Commentary
Anthropology and epidemiology on drugs: the challenges of cross-methodological and theoretical dialogue

https://doi.org/10.1016/S0955-3959(02)00115-9Get rights and content

Abstract

Many of the principal public health strategies for preventing HIV and substance use among injectors at the turn of the 21st century—such as needle exchange, rinsing syringes with bleach, distributing condoms, and prescribing methadone—were implemented with little knowledge of how, why, and even if they worked. Epidemiological researchers often document bizarre associations between behaviours, demographics and serostatus. From a pragmatic practical perspective epidemiologists might be able to collect and crunch statistics more effectively if they did not exclude from their design and their analysis the larger political economic contexts, cultural meanings, and explanatory dynamics for the socially taboo behaviours surrounding addiction and infection that their protocols attempt to document. Drawing on over a dozen years of participant-observation with street-based injectors, I discuss the practical dialogue, I engaged in with four epidemiological research projects that have documented unexpected dynamics requiring clarification: (1) dramatically disproportionate HCV seroconversion among young women injectors; (2) high HIV seroconversion rates among Canadian cocaine injectors who patronise needle exchange; (3) low HIV seroconversion among homeless heroin addicts in San Francisco who regularly engage in risky injection practices; and (4) unenthusiastic acceptance of heroin prescription by long-term street addicts in Switzerland. Quantitative and qualitative researchers concerned with the social suffering of street-based drug users have a great deal to offer one another. They both have to overcome their dogmatic methodological and theoretical blinders to address how social power relations propagate illness in identifiable patterns across vulnerable populations. The theoretical insights of Foucault, Bourdieu, Marx and Mauss—if not of postmodernism—might have practical applications on the street.

Introduction

The absence of a dialogue between epidemiological and qualitative researchers—especially ethnographers who engage in cultural anthropology's version of participant-observation methods—is a failure from the perspectives of both the pragmatic positivism of public health and also the critical theory of anthropology. From the vantage point of rational scientific endeavour it is surprising that most epidemiologists and biostatisticians do not introduce a minor ethnographic component to their research projects in order to improve the precision of the data they collect or to augment the clarity of their analysis. One would think that training programs in epidemiological methods in schools of public health and medicine would want to expose students and faculty to a minimal dose of qualitative techniques—even if only to improve the language, logic and triangulation capacities of their questionnaires.

Of course, the converse is also true: it is surprising that most anthropologists know nothing about the quantitative methods to which they are often hostile. They do not recognise how useful it can be to consult already-existing, easily accessible quantitative databases that might allow them to situate their research subject with little effort and no expense. One would also think that training programs in ethnographic methods in departments of anthropology would require students and faculty to acquire minimal competence in quantitative techniques—even if only to gauge statistical significance and to locate basic demographic datasets on the web.

Section snippets

Power/knowledge and disciplinary boundaries

As an ethnographer who engages in the participant-observation methods that have been developed in the discipline of cultural anthropology over the past century, I have always been impressed by how deeply epidemiologists care about the precision of their data in contrast to ethnographers. Anthropology is premised on the cultural contingency of reality. Facts are treated as cultural constructions. Furthermore, the advent of postmodern theory in US anthropology during the mid-1980s has

Crunching numbers in a vacuum

Public health journals aggressively enforce the quantitative/qualitative divide by almost exclusively publishing quantitatively-based research. They subject the statistical data of the manuscripts they receive to rigorous mathematical peer review. They fail, however, to request authors to provide even the simplest qualitative, contextual information to explain how the data were collected or how the samples were structured. Aside from standardised slogans such as “with informed consent;”

Failed magic bullets: needle exchange, bleach, methadone and condoms

A polemic erupted in the 1990s around the pros and cons of needle exchange programs: Do they protect from HIV or spread HIV? This prominent harm reduction debate was waged almost exclusively on the basis of statistical re-analyses of published data presented in public health journals (see, for example, special issues of the American Journal of Epidemiology, 1999, American Journal of Public Health, 2000). Even a superficial qualitative analysis of the half dozen needle exchange studies that are

The surprises of heroin maintenance

My visits to heroin injection clinics in Geneva (not real participant-observation ethnography by any definition) suggest that heroin prescription stabilises most long-term heroin addicts, with the exception of some cocaine injectors. The most surprising preliminary ethnographic finding from the Swiss Diversified Opiate Prescription Program, is that a significant sub-group of the addicts complain that the pharmacological grade heroin prescribed to them is ‘bunk.’ This was further corroborated in

Gender power relations and HCV seroconversion

Qualitative methods are not superior to quantitative methods. It would be impossible to know much of anything of importance in the field of public health without following the dictum of the founder of epidemiology quoted in the epigram: “… weigh life for life and where the dead lie thicker… (Virchow, 1848, cited in Farmer, 1999).” I am currently collaborating with Andrew Moss's UFO [author: in full] project which is an epidemiological cohort study documenting HCV seroincidence among youth

