Contents
Definition of Terms
Research Questions
Methodology
Characteristics of Research Participants
Representativeness
References
In this chapter the terms used in this thesis are defined and the research questions and hypotheses presented. Ensuing, the methodology of the ethnographic study is discussed and some characteristics of the study participants are described. Most of this thesis is based on this empirical study. Where additional material or data sources are used these are described.
Chapter 2. established that all definitions of ritual shared some condition of form. Ritual behavior should be either stylized, stereotyped, determined, standardized, repetitive, reassertive, or exhibit striking or incongruous rigidity --different terms for the same requirement. Uncertainty about the direct aim of the behavioral sequence of acts and signals is not allowed. It may not convey new information, it is fixed, prescribed and directed at creating a common emotion. Opinions diverge regarding the object of the ritual action. Some authors put an emphasis on the sacred character of the acts, others do not. Be it sacred or secular, the event should, however, have some symbolic meaning. This characteristic must have a preponderance over the technical purposiveness. This formulation leaves room for individual differences in the perception of the symbolic value of the actions. Thus, when Zinberg et al. found that rituals do not distinguish between, the individuals they classified compulsive or controlled drug users (1), this cann also be applied to the formal religious rituals of any church. Church rituals do not distinguish the deep religious devotees from the opportunistic non-believer who visits church to meet with social expectations or control.
Zinberg's definition is largely focussed on the process of drug administration. Using it strictly may lead to some omissions in the analysis of ritual behavior of drug users. For this reason Agar's definition seems the most suitable and, therefore, it is used in this study.
Definition of a Ritual Event
For an event to be a ritual event it must prescribe a sequence of psychomotor acts and this prescribed psychomotor sequence must be invested with a special meaning for the person performing that sequence (2).
Besides rituals, drug users share a specific set of rules or norms regulating the use of drugs and group interactions. Zinberg distinguished two kinds of norms or social sanctions; formal ones --those enacted in laws and policies-- and informal ones --those developed in the drug using peer group. Both drug taking rituals and informal social sanctions regarding drug use provide the user with "instruction in, and reinforcement for maintaining patterns of illicit drug use which do not interfere with ordinary functioning and methods for use which minimize untoward drug effects" (3). Formal social norms regarding drug use, i.e. the drug laws, do no such thing. They merely prohibit drug use. Consequently, they are de facto broken by all users of illicit drugs. For recreational drug users, who may be more eager to adhere to the formal laws, this may be a source of stress. However, heavy or regular drug users break the formal norms regarding drug use on a regular basis and therefore these laws seem to have lost much of their deterrent power. The worries of heavy drug users do not so much concern the actual breaking of the formal norms, but rather staying a few steps ahead of the enforcers of the norms.
Formal norms may have some influence on whether or not people start using illicit drugs, but do not have a regulating effect on the actual use of drugs, as they do not provide instructions or rules for safe or controlled use. Such a situation does not foster and reinforce the development of socially accepted models of controlled drug use. As a consequence, norms of controlled use have been developed by users themselves through interaction and diffusion processes in, and between social groups, intrinsic to the practice of social drug use. Formal rules regarding illicit drug use not only fail to reinforce safe use, their active enforcement even obstructs the development and communication of safe standards to a large extend. As a result, both rituals and informal norms surrounding the use of illicit drugs can be seen to possess idiosyncratic features (1).
Zinberg et al. found that in their study, in contrast with rituals, social sanctions differentiated controlled users from the compulsive ones (1). Control, however, is a relative notion. Many careers of heavy drug users are characterized by alternating periods of abstinence, controlled and uncontrolled use (4). Thus, it is here hypothesized that social sanctions aimed at control and reduction of harm are also expected among drug users, whose drug use, according to certain standards (e.g. those applied by Zinberg), may be called uncontrolled. Determination of such categories as controlled v.s. compulsive use, or e.g. recreational v.s. addicted use is, however, hampered by huge definitional problems. This problem will be discussed at the end of this section. Furthermore, norms "identify behavior that ought or ought not to occur, [and therefore] behavior may (and often does) depart from norms" (5). As his main study theme was the distinction between controlled and compulsive users of illicit drugs, Zinberg's definition of norm or social sanction (the norms regarding how or whether a particular drug should be used) centers strongly around the actual intake of the drugs. The norms found in the drug subculture are, of course, often centered around drugs, the object of common interest. However, his definition may lead to omission of other important social rules prevalent in the drug subculture. A more general definition of norm or rule is expedient; one that includes both the rules directly tied to the intake of drugs, and those that deal with other situations that occur in the drug subculture. Becker's definition covers these requirements:
Definition of Social Rules
Social rules define situations and the kinds of behavior appropriate to them, specifying some actions as right and forbidding others as wrong (6).
