DRUG USE CONTEXTS AND HIV-CONSEQUENCES: THE
EFFECT OF DRUG POLICY ON PATTERNS OF EVERYDAY
DRUG USE IN ROTTERDAM AND THE BRONX
Contents
Introduction
The Micro Settings of Everyday Drug Use
The Larger Social Context of Drug Use in Rotterdam and the Bronx
Policy Determinants of Drug Use Contexts
Future Work in Research, Practice and Policy
References
Because of the urgency of the AIDS problem, the initial research exploring the connections between HIV and injecting drug use tended to focus largely on quantifiable variables seen as directly related to the routes of transmission of HIV e.g. injecting frequency, number of needle sharing and sexual partners, the use of bleach or sterile needles. But the context of drug use, its natural settings, characteristic local user networks, larger social structures and official drug policy may have more significance for determining and, ultimately, for changing those concrete behaviors which are the basis of HIV transmission.
If any lesson can be learned from the AIDS epidemic so far, it is that biomedical research on the epidemics' patterns must be wedded to concomitant psychosocial research. While both the origins of AIDS and the prospects for efficient vaccines and treatments are still cloudy, the spread of infection is much better understood. This is largely due to the efforts of social science research. The first wave of HIV in the US and Europe occurred through several relatively well-specified routes of transmission --among them the sharing of contaminated injection equipment, generally referred to as needle sharing. This has been the basis of the very high incidence of AIDS cases among some populations of IDUs. (1 2 3 4) Social scientists, using network analysis, were able to identify the vectors of spread within the homosexual community (5) where this knowledge was almost immediately utilized by gay community-based organizations to mobilize and educate in the interest of AIDS prevention. Likewise the later findings of social science research relevant to AIDS in the IDU community have been a strong stimulus to encourage outreach activities and organizing of prevention programs in many countries, The Netherlands and the U.S. among them. (6 7 8 9) However these findings have sometimes led to a certain narrowing of focus in which the physical instrument of transmission --the syringe and needle-- have been somewhat fetishized. Perhaps because of the involvement of biomedical researchers unfamiliar with the worlds of the drug users, almost exclusive attention has been focused on the physical objects responsible for transmitting the virus -- needles and syringes-- often obscuring the fabric of social relationships in which these objects are used. None the less prevention strategies and messages (stop shooting and bleach before sharing), the institution of bleach bottle distribution and needle exchange programs, have all been a positive result of this research. Yet while such initiatives are a healthy antidote to some deep-seated prejudices and pessimism that drug users are so socially deviant and disorganized that they are either unwilling or unable to change their behavior; they bear the danger of too narrow a focus on one limited aspect of the complex realities of drug use. Several recent studies (10 11 12 13) have reported non IV drug use related to increased risk for HIV-transmission, e.g. crack use and its relation to sexual exposure. These should lead to a revision of the concept of risk and the ideas for prevention of HIV in this group.
The concept of needle sharing is both analytically and practically an incomplete notion --even for understanding the spread of HIV among IDUs. The focus on the physical instrument of transmission may inhibit a deeper look, beyond needle sharing, into drug use contexts - the world of multiple sharing and care taking practices that constitute the bonds of relationships of drug users and their social networks. The earliest descriptions of these networks (14 15) emphasized the more negative aspects of the lives of drug users, characterized as ripping and running, and also revealed important structural features of a more positive nature. Subsequently, distinct temporal and social variables of drug use contexts were characterized (16) and daily, weekly and monthly variations were found to effect many IDU behaviors including congregating, buying drugs and seeking treatment --all with consequences for HIV risk. (17 18) Location and sites of drug use also provide important contextual variables as can be witnessed by the early recognition of the importance of shooting galleries for HIV-spread among IDUs in the Bronx. (17 19)
This paper compares the drug use contexts and their potential HIV consequences in two very different communities- Rotterdam and the Bronx. Rotterdam with a population of 580.000 has 2500 -3500 opiate users (4.3-6.0/1000) of which an estimated 23% are injectors and 77% smokers. (20) In contrast, the Bronx with a population of 1.2 million, has 30-40,000 regular opiate users (25-33/1000) who are overwhelmingly injectors (>90%). If the South Bronx (population 500,000 / 20-30,000 IDUs) is considered separately, this rate is 40-60/1000. Rotterdam and the Bronx have both known massive physical and social destruction. Rotterdam was heavily bombed in May of 1940 devastating thousands of its buildings and displacing tens of thousands of families for a decade or more. Since the war, the city has slowly and carefully been rebuilt and today has an international reputation for its architectural innovations and urban renewal projects, especially the availability of high quality affordable housing for working class families. The Bronx is a city that has also been devastated -- in this case by urban blight and fire which, in the twenty years between 1960 - 1980, destroyed numerous buildings and displaced large populations. (21) The Bronx, however, has seen only limited urban renewal and its problems have worsened throughout the last decade.
