gendered inequalities, drug use, and state interventions in rural appalachia

334 Pages·2017·1.64 MB·English

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Theses and Dissertations--Anthropology Anthropology
2018
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Lesly-Marie Buer
University of Kentucky, [email protected]
Author ORCID Identifier:
https://orcid.org/0000-0002-7193-7023
Digital Object Identifier: https://doi.org/10.13023/etd.2018.242
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Buer, Lesly-Marie, "UNENDING MAZES: GENDERED INEQUALITIES, DRUG USE, AND STATE
INTERVENTIONS IN RURAL APPALACHIA" (2018). Theses and Dissertations--Anthropology. 30.
https://uknowledge.uky.edu/anthro_etds/30
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The document mentioned above has been reviewed and accepted by the student’s advisor, on
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Lesly-Marie Buer, Student
Dr. Mary K. Anglin, Major Professor
Dr. Sarah Lyon, Director of Graduate Studies
UNENDING MAZES: GENDERED INEQUALITIES, DRUG USE, AND STATE
INTERVENTIONS IN RURAL APPALACHIA

DISSERTATION

A dissertation submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy in the College of Arts and Sciences at the University of Kentucky

By
Lesly-Marie Buer

Lexington, Kentucky

Director: Dr. Mary K. Anglin, Associate Professor of Anthropology

Lexington, Kentucky

2018

Copyright © Lesly-Marie Buer 2018
ABSTRACT OF DISSERTATION

UNENDING MAZES: GENDERED INEQUALITIES, DRUG USE, AND STATE
INTERVENTIONS IN RURAL APPALACHIA

Prescription opioids are associated with rising rates of overdose deaths and
hepatitis C and HIV infection in the US, including in rural Central Appalachia. Yet there
is a dearth of published ethnographic research examining rural opioid use. The aim of this
dissertation is to document the gendered inequalities that situate women’s encounters
with substance abuse treatment as well as additional state interventions targeted at
women who use drugs. These results are based on ethnographic fieldwork completed
from 2013 to 2016 and centered around one county seat in rural Central Appalachia. Data
are ascertained through semi-structured interviews with women who have experiences
with at least one of three types of substance abuse treatment offered in the area.
Additional interviews were completed with program staff, institutional administrators,
and community leaders. These data are supplemented with the collection of program
documents, informal and follow-up communications, and participant observation in
Eastern Kentucky communities, substance abuse treatment programs, and funding
agencies. Social locations based on gender, income, access to quality health care, and
place of residence contextualize women’s participation in illicit economies, entrance into
and maintenance of drug use, particularly but not limited to opioids, and efforts to limit
deleterious use. The state’s responses to drug use are manifested in these women’s lives
through child protective services, incarceration, and substance abuse treatment. The
sociopolitical and financial limitations on institutions often create instances in which
policies exacerbate women’s marginalization. These policies are based on specific
cultural understandings of women who use drugs, motherhood, Appalachia, and care.
Women develop strategies, often based on care networks, to make it through these
programs. Despite their navigations of marginalized and marginalizing programs, clients
and institutional staff are materially and discursively constrained in their actions.

KEYWORDS: medical anthropology, Appalachia, substance use, gender, the state
___Lesly-Marie Buer__________________
Student’s Signature

___April 25, 2018___________________
Date
UNENDING MAZES: GENDERED INEQUALITIES, DRUG USE, AND STATE
INTERVENTIONS IN RURAL APPALACHIA

By

Lesly-Marie Buer

___Dr. Mary K Anglin_________________
Director of Dissertation

___Dr. Sarah Lyon____________________
Director of Graduate Studies

___April 25, 2018____________________
For those who led me down this path, but are gone and sorely missed.

“I’ve learned something about times like these. In times like these you have to grow big
enough inside to hold both the loss and the hope.”
– Ann Pancake, Strange as this Weather Has Been
ACKNOWLEDGEMENTS

The following dissertation, while an individual work, benefited from the insights
and direction of several people. First, my Dissertation Chair, Dr. Mary K. Anglin,
exemplifies the high quality scholarship to which I aspire. I wish to thank the complete
Dissertation Committee: Dr. Ann E. Kingsolver, Dr. Erin Koch, Dr. Carl G. Leukefeld,
Dr. Carol A. Mason, and Dr. Shaunna L. Scott. Each individual provided insights that
guided and challenged my thinking throughout the process. In addition, Dr. Heather
Worne gave instructive comments on my proposal. I thank the University of Kentucky
Appalachian Center for providing partial funding for this dissertation through research
grants.

