Philippe Bourgois

Hepatitis C Virus Seroconversion among Young Injection Drug Users: Relationships and Risks

The present study examined reasons for the high incidence of hepatitis C virus (HCV) infection among young injection drug users (IDUs). IDUs <30 years old who tested negative for HCV antibody were enrolled in a prospective cohort. Risk factors for seroconversion were examined using time-dependent regression analyses: 48 of 195 IDUs seroconverted to HCV, for an incidence rate of 25.1/100 person-years (95% confidence interval, 18.7-32.9/100 person-years). Independent risk factors included sharing needles with an HCV-infected sex partner (borderline statistical significance, P=.11) or a person who was not a sex partner, sharing nonsterile drug-preparation equipment, pooling money with another IDU to buy drugs, and exchanging sex for money. Ubiquitous behaviors among young IDUs, such as the forming of injecting or sexual partnerships and consequent sharing of needles and drug preparation equipment, are risk factors for HCV. Interventions to reduce HCV transmission must recognize the importance of relationships on injecting risk.

Disciplining Addictions: The Bio-politics of Methadone and Heroin in the United States

Biomedical understanding of methadone as a magic-bullet pharmacologicalblock to the euphoric effects of heroin is inconsistent with epidemiologicaland clinical data. An ethnographic perspective on the ways street-basedheroin addicts experience methadone reveals the quagmire of powerrelations that shape drug treatment in the United States. The phenomenonof the methadone clinic is an unhappy compromise between competingdiscourses: A criminalizing morality versus a medicalizing model ofaddiction-as-a-brain-disease. Treatment in this context becomes a hostileexercise in disciplining the unruly misuses of pleasure and in controllingeconomically unproductive bodies. Most of the biomedical andepidemiological research literature on methadone obscures these powerdynamics by technocratically debating dosage titrations in a socialvacuum. A foucaultian critique of the interplay between power andknowledge might dismiss debates over the Swiss experiments with heroinprescription as merely one more version of biopower disciplining unworthybodies. Foucaults ill-defined concept of the specific intellectualas someone who confronts power relations on a practical technicallevel, however, suggests there can be a role for political as well astheoretical engagement with debates in the field of appliedsubstance abuse treatment. Meanwhile, too many heroin addicts who areprescribed methadone in the United States suffer negative side effectsthat range from an accentuated craving for polydrug abuse to aparalyzing sense of impotence and physical and emotional discomfort.

Structural Vulnerability and Health: Latino Migrant Laborers in the United States

Latino immigrants in the United States constitute a paradigmatic case of a population group subject to structural violence. Their subordinated location in the global economy and their culturally depreciated status in the United States are exacerbated by legal persecution. Medical Anthropology, Volume 30, Numbers 4 and 5, include a series of ethnographic analyses of the processes that render undocumented Latino immigrants structurally vulnerable to ill health. We hope to extend the social science concept of “structural vulnerability” to make it a useful concept for health care. Defined as a positionality that imposes physical/emotional suffering on specific population groups and individuals in patterned ways, structural vulnerability is a product of class-based economic exploitation and cultural, gender/sexual, and racialized discrimination, as well as complementary processes of depreciated subjectivity formation. A good-enough medicalized recognition of the condition of structural vulnerability offers a tool for developing practical therapeutic resources. It also facilitates political alternatives to the punitive neoliberal policies and discourses of individual unworthiness that have become increasingly dominant in the United States since the 1980s.

Every 'never' I ever said came true: transitions from opioid pills to heroin injecting.

This qualitative study documents the pathways to injecting heroin by users in Philadelphia and San Francisco before and during a pharmaceutical opioid pill epidemic. Data was collected through in-depth, semi-structured interviews (conducted between 2010 and 2012) that were, conducted against a background of longer-term participant-observation, ethnographic studies of street-based drug users and dealers in Philadelphia (2007-12) and San Francisco (1994-2007, 2012). Philadelphia and San Francisco were selected for their contrasting political economies, immigration patterns and source type of heroin. In Philadelphia the ethnographers found heroin injectors, usually white users, who had started their opiate using careers with prescription opioids rather than transitioning from other drugs. In both Philadelphia and San Francisco, most of the young heroin injectors interviewed began, their drug-use trajectories with opioid pills--usually Percocet (oxycodone and acetaminophen), generic short acting oxycodone or, OxyContin (long-acting oxycodone)--before transitioning to heroin, usually by nasal inhalation (sniffing) or smoking at first, followed by injecting. While most of the Philadelphia users were born in the city or its suburbs and had started using both opioid pills and heroin there, many of the San Francisco users had initiated their pill and sometimes heroin use elsewhere and had migrated to the city from around the country. Nevertheless, patterns of transition of younger injectors were similar in both cities suggesting an evolving national pattern. In contrast, older users in both Philadelphia and San Francisco were more likely to have graduated to heroin injection from non-opiate drugs such as cannabis, methamphetamine and cocaine. Pharmaceutical opioid initiates typically reported switching to heroin for reasons of cost and ease-of-access to supply after becoming physically and emotionally dependent on opioid pills. Many expressed surprise and dismay at their progression to sniffing and subsequently to injecting heroin. Historically and structurally these users found themselves caught at the intersection of two major developments in the opiate supply: (1) an over 500% increase in opiate pill prescription from 1997 to 2005 resulting in easy access to diverted supplies of less stigmatized opiates than heroin and (2) a heroin supply glut, following the US entry of Colombian-sourced, heroin in the early 1990s, that decreased cost and increased purity at the retail level. A nationwide up-cycle of heroin use may be occurring among young inner city, suburban and rural youth fueled by widespread prescription opioid pill use.

