Upload
robert-power
View
213
Download
0
Embed Size (px)
Citation preview
The application of ethnography, with reference to harm reduction inSverdlovsk Russia
Robert Power *
Department of STDs, Mortimer Market Centre, University College London, London WC1E 6AU, UK
Abstract
This article describes and explores ten ways in which ethnography has and can be utilised in relation to harm reduction and illicit
drug use. These are by no means exclusive, nor mutually exclusive, but indicate the range of practical applications of ethnographic
methods: (1) as part of a multi-indicator research strategy; (2) in developing action research projects; (3) in formative evaluations
and rapid assessments; (4) as part of social network and mapping exercises; (5) in setting the scene for prevalence surveys; (6)
complementing epidemiological studies; (7) confirming and augmenting other research findings; (8) as an integral part of process
evaluation; (9) in the context of randomised controlled trials; and (10) of value in its own right. Ethnography has much to offer the
study and promotion of harm reduction and should be encouraged as an integral part of project evaluation, as well as in furthering
our appreciation of the context and subtlety of social behaviour.
# 2002 Elsevier Science B.V. All rights reserved.
Keywords: Ethnography; Harm reduction; HIV/AIDS; Drug use
Introduction
Following good sociological practice, let me, from the
outset, state my position as a researcher. Principally, I
have a pragmatic approach to research strategy and an
eclectic attitude to methodology and analysis. In other
words, I believe a prime task for any researcher is to fit
the method or methods to the research question under
examination. In this context ethnography (especially
through participant observation) is one of a range of
interchangeable options open to the qualitative (or
quantitative) researcher. It is my experience that the
general principles and practice of ethnography can be
used flexibly and imaginatively to supplement and
complement other methods. Unlike classical anthropol-
ogy and ethnography, it is not always necessary nor
feasible for the contemporary researcher to totally
immerse his or her self into the field of study. Famously,
during the First World War, Bronislaw Malinowski
(1884�/1942) spent several years studying the Trobriand
Islanders (Malinowski, 1922). In July 2001, I spent one
evening on a mobile syringe exchange in the small town
of Pervouralsk, in the Urals in Russia, observing the
comings and goings of drug injectors. Here is an excerpt
from my field notes:
‘‘. . . Everyone was really proud of the new bus.
They had inherited it from the city health author-
ity, that had gotten it from the tax department,
that had originally acquired it from a coach
company, that had gone to the wall owing back-
tax. It was unrecognisable from the shell we had
seen last winter. It had new wheels, the bench-seats
had been taken out and a new door put on the
side. Shelves had been built to hold the materials
(needles, syringes, condoms etc) and there was a
place for Marina (exchange worker) to sit when
the bus was stationary. This showed the value of
the London and St. Petersburg study tours, with
the Sverdlovsk team adapting what they saw to
their own resources and needs. Marina’s bus had
features of the mobile exchange programmes from
both London and St. Petersburg. Four sites in the
town had been identified as good places to
distribute syringes and now after 3 months drug
users were coming regularly (or so we were told
and so the Urals Medical Academy monitoring* Tel.: �/44-207-380-9949; fax: �/44-207-388-4179
E-mail address: [email protected] (R. Power).
International Journal of Drug Policy 13 (2002) 327�/331
www.elsevier.com/locate/drugpo
0955-3959/02/$ - see front matter # 2002 Elsevier Science B.V. All rights reserved.
PII: S 0 9 5 5 - 3 9 5 9 ( 0 2 ) 0 0 1 1 7 - 2
statistics showed). Decided to check it out and
asked Sergie (project manager) if it would be ok to
go on the bus this very day. I did not want any
special plans made. He was happy about it, so wasMarina. The drug users would be ok as they were
getting used to research and to seeing the occa-
sional new face. Baseline data and a ‘‘satisfaction’’
type survey had already been collected by research
workers from the Medical Academy, and, in fact, I
am part of the same team.’’
‘‘The first stop was a housing estate on the fringes
of town. The bus had no markings. It was muchlike many of the battered old trucks that trundled
around the towns and cities. We parked up on a
non-descript bit of ground surrounded on three
sides by ten-storey Soviet-style apartment blocks.
For some of the time I sat in the back and chatted
with Marina. Helped with the stocks. The drug
users were used to the timing of the bus’s visit and
within a few minutes the first group arrived. Twoyoung men and a woman. One had a plastic bag
full of syringes. He came into the bus while the
other two stood around smoking. He gave his code
number and Marina found his card. She and
Valerie (the interpreter and project administrator)
explained who I was. Marina handed out the
needles and syringes and then talked about safe
sex and offered condoms. These were accepted. Wespoke with the group of three for a while and they
said how much they valued the bus and were
telling all their friends about it.’’
