Shame

Broken, Cambria Street, Kensington

Tranq wounds smell bad. That means people who have lesions advanced enough to have a noticeable odor suffer more than just the physical pain of having them, or the emotional reaction to seeing them on one’s body. In warmer weather, they are often on public display without the camouflage of winter clothing. The shock of the injury can be very hard to look at, especially when there’s deep tissue exposure. Kensington and the surrounding area is rough, and not known for being a sensitive, warm place to call home. Gun violence, gang activity, random assaults, daily cruelties leveled at the population of people on the street is the context in which those with tranq wounds exist.

Mike with his clothes, Cambria Street, Kensington
Struggling to remove clothes from the surface of the wound before complete adherence occurs as a result of the weeping tissue.

Entering a store with a wound can be more than just a casual act. It’s an ordeal, an event to be endured if someone in the store, customer or employee, decides to verbally attack the person with the wound. If the odor is noticeable, it gets very embarrassing and difficult to make simple purchases, to obtain necessities in the drugstore or food items before getting thrown out. Riding the subway can result in anger and cruelly abusive words, turning a quick ride into an experience of humiliation.

T uses a needle to exfoliate Mike’s skin and remove dead cells. Some people do not like to have their wounds covered, especially if they don’t feel that the practitioner understands how to properly care for the lesions. People pick at the injury, scratch….and sometimes allow others to help on the street in ways that can cause further damage.

Not everyone is eager to have their wounds dressed, bandaged or otherwise looked after. I’m told that sometimes things get much worse, and more fluid builds up when air cannot reach the skin and tissues. Some people have had ineffective wraps or felt that those trying to care for the wounds don’t really possess the skill to address the situation medically, despite having the best intentions. The lesions are tricky to care for, and require expertise to effectively treat. The real problem is the need to get well….a trip to the hospital means that a person cannot use during time spent in the emergency room. This is huge, and a massive roadblock, insurmountable for most. Additionally, hospital nurses and doctors can display insensitivity and create more stress, as well as not practice addiction management techniques. With all of this on his mind, Mike’s contemplation of a trip to get desperately needed care resulted in dismissal of the option. Even the fear of sepsis wasn’t enough to propel Mike into the hospital on this overcast Saturday afternoon.

Whose fault is the wound? Assigning blame is irrelevant. The cause, Xylazine, is in the drug supply. The cessation of use is not an option for most…no amount of straight, factual talk with the most heartfelt delivery will change the trajectory of someone else’s life. Just listening is sometimes proactive, even though it feels totally insufficient. I’m recording my observations and what other people relate to me about their experience. The complexities of addiction and choice and self determination aren’t part of my work. The obvious penalties of addiction unfortunately in these situations often include being the subject of ridicule or recklessly insensitive behavior. People in this intractable addiction trap on the street in Kensington often depend on the help they receive from strangers, strangers who sometimes become familiar and dependable, and strangers who appear only once to give a quick gift. Outreach personnel, private individuals who show up in the neighborhood with food, well intentioned church groups, or an empathetic troupe of friends who get together and head to Kensington to give out cups of coffee, or a few cookies with hot chocolate on a brutally cold day.

From a distance….the dilemma and pain of Mike’s situation blending into the mundane in this view of Kensington.

Tranq.

Graphic Content

Kari, Cambria Street, Kensington, Philadelphia

I returned to Philadelphia on September 20, 2022. I had been in New York City since 2017, and before that, Southern California, Austin, Texas and very briefly in Charleston, South Carolina. Living in different places during various phases of my life as a single parent, trying to find a place to call home where I actually felt at peace with my son. I had fled Philadelphia originally because of bad memories growing up, and rough, Philly-style experiences on the street that made me think twice about raising a small child in the City of Brotherly Love. During the time I was in New York City, I spent a month in the Summer of 2018 in Philadelphia. One day I visited an area located on the fringes of Kensington. I had read of the neighborhood, and I knew that I needed to see it for myself. I photographed a few people on the outskirts, near York Street and Aramingo Avenue. But I didn’t have the courage to head in to the heart of the chaos….so I did not. I didn’t go, and I regretted not having done so. I spent four years thinking about Philadelphia. My life in New York finally came to an end after I had Covid. I decided that whatever time I had left was going to be spent elsewhere, and the very first place I needed to be in was Kensington.