Chapter 2.3.3 extensively discussed the influence of the restricted availability of drugs on their potential to become an object of ritualization. At this point this property will be defined.
Definition of a Ritual Object
In order for an object to get ritualized, that is, obtain ritual value, it must be of substantial subjective importance (special meaning) to the persons involved, and be structurally scarce, that is, have a low availability.
The term drug availability is rather complicated to define, because it is dependent on several variables, functioning at different levels. A certain commodity can be highly attainable, but have a price so high that only few can afford it. Therefore, a definition of drug availability must take into account not only the actual presence of the product, but also its price level (as e.g. influenced by restrictive measures of the enforcers of the drug laws) related to the financial position of the user, which, for example, depends on the "possession of the conventional and/or criminal skills to provide money to purchase [drugs]" (7). The User's financial position in relation to the drug is, however, not only dependent on her/is income (and, of course, other expenses), but also on her/is tolerance and/or craving. This, in turn, brings up the pharmacological properties of the drug. Although equally available, heroin availability may be perceived completely different than cocaine availability, depending on preference or, more significantly, use level. Still, there is more at issue. Access to illicit drugs requires knowledge of, mostly surreptitious vending sites and the skills to distinguish a good deal from bogus drugs. This routinely leads to active participation in drug use / dealing networks or dependence on other drug users. Finally, the user must have the skills to actually use the drug. For example, a substantial number of female injecting drug users (IDUs) lack this skill and are consequently dependent on their male partner to get off (8). "In short, availability is a product of all those opportunities and obstacles that may influence a ... user's prospect for ultimately introducing a quantity of the drug into his or her [system] (7). It is thus clear that availability is highly variable, depending on many factors that may differ with individuals and situations. In this study the perception and experience of the users is of main importance, as this ultimately has consequences for the level of ritualization. For that reason, the definition utilized must include the perception of the users.
Definition of Perceived Drug Availability
Perceived drug availability refers to the efforts a user must go through in order to procure the desired drug, as assessed by the user. It includes general aspects, such as price and quality, and personal aspects, such as financial position and money making skills, knowledge of drug distribution networks, drug taking skills and drug of choice.
Throughout this thesis the research participants are addressed as drug users or users, sometimes as recreational or, in contrast, as heavy or regular users. Likewise, their use of intoxicating substances is referred to as (heavy) use. Terms such as addict, junkie, abuse, misuse, (physical and/or psychological) dependence and addiction are, as much as possible, avoided. This choice is grounded in both pragmatic and conceptual reasons.
To start with the latter, although efforts to formulate appropriate terms, definitions and concepts are undertaken for decades, in particularly by successive WHO Expert Committees on Drug Dependence (9), consensus on nomenclature remains absent in the scientific community, in particular in the medical and social sciences. In 1984 the author conducted a literature review into the definitions of the addiction concept. The main conclusions of this study are here summarized.
The development of the addiction concept (and related concepts) has been severely influenced by moral, political and legal forces. These concepts and the resulting definitions are furthermore developed based on experiences with non-random samples, generally in treatment settings. In practice, the developed terminology (abuse, misuse, addiction, dependence, etc.) is hardly workable. A scientifically sound distinction of these terms is absent. The majority of the reviewed literature did not define the terminology used. This is a major shortcoming, in particular because in many of the reviewed literature, some theory regarding addiction was presented. The definitions encountered in the review were in majority so dissimilar, that it is impossible to speak of, even a semblance of scientific agreement (10).
A major shortcoming of the efforts to produce a definition of, for example, addiction or drug abuse is not only that already in the word choice a (linguistic) value judgment is apparent, but even more, such concepts are often presented as isolated notions, without acknowledging the inevitable "central cultural conceptions of motivation and behavior" (11) akin to, and variable with, every culture. As Cohen formulated it recently: "[The medical and social] sciences seem to be unable to describe and explain the phenomenon of drug use without an unusually strong bias. This bias is produced by a cultural dependency on concepts of much larger significance than drug use itself" (12). The first efforts to formulate a nomenclature (and theories) on the phenomenon of drug use date from the late nineteenth century; a period in which the booming medical and psychiatric disciplines were poignantly influenced by the temperance and anti- opium movements. As Berridge writes: "In many respects the apparent scientific progress represented by their elaboration marked only the reformation of moral reactions to opiate use in a changed setting. Moral views were given scientific respectability through their propagation by medical specialists. Doctors were reformulating and presenting old moral concepts in an area where, as examination of treatment methods very clearly shows, they had little to offer" (13). Current thinking about and concepts of drug use are thus largely rooted in reformulated moral concepts. This led Szasz to question and ultimately deny the legitimacy of the (psychiatric) notion of addiction. He argues that addiction and related dogma's have never been questioned and are based on acceptance of conventional (moral) definitions of certain behaviors and circular reasoning in constructing a pseudo-scientific explanation, justifying the moral choice. Without repudiating the possible negative aspects of drug use he writes: "[T]he difference between someone using a drug and his being addicted to it is not a matter of fact, but a matter of our moral attitude and political strategy toward him" (14). In this line of thinking one can easily substitute drug use for other behavioral expressions, not sanctioned by mainstream culture (those in power), such as non-chemically induced altered states of consciousness (madness), homosexuality, masturbation and other forms of divergent sexuality, abortion and even various forms of criminality. It is therefore not surprising that in late nineteenth century similar disease views emerged on e.g. madness, alcoholism and homosexuality (13). Such a comparison illustrates the relative status of these concepts, as it is clear that the values, and thus the definitions connected with them, are subject to change, both geographically and over time. It is thus clear that, although current definitions are often presented as such, it is not possible to formulate objective definitions of the social phenomena such as the above. This led Cohen to call the complex of activities and realities around the phenomenon of drug use social constructions (12). For further information on the theoretical aspects of this discussion (such as e.g. the power aspects) the reader is referred to the writings of, among others, Szasz (14, 15) and Peele (11).
