Governing street-based injecting drug users: a critique of heroin overdose prevention in Australia

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Governing street-based injecting drug users: a critique of heroin overdose prevention in Australia David Moore* National Drug Research Institute, Curtin University of Technology, GPO Box U1987, Perth WA 6845, Australia

Abstract This article provides a critical analysis of existing approaches to the prevention of heroin overdose in Australia. It draws on almost 2 years of ethnographic research with street-based injecting drug users (IDUs), street-based sex workers and service providers in Melbourne, Australia’s second largest city, and on recent anthropological and sociological work on governmentality. The substantive sections of the article argue: (1) that heroin overdose prevention in Australia contains implicit or explicit assumptions of rationality and personal autonomy, continues to emphasise individual behaviour change and inscribes a self-disciplined, self-aware, self-regulating subject; and (2) that the social, cultural and economic realities—the ‘lived experience’—of street-based IDUs and sex workers may undermine or hinder the successful adoption of overdose prevention strategies. The paper concludes by arguing that the ‘chaotic’ practices of street-based IDUs and sex workers arise in response to particular ‘risk environments’, and that individually focused overdose prevention strategies, while an important first step, need to be complemented by measures addressing the macro- and micro-aspects of risk environments. r 2004 Elsevier Ltd. All rights reserved. Keywords: Overdose; Injecting drug use; Governmentality; Risk environments; Ethnography; Australia

pological Association has been conducting sessions, planned by each of its sections, on policy matters. There has long been a theoretical and individual divide between anthropologists focusing on pure research and those focusing on the problems faced by humans, including the growth of inequality.

Introduction This paper addresses the intersection between medical anthropology and sociology, and one aspect of public policy—the prevention of heroin overdose. Okongwu and Mencher (2000, p. 109), reviewing the anthropology of public policy, have argued that: Anthropologists have tended to write mainly for other anthropologists, not for those who have the power to change the world. Reacting to this trend, Peacock (1997) has pointed out the importance of anthropology moving to shape public policy, to assist in formulating the critical issues of our society and all societies on this planet, to propose solutions that meet the desires and needs of local people, and to create a synergy between theory and practice. In an attempt to bridge this gap, the American Anthro*Tel.: +61-8-9266-1616; fax: +61-8-9266-1611. E-mail address: [email protected] (D. Moore).

The theoretical and individual divide between ‘pure research’ and problem-oriented research has also been addressed by medical sociologists, who have made a distinction between a sociology in, or for, health policy and a sociology of health policy (e.g. Nettleton & Bunton, 1995; Petersen & Waddell, 1998). In the former, the aim is to employ sociological perspectives and methods in order to refine or improve health policy whereas, in the latter, health policy itself—its theories, methods and ideological bases—becomes the object of inquiry. Those engaged in the analyses of health policy criticize those engaged in applied research for their collusion in expert-driven social control. The refinements or improvements made to health policy are

0277-9536/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2004.01.029

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portrayed as little more than new forms of governmentality. Those engaged in more applied health research sometimes characterize the ‘of’ research as being theoretically elegant but of little practical value. More specifically, US anthropologist Philippe Bourgois has written a series of articles addressing what he sees as the gulf between theoretical and applied anthropology in relation to drug use. In the first article, published in 1998 (Bourgois, 1998), he accused public health (including applied anthropologists working in public health) of perpetrating ‘symbolic violence’ in its delivery of hypersanitary AIDS prevention to marginalized street-based IDUs, that manifestly fails to address the cultural, social and economic dimensions of their use. In 1999 (Bourgois, 1999), he criticized postmodern anthropologists in ‘elite’ US universities for failing to address the ‘social suffering’ caused by injecting drug use and HIV/AIDS—‘[c]ontemporary anthropology is not concerned with the ugly nuts and bolts of postindustrial social suffering’—and applied anthropological drug researchers for uncritically accepting the paradigms of other drug research disciplines. In 2000 (Bourgois, 2000), he published a critical ethnographic analysis of methadone maintenance treatment in which he argued that such treatment could be seen as a graphic example of Foucault’s ‘bio-power’ in its regulation of the ‘unruly bodies of self-destructive street addicts’. Although Bourgois acknowledges the analytical usefulness of the poststructuralist perspective, he also recognizes the paralysis potentially engendered by frameworks in which power is omnipresent (see also Keane, 2003). To break with this ‘second-generation of foucauldian scholarship’, he cites Foucault’s notion of the ‘specific intellectual’ who engages with ‘real, material everyday struggles’ and who poses concrete alternatives as providing one way of moving beyond existing discourses to construct new, technically applicable ‘specific knowledges’ (Bourgois, 2000). He accepts that the role of the ‘specific intellectual’ is ‘treacherous’, and open to charges of complicity in constructing what could be seen as merely new and more efficient ways of regulating citizens. But, given the high rates of imprisonment, continuing spread of HIV/AIDS and HCV, and the widespread street violence associated with current US drug policies, he asks, What form of regulation, what combination of drugs, laws and medical/health discourses might produce less social suffering? He compares the devastating effects of the US methadone treatment regime with the more favourable outcomes of the Swiss trials of prescribed heroin— lower indices of mortality, hospitalization, psychological distress, criminal activity, unemployment and use of illegal drugs. Following Bourgois, my aim is explicitly to link an anthropology of street-based injecting drug use and heroin overdose prevention with an anthropology for heroin overdose prevention.

