At his Congressional confirmation hearing in January 2001, the then Secretary of Defense-designate Donald Rumsfeld was asked whether US drug problems were best attacked by reducing demand or targeting drug supplies. Rumsfeld said that he believed that illicit drug use was “overwhelmingly a demand problem”. He added, “If demand persists, it’s going to find ways to get what it wants” and “if it isn’t from Colombia, it’s going to be from someplace else.” This might have been an unconventional view 14 years ago but it’s becoming a mainstream perspective these days.
The conventional view is that young people make bad choices about illicit drugs because of an information deficit. Tell young people how bad illicit drugs are, so Conventional Wisdom asserts, and they won’t touch the stuff. Unfortunately, the experience of evaluating decades of educational mass and school-based campaigns is that, at best, modest and temporary benefits are achieved. But some studies have found that educational interventions often achieve no benefits or even increased drug use and problems. Community and therefore political expectations, are stubbornly unrealistic. In the various National Drug Strategy Household Surveys conducted for the Commonwealth Department of Health and Ageing every three years, the community always notionally allocates the lion’s share of government expenditure to drug education. Drug education is clearly the community panacea for drug problems.
My personal journey thinking about these issues started after I spent an evening in a shooting gallery in Williamsburg, Brooklyn, New York City, in October 1987 while looking at HIV among people who inject drugs in Europe and North America. ‘Shooting galleries’, common in much of the USA, are derelict houses where people can bring drugs secreted on their person and hire (used) needles and syringes for a few hours to inject with. Shooting galleries helped to spread HIV extensively in the USA. The local police are usually paid to ignore shooting galleries.
The Williamsburg area, now gentrified, was then clearly extremely dangerous. Abandoned cars rested propped on bricks on the side of the road. Many tenement buildings were derelict and lay empty after a fire. We gathered in a basement room carpeted with filth and broken glass. We had brought candles, as there was no electricity in the building. The front door of the house was missing. I watched aghast as four Hispanic people injected speedballs of heroin and cocaine for several hours. I could not stop wondering why these two men and two women were so ridiculously indifferent to their health. I wondered why they made so little effort to avoid HIV? I established that they knew some people who had injected drugs and had AIDS, including some who had died of AIDS. But I was then instructed to stop asking further questions. I realized that these four people had lost all hope of decent housing, healthcare, education and employment. Not just for themselves but also for their children and grandchildren. Given the inevitability of a bleak future for them and their families and friends, enjoying a few hours of intense pleasure made some sense after all.
In 2009, Richard Wilkinson and Kate Pickett published ‘The Spirit Level: Why Equality is Better for Everyone’. This influential book argued that many important public health and social outcomes were worse in countries with high levels of inequality, such as the USA and Australia, and better in countries with lower levels of inequality, such as Japan and Scandinavia. Illicit drug use was one of the issues that they included in their studies. This book has its critics but overall, the reception has been quite positive. My 1987 experience in Williamsburg, Brooklyn seemed to fit their theory like a glove.
Last October I was invited to give some talks on harm reduction in Japan. I was struck by the fact that after a quarter century of economic stagnation, average unemployment was still only 3.1% in Japan while after almost a quarter century of uninterrupted growth, average unemployment in Australia was more than double. Youth unemployment in both countries would have been several multiples of average unemployment. Heroin use is almost unknown in Japan but continues to be a significant problem in Australia. Amphetamine use in Japan is also tiny compared to Australia.
In 2011, I was asked to give a presentation on demand reduction to the Global Commission on Drug Policy in Geneva. I argued that the results of conventional attempts to reduce drug use and problems through education were disappointing. The Chair of the Commission, Fernando Henrique Cardoso, who had been the President of Brazil from 1995- 2003, did not seem impressed by my negative assessment of demand reduction. Cardoso, a hero in Brazil for conquering hyperinflation in the 1990s, asked me what I would do to reduce the demand for drugs. I replied that his slaying of Brazilian hyperinflation had done more to reduce the demand for drugs than all the conventional drug education in the world. Although he did not seem to like that answer either, many clinicians and researchers around the world do accept that higher levels of illicit drugs use and problems are very likely if severe social and economic disadvantage is common.
The conclusion seems inescapable to me: if we in Australia want lower levels of illicit drugs use and problems, we will have to reduce our high level of inequality. This may seem counter-intuitive to some but there are many examples of dangerous health conditions being conquered as much by improved social conditions as by powerful medical treatments. In the USA, with improved social conditions the prevalence of TB fell by more than two thirds in the early decades of the twentieth century before the advent of antibiotics.
Dr Alex Wodak AM
Emeritus Consultant, St Vincent’s Hospital, Darlinghurst, NSW 2010