Structural Violence and Structural Vulnerability Within the Risk Environment: Theoretical and Methodological Perspectives for a Social Epidemiology of HIV Risk Among Injection Drug Users and Sex Workers

Abstract

The transmission of HIV is shaped by individual-environment inter­actions. Social epidemiologic approaches thus seek to capture
the dynamic and reciprocal relationships of individual-environment interactions in the production and reduction of risk. This
presents considerable methodological, theoretical and disciplinary challenges. Drawing upon four research case studies, we
consider how methods and concepts in the social and epidemiologic sciences might be brought together towards understanding
HIV risk as an effect of social, cultural and political condition. The case studies draw upon different combinations of methods
(qualitative, ethnographic and quantitative) and disciplines (sociology, anthropology and epidemiology) in different social
contexts of HIV vulnerability (street settings in Russia, Serbia and North America and a cross-border setting in Mexico) among
a range of marginalised high-risk populations (injection drug users and female and transvestite sex workers). These case studies
illustrate the relevance of the social science concepts of “structural violence” and “structural vulnerability” for a social
epidemiology of HIV risk. They also explore how social epidemiologic work can benefit from the mixing of social science methods
and theories. We contend that social epidemiology cannot advance in its understanding of structural vulnerability without
embracing and relying upon ethnographic and qualitative approaches. We put ­forward the linked concepts of “structural violence,”
“structural vulnerability” and “risk environment” as building blocks for a theory-informed social epidemiology of HIV risk
among marginalised populations.

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Contents
10.1 Introduction .................................................................................................................
10.2 From the Individual to the Social ................................................................................
10.3 Methodological Challenges .........................................................................................
10.4 Four Case Studies ........................................................................................................
10.4.1 Case Study One: Policing and the “Structuration” of HIV
Vulnerability Through Fear ...........................................................................
10.4.2 Case Study Two: Gendered Power Relations and HCV
Seroconversion Among Street-Based Youth IDUs ........................................
10.4.3 Case Study Three: Structural Violence, Power and HIV
Prevention Among Female and Transgendered Sex
Workers in an Urban Setting..........................................................................
10.4.4 Case Study Four: HIV Risk in the Context of Deportation:
The Modifying Role of Gender .....................................................................
10.5 Discussion ....................................................................................................................
10.5.1 Structural Vulnerability .................................................................................
10.5.2 Mixing Method and Theory ...........................................................................
10.6 Conclusions .................................................................................................................
References ...............................................................................................................................
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T. Rhodes (*)
London School of Tropical Medicine and Hygiene, 15-17 Tavistock Place,
London WC1H 9SH, UK
e-mail: Tim.Rhodes@lshtm.ac.uk
????????????????????????????????????????
Division of Global Public Health, Department of Medicine, UC San Diego, California, USA
K. Shannon
Department of Medicine, University of British Columbia
and BC Centre for Excellence in HIV/AIDS
P. Bourgois
Department of Anthropology, University of Pennsylvania
Chapter 10
Structural Violence and Structural
Vulnerability Within the Risk Environment:
Theoretical and Methodological Perspectives
for a Social Epidemiology of HIV Risk Among
Injection Drug Users and Sex Workers
Tim Rhodes, Karla Wagner, Steffanie A. Strathdee, Kate Shannon,
Peter Davidson, and Philippe Bourgois
P. O’Campo and J.R. Dunn (eds.), Rethinking Social Epidemiology:
Towards a Science of Change, DOI 10.1007/978-94-007-2138-8_10,
© Springer Science+Business Media B.V. 2012

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T. Rhodes et al.
Abstract The transmission of HIV is shaped by individual-environment inter-
actions. Social epidemiologic approaches thus seek to capture the dynamic and
reciprocal relationships of individual-environment interactions in the production
and reduction of risk. This presents considerable methodological, theoretical and
disciplinary challenges. Drawing upon four research case studies, we consider how
methods and concepts in the social and epidemiologic sciences might be brought
together towards understanding HIV risk as an effect of social, cultural and political
condition. The case studies draw upon different combinations of methods (qualita-
tive, ethnographic and quantitative) and disciplines (sociology, anthropology and
epidemiology) in different social contexts of HIV vulnerability (street settings in
Russia, Serbia and North America and a cross-border setting in Mexico) among a
range of marginalised high-risk populations (injection drug users and female and
transvestite sex workers). These case studies illustrate the relevance of the social sci-
ence concepts of “structural violence” and “structural vulnerability” for a social epi-
demiology of HIV risk. They also explore how social epidemiologic work can benefit
from the mixing of social science methods and theories. We contend that social epi-
demiology cannot advance in its understanding of structural vulnerability without
embracing and relying upon ethnographic and qualitative approaches. We put forward
the linked concepts of “structural violence,” “structural vulnerability” and “risk envi-
ronment” as building blocks for a theory-informed social epidemiology of HIV risk
among marginalised populations.
Abbreviations
GIS
HCV
IDU
SRO
Geographic Information Systems
Hepatitis C virus
injection drug user
single room occupancy
10.1 Introduction
HIV transmission is influenced by an interaction between biological, individual and
environmental factors. Social epidemiologic approaches thus seek to delineate how
the distribution of HIV in populations is shaped by the “risk environment,” that is,
by determinants that extend beyond “proximal” individual-level factors and their
behavioural mediators (Farmer 2009; Krieger 2008; Rhodes 2002). This presents
considerable methodological, theoretical and disciplinary challenges. In this chapter,
we consider how methods and concepts in the social and epidemiologic sciences
might be brought together towards understanding HIV risk as an effect of social,
cultural and political condition. Our interest is in mapping how social, political and
economic structures generate and reproduce vulnerability to HIV, especially among

