The “4th wave of the overdose crisis” has arrived, tweeted Brett Giroir, a top official in the US Department of Health and Human Services, on August 15. He was referencing a surge in stimulant-involved overdose deaths, which in 2018 exceeded those involving prescription opioids, as the Centers for Disease Control and Prevention provisionally observed.
Asian Americans could be facing this fourth wave in unsuspected numbers—and they have far too often been invisible in harm reduction conversations.
While Black and multiracial people saw increases (and whites decreases) from 2017 to 2018 in stimulant “misuse” in the month prior to being surveyed, Asians experienced by far the most intense spike, leaping from 34 people to 110 per 100,000—a 220 percent increase, according to the 2018 National Survey on Drug Use and Health published on August 20. Additionally, this was the only racial demographic with an increase in both past-year and past-month cocaine use in this time period.
It’s unclear how many Asian Americans are among the provisional death toll reported by the CDC. If the overdose and overamping fatalities haven’t already hit this cross-section of the country, they could be on the way. Service programs have not prioritized or had the capacity to effectively serve Asian Americans and break down specific barriers to care—leaving these commmunities vulnerable.
“Falling Through the Cracks”
John, a Chinese American man whose name has been changed for his privacy, has seen “a lot of overdoses” within his immediate circle of fellow drug users, one of whom was “a young father who left behind his wife and daughter,” as recounted by Perla Romero, a harm reductionist in New York City.
John and his friends participate in the syringe service program operated by the Lower East Side Harm Reduction Center (LESHRC), wedged between wholesalers branded with both Chinese and English text on a street in lower Manhattan’s Chinatown.
His observation was “very alarming” to Romero, a harm reduction coordinator at LESHRC, given that the program also dispenses naloxone, the opioid overdose reversal medication.
In fact, she’s heard that clients like John, who primarily speak Cantonese, are not even aware of naloxone’s existence. This could in part be because they are unable to communicate with LESHRC staff.
“We don’t have the capacity to understand people so they can access higher services” beyond the anonymous, low-threshold syringe exchange, Romero told Filter. “How are they going to feel comfortable with telling us about their experiences if they can’t express themselves?”
LESHRC does not currently have any staff or peer workers who speak Cantonese or have close ties with Chinatown’s Cantonese communities. Over the past few years, they’ve had two peer workers who spoke the language, but both had short tenures for individual reasons. As yet, LESHRC has been unable to recruit a new one.
“People say that substance use is not an issue in the Asian community.”
LESHRC hasn’t allocated “agency-based funding for that demographic,” Noah Heau, a harm reductionist formerly employed by LESHRC who now works for the city’s health department, told Filter. He attributed this lack of prioritization partly to the relatively low number of fatal overdoses among Asian New Yorkers. Between 2013 and 2017, they consistently saw the fewest deaths, totaling 102 in this time period, according to unpublished health department data obtained by Filter. Black, white and Hispanic New Yorkers meanwhile all saw fatal overdoses in the thousands.
But Heau has known of cases similar to John’s: “I’m worried because people are still falling through the cracks.”
The Alliance for Positive Change, LESHRC’s parent organization, did not respond to Filter’s request for comment by publication time.
The storefront of the Lower East Side Harm Reduction Center in New York City’s Chinatown (Google Street View)
Despite insufficient resources, Romero has put in work to better connect with Asian Americans. After seeing the barriers faced by clients who primarily spoke Cantonese, she and her former colleague Heau sought to recruit a peer worker directly from the community. But that was easier said than done.
“Whenever I’ve encountered organizations that primarily serve Asians and Pacific Islanders (API), or even more specifically the Chinese community, I ask if anyone would be interested in volunteering for the peer worker position,” said Romero. She’s found that some organizations did have suitable candidates, but they were undocumented; LESHRC, she said, requires applicants to have a Social Security Number.
But Romero has also heard flat-out dismissals of the rationale for her request. “People are quick to respond: They say that substance use is not an issue in the Asian community.”
LESHRC is not the only provider in the area that serves API people who use drugs. Apicha, a community health center formerly known as the Asian and Pacific Islander Coalition on HIV/AIDS, dispenses naloxone and has “the capacity to do Narcan training in Cantonese or Mandarin,” said Romero. “Maybe it’s not being promoted.” The organization’s spokesperson declined Filter‘s request for comment.
Despite Apicha’s services, Heau said that some neighborhood residents don’t “enjoy using those facilities” because they feel too “clinical.” Unfortunately, he added, “there is no low-threshold radical syringe service program for API.”
And it shows in the numbers. Only 367, or 2 percent, of the city’s nearly 17,000 syringe service program participants were API in 2018. Other key services frequently offered by harm reduction centers are not reaching this population. From 2013 to 2015, Chinese (65.5 percent) and Korean (61 percent) New Yorkers were almost twice as likely to have never been tested for HIV as New Yorkers overall (37.4 percent).
Overlooking Asian Americans is not exclusive to harm reduction. The racist “model minority” myth pedals the idea that Asian Americans have “overcome their ‘cultural delinquencies,’ like drug use and sex work, in place of a hard-working, law-abiding, education- and family- focused lifestyle,” said Heau, who is himself Chinese and Native Hawaiian.
