta et al., 2016, 2011; Office of the Chief Medical Examiner, 2019). In this article, we present and analyze qualitative data from two institutional ethnographies and three focus groups that sought to elicit migrant PWID’s perspectives on the limitations of existing harm reduction services in meeting their service needs, and the feasibility of a ganchero-led intravention as a way to improve migrants’ drug-/injection-related health.

Methods

Study Overview

Findings derive from an ethnographic study (NIDA-R03DA041892) conducted in the Bronx, NYC in 2017–2019, which aimed to identify the injection risk norms and behaviors of migrant Puerto Rican PWID, institutional barriers to health, and avenues to promote harm reduction in this population. Overall, the study had three components: 1) a longitudinal ethnography (consisting of field observations and monthly qualitative interviews with 40 migrants over a 12-month period); 2) institutional ethnographies (IEs) of two Bronx-based harm reduction organizations that serve migrant Puerto Rican PWID; and 3) three focus groups (FGs) with migrants to explore risk-reduction intervention ideas based on results from our longitudinal ethnography. Observational data from the institutional ethnographies were triangulated with data from in-depth interviews with harm reduction program staff and migrant clients, and focus group data from migrants, to increase the validity of the findings. While findings from the longitudinal ethnography have been published elsewhere (Gelpí-Acosta et al., 2019), here we present findings from the IEs and FGs, which sought to identify institutional barriers to migrants’ HIV/HCV and overdose risk reduction, and solutions to these barriers including exploring the idea of engaging gancheros as risk reduction promoters. Our study was approved by the Institutional Review Boards of National Development and Research Institutes (reference number: 00000634) and New York University (reference number: FY2017-819).

Institutional Ethnographies

Following the tenets of institutional ethnography (Campbell, 1998; Smith, 1978), which aims to understand behaviors in the context of the structures that influence them, we conducted two institutional ethnographies (IEs) to examine migrants’ sustained injection risk behaviors in relation to the risk reduction services available, as well as staff understandings of sustained risks in this population. The IEs were conducted from December 2017 through January 2018 at the first institution (“UNO”) and from January 2018 through February 2018 at the second institution (“DOS”). Because UNO hosts a small mobile program (“UNIDOS”) exclusively targeting Latinx PWID who are not engaged with SSPs, our study was designed to focus its observations on this small mobile program, but staff and participant interviews were not limited to UNIDOS. When we started the IE component, and before conducting the FG component, we had already completed baseline interviews and 5 months’ worth of monthly face-to-face follow-ups with 40 migrants for the longitudinal ethnography component of the study. Consistent with a grounded theory approach, qualitative data from these interviews informed the IEs. Overall, we spent 144 hours (72/institution) observing the dynamics of program staff and participant interaction.

Recruitment and sample.

Before the study started, the Principal Investigator (PI, Gelpí-Acosta) had secured referrals to migrant-serving staff from both institutions. During the 6-week IE at each organization, three staff members were interviewed and asked to collectively identify five migrant clients who engaged in risky injection behavior (e.g., shared syringes and/or other injection equipment in the past 90 days) despite access to their SSP. Each of these clients was then asked to participate in an in-depth interview. Thus, a total of six staff and 10 clients were formally interviewed during the IE component of the study.

Data collection.

Data collection activities at each institution consisted of: 1) observations, 2) staff interviews, and 3) client interviews, all of which were conducted by the PI and a research assistant (RA). First, during the entire 6-week period we conducted observations for 12 hours/week at each agency, and wrote comprehensive field notes about activities in the following domains: interactions between staff/migrants, migrants/migrants, and migrants/non-migrant-clients; migrants’ interactions with written prevention materials (e.g., HIV, HCV and overdose prevention flyers, booklets, etc.); and migrants’ program attendance and service utilization. Second, during the fifth week at each institution, we conducted interviews with three staff members to explore their knowledge of the migrant population, including barriers to meeting risk reduction service needs. Third, during the 6th week at each institution, we conducted interviews with five staff-identified migrant clients to explore their experiences with the program’s services, and whether these services facilitated injection risk reduction. Staff and migrants were asked about data collected during the longitudinal ethnography component, which included probes on the ganchero as a health promoter, and specific risk behaviors identified such as syringe littering, public injection, and receptive and distributive sharing after engaging in the practice of water-rinsing and air-blowing.

Interviews lasted from 60–90 minutes and were conducted in private spaces at the respective agencies. All migrant interviews were conducted in Spanish; two staff interviews were conducted in Spanish, and four in “Spanglish” (i.e., a mixture of Spanish and English). Interviews were audio-recorded and transcribed in Spanish. The PI performed all Spanish-to-English translations. Staff and migrant interviewees provided written informed consent, and all were given a pseudonym to ensure confidentiality. Migrants received US$30 for their time.

Focus Groups

After components one (longitudinal ethnography) and two (IEs) had been completed, and maintaining our grounded theory approach, in July and August 2018, three FGs were conducted with migrant PWID to identify potentially effective ways to change migrants’ risk norms (“air and water kill HIV”) and injection-related risk behaviors (“water-rinsing and air-blowing”), in light of the challenges that had been identified in the IEs. The ganchero as a health promoter was a key topic because of its pervasiveness across study components one and two. Likewise, identifying solutions to migrant/staff-identified institutional barriers to migrant health were also a key topic.

Recruitment and sample.

During the IEs, the PI asked UNO/UNIDOS and DOS migrant-serving staff to refer 15 additional migrants who accessed SSPs but maintained injection risk behaviors to participate in one of three FGs. The PI and the RA co-facilitated the three FGs (90 minutes each) with a total of 15 migrant PWID participants (five per group).

Data collection.

