Structural vulnerability to narcotics-driven firearm violence: An ethnographic and epidemiological study of Philadelphia's Puerto Rican inner-city.

BACKGROUND: The United States is experiencing a continuing crisis of gun violence, and economically marginalized and racially segregated inner-city areas are among the most affected. To decrease this violence, public health interventions must engage with the complex social factors and structural drivers-especially with regard to the clandestine sale of narcotics-that have turned the neighborhood streets of specific vulnerable subgroups into concrete killing fields. Here we present a mixed-methods ethnographic and epidemiological assessment of narcotics-driven firearm violence in Philadelphia's impoverished, majority Puerto Rican neighborhoods. METHODS: Using an exploratory sequential study design, we formulated hypotheses about ethnic/racial vulnerability to violence, based on half a dozen years of intensive participant-observation ethnographic fieldwork. We subsequently tested them statistically, by combining geo-referenced incidents of narcotics- and firearm-related crime from the Philadelphia police department with census information representing race and poverty levels. We explored the racialized relationships between poverty, narcotics, and violence, melding ethnography, graphing, and Poisson regression. FINDINGS: Even controlling for poverty levels, impoverished majority-Puerto Rican areas in Philadelphia are exposed to significantly higher levels of gun violence than majority-white or black neighborhoods. Our mixed methods data suggest that this reflects the unique social position of these neighborhoods as a racial meeting ground in deeply segregated Philadelphia, which has converted them into a retail endpoint for the sale of astronomical levels of narcotics. IMPLICATIONS: We document racial/ethnic and economic disparities in exposure to firearm violence and contextualize them ethnographically in the lived experience of community members. The exceptionally concentrated and high-volume retail narcotics trade, and the violence it generates in Philadelphia's poor Puerto Rican neighborhoods, reflect unique structural vulnerability and cultural factors. For most young people in these areas, the narcotics economy is the most readily accessible form of employment and social mobility. The performance of violence is an implicit part of survival in these lucrative, illegal narcotics markets, as well as in the overcrowded jails and prisons through which entry-level sellers cycle chronically. To address the structural drivers of violence, an inner-city Marshall Plan is needed that should include well-funded formal employment programs, gun control, re-training police officers to curb the routinization of brutality, reform of criminal justice to prioritize rehabilitation over punishment, and decriminalization of narcotics possession and low-level sales.

The Textures of Heroin: User Perspectives on "Black Tar" and Powder Heroin in Two U.S. Cities.

Since the 1990s, U.S. heroin consumers have been divided from the full range of available products: east of the Mississippi River, Colombian-sourced powder heroin (PH) dominates the market while, to the west, Mexican-sourced "black tar" (BTH) is the main heroin available. By conducting qualitative research in two exemplar cities, Philadelphia (PH) and San Francisco (BTH), we compare users' experiences of heroin source-types, markets, health consequences, and consumption preferences. The strict division of heroin markets may be changing with novel forms of powder heroin appearing in San Francisco. Our researchers and interviewees perceived vein loss stemming from the injection of heroin alone to be a particular problem of BTH while, among the Philadelphia sample, those who avoided the temptations of nearby cocaine sales displayed healthier injecting sites and reported few vein problems. Abscesses were common across both sites, the Philadelphia sample generally blaming missing a vein when injecting cocaine and the San Francisco group finding several explanations, including the properties of BTH. Consumption preferences revealed a "connoisseurship of potency," with knowledge amassed and deployed to obtain the strongest heroin available. We discuss the reasons that their tastes take this narrow form and its relationship to the structural constraints of the heroin market.

Heroin-related overdose: The unexplored influences of markets, marketing and source-types in the United States.

Heroin overdose, more accurately termed 'heroin-related overdose' due to the frequent involvement of other drugs, is the leading cause of mortality among regular heroin users. (Degenhardt et al., 2010) Heroin injectors are at greater risk of hospital admission for heroin-related overdose (HOD) in the eastern United States where Colombian-sourced powder heroin is sold than in the western US where black 'tar' heroin predominates. (Unick et al., 2014) This paper examines under-researched influences on HOD, both fatal and non-fatal, using data from a qualitative study of injecting drug users of black tar heroin in San Francisco and powder heroin in Philadelphia Data were collected through in-depth, semi-structured interviews carried out in 2012 that were conducted against a background of longer-term participant-observation, ethnographic studies of drug users and dealers in Philadelphia (2007-12) and of users in San Francisco (1994-2007, 2012). Our findings suggest three types of previously unconsidered influences on overdose risk that arise both from structural socio-economic factors and from the physical properties of the heroin source-types: 1) retail market structure including information flow between users; 2) marketing techniques such as branding, free samples and pricing and 3) differences in the physical characteristics of the two major heroin source forms and how they affect injecting techniques and vascular health. Although chosen for their contrasting source-forms, we found that the two cities have contrasting dominant models of drug retailing: San Francisco respondents tended to buy through private dealers and Philadelphia respondents frequented an open-air street market where heroin is branded and free samples are distributed, although each city included both types of drug sales. These market structures and marketing techniques shape the availability of information regarding heroin potency and its dissemination among users who tend to seek out the strongest heroin available on a given day. The physical characteristics of these two source-types, the way they are prepared for injecting and their effects on vein health also differ markedly. The purpose of this paper is to examine some of the unexplored factors that may lead to heroin-related overdose in the United States and to generate hypotheses for further study.

