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Until the resolution of the East-West antagonism a decade ago, illicit drugs were always considered to be one of the vices of the »free Western world«, particularly in Communist regimes’ political propaganda. The 1990s, however, have witnessed a worldwide »Westernization«—the evolution of a »global village« of communication and trade, unprecedented world migratory processes, as well as an internationalization of phenomena such as production, trade and consumption of illicit drugs. Like many other countries, Germany, Israel and the United States—three representatives of the former Western Hemisphere—recognize a persisting »drug problem« in their societies, which is increasingly affected by cross-national and global factors. The problem persists despite extensive »Drug Wars« currently being fought. For instance in the year 2000, the American government was scheduled to spend almost 18 billion US dollars on measures to reduce the impact of illicit drugs—an increase of almost 40% since 1996 (The White House 1999).
However, large parts of the national annual anti-drug budgets are directed towards areas of law enforcement, particularly to dissolve the internal and international networks of drug trade. Competing with the law enforcement systems are the prevention and treatment systems, which are yet the most interesting areas of drug policy from the social science and public health viewpoints. The rapid expansion of service systems and the development and incorporation of new approaches coupled with the increasing budgetary hardships in the social sector, mostly due to limited public funding, foster the import and export of efficient models for treatment.
Thus, careful transnational contemplation can open new perspectives and initiate improvements in national treatment modalities. Furthermore, the need for public action through treatment intervention becomes magnified usually on the municipal level, since it is in the large cities and metropolitan areas, where societal phenomena considered deviant, such as drug use, emerge first. It is obvious that treatment models developed within these frameworks are likely to be most advanced, and therefore should be subject to scrutiny. Yet, the metropolis is also the focal point of those among the social scientists who deliberate over issues of migration and ethnic configurations within a society. Soon, one will observe the interaction and interdependence between the two broad urban problem-issues ...
The central topic of this book—an elaboration on drug treatment delivery set against the background of ethnicity in three metropolitan areas—evolved on multiple grounds. During a practical training period in a substance abuse treatment agency in San FranciscoI found myself intrigued by the circumstances of an idiosyncratic multi-ethnic urban society (the city has a non-White »minority« representation of about 60%). Its local drug treatment system is conspicuously differentiated, reflecting »multi-ethnicity« by providing specialized substance abuse services for most of the ethnic minority communities. Upon returning to Germany, endowed with increased awareness towards such issues as they prevail in the truly diverse and multi-ethnic city of Frankfurt am Main, I had to understand that involvement of foreigners and other ethnic minorities in drug treatment has scarcely been studied. Furthermore, contrary to the U.S., the scant body of literature in Germany discussed the difficulties for ethnic minorities in accessing and utilizing the existing mainstream drug treatment services, rather than setting a focus on culturally specific delivery of services. There appeared to be significant, multifold access barriers. Thus, I became interested in studying the opportunities for ethnic minorities to receive substance abuse treatment in Frankfurt, exploring and highlighting these ostensibly prevailing access barriers. In comparison with Frankfurt, San Francisco provided a good example of current and beneficial practices for the incorporation of ethnically and culturally sensitive models to service delivery.
The inspiration to attempt a tri-national juxtaposition of multi-ethnic issues in substance abuse treatment finally arose within the framework of an academic exchange program, which brought me for one semester to Beit Berl College, an academic institute located in proximity to the culturally diverse metropolis of Tel Aviv in Israel. The inclusion of the Israeli case with the expectancy of finding yet another situation of ethnic minorities and drug use further helped to clarify practicable areas of discussion and hypothesis.
Namely, it made clear some basic traits shared by all three societies: Germany, Israel and the United States are among the world’s most important and idiosyncratic immigrant countries for which, undoubtedly, the above mentioned global migratory phenomena were of crucial importance, particularly in recent years. The U.S. annually admits the highest absolute number of immigrants in the world, whereas Germany and Israel are the two countries presenting the highest quota of immigrants relative to their total population (DellaPergola 1998). Additionally, the three societies each have significant groups of citizens who might be termed »internal others« in the broadest sense: African-Americans and indigenous peoples in the United States, an endemic Arab minority in the state of Israel, and ethnic Germans from countries of the former Warsaw Pact in the Federal Republic (the latter belong to the group of immigrants to Germany, although they have been regarded by law as members of the »German nation« even before the act of immigration).
