Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach

Cornell University, Итак, New York, United States
PLoS Medicine (Impact Factor: 14.43). 11/2006; 3(10):e452. DOI: 10.1371/journal.pmed.0030452
Source: PubMed


Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level.
We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its "War on Drugs." African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off "dopesickness" rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories.
Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.

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    • "African Americans may have also had increased exposure to harm reduction messages over a longer period than whites. The racial disparity in abscess prevalence observed here is consistent with the prior study suggesting that whites practice riskier injection behaviors compared with their African American peers (Bourgois et al., 2006; Williams et al., 2013). Contrary to other studies, speedballing was not correlated with a current abscess or abscess history. "
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    • "To reduce distortion of data due to social desirability responses, interviews were conducted in a conversational format as drug users were actively involved in their routine activities. This classical anthropological strategy of participants’ observation allowed a triangulation of responses to conversational prompts [19]. "
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    • "Another African American man, who had just been treated for an abscess, explained that the abscess had been caused by missing a cocaine injection and not by purposefully injecting heroin into fatty tissue. He insisted defensively that this was the first abscess he had ever had in his injection career (Bourgois et al., 2006). Nonetheless, the fact that relatively large numbers of whites engaged in practices that violated ethnic patterns identified as relatively absolute by the ethnographic data demonstrates the importance of considering ethnic crossover behaviors at the larger population level. "
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