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This powerful work of gonzo journalism, predating the widespread acknowledgement of the opioid epidemic as such, immerses the reader in the world of homelessness and drug and alcohol abuse in the contemporary United States. For over a decade Philippe Bourgois and Jeff Schonberg followed a social network of two dozen heroin injectors and crack smokers in the San Francisco drug scene, accompanying them as they scrambled to generate income through burglary, larceny, panhandling, recycling, and day labor. Righteous Dopefiend interweaves stunning black-and-white photography with vivid dialogue, oral biography, detailed field notes, and critical theoretical analysis to viscerally illustrate the life of a drug addict. Its gripping narrative develops a cast of characters around the themes of violence, racism and race relations, sexuality, trauma, embodied suffering, social inequality, and power relations. The result is a dispassionate chronicle of fixes and overdoses; of survival, loss, caring, and hope rooted in the drug abusers' determination to hang on for one more day, through a \"moral economy of sharing\" that precariously balances mutual solidarity and interpersonal betrayal.

After an uninsured Puerto Rican man with back pain, other chronic conditions, and a history of incarceration admits to a doctor at a free clinic that he’s bought oxycodone illegally, he refrains from filling his prescription or returning to the clinic, fearing rearrest.

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. 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. 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. 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 present study examined reasons for the high incidence of hepatitis C virus (HCV) infection among young injection drug users (IDUs). IDUs <30 years old who tested negative for HCV antibody were enrolled in a prospective cohort. Risk factors for seroconversion were examined using time-dependent regression analyses: 48 of 195 IDUs seroconverted to HCV, for an incidence rate of 25.1/100 person-years (95% confidence interval, 18.7–32.9/100 person-years). Independent risk factors included sharing needles with an HCV-infected sex partner (borderline statistical significance, P=.11) or a person who was not a sex partner, sharing nonsterile drug-preparation equipment, pooling money with another IDU to buy drugs, and exchanging sex for money. Ubiquitous behaviors among young IDUs, such as the forming of injecting or sexual partnerships and consequent sharing of needles and drug preparation equipment, are risk factors for HCV. Interventions to reduce HCV transmission must recognize the importance of relationships on injecting risk

The cultural and political-economic valences of psychoactive drugs in the Global South offer critical insights on local and international fault lines of social inequality and profiteering. Historically, in a classic primitive accumulation process the trafficking of industrially produced euphoric substances across the globe have wreaked havoc among vulnerable populations while extracting profit for the powerful. The complex flows of capital generated both by illegal addiction markets and also by the mobilisation of licit public funds to manage their mayhem, however, suggest the contemporary utility of the concept of 'predatory accumulation'. The Enlightenment-era concept of 'primitive accumulation' usefully highlighted state violence and forcible dispossession in the consolidation of European capitalism. A contemporary reframing of these processes as predatory accumulation, however, highlights contradictory, nonlinear relationships between the artificially high profits of illegal drug sales, repressive governmentality and corporate greed. It sets these patterns of destructive profiteering in the context of our moment in history.

This article explores family separation and reunification of the disappeared Salvadoran children separated from their families during El Salvador's civil war (1980–1992) from the perspectives of adult relatives. During separation, adult relatives experienced an \"unresolvable loss.\" Following reunion, families experienced an immediate relief that was often accompanied by an \"ambiguous reunification.\" Emotions were especially complicated and painful when the separation had been a \"forced choice\" by the parent under coercive wartime political conditions. Adoptive parents strongly influenced reunification. Findings suggest that disappeared children and biological and adoptive family members need psycho-social support throughout separation and reunification.

OBJECTIVE: To identify ways in which undocumented day laborers' social context affects their risk for occupational injury, and to characterize the ways in which these workers' social context influences their experience of disability. DESIGN: Qualitative study employing ethnographic techniques of participant‐observation, supplemented by semistructured in‐depth interviews. SETTINGS: Street corners in San Francisco's Mission District, a homeless shelter, and a nonprofit day labor hiring hall. PARTICIPANTS: Thirty‐eight Mexican and Central American male day laborers, 11 of whom had been injured. PRIMARY THEMES: Anxiety over the potential for work injury is omnipresent for day laborers. They work in dangerous settings, and a variety of factors such as lack of training, inadequate safety equipment, and economic pressures further increase their risk for work injury. The day laborers are isolated from family and community support, living in a local context of homelessness, competition, and violence. Injuries tend to have severe emotional, social, and economic ramifications. Day laborers frequently perceive injury as a personal failure that threatens their masculinity and their status as patriarch of the family. Their shame and disappointment at failing to fulfill culturally defined masculine responsibilities leads to intense personal stress and can break family bonds. Despite the high incidence of work injuries and prevalence of work‐related health conditions, day laborers are frequently reluctant to use health services due to anxiety regarding immigration status, communication barriers, and economic pressure. IMPLICATIONS: On the basis of these ethnographic data, we recommend strategies to improve ambulatory care services to day laborers in 3 areas: structural changes in ambulatory care delivery, clinical interactions with individual day laborers, and policymaking around immigration and health care issues.