There was further evidence that the three cities might be considered important, if not the most important multi-ethnic centers in the national context of each country. Both their above-average representation of ethnic minority groups, as well as their similar intermediate size (Frankfurt and San Francisco both have just above 700,000 inhabitants; Tel Aviv/Jaffo has 350,000) foster a comparison. It was upon consideration of such urban realities that cities have been described as »immigrant countries in miniature«1. With regard to the prevailing local drug treatment systems, it is non-residential (outpatient) counseling and treatment modalities in these urban areas, which stand out (in contrast to residential treatment). Consequently, these settings are the focal point of comparative considerations.
In most places in the world, immigrants, foreigners and »internal others«—in short ethnic minorities—commonly differ from mainstream society. They often belong to lower socioeconomic, educational or vocational classes. Furthermore, they are frequently disadvantaged and subject to racist hostility and discrimination in mainstream society. These »general« perceptions mark a starting point for an underlying hypothesis which claims that patterns of exclusion, disadvantage and discrimination, as well as the overall status of ethnic minorities in each society may be reflected and perpetuated in the drug treatment systems. This study’s core topic of »drug treatment and ethnicity« in metropolitan areas hence provides one framework to contribute to an exploration of this hypothesis, by giving room to the discussion of several of the above mentioned aspects and assumptions of interest.
It is the initial task of this book to include some broad introductory descriptions of essential structures and systems, which underlie or precede the very sectional topic to be considered. This is of increased importance, if such complex societies like those of Germany, Israel and America are examined.
On these grounds, chapter 1 seeks to sensitize the reader to the multicultural realities of the three countries and cities respectively. Figures on the representation of immigrants and other ethnic groups within the urban geography of the three cities are presented. Excerpts from recent publications further attempt to provide a brief overview of the societal and political concepts of immigration and multi-ethnicity—the prevalent »migration regime« (Joppke 1999) in each country.
This study understands and utilizes the terms ethnicity and ethnic (minority) group in a most comprehensive form. Max Weber stated that »we shall call ›ethnic groups‹ those human groups that entertain a subjective belief in their common descent because of similarities of physical type or of customs or both, or because of colonization and migration: this belief must be important for the propagation of group formation ...« (Weber 1997, pp. 18/19). This definition fits most discourses well; however, it is this author’s conviction that an even broader definition is necessitated to encompass all the groups as they are differentiated within this study. For instance, it appears highly questionable whether a Turkish Kurd or Armenian would affirm a »common descent« with a Turk. However, they would both be grouped as members of the Turkish minority group in Germany. Similar limitations may apply for the various Latino and Asian communities in the United States. Therefore, a definition provided by Willemsen and van Oudenhoven (1989; in Trimble 1995) is more appropriate. These two writers define ethnic minority groups as those that »differ from the majority of the people in the country or society in which they live. Differences may refer to language, race or religion or a combination of these characteristics« (ibid., p.12).
Because of its inappropriateness and widespread negative connotations, the term »race« is all but eliminated from this study. In the United States, however, the concept is not as elusive and is still utilized to denote the broadest ethnic differentiation, primarily by biological and physical criteria. Thus, »race« occurs occasionally herein in quotations or adaptations from sources that use the term. Multiculturalism (or a multicultural society) is understood as a status quo rather than an idealistic societal concept. If Germany, Israel and the United States are referred to as (de facto) multicultural societies, this term is merely for descriptive purposes—indicating the existence of significant groups in the population that differ ethnically from the prevalent majority. The use of this definition leaves open the question whether the ideal of multiculturalism is fostered or achieved in any of the three countries. This ideal in its very basic form would be compatible with equality of opportunity in »a society which is unitary in the public domain but which encourages diversity in what are thought of as private or communal matters« (Rex 1997, p. 208).
