Dr Sylvie C. Tourigny

1. The Outer Limits of Drug Survey Monitoring Systems: Ethnographic sense makingcontributions to "hard data" Dr Sylvie C. Tourigny Senior Lecturer, Social ScienceSenior Lecturer, QADREC Founding Director, Behavioural Studies [1999-2003] The University of QueenslandS.Tourigny@mailbox.uq.edu.au

2. “Terence” • Male • DOB: 23/07/1970 • 6’2”, 220 lbs [1.9M, 100 kg] • African-American • City of residence: Detroit, Michigan, USA • Left school year 10; • Adequate literacy; • Single • Eldest son, one younger brother • Drug: alcohol (social only);

3. “Terence” (cont’d) • Attire: Black + gang colours; • Job: Gang leader & drug dealer; • Weapons: • AK 47; • Tek 9; • Colt 45 Special • Juvenile Criminal Record: Attempted Vehicular homicide [“DWB”]; • Defunded through welfare “reform” • Living circumstances: sole wage earner and carer, AIDS-afflicted mother and HIV-positive mentally impaired brother.

4. What is the weakest link in Drug & Alcohol research? • We have yet to understand the cultural, psychosocial and opportunistic decisions that ultimately guide the market, including: • Motivations for onset of and shifts in use; • Links between cognition, emotion, and substance use; • Decision making processes guiding behaviour around questions of substance use; • Motivational structures that sustain change.

5. This presentation will … • Use the US crack epidemic as a case study of the • Transitory • Emergent • Ever-fluid realities of drug use patterns; • Argue the importance of ethnography as integral to monitoring studies; • Recommend ways to achieve that integration.

6. Epidemiological knowledge • Epidemiological researchers argue that we have • sturdy, reliable and trustworthy data • about patterns of distribution and use of both licit and illicit substances, • acquired through validated, comparable, aggregatable, and dependable surveys • repeated year after year. • We currently have developed classificatory schemes about • types and frequency of use, • behaviours associated with various substances, and • quantities and degree of purity. • These appear to • map out the illicit substance world, and • leave us feeling as though we have created order out of chaos.

7. Epidemiology’s achievements • Epidemiology and monitoring strategies generally seem to make sense of an otherwise seemingly socially disorganised environment: the world of drug markets and its clients. • Research relies on last year’s findings to adapt this year’s instruments; • Questionnaires sometimes include some open-ended questions intended to help identify changing trends.

8. Crack: that which spawned nightmares • Crack epidemic startled researchers, health care providers, law enforcement and policy makers; • Crack became significantly more societally costly than it might otherwise have been. • Much of its impact was estimated as a result of the consequences, rather than the process, of the epidemic.

9. Crack, early days • Newer preparations of cocaine, such as crack or free-base were suddenly playing an increasingly important role on the streets, • These preparations were far more toxic than cocaine hydrochloride (Escobedo 1991), and • The context of their use meant there were few or no cultural safeguards inhibiting epidemic use.

10. Crack loyalty • A highly addictive, inexpensive substance with extremely potent properties, crack yields progression patterns that tend to reinforce its addictive potential. • Crack-initiated users typically remained loyal to crack; • Powder cocaine and crack used interchangeably can interact and prove mutually reinforcing, yielding a higher level of use and dependence on both forms of the substance (Shaw et al 1999: 47).

11. The power of crack • Crack was much cheaper than powder cocaine, so its popularity grew astronomically rapidly … • The implications of increased supplies of cocaine – an upper-middle-class recreational drug at the time – did not alert monitoring systems (Sloboda 2002); • Exclusion of those most-at-risk from regular context and systematic surveying further clouded reporting; thus • The lack of contextualised understanding of drug use delayed responses far too long.

12. Impact of Crack cocaine in the US • Dramatically increased incidence and prevalence of cocaine addiction (Watkins, Fullilove & Fullilove, 1998). • Significant increases in • Social and public health problems, and • Risk- taking, including: • Extremely high-risk behaviours themselves associated with co-morbidities including HIV and Hepatitis C.

