My purpose here is to describe the ways in which the US drug policy, based as it is on drug prohibition and criminalizatïbn, explicitly contradicts the development and implementation of effective harm reducfion approaches to drug use and severely limits the potential of public health programmes aimed at dealing with AIDS. To illustrate titis point, I shall describe the context of the public presentation — the climate which currently prevails in the US — and discuss some of the limitations that this image places on our practical and policy options.
The first part of this climate is the public representation of the drug problem in the United States. There is little discrimination between the different types of drugs and the wide spectrum of drug use. The uncontrolled or addicted user of hard drugs, i.e. the most desperate and troubled segment of titis population, is portrayed as the typical user and the model for what will happen to people who use drugs. Drug-related advertisements and newspaper headlines frequently greet the subway rider each morning on his way to work. 'The Partnership for a Drug Free America', a heavily endowed corporate anti-drug consortium, will spend over $30,000 for a one-day ad in the New York Times. The most famous shows a fried egg in a pan This is your brain on drugs); another, a businessman crouched in a toilet stall fumbling with a spoon of cocaine ("Welcome to the glamorous world of drugs"). The Daily News and New York Post, more proletarian papers in New York City, feature schoolroom 'show and tell' 1980s style, headlining the eleven year old bringing 411 phials of crack to school, or the school principal busted buying crack — tried and sentenced in the press.
But the spectrum of drug use is acknowledged to extend beyond the inner city core to some other areas of American life, especially to sport. The baseball star Dwight Gooden, of the New York Mets, is a twenty-two year old earning over one million dollars per year and spending some of it on cocaine. When this became public (headlines of `SHAME' and 'SAY IT AIN'T SO') it was dealt with by 28 days of treatment at the highly regarded $1,000-a-day Smithers Center at New York's Roosevelt Hospital. But, following his 'rehabilitation', Dwight was taken back and embraced by the team: 'The only thing that really mattered', said the team management, 'was his health.'
Then there is the public campaign to blame drugs for all of America's problems. Drugs are undermining America. It is drugs that are making it impossible for us to do anything well — from controlling the behaviour of our children, to competing with Japanese electronics. Drug use in the workplace must be ferreted out by widespread programmes of drug testing — often bordering on the unconstitutional.
But the hard core of American drug policy is criminalization. The intent is to identify as many drug users as possible and to lock them up. Presently in the US, 3.7 million people are under the control of the criminal justice system — 1.2 million in prison on any given day, and another 2.5 million on probation or parole. It costs approximately $40,000 per year to keep someone in prison in the US — so that bill alone is over $60 billion a year. Over 50 per cent of those who go to jail these days are there in association with drugs — not necessarily for drug possession or use, but for drug-related acquisitive crime — typically robbery. As a result, the US prison system has expanded by 100 per cent in the last ten years to accommodate the increased pressure for arrest of this population. So at least $30 billion is being spent on this side of the drug war. In times of restricted budgets, little is left for other approaches — e.g. treatment or the prevention of AIDS.
Of course, as you extend and enforce this policy more efficiently, you begin to see a sharp increase, the number of drug arrests and the proportion of arrests associated with drugs comes to dominate, then flood, the criminal justice system. The inevitable delays in trial, and the inability of many drug defendants to raise bail, clogs the city jails. New York's Rikers Island jail processes over 140,000 cases per year — more than half for drug-related offences. These are, overwhelmingly, minorities from the poor areas of the city. They are the prisoners of drug war campaigns waged with military enthusiasm. Heavily armed SWAT squads block off both ends of the street and make a sweep taking every young male, and some young females. They spread-eagle them up against the walls and search them for drugs. These are all Black and Hispanic neighbourhoods, of course, and the police deliberately do this in full view of everyone in the neighbourhood — a shock tactic meant to convey a strong message. In New York last year we spent $169 million on SWAT teams, which made around 9,500 arrests. That works out to about 117,000 per arrest — more than the annual cost of most residential drug treatment centres.