Besides these conceptual considerations, there is a strong pragmatic argument for the above choice, largely determined by the design of the study (discussed in depth in section 3.3). The most important mode of data collection has been participant observation. Drug users were observed using drugs in their own territoria, mainly at so called house addresses where heroin and cocaine are sold and used. How can this group be characterized? Are they abusers, uncontrolled or compulsive users, problematic users of the drugs they consume? Are they addicted? The people frequenting these places are mostly involved in drug use on a daily basis, but this does not count for all visitors. Therefore, these labels cannot be attached.
Since some years now, one can observe a -scientifically correct-- trend away from the term addicts, substituting it for drug users or merely users (16). Recent Dutch interview studies have utilized more objective and quantifiable inclusion criteria based on the frequency of opiate use (e.g. a regular opiate user defined as a person who uses opiates at least four days a week or a daily user defined as a person who uses opiates each day or almost each day (five to six days a week)) (16, 17). In the participant observation approach utilized in this study it was not possible to assess data on frequency of use. This would have severely affected the principal non-intrusive character of the methodology. But, more important, there was no need for such criteria, as the main interest of the project was to study the actual drug self- administration rituals surrounding the use of heroin and cocaine. As the studies of Zinberg determined, the rituals do not distinguish between user groups --the actual behavioral sequence is in essence the same.
This dissertation presents the results of an explorative ethnographic field research into the drug taking behaviors of regular users of heroin and cocaine in Rotterdam, The Netherlands. For this purpose the study used the concept of ritual. This concept has been utilized in a large number of classic cultural anthropological studies and, in a somewhat lesser extent, in sociological studies. Its explicit application in studies of illicit drug use, however, is limited to a few, though very interesting, ones. As a consequence, this study started with rather general research questions, resulting in an open focus ethnographic approach. Its major aim was to generate knowledge and hypotheses about the ritualized behaviors surrounding the intake of heroin and cocaine; about the patterns, meanings, functions, and possible health implications of these rituals, grounded in the descriptions of the everyday behaviors of active users. The research questions of this dissertation can be grouped in the following clusters:
1.1 What ritualized behavior patterns can be distinguished surrounding the self- administration of heroin and cocaine?
1.2 Which factors determine the choice for a certain drug administration ritual (smoking or injecting), and how stable are these rituals?
1.3 To what extent can the recurrent sharing of drugs be considered a ritualized interaction?
1.4 What drug use related social rules can be distinguished in relation to the observed ritualized behaviors?
1.5 What are the functions and meanings of these rituals and rules, for the individual as well as for the community of drug users?
1.6 Are there differences between the two subpopulations (smokers and IDUs)?
1.7 To what extent do drug use related rituals and rules contribute to self-regulation of drug use and to the reduction of drug use related harm?
1.8 What other determinants of drug use self-regulation processes can be distinguished and how do these interact with rituals and rules?
1.9 What external factors influence the efficacy of these self-regulation processes?
2.1 What are the (physical) health consequences of the distinguished drug administration rituals?
2.2 Can the drug sharing patterns of IDUs put them at risk for contracting or transmitting HIV and other microbiological infections?
2.3 Under which conditions does needle sharing occur?
2.4 Is the sharing of needles a distinct ritualized interaction pattern?
3.1 What are the effects of different drug policy options on the ritualization processes surrounding the use of illicit drugs?
3.2 How can the findings of this study be used (i) in the promotion of safer and more controlled patterns of intoxicant use and (ii) to reduce the with drug use associated hazards and harm, for example HIV infection?