FG participants were asked to identify pathways to undoing HIV/HCV risks, with prompts that emerged from our grounded theory analyses of all interviews (e.g., longitudinal and IE). The main prompts were: 1) the risk norm of “air and water kill HIV;” 2) the associated risk behavior of sharing syringes after “water-rinsing and air-blowing” them; 3) rationales for unsteady SSP use (e.g., trust, competing priorities, desperation); and 4) the ganchero as health promoter.

Migrants consented in writing to be a part of the study. FGs were conducted in Spanish at the SSP DOS and were audio-recorded and transcribed in Spanish. Participants were assigned pseudonyms and were compensated US$30.

Integrated Data Analysis

Interview and FG recordings were transcribed verbatim in Spanish by the RA (concurrently with data collection), translated into English by the PI, and entered into the MAXQDA 12 program for analysis. Following a grounded theory approach (Glaser & Strauss, 1967), four individuals (PI, RA and two Co-Investigators) independently coded transcripts of four interviews and one FG. We reviewed all emerging codes, created a unified code list, defined each code, and secured inter-coder reliability in consensus sessions. The PI and the RA coded the rest of the data. Emerging themes in the IEs were language and other cultural and institutional barriers to health, trust, history, drug quality and effects, law enforcement, prison power groups (i.e., Ñetas, Los 25) and gancheros. FG themes were institutional barriers to effective service provision and the benefits and potential challenges of equipping gancheros as health promoters.

Results

Sociodemographics

As Table 1 shows, 10 migrants were interviewed as part of the IEs (five/institution) and 15 participated in three FGs (five migrants/FG). Mirroring other studies with migrant Puerto Ricans in NYC, the sample was predominantly male (92%) (Gelpí-Acosta et al., 2016, 2011). Overall, 32% had not completed high school. With only one person employed, most (96%) received some type of welfare benefit (mainly food stamps), all 25 performed “off the books” employment activities and four (16%) were gancheros. All participants injected speedballs (heroin and cocaine mixed together) on a daily basis, and 52% also smoked the synthetic cannabinoid known as “K2.” In addition, most (68%) were not enrolled in opioid agonist therapy and 40% had experienced an overdose at least once in the 12 months prior to the interview/FG. Finally, 84% self-reported being HIV negative and 80% HCV positive. Two of the HCV negative migrants were cured after undergoing treatment in NYC. All participants except one were Spanish monolingual.

Table 1.

Sociodemographics of Migrant Puerto Rican PWID in Institutional Ethnographies (IEs) and Focus Groups (FGs).

		IE (N = 10)	FG (N = 15)	TOTAL (N = 25)
		N (%)	N (%)	N (%)
Age	18–24	0 (0%)	1 (6.7%)	1 (4%)
	25–34	3 (30%)	2 (13.3%)	5 (20%)
	35–44	6 (60%)	10 (66.7%)	16 (64%)
	45+	1 (10%)	2 (13.3%)	3 (12%)
Gender	Male	10 (100%)	13 (86.7%)	23 (92%)
	Female	0 (0%)	2 (13.3%)	2 (8%)
Educational Attainment	< HS	3 (30%)	5 (33.3%)	8 (32%)
	HS/GED	7 (70%)	6 (40%)	13 (52%)
Income Sources †	> HS	0 (0%)	4 (26.7%)	4 (16%)
	Employment (on-the-books)	1 (10%)	0 (0%)	1 (4%)
	Off-the-books work*	10 (100%)	15 (100%)	25 (100%)
	Gancheros**	2 (20%)	2 (13.3%)	4 (16%)
	Welfare	9 (90%)	15 (100%)	24 (96%)
Housing Status	Homeless	3 (30%)	5 (33.3%)	8 (32%)
	Three-quarter house***	2 (20%)	5 (33.3%)	7 (28%)
	Room rental	2 (20%)	4 (26.7%)	6 (24%)
	SRO	3 (30%)	1 (6.7%)	4 (16%)
Drugs Used Daily	Speedball	10 (100%)	15 (100%)	25 (100%)
	K2	6 (60%)	7 (46.7%)	13 (52%)
Current Opioid Agonist Treatment (OAT)	Yes	3 (30%)	5 (33.3%)	8 (32%)
	No	7 (70%)	10 (66.7%)	17 (68%)
Overdose Experience ††	Yes	3 (30%)	7 (46.7%)	10 (40%)
	No	7 (70%)	8 (53.3%)	15 (60%)
HIV status (self-report)	Positive	3 (30%)	1 (6.7%)	4 (16%)
	Negative	7 (70%)	14 (93.3%)	21 (84%)
HCV status (self-report)	Positive	8 (80%)	12 (80%)	20 (80%)
	Negative****	2 (20%)	3 (20%)	5 (20%)

^†More than one category may apply to some participants.

^††At least once in the past 12 months.

^*Panhandling, washing cars, aluminum recycling, etc.

^**Within “off the books:” Vein-finding experts who get paid for injection services. All males.

^***OAT-assisted housing.

^****Two participants were treated and cured in NYC.

Of the six staff (not shown in Table 1), all were Puerto Rican from NYC (five) and from PR (one), and three were women. All had been working in the harm reduction field in NYC for at least 10 years.

Ample Services With Limited Reach

The first program we observed was UNO, which employs 40+ staff and offers SSP services in many locations. Our observations focused on UNIDOS, a small mobile program hosted by UNO, which exclusively engages PWID who are Latinx (not exclusively migrant Puerto Ricans) and not regularly SSP-engaged. Because its aim is to assess the mental health and counseling needs of out-of-SSP Latinx PWID, UNIDOS does not provide syringe services and offers only limited risk reduction literature. With only one staff member (Sonia), UNIDOS’ intake takes between 20–30 minutes to complete and involves HIV/HCV and drug treatment knowledge dissemination, and streamlined mental health assessment and counseling. UNIDOS offers a small amount of cash for each intake and follow-up session. During each encounter observed (55 Latinx PWID—of which 20 were migrant Puerto Rican PWID—in 6 weeks) inside UNIDOS’ mobile unit and across five Bronx neighborhoods, Spanish was the organic way of engaging Puerto Rican migrants, while other Latinx PWID were more comfortable with English. UNIDOS is led by a veteran harm reduction staff member who is Puerto Rican and fully bilingual, and with a manifest commitment to helping participants.