The Moral Economy of Violence in the US Inner City.

In an 8-week period, there were 16 shootings with three fatalities, three stabbings, and 14 additional "aggravated assaults" in the four square blocks surrounding our field site in the Puerto Rican corner of North Philadelphia. In the aftermath of the shoot-outs, the drug sellers operating on our block were forced to close down their operations by several mothers who repeatedly called the police. Drawing on the concept of moral economy (Thompson, Scott, Taussig), Mauss's interpretation of gift exchange, and a political economy critique of hypercarceralization in the United States, we understand the high levels of US inner-city violence as operating within a moral logic framed by economic scarcity and hostile state relations. Residents seek security, self-respect, and profit in social networks that compel them to participate in solidary exchanges of assistive violence dynamized by kinship and gender obligations. A hierarchical, extractive drug economy fills the void left by deindustrialization, resulting in a dynamic of embodied primitive accumulation at the expense of addicted customers and chronically incarcerated just-in-time street sellers at high risk of assault. Nevertheless, the mobilization of violence organizing the illegal drug economy also follows ethical norms and obligations that are recognized as legitimate by many local residents.

Urban segregation and the US heroin market: a quantitative model of anthropological hypotheses from an inner-city drug market.

BACKGROUND: We hypothesize that the location of highly segregated Hispanic and in particular Puerto Rican neighborhoods can explain how Colombian-sourced heroin, which is associated with a large-scale decade long decline in heroin price and increase in purity, was able to enter and proliferate in the US. METHODS: Our multidisciplinary analysis quantitatively operationalizes participant-observation ethnographic hypotheses informed by social science theory addressing complex political economic, historical, cultural and social processes. First, we ethnographically document the intersection of structural forces shaping Philadelphia's hypersegregated Puerto Rican community as a regional epicenter of the US heroin market. Second, we estimate the relationship between segregation and: (a) the entry of Colombian heroin into the US, and (b) the retail price per pure gram of heroin in 21 Metropolitan Statistical Areas. RESULTS: Ethnographic evidence documents how poverty, historically-patterned antagonistic race relations, an interstitial socio-cultural political and geographic linkage to both Caribbean drug trafficking routes and the United States and kinship solidarities combine to position poor Puerto Rican neighborhoods as commercial distribution centers for high quality, low cost Colombian heroin. Quantitative analysis shows that heroin markets in cities with highly segregated Puerto Rican communities were more quickly saturated with Colombian-sourced heroin. The level of Hispanic segregation (specifically in cities with a high level of Puerto Rican segregation) had a significant negative association with heroin price from 1990 to 2000. By contrast, there is no correlation between African-American segregation and Colombian-sourced heroin prevalence or price. CONCLUSION: Our iterative mixed methods dialogue allows for the development and testing of complex social science hypotheses and reduces the limitations specific to each method used in isolation. We build on prior research that assumes geographic proximity to source countries is the most important factor in determining illicit drug prices and purity, while we find more complex, potentially modifiable determinants of geographic variation in retail drug markets. We show that specific patterns of ethnic segregation, racism, poverty and the political economy of socio-cultural survival strategies combined to facilitate the entry of pure, inexpensive Colombian-sourced heroin.

"Every 'never' I ever said came true": transitions from opioid pills to heroin injecting.

