ETNOGRAPHY OF THE USE OF

HEROIN IN THE EAST VILLAGE OF

SAN DIEGO
Care techniques and environmental contingencies

UCSD
Department of medicine
1. Problem statement

Heroin as a public health issue

The percentage of admissions in San Diego County's treatment programs that

has heroin as the drug of choice has been increasing since 2010; according to the 2016 Rx

Report Card, and, in 2015, this number matched that of methamphetamine. Heroin abuse

is often preceded by problematic prescription-type opioid use (Pollini, 2011). The use of 1

methamphetamine by people who inject drugs (PWID) in San Diego is a problem in itself,

but the simultaneous injection of both heroin and meth, this depressant-stimulant

combination, is prevalent in 19.8% of the PWID. Although this practice is more common

in Tijuana than in San Diego, it had a stronger association with overdose in San Diego

than in Tijuana (Meacham, 2015). Risk behaviors and health outcomes differed between

PWID living in San Diego who primarily inject heroin vs. those who use meth (Roth et

al., 2015). Having friends who injected drugs with used syringes, injecting with friends

or sexual partners, and injecting heroin were associated with unsafe injection practices;

and with the increase of the risk of hepatitis C virus (HCV) and human immunodeficiency

virus (HIV) infection among young adult drug users in San Diego (Muoz, 2014).

The prevalence of the HIV and Hepatitis C Virus (HCV) are significantly lower

among PWID in San Diego compared to PWID in Tijuana (Horyniak, 2017), although

both Tijuana and San Diego PWID reveal a heterogeneity in substance use patterns

(Meacham, 2015). The experience with the police can influence PWIDs behavior. In a

survey involving residents of San Diego and Tijuana, it was found that the way police

treated them when they were in Mexico was different. Police was harder when dealing

with residents of Tijuana compared the way they acted towards residents of San Diego.

This made feelings such as stress, anxiety, and powerlessness present and suggests that
residents of Mexico are exposed to higher health harms related to law enforcement

officers practices compared to those people who reside in the USA (Wood et al., 2017).

Harm can also be increased by variations in the techniques of use and access to

paraphernalia. The preparation of black tar heroin in the cold, without heating when

dissolving the drug, may increase the risk of HIV transmission (Roth et al., 2017). The

increase of the risk for blood-borne virus (BBV) infections can also occur when using 2
prefilled syringes (PFSU). This practice is common and associated with environmental

factors in San Diego (Armenta, 2015). Another factor that increases the acquiring and

transmitting of blood-borne infections among people who inject drugs (PWID) is the

sharing of blood-contaminated syringes. This sharing is possibly greater in San Diego

compared to San Francisco, probably because this city has legalized the non-prescription

syringe sales after approving the disease prevention demonstration project (DPDP). The

legalization of the purchase of syringes in pharmacies made this practice more common

in San Francisco (Siddiqui, 2015).

Analysis benchmark

Howard Becker (1953) in his classic study Becoming a marihuana user he

showed us how, in the user's journey, from the development of physical experience and

the form of reaction to existing social controls related with the drug, a series of changes

in attitude towards the group of users and non-users take place. It is also under the decisive

influence of Howard Becker that Norman Zinberg (1986), after considering the use of

heroin by Vietnam war veterans, concludes that it would not be possible, in order to

understand drug experience, to limit it to pharmacology (drug) and the personality of the

user (set), but one should also be attentive to the physical and social setting in which the

use occurs. The setting provided by the war did not allow for the development of social

sanctions of control and rituals. However, as heroin abusers were removed from the
noxious environment, the abuse virtually ceased, and in pursuing its research with other

heroin users, Zinberg realized there were numerous usage patterns, such as weekend users

and even long term occasional.

Thus, even a drug like heroin allows for various patterns of use and this use is

largely influenced by social and ritual sanctions available, or not, in the setting. Zinberg's

work - originated from extensive research with users of marijuana, heroin and LSD - 3
triggered a profound shift in how drug use was seen until then. However, even before

Zinberg drew attention to the importance of the environment, Timothy Leary (1966) had

already found out through his research on LSD, the importance of preparing an

environment conducive to obtaining the desired effects of the drug.

