Habitus and Drug Using Environments

Health, Place and Lived-Experience

Stephen Parkin

• Publisher: Routledge
• Year: 2016
• ISBN:
  9781317124177
• Edition: 1
• Topic: Sciences sociales
• Subtopic: Sociologie

Informed by the thought of Pierre Bourdieu and framed by the philosophy of harm reduction, Habitus and Drug Using Environments provides a sociological analysis of public environments affected by injecting drug use. Drawing on ethnographic research across several locations, this book offers a qualitative and phenomenological account of the social organisation of public settings used for the preparation and administration of illicit drugs, informed by interviews with both injecting drug users and those whose employment is directly affected by public injecting drug use. With attention to current policy-related questions concerning the lived experience of 'place' upon the health of injecting drug users, how wider social structures contribute to participation in public injecting and the manner in which participation in public injecting amplifies drug-related harm, Habitus and Drug Using Environments sheds light on the ways in which health and place interact to produce and reproduce already established hazards associated with injecting drug use. As such, it will be of interest to sociologists, geographers, criminologists and policy makers working in fields such as drug use, risk behaviours and their relation to place, and health studies.

Chapter 1
Drug Using Environments

This book is concerned with the role of ‘place’ on influencing harm and hazard upon the health of particular individuals. More specifically, it adds a further contribution to the relevant literature regarding various health harms associated with drug-using environments, in which illicit drugs (typically heroin and crack-cocaine) are prepared and ingested by means of injection. Yet more significant is that all of the drug using environments described in this text are each located in public spaces and may be best summarised as ‘street-based’ settings. Whereas these environments will be discussed at great length throughout this text, it is suffice here to simply state that public toilets, parking lots, derelict buildings, secluded stairwells, rooftops and doorways characterise the ‘drug-using environments’ central to this text. Indeed, the aforementioned examples best illustrate the ‘paradox of invisibility’ in which environments of public injecting drug use are almost always ‘hidden in open view’. What will also become apparent throughout this text is the way in which injecting drug users manage to maintain a relative ‘invisibility’ of their injecting practices and the locations in which this may occur. Therefore, in academic terms, this book is concerned with an ethnographic inquiry of injecting drug use that prioritises a particular health-place nexus. In more simplistic terms, it is a sociological account of the public places visited by people for the purposes of injecting illicit drugs.

A Concise History of ‘Drugs’ Research

This book does not claim to be unique in terms of the principal subject matter presented within (regarding injecting drug use). Instead, this text follows a long tradition of sociological and anthropological research interest in substance use in which social scientists have observed the use, effect and impact of illicit drugs in community settings (see Becker 1953). Perhaps the earliest examples of this interest in injecting behaviour may be noted in Larner and Tefferteller’s (1965) account of The Addict in the Street; Fiddle’s (1967) Portraits from a Shooting Gallery and Howard and Borge’s (1970) observations of Needle Sharing in the Haight. Each of these innovative studies was specifically concerned with community-level heroin dependency noted in areas of New York City and San Francisco (Howard and Borge). This early body of ‘heroin research’ was completed during the 1950s and 1960s and all may be equally viewed as prototypes of a particular ‘public health sociology’. That is, despite their use of some now ‘anachronistic’ terms, the various scholars typically combined academic, humanistic and compassionate approaches to drug dependency in attempts to inform community safety and public health intervention (regarding overdose, hepatitis B and sex work). Furthermore, each author recognised the value of qualitative research methods in obtaining descriptive accounts of the various social and cultural experiences associated with heroin dependency in the relevant settings. This is a particularly pertinent observation, given that sociology during the 1960s, a decade containing the ‘Summer of Love’ and the American War with Vietnam, was a discipline almost certainly influenced by issues of deviancy, subculture and counter-culture. For example, the theory of anomie, as forwarded by Merton (1957), posits that participation in behaviours such as drug use (and the development of a particular dependency) represents individual-level responses to successive failures in the conventional world (in areas such as education, employment and material gain) and the subsequent rejection of this world. Indeed, it was perhaps due to the discipline’s preoccupation with theories of deviance that scholars such Lindesmith and Gagnon (1964) challenged the concept of anomie in the context of drug use. Such theories were eventually dismissed as inappropriate explanations for drug taking, especially when the arduous realities of maintaining a dependency to heroin and the fortitude attached to ‘taking care of business’ (Preble and Casey 1969) in street-based settings became more apparent via ethnographic research.

