The Unequal Financial Burden for Black Caregivers

Carlo St. Juste Jr. is on his way to bring his mother to a hospital appointment when he takes OZY’s call. A part-time acupuncturist and businessman, St. Juste is also the primary caregiver for his 69-year-old mom, who suffers from chronic kidney disease and diabetes.

“I’ve organized my time so I can do these things for her,” says St. Juste, 38. Before taking care of his mom, he did the same for his paternal grandmother, so he’s used to the commitment and balance that constant care for loved ones require. But that’s not to say it’s easy.

St. Juste, who was born in the United States to immigrant parents from Haiti, is one of an estimated 41 million caregivers in the U.S. who handle such commitments in addition to other duties, which often include full- or part-time jobs and other family responsibilities. In St. Juste’s case, that includes a young daughter.

African American caregivers are about four times as likely as White ones to spend more than a third of their income on care costs.

All caregivers could use more support for what is a fundamental but often invisible role. But the financial strain on African American caregivers is particularly acute when compared with their White counterparts. Generally, African American caregivers have lower household incomes than White caregivers, but spend similar amounts of money on caretaking, according to research by the AARP. Effectively, they face a greater financial “care burden.”

Some 57 percent of African American caregivers spend more than 34 percent of their annual income on costs associated with providing care, compared with 14 percent for White caregivers. This commitment extends to people’s time — 57 percent of African American caregivers meet the standard of “high burden” and spend on average 30 hours a week caring for their loved one.

The public depiction of the kind of attention that the sick or elderly need at home tends to be simplistic, but the duties that those caring for relatives and even friends face are complex. It’s not just about bathing and feeding — millions of caregivers have to perform tasks such as administering medication, tending to post-surgery wounds and helping rehabilitate patients after illnesses or operations. Although St. Juste is a qualified acupuncturist, which gives him a greater understanding of and empathy for those who need care, he says that it has been hard to find help with and advice on dealing with some of the challenges that he encounters caring for his mother.

There are socioeconomic factors that contribute to the disparities between caregivers from different ethnic groups, but cultural elements also explain why the strain caregiving places on African Americans is heavier, according to observers. 

“One of the things that we’ve learned is that in diverse communities what happens in the home stays in the home. There has not been a lot of external conversation about these challenges,” says Rita Choula, director of Caregiving Projects for the AARP Public Policy Institute and a former caregiver herself. She says that for African Americans there is an expectation that “we manage many things and we manage it on our own. Many African American caregivers in the past haven’t felt comfortable talking about this and what they’re carrying.”

Choula says that few would use the word “burden” — even though 1 in 3 African American caregivers are “sandwiched” (i.e., they’re caring for a child or grandchild as well as an elder). “We’re trying to shift that conversation to ‘You’re doing the best that you can and it’s OK to ask for help and here are some ways to ask for help,’” Choula says.

There have been significant movements in policy around the issue of caregiving in recent years. The Credit for Caring Act provides tax relief for caregivers, and the enactment last year of the Recognize, Assist, Include, Support and Engage (RAISE) Family Caregivers Act means that a family-focused caregiver support strategy is in sight. “It provides an opportunity for agencies in the federal government to take a closer look at the needs of family caregivers,” says Choula.

For caregivers like St. Juste, any help is welcome. Yet, he says, the experience of being a caregiver for years has changed him for the better.

“One thing I have learned from caregiving is that you start having empathy for other people and other caregivers in general. When you meet other caregivers you just want to tell them, ‘Hey, you got this!’” he says.

The UK Used to Be LGBTQ-Friendly. What Happened?

Melania Geymonat and her girlfriend, Chris Hannigan, got on a London bus and were attacked by a gang of four teenagers. Geymonat said the young men “started behaving like hooligans,” asking the couple to kiss, calling them “lesbians” and describing sexual positions. She ended up with a broken nose in the May attack, which was condemned by London’s mayor, Sadiq Khan, and the country’s then-prime minister, Theresa May, who both said that violence against the LGBTQ community would not be tolerated.

But the attack was a reflection of what observers say are increasingly homophobic tendencies in the United Kingdom.