This innovative way of looking at the use of substances made psychoactive is

fruitful and the work of Jean Paul Grund (1993) provides an important contribution to its

further development. The author draws on data from an ethnographic survey of heroin

and cocaine users in the city of Rotterdam / The Netherlands. In this research, the disparity

between the dire consequences of substance use among Surinamese and Dutch

populations was observed, mainly. The former consumed a greater amount of substances,

without necessarily going through greater harm compared to the Dutch users. On the

contrary, because of their community ties and obligations as drug traffickers, the

Surinamese ended up enjoying a better life quality than the Dutch users, that is, they had

more affective bonds, commitments, obligations and responsibilities, which enabled them

to better relate to the use of cocaine and heroin. In addition, the availability of the drug

described in the research, was an important element to enable the development of rituals

aimed at preserving health rather than those directed, preferably, to obtaining funds for

the acquisition of cocaine and heroin. In this respect, the Surinamese, due to their

proximity to drug traffic, did better than the Dutch users.

2. Justification

Ethnographies of heroin use have been carried out since the 1970s, as in the case of

the Agar study (1973). In the 1980s, with the advent of AIDS and the transmission of HIV

through needle sharing, new studies focused on public policies and intervention strategies

(Feldman, 1988). Concern about HIV transmission will run through the 1990s and remains

to this day. Ethnographic studies cover a wide range of topics. Bourgois (1998) has devoted 4
his work to understanding how practices of daily shares of drug preparation paraphernalia

are built from street-based income-generating strategies and the moral economy of social

networking among self-identified "dope fiends". Through fieldwork he sought to

demonstrate how power relations structure individual behavior in the transmission of HIV

(Bourgois et al., 1997).

The belief that injection is a more efficient route than smoking or sniffing heroin

has led to the popularization of this particular route of heroin administration (Bravo, 2003).

The setting of drug use, how heroin is obtained and the obtained amount can lead,

consequently, to high-risk injection practices (Koester et al., 2005). Overdose is among these

risks. Ethnographic research linking heroin use to overdose has been conducted in Australia,

such as Melbourne's street-based injecting drug users (IDUs) (Moore, 2004); in the UK with

users commencing drug treatment (Neale and Robertson, 2005); or the comparative study of

the market structures and marketing techniques of the heroin trade in San Francisco and

Philadelphia (Mars et al., 2015).

The social context can inform a great deal on the factors that lead to offset fears

commonly associated with injection and the initiation in the use of heroin. Curiosity,

pressures of drug dependence and economic need, influence of intimate and group relations

were all identified in a study of a rural area (Draus and Carlson, 2006). Participant-

observation proved to be effective in detecting the factors involved in the transition from
opioid pills to heroin injecting (Mars, 2014). People who use heroin are victimized by the

adulteration of the drug with fentanyl, a more potent 30-50X substance. A brief ethnographic

study was able to demonstrate that heroin users are concerned about this new situation and

develop techniques to recognize the degree of contamination of heroin with fentanyl, such

as taste, solution appearance and powder color (Ciccarone, 2017). In British Columbia (BC),

drug quality information can be obtained primarily from a reputable dealer or peer networks
5
(Soukup-Baljak, 2015).

The research cited here demonstrates the longevity of ethnographies in this specific

area of public health, and gives us an idea of the extent of its potentialities, especially in the

current epidemic of overdoses (Davis et al., 2017) that victimizes stigmatized and

criminalized groups and, therefore, complicate the access.

We chose the East Village as the privileged geographic region of our research for

containing a significant contingent of street people and drug users on its streets, squares, and

sidewalks (Mitchell, 2006). The region has undergone a process of gentrification (Mitchell,

2006, Conroy, 2013, Brown-Saracino, 2011, Kayzar, 2008), which causes a profound change

in the use of space that is nowadays more often used for parks for tourists than urban places

for residents.

