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Abstract
Opioid drug overdoses in the United States have continued to rise since 2014. Overdoses are one of several interlinked health challenges faced by marginalized populations. Here we side with the argument that these populations can also be a valuable resource to address these challenges, and we use methods that can elevate this critical belief into real-world application. In this article, we use spatially inspired interviews from both marginalized and provider participants in the Los Angeles Skid Row to map out the microspaces of drug activity. The resulting map reveals a complex space in terms of drug types and associated social activities. These geonarratives reveal a nuanced space of locations, activities, and context—how these substances enter Skid Row, the associated violence, and the physical and emotional toll on the marginalized. We find both quantitative and qualitative support that the “street” community is complex, full of variation in terms of where people live, how they live, and the social fabric that has evolved. We suggest that these data can be used to reduce the structural violence often found in many “solutions” to the homeless and their problems. Instead we show that the marginalized could be used to provide a vital resource not only in terms of their knowledge and their communities but also in delivering medical care. We end by suggesting that this approach to data collection could evolve into an ongoing resource that could develop into a near-real-time tool to reduce overdose mortalities. Key Words: geonarrative, GIS, marginalized, overdose, Skid Row.
在美国, 鸦片类药物成瘾自 2014 年开始便不断增加。药物成瘾是边缘化人口所面临的若干相互连结的健康挑战之一。我们于此支持这些人口同时也是应对这些挑战的宝贵资源之主张, 并运用能够将此一批判理解提升至真实世界应用的方法。我们于本文中, 运用对洛杉矶贫民区中受到边缘化者与供养人之参与者进行受空间启发的访谈, 以绘製药物活动的微观空间。我们获得的地图, 揭露出药物种类和相关社会活动的复杂空间。这些地理叙事, 揭露出地点、活动与脉络的细緻空间——这些物质如何进入贫民区、与之相关的暴力, 以及边缘化者的物质和情绪损失。我们同时发现质化与量化的支持, 证实“街头”社群是复杂的, 且在何处生活、如何生活、及其形成的社会纹理上充满了变异。我们主张, 这些数据能够用来减少针对游民及其问题的诸多“解决方案”中经常发现的结构性暴力。我们反而展现, 边缘化者不仅在其知识与社区上、更在传递医疗照护上, 能够用来提供有效的资源。我们于结论中主张, 此般数据搜集方法, 能够演变成为持续不断的资源, 并能发展成为近乎及时降低药物成瘾致死率之工具。
Las sobredosis con drogas opioides en los Estados Unidos han seguido en aumento desde 2014. Las sobredosis son uno de los varios retos entrelazados de salud pública que enfrentan las poblaciones marginadas. Aquí concordamos con el argumento de que estas poblaciones pueden a su turno ser un valioso recurso para abocar esos retos, y usamos métodos que pueden promover esta crítica creencia en una aplicación para el mundo real. En este artículo usamos entrevistas inspiradas espacialmente tanto con los marginados como con proveedores participantes en el Skid Row de Los Ángeles para cartografiar los microespacios del tráfico de drogas. El mapa resultante revela un espacio complejo en términos de los tipos de drogas y actividades sociales asociadas. Estas geonarrativas revelan un espacio matizado de localizaciones, actividades y contexto—cómo entran estas sustancias al Skid Row, la violencia asociada y el estrago físico y emocional que recae sobre los marginados. Hallamos apoyos tanto cuantitativos como cualitativos en el sentido de que la comunidad “callejera” es compleja, plena de variación en términos de dónde vive la gente, cómo viven, y la fábrica social que ha evolucionado. Sugerimos que estos datos pueden usarse para reducir la violencia estructural que a menudo se encuentra en muchas de las “soluciones” que se plantean sobre los sin hogar y sus problemas. En su lugar, mostramos que los marginados podrían servir como un recurso vital no solo en términos de su conocimiento y de sus comunidades, sino también para distribuir cuidado médico. Terminamos sugiriendo que este enfoque de recolección de datos es susceptible de transformarse en un recurso actuante que podría desarrollarse como una herramienta casi de tiempo real para reducir las mortalidades por sobredosis.
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Acknowledgments
The authors thank Homeless Health Care for their guidance and continued work in Skid Row; Eric Shook for developing the prototype geonarrative code that made this type of work possible; students in the GIS Health and Hazards Lab; Jacqueline Curtis for reading early versions of the article; Kenneth Wilson for his work with the homeless; and Martin Kennedy for being a supporter and inspiration.
Notes
2. Accurate data on overdoses are difficult to obtain in any location. Police calls, Narcan use, medical 911 calls, hospital and clinic admission data, or the coroner's office all might have overdose-related data, much of which are not cross-referenced or shared. This means being able to understand that a developing problem, especially through mapping, is extremely difficult, even if the victims have known addresses. The combination of all of these factors means that there is no alternative mapping strategy available to the one proposed in this article.