The racial and class aspect of this war must not be overlooked. The target population is inner city, youthful, minorities — groups with poor education, health and social support. Their drug use patterns are the most visible and destructive and they are easy to round up. Today, more than 25 per cent of all Black men in the US between the ages of twenty and thirty have been arrested and convicted of a crime. They tend to remain in the control of the criminal justice system — either in prison, on probation or on parole, with recidivism rates of 80 per cent. The lifetime expenditure on arrest, prosecution and imprisonment of each such case exceeds $1 million.
With this immense effort of local law enforcement and its disruption of the street drug trade, we should expect some diminution of availability or increase in the price of the commodity. But the reverse is true. The multiple avenues of supply in New York City and the inventiveness of drug smugglers are quite formidable. A recent example is the-Colombian airliner which crashed in a New York suburb because it ran out of fuel before making it to Kennedy Airport. But, since it had no gasoline left, it didn't bum when it crashed. Although half the people on board were killed, about 100 survived and were sent to hospital — where tvvo were found to have intestines fill' of cocaine. Each had swallowed about thirty or forty double condoms, containing about an ounce of cocaine. If this is a true random sample of South American airline traffic into New York, and just one plane had 4 kilos of cocaine, then three flights per day from Colombia alone would provide 4,380 kilos of pure cocaine annually to New York City. From this example, one can see the scale and the range of options for people bringing drugs into the US, which has over 10,000 miles of (mostly) unguarded border. So the market is continuously fed from outside with only the occasional bust of big-time distributors. Most of the drug-related crime and arrest stems from sales and distribution at the lowest street level — i.e. of users.
The pattern of vastly increased seizures of large quantities of drugs in every category across the years is something that would normally be considered evidence of great success in an interdiction programme. Yet the economy of the international drug trade seems to grow with tinie, diversifying and extending to new areas. As the seizures increase, the basic supply from producer countries increases to take those seizures into account and the increased profits that the pressure produces induce new countries and regions to enter the game (keep your eye on the Soviet Union). And this 'industry', once it is established, becomes the major economic support of many inner city communities. We estimate the drug trade in New York City to be about $4-5 billion a year — most of it taking place in communities that have a 50 per cent unemployment rate and little prospect for change. Thus the drug trade provokes entrepreneurial activities — an American virtue now tumed to a new purpose. It also leads to political corruption. The major money associated with drugs attracts attention and becomes a part of the context of larger scale political corruption — from pay-ME of cops to multi-million dollar bank money laundering schemes. Every major political figure in the Bronx was either indicted or jailed between 1980 and 1990. That includes the Borough President, two United States Congressmen (one of whom represented the most devastated area of the South Bronx), a State assemblyman, and the leader of the County Democratic party for the Bronx. People from other countries who visit the Bronx ask, 'How could this devastation possibly be prevented? Where are your political leaders?'
But these days it is the violence associated with the US drug trade that captures most public attention. You can hear the guns going off every Mght in the South Bronx and Harlem; everyone knows someone who was killed in this battle. New York City will have over 2,000 murders this year — perhaps half of them 'drug related'. The crack tra'cle plays a central role in this violence — but not in the way one might think. A study by NDRI's Paul Goldstein (1989) of 500 drug-related homicides in five police precincts in New York City revealed that 96 per cent of those murders were associated with the structural or economic characteristics of the drug trade — as opposed to the pharmacological properties of the drug. While crack is often described as a drug that makes crazed killers out of the single-time user, it is in fact the political economy of it that seems to drive the violence, i.e. the battle for lucrative and powerful turf in the absence of other economic or social opportunities. Ansley Hamid, an ethnographer, has looked very closely at the way in which a Jamaican conununity in Brooklyn, previously involved in marijuana importation and distribution, has recently moved into crack dealing (Hamid, 1990). This has proved quite destructive in part because the sporadic or binge use of crack-cocaine is far less stable than the regular use of marijuana — or even of heroin. A street level user-dealer may take $100 worth of crack on consignment, but instead of selling it he smokes it, and so he gets into trouble with his distributor. This economy is at the core of a lot of the disruption and violence associated with the crack trade in New York.