13. Crack and sexual risks High numbers of • sexual partners, • drug-injecting sexual partners, • times having sexual relations while high, • times trading sex for drugs and/or money, and • proportion of all sexual acts involving the use of protection.

14. High-frequency & intensity use and risks • Crack users are most heavily involved in risky sexual behaviours in terms of their HIV risk behaviour involvement and of their actual HIV seroprevalence rates (Hoffman et al, 2000). • Crack users report the highest levels of risk and the lowest levels of condom use when compared to both non-cocaine drug users and to non-drug users (Ross, 2003). • Crack contributes dramatically to the spread of STDs and STIs including syphilis, gonorrheae and HIV, via • injection of cocaine, "speedball" and heroin, • "crack" smoking, • backloading of syringes, • injecting with others, • exchanging drugs or money for sex, • multiple sex partners, and • non-heterosexual sexual preference (Lopez-Zetina, 2000).

15. Clinical presentation of crack users • Problems arose with assessing the best clinical and decontamination responses to vial-stuffers who ingested the glass crack containers to elude arrest (Hoffman et al, 1990); • ‘Crack' cocaine associated morbidities include • significant impact on pulmonary alveolar permeability (Tashkin, 1997), • can induce persistent renal failure, hematuria, and thrombocytopenia (Volcy et al, 2000). • “noticeable increases in the incidence of neurovascular complications” (Darras et al, 1991), including ischemic cerebrovascular events. • A potent topical vasoconstrictor, cocaine also causes • nasal mucosal and dermal ulceration; • perforated gastropyloric ulcer (Abramson et al, 1991), and • a condition now known as “crack lung” (Gatof, 2002).

16. Mental health presentation of crack users • Crack users report greater current • depression, • anxiety, and • social isolation (Word & Bowser, 1997). • Crack and cocaine have been associated with heightened suicide risk (Marzuk et al 1992), and • Crack is linked to • violent outbursts, • epidemic increases in violent injuries and homicides, and to • significantly heightened risks for law enforcement personnel’s safety.

17. In Vitro exposure to crack • The incidence of unsuspected, passive cocaine exposure in ill infants seeking medical care primarily throughan emergency service providing care for predominantly inner city population may be as high as 1 in 3 to 6 infants (Lustbader, 1998). • HIV positive or congenitally syphilitic infants have mothers who are 3.9 more likely than controls to test positive for cocaine (Greenberg et al, 1991).

18. In Vitro exposure to crack • Increases in vascular anomalies (Dominguez, 1991) and • Decreased state regulation, attention, and responsiveness among cocaine-exposed neonates raiseconcerns about • later developmental abilities; • the infants’ effect on caregivers (themselves often compromisedin their parenting abilities) (Eyler, 1998). • Whether infants born crack addicted and underweight will experience lifelong sequelae remains an empirical – and much debated – question.

19. Crack & families • The crack epidemic decimated families (Dunlap 2000, 2001) • Grandmothers became sole caregivers for literally tens of thousands of young children (Dunlap, Tourigny, Johnson, 1999), many of them ‘crack babies’ • Grandparents, stressed, demoralised, often threatened by their own children and generally poor, came to be recognised as “the "hidden patients" of the crack cocaine epidemic” (Roe et al, 1996: 1072).

20. Crack & communities At community levels, crack distribution triggered • Violent and escalating gang wars (Tourigny, 1998; 2001a, 2001b, 2001c), • Property crime (Best, 2001) and • Very significant community destabilisation (Tourigny, forthcoming; 2001a, 2001c). • Erosion of neighbourhoods, particularly in inner cities; • Upturn in racial incidents and racism; • Dramatic upswing in arrests, prosecution and incarcerations, particularly of young black males.

21. Why didn’t we know? • Even the US General Accounting Office acknowledged that monitoring surveys are fundamentally • Unwieldy; • Time-lagged; and therefore • Prone to misjudgments about future drug trends. • USGAO endorsed supplementation through ethnographic research; • USGAO actually contracted out analyses of under-theorised data to ethnographic teams.

