"An act which is subject to a rule of conduct is a communication, for it represents a way in which the selves are confirmed — both the self for which the rule is an obligation and the self for which it is an expectation. An act that is subject to rules of conduct but does not confirm to them is also a communication — often more so —for infractions make news and often in such a way as to dis-confirm the selves of the participants. Thus rules of conduct transform both action and inaction into expression, and whether the individual abides by the rules or breaks them, something significant is communicated." (Goffman 1956, 475)

Former users play an invaluable role as street outreach workers in our efforts to prevent the spread of HIV among active users, their significant others, and through perinatal transmission. The notion that they are suited to this task is based on several conceptual arguments (Friedman et al. 1986; Wiebel 1988) and, more recently, on considerable national experience in the deployment of former users as outreach workers in National AIDS Demonstration Research (NADR) projects. Indeed their value has proved so significant that some projects deploy ex-users as the only means of access to the active user population. The use of former users (as 'insiders') has been grounded on the assumption that they are most likely to be best at persuading drug injectors to use bleach or condoms, and as effective brokers between the streets and institutional settings as shelters, antibody testing sites, or drug abuse treatment.

It has been argued that their past inside experience in the drug scene gives them considerable advantage in developing rapport and credibility with current users. This is based on their understanding of the informal rules that govern the street scene, and in their ability to negotiate personal attributes to gain access (Friedman et al. 1986; Wiebel 1988, 1990; Lundberg 1968; Hymes 1964).

There are, however, circumstances that may qualify the claim that former users have a unique capacity to access active users. A failure to consider the implications of these circumstances can be detrimental to outreach programs. Of concern are the resocialization that occurs when users quit using, on-the-job institutional pressures, and the potential for conflict between these and other sources of outreach worker status. One must therefore address several questions. Are former users still Insiders when they are working within roles that are outside of, and not compatible with, those common to the streets? What kinds of limitations attend their changed status when former users are seen as representatives of an institutional, and probably official, entity? In what ways does the experience of leaving an addiction resocialize former users, and does this create implicit distance from the subjects to whom outreach is directed? What are the implications of this role change both for who is reached, and for the kind of relationship that is established, between the street user and the institution that is represented by the outreach worker?
 

Methods

The material presented here was gathered in the course of conducting process ethnography for an AIDS Outreach Project in New York City. I traveled through the streets and agencies of the city with four teams of outreach workers whose goals were to educate active users and their significant others on risk reduction and to recruit them for HIV testing. All the outreach workers were former users and occupy full-time salaried positions. The users and others' who receive these services were not paid for their participation. This paper will describe three episodes of street outreach conducted in New York City and attempt to analyze them for what they may shed on the above questions.

Vignette 1

It was January, and I was with a team of outreach workers in a large New York City shelter for homeless men. There was a lot of client movement in the facility: everyone was coming from or going to some destination. Lonnie and Craig, African-American outreach workers, are well known among the client population. Upon entering, Lonnie was stopped by Evie, a Latino transvestite client who bummed a cigarette. Lonnie casually gave her the cigarette and asked Evie when she planned to get tested. Evie responded by asking him, "When are you taking me out for breakfast?" Lonnie smiled and agreed to buy her breakfast.

As we continued along the corridor, Lonnie and Craig were met with a continuous stream of greetings ranging from "Yo! How ya doing?" to affirming nods of recognition. Craig spotted and hailed John, who was switching course away from us. Craig greeted John, an African-American client, and asked him how he was doing and whether he was keeping clean. John answered in the affirmative but his way of shifting his body made it clear that he wanted to leave. Craig discreetly placed several condoms in John's hand but he resisted accepting them. Craig became angry and expressed this directly to John with a rhetorical "What!" John then accepted the condoms and walked away. In explaining his reaction, Craig justified his anger by saying that "He knew the guy was seropositive", and "He had spent a lot of time talking to this guy."

Vignette 2

There were four of us, Carmen, Julio, Steve and me: two outreach workers and two ethnographers. We strolled across and around a city block chock full of street dealers peddling their wares. It was an unstructured drug scene and each dealer's hawking of his heroin's brand name, e.g. "Guarico," "Bad Medicine," filled the otherwise empty air, the vacant buildings with their boarded windows, and the adjacent school yard. The drifting echoes merged with the hustle and bustle of the neighboring street scene bodegas, shoe stores, bakeries, and all manner of fast and slow food.