CC, Kensington Avenue near Allegheny, Kensington, Philadelphia
Kensington and Allegheny Avenue
Kensington Avenue and E. Schiller Street, Kensington

As soon as I arrived in Kensington I began to learn about the ravages of Xylazine, or Tranq, as it’s nicknamed, combined with fentanyl. Read: https://time.com/6164652/xylazine-overdose-crisis/

The necrotic lesions can show up anywhere on the body, far from the injection site. Xylazine causes vasoconstriction, which interrupts blood supply to the skin. The lesions are not always infected, but when infection does occur it can be catastrophic, sometimes resistant bacteria strains that colonize deep tissue and even bone, resulting in amputation and disfigurement.

Brooke, on Kensington Avenue near Clearfield Street

Brooke is a beautiful person to photograph. I was in a state of shock on the day I made these images with her. She explained how she manages her massive forearm injury created by Xylazine/Tranq. She has already lost a leg to Tranq, and is very careful about her wound management. Unfortunately, the addiction and all of the related issues that she grapples with daily create an impossible situation for her. The injectable drug that causes the wound she has is in the supply of fentanyl that she depends on…and so the wound never heals. Sometimes there is healing, often requiring a hospital stay, surgery, intravenous antibiotics….not always an option for most people, who are often resistant to going to the hospital. Some hospitals are not compassionate, or well versed in medical addiction management techniques to make patients comfortably able to tolerate a hospital stay without a supply of fentanyl obtained from the street. So many don’t go to the hospital, and the situation deteriorates madly. There are many amputations that result from these massive lesions, young people without legs, hands, feet and arms. People sometimes inject directly into the wound, as Brooke is doing on Kensington Avenue.

Brooke with witch at Somerset and Kensington Avenue, Kensington

Not everyone is able to properly care for their injured skin, and find themselves in horrible, nearly impossible situations with clothing that binds to the wound, requiring one of the incredibly devoted outreach wound specialists that set up in the area periodically to painstakingly correct these situations as best they can. I was with one such group of devoted nurses and social workers who patiently explained to me the history of the problem, and the practicalities involved with on the street wound management techniques.

This man had multiple lesions on both legs. He also had a switchblade knife in one hand, and was intoxicated. He was somewhat articulate, and was able to tolerate being cleaned and bandaged.
Painstaking work removing dried, adherent shirt fabric from an advancing lesion
A young woman waits for a team of nurses on the street to care for a deep lesion on her forearm
Wound specialist cleans and bandages on Ruth Street in Kensington

It was one of the first days I spent on Kensington Avenue, openly photographing, and it was only the second time I had ever seen the inexplicable wounds generated by the use of Xylazine. Because the people who are suffering with the catastrophic, disabling lesions are often high on opioids, they do not feel as much of the agonizing pain and discomfort as they would if they were not using fentanyl and Xylazine. But when the effects of the opioids wear off, the pain becomes much more intense and even removing basic clothing is nearly impossible, especially if the wounds are not dressed. Many people do not go to get their lesions cared for for logistical reasons or because they just cannot get there. The longer a wound goes uncovered—sometimes adhering to clothing— the easier it is to put care into the distant future.

Man examines his leg while waiting for an assessment on Clearfield Street in Kensington
Extremely advanced and necrotic wound, showing deep tissue involvement. This man did not wait for treatment, and left abruptly. This lesion was populated by maggots, and he was in a critical situation that required hospital care. Outreach patiently explained the seriousness of the situation, but were unable to persuade him to go to the hospital.

Some of these images are from warmer days last fall. Colder months mean more clothing, more restrictive fabric and less air able to circulate, more fabric that complicates the potential to heal.

