The application of ethnography, with reference to harm reduction inSverdlovsk Russia

Robert Power *

Department of STDs, Mortimer Market Centre, University College London, London WC1E 6AU, UK

Abstract

This article describes and explores ten ways in which ethnography has and can be utilised in relation to harm reduction and illicit

drug use. These are by no means exclusive, nor mutually exclusive, but indicate the range of practical applications of ethnographic

methods: (1) as part of a multi-indicator research strategy; (2) in developing action research projects; (3) in formative evaluations

and rapid assessments; (4) as part of social network and mapping exercises; (5) in setting the scene for prevalence surveys; (6)

complementing epidemiological studies; (7) confirming and augmenting other research findings; (8) as an integral part of process

evaluation; (9) in the context of randomised controlled trials; and (10) of value in its own right. Ethnography has much to offer the

study and promotion of harm reduction and should be encouraged as an integral part of project evaluation, as well as in furthering

our appreciation of the context and subtlety of social behaviour.

# 2002 Elsevier Science B.V. All rights reserved.

Keywords: Ethnography; Harm reduction; HIV/AIDS; Drug use

Introduction

Following good sociological practice, let me, from the

outset, state my position as a researcher. Principally, I

have a pragmatic approach to research strategy and an

eclectic attitude to methodology and analysis. In other

words, I believe a prime task for any researcher is to fit

the method or methods to the research question under

examination. In this context ethnography (especially

through participant observation) is one of a range of

interchangeable options open to the qualitative (or

quantitative) researcher. It is my experience that the

general principles and practice of ethnography can be

used flexibly and imaginatively to supplement and

complement other methods. Unlike classical anthropol-

ogy and ethnography, it is not always necessary nor

feasible for the contemporary researcher to totally

immerse his or her self into the field of study. Famously,

during the First World War, Bronislaw Malinowski

(1884�/1942) spent several years studying the Trobriand

Islanders (Malinowski, 1922). In July 2001, I spent one

evening on a mobile syringe exchange in the small town

of Pervouralsk, in the Urals in Russia, observing the

comings and goings of drug injectors. Here is an excerpt

from my field notes:

‘‘. . . Everyone was really proud of the new bus.

They had inherited it from the city health author-

ity, that had gotten it from the tax department,

that had originally acquired it from a coach

company, that had gone to the wall owing back-

tax. It was unrecognisable from the shell we had

seen last winter. It had new wheels, the bench-seats

had been taken out and a new door put on the

side. Shelves had been built to hold the materials

(needles, syringes, condoms etc) and there was a

place for Marina (exchange worker) to sit when

the bus was stationary. This showed the value of

the London and St. Petersburg study tours, with

the Sverdlovsk team adapting what they saw to

their own resources and needs. Marina’s bus had

features of the mobile exchange programmes from

both London and St. Petersburg. Four sites in the

town had been identified as good places to

distribute syringes and now after 3 months drug

users were coming regularly (or so we were told

and so the Urals Medical Academy monitoring* Tel.: �/44-207-380-9949; fax: �/44-207-388-4179

E-mail address: rpower@gum.ucl.ac.uk (R. Power).

International Journal of Drug Policy 13 (2002) 327�/331

www.elsevier.com/locate/drugpo

0955-3959/02/$ - see front matter # 2002 Elsevier Science B.V. All rights reserved.

PII: S 0 9 5 5 - 3 9 5 9 ( 0 2 ) 0 0 1 1 7 - 2

statistics showed). Decided to check it out and

asked Sergie (project manager) if it would be ok to

go on the bus this very day. I did not want any

special plans made. He was happy about it, so wasMarina. The drug users would be ok as they were

getting used to research and to seeing the occa-

sional new face. Baseline data and a ‘‘satisfaction’’

type survey had already been collected by research

workers from the Medical Academy, and, in fact, I

am part of the same team.’’

‘‘The first stop was a housing estate on the fringes

of town. The bus had no markings. It was muchlike many of the battered old trucks that trundled

around the towns and cities. We parked up on a

non-descript bit of ground surrounded on three

sides by ten-storey Soviet-style apartment blocks.

For some of the time I sat in the back and chatted

with Marina. Helped with the stocks. The drug

users were used to the timing of the bus’s visit and

within a few minutes the first group arrived. Twoyoung men and a woman. One had a plastic bag

full of syringes. He came into the bus while the

other two stood around smoking. He gave his code

number and Marina found his card. She and

Valerie (the interpreter and project administrator)

explained who I was. Marina handed out the

needles and syringes and then talked about safe

sex and offered condoms. These were accepted. Wespoke with the group of three for a while and they

said how much they valued the bus and were

telling all their friends about it.’’

