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Epidemic in the Borderland

Dr. Thomas Patterson Is Pioneering Hiv Prevention in Tijuana’s Most Dangerous Districts—and the Results Are Staggering.
DISCUSSED
Palou’s Rock, Marketing by Socialist Revolutionaries, Sparrow-Song Dialects, The Birth of a Standard of Care, Cartel Ranches, Hit Doctors, La Mallila, A Bespoke Jacket, The Same Old Shit, The Blessing of the Tijuana Bar Owners’ Association, Professional Empathy

Epidemic in the Borderland

Dan Werb
19 Snaps

On August 19, 1773, roughly three years before America declared its independence from Britain, a Franciscan friar named Francisco Palou erected a cross on a rock near Tijuana, Mexico, to mark the division of power between the Reverend Franciscan Fathers of Alta California and their rivals to the south, the Dominicans of Baja California. Despite this division, both Californias remained the property of the King of Spain and then, in 1821, of the newly independent state of Mexico. Throughout this time, Tijuana remained a bubble district, the southern edge of an economically integrated urban area that was centered in the larger settlements to its north. In 1848, during the Mexican-American War, the United States conquered territory southward across California. The unassuming cross came to mark the site of an international border, and Tijuana was politically severed from the Spanish-speaking settlements to its north.

The Mexican central government did little in the following years to draw Tijuana in; in the era of postwar instability, Tijuana’s proximity to the United States likely made it look less like a reliable Mexican outpost and more like territory waiting to be overrun by American forces. Isolated from the rest of the country, Tijuana embarked on an economic renaissance built on alcohol, gambling, sex, and drugs. “There are more saloons in Tijuana than buildings,” wrote a correspondent for the Nation, in 1889. Even the Mexican Revolution, a bloody, decade-long civil war that began in 1910, was cannily marketed by the city’s socialist revolutionaries. American tourists were actually encouraged to come down to Tijuana to experience the war up close. Of course, soldiers charged twenty-five cents apiece to spectators wishing to view impending battles. And that was ten years before Prohibition would drive an influx of American investment in the numerous forms of illicit entertainment Tijuana had to offer. Tijuana’s mixture of danger and convenience became increasingly desirable, especially as America’s temperance movement gained steam. “Everything goes at Tia Juana,” wrote the American Board of Temperance, Prohibition, and Public Morals of the Methodist Church in 1920. “There are scores of gambling devices, long drinking bars, dance halls, hop joints, cribs for prostitutes, cock fights, dog fights, bullfights… The town is a mecca of prostitutes, booze sellers, gamblers and other American vermin.”

Tijuana has continued to be marked by its economic reliance on the United States and its remoteness from the rest of Mexico. Some of the city’s rougher areas abut the border fence, separated from the States by a terminally congested highway notorious in the area for fatal traffic accidents involving drug addicts fleeing police brutality. One such area, the Zona Norte, is the site of Tijuana’s quasi-legal red-light district, hosting the majority of the city’s estimated nine thousand sex workers. It has been in continuous operation for decades and is in some ways as mythic as Paris’s Place Pigalle. On my first trip to the city, a local medical doctor took me on a morning stroll through the Zona Norte. The streets were lined with female sex workers, and a chorus of hisses followed us as we walked. On subsequent visits, I noticed the heavy police presence, with squad cars often abruptly blocking intersections and police pickups loaded with drug users rumbling, presumably, toward city remand facilities.

You have to walk only three blocks to get from the Tijuana Arch (a rather underwhelming monument at the center of the city’s tourist district) to the red-light district: the heart of the city’s sex trade, the physical locus of cartel power, and the center of Tijuana’s HIV epidemic. There are believed to be ten thousand people who inject drugs in Tijuana. The epidemic diverges along gender lines: while 4 percent of men who inject are HIV positive, the proportion jumps to 10 percent among women. Thousands of people who inject drugs live in the Zona Norte as well as in El Bordo, an open-air section of the polluted Tijuana River canal that lies a few blocks away from the red-light district. Of course, the two populations at the highest risk of HIV—injectors and sex workers—aren’t just physically close but often overlap. Roughly 25 percent of sex workers in Tijuana also inject drugs, and they are the most at risk of HIV infection: at minimum 12 percent, and likely many more, are believed to be HIV positive.

Dr. Thomas Patterson, a scientist born and raised in San Diego, has been working in the region most of his life. Strapping and friendly, he comes across like a self-effacing Richard Branson, with the same impressive silver hair, fierce intelligence, and casual air of authority. This last is well earned: Patterson is one of the world’s premiere HIV experts, and for over a decade his focus has been on stopping the spread of HIV among sex workers along the United States–Mexico border. As a behavioral psychologist, Patterson has spent his career figuring out what motivates decision-making and how a person’s environment impacts the kinds of risky behaviors he or she engages in (such as having sex without a condom and sharing needles). Patterson has spent an enormous amount of time thinking about how power is negotiated in intimate moments, and how the threat of violence among vulnerable people propels diseases across a population.