Britain has dropped from the most LGBTQ-friendly country in Europe in 2014 to seventh this year.

That’s according to the Rainbow Europe rankings, which rate all 49 countries in Europe on human rights and policy for the LGBTQ community. The U.K. has dropped from a rating of 82 percent LGBTQ-friendly to just 66 percent in this year’s rankings.

The biggest storm to envelop Britain in recent years has been that of Brexit, as the nation prepares to leave the European Union. “The impact of Brexit is relevant because there is a whole debate going on about who should be in and who should be out. It’s uncomfortable, and minorities are feeling the brunt of that,” says Robert Berkeley of BlackOut UK, a nonprofit social enterprise run and owned by a volunteer collective of gay Black men.

Hate crimes are increasing in the U.K., according to Berkeley, against all protected minorities. Singer-songwriter Grace Petrie agrees, referencing the anti-trans protests that were very visible at the 2018 London gay pride march. A small group of women made their way to the front of the march, handing out literature about how transgender women aren’t “real” women. Media reports said they accused trans women of “raping” lesbians.

In the U.K., the Trans-Exclusionary Radical Feminism (TERF) movement places its anti-trans views in the context of a fear of “female erasure.” In the United States, the anti-trans movement is significantly more scattered. Observers say that in part this is due to a number of high-profile TERFs being given credibility and visibility in the U.K.’s mainstream media. In England and Wales in 2014, there were 607 hates crimes reported against transgender people. In 2018, there were 1,651, an increase of 171 percent.

London Trans Pride 2019

Activists take part in London’s first-ever trans pride march this year. (Photo by Guy Smallman/Getty Images)

Source Getty Images

Petrie believes that a schism within the U.K.’s LGBTQ community has contributed to a lessening in tolerance in general for those who identify as transgender.

“It’s been my view for a number of years that if we allow the demonization and marginalization of a part of our community to be tolerated within the queer community, then it’s a really short distance from debating the rights of trans people to the rights of lesbian, gay and bisexual people,” Petrie says. “That’s what’s happened in Britain.” Gay pride events this year were followed by protests outside some primary schools in Britain against teaching children about the existence of gay and queer people.

“These conversations about whether or not it’s OK for children to learn about the existence of queer people is something that is now being called into question,” says Petrie. “That has been massively allowed and exacerbated by the fact that people within the queer community were debating the rights of trans people — one thing follows the other. If we don’t have solidarity within the community, then it’s very easy for us all to be marginalized.”

And as the U.K. fell from grace in the Rainbow rankings there was another surprise shift: The tiny island state of Malta, a deeply Catholic and conservative nation, is now Europe’s No. 1 for LGBTQ rights — in 2014, it was No. 11.

Gabriella Calleja, who oversees LGBTQ rights for the Maltese government, says that several legal changes in recent years have helped improve the country’s ranking. In 2014, legal civil unions and adoption by same-sex couples were introduced; in 2016, the nation was the first in Europe to ban conversion therapy, which aims to change sexual orientation from homosexual or bisexual to heterosexual. Then, in 2017, lawmakers legalized same-sex marriage. 

All of those legislative changes helped shift attitudes, says Calleja. “I think the increased visibility and inclusion in political discourse of LGBTQ figures also helped transform the island — there is a general acceptance that wasn’t there a few years ago.”

Elaine, who preferred not to give her full name, lives in Malta with her girlfriend. “That’s not to say that there is no discrimination,” she says. “Those things take years, I assume, but in general, I can’t complain.”

Legal changes are often ahead of public opinion, and Malta is no exception — it’s still lacking legislation that softens its stance on other keystone issues for the left, such as abortion, which remains a crime in all circumstances. But for an island that only began allowing divorce in 2011, the advances and changes in laws and attitudes affecting the LGBTQ community are ahead of the curve.

OZY Investigation: America’s Opioid Crisis Heads South to Mexico

Julio Moreno is 31. He’s been using drugs since the age of 12. Living in the Mexican border city of Mexicali, he’s seen it all: heroin, cocaine, crack, meth, marijuana. But in September this year, Moreno tried something for the first time: fentanyl.