The two settings constitute a natural experiment in process for over 40 years. This paper aims at identifying a common set of variables that function (albeit under very different conditions) to influence injecting drug use practices in the two areas. These variables are differentially determined by social context and drug policy options all of which have HIV consequences. By identifying common variables that are sensitive to policy interventions, even though they are imbedded in very different conditions, it becomes possible to generalize and weigh the consequences of such policies beyond their particular application in a local community.
The Micro Settings of Everyday Drug Use
Rotterdam
The Addiction Research Institute of Erasmus University has conducted a field research study into the drug taking practices of heroin users in Rotterdam. In this study, 95 drug administration rituals were recorded: half involved injecting and two-thirds of those injecting used new, sterile syringes. Only three cases of re-using another's needle and syringe were recorded and, in these cases, circumstantial factors led to unsafe injecting interactions. (22) Needle sharing defined as two or more people actually using the only available syringe one after the other in a predictable, stereotypical and planned (ritual) sequence was not observed in the Rotterdam study. Thus, needle sharing does not appear to be a major feature of injecting drug use in Rotterdam. The sharing of drugs (23) however was found to be an important and frequent phenomenon, both among IDUs and non-IDUs, as drug use was rarely an individual act. Dealing places, private homes, and homes of friends were the most common places where drugs were ingested. Most of the drug sales observed at dealing address were followed by direct ingestion of (at least a part of) the drugs purchased. To have more individuals present than the dealer and the buyer was a typical feature of these dealing addresses. Often users purchased drugs in pairs, and frequently a pub atmosphere prevailed. While needle sharing was rare, in half the observations of injecting and non-injecting use, drugs were shared. IDUs were very frequently found to share drugs by a special technique using two syringes which has been termed frontloading (24). Discussion with researchers and drug users from numerous countries revealed that this technique is utilized far beyond Rotterdam. (25 26) It was hypothesized that this technique bears the risk of passing on microbiological and viral infections (including HIV) (27 28 29) but this is unknown to most IDUs. In both Rotterdam and Amsterdam drug agencies have included frontloading in their prevention campaigns. But this kind of information campaign, aimed at rapid behavior change, may again function to isolate and emphasize the instrument of transmission (the needle) and overlooks the larger picture of drug sharing practices, which are embedded in a much broader pattern of social behaviors of heroin users. The Rotterdam data provide abundant evidence of a range of sharing behaviors among users which contradict the stereotype of predators, ripping off society and each other. While such behavior does indeed occur, another more prevalent pattern seems to be sharing and mutual support. Drug users share many valued things such as housing, food, money, clothing and child care. Often they help one another with daily problems associated with drug use lifestyles where sharing fits the broader context of coping with craving, needs for human contact, and the hardships of life on the margins of society. In this context the ritualized sharing of drugs serves as a strong symbolic binding force. These social behaviors were documented in many studies and in different places. (14 30 31 32) Sharing and its associated pattern of reciprocal aid, somewhat balances the constraints of the ripping and running world, (15) the competition, violence and mistrust of everyday life. Both the helping and sharing, and the ripping and violence, are all normal behaviors under abnormal and extreme conditions.
