Dr. Ho Thi Hien

1. Culture, risk, and vulnerability to blood-borne viruses among ethnic Vietnamese injecting drug users in Australia: a focus on a case study on overdose management practice Dr. Ho Thi Hien

2. Background • Increase in HIV notifications among Vietnamese IDUs (VIDU) in NSW and Victoria • High rates of incident and prevalent HCV infection • High rates of exposure to HBV among IDUs in SWS (28%) - HBV core antibody positivity associated with Asian COB • Low rates of BBV testing, high levels of risk behavioursand under-utilization of services by Asian IDUs

3. Aim and Objectives AIM: • Investigate cultural influences on risk-taking behaviors & the prevalence of HIV & HCV OBJECTIVES: • Identify cultural beliefs & practices (Explanatory Model) & influences on risk behaviors • Determine the prevalence of risk behaviours & barriers to health behaviours • Document HIV & HCV prevalence

4. Research Design Ethnography Behavioral Survey Seroprevalence Survey N= 56 N= 109 N= 109 Behavioral Questionnaire Link with National NSP data In-depth interviews & ethnographic observation HIV & HCV testing

5. Ethnographic Study Ethnography is “a family of methods involving direct and sustained social contact with agents” (Willis & Trondman, 2000) involving a systematic approach to witnessing and describing the social organisation, culture, geography and political economy of human groups. It entails intensive observation and extended fieldwork in order to provide a “thick description” of groups or cultures (Geertz, 1973).

6. Ethnographic Study Ethnographic approaches refer to a range of research techniques, including fieldwork, observation, in-depth interviews, social survey methods and the use of visual images in order to encourage discussion and elicit information (Maher et al., 1998).

7. Fieldwork South Western Sydney Bankstown Liverpool Cabramatta

8. Main Themes Cultural Characteristics Health Beliefs Barriers to Accessing Services Blood Beliefs Sexual Risks Injecting Risks

9. Main Themes Barriers to Accessing Services Cultural Characteristics Health Beliefs Blood Beliefs Risks Bodily Balance Natural Process Self Medication Western Medicine for symptomatic reliefs Stigma Confidentiality Resistance treatment Late presentation Language Importance of Blood Effects of Drugs on Blood Withdraw blood in overdose Injecting Risks: “Jump in” Sexual Risks Trust and Obligation Stoicism Maintaining the ‘face’ Belief in fate

10. Case Study: Blood Beliefs Blood as the essence of life, “keeping life”. Blood keeps internal organs functioning by balancing the body & helping fight sickness. Blood balances our body. For instance, if blood balances well, we don’t have diseases. If it balances badly, we are sick, not healthy. [Blood] is very important thing. When it [sickness] goes in your blood, it might kill your system, the whole system. Blood was seen as a vector, for BBVs & common illnesses It is very easy to contract diseases through blood. We inject the unclean needles, we easily get diseases. For example, if they got flu, we got flu too. We got what they have, all by sharing needles. All diseases can be transmitted through blood. Good blood is red and thin. Bad or “dirty blood” is dark and thick. If people are healthy, the blood is average red, not too dark and not too thick.

11. Blood - Traditional Medicine • These beliefs are consistent with traditional Vietnamese medicine where blood (huyÕt) is analogous to Qi (life force) which contains nutrients and flows throughmeridians (pathways) to all parts of the body, “keeping life” (Oriental Medicine, Hanoi Medical University 1994). • The flow of Qi through the meridians roughly corresponds to the flow of blood in veins and arteries.

12. Effects of Drugs on Blood Like other forms of western medicine, drugs were “hot” & heated the blood. Heroin makes your blood hot… It’s like taking western medicine. It makes your blood hot because it has a lot of chemical in it. Because most of the medicine, after you take it, your body feels hot. Drugs, particularly heroin, were widely believed to be responsible for “bad blood” & made blood thick, dark & dirty. For instance, we play heroin too much, blood will be blacker and darker. Blood seems to changes into black and purple.

13. Causes of Overdose Over the dose Poly-drug use Greed Illegality Overdose

14. Mechanisms of Overdose The circulatory system, rather than the central nervous system (biomedical explanatory model) was the major system implicated in heroin overdose. Overdose is overcirculating drug in the blood. Make your heart pump blood too fast and make your vein explode and you gone Blood becomes hot and thick and the heart is placed under increased strain as it works to circulate the thick blood in order to overcome or “balance” the effects of drugs. Heroin “hits” the blood, making it so “bad” or “thick” that it canno longer circulate.

15. Withdrawing Blood Withdrawing blood reduces the amount of drugs in the body. After you have a shot, the white [heroin] still in your blood system so you suck the blood out, take the drugs out and reduce the amount of drug in the blood. Withdrawing blood is a well-established folk practice I thought it came from one of my friends. She the first I know I have used that. Told me and then done it, yeah, then like got from one person and spread around, yeah, that’s who I found out from. Obligation andresponsibility to friends We are friends, we play together, if something happens, we have to help him. Of course we withdraw blood.

16. Withdrawing Blood • Practice confirmed by survey with 38% of participants. • Withdrawing blood is widely believed by VIDUs to be an effective antidote to overdose. • The practice is informed by the belief that drugs primarily affect the cardiovascular system.

17. Withdrawing Blood

18. Risk Associated with Withdrawing Blood For overdose victims, medical assistance is not sought or sought too late. We only call the ambulance after taking out blood and the person not awake. I don’t call ambulance, they will think I am a dog [informer]. You know, because when ambulance come, police come too. It the person is awake, he will ask you why you called the police, because he doesn’t know what has happened to him. • Risk of criminal charges in the event of death or injury • When I finished taking the blood out, he’s sleeping. Yeah we leave him sleeping and he died. He breathing and he sleeping but he died! I don’t know how! You know. Yeah. But we came back and he’s died. We got blamed for murder. We got blame for the murder!

19. Risks Associated with Withdrawing Blood Risk of BBV transmission through theuse of contaminated N&S And you know what? He still get you know, the white stuff, bubble coming out, you know like that…biting tongue, like that. So me, my friend get the fit, 2 ml and 1 ml, you know, we take it out? OK? … 21 fit, take itout, all his blood! Me and another four friends …Fuckin he still die.

20. Drug Effects on Blood Causes Blood Beliefs Mechanism Withdraw Blood Explanatory Model of Overdose Withdraw Blood

21. Conclusion • Case study illustrates how different EMs of overdose mechanisms lead to differences in management and response. These differences result in preventable deaths. • Health services and interventions are unlikely to be effective unless they explicitly take into account the beliefs and practices of diverse cultural groups. • Need for interventions based on culturally specific meanings and contexts of health, illness and risk.

22. Acknowledgements • Parents and Family • AusAID scholarship • A/Prof Lisa Maher • A/Nicolas Crofts • ICON Network (Tram Nguyen, Steve Pham, Heidi Coupland, Anna Bates, Khanh Duy Le, Jarlienne Enriquez) • Study Participants • School of Public Health and Community Medicine

23. Publications on overdose Overdose beliefs and management practices among ethnic Vietnamese heroin users in Sydney, Australia Co Vay Co Tra (What Goes Around Comes Around): Culture, Risk and Vulnerability to Blood-borne Viruses among ethnic Vietnamese Injecting drug users