to the world, but to create a new one. By this logic, prosthesis (such as medications or psychotherapy) only delay the liberation awaiting addicted people when they reject the world. The self is not permanently damaged; rather, the self is an embryonic seed, stunted by addiction, whose capacities must be cultivated with spiritual practice. This is in contrast to an inward-looking biomedical concern with inherited or historically shaped individual flaws; Pentecostal discourses of addiction are future oriented, calling on communities of worship and spirits as agents of change. The street ministry pastors that I knew had their own critique of biomedical addiction clinics, saying “You can’t cure drug addiction with drugs.”
As a prescriber of methadone and other medications used to treat addiction, I agreed with them. Drugs do not cure addiction. Yet, clinicians do not claim to cure, they only claim to manage a chronic disease (of addiction) with their medications. The most committed and skilled addiction doctors do help people to transform their lives, in part with medications that make withdrawal and cravings tolerable, medications that enable addicted people to face the complexities of family and work with less distraction.
Apart from a small, committed group of addiction specialists, however, most doctors are not eager to treat addicted patients. The chronic disease concept of addiction has only penetrated biomedicine so far. In both Puerto Rican and U.S. mainland medical schools, students and clinical residents run from patients who have “drug dependence” on their charts, delaying their admission exams for the next shift, or scanning their medical histories for reasons to refer them to a specialist. Addicted patients are non-compliant, have hidden motives, and are comorbid: sick with many diseases at once, including infections, liver disease, vascular disease, psychosis, and depression. They are the nemesis of overworked clinicians. Also, like many North and Latin Americans, clinicians often doubt that addicts deserve care.
In my own medical training, I was drawn to addicted patients. I pored over their social histories, convinced that they held the key to patients’ compulsions. I did find a pattern: almost all of these patients grew up neglected; were sexually, physically, or emotionally traumatized; or lived in violent neighborhoods, with unstable housing, pervasive unemployment, truncated schooling, and other deprivations. Population studies show that drug-use rates increase when industries leave local towns, or when people are forcibly relocated to reservations (Shkilnyk 1985) or to new housing projects under Urban Renewal (Fullilove 2004) or planned shrinkage (Wallace 1999) when extended family systems are broken apart by welfare eligibility policies (Pessaro 1993) or forced migration (Borges et al. 2007, Alaniz 2002), or when organized crime targets fragile neighborhoods for narcotics retail (Agar and Schacht Reisinger 2002). The flooding of inner-city drug markets by drug cartels selling cheap Columbian and Mexican cocaine and heroin, and the disproportionate incarceration of blacks and Latinos from the War on Drugs have converged with unparalleled toxic effects on city neighborhoods (Singer et al. 1992, Bourgois 1995, Hamid et al. 1997, Agar 2003, Singer 2008), visible in “million dollar blocks”: geomaps showing the low-income, black, and Latino census tracts whose residents cost the state the most due to high rates of incarceration (Badger 2015). Yet, nothing in my clinical training prepared me to treat addiction as anything other than an individual biological and behavioral problem.
In fact, some ethnographers argue that biomedical treatment that lacks a social perspective actually perpetuates addiction. Philippe Bourgois (2000) describes methadone programs as tools of neurochemical discipline that consign patients to long-term opioid maintenance upon pain of withdrawal. Angela Garcia (2010) followed heroin-using New Mexican Hispanos in addiction programs that, she discovered, are structured around the expectation of relapse—assuring the chronicity of addiction that they claim to treat. Summerson Carr (2010), in her linguistic analysis of group therapies, found that clients are forced to learn a “script” of sobriety to meet the expectations of their therapists, deepening the gap between their goals and those of their treaters.
As Wanda at Victory Academy told me, she preferred Christian treatment because “In the ministry they don’t say once an addict always an addict.” In this way, ministries diverge from another well-known spiritual approach to addiction, that of Twelve-Step programs such as Alcoholics Anonymous. In both evangelism and Twelve-Step programs, uncontrollable drug use is the consequence of a lack of humility and the need to submit to a higher power. Both require personal re-formation based on principles of the Bible (among charismatic Christians) or of the “Big Book” (among Twelve-Step followers). This similarity is not coincidental. In the 1930s, Alcoholics Anonymous co-founders Bill W. and Dr. Bob were members of the Oxford Group, a Protestant evangelical organization. Early on, Dr. Bob told hospitalized alcoholics to give their lives to Jesus (Dick B. 2005). The founders later expanded their membership by making the twelve steps non-denominational, and referencing a Higher Power rather than God (Valverde 1998). Yet, the Twelve Steps remain classic Protestant liturgy: admitting one’s shortcomings, turning one’s life over to a Higher Power, making reparations, and carrying the message to others (Alcoholics Anonymous 2004). The language has been secularized, but the steps refer to confession, salvation, penance, and evangelization.
At the same time, Twelve-Step programs identify addictions as incurable diseases that require sufferers to attend meetings indefinitely for sobriety, with the lifelong threat of relapse. This discourse of addiction as a disease of the individual was the product of a cultural compromise struck in post–World War II United States, in which Alcoholics Anonymous and the medical profession appeased public resistance to alcohol prohibition by attributing alcoholism to individual vulnerabilities, rather than the properties of alcohol itself (Peele 1989).
Although Pentecostal street ministries recruit and convert on the basis of problem drug use, addiction is not the primary issue to be addressed through conversion. As one convert told me, “The problem isn’t drugs or alcohol. The problem is sin.” Street ministry sermons give equal time to adultery, promiscuity, jealousy, and egoism; they place addicted people on the same plane as all unconverted people who need to align themselves with the Holy Spirit. For them, sobriety is not a goal in itself, it is the result of conversion.
The Book of Acts mentions faith healing as a gift bequeathed to early Christians during the Pentecost, along with speaking in tongues and prophecy, so faith healing—including prayer and laying hands on the ill with the expectation of their recovery—is widely practiced in Pentecostal ministries. Yet, I never heard street ministers speak of healing addiction. They measure their success not by the number of converts who return to their lives as they were before substance use, but by the number who devote their lives to the ministry, who live on the ministry grounds, who complete missions to other parts of the island or to other countries, and eventually open new ministry homes. Unlike Twelve-Step programs, whose twelve traditions forbid them to own property in the name of the organization, street ministries own, rent, or squat on properties that are full-time residences. In street ministries, conversion means gaining a new address, a new vocation, and a new identity.
Despite my biomedical training and my religious agnosticism, my own concept of addiction resonated with that of street ministers in unexpected ways. Where street ministers rallied to locate spirits, I saw a movement of people striving to relocate themselves. Where ministries made addicts into prophets, I saw social technologies of transformation. With the ministers, I wondered if the disease concept of addiction constrained the possibility of recovery. This paradox is highlighted by studies finding that defining addiction as a disease, rather than de-stigmatizing addiction as intended, can increase stigma against addicted people because the concept of disease casts them as irreversibly flawed (Pescosolido et al. 2010, Link and Phelan 2010).
My travels in street ministries required multiple ways of seeing addiction, and required holding the tension between a clinical gaze and ethnographic engagement. In a world where clinical medicine is dominant, where allopathic health care industries and pharmaceuticals represent the largest single sector of global industry (IMS 2012), I strove to understand strategies and ways of knowing that lay outside of biomedicine. How did conceiving of addiction as a spiritual disorder affect the possibilities for personal and social change?
PORTALS