In the 1980s and 1990s, many scientists working on HIV prevention were recruited after witnessing the ravages of the virus. Patterson’s wife, Dr. Steffanie Strathdee, the associate dean of Global Health Sciences at the University of California, San Diego, was one of those people. (Full disclosure: I work with her on a project exploring how police activity impacts HIV risk in Tijuana.) After both her best friend and her PhD supervisor passed away during the early years of the epidemic, working to end HIV seemed like Strathdee’s only plausible career path. Many physicians were also spurred to action after seeing hospital wards fill up with patients dying en masse. But originally Patterson was interested in animals: the significance of their movements and interactions, what their behaviors might say about their capacity for thinking and social organization. He sought out laboratories that could train him in methods to better understand their behavioral patterns; his first project, a job he took as an undergraduate to support his education, was testing the memories of gorillas, orangutans, and chimpanzees. While interesting, the staid laboratory setting didn’t have a lasting appeal: Patterson wanted to work in the field. So he moved on, eventually finding a scientific home at the University of California, Riverside, where, for the next seven years, he would study—and chase—white-crowned sparrows across San Francisco. The bird proved to be a valuable research subject, and Patterson made a name for himself by publishing his findings in leading scientific journals like Science. There is a beauty to his early studies, which contain visualizations of sparrow-song dialects across species in the San Francisco region, the images and graphs recalling Russian futurist paintings.

In practical terms, Patterson came away from these early studies with an expertise in using statistical techniques to analyze behavior. While he had carved out a sizable scientific niche of his own, the real world soon encroached on his work: the US recession of 1981 meant that science with a clear and cogent purpose became the priority for government grants, and money to support the study of animal behavior became scarce. Patterson, seeing the writing on the wall, found a job in San Diego researching how to prevent heart problems in families. He says that career shift started him thinking about ways not only to study behaviors but to try to change them. At the same time, he was working with the Department of Psychiatry at UCSD on how stress affects the immune system. And then, Patterson says, “HIV came on the scene.”

Patterson’s reputation as one of the United States’ best scientific methodologists meant that he was quickly recruited into the growing fight against HIV. He recalls, “[HIV] was a death sentence. Some people would get infected and they would die in three years; some people would go ten. You never knew what was going to happen. So the question was: does stress moderate that?” Patterson, like everyone else, was searching for solutions, and he became convinced that the only way to make a dent in the disease—barring a cure—was to start seeing people who had become infected as critical to the fight rather than as victims who had already succumbed. If you could change the behaviors of HIV-positive people so that they were less likely to infect others, Patterson hypothesized, you would be able to slow the epidemic.

That meant focusing the attention of scientists on those who already had HIV instead of on those who were at risk of acquiring the virus. When he presented his plan to his funders at the National Institutes of Health, they balked. “You have to remember that at that time people were afraid that they would get infected if they touched a doorknob that somebody had gone through. So it was this paranoia—there was a worry that if you identified these folks and focused on them, you’d have a real problem.” For Patterson, the fact that the government was bowing to the stigma meant that it was willing to sacrifice effectiveness to maintain the status quo. And, from a practical standpoint, it made no sense. “It’s crazy: if you focus on noninfected people you have the whole world to deal with.” After two years of battling the NIH, Patterson finally convinced it to focus its risk-reduction efforts on people who were already HIV positive. Now it’s the standard of care. Patterson was one of the first to make that happen.

For a time, Patterson was satisfied working in the United States, where there were more than enough issues related to HIV and human behavior to keep him occupied, not to mention generous research funding to support his career. But the disease’s toll was starting to be counted in more than just human lives. “It was a bit over a decade ago that the National Institutes of Health realized that HIV was destabilizing whole governments, particularly in Africa,” he recalls, talking to me from his sunny office at UCSD. “The military, the police, the aid structures—all were really being affected. And whereas before they viewed HIV as a problem for the US, they started to view it as something that could actually impact foreign relations and the ability of governments to govern themselves.”

The HIV epidemic soon stopped being the purview of public-health officials and became a matter of national security. “They were looking for senior people, and the quote that I was given was that ‘we want senior people who can’—I don’t know if the word was tolerate, but—‘who can deal with the complexities of international work.’” Patterson, at the apex of a distinguished career and with a successful track record designing interventions to reduce HIV infection risk, fit the bill. Nevertheless, he wasn’t prepared to upend his life completely and move to Africa. “Because we live on the border here in San Diego, Mexico seemed like a logical place,” he says. Tijuana, just twenty minutes from downtown San Diego, was the ultimate laboratory: close, convenient, and seething with public-health problems made worse by shifting regional economics. “I grew up in San Diego, and when I was a young person, you went to Tijuana to party,” recalls Patterson. “It’s a bar scene, and you go down there for cheap liquor. There was a lot of tolerance of all kinds of behavior.” Instead of the post-9/11 security perimeter that exists now, “the border was more or less open—there wasn’t the kind of fencing that we have now, the paranoia about undocumented aliens.” So when Patterson started making research trips to Tijuana in the early 2000s, he recalls “a very lively [scene], colorful, lots of street musicians, lots of people coming in on buses—in particular for the sex-work area, where we were focused. You would find a busload of Japanese tourists who would go to certain bars that would cater to tourists of that particular ethnicity. It was bustling day and night. And it felt very safe.”

Patterson didn’t count on the wave of violence that would soon be unleashed on Tijuana, but by then he was far too committed to back out. When he began his work there, in 2000, Mexico was on the precipice of a bloody war on drugs, and the Mexican military (with financial backing from the United States) was ramping up attacks on drug cartels across the country. But the cartels would soon strike back. In 2006, Tijuana erupted into violence, and the Zona Norte, as one of the city’s prime areas for selling drugs, was hit especially hard. Even so, the Zona Norte’s sex trade remained in operation, though it served a dwindling clientele. Unfortunately for the women who worked there, the loss of revenue and the dangers clients faced traveling to the district turned the sex trade into a buyers’ market. The little power that Tijuana’s sex workers had once had to negotiate safe sex crumbled; in turn, their risk of being infected by diseases like HIV skyrocketed. Prior to 2002, less than 1 percent of female sex workers in Tijuana were HIV positive; by 2006, as the drug war lurched into full swing, 6 percent were infected. The United States’ nightmare was coming true: a brutal civil war was taking place right next door, and an expanding HIV epidemic was about to destabilize its southern border.

