Penn State Assistant Professor of Sociology and Public Policy Sarah Brothers was a college undergraduate volunteering at a San Francisco syringe exchange center when she was introduced to what’s colloquially known as a “hit doctor,” a job she had never heard of before.
From that first interaction came the impetus of her doctoral dissertation at Yale University and, eventually, her first book, “Hit Doctors: Care, Harm, and the Art of Survival,” which was recently published by University of California Press.
The book details the uncredentialed expertise of “hit doctors,” a term used among people who inject drugs for fellow drug users, usually for a few dollars or a share of drugs.
“Hit Doctors” is part of Brothers’ broader scholarship examining how vulnerable groups, particularly people who use drugs and those experiencing homelessness, navigate and protect themselves from the harms of criminalization, an unregulated drug supply, and a lack of medical care and housing. Earlier this year, the American Sociological Association awarded her with its inaugural Early Career Award for Community-Engaged Scholarship for her “transformative work in drug policy” and for incorporating the expertise of marginalized populations in her research.
The award specifically recognized Brothers’ work identifying and understanding barriers to methadone treatment, including her finding that a COVID-19 pandemic guideline allowing take-home methadone treatments enabled more access. That led to the Substance Abuse and Mental Health Services Administration’s decision to formalize the flexibility of the take-home treatments after COVID-19 restrictions were lifted.
People like “hit doctors” hold critical knowledge that doesn’t always reach the researchers and policymakers who could help reduce stigma and improve treatment, medical care, housing and overdose prevention, said Brothers, who serves as co-funded faculty for Penn State’s Social Science Research Institute and affiliated faculty for the Consortium on Substance Use and Addiction, the Population Research Institute, the Community-Engaged Research, Action, and Partnerships unit, and the Rock Ethics Institute, which awarded her a fellowship that assisted her work on the book.
“I’m interested in other knowledge forms,” Brothers said. “My argument in the book is that being a ‘hit doctor’ is a form of expertise. How do people develop it, how do they practice it? There are no codes, no offices. What I really wanted to do was center these knowledges that people develop at such a huge cost. … These are people with very few resources who, under terrible circumstances, are trying to figure out how to make it through life, often while helping other people as well.”
For Brothers, the book’s research essentially began at that San Francisco syringe exchange center. There, she served people experiencing homelessness, but also high-income middle-aged couples who “would drive to the center in their Mercedes from Marin County.”
“What got me interested from a research perspective was I’d see all these people coming in, like this sweet woman who would come in with bins of 500 syringes each,” Brothers said. “Even as an undergraduate, I was like, ‘What is going on here?’ And then I found out that this secondary syringe exchange was super common. That most of these syringes, these public health supplies, were being distributed by a small percentage of people who were incredibly important to public health efforts. And it wasn’t money motivated — they were doing it to make a difference.”
It didn’t take long before she encountered a unique subgroup within the group.
“In one of my very first interviews, I asked this man what else he did for people, and he said, ‘I’m a doctor, actually,’” Brothers said. “I asked, ‘What do you mean?’ He said he injected people for compensation, and he was very good at it.”
In the ensuing years, Brothers conducted longitudinal ethnographic fieldwork — a research approach that focuses on human experiences and changes across time — with seven people and their social groups while interviewing 80 people overall for the book, often multiple times. Many of them lived on the street, while others had housing.
A woman Brothers refers to in the book as “Kathryn” was the “hit doctor” who first allowed her to watch her work. Kathryn was extremely careful and would only allow Brothers around “clients” who were OK with it and wouldn’t potentially act aggressively toward her.
In addition to the injections, Kathryn also provided a sympathetic ear, Brothers said.
“She’d let them vent about something that had happened to them, and for a lot of these people, this was one of the only times they could be vulnerable,” she said.
As Brothers eventually came to find out, women like Kathryn tended to dominate the ranks of "hit doctors" in the Bay Area. For them, it was not only a means of earning money, but also a way to serve others and to keep themselves from being taken advantage of or abused, she said.
“It gave women a way to refuse and set boundaries, which kept them safer,” Brothers said. “This was a space where they could earn some income and provide a service that many people obviously needed, whatever ethically you think of it. It wasn’t an option — it was going to happen, regardless. So, this was a way to do it with less injury, and to protect people against fatal overdose.”
Unfortunately, fatal overdoses became an increasingly dire reality as Brothers finished up her research in the early 2020s. The culprit — fentanyl. One of the women she spent the most time with told her that of the 30 or so people who would look out for her when she slept outside, “only four or five were still alive,” she said.
As she looks back on her time with her participants, Brothers said most of them agreed to talk to her because they hoped their insights could lead to further interventions on a policy level, from expanding access to methadone to continued distribution and training for naloxone to enhancing trauma support services.
“And so many of these issues come out of not having housing — in the long term, when it comes to overall medical costs and impacts on cities, it’s so much more expensive to not have people in housing,” Brothers said. “The focus should also be on reducing the stigma in general, so people feel safe entering into treatment, as well as seeking the medical care they need for the issues that are causing them so much pain and likely more harm.”