By Arthur Evenchik
In a decaying neighborhood on Cleveland’s West Side, a van carrying public health workers arrives on a fall afternoon and parks in its usual location. A few minutes later, heroin addicts who live in the area begin to come by, bringing used syringes they will exchange for new ones. Every day, the Free Medical Clinic of Greater Cleveland sends the van into communities like this, where drug abuse is a significant problem and services for addicts are scarce. Taking used needles out of circulation is one of its strategies to prevent the spread of HIV.
On this particular afternoon, graduate students from Case Western Reserve’s Department of Anthropology accompany the clinic staff. They belong to a team led by Assistant Professor Lee Hoffer, who has spent the past 20 years exploring the lives of addicts and the operational intricacies of drug markets. The team is assessing the syringe exchange program’s effectiveness, but its fieldwork will yield data relevant to other research questions as well.
As they carry out their project, Hoffer and his students won’t merely interview users. They will also enter their worlds—visiting their homes and communities, observing their daily behavior, and documenting the pressures and challenges they face. In doing so, they will be employing a research method called ethnography.
This approach is valuable in part for the stories it yields—richly detailed accounts of how individuals manage their day-to-day existence. But Hoffer also incorporates ethnographic data into computational models that generate a larger view of the drug economy. He hopes that his results will inform both drug control policy and the design of treatment programs and other health services for this population.
Recognizing the significance of his work, the National Institute of Drug Abuse (NIDA) awarded Hoffer a five-year, $1.6 million grant in 2009 to study the methamphetamine market in Summit County, Ohio. His computational research, conducted in partnership with Case Western Reserve’s High Performance Computing Cluster, has won grant support from the National Science Foundation (NSF).
“Lee’s deep knowledge of issues surrounding illegal drug use has added a valuable component to our curriculum,” says Lawrence Greksa, chair of anthropology in the College of Arts and Sciences. “So has his expertise in ethnographic methods and his innovative use of ethnographic data as the basis for the computer modeling of complex social behaviors. His work has brought a new dimension to our research and teaching in the field of medical anthropology.”
Hoffer entered the field of drug abuse research at the University of Colorado, Denver, where he earned a master’s degree in anthropology and a doctorate in health and behavioral sciences. He got his start when the Department of Psychiatry at the university’s Health Sciences Center hired him to administer surveys to out-of-treatment drug users.
Although survey research is still a component of his work, Hoffer’s early training made him aware of its limitations. “I spent a lot of time talking with people who were coming in to do the surveys,” he recalls. “And in those informal chitchats, I was learning so much more about what was important to them.”
Then, in a research methods class, Hoffer discovered ethnography. In some ways, it was an extension of what he was doing already—talking with people. But he saw that by interacting with users in their social environments, he would gain a more accurate and nuanced view of their experience.
Under a faculty mentor’s guidance, Hoffer threw himself into street-level anthropology. “Researchers in this field do things that might appear crazy to most people—visiting crack houses, staying out all day and night with users in these settings,” he says. “When I was starting out, I did things I probably shouldn’t have, like getting in cars with people I didn’t know and spending hours of unaccounted time on the streets. Yet there was really only one instance when I felt that I was at risk.”
Understanding addiction meant unlearning clichés. “There are so many stereotypes of drug users that view them as dangerous, irrational, devious and greedy,” Hoffer says. But in many respects, his research subjects turned out to be “regular folk”—interesting, friendly and smart. At times, he identified with them more easily than he could have imagined.
“I would interview people who were exactly my age or younger, and just becoming addicted,” he recalls. “What I realized was, they didn’t decide, ‘I want to become a heroin addict.’ They were just doing stuff that kids do—experimenting. But I could see that in 20 years, they were going to be like the other addicts I interviewed.”
Hoffer wrote his dissertation about heroin dealers in Denver, a project that led to his book, Junkie Business. He went on to a postdoctoral position at Washington University School of Medicine, where he continued his research and taught courses in medical anthropology. In 2004, he completed a second master’s degree, in psychiatric epidemiology. And four years later, he came to Case Western Reserve.
Hoffer is the principal investigator on several projects in Northeast Ohio, including his NIDA-funded study of Summit County’s methamphetamine market. Two years ago, police in Akron cracked down on meth producers and dealers, but their campaign had an unfortunate side effect: While meth use seemed to decline, heroin use went up. Hoffer thinks that two mutually reinforcing factors were at work. As the police focused their efforts on the meth trade, heroin dealers were under less pressure, so the heroin supply increased. And as meth users found it harder to buy their drug of choice, some switched to heroin, fueling a rise in demand.
To recruit subjects for his studies, Hoffer begins with clients of community-based organizations such as the Free Clinic and the Hispanic Urban Minority Alcoholism and Drug Abuse Outreach Program. In turn, these users introduce him to others who aren’t getting help with their addictions or related health issues.