“It really knocked me out, but it’s better than heroin,” he told OZY on a recent Sunday morning at the local outreach center, Verter, where he goes to exchange his old syringes for new ones. Fentanyl is a synthetic opioid at least 50 times stronger than heroin and gives users a stronger high. The biggest cause of drug overdoses in the United States in 2019, fentanyl has now crossed the border into Mexico, where those who work with drug users are seeing overdoses spike.

Official figures in Mexico reported only six fentanyl overdoses in 2015. In 2017, they reported 37 — but that’s likely the tip of the iceberg. This week, Mexico President Andrés Manuel López Obrador (AMLO) announced that addiction is now a major focus for his administration due to the scale of the problem.

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Moreno, a longtime drug user, falls asleep after injecting himself with heroin and meth. He tried fentanyl for the first time last month. Said Slim, co-founder of the local outreach center Verter, later went to check on Moreno to make sure he hadn’t suffered an overdose.

Source Alejandro Cossío

“This is all you’re going to be hearing and seeing on the radio and on television and in the newspapers — only this for a while. And going forward … we are going to dedicate a day a week showing advances in our plan: why fentanyl is spreading, its effects, everything,” he said.

Ricardo Mejía Berdeja, Mexico’s deputy director of public security, said that growing consumption of the synthetic opioid is a new problem: “It’s mostly invading the North American market, but now it’s damaging our country too.”


A poster for the Mexico government’s current anti-drug use campaign reads: “Fentanyl kills – sometimes the first time you try it.”

Source Government of Mexico

An OZY investigation reveals that fentanyl is part of a two-pronged crisis that’s turning the country — traditionally known more as a route for drugs meant for the U.S. — into a bigger domestic market for narcotics than ever before. With American authorities under the Trump administration tightening border security and cracking down on the production of illicit drugs in their territory, Mexican cartels are increasingly flooding their homeland instead with fentanyl and methamphetamine, another synthetic drug.

“We’re going to get to the root of this, getting rid of the cancer of addiction, as a way of taking resources out of criminal organizations that get money and power from the local [drug] market,” said Mejía.

The number of Mexicans who reported having used drugs once in their lives nearly doubled between 2011 and 2016, from just over 5 percent to roughly 10 percent, according to a government survey. That explosion in drug use coincides with the highest homicide rates the country has seen in modern history, with an average of 90 murders every day.

The Mexican state is struggling to cope with the expansion in drug consumption and doesn’t have the infrastructure to provide the care that people need, its officials concede. That’s placing NGOs like Verter on the front lines of the battle to contain this growing epidemic. 

Overdoses start to spike at the border

A two-hour drive west from Verter in Mexicali, the local needle-exchange program Prevencasa confronts the same reality in the border town of Tijuana. Some 18 months ago, they started to see a new trend: a spike in overdoses that coincided with the arrival of a white powder “heroin” known as China White. But this isn’t the infamous China White — pure heroin from Southeast Asia — of the 1980s. It’s just another name for synthetic, black-market fentanyl, and Prevencasa has the tests to prove it.

“Today, they have taken the same label and applied it to fentanyl, since it is also white and most of it comes from China,” says Mike Vigil, who, as the former chief of international operations at the Drug Enforcement Administration (DEA), spent nearly two decades working in Mexico.

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Hugo Arroyo, 49, is a heroin and meth user who works at Prevencasa as a cleaner. He sleeps outside in a parked camper van.

Source Alejandro Cossío

“Fentanyl is now the majority of the ‘heroin’ consumed in Tijuana, based on what we’re seeing in Prevencasa,” says Joseph Friedman, an MD/Ph.D. student from the University of California, Los Angeles, who is doing research with the outreach program on heroin use in Tijuana.

“It’s faster-acting and has led to a big spike in overdoses, which are fatal if you don’t treat them,” Friedman notes. “There is a subjective difference that a lot of people report between what you experience with a black tar heroin as opposed to China White/fentanyl — a stronger initial come-on that goes down faster and provokes other weird sensations. Something is different.”

The United States is deporting some of its opioid crisis south of the border, says Friedman.

Friedman notes, “The U.S. opioid epidemic is a massive wave of suffering, and some percent of that wave is deportable — and the deported fraction ends up here and then what happens to them? A big fraction of the population became addicted in California and then got deported.”

