A man takes methadone at the Muhimbili National Hospital's methadone clinic in Dar es Salaam, Tanzania. Erin Byrnes

DAR ES SALAAM, Tanzania — Every morning, hundreds of Tanzanians make their daily sojourn to a breezy open-air methadone clinic at Muhimbili National Hospital. The journey is not always smooth. Some travel on overcrowded local buses, and others walk for hours in Dar es Salaam’s sweltering heat. One by one, the patients are called to a window, where a nurse behind a metal grate offers a plastic cup filled with liquid methadone. They drink the viscous concoction under her watchful eye, after which they can continue their day without craving heroin. “For a long time, I couldn’t live without heroin,” said Stamil Hamadi, a 34-year-old woman with a heart-shaped face and calming presence. “I decided to try methadone to become a new Stamil. My health began improving, and I started gaining weight.” Muhimbili’s methadone clinic is the first of its kind in mainland sub-Saharan Africa. Few governments, donors or nonprofits in Africa work with heroin users. Médecins du Monde (MDM), an international nonprofit that serves heroin users in Tanzania, estimates that fewer than 1 percent of drug users on the continent have access to support services, let alone treatment plans like methadone. Tanzania is a striking exception. In 2009 the national government publicly declared that its drug users needed evidence-based treatment options. With aid from the United States and Canada, Tanzania’s Ministry of Health approved a comprehensive plan to help prevent and treat heroin addiction.

This AJ+ short documentary follows Stamil Hamadi, an addict and sex worker who has cycled in and out of treatment since 2012. She hopes to kick the habit for good, but every day is a struggle.

Heroin use has surged in the U.S. in recent years, and it has gained popularity elsewhere around the world. According to the United Nations Office on Drugs and Crime (UNODC), there are more than 500,000 heroin users in East Africa, where popular Indian Ocean drug trade routes make landfall. Nearly 60 percent of these users may live in Tanzania, UNODC believes, with a heavy concentration in the port city of Dar es Salaam. Soon after heroin entered Dar es Salaam in the 1990s, its cruder form — brown instead of white — snaked its way into bustling urban neighborhoods like Temeke, where Hamadi lives. A dose of brown heroin, known on the street as brownie, costs as little as a dollar. (White heroin is sometimes called Obama.) “[The port] provides a lot of economic benefits, but unfortunately it also provides opportunities for an illicit trade in drugs,” said Brian Rettmann, who coordinates the United States’ President’s Emergency Plan for AIDS Relief (PEPFAR) in Tanzania. “Prices for heroin here are some of the lowest [in the world], which has really caused an epidemic.” Since the country’s per capita income is just under $700, heroin’s low price allows Tanzanians across income groups to try it. Some heroin users scrape the money together through odd jobs like helping bus operators find passengers. Others turn to illegal means. One of Hamadi’s friends boasted an eagle tattoo on his chest, symbolizing how he swoops down, quickly steals and gets high. Many female heroin users at some point pay for their addictions through sex work.

A drug dealer shows heroin packets on the street in Dar es Salaam, where a dose of brown heroin costs as little as a dollar. Erin Byrnes