Street-based heroin injectors represent an especially vulnerable population group subject to negative health outcomes and social stigma. Effective clinical treatment and public health intervention for this population requires an understanding of their cultural environment and experiences. Social science theory and methods offer tools to understand the reasons for economic and ethnic disparities that cause individual suffering and stress at the institutional level. We used a cross-methodological approach that incorporated quantitative, clinical, and ethnographic data collected by two contemporaneous long-term San Francisco studies, one epidemiological and one ethnographic, to explore the impact of ethnicity on street-based heroin-injecting men 45 years of age or older who were self-identified as either African American or white. We triangulated our ethnographic findings by statistically examining 14 relevant epidemiological variables stratified by median age and ethnicity. We observed significant differences in social practices between self-identified African Americans and whites in our ethnographic social network sample with respect to patterns of (1) drug consumption; (2) income generation; (3) social and institutional relationships; and (4) personal health and hygiene. African Americans and whites tended to experience different structural relationships to their shared condition of addiction and poverty. Specifically, this generation of San Francisco injectors grew up as the children of poor rural to urban immigrants in an era (the late 1960s through 1970s) when industrial jobs disappeared and heroin became fashionable. This was also when violent segregated inner city youth gangs proliferated and the federal government initiated its \"War on Drugs.\" African Americans had earlier and more negative contact with law enforcement but maintained long-term ties with their extended families. Most of the whites were expelled from their families when they began engaging in drug-related crime. These historical-structural conditions generated distinct presentations of self. Whites styled themselves as outcasts, defeated by addiction. They professed to be injecting heroin to stave off \"dopesickness\" rather than to seek pleasure. African Americans, in contrast, cast their physical addiction as an oppositional pursuit of autonomy and pleasure. They considered themselves to be professional outlaws and rejected any appearance of abjection. Many, but not all, of these ethnographic findings were corroborated by our epidemiological data, highlighting the variability of behaviors within ethnic categories. Bringing quantitative and qualitative methodologies and perspectives into a collaborative dialog among cross-disciplinary researchers highlights the fact that clinical practice must go beyond simple racial or cultural categories. A clinical social science approach provides insights into how sociocultural processes are mediated by historically rooted and institutionally enforced power relations. Recognizing the logical underpinnings of ethnically specific behavioral patterns of street-based injectors is the foundation for cultural competence and for successful clinical relationships. It reduces the risk of suboptimal medical care for an exceptionally vulnerable and challenging patient population. Social science approaches can also help explain larger-scale patterns of health disparities; inform new approaches to structural and institutional-level public health initiatives; and enable clinicians to take more leadership in changing public policies that have negative health consequences.

Between 2018 and 2021 in the USA, estimated fatal drug poisonings involving xylazine, often co-occurring with synthetic opioids such as fentanyl, increased from 260 to 3480 cases.1 This use of xylazine takes place in the context of the ongoing US opioid overdose crisis, which is expected to claim an estimated 1·2 million additional lives by 2029, barring urgent substantial policy reforms.2 The White House Office of National Drug Control Policy identified fentanyl adulterated or associated with xylazine (FAAX) as an emerging threat and in July, 2023, issued a response plan leveraging the Emerging Threats Committee and other vital stakeholders.3 Although this is a welcome strategy that sets out the federal government's plan to address xylazine, further non-punitive efforts and public health interventions are needed from health-care systems, policy makers, and community leaders to address the longer-term structural factors driving this crisis. Additionally, these drug monitoring efforts should be complemented with non-punitive supply-side harm reduction and surveillance initiatives.7 Such efforts could entail structured surveys of wholesale or retail-level drug sellers to elucidate the pathways through which FAAX infiltrates the supply chain, as well as contextualising the social and structural conditions that promote xylazine distribution; narcotics entrepreneurs should be pragmatically recognised as crucial interlocutors who may be potential risk-reduction allies.7 In clinical and community-based settings, FAAX should be routinely integrated into toxicological testing, together with rapid point-of-care testing technologies such as Fourier-transform infrared spectroscopy machines and test strips. People who use drugs might also avoid clinical-based wound care due to negative past experiences and stigma.1,17 The severity of these skin ulcers could compound the pervasive stigma already experienced by people who use drugs from some health-care providers, resulting in inadequate care.5 Dehumanising and sensationalist news media portrayals of people who use xylazine could also exacerbate their social exclusion.5 To address these issues, health-care systems must implement evidence-based risk-reduction clinical guidelines to offer accessible, trauma-informed, non-stigmatising urgent and continued care for patients affected by FAAX, while also expanding basic science and clinical research to clarify the effects of chronic xylazine use in animal models and humans. [...]expanding opioid education and naloxone distribution programmes to address the unique public health challenges of the FAAX syndemic is essential.