The research design established within those early studies of injecting drug use continued throughout the 1970s with further ground-breaking accounts added to the literature. As in the previous examples, these studies also adopted ethnographic approaches but were typically less focused upon drug use, and were often more concerned with a particular identity of drug users. Examples here may include Preble and Casey’s (1969) aforementioned study of Taking Care of Business concerning the organisation of drug markets within public settings; Young’s (1971) portrayal of the social and symbolic meaning of substance use in The Drugtakers and Agar’s (1973) account of the Ripping and Running lifestyle of urban heroin users.

Overall, these initial studies of opiate use that contested notions of deviancy were possibly as trailblazing as they were visionary in terms of the public health value and academic outcome attached to the relevant work. This is because each of the aforementioned studies occurred during an era in which the world was oblivious to, and unprepared for, the advent of various drug-related epidemics and the prevalence of associated infectious disease. However, in the decade that was the 1980s, two cataclysmic events greatly influenced studies of injecting drug use in the UK; the aftershocks of which are still felt over three decades later. These events were a decade of recession and high unemployment experienced in the United Kingdom during commencing around 1980 (Parker et al. 1988); and the identification, and subsequent global spread, of the human-immunodeficiency virus (HIV) that was closely followed by the identification of the hepatitis C virus (HCV).

There is little doubt that the consequences of mass unemployment and deindustrialisation greatly influenced Pearson’s (1987) account of The New Heroin Users, as well as Parker, Bakx and Newcombe’s (1988) study of Living with Heroin. These landmark British texts document the effect of recession and unemployment upon the prevalence and uptake of heroin use in areas of socio-economic decline and deprivation throughout the north of England. These studies are equally informed by qualitative methods and provide a synthesis of sociological and epidemiological inquiry regarding the way in which heroin use may spread through social networks within particular communities. Furthermore, the various authors provide a summary of the optimal social and economic conditions required for the rapid uptake of heroin use, (including the transition to injecting) that is arguably as valid and relevant in the 21st century as it was when first written almost 30 years ago.

However, it was the possibly the second of the two aforementioned events during the 1980s that has possibly had more long-reaching and current consequences. Namely, the identification of HIV/AIDS, in 1980, and HCV (hepatitis C) in 1989; both of which are blood borne viruses and each are synonymous with current public health intervention and injecting drug use policies. The emergence of the HIV pandemic during the 1980s was to lead to previously unprecedented changes in health promotion, education, policy and practice on a truly global scale (McKeganey 2011). For example, research during this period concerning Edinburgh’s heroin-related HIV epidemic (Robertson 1990) greatly influenced the introduction of harm reduction intervention (such as needle and syringe provision and methadone programmes) in the UK. Indeed, such ‘controversial’ intervention was to be considered as a legal and legitimate response to managing drug use and infectious disease instead of the informal, altruistic activism previously conducted at a grassroots level within injecting drug user networks (Davis et al. 2004). The formalisation of harm reduction is perhaps validated in an Advisory Council on the Misuse of Drugs Report (1988) to the UK government regarding its inquiry into AIDS and Drug Misuse that stated:

The spread of HIV is a greater danger to individual and public health than drug misuse (ACMD 1988: 17)

In response to such recommendations, international health authorities established ‘target populations’ considered as ‘high risk groups’ that included homosexual men, female sex workers and their clients, and those who injected illicit drugs. Such populations were regarded as priority for intervention, in which sociological, epidemiological and applied qualitative research were (and continue) to play significant roles in shaping understandings of the social context of HIV infection and transmission. Two significant texts to emerge during this time in a British context were McKeganey and Barnard’s (1992, 1996) ethnographic accounts of injecting practices amongst drug users in Glasgow. With AIDS, Drugs and Sexual Risk McKeganey and Barnard provided an ethnographic account of the social value and solidarity attached to sharing drugs, needles and syringes within a deindustrialised, working-class community affected by HIV in order to illustrate that ‘risk awareness’ need not necessarily equate ‘risk resilience’. This view was further consolidated in McKeganey and Barnard’s (1996) analysis of intimate partner relationships and female injectors’ participation in Sex Work on the Streets, in which women were noted in establishing acceptable boundaries of ‘risk-taking’ with regard to sexual practices.