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10 Structural Violence and Structural Vulnerability Within the Risk Environment…
socially marginalised populations, including injection drug users (IDUs) and sex
workers. This brings into focus how multiple interacting social factors create a
context of vulnerability to HIV risk across multiple marginalised populations. We,
therefore, outline a case for a “social epidemiology of structural vulnerability”
applied to HIV. In doing so, we emphasise the critical role of qualitative methods
and social science theory in capturing and representing the “lived experience” of
embodied structural vulnerability inside a mixed-method and cross-disciplinary
approach. We suggest that social epidemiology cannot advance in its practical
understanding of structural vulnerability without embracing and relying on
ethnographic and qualitative approaches. Our aim is not merely to outline a case for
a social epidemiology of structural vulnerability but also to reflect upon some of
the limits, opportunities and challenges likely to be created through such cross-
methodological and disciplinary work.
10.2 From the Individual to the Social
The field of public health, and in HIV specifically, has increasingly moved towards an
understanding that health is an outcome of social and structural conditions and, in
particular, sociocultural, economic and political inequalities (Farmer 1999; Navarro
and Mutaner 2004). Accompanying this understanding is a growing critique of
biomedical approaches to health research, which tend to emphasize individual-level
factors over environmental or structural ones and which fail to adequately capture the
social structural production of risk or the facilitators of change. In the case of HIV,
however, the interplay between health and social marginalisation is, or should be, so
visible as to be unavoidable (Farmer et al. 1996). This critique identifies a tendency in
public health and the behavioural sciences to operationalize risk as primarily resulting
from individual action and responsibility and, in doing so, cautions against an over
reliance upon individual-level models of rational choice decision making. Behavioural
interventions alone have been shown to only account for a modest reduction in HIV
incidence in the absence of social and structural interventions and policies (Copenhaver
et al. 2006). This critique also cautions against the “victim blaming” tendency of
individual-level models, which give sole or primary emphasis to individual choice and
agency as determinants of risk and risk behaviour. In contrast, social epidemiologic
approaches seek to situate risk and risk responsibility as something shared between
individuals, communities and environments – especially among the social and politi-
cal-economic institutions that have a key role in risk production. While epidemiologic
research has shown that physical, social, economic and policy environment factors are
independently associated with HIV infection among vulnerable groups such as drug
users, few studies have fully operationalized a social epidemiologic approach from the
outset (Strathdee et al. 2010). Here we advocate for a shift “from the individual to the
social” in public health, which emphasises, first, that the health of individuals and
communities is an embodiment of their social condition and, second, that health
improvement requires social and structural change.

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One overarching heuristic for guiding research and intervention on HIV risk as
an effect of social condition is the “risk environment” framework (Rhodes 2002,
2009; Rhodes et al. 2005; Strathdee et al. 2010). This has been defined as the space,
whether social or physical, in which a variety of environmental factors interact to
increase the chances of risk occurring (Rhodes 2002; Rhodes et al. 2003). The risk
environment is conceptualised as comprising types of environment (physical, social,
economic and policy) interacting with levels of environmental influence (micro and
macro). This same logic implies an “enabling environment” framework of social
and structural change (Table 10.1). This heuristic has given impetus to a number of
studies investigating the primacy of social context in HIV and other risks related to
injection drug use and sex work (Strathdee et al. 2010, 2008b; Rhodes et al. 2005;
Moore 2004; Small et al. 2006; Shannon et al. 2008a, b; Cooper et al. 2009; Green
et al. 2009). Within an overarching framework of risk environment, there are a
number of overlapping (and to some extent competing) concepts in social science
that have provided the conceptual foundations for social epidemiologic work,
including in the field of HIV and drug use. These concepts include “political econ-
omy” and “structural violence.” Social epidemiologic approaches have long drawn
attention to an overlap with political economy (Krieger 2001, 2008; Doyle 1979).
For Krieger (2008), health “cannot be divorced from considerations of political
economy and political ecology.” This reflects parallel assertions in the social
sciences that the HIV risks of drug use or sex work are “virtually meaningless out-
side their sociocultural as well as political economic contexts” (Bourgois 2003) and
that drug use is “the epiphenomenonal expression of deeper, structural dilemmas”
(Bourgois 1995). Crucially, political-economic perspectives posit social conditions
as rendering particular sectors of the population vulnerable to harm. This “struc-
turation of risk” is illustrated through the incarceration and enforcement-based
policies that disproportionately affect those using drugs and working in the sex
industry as well as those already suffering intense and systematic discrimination,
including racial discrimination (Jurgens et al. 2010).
A related concept informing social epidemiologic work to date is structural
violence. Structural violence is distinct from personal or direct violence in that it is
embedded in social structures whereby “unequal power” shapes “unequal life
chances” (Galtung 1990). Poverty, racism and gender inequalities provide examples
(Farmer et al. 1996; Walter et al. 2004). Each of these may perpetuate constraints in
agency, leading to unequal opportunity and disproportionate social suffering for the
marginalised (Farmer 2010). Crucially, the institutionalisation and everyday inter-
nalization of structural violence can render it invisible or unnoticeable (Scheper-
Hughes 1996). The embodied effects of structural violence may be understood as
“oppression illness,” which is the “product of the impact of suffering from social
mistreatment,” a type of “stress disorder,” where the source of stress is “being the
object of widespread and enduring social discrimination, degradation, structural
violence and abusive derision,” whether overt or hidden (Singer 2004). Drug use,
itself, can be seen as a form of “self-medication” for oppression illness, providing
“pain intolerance,” “chemical intervention” and a “solution” (Singer 2004). The
internalization of social suffering (Kleinman et al. 1997) reproduces a cycle of