[fieldnotes: Thursday 20 July 2001, Pervouralsk, Sver-
dlovsk].
Would Malinowski have considered this to be ethno-graphy? There are no deep insights into social relation-
ships, no immersion into the culture of the drug users,
no great time commitments. I was not even a fluent
Russian speaker, which meant I had to rely on our
interpreter. Yet, and I will argue and illustrate further in
this article, that the adaptation and application of
ethnographic methods can result in valuable insights
into social phenomenon. In the example cited above,this brief piece of participant observation allowed me to
confirm a number of research questions that needed
ratifying (something along the line that ‘seeing is
believing’). Let me list some of these: (1) The bus had
been repaired and refurbished appropriately. (I was part
of the project team that allocated funding for this). (2)
The bus was stocked with a good supply of needles,
syringes, other injecting paraphernalia, condoms andhealth promotion literature (rapid assessments had been
conducted at each site to assess drug trends and injecting
patterns to inform supply decisions). (3) The bus was
stopping at sites where drug users congregated and
where they felt safe to use the service (the rapid
assessment and research interviews with drug users
attending the narcology service had identified appro-priate stop-off points). (4) Drug users were returning
used syringes and collecting sterile ones in return. (Most
Russian syringe exchange programmes operated one-to-
one exchange, but we were encouraging secondary
distribution where possible). (5) Marina (the worker
on the bus) took time to discuss health promotion issues
with the drug users and to offer them condoms as well as
injecting equipment (although currently drug injectingaccounts for over 80% of HIV cases in Russia, a
comprehensive approach to harm reduction was being
encouraged).
As well as being satisfied by these various service
delivery or process evaluation observations, this bite-
sized piece of participant observation ethnography gave
me insights into the way in which Marina related to the
drug injectors. I noticed an ease in her manner, laughterand rapport with the drug users, which is so crucial in
delivering low-threshold harm reduction programmes.
These type of data can only be witnessed first hand,
through observation and ethnography. The lessons from
these field notes complemented data we were collecting
from other sources including questionnaire surveys,
monitoring forms, focus groups and semi-structured
interviews.
The practice and application of ethnography
I have argued elsewhere that one of the main
problems with much research in the field of drug use
is the over-reliance on self-reported accounts, especially
concerning risk behaviour (Power, 2001). Here I want to
stress the practical value of an eclectic approach to
ethnography, both in terms of process and outcome
research and also in the ways in which it complements
other research methods and paradigms. I will suggestten ways, neither exclusive nor mutually exclusive, in
which ethnography can be usefully employed in social
behavioural research related to drug use and harm
reduction.
As part of a multi-indicator research strategy
At the most general level, ethnographic observation is
invaluable as part of a composite package of research
tools, where each endeavours to provide complementary
and/or confirmatory data to shed light on social
behaviour, or even treatment outcomes (Stahler &Cohen, 2000). We can use questionnaire surveys and
focus groups, semi-structured and in-depth interviews to
hear what people have to say about a social phenom-
R. Power / International Journal of Drug Policy 13 (2002) 327�/331328
enon, but ethnography (through participant observa-
tion) encourages us to see it for ourselves.
In developing action research projects
Action research projects require rapid feedback in
order to tailor and refine interventions. This is often the
case for harm reduction projects, especially in the
context of emerging epidemics, such as in the Newly
Independent States and the Russian Federation, where
intervention and evaluation often takes place in tandem.
There is a clear role for ethnographic research here,
especially when outreach workers are trained in quali-tative research skills. A precedent for this was the AIDS
Demonstration Projects in the USA during the 1980s
and 1990s, where an ethnographer was included in the
outreach teams (Broadhead & Fox, 1990). Part of this
individual’s task was to feed-back information from the
street so that interventions could be adapted accord-
ingly. In order to maintain contact with the drug user
population, long-term commitment of the ethnographermay be the preferred option. However, time and
resource limitations do not always permit this.
Through formative evaluations and rapid assessments
A prerequisite for any harm reduction intervention
should be a formative evaluation to describe the target
group, drug patterns, drug scenes, existing drugs, socialand health service provision and other related factors.
