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“A new and refreshing study. . . This is a powerful testament, and Garcia presents a vision of where we need to go when it comes to preventing the slow suicide of addictions.”
The Pastoral Clinic takes us on a penetrating journey into an iconic Western landscape—northern New Mexico's Española Valley, home to highest rate of heroin addiction and fatal overdoses in the United States. In a luminous narrative, Angela Garcia chronicles the lives of several Hispano addicts, introducing us to the intimate, physical, and institutional dependencies in which they are entangled. We discover how history pervades this region that has endured centuries of material and cultural dispossession, and we come to see its heroin problem as a contemporary expression of these conditions, as well as a manifestation of the human desire to be released from them. Lyrically evoking the Española Valley and its residents through conversations, encounters, and recollections, The Pastoral Clinic is at once a devastating portrait of addiction, a rich ethnography of place, and an eloquent call for a new ethics of care.
PAST AS PROLOGUE
The heroin detoxification clinic lies at the end of a typical road in the Española Valley. Little more than a path, the road is unpaved, deeply rutted, and strewn with shards of broken glass. Pack dogs roam along it and are prepared to chase—for a few moments at least—the occasional passing car or three-wheeled ATV. Crumbling adobe houses line the road, abandoned for newer trailer homes. The adobes and the trailers sit adjacent to one another, marking a transition between generations. Both are set on small plots of land once used for cultivating squash, chile, and corn. Like the adobe, artifacts of a prior agricultural life remain: there is the ubiquitous tractor, broken down and stripped of its tires; the empty storage shed, once brimming with apples. Both appear to be sinking into the land from the force of years, sun, and neglect.
The road to the clinic is like any other. Except for a small handpainted sign that reads "Nuevo Día," there is no obvious indication of institutional presence or, for that matter, of heroin.
* * *
The clinic spans several buildings. First, there is the cluster of small adobe houses, whose curved, earth-colored walls closely resemble the traditional architecture of the region. These surround a much larger, central building, whose gray-painted exterior and crisp lines suggest an institutional aesthetic. Like the adobe and the trailer, the juxtaposition of the clinic's structures suggests a transition from tradition to modernity, intimacy to order. During the early stage of its operation, the detox program was fully located in one of the adobe houses and was affectionately referred to as "la casita," the little house. However, as the program expanded to accommodate an increased patient load, it was moved into the larger building, and the term la casita fell out of use.
In the past the clinic was a state-run residence for mentally ill adolescents named Juniper Hills. Its patients were primarily from the Española Valley, and they suffered a range of afflictions—bipolar disorder, depression and schizophrenia, physical and learning disabilities, substance abuse. Many had a history of physical or sexual abuse, and some had had run-ins with the law. Despite its idyllic name, Juniper Hills led a troubled existence. It was underfunded, short-staffed, and overcrowded. The structure displayed scars wrought by its previous inhabitants: fist-sized holes in plaster walls, obscenities etched into windowsills. By the time I arrived, it was hard to tell to which institutional generation the scars belonged.
According to a former patient attendant at Juniper Hills, the sheriff's department was frequently called in to settle fights, or to take away the most unruly or the suicidal. Most of the kids would return after a few nights in juvenile detention, or "5150," the code for involuntary psychiatric evaluation. The sickest patients, the attendant said, "stayed inside like chickens," pecking at themselves and at each other, while the healthier patients sought refuge outside, spending long hours wandering the facility's expansive grounds.
The attendant was eighteen years old when he worked at Juniper Hills—the same age as many of its patients, some of whom he'd known since grade school. During his period of employment, he said he felt that he was "going crazy" himself, a feeling he attributed to the institution's unsettling environment. He recalled the lure of the Rio Grande, on the western boundary of the facility. Patients often escaped to the river like stowaways, wandering upstream or down. Most of them would return within a few hours; they had nowhere else to go. Usually, they would set off again, until a tall chain-link fence topped with barbed wire was erected along the perimeter of the grounds.
It is said that a young girl diagnosed with schizophrenia set fire to one of the Juniper Hills buildings. According to the stories, she died in the fire and the facility closed. Numerous people recounted the story to me in similar order and detail, which went something like this:
The girl was depressed, crazy. One night she locked herself into a room and started lighting matches. Her clothes caught fire and so did the room. But the girl didn't make a sound. She stayed quiet, even while she burned. Clearly, the girl just wanted to die, you know what I mean? Eventually, the other patients smelled the smoke, but by then it was too late ... no, I don't remember her name.
I consulted police reports and newspaper archives looking for "evidence" of the story. There was only the building itself; its walls were still scorched from the long-extinguished flames. For months, I visited the building as if I were visiting the grave of an estranged friend. Staring at its blackened walls, I imagined that the fire was still raging, that the girl inside was burning, and that the flames she started had spread to me.
