Philippe Bourgois: Ethnography and Medicine

Philippe Bourgois has a problem with the law. Not long after becoming a Richard Perry University Professor last year, the renowned medical anthropologist ventured into North Philadelphia. He was looking for drug dealers who could give him entrée into a community that is chronically underserved by healthcare institutions and overserved by gun merchants. The Philadelphia police were not happy to find him there.

“I’ve managed to make friends with a bunch of dealers who were thrilled to let me hang out with them and see what’s going on,” says Bourgois, whose tall, lanky body seems at times to vibrate with spare energy—at least when he’s pent up in his Penn Museum office. “The trouble is that whenever I show up, the cops keep coming and beating everyone up, and threatening to beat me up. So far they haven’t, thank god. I tell them I’m a Penn professor and beg them to Google me.”

That claim is not always persuasive. At midnight on a drug-copping corner, it doesn’t take a whole lot of imagination to mistake Bourgois for a junkie. Plenty of people pegged him as one in East Harlem, where he spent the latter half of the 1980s living in a tenement to research his much-praised ethnographical study of Puerto Rican crack dealers. So perhaps because North Philly beat cops don’t exactly while away their shifts doing Web searches, one squad hit the self-declared professor with a sarcastic pop quiz instead.

“They actually asked me what the name of the president of Penn was,” Bourgois recalls. “Thank god she’s famous and hired me personally, so I could remember her name! I wouldn’t even be able to tell you what the name of UCSF’s president is—my previous university.”

At the University of California, San Francisco, Bourgois was a professor in the medical school as well as vice chair of the department of anthropology, history, and social medicine. His appointments at Penn are in the anthropology department in the School of Arts and Sciences and the department of family practice and community medicine in the School of Medicine. But the trilingual professor is hardly the ivory-tower type. The company he kept during his five-year immersion in East Harlem would have had most academics cowering in the nearest faculty club.

“What’s the matter, Felipe?” one of his informants asked him at a particularly dispiriting moment in his fieldwork there. “You never murdered an animal, or try to throw a cat off a high building to see it smack down hard on its feet?”

One of the insights in Bourgois’ resulting book, In Search of Respect: Selling Crack in El Barrio, which won the 1997 Margaret Mead Award, was that this kind of behavior and bravado made good business sense for the thousands of petty entrepreneurs who took part in the drug trade. “Indeed, upward mobility in the underground economy of the street-dealing world requires a systematic and effective use of violence against one’s colleagues, one’s neighbors, and, to a certain extent, oneself,” he observed. “Behavior that appears irrationally violent, ‘barbaric,’ and ultimately self-destructive to the outsider, can be reinterpreted according to the logic of the underground economy as judicious public relations and long-term investment in one’s ‘human capital development.’”

When his informants grew to trust Bourgois deeply enough to confide their accounts of gang rape, he found himself confronting a “Pandora’s box of gender-based brutality that the cultural relativism of my anthropological training was, once again, incapable of accommodating.”

Yet these men were not “‘exotic others’ operating in an irrational netherworld,” Bourgois insisted. “Highly motivated, ambitious inner-city youths have been attracted to the rapidly expanding, multibillion-dollar drug economy during the 1980s and 1990s precisely because they believe in Horatio Alger’s version of the American Dream.” That they resorted to criminal violence to achieve it was testament that “[t]he private sector and the free market over the past several generations have proven themselves incapable of generating materially and emotionally rewarding entry-level jobs.” The only way to change the dynamics of substance abuse and criminal entrepreneurship in urban America, he argued, is to address the structural roots of economic inequality and social marginalization.

As his career has progressed, Bourgois has become increasingly committed to developing a less restricted sort of human capital than the variety prized on the mean streets—one rooted in health and wellness. In fact it was his time in the shooting galleries of East Harlem that first spurred him in this direction. In the midst of his ethnographical research, a mysterious autoimmune disease began to emerge virtually before his eyes.

“I was dragged into AIDS before we knew what AIDS was,” he recalls. Bodies were piling up and the young academic felt like he needed to snap to attention. He was in the right place. “All of a sudden, funding opened up for exploring the social context of this disease. And so that brought a lot of people like me, anthropologists—primarily, actually, anthropologists and medical anthropologists—into the field of substance abuse and public-health studies.”

The political analysis that features in Bourgois’ ethnographic writings also informs his approach to public-health issues.

“Most of public health has been driven primarily by behavioral research that focuses on individuals and individual behavior change,” he says. “But there’s a growing—and hopefully rapidly growing—awareness of structural forces, and social and cultural forces. Part of it is just frustration at the traditional model. It’s very hard to get people to change their individual behaviors. It’s much easier to give them clean running water.”

That was the lesson of the 19th century, Bourgois points out, when a misguided theory of infectious disease prompted governments to invest in ambitious public-works schemes that nevertheless paid huge social dividends. “We thought [disease arose] from miasma,” he says. “So as a result they poured huge amounts of money into draining swamps and providing sewers and potable water. And that’s what created the health revolution. It wasn’t the discovery of germs. And it’s something that we often forget. That was a structural intervention that transformed the massive levels of dying that were taking place in the newly industrialized world. And ironically, with the scientific discovery of germ theory, that whole social, epidemiological foundation of public health just disappeared. And so that’s what I want to bring back, in a sense.”

Among other projects, Bourgois is currently trying to bring together anthropology and public health in a program that will seek to boost HIV-medication adherence among poor AIDS patients in Philadelphia. The city has one of the largest HIV epidemics in the country, and it mirrors global patterns in that the disease is identified with heterosexuality and disproportionately affects the poor. 

“One of the tragedies of the HIV epidemic is that we’ve got these extraordinarily powerful medications that can keep you alive pretty much forever, at this point. But they’re unbelievably expensive,” he says. “And they’re hard to take. You need a good doctor prescribing them, to figure it out, because you develop resistances and so forth. And they’re uncomfortable to take, often. So what’s happened is that the very poorest of the poor, their death rate hasn’t gone down. Rich people are basically not dying of HIV anymore, in wealthy countries and the United States. But the very poor are still dying at the same rates.”

Despite the presence of dozens of free clinics that specifically target HIV patients in Philadelphia, and subsidy funding for antiretroviral medications, treatment for the very poor remains fraught by problems of access and patient adherence to drug regimens. That is the pressure point Bourgois has targeted. “Basically, it’ll be a collaboration with clinicians and epidemiologists, and then, me and my team doing personal observation with the people who aren’t able to adhere, to try to figure out what’s going on.”

And if he runs afoul of Philly’s finest as he makes his rounds, one can only hope he’ll be able to name a few deans and the provost in case the president’s name alone doesn’t cut it.

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