The second program we observed was the SSP “DOS.” At this agency’s brick-and-mortar site, PWID and non-PWID participants access HIV/HCV and other infectious diseases testing and treatment, and other prevention services. Coffee, internet, television, and meals are also offered daily to this predominantly African American and Puerto Rican community. Many PWID at DOS are Puerto Rican migrants. At DOS’ drop-in center, several primarily English-monolingual case managers can be seen walking in-and-out of their offices calling on participants. DOS also hosts a pharmacy and provides food services and support and educational groups (mainly in English).

Compared to UNIDOS, DOS is less inclined to deliver Spanish-language educational sessions. Yet, it has far greater resources to address migrants’ injection risks. While SSP personnel are bilingual and many are Puerto Rican, educational and support groups are mainly conducted in English and by staff who are unfamiliar with the specific service needs of this migrant population. While migrants engaged in HIV/HCV risk and mental health assessment sessions with Sonia in UNIDOS, being a mobile program means it lacks the stability of a drop-in center where clients can access crucial services such as syringe services, naloxone, housing assistance, food, clothing, and showers. Migrants attending the more service-robust DOS almost exclusively did so for syringe exchange (≥240 syringe transactions with migrants observed over the 6-week DOS IE) or food and mail services (DOS is the mailing address of homeless clients), but did not interact with educational texts, non-SSP staff, or staff who do not speak Spanish. In both programs, all but one of the observed migrants were male. This is not surprising as recent quantitative studies on this population report a 9:1 male-to-female ratio (Gelpí-Acosta et al., 2016, 2011).

On Trust and Risk: How History and Culture Matter

They don’t have enough services over there and they come here [NYC] to seek a better life. I mean, every [expletive] body does it. And it’s sad because when they come here, they are [expletive], excuse my language, they are also given the short end of the stick because there are not enough services for them. They need social work in Spanish, they need overdose prevention in Spanish, they need more groups in Spanish, more education in Spanish. They need medical providers in Spanish. (Ramonita, UNO staff)

Ramonita is a fully bilingual Puerto Rican woman born and raised in New York. Unlike Sonia, who singlehandedly runs UNIDOS, Ramonita is part of UNO’s mobile SSP in the Bronx, which does not focus on Latinx PWID. During a nearly 2-hour interview, she explained the service gaps migrants face with evident frustration. Her bilingual UNO/SSP outreach partner, Diego, also stated that the first barrier migrants face is language. Although the staff members who work with migrants at UNO and DOS are fully bilingual, they do not perceive the overarching NYC health care system, including their institutions, as being linguistically accessible or culturally appropriate for migrant Puerto Rican PWID who are overwhelmingly Spanish monolingual.

Staff and clients agreed that another structural barrier fuels migrants’ risk behaviors: poor heroin quality in NYC.

First of all, they can’t get their use under control because of the different potencies. Puerto Ricans from the island are not going to survive over here [NYC] with that. It’s hard enough to get a couple of bags here alone, to throw out money like that, imagine trying to get two and three bundles daily. They are being put in a real bad position. We’ve got to help them get that under control.

(Diego, UNO staff)

Over here [NYC] I am using more than in Puerto Rico. In PR I used to inject every day, but here I inject more times per day. It’s also easier to get the money for it over here. But drug quality in PR is better. It’s very weak here. So much money is spent on it and you can’t even get high.

(Sinti, DOS client)

There was consensus regarding the poor quality of drugs in NYC compared to PR, and the impact poor drug quality has on injection frequency and risk behaviors. As Diego (UNO staff member) mentioned, many migrants have up to 15 or more injection events per day. This frequency of injection makes them more vulnerable to sharing injection equipment, given the practical difficulty of carrying a large supply of sterile injection equipment on one’s person. Importantly, it also makes migrants less likely to seek services.

Diego: Man, it’s hard to explain, you would have to be in the shoes of a Puerto Rican in that level. It’s hard to really explain, you just go for whatever, you know what I mean, and you just don’t care and the only [expletive] thing on your mind is to get that next one [injection].

Interviewer: Are they seeking HCV and HIV testing and treatment?

Diego: Sometimes, not as much as they should. There are a lot of things we try to offer but what I found is that they are always in a hurry because they’ve got to hustle and bustle you know a mean … every minute is a dollar and they are trying to make that money.

Poor drug quality and high injection frequency combine with severe poverty to reinforce syringe and cooker sharing practices, mainly through frequent “caballo” sessions (e.g., 2+ migrant PWID pool their money to buy and share drugs) to guarantee more immediate injection events. Abadie and colleagues noted the pervasiveness of caballo on the island (Abadie et al., 2016). Everyday risks in PR are replicated in the new context of NYC. For instance, our FGs confirmed that migrants trust the Puerto Rican-native belief that “air and water kill HIV” (Gelpí-Acosta et al., 2019). In the words of Cano (FG):

So many times, you wake up very sick and the first thing you do is get the money to score and get straight because many things can happen in a few seconds. The addict knows he will blow air and rinse with water because in his mindset it works.

Migrants are convinced of the efficacy of the “water-rinsing and air-blowing” practice in preventing syringe-mediated HIV transmission, and programs serving migrants are not directly addressing this norm (Gelpí-Acosta et al., 2019). Solidifying their trust in this risk norm and practice is their maintenance of an HIV negative status (only four participants were HIV positive) despite years of injecting with used syringes after “water-rinsing and air-blowing” in PR and now in NYC.

