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Introduction
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 Statesthree
representatives of the former Western Hemisphererecognize 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 drugsan 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 bookan elaboration on drug treatment delivery
set against the background of ethnicity in three metropolitan areasevolved
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 worlds 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 minoritiescommonly 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 studys
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-ethnicitythe
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 authors 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 purposesindicating 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 Franciscos colorful
drug and counterculture history and Frankfurts 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 Israels 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. Additionallyby
means of a small study involving 66 drug usersone 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 theyet
scarceIsraeli 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 agencys history and its remarkable
development. Hence, by surveying clinical client data, both the programs
role in the consortium of local drug service providers and its direct
relevance for members of San Franciscos ethnic minority communities
are illuminated.
The final section of this booka conclusive discussion of the studys
results in chapter 7encompasses 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 immigrantsparticularly those that enter the
country illegallyreflect 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 issuea 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 inappropriateeven prejudicialtowards
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 treatmentpassing 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 societys 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.
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