The paper is divided into three sections. In the first, I draw on recent poststructuralist critiques of public health, health promotion and drug policy to argue that heroin overdose prevention in Australia can be seen as one technology in the governing of drug users. IDUs, particularly street-based IDUs, are frequently described as ‘chaotic’ in popular, biomedical, research and practitioner discourses (Moore, 2003). Overdose prevention is one way of inculcating moral discipline into the ‘hearts, minds and bodies of deviants who reject sobriety and economic productivity’ (Bourgois, 2000). In the second section, I draw on recent ethnographic research in the St Kilda area of Melbourne, Australia’s second largest city, to show how the social, cultural and economic realities—the lived experience—of streetbased IDUs and sex workers may undermine or hinder the successful adoption of overdose prevention strategies. Anthropological accounts of street-based IDUs have a role to play in challenging existing governmental technologies through providing alternative frameworks for drug policy. Finally, I argue that the construction of new forms of governmentality, which might produce less social suffering, should begin by acknowledging and addressing the role of risk environments in the production or reduction of drug-related harm (Rhodes, 2002).

Governing chaotic subjects In the wake of Foucault’s expansive investigation of the emergence of the modern, individual human subject of classical liberalism, there has developed a body of work concerned with the way ‘subjects’ are governed under the ‘advanced’ or neo-liberalism of late modernity (e.g. Dean & Hindess, 1998; Gordon, 1991; Rose, 1989; Rose & Miller, 1992). Whereas, in classical liberalism, a ‘welfarist’ rationality emphasized State responsibility for the care of citizens, in neo-liberalism, there has evolved a rationality in which citizens are increasingly responsible for the ‘care of the self’. There has been a move to noncollective and low-cost solutions to spiralling welfare budgets, a de-institutionalization of health care, and promotion of more active forms of citizenship (Nettleton & Bunton, 1995). This has been achieved through the emergence of new forms of governmentality, involving a shift from individual subjects at-risk, and in need of intervention, to the expert surveillance and regulation of populations on the basis of the collation of a range of abstract factors deemed liable to produce risk in general (Castel, 1991). The notion of ‘risk’ and its avoidance has become a key technology of social control. Since the mid-1990s, this poststructuralist perspective has produced critiques of ‘the new public health’ (e.g. Petersen, 1997; Petersen & Lupton, 1996), emerging alongside established and ongoing structuralist critiques

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of public health, HIV/AIDS prevention, and alcohol and other drug policy (e.g. Singer, 1994). Medical anthropologists and sociologists have been concerned with ‘bio-power’, or the ways in which ‘historically entrenched institutionalized forms of social control discipline bodies’ through ‘laws, medical interventions, social institutions, ideologies and even structures of feeling’ (Bourgois, 2000), and the implications of such forms of social control for health (e.g. Lupton, 1995; Petersen, 1994; Petersen & Bunton, 1997). In keeping with the shift from classical to neo-liberal governmentality, there has been a marked rise in preventative medicine and health promotion—in leading a ‘healthy’ lifestyle (Burrows, Nettleton, & Bunton, 1995). Citizens are urged to stop smoking, to eat less fat, to exercise more, to monitor their alcohol intake, and so on, and thus risk is redistributed from the state back to individuals. Epidemiology, the dominant research paradigm in public health, has played an important role in the move to population surveillance by constructing and measuring the ‘truth’ about disease, risk factors and categories of at-risk subjects, and by creating and allocating ‘normal’ and ‘abnormal’ or ‘pathological’ categories (Miller, 2001; Petersen, 1997). There has also been a shift from the ‘patient’ as a passive recipient of expert care to ‘clients’ with the capacity for healthy choice. Consumption becomes the duty of modern citizens (Henderson & Petersen, 2002), who are ‘free’ to choose health. However, the citizenas-(healthy)-consumer rationality does not acknowledge the constraints on ‘choice’ or the compulsion to make a choice. Health experiences vary because of age, gender, class and race/ethnicity and the attendant unequal access to the resources necessary for health and well-being. Those marked by stigma—such as IDUs—may behave in apparently ‘irrational’ ways. Health promotion, it is argued, becomes a ‘technology of the self’. Similar changes in governmentality have been noted in relation to alcohol and other drug policy. Poststructuralist accounts of alcohol policy have documented a shift from the ‘pastoral care’ of the state to new forms of self-regulating, self-disciplining consumption (e.g. Bunton, 1990; Gusfield, 1981; Levine, 1978; Room, 2001; Sulkunen, 2002; Valverde, 1998). Sociological and historical analyses of British, European and Australian drug policy (e.g. Brook, 2002; Bunton, 2001; Mugford, 1993; O’Malley, 1999; Rhodes, 2002) draw attention to changes in the ‘addict’ subject and the construction and disciplining of intoxicated bodies, particularly in the wake of the HIV/AIDS pandemic. In earlier forms, the IDU was depicted as a ‘slave’ to addiction, as incapable of rational decision-making and as living only for the next injection. In later forms, particularly under harm reduction policy, the IDU subject is a health-conscious citizen capable of rational decision-making and self-