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Table 10.1 The risk and enabling environment: selected examples related to HIV, drug injecting and sex work
Micro-environment
Macro-environment
Physical
Risk
Drug using, injecting and sex work locations Drug injecting in public spaces
Prisons and detention centres
Drug trafficking and distribution routes
Trade routes and population mobility
Geographical population shifts and population mixing
Intervention
Creating safer drug using sites (e.g., sharps disposal, lighting)
Developing supervised injecting facilities
Prison-based harm reduction interventions and alternatives to
prison
Changes to trafficking interdiction policies
Interventions at truck stops and train stations
Cross-border interventionsChanges to immigration laws and routine enforcement practices
Social
Risk
Social and peer group “risk” norms and intimate partner violence
Local policing practices and “crackdowns”
Community health and welfare service access and delivery
Gender inequalities and gendered risk
Stigmatisation and marginalisation of drug users
Weak civil society and community advocacy
Intervention
Social network and peer-based interventionsShelters for homeless and for battered partnersPolice partnership and training projects
Developing low threshold accessible services for drug users
Fostering collective actions and political mobilization for social
and human rights in combination with policy changes
Mass media and social marketing of harm reduction
Strengthening civil society infrastructure and self-help
Economic
Risk
Cost of living and cost of health treatments Cost of prevention materials
Lack of income generation and employment
Lack of health service revenue
and spending
Growth of informal economies Uncertain economic transition
Intervention
Subsidised and free treatment
Distribution of free prevention materials
Micro-economic enterprise and employment schemes
Increase investment in harm reduction relative to enforcement
National health insurance schemes
Laws governing employment rights
Policy
Risk
Availability and coverage of clean needles and syringes
Program-level policies governing distribution of materials
Access to low-threshold and social housing
Public health policy governing harm reduction and drug
treatment
Laws governing possession of drugsLaws governing protection of human and health rights
Intervention
Scaling-up pharmacy-based syringe provisionSecondary syringe distribution programmes
Hostel-based and housing neighbourhood development
Legal reform enabling the scaling-up of harm reductionLegal reform enabling the protection of drug user rights
National policy changes regarding public health strategy
Source: Rhodes (2009)

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risk production in which those marginalised can become complicit, including
unconsciously, in their ongoing structural subordination (Bourdieu 2000).
Critiques of political economy perspectives and the ways in which structural
violence informs social epidemiologic work emphasise that they tend to be “over
deterministic,” underplaying the role of agency, subjectification and non-material
forces in the reciprocal processes of individual-environment interactions (Bourgois
and Schonberg 2009; Duff 2007; Giddens 1984; Biehl et al. 2007; Butler 1997;
Foucault 1995; Pine 2008). It is critical that social epidemiologic approaches capture
the dynamism of agency-structure transformations, in which environments constrain
as well as enable agency, and are thus also produced and reproduced by participant
practices. We take up these points below in the case study descriptions and discussion
of the “structural vulnerability” of HIV risk.
10.3 Methodological Challenges
Rather than relying on reductionist models that hypothesize direct, linear associations
between “risk factors” and “outcomes,” a shift towards a social understanding of
HIV vulnerability can “scale up” an understanding of risk to embrace the dynamic,
reciprocal associations amongst individuals and their social, physical and political-
economic environments. Attention to the multilevel, complex systems that influence
health outcomes, however, is not without its methodological challenges. In fact,
developing research methods that can delineate causal and theoretical pathways in
the social determinants of HIV is a critical step to informing social and structural
interventions for reducing HIV risk (Strathdee et al. 2010; Rhodes 2009).
Researching causal pathways to HIV transmission demands a shift from binary
epidemiologic models of simple “cause and effect” to “multilevel” models, which
emphasise HIV as an outcome of multiple contributing factors at once interacting
together (Galea and Vlahov 2002). Social determinants that derive from the risk
environment perspective are often “non-linear” and “indirect” in their effects, and
this presents considerable challenges to delineating causative relationships (Krieger
1994). Measuring the effects of structural violence, for example, is not as simple as
assessing phenomena such as the direct experience of physical violence or eco-
nomic dislocation; structural violence extends beyond the individual to the social
structures that perpetuate poverty, racism, gender inequalities and other forms of
systemic marginalisation, which ultimately shape HIV risk. HIV is thus an outcome
of a “complex system” of interactions occurring within and between individuals and
their environments, with the challenge being to better capture the dynamism of
these reciprocal relations through mixed-methods research.
Understanding these complex systems requires an iterative and multidisci-
plinary approach in which qualitative evidence and social science theory help to
map conceptions of “risk environment” and related risk pathways. Although there
is a rich theoretical and empirical tradition in the social sciences of investigating
health as an effect of social inequality and condition (Engels 1892), public health

