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Understanding culture, stigma and drug as a lifestyle in the life of people living in the streets
Aline Basso da Silva¹
Agnes Olschowsky²
Christine Wetzel³
Thomas Josué Silva4
Fabiane Machado Pavani5

1Enfermeira. Doutora. Universidade Federal do Rio Grande do Sul (UFRGS), Escola de Enfermagem. Porto Alegre, RS – Brasil. ORCID iD: https://orcid.org/0000-0001-6711-4553. E- mail alinee_basso@hotmail.com
2Enfermeira. Doutora. Professora Titular. UFRGS, Departamento de Assistência e Orientação Profissional. Porto Alegre, RS – Brasil. ORCID iD: http://orcid.org/0000-0002-9125-0421. E-mail agnes@enf.ufrgs.br
3Enfermeira. Doutora. Professora Adjunta. UFRGS, Departamento de Assistência e Orientação Profissional. Porto Alegre, RS – Brasil. ORCID iD: https://orcid.org/0000-0003-1386-8477. E-mail cwetzel@ibest.com.br
4Antropólogo. Doutor. Professor Associado. Universidade Federal do Pampa – UNIPAMPA. Departamento de humanas. Jaguarão –RS. ORCID iD: https://orcid.org/0000-0002-8594-4259. E-mail thomasjosuesilva@gmail.com
5Enfermeira. Mestranda. UFRGS, Escola de Enfermagem da UFRGS. Porto Alegre, RS – Brasil. ORCID iD: http://orcid.org/0000-0002-3858-8036. E-mail fabianepavani04@gmail.com

ABSTRACT
This study aimed to analyze how people living in the streets experience drug use and their intertwining with their cultures and lifestyles. This is an ethnographic study conducted in a Brazilian capital, with the support of the National Street People Movement, in which six representatives and three supporters of the Movement participated. The data were collected through participant observation recorded in a field diary and semi-structured interviews. The analysis was performed by synthesizing data generation throughout the work process. In the course built with street experts, a street culture was identified, in which drugs appear as a collective way of life, a developing identity that is resistant to stigma and suffering and the construction of relationships. Life stories have revealed social suffering, exclusion and non-adaptation to the conventional and formal system. Thus, people living in the streets have a social organization that helps to withstand the difficulties of social acceptance and the failing organization of services that do not understand their ways of life. Drugs are part of this culture, as yet another lifestyle that must be known understood and worked on openly and consciously by health professionals.
Keywords: People living in the streets, Drug users, Mental health, Anthropology.

INTRODUCTION
Seeking to understand the complexity of the drugs and their relationship with care, drug use and the recent Public Policies on the subject have brought the street population to the fore of discussion, also drawing attention to the drug use territories of these people, such as the so-called “crack lands”. These places of the city are the face of the invisible, who have exposed the distancing of public social and inclusive policies aimed at this population, which ends up being at the mercy of one-off urban space clean-up actions.
People living in the streets (PLIS) are a heterogeneous group with a shared status of extreme poverty, broken or weak family ties and the lack of regular conventional housing. In Brazil, in a survey of street people in 71 cities identified 631,922 adults living in the streets, of which 82% were men, and 53% were aged 25-44 years1,2.
On the other hand, these same people have their particularities, ways of life and power forms (relationships) that make them resist in contexts of repression, stigma, and weak public policies. Thus, a street is also a place of living and informal work for these people: car keepers, cargo unloaders, paper or can pickers, among others. Also, it is a territory of affection and protection to overcome the difficulties of living with few resources and the stigmas they endure. Streets are not such a threatening place to street people since it is where they develop their relationships, identities and social organizations3.
This paper corroborates the discussion bringing the relevance of understanding drugs as an experience that is not merely individual, but part of the individual’s relationships with the groups and their life contexts. A study found that drug use was embedded in the networks of relationships and affections – family and friends – that marked the motivation for the onset of this use. It is a common practice that occurs mainly as a model in social events – parties – in conjunction with affective networks4.