“If you only work with people in treatment, or people who come to the needle exchange, you’re missing a big segment of the population,” Hoffer explains. “But it only takes a couple of links before you’re interacting with people who don’t access those services or don’t know about them.”
Because the users are engaged in illegal activities, it may seem surprising that they would agree to join a study. But Hoffer has no trouble finding subjects, and he doesn’t think that’s merely because he pays them. “They’re really interested in giving us their stories,” he says.
First, however, Hoffer and his students must build trusting relationships with these users. The process begins with their very first interviews. “The point is to demonstrate that you aren’t the police, that you don’t have any ulterior motives, that you aren’t trying to moralize or get them to change their behavior,” Hoffer says. “What you’re really trying to do is develop rapport.”
Before they go out on the streets, Hoffer tells his graduate students to take precautions. “We don’t go where people don’t invite us,” he says. “We’re always very up front about who we are and what we do. At any point, if you’re uncomfortable in a situation, you should leave. The data are the data; your life is your life.” These rules sound pretty basic, he admits. “But when people are really into the research, they might not be thinking about these things.”
Hoffer also prepares his students for the psychological toll fieldwork can take. “It’s hard emotionally to deal with some of the things you see over time,” he says. “The stories are powerful. What people are doing is really hurting them, and you want to help. But a lot of times, they’re only telling you these stories because they know you aren’t trying to change their behavior. If you start trying to change their behavior, you lose access.”
Graduate student Allison Schlosser may feel this dilemma more keenly than most. She first learned about the impact of illegal drug use on poor communities as an AmeriCorps volunteer at an elementary school in St. Louis. The children came from neighborhoods where drug dealing was common. When she visited their homes, Schlosser says, she learned that many “had issues with drug use in the family—parents or siblings who were either incarcerated or had been through treatment for addiction.”
After she left AmeriCorps, Schlosser pursued a master’s degree in social work at Washington University. Hoffer was teaching there at the time, and she took his course in medical anthropology. It was exciting to discover a discipline that addressed the kinds of problems her students and their families had confronted. “I saw how they struggled to navigate health and social services related to drug use,” she says. “I wanted to better understand how families experience those services in order to contribute to improving them.”
With this goal in mind, Schlosser applied to the doctoral program in anthropology at Case Western Reserve and began her studies in fall 2009. “The opportunity to work with Lee Hoffer, and also this department’s focus on medical anthropology, brought me here,” she says.
Since joining Hoffer’s research team, Schlosser has contributed to a study of heroin users who are not in treatment. “It’s frustrating to be talking with people who aren’t getting the help they need,” she says. “For someone trained in social work, it is difficult not to want to intervene immediately. But that’s not my role as an ethnographer. To come in with a social worker’s mindset would potentially diminish my ability to get the perspective of people who might not want intervention, but whose experience is really important to understand in order to develop better services.”
For her dissertation, Schlosser plans to explore clients’ experience in residential drug treatment and their transition back to life in the community. NSF funded her preliminary fieldwork with a Research Experience for Graduates award. This was one more benefit of having Hoffer as her advisor: Only doctoral students working with NSF grantees are eligible for this support.
In recent years, Hoffer has tried to increase ethnography’s impact on drug control policy. Unfortunately, he says, “ethnographic data tends to be considered anecdotal, and not on the same level as quantitative data. People think, ‘Well, it’s just stories.’ And this is problematic, because the stories are important. They really give a sense of what people’s lives are like.”
In response, Hoffer has developed a new application for ethnographic data. Adopting an approach called agent-based modeling, he creates computer simulations that reveal the hidden dynamics of drug markets. In these simulations, imaginary users and dealers are programmed to behave in many of the ways that Hoffer’s research subjects do. The simulations then show the ramifications of such behaviors for the drug trade and the people involved.
Agent-based modeling is illuminating because it generates answers to questions that can’t be studied directly; for instance, it can calculate the quantity of drugs being sold in a community. It also enables researchers to see how discrete features of illegal drug markets interact to produce outcomes no one would have expected.
For instance, heroin users often buy the drug from friends or acquaintances, not directly from dealers. Distribution networks are inherently unstable, since dealers can get arrested. When Hoffer constructed a virtual drug market with such conditions, he found that it defied conventional economic logic: When the supply decreased, retail prices didn’t rise.
The policy relevance of this finding couldn’t be clearer, Hoffer says. Supply-reduction efforts are central to the War on Drugs, accounting for 60 percent of federal spending related to illegal drug use. But Hoffer’s model shows that one of the hoped-for consequences of these efforts—raising the price of illegal drugs beyond the means of users—doesn’t materialize.
For this reason, among others, Hoffer favors shifting resources to reducing demand—through expanded drug treatment programs, for example. “The cost of one drug-interdiction helicopter could put a lot of people in treatment,” he says. “And this would have a much larger impact on the drug market than simply arresting users and dealers.”
Freelance writer Lee Chilcote contributed reporting to this story.