“The Power of Violence in War and Peace: Post-Cold War Lessons from El Salvador

The Cold War sanitized the authors analysis of political violence among revolutionary peasants in El Salvador during the 1980s. A 20-year retrospective analysis of his fieldnote(s) documents the ways political terror and repression become embedded in daily interactions that normalize interpersonal brutality in a dynamic of everyday violence. Furthermore, the structural, symbolic and interpersonal violence that accompanies both revolutionary mobilization and also labor migration to the US inner city follows gendered fault lines. The snares of symbolic violence in counter-insurgency war spawn mutual recrimination and shame, obfuscating the role of an oppressive power structure. Similarly, everyday violence in a neo-liberal version of peacetime facilitates the administration of the subordination of the poor who blame themselves for character failings. Ethnographys challenge is to elucidate the causal chains and gendered linkages in the continuum of violence that buttresses inequality in the post-Cold War era.

Social Misery and the Sanctions of Substance Abuse: Confronting HIV Risk Among Homeless Heroin Addicts in San Francisco

Participant observation fieldwork among street-level heroin injectors in San Francisco demonstrates the need for contextualized understandings of how power relations structure individual behavior in the transmission of HIV. Problematizing macro/micro dichotomies, we explore how externally-imposed power constraints are expressed in everyday practices constituting differential HIV infection rates within distinct population groups. The pragmatics of income-generating strategies and the symbolic hierarchies of respect and identity shape risky behavior. The political economy and symbolic representations of race, class, gender, sexuality, and geography organize chronic social suffering and distort research data. Traditional paradigms of applied public health elide power relations and overemphasize individual behavior. Ignoring the centrality of power prevents a full understanding of the who, why, how, and where of HIV infection.

Social Context of Work Injury Among Undocumented Day Laborers in San Francisco

AbstractOBJECTIVE: To identify ways in which undocumented day laborers’ social context affects their risk for occupational injury, and to characterize the ways in which these workers’ social context influences their experience of disability. DESIGN: Qualitative study employing ethnographic techniques of participant-observation, supplemented by semistructured in-depth interviews. SETTINGS: Street corners in San Francisco’s Mission District, a homeless shelter, and a nonprofit day labor hiring hall. PARTICIPANTS: Thirty-eight Mexican and Central American male day laborers, 11 of whom had been injured. PRIMARY THEMES: Anxiety over the potential for work injury is omnipresent for day laborers. They work in dangerous settings, and a variety of factors such as lack of training, inadequate safety equipment, and economic pressures further increase their risk for work injury. The day laborers are isolated from family and community support, living in a local context of homelessness, competition, and violence. Injuries tend to have severe emotional, social, and economic ramifications. Day laborers frequently perceive injury as a personal failure that threatens their masculinity and their status as patriarch of the family. Their shame and disappointment at failing to fulfill culturally defined masculine responsibilities leads to intense personal stress and can break family bonds. Despite the high incidence of work injuries and prevalence of work-related health conditions, day laborers are frequently reluctant to use health services due to anxiety regarding immigration status, communication barriers, and economic pressure. IMPLICATIONS: On the basis of these ethnographic data, we recommend strategies to improve ambulatory care services to day laborers in 3 areas: structural changes in ambulatory care delivery, clinical interactions with individual day laborers, and policymaking around immigration and health care issues.

Crack and the Political Economy of Social Suffering

A comparison of cocaine, crack and heroin epidemics documented through participant-observation methods in the United States and Canada reveals dramatically distinct patterns of abuse across differentially vulnerable population groups. Political economic and cultural forces, rather than pharmacology shape the trajectory of drug epidemics. The de facto apartheid of the U.S. inner city and its associated prison industrial complex spawned the massive epidemic of crack smoking in the late 1980s and early 1990s. A contradictory Canadian public policy of police repression combined with centralized, paternalistic social services explains that countrys particularly destructive intravenous cocaine epidemic, particularly among its aboriginal and francophone urbanized populations. The United States suffers from the iatrogenic consequences of its failed war on drugs. Heroin and cocaine have never been purer or cheaper despite the massive investment of U.S. public resources in repression at great humanitarian cost.

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

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 hav et o 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. # 2002 Elsevier Science B.V. All rights reserved.

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

An epidemiological cohort study of injection drug users in Montréal documented a significant statistical association between HIV seroconversion and needle exchange patronage from 1989 to 1995. The polemics generated by this counterintuitive quantitative data demonstrate the urgent need for a cross‐methodological dialogue between epidemiology and ethnography. Participant observation on the streets of Montréal documented the multiple HIV risks associated with the compulsive behavior and emotional craving often accompanying cocaine injection. Needle exchange programs by themselves cannot be expected to stem HIV infection in cities where intravenous cocaine is the drug of choice. Are there unintended consequences (effets pervers) to public health interventions? We need an open debate to improve risk‐reduction strategies. Public health should expand its scientific paradigm to include ethnographic documentation of the daily lives of vulnerable street addicts. On a deeper theoretical level, needle exchange polemics illustrate how power relations frame both HIV risk taking and science.