Care is part of these networks of street relationships in the street, and the use of drugs may be an element of communication, culture and lifestyle. It is understood that the use of the concept of lifestyle is relevant insofar as it considers social vulnerability, characterized by a dynamic process involving multiple dimensions and the existence of a social context. Individuals are not only the response of their behavior but instead the cultural, sociopolitical environment, and their relationships are considered in that process5.
Therefore, drug use should not be considered solely by its effect on the body, pleasure and dependence. It is necessary to look at other aspects that perceive these individuals as subjects enveloped in their social context and life history, which encompasses a dynamic and multifactorial perspective, cultural aspects and networks of relationships.
Entering the universe of people living in the streets and drug use requires studies and research on this subject, showing the need for an understanding of their ways of life and a new model of care. Thus, this paper aims to analyze how PLIS experience drug use and their intertwining with their cultures and lifestyles. The discussion of this subject is justified so that we may advance in the health area in care models more attuned to reality, experience and cultures of PLIS who use drugs.
METHODS
This is an ethnographic study, a method used by Anthropology in the study of groups based on the context in which people live, and researchers introduce themselves into their field of study, interacting with people, both as observers and study participants6.
In this study, ethnography is a suitable and potent method for the study of PLIS, as this group is very particular, with differentiated, itinerant, distinct cultures, and besides ethnography features, likes and dislikes, facilities, difficult interaction, together with the investigator’s emotions and concerns in working with this reality with sensitivity, enabled a greater approximation and in-depth analysis of the question under study.
The research was conducted in Porto Alegre, Brazil, in 2015 and 2016. A previous census of the street population of the capital had 1,758 participants, of whom 85% were male, 29% aged 35-44 years, and 51% had been living in the capital for more than 20 years. According to the mental health coordination of the capital, a public hearing estimated four thousand PLIS in 20177.
It is also important to highlight the context during the survey, in which the municipality council, in the final months of 2016 and early 2017, carried out actions to remove street people from the city center, one of the territories with the highest concentration of people and housing hamlets, without prior discussion in social control and planning institutions. This fact corroborated the emergence of this research, coupled with the need to discuss violations of PLIS rights, cleaning, hygienist actions, and social exclusion, among others.
The fieldwork was based on the characteristics of ethnography of establishing relationships, selecting informants, transcribing texts, mapping a field, keeping a diary, and the intellectual effort undertaken to practice a “dense description”8. The following were used in contact with interlocutors: participant observation, an instrument that portrays interactions with the group, the linkages and contacts made; and the field diary recording, a technique that consists of recording each field visit in detail6.
These instruments considered the contextualization of macro-social and micro-social structures. Also, macro-social structures were identified through the monitoring of the collective National Street Population Movement (MNPR), and the micro-social ones, through the stories and individual paths of the interlocutors produced through semi-structured interviews, which aimed to further analyze elements of the object: living territory, drug use, relationships, cultures, ways of life6. In this paper, the fragments used refer to the records of the field diaries of the research of two participants/interlocutors.
There were different “interlocutors” throughout the research, coming from the spaces of the MNPR, events, conferences and meetings. The interlocutors who collaborated in the macro-social analysis were identified by the letter R when they were representatives/militants of the community.
Among the participants, those with whom the ethnographic monitoring was carried out were considered as privileged interlocutors. This relationship employed different methods for each individual, which was related to their life stories. The following inclusion criteria were considered for the meeting and invitation to the participants: (1) Currently living or has lived/experience in the streets for at least one year; (2) Currently using or has used drugs (alcohol and other drugs) for at least one year; (3) Being of age (18 years).
In this paper, we present two research situations to discuss the proposed theme, one related to macro-social (situation 1) and one related to micro-social structures (situation 2), through the follow-up of João (privileged interlocutor), male gender, residing in a shelter for homeless people with health problems, with a 20-year street experience. He reports using drugs such as crack, marijuana and alcohol, and wishes to leave the streets and drugs, using the health care and assistance network (shelter, Psychosocial Care Center for alcohol and other drugs (CAPS AD).