As in many other places around the world, heroin in Dar es Salaam takes its firmest grip among the young, unemployed and bored. Hamadi was 18 when she first smoked heroin, as part of a koktelin (“cocktail”) with marijuana. She lived with her father but would sometimes stay with a friend for several days at a time. While partying with her friend one night, Hamadi met a man who, in 1998, offered her an oddly strong joint. “Honestly the first time I didn’t feel good,” Hamadi recalled. “But then I missed it the next day. I felt cold and had symptoms of fever. [The man] told me it was not fever. It was addiction. I asked him what addiction was because I didn’t know. He told me to sniff this thing. I took two hits and all of a sudden I felt cheerful and strong.” Hamadi fell in love fast, with both the guy and the heroin. Ellen Tuchman, who researches women’s substance abuse at New York University, said this story is not uncommon. “We know that social networks of women matter a lot, from adolescence onwards,” she said. “If she has a male partner, he can be very influential in getting her to start [using].” Though most Tanzanian women either sniff or smoke heroin, within two years Hamadi started experimenting with needles. She was seeking the purer highs she remembered from when she began using. The same year, she gave birth to a healthy baby boy. Her partner supported the family, she said, by conning people into believing he was a fortuneteller. Around their son’s fourth birthday, Hamadi recalled, her partner developed a toothache that didn’t go away. She said his jaw swelled and he died within a few months, cause unknown. “I felt so lonely,” Hamadi said. “He protected me until the day he died. [Until that point], I didn’t know how to sell my body. I didn’t know how to steal.” Hamadi entered both those professions after his death. She found regular clients, and when sex work didn’t fulfill her financial needs, she broke into people’s homes and stole their iron pots. Several years later, Hamadi participated in a class for people who inject heroin at MDM. (The nonprofit operates independently of Muhimbili.) As the teacher explained the dangers of sharing needles, she realized her partner had shown symptoms of HIV. Suspicious of her own status, she volunteered for a test and learned she was HIV-positive. “I’m glad I learned before I got more problems,” she said. “I now use [antiretroviral] drugs.” She was growing tired of the way her life was progressing. Her son lived with his grandmother, and she was rarely consulted on any family decisions. Sex work and robbery had their difficulties and indignities. It was getting more difficult for her to inject heroin, since the veins in her arms and legs had been used so often. She became impossibly frail. Fortunately for her, this was when the Tanzanian government began consulting with international donors to offer heroin users a path out of addiction.

Heroin users, including Hamadi, inject each other in Sheraton, a corner of the Temeke neighborhood in Dar es Salaam where addicts congregate. Almudena Toral

International donors became interested in Tanzania because heroin use correlates highly with HIV/AIDS prevalence. An estimated 40 percent of Tanzanians who inject drugs are HIV-positive — compared with 5 percent of the general population. Statistics are worse for women who inject heroin; the Tanzanian Ministry of Health estimates that two-thirds of them are HIV-positive. These alarming statistics are partially due to a worrying practice called flashblood, in which a user shoots up heroin, draws a syringe of blood and gives the full needle to a fellow user. If someone is short on cash, users say that injecting heroin-laced blood can give a mild high. A walk through a dusty heroin shooting gallery in Temeke — which heroin users nicknamed Sheraton, since they equate getting high with going to a five-star hotel — gives an indication of how common this practice is. Several addicts drifted by with blood-filled needles attached to their limp arms, eyes glazed and mouths agape. In 2009 the Tanzanian government agreed to test community outreach efforts, including a needle exchange and education program. Government representatives visited a methadone clinic in Vietnam, which they believed could be replicated back home. “We saw that it worked elsewhere,” said Frank Masao, who directs the Muhimbili Rehabilitation Center. “But it had not yet been proven in a Tanzanian or sub-Saharan African context.” The decision to offer methadone was an easy one for PEPFAR. “It’s an inexpensive alternative and is also very effective,” said Rettmann. “And it’s already on the essential drug list, so getting it into the country was [not difficult].” Since 2009, PEPFAR has spent $15 million to work with intravenous drug users in Tanzania, much of which has been used on methadone treatment. Methadone, a synthetic opioid classified as anti-addictive, works by reducing the craving for heroin. It is usually given in liquid form, with a person’s dosage based on the perceived level of physical addiction. Methadone also quells heroin’s infamous withdrawal symptoms, known in Swahili as arosto. “You cannot sleep, cannot eat. You have abdominal cramps and diarrhea,” said Masao. “The majority [of heroin users] wish to stop, but because of this pain, they cannot.” Quitting without a replacement, users say, is infernal. “[Withdrawal] was like a mosquito moving deep inside my skin,” recalled 35-year-old Happy Assan, shuddering at the memory of one of her darkest days. “Now when I wake up, I first think of the clinic. I love the clinic.” Assan is proud to have not touched heroin in three years because of Muhimbili’s methadone program. After years of illegally selling perfume on the street, she recently became employed with TANPUD, a national advocacy group for substance abusers. She also leads a weekly support group for female methadone patients. Methadone treatment has its critics as well, particularly regarding its duration. In 1998, New York City Mayor Rudolph Giuliani famously said that methadone was like “substituting one addiction with another,” since patients would remain on it for decades. Researchers like Tuchman believe that focusing on methadone’s downsides undermines its proven cost effectiveness. “We know from 40 years of research that it works,” she said. “I liken [methadone’s treatment duration] to people with diabetes. Once they’re on insulin, they require it every day for maintenance.”

