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I've noted some ways in which the public health model is better--more rational, realistic, and compassionate--than prohibitionism. Now I'd like to suggest some ways in which it is as bad and possibly worse. Both prohibitionism and public health tend to gloss over individual differences in tastes, preferences, and behavior. They seek to achieve a collective goal using the coercive power of the state. Neither approach sets a clear limit to the use of such power.
But at least prohibitionists implicitly recognize that drug use is a matter of choice; they say it is a crime for which people may rightly be punished. Public health specialists call it a disease. At one time, the phrase "epidemic of drug use" was controversial; now it is used routinely, and people often seem to mean it literally. The consensus statement of Physician Leadership on National Drug Policy declares, "Addiction to illegal drugs is a chronic illness."
While compassion may be the motive, the main function of the disease metaphor is to banish the notion that a drug user's choices and desires should matter. A happy, productive, well-adjusted drug user is still sick, still part of an epidemic, even though he doesn't realize it. Alternatively, he is an asymptomatic carrier, spreading misery to others by setting a bad example. Either way, he has to be isolated and cured, whether he likes it or not. I'm not saying that everyone who calls addiction a disease must support coercive treatment, but we have to be aware of how such terminology affects public perceptions.
Consider how tobacco's opponents use the disease metaphor to manipulate the debate about smoking. According to the 1988 surgeon general's report on nicotine addiction, "Smoking is a disorder that can be remedied through medical attention." Former FDA Commissioner David Kessler calls it "a pediatric disease." Others have called smoking "Public Health Enemy Number One," "the greatest community health hazard," "the single most important preventable cause of death," "the manmade plague," "the global tobacco epidemic."
Thus smoking is something to be stamped out, like smallpox or yellow fever. This view of smoking is part of a public health vision that encompasses all sorts of risky behavior, including not just smoking, drinking, and other kinds of drug use but overeating, failure to exercise, owning a gun, speeding, riding a motorcycle without a helmet--in short, anything that can be said to increase the incidence of disease or injury.
Public health used to mean keeping statistics, imposing quarantines, requiring vaccination of children, providing purified water, building sewer systems, inspecting restaurants, regulating emissions from factories, and reviewing drugs for safety. Nowadays it means, among other things, banning cigarette ads, raising alcohol taxes, restricting gun ownership, forcing people to buckle their seat belts, and making illegal drug users choose between prison and "treatment." In the past, public health officials could argue that they were protecting people from external threats: carriers of contagious diseases, fumes from the local glue factory, contaminated water, food poisoning, dangerous quack remedies. By contrast, the new enemies of public health come from within; the aim is to protect people from themselves rather than each other.
Because the public health field developed in response to deadly threats that spread from person to person and place to place, its practitioners are used to enlisting the state's assistance. Treating risky behavior like a contagious disease therefore invites endless government meddling.
According to John J. Hanlon's widely cited textbook Public Health Administration and Practice, "public health is dedicated to the common attainment of the highest levels of physical, mental, and social well-being and longevity consistent with available knowledge and resources at a given time and place." If this is the vision of people who call for government action in the name of "public health," I'd rather take my chances with the drug warriors. Their ambitions are modest by comparison.