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has not dialogued systematically with social science theory and methods. In a
research environment increasingly characterized by transdisciplinary and mixed-
methods approaches, both social science and traditional epidemiologic approaches
can benefit from the strategic integration of the other’s theoretical approaches and
research methods (Mason 2006). Such a synthesis has the potential to increase the
public health impact of both fields by generating grounded conceptual frameworks
with testable causal pathways contributing to intervention development on the one
hand and by providing socially-situated interpretations of epidemiologic data on
the other.
10.4 Four Case Studies
We will draw upon four short case studies to illustrate the relevance of the concepts
of structural violence and structural vulnerability in social epidemiology studies of
the HIV risk environment. Our four case studies explore relationships between viral
harms (HIV and hepatitis C virus) and social condition. Case Study One explores
the “structuration” of HIV risk through the everyday internalization of fear induced
by policing practices among injection drug users in Russia and sex workers in
Serbia. Case Study Two explores the legitimization of violence against young
female IDUs in San Francisco leading to heightened vulnerability to hepatitis C
(HCV). Case Study Three focuses on police-enforced displacement of female sex
workers in Vancouver to remote, violent neighbourhoods that heighten their risk of
violence and limit their capacity to negotiate condom use. Case Study Four explores
gendered patterns of international migration and deportation associated with the
risk of HIV infection in the United States/Mexico border region.
Each case study employs a different design and, taken as a group, show the
strategic advantage of integrating multiple methodological approaches. Case Study
One emphasises the critical role of ethnographic and qualitative research in captur-
ing and representing the “lived experience” of embodied structural vulnerability,
including as a means of informing subsequent epidemiologic study. Case Study
Two demonstrates how the simultaneous use of ethnographic participant observa-
tion and epidemiologic survey research can both inform and refine research ques-
tions when ethnography uncovers associations that may be difficult to detect using
quantitative measures. Case Study Three uses a participatory research approach to
incorporate quantitative questionnaire data, social mapping and in-depth qualitative
interviews in an iterative design that explicitly accounts for the complex physical
and social environment in which HIV risk behaviour occurs. Case Study Four shows
how counterintuitive findings from a classically-designed epidemiologic cohort
study can be contextualized and interpreted through the use of supplemental
qualitative research informed by social science theory. Our aim is not only to make
a case for a social epidemiology of structural vulnerability (as applied to HIV) but
also to highlight some of the methodological and theoretical challenges facing
cross-disciplinary public health research.

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10.4.1 Case Study One: Policing and the “Structuration”
of HIV Vulnerability Through Fear
Data were drawn from qualitative studies among injecting drug users in Russia, in 2003,
and sex workers in Serbia, in 2005, to capture the lived effects of HIV risk environment in
which policing practices played a key role (Sarang et al. 2010; Rhodes et al. 2008).
One of the most visible structural mechanisms perpetuating social suffering and
HIV risk among vulnerable populations of IDUs and sex workers is the criminal
justice system, especially policing practices. International evidence links policies
emphasizing repressiveness through law enforcement with higher levels of risk for
health and HIV, and a growing epidemiologic literature points towards policing prac-
tices and fear of the criminal justice system as important factors (Strathdee et al.
2010; Rhodes 2009; Cooper et al. 2009; Friedman et al. 2006; Pollini et al. 2008).
Russia provides an acute example (as do other parts of Eastern Europe witness-
ing massive outbreaks of HIV among drug injectors). The enactment of criminal
and administrative codes relating to drugs possession combine with aggressive
police surveillance, resulting in the mass incarceration of drug users and other
minority groups and a prison system linked to HIV outbreaks (Bobrik et al. 2005;
Sarang et al. 2006). Intense police surveillance fosters reluctance to seek help or
carry sterile needles for fear of arrest, caution, fine or detention (Rhodes et al.
2003). Police contact, from arrest to assault, is associated with increased risk of
syringe sharing (Strathdee et al. 2010; Sarang et al. 2010; Pollini et al. 2008;
Rhodes et al. 2004).
Qualitative research among 209 IDUs in three Russian cities (Moscow, Volgograd
and Barnaul) illustrates the “structural violence” of drug policies emphasizing crim-
inalization (Sarang et al. 2010). Everyday policing practices, and especially extraju-
dicial practices, generated a pervasive sense among drug injectors of being at risk,
in turn reinforcing a sense of stigma, powerlessness and, importantly, a fatalistic
acceptance of harm and suffering. Through the internalization of the effects of
policing practices, we see the embodiment of social conditions into everyday risk
perceptions and practices. Of key importance is the fear of policing practices and
how this acted as an indirect force of structural violence affecting capacity for HIV
risk avoidance.
First, drug injectors felt under inescapable surveillance (“You cannot hide from
them” and “They know everything about us”). While the sense of being under per-
vasive surveillance was presented as normative, it is what police might do with such
surveillance opportunity that drug users feared. The power of the police was ubiq-
uitously perceived among drug injectors as limitless (captured by the Russian term
bespredel ).
The extortion of money and the planting of evidence were, for example, presented
as common practices, with the latter also resulting in unjust incarceration. Yet extor-
tion was seen as mundane. Drug users were participants in, and complicit with,
extortion. It had an immediate function, for money was exchanged for freedom.
This was seen as a risk management strategy.