Although the migrants in this study met each other in NYC, profound commonalities in their drug subculture, which includes familiarity with concepts such as caballo, droga (heroin), and bichote, leads to cementing trust quickly. Non-migrant PWID in NYC do not use and do not understand this subcultural argot. While the rapid development of trust among migrants has been noted before (Gelpí-Acosta et al., 2011), the present study confirms how their deep subcultural similarity enhances social and emotional bonding.

Ramonita (UNO staff member) describes how a migrant’s power group affiliation is another crucial connection:

They inject together, they find money together, they get into programs together. They bring others to get the services they are getting. They come here with their community-based organization connection, whether it’s Ñetas [i.e., prison power group] … most of them come from PR with that connection. It’s not in a negative way, it’s them connecting to their culture and what they know and a lot of them come from PR with that mindset and that’s what you see them gravitating toward.

As Ramonita observes, a common denominator linking migrant PWID to each other, in addition to birthplace and language, is time spent in Puerto Rican prisons, where they became affiliated with prison power groups, such as the Ñetas. This commonality leads to trust.

Similarly, migrants trust other migrants’ HIV negative self-reports, which in turn promotes risky injection behavior.

Interviewer: Why do you share syringes having SSP here?

Samuel: Here [in NYC], I share with people I trust. Brotherhood. I don’t do it with everyone. Not everyone will be honest with you [about their HIV status]. I have my chosen ones, my “corillo” [close group of peers]. I know they don’t have HIV. They have HCV but I have it too. Honestly. I share with Pito. He and I have boxes of new syringes, but we still share.

Interviewer: Why sharing if you have boxes?

Samuel: Because in that moment we don’t have the box. Right now, our box of syringes is in the shelter.

The disposition to trust those who are part of their “corillo” invariably unfolded first in PR. There, they learned to inject drugs, they formed their drug user subjectivities, and they were exposed to the following experiences over many years: prison as a rite of passage; heavy injection drug use inside prisons; prison power group membership; access to gancheros inside and outside prisons; shooting gallery use; and the street rules of bichotes (Gelpí-Acosta et al., 2019). All a migrant PWID in NYC requires to have a sense of “brotherhood” with another Puerto Rican PWID is to know that s/he injected drugs in PR.

But when it comes to trusting fellow migrants’ self-reports of HIV status, Tito and Juancito, who were both observed during the UNO IE, explained the rules that lead them to trust migrants’ self-reports of HIV status:

Juancito: Before sharing syringes in a shooting in Puerto Rico, you ask “Are you [HIV] clear? You are not sick [HIV], right? You don’t have the condition [HIV], right?” And they respond, “No, no, no. I’m good.” If anyone knows you are sick and you lied and gave your “gancho” [syringe] to someone else, you will be beatdown and/or outcasted from the “caserío” [public housing] by the bichote.

Interviewer: So, you must say the truth then, like a rule?

Juancito: It’s a rule, yes.

Tito: adds an ethical component

Interviewer: Can you describe the norms before sharing syringes in Puerto Rico?

Tito: If I have HIV or HCV, I have to say it before sharing my works with you. If we are going to share, and what we have is a syringe I have already used, then I have to say it. If we have a new syringe, then I’m going to let you use it first. But if I used it already, and I tell you I am sick, it’s now your decision if you want to use it.

Interviewer: And where did you engage in this practice in Puerto Rico?

Tito: At the shootings. If you don’t say it, you don’t have a heart, you’re worthless.

We found at least two sources regulating honesty in migrants’ HIV status self-reports: the threat of violence at the hands of bichotes, and a sense of morality. In terms of violence, the influence of bichotes in regulating PWID behavior in PR is conclusive, and it has been argued elsewhere that the absence of this character in the diaspora helps trigger undesirable behavior such as syringe littering in public areas and widespread public injection among migrants (Gelpí-Acosta et al., 2019). Arguably, the bichote’s absence may also trigger a false sense of security in the honesty of HIV self-reports, since there are no bichotes enforcing the honesty norm in the Bronx.

In terms of morality, it is considered immoral to fail to inform a potential injection partner if one is HIV and/or HCV positive. Since Tito’s injection partner’s decision is an informed one, Tito’s moral culpability is nonexistent. These excerpts showcase how most (if not all) of the injection rules Tito and other migrants in this study practice in NYC were learned in prisons and shooting galleries across PR. When they meet in the Bronx, the spontaneous historical commonalities that quickly surface in their initial interactions pave the way for swift intimate connections and ultimately trust. That so many of them are also homeless or unstably housed further reinforces and cements this trust.

But trust stemming from common histories and subcultures is not the only factor influencing migrants’ health risks in the diaspora. Migrants do not want to carry the syringes UNO and DOS provide for fear of arrest. This is because the New York Police Department (NYPD) continues to use syringe possession to justify arrests, even if only to release detainees from custody quickly thereafter. As Rafael (DOS client) explains:

Sometimes the high of the speedball [a mixture of heroin and cocaine], the cocaine in particular, makes you paranoid. “La perse” [persecution complex.] So, you think of the police. Even though I know the SSP card makes it [syringe possession] legal, there are cops that don’t care about that and arrest you anyway. To avoid that, you throw the used syringe out and don’t have them on you.

Indeed, during our longitudinal ethnography observations, we witnessed countless and often aggressive police interventions with migrants. The negative effects of law enforcement’s misalignment with public health efforts is well documented (Beletsky et al., 2014; Heller et al., 2009; Howell, 2009) but the extent of this misalignment, and perhaps even the threat law enforcement sometimes poses to the lives of these migrants (and arguably poor drug users in general), is best showcased by Bebo’s reported experience with the NYPD. Bebo is a 35 year-old male who moved from PR to NYC four years ago. He sells heroin and cocaine in NYC, and was a bichote back in PR. During our IE observations at DOS, Bebo shared how two police officers in a patrol car passed by the drug selling spot where he worked. They started calling his name, saying “Hi!” and acting in a friendly manner, as if to show a personal relationship was in place. Bebo was scared for his life, for he was being falsely portrayed as a “chota” (snitch). Eventually the threat went away, and no harm came to Bebo. And yet this type of policing puts people who use drugs at unnecessary risk, not only of sharing syringes and contracting HIV/HCV, but of violence and even death.