During the early period of the HIV pandemic a wealth of qualitative research was also published in the social science literature in addition to the selected texts described above. The volume of significant material produced during this time is so extensive that it is simply not possible to summarise all the innovative work conducted by so many researchers during this particular time in a single chapter. Nevertheless, the ethnographic record during this period is dominated by a collective mass academic observation of injecting drug users’ lifestyles as a means to understand the social and epidemiological nature of HIV transmission. Noteworthy contributions to current understandings of these issues however would unquestionably include the numerous ethno-epidemiological studies led by Gerald Stimson, Tim Rhodes (and their respective colleagues), Jean-Paul Grund (and colleagues) and Don Des Jarlais and Sam Friedman (and their colleagues) concerning their respective studies of injecting drug user cohorts resident throughout Western Europe and North America. Whilst this is by no means an exhaustive list of key contributors to the sociology and aetiology of HIV, the collected publications of these particular individuals typically demonstrate that injecting drug use per se is situated within and across an assemblage of supportive and/or sexual relations in which friendship, trust, intimacy and even ‘power’ within social networks is reflected and confirmed.

Since the ACMD reported to the UK government in 1988, there has been a literal super-abundance of studies of injecting drug use conducted throughout the world and is a trend that seems unlikely to end soon. This may be noted in an online search of academic publications concerning the issue of ‘injecting drug use’ using Scopus (an online database that claims to be ‘the world’s largest abstract and citation database of peer-reviewed literature’). For the period 1960-2012, Scopus retrieved 25,500 documents concerning the generic issue of ‘injecting drug use’. However, for the year 1961 only one such document was noted; for 1971 there were eighteen publications that rose to 99 and 156 outputs for the years 1981 and 1991 respectively. By 2001 however, the annual output on publications concerning ‘injecting drug use’ rose almost sevenfold to 1,080. In the subsequent decade the volume of publications on the matter continued to grow and stood at 1,862 publications for the year 2011. Overall, the academic focus upon injecting drug use has been one of continuous increased and increasing interest over the last 50 years.

The identification of a new strain of hepatitis in 1989 (O’Shea 2010) almost certainly contributed to a second wave of public health research regarding the social transmission of viruses associated with injecting drug use. As with HIV, hepatitis C (HCV) is a degenerative blood borne virus with no current vaccine providing immunity. Unlike HIV (that leads to AIDS and the degeneration of the immune system), HCV is a viral infection of the liver. In cases of chronic infection, cirrhosis of the liver may occur, leading to organ failure, cancer and possibly death. According to the most recent annual report by the UK’s Health Protection Agency (HPA 2012) on drug-related infections, the estimated prevalence of HIV amongst injecting drug users was in the region of one per cent, whereas the estimated prevalence of HCV was around 50 per cent. In more simplistic terms, these prevalence figures may be translated to read that, of those who inject drugs in UK settings, one in every 100 had been infected with HIV, compared to one in every two that had been infected with HCV. The sociological (and not statistical) significance of these figures is made apparent when one considers that the number of opiate and crack-cocaine users, aged 15-64, in England during 2010 was estimated to be in the region of 306,150 individuals – of which approximately one third (103,185) are believed to be injecting drug users (Hay et al. 2011).

For the above reasons, the international ethnographic literature concerning HCV has followed a similar trajectory to that of HIV. A similarly voluminous body of work in this field has made considerable steps towards providing applied understandings of HCV (including stigma, identity management and informing health intervention). Injecting drug use is therefore a contemporary and significant health matter. It is also a significant political concern that bridges not only individual and public spheres, but also spans academic disciplines, methodologies, methods and theoretical paradigms. In addition, it is also necessary to add that the sociological literature is generally supportive of reducing harms associated with illicit drug use and serves to confirm that injecting drug use is no longer the ‘fringe concern’ it was during the decades pre-HIV/HCV. Instead, the prevention of infectious disease has played a significant part in placing injecting drug use on the main stage of international policy and practice. Similarly, in 2012, despite its critics, ‘harm reduction’ has become firmly anchored within UK legislation and is also an international movement that is associated with human rights and responsibilities. It is therefore within these traditions of public health sociology with applied outcome that this book should also be considered (see Chapter 4 for a more comprehensive account of this particular stance).