3.3 What are the implications of the study for future research, drug policy, and the provision of drug treatment and care?
Introduction
Discussions on the value of quantitative and qualitative research designs and techniques have a lengthy tradition in the social scientific literature. Quantitatively oriented researchers often question the generalizability of qualitative data. Ethnographers themselves have also discussed the intellectual legitimacy of their methodologies (18). Qualitative researchers have expressed doubts about the validity of quantitative instruments and the interpretation of numeric data. Both methodologies have strong and weak points and they often describe different aspects of the same social world. Of importance and seemingly rather obvious, is that the specific research question should determine the methodological approach. Some research questions require a quantitative design, for example, when researching known populations and when dealing with phenomena about which already some scientific knowledge exists. For the research questions posed in this thesis, in an area where little scientific knowledge exists, an explorative, and primarily qualitative design is suitable. As Lambert and Wiebel stated:
"[e]thnographic research methods are appropriate for topics about which little is known, primarily because ethnography is by its nature fundamental and exploratory, preparing the way for more rigorous studies that strive for precision and quantification. ... Ethnography serve[s] to fill knowledge gaps and set[s] the groundwork for further scientific inquiry. ... It is at this exploratory, descriptive stage of research that ethnographic and qualitative methods can make significant contributions to the knowledge and understanding of problems and to the formulation of subsequent questions for quantitative research, including clinical studies, laboratory experiments, and population-based surveys" (19).
Working with unknown or hidden populations makes it nearly impossible to use standard random sampling techniques. As Wiebel writes:
"Because the use of illicit intoxicants is largely a covert activity in our society, it is not possible to enumerate all individuals who engage in such behaviors. Representative sampling, irrespective of scientific merit, is quite simply not possible in relation to the numerous varieties of phenomena at issue (20)".
Moreover, data collected by self-report techniques may often be highly biased if they reflect socially undesirable and criminalized activities. Ethnographic field observations can provide an opportunity to overcome the potential disadvantages of questionnaires or interviews by directly recording behaviors. Biases of memory, self perception, fear and mistrust are traversed. Nevertheless, ethnography has its own limitations. As previously noted, the validity and generalizability of findings have been questioned (21). The researchers presence might alter the context and behaviors of the study group. However, the collective experience of the ethnography of socially undesirable behaviors has indicated that with due care and time the researcher can become part of the furniture (13). Group members live within well- established traditions that constrain their actions. While the presence of the researcher may introduce a new constraint, the weight of traditional constraints routinely prevails (22). The validity of ethnographic data can be further improved through appropriate controls on site and subject selection, development of trust, observational strategies and protocols of data recording (23).
The data for this research were mainly collected between February 1988 and May 1989, while some additional observations were recorded between May 1989 and December 1991. The principal methodology can best be described as open focus street ethnography. Intensive participant observation was conducted of drug users' self-administration of heroin and cocaine at dealing places, their homes, and public places in two neighborhoods of Rotterdam characterized by high concentrations of drug activity. This open focus ethnography permitted the research team to see things they were not looking for. The discovery of frontloading provides an excellent example of the scientific value of such serendipity. In 1754, Horace Walpole first coined the term serendipity. The term was first printed in 1833 when a collection of Walpole's letters were published. Walpole introduced the term as follows: (24)
"This discovery, indeed, is almost of that kind which I call Serendipity, a very expressive word, which, as I have nothing better to tell you, I shall endeavour to explain to you: you will understand it better by the derivation than by the definition. I once read a silly fairy tale, called "The Three Princes of Serendip:" as their Highnesses travelled, they were always making discoveries, by accident and sagacity, of things they were not in quest of: for instance, one of them discovered that a mule blind of the right eye had travelled the same road lately, because the grass was eaten only on the left side, where it was worse than on the right --now do you understand Serendipity?" (25).
Fleming's discovery of the antibiotic activity of the penicillium fungus in 1928 is perhaps the most famous example of serendipity.
The serendipitous discovery of frontloading strongly influenced the further development of the research project and the theoretical analysis of the data. Empirical facts help with starting a theory, as Merton in 1957 remarked: "The serendipity pattern concerns the rather common experience of observing an unanticipated, abnormal and strategic fact that becomes the reason for the development of a new theory or for the extension of an existing theory" (26). The discovery of frontloading and the realization of its potential significance served as the stimulation to further scrutinize the phenomenon and place it in a wider frame of knowledge. Evidently, this has resulted in some diversion from the ideas in the original research proposal, but "[t]he development of science cannot be straightjacketed. The most interesting discoveries [are found] outside of the vested structures" (24).