3. Expected results

Lofland and Lofland (1995) propose units of analysis from the personal to the social

level. These units include, among others, the linguistic categories, or meanings used by our

interlocutors in the field to refer to social life, such as definitions, ideologies, or stereotypes

such as crack head, for example. We will also focus on the shared meanings such as rules

and norms present in the researched environment. We will also throw light on the practices

that can be defined as routine activities in this context and that come to contrast with episodic
or accidental events, no matter how detached and effective they may present themselves to

observation; to the meetings, dynamic units designed to complete a task like consuming

heroin, for example; the different social roles, such as of the dealer, for example. All of those,

performed as consciously articulated categories to organize or give meaning to practices.

These roles allow us to develop typologies that help us to typify and 'codify' the abundant

diversity of social life. We should also be attentive to longer-term relationships between

6
peers such as conjugal, paternal, friendship; in its origin, intensity and internal processes.

Within these broader relations, we will find out whether there are groups of people who

interact for longer periods and who will come to consider themselves as an entity. We will

also find out about lifestyle or adjustments and accommodations that a large number of

people in similar situation, in the case of being heroin users, are able to do.

Other analysis units from our theoretical basis (Zinberg, 1984; Faupel, 1987;

Grund, 1993) will serve as parameters. The development, or not, of group-centered rituals

and rules that promote less heroin use; the availability of the drug and the stabilization, or

not, of a certain pattern of consumption. The life structure, marked by commitments,

obligations and responsibilities and their relationship with greater or lesser self-control

regarding heroin use.

We will remain attentive to the forms of self-care developed by East Village heroin

users in order to avoid HIV contamination and overdose. We want to focus our attention on

the practices that aim to reduce the harm present in the culture around the drug; the values

that enable and foster these practices, as well as the main environmental contingencies that

may hinder or even promote this self-care by exposing themselves to less risk while using

(Drumm, 2005).
 Objectives:

The present project presents the following objectives that will structure the knowledge

about the heroin user in the East Village in San Diego.

1) Describe the pattern of heroin use and associated personal factors among users of the East

Village in San Diego, through data obtained by ethnographic research.

2) Determine the prevailing factors in greater or lesser self-regulation of heroin use (such as: 7

drug availability, life structure, rituals and rules).

3) Describe the meanings associated with daily practices linked or not with heroin

consumption; and how these practices relate to self-care, especially when associated with HIV

virus infections and overdose.

4) Describe how heroin users are referred to social and health care services.

5) To verify whether the consumption of heroin corresponds to a lifestyle that this population

adapts to the conditions imposed by the context; and how badly these conditions hamper self-

care, especially in what concerns the care associated with HIV virus contagion and overdose.

Practically, this study should generate at least three scientific papers: 1) Life structure,

rituals, rules, and drug availability related to the pattern of heroin use; 2) Self-care practices,

mainly associated with HIV virus contagion and overdose among East Village heroin users; 3)

Environmental factors that hinder self-care to reduce the risk of HIV infection and overdose.

4. Scientific and technological challenges and the means and methods to overcome

them

Methodology
 Ethnography does not serve the purpose to delegitimize or replace quantitative

research. It proposes a methodological dialogue with practical utility in the creation of more

efficient public health policies that can alleviate human suffering (Bourgois, 1999). In this

sense, we intend to spend time with heroin users and get in touch with their culture marked

by their own terminology, rituals of use, social roles, exchanges of objects, corporality,

technologies for shelter and sexuality. Thus, we can define as the central objective of the
8
research: to discover the characteristics and meanings of ritualized behavior related to

heroin; and whether these behaviors provide infrastructure for the self-regulatory process of

use.