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regulation in keeping with risk-avoidance campaigns (e.g. Stimson, 1990; Stimson & Donoghoe, 1996). Heroin overdose research and prevention in Australia Poststructuralist critiques of public health, health promotion and drug policy provide a useful framework for examining heroin overdose research and prevention discourses in Australia, which seek to regulate the ‘chaotic’ bodies of IDUs. Australian research on heroin overdose has involved the expert power/knowledges of (mainly) medical researchers, epidemiologists and psychologists. It has produced data on the epidemiology, circumstances and definition of overdose and ‘multiple drug toxicity’—including heroin-related mortality and morbidity; drug market characteristics associated with overdose; and the role of suicide in heroin overdose (e.g. Darke, Kaye, & Ross, 2001; Darke & Ross, 2002; Darke, Ross, & Hall, 1996a, b; Darke & Zador, 1996; Dietze, Cantwell, & Burgess, 2002; Dietze, Fry, Rumbold, & Gerostamoulos, 2001; Lenton & Hargreaves, 2000; Warner-Smith, Darke, & Day, 2002). ‘Risk factors’ for overdose identified in this research include: (i) mixing heroin with central nervous system (CNS) suppressants such as benzodiazepines (eg, Valium, Normison, Temazepam, Rohypnol) and alcohol; (ii) being out of drug treatment; (iii) using the drug under conditions of changed tolerance (e.g., resuming drug use following a period of abstinence—often the result of imprisonment—or increasing use following a reduction in use); (iv) using heroin by oneself; and (v) failing to call for assistance with an overdose for fear of arrest or because of lack of knowledge. Based on this expert power/knowledge, a number of ‘technologies of the body’ for the prevention of heroin overdose have been recommended. The most widespread strategy is public and peer-based education and health promotion to address the behavioural risk factors outlined above. Thus Needle and Syringe Program (NSP), outreach, peer and other practitioners involved in harm reduction advise IDUs to: (i) sample their heroin first, in order to gauge its strength; (ii) avoid mixing heroin with other CNS suppressants; (iii) avoid injecting alone; (iv) always call an ambulance in the event of overdose; and (v) monitor their tolerance. Other strategies—some recommended but not yet instituted— also target the behaviour of IDUs (i.e. trials of the peer administration of naloxone hydrochloride and CPR) or require further policy and political support (i.e. Safe Injecting Facilities in states other than NSW; expanded treatment services; greater regulation of benzodiazepines; overdose-specific support, recovery and referral services; court diversion into treatment; and law enforcement that does not increase drug-related harm). I focus here on the behavioural advice provided to IDUs (i.e. to sample their heroin first; avoid mixing

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heroin with other CNS suppressants; avoid injecting alone; always call an ambulance in the event of overdose; and monitor their tolerance), which inscribes a self-disciplined, self-aware, self-regulating subject. The IDU subject of these messages is characterized by the following attributes: cautious, rational, orderly, stable and self-aware. They protect themselves from infection with blood-borne viruses through the adoption of sterile injecting equipment and procedures. They reduce the risk of heroin overdose through assessing pharmacology, consuming their drugs separately, ensuring that they are with others they trust to aid them, responding to drug-induced crisis sensibly, and monitoring their bodies’ stamina and capacity for drugs. The overdose prevention discourse also inscribes a particular type of social context for injecting, one similarly characterized by stability and orderliness. IDUs are in control of their lives and extend this control to their drug use—seeking always to avoid risks. Heroin overdose prevention assumes that, provided with epidemiologically derived ‘objective’ information, IDUs will freely make rational decisions without recourse to contextual constraints or to the context-dependent nature of risk and risk perception (Rhodes, 2002). Participant-observation ethnography with street-based IDUs and sex workers demonstrates that the successful adoption of overdose prevention may be undermined or hindered by the social, cultural and economic production and reproduction of street life.