Emphasising – not Identifying – Harm

This book does not seek to provide any novel contributions to the literature regarding the harmful consequences of injecting drug use. Harms associated with injecting drugs are well established and documented throughout the literature. In short, these harms and hazards may be broadly categorised as those relating to viral infection (through blood/semen contact, sharing injecting equipment, peer injecting); overdose (via drug purity, poly-drug use, overconsumption, injecting technique), vein/vascular damage (including deep vein thrombosis, blood clotting, amputation, groin/neck/peer injecting, inappropriate injecting technique), bacterial infection (resulting from contaminated/adulterated drug supplies, injecting injury, inappropriate wound care management, ‘dirty hits’) and the physical harm and injury that may result from drug-related violence (drug debts, drug thefts, sex-work, drug-effect). Accordingly, this book makes no audacious claims regarding the identification of previously unknown harmful practice. Instead, the thesis outlined in this work is that the various environments that house public injecting drug use serve to amplify this array of established harm and hazard. Furthermore, this amplification of harm is emphasised and explained throughout the text with specific reference to theoretical frameworks advocated by Pierre Bourdieu concerning the habitus construct.

Drug Using Environments

In addition to the theoretical basis above, and as explicated in the first sentence of this chapter, this book is concerned with the role of ‘place’ on influencing drug-related harm. Again, this is not necessarily ground that has not already been covered by previous ethnographic research. As such, it has to be reiterated once more that this author respectfully follows in the footsteps of numerous other researchers that have previously focused attention upon specific injecting environments. However, foregoing work of this nature typically concerns settings established by injectors for the primary purposes of injecting and, with few exceptions, are predominantly located in North American settings. More specifically, contributions to understandings of the health-place nexus regarding injecting drug use generally emphasise the so-called ‘shooting gallery’ and ‘crack-house’ phenomena.

‘Shooting Galleries’

‘Shooting galleries’ is a term that has been embraced by the academy and is used to provide a generic description of indoor, communally-oriented settings (such as tenement housing, derelict buildings, private housing, abandoned housing/business stock) that facilitate injecting drug use (Klee 1997, Murphy and Waldorf 1991, Snyder and Lader 1988). Whereas various ethnographic studies (Carlson 2000, Des Jarlais et al. 1986, Murphy and Waldorf 1991, Oullet et al. 1991, Parkin and Coomber 2009) have attempted to classify ‘shooting galleries’ into models that prioritise social organisation, ease of access and economic exchange almost all are unanimous in concluding that such settings provide temporary safety in locations where injecting drug use is considered raison d’être. In addition to providing temporary refuge from detection, such settings may also provide access to drugs, injecting paraphernalia, assistance with injections and may be geographically near to local drug markets and/or areas of street-based sex work (ibid.). Due to the social organisation within ‘shooting galleries’ the same corpus of research has identified a wide range of health harm associated with places of temporary, multi-person, occupancy. For example, in addition to accounts of harmful poly-drug use, overdose (fatal and non-fatal), police raids, unsanitary conditions characterised by violence, intimidation and discarded injecting equipment, ‘shooting galleries’ typically lack the basic amenities (water, sanitation, lighting, space) necessary to conduct ‘safer injecting practices’ (Page et al. 1991, Bourgois 1998, Kimber and Dolan 2007). Other harms identified (ibid.) generally relate to the optimal procedures required for HIV/HCV transmission; including access to used injecting equipment; syringe-mediated drug sharing, participating in sex-for-drug exchanges, conducting inappropriate drug preparation practices, and the co-presence of established and novice injectors who may be known and/or socially distant to one another (in which the latter may establish an epidemiological bridge for viral transmission to occur between injecting populations (Fuller et al. 2003, McKeganey et al. 1998)).

‘Crack-houses’

A similar environment to that described above is the so-called ‘crack-house’ setting, in which the use of crack-cocaine predominates (whether by injection or other). Nevertheless, the ethnographic record (Bourgois 1995, Ratner 1993, Williams 1992) of these settings parallels the ‘shooting gallery’ phenomenon in providing drug users with a social, semi-protective and private environment for the preparation and use of crack-cocaine (in addition to other substances). ‘Crack-house’ settings (in North American cities) have also been similarly arranged within various hierarchical taxonomies that prioritise function, role and purpose of such venues. Whilst similarities may exist with ‘shooting gallery’ typologies, the crack-house literature during the 1990s tends to portray a greater emphasis upon sex-for-drug exchanges provided by women (French 1993, Fullilove et al. 1992, Inciardi 1993, Leonhardt et al. 1994, Ouellet et al. 1993). Accordingly, harms emerging within the ‘crack-house’ have had a tendency to relate to the social organisation of sex (multiple partners, unprotected penetration, blood/semen contact) that is further augmented by the stimulant effect of crack-cocaine and the repeated, communal use of crack-pipes to sustain short periods of drug-related euphoria. Other...