Meanwhile, to push meth — known locally as cristal  — in the border cities, drug sellers have in recent years offered a bonus dose free with heroin, says 41-year-old Lourdes Angulo, who co-founded Verter in Mexicali. “That was to get them hooked, and that’s how the use of cristal started to increase here.” 

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A drug user leaves used syringes in a container inside Prevencasa facilities.

Source Alejandro Cossío

The scale of the crisis is visible to Dr. Clara Fleiz at Mexico’s National Institute of Psychiatry, who has been working with organizations such as Prevencasa and Verter to study causes for the rise in overdoses. A survey conducted by her team in the border cities of Tijuana, Mexicali, San Luis Río Colorado and Ciudad Juárez shows that overdoses from fentanyl are going “higher and higher every day,” she says. “Now, 25 percent [of drug users] have had one in the last year.”

That’s only going to get worse. As the U.S. doubles down on border security, getting drugs across the international line is getting harder and more complicated for criminal organizations. Seizures of fentanyl by U.S. Customs and Border Patrol (CBP) more than doubled between 2017 and 2018, from 181 to 388 pounds. Meth seizures by the CBP increased from 4,000 pounds in 2014 to 13,400 pounds already this year. In turn, homegrown markets are becoming more of a focus for crime groups, and the protection of local street sales is emerging as a parallel reason for homicides in Mexico.

“Sadly, we are prey to what the United States does,” says Jaime Arredondo, who researches drug and security policy in both the U.S. and Mexico.

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Lourdes Angulo and Said Slim, the founders of outreach center Verter, on a recent Sunday. The group runs a needle-exchange program and other services for drug users in the city of Mexicali on the U.S./Mexico border.

Source Alejandro Cossío

A 50-peso dose to get through the night

In the city of Irapuato, in the central state of Guanajuato, Luciano Salazar, 35, squints as he looks at his phone. He points to dozens of local users of the Grindr dating app who have put a diamond symbol in their profiles. “That shows that they either want to buy or sell cristal,” he explains. One baggie of meth costs just 50 pesos ($2.50).

Salazar is gay. He estimates that most of those he comes across in the gay community in the city of 600,000 people use cristal — including in ChemSex parties popular in the male gay population. He himself was an addict for two years. “I weighed 83 kilos when I started using cristal — by the end of my addiction, I weighed 53,” he says.

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Moreno has been using drugs since he was 12. Here, he prepares his combined dose of heroin and meth.

Source Alejandro Cossío

Cristal is today the most popular drug in Guanajuato, says Raul Espinosa, who works at Irapuato Vive, a nonprofit that assists drug users. Demand for treatment for meth use has grown more than seven-fold in the state, from fewer than 200 in 2013 to nearly 1,400 people seeking help in government clinics in 2018, according to official figures. More than two-thirds of addicts at the state’s treatment centers, known by their acronym CIJ in Spanish, are looking for treatment for meth use, and the CIJ is overwhelmed.

Irapuato Vive lies along an industrial corridor that runs through the state and also includes the cities of Celaya, Silao, Salamanca and Leon. Observers say that the long shifts people need to work at car assembly lines and factories or while trucking long distances also encourage meth use — it helps them keep feeling alert and keeps fatigue at bay. The car industry in Guanajuato — including factories for General Motors, Pirelli, Volkswagen and Ford — accounts for 18 percent of the state economy, according to Sophia Huett, Guanajuato’s chief of public security. “One 50-peso dose gets [truck drivers] through the night or all the way to Monterrey,” says Espinosa.

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Intravenous drug users in the north of Tijuana’s center prepare their doses. Outreach workers have begun handing out Naloxone spray to reverse the increasing amount of overdoses they’re seeing in this community, likely caused by fentanyl.

Source Alejandro Cossío

That pattern is also evident in Tijuana, which is littered with factories known as maquilas that produce everything from cars and electronic home appliances to laptops and mobile phones. “I could concentrate more and think faster when I first started using cristal at work,” says German Navarro, 49, a recovering addict in Tijuana. When he was using meth a few years ago, he worked as a dispatcher in the border city, organizing drivers who would truck goods into the U.S. A strong stimulant, meth improved his performance on the job and allowed him to stay alert and awake for longer.