Along with the threat police represents to migrant health, drug pharmacology presents an additional barrier to risk reduction, as all of the IE and FG migrants inject speedballs. The effects of cocaine are shorter lived than those of heroin, triggering more frequent injection episodes. The cocaine high also leaves many in a paranoid state (what Rafael earlier called “la perse”), which combines with aggressive policing to disincentivize steady possession of sterile syringes. In addition, this complex situation fuels syringe littering and overdose. All study migrants injected speedballs and 52% did so concurrently with K2 smoking. Considering such a potent mix of drugs (i.e., cocaine, heroin, illicitly manufactured fentanyl and K2), it is not surprising that 40% of the migrants in this sample had experienced a fentanyl-linked overdose in the 12 months prior to the IEs/FGs. When asked about naloxone, many participants explained that other migrants and SSP staff had used it on them to reverse their overdose event(s). Yet our IE observations identified a lack of consistency in their practice of carrying of naloxone.

Insightfully hinting at how history and culture can be used to resolve the puzzle of the sustained HIV/HCV and overdose risks of this population, Armando (DOS staff member) is convinced that migrant trust and empowerment hold the key for behavioral change:

They are like one already. But they need a drop-in center that would focus on the PR culture. They need a six-month shelter with workers to connect them with services. Education on using safely in Spanish, Narcan, test their drugs, and have a mobile unit that represents their culture. Give them incentives! Educate them so that they can create and run programs. Give them that empowerment. Create a safe environment for them to maintain their housing. What I mean is empowering them and giving them control to maintain their atmosphere safe for them. Let them tell their stories. It’s sad that even though harm reduction has been around for decades … but I guess it speaks to the need for continuous education.

(emphasis added)

Armando here is practically enunciating what Jauffret-Roustide (2009) and Friedman and colleagues (2004, 2007) have argued needs to be fomented by harm reduction programs: tapping into and harnessing the pride they have as drug users from PR to facilitate effective and sustainable risk reduction through empowerment. For these staff, surmounting the language barrier helps them connect with migrant clients. Yet they think their institutions are not adequately tailoring their services to better address migrants’ specific risk reduction needs. For them, the key to success with this population lies in empowerment. To be effective, institutions must embrace the broader culture of migrants, not just language, and actively learn from migrants’ past experiences of empowerment in PR (e.g., including prisons and shooting galleries) to develop a space in the diaspora where migrants can feel they matter, belong and experience a sense of control.

Alongside this empowerment approach, SSPs could also try to engage these migrants more actively on the streets. When migrants were asked in a FG what SSPs could do to improve their reach within the migrant community, two responded in the following ways:

Betances: They [SSP workers] need to stop being inside their offices. They need to go out to the street with the people. Not sitting here [office]. Talk to the addicts outside, bring the message “you can do this, here is a new syringe, alcohol, so you don’t have to walk all the way over there [to the SSP].” The ganchero will do that!

Interviewer: Do you think a ganchero would work?

Betances: “Ay bendito” [Oh blessed] the drug spot is over there! [frustrated] Not here! [at the SSP]. You have to go to the drug spot. The addict doesn’t come here [SSP], he goes there [drug spot]. That’s where he needs you! [frustrated].

Interviewer: Don’t you think we’d get in trouble with the drug dealer if we are too close?

Noah: Nope. Just close enough to the spots. One or two blocks away. It’ll work. Right now, there are workers here that are laid-back and don’t do anything, stealing the money. I’m going to be honest with you, if I were in a position like that, I like working, I wouldn’t mind going out to the community and do needle exchange. More so if I’m getting paid for it.

Betances: If you go to a motel, they have condom dispenser machines, lubes, etc. You go to the women’s restroom, you see machines with sanitary napkins, even baby changing stations. It’s just common sense.

While this excerpt exemplifies migrants’ sentiments across three FGs, migrants in this session were particularly puzzled by SSP staff not reaching out to them at “el punto” (drug spots, venues where drugs are sold). To them, providing harm reduction services at or near the drug spots is commonsensical. In this excerpt, Betances also endorses the ganchero as ideally situated to deliver risk-reduction information and resources to migrant PWID.

However, there are SSP staff taking forward steps and unofficially using gancheros as health promoters. When we interviewed Armando, we were surprised by his proactive approach to using this indigenous figure as a pathway to migrant health, albeit not having cleared it with his supervisor. When we asked him about using gancheros he replied, “I’m already targeting gancheros, I give them more syringes than usual because I know they will use them on others. It’s secondary prevention. It works.” The high caliber of SSP staff we documented cannot be overstated, as much as the need for their institutions to enhance their support of the capacities of staff and participants to innovate and creatively reduce harms.

Enter Community Empowerment: The Ganchero Path

We are the ones who know our community. We are ideal to serve our community. We can update any institution [SSP] on what needs to be done. We can help and talk to a “bichote” [Puerto Rican-based drug dealer] about any of our guys who owe him money. We are the leaders. We are the gangs [power groups], and we know and did all the positions [in PR]. We are anywhere from gancheros to bichotes. We have magic. An addict sells a matchbox to the matchbox manufactory.