22. Three problems… Three problems exist with monitoring programs that epidemiology, used alone, neither anticipates well nor begins to overcome. • The fundamental “datedness” of such data as compared to the emerging, ever-fluid reality of the drug markets themselves. • The loss of very significant data about meaning and the • Psychosocial; • Sociocultural; • Emotional; and • Experiential embeddedness of behaviour, and • The policy implications of insufficiently culturally grounded research findings.

23. Datedness of data • Surveys perforce integrate what we know at the time of design into what we think of asking, which is itself contingent on what participants told us in the last round of data collection. • The format compels selection of “least bad options”; • Settings are generally intimidating, and the insistence on consistency silences feedback, so “innovations” go unvoiced; • New drug trends are NOT necessarily tantamount to new drugs; • The streets do not honour research time lags.

24. Under-theorized evidence • Despite their analytic power, statistical analyses can leave one bereft of an understanding of the reasons why, or the process through which, behaviours occur; • As Reutler and Malik point out in their critique of the DSM-IV, “the same (or very similar) phenomena can be categorized in strikingly different ways across different cultures and periods of time, illustrating that there are always alternatives available. [A]ll classification schemes, however seemingly objective the criteria, are developed and agreed upon … to meet particular human needs … making it reasonable to suppose that even quite different approaches … may be useful depending on the particular needs at hand” (2002: ix-x).

25. Policy “insufficiencies” • Lack of understanding of the norms underpinning the “why” of much behaviour, and particularly of behaviour that is only subculturally normative, yields policy that is unlikely to be: • Effectively designed; • Responsive to cultural or subcultural imperatives; • Timely in impact • Policy imperatives become guided by reactions to, rather than an understanding of, the way drug markets actually operate.

26. Ethnography – any fool with a clipboard? • Is premised on the cultural embeddedness of human behaviour; • Operationalises the importance of understanding predicated on walking a mile in the other’s shoes; • Focuses on getting to know people and their contexts in • Holistic; • Embedded; • Process-oriented ways, in real time, facing real situations; • Seeks patterns across events and persons, through individual and collective sense-making processes.

27. Complementarities • Epidemiology seeks to know the “what”; ethnography seeks the “how” and the “why”; • Epidemiology centres on the precision of data and robustness of power calculation; ethnography focuses on the cultural contingency of reality; • Epidemiology devotes itself to isolating variables; ethnography is committed to understanding how humans and their context interplay to yield particular behaviours; • Procedurally, epidemiology seeks to ensure uniform delivery of instruments; ethnography immerses itself in the lived reality of respondents; • Analytically, epidemiology seeks strong statistical support of claims; ethnography seeks convergent explanation.

28. Ethnographic Contributions Ethnography can complement epidemiology by: • Facilitating enrolment and retention of cohorts; • Providing comprehensive life and network histories, including cross-validations; • Remaining abreast of changes in • Culture • Patterns of use/distribution; • Supply issues; • ‘on the street’ impact of changing policies; • Drug trends • Making sense of the seemingly incongruous.

29. Contributions to cohort retention • Ethnographers create relationships and ongoing, soon reciprocal, involvement, which forms a source of sustained engagement; • People wish for their version of their life to make sense to someone. Participant-ethnographer relationships are extraordinarily resilient. • Our ongoing presence in the field means that even as people's behaviours or circumstances change, they are unlikely to disengage from the research. We are often amongst those first called in a crisis, and updated on changes; • Respondents typically don’t bother to lie to researchers who are part of their everyday background, and as such are very difficult to significantly mislead; • Participants come to value “their” project, which means they become invested in the process.

30. Contributions to analytic process • Ethnographers provide insights into the microstructural and cultural elements of changing social reality; this contributes significantly to making the "hard data" and its analysis relevant by facilitating the updates of instruments; • Ethnographers who are on the streets regularly and who have a complex network of informants keep colleagues sensitised to the dramatic impact of sometimes seemingly subtle changes in norms, cultures, or market structures; • The value of ethnographic insights is demonstrated time and again when data become incongruent, seemingly ill-fitting to theory, or otherwise unexplainable, except through the insights gained “on the ground”.