Chapter 2 devotes itself to a broad overview on the prevalence of illicit substance use within the general societies, drawing from the results of large national studies. Each sub-chapter illuminates a particular country with its own history of illicit drug use, the emergence of a »drug problem«, as well as the development of a treatment system. While there is considerable coverage of San Francisco’s colorful drug and counterculture history and Frankfurt’s role in determining alternative approaches of harm reduction in municipal drug policy, the focus in Israel is on the drug treatment system. Its history is a very recent and idiosyncratic one, since Israel did not recognize a »drug problem« for a long time. Furthermore it appears that little has been published in English on Israel’s approaches to drug abuse treatment. The final paragraph of chapter 2 (2.4) attempts to merge the results from the three countries and develop some conclusions and implications from a cross-national perspective, particularly a comparison of drug use prevalence rates.
As a precondition for the discussion of barriers for ethnic minorities in utilizing the drug treatment services, an overview of minorities’ general involvement in substance use or abuse is indispensable. This overview is undertaken in chapter 3. Compared to relatively poor epidemiological evidence in Germany and Israel, comprehensive data is available in the United States. Here, primary sources for general prevalence rates of drug use among ethnic groups are the broad national surveys. It is their major shortcoming, however, that they do not yet provide a satisfactory differentiation between distinct communities within the broad ethnic groups. In Israel, some limited figures could be drawn from the national survey and other studies. These data are supplemented by anecdotal information from clinicians in the Israeli drug treatment field, which I gathered during field studies. For the German component, the discourse has to rely almost exclusively on citing field reports and small-scale institutional client surveys published as professional accounts or presented at conferences. Whenever they appeared essential, data from national police statistics were supplemented. So far, the large national surveys have neglected any ethnic or national differentiation of its subjects.
Chapters 4 through 6 contain city-specific examinations of the local outpatient treatment system and its reception by ethnic minority groups. Against a backdrop of significant disparities in both the conceptual and structural systems of service delivery, and also in the available data and status of research, it was considered necessary to apply various scientific methods in order to elucidate ethnic minorities’ service utilization and access barriers.
In the case of Frankfurt am Main, which is presented in chapter 4, data on the representation of non-German minorities among the treatment population of each outpatient counseling center was gathered. Additionally—by means of a small study involving 66 drug users—one of the typical harm reduction services was examined in detail in order to illuminate the discrepancy between ethnic minority representation in such low-threshold settings and that in counseling and treatment settings. Accounts by treatment providers in the professional literature were maintained as a source to explain the broad spectrum of possible access barriers as they prevail for foreigners and other ethnic minority groups to the overall treatment system in Germany, as well as to illustrate widespread under-representation (4.1 and 4.2).
In chapter 5, a brief national perspective on ethnic minorities’ access to the general Israeli treatment system (including detoxification and residential services) is contrasted with empirical observations in the five outpatient drug treatment units in Tel Aviv/Jaffo. Limited publications in English and the fact that I do not have sufficient command of the Hebrew language preclude a comprehensive review of the—yet scarce—Israeli literature. The research in Tel Aviv referred to a series of interviews that explored issues of limited treatment access for ethnic minorities. I conducted the first series of interviews among treatment providers, most of them with the programs’ directors. The second series involved clients in two of the treatment centers. Conducted by two associates, they were intended to compare and contrast (or correct) the »official« picture obtained from both literature and treatment providers with the clients’ viewpoint.
Chapter 6 on the situation in San Francisco sets its core emphasis on a case study of one exemplary substance abuse treatment agency. This thorough examination introduces different models and strategies for a culturally relevant treatment delivery that may also yield significant relevance for other metropolitan areas, countries and systems. The case study embodies a description of the agency’s history and its remarkable development. Hence, by surveying clinical client data, both the program’s role in the consortium of local drug service providers and its direct relevance for members of San Francisco’s ethnic minority communities are illuminated.
