Our cross-methodological inquiry found substantial agreement between the ethnographic and epidemiological data. Among older injectors, statistically significant differences were found in nine of the 14 epidemiological variables that our ethnographic data and clinical observations predicted would differ between older African Americans and older whites. There were some discrepancies, however, between the ethnographic and epidemiological data. On five of the 14 variables older African Americans and older whites did not differ significantly (cocaine injection and income from: job, illegal sources, social services, and family/friends), contrary to what we expected from our ethnographic data. Furthermore, in several of the variables that differed significantly, the differences were considerably smaller than anticipated.
Some of these differences between the ethnographic and epidemiological data are worthy of interpretation. The unexpected lack of difference with respect to cocaine injection may be due to the fact that the UHS samples a wider range of white social networks in which cocaine is more prevalent than in our ethnographic sample, such as among sex workers or among higher status street injectors. The lack of statistical significance for most of the income variables, on the other hand, may simply be due to recall error and/or to social desirability bias, especially when reporting criminal versus legal income in a formal, face-to-face interview. Most importantly, the epidemiological data indicate that in everyday practice individuals often violated the “ethnic ideal types” that we identified ethnographically. The small differences between African Americans and whites on several of the variables demonstrate the risk of stereotyping racial and cultural categories. For example, even though older African Americans were significantly less likely to report income from panhandling, a practice they considered low in prestige, 17% still reported that source of income. Similarly, although we never observed older whites purposefully injecting speedballs during our decade of ethnographic fieldwork, 41% of whites on the epidemiological survey reported having injected a speedball in the last 30 days. Furthermore, even when distinctions were substantial between ethnic groups on a variable, diversity around those distinctions existed among individual members within the same ethnic group.
Our ethnographic data suggest that the meaning of ethnicity is affected by “social structural” forces such as the existence of youth gangs, the disappearance of industrial jobs, the segregation of neighborhoods, and the organization of families, which in turn are also affected by public policies such as law enforcement, public education, or job training. The congruence of these macro-power vectors may explain the generational ethnic patterns in drug use and homelessness that have been documented by ethnographers [24
], epidemiologists [21
], and historians [23
]. For example, the outlaw persona that most of the older African Americans in our ethnographic network projected can be understood as a specific relationship to a definition of masculine dignity that was persuasive for a historical cohort of poorly educated, young inner city men from working-class families headed by parents who were rural immigrants fleeing the economic servitude and racist legislation of the Deep South [56
]. This older generation of African American heroin addicts came of age in San Francisco in the 1960s and 70s when heroin was fashionable and readily available to street-based youth who celebrated an oppositional outlaw identity. The loss of unionized jobs for high school drop-outs simultaneous with the rise of segregated youth gangs in Californian inner cities that excluded whites in the mid-1970s and decreased funding for public schools in impoverished neighborhoods resulted in the disproportionate incarceration of African American teenagers for gang fighting. This pattern is consistent with national statistics revealing that urban African American and Latino communities experienced the brunt of the expansion of incarceration rates under the prosecution of the War on Drugs [58
]. In this institutional and political economic context, masculine models of achievement among a subgroup of poor African American youth may have shifted away from the legal manual labor employment that their parents had actively sought.