But the rise in meth use isn’t isolated to a few cities. Multiple Mexican states have seen a sharp increase in its use. Demand in five states — Guanajuato, Jalisco, Michoacán, Sonora and Sinaloa — more than doubled between 2008 and 2016, according to government figures. Colima saw an eight-fold increase in people reporting use over this period. And most experts interviewed by OZY think government surveys underestimate the scale of the problem.

Homicide rates spiral near tourist hot spots

Meth addiction is more than just a medical issue. The rising levels of meth use also correlate with more homicides. The state of Guanajuato is home to the popular tourist destinations of San Miguel de Allende and the city of Guanajuato, and had never been a homicide hot spot before 2017. But for the past two years, it has witnessed the highest rate of killings in the country. There were 2,609 in 2018, according to the Public System for National Security, and the homicide rate was 57 per 100,000 compared to a national average of 29. This year is on track to be just as bad — 1,790 murders in the first eight months. 

“The murder rates that we’re seeing are scandalous,” the state’s prosecutor Carlos Zamarripa Aguirre tells OZY.

Guanajuato isn’t alone. Where meth use has grown most noticeably, homicides are at brutal levels. Colima’s homicide rate currently stands at 103 per 100,000 — in 2015, it was 19.2. In the southern state of Michoacán, homicide rates have doubled in recent years, from just over 25 per 100,000 in 2015 to nearly 55 this year. 


Neighbors gather around the crime scene after a man was murdered at a grocery store in eastern Tijuana.


Over the last decade, territorial disputes between cartels over routes into America were the motive for such killings. 

“Slum and urban violence amongst youths tend to be related to retail sales, whereas violence out in the mountains are more high-level hits by the cartels, major confrontations between organizations and disputes over export routes,” says Jaime Lopez, a former Mexican law enforcement official who is now a security analyst.

Photos provided by Zamarripa’s office show packets of meth and marijuana clearly marked with branding of the New Generation Jalisco Cartel (CJNG), one of the country’s most notorious crime syndicates along with the Sinaloa cartel that Joaquín “El Chapo” Guzmán used to share control of. In August last year, the Mexican military recovered 50 tons of meth in a mountain lab in Sinaloa. Mexican authorities have also seized fentanyl in states such as Michoacán, Jalisco and Sinaloa, and in the last 12 months have found four clandestine laboratories around the country.

Espinosa and drug users at the Irapuato Vive center say that many homicides involve low-level dealers and addicts who are punished by their dealers for buying meth from rival suppliers. 

“The biggest challenge to public security is drug consumption,” says Huett. But neither her state government nor the federal administration appears prepared to tackle the crisis.

A crisis of America’s making

Gady Zabicky knows that he has a problem on his hands. The new head of Mexico’s addiction treatment agency — known by its acronym CONADIC — is worried not only by the growing use of meth and fentanyl, but also by the falling age of users and the growing number of women getting hooked, according to recent government surveys. “This is a red flag,” says Zabicky. 

In many ways, the arrival of fentanyl use in Mexico is of America’s making and a consequence of the opioid crisis currently rocking the U.S., where for years unfettered pharmaceutical companies marketed highly addictive opioid painkillers to medical professionals and patients. Patients got addicted, and when their insurance or prescriptions ran out, they turned to street-market Mexican heroin to feed their habits. Some of that heroin contained fentanyl to make it stronger, although drug users weren’t necessarily aware of that because these were illegal drugs. 

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A drug user leaves his used syringes for new ones at the Prevencasa facilities in Tijuana.

Source Alejandro Cossío

Once addicts discovered they were taking fentanyl and that it was a stronger opioid than heroin, some of them left heroin behind altogether. The fentanyl industry that grew out of that demand — the drug goes into the U.S. direct from China in the postal system as well as via the border produced by Mexican cartels — has found a new market.

“Because of our insatiable demand for all kinds of drugs, other countries such as Mexico supply them,” says Vigil, the former DEA agent. “And they also supply users in their own country. Source countries eventually create addiction, drug overdose deaths and devastated communities. Mexico is no exception.” 

