Facing a myriad of public health problems, many of the women who reside in the inner-city neighborhoods of southwest Atlanta had never been asked to share their stories before anthropologist Claire Sterk came to call. All work and some play: Claire Sterk recruits a young community helper.

white woman of medium build with a Dutch accent, Claire Sterk was an obvious outsider on a street in Manhattan commonly frequented by drug dealers and prostitutes. But Sterk had sought out the area on purpos e. She was there to study the role of prostitutes in transmitting HIV to the general population. As she wandered up and down the street, she hoped the regulars would become accustomed to her presence. After several days, one of the women, Ann, responded to Sterk's greeting. "Are you looking for something special?" Ann sneered. The researcher answered vaguely that she was just walking around. Ann pursued the conversation, wanting to know where Sterk was from, why she was there. Being from Amsterdam turned out to be the lucky break Sterk needed to penetrate the prostitute subculture. Ann had a friend who had worked in the sex business in Amsterdam, and she was familiar with a club that Sterk also knew . Once Ann opened up to Sterk, others followed. Although rumors spread that Sterk was a potential prostitute, a drug user, even an undercover police officer, her continued assurances and honesty eventually led people to trust her. That trust enabled her to interview some 109 female prostitutes in the New York metropolitan area between December 1986 and November 1987. Sterk conducted her interviews in cooperation with the Centers for Disease Control and Prevention (CDC). The questionnaires, developed at the CDC, asked for detailed information about sexual history and injection drug use. Blood was drawn and tested fo r HIV antibodies as well. During the first months of interviewing, however, Sterk realized that the questionnaires were failing to tap into the reality of the life she was observing. She noticed a growing number of women were addicted to crack cocaine rather than injection drug s. When Sterk began asking additional questions about drug use that were not a part of the larger CDC study, she found a significant relationship between crack users and HIV infection. In fact, the levels of HIV were higher among those who smoked crack th an among the women who injected drugs. Her findings, surprising at the time, prompted her to write to The Lancet. "These findings, and other observations, indicated that it is the number and type of sexual encounters that place female (and male) crack users at risk," Sterk wrot e in the letter that was published in 1988. "Typically, female users trade sexual favours for crack, and during one night they may have sex with many partners." Her letter concluded with a suggestion: HIV prevention efforts should concentrate on crack coc aine users as well as injection drug users. Sterk's Lancet letter provoked a storm of angry responses. "I was threatened with a lawsuit," she remembers. "People said I was crazy." But within a year, her findings that sex related to crack cocaine use was putting people at risk for AI DS had become common and accepted knowledge.

To penetrate the neighborhoods that she studies, Sterk draws on community consultants, such as Leitha Givens (left), who live in the communities and help identify potential research participants.

laire Sterk is an anthropologist by training. She calls herself a "natural researcher," one who wants to understand the causes of social problems. She became interested in AIDS research in the summer of 1986 , while setting up an exchange program in New York City for Erasmus University. She believed her experience with prostitutes and drug users in Amsterdam might contribute to understanding the AIDS epidemic in the New York metropolitan area, including north ern New Jersey. She worked as a research associate in New York City before joining CDC's division of STD/HIV prevention in Atlanta as a visiting scientist. After her stint at the CDC, she served as a faculty member in Georgia State University's department of anthropol ogy. In 1995, she became associate professor and the associate director of the Women's and Children's Center at the Rollins School of Public Health. Since 1986, Sterk's work increasingly has focused on public health. She is a social scientist particularly concerned with research on women and HIV. Her first groundbreaking discovery that crack cocaine use places women at risk for HIV has led to other significant findings. Over the past ten years, her work has earned her the status of an internationally known expert on how the AIDS epidemic affects women and has even brought her to testify before the US Congress. "Most research in HIV and AIDS has been largely focused on men," Sterk says. "The use of illicit substances was seen as a male problem, and women were included in studies only as a control group." Even when research examined the problem of female drug use, it often dwelled on negative images such as insecurity, incest, or sexual abuse, according to Sterk. She disapproves of sensationalizing the sexual activity associated with crack use. Such sensationalizing, by drawing attention primarily to the sexual component, fails to recognize the bigger underlying problems of crack cocaine use, she says. Working in the Women's and Children's Center allows Sterk to serve as an advocate for women. Usually, the women she studies are either ignored or judged in negative stereotypes. "The prevailing image of female drug users is one of 'bad' women who are s elfish, irresponsible, and unworthy of motherhood," Sterk writes in a report presented to the National Institute on Drug Abuse (NIDA). She believes, however, the problems and concerns of these women are not that simple. Sterk approaches women's addiction to drugs and the risk of HIV infection in the context of her subject's lives. "Your subjects are the experts," she says. "I don't go into a situation with a list of predetermined questions. Instead I look at behaviors in context." To study the lives of these women in context, Sterk has gone to drug-riddled neighborhoods, crack cocaine houses, and shooting galleries. She becomes vested in the communities where she works and considers herself a facilitator who helps women set thei r own priorities and programs. "I am not there just to take information," she says, "but also to give back."