3. It should be noted that Housing First approaches vary geographically and as with many “solutions,” there is debate surrounding their effectiveness in terms of concept, implementation, and outcomes.
4. “They are totally trying to gentrify, and you know kind of use reverse broken windows theory, where like if we make it look nice then it will be easier to get these people out of here. They do sweeps on Fridays so they can hold people til Monday, and then they will release them in Long Beach at like 2 a.m. and they will overdose 'cause they didn't use for three days so their tolerance changed.” (Health provider)
5. “It's out here twenty-four hours a day. You ain't got the neighborhood watch, which always want to harass you and call the police, ‘Hey it's (twelve o'clock) you got three guys over here on the corner standing around, look suspicious.’ … but see down here, all you got to do is walk, you going to get what you want. You can wake up, two o'clock in the morning, they out here all night long (24/7) … so whatever corner you turn, you going to find it. And drugs play a big role in that. That's basically why we're all still homeless. Yeah, 'cause we cannot afford to support our habit plus rent … your body needs it, it depends on it and if you don't get it, you get physically ill, it's not in the brain either, it's not psychological … your body depends on it, and you vomit, you can't eat, you shake, you shiver, you got chills you got fevers, you’ re basically miserable—trust me and I was hooked on heroin for a while, you will do whatever it takes, no matter how bad, demoralizing, or illegal it is, so you don't feel that way.”
6. “About two weeks ago a guy died right there in a wheelchair, this old guy, and he took a hit of crack and just had a heart attack and died right there. It took two hours before the coroner came and we're all just looking at his dead body. Nowhere else would they leave a body in the street but down here, right? And the impact that it has on anybody that walks by, like the message is clear, you can literally die in the streets down here and don't nobody in LA give a shit about it, and we are going to leave your body in the street until we get to it, cause you guys don't count, we don't care about you.” (Provider)
7. A further benefit of this approach is that the individual might also feel more at ease in his or her environment, especially if precautions are made to minimize the identity of the subject. The vehicles have tinted windows, the windows are rolled up, and the car drives at normal road speed. The cameras have a very small footprint and if positioned correctly in the corner of the window are extremely hard to see from the outside.
8. This was in accordance with what was passed by the institutional review board.
9. It is understandable that there is concern with regard to how information from these rides is used. We believe that insight into the social and spatial structures of the marginalized could prove invaluable insight for effective health outreach. None of these findings would ever be supplied to law enforcement.
10. The initial rationale for data collection was to gain an understanding of the health situation in SR, more specifically responding to recent tuberculosis and sexually transmitted infection outbreaks. The spatial video interview technique is freeform, however, and encourages discussion about any topic deemed important by the participant.
11. The original computer code was developed by Eric Shook, Department of Geography, University of Minnesota.
12. The size of this window will result in heat maps showing localized patterns (along one street) to more generalized areas (the whole of SR).
13. Provider rides were employees and volunteers who worked in health care, housing, and food distribution in SR.
14. “That corner is owned and operated by the DDs (a proxy name we use) and they hit that corner every frigging day. … I don't even like walking down this corner, you know it's wild, and not only that there's a lot of crime, a lot of violence on that corner, too. It happens more so than other areas and when it does, you can pretty much bet it's over a drug deal gone wrong, cause the XXs don't play.”
15. “[L] park ain't nothing but dope dealers in there and people financing it and you will never, ever see a cop in there.”
16. “You know how many times I've bought dope on those steps, sometimes smoke a little bit of it, too, well what better place to do it, right under their nose they'll never see you. This wall along here, even though it's connected to the police station, is notorious for people hanging out and selling crack. When I used to smoke crack this was my favorite spot to come, I'd go sixteen blocks out of my way just so I could smoke right here, I wouldn't smoke anywhere else, I don't know why I felt comfortable there and felt safe but I did … it was weird.”
17. “But I don't know if you've been down there by the X mission and all that, it's really, really crazy, I mean literally crazy, insanity. Going to the bathroom, it's wild man, it's the only place I know in the world you can use the facilities and take a shower, buy your dope, do your dope and get robbed all at the same time, you don't even have to move. It's just a dope spot, it's a huge, huge dope spot.”
18. “This is where most of our overdoses are, [C] and [J], and [C] and Town, here and right there. Well we give out our (Narcan) kits and if they use them on somebody they come tell us about it and we give them another one. And then also [D] and [K], over by the police station.” (Health provider)
19. “Yea, these tents are used for dealing and they store their drugs in the tents from the distribution centers where they get more drugs and take them back out to where they are selling.”
20. “There are some that are called jump outs and basically they'll be in an undercover car and they'll just roll up to a tent and literally jump out of the car, swarm the tent, guns drawn. Make you all come out of the tent, they'll search everybody, search the tent, check everybody for warrants or if they're on parole.”