But whatever the origins of the crisis, Zabicky admits that the current Mexican administration simply doesn’t have the network to cope. There are state clinics across the country that mostly provide free treatment; 104 CIJ centers and another program known as CAPA, which has some 341 units around the country. They’re not enough, and those drug users left out depend upon thousands of private drug treatment centers, the majority of which aren’t regulated.

A minority of them can provide the tools people need to get off drugs, but others known as annexos are notorious for imprisoning addicts and abusing their human rights with the aim of curing their habits — which is illegal but tolerated. Zabicky says that there are some 2,200 around the country, but there are likely many more. In the city of Irapuato alone, users say there are more than 50 private clinics. “The majority of them don’t comply with government norms,” admits Zabicky, but the government can’t close them down because there isn’t enough state help to go around. “The system would collapse.”

Instead, Zabicky plans to bring all the private drug clinics operating around Mexico onto the government’s radar in order to better train their staff and establish basic norms. But his approach contrasts with that of the government he serves. 

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Used doses of Naloxone at outreach center Prevencasa. The organization has been handing them out to drug users to reverse spiking overdose rates the organization thinks were caused by fentanyl.

Source Alejandro Cossío

Although observers welcome President AMLO’s renewed focus on addiction, many worry about the tone and approach. The government’s current anti-drug-use campaigns warn users that fentanyl kills — even the first time it’s used.

“I think these kinds of campaigns produce more fear instead of educating people about substance use, which generates negative consequences. These scare tactics don’t contribute to a more elevated conversation about drug policy,” says Arredondo, the drugs policy researcher.

And despite AMLO’s publicized push against addiction, federal government money to private organizations such as Prevencasa and Verter in the border cities of Tijuana and Mexicali was cut off at the beginning of the year when he entered office. The cuts were part of the president’s fight against corruption. 

Fleiz at Mexico’s National Institute of Psychiatry says that while it’s important to filter out corrupt organizations, all groups shouldn’t be painted with the same brush. “I’m in complete disagreement with these budget cuts,” she says. “The people that have been really hard hit are drug users, as there are less resources to help them.” 

New solutions for old problems?

Apart from its media campaign, part of the government’s efforts to address addiction are legislative. A bill for decriminalizing marijuana use and cultivation is currently being debated in the country’s senate. It’s not clear if and when the bill will pass, and there are doubts as to how effective it could be.

On the border, activists are taking a more vanguard approach than AMLO. Nancy Sanchez, 43, visited the Verter center in Mexicali early on a recent Sunday afternoon to exchange her dirty needles for clean ones. She then went into the back room and tied a blue tourniquet around her tiny arm before shooting up heroin, as Angulo watched her. This tiny space is the first of its kind in the entire region — embracing the principle of harm reduction for drug users, rather than criminalization. 

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Nancy Sanchez is a sex worker and drug user in Mexicali. She injects herself at Verter’s safe space in Mexicali.

Source Alejandro Cossío

Angulo and her colleagues are trying to get vulnerable women like Sanchez to slowly embrace other services they offer such as HIV tests, counseling services and health education. “We have had to adapt. Here, women can stay as long as they want or need — and our adviser has to be with them here all the time,” says Angulo. 

Such an approach could be a welcome change in Latin America, where laws and policies generally stigmatize users of hard drugs like Sanchez and Moreno. When the Verter safe room opened in September last year, it caused a scandal — betraying the conservatism of large slices of Mexican society. A national newspaper called it a legal picadero — slang for places where addicts consume drugs — and an embarrassed local government shut it down. After a dogged bureaucratic effort by Angulo and her co-founder, the room is operating in a bureaucratic gray zone, registered as a business when it’s a nonprofit. “It’s better to ask for forgiveness than permission,” says Angulo, shrugging. She doesn’t know how much longer the room will remain open.

For users like Moreno, the government’s focus on addiction is too little, too late, but it is early days for other users. In the United States, the government failed to realize what was happening until the situation was critical. Mexico’s authorities won’t be able to use that excuse if fentanyl addiction here reaches the same levels.