On our way back to the office, we witnessed what I call a "surgical bust": two undercover cops descended on one guy, handcuffed him, and radi oed an unmarked car for pickup. The next day Steve told Maria, the outreach supervisor, about our stroll and the street scene. Maria, whose presentation of self routinely includes a detailed history of her former drug use and time spent in prison, expressed concern for both our safety and the integrity of their outreach operation. She questioned the wisdom of speaking to the dealers by grounding her objections in her experience in that particular street scene. She said, "I recall the first time Angel drove me through that street. All them guys were staring into the car. I wanted to slide under the seat. I had to ask him to stop and let me out. I went out there and told them who I was, and who I worked for. I was scared."

Vignette 3

I accompanied Willie and Lita, two Latino outreach workers, to an all-male working shelter. (This facility only admits working clients, and job placement is available for men who subsequently loose their jobs.) Willie immediately recruited a client for serologic testing. Lita remained at the shelter. Quickly, she opened shop on a table in the cafeteria. Condoms and literature were neatly laid out. Three Latinos joined us. Freddy and Jose sat down, while Eddy remained standing. Several other men came by the table to take a look. Some took condoms and walked away, some stood and chatted with us. All the men present were either African-American or Latino. After discovering that not one of them lcnew what a dental dam was, Lita used the friendly chit-chat between her and the men as a springboard for Safe Sex 101. She pulled a dental dam out of her bag and showed it to the men. Then, she explicitly instructed on its safe use ("lubricant should be placed on the side facing the vagina") and its creative use ("Place whip cream, or jelly, and eat to your heart's delight!"). She closed with a discussion on the use of gloves and condoms. Most of the men, who had sat grinning widely throughout the presentation, took condoms. Ed didn't take any, and explained his reluctance by suggesting he feared they would tear. Lita took a good look at Ed, and answered with aplomb that "The condoms fit all sizes but, as I've said before, Honey, if your thing is that big, you should put it over your shoulder and burp it!" The other men burst into howls of laughter. When they left, every one of them had taken condoms, including a now-smiling Ed.

Discussion
These field vignettes suggest two major conclusions:

1) The "insider" recognizes the complexity of the user as a person: (s) he sees him as a father, brother, uncle, son, cousin; a lover of mysterious novels, jazz, salsa; as the daughter of the 'floor girl' who for the past 30 years has punctually left work every morning at 7:30 AM, or as Ed who is homeless, works, and limits his drug use to the weekends. Or consider Lonnie, who recognizes that Evie can reject his request and even make demands on him. Similarly, Lita doesn't accept the distancing and disrespect implied by Ed's reference to his organ. Lita is not merely clever in turning the tables on Ed; she wins the respect of all the men, including Ed, because she looks at him directly, not up at him (like a traditional Latina) or down to him (as a service provider). Establishing insiderness depends on the capacity and willingness of the outreach worker to look beyond the status of the individual as a "user." This affirms the complexity and dignity of the user, conveys respect, and creates space for relations of mutuality. It requires an empathy bred of the capacity to recognize the person beneath the simplifying label, and an ability to act accordingly within the relation of mutual recognition.

2) Former users may be defined in key respects by active users as outside of, and deviant to, the street scene; and they may knowingly or unknowingly define themselves that way. The "outsider," by being unable or unwilling to see beyond the user status of the individuals, tacitly denies their complexity as persons. This negation sets into motion the assertion of boundaries to be defended or challenged, and is consequently adversarial. When the outsider is also a former user, his or her newly ascribed status may be seen as deviant to the street scene: evidence of a user who has rejected authentic mutuality. Such a person may know more than a non-user, but he or she may be seen as having new and non-negotiable agendas and threaten the status of the active user. They must recognize that formerly using does not exempt them from the necessity for extending respect to the active user. This respect conveys confirmation of their common humanity (Lundberg 1968), not the privileged status of one (the former user) over the other (the active user).

In vignette 2, Maria's concern for our safety and the integrity of the outreach operation are real. Maria generalizes, however, from her particular experience, which as she said, is one that involves danger and therefore arouses her fear. She tries to requalify herself, but in doing so, denigrates the status of the active user. Thus the problem here is that the active roles in that street scene are precisely the ones from which she has, at least partially, distanced herself. As a result, she is unable to negotiate access to the scene itself.