I received equally important assistance from family and friends. My husband,
Arie Buer, supported me throughout the dissertation and successfully prevented our
family and home from falling into chaos when I was in the field. My family, especially
the strong women, inspired me to continue my education, seemingly without end at some
points. I have a group of friends from East Tennessee who invaluably keep me grounded
in our roots. I am truly blessed to have such a fine arrangement of folks who I have been
connected to for decades and who share a similar sense of caring. Friends and peers from
the University of Kentucky, the University of Colorado Denver, the Appalachian Studies
Association, the Tennessee Department of Health, and numerous national and regional
social justice organizations have provided intellectual support and suggestions that have
helped me grow into a more thoughtful scholar and resident. I could not have completed
this dissertation without the women (and grandpa) who provided my family with safe
and stable childcare.

I wish to thank the participants in my study, may they continue to “Pray for the
dead, and fight like hell for the living,” in the apt words of Mother Jones. I sincerely hope
that all are able to find some sort of peace in this life.

iii
TABLE OF CONTENTS

Acknowledgements ............................................................................................................ iii
List of tables ....................................................................................................................... vi
List of figures .................................................................................................................... vii
List of acronyms ............................................................................................................... viii

Chapter One Weaving through the Mazes of the State: The Value of an Ethnographic
Compass .............................................................................................................................. 1
Notes on the state ............................................................................................................. 4
Quasi-state institutions .................................................................................................. 12
Neoliberalism, care, and categorizing the poor ............................................................. 16
Situating Appalachia as part of the US .......................................................................... 23
The ACA and Medicaid Expansion ............................................................................... 31
Organization of the dissertation ..................................................................................... 37

Chapter Two Navigating the Familiar Unfamiliar: Political Economies of Home .......... 38
Entering the field .......................................................................................................... 38
Knowledge sources ........................................................................................................ 41
Analyses ........................................................................................................................ 55
Dilemmas ....................................................................................................................... 56
The five counties ........................................................................................................... 64
Local health care reform ................................................................................................ 71

Chapter Three Gendered Subjectivities of Pharmaceuticals and the Criminalization of the
Poor .................................................................................................................................... 77
Overview of prescription drug use and misuse ............................................................. 78
Marketing pain and pills ................................................................................................ 85
Who is nominally fined and who is incarcerated? ......................................................... 98

Chapter Four Strategies in Therapeutic and Rehabilitative State Iterations .................... 115
Treatment for mothers ................................................................................................. 116
Criminalized treatment ................................................................................................ 126
Buprenorphine ............................................................................................................. 137
Meeting needs and jumping through hoops ................................................................. 145

Chapter Five Making It to Recovery: Care, Violence, and Violent Care ........................ 153
What is care? ............................................................................................................... 154
Surviving ..................................................................................................................... 160
The violence and necessity of care and caregiving ..................................................... 173

Chapter Six Relatedness, Reproduction, and CPS .......................................................... 189
Understandings of motherhood ................................................................................... 190
Intervening in motherhood .......................................................................................... 194
Navigating impossible identities ................................................................................. 211

iv
Chapter Seven A Curation of Stories .............................................................................. 221
Sissy ............................................................................................................................. 222
Ashley .......................................................................................................................... 229
Katie ............................................................................................................................ 235
Maggie ......................................................................................................................... 241
Alisha ........................................................................................................................... 246
Star ............................................................................................................................... 252

Chapter Eight Conclusions .............................................................................................. 257
Methods and representation ......................................................................................... 258
Major findings ............................................................................................................. 263
Recommendations ....................................................................................................... 267
Limitations ................................................................................................................... 270
Further research ........................................................................................................... 272

Appendices ...................................................................................................................... 276
Appendix A: Glossary of relevant programs and policies .......................................... 276
Appendix B: List of women interviewed .................................................................... 281
Appendix C: List of gatekeepers interviewed ............................................................. 284

References ....................................................................................................................... 288

Vita .................................................................................................................................. 319
v