The Qualitative Methods Journal Club discuss an article which sought to identify and explain assorted health disparities associated with ethnicity, age and gender within a community of homeless people who use drugs. ‘Remarkable’ and ‘ground-breaking’ findings included the observation of different survival strategies between African American and White men. The article was selected to coincide with the UK’s Black History Month in October.

About this month’s Journal Club

The article (available here) was selected for inclusion in the October QMJC at the National Addiction Centre, King’s College London, to coincide with Black History Month in the UK (although the article focuses upon the experiences of African-American and White men in the USA). By coincidence, the selection of this article also marked the 15th anniversary of its publication (24.10.06), which inadvertently added to the ‘historical’ aspect of Black History Month.

Summary of the article

This article summarises a large scale, multi-disciplinary study that took place in San Francisco during 1994–2006 amongst people who were homeless and who used drugs. The study was primarily ethnographic in design but took the novel approach of including local epidemiological data (generated in a separate longitudinal study) as an analytical resource.

The ethnographic element involved an extended period (1994–2004) of immersion in homeless encampments of San Francisco, in which some of the authors observed, interviewed and photographed people about their various survival strategies (and substance use) whilst living on the street. This was complemented by a ‘clinical ethnography’ in which a physician/researcher recorded clinical fieldnotes and conducted interviews with 70 individuals during the course of medical intervention in naturalistic environments on the street.

The epidemiological aspect of the study involved analysis and interrogation of data gathered from 37 semi-annual surveys conducted during 1986–2005 – involving over 30,000 interviews from 12,000 people who use drugs.

The authors situated their ethnographic study within the large scale longitudinal epidemiological study in an attempt to identify and explain assorted health disparities associated with ethnicity, age and gender within a community of people who use drugs while living on the street (or in unstable, insecure housing).

Discussion of the article

This article was considered to be a good example of a qualitative research article, not only due to the above ‘cross-methodological dialogue’, but also due to the ‘aims/goals of the study’, the ‘ethnographic components’ and the ‘clinical implications’ of the large-scale, longitudinal study. These are summarised below.

Aims and goals of the study

In recognition of the long-standing health disparities associated with class and ethnicity throughout the US, the authors sought to develop an understanding of the patterns of drug use and survival strategies of people who inject drugs. More specifically they aimed to identify the range of health inequalities (and associated harms) that existed between different ethnic groups (African-American, White, Latin etc.) within populations of people who use drugs (that may be influenced by structural constraint, poverty and institutional racism).

In addition, the authors had the goal of using their findings to “contribute to improvements in clinical cultural competence toward socially vulnerable patients” (emphasis added). This goal was considered particularly relevant to the current political climate, in which institutions seek to reduce unconscious/conscious bias and improve cultural competence of staff/employees as part of Diversity and Inclusion agendas.

In essence, the goal of this study (the improvement of clinical intervention via a better understanding the lives of those affected by substance use while sleeping in homeless encampments) was considered to be ‘ahead of its time’ (in 2006) due its focus upon cultural competency within clinical settings.

The ‘ethnographic components’

The long-term immersion in the field by the researchers (1996–2004) and the various strands of ethnography (clinical ethnography, photo-ethnography and ethnographic attachment to encampments) reflect outstanding and committed academic performance in the conduct of applied health research. In addition, these ethnographic components, when synthesised with epidemiological data (from the survey), contributed to the generation of findings that met the aims of the study. Indeed, the findings reported in this article are genuinely remarkable (ground-breaking in fact), particularly those that relate to the different survival strategies noted between African American and White men respectively. For example, not only were there differences noted in the types of drugs used (and how they were used and how harms emerged from these practices) but also differences in how different ethnic groups presented their self to others and to wider society.

Bourgois et al. describe these identities as ‘outlaws’ and ‘outcasts’, in which African American men typified the former and White men the latter. These identities were considered to originate in (historical) forms of stigma, inequality and social exclusion – and were identities that reflected and responded to these experiences while involved in street-based drug use / homelessness. As such, the behaviour patterns associated with ‘outlaws and outcasts’ were considered to be misunderstood in clinical (and other professional) settings, that in turn perpetuated inequality and exclusion along ethnic groupings. Accordingly, the clinical implications of this study are particularly noteworthy.

‘Clinical implications’

This article demonstrates the value of qualitative research in developing and advancing clinical practice (in both the sphere of public health per se and in specific health inequalities associated with substance use and/or homelessness). With the authors’ emphasis on the role of ‘cultural relativism’ (a position that involves the suspension of individually-held moral values) and its relevance to ‘cultural competence’ (recognising that people don’t behave in accordance to a single set of mono-cultural practices), they provide a convincing argument regarding how clinical practice may be better informed by the methods and methodologies of social science. For example, in learning to recognise that substance use behaviours may adhere to practice and preferences guided by ethnic, gendered or cultural identities, may in turn complement those understandings that relate to physiology and pharmacology.

Such wider recognition, the authors argue, would provide opportunities for more effective intervention to occur. Although written 15 years ago, these sentiments would certainly appear to be as valid in 2021 as they were in 2006.

About the article

Bourgois P, Martinez A, Kral A, Edlin BR, Schonberg J, and Ciccarone D (2006). Reinterpreting Ethnic Patterns among White and African American Men Who Inject Heroin: A Social Science of Medicine Approach. PLoS Medicine 3(10): e452.

The article can be accessed here.

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