Craig, in vignette 1, denies any choices for John other than the ones that he, because of his need to assert his professional role, deemed appropriate. Craig, however well-meaning, sees John as a seropositive user, with whom he says he "spent a lot of time talking." Whether or not John wants to change his behaviors, Craig has become invested in changing them. Sadly, John doesn't legitimately exist for Craig outside of his status as a seropositive user and it is to the negation of his persona that John responds. His earlier attempt to avoid Craig, and his later resisting the offer of condoms — which have now taken on the form of a donation — were an assertion, however oblique, of boundaries. As such, they were a response to the distance John had created by relying on status ascription. Craig has pushed John to affirm himself, but by means of the only option that would maintain a measure of dignity to him: utilizing the social distancing that Craig had already established between them.

Conclusion

Former users, in their role as outreach workers, may be caught in struggles between conflicting roles and sources of status that are played out, for better or worse, on the streets. On the one hand, outreach projects thrust upon the former user recognition and status for one of the many roles (s) he has lived. However, the using experience that is the object of affirmation is also an object of negation. Thus from the stigmatizing experience of using comes status and affirmation. On the other hand, emphasis remains on the user experiences of the outreach workers, to the exclusion of their many other abilities and potential roles.

A similar situation may exist with those detoxification practices that inculcate an understanding of not using as an ongoing and unending process that may depend not solely on the complete absence of drugs, but on the avoidance of the former users' friends, family and all other social connections to the street scene. These practices offer a simple solution to the immediate problem confronting the former user, i.e. cut off your connections to active users even though they may be family, friends or long-standing neighbors. The former user is now confronted with a two-fold dilemma: the contingency of his/her sobriety, and how that fragile sobriety can now be threatened by relationships that encompassed much more than the using experience. Thus, on the one hand, relinquishing a drug addiction earns the former user recognition and affirmation. On the other hand, as a source for building a new social (and possibly, institutional) status, it may depend too heavily upon the negation of the personal and social resources that ironically were also the motivation for seeking affirmation in the first place.

'Insider' capability arises out of social relations and is not self-sustaining. The ability (or willingness) to remain an Insider may depend therefore on the supports provided by those constituent social relations that existed before stopping drug use. Utilizing former users in street outreach remains an important innovation in practice. However, the failure to appreciate the struggles confronted by former users undermines their effectiveness and ultimately threatens the viability of the outreach project itself.

What is insider capacity for the user cannot be duplicated by the former user. What the former user brings to outreach is significant, but programs need to develop the procedures by which these two different types of insider can become complementary within outreach. It may be useful to employ active users and non-users, as well as former users, and let this mix become a basis for mutual support. Finally, as with all resources we care for and depend upon, the outreach team requires ongoing structural support. There is much to be mutually gained from all team members gaining mutually. •

Joyce A. Rivera is the founder and director of St. _Ann 's Corner of Harm Reduction in the Bronx. Rivera has been awarded DPF's 1996 Robert C. Randall Award for Achievement in the Field of Citizen Action.

1 In order to protect anonymity, fictitious names are used throughout.

REFERENCES

Friedman, S.R., et al. 1986. "AIDS Health Education for Intravenous Drug Users." Health Education Quarterly. 13:383-394. Reprinted in R.P. Galea, B.F. Lewis and L.A. Bakers, eds., AIDS and IV Drug Abusers, pp. 199-214. Owing Mills, MD: Rynd Communications.

Goffman, E. 1956. "The Nature of Deference and Demeanor." American Anthropologist. 58:473-502,

Hymes, D.H. 1964. "Introduction: Toward Ethnographies of Communication." American Anthropologist. 66:6, pt. 2:1-34.

Lundberg, C.C. 1968. "A Transactional Conception of Fieldwork." Human Organization. 27:1:45-49.

Wiebel, W. 1988. "Combining Ethnographic and Epidemiologic Methods for Targeted AIDS Interventions: The Chicago Model." In Needle Sharing Among Intravenous Drug Abusers: National and International Perspectives. (NIDA Research Monograph #80). Rockville, MD. Department of Health and Human Services.

---. 1990. "Identifying and Gaining Access to Hidden Populations." In The Collection and Interpretation of Data from Hidden Populations. (NIDA Research Monograph #98). Rockville, MD. Department of Health and Human Services.