The analysis of the information collected was performed by the synthesis of data generated throughout the work process. According to Victora et al6, the first systematization is not the final research report. It is the initial organization of the raw data of the research, indicating main paths and themes to be discussed in the analysis and interpretation of the results. This first systematization and data organization guided the fieldwork, indicating the paths constructed with the interlocutors, pointing out themes, incorporating new questions, observations and new participants.
The research observed the ethical-legal precepts in human studies and specificities in their conceptions and practices of research in human and social sciences. It obtained a favorable opinion from the Ethics Committee at the Federal University of Rio Grande do Sul (UFRGS) under Opinion Nº 1.802.718.
RESULTS
Situation 1- macro-structural experience: understanding drugs as a lifestyle
In June 2016, in an event organized in partnership between MNPR and the municipality with a professor from a Brazilian public university, this one talks about drugs and human rights. The teacher exposes his practical experience in the subject of human rights, social vulnerability and drug use. He says life issues are essential in understanding drug use in society. He says that PLIS issues are abandonment, lack of perspective and non-recognition by society. What would this non-recognition be? They are not seen as humans, as people, so, more often than not, drugs are a device of life, the only prospect of survival in a society of abandonment.
In the audience, one dialogue causes a stir. A former drug user reports that he is not concerned with people who make functional use of the drug, but with those who make dysfunctional use, for example, the “crack-land” people. The teacher exposes his experience in the “crack-land”, and says that he sees that abuse and dependence are closely linked to the need of those people to survive their vulnerabilities, lack of opportunities, neglect of formal care and lack of public policies. He says, then, that drugs become a life device, the only possibility of social inclusion in that context.
The dysfunctional concept is deconstructed by the teacher when he says that throughout society there will be people who do not adapt to the model, not because they are wrong, but because they do not feel they belong to it. He says that caring for these people should be thought of differently since drug withdrawal would be the actual death and that the great challenge was to include them with their differences in the system.
This debate instigates to reflect on the different ways of using drugs in society; it is possible to relate crack-land to the PLIS, because some daily situations are perceived: the lack of opportunities, neglect of public policies and the survival of vulnerabilities. At the end of the lecture, walking the streets with a militant, he reports some of these situations:
R5 is a movement activist, does not use or never used drugs. He lived in the streets for many years and is now in a shelter for health reasons. He is a medium-sized, white man with light hair and eyes. At first glance, when I met him, I believed he was a supporter of the movement, not because of his appearance, but much more because of his way of relating. He appeared to be very serious, with a quite elaborate language, but this severe posture was giving way to a gentle man who liked to talk about street issues.
[...] You work with drugs; I believe you have to listen to people who do not use them in the streets. This is because you will understand this topic better. Maybe you will understand even what the teacher said more practically. People in the streets suffer everything that is violence, disrespect, things are lacking, but we get used to it. However, most use the drug to endure this, and those who do not use it are considered inadequate ... (R5)
[...] Yes, I can tell you that I have never used drugs, ever. Moreover, people never understood how I endured living in the streets without drugs; I’m tired of hearing things such as "You’re not going to take it. One day you will break down; you cannot bear this lack of everything without using drugs..." (R5)
[...] I’ve also heard from street companions: “If you don’t use drugs, this place is not for you, only those who use drugs live here...” (R5)
[...] I can tell you this: people have a prejudice against people who do not use drugs in the streets. If you are not a user, you end up being left out, as if I was the odd one out. What he said about the dysfunctional back there. If you don\'t use the drug, you are dysfunctional in that system ... (R5)
I listened carefully to R5 and his statement “You should also listen to those who do not use drugs, only then will you understand what the streets are like”, echoed in my thoughts. Thus, I have been able to raise the argument: there may be a lifestyle for the street populations in which drugs have a social, cultural and symbolic value that also demarcates survival. That is, as in that debate, “drugs are a life – and not death – device”.