Patterson would be the first to tell you that safety is relative to your social role, especially in Tijuana. American tourists spending dollars generally won’t come to much harm, as long as they don’t veer too far from the commercial strip along Avenido Revolución (“La Revo”) or the main sex clubs in the Zona Norte. But the women working in Tijuana’s sex trade have a different experience. Ana (whose name and identifying details have been changed, at her request), twenty-six, a large and delicate woman with the face of a young girl, was, like many of those working in the Zona Norte, recruited into the sex trade early. At the age of fourteen, she was taken into the care of a “mister”—a pimp—along with seven other girls. “It was a house that we rented. All the girls used to pay the rent but he was the one that handled us. We were all minors; we all used to work.” Heavily surveilled, Ana and the others were, essentially, prisoners. When not in the house, the mister would shuttle them to private parties, where they would mostly service narcos—cartel members. “They would take us to houses or ranches around Tecate, Ensenada, in a van,” says Ana. “They had so many guns and drugs… it was part of the job: if they wanted you to use drugs you had to.” In these remote places, the threat of sexual violence was implicit. “Basically, they would pay and you had to do whatever they wanted.” If the girls refused, Ana remembers, “we could get killed.” During this time, in the early 2000s, cartel ranches were a prime target. Ana describes some of these episodes as “pure violence,” with her and the other underage sex workers sometimes caught in the crossfire. “We were in a ranch in Ensenada, and they started to shoot each other and we were there with them… They killed some of the narcos and we left before the police got there.” In this climate of fear, negotiations around sexual services were left to Ana’s pimp, who would, crucially, decide whether she could use a condom or not (in practice, that meant rarely). Avoiding disease was further complicated by drug use. Ana recalls having pills put into her drinks by her cartel clients, and the night becoming a blur. “You wake up and you don’t even know what happened.”

Aside from narcos, Ana’s other regular clients were the police, who would check in every month with the mister at the small house in which she and the other girls were kept. “They knew what was going on there, that we were all underage,” she says. “It was like [the mister] would pay them with women.” With police collusion, Ana’s chances of escaping were nonexistent; the one time that two of the girls tried to leave, she recalls, they were savagely beaten.

Eventually, though, Ana was freed by a client who had taken a shine to her. She assumes money changed hands to secure her release, though she doesn’t really know. Still underage, she left the house to be with her new partner, and they were quickly married and had a son. Had everything gone according to plan, her career in the sex trade would have ended when she was still a teenager. But her husband was in the cartel, as evidenced by the piles of drugs and money that littered their home. “I felt safe with him,” she says, “but I was also scared because I would think, They are going to get me when they get him.” Her fatalism was well placed: after two years together, one day the police came to their door. “They came and took him outside, and I thought they were going to take him to jail, but maybe six blocks away they killed him.” Later, the word she uses is levantarlo, meaning her husband was “disappeared” by the police, an all-too-common cartel practice. Ana, for her part, has no doubt that while the police carried out her husband’s murder, it had been ordered by the cartel. With no other options, she soon returned to the sex trade.

Suzy, a tough-looking former drug user, has spent decades in the Zona Norte. She was never a sex worker, but she played a bit part in the red-light district as a “hit doctor”—someone highly skilled in injecting other people. Hit doctors are mainstays of injection-­drug scenes. After years of damage from injecting, veins can collapse; after arm veins are no longer viable, users then turn to injecting in places like the groin, between the toes, the armpits, or the jugular vein. In Tijuana, most people inject “black tar” heroin—a local form of the drug that is sticky and hard to break down, meaning the risk of vein damage is high. Injecting it into the neck or armpit isn’t an easy feat, so hit doctors do it for drug users, often for a fee or a cut of drugs. Collapsed veins aren’t the only reason people need hit doctors. Gendered power dynamics are often deeply entrenched in injecting scenes, and women are less likely to have been taught to inject themselves with drugs, making them dependent on others—often older men—to do it for them. Tijuana’s deep social imbalance means that hit doctors have steady work, and some of the research that Patterson’s been involved in has shown that people here who need help injecting are more likely to be women, more likely to be from far away, and more likely to share used needles—which makes them more likely to get HIV. (In Tijuana, about 60 percent of people who inject drugs report sharing needles, but the figure rises to 70 percent among those who need help injecting.)

At a Zona Norte taco stand, Suzy tells me her story in a barely comprehensible Tijuanensis slang. She had the kind of vulnerable life that Patterson describes in his research. “My friend Angie was a sex worker for nine years.” Suzy and Angie were friends and injecting partners, and they also worked together robbing Americans. “She called me ‘Aunt,’” Suzy recalls with a smile. When Suzy got tested in 2001 and discovered that she was HIV positive, none of her friends would take her seriously. She warned Angie, “but when I told her, she replied, ‘No, that’s not true, that doesn’t exist.’” Suzy pauses, shakes her head; it’s been thirteen years, but the memories clearly haven’t settled. Suzy had nowhere to go, and no other friends to turn to. “There was a lot of risk. Many times I wanted to leave but didn’t know how.” Methadone was practically nonexistent in Tijuana then, and there was no recourse for drug-­dependent people other than in-­patient treatment in dubious addiction centers. “We would try to break away by ourselves or with pills—roches, or Valiums, and so on… but that simply meant that one would get even higher because you wouldn’t stop taking them. It was self-deceit that you could quit on your own.” In the absence of treatment, Suzy continued to use. In the absence of clean needles, she continued to share.