31. Ethnographic enhancement of epidemiological understanding: some examples • Q: Major studies found positive correlations between seroconversion and self-reported bleach rinsing of syringes; • A1: Users by and large do NOT use bleach, despite what they say they do. However, flushing with water works, and allows the necessity to share works to continue as part of the moral economy of drug use. (Bourgois, 2002) • A2: After incorporating ethnographers’ insights, Moss confirmed, as participant observation suggested, that “pooling economic resources” was the strongest predictor of HCV seroconversion. (Bourgois, 2003)

32. Ethnography enhancement of epidemiological understanding: some examples • Q: HIV-seropositivity is stigmatising and life-threatening, and self-evidently to be avoided. • A1: Shared marginalisation/stigmatisation can be one’s only way of belonging. Risking seroconversion is then a way of showing solidarity. Thus, public self-injection with potentially HIV-contaminated syringes became a jumping-in ritual in some urban gangs. (Tourigny, 1998a) • A2: Tourigny, S.C. (1998b), 'Some New Dying Trick: African American Youths "Choosing" HIV/AIDS', Qualitative Health Research, 8, 2, March, 149-167.

33. Ethnography enhancement of epidemiological understanding: some examples • Q: Drug markets are fairly self-contained, isolated economic and social structures. • A: I am currently aware of three “average middle class” couples who regularly undertake Brisbane-Sydney-Brisbane runs to visit families… and return with drug shipments. They get significant cash, and distributors get arms’ length relationships and some lessened law enforcement scrutiny. (Tourigny, in progress)

34. Why the disparity in knowledge? • Epidemiology sometimes forgets that participants, too, are ‘reflexive’; • Isolating research involvement from the process of living that is integral to the reality of substance users yields significant doubt as to the integrity of the relationship; • We acknowledge, as professor David Kavanaugh did, that “ rapport-based intervention may be as good as full SOS”… without recognising the deeper truth that such a comment reveals about rapport: TRIBAL STUFF MATTERS… perhaps to the marginalised most of all!

35. How do we close the gap? Collaboration • Include ethnographic input into study design from the outset; • Incorporate a cohort-sustenance element that makes use of ethnographic skills and competencies; • Sustain a “street presence” throughout the project – ethnographic research is not best done sporadically; • Utilise ethnographic insights as hypothesis generating evidence; • Incorporate ethnographic insights into the analytic dimension; • For the very brave: Consider allocating a randomly selected group to an ethnographically designed interview and intervention protocols. Compare the results!

36. The stranger on the train • People talk to us, and allow us to witness private and potentially damning behaviours, because everyone wishes to be understood in some fundamental way. • We are the stranger on a train, in whom one can confide – perhaps even unburden – and still walk away unscathed. • Ethnography is not a threat to quantitative knowledge, but does provide insights that monitoring strategies are neither designed nor conceptualized to offer.

37. A convert’s comment • Integrating ethnographic elements into broader-based quantitative monitoring studies “enhance[s] comparability and understanding of findings, particularly when there are differences in behaviors between communities.” (Derren et al, 2003).

38. A closing story While training ADAM interviewers in New York City, I found myself interviewing someone whose drug dealing and drug-using behaviours had been familiar to me for several years. “Ink” was savvy, and admitted to what he knew the urine sample would give away… but lied about everything else. So I filled the boxes until finally asking him what he was doing. He looked at me, standing proud in a jail cell, and said “Sylvie, when I talk to you, it’s on my street, you’re on my turf and you show respect. Those folk that ask questions like that, they don’t care about me, and they don’t care about my truth. So why should I give a fuck about theirs?”

39. A simple reminder… People reveal themselves honestly when, to the extent that, and in a context where, they trust they are being heard, understood, and supported.