Review of addicted. pregnant. poor, by Kelly Ray Knight, Durham: Duke University Press, 2015
School of Health Studies, Western University
Kelly Ray Knight asks us to ‘follow her’ into the world she documents in this gripping ethnography of the lives of nineteen women enmeshed in the drug-sex economy that occupies several neighborhoods in San Francisco’s Mission district. In some ways, this invitation is easy to accept because her careful research takes us there- down the dark hallways of the daily-rent hotels and out into the bright, unforgiving light of the world(s) outside who treat these women as a “public secret”- we can trace her footsteps and those of the women she cares about. In other ways, following her is very hard because we are reminded of the historically entrenched and on-going ways that the systems (i.e., housing, health, social services, welfare) set up to ‘help’ these women deal with addiction, pregnancy, and homelessness not only fail them, some profit from their individual and structural vulnerabilities. Reading this book involves oscillating between feeling grateful for being allowed inside the intimate contours of the women’s lives and recoiling at the socio-political, moral, and ethical abandon with which they are treated; thus we stand alongside the author as she asks: “What forms of life are possible here?” (208).
This question threads through each chapter and provides the over-arching framework for the book, which is based on ethnographic fieldwork conducted from 2007-2011. Chapter One lays out the housing ‘options’ and practices that determine where women live and for how long, including government subsidized hotel rooms, shelters, the street, and privately run daily-rent hotels. Often excluded from the government hotels because they are unable to meet the residency requirements, the women live predominantly in the daily-rent hotels that are run like de-facto brothels. Although the conditions are wretched and the management exact fees above and beyond rent (i.e., visitor fees for sex work clients), they choose these places because they offer a modicum of security versus the streets and are located in the hub of the drug-sex economy. Referred to as “musical rooming”, their residential patterns follow a routinized cycle of being evicted from one hotel every twenty-one days, so they are prevented from obtaining residency status and advocating for better conditions/rates, and hunting for another room – month after month after month. As illustrated in Chapter Two, this transience sets in motion a constant state of disruption and makes the competing temporal constraints they have to manage related to their pregnancy, making appointments, generating income, and the frenetic rhythms of the drug world even more difficult to manage.
Chapter Three introduces us to the “neurocrats”, the social actors who control the siloed governance of poverty in what Knight terms the “disability economy.” Within this system, parameters of service eligibility circulate among health care and service providers in accordance with shifting definitions of addictions and mental health. Of particular relevance is the removal of addictions and the inclusion of PTSD, bi-polar illness, and trauma to the list of disabling conditions required to receive social assistance or welfare. Although most women have one or more of these conditions, they must hide what is arguably the most debilitating force in their lives (addictions) and highlight their more pressing disabilities to have a fighting chance at getting the state support they sorely need. It is no wonder, as discussed in Chapters Four and Six, that most women devise their own ways of taking care of themselves that involve a combination of “street psychiatrics” (self-diagnosis and treatment with licit and illicit substances) and hustling as well as disengaging from the socio-medical systems that constrain their well-being at nearly every turn. These practices are sometimes supported by sympathetic neurocrats who recognize the harmful and ludicrous nature of the disability economy, including the clinician who uses the code “tucked away for a while” to ensure women get the medical care they need without being detected as a ‘frequent flyer’ or another non-deserving, under-served category.
In Chapter Five Knight pays special attention to the medico-moral forces and beliefs that inform how motherhood is both constructed and experienced. The legacy of the doomed “crack baby”, which has been debunked through decades of research that demonstrates the not-necessarily-dire effects of smoking crack while pregnant, has particular valence in this context. This is because most women smoke crack cocaine, but also because state-run services for pregnant women continue to disseminate eugenic, disparaging messages about birth control and the rights of babies to have a ‘sober start’, even offering the women money to take birth control. Although many cease smoking crack during part of their gestation (“I didn’t want to have no crack baby”-pg. 152), the women often internalize feelings of shame and defeat associated with the discourse of the ‘toxic mom’, the failed mother, the risky citizen who is worth less investment than her fetus. Of the twenty-three pregnancies recorded during Knight’s fieldwork two or three babies stayed with their mothers, some entered the foster care system, and most women endeavoured to give their children to family members or “kin of last resort” despite the tangle of socio-moral and ethical challenges associated with this practice.
Knight’s book generates important new empirical and theoretical insights within the field of urban anthropology and will be useful to researchers, policy makers, and public health advocates who seek to help ameliorate the complex landscapes within which addicted, pregnant, poor women struggle to live. Her attention to what “co-morbidity” means, how it is marked on the women’s bodies, and the ways it figures in the multitude of competing medical, health, and service provision discourses used to govern their existence is an especially significant contribution. Knight’s representation of her participants is also noteworthy because she does not describe them as ‘merely’ victims of a series of unforgiving systems or romanticize the limited agency they can exercise. They appear as active participants who make decisions and have desires that are their own, but which are also tightly bound by the many strings that make up the ‘safety’ net through which they dangle precariously. While there are few unanswered questions raised in this ethnography, her silence on the legislative status of sex work is curious considering its integral role in the systemic violence and marginalization her participant’s experience. There are also moments when her former public health worker slip shows, as it were, including when she mentions wanting to “save” these women and her repeated discussion of one participant’s reproductive system (i.e., Lexi’s open cervix). However, these are but tiny blights in this powerful testament to structural inequality in the U.S. today.