Research Sites
In order to study drug users, one first has to make contacts with them. Most studies of compulsive drug users have been carried out in treatment settings such as methadone programs, residential therapeutic communities, clinics or other institutional settings such as prisons. When one wants to study drug users and their behaviors in their natural setting these locations are not suitable. In some instances, they can be used as a starting point to make contacts with users that are willing to take the researcher to natural congregation sites, such as copping (buying) zones, house addresses or shooting galleries. That was not the case in this study. Rotterdam is a city with approximately 580.000 residents. The number of heroin users is estimated between 2500 and 3500 (27, 28). Although, drug users are not confined to a particular part of the city and in many neighborhoods drugs such as heroin and cocaine can be bought, there are a few areas with heightened drug activity. As a result of prior experience in the Rotterdam drug field, these areas were identified beforehand. Two strategic research sites (29) were selected because they represented significant variations in the areas of high concentration drug activity.
The first research site was the zone around the Rotterdam Central Railway Station and the adjacent neighborhood. The Central Station served as a meeting place for heavy drug users, alcoholics and other marginals since the middle of the 1970s. It is the only remaining open drug scene in Rotterdam and the center of the street dealing of methadone (especially on Fridays when methadone program clients get their take home doses for the weekend) and prescription drugs, such as the popular benzodiazepine Rohypnol. Some small scale street dealing of heroin and cocaine also occurs in this area. Because of factors relating to both the drug packaging (in contrast with drugs sold at house addresses, the drugs sold in this open scene are prepackaged) and the rushed atmosphere of a street drug sale, the consumer has much less control over the purchased product. According to well informed users, who have access to house addresses, heroin and cocaine bought at the Central Station are the worst buys in the city. Many users at the Central Station do not have access to or knowledge of house addresses, the most common setting for drug dealing in Rotterdam. Some users are temporarily denied entry to house addresses if they do not buy or are known to be in financial need. Other users are denied access more permanently. This is usually because their behavior and reputation does not conform to subcultural expectations. Among the permanently barred users, the most marginalized ones can be found. The other group using the Central Station market consists of drugs tourists. Korf et al. studied heroin tourists in Amsterdam, a city with an international reputation for drugs tourism. They found that most of their subjects (N= 382) came from Germany (35%), Italy (21%), the United Kingdom (10%) and Spain (7%). To their surprise, they only found a small percentage of French (3%) and Belgian (2%) heroin users, comparable with the percentage of North Americans (2%) (30, 31). In contrast, in Rotterdam, although no systematic research has been undertaken, it seems that the majority of drug tourists come from France and Belgium. They are mostly serviced by (both drug using and non using) French speaking Moroccans, who either sell them small quantities or guide them to house addresses, when larger quantities are desired (32). Few drug tourists have steady contacts outside the Central Station themselves.
At one side of the Central Station, throughout the day several low-threshold mobile methadone maintenance programs (modified city transport busses) dispense methadone to their clients. At the other side stands a small portable shelter where the, often homeless, visitors of the station can drink a cup of coffee or have a first contact with a social worker. In this shelter syringes are dispensed.
The neighborhood adjacent to the Central Station has a long history of drug use and dealing. In the late 1970s the main street of this neighborhood provided a dense and large street copping area. In the early 1980s the police cracked down on this overt drug scene with the result that drug dealing spread over the older neighborhoods of town undergoing renovation. However there is still drug dealing in the neighborhood mainly indoors. Also in this neighborhood is a church, that runs a day shelter. This shelter is visited by people with drug, alcohol, housing and other problems. It offers such services as sanctuary, a cheap meal and initial help with social problems. Many steady visitors of the Central Station frequent the church shelter.
The second research site is one of Rotterdam's oldest neighborhoods. Close to the center of town, the first building of this neighborhood stems from 1725. Hundred and fifty years later the neighborhood grew rapidly as a working class residential area due to an agricultural crisis and the rise of industrial and harbour activities in Rotterdam. Houses were cheap and the area became densely populated. Families lived from generation to generation in the neighborhood, often in the same street and houses. The neighborhood knew an intense social and corporate life for decades, e.g. many streets had their own social club. However, in the twentieth century, especially after the second world war, the quality of the housing rapidly deteriorated. In the 1960s and early 1970s many inhabitants who were in a position to leave, did so and they were succeeded by foreign laborers, students and squatters. Social life and relations drastically changed. In the Seventies the urban renewal began in the area. Although this improved the housing situation, it also meant an additional burden on the already weakened social structure (33).
In 1982 it became apparent that the use of hard drugs among neighborhood youth had risen rapidly and due to the above mentioned police activity in the original drug area of the Central Station, drug dealing entered the neighborhood and quickly multiplied. In some streets under renovation more than 10 dealing places could be identified and the police estimated that the total number of dealing and using places in the neighborhood was around 80. In 1982 the total number of heroin users living in the neighborhood was estimated at � 250 (33). At the end of the 1980s the neighborhood began recovering from the urban renewal process, which was near completion. Although drug activities have decreased to a certain extent, there is a stable group of drug users living in the neighborhood. Many of them were raised in the neighborhood. Besides this group another, floating population of users, frequent the neighborhood to buy and use drugs and to socialize with friends at the house addresses. Some of them are dealing from time to time. Others live for shorter or longer periods in squatted houses or with friends that have legal housing in the neighborhood.