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But police physical violence and assault was perceived entirely differently. Physical
violence by the police was experienced as an extreme act of moral indignation, aggres-
sion and subordination. It was police brutality that induced most fear: “I’m very
afraid;” “I was so shit scared;” and “Fear, fear, that is the main thing.” Fear acts as both
an effect and a force of structural violence. Here, Sergei (aged 27), an occasional
injector from Volgograd, tells a story of how police violence produces fear:
We were just standing, talking, with my girlfriend. So a policeman comes by and asks to
show my passport, as they always do. I didn’t have them. …So he takes me out into his
booth. …After they searched me and couldn’t find anything, they just started to call
someone, peek into my eyes, and say like I’m high or something. And they just start to get
to me. Then my girl comes in. They searched her too, and found the pack of Russian ciga-
rettes [where the cannabis was]. And that was it. Now we’re 100% junkies, and things are
off and rolling. He locks us both on to these bars. There were maybe five other people in
there. And he just starts to bully my girl. He says, “Your girl is a bitch, she’s a toad, a turd,
I can see it in her eyes.” And he starts to wind me up. And when I start reacting, he just tears
me out of there and starts to beat me, methodically on my belly, legs, and other parts so as
not to bruise me too much. Then when he got tired, he just stretched me out on the floor, put
handcuffs behind my back, pulled my legs through my arms and just left me there. I don’t
know how long I just laid there, or why they bullied me, even though I didn’t even have
anything. No reason. I don’t know what to call that. This is just scary. …I don’t know. I’m
still in a trance from all this horror.
The physical suffering narrated by Sergei has human rights and public health
implications. It also has practical consequences, as the internalization of fear exac-
erbates structural vulnerability to HIV and other health risk. A state of fear height-
ens concerns to evade detection, resulting in rushed injections, short-cuts in needle
hygiene, injecting in “hidden” locations (such as at dealers’ houses) and sharing
needles and syringes to reduce the risk of arrest for carrying injecting equipment:
“Fear. This is the main reason [for syringe sharing]. …You just try and inject quick,
quick, quick, and you don’t give a damn whether it’s clean” and “I am afraid, and so
I hide. And so everything [drug injecting] takes place [on the street] in filth.” Fear
can also lead to avoiding pharmacies and other needle and syringe outlets in an
attempt to avoid arrest should the police be present. More subtly, all state represen-
tatives, including helping agencies, become feared as a source of risk: “Although the
pharmacy was two houses away from me, always, always, the police stood there”
and “Why I haven’t gone to the exchange? Well, shit, I’m scared, that’s why. It’s
dangerous. Who knows who is there.”
It can be seen here how political processes of everyday violence cross over from
public space to traumatize personal space and then cross back as collective experi-
ence (Kleinman 1991). Policing practices feature inside a broader complex of
multiple interacting social and material inequalities, which over time become insti-
tutionalized and normalized. When internalized, the effects of such structural
violence may be expressed as individual deficits, as psychological harm, powerless-
ness, and fatalism to risk.
A second example of qualitative research, focusing on the policing of female and
transvestite sex workers in Serbia (Rhodes et al. 2008), illustrates further how polic-
ing practices targeting the vulnerable are best seen not in social isolation but as