21. “See that corner right, the tents we just passed back there, they just got busted like last night … well they be hanging out like wet clothes right there, that is a hot spot, a very hot spot, (for) everything.”
22. On crack users: “They are all dirty,” these “dope fiends,” “look how dusty they looking, they sucked up in the face. Like skeletor their jaw is all sucked in.” On one ride the subject started to become nervous, telling the driver to keep up his speed because “so now you're in like a lot of desperation. I don't know if you can kind of feel the energy's changed. The vibe is different, they definitely like looking at the car, but this is how it used to be.”
23. Three different KDE kernel or window sizes were chosen to examine variations occurring with distance; only the middle, 50 meters, is presented in this article.
24. These maps also display visible camps from the first spatial video ride in September 2014. The location of daytime camps suggests considerable variation across the different streets of SR, with intensity varying from one block to another and even from one side of the street to the other.
25. Outside dealers once made the mistake of dressing too well, but now they “camouflage” themselves, “so basically they started switching up, wearing plain t-shirts, jeans, tennis shoes, blending in, looking like the area.” Participants, however, could still tell outside dealers by their shoes. Another visual and audio cue are the way dealers “post up,” which means the way each walks, holds himself or herself, and what is shouted out.
26. “Because crack users and dope fiends don't like each other. It's totally different (kind of high) and if you're on heroin you don't want to deal with a crack head or a meth smoker bouncing around being paranoid and stuff. They are just trying to sleep basically.”
27. A commonly used phrase to describe SR.
28. “You gotta know the streets, 'cause if you know what you doing, ain't nobody going to fuck with you. (How long does it take you to learn the streets?). Not long at all. Pretty much, keeps me alive. [A] street is one of the streets that's very dangerous to be on. A lot of people have nothing to live for. Some do, those who do I advise them to keep on living … those who don't, I don't fuck with them … experience is the best teacher, man.”
29. SV rides were also conducted at night and during the very early hours of the morning to capture this nighttime change.
30. “It varies certainly and there are degrees of homelessness and degrees of drug use. The more drugs a person uses, unless it's marijuana, that's pretty social. Crystal meth, heroin, and crack cocaine, those are isolating drugs, people use those on a regular basis, will often isolate to primarily be alone. If they communicate with any other people, it's usually other users who use what they use, to get more. Many people prefer to isolate if they are using any of their drugs.”
31. “It's not going to make the headlines but there's so much good that goes on down here. The true good people, they shine out over everybody.” Homeless Health Care was identified: “There's not a person that doesn't volunteer in there or work that does not care, even the ones that have never stuck a needle in their arm in their life, never smoked a joint, but they're there to help, they care. They got time for us.”
32. “I miss when you could go in there and hang out and be safe from everything. A lot of people liked that. People started selling drugs so it was shut down. Now nobody can go in there, so you get your needles and leave. Shitty people ruined it … it was nice to have a place to go sit down and watch TV and talk, chill, feel safe.”
33. “And everybody shares drugs down here, everybody shares resources, everybody shares clothes and food. You'd think they'd be super stingy with it, but it's the opposite, so when I do their overdose training I'll give them two (Narcan) kits, like this one is yours, you go give this to somebody else ’cause otherwise they will split it up.” (Health provider)
34. “I mean we usually know where to find people, like either that corner or that corner like they might go to that corner to get their drugs but then they hang out at that corner but it's usually not very far.” (Health provider)
Additional information
Notes on contributors
Andrew Curtis
ANDREW CURTIS is the Co-Director of the GIS, Health & Hazards Lab and Professor of Geography, Kent State University, Kent, OH 44240. E-mail: [email protected]. His interests include spatial data collection and analysis in the most challenging environments and adding context in the geospatial analysis of fine-scale health problems.
Chaz Felix
CHAZ FELIX is a senior government administrator and public health policy attorney with the Tulare County Health & Human Services Agency, Visalia, CA 93277. E-mail: [email protected]. His research interests include rural homelessness, public health law, and access to health care within vulnerable populations.
Susanne Mitchell
SUSANNE MITCHELL is a doctoral candidate in the Department of Public Health, Kent State University, Kent, OH 44240. E-mail: [email protected]. Her research interests include the social, behavioral, and environmental aspects of intentional injury, violence, and crime, as well as violence prevention in schools.
Jayakrishnan Ajayakumar
JAYAKRISHNAN AJAYAKUMAR is a doctoral candidate in the Department of Geography, Kent State University, Kent, OH 44240. E-mail: [email protected]. His research interests include spatial video geonarrative analysis, spatiotemporal social media data analysis, and high-performance computing for large spatial data sets.
Peter R. Kerndt
PETER R. KERNDT is an Adjunct Professor in the Department of Epidemiology, University of California at Los Angeles, Fielding School of Public Health, Los Angeles, CA 90095. E-mail: [email protected]. His research interests include HIV/AIDS, sexually transmitted infections, and tuberculosis control and prevention in domestic and international settings.