The Bronx
Between 1985 and 1989 a series of studies were conducted in the Bronx at the Montefiore Medical Center, and elsewhere in N.Y.C. to determine HIV prevalence, rates and risk factors among IDUs in methadone treatment (40-50%) (11 33) and in street samples (50-70%) (34). These studies and others have demonstrated the clear connection between injection histories and practices and HIV risk, specifying frequency of injection, sharing of injection equipment and especially the use of shooting galleries and of cocaine. (11 33) Clearly injecting practices occupied a central place in the transmission of HIV in the Bronx. Yet little was systematically known about the motivations or details of these practices, nor much about the specific settings in which injecting took place, or the experiences of the drug users themselves. While ethnographic studies examining the social context of drug use in New York and elsewhere in the U.S. did in fact continue throughout the AIDS era (35 36 37) these perspectives were often divorced from larger AIDS policy considerations. In New York City thinking about AIDS is dominated by the demands for acute medical care of the immense case load of people sick with AIDS -- 2000 per day in hospital beds and another 20 - 30.000 symptomatic in the community. This context would not normally be considered a promising environment for ethnographic research aimed at illuminating the context of drug use or discovering interventions which promote effective long term measures to minimize HIV spread. Yet, even in the Bronx, it has been possible to initiate a range of activities which produce ethnographically valid data and should form the basis for more effective outreach and AIDS prevention activities. These include studies of natural support systems in families of IDUs with AIDS (38), the emergence of durable support groups for HIV positive drug users and their partners, (39) new volunteer services (40), the incorporation of HIV infected individuals and former drug users as paid outreach staff (39) and engaging the issues of reproductive choice in groups of HIV+ women. (41) These activities are possible because they all operate within and build upon the natural support systems of drug users. By entering these systems in their natural settings it is possible to both learn and help.
Several outreach programs have been created in the Bronx intended to provide AIDS education and risk reduction services to women involved in street life, active drug use and sex sales. But it was often found that in this population, concerns about HIV and AIDS were low on the list of priorities. The context of everyday life of drug use in the Bronx entails a broad spectrum of more immediately threatening risks. AIDS education, as it is commonly delivered in NYC, does not satisfy the needs of this population if it focuses only on AIDS and does nothing to address the more visibly stigmatizing and very damaging aspects of their everyday lives. An outreach approach for this group must include lessons in safer professional sex and proper needle use, and must match clients' perceived needs with public health goals. Merely teaching needle sterilization is not well accepted because it requires an extra step and more time and effort to prevent something that this group does not chronically worry about. But teaching trackmark prevention and more competent injection technique was well received in this group as it requires no extra time, no major change in behavior, can be taught in a few simple lessons, and provides information most IDUs desire because it helps them economically and permits more efficient use of drugs. An individual who is able to find veins quickly not only lessens his or her own risk of infection, theft of drugs, or arrest; but now has a skill for which other less talented injectors are willing to pay. This puts safer self-injection practices and AIDS education into the economic framework -- a perspective that is never absent in the Bronx drug scene. AIDS education, offered in this context, is perceived as more meaningful by the drug user and facilitates better connections with health care professionals.
The Larger Social Context of Drug Use in Rotterdam and the Bronx
Great differences exist between everyday life in the drug subcultures of Rotterdam and the Bronx; In large part because the social policies in the two cities have been so different. In Rotterdam, as in other Dutch cities after W.W.-II, much effort was put into the process of urban renewal of the old neighborhoods, and provision of health care, education and social services. The housing situation of even the lowest income groups in The Netherlands can be called decent. The devastated areas, and burnt out buildings characteristic of the South Bronx and other slum areas of New York are, in Rotterdam, only memories of the enormous bombing of the city in May 1940. In Rotterdam only a small minority of drug users do not have regular housing. (42) When unemployed, they receive social benefits (like any other unemployed citizen) and these are high enough to support the basic costs of living. Tied to this social benefit people receive free medical care on demand and legal and social services are generally free or at low cost. Drug treatment was funded beginning in the early l970s and is readily available for those who want it. In Dutch political organization these matters have the status of requirements of the state constitution. Recently Peter Hartsock from NIDA has described this as the social responsibility characterizing Dutch society. (43) Since the beginning of the 1980s a relatively open atmosphere concerning drugs and addiction has existed in The Netherlands. The drug problem is viewed as one of the many social problems society faces which cannot be solved by repression. A higher priority is placed on the strategy of controlling the use of drugs and their damage rather then on their elimination. (44 45) This policy is supported by broad political consensus.
If Rotterdam reflects the positive consequences of a policy of social responsibility, the Bronx can be said to display the effect of decades of neglect, exploitation and political corruption. Between 1960 and 1980 large areas of the Bronx burned. This massive destruction of low cost housing (60,000 units) was due to several interacting factors - aging buildings, overcrowding associated with the influx of immigrants to NYC, and the reduction of vital city services, such as fire, sanitation, and building safety inspection. Consequently a large population (250,000) was uprooted and once vital communities were left in tatters: the total population shrank by 20% as middle class families fled to the surrounding suburbs. This lead to the formation of a large underclass population in which over one million New Yorkers have now lived for two or more generations. New York estimates the number of adults periodically or permanently homeless to be as high as 50,000, (46 47) while the city's emergency shelter capacity stands at around 9000 beds. There is little existing stock of rooming houses, or SRO's (single room occupancy) remaining - most of these have been gentrified.