Gaining Access
Once the research sites were chosen, the field research team, consisting of a community field worker (a respected post user) and the principal investigator, started hanging out at the Central Station and wandering through the streets of the second site. While doing so, old contacts with known users were reestablished and new contacts were made. The primary goal in this phase was to develop relations with high status users, (20) such as dealers and house address owners or with people that could introduce the team to these places. "For a successful research relationship to evolve, ethnographers must establish legitimacy both for their presence and for their intentions" (20). Therefore, trust, acceptance, and credibility are of vital importance. Both the community field worker and the principal investigator have worked in the drug field before and were known to be trustworthy. During informal conversations with drug users on their problems and life in the drug scene in general, the project's goals were discussed. Although many of the users were aware of the position of the researchers, this cannot be said of all the drug users that were observed in the course of the fieldwork. Often at busy house addresses where in the course of a few hours the composition of the premises would almost change completely the field researchers became almost invisible. A few times the principal investigator was suspected of being an undercover police officer. However, there were always one or more users around who could alleviate suspicions. These situations usually ended in laughter or an interesting conversation.
Enduring relationships have developed with a considerable number of the study participants. This is an inevitable consequence of spending many hours with the participants and interacting with in a non-judgmental manner. Developing such trusting relationships can be seen as a sentinel for sound ethnography. It can, however, bring the researcher into difficult situations that cannot be anticipated. People often tell very intimate details about themselves and about their relationships with others. Gossip is frequent and the researcher must resist the temptation to offer opinions. Being a close observer, one witnesses the positive and negative elements of people.
In situations of need, the ethnographer is sometimes called upon to leave the role of participant observer and intervene. Such was the case when Harrie, one of the most important field contacts got into problems. Harrie had been using hard-drugs for about 23 years; methadone, heroin and primarily amphetamines (speed). During the time the research team was in contact with him, Harrie was almost always optimistic. Some months previously he began dealing heroin and cocaine and stopped using methadone and speed. Instead he began shooting cocktails of heroin and cocaine. The first months went alright. Later he started having problems; he was robbed twice, his girlfriend left him and his cocaine use escalated. Attempting to feel better Harrie continued using large amounts of cocaine but grew more and more depressed. Two days after we had given him our phone number, Harrie called asking us to come over. When we entered his room we found him in a deplorable state. We talked about his problems. His life seemed "one black hole" to him in which he was stuck. He seemed exhausted and had not eaten for days. When we offered him to buy some food he refused, saying a shot of cocaine would make him feel better. He almost begged several times for money to get some coke, but did not consider cocaine to be a part of his problem. He agreed to go out and look for help. When we left, the fieldworker bought him some food; he ate it all. The following excerpt from that day's fieldnote documents this role change from observer to, in this case, case manager:
First we go to his methadone program. The staff is surprised and somewhat embarrassed. Harrie is asked why he had not said he was feeling poorly. However, days before Harrie made an appointment for a talk with the program's psychiatrist. This appointment had been postponed. First it looks like the staff does not know how to handle the situation. One staff member asks me to phone the on-call psychiatrist. I ask "should I do that?" Then they call the crisis center for drug users where it is agreed that Harrie can stay until his psychiatric appointment. We escort him to the center where the intake clerk underscores that he can only stay until Monday, the appointment date.
Some of the research participants, enduring relations were developed with, became key informants. They provided important supplemental information and insights. All locations were initially selected through neighborhood exploration and information from key- informants. At times, the research team accompanied participants on their daily rounds. In this way they also were introduced to new dealing places, using places, and private homes. During the fieldwork, some of the dealing places were closed down by the police. Although these busts caused some turmoil, they did not seem to have a significant impact on the availability of drugs. New places quickly opened, sometimes on the same day at the same address. Often the researchers were introduced to the owner of a (new) address by a key- informant. By following the dynamics of the drug scene most of the neighborhood house addresses could be observed.
Instruments and Data Collection
The observations were structured using an observational protocol of endogenous and exogenous cues pertaining to the heroin rituals of injecting and smoking (chinesing or chasing the dragon). As the study was primarily concerned with the actual behaviors of the drug self-administration sequence (the preparation and ingestion of the drug, the use of paraphernalia, order/sequence, places, setting, time) and secondarily with demographics and other characteristics of the people performing the observed behaviors, the former are highlighted in the fieldnotes. Appendix A presents the protocol.