Over time I began to understand the story of the girl who immolated herself as an allegory for the precariousness of Hispano life and as a means to situate the multiple and overwhelming wounds of past and present. Flowing through locals' recounting of the fire were sentiments of sorrow, helplessness, and rage. The story of the girl seemed to enable locals to talk about their deep ambivalence toward the very presence of the institution along the Rio Grande and their collective failure to have cared for such a girl, whatever her name may have been, or will ever be. Like the Mexican folktale of La Llorona, the Weeping Woman, the story's continued circulation seemed to insist that we must all be more careful next time—that we must listen more closely for the girl's silent cry.
After its closure Juniper Hills was again transformed, this time into a picadero, or shooting gallery. Several addicts described it to me as a perfect setting for heroin binges. Parts of the facility were relatively intact, providing shelter from sun, rain, or snow. There were beds, forgotten medical supplies, and bathroom mirrors, the latter of which enabled addicts to inject heroin into areas of the body that were otherwise impossible to see. Juniper Hills remained a popular picadero even after the rodents, mold, and asbestos set in. Eventually, county officials considered condemning the building, but a 1999 special congressional hearing on the region's heroin problem identified it as a potential site for a much-needed drug treatment center.
Five years later Nuevo Día's detoxification clinic opened its doors.
* * *
The opening of the clinic was celebrated with much fanfare. Musicians performed traditional rancheras as journalists and state politicians toured the facility, carrying with them paper plates heavy with tamales. County representatives spoke movingly about the opportunity to stem the endless tide of heroin overdose, and many recounted their own struggles with alcohol and drug addiction. A prayer for healing was murmured. With the cutting of the yellow ribbon, the troubled memory of Juniper Hills was laid to rest and Nuevo Día was born.
The year Nuevo Día opened there were forty fatal heroin overdoses in the Española Valley, testament, in part, to the inadequacy of addiction services in the region. At the time those services included two residential recovery programs with a length of stay ranging from two years to less than thirty days, several outpatient programs that rely on Twelve Step Fellowship principles, and a harm reduction program specializing in needle exchange and methadone maintenance. At one point there was one residential alcohol detoxification facility in the valley. The center experienced several temporary closures between 2003 and 2006. It was closed permanently in 2007 as a result of conditions that placed the health and safety of patients at risk.
Despite the many psychological and emotional issues that are often broached in the context of drug addiction, mental health was not an integral component of these programs. Nor were educational or vocational rehabilitation services. Also lacking were detoxification facilities explicitly for drug addicts; heroin addicts were referred to facilities in other parts of the state, many of which had waiting lists ranging from three to six months. Significantly, these referrals were court ordered—that is, they were made in the context of an addict's legal troubles, most often stemming from a drug-related offense. In many instances prospective "patients" were forced to remain incarcerated for a longer time than necessary in order to facilitate their entry into a residential recovery program.
Given such dire circumstances, the opening of Nuevo Día's detoxification clinic was significant on both practical and symbolic registers. It was the first detox facility in the region specifically for drug addicts that focused on heroin addiction. It was also the first to promote and use a medical model for detoxification by offering anti-opioid medications and what it considered a "clinical setting." The clinic's "modern sensibility" signified certain cultural, economic, and medical advancements that were celebrated in a historically impoverished and drug-weary region. Behavioral health workers and locals in general embraced these developments as a major step forward. The wound of Juniper Hills finally seemed healed.
The timing of the clinic's opening was fortuitous. I had just returned to New Mexico to begin ethnographic fieldwork on the region's epidemic of heroin addiction and felt lucky to be among the first people hired to work as a detox attendant. My shift was the "graveyard"—six o'clock in the evening to seven o'clock in the morning—and I hoped that by working at the clinic I would be afforded an "insider" view of the intimacies of addiction, recovery, and institutional life. I wanted to gain a deeper understanding of the acute physical and psychic aspects of heroin addiction and recovery, especially as they are experienced in an institutional setting. Given how deeply entrenched heroin had become in the valley, I wondered if the workings of institutional life reflected or differed from the world "outside." Could the clinic provide enough of a counterpoint to the pressures of addiction and everyday hardship to enable addicts to begin the process of recovery? What might such a process look like? Or was the very idea of an alternative to the harsh realities of addiction naive, even counterproductive?
The night before my first shift a heroin addict named James advised me that I should quit before I even started, that "detox attendant" wasn't the kind of job that afforded the luxury of time to "think," which is how he understood my role as an anthropologist. I met James at a Narcotics Anonymous meeting. He was a "veterano," or longtime heroin user, a respected status that implied he'd witnessed and experienced the harsh realities that accompany addicted life. Over the course of my research, I often turned to James for advice with my project. He was a practical and protective man and discouraged me from working the graveyard shift. What are you going to do, James asked, when an addict from the village of Chimayó gets in a fight with another addict from the village of Hernández? Or, what are you going to do when you're the only "authority" in the middle of the night, and someone breaks into the clinic in a desperate attempt to deliver a heroin-filled syringe to a detoxing lover? Or, what are you going to do when someone jimmies the lock to the medicine cabinet, swallows a bunch of pills, and starts convulsing? The scenarios James offered (which were, he said, based on years of "experience") were endless, and with each he warned: There's no time to think, Angela. What are you going to do?
