Since the theme of this panel is "Public Health As an Alternative to the War on Drugs," I thought I'd start things off by comparing the public health model to the prohibitionist approach that has long dominated U.S. drug policy. In doing so, I'll use illustrations drawn from the anti-smoking movement, for several reasons.
First, tobacco is a drug in transition: Today it is primarily the concern of public health specialists; tomorrow it could be another target in the war on drugs.
Second, there are often tensions within the anti-smoking movement between public-health and prohibitionist impulses.
Finally, talking about the anti-smoking movement is a way of reminding you that my book is coming out in the spring, and you really ought to buy it.
Let's begin with slogans. It's hard to beat "a drug-free America" for sheer hubris, but "a smoke-free society" comes close. And while "Just Say No" and "zero tolerance" are admirably mindless, "Health for All"--the official goal of the World Health Organization--is breathtakingly so. Both "a smoke-free society" and "Health for All," by the way, were supposed to be achieved "by the year 2000." They've still got time.
Slogans, of course, can be misleading as well as revealing. Let's dig a little deeper. The stated aim of the prohibitionists is to eliminate drug use--by which they generally mean the use of certain drugs, set apart from accepted intoxicants by custom, superstition, and historical accident. The stated aim of the public health specialists is to minimize morbidity and mortality--including the harm associated with the use of all drugs, whatever their current legal status.
Already we can see that the public health specialists are in some ways more realistic than the drug warriors: They acknowledge that any drug, licit or illicit, can be harmful in certain circumstances. And they stress harm rather than drug use per se. This implies that the consumption of psychoactive substances is not necessarily problematic. It also suggests a willingness to consider the undesirable effects of attempts to discourage drug use.
Public health specialists recognize that the costs of a given anti-drug policy may outweigh its benefits, even if it succeeds in reducing drug use. In practical terms, this willingness to consider all costs, which also implies an openness to evidence, is the most important way in which public health specialists differ from prohibitionists.
This open-mindedness leads public health specialists to oppose restrictions on access to clean injection equipment, because dirty needles spread disease. It leads them to criticize state and federal regulations that discourage the proper treatment of pain. It leads them to question the Schedule I classification of marijuana, which prevents doctors from prescribing a potentially useful medicine. It leads them to reject punishments for drug offenses that seem disproportionate to the harm caused by use of the substance. It leads some public health specialists to go further, calling for decriminalization of drug use.
Even the most moderate prohibitionist is not likely to go that far. The prohibitionist orientation is basically punitive: Using certain drugs is a crime; people who do it deserve to be arrested, humiliated, imprisoned, and divested of their property. The public health orientation, by contrast, is therapeutic: Drug use is a disease; people afflicted by it need to be treated. There is a wide range of opinion about what kind of drug use constitutes a disease and whether treatment should be voluntary. But the disease model, to which I'll return, is central to the claim that drug use is a public health issue.
In terms of policy, both prohibitionists and public health specialists talk a lot about "education." Prohibitionists seem more willing to bend the truth if they think it will help scare people away from drugs, while public health specialists are more likely to insist that drug "education" have a sound scientific basis. They note that scare tactics tend to backfire in the long run, as people recognize that they've been misled and learn to distrust the source. Still, public health messages about drugs, like public health messages in general, are aimed at changing behavior, not simply disseminating facts.
Aside from education, the policy prescriptions offered by public health specialists sound quite different from those offered by drug warriors. Prohibitionists emphasize interdiction, crop eradication, and other attempts to reduce the supply of drugs, along with arrests, fines, property forfeiture, and imprisonment for producers, sellers, and buyers. Public health specialists emphasize treatment, taxes, and regulations.
Both sets of policies are aimed, in part, at deterring certain kinds of drug use by making them more expensive and less convenient. While the public health prescriptions certainly seem milder, their effects can be similar. Voluntary treatment, for example, is clearly preferable to incarceration, but many advocates of drug treatment would send uncooperative "patients" to jail. In her recent history of drug use in America, the journalist Jill Jonnes explains the rationale for coercive drug treatment: "It is well known in the drug world that most addicts will not seek treatment except under some sort of duress," she writes. "Nor, for the most part, will they stick with it unless forced."
This attitude is encouraged by the disease metaphor that is central to the public health model. A disease is something inherently undesirable that happens to people against their will. No one in his right mind wants to be sick. Furthermore, this is a disease that is said to impair the patient's judgment; one of its symptoms is "denial." Where's the harm, then, in forcing an addict to be well? Under the circumstances, this would seem the compassionate thing to do.
Just as treatment can resemble prison, taxation can resemble prohibition. Prohibition itself can be viewed as a tax, raising the prices of certain goods by making them riskier to produce and sell. Conversely, a high enough tax produces some of the dramatic side effects associated with prohibition.