Ironically, most of New York City's poor and homeless are by legal statute entitled to social and financial benefits, but not without identification documents. It is difficult for a person to get or retain the necessary ID (birth certificate, social security card) without a mailing address. Those who do manage to secure ID and public assistance benefits can easily lose them by failure to meet requirements for recertification of eligibility e.g. a quarterly face-to-face interview with a welfare worker in the central office. Health insurance (Medicaid) does come as part of the public assistance package, but only part of the drug users manage to maintain their eligibility. Furthermore most NYC public medical facilities are chronically overcrowded and are not receptive to any but the emergency needs of drug users and even to these only reluctantly. The demand for drug treatment greatly exceeds the available slots.
Policy Determinants of Drug Use Contexts
The Dutch drug policy has resulted in a stable availability, moderate prices and more consistent quality of drugs on the Dutch illegal market throughout the years compared with neighboring countries and the U.S.. (48) As in many other Dutch cities heroin and cocaine are mainly sold at so called house addresses: places where more or less stable social friendship groups of drug users gather and where they can buy and use their drugs in a relatively calm atmosphere. These places are often tolerated if they do not cause too much nuisance in the neighborhood. (see chapter nine) Only a minority of the subjects (23%) in the Rotterdam study used injecting as the main mode of administration, the other 77% smoked their drugs. This is made possible by the nature and purity of heroin available in The Netherlands. South West Asian base heroin (which is designed for smoking) has been available since the early 1980s and the purity has been rather constant at � 40%. (49 50) The average purity of (ceased) cocaine in 1991 was 80%. (51) Mainly because of economic considerations, it seems that many Dutch users do not feel the necessity to start injecting, as do many of their foreign counter- parts. (48 52 53 54 55) The Dutch experience shows that when drug market variables are relatively stable over time, a well defined and stable smoking pattern can develop. (56) Widespread injecting can thus be seen as adaptation to a situation of low availability of drugs of known purity. Furthermore in The Netherlands the sale or possession of injecting equipment has never been restricted or a reason for arrest. Nowadays in Rotterdam (and in Amsterdam), when an IDU gets arrested (for example for committing acquisition crime) and is found to be carrying a used syringe, it is routinely taken in and exchanged for a sterile one. In 1991 the Rotterdam police precincts exchanged 2500 needles of arrested IDUs. (57) Finally the easy accessible drug treatment system in Rotterdam, ranging from low threshold methadone maintenance to detoxification clinics, therapeutic communities and resocialization and education projects, also adds a great deal to the stability of Rotterdam users. 1100 treatment places are available for a population of 2500 - 3500 heroin users (>33%).
New York is a frontline of the War on Drugs. Over 250,000 drug related arrests occurred in 1989. At any given moment, 20 to 25.000 drug users are incarcerated in city jails and an additional 10 - 15.000 in state prisons. (58) The majority of drug sales occur in unstable and dangerous settings. Packaged drugs are sold through holes in the boarded up doors or windows of abandoned buildings from which an unseen person passes an untried quantity of pre-packaged drugs to an anonymous customer, or pre-packaged drugs are sold by small groups of people who wander a particular block, or hover in a particular doorway. There is no privacy, and little time is allotted for each interaction. A good brand (quality) may attract lots of business, but this also attracts more police activity. This causes the constant moving around of dealer-collectives, resulting in the breaking of friendship ties and no quality guarantees whatsoever. Frequently, large numbers of young homeless drug users live together in abandoned apartment buildings, sharing the available resources. As there are no public toilets or washhouses, many homeless people live without access to clean water. Occasionally the crack house becomes a stable shelter. In one case in the Bronx, one functioned this way for nearly a year for more than 70 people. The place had two suspicious fires (and was ultimately demolished by the fire department) but not until the buildings were actually flattened and the rubble hauled off did the population disperse. Due to their high visibility and large numbers they were forced to take up residence in different locations and their own community support system was destroyed.