[fieldnotes: Thursday 20 July 2001, Pervouralsk, Sver-

dlovsk].

Would Malinowski have considered this to be ethno-graphy? There are no deep insights into social relation-

ships, no immersion into the culture of the drug users,

no great time commitments. I was not even a fluent

Russian speaker, which meant I had to rely on our

interpreter. Yet, and I will argue and illustrate further in

this article, that the adaptation and application of

ethnographic methods can result in valuable insights

into social phenomenon. In the example cited above,this brief piece of participant observation allowed me to

confirm a number of research questions that needed

ratifying (something along the line that ‘seeing is

believing’). Let me list some of these: (1) The bus had

been repaired and refurbished appropriately. (I was part

of the project team that allocated funding for this). (2)

The bus was stocked with a good supply of needles,

syringes, other injecting paraphernalia, condoms andhealth promotion literature (rapid assessments had been

conducted at each site to assess drug trends and injecting

patterns to inform supply decisions). (3) The bus was

stopping at sites where drug users congregated and

where they felt safe to use the service (the rapid

assessment and research interviews with drug users

attending the narcology service had identified appro-priate stop-off points). (4) Drug users were returning

used syringes and collecting sterile ones in return. (Most

Russian syringe exchange programmes operated one-to-

one exchange, but we were encouraging secondary

distribution where possible). (5) Marina (the worker

on the bus) took time to discuss health promotion issues

with the drug users and to offer them condoms as well as

injecting equipment (although currently drug injectingaccounts for over 80% of HIV cases in Russia, a

comprehensive approach to harm reduction was being

encouraged).

As well as being satisfied by these various service

delivery or process evaluation observations, this bite-

sized piece of participant observation ethnography gave

me insights into the way in which Marina related to the

drug injectors. I noticed an ease in her manner, laughterand rapport with the drug users, which is so crucial in

delivering low-threshold harm reduction programmes.

These type of data can only be witnessed first hand,

through observation and ethnography. The lessons from

these field notes complemented data we were collecting

from other sources including questionnaire surveys,

monitoring forms, focus groups and semi-structured

interviews.

The practice and application of ethnography

I have argued elsewhere that one of the main

problems with much research in the field of drug use

is the over-reliance on self-reported accounts, especially

concerning risk behaviour (Power, 2001). Here I want to

stress the practical value of an eclectic approach to

ethnography, both in terms of process and outcome

research and also in the ways in which it complements

other research methods and paradigms. I will suggestten ways, neither exclusive nor mutually exclusive, in

which ethnography can be usefully employed in social

behavioural research related to drug use and harm

reduction.

As part of a multi-indicator research strategy

At the most general level, ethnographic observation is

invaluable as part of a composite package of research

tools, where each endeavours to provide complementary

and/or confirmatory data to shed light on social

behaviour, or even treatment outcomes (Stahler &Cohen, 2000). We can use questionnaire surveys and

focus groups, semi-structured and in-depth interviews to

hear what people have to say about a social phenom-

R. Power / International Journal of Drug Policy 13 (2002) 327�/331328

enon, but ethnography (through participant observa-

tion) encourages us to see it for ourselves.

In developing action research projects

Action research projects require rapid feedback in

order to tailor and refine interventions. This is often the

case for harm reduction projects, especially in the

context of emerging epidemics, such as in the Newly

Independent States and the Russian Federation, where

intervention and evaluation often takes place in tandem.

There is a clear role for ethnographic research here,

especially when outreach workers are trained in quali-tative research skills. A precedent for this was the AIDS

Demonstration Projects in the USA during the 1980s

and 1990s, where an ethnographer was included in the

outreach teams (Broadhead & Fox, 1990). Part of this

individual’s task was to feed-back information from the

street so that interventions could be adapted accord-

ingly. In order to maintain contact with the drug user

population, long-term commitment of the ethnographermay be the preferred option. However, time and

resource limitations do not always permit this.

Through formative evaluations and rapid assessments

A prerequisite for any harm reduction intervention

should be a formative evaluation to describe the target

group, drug patterns, drug scenes, existing drugs, socialand health service provision and other related factors.