Street lives I conducted ethnographic research with street-based IDUs, street sex workers and service providers in the St. Kilda area of Melbourne from August 2000 to June 2002, and, after I moved to Perth in July 2002, in 4 week-long field trips undertaken in September and December 2002, and May and August 2003. Ethical approval to conduct the research was granted by the Victorian Department of Human Services Ethics Committee and the Deakin University Human Research Ethics Committee (I was based at Deakin University at the time.) The data include ethnographic field notes, sociodemographic material, interview transcripts and documentary materials (e.g. media coverage, minutes of council meetings, program policy and procedure statements, ambulance attendance indicators). Their collection involved multiple methods: (i) extended interactions with IDUs and sex workers in street settings; (ii) participation in late-night outreach work to street-based IDUs and street sex workers; (iii) observation of officebased service provision and client/worker interaction; (iv) 78 in-depth interviews with 67 clients of a fixed NSP; (v) a snapshot survey of clients of the same NSP conducted over a 6-week period in 2002; and (vi) 56 in-

depth interviews with local practitioners delivering drug or related services. Melbourne, capital of the State of Victoria, had a population of 3.16 million at the 2001 census. St. Kilda, a suburb located approximately 6 km south of the Central Business District (CBD), has long been associated with both drug use and sex work (Arnot, 1986; Attorney-General’s Street Prostitution Advisory Group, 2002; Longmire, 1989). Over the last 2 decades, it has experienced gentrification and urban redevelopment, leading to rising property values and a consequent decline in low-cost accommodation. Culturally, the changes are often represented by the long-term residents and older street sex workers as a steady erasing of the ‘old St. Kilda’, which tolerated diversity, eccentricity and the public manifestations of drug use and sex work, by the ‘new St. Kilda’ in which newly arrived ‘yuppie’ residents are perceived to be more concerned with property values than the plight of their fellow citizens or the ‘alternative’ cultural heritage of the area. These changes have led to increased pressure on its low-income inhabitants and those who come to earn money for drugs through dealing or sex work. St. Kilda remains a service-rich area, with numerous agencies dealing with drug use, sex work, homelessness and general welfare. Many of the street-based IDUs and sex workers with whom I worked reported circumstances leading to heroin overdose that were consistent with the five behavioural risk factors outlined earlier—i.e. (i) mixing heroin with CNS suppressants; (ii) being out of treatment; (iii) using heroin under conditions of changed tolerance; (iv) using heroin by oneself; and (v) failing to call for assistance with an overdose. Contrary to the findings of previous Australian research, overdose prevention focusing on these behavioural risk factors appears to have penetrated the St. Kilda street drug market. Most research participants were aware of overdose prevention messages and, depending on the specifics of particular injecting episodes or periods (e.g. who they were with, time of day, recent heroin and other drug use, size of ‘habit’, income levels and time since last injection), sometimes employed prevention strategies such as testing heroin strength (particularly amongst couples), injecting with another person present (even if this occurred as a by-product of being in a sexual relationship with another IDU) and/or calling for assistance in the event of an overdose. However, despite the high levels of awareness of overdose risk factors, and the partial adoption of prevention strategies, ‘risky practices’ remained common—such as ‘whacking the lot [using all of one’s drugs in a single injection]’, using alone and mixing heroin with CNS suppressants. To begin to explain why street-based IDUs engage, at least some of the time, in these apparently ‘irrational’ practices, we need to employ developments in understandings of ‘risk’ as contextual (e.g. Bourgois, 1998;

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Connors, 1992; Douglas, 1986; Koester, 1994; Maher, 2002; Rhodes, 2002). The argument of this section is that existing heroin overdose prevention messages, when considered in the context of the St. Kilda street-based drug and sex-work scene, ignore the complexity of risk practices and therefore leave many important issues unaddressed: (i) the sociodemographic characteristics and cultural logics of those participating in high-risk, marginalized lifestyles such as street-based injecting drug use and sex work; (ii) the precarious nature of income-generation strategies in the underground economy; (iii) the transience of street-based drug scenes and the types of social relationships formed as a result; (iv) IDU perceptions of police; (v) the experience of street-based withdrawal; (vi) the desire for heavy intoxication (including, but not limited to, ambivalence about death); and (vii) the reasons for polydrug use. High-risk lives ‘Jackie’ is a women in her late-20s, originally from rural Victoria, who has been living in St. Kilda for just over 4 years. She is of Anglo–Celtic background and completed Year 10 at secondary school. She left home at 16, and first came to St. Kilda on a holiday but ended up staying. She does not want to return to her home town because of past ‘trouble’ with the police and because of a difficult relationship with her parents. Her work history involves low-paid, unskilled work, periods of unemployment, petty street crime and street sex work. When I first met her, in late 2000, she had been sleeping in an abandoned car until the ‘jacks [police]’ had it towed away. Her main source of income was street sex work, supplemented by a disability pension, and she usually slept in public places—in stairwells, parks and unlocked cars, and behind public buildings— and frequently sported cuts and bruises from recent assaults (allegedly by residents hostile to street sex workers as well as by other members of the street scene). By her recollection, in 2001 she used heroin, amphetamine, cocaine, cannabis, benzodiazepines, alcohol and methadone, injecting the first three drugs. She first used heroin at 16, injecting it, and spends anywhere between AUD50 and AUD400 on heroin each day. She has hepatitis C and ‘teeth problems’ caused by her drug use. In her own words, she ‘normally uses alone’, and, although well known on the streets of St. Kilda, has learned to trust few people. She had experienced ‘four or five, maybe six’ overdoses. Here is her account of the most recent: The last one, it was only a couple of doors up the road from where I used to work at [location of sex work]. I couldn’t score off of who I normally score from, so I went and saw a friend of mine and he knew