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institutionalized expressions of a wider complex of normative social and moral
regulation. Among street-based sex workers in Belgrade and nearby Pan?evo,
violence, especially police violence, was a primary concern. While client violence
was not uncommon, police violence was perceived as the greater threat and as less
open to risk management: “You can manage your clients somehow, but to be honest,
the greatest threat to us is the police.” Sexual services were provided to police with-
out payment as well as secured by them through deception and coercion, often
involving violence or the threat of it: “And at the end of the job he shows me his
badge, and says like ‘Give me my money back now’. That’s what he does” and
“They want blowjobs, fucks. I work for free, just so they don’t take me in.” Attempts
to resist such demands could also incite violence: “He wants me to blow him for
free. I don’t want to. Later, when he gets me on my shift, he beats me silly. Beats me
silly” and “He beats me up with a baton. And several times I had to be [have sex]
with him. I really had to. I was forced.”
Being coerced into providing sex to police in this setting was described as an
exchange for freedom (from detainment, arrest or fine) enforced by a pervasive risk,
sometimes realized, of physical violence (Rhodes et al. 2008). Again, we see fear
induced by policing practices acting as an indirect force of structural violence.
Embodied fear produced fatalist risk acceptance to the inevitability of violence
(“I can’t fight destiny”) and an internalized sense of police “rights” to victimize
(“They have a right to beat us because we do this prostitution thing”).
This study shows that while serving to protect state and public interests, policing
practices can reproduce underlying societal injustices, fears and inequalities, includ-
ing regarding gender, sexuality, drug use and ethnicity. Enforced sexual acts and
payments to police were experienced as a form of governmentality, as if for moral
wrong doing, to “bring sex workers to their senses.” Significantly, police “moral
punishments” for selling sex were inextricably linked inside a broader complex of
social discrimination, especially towards Roma and transvestites. In Serbia, Roma
are a minority ethnic group subjected to immense social discrimination and Roma
sex workers, most of whom were Kosovo refugees and all of whom were working
as transvestites, were subjected to extreme acts of police violence:
They [police] kicked, kicked, kicked the hell out of us. Just transvestites. They took me to
the woods, down by the bridge. They stripped everything off me. Flashlight in the eyes. I
said a million times “Take me away. Did you come to arrest me? Arrest me then, but do not
beat me up”. That makes it worse: “Shut up, motherfucker, shut up!”
They [police] started going wild, only on us transvestites. They let the girls go. They just
pick us up, and go to the woods, and go wild on us. …First, they beat us in the woods, and
then they take us to the station. And then, they tell us at the station “Hey, freshen up”, and
they beat us up in the bathroom.
I didn’t know where the blows were coming from. …They just have this hate. Whether
it’s towards prostitutes or specifically trannnies. But it’s terrible.
We see in these examples how qualitative research documents the everyday lived
effects of the risk environment, shaping risk identities. Mapping pathways between
individual risk actions and their structural contexts is inherently complex because
these effects are reciprocal as well as often indirect and non-linear. They shape

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values and patterns of subjectivities that can promote risk-taking practices. In this
case example, fear and discrimination have direct as well as indirect effects on
individual and collective capacity to reduce risk. Fear and discrimination are vectors
of structural violence that can promote HIV risk. It is unlikely we could have
uncovered their importance through traditional epidemiologic methodologies.
10.4.2 Case Study Two: Gendered Power Relations
and HCV Seroconversion Among Street-Based
Youth IDUs
Data were drawn from a prospective cohort study of young out-of-treatment IDUs in San
Francisco (2000–2002) that included the simultaneous coordinated collection of epidemio-
logic survey research and anthropological participant observation.
In coordination with a prospective epidemiologic study of HCV and HIV
transmission among out-of-treatment youth injectors, we simultaneously collected
classic anthropological participant observation data among participants involved in
an epidemiologic study. The epidemiologic study screened young (< 30 years old)
IDUs for HCV and HIV and enrolled HCV-negative individuals into a prospective
cohort. Participants were re-tested for HCV and HIV and quantitatively interviewed
on a quarterly basis. A central aim was to explore behavioural differences between
those who seroconverted for HCV and those who did not. The primary ethnographer
was a young woman (approximately the same age as the average age of the youth
injectors) and also a former outreach worker and epidemiologic questionnaire
administrator for the project. She befriended and accompanied members of a series
of extended social networks of neighbourhood-based youth injectors in their natural
environment on the street. This involved frequenting street corners, parks, single
room occupancy (SRO) hotels, hidden injection locales, homeless encampments,
jails, hospitals, clinics, social service waiting rooms and needle exchange sites. She
also accompanied the youth injectors in their daily search for drugs and income
(primarily through panhandling, shoplifting, street-based sex work and retail drug
sales). Ethnographic participants were initially selected through a classic opportu-
nistic snowball sample of young women and men. Over time participants were then
more strategically selected through the infrastructure of the epidemiologic project
to develop causal explanations for social processes that might explain or contradict
the emerging findings on risky practices and seroconversion.
Almost immediately, because of the positionality of the ethnographer, the subject
of intimate partner violence within romantic relationships emerged as the primary
theme organizing the lives of the young women surviving on the street in these
social networks. The ethnographer was able to triangulate observational and self-
report data on how romantic sexual relationships affected the details of heroin and
methamphetamine injection practices as well as income generating strategies.
The ethnographic data revealed that newly arrived young women – especially those
under 18 – entering this adolescent drug scene developed romantic relationships