This has intrinsic value in increasing our knowledge

base, but, perhaps more importantly, sets the scene and

lays the foundation for developing community-level

interventions. When targeting hidden populations, and

especially those involved in illicit activities, such as drug

abuse, ethnographic research is one of the best (if not

the best) methods of describing the drug patterns,behaviours and contextual factors. Without this depth

of knowledge the subsequent design of an intervention

may be inadequate or inappropriate. Rapid assessment

studies, with ethnography and participant observation

as integral components, have become increasingly

popular as a method of formative evaluation. Rapid

assessment and modified ethnography are particularly

well suited in developing countries where researchresources and expertise are often lacking (Rhodes et

al., 1999; Power, 2000).

Social network and mapping exercises

Drug use and the spread of HIV takes place between

networks of people and in a variety of spatial and

temporal locations (Friedman et al., 1997). Conse-quently, we need to deepen our understanding of social

networks and also map the venues and locations where

drug use and high-risk activities take place. This not

only increases our knowledge and appreciation of the

dynamics of drug user networks, but it is critical in

planning and refining targeted health interventions.

Ethnography, through observation, snowballing andcontacting and nurturing key informants, provides the

means and the methods to accomplish these important

tasks.

Setting the scene for prevalence surveys

There is currently much emphasis on the need for

HIV harm reduction interventions to demonstrate that

they are reaching substantial proportions of the targetpopulations of injecting drug users. The issue of ‘cover-

age’ can only be meaningfully assessed if there is some

indication of drug use population prevalence. Viable

methods, such as capture/recapture, rely on a clear and

concise understanding and description of drug trends,

treatment and enforcement systems. Ethnographic stu-

dies can contribute to this process and inform preva-

lence studies by providing key qualitative data, such asthe characteristics and profiles of the target populations

and their help-seeking patterns (Agar & Kozel, 1999).

Complementing epidemiological studies

Kane (1991) noted that qualitative research has an

important role to play in our understanding of social

aspects of AIDS by augmenting and enriching thestatistical predictions of epidemiological research.

More specifically, we could say much the same about

ethnography, where direct observations have comple-

mented epidemiological studies. This is most notable

around the nuances and variations in injecting practices

and issues relating to risk behaviour. In the early years

of HIV research epidemiological studies used blanket

concepts of HIV risk behaviour relating to injecting. Butthe work of ethnographers was valuable in complement-

ing, explaining and expanding on these quantitative

findings. For example, Grund, Kaplan, Adriaans and

Blanken (1991) described in detail the process of front

and back-loading when preparing and using heroin and

Koester, Booth and Wiebel’s (1990) ethnography high-

lighted the significance (and dangers) of the sharing of

drug injecting paraphernalia. This is a two way processand ethnographic findings such as those described can

lead to quantitative and epidemiological studies.

Confirming and augmenting other research findings

Ethnography can also be used to explain and explore

findings and conclusions from other research studies.

Notable in this respect was the surprisingly negativeresults from the monitoring of the needle and syringe

exchange in Montreal. A cohort study had shown high

rates of HIV infection among injecting drug users

R. Power / International Journal of Drug Policy 13 (2002) 327�/331 329

participating in the needle exchange programmes (Bru-

neau et al., 1997). An ethnographic study reinforced

previous qualitative research to show this could in part

be explained by factors that were not picked up by thequantitative study, including prolific cocaine injecting

and the fact that many of those who used the needle

exchange programmes led chaotic and high risk lifestyles

(Bourgois & Bruneau, 2000). This augmenting and

refining of research findings between quantitative and

qualitative studies can work in both directions. In a

study of injecting behaviour in Britain, an interesting

observation relating to social etiquette around filtersharing was observed during ethnographic fieldwork. To

explore the extent of this practice, a number of relevant

questions were appended to the British arm of a

quantitative WHO study. The results confirmed the

researchers’ hunch that the practice was not an isolated

one, but occurred in other parts of the country (Power,

Hunter, Jones & Donoghoe, 1994).

As an integral part of process evaluation

Harm reduction programmes to arrest the spread of

HIV infection amongst injecting drug users (especially

focusing on needle and syringe exchange programmes)

are promoted world-wide. It is now common practice, as

well as desirable, for such initiatives to be evaluated, at

the very least in terms of processes, if not outcomes (As

an aside, social behavioural research in the drugs-fieldremains poor on outcome evaluation, both in terms of

methodology and output). Ethnography can be usefully

employed in process evaluation and service delivery

studies in a number of ways. One, to witness and record

the interaction between service providers and the target

group. Two, to describe whether or not the service is

being delivered as assigned. Three, to observe the setting

and context in which the intervention takes place. Thislatter point is particularly relevant when harm reduction

activities (such as outreach and mobile needle and

syringe exchange programmes) take place in the com-

munity, where it is critical that the most appropriate

locations are selected. The Sverdlovsk experience briefly

described above is illustrative of the role of ethnography

in assessing community-level service delivery.