This then is the background of the drug problem and the way in which US drug policy is perceived by most Americans: The Drug Wars. Drug users are people who shoot, kill and maim others; they sell crack to eleven-year-olds and undermine the performance of some of our most revered sportsmen and political figures. Titis is the daily meal fed to the American public and forms the infrastructure of public support for the war on drugs. In 1989, 65 per cent of Americans saw drugs as the most serious national problem. A similar proportion of Americans agreed that no search and seizures warrants should be required for drug raids and that the military should be able to go into houses and search for drugs, while many were willing to forfeit some of their own fundamental rights to support the war on drugs. Of course, most believe that it is someone else who is going to be thrown up against the wall and have their bodily cavities searched But politicians are very aware of this enormous support, and drugs have been an extremely serviceable political issue in the US throughout the 1980s.
Then along comes AIDS, which begins to create a pressure to re-examine our drug policy. Some of the original panic about the epidemic (i.e. the feeling that everybody could get it. indiscriminately), has begun to fade. But in the US, we do have one million people infected: 150,000 have already been diagnosed with AIDS, and over 80,000 have died, making it the worst epidemic in, the US in the twentieth century. The characteristics of the epidemic in the US are important for understanding who is at risk and what that risk means for the future of the epidemic in this country. The bulk of infections in the gay communities in San Francisco and New York, and in the IV drug users in New York, took place before 1985, prior to our really knowing anything about the AIDS epidemic. Recall that it wasn't until 1985 that we first had a test that enabled us to detect antibodies to the virus.
Further, AIDS presents itself differently in different places, leading to different impressiones of the epidemic. The ratio of male to female cases of AIDS in the country as a whole is about 1 : 10. In New York City as a whole it is 1 : 5, and in our hospital (where we have seen over a thousand AIDS patients) it is 3 : 2. Between 17 and 20 per cent of national cases are now drug related. But in New York, since August 1988, the monthly report of new AIDS cases among drug users (by the NYC Department of Health) has outstripped those of gay and bisexual men. In our own hospital it is now up to about 60 per cent IV drug users. And, by 1992, there will be more new cases among women than among gay men. This indicates the significance of drug use in the US AIDS epidemic. The fact that some people were infected through sharing needles is significant, but the fact that they are also sexually active heterosexual individuals living in a community with a high rate of HIV infection has implications for the future of the epidemic independent of the original drug use.
One of the ways to observe that is to look at the physical geography of New York and see how AIDS relates to it. For any epidemic, geography is destiny - and that is certainly true of the AIDS epidemic in New York. In fact, there are really two AIDS epidemics in New York, the one among gay men and the other among drug users. The astonishingly separate maPs in Figure 7.1 denote the areas of New York where gay men live - lower Manhattan, Greenwich Village, Chelsea and Murray Hill, some areas of Manhattan, and a small area of Brooldyn, Brooldyn Heights - as compared to the IV drug use epidemic of AIDS which is seen in distinct neighbourhoods, the South Bronx, Central Harlem and the core of Brooklyn.
Other related factors follow the same geographic pattern. If we consider teenage pregnancy in the South Bronx, we see close to 30 per cent of all births involve women below the age of nineteen. Teenage pregnancy is not a health problem, but it is certainly an indication of early unprotected sexual exposure to anything from pregnancy to sexually transmitted diseases. And the map of teen pregnancy is exactly in accordance with the map of the AIDS epidemic in New York City among heterosexuals. As is the map of segregated neighbourhoods. The Black and Hispanic conununities, which correspond to the poor areas of the City, are those same high AIDS districts. So it's not surprising that 80 to 90 per cent of drug-related AIDS cases are among minorities and over 90 per cent of AIDS babies are born to Blacks and Hispanics in New York. And finally, of course, the map of drug-related events - crimes, arrests, overdose deaths - is identical.
Looking more closely at the Bronx in Figure 7.2, you can see how, over time, the AIDS epidemic setdes into a community and develops. In 1982, the first year in which we had AIDS data, there were about a dozen cases. In 1983 you can see the rapid growth. Also in 1984...and 1985. You don't need a PhD in epidemiology to know whaes going on here. The way this looks to people within these communities is that, soon, everybody knows somebody who has AIDS. There are large families with four or five people with AIDS.