It turns out that James was both right and wrong. He was right that urgent situations arose requiring immediate and unconsidered responses. But these situations, and how I responded to them, would form the basis of my thought. In what follows I sketch the first emergency that I encountered, one that James did not anticipate but that nevertheless offers an entry for considering the structures and fractures of clinic life.
There was no indication of turbulence that afternoon. At home, the cottonwood leaves shivered in the breeze and the dogs lay belly-up in the sun. Reluctantly, I drew the shades to shut out the bright June light. Dr. Bustos, the clinic's medical director, had suggested a midday nap to store up energy for the long night ahead, but my body was unaccustomed to these new hours, and I found it impossible to sleep.
I arrived at the drug detox clinic at 5:30—just as Maria, the day-shift attendant, put away the evening meal. She offered me a bowl of pinto beans and warmed a tortilla. The beds were full, she said. There were four women and six men, eight heroin addicts and two alcoholics. As she washed dishes, Maria reported that nothing unusual had happened on her shift and that the patients had retired to their rooms.
I signed into the Daily Log—a wide-ruled spiral notebook that detailed the events of the day. It was my first shift, and I didn't know what I was supposed to write, so I flipped through previous entries for clues. Copying the language of earlier entries, I wrote, "June 9, 2004. 5:45 p.m. A.G. assumes shift from M.G.M.G. says there is nothing unusual to report. Patients resting. Facilities secure."
Maria led me into the nurse's station—although at the time and during much of my employment there was no nurse, only minimally trained detox attendants such as myself. We reviewed the medication schedule. Two tablets of the muscle relaxant Robaxin and four tablets of Vistaril, a medication for panic disorder, were to be given at midnight and 6:00 a.m. Residents in Dorm One were to receive fifty milligrams of the sedative Librium at 10:00 p.m., followed by doses at 2:00 and 6:00 a.m. Five patients were to receive three milligrams of the antipsychotic medication Haldol at 9:00 p.m. and 6:00 a.m., and all patients were to be given their respective SSRIs, prescribed for the treatment of depression, anxiety, or both.
Maria showed me a corresponding graph of the medication schedule. Patients' names and ages were in one column, and in another, medication, dosage, and dosing hours. Some indications were notated in milligrams, others descriptively—by the color and shape of pills. The graph was incomprehensible and sent me into a panic. What if I incorrectly dosed patients? Maria told me not to worry, that the patients knew exactly what they needed; they were experts in their own treatment.
"Just don't let them fool you," she said.
* * *
The night attendant's station was an L-shaped desk located where two hallways met—one led to the men's dormitory, the other to the women's. Beneath harsh fluorescent lights, the hallways glowed like highway tunnels. I instinctively felt the need to shield my eyes when I walked to and from the rooms.
The hallway lights washed over the attendant's desk, where I was to remain throughout the night, monitoring the patients and recording events in the Daily Log. During my orientation, I was warned that sleeping was grounds for termination. I wondered how an attendant could possibly sleep with the shock of those lights, especially after hearing the famous "graveyard stories" and their gruesome details: patients jumping out of dormitory windows; rival gang members stabbing each other in bed; desperate addicts overdosing on stolen bottles of rubbing alcohol. I wasn't worried about falling asleep.
Within seconds of Maria's departure, closed doors opened, and patients emerged from their rooms. From my station I watched men and women shuffle down the hallway in slippered feet. They moved toward me unsteadily and met my greetings with silence or high-pitched requests for "algo," "something"—something to take the pain out of legs, arms, and backs contorted by the absence of a fix. Even before introductions were made, I could tell the heroin addicts from the alcoholics by the way clothes hung from bodies. My initial assessments were confirmed on closer inspection—by the fresh track marks and swollen abscesses on arms, hands, ankles, and necks.
For the next three hours I deflected growing demands for something by filling bowls with vanilla ice cream and permitting the use of a boom box. Soon, the sounds of Tejano and hip-hop music filled the clinic. Though the volume was turned up high, the music inspired no movement, no recognition. The patients sat motionless on tattered couches, their eyes fixed on a clock hanging high on the wall. At one point a young addict named Yvette said that she felt like we were stuck on a deserted island. Together, we waited for the dosing hour like the arrival of a rescue plane.
Excerpted from The Pastoral Clinic by Angela Garcia. Copyright © 2010 Angela Garcia. Excerpted by permission of UNIVERSITY OF CALIFORNIA PRESS.
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List of Illustrations Acknowledgments
Introduction: American Pastoral
2. The Elegiac Addict
3. Blood Relative
4. Suicide as a Form of Life
5. Experiments with Care
Conclusion: A New Season
Notes Bibliography Index