Transcript The Outer Limits of Drug Survey Monitoring Systems

The Outer Limits of Drug Survey
Monitoring Systems:
Ethnographic sense making
contributions to "hard data"
Dr Sylvie C. Tourigny
Senior Lecturer, Social Science
Senior Lecturer, QADREC
Founding Director, Behavioural Studies [1999-2003]
The University of Queensland
[email protected]
“Terence”
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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);
“Terence”
(cont’d)
 Attire: Black + gang colours;
 Job: Gang leader & drug dealer;
 Weapons:
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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, AIDSafflicted mother and HIV-positive mentally impaired brother.
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.
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This presentation will …
 Use the US crack epidemic as a case study of the
Transitory
 Emergent
 Ever-fluid
realities of drug use patterns;
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 Argue the importance of ethnography as integral to
monitoring studies;
 Recommend ways to achieve that integration.
Epidemiological knowledge
• Epidemiological researchers argue that we have
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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
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types and frequency of use,
behaviours associated with various substances, and
quantities and degree of purity.
• These appear to
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map out the illicit substance world, and
leave us feeling as though we have created order out of chaos.
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.
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.
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.
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).
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.
Impact of Crack cocaine in the US
 Dramatically increased incidence and prevalence of
cocaine addiction (Watkins, Fullilove & Fullilove,
1998).
 Significant increases in
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Social and public health problems, and
Risk- taking, including:
Extremely high-risk behaviours themselves associated
with co-morbidities including HIV and Hepatitis C.
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.
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
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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).
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
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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).
Mental health presentation of crack users
 Crack users report greater current
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depression,
anxiety, and
social isolation (Word & Bowser, 1997).
 Crack and cocaine have been associated with heightened
suicide risk (Marzuk et al 1992), and
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violent outbursts,
epidemic increases in violent injuries and homicides, and to
significantly heightened risks for law enforcement personnel’s
safety.
In Vitro exposure to crack
 The incidence of unsuspected, passive cocaine
exposure in ill infants seeking medical care
primarily through an 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).
In Vitro exposure to crack
 Increases in vascular anomalies (Dominguez, 1991) and
 Decreased state regulation, attention, and responsiveness
among cocaine-exposed neonates raise concerns about
 later developmental abilities;
 the infants’ effect on caregivers (themselves often
compromised in their parenting abilities) (Eyler,
1998).
 Whether infants born crack addicted and underweight will
experience lifelong sequelae remains an empirical – and
much debated – question.
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).
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.
Why didn’t we know?
 Even the US General Accounting Office acknowledged
that monitoring surveys are fundamentally
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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.
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
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Psychosocial;
Sociocultural;
Emotional; and
Experiential
embeddedness of behaviour, and
• The policy implications of insufficiently culturally grounded
research findings.
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.
Under-theorized evidence
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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).
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:
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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.
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
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Holistic;
Embedded;
Process-oriented ways, in real time, facing real situations;
 Seeks patterns across events and persons, through
individual and collective sense-making processes.
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.
Ethnographic Contributions
Ethnography can complement epidemiology by:
 Facilitating enrolment and retention of cohorts;
 Providing comprehensive life and network histories, including crossvalidations;
 Remaining abreast of changes in
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Culture
Patterns of use/distribution;
Supply issues;
‘on the street’ impact of changing policies;
Drug trends
 Making sense of the seemingly incongruous.
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.
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”.
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)
Ethnography enhancement of epidemiological
understanding: some examples
 Q: HIV-seropositivity is stigmatising and lifethreatening, 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.
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-SydneyBrisbane 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)
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!
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!
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.
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).
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?”
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.