We intend to carefully observe, through ethnographic research, individuals in their

daily lives, recording what they do, when, where, with whom, and the reasons why they do

it, avoiding the blindness of the preconceived notions. To do so, in our research on heroin

users we will enter the study community, much like the classical cultural anthropologist who

studies a traditional society (Grund, 1993). The resulting analysis will be based on the study

of the experience and perception of the subjects about their context, seeking to learn, through

immersion in the group, ways of life and patterns of meaning. Our participant observation

will explore the environments, contexts, subcultures, and most aspects of social life (Grinell,

1997). We aim at describing these environments and their activities, as well as the people

and the meanings attributed by them to these activities (Patton, 1980). Understanding

processes, personal relationships and their circumstances, events in time and possible

patterns developed in social contexts (Jorgensen, 1989). Finally, identify problems and

generate hypotheses for future studies (Grinell, 1997).

In qualitative observation, we can not stick to mere contemplation. We have to

maintain an active role, permanent reflection and be attentive to details. Everything is

relevant. We want to monitor heroin users in their daily routine, remaining attentive to the
physical environment, colors, aromas, spaces, lighting, non-verbal language, specific words,

facts, events and interactions. In our ethnographic research, in order to be able to describe

the contexts and activities being developed, we should make notes from direct observation

shortly after our return from the field. Considering the difficulty of handling electronic

equipment or field notebooks in this environment.

Qualitative interviews should be flexible and open, very much as if a conversation

9
is underway. In the end, a guide to issues to be addressed may lead the researcher (Grinnell,

1997). One should try to put aside the presuppositions regarding the users of heroin so that

they do not get embedded in the way of posing the questions. Questions about heroin use

should be asked as much as possible from the user's point of view (Becker, 1970, 2008). One

must always keep in mind and have as an objective in an interview relation, to reduce as

much as possible the symbolic violence (Bourdieu et al., 1993) originating from the social

dissymmetry between interviewer and interviewee.

Above all, we must point out that we are aware of the numerous difficulties

involved when developing a project with this design. The collection of our qualitative data

should occur in the everyday environments of our interlocutors. A first difficulty will be the

initial immersion in the field. We intend to seek the support of social service caseworkers,

such as those of Father Joe's Villages that operate in the East Village; the Family Health

Centers of San Diego (FHCSD); San Diego Association of Governments; City of San Diego

Community and Economic Development Department; McAlister Institute; and East Village

Association.

Another important challenge we have already faced during the doctoral research on

the use of crack in the central region of the city of So Paulo/Brazil is to obtain the necessary

rapport with our interlocutors. We know that to gaining trust requires a great level of

empathy, as well as avoiding elements that make conversation impossible (Grinnell, 1997).
 In order to do this, we must always seek, without interruption, to let the interviewee's unique

and profound point of view flow. Our tone should be spontaneous, inductive, careful and

with a certain air of "curiosity". Not questioning in a way that might sound too direct, biased

or inductive to the answer. We can then state with Englund et al. (2000) that the context of

the relationship we will experience in the field will be built by our heroin users.

We are aware that while we are observing we will also be observed in a reverse way
10
(Wagner, 1975), therefore, everything we are told will be based on the concept that our

interlocutors form about us and our role in the field. Marilyn Strathern (1999) pointed out

that the social relations used in the field must be appreciated in themselves, for from them

comes the knowledge of the ethnographer. Social relations, therefore, constitute knowledge

previous to the search for knowledge of social relations. That is, the ethnographic work in

its two periods, that of the field itself, and that of the office, that is, of writing, takes place in

the sense of going from the relation to the notion, so that one can make the subsequent

movement of returning the notion to the relations described.

5. Schedule

Activity Semester 1 Semester 2 Semester 3 Semester 4

Project
Planning X X
Data collection
Ethnography X X X X X X X X X X
Coding of
ethnography
data X X X X
Report Writing
and Scientific
Articles X X X X X X X X

6. Dissemination and evaluation

 The data obtained during this study will be disseminated to the academic population
through four scientific articles. Evaluation, monitoring and follow-up will take place at all times
of the research. Ex-ante, with the previous field experience of the researcher, it is already
possible to make a diagnosis of the viability of the project. The monitoring of all actions
foreseen in this project will allow any immediate corrections that might become necessary; in
the evaluation, we will seek practices that can be improved or that explain the successes
obtained.

11

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