This has intrinsic value in increasing our knowledge
base, but, perhaps more importantly, sets the scene and
lays the foundation for developing community-level
interventions. When targeting hidden populations, and
especially those involved in illicit activities, such as drug
abuse, ethnographic research is one of the best (if not
the best) methods of describing the drug patterns,behaviours and contextual factors. Without this depth
of knowledge the subsequent design of an intervention
may be inadequate or inappropriate. Rapid assessment
studies, with ethnography and participant observation
as integral components, have become increasingly
popular as a method of formative evaluation. Rapid
assessment and modified ethnography are particularly
well suited in developing countries where researchresources and expertise are often lacking (Rhodes et
al., 1999; Power, 2000).
Social network and mapping exercises
Drug use and the spread of HIV takes place between
networks of people and in a variety of spatial and
temporal locations (Friedman et al., 1997). Conse-quently, we need to deepen our understanding of social
networks and also map the venues and locations where
drug use and high-risk activities take place. This not
only increases our knowledge and appreciation of the
dynamics of drug user networks, but it is critical in
planning and refining targeted health interventions.
Ethnography, through observation, snowballing andcontacting and nurturing key informants, provides the
means and the methods to accomplish these important
tasks.
Setting the scene for prevalence surveys
There is currently much emphasis on the need for
HIV harm reduction interventions to demonstrate that
they are reaching substantial proportions of the targetpopulations of injecting drug users. The issue of ‘cover-
age’ can only be meaningfully assessed if there is some
indication of drug use population prevalence. Viable
methods, such as capture/recapture, rely on a clear and
concise understanding and description of drug trends,
treatment and enforcement systems. Ethnographic stu-
dies can contribute to this process and inform preva-
lence studies by providing key qualitative data, such asthe characteristics and profiles of the target populations
and their help-seeking patterns (Agar & Kozel, 1999).
Complementing epidemiological studies
Kane (1991) noted that qualitative research has an
important role to play in our understanding of social
aspects of AIDS by augmenting and enriching thestatistical predictions of epidemiological research.
More specifically, we could say much the same about
ethnography, where direct observations have comple-
mented epidemiological studies. This is most notable
around the nuances and variations in injecting practices
and issues relating to risk behaviour. In the early years
of HIV research epidemiological studies used blanket
concepts of HIV risk behaviour relating to injecting. Butthe work of ethnographers was valuable in complement-
ing, explaining and expanding on these quantitative
findings. For example, Grund, Kaplan, Adriaans and
Blanken (1991) described in detail the process of front
and back-loading when preparing and using heroin and
Koester, Booth and Wiebel’s (1990) ethnography high-
lighted the significance (and dangers) of the sharing of
drug injecting paraphernalia. This is a two way processand ethnographic findings such as those described can
lead to quantitative and epidemiological studies.
Confirming and augmenting other research findings
Ethnography can also be used to explain and explore
findings and conclusions from other research studies.
Notable in this respect was the surprisingly negativeresults from the monitoring of the needle and syringe
exchange in Montreal. A cohort study had shown high
rates of HIV infection among injecting drug users
R. Power / International Journal of Drug Policy 13 (2002) 327�/331 329
participating in the needle exchange programmes (Bru-
neau et al., 1997). An ethnographic study reinforced
previous qualitative research to show this could in part
be explained by factors that were not picked up by thequantitative study, including prolific cocaine injecting
and the fact that many of those who used the needle
exchange programmes led chaotic and high risk lifestyles
(Bourgois & Bruneau, 2000). This augmenting and
refining of research findings between quantitative and
qualitative studies can work in both directions. In a
study of injecting behaviour in Britain, an interesting
observation relating to social etiquette around filtersharing was observed during ethnographic fieldwork. To
explore the extent of this practice, a number of relevant
questions were appended to the British arm of a
quantitative WHO study. The results confirmed the
researchers’ hunch that the practice was not an isolated
one, but occurred in other parts of the country (Power,
Hunter, Jones & Donoghoe, 1994).
As an integral part of process evaluation
Harm reduction programmes to arrest the spread of
HIV infection amongst injecting drug users (especially
focusing on needle and syringe exchange programmes)
are promoted world-wide. It is now common practice, as
well as desirable, for such initiatives to be evaluated, at
the very least in terms of processes, if not outcomes (As
an aside, social behavioural research in the drugs-fieldremains poor on outcome evaluation, both in terms of
methodology and output). Ethnography can be usefully
employed in process evaluation and service delivery
studies in a number of ways. One, to witness and record
the interaction between service providers and the target
group. Two, to describe whether or not the service is
being delivered as assigned. Three, to observe the setting
and context in which the intervention takes place. Thislatter point is particularly relevant when harm reduction
activities (such as outreach and mobile needle and
syringe exchange programmes) take place in the com-
munity, where it is critical that the most appropriate
locations are selected. The Sverdlovsk experience briefly
described above is illustrative of the role of ethnography
in assessing community-level service delivery.