Clinically oriented ethnographic research provides rich contextual data that can help explain problems and paradoxes affecting the health and health care of populations. It can also offer interpretations of epidemiological data as well as socially plausible causal explanations for associations. Bringing quantitative and qualitative perspectives into conversation among researchers collaborating across disciplines has the potential to create an analysis that is richer than the sum of its parts, especially for clinicians who rely on quantitative evidence-based data, but whose practices include diverse patients with complex case histories [59
Understanding patients—their histories, perspectives, and expectations—enables successful clinical encounters. The anthropological technique of cultural relativism, which is distinguished by suspension of moral judgment, self-reflection on biases, and an attempt to see the clinical encounter through the eyes of oppositional patients is key to this endeavor. Clinical practices and protocols can benefit from an understanding of how risk behavior and resistance to authority are ethnically scripted. When we accompanied injectors to the county hospital we sometimes observed confrontational interactions with hospital staff and medical practitioners. If oppositional behavior is taken at face value and is treated as a personal, racial, or fixed cultural characteristic, health care providers may define patients as belligerent and cease attempting to deliver optimal care. For example, behaviors that are seen as unacceptable in the clinic, such as cursing, shouting, threatening, and acting angry may be seen by the patient as functional and respected—even dignified—ways of asserting one's rights, self-control, and intelligence on the street. Clinicians who recognize the “outlaw” and “outcast” as socially determined personae, and who understand the dramatic social structural vulnerabilities that can prevent patients from interacting effectively in health care settings, may be able to engage more productively with these challenging and nonadherent patients. Effective clinicians set clear, explicit expectations and respond consistently to behaviors that violate those expectations, without terminating or withholding care unless absolutely necessary [34
]. (See also pp. 164–167 in [61
One under-reported aspect of culturally competent care potentially benefits clinicians because more understanding may cause less frustration. In our observations of clinical interactions, physicians often reported encounters as frustrating even when the street-based injector felt that it was positive. On several occasions exhausted medical residents who were well liked by our participants broke down when describing their cases to us. They interpreted the oppositional and nonadherent behavior of their patients as a personal affront. Disengaging from this sense of personal betrayal and/or failure is key to improving the clinical relationship with challenging populations. Furthermore, we found that even when behaving negatively in the clinical encounter, street-based injectors often wanted more care but faced logistical challenges to adhering to medical instructions due to their precarious physical living conditions (see photo by JS at http://www.publicanthropology.org/Photogallery/B&SFelix-recuperates.htm
). The most frequent complaints to us by older injectors revolved around early release from inpatient care and refusal of admission to emergency care. (The patient shown in the intensive care unit photo by JS at http://www.publicanthropology.org/Photogallery/B&S-Jesse,Hank,Petey.htm
spent six weeks in the hospital recovering from hepatic failure. The day before falling unconscious, he insisted that he was not “sick enough” to warrant admission when the photoethnographer offered to drive him to the emergency room. This photograph also reveals a cross-ethnic expression of solidarity and emotional vulnerability in the safety of the intensive care unit.) In sum, a culturally and institutionally competent understanding of ethnic populations of drug injectors may reduce difficult clinical interactions and resultant physician frustration while improving patient access and adherence to care—and diminish extreme forms of suffering.
Two of the epidemiological variables we used to explore ethnic distinctions directly measured health outcome and clinical care delivery—self-reported abscesses and receipt of methadone treatment. Consistent with national epidemiological data [62
], our methadone findings suggest that institutional barriers blocking African American access to methadone treatment need to be addressed. Our ethnographic findings confirm the anthropological literature from across the US suggesting that methadone clinics are organized in a manner that is overbearing and repressive to many patients. Some injectors, especially self-respecting outlaws, consider methadone maintenance to be a badge of shame [63
]. (We did not include HCV and HIV infection as variables for ethnic comparison, because HCV is highly infectious and exceedingly prevalent in our population. HIV, in contrast, has a relatively low prevalence and responds to many confounding behavioral and structural risks. Every member of our ethnographic network was HCV positive, compared to 85.1% of the larger UHS sample of men who inject heroin. Only one member of our ethnographic sample was HIV positive, and he was the only man to report having sex with men. Overall HIV prevalence in the larger UHS sample of men was 9.1%.)
Ethnic differences in injection practices may explain the higher rates of abscesses among white injectors, but they do not sanction ethnic-specific clinical and preventive practices. Clinicians can engage effectively with injectors of any ethnicity by discussing practices that promote vein longevity [67
] and that reduce bacterial and viral infection risks [69
]. (See again photos by JS at http://www.publicanthropology.org/Photogallery/B&S-Sid-in-Hole.htm
, to note the practical challenges to adhering to hygienic injection practices on the street.) On an institutional level, outpatient wound clinics specializing in management of injection-related complications in a nonjudgmental manner can provide a high level of care at less expense than the inpatient and emergency units at which most injectors access abscess care [32
]. Similarly, needle exchanges and clinics tailored for specific categories of injectors such as youth, women, sex workers, or men who have sex with men can bring especially high-risk drug users into regular contact with treatment and prevention services.