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someone who was living in the same building just downstairs and he went and got a 100 dollar deal for me. I mixed it up and I gave him a third of it, for, you know, it’s like, he was going to let me stay in his room that night, so, for letting me stay in his room that night, and for scoring for me, I gave him a third of it. He wasn’t using at the time, so he just put his aside to keep it for later and he goes and sits on his bed and he’s, you know, just sitting on his bed looking out his window, staring out over [y] Street. I’m sitting on his couch, tourniquet around my arm, whack it up into my hand, and I remember, I remember saying, ‘Oh yeah, that’s nice, that’s all right’, then apparently, after that, apparently I said something along the lines of, ‘Oh shit’, and then he didn’t hear another word out of me. And I said ‘Oh shit’, and, you know, he didn’t, my mate didn’t pay any attention to it, and, you know, he’s still sitting on his bed staring out of his bedroom window, like in his own little world. A few minutes later, he turns around, you know, he said to himself ‘Oh, I haven’t heard anything from [Jackie] for a minute’, turns around and I’m fucking laying on my back on his couch, tourniquet still round my arm, pick [needle] still in my hand, blue. He gives me mouth-to-mouth, gets me breathing, picked me up, threw me over his shoulder to take me downstairs to the phone. By the time he threw me over his shoulder and turned around to see if I was still breathing in the mirror, I’d gone blue again. Four times he did this, threw me down, got me breathing, threw me over his shoulder, four times he did that and each time I just kept going out. So the fourth time, he just [thought], ‘Fuck it, you stay on the shoulder and I’ll just take you downstairs to the phone’. Well what actually got me going was me over his shoulder, walking down, carrying me down the stairs, it must have been like the movement of me, you know, you know, bouncing up and down over his shoulder down the staircase, is what must have got me going again. And he called the ambulance, and, yeah, all of that shit and two paramedics y MOORE: THEY NARCANED YOU [ADMINISTERED NALOXONE HYDROCHLORIDE]? No, no, he, he kind of, he knew, knew, what effects that could bring and refused to let them Narcane [sic], thank fuck, because he was dead right, I would’ve fucking snatched his head off and the paramedics’ fucking head off if they had. MOORE: SO THEY JUST TOOK YOU TO HOSPITAL THEN? No, I didn’t, they didn’t take me to hospital either, they just, they had to hang around for an hour and [they said to Jackie’s friend], ‘Yeah all right, she’s, you know, kind of with it now. OK, we’ll leave her with you’.

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MOORE: SO ANYTHING, JUST THE DIFFERENT GEAR [HEROIN], THAT WAS WHAT y? Yeah. Different gear, gear that I hadn’t tried before and it’s just better than average and knocked me out. MOORE: HAD YOU BEEN DRINKING ANY [ALCOHOL] THAT DAY OR ANY PILLS? Yeah, I’d, I’d gone through one and a half, two bottles of port that morning. MOORE: SO THE MIXTURE, MAYBE? Yep. Yep. (Jackie interview transcript, November 2001) Jackie’s biography and her overdose account highlight some aspects of street-based injecting drug use that work against the success of existing heroin overdose prevention. Like Jackie, my data show that the majority of participants in street-based injecting drug use and sex work are aged between 20 and 29 years, are of Anglo– Australian background, have few qualifications beyond basic schooling, are officially unemployed, have short or non-existent employment histories, have experience of drug treatment and sometimes extensive criminal records. Almost all are polydrug users, about threequarters have experienced at least one overdose, and about half have HCV. Those who do not live in St. Kilda (roughly one in two) are drawn there by the economic imperatives of heroin dependence and participation in the underground economy of street sex work and drug dealing. Street sex work, although potentially lucrative, is an extremely hazardous occupation that involves the high probability of physical and/or sexual assault (and, in some cases, murder), robbery, arrest and sexually transmitted infection. Some of these women, and many of their male partners, are also involved in various forms of underground economic activity known as ‘rorts’ (e.g. fraud, shoplifting, ‘burgs’ [burglaries], the sale of stolen goods such as mobile phones) and live in unstable accommodation. In this context, messages about overdose prevention are added to a long list of ‘possible risks’ encountered during the course of a typical day. This is not to say that all street IDUs and sex workers are unconcerned about their health but that, seen in context, there are many other, more pressing, priorities that must also be met— e.g. avoiding arrest and assault, evaluating potential ‘mugs [sex work clients]’ for safety, finding the money to score and use drugs, avoiding creditors and securing accommodation (see also Rhodes (1995) for a similar discussion of ‘risk priorities’). One telling illustration of the different views of what constitutes ‘risk’ for those engaged in such work came from a female street sex worker who told me, contrary to the advice of outreach workers to avoid drunken ‘mugs’, that intoxicated