“Nobody gave syringes away; I picked up syringes that had been thrown away, dirty. I washed them with water or I burned them with a lighter to make a syringe out of other syringes that I picked up. I would make my own syringes because they didn’t used to sell them. They would sell them to us, but in veterinary clinics, already used to inject chickens or little animals in the clinic. We would buy them for five pesos or two fifty.” Suzy puts her right arm on the table and runs her finger along a thick, discolored mass of scarring running from her wrist halfway to her elbow: the result of years of injecting with whatever instrument she could assemble.

Suzy was protective of Angie, whom she describes repeatedly as “a kid”; the two of them seem intimately connected, the intensity of their relationship no doubt amplified by the dangers of the Zona Norte. And what more intimate act than sharing drugs to help each other stave off la malilla—heroin withdrawal? “She would always change hotels; I always had to look for her. And then I would arrive and I would say, ‘Hey, don’t you have any R [heroin]? I have some chills [withdrawal pains]’… and Americans were always coming and people went into those rooms, so she would already have [injected]… but because I had the chills she would lend me the syringe and we would get high.”

HIV scientists sometimes refer to sex workers as a “hidden” population, meaning that their information isn’t easily captured by a census or government health survey, because they are often trying their best to avoid authorities of any kind—health officials included. The women of the Zona Norte are no different, but in Tijuana there is one population perhaps even more hidden than sex workers: their clients. Patterson was convinced that clients were the key to understanding the totality of the risks for HIV that women in the Zona Norte were facing. It was a counterintuitive focus, given that everybody—Patterson included—assumed that men who were coming to Tijuana to do drugs and pay for sex would have no interest in participating in a public-health study. But Patterson, ever the rigorous methodologist, was intent on connecting the dots between all the populations involved in spreading the HIV epidemic. “Obviously the clients are a big part of that equation when you’re studying sex workers,” he says. “And I thought, Let’s give it a shot, and it was really quite surprising, actually. These guys—many of them were really anxious—they lined up out the door to participate. And much to our surprise, they felt that they had been ignored, and they were hungry for information.” Part of the process was undergoing testing for HIV, and Patterson found that 4 percent of the clients (drawn from a sample of men from both Tijuana and San Diego) tested positive; those who reported crystal meth use were more likely to be positive. The clients, it turned out, constituted a significant reservoir of HIV. More troubling, they were a potential bridge to a generalized HIV epidemic beyond the population of sex workers in Tijuana: the clients had the potential to spread HIV to their wives and families in both Mexico and the United States.

The publications that Patterson produced from these studies, which include testimonials from clients, paint a complex portrait of HIV risk, sex, drugs, and despair. Many of the clients were deported from the United States, and their anxiety and isolation, juxtaposed against the clinical language of scientific writing, are palpable. “Loneliness… immense loneliness. That this city cannot fulfill,” said one client, recently deported back to Tijuana from the States. “The way we live our lives here in TJ, in this little area,” said another, “you live a fast life anyways. We are hustling to survive, so every day that you live is a risk… Having sex without a condom is part of that. If you don’t want to have risks in your life, you need to go somewhere else.” That expression of fatalism has another common manifestation: “Normally I try to keep safe, but if I’m drunk or high, I don’t care in the moment. Then later I think, What if the girl has an infection? Especially in this part of Tijuana…”

Salvador, a vendor of second-hand clothes in the Zona Norte, is one of the clients who took part in Patterson’s study. An amiable man probably in his late forties, Salvador describes paying for sex as a natural consequence of spending time in the neighborhood. “I sell things here, you know… so that’s how I get to know [sex workers]… They buy my things, they ask for money, I give them money, and that’s how we start having relations. Sometimes they don’t have money, and I can offer them a place to stay for two or three days and that’s how I interact with them.” Salvador first moved to the Zona Norte in 1991, and he has witnessed the contraction of the neighborhood’s fortunes and the ways in which drug use and desperation shape the risk of disease facing women in the sex trade. “If [women] are going to receive five hundred pesos and [clients] offer one thousand pesos without a condom, well, I think they take it. I think they shouldn’t do it, and the clients—I mean, sometimes they have families, you know? And even if you are a client with a woman that just went to the clinic, you never know, because they can get [HIV] at any moment.” As a crystal meth user, he also worries about the kinds of risks he faces sharing a pipe. “You don’t know if [the person you’re smoking with] is sick or if it’s you, and passing the pipe around can get the others in trouble… Imagine that this happened and that it would be my fault.” That lack of information about risks prompted him to join Patterson’s study. “I was really interested in [HIV risk], and also to be able to explain all this to my kids and also to be able to tell my friends, to have an opinion. Now I can explain to someone what this is all about, and it’s not only [about putting a condom on or taking something] to cure yourself… The point is to be careful… to avoid all these diseases, right? And then know what to do if you get it.”

The knot of intimate behaviors, gender roles, economies, and the imposing intangibles of the red-light district is at the heart of Tijuana’s HIV epidemic—and the focus of Patterson’s research here. The task was to first untangle it, and then find a way to rewrite the neighborhood’s power dynamics enough to allow sex workers to counter, even in the smallest of ways, the base economics that drive the district’s prosperity and place them at risk.