“Honestly, the harm reduction community is a microcosm for the world outside,” said Dr. Sheila Vakharia,* a Drug Policy Alliance researcher. “In the same way that Asian American issues aren’t clearly represented or articulated here, they aren’t that well in mainstream American society either.”
A Much-Needed Culture Shift
Harm reductionists are always limited by their resources. But even organizations that were originally designed for API folks still face barriers to connecting API clients—often grappling with deep-seated stigma and shame—with harm reduction services related to their drug use and HIV status.
The San Francisco Community Health Center (formerly known as API Wellness) is located in a city with a population that is more than a third Asian. It avoids some of the issues faced by LESHRC by having staff who speak Mandarin, Cantonese, Tagalog and Vietnamese on site during service hours. Staff can therefore communicate with their 5,000-plus API clients; but they sometimes face cultural barriers when speaking about stigmatized topics.
Participants of Joyluck Club, the Center’s program for HIV-positive API folks, “rarely talk about substance use”—even though “a lot of” the 40 or so members “are using drugs [particularly methamphetamine],” said Angelina Huynh, a medical case manager at the Center’s Tenderloin Area Center for Excellence (TACE).
“A lot of clients are still struggling to accept themselves as positive” and, potentially as a result, “are not accessing” TACE’s syringe exchange, Huynh told Filter. She suspects that they may be getting sterile needles and injection equipment from drop-in programs instead. Between 2014 and 2018, only one API client participated in the syringe exchange—even though 30 percent of TACE clients are of this demographic, according to data provided to Filter by the San Francisco Community Health Center.
The Center’s syringe service program requires participants to fill out an anonymous survey with demographic information. “I’ve seen a lot who have not wanted to complete that,” Huynh explained. “I think they are shameful so they are not accessing our needle exchange.”
And it’s not just syringes. Being disconnected from resources may have played a role in preventable overdose deaths. In spring 2018, a client of one of Huynh’s colleagues fatally overdosed from what she heard was methamphetamine cut with fentanyl.
This client—an HIV-positive, undocumented trans API woman and sex worker—had not been responding to the Center’s outreach attempts, and so “didn’t have access to fentanyl test strips and Narcan training,” said Huynh.
“The tricky thing about targeting harm reduction services (or any) for the API community is that our community is incredibly diverse.”
In addition to promoting harm reduction utilization amongst clients, Brian Ragas, the Center’s communications manager, believes that “a larger conversation about drug use is needed within the API community,” noting that this has mostly remained taboo in some API networks. Heau also explained that “there appears to be an internal lack of acknowledgement or dialogue around the prevalence of drug use.”
The API demographic category covers a huge range of cultures, all of which may experience different issues and barriers. “The tricky thing about targeting harm reduction services (or any) for the API community is that our community is incredibly diverse,” said Vakharia, who is Indian American. “Our API umbrella covers so many—including people who speak dozens of languages and dialects, hail from a diverse range of countries, represent different ethnic groups and communities, practice a variety of faiths, have different immigration/migration experiences, and are grappling with a variety of issues beyond substance use.”
Heau, who is Chinese and Native Hawaiian, said for example that he has experienced “Brown Polynesian drug use culture” to be “much different than mainland Asian American culture.” He described how the former is seemingly more open about drug use, which he attributes to experiences of “land seizure, forced displacement, genocide, destruction of the natural landscape, forced assimilation.”
Some Asian American people also have cultural norms that do not stigmatize drug use. Folks with heritage from Southeast and East Asia “who’ve been on the [Hawaiian] islands for a while may think of drug use more like Polynesians,” Heau suggested. This might in part be related to trauma incurred from working in exploitative conditions on sugar cane plantations, and the subsequent normalization of heroin and opium use “to mitigate the drudgery of hard labor.”
In the San Francisco area, Chinese-American and other youth of East Asian descent have identified club drug use, particularly ecstasy, as being normalized within their social scenes, according to a 2008 study published in the Journal of Ethnicity in Substance Abuse. “For these respondents, the two (Asians and ecstasy) go hand-in-hand,” observed the researchers, citing a typical description from one participant: “There were a lot of Asians. Everywhere, on the dance floor,” said a young Chinese-American woman, describing her impressions of her first rave. “It felt like everybody was on E.”
In contrast, though, the study found “near unanimity” amongst the 16 interviewed South Asian-American youth: Drug use was still highly stigmatized in their youth cultures.
Despite institutional and cultural obstacles, harm reductionists do find ways to build bridges. Perla Romero of LESHRC stands committed to serving Chinatown’s Cantonese-speaking community, despite the dearth of resources needed to effectively engage them.
“Even if it’s like smaller things: For Lunar New Year, we made sure to decorate the place. It makes people curious and look in. Before, people wouldn’t do that,” said Romero. “Regardless of this being a harm reduction center, we are here to help the community in any way we can.”
Harm reduction for everyone means having a complex understanding of how social and cultural nuances impact a common experience, drug use. But awareness of the unique conditions of API folks’ lives must be matched with the organizational will and commitment to hold them in the care of the harm reduction community—not letting them fall through the cracks.
*Dr. Vakharia is a member of the board of directors of The Influence Foundation, which operates Filter. Drug Policy has funded The Influence Foundation through a restricted grant to support a Drug War Journalism Diversity Fellowship.
Screenshot of an Asian & Pacific Islander Wellness Center archival photograph, via Youtube