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with older, more experienced men who had violent reputations and who displayed
jealous dispositions. These relationships protected them from harassment and rape
by other men and also initially provided them with abundant access to drugs and
advice on how to be street smart. Because of their number of years on the street,
almost all of these “successful” domineering male street injectors were HCV
infected. Some women were self-consciously aware of the protective benefits of
selecting a partner with a “macho” and violent reputation. Most, however, under-
stood their choice of partner in romantic terms. Many interpreted violent male love
as inevitable and even desirable: “The more he hits you the more he loves you.”
The male partners generally attempted to oblige the women to conduct all their
drug consumption exclusively with them. They often insisted on maintaining physi-
cal control over needle use and administered injections to the women. This allowed
them to consume more than half of all the drugs they consumed together. It also
reduced the opportunities for the women to meet other men and form alternative
romantic relationships. Almost all the women eventually gravitated towards sex work
to raise money for drugs, both for themselves and for their romantic partner. Over
time, they would become the primary income generators within the relationship.
The ability to explore and document the details of the social logics for gendered
violence was informed by social science theories of gender power relations with an
emphasis on the concept of structural violence and the normalization of everyday
interpersonal violence. The ethnographer’s findings about the prevalence of violence
against women among street youth injectors and the romantic discourse surround-
ing it was also consistent with Bourgois and colleagues’ (2004, 2009) simultaneous
documentation of violence against women in other street-based drug use scenes.
Regular monthly meetings with the epidemiologic team allowed the project to
compare the emerging qualitative and quantitative findings and to redefine priorities
for both qualitative data collection and for statistical analyses. The primary epide-
miologic outcome measure for statistical analysis was seroincidence. At first
there was no detectable association between HCV seroincidence and gender,
despite the fact that the ethnographic findings strongly suggested that gender and
violence were primary factors driving risk for bloodborne pathogen infection. The
epidemiologists worried that the qualitative findings were driven by an ideological
bias towards feminist theory and had “no basis in the science.” Unfortunately, there
were no questions in the epidemiologic survey that assessed the factors uncovered
in the ethnographic research – particularly with respect to exposure to violence and
the details and influence of romantic relationships. New questions were drafted, but
the field staff responsible for quantitative interviewing expressed concerns that
asking sensitive questions about intimate partner violence and related issues might
be potentially traumatic for respondents. The field staff felt that asking such questions
might be considered unethical, given their lack of psychological therapeutic training
and dearth of services available. A number of the investigative team concurred, and
the proposed questions were never added. In contrast, using ethnographic methods
to discuss intimate violence was not ethically problematic. The research partici-
pants actively sought the company of the ethnographer to discuss their personal
concerns over violence in their lives. This occurred in the context of warm, long-term

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friendship relationships in their natural environment. It sometimes led to improved
self-protective behaviours on the part of the women.
By the end of the second year, the epidemiologic project documented an elevated
rate of seroconversion among women compared to men (34.4% versus 23.4%), but
this association did not reach statistical significance, possibly due to the inadequate
number of seroconverters (approximately 27 seroconversions per year). We searched
the epidemiologic survey for proxy variables for the social dynamics that were
being documented ethnographically. One factor we were able to document was an
age differential in sexual partnerships (i.e., men older than women). Also docu-
mented was a biologically implausible predictor of HCV seroconversion in the
survey data, i.e. having a sexual partner who is an injection drug user, despite the
current understanding that hepatitis C is very rarely sexually transmitted. This same
biologically implausible association has also been reported in the literature on other
large epidemiologic studies of HCV seroconversion (Miller et al. 2002). We were
able to draw on our qualitative data to identify this finding as being a proxy variable
reflecting gender power dynamics in romantic or sexually active dyadic relation-
ships generally permeated by violence, jealousy and control.
This case study highlights one of the multiple challenges of integrating theory
and methods into a social epidemiology of risk. The association between being a
woman and HCV risk was tenuous and difficult to document through the quantita-
tive data, despite the overwhelming qualitative evidence of the young women being
at consistently more elevated risk then young men immediately upon entering the
street scene. How can this lack of concordance between the two approaches be
explained? One explanation is that variables that measure significant social power
categories (such as gender and race/ethnicity) are highly correlated with many other
variables and behaviours; therefore, it is difficult to disentangle them from other
closely related variables. This is further complicated by the fact that significant
power categories often have contradictory effects on risk. In certain contexts they
can be protective and in others risk-enhancing. As an example, a woman in a
relationship with an older, violent, highly controlling male who forbids her to inject
with others may be both protected by the power relationship (in that the size of the
pool of people she injects with shrinks) and put at risk by that same violent power
relationship (if the male partner is infected with hepatitis C and controls all aspects
of injecting). The complexity of overlapping disjunctive risks and vectors propelled
by social dynamics may explain the often contradictory findings across studies and
within studies around the category of gender and sexuality in the United States (e.g.,
Bourgois 2002; Bourgois et al. 2004; Collier et al. 1998; Strathdee et al. 2001; Hahn
et al. 2001). These inconsistent quantitative findings illustrate the utility of introduc-
ing the social science concept of “social structural plausibility” in conjunction with
that of biological plausibility and statistical association (Auerbach 2009).
A second explanation for the lack of concordance rests in the differing aims and
methodological foci of the epidemiologic and ethnographic components of the
research. The stated aims of the quantitative research were to find behavioural dif-
ferences between those active injectors who became infected with hepatitis C and
those who did not. Within this framework, an ideal outcome would have been to