The supply of heroin is often unstable in New York and this affects both price and purity. In fact, the purity level of New York City heroin is a complicated and confusing matter. Very little scientific data on the subject is available. Anecdotal sources (accounts from heroin users, service providers, field researchers and newspapers, such as the New York Times) present conflicting information. The quality of street level heroin is generally regarded as extremely unstable and varying by dealing site, time and brand name. (see below) The June 1990 Drug Price List Guide of the Narcotics Division of the New York City Police Department lists a 3% to 5% purity for $10.- glassines (dime bags), supposedly containing 1 to 3 grains (1 grain equals 65 mg), but also remarks that in some areas of the city purity may be as high as 25% to 35%. (59) With a 1991 market share exceeding 70%, China White, a No.4 heroin has become the undisputed market leader of New York City's illicit heroin trade, supplemented by Pakistani, Nigerian and Mexican products. (60 61)
Recent press publications have reported an upsurge in street heroin quality to levels averaging 20% (62) to 40%. (60) A recent DEA Domestic Monitor Program study to determine the purity and price of retail level heroin showed an average purity in 20 exhibits analyzed of 41.4%, with a range between 2 and 76%. (63) The higher heroin quality has been related to bountiful supplies in the Golden Triangle, increasing import and dropping wholesale prices, and the increased control of traffickers over distribution, preventing that the drug is diluted as it passes down to the level of the street dealer. (60) To get some sense of the street validity of these figures, the author discussed them with three active NYC heroin users and several New York based colleagues, involved in drug use research, during work visits in June 1990, June 1991 and October 1992. The information indicating rising street purity was met with considerable skepticism. The consulted heroin users relegated the press publications to the realm of fiction. They felt that the bags they had scored over the last years at their regular copping zone's (South Bronx; Lower East Side; Williamsburg, Brooklyn) were of "the same shitty quality as always". "If the dope was that strong as these stories claim it is, people would fall out (overdose) the moment they got off". (64) In June 1990, one NYC researcher put it like this: "Rising quality? I don't believe that, The quality of heroin is about the same as it was 5-8 years ago and 15 years ago. Everything is in it, but the kitchen sink". (65) John Galea of the Street Research Unit in New York sincerely questioned the representativeness of the DEA survey for the NYC street scene. (66) And indeed, the sample is small, the sampling method unclear (location, undercover purchase or confiscated, etc.), and the established purity range extremely wide.
Puzzled by the apparent discrepancies between the different sources, in June 1991, the author visited the laboratory of the New York City Police Department (NYCPD), where all confiscated drugs are tested in the process of preparing court cases. The following figures were kindly supplied by Ms. Bianchi, the chemist in charge of drug analyses. In 1990 her staff conducted 98.000 analyses (excluding FBI and DEA cases), 70.4% concerned cocaine and 17.3% heroin. (67) Analyses results are recorded in hand-written logs. Because of this immense case load and the juridical incentive for the analyses, the results are not registered in a manner that makes scientific processing of these data possible. Browsing over the pages of the log with the results of quantitative analyses of heroin indicated that over the period from june 1989 to june 1991 purity of street level samples (glassine $10.- bags) ranged from less than 1% to almost 75%, while a few larger samples contained up to 98%. A subsequent conversation with the chief of the Special Projects Unit of the NYCPD Narcotics Division confirmed this picture. He claimed that for those users that have good connections ballpark heroin (high quality; � 40%) is increasingly easy to procure. In his opinion, the purity of street heroin has definitely increased, but may fluctuate highly. (61) Clearly, these sources do not contradict the results of the DEA survey.
The mismatch of these results with the opinions and experiences of the consulted researchers and heroin users is conspicuous. In addition to the already mentioned instability, two additional reasons may account for this discrepancy. First, these users may have unwittingly been using heroin which gradually increased in purity over a period of years. This assumption is supported by the account of a user who frequently traveled between New York and Amsterdam. His cross-atlantic consumer comparisons did not indicate large differences in purity. (68) Second, the average heroin quantity per street bag analyzed at the police laboratory decreased from � 1.5 to 2 grains "some years ago" to only 0.25 to 0.5 grains in recent analyses. (67) Thus, while quality went up, quantity went down. A current purity of New York City's heroin of � 40% on average does therefore not seem an unrealistic estimate, but local and temporal variations still make the product very unpredictable. The purity of ceased crack and cocaine hydrochloride is generally higher and more stable. Although the NYCPD laboratory has the impression of a slight decrease in purity over 1990 and 1991, 70% and up is normal. Because of the unstable purity, smoking heroin, which can be perceived as a protective factor for HIV contamination (69), is hardly a serious option for New York's opiate using population.