Ethnography in the context of randomised controlled

trials

Much emphasis has been placed on the potential for

randomised controlled trials and other experimental

methods in social behavioural research (Oakley, Full-

erton & Holland, 1995; Stephenson & Imrie, 1998).

While there have been a number of ethical concernsaround randomisation issues in the context of harm

reduction, the potential for comparing ‘standard’ and

‘enhanced’ interventions should be explored further

(Rietmeijer et al., 1996). Qualitative research and

ethnography can add a much needed dimension to

what is classically deemed the preserve of quantitative

research. This is at three levels. First, as part of theformative evaluation to develop the intervention to be

trialed. Second, during the process evaluation stage,

when the ‘black box’ of service delivery is examined.

Third, at the outcome evaluation stage by encouraging,

in part through ethnography and contact with drug

users, a participatory approach whereby the findings are

appraised by the target population.

Ethnography is of value in its own right

Articles of this nature normally begin by stressing the

long and proud tradition of ethnography and partici-

pant observation in the drugs field. Indeed, ethnography

has in the past, does in the present (and surely will do in

the future) have credibility and intrinsic value in its own

right. It is exciting, unique and instructive to read raw

observational accounts of the lifestyles and experiencesof drug users and others forced to the margins of

society. There are many examples of studies that have

provided a rich vein of marvellously detailed data to add

to our collective and historical knowledge base, in a way

that would not have been possible without an ongoing

commitment to ethnography [see for example, Grund et

al., 1991; Agar, 1979; Becker, 1953; Adler, 1985; Feld-

man, 1968; Moore, 1993; Murphy & Waldorf, 1991;Taylor, 1993; Williams, 1989). We should emphasise and

reiterate the value of classic ethnography.

Concluding remarks

I have worked as an ‘immersive’ ethnographer,

spending hours and days with groups of drug users. Ihave used ethnographic techniques as part of a multi-

indicator approach and as an integral part of rapid

assessment. And I have used ethnography to confirm

and augment findings from epidemiological studies. I

am sure this depth of experience has equipped me with

something of an ‘ethnographic imagination’ (to borrow

from C. Wright Mills), one which sharpens the eye and

senses, allowing and enabling a switch between varyinglevels and depths of investigation. Some may argue

much of what I have described in the body of this article

is at best ‘parachute ethnography’ (Bourgois & Bruneau,

2000) and at worst heretical. I am not overly worried

either about semantics or orthodoxies. At one level, the

body of individuals committed to the international harm

reduction movement contains a healthy mix of practi-

tioners and academics: those who intervene and thosewho research. I hope the approach to ethnography I am

espousing will go some way to bridging the divide and

demarcation of labour that often exists between these

R. Power / International Journal of Drug Policy 13 (2002) 327�/331330

two camps. I will leave the semantic and academic

debate to others.

About 6 years ago I moved from an academic

department in which social science and the qualitativeresearch paradigm was largely unchallenged to an

academic department in a medical school sited in a

busy STI and HIV clinic. Here, epidemiology, clinical

trials and basic science formed the predominant research

approach. Yet over recent years there has been a sea-

change, which has impacted on research agendas at local

and national levels. In British medical research (if not

elsewhere), there has been a gradual paradigm shift inrelation to methodology. The qualitative approach is

now viewed, if not an equal partner, then at least

complementary to quantitative methods. This shift in

ethos was reflected in a series of articles in the British

Medical Journal outlining the value of qualitative

research and ethnography to medical practitioners

(Pope & Mays, 1995). Around the same time this debate

was mirrored amongst British researchers working in thefield of illicit drug use (McKeganey, 1995). As the

opening remarks and the example of harm reduction

development and monitoring in Sverdlovsk implied,

ethnography is of direct practical value. It has a role

to play at all levels of evaluation, can complement

epidemiological research and can inform the develop-

ment of targeted interventions. It is incumbent upon us

to ensure that ethnography, in its various shapes andforms, retains a prominent place in a multi-disciplinary

and multi-indicator research and development para-

digm.

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