Just prior to the 1996 Summer Olympics, former residents of Techwood Homes in downtown Atlanta staged a protest after being displaced from housing that was slated for Olympic renovations. Leitha Givens, a community consultant for Project FAST (Female Atlanta Study), listens as two of the women air their grievances while carrying on with the chores of daily life. As a faculty member of the Women's and Children's Center in the Rollins School of Public Health, Claire Sterk sees herself as an advocate for all women, including the disenfranchised women of Project FAST, some of whom believe that societ y perceives them as its "bad women."

terk's office on the second floor of the Rollins Public Health Building overlooks the campus of Emory University. But just 15 minutes away lie the inner-city neighborhoods of Atlanta where she collects her r esearch. "Within just a few miles of here, there is so much work to be done," Sterk says, seated in her Emory office. "There are incredible needs in communities close to here." Sterk believes it crucial to take her work to these communities. "People are surprised when you approach them in their own community," she says. "Usually, they have to go somewhere to participate in a study. So we score some points for going into the c ommunity. Also, many of these women have never been asked to tell their own stories. They are excited that someone will listen to them for three or four hours." Sterk earns more sympathy by being from Amsterdam - which, she says, is perceived as "the drug capital of the world." Her foreign accent also helps her gain the trust of the women she studies. "They wonder why a woman from Amsterdam wants to know what' s going on in their lives," Sterk says. "It creates a dialogue." In 1988, with funding from NIDA, Sterk began working in Atlanta communities to identify the impact of drug use patterns on the lives of female drug users. Her original study, known as Project FAST - an acronym for Female Atlanta Study - collected infor mation from 164 female drug users in 14 communities. Some residents became community consultants, assisting in mapping neighborhoods and working with the researchers to identify potential participants. The identified women participated in in-depth individ ual interviews that covered topics ranging from family background to reproductive history, from drug treatment experiences to abuse. Among her findings, Sterk uncovered a consistent view among the participants that society portrayed them, as female drug users, as "bad women." By contrast, they saw male drug users as able to "get away with much more." "The women frequently introduce d topics that appeared to be linked to the image of bad women," Sterk writes in a monograph for NIDA. The participants discussed how sex-for-drug exchanges were an easy route to take, but a route which left them vulnerable to abuse. The interviews also re vealed related issues for female drug users not discussed in literature on male drug users, indicating to Sterk that studies on women should ask questions different from those traditionally tailored for men. Sterk's work on Project FAST continues. She now has collected data from more than 250 female drug users in 18 communities in the Atlanta metropolitan area. She has compiled a profile of the patterns of female drug users and is now at work on a study th at examines multi-generational drug use. Her data emphasize that public health solutions must incorporate the community's priorities. She cites public health's AIDS prevention campaign to encourage condom use as an example of a policy that often fails to work in the community. "Although a lot of people are well informed about condom use, they still end up in a situation where they engage in unsafe sex," she says. For her subjects to suggest the use of a condom implies a lack of trust of their partners, she explains. That distrust can lead to violence or the loss of economic support. "We can't simplify life," she says. "A simple message like safe sex is in reality complex. We need a comprehensive approach."

Building an investment: Sterk wants not only to take away information but also to give back to the communities where she works and where this man and the child pictured above reside.