IDUs have minimal access to sterile syringes in New York. The city's modest syringe exchange experiment was closed down for political reasons after one year of operating and the distribution of less than 400 syringes. The former Health Commissioner, Dr. Woodrow Myers, has withdrawn City funding for bleach distribution programs, contending that these approaches give the wrong message and condone drug use. The possession of a syringe is a misdemeanor, using it for drug injection a felony, and carrying a syringe is an invitation for police harassment. Given the legal status of syringes in NYC, renting injection equipment in a gallery is advisable. Not only does it protect the IDU from arrest on needles charges but may serve to convince (necessarily distrustful) dealer/gallery managers that an unfamiliar user is safe to admit to the venue. Shooting galleries with stable populations, consistent brands and family atmosphere exist, but this safer atmosphere is often threatened by chronic shortages of privacy, money, food, heat, drugs, or by intense harassment from police. Thus current drug policies foster less stable settings (abandoned buildings, cars, shooting galleries) where the same injection equipment is used over and over again by people often having no other relationship.
Rotterdam's current policies have resulted in a relatively stable, aging heroin using population, (70 71) where annually, approximately 70% of the population is in contact with one or more drug agencies - 35% on a daily basis. Most Dutch drug users have more in common with their unemployed, but non drug using neighbor, than with the stereotypical alienated dope fiend. (69) In this context the messages of safe drug use and AIDS prevention can be communicated and more easily implemented and the actual sharing of needles and syringes has decreased significantly. (4 9 72) In New York City, with an estimated 200,000 IDUs, there are over 35,000 high threshold methadone maintenance slots available and another 6000 drug free therapeutic community beds. But, on a lifetime basis, fewer than 50% of New York's IDUs have had any contact with a treatment program and only 15 to 20% has daily contacts - most of these in methadone programs offering only minimal social services. (73) The typical New York IDU seems to be in far worse shape regarding health, legal and socioeconomic status then his or her Rotterdam counterpart. With the constant threat of arrest, unstable housing, and little secure income, AIDS just is not the biggest problem on the block for New York's drug users.
Still the drug subcultures in both cities bear some remarkable similarities. Heroin and cocaine are the most used drugs in both populations and a large proportion of users substitute or supplement their use with methadone. Benzodiazepines and barbiturates are widely used to modulate the negative side effects of excessive cocaine use and to boost insufficient methadone doses. In New York it seems that drug users have complete pharmaceutical manuals in their heads and use whatever drugs they can lay their hands on. In Rotterdam this is an obsolete phenomenon, not seen since the early seventies when Dutch drug policy was still rather similar to American drug policy.
The sharing of drugs and other resources is an important feature of the drug subculture in both cities. Drug users, labeled as structural outsiders and ostracized by mainstream society, have become mutually dependant in order to fulfill some basic human needs. The ritualized sharing of a most precious, scarce and binding object or substance has symbolic value and separates the in-group from the out-group. (74) In both cities drugs fulfill these requirements. But in Rotterdam, with sufficient availability of sterile syringes and AIDS education efforts, needle sharing has become a deviant act. There just is no structural scarcity, justifying a need to share injection equipment and hence the HIV risk is lowered. In the Bronx, even though there is clear evidence of drug user awareness of the risks of sharing needles or syringes, conditions dictate that even the most motivated IDU will still share injection equipment some of the time. (11)
Interesting differences can also be seen in the level of ritualization expressed in the use of symbols and the different degree of organization and monetarization of mutual services. As explained before, retail drug sales at house addresses in Rotterdam are almost always weighed in the presence of the customer in a rather calm atmosphere. Buyers often sample their purchase on the spot, which gives them some degree of genuine control over purchased quality. Purchases are simply wrapped in packs of torn up magazine paper. In the lingo of the Rotterdam drug scene, heroin and cocaine have simply been known as bruin (brown = heroin) and wit (white = cocaine) for more than five years. In New York, drugs are almost always sold in public settings with great tension on the part of both the buyer and seller to move on quickly. Buyers have very little control over the pre-packed drugs they procure. The glassine heroin bags are stamped with striking and poignant brand names such as Miracle, Deathwish, Overkill, Untouchables, Check Mate, Obsession, Passion, Bodybag, Divinity, and Asesi�o, (the murderer). A brand name symbolizes the dealing organization and the quality it represents. Thus, the New York buyer's only control is in this symbolic brand name.
