Drug Trial

Jacob Sullum from the March 1998 issue

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The problem with public health comes from its close historical association with clinical medicine, i.e., an over-reliance on the disease model. While a perfectly appropriate way of understanding the course and characteristics of individual illness, the disease model is only a small part of what is required to appreciate the complex biological and social circumstances that contribute to morbidity and mortality. Many critics of the public health perspective fail to distinguish its perspective from that of medicine. Workplace injuries, highway accidents, and home poisonings are not diseases, but they are well understood (and prevented) using a public health model.

When it comes to drugs, public health data usually focus on the most negative outcomes (disease and death) and the "hard realities" of drug use: addiction, overdose, AIDS, crime, domestic violence. But this is only part of the picture. In the vast majority of cases, the positive aspects of drug use, such as psychological benefits and social involvements, outweigh any harm. Because of the stigma attached to illegal drug use, these "soft realities" are largely ignored in public discourse. But they can be inferred from public health data.

While tens of millions of Americans have used illicit drugs--70 to 80 million marijuana, 40 million cocaine, and 20 million heroin--the number of heavy or problematic users is only 5 percent to 10 percent of those figures, similar to the proportion seen with alcohol. Public health data on moderate alcohol use (one or two drinks per day) suggest it is not only harmless but actually beneficial. I suspect a similar case could be made for other drugs, which are often used (successfully) to "self-medicate" anxiety, depression, and attentional difficulties.

Through public health data we can also see that, despite an overall reduction in the number of drug users during the most vigorous prosecution of the war on drugs, from 1972 on, the consequences of drug use have generally gotten worse: There has been an absolute increase in drug-related health problems such as AIDS and overdose deaths. Meanwhile, the huge economic and social costs of massive incarceration and criminalization associated with drug prohibition generate a cascade of adverse consequences in the targeted communities. These are consequences not of drug use but of drug policy. And it is public health methods that make them visible to the naked eye.

So who could be against public health? Well, for a start, our gracious editorial host, Jacob Sullum. His forthcoming book about America's current "war on tobacco" bears the subtitle The Tyranny of Public Health. The phrase is provocative, suggesting that public health could operate contrary to the public interest, and possibly oxymoronic, since most of us who work in the field are impressed by our relative powerlessness to affect policies. But it does capture something of the battle for the right to use the "trademark" of public health: One can cite many moralistic (and often useless) restrictions imposed on victims of past epidemics in the name of public health, or the contemporary use of imaginary or overblown health risks to exert social control, as in bans on smoking in outdoor spaces.

On the face of it, any public which is fully and accurately informed of a serious risk to its collective well-being may fairly decide that it wishes to protect itself and restrict the freedom of some individuals to achieve that goal. But if the advocates of drug prohibition want to justify their position on public health grounds, why do they consistently overlook public health data suggesting measures that might actually save lives? The continued ban on the use of federal funds for needle-exchange programs, for example, defies a large body of scientific literature demonstrating their efficacy and ignores the recommendations of multiple expert commissions. As a consequence of this failed policy, my colleague Peter Lurie and I estimate, 10,000 to 20,000 preventable AIDS cases have occurred in the United States.

The message of history is that most people are willing to forgo some individual freedom for the larger good if the threat is real, the process is fair, and the response is effective at saving lives--as with confining or isolating carriers of easily infectious diseases such as typhoid or bubonic plague. These examples seem to me the opposite of tyranny. But current attempts to justify our demonstrably unhealthy drug policies in public health or medical terms make a mockery of both professions, whose best efforts are sorely needed to deal with our all-too-real drug problems.

Ernest Drucker is professor of epidemiology and social medicine at Montefiore Medical Center/Albert Einstein College of Medicine, a senior fellow of the Lindesmith Center, and editor-in-chief of the journal Addiction Research.