R5 states in his reports that his survival in the streets was always troubled when associated to the group relationships. He always sought the company of a friend with similar ideas or individuality. The affirmation that life in the streets was possible was related to a sentence that R5 always repeated: “people get used to it.”
Situation 2 – Microstructural experience: João and his relationship with the PLIS group.
Walking with João, one of my privileged interlocutors, we arrived at a park where there were several street people: men, women, children eating barbecue they received from a group of people that used the public space to make a community lunch among friends in the streets. People (PLIS) greeted João first, very excited to see him. Then, João introduced me, and someone from the group said: “I already know this girl, she’s always with us in the activities, the newspaper’s stuff, she goes along with our people...” (R6).
Gradually, the suspicious looks and discomfort with my presence eased away. They finished eating and invited us to take a walk around the park; the idea was to make a circle to use marijuana; we were six in a circle. In the marijuana use ritual, one of the people wrapped and sealed the joint, while they talked about different subjects, including how it was like living in that hamlet near the park, the issue of bathing, and food organization.
One of the women there said how difficult it was to work those days, hunger in the streets, and cold days. Regarding bathing, this usually is performed at the Specialized Reference Center for the PLIS (POP Center). However, there was always an intrigue, considerable queues to bathe; so sometimes they bathed in a faucet located in the park. “You can imagine the hardship”, said R6 with his sorrowful face.
People say that we do not want to work. First of all, what\'s left out for us to do is to pick up garbage or take care of cars: who will give jobs to those who do not have a home? Second, life is more comfortable for whoever has a home; you can take a shower any time you want. We need the POP Center; it opens at eight, eight-thirty: at this time, in a regular job, you should already be working, right? (R6)
The POP center cannot be a reference for anything. Actually, we are nothing there, queues for the bath, few professionals: they also do not understand us, they are fed up with having to work with us, I think they are disgusted with... (R6)
I agree with her. I do not ask questions. I just say that it is a tough life and that few people know, and people talk about what they do not know. She stands pensive, stirring her feet on the damp earth.
At the wheel, they offered me marijuana; I refused it by saying that I was there to meet them and accompany João. João laughed, telling them that I was a nurse, that I was doing research, that they could not lead me to “the wrong track”. I laughed with them, commenting: “Well, folks, it’s a bad idea for me to be \'stoned\' when I’m working ...” (researcher). Everyone laughed, they said they had never met a nurse who was so calm in their presence: “They are strict and seem to be disgusted and afraid of us, but we know that not all of them are this way...”
At the time of the marijuana ritual, I listened to what they were saying. I did not feel comfortable asking questions; I felt that I was being accepted in that space, as long as I did not cross a certain line. The conversation between them flowed; they never asked anything about me or put me on the wheel as an “acquaintance”. I was merely accepted by the strong presence of my interlocutor in that space.
The marijuana wheel lasted less than half an hour. Soon the group headed for the hamlet and João and I returned to the shelter. At some point, while going back, he said that those people were a part of his street friends, people with whom he had a history of friendship and companionship when he was homeless. Nowadays, they keep meeting, maintaining the bond, from unscheduled meetings, using drugs and talking, remembering stories.
He told me that not all “street friends” have the same friendship as before, some are prejudiced because of him wanting another kind of life, leaving the streets. He thinks they envy him because he is “trying to organize himself”:
This is what happens in the streets: if a guy is trying to organize himself, some envious people do not want to see you well, see you in a better situation, leaving situations that cause pain, but this is some people. You have true friends, who are in the streets because they want to, and understand if you want to get out of it, get better and such ... (João)
“I have lived in many hamlets, hamlets of all kinds, I made many friends in the streets, so now I also need to get off the streets because I want to reduce drug use, and if you are in a hamlet, you are going to use drugs...” (João).