Public health institutions and clinicians are in an effective position to take more leadership to reduce the unintended negative consequences of law enforcement practices on the health of street-based populations. The efforts of clinicians and public health outreach workers are too often directly contradicted by police in the very same community—especially when officers aggressively confiscate the possessions of street people and repeatedly search suspected addicts for syringe possession [72
]. Addressing the unintended health consequences of law enforcement at both the policy and the community level is especially important for African American injectors who are in disproportionately negative contact with the police. More broadly, regardless of the ethnicity of patients, clinical and public health initiatives are most successful when they lower barriers to care by engaging drug injectors nonjudgmentally around risk reduction to prevent the harm associated with drug use. These approaches do not necessarily demand abstinence as a prerequisite for accessing services and are generally referred to as “risk reduction” or “harm reduction” (see, for example, the World Health Organization definition of the term [79
Self-report distortion with respect to sex, drugs, and crime is well documented in both the ethnographic [49
] and epidemiological literatures [80
]. An NIH/National Institute on Drug Abuse-funded cooperative agreement, for example, documented validity and test-retest reliability for injection drug use data, but low reliability for the details of needle sharing practices [85
] The challenge posed by socially desirable responses is not limited to quantitative data. All of the older injectors had received public health counseling on numerous occasions and knew the details of HIV transmission risk through injection practices. In the shooting encampments, for example, we photographed addicts engaging in unsanitary sharing of paraphernalia at the same instant that we tape recorded them asserting their commitment never to share paraphernalia.
Our ethnographic research participants do not represent the range of street-based injection drug users in San Francisco, because we purposefully limited our sample to one social network of older heroin injectors to document risk behavior through participant observation in a natural setting. Our qualitative data benefit from being put in quantitative context within the large UHS epidemiological database, but their generalizability remains limited. Ethnographic methods are subjective by definition. An ethnographer's personality and theoretical orientation as well as the serendipity of everyday social interaction affect access to participant-observation data.
Our epidemiological data benefited from 17 years of community-based sampling and interviewing by an experienced staff. Targeted sampling avoids the selection bias inherent in recruiting drug users from institutions such as clinics, emergency rooms, substance abuse treatment facilities, or the criminal justice system. It is not possible, however, to obtain a definitively representative sample of hidden populations who engage in illegal drug use. Our street-based recruitment disproportionately sampled injectors who were able to participate in study procedures during daytime hours; those who wanted and needed the nominal stipends we offered; those who were willing to identify themselves to study staff (and other study participants in their community) as illicit drug injectors; and those who liked their previous experiences when participating in the UHS. Finally, age effects are part of the African American versus white differences we are documenting epidemiologically, and they may also confound the ethnic categories, because African Americans had a higher median age than whites in all quartiles (49 years [interquartile range 45–53] versus 40 years [interquartile range 33–47]).
Conclusion: Replacing Race with Ethnicity
Merging epidemiological, clinical, and ethnographic data demonstrates the importance of understanding ethnicity as a product of social and historical configurations. An individual's relationship to ethnic ways of being in the world is fluid and changes over time. It is shaped by identifiable social structural forces including immigration patterns, labor market segmentation, and social and spatial interaction. The variable “race” that is collected on all NIH-funded studies is more usefully understood as a socially constructed form of ethnicity that is specific to the US, where skin color imposes an experience of racism at the everyday level which sometimes results in distinct patterns of behaviors, values, and demographic characteristics.
Clinical cultural competence requires an awareness of the social embeddedness of individuals and populations. Understanding the social and structural forces that affect group identities allows for a better appreciation of the variation in individual behaviors that harm health. It also provides a tool for reducing institutional barriers to optimal care for socially vulnerable populations. Excellent cultural competency requires an excellent evidence base. Sociobehavioral epidemiology needs to expand its database on the social and cultural determinants of health and health disparities, including deeper exploration through multidisciplinary approaches of the underlying reasons for observed associations or differences. Social epidemiology requires not only the usual standard of biological plausibility to identify credible casual associations, but also social plausibility. Providing clinicians and public health advocates with the tools to identify the social and structural logics that produce nonadherent behaviors that appear to be racially inscribed or to be the product of individual malevolence may be a first step toward addressing economic and ethnic disparities in health.