What are these communities like, in which about 2 million people are living? They are burnt-out stores and buildings; 200,000 units of houses destroyed by fire in New York over a ten-year period from 1970 to 1980; vast areas of destruction and social dislocation, with many children growing up in these conditions.
Within this lethal environment, the AIDS map quickly becomes a map for the drug wars, and a guide for the assault on that same population. Not surprisingly, AIDS has become a major feature in the prospects of drug users - the major cause of death among addicts. The baseline mortality rate for drug use associated with adulterated drugs and dangerous injection practices prior to HIV was always high. Now, more and more deaths appear to be HIV related, with AIDS per se accounting for a five-fold excess of deaths. Other causes are HIV-related pneumonia, tuberculosis and endocarditis - infections which addicts always endured, but which have become lethal because of HIV.
Drug treatment and other public health measures (street outreach, bleach, needles) should clearly be of great interest in New York at this dme. It 'has been demons-trated quite clearly that methadone helps - injection stops over time, there is a reduction in IV drug use clearly related to dosage and time on the programme - as well as decrease's in arrests associated with drug acquisition, and decreasing criminal complaints. In New York, during an earlier time (when we had the political will to take care of business), New York City went from having no drug treatment slots in 1968, to having 35,000 by 1974. Changes in drug-related mortality rates clearly show that methadone in New York City worked in this period. Yet, we have been unable to open any new drug treatment programmes since 1976. There is increased hostility in most conununities to drug programmes - which are seen as importing drug users or treating them too well.
Dr Stephen C. Joseph, the NYC Health Commissioner from 1986 to 1989, opened a small needle exchange program, only to have it closed in 1990 by the new Mayor, David Dinkins. Elsewhere in the country, there are attempts to promote AIDS risk reduction programmes such as 'Bleach Man' from San Francisco (Pappas, 1989) - but he has never walked the str- eets of New York. In the face of this hostility, it is increasingly difficult to get bleach progranunes in New York where the teams that are doing it are being severely cut by budget reductions. Increasingly, AIDS activists are being arrested for giving out needles. Jon Parker was exonerated by a court in Boston, only to be arrested in New York (and in ten other cities) for continuing to defy the laws prohibiting needles. What is happening more and more around needle distribution, drugs information and access programmes is civil disobedien-e. Gay activist groups (e.g. Act Up) have set the tone for confrontative AIDS politics as one way of getting attention for clinical trials and AIDS care resources. But this approach does not diminish the perception of the rest of America that AIDS is not their problem. Thus, in combination with the cirug wars and their huge criminal justice apparatus, the climate, or tone, for a discussion of drug policy in the US is hardly a civil one. The agenda is not public health, but prohibition - Just Say No, Zero Tolerance.
'There is' an intimate relation.ship between a drug policy based on prohibition and criminalization of drug use, and the difficulties in development of effective preventative and treatment approaches to addiction. And by our failure to develop and offer effective treatment and preventive approaches, we are ultimately bound to fail in our public health approaches aimed at reducing drug-related harm. The response to AIDS is just one example.
We are at a critical juncture in the US regarding people's consciousness about drugs. There is now a sense that the war on drugs is failing. Drug Czar William Bennett has resigned. Even if the USA is a country that was crazy enough to institute alcohol prohibition in 1920, it was also a country that was sane enough to repeal it fifteen years later. I believe it is the repeal of drug prohibition policies that we must seek. Unless we repeal drug prohibition and all the baggage of public attitude it carries with it, things will continue to deteriorate. We must work for the availability of funds for a range of drug treatment services appropriate to the population that needs help, and end the marginalisation not only of the drug user, but of those professionals who would choose to work in this area. But moving drug issues into the mainstream of medicine and public health will be impossible as long as criminalization policies continue.
Goldstein, P., Brownstein, H., Ryan, P and Bclluci, P. (1989) 'Crack and homicide in New York City in 1988', Contemporary Drug Problems 16: 651-8.
Hamid, A. (1990) 'The political economy of crack', Contemporary Drug Problems 17.
Pappas, L. G. (1989) 'Bleachman: A superhero tcachcs AIDS prevention', presentation at V International Conference on AIDS, Montreal, Canada, June 4-9.