The observations were collected by carefully watching drug users perform their drug taking routines. Sometimes this was done while sitting a few meters from the observed person and sometimes while interacting with the observed person or another user. The contents of these interactions ranged from general conversation topics to specific discussions on the actual drug taking. Never were questions experienced as intrusive. Only on a few occasions written notes were taken while observing. In general, such note taking would be too intrusive. No structured interviews were conducted. When possible, additional information was collected from informal conversations. Other than providing an occasional sandwich or cup of coffee, no participation fees were paid. Detailed fieldnotes were recorded of 95 rituals. In 44 observations, subjects were smoking; in two, subjects were snorting; and in 49, subjects were injecting. The observations were recorded in the afternoon (94 percent) and early evening (6 percent). 93 percent of the observations were recorded at 14 different houses, where drug users live, deal drugs, or both. In 53 percent of the observations those houses were legally rented, in 9 percent they were subleased and in 38 percent squatted. The remaining observati- ons were recorded in public places , a greenhouse, deserted sheds behind abandoned buildings awaiting renovation and on the streets.
Data Processing, Coding, and Analysis
Fieldnotes were produced independently by the researchers after each fieldwork session or the following morning, based on short notes generally taken immediately after the observations. The fieldnotes were processed on personal computers using WORDPERFECT word processing software (34), transformed into ASCII files and entered into the ETHNOGRAPH, a computer program for the analysis of qualitative data (35). Appendix B presents an overview of this procedure. In this program the qualitative data were numbered line by line and coded in concordance with the observational protocol. The codes evolved constantly during the data collection and concurrent coding process. The coding process was primarily the responsibility of the researcher. However, some data was also coded by the fieldworker and the supervising professor and sometimes jointly coding sessions of researcher and fieldworker were held. Analysis was performed by the researcher in a continuous consultation and discussion process with the fieldworker and the supervisor. Memos were exchanged on diverse aspects of the data, coding and analysis. These memos were the material of regular research staff discussions. In these meetings innovative ideas were brought up that enriched and steered the analysis to a great degree. During this recurrent process of data collection, coding and analysis the from the outset general research questions were increasingly specified, while new ones emerged. Although its formal procedures were not always exactly utilized, the project methodology shares many characteristics with Anselm Strauss' grounded theory analysis (36).
In order to complement the qualitative analysis, the data were quantified by counting significant events and by recording available demographic and background characteristics of the subjects. These data were stored in two separate SPSSX data files. The numbers presented in this thesis were generated through these quantifications and are intended to support the qualitative analysis. Drawn from a selected sample, they may not represent all drug users in Rotterdam, a common feature in studies of hidden populations.
In order to obtain information on the regular visitors of the Central Station, a survey was conducted. Every fifth visitor of the shelter adjacent to the Station was interviewed by indigenous interviewers who were trained by the community field worker. Sex and race of the interviewers resembled those of the C.S. population. In total 61 interviews were conducted on living conditions, social status and work situation, drug use, and time spent on the C.S. The data from the survey on the Central Station zone population have been used to supplement the data obtained from the observational protocols and cross-validate interpretations.
Where opportune Rotterdam methadone treatment data have been used. These data are collected in intake interviews and registered in the Rotterdam Drug Information System (RODIS). Most RODIS data stems from the yearly reports, except for those used in the secondary analysis in chapter seventeen. These were supplied by Drs. Jaap Toet of the epidemiology unit of the Rotterdam department of Health.
Characteristics of the Research Participants
The total number of research participants contacted was 192 --168 males and 24 females. Because no formal interviews were held not all the characteristics could be recorded. Hence, on the demographic variables, there are considerable missing data. Of the ages that were recorded, some were known exactly but most were estimated by comparing independent fieldworker ratings. 30% were 25 years or younger, 50% between 25 and 36 and 20% over 35 (N = 106).
Figure 3.1
This distribution resembles that found in the Rotterdam registration system of heroin users in methadone treatment (RODIS) (27%, 60%, 13% N = 1797) (37). 45.7% of the participants are native Dutch, 26.9% are of Moroccan, and 23.7% of Surinam origin. 3.7% have their roots elsewhere (N = 186). For a minority of 23% injecting was the main mode of administration. 77% were smoking their drugs (N = 162). Although 72.6% of the chasers were 30 years or younger, and 60.5% of the IDUs were over 30 years (N = 95), the chasers outnumbered the IDUs in the group above 35 years by 57% to 43%. 96% of the research participants used both heroin and cocaine (N = 105). This pattern of combined heroin and cocaine use started in the beginning of the eighties when an increasing number of heroin users added cocaine to their menu. That cocaine has become increasingly important to Dutch heroin users is cross-corroborated by the RODIS system where in the 1988 intake cohort a prevalence of 72 percent cocaine use is reported in the treatment population (37). Over the following two years this percentage decreased somewhat and stabilized in 1990 at 68% (38). Moreover, the fieldwork established that, at all house addresses and at the Central Station, both heroin and cocaine were available. Cocaine has become increasingly important to Dutch heroin users. A small group of older IDUs were also regular amphetamine injectors.
