1994 VOL 5 NO 4
Copyright© IJDP Ltd.
THE WORLD ILLICIT DRUG CRISIS
FROM PROHIBITION TO REFORM
Alex Wodak gave this address to the InternatioNal Network of Cities on Drug Policy, Peabody Library, Baltimore, Tuesday 16 November 1993.
Many of you have heard the story of a patient who went to his doctor and asked what was wrong only to be told 'you have cancer'. When the patient asked his doctor for a second opinion the doctor said 'you want a second opinion - I think you're ugly'.
I am sure we would all agree that prohibition has been a failure. If asked for a second opinion, we would probably also agree that prohibition has been an expensive, resounding and ugly failure. After 80 years, all we have to show is gold-plated speed humps. But the real question now is not what we think is wrong with prohibition, but how we change it. How do we convert drug policy reform from a vote-losing plat-form to an election winner? How do we convert a notion associated with intellectuals, academics and researchers into a proposal that has mass support? How do we convert a complex series of arguments into a simple but representative set of choices?
Stripped to its essentials, the arguments between prohibition and reform boil down to choosing between competing judgement on simple premises.
Prohibition is based on an assumption that increasing the health, social and economic costs of drug use to drug users is an effective deterrent thereby minimising the number of drug users in the community. The reform argument is based on two premises: firstly, that minimising the health, social and economic costs of drug use to individual drug users self-evidently reduces individual and community-wide harm and, secondly, that taking the enormous profits out of the drug trade decreases the number of drug users. These two competing positions cannot be resolved by research data or logical argument. Research cannot help because we are unable to estimate with sufficient accuracy the number of drug users in the community. Logical argument cannot resolve the impasse because these positions are based on judgements of likelihood and personal values. There is a role for research and logical argument but only at the margins of the debate and not at the core issues. The drug policy debate is likely to continue to be fought with unsatisfactory rhetoric on both sides until it is resolved, as I believe it will be, with creeping reform propelled by the high financial cost of prohibition and the rapidly diminishing resources for public sector expenditure.
There can be little doubt that we are here today, at least in part, because of the HIV epidemic and its association with injecting drug use. That is why I personally started to think about drug policy reform. AIDS has tipped the balance towards reform because drug use has become a much more dangerous activity not only for individual drug users but also for the entire community. And while we were mesmerised by the epidemic of HIV infection among injecting drug users during the last decade, epidemics of hepatitis B virus and hepatitis C virus infection among injecting drug users snuck in under our radar. In Australia, there are at least five times as many people estimated to have hepatitis C infection than HIV and fifteen times as many new infections with hepatitis C every year than HIV. Most new hepatitis C infections are attributed to injecting drug use.
HIV is a more devastating infection than hepatitis C but hepatitis C is not a trivial infection. Ten to twenty per cent of people infected with hepatitis C gets cirrhosis within five to ten years. Five to ten per cent of people with cirrhosis due to hepatitis C get liver cancer. Current treatment of hepatitis C is expensive and not very effective. There can be little doubt that these epidemics of HIV and other blood-bome viruses have profoundly changed the arguments between prohibitionists and reformers and will con-tinue to do so in coming years.
Prohibition makes control of epidemics of blood-borne viral infections in injecting drug users exceedingly difficult. Modifying behaviour of injecting drug users will never be easy but it is clearly much more difficult when this population is underground and ostracised. The high prices and low purity of street drugs under prohibition make it more difficult to encourage drug users to snort, smoke or swallow drugs rather than inject. If drugs are expensive and impure, they will continue to be mainly used in the most efficient method of administration - injection - and if injected, equipment will continue to be shared and blood-borne viruses will continue to spread. The opium dens of Asia were closed in the name of prohibition. Smoked opium was replaced by injected hero-in. This prepared the way for the HIV epidemics which have devastated Thailand, Burma, south-west China, north-east India and are now spreading into northern Malaysia.
Perhaps this seems an overly medical view of the drug policy debate. But medicine is an important part of the debate if for no other reason than the fact that the relevant international treaties exempt the provision of prohibited psychoactive drugs for scientific research or medical treatment. We seem to often overlook the fact that attempts to find alternative ways of dealing with drug users other than by prohibition will have to be within the limits imposed by these treaties until such time as the treaties are discarded. Medicine is important also because leaders of the medical pro-fession will probably play an important role in the debate.