Muhimbili National Hospital’s methadone clinic. Erin Byrnes

When the Muhimbili clinic opened in 2011, Masao said it planned to see 150 patients. But demand for methadone quickly ballooned as heroin users across the city sought out an alternative to their addiction. Within a year, the clinic secured $500,000 funding to open two more branches in other parts of the city. In the last four years, over 2,000 heroin users have begun the methadone program. Sixty percent of these patients were able to maintain the strict daily regimen, said Masao. One reason the clinic opened additional branches was to test initiatives to attract women. Masao acknowledged that recruiting and retaining women in Muhimbili has been challenging. Only 1 in 10 of their clients is female. A newer clinic, Mwanyamala, features women-only spaces and nighttime outreach that engages sex workers. It relaxed the condition to accept only people who inject heroin; it found that women who sniff heroin still have an elevated risk of contracting HIV. As a result of these changes, over 30 percent of its patients are women. In addition to methadone, patients have full access to mental and physical health services. “We like to comprehensively attend to patients,” said Masao. “We know that when they come here, it’s not just for methadone.” Many heroin users have a background of psychological trauma, which hospital staff can help treat. Also, clinic staff can ensure that HIV-positive patients receive their medication. Partly because of the Muhimbili clinic’s holistic approach, public health teams from several African countries — including Mozambique, Kenya and Nigeria — have visited the clinic.

Signs at the clinic depict various forms of illicit substances. Erin Byrnes

A year after the clinic opened, Hamadi became inspired after seeing her peers at MDM, where she often showered and studied. Several of them looked healthier, less gaunt. Community outreach workers from the Muhimbili clinic encouraged her to start using methadone as well. (The Mwanyamala clinic had not opened yet.) For several weeks, Hamadi diligently paid the 800 shilling ($0.50) bus fare to visit the clinic every morning before 11 a.m. She said she noticed feeling better almost immediately. But a mere month after starting, Hamadi disappeared. “When I stopped using methadone, I said that I would also stop using heroin,” she said, embarrassed and avoiding eye contact. “But the third day, I started feeling the thirst again. It’s like it has evil power.” Anywhere in the world, it is enormously difficult for patients to maintain a daily methadone regimen for years on end. There are the obvious logistical challenges of visiting a clinic every day, especially if it is far, expensive or inconvenient to reach. For the first few months of methadone treatment, the medical professional may still be fiddling with the dosage. If a patient’s methadone dose is too low, said Tuchman, he or she may begin craving heroin before the next scheduled treatment. Alternatively, a user may not be physically or psychologically ready to drastically alter his or her lifestyle. “There is this interplay between using heroin and not using heroin,” said Jessie Mbwambo, a psychiatrist at the Muhimbili Rehabilitation Center. “Recovery is not a straight line, unfortunately. People go back and forth, back and forth, into heroin, out of heroin, into methadone, out of methadone, until they are really ready.” Women like Hamadi face added challenges. In most places, including Dar es Salaam, there is an enormous stigma associated with being a woman addicted to heroin. “Women are supposed to be good mothers, wives and daughters,” said Tuchman. “She may be shamed or embarrassed to visit a big clinic.” While Muhimbili’s open-air setting may be inviting for users seeking community, it may have scared away people who value anonymity.

Juma Omari, a 25-year-old addict, shows his tattoos, including one of the Statue of Liberty. Almudena Toral