You need only to take a cab in Tijuana to understand the many intersecting roles people play here. The city’s taxi drivers are notorious for gently trying to steer fares toward the Zona Norte’s premiere sex clubs, like Hong Kong and Las Chavelas. Many of them will also happily connect you directly with polleros (literally “chicken dealers”), the guys who smuggle people north across the border. Sure, they likely get a cut from the club owners or the polleros for bringing customers over, but nobody along the chain would consider it corruption—it’s simply a way to connect people with what they want. The same patterns resonate across Mexico’s northern border region, according to Patterson. He relates the story of the time he found out that a doctor his team had hired to coordinate a study in a small eastern border town was also on retainer by the local cartel to care for gunshot wounds. This duality and these hidden identities appear like fractals across northern Mexico’s many social and political strata.

“It’s a local problem, one that everyone knows about,” agrees Victor Alaniz, the head statistician of the Tijuana police department and a veteran of the force for thirty-one years, fifteen of which were spent on the street. “When you live in a city where you have cousins, uncles, grandmothers, mothers-in-law, brothers-in-law… more than one is involved in something that is not good. When the police are friends with the thugs, when the thugs work within the police, that becomes very common, until it explodes.” The squat headquarters of the Tijuana police department have the look and feel of an upscale urban parking lot, with well-washed concrete walls and circular pillars. The day I go in to meet Alaniz and his colleague Contador Arnulfo Bañuelos, a senior police commander, I have to pass through various levels of security—polite, machine-gun-toting military police, a distracted security-desk clerk—all of which feel slightly sinister (a feeling, I’m sure, that most everyone gets when they are ushered into a foreign country’s security apparatus). Once inside the building, the mood is relaxed, casual, with officers standing and chatting at cubicles, offering me friendly nods and smiles as I walk by.

Bañuelos loads up a PowerPoint presentation and traces the computer screen with his fingers. His office is big and tidy, and on the wall hangs a thick-backed, laminated poster of Tijuana with fat red arrows drawn over it in marker and the names of some of the city’s delegaciones scrawled in an impatient hand—Playas, La Mesa, Centro, Otay. Both Alaniz and Bañuelos were on the ground when Tijuana’s cozy relationship with the cartels exploded. Bañuelos calls up a graph of violent crimes in Tijuana. The number rose dramatically after 2006, when Felipe Calderón, then the president of Mexico, launched a Mexican version of the war on drugs. Unlike the American equivalent, which targeted kids with anti-drug ads, drug addicts and dealers with jail time, and traffickers with counternarcotics operations, Mexico’s drug war had a major objective: to weaken the country’s cartels by military force. Nine years out, it is widely understood to have been a brutal and bloody failure, especially along its front lines in Mexico’s northern border cities like Tijuana and Ciudad Juárez, the epicenters of cartel power. But Bañuelos and Alaniz see things differently. When I politely interrupt Bañuelos’s presentation to ask him what Tijuana was like during the war on the cartels, he replies, “How was the city doing? In 2006, in Tijuana, kidnappings exceeded one hundred sixty. Now in a bad year it doesn’t reach thirty. For example, [2014] is going to be a bad year, and we are going to have around thirty or thirty-two kidnappings.”

Bañuelos returns to the PowerPoint, this time bringing up a slide of mug shots. “This is what you saw back then: organized crime, common crime, acting with impunity.” He flips to a new slide: rows upon rows of clean-cut faces. In the middle of the screen are press shots of men being led away in handcuffs by heavily armored police. I ask Bañuelos who the faces in the bottom row are. He pauses and looks at me. “The main commanders of this institution.” Beginning in 2000, the usual corruption of the Tijuana municipal police became twisted beyond recognition. “You used to watch the director as he brought ten people [into the academy] one day, and then the next day they would be in uniform and armed,” he says. Some—the faces he shows me—had even gained access to the police command structures. Bañuelos and Alaniz could only quietly bear witness as their department started to resemble a unit of mercenaries.

The infiltration of the department and the impunity of the corrupt recruits reached its peak during the 2004–07 mayoralty of Jorge Hank Rhon, Tijuana’s flamboyant casino magnate and a longtime shady political operator. “In Hank’s administration, that’s when the collision begins, cops killing cops,” says Alaniz. “Because they no longer were even cops… that is, the bad cops killed the good cops, yes?” But the violence was only the most visible manifestation of a change in the old order and of the eventual overreach of Tijuana’s corrupting influences. Even before the cartels went on their killing spree after 2006 (El Pozolero, “the soup-maker,” boasted to prosecutors that he had personally dissolved three hundred bodies in vats of acid), average Tijuanenses were beginning to question the corruption that had settled over the city. For decades, there had been only a few lonely voices challenging the status quo, most notably that of Zeta, a fierce and sensationalistic weekly magazine that made its bread and butter by publishing biographical information about gang members, sometimes even with photos—a huge risk given the climate of fear brought about by the Mexican cartels’ threats to journalists.

Zeta’s favorite target was Hank Rhon. Aside from his former tenure as mayor, Hank is the owner of Grupo Caliente, Mexico’s biggest sports-betting company, along with the Agua Caliente racetrack, a giant casino in Tijuana, and the Club Tijuana Xoloitzcuintles de Caliente, Tijuana’s football club. The Xoloitzcuintle, or Xolo, is a type of Mexican hairless dog, and after buying the team, Hank had a vest made out of Xolo skin—unsurprising for a man who boasted a menagerie of twenty thousand exotic animals and claims to have had a bespoke jacket made out of donkey penises. Since the 1980s, Hank has been dogged by allegations of criminal behavior. In 2009, confidential diplomatic cables from the US consulate in Tijuana stated, “Hank is widely believed to have been a corrupt mayor and to be still involved in narco-trafficking.” The cable, with the subject heading “Law Enforcement High Jinks in TJ,” was sent after an incident in which consular officials watched helplessly as a drug trafficker at the consulate evaded a planned capture by local police, and was instead taken away by bodyguards driving a black Crown Victoria, the usual vehicle for undercover enforcement operations. The local police gave chase, but refused to follow once the car entered the grounds of Hank’s racetrack. When asked why, they told consul officials that they simply “could not enter” Hank’s compound. And they had their reasons: in 1988, a Zeta cofounder, the journalist Héctor Félix Miranda, an unrelenting critic of Hank’s, was shot and killed while waiting in traffic on the way to work. Later, two security guards at the Agua Caliente racetrack, one of whom was Hank’s personal bodyguard, confessed to the killings; shortly thereafter, one of the guards recanted, saying that he had been tortured into a false confession. For over two decades after the murder, Zeta ran a full-page ad each week, personally addressed to Hank, demanding to know why Miranda was killed.