DISCUSSION
At first, we see the experience with R5 who mentions that he is not on drugs. The conversation with R5 and the event instigate a reflection on “drugs as a value”. Becker9 reflects that whenever there is a group of people who have a life in common, with a small level of isolation from others, common problems and the same position in society: some culture is found there.
Culture arises essentially in response to a problem that is shared by a group of people as they manage to gather and communicate effectively. People who engage in deviant activities – for example, heavy drug users living in the streets – face the problem that their conception of what they do is not shared by other members of society, and their cultures are often considered subcultures9.
The experience of R5 reveals the conflict with the PLIS group since they do not share their use of drugs, and also the culture of street drug use. It shows this culture as a way of life that is not individual but community-based; drug use unites them to the common problems that they experience in the streets.
There is a tension in the concept of normality, in which the deviant does not have the purpose and intention to deviate. They ignore the existence of the rule – in which “normal” people are not exactly those linked to conventional institutions and behaviors – to which most people in society are subject over time. In this case, the “deviant” affirm that there is no reputation to watch over since according to their concepts and experiences, their behavior is adequate9.
R5 states that the fact of not using drugs puts him in a deviating position; he becomes “dysfunctional” in that system. This idea is approached by Becker9, in which a “normal” society, legitimized by conventional models and by the biologicism of drug use, R5 is correct because he can live without drugs. However, “normal” for this street society is drug use, making R5 the outsider, the other, the “different” in that place.
It is observed that the social world of the homeless is considered a subculture, since the most people do not choose this world but are pushed by social circumstances: these people live a precarious life, suffer constant violence and stigma, and there are no public policies and formal networks suited to their needs, and they are more vulnerable to disease and drug use. So they share the same fate, survive these circumstances and the difficult life in the streets and alleys of large cities10.
The subculture concept is associated with a complex society because it is about different classes, religions, and ethnicities. One can exemplify with the bourgeois culture that established a set of standards and dominant rules: traditions, inheritances – humanism, Christianity – and the origin can be linked to the idea of a social class of the bourgeoisie. Thus, cultures that are not dominant – minorities – have common behaviors, beliefs and values, opposing dominant cultures, and are considered subcultures11.
Street people and drug use are perceived as a subculture because they reveal a universe of very particular meanings that oppose dominant cultures. However, from the standpoint of ethnography, one observes a street culture, since the definition of subculture is still considered by common sense as an underdeveloped culture. Street culture reveals its negative aspects of life with few resources and much suffering to these subjects, and, at the same time, it is a resistance, from a world of meanings and identities that reinforce it and make them survivors: group organization seems to be the strongest of these meanings.
The second situation brings a moment with João who, from his presence, puts on the scene a possible contact with the PLIS group. We can observe that these contexts are rich in information about how people organize themselves, an organization linked to group life, from the hamlets: collective street communities.
João says he wants to change his life, leave the streets and reduce drug use. To that end, the health care and assistance network institutions are activated, both the shelter that is allowing him to have a roof over his head and the CAPS AD, in which he receives his treatment based on medications, which he does not want to take, and damage reduction that still allows him some meeting rituals with street friends.
The street drug use ritual is understood as part of this social organization. The use of cigarettes and marijuana are a way of “life structures”. Life structures are understood as regular activities, both conventional and drug-related, which organize the daily living patterns. This includes personal relationships, commitments, obligations, responsibilities, goals, and expectations12.
João says life on the streets is only possible with drug use because they are part of that social reality. Because his treatment allows him to use drugs, albeit only marijuana, from the harm reduction, also allows him the contact with some of his street friends, the ones that remained. His relationships with friends are still positive; he still feels belonging to the group. Marijuana use rituals are familiar in these meetings, which may not last long, but demarcate the relationship: they can talk, recall stories with drug use.
Thus, drug use is a ritual of socialization and relationship strengthening. It is also a territory of recognition, marking a place of coexistence among drug users in the street space. The group assumes the role of reception and affection, in the absence of family ties, promoting feelings of equality13,14.