(Romero, FG#1)

Despite the structural vulnerabilities migrants face, there is a sense of self-efficacy among them. They have held positions of authority in PR (as bichotes, gancheros, and prison power group members), and while admittedly in NYC these positions have mutated, they have not entirely dissipated. The retention of aspects of who they once were in PR may be a source of empowerment and collective efficacy in NYC. Similar to Bourgois and Schonberg’s (2009) “righteous dopefiend,” there is a sense of pride for having been bichotes in PR, for belonging to their respective prison power groups, and for being drug users. They are not ashamed of the latter, although they are pained by the hurt they feel they have caused their mothers (Gelpí-Acosta et al., 2019). Because this past also cements trust among migrants, collective efficacy is within reach. But because migrants who deal drugs in NYC are not bichotes in the Puerto Rican sense (e.g., heavily armed, violent and territorial), and because prison power groups such as Ñetas and Los 25 are not operational in NYC/NY State jails/prisons, the still operational ganchero may be the best avenue to pave the way for positive health behavior change through empowerment.

During our FGs, we extensively discussed with participants whether gancheros could help counter the normative belief that “air and water kill HIV,” and help reduce syringe sharing, littering, and overdose. Study participants explained that gancheros are already working in the community and delivering safer injection services to these migrants close to the drug spots. Native members of the Puerto Rican PWID scene, gancheros are popular members of this population, understand the culture and have a shared history with non-ganchero migrant PWID. Indeed, gancheros are a tempting pathway to promote effective and sustainable migrant health.

And yet, while there was consensus on the importance of developing an initiative that would be led by migrants, and the ganchero figure per se, this agreement was also characterized by ambivalence. As Romero, a ganchero in NYC who was also a ganchero in PR, explained:

I was a ganchero in Aguadilla, PR. The bichote assigned me to a three-story mansion to work over there, and I had everything. I would serve over ninety people every two hours. I earned a lot of money doing it but imagine how much I was using. My habit skyrocketed.

(FG#1)

A main concern expressed across FGs was that very high tolerance is an occupational hazard for gancheros, and that this vulnerability may compromise their health as well as their ability to perform as “honest” community leaders. Dylan, another ganchero who participated in our FGs, went further:

Menor: A ganchero may or may not work. Addicts are very clever. He will find a way to take advantage of the situation. He only thinks of himself. Remember, the ganchero is helping many people, and while doing it his addiction is growing. So, when a client comes to him, if he’s not straight yet, he will take from the client.

Dylan: And can also inject you with water, can have a hidden syringe with water and swap the one with the drug.

Interviewer: So, a ganchero initiative wouldn’t work then?

Flor: Yes, it would.

Dylan: It could, but we need training. Just like nurses have to study medicine and lawyers study law.

Interviewer: But he could still scam the operation?

Dylan: It’s best if the client pays, not the program.

Interviewer: If I pay a group of gancheros to do this work, will they lie to secure payment from me and the clients?

Cano: Yes, and will ask for a loan.

Dylan: Not necessarily. Even though we are addicts, we are people with good hearts. Trust me, if this guy [points at Cano] sees me sick, trust me he will give me a few units from his drug. Why would I need to steal from him, if it’s all there [in the cooker] anyway? He’ll say, “do me and I’ll give you ten units.”

For some migrants, a ganchero’s ever-increasing drug dependence compromises trust and the efficacy of a ganchero path to risk reduction. Solutions ranging from training to maintaining and/or changing the organic ganchero-client payment mechanisms were discussed as possible strategies to maintain honesty in the ganchero. There was contention on the latter point, however, as the following exchange indicates:

Interviewer: Would a ganchero initiative work?

Jorge: So long he does it as he should.

Eddie: Can’t do it to make a business out of it.

Ernesto: Having a ganchero with all those supplies, of course it’ll work! [Ñeta affiliation]

Eddie: But he needs to work for a SSP, he can’t be asking clients for payment.

Santiago: No “give me a dollar” anymore.

Eddie: And can’t be charging a dollar for a syringe anymore.

Santiago: I really think it could work. For instance, my group [Los 25, prison power group in PR] is one of norms. My group would actually be organizing these kinds of initiatives over here.

Eddie: That’s true [also affiliated with Los 25].

Migrants also explained that payment demanded by the ganchero is a main source of mistrust (i.e., US$1 for a new syringe, and units of the drug solution). This problem may be eliminated if gancheros are paid by SSP instead of clients. Despite these ambivalences regarding gancheros’ ability to be honest, migrants agreed that an empowered community-led approach to reducing risks is an effective pathway to health. They even compared the ganchero intravention to the types of community organizing they are used to having in PR through their prison power group affiliations. Further, the two most well-represented prison power groups in this study (Ñetas and Los 25) can work together in NYC, for there they don’t foster the divisions they had in PR, and that arguably would get in the way of an effective ganchero intravention. A past (in PR) cemented by friction between prison power groups may as well now (in NYC) be re-signified as a migrant trait enhancing collective efficacy. These community affiliations remain relevant in the diaspora and may assist in the process of effecting positive health behavior among these migrants.

Discussion

Access to SSPs in NYC is a positive health event for these migrants. In contrast to the environment in PR, they have ample and low-threshold access to supplies and services tailored to helping people inject drugs more safely. For many, it is also the first time they have accessed services provided by staff who treat them as human beings. In addition to sterile injection equipment, at the programs we observed migrants also have access to services such as food, mail, HIV/HCV testing and treatment, support groups and case management. Yet, sterile injection equipment, mail and food services appear to be the most popular of the available options. But there are many challenges limiting SSP’s ability to fully address migrants’ risks.

Although UNO, its small UNIDOS mobile program, and DOS all employ staff members who can organically connect to these migrants, these programs can be understaffed and under-resourced (especially UNIDOS). In addition, the well-resourced and well-staffed DOS provides mainly office-based services (counter to what migrants consider commonsensical: having syringe services by the drug spot), and their core educational and support groups are mainly conducted in English and do not address influential migrants’ risk beliefs (e.g., the “air and water kill HIV” norm and the associated behavior of “water-rinsing and air-blowing”). For instance, drug pharmacology is a potent factor making migrants more likely to engage in injection risk behavior such as syringe reuse, sharing and littering, regardless of SSP access. While using speedballs is linked to higher injection risks across PWID groups (Archibald et al., 1998; Tyndall et al., 2003), among migrants from PR in NYC this may be of particular concern. Drug quality in PR is widely perceived to be much higher and, after migrating to a setting where quality is experienced as significantly lower, their speedball injection practices typically intensified. As injection frequency increases, so too does vein deterioration (which in turn explains the high demand for gancheros who are skilled in accessing hard-to-reach veins). In addition, injection risk behavior and overdose vulnerability increase. Accessing SSPs (and the HIV and HCV testing and treatment and overdose prevention services that accompany SSPs) becomes secondary to satisfying their desire for speedballs.