By 2006, two years into Hank’s mayoralty, the cartels had so deeply infiltrated Tijuana’s echelons of power that nobody quite knew how far their influence extended. So one of the first missions of the drug war for Bañuelos and Alaniz was to figure out who among the police could be trusted. To do this, the department was put under the command of a well-known civil-rights advocate named Alberto Capella, along with a hard-nosed military officer, Julián Leyzaola. While Capella had no police experience, he was one of the few civic leaders brave enough to organize rallies against the cartels. Leyzaola, for his part, had a reputation as a dispassionate and ruthless commander. By capturing high-­ranking cartel members and digging into their officers’ files, an idea emerged of how deeply their department had become infiltrated. “Before, policemen were bought. Now the bad guys are inside of the police force,” remembers Alaniz. “But it wasn’t an open war. It wasn’t public.”

It soon would be. In one day, in 2008, the Tijuana municipal police arrested twenty-one of their own officers for suspicion of involvement with local drug cartels, while another one hundred officers were fired. Later that year, five hundred more officers were sent back to the police academy for training and background checks—all in all, more than a quarter of the entire twenty-two-hundred-member force. It was an unprecedented move in Tijuana, where collusion with the cartels had reached such heights that it seemed impossible for the cycle of corruption to be broken.

The mission was hailed as a success. But the day that the arrests were announced on Mexican television, the Tijuana Cartel (at the time, one of the three major cartels controlling drug trafficking in Mexico) sent a simple message. Bañuelos remembers it well: “Kill every cop you run into.” By the end of that first night, seven police had been murdered. Over the next few weeks, forty-six officers would be killed by the cartel in retribution for the sting operation—more than double the number of corrupt cops that the police had arrested in the first place. Officers began hiding their faces behind balaclavas during press conferences; a high-ranking officer was shot dead as he slept, along with his wife and their eleven-year-old daughter.

Bañuelos claims that the deaths and dismissals were worth it, and that in the space of a few short years, the police were able to weaken Tijuana’s cartels, mostly by arresting senior leadership. But doing so meant pushing the city over the edge into what amounted to a civil war. Across Mexico, in the six years after the war on cartels was launched, observers estimate that more than one hundred thousand Mexicans were killed in drug-related violence, often in sadistic and increasingly gruesome ways as the years dragged on. (The situation got so bad that Mexico’s federal government stopped releasing statistics about drug-related homicides, a strange way of trying to make the problem disappear.) The pressure of the drug war pushed the Tijuana Cartel and Los Teos (another of the factions vying for control) into open battles with police, the Mexican military, and each other. Meanwhile, smaller factions and outside syndicates emerged, became aligned, and split apart again, violently. Corpses were hung from a bridge near Tijuana’s airport. A severed head was found under a bridge near the Zona Norte, the headless body later retrieved on a placid stretch of highway linking Tijuana to Ensenada, one hundred kilometers to the south. Bodies were used to deliver notes between cartels—some threatening violence, others exhorting rivals to avoid killing minors.

During the war, decapitations, hangings, and kidnappings fed the news cycle, but the murder of the women in the border areas barely caused a ripple of outrage. “Well, many got killed in those years,” Suzy says, shaking her head. “La Paloma, La Paniqueada, La Osa, La Lobita—those that were my friends… They would pick them up and many of them didn’t come back.” Who picked them up? “Well, the men would pick them up as if it was a job and then they wouldn’t come back…” Suzy’s close friend Angie, her partner in theft and needle sharing, was found dead along one of Tijuana’s highways—another victim of a bad date gone horribly wrong. In just the first two years of the Mexican war on drugs, 105 women were reported murdered in Baja California, many of them sex workers.

For women in the sex trade, working in a club is generally recognized as safer than taking chances on the street, given the kinds of risks they face once they are alone. But for those addicted to drugs, for whom making money can mean avoiding excruciating withdrawal pains, the options are often limited—as Suzy can attest to firsthand. “It is riskier for a sex worker who uses injectable drugs than for a sex worker who doesn’t. Men come here [to the sex clubs] and the women don’t go out with them. But women who are addicted, that’s another story… They just go, they get into the cars, just like that.”