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discover a significant association between seroconversion and a specific injecting
practice, leading to an individualized behavioural intervention that would assist
individual injectors to avoid infection. By contrast, the ethnographic research was
inherently more oriented toward exploring and describing structural risks – in this
case, the complex interplay between gender power roles and the normalization of
romantic violence and seroconversion described above. It is, therefore, perhaps
unsurprising that the micro-practice-oriented quantitative data did not speak well to
the broader structural issues emerging from the qualitative data.
Large-scale epidemiologic projects also have what might be termed a “logistic
inertia.” Statistical methods usually hinge on testing specified hypotheses, which, in
turn, tend to require large sample sizes to produce statistically significant outcomes.
As such, re-purposing a quantitative study in midstream to respond to emerging
findings requires a fundamental re-design of the study. In anticipation of this logisti-
cal inertia, the co-investigators and project directors of the ethnographic arms of the
study held discussions during the grant writing phase before beginning the study to
develop one neutral, quantifiable question about whether respondents had “pooled
money with others to buy drugs to inject.” This question tested an anthropological
hypothesis about the risk imposed by the reciprocal obligations for paraphernalia
sharing imposed by the “moral economy” of drug exchanges (Bourgois 1998). This
variable had no biological meaning, in that pooling money in itself cannot result in
the transmission of a bloodborne virus, but it did have clear connections to the social
contexts in which paraphernalia sharing can occur. Interestingly, this variable was
one of only four variables independently associated with HCV seroconversion in
multivariate analysis (Hahn et al. 2002).
The overarching pragmatic lesson from this collaborative study was that planning
for mixed-methods studies must go beyond the boilerplate text now often used to
justify such collaborations on grant proposals and must assume from the beginning
of the study that both qualitative and quantitative processes will generate observa-
tions that can be tested or explored by the other. As such, thought needs to be given
to how this will be carried out, for instance, through regular meetings, circulation of
fieldwork notes and preliminary statistical analyses, development of proxy variables,
additional targeted sampling and so on.
10.4.3 Case Study Three: Structural Violence, Power and HIV
Prevention Among Female and Transgendered Sex
Workers in an Urban Setting
Data were drawn from a multi-methods, community-based research study (2005–2008) in
partnership with a local sex work agency in Vancouver, Canada.
This study was developed as a community-based research partnership between an
academic institution and a local sex work agency to examine the factors shaping HIV
prevention among street-based sex workers over a 2-year period (Shannon et al.
2007). The study was conceived as a multi-methods study using a participatory action

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research approach, including an open prospective cohort (interview- administered
research questionnaire and HIV screening at baseline and semi-annual follow-up
visits over a 2-year period), social mapping completed alongside each questionnaire
study visit and purposive sampling for qualitative in-depth interviews with a subset
of the study sample (street-based sex workers). The study was purposefully designed
to integrate a team of current and former sex workers as “peer researchers.” This
team of peer researchers served as both key informants or experts and research facili-
tators. They were involved in content and questionnaire development and facilitation
and interpretation of results, together with the academic research team. Their lived
experience as sex workers and sometimes inconsistent consumers of public health
messages provided critical “insider” insight into the complexities and dynamics
shaping HIV prevention in the street-based sex industry.
Within Vancouver, Canada, as in many other international settings, the buying
and selling of sex is legal, and yet criminal sanctions exist around most aspects of
sex work (such as communicating and soliciting in public spaces, operating a brothel
and living off the avails of prostitution). This study contributes to the growing litera-
ture on how enforcement of criminal sanctions facilitates the exacerbation of “risk.”
Specifically, despite substantial program availability of HIV prevention resources in
the inner city community of Vancouver (an area known as the Downtown Eastside),
this study’s findings collectively revealed how structural violence mediates
individual agency, reducing the capacity of sex workers to access resources and
negotiate risk reduction (Shannon et al. 2008a). Our analyses of narratives drew on
the risk environment framework (Rhodes 2002) and theoretical constructs of vio-
lence and power that emphasize the interconnectedness of interpersonal (Scheper-
Hughes 1996; Bourgois et al. 2004), structural (Farmer 2004) and symbolic (Epele
2002; Bourdieu 2001) violence. We drew on a broad understanding of power and
agency, building on earlier ethnographic studies (Bourgois 1998; Wojcicki 2002;
Wojcicki and Malala 2001), which explored ways in which sex workers’ decision
making and interpersonal risk negotiations might be rational, economic coping
strategies in the face of social and structural violence. This relational understanding
of power is developed in post-structural feminist critiques of institutionalized forms
of social control and the discursive production and regulation of sexuality (Foucault
1981; Nencel 2001; Weedon 1987). At the micro level, the ubiquitous “everyday
violence” of “bad dates” (i.e., violent clients) intersected with a discourse of dis-
posal of symbolic violence and a lack of legal recourse to violence at a macro level
in forcing sex workers to prioritize the immediate threat of violence over the nego-
tiation of condom use with clients. At the meso level, local policing and enforce-
ment of criminal sanctions (such as legal restrictions on working indoors) affected
sex workers’ control over dates and their ability to negotiate HIV risk reduction,
both directly through the threat of police violence, harassment and coercion and
indirectly through displacement to isolated public spaces and lack of access to safer
indoor spaces to service clients.
This study’s qualitative work was conducted by the same team members in
parallel with social mapping and baseline quantitative data collection and helped
inform questionnaire development and subsequent social epidemiologic constructs,