The theoretical politics of epidemiology

Over the past century and a half of rapid urbanisation and industrialisation, epidemiology has a better record than ethnography with respect to critiquing the social structural power relations that make the socially vulnerable suffer. Arguably, the field of epidemiology was founded as a radical social critique of inequality and injustice under capitalism. Virchow (cited in the epigraph) unabashedly proclaimed his political humanitarian purpose for counting the sick and dying, “… to see where

The symbolic violence of HCV prevention

Hepatitis C is a particularly problematic virus because no magic bullet solution prevents its spread. At a 40% per year seroconversion rate among young homeless women in San Francisco it becomes almost impossible for street injecting youth to escape HCV infection unless they are anti-social outcasts. It is useless to tell young injectors “Never share cookers, cottons or rinse water” when they are living in a city where the heroin consists of black tar requiring it to be put into solution in

Postmodern tolerance

In the name of straightforward positivism as well as intellectual and political logic, quantitative drug researchers have to be the ones to reach out to their qualitative brothers and sisters. In the field of public health, epidemiologists hold the institutional power and set the agenda. Qualitative researchers usually cannot garner significant sources of research funding. They are excluded from publishing in the field's prestigious journals. Qualitative researchers can be frustratingly slow to

Acknowledgements

Written with the support of National Institute on Drug Abuse (NIDA) grant R01-DA10164 and the Trustees’ Grant-in-Aid program of the Wenner-Gren Foundation for Anthropological Research. Comparative data were also drawn from related NIDA-supported projects: R01 DA12803-01, R01 DA1159, NO1DA-3-5201, PSC 263-MD-519210, R01 DA10164R99-57-115 and the University of California's Universitywide AIDS Research Program R99-SF-052. Four and a half years of participant-observation fieldwork in East Harlem

References (42)

  • P. Bourdieu

    Masculine domination

    (2001)
  • P. Bourgois

    The moral economies of homeless heroin addicts: Confronting ethnography, HIV risk, and everyday violence in San Francisco shooting encampments [see comments]

    Substance Use and Misuse

    (1998)
  • P. Bourgois

    Disciplining addictions: the bio-politics of methadone and heroin in the United States

    Culture Medicine and Psychiatry

    (2000)
  • P. Bourgois et al.

    Needle exchange, HIV infection, and the politics of science: Confronting Canada's cocaine injection epidemic with participant observation

    Medical Anthropology

    (2000)
  • Bourgois, P., Ciccarone, D. (Under review). Explaining the geographic variation of HIV among injection drug users in...
  • Bruneau, J., Schechter, M.T. (1998). The politics of needles and aids. New York Times, April...
  • J. Bruneau et al.

    High rates of HIV infection among injection drug users participating in needle exchange programs in Montreal: results of a cohort study [see comments]

    American Journal of Epidemiology

    (1997)
  • C. Contoreggi et al.

    Effects of varying concentrations of bleach on in vitro hiv-1 replication and the relevance to injection drug use

    Intervirology

    (2000)
  • T. Dehue

    A Dutch treat: randomized controlled experimentation and the case of heroin maintenance in the Netherlands

    History of the Human Sciences

    (2002)
  • D. Des Jarlais et al.

    HIV/Aids prevention for drug users in natural settings

  • V.P. Dole et al.

    Heroin addiction—a metabolic disease

    Archives of Internal Medicine

    (1967)
  • Cited by (113)

    • Ayahuasca's entwined efficacy: An ethnographic study of ritual healing from ‘addiction’

      2017, International Journal of Drug Policy
      Citation Excerpt :

      Yet, as social theories of addiction have shown, addiction is a complex, enmeshed and biosocial process (Garriott & Raikhel, 2015). There are many addictions (Bourgois, 2002; Campbell & Lovell, 2012; Netherland & Hansen, 2016). In our ethnography, which took place entirely outside of specialized addiction treatment centres, we seldom encountered the term ‘addiction’.

    • Moral ambivalence and the decision to initiate others into injection drug use: A qualitative study in two California cities

      2016, International Journal of Drug Policy
      Citation Excerpt :

      The term moral economy was originally employed by E.P Thompson to examine how certain groups establish consensus about what are legitimate and illegitimate practices (Thompson, 1971). In recent years, the notion of a moral economy among inner-city drug users has been used to understand how minimal resources and a social expectation of sharing drugs can lead to risk-taking by sharing of injection paraphernalia such as syringes, cookers, and cottons (Bourgois, 1998b, 2002; Bourgois, Prince, & Moss, 2004; Zule, 1992). Understanding the nuances of the moral economy elucidates the ways that social norms and acceptable practices are established among street-based PWID.

    View all citing articles on Scopus
    View full text