In Rotterdam, IDUs often administer their drugs at places that, on a face level, have some similarities with New York shooting galleries. However no explicit financial charges are asked for use of the setting although sometimes drugs are shared with the owner of the place. In both cities many IDUs suffer from collapsed veins and abscesses due to insufficient hygiene. Although many IDUs insist on injecting themselves, others are happy to get help from another, more experienced, injector. In contrast with the New York practice involving paid house doctors or professional hitters in shooting galleries (75 76 77 78), no explicit commercial counterpart of this service was found in Rotterdam.
The presence of antibiotic dealers alongside heroin and cocaine dealers in the South Bronx is indicative of the interest that the street population takes in maintaining their health, and treating illnesses that do occur -- even if only to permit them to still hustle for drugs. In Rotterdam where most drug users have full health insurance this phenomenon has not occurred.
All these phenomena, with similar or different outcomes in both cities, are firmly rooted in the respective drug subcultures. Although the drug subculture to many people seems a closed parallel world, mainstream cultural norms, policies and responses to (illicit) drug use plainly have important consequences on the everyday practice of drug users. These norms actually define and structure the features and social position of the drug subculture to a great extent. As Becker pointed out, the more any deviant group (i.e. deviant from the dominant cultural norms and values) is repressed and ostracized, the more it will profile itself as a deviant group and the more the deviant behavior, norms and values will get emphasized and reinforced in that group. (74) This results in a highly separated, intra-dependent, mono-focused subculture, in which members are very distrustful of mainstream culture. Inevitably this leads to skepticism about mainstream AIDS campaigns. In this respect the differences between the two cities are clear. Sharing and caretaking behaviors tend to be much less stable in New York than in Rotterdam and the more stereotypical negative behaviors associated with drug use are more likely in this harsh environment. Hence the powerful association of drug use, drug dealing and violence in NYC and the predictable hostility of the general public to the drug user.
Future Work in Research, Practice and Policy
The dynamics of the AIDS epidemic among IDUs in these two cities highlights the importance of basic knowledge of the lifestyles, behaviors and interaction of drug users in their naturally occurring social networks. Needle sharing is a partial representation of this complex reality, but overemphasizing the physical instrument of transmission is erroneous. The complex interaction patterns of economic and sociocultural factors involved in illegal drug use are equally important to the spread of HIV. It is this complex arrangement of interacting factors which should be the object of intensive future research. Without a clear concept of the everyday reality of drug use, quantification can be risky. Frontloading would not have been identified using a questionnaire, simply because, at first, the researchers were not looking for it. It was a serependipitous finding based on observation of the natural setting of drug use. Ethnographic studies provide the best opportunity for assembling a database pertaining to these naturalistic phenomena. Following this, quantitative instruments can be designed and utilized to test the specific hypotheses generated.
Both qualitative and quantitative research can gain much in value if the knowledge of active drug users can be employed in all phases of research. This requires the active collaboration of practicing drug users, an idea that is gaining attention and application. (79 80) For example, the use of focus groups which can be very important in validating new instruments and evaluating analysis outcomes. (40 81) Employing stabilized drug users in research teams will create natural entry into what is, for most researchers, a hidden parallel world. It can add a great deal of depth to analysis, disclose new leads and perspectives, and will surely stimulate scientific discussion in research teams on matters that before were undisputed or unrecognized (e.g. the extent and significance of needle sharing). It furthermore empowers the drug users as it gives them the opportunity to correct stereotypical or incomplete depictions.
Priorities regarding goals and methods of drug services need to be reconsidered, particularly in places like the Bronx where only a minority of drug users are in daily contact with treatment and helping agencies. When it is acknowledged that the prevention of AIDS must have a higher priority than the dubious goal of a drug-free society, effective harm minimization strategies have to be designed, brought into practice and evaluated. (82) Active drug users without contacts with treatment or helping agencies will find themselves more often in risk situations than users who are in contact with these institutions. Reaching and educating this hidden population must be given top priority. This should be accomplished through a permanent street outreach and organizing process of active IDUs equipped with the necessary tools to change their behavior in the desired direction. Outreach work plays a crucial role in this process, as the only possible way to reach this population is to enter its own territory.