clients were more likely to pay extra for sexual services (and, she might also have added, are potentially easier to ‘rort’). Precarious income generation The relative stability of income generation through street sex work was periodically disrupted by police ‘blitzes’. Commonly understood as being more likely at times of high tourism—such as the Formula One Grand Prix when the ‘jacks’ were seen as responding to political imperatives to ‘clean up the streets’—or as the result of hostility from local residents concerned about public order problems resulting from street sex work and injecting drug use, these blitzes disrupted one relatively steady source of income. One older man, who, as a result of a relationship with a street sex worker, had become embroiled in the street scene, expressed it in the following way: ‘St Kilda floats on the girls’ money; if that dries up, everything gets crazy’. Denied drug money from street sex work, female IDUs and their partners— commonly known as ‘spotters’ (because they note the registration numbers of mugs’ cars, to be reported to police in the event of the woman failing to return)—were forced into, or increased their involvement in, other forms of crime. Making money through street sex work was one reason why IDUs were drawn to St. Kilda. Another was the money to be made from ‘selling’ drugs. Several ‘spotters’ I came to know, while watching their girlfriends, also sold drugs (mainly heroin and amphetamines) to those spending time on the streets. Another strategy was to position oneself as a go-between. People came to St. Kilda looking for drugs but without local contacts. They would approach street sex workers or others on the street and ask if they knew where to score. In return for gaining drugs, the go-between, with or without the consent of the buyer, would ‘chop out a few lines’ (referring to the lines on a syringe barrel) for his or her own use. Transience In addition to unstable accommodation and participation in the underground economy, there were also other factors that contributed to the transience of the street-based population. The Australia-wide heroin shortage that began in late 2000 forced IDUs further afield than usual in the search for heroin. With their usual contacts running ‘dry’, IDUs from other Melbourne street drug markets were seen in St. Kilda asking people to ‘help [them] out’. For those who regularly visited St. Kilda, the police were also a constant threat. Street participants might spend a few days ‘in the cells’ before being bailed or, in the case of more serious crimes, be remanded in custody while awaiting a court

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date—sometimes to disappear from the street for several months or years, if convicted. And people also disappeared for varying lengths of time (from a few days to several months) as a result of entering detoxification or residential treatment programs. This transience created a form of labile social relations that is ignored by overdose prevention inscriptions of a stable social context for injecting drug use. Most streetbased IDUs distinguished between ‘friends’ and ‘associates’. The former, often a very small category, numbered one’s partner (if in a relationship), sometimes siblings or friends who were known prior to involvement in drug use, and one or two street participants who had proven their trustworthiness. Those in the ‘associates’ category (and sometimes those in the ‘friends’ category) were seen as available for exploitation, and that they would, in turn, seek to exploit others. Although, in the account of overdose provided above, Jackie was fortunate in being in the company of one of the two ‘friends’ she said she had, more often people inject heroin alone or with those less well known, who cannot be relied upon to render aid in an emergency. The ‘never-inject-alone’ prevention advice is undermined by these tensions between trust and exploitation. One exchange I witnessed featured a female sex worker urging a female associate not to inject heroin alone in a nearby park. The sex worker suggested that she take her (i.e. the sex worker’s) boyfriend with her to be safe. The would-be park injector looked a little hesitant. The sex worker assured her that the boyfriend would not expect a ‘shot [injection of heroin]’ in return for his company and that she (and her money and drugs) would be quite safe with him. The point here is that the widely disseminated behavioural advice to ‘never inject alone’ was being mobilized but not in any straightforward, unproblematic way. On another occasion, one young man, with a history of sexual abuse, schizophrenia, suicide attempts and institutional care, calmly described to me how he took no role in the purchase and preparation of the heroin that was then injected into him by a newly made friend. In a street drug market, where ‘friendship’ is relatively rare and network composition changes rapidly over time, he trusted his accomplice to provide the ‘right’ dose to produce intoxication but not overdose. He also risked blood-borne virus infection (by being unable to insure a sterile injecting environment) and (perhaps the more likely scenario) being ‘ripped off’ by being injected with a heavily diluted heroin mixture. This young man’s apparently carefree attitude to heroin injecting is starkly at odds with the rationality, calculation and selfregulation of overdose prevention. Fear of police Although Jackie’s friend called the ‘ambos [ambulance officers]’, there were good reasons for not doing