Rosa, now in her fifties, has been working as a sex worker in the Zona Norte for twenty years. She is unsmiling, with jet-black hair; her words come quickly and she peppers her speech with hard-edged Tijuana street slang. She also describes the early 2000s as chaotic and steeped in violence—and she remembers who the perpetrators were. “I do feel it was more violent back then, because they would do whatever they wanted with you: they would threaten you, take you away to an isolated place—not only clients but also the police. They would take you and make you have sex with them or make you give them a blow job. Or when they took us to la veinte [jail] we would have to give a blow job to the judge so they would let us out.” For Rosa, the greatest danger from that time came from the police. “They would take us to isolated places and do whatever they wanted to us. The policemen were real assholes to us, and you could see that they were high.” Officers would regularly search the rooms of the Hotel Michoacán, where Rosa and other sex workers lived and worked. “Policemen would get there hooded and would take you out of the hotel room… One time I was able to hide in one room, but a policeman went to my friend’s room and raped her. That was really scary.” Asked if there’s less corruption now, Rosa is agnostic. “Maybe it’s the same chingadera [the same old shit] now, but it used to be more shameless.” The hardest edges of the violence, though, seem to have lessened. “Well, yes, [the cartel members] would arrive to the brothel with guns, and no one, not even the police, would do anything, and they would do whatever they wanted to us. I feel that has decreased a lot. Before, you used to hear shooting and see a lot of killings. You would see the violence everywhere.”

For Tom Patterson, the endgame was to design some kind of behavioral intervention that could help women in the sex trade—and especially those who inject drugs—avoid the HIV risks that they encountered every day. The first step, of course, was to recruit the women themselves. But when Patterson’s team started doing field outreach in the heavily surveilled Zona Norte, they were quickly stopped in their tracks. The Tijuana Bar Owners’ Association, which regulates business in the Zona Norte, was displeased by the unauthorized incursion into its territory.

It is difficult to write about the bar owners’ association without a vague sense of unease. On the one hand, despite its recent plunge, the Zona Norte’s red-light district is still one of the major economic engines of the city, along with Tijuana’s massive agglomeration of maquiladoras (manufacturing plants). On the other hand, the cozy relationship between the sex clubs, narcos, and the police in the Zona Norte makes it difficult to know where the line between legitimate business and illegal activity lies (as is true of so many of the power sources in the city). Police are everywhere in the red-light district, directly hired by the clubs for protection. According to Victor Alaniz, “it is not protection for illegal actions, obviously—it is precisely to give security, and then you control within the zone.” But the cartel presence in the Zona Norte is strong, too. While the level of coordination between the sex clubs and the drug cartels is unclear, it’s evident that the clubs, the cartels, and the police all benefit economically from the arrangement. Suzy, at least—having spent almost three decades here—is convinced that the cartels and the owners of the district’s major brothels are one and the same.

Patterson was well aware of the stakes as word came down that his field recruitment had been halted, and that the bar owners’ association wanted to meet with him. It wasn’t his first time setting up HIV prevention work along Mexico’s border, and he knew how critical having his work sanctioned could be: the husband of a research coordinator in Ciudad Juárez, who worked as a lawyer, was killed, point-blank, as he opened his front door, in apparent retaliation for defending some alleged cartel members facing jail time. So it was with some trepidation that he went to the meeting. “It was a pretty large restaurant. And that restaurant had been completely cleared out—there was nobody there. They made a little square of tables in the middle… On the outside of the restaurant there were Mexican police patrolling.

“There were the bar owners sitting around the table with me and the two people accompanying me, and around us were a whole group of gentlemen in trench coats and whatnot that had Uzis and other guns under their jackets… and not so under their jackets. And basically this group—I gave my usual sort of geeky academic presentation of what the study was about. And they all sat there and nodded their heads very nicely. And the head of the bar owners’ association turned to me and said, ‘But Dr. Patterson, why would we want to be involved in this study? What is in it for us?’”

From his early days studying primates behind glass and chasing white-crowned sparrows through forests in the Bay Area, Patterson has had to justify his study of animal and human behavior to a wide cross section of interested parties, and this stage of his career has revolved around gaining a better understanding of people’s motivations so that he can help them reduce the risks they face. Perhaps it was this capacity—call it professional empathy—that helped him put aside his own interests in that moment and understand the rules of the game. “I guess I was quick enough to realize these are businessmen and -women… And I thought, This is a business, and their commodity is women, women they are selling: sex workers. So I said, ‘The reason why you’d want to involve me is because I’m going to teach your women how to stay healthy, and because of that you’re going to make more money.’

“And they said, ‘Fantastic. You can work here in Tijuana.’”

The blessing of the bar owners’ association gave Patterson the entry point he needed, and he quickly got to work harnessing the unique expertise of sex workers to help design a way to stop the HIV epidemic in its tracks. Since that initial meeting (“Burned in my memory,” recalls Patterson), he and his team have put together a groundbreaking HIV-prevention program in Tijuana, despite the ongoing risk of violence and addiction facing women who work in the district. “Our research has continued without any hitches in the midst of the drug war,” says Patterson, “and I think it’s because we have partners who are on the ground, and because… we’re not there to shut down the whole sex-work industry; we’re trying to do harm-reduction approaches. We aren’t a threat.”

Called Mujer Segura (Safe Women), the first intervention Patterson developed centered on helping women develop strategies to better negotiate condom use with clients, which remains a central driver of the epidemic along Mexico’s northern border. After two years, Patterson saw a 40 percent drop in new cases of sexually transmitted diseases, including HIV, among women who participated in the intervention, as compared with a control group.

While buoyed by these initial findings, Patterson and Strathdee found that women in the sex trade who also injected drugs—those at highest risk of transmitting HIV—had poor results. So they designed another two-year randomized clinical trial, carried out in the heart of the Zona Norte (with a second site in Ciudad Juárez), between 2008 and 2010, to test the effectiveness of a program to improve both condom use and the use of clean needles for injecting drugs in combination. As part of the intervention, sex workers put together a video called Contamination, in which they present scenarios and demonstrate ways to avoid HIV infection, and groups of women discuss negotiation tactics, engage in role play, and educate their peers on how to access clean needles and condoms. Amazingly, after two years, the groups of women in Tijuana who participated in the experimental arm of the new Mujer Mas Sugura (“Safer Women”) intervention saw even better results than Patterson’s first trial: over 50 percent fewer new cases of HIV and other sexually transmitted infections than the control group: eight cases as compared with eighteen. Patterson and his team also saw the proportion of needle sharing plummet from 100 percent of participants at baseline to 5 percent at the close of the study. These kinds of results are almost unheard-of for behavioral interventions, especially those carried out in the midst of a drug war.