The survey held at the end of 1987 among the visitors of the shelter at the Central Station revealed figures, that in some respects are comparable and in others are somewhat different. There were less males in this sample (67%), the ages seemed somewhat lower (48% under 26 years (although 15% being 25), 42% between 25 and 36 years and 10% over 35) and the vast majority were white Dutch. The distribution of injecting and chasing was, however, very similar; Only 23% injected heroin and 28% injected cocaine. The prevalence of cocaine use was 74%. This survey furthermore indicated that the large majority (75%) of this specific population is hanging around the Central Station more or less all day. Almost half (45%) visits the station to meet other people and one-fifth come because of the stationed methadone busses. Almost half (41%) uses and buys drugs at the station and dealing is not an infrequent activity (15%). Unemployment and unfinished education are main characteristics and one out of five is homeless. The main complaints that have been recorded are boredom, loneliness, absence of or poor housing and addiction.
This study reports in the first place on the drug users studied at the house addresses, private homes and public places in the two research sites. The results are, nevertheless, applicable to the larger population of users of heroin and cocaine. In particular to those who buy and use these intoxicants at house addresses or around the Central Station in Rotterdam. Although the drug scene in Rotterdam has some specific features, many aspects may well be comparable with those in other Dutch cities.
A possible source of bias may be found in the selection of the research sites. In theory, it is possible that in other areas, different behavior can be observed. However, a number of observations were recorded in other areas of the city and the use of heroin and cocaine has also been observed outside of Rotterdam and even outside The Netherlands. These observations were not in contrast with the general picture that emerged from the data.
The characteristics of the research participants may have biased the results in another fashion. When compared to recent studies of heroin users (both in and out treatment settings), it can be determined that the distribution of ages and administration rituals is rather similar (16, 27, 28, 37, 39). Regarding sex, ethnic distribution and prevalence of cocaine use the sample diverges, in particular from treatment populations (28, 37, 39). These differences may well be explained by the unique design of the study --the observers were present where the action is, though not undercover, often unnoticed, ignored or even forgotten-- which did not require active or conscious cooperation of each participant. At the other hand, users that have others buy their drugs for them are excluded.
As the majority of observations were conducted at places where these drugs are sold, the high proportion of minority users in this sample may be due to a larger presence at these places or a higher involvement in consumer level heroin and cocaine dealing (40). It can, however, not be excluded that the found distribution presents a more realistic image of the actual proportion of minority drug users, as they seem less willing to participate in (survey) research (17) and are probably underrepresented in drug treatment facilities (28). This latter suggestion is somewhat supported by the higher proportion of ethnic minorities that received methadone in custody at Amsterdam Police stations, (39) although this may also indicate that minority drug users are simply more often arrested (16).
The comparably low proportion of women in the sample needs a somewhat more elaborate explanation. It is sometimes assumed that female drug users are underrepresented in drug treatment programs (41, 42). Although the found distribution seems to contradict this assumption, this may not be the case. First of all, the low number of women is caused by the high proportion of ethnic minorities --the percentage of women is about three to six times lower in these groups (28). Further reasons for the low proportion of women in the sample may be similar to those put forward for their relative absence in treatment programs. In general, the drug scene, including the treatment programs is male oriented and driven. Female users may come less often to house addresses, because, if around, their husbands or boyfriends score the drugs, while they wait at home (and sometimes take care of children) for their partner to return with the drugs. Alternatively, independent women may use at other times and places than observed. For example, female users involved in sex work may frequent addresses, that only sell to sex workers. Nevertheless, the observations of the drug use rituals of women did not cause reason to assume that, within the two main rituals, women partake in conceptually distinct rituals (however, the functions and meanings for women may differ).
The higher prevalence of cocaine use may also partly be explained by the high proportion of minority users, who use cocaine more often (16, 28). In addition, the subjects of the observations were all active users --they were caught in the act of using heroin and/or cocaine. As the level of heroin use is positively related with the use of cocaine, (17, 28) non- users of cocaine may have been somewhat underrepresented at the house addresses --they come less often. At the other hand, participation in methadone programs decreases (the frequency of) both heroin and cocaine use (43). Methadone treatment data is thus not representative for active out-of-treatment users.
Having taken these factors into consideration, it can be assumed that the study sample presents a rather fair representation of the population involved in regular use of heroin and cocaine in Rotterdam.