The type of aggressive policing employed by the NYPD further enhances risk-taking behaviors among migrants. Because police presence is ubiquitous in the areas of the Bronx, the likelihood of arrest is, to these migrants, imminent. To many, carrying syringes, regardless of legality, gives the police an excuse to arrest. This public health-hostile context is not only conducive to syringe sharing, but also to syringe littering. Aggressive policing combines with the pharmacological effects of speedballs (i.e., paranoia) to compel the immediate discarding of any evidence of wrongdoing (i.e., a used or sterile syringe) on the street or in parks.

As noted earlier, the Bronx ranked first in 2018 in overdose fatalities in NYC (Nolan et al., 2019). The Puerto Rican migrants in this study are implicated in these statistics, for concomitant risk factors render high overdose vulnerability in this group: very high daily injection frequency (explained by perceived poor drug quality and by the short duration of cocaine’s effects) combined with polydrug use (i.e., cocaine, heroin, fentanyl and K2). In NYC, illicit fentanyl is present in both heroin and cocaine (Nolan et al., 2019a). Most drug overdoses result from mixing drugs, and many migrants (52%) are adding K2 to an already heavy drug diet. While we suspect factors such as ongoing desperation (to secure drugs), homelessness and aggressive policing may make it hard for migrants to carry naloxone at all times, more research is needed to understand inconsistent naloxone carrying.

Finally, migrants’ trust in their “air and water kill HIV” norm, and in the HIV-negative self-reports of their “brothers,” reinforces their continued syringe-sharing in spite of their access to sterile injection equipment through SSPs. Migrants’ multilayered trust stems from common injection drug use trajectories. Those trajectories took shape in PR, and SSP access after migration does not erase that embodied history. Years—sometimes decades—of sustained syringe sharing and maintaining an HIV-negative status are powerful sources of trusted knowledge, and SSPs in NYC are (perhaps naively) dismissive of the importance of this history. Upon arrival to a puzzling new setting (NYC), they swiftly develop trust in their migrant compatriots because they share a core experience: they come from PR but most importantly, they belonged to the same prison power groups. Since imprisonment is a rite of passage for PWID in PR, prison power groups became main sources of (informal) education, legitimate authority and familial support. A profound subject-formation process took place prior to their migration to NYC, and prison power groups, along with the ganchero, were pivotal agents in that process. We found they remain pivotal in NYC.

Casting Empowerment

It was Ramonita (UNO staff member) who most eloquently explained that prison power groups are community affiliations that remain relevant to migrants in the diaspora. While power groups functioned as sources of often violent behavioral control inside prisons, they also provided incarcerated Puerto Rican PWID with a sense of empowerment and collective efficacy. Through their affiliation with these groups, these individuals felt they belonged to something bigger than themselves, a hierarchical organization with the rules and norms needed to maintain justice for incarcerated drug users. During one of the FGs, Segundo and Adrián (both Ñetas) explained: “Over here [NYC], we need a structure with a hierarchy. A pyramid-like structure. And it must have a philosophy.” In NYC, the differences of the past (while in PR) are no longer fueled by the Puerto Rican-specific prison power groups. What remains from that past resembles a collective migrant trait (or disposition) that endorses and supports a sense of PWID-empowered order and unity. The confrontational aspects of their past become secondary to their newfound diasporic-need for collective efficacy.

Gang researcher John Hagedorn (2008) has argued that “gang members memorize the literature, laws and prayers of their gang, and learn about past warriors, often with titles such as ‘kings’ or ‘lords’” (p. 11). Across the world, gangs (or power groups) are main sources of informal social control, which means they are also sources of education. Members, usually starting at a young and impressionable age, grow to love and admire their power group emotional associates, their brothers. Drawing from Löic Wacquant’s work, Hagedorn also argues that prison gangs (like the Ñetas) are not truly confined to the prison space, for the ghetto and prison are connected in a “continuum of domination” (2008, p. xxx). Although the Ñetas emerged in and rule Puerto Rican prisons, their power extends into the communities where their members and families live. In PR’s case, more research is needed to understand the role—if any—of prison power groups over bichotes. This is an important research avenue insofar as bichotes are clearly the most powerful authority figures in street settings, perhaps countering what Hagedorn argues regarding the continuum of domination. But it remains unclear if power groups are completely devoid of power outside prisons and over bichotes. What is clear, however, is that the fraternal love migrants feel in the diaspora stems from having belonged to prison power groups, and in that sense the continuum of domination remains relevant. Similar to the argument made by Jauffret-Roustide (2009) regarding drug users’ identities as tools for improving life, the continuum of the domination of these power groups can be a stepping stone to improving life in the diaspora.