However, outreach to this population should meet specific conditions. Rescue-style outreach programs frequently alienate or insult those they seek. AIDS education programs, while generally more comfortable dealing with sex and drug issues, frequently make the mistake of only talking about AIDS, sterile syringes, bleach and condoms. The outreaching hand is either trying to grab and rescue the people it wants to reach or pushing a message upon them. The AIDS prevention message is naturally of great importance, but can only be properly received when it fits within the existing knowledge base and everyday life of those involved. Active drug users themselves can have significant roles in the prevention of HIV spread and infection. Their information and exchange networks might be utilized in promoting risk reduction messages and behavior change through the social organization of the drug subculture. The message should be wrapped in a package that addresses the concrete and recurrent problems tied to this specific lifestyle and links up with existing norms and practices. Employing indigenous people as outreach workers in such programs will be of essential value. This is especially important in Europe as drug use among immigrant populations emerges as a major issue requiring attention.
Both in Rotterdam and New York good examples can be found of innovative working methods that are in concordance with the rules and daily practices of the drug subculture. In Rotterdam most syringe exchange programs are tied to the methadone programs, which are in contact with less than 40% of the heroin users. These needle exchanges only reach a limited number of active, out-of-treatment users. As these users are perceived as being most at risk, HADON tries to fill this gap by running a needle exchange in close cooperation with active IDUs. At highly frequented places where drug injection is allowed (some dealing places, some private homes of injectors; not actual shooting galleries) sharpsafe containers and boxes of sterile syringes are available. The syringes are exchanged among the visiting injectors and distributed through the networks by IDUs themselves. (83)
In New York, an underground needle exchange is run by volunteers from ACTUP and the National AIDS Brigade. These volunteers (many of them (ex-)users) do their covert work at places that are frequently visited by IDUs -- shooting galleries, street copping zones and other congregation sites. They offer a wide variety of injecting paraphernalia such as syringes, cookers, cotton, alcohol wipes, antibiotic ointment, bleach, water, a choice of needles, and also condoms. When needed and asked for, IDUs are referred and guided to methadone maintenance and other treatment modalities. (84) In addition, IDUs are thought valuable street skills for safer self-injection (preventing trackmarks, abscesses, edema, cellulitis, venous collapse, etc.) and safer professional sex (assessing the violence potential of johns, sneaking condoms onto them during oral sex, faking vaginal and anal sex with the hands). (75)
Both these initiatives are well accepted by the consumers and therefore offer a potentially effective mode for teaching and promoting lasting behavior change. However, both programs experienced strong opposition from established drug treatment programs, municipal policy makers and, in New York, the law: institutions not used to looking at these issues from a user perspective. So in Rotterdam, HADON got restricted from supplying drug wrappers printed with AIDS-prevention messages and needle exchange addresses to dealing drug users, although this was a perfect example of the application of marketing theory principles. And in New York, street health educators risk arrest and prosecution for their efforts to save lives, and bleach distribution programmes experience punitive budget cuts. It should be understood that mainstream morality regarding drug use, and old concepts of dealing with drug problems have become obsolete in the AIDS-era, and do not meet the criteria for effective AIDS- prevention efforts. The drug services field is in serious need of pragmatic approaches based on sound knowledge of the drug subculture and its mechanisms.
Drug policy is a decisive factor (for better or for worse) in the course and development of the AIDS epidemic among drug users and, potentially, the wider population. Inappropriate drug policies in many countries may actually facilitate the dissemination of HIV infection. (85) Thus the continued spread of AIDS among IDUs should become a sentinel for the failure of prevalent drug policies. Several countries, among them Australia, France, Germany and Switzerland, are all in the process of reconsidering their current drug policy --especially about the use of methadone and possession of clean injecting equipment. While the AIDS epidemic appears to support the need for a public health approach and pragmatic drug policies built on harm minimization principles, the U.S. government still aggressively promotes its drug policies as an example for many western countries, despite its evident failure at home. And, while many Americans have raised their voice against this harm maximization policy (86), the war on drugs rhetoric is getting more and more intense. Oddly enough, this situation shows some peculiar similarities with the situation in the Soviet Union just before Michael Gorbachov took over, or the last days of the Berlin wall. In these cases the old fashioned communist rhetoric were the last desperate cries of a system on the verge of collapse, and completely discredited and rejected by the population. After more than 70 years of prohibition of free enterprise, Eastern Europeans now admit the failure of the communist experiment, abandon its ideologies and turn to pragmatic approaches to their countries' cataclysmic economic problems. Likewise, 75 years of policies based on drug prohibition have brought the world no solution for compulsive use by a minority of drug users -- indeed the problem worsens as this dogmatic policy is extended and it has brought our societies nothing but devastation and an ever increasing social and political predicament.
Perhaps it is time for some perestroika in the drug wars.