Some months ago, a colleague and I had an extend ed discussion on drug policy with a senior Australian politician. Our arguments would be very familiar to this audience - the high cost, the lack of evidence of benefit, and the heavy burden of which the military call 'collateral damage'. I learnt three things from this meeting: firstly, that however strong the arguments for reform, the lack of support for reform in opinion polls will prevent change occurring; secondly, that Australia could not afford to proceed with reforms faster than the international community; and thirdly that the opinion of the leaders of the medical profession was critical.
After that meeting, I rang a number of leaders of the medical profession. I enquired about their attitudes to drug policy reform using a similar approach in each call. Firstly, what was their attitude to shifting resources from illicit drugs and law enforcement to health and welfare. Secondly, what was their attitude to national adoption of a 'parking infringement' approach to possession of personal quantities of cannabis as has been already adopted in two of Australia's eight jurisdictions. Thirdly, what was their attitude to dispensing drugs like heroin from methadone type outlets. A very influential professor of medicine said that he did not wish to discuss the first two propositions. When I meekly asked why he replied 'because no intelligent person could oppose them'. He was prepared to support heroin being dispensed from methadone type clinics if this was first conducted as serious research broken up into a series of component steps with each step evaluated and further stages contingent upon favourable evaluation. One of the people I spoke to was the President of the Australian Medical Association. This organisation is comparable to the American Medical Association. Dr Brendan Nelson, the President of the AMA, is a strong supporter of needle and syringe exchange programmes. He recently spoke publicly about how he finds it increasingly difficult to justify the fact that drug users are provided with sterile needles and syringes yet are denied clean drugs to inject with. Dr Nelson has supported a comprehensive national debate about drug policy.
I was surprised by the extent of support for these drug policy reform propositions from the half dozen leaders of the Australian medical profession I spoke to. Perhaps I should not have been. It is clear that, like the slow and grinding movements of tectonic plates, a major international shift of opinion is taking place.
You will be familiar with the changing attitudes to drug policy reform in the United States which have been reflected in numerous public statements from influential community leaders and actions like the withdrawal from drug cases by more than fifty senior US Federal judges. The Swiss heroin trial, the Italian referendum in April, the recent English Law Lord pronouncement and the decreasing emphasis on pro-hibition in a number of United Nations Jrug agencies are just some of the portents of change.
Like most difficult social policy questions, the drug policy debate is fundamenlly about values. What kind of society do we wish to live in ? Racial equality, abortion rights for women, abolition of capital punishment, welcoming gays in the military-these are all questions about values such as compassion, tolerance, acceptance and inclusiveness. So is the drug issue.
Ladies and gentlemen, we shall overcome some day. We have to overcome so that the poor, the tired and the huddled masses yearning to be free do not succumb to the terrible scourges of HIV, hepatitis B and hepatitis C. We have to overcome so that trickle down economics does not end up becoming trickle up HIV and multi-drug resistant tuberculosis.
How will we overcome? Firstly, by being clear about what we want. Secondly, by building coalitions.
Thirdly, by persistent advocacy. Fourthly, by demonstration projects of innovative reform and fifthly by mobilising a grass roots campaign.
Sixty years ago - on December 5th 1993 - the Twenty-first Amendment to the US Constitution was passed. This repealed the Eighteenth Amendment which had ushered in the era of Prohibition of Alcohol. A fifteen year struggle was ended. The commonalities and the differences in that struggle and our reform must not be lost on us.
Thirty years ago, a US Presidential campaign was fought on the slogan 'moderation in the defense of freedom is no virtue; extremes in the defense of liberty is no vice'. Senator Goldwater, who used this slogan, was rejected by what was at that time a record land-slide. We have witnessed similar extremes in the defence of Prohibition since the earlyyearsofthis century. There can be little doubt that the main instigator ofthis international experiment with prohibition and the main country maintaining this international cornmitment was and remains the United States. WHenever the policy was seen to be failing, it was tightened up a notch or two. Countries like Australia will not be able to begin reversing this process to any meaningful degree until the United States begins this process.
At the end of the day, the choice is fairly simple; in the present system, contaminated street drugs of unknown concentration are distributed by incorrigible criminals without discrimination. The alternative will require sterile drugs of known concentration being distributed to selected individuals by health professionals - also an imperfect option. Our task is clear - to convince our communities that the second approach is the lesser of the two evils.
Dr A. Wodak, Director, Drug and Alcohol Service, St Vincent's Hospital, 366 Victoria Street, Darlinghurst NSW 2010, Sydney, Australia.