he problems of the women we work with are complex," Sterk says. "To understand those problems and come up with appropriate solutions, you need a multidisciplinary team." Sterk has joined with psychologists, health care providers, social workers, attorneys, and community residents to understand the problems of women who use drugs. Currently, she is working with epidemiologist Richard Rothenberg to examine HIV transmission in social networks. Her recent collab oration with criminal defense attorney John Lieb focused on how the US legal and medical systems treat pregnant women who use crack cocaine. In that study, Sterk and Lieb found that many pregnant drug users do not seek prenatal care because they fear losing custody of their infants. Uncertified midwives often deliver these babies, further complicating an already high-risk pregnancy. When a pregnant woman secures a position in a drug treatment center - a considerable feat in light of the yearlong waiting lists - child care or other comprehensive services are rarely available. If the drug user has other children and no relative or other resou rces to provide for them, she often loses custody of them as well. In "Crack in the Cradle," published in the Winter 1995 issue of Contemporary Drug Problems, Sterk and Lieb explore whether justice is served by prosecuting the pregnant drug user. According to the authors, pregnant African-American women a re particularly likely to be reported and prosecuted for substance abuse, at nine times the rate of their white counterparts. The policy of prosecuting pregnant drug users appears counterproductive, they suggest, because it results in greater harm to infa nts when mothers do not seek prenatal care for fear of detection. Sterk's approach is to treat the addiction of crack cocaine rather than criminalize it. "The current policy seems to equate the war on drugs with a war on women," she concludes. Sterk is applying her findings to several Atlanta drug treatment programs. One solution that seems to be working is when facilities allow women to bring their children with them when they undergo treatment. With that simple policy, Sterk says, the wome n "stand a better chance of staying."

Claire Sterk brings an interdisciplinary team to tackle the complex public health problems of women who live in inner-city communities.

lthough most of Sterk's research for the past ten years has focused on drug users from the lower classes, this year she completed her first study on drug use among middle-class women. "It was important to re cognize that drug use isn't a problem just for poor people," Sterk says. Identifying the middle-class subjects was more difficult than locating the lower-class drug users, who often work in highly visible locations on city streets. With persistence, however, she managed to locate and interview 30 middle-class female drug us ers from January 1993 to February 1994. Her findings, recently published in The Journal of Drug Issues, show that most of these women's first encounters with cocaine were connected with "having fun." At some point, however, the women became m ore serious users and started developing their own connections to procure drugs. The main factor influencing control over drug use proved to be the amount of resources. Middle-class women with greater financial resources were more able to keep their cocaine use within bounds. "The more resources you have, the longer it takes to hit rock bottom," Sterk says. "You're less likely to hit that point because you have a lot more at stake." Sterk postulates that cocaine use among middle-class women might be more prevalent than currently assumed. Her small sample size provides only a glimpse into the larger problem, but it provides the baseline data for future studies. Sterk next plans to expand her study of this group to include connections to HIV.

This Project FAST participant felt comfortable in sharing her anger with Sterk and Givens during a recent visit. After venting her anger, however, she changed her tune and sang for the research team.

o observe drug users in their natural environment is the best way to get an understanding of their lives and why they behave the way they do, Sterk says. But to observe behavior in this natural setting also means the researcher must not interfere. That is the ethical high-wire that Sterk negotiates daily. "I struggle with the need to understand what is going on on the one hand, and the awareness of allowing some harm," she says. One way she tries to prevent situations that will challenge her boundaries is to thoroughly discuss informed consent with her research participants. She lays out her role clearly at the beginning of an encounter. "There are some personal values that I carry into my work," Sterk says. "I explain that if someone goes too far, there will be repercussions." For example, she has taken women involved in an abusive situation to a shelter as well as reported child abuse cases. "People might ask, why would your subjects still trust you and participate in your research," Sterk says. "But they do because they realize these are situations that need to be taken care of." There is a certain amount of risk in directly and intensely involving oneself in drug-using communities. Sterk acknowledges that risk, having experienced firsthand threats to her personal safety. She believes, however, that common sense and general pre cautions greatly lessen the danger. The members of her research team initially approach the field in teams of two. They always let someone know their location. And they immediately leave a situation if they feel uneasy. In all of her research projects, Sterk tries to avoid passing judgment on the people she studies. Interestingly, her conclusions, which often support the rights of those whom society disparages, have met with little controversy. In 1990, when Sterk tes tified before a politically conservative US Congress, her recommendations on drug treatment and AIDS prevention met with support. "If you present people as people," she says, "it becomes a lot harder to make untrue statements than if you talk only in numb ers. The way in which we show what is going on and what we are finding indicates that very often you can't really blame the women." "Yes, there are women from the same environment, who are very successful so you can't just blame the environment," she continues. "But if you step back and look at the problem, it is not something over which these women necessarily have a lot of contro l." In other words, being judgmental isn't necessarily constructive for these women nor does it help them gain any control over their lives. Sterk refuses to classify her subjects as "bad women." She refuses to accept the prejudged image of female drug users as selfish, irresponsible, and unworthy of motherhood. Instead she sees women with serious and complex problems. She hopes that greate r understanding of their lives may lead to solutions that work in the real world.