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so. I have already indicated that social relations are frequently superficial and involve tensions between trust and exploitation. Another reason for leaving the scene of an overdose is fear of the police. Practitioners in St. Kilda and elsewhere were at pains to point out to their clients that police were only called to a relatively small percentage of ambulance attendances at overdose (13% in Melbourne (Dietze, Jolley, & Cvetkovski, 2003)). However, street-based IDUs with outstanding arrest warrants, the discovery of which would often lead to court appearances and incarceration, were not always prepared to play the odds. Some also alleged that they had been the victims of past police violence. Withdrawal The prevention advice to test one’s heroin first cuts across conceptions of the intoxicated body articulated by street-based IDUs such as Jackie, which emphasize the pain of withdrawal. One common refrain is ‘You’ll do anything when you’re hanging like a dog [suffering from severe withdrawal]’. Jackie described this to me in relation to ‘cheap sex jobs’. Female street sex workers often claimed that ‘other girls’, particularly ‘younger girls’, were engaging in sexual services at below the generally agreed prices of AUD50 for ‘oral [sex]’, AUD80 for ‘straight sex’ and AUD100 ‘for both’, or, in the face of repeated requests from ‘mugs’, agreeing to provide services without condoms (sometimes for a higher price). In a highly competitive street sex market, this practice put pressure on those women who attempted to maintain price or practice safe sex. Jackie repeated the familiar declaration of the ‘other girls’ before confessing that she, too, sometimes ‘did cheap jobs’ (although, she claimed, always with a condom), particularly in the morning when she was ‘hanging’ and needed ‘that first shot’. More generally, having expended great effort to ‘get up the money’ to ‘score’ (which, in the case of street sex workers, may have involved standing on a street corner for several hours on a cold, wet Melbourne winter’s night, in the hope of getting a ‘job’, or, in the case of their male partners, spending the day ‘rorting’), waiting around for dealers to show with the drug, and feeling ‘sick’ throughout, one sought immediate and urgent relief in the heroin injection. This is not a situation in which injunctions to be cautious at the point of injecting are likely to gain much traction. Heavy intoxication A second aspect of the construction of intoxicated bodies ignored by prevention advice to test heroin first, or to use small amounts, is the high value placed on heroin or polydrug intoxication, particularly the fine line between heavy intoxication and overdose (evident in Jackie’s refusal to accept Narcan). There are several

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reasons for this valuation. Accounts of heroin careers frequently included descriptions of a ‘honeymoon’ period during the early stages of use, a central aspect of which is ‘getting smashed [i.e. being heavily intoxicated]’. One’s tolerance is low, the money required is not prohibitive, and the drug’s effects are powerful and intensely pleasurable. IDUs also spoke of ‘pigging out [on drugs]’, or described themselves and others as ‘drug pigs’. Sometimes this perceived gluttony was attributed to drunkenness or drug intoxication and, consequently, to impaired judgment. In other accounts, the reported motivation for overconsumption was emotional crisis. The emotionally numbing qualities of heroin intoxication were deemed perfectly suited to coping with family deaths, memories of childhood abuse and acrimonious struggles over child custody, and to dealing with the emotional distress caused by engaging in street sex work. In the eyes of many, polydrug use, including heroin, was a recognized, available and appropriate response. Heroin was perceived not as ‘the problem’ but as ‘the solution’ (see also Cooper, 2001). In such cases, accidental over-consumption was certainly a feature but much more striking were the accounts of either intentional or quasi-intentional suicide. In accounts of ‘intentional suicide’, IDUs reported either their own over-consumption, or that of their friends, as a specific and deliberate attempt to suicide. In other accounts, IDUs described not so much a specific and deliberate attempt to suicide but either a more generally ‘risky’ or ambivalent orientation to life and death (in response to biographies featuring extensive and ongoing social, cultural and economic marginalization); for example, the fatalistic ‘If I drop, I drop’ or, describing the lead-up to an overdose, ‘I knew I was taking a risk but I didn’t care’. In describing the drugrelated deaths of friends, many were unable to rule out suicide, reporting that the deceased ‘didn’t have much to live for’. These points raise the possibility that avoiding death, the primary logic driving overdose prevention, is viewed with considerable ambivalence by some streetbased IDUs (see also Heale, Dietze, & Fry, 2003; Miller, 2002; Neale, 2000). Polydrug use Despite overdose prevention advice to avoid polydrug use, it remains a common practice. Some long-term IDUs, whose tolerance had risen over the years, deliberately mixed their heroin with ‘benzo’s’ (or ‘pills’) in order to ‘get on the nod’, or had begun doing so as a result of the heroin shortage and the consequent decline in heroin quality and increase in price. In other cases, such as Jackie’s, polydrug use occurs not as the result of planning, but was an outcome of relatively unstructured days (with the notable exception of obtaining money and heroin on a regular basis) and the search for action

and purpose. Because of the relatively low cost of benzodiazepines and highly alcoholic drinks, many study participants had consumed several units of one or both before being unexpectedly presented with the opportunity to inject heroin, which, given the desire for intoxication, they then took. In other cases, polydrug result was the result of a mistake or ignorance—‘I didn’t know what they [the pills] were’.