An understanding of this Puerto Rican drug user ethos is important, and perhaps even crucial, for public health efforts that aim to encourage the development of an effective culture of intravention (Friedman et al., 2004) among migrants, which would seek to reduce disease and overdose risk, as well as syringe littering, and their relationship with group membership. The history of migrants matters, and any intervention aiming to address their vulnerabilities must awaken their latent collective sense of order and self-efficacy, which was invariably provided by the prison power groups to which they remain attached, albeit remotely. These groups provided rules and a sense of self-respect largely lost by migrant PWID in the diaspora. Judging by FG responses, an intervention strategy that equips gancheros (who were members of prison power-groups and also served as gancheros in PR) to disseminate targeted messages to embolden migrants’ sense of collectivity and self-care seems appropriate and feasible. Gancheros are organic to this population and are already incorporating safer injection practices by always using new syringes with their clients. In addition, their vein-finding skills are in high demand. With appropriate, culturally informed training, gancheros may enhance the harm reduction components of their occupation, promote HIV, HCV and harm reduction awareness, disseminate anti-syringe sharing and littering messages, and promote naloxone access and education. Present findings suggest that migrants may welcome such an initiative, paving the way for efficacy and sustainability.

Conclusion

Migrant Puerto Rican PWID in NYC occupy a vulnerable position. Along with the now decades-old NYC and State Departments of Health clearance for SSP activities, the institutions serving these migrants are responsible for the steep decline in HIV prevalence and incidence among PWID in NYC (Des Jarlais et al., 2005, 2011). These institutions are also responsible for saving countless lives from opioid overdose.

Yet, certain modifications to the existing service portfolio may help NYC bring HIV incidence among PWID even closer to zero, as well as reduce HCV infection and overdose rates. Strategies SSPs may pursue to more effectively address the disease and overdose risks of migrant Puerto Rican PWID include:

1. employ staff who not only speak Spanish fluently, but who are well versed and understand the drug argot used by migrants, which is native to PR;

2. target education to address the “air and water kill HIV” norm and the associated behavior of “water-rinsing and air-blowing;”

3. hire gancheros to distribute sterile syringes and other injection equipment and help reduce syringe littering, and document successes and barriers associated to working with gancheros as health promoters;

4. insure gancheros (and migrants in general) carry naloxone at all times. While migrants are at high risk of overdose due to their high frequency of injection and polydrug use, gancheros are particularly vulnerable. Generating a naloxone-centered collective consciousness is not only possible but could save many lives;

5. develop migrant-led educational and mutual support groups, and encourage formal organization among migrants (as recommended by Friedman et al., 2007);

6. have staff (in addition to gancheros) deliver syringe services at or near drug spots on a daily basis;

7. ask migrants to train agency staff on cultural logics, including power groups, bichotes, gancheros, and any other culturally specific material that could help staff improve services; and

8. continue advocating for safer injection facilities as another means to help reduce risk behavior, public injection, syringe littering and overdose.

Overall, these data suggest that migrant Puerto Rican PWID are in urgent need of disease and overdose prevention services that incorporate their past experiences with community organizing. As an organic member of the migrant community, gancheros could function as an important conduit for community health narratives and practices.

Glossary

Ay bendito

A common phrase used in PR to express either pity or frustration. The use of this word is not limited to people who use drugs

Bichote

Bichote stems from the term “bicho,” which in PR means penis. Bichote typically refers to a male who controls the drug trade in a specific neighborhood. It is associated with hypermasculinity and power

Caballo

Literally, “horse.” Yet, for PWID in PR and migrant Puerto Rican PWID in NYC it means to pool monies to buy drugs (typically, 2 PWID)

Caserío

Commonly used name for government-assisted housing in PR

Chota

A snitch. Someone who gives information to the police or correctional officers. A highly disrespected behavior among migrants

Corillo

A common term to refer to people who are closely networked. The use of this word is not limited to people who use drugs

Droga

Literally, “drug.” Yet, for PWID in PR and migrant Puerto Rican PWID in NYC it means heroin

El punto

A drug spot closely ran by a bichote, and usually located in poor communities across PR. While illicit drugs in PR can also be accessed in non-poor communities, the phrase “el punto” typically refers to those located in poor communities

Ganchero

The syringe man. A person with injection supplies who exchanges his vein-finding expertise for drugs or money. Gancheros are pervasive across shooting galleries and prisons in PR, and are also present and providing injection services in NYC

Gancho

Literally, “hook.” Yet, for PWID in PR and migrant Puerto Rican PWID in NYC it means syringe

La perse

Common phrase to refer to a usually drug-induced paranoid state of mind

Los 25

A prison-based power-group in PR

Ñetas

A prison-based power-group in PR. Known as the largest and most powerful of prison power groups in PR

Shooting

A shooting gallery. A venue controlled by bichotes where PWID in PR congregate to inject drugs

Author Biographies

Camila Gelpí-Acosta is a sociologist and the Principal Investigator of this study (NIDA R03DA041892), and an Associate Professor of Criminal Justice at LaGuardia Community College, CUNY. She is an affiliated investigator with the Center for Drug Use and HIV/HCV Research at the NYU College of Global Public Health. She cofounded and is Board Vice-President of El Punto en la Montaña, a syringe exchange program in her homeland, Puerto Rico.

Honoria Guarino is an anthropologist who specializes in mixed-methods research on drug use and HIV/HCV infection, with a particular focus on the influence of multi-level contextual factors on vulnerability and resilience. She has expertise in the development and evaluation of behavioral interventions, especially technology-based interventions, for a broad array of drug users in urban settings, as well as immigrant/migrant groups and people living with chronic pain.

Ellen Benoit is a sociologist who conducts qualitative and mixed-methods research on health inequality, particularly as it relates to HIV risk, mental health and substance use among Black and Latino sexual minority men. She is engaged in community-based participatory research in Newark, NJ, using critical consciousness theory to develop and test an intervention designed to reduce substance use among formerly incarcerated men.

Sherry Deren is a social psychologist and has been Principal Investigator of many NIDA-funded research projects related to HIV and drug use. One of her primary areas of study has been the HIV epidemic among Puerto Rican drug users. She was the founding director of the NIDA-funded Center for Drug Use and HIV Research, currently located at the NYU College of Global Public Health.

Alicia Rodríguez is a harm reduction advocate and service provider who has served as Research Assistant in multiple NIDA-funded studies with people who inject drugs.