Sometimes caring for severe lesions is complicated by the effects of a drug mixture that causes people to remain in awkward body positions for long periods of time, restricting circulation. Sometimes no matter how imperative immediate attention is, intoxication makes effective treatment impossible.
Not everyone in the area of Kensington Avenue has knowledge of or access to one of the wound care pop-ups in Kensington. This man has little mobility. He is mostly hidden from view, as the image below illustrates. People like this need mobile wound care that winds through the area, seeking out those who are unable to gain access to necessary care.
Unseen, Kensington Avenue

A safe drug supply would effectively eliminate the contamination by Xylazine. Not one user on the street I’ve spoken to wants Tranq mixed in, although that doesn’t mean that nobody objects….I just haven’t found anyone. They dislike Tranq immensely but have absolutely no control over the situation. Since there’s no availability of test kits to determine the amount of Tranq adulterating purchases of fentanyl, it’s impossible to gauge its effect. Ratios change hourly, and dealers often give out free samples to eager users willing to test the supply as it becomes available on the street. I’ve witnessed large groups of people almost running en masse to pop up sample spots buried on side streets. Overdoses involving Tranq and fentanyl have opposing effects. Fentanyl requires Narcan. Narcan is readily available but has absolutely no effect on an overdose caused by Tranq. Tranq excess requires breathing support and resuscitation and, because the drugs are mixed, Narcan and rescue breathing are often necessary.

Sample, Allegheny Avenue

Overdose happens every day, in inaccessible areas. The ratio of drugs in the supply of dope is not predictable. One person described the situation as one in which he felt as though the population of users was being experimented on by those in control of the drug supply. Trying to find that magic combination of substances that will create a desirable high that’s reliable, fast and cheap enough to be profitable. Not everyone buying is unhoused….teenagers are dying in their bedrooms, suburban dads can be seen in parked cars, blacked out in the parking lot of the Walgreens drug store on Kensington and Allegheny Avenues. It happens everywhere, just much more visibly on the streets of Kensington.

Gurney Street, Kensington
Near Torresdale avenue, Kensington
Kensington Avenue near Somerset

There are a lot of issues surrounding these images. Privacy, documentary image making practices, various people and their sometimes dogmatic views aren’t always a terrific combination. Documentary work in other countries, Ukraine for example, is well tolerated generally. But images made in America of this catastrophe do not always bring people together harmoniously. It is critically important to take pictures that convey absolutely what is happening. It means that faces, places, and circumstance are on display. Corporate media outlets need to consistently address the issue as graphically as is necessary to effectively illustrate the problem, as done here: https://time.com/james-nachtwey-opioid-addiction-america/

Kari, Cambria Street

The graphic and intolerably despairing images in this post should be considered in the context of a problem that is killing, maiming or otherwise causing grave dysfunction to hundreds of people each day in the United States, adding up to many, many thousands each year. Images like these are necessary and should not be omitted or eliminated by social media and news outlets. Mainstream media and social media platforms inability to risk offense to describe distressing situations that are clearly visible in the community do nothing to forcefully and properly illuminate social issues. Dilemmas that require reflection, sensitivity and societal admissions of guilt need to be examined without reservation. Issues such as the one described in this post will continue to fester and ravage masses of people every day unless enough of us are sufficiently angry to start vehemently demanding immediate solutions. That’s how I justify my work on this particular subject. I wish I didn’t feel the need to justify and explain and persuade….but I do.

Clearfield Street near Ruth Street….It all starts with injection. Some people are unable to hit themselves, and require help from someone more facile with injection techniques. People are blindsided by addiction, and many are unable to find good veins, some are uneasy using needles…not the usual stereotype. The process of injecting is immensely stressful and sometimes extremely uncomfortable. There are people on the street that are known to be excellent injectors, and people quite literally become agonizingly dope sick without their assistance.
After assisting the woman above, J shows his most difficult to manage leg wounds.
Clearfield and Ruth Streets, Kensington

I am grateful to every person that allowed me to photograph. I am also thankful to those in my candid images done on the street, taken without permission. In Kensington permission is often necessary, but in some cases I use street photography techniques which are equally important for me as an artist and photojournalist.

Pain is Inevitable, Suffering is Optional, Cambria Street, Kensington
Kensington Avenue near Clearfield, Kensington