Towards an alternative governmentality Heroin overdose prevention in Australia can be seen as an example of neo-liberal governmentality. An individualized, rational, autonomous agent is ‘free’ to choose to change ‘risky’ injecting practices, and is labelled ‘chaotic’ if he or she fails to regulate the intoxicated body (Moore, 2003). But my ethnographic account emphasizes that injecting practices are shaped by social, cultural and economic contexts, which may work against or undermine heroin overdose prevention as it is currently formulated. According to the cultural logics of street-based IDUs, there are many valid reasons for continuing to engage in practices that put them at risk of heroin overdose and other drug-related harm. My analysis suggests the need to complement individually focussed behavioural strategies for the prevention of overdose with attention to the social, cultural and economic marginalization of street-based IDUs and sex workers. This switch of focus is consistent with the ‘risk environment’ approach recently outlined by Rhodes (2002). He defines a ‘risk environment’ as ‘the space—whether social or physical—in which a variety of factors interact to increase [or reduce] the chances of drug-related harm’. The macro-aspects of risk environments include the public and legal/policy context; economic, gender and ethnic inequalities; the cultural organization of risk and harm, and the political economy of health. The micro-aspects of risk environments include group norms, rules and values; social relations and networks; peer, group and social influences; the immediate social settings of drug use; and the local context. A focus on risk environments ‘helps to overcome the limits of individualism characterizing most (drug) prevention interventions as well as to appreciate how drug-related harm intersects with health and vulnerability more generally’ (Rhodes, 2002, p. 85). He argues that the aim of drug policy should be to create ‘enabling environments’ for the reduction of drugrelated harm through step-by-step identification and removal of micro-barriers to harm reduction (e.g. local policing strategies, low-threshold drug services), and the creation of wider policy initiatives around such issues as housing, public infrastructure and labour market reform. A ‘risk environment’ approach provides a useful

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framework for bridging the theoretical divide between an anthropology of drug use and drug policy, and an anthropology for drug policy. Two examples drawn from the St. Kilda material illustrate the value of such an approach. Firstly, many street-based IDUs and sex workers are homeless or live in insecure housing (see also Rowe 2003). At the macrolevel, there has been a drastic reduction in affordable housing in Melbourne generally and St. Kilda specifically. There are long waiting lists for public housing, and the number of low-cost rooms has decreased as a result of gentrification, inner-urban redevelopment and the conversion of inexpensive hotels and rooming houses into backpacker hostels. There is, therefore, an urgent need for policy to ‘ensure an adequate supply of secure and affordable housing’ in order to meet rising levels of homelessness (Bartholomew, 1999, p. 147). Secondly, at the local level, there needs to be renewed advocacy for ‘designated zones’ for street sex workers, as originally proposed by the Victorian Attorney-General’s Street Prostitution Advisory Group (involving representatives from state and local government, non-government organizations, police, residents’ groups and the street sex industry) (Attorney-General’s Street Prostitution Advisory Group, 2002). This proposal was later shelved as the 2002 state election loomed. In brief, the designated-zone proposal envisaged demarcated areas within which street sex workers could solicit clients without fear of prosecution, and the installation of street-worker centres where they could go to service clients. Soliciting and servicing clients, and the associated public order problems, would continue to be policed outside these areas. Other recommendations included the establishing of a range of health, education, support and referral services for street sex workers and improved amenities. The proposal thus addressed the concerns of local residents, the need to develop innovative forms of service delivery to a highly marginalized group and some of the financial, health and safety issues confronting street sex workers. Law enforcement, biomedical and epidemiological knowledges continue to frame IDUs in particular ways and to advocate particular forms of governance. The governmentality critique of existing overdose prevention, combined with ethnographic knowledge of streetbased IDUs and sex workers, has led me in another direction—to the risk-environment framework. Although Bourgois is right to argue that new forms of drug policy emphasizing harm reduction, such as the risk-environment framework, can be seen as new forms of governmentality—as new ways of regulating the ‘unruly bodies of self-destructive street addicts’—this should not prevent those of us working at the intersection of social science and drug policy from developing alternative frameworks that might produce less social suffering.

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Acknowledgements The research reported in this article was funded by Victorian Health Promotion Foundation Project Grant 1999-0263. An earlier version of the article was presented to the Discipline of Anthropology and Sociology Seminar, School of Social and Cultural Studies, University of Western Australia, in March, 2003. I am greatly indebted to my co-investigators Paul Dietze and Greg Rumbold, and to the staff of various St. Kilda agencies who facilitated the research in all kinds of ways—in particular, the Inner South Community Health Service, the Salvation Army Crisis Centre and Health Information Exchange, and the City of Port Phillip. Shelley Mallett, Peter Miller and two anonymous referees provided helpful comments on an earlier version. Above all, I thank Jackie and the other St Kilda IDUs and sex workers who shared their stories with me.

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