Since the publication of Patterson’s team’s findings, the Mujer Segura program has been expanded to thirteen cities across Mexico, mostly in the northern border region, to help sex workers find ways to negotiate condom use with their clients and avoid HIV transmission. Patterson credits the success of this work to the support that he’s received from his Mexican partners. “There are so many people who have benefited from this work and who have gone out of their way to help us be successful.” One of those people is Suzy, who has put her deep knowledge of the Zona Norte to use as an outreach worker for the Division of Global Public Health at UCSD, where Patterson works. Nowadays, instead of injecting others, Suzy travels to her old haunts in the Zona Norte and El Bordo to find people who inject drugs, recruit them for health studies, and connect them with care.

Spurred by the research on HIV risk done by Patterson and others at UCSD, condom and clean-needle distribution has ramped up across Zona Norte and other areas of high drug use in Tijuana. Salvador, the Zona Norte vendor, credits his own change in behavior to the combination of greater access to condoms and the knowledge of disease risks he gained from Patterson’s study. “There’s more access; it’s easier; all these campaigns, you can find them everywhere. Before, you couldn’t see it—before, if you wanted to use a condom, you would have to buy them, and if you didn’t have money you simply wouldn’t use them. I would have sex without condoms, but now you can get them anywhere: here, in the streets. Now I can tell you that I definitely use them. And because of what I’ve learned here, it has made me more conscious that I need to use them.”

Ana agrees, citing increased condom access and better access to HIV testing as game changers for Zona Norte’s sex workers. “I feel that it has helped because I know I’m healthy,” she says. Prior to joining Patterson’s study, the only other time she was tested was when her son was born, almost ten years ago—despite working in the sex trade for most of the last decade.

As we sit in a small interview room in Patterson’s field offices in the Zona Norte, Rosa, who still uses heroin and crystal meth, lists the many ways that project staff members have helped her. “Once, they diagnosed me with human papilloma and every day they called me. I got surgery, and they paid the two thousand dollars that I needed. The project, Mujer Segura, supported me in everything.” Rosa says that the way she manages HIV risk has changed as well. “They always have free condoms, every time we need them, do you get me? I used to share needles; I even used to sell the needles, the used ones, to drug users that had malilla [withdrawal]… In the crappy hotel [where I live], people have TB, hepatitis. I mean, you can tell when a person is sick, so imagine using the same needles? Oh no, not anymore. I have learned so many things. I go to all these talks and I don’t do all the shit that I used to do.”

After our interview, Suzy walks me through the Zona Norte and toward the research field office where she now works. As we approach the door, on a busy, narrow street in the middle of the red-light district, two uniformed police walk by, giving polite nods to her and the study coordinator, a Mexican physician, who accompanies us. As we climb the stairs, the two of them look at each other and laugh mirthlessly; they explain that those two officers are known as particularly vicious extortionists among Tijuana’s injection-drug users. And there is no sense that any of that will change anytime soon. While violence has decreased from those drug-war years in the late 2000s, its impact is still felt in the cross-border sex trade. The American customer base has all but dried up, a fact that haunts the neighborhood’s sex workers. “I used to make so much money,” Ana says. “Like, there were so many clients, I would have around ten clients [per day] or so, maybe eight years ago. Now I only have one or so.” Rosa concurs, saying that in her prime she had twenty-five clients per day. Nowadays, she is down to about three, many of who pay her only 100 pesos, or about $6.50, per visit. Both tell me that with so few customers, it is often hard to avoid dangerous clients.

For Bañuelos and Alaniz, the drug war never really ends. The year 2013 saw 492 homicides, a spike of 54 percent from the previous year, as well as increasingly audacious messages from new cartel factions, who are once again threatening police who interfere with cartel business. Some measure of calm returned in 2014, when homicides dropped by 40 percent, though no one is celebrating quite yet. Meanwhile, the police department is still recovering from the purging of corrupt officers and the stricter enrollment procedures put in place. Bañuelos, despite it all, seems optimistic. “Even though we are less,” he says, as he leans back in his chair, “we are now more dependable, more effective.”

Before we finish our interview at the police station, Alaniz wants to make one thing clear: “Tijuana is not an isolated phenomenon.” When I ask him what he means, he waves my question away. “Americans are always afraid of everything. They are phobic. And it’s not me who says that… we all know. And through their own fears they see a different perspective than that which we’ve lived in Tijuana during that time. Those weren’t pretty times, but they magnify it even more. I’ve been to New York, Tennessee, Jersey, places where they have their areas, just like the Zona Norte.”

I ask Alaniz if he is ever scared, given the ongoing corruption and the ever-present threat of violence. He shakes his head. “You know your work area, you know your past, and you can work with satisfaction.” When there’s trust in the state institutions, he says, “you can work with the bosses that have been there, because of the trust that has existed. When there’s no trust, well… you can only draw yourself back and work on the more practical stuff, no? You remain. That’s why I am able to tell you the story that I’m telling. You don’t talk much. ” 

Teresita Rocha Jimenez, Iván González, and Jaime Arredondo provided additional interview and translation support.

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