This qualitative study documents the pathways to injecting heroin by users in Philadelphia and San Francisco before and during a pharmaceutical opioid pill epidemic. Data was collected through in-depth, semi-structured interviews (conducted between 2010 and 2012) that were, conducted against a background of longer-term participant-observation, ethnographic studies of street-based drug users and dealers in Philadelphia (2007-12) and San Francisco (1994-2007, 2012). Philadelphia and San Francisco were selected for their contrasting political economies, immigration patterns and source type of heroin. In Philadelphia the ethnographers found heroin injectors, usually white users, who had started their opiate using careers with prescription opioids rather than transitioning from other drugs. In both Philadelphia and San Francisco, most of the young heroin injectors interviewed began, their drug-use trajectories with opioid pills--usually Percocet (oxycodone and acetaminophen), generic short acting oxycodone or, OxyContin (long-acting oxycodone)--before transitioning to heroin, usually by nasal inhalation (sniffing) or smoking at first, followed by injecting. While most of the Philadelphia users were born in the city or its suburbs and had started using both opioid pills and heroin there, many of the San Francisco users had initiated their pill and sometimes heroin use elsewhere and had migrated to the city from around the country. Nevertheless, patterns of transition of younger injectors were similar in both cities suggesting an evolving national pattern. In contrast, older users in both Philadelphia and San Francisco were more likely to have graduated to heroin injection from non-opiate drugs such as cannabis, methamphetamine and cocaine. Pharmaceutical opioid initiates typically reported switching to heroin for reasons of cost and ease-of-access to supply after becoming physically and emotionally dependent on opioid pills. Many expressed surprise and dismay at their progression to sniffing and subsequently to injecting heroin. Historically and structurally these users found themselves caught at the intersection of two major developments in the opiate supply: (1) an over 500% increase in opiate pill prescription from 1997 to 2005 resulting in easy access to diverted supplies of less stigmatized opiates than heroin and (2) a heroin supply glut, following the US entry of Colombian-sourced, heroin in the early 1990s, that decreased cost and increased purity at the retail level. A nationwide up-cycle of heroin use may be occurring among young inner city, suburban and rural youth fueled by widespread prescription opioid pill use.

[The Habit of Rage in a United States Ghetto.] / Habitus furibundo en el gueto estadounidense.

For five years, the open air drug sales block where the authors resided and conducted participant-observation fieldwork in the Puerto Rican corner of inner-city Philadelphia was subject to a routinized whirlwind of shootings, stabbings and assaults. The narcotics industry filled the void left by deindustrialization, turning the city's former factory district into an open-air narcotics supermarket staffed at the entry level by young Puerto Ricans serving primarily poor white injectors. A capacity to mobilize rage ensures success in the drug economy, protection in prison, and minimal income for the no-longer-worthy poor who are diagnosed as cognitively disabled. Many residents seek alliances in social networks that oblige them to participate in solidary exchanges of assistive violence. A dynamic of embodied, primitive accumulation kills, maims, disables or incarcerates most of this industry's entry-level employees and customers. Artificially high profit margins depend on violence and coercion. A rage-filled habitus propels street-level sellers into violently defending the micro-monopoly power of their bosses in the underground economy as if it were fun. They rush to enforce commercial transactions in the absence of protective legal sanctions in an environment of scarcity that is flooded by streams of cash, addictive drugs and automatic weapons. With the end of welfare entitlements, the left hand of the state, in the form of social services, attempts to continue subsidies for vulnerable individuals by diagnosing scarred bodies and brains as proof of permanent cognitive disability in need of heavy pharmaceutical medication. Periodic outbursts of interpersonal or of self-inflicted rage-filled violence emerge as the best way to ensure the continuity of that fragile public subsidy. Simultaneously, within the bowels of the right hand of the state, in overcrowded, hostilely-supervised violent prisons, rage becomes a valuable physical self-protection strategy for inmates. In short, expressive violence becomes a practical basis for economic sustenance and masculine and feminine self respect.

Methuselah's medicine: pharmaceutical innovation and mortality in the United States, 1960-2000.

Although there is a good deal of speculation surrounding the role of pharmaceutical innovation in late 20th century mortality improvements in the United States, there is little empirical evidence on the topic and there remains a good deal of doubt regarding whether pharmaceuticals matter at all for mortality. Using a reliable indicator of pharmaceutical innovation-yearly approvals of new molecular entities (NMEs) by the Food and Drug Administration, along with information on priority status and disease-category indication-this study examines the relationship between pharmaceutical innovation and life expectancy between 1960 and 2000. The study demonstrates a significant relationship between pharmaceutical innovation and life expectancy at birth, which is robust to controls for gross domestic product, as well as controls for various forms of medical spending. The relationship with life expectancy is robust, in part, because pharmaceutical innovation has a stronger relationship with early-life mortality (between 20 and 50) than with later-life mortality (65 and over), even though older persons consume more pharmaceuticals and many recently approved drugs target conditions more common in later life. There is, to be sure, another side to the results. There is some evidence, for example, that the relationship between pharmaceutical innovation and mortality has declined over time, suggesting a change in the kind of innovations now entering the market. Nevertheless, there is more to contemporary pharmaceutical innovation than the development of mere "halfway" technologies. The overall relationship between innovation and mortality is sufficiently strong to warrant further consideration as a key determinant of trends in mortality.