Ethnography in the context of randomised controlled
trials
Much emphasis has been placed on the potential for
randomised controlled trials and other experimental
methods in social behavioural research (Oakley, Full-
erton & Holland, 1995; Stephenson & Imrie, 1998).
While there have been a number of ethical concernsaround randomisation issues in the context of harm
reduction, the potential for comparing ‘standard’ and
‘enhanced’ interventions should be explored further
(Rietmeijer et al., 1996). Qualitative research and
ethnography can add a much needed dimension to
what is classically deemed the preserve of quantitative
research. This is at three levels. First, as part of theformative evaluation to develop the intervention to be
trialed. Second, during the process evaluation stage,
when the ‘black box’ of service delivery is examined.
Third, at the outcome evaluation stage by encouraging,
in part through ethnography and contact with drug
users, a participatory approach whereby the findings are
appraised by the target population.
Ethnography is of value in its own right
Articles of this nature normally begin by stressing the
long and proud tradition of ethnography and partici-
pant observation in the drugs field. Indeed, ethnography
has in the past, does in the present (and surely will do in
the future) have credibility and intrinsic value in its own
right. It is exciting, unique and instructive to read raw
observational accounts of the lifestyles and experiencesof drug users and others forced to the margins of
society. There are many examples of studies that have
provided a rich vein of marvellously detailed data to add
to our collective and historical knowledge base, in a way
that would not have been possible without an ongoing
commitment to ethnography [see for example, Grund et
al., 1991; Agar, 1979; Becker, 1953; Adler, 1985; Feld-
man, 1968; Moore, 1993; Murphy & Waldorf, 1991;Taylor, 1993; Williams, 1989). We should emphasise and
reiterate the value of classic ethnography.
Concluding remarks
I have worked as an ‘immersive’ ethnographer,
spending hours and days with groups of drug users. Ihave used ethnographic techniques as part of a multi-
indicator approach and as an integral part of rapid
assessment. And I have used ethnography to confirm
and augment findings from epidemiological studies. I
am sure this depth of experience has equipped me with
something of an ‘ethnographic imagination’ (to borrow
from C. Wright Mills), one which sharpens the eye and
senses, allowing and enabling a switch between varyinglevels and depths of investigation. Some may argue
much of what I have described in the body of this article
is at best ‘parachute ethnography’ (Bourgois & Bruneau,
2000) and at worst heretical. I am not overly worried
either about semantics or orthodoxies. At one level, the
body of individuals committed to the international harm
reduction movement contains a healthy mix of practi-
tioners and academics: those who intervene and thosewho research. I hope the approach to ethnography I am
espousing will go some way to bridging the divide and
demarcation of labour that often exists between these
R. Power / International Journal of Drug Policy 13 (2002) 327�/331330
two camps. I will leave the semantic and academic
debate to others.
About 6 years ago I moved from an academic
department in which social science and the qualitativeresearch paradigm was largely unchallenged to an
academic department in a medical school sited in a
busy STI and HIV clinic. Here, epidemiology, clinical
trials and basic science formed the predominant research
approach. Yet over recent years there has been a sea-
change, which has impacted on research agendas at local
and national levels. In British medical research (if not
elsewhere), there has been a gradual paradigm shift inrelation to methodology. The qualitative approach is
now viewed, if not an equal partner, then at least
complementary to quantitative methods. This shift in
ethos was reflected in a series of articles in the British
Medical Journal outlining the value of qualitative
research and ethnography to medical practitioners
(Pope & Mays, 1995). Around the same time this debate
was mirrored amongst British researchers working in thefield of illicit drug use (McKeganey, 1995). As the
opening remarks and the example of harm reduction
development and monitoring in Sverdlovsk implied,
ethnography is of direct practical value. It has a role
to play at all levels of evaluation, can complement
epidemiological research and can inform the develop-
ment of targeted interventions. It is incumbent upon us
to ensure that ethnography, in its various shapes andforms, retains a prominent place in a multi-disciplinary
and multi-indicator research and development para-
digm.
References
Adler, P. A. (1985). Wheeling and dealing: an ethnography of an upper-
level drug dealing and smuggling community . New York: Columbia
University Press.
Agar, M. H. (1979). Angel dust: an ethnographic study of PCP users .
Lexington: Lexington Books.
