J. Bryan Page
I did not expect the tears. Here I was, reading an academic book at the behest of my life-giving journal, wading through the thoroughly expected discourse about familiar territory—marginalized drug users, policy aimed at suppressing them, imaginaries of addiction, socio–political upheaval, agencies of compassion, bureaucratic insensitivity, if not malevolence, controversies about methadone treatment and HIV—nothing particularly new to a veteran of four decades of drug studies. Nevertheless, here came the tears, spilling out over the fate of Dima, who had aspired touchingly to have a “normal life,” but died after massive closures of what Carroll calls “medically assisted treatment” (MAT) facilities. The final, draconian end of MAT in both Crimea and Donbas in 2014, in all likelihood, accounted for hundreds of deaths among MAT patients. Its rationalization on the part of the Russian administrators lay in a concept, svoi, explained aptly by Carroll, that defines the proper parameters of responsible citizenship. In the administrators’ view, people addicted to drugs did not measure up to the standards expected of people who performed as good citizens of Russian society.
How did Jennifer Carroll take me to this emotional reaction? She worked patiently through both the personal experiences of drug users in pre-invasion Ukraine and the political economic developments from 2007 to 2018—eventful times that included the Russian attempt to install a puppet government and the crisis over natural gas transport. I appreciated her attention to the details of local geography and local use of Ukrainian language, providing a two-page glossary of essential vocabulary items. She introduced me quickly to Elena, a patient in an MAT program, as well as a sometime user of street drugs, giving a face to the people inside and outside these clinics.
In deciding which ethnographic perspective to pursue, drug ethnographers have often chosen either treatment- or street-based drug users, but Carroll committed emphatically to an “inside–outside” ethnographic perspective, which requires strong ethnographic method and establishment of trust between ethnographer and key informant. Until they have decided that the ethnographer is trustworthy, patients in a treatment facility may not provide much valid information because of uncertainty about the ethnographer’s allegiance. To be approached by a stranger within a treatment setting at minimum arouses suspicion that the ethnographer is “checking up” on patients. On the street, a drug user may first suspect that the ethnographer is some kind of law enforcement officer or informer. Carroll’s introduction of Elena’s status as a patient in good standing and as a drug user outside the system demonstrates the quality of her ethnographic process in building rapport and trust. Carroll also introduces Elena in a way that leads to appreciation of Elena’s acumen in classic Russian and Ukrainian literature.
In terms of large-scale processes, Carroll succeeds in giving the reader as thorough as possible a landscape of Ukraine’s recent history, including its scrapes with previous Russian attempts to dominate and control that polity. Sovereignty is not, however, always threatened by external governments. Nongovernmental organizations peddling neoliberal approaches to nation building can disrupt local social and governmental functions, as seen in Carroll’s narrative about the interaction among Ukrainian governmental representatives, MATs, and Global Fund reporting requirements. Her account of the heuristic “work arounds” set in motion by the NGOs’ reporting requirements reflects a reality of treatment for drug abuse that may be universal: Required documentation may be impossible to obtain in the form required, but the bureaucracy responsible for the paperwork may be unlikely to read it or act on it.
The reader learns from Carroll that the MAT system, however inefficient it may be, has clientele who, without the MAT clinics, would not be able to lead any semblance of a “normal” life. To her credit, Carroll richly describes the environments in which the MAT clinicians deliver services to their clientele, complete with lounging cats and threadbare furnishings. Perhaps that made the abrupt closings in Crimea and Donbas especially poignant to me—with very few resources and amenities, the MATs were maintaining their clients’ will to live and “normalize.”
The lone deficiency in Carroll’s Narkomania involves the background narrative about drugs of choice. What are they? According to Carroll, the primary drugs of choice include shirka, a “dilute” preparation made of poppy plant material, and the Russian product, synthesized desomorphine made by extracting codeine from pharmaceutical products. The latter product, sometimes called krokodil, has a terrible international reputation, as it has a history of causing massive cases of rotting flesh. Given its perilous reputation, it is hard to imagine a sizable population in Ukraine choosing krokodil as a drug of regular consumption. The scores of MAT centers in Ukrainian cities bespeak a large population of addicted drug users who feel the need to be enrolled in methadone or buprenorphine dispensing programs.
Shirka would seem to be the principal drug of choice for this addicted population, but what is it? With no further explanation than being a dilute preparation made from poppy plant material, too many steps in manufacture go undefined. First and foremost, the morphine alkaloid is not water soluble, and human beings who self-inject drugs only do so with water soluble drugs. How do Ukrainian addicts go from poppy “straw,” or plant material to something injectable? These practices bear little resemblance to the known steps for refining heroin or morphine, and their unknown quality leaves the reader wanting more information. Does this shirka contain sufficient morphine to generate addiction? What kind of morphine or codeine compound is delivered by injection into the bodies of users? A paragraph answering these questions would have been helpful to me in trying to understand addictive process and epidemiology in Ukraine.
This deficiency notwithstanding, Jennifer Carroll has done a magistral job in helping the rest of us understand the global and local processes that have produced the current predicament of Ukrainian injecting drug users. The single most cautionary aspect of this book lies in its warning against the use of dismissive discourse in discussion of drug users’ presence in society.