The final section of this book—a conclusive discussion of the study’s results in chapter 7—encompasses two broad divisions of thought. The first (paragraph 7.1) is an analysis of political and societal convictions that inhibit the drug treatment systems’ development towards multicultural competencies or the delivery of appropriate services to ethnic minority groups. Particularly in Germany and Israel, these theoretical observations reveal the prevalent generic views within each majority establishment on the integration and status of immigrants and other ethnic minorities. Although the German federal government has properly ascertained recently that »help and treatment which considers the clients’ cultural background is an essential prerequisite for attracting drug-using immigrants at all, as well as for offering them appropriate services« (BMfG 1999, Drogen- und Suchtbericht), drug policy and the treatment system still largely exclude ethnic minorities. There are few options for receiving appropriate services for individuals who are not able to fully adapt to the mainstream. Similarly, the ongoing Israeli liaison with a Zionist melting pot ideology and the »failure to legitimize the use of ethnicity as a framework for politics, life-style and education« (Ben-Yehuda 1990, p. 175) inhibits culturally sensitive drug treatment delivery. In the U.S., due to a stronger focus on ethnicity and ethnic group affiliation and the far-reaching acceptance of ethnic pluralism, American addiction medicine has gone a long way towards creating distinguished treatment models for its ethnic minority groups. However, insufficient funding for public health care and an increasingly hostile attitude towards new immigrants—particularly those that enter the country illegally—reflect on multicultural drug treatment delivery and inhibit the full incorporation of broad scientific knowledge onto issues of cultural sensitivity.
The final large paragraph (7.2) gives an overview of various measures that may foster service utilization by different ethnic minority groups, since recently, it has become a commonplace that »effective multi-cultural social work requires both individual and institutional learning« (Husband 2000, p. 225). As much has been written about individual competencies, this study sets a focus on the organizational learning processes. Drawing from a multiplicity of results, these measures are presented in two models for conceptual consideration within service institutions. While it is argued from a transnational perspective, several leitmotifs of organizational sensitivity towards ethnic minorities, particularly as they apply for Germany, are suggested in the conclusion.
A few final remarks and limitations on technical and conceptual matters must be mentioned: This study cannot be clearly associated with one distinct academic or professional discipline. Rather, it reflects multidisciplinary tasks and viewpoints on a certain issue—a quality that should be intrinsic to the »science of social work«. Thus, I would like to stress that the paradigmatic and conceptual framework is generic, involving (with varying emphasis) theoretic and methodological perspectives of sociology, addiction medicine, psychology, and political sciences, which integrate into an enlarged psychosocial or social-work-view on the topic.
Comparative studies like the present one are always prone to generalizations and assumptions, which may be premature or inappropriate—even prejudicial—towards certain groups or individuals; particularly if the ethnic minorities of three such different societies as the German, Israeli and American ones are considered. I wish to emphasize that this is clearly not intended. However, some generalizations are all but inevitable, if certain literature and data are to be incorporated (for instance, the »lumping« of distinct national communities into broad ethnic groups, while attributing a certain trait or mentality to this newly created ethnic entity per definition).
This study maintains a somewhat »distant« level in the sense that it describes drug use and abuse rather than explaining it. Thus, the approach is pragmatic and aimed at discussing the current situations and possible improvements for those who have drug problems already and require treatment—passing over the field of prevention. Moreover, the main focus is on the treatment of adults, since the adult treatment system is easier to differentiate than other areas. Drug treatment and prevention among youth is still much more interwoven within the frameworks of school, youth work and non-formal education and will be omitted for the most part from the discourses.
Furthermore, there is not always an equilibrium in the presentation of contents for the three countries and cities, i.e. several phenomena which are unique within one society’s context experience a more detailed analysis, whereas others are neglected or mentioned with less emphasis.
Several quotations within this book were directly translated into English from German publications; the given reference pages refer to the original sources.