Agar, M. & Kozel, N. (1999). Ethnography and substance abuse:
talking numbers. Substance Use and Misuse 34 , 1935�/1949.
Becker, H. S. (1953). Becoming a marijuana user. American Journal of
Sociology 59 , 235�/242.
Bourgois, P. & Bruneau, J. (2000). Needle exchange, HIV infection,
and the politics of science: confronting Canada’s cocaine injection
epidemic with participant observation. Medical Anthropology 18 ,
324�/350.
Broadhead, R. & Fox, K. (1990). Takin’ it to the streets: AIDS
outreach as ethnography. Journal of Contemporary Ethnography
19 , 322�/348.
Bruneau, J., Lamothe, F., Franco, E., Lachance, N., Desy, M., Sobo,
J. & Vincelette, J. (1997). High rates of HIV infection among
injecting drug users participating in needle exchange programs in
Montreal: results of a cohort study. American Journal of Epide-
miology 146 , 994�/1002.
Feldman, H. (1968). Ideological supports to becoming and remaining a
heroin addict. Journal of Health and Social Behaviour 9 , 131�/139.
Friedman, S., Neaigus, A., Jose, B., Curtis, R., Goldstein, M.,
Ildenfso, G., Rothenberg, R. & Des Jarlais, D. (1997). Sociometric
risk networks and HIV risk. American Journal of Public Health 87 ,
1289�/1296.
Grund, J.-P., Kaplan, C., Adriaans, N. & Blanken, P. (1991). Drug
sharing and HIV transmission risks: the practice of frontloading in
the Dutch injection drug users population. Journal of Psychoactive
Drugs 23 , 1�/10.
Kane, S. (1991). HIV, heroin and heterosexual relations. Social Science
and Medicine 32 , 1037�/1050.
Koester, S., Booth, R. & Wiebel, W. (1990). The risk of HIV
transmission from sharing water, drug mixing containers and
cotton filters among intravenous drug users. International Journal
of Drug Policy 1 (6), 28�/30.
Zwi, A.B., Cabral, A.J. (1991) Identifying ‘‘high risk situations’’ for
preventing AIDS. British Medical Journal, 303(6816) 1527�/1529
McKeganey, N. (1995). Quantitative and qualitative research in the
addictions: an unhelpful divide. Addiction 90 , 749�/751.
Moore, D. (1993). Penetrating social worlds: conducting ethnographic
research into alcohol and other drug use within Australia. Drug and
Alcohol Review 11 , 313�/323.
Murphy, S. & Waldorf, D. (1991). Kickin’ down to the street doc:
shooting galleries in the San Francisco Bay area. Contemporary
Drug Problems 18 , 9�/29.
Oakley, A., Fullerton, D. & Holland, J. (1995). Behavioural interven-
tions for HIV/AIDS prevention. AIDS 9 , 479�/486.
Pope, C. & Mays, N. (1995). Reaching the parts other methods cannot
reach: an introduction to qualitative methods in health and health
services research. British Medical Journal 311 , 42�/45.
Power, R. (2000). The empirical and methodological comparative
value of the rapid assessment of drug use patterns. International
Journal of Drug Policy 11 , 181�/191.
Power, R. (2001). Reflections on participant observation in drugs
research. Addiction Research 9 , 325�/337.
Power, R., Hunter, G., Jones, S. & Donoghoe, M. (1994). The sharing
of injecting paraphernalia among illicit drug users. AIDS 8 , 1509�/
1512.
Rietmeijer, C., Kane, M., Simons, P., Corby, N., Wolitski, R.,
Higgins, D., Judson, F. & Cohn, D. (1996). Increasing the use of
bleach and condoms among injecting drug users in Denver:
outcomes of a community-level HIV prevention programme.
AIDS 10 , 291�/298.
Rhodes, T., Stimson, G., Fitch, C. & Renton, A. (1999). Rapid
assessment, injecting drug use, and public health. Lancet 354 , 65�/
68.
Stahler, G. & Cohen, E. (2000). Using ethnographic methodology in
substance abuse treatment outcome research. Journal of Substance
Abuse Treatment 18 , 1�/8.
Stephenson, J. & Imrie, J. (1998). Why do we need randomised
controlled trials to assess behavioural interventions. British Med-
ical Journal 316 , 611�/613.
Taylor, A. (1993). Women drug users . Oxford: Clarendon Press.
Williams, T. (1989). The cocaine kids . New York: Addison-Wesley.
R. Power / International Journal of Drug Policy 13 (2002) 327�/331 331