This scenario is also symbolic and cultural since individuals organize processes of singling out, construction of identities, symbolic networks of protection, belonging, solidarity, to create and reinforce cultural ties, to live their experiences in the world and to establish rules and norms for care for their survival15.
A duality/contradiction is seen in this street identity that is perceived by PLIS as a resistance, in which drug use is also seen as survival, and the possibility of some organization even amid difficulties. This is exemplified by the account of R6, who mentions the several facets of street life, through his story about bathing and lack of employment. From the viewpoint of society, only drugs and crime are evidenced when it comes to street populations, disregarding the complexity of their life structures.
It is impossible to separate street culture from the notion of stigma, a derogatory attribute conferred on an individual, and part of a particular characteristic, making it totalizing, such as PLIS who are the opposite of the created stereotype, about how people should be or behave (they do not have a home, eat and make use of trash, pick up trash, they do not have formal jobs, they use drugs and live in the dirt).
The stigma exists from the relationships between people, from the clash between the “normal” and the “abnormal”. The stigma is attributed from certain people’s characteristics and begins to shape an identity. Conversely, stigmatized individuals manipulate their identity, and attempt to show its best trait. It is the rationalization and relativization of identity process that also builds it, from the way one sees oneself, which groups one belongs to and how other members of society conceive their actions and conducts16.
Street culture is stigmatized by society. It has bodily marks (dirt), and the social identity of doom that they carry in their vulnerable and sad existences, from the worldview of the so-called “normal”. Living in the streets can be a sign of “dishonesty” and “vagrancy”, revealing a mark of misconduct marked by elements such as the lack of formal employment, homelessness, weak family ties and garbage collection.
We noticed that a different relationship is developed with the social institutions in the groups that live in the streets. Just as they see the influence of these services as necessary, often for fundamental issues like bathing, they feel rejected by them. The organization of the service impairs different life forms, as reported, getting a formal job, and professionals seem to be continually judging and stigmatizing them, for example, what was said about nurses: “they seem to be disgusted and afraid of us...”.
Then, João accepts the influence of the institutions, because he wants to “organize himself”, seeking CAPS AD, shelter and harm reduction, and so his identity is questioned by street friends; he is isolated, that is, João becomes a deviant in the streets.
There is a discussion about social stigmatization, as an individual issue, people who have marked disapproval of others, classifying them by prejudice. However, it is not possible to discern at the individual level something that cannot be detached from a relationship at the group level. Groups are stigmatized by others, not because of their values and qualities, but because they belong to certain groups, collectively considered different and inferior to their own17.
Therefore, street culture means resistance to stigma and policies and services that are unaware of street life reality. The group seeks to transform the idea that they are “deviant”, they can see and relativize their ways of life, organization, social structures as a way of surviving. Thus, drugs are part of this culture, and a way of life that must be known, understood and worked out openly and consciously by health professionals. Knowing street culture demystifies stigmas and works out the drug theme in its sociocultural complexity.
FINAL CONSIDERATIONS
From the two situations presented, it is observed that there is a drug use culture in the streets that translates into a non-individual, mainly collective lifestyle. Thus, drug use gathers PLIS before the common issues that they experience in the streets.
The street identity is perceived by the interlocutors as a resistance, in which drug use is mainly seen as survival, and the possibility of an organization, even amidst difficulties. It is observed that PLIS have a social organization that helps them withstand the difficulties of social acceptance and the poor organization of services that do not understand their ways of life.
Thus, street people are stigmatized and associated with the image of criminals and drug addicts. The possibility of knowing and understanding their culture facilitates reflecting on the need for new models of drug and health care that are not only linked to “drug-disease” and “drug-crime”. To this end, professionals and society require information, discussion and practices that consider this theme.
Ethnographic research becomes an essential means of dialogue, interaction and understanding of the complexity of drug, health and care for street people, who have differentiated lifestyles, dynamics and diversities that must urgently be understood and incorporated into the reflections and actions of the field of health.

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