Harm reduction is used in many policy areas and found to be generally effective, safe, cost-effective and well accepted. But when pragmatic harm reduction is applied to psychoactive drugs, it is often fiercely resisted by those preferring prohibition. The war on drugs provides media with attractive eye candy in the form of mounds of recently intercepted illicit drugs.
In 2018, 1,135 Australians died on our roads. That is a shocking figure, but a great improvement on 1970 when road fatalities in Australia peaked at 3,798, equivalent to 30.4 deaths/100,000. By 2018, the road fatality rate had fallen to just 4.6 deaths/100,000. Australians travelled further by road in 2020 than half a century earlier but the number of road fatalities per one billion vehicle km per year had fallen from 44 in 1971 to just 4 in 2018 while the number of road fatalities per 100,000 vehicles had declined from 80 in 1971 to only 4.5 in 2014.
By any measure, the staggering saving in lives and costs from improved road safety in Australia over the last half-century has been a remarkable public health and public policy advance. How was it achieved despite substantial increases in population size, car ownership and distances travelled by road each year? Multiple factors contributed to improved road safety including better designed roads and cars, better street lighting and signage, car seat belts, airbags, random breath tests, lower speed limits and improved policing.
What lessons for drug policy can be drawn from Australia’s experience with road safety? Road safety authorities achieved these improvements without reducing the road distance travelled. No one suggested banning or limiting the number of cars.
Instead, road safety authorities set about reducing the risk of cars colliding with other vehicles and other road users and reducing the risk of death or severe injury to drivers, passengers and pedestrians in the unfortunate event of a car crash. Car seat belts, airbags and changes in the design of vehicle interiors greatly reduced the risk of death or severe injury to drivers and passengers. Most of these changes involved road safety harm reduction. That is, a specific focus on reducing death, injury and cost without reducing car use. The community generally supports, or at least strongly accepts, road safety harm reduction.
In 1971 I was a junior doctor at the Alfred Hospital in Melbourne where a new tower block was being constructed. I asked an architect explaining a scale model of the building how the new floors were going to be used. The architect provided this information but added a critical detail. Scores of beds previously required to provide combined neurosurgical, orthopaedic and dental care for patients with complicated skull fractures from car crashes were now no longer needed for this purpose. Recently introduced car seat belts had slashed the number of people with these particular kinds of injury. This is a lesson I have never forgotten. Harm reduction is truly the gift that keeps on giving.
In contrast to road safety, drug policy is a much more emotional field. There is an ever-present conflict. Some are determined to create a drug-free utopia, eradicating or at least greatly reducing the consumption of drugs they strongly disapprove of. Others are pragmatic realists focused on the world as it is and determined to reduce the health, social and economic costs of both drug use and drug policy. Road safety harm reduction reminds us that harm can be decoupled from consumption.
Despite its abysmal track record with many drugs in many countries, drug prohibition and its friend – severe repression – remain ever popular. Draconian drug policies have helped win many elections. Poor drug policy is usually great politics.
Poor drug policy, it should not be forgotten, is often also great for the media. It provides clickbait on steroids. Good versus evil. Law enforcement righteousness versus unscrupulously evil drug traffickers. Politicians and the media are absolved from discussing how complex but important problems often worsening drug harm like poverty, racism, discrimination, urban squalor and homelessness could be reduced.
Readers are usually also provided an estimate of the street price of the recently captured drugs. A standard police and media trick is to estimate the value of seized drugs quoting a much higher retail price even though the drugs would have been captured in wholesale quantities and will be replaced by drugs at much lower wholesale prices. The subsequent effect or lack of effect of a major drug seizure on street prices or drug availability is not something that the media concerns itself with. But you can bet that the police and the Police Minister love media items about major drug seizures.
Some years ago I gave a talk about drug policy to the United Nations Correspondents Association in New York. The last question I received stumped me. ‘Your presentation that drug prohibition has been an abject failure was very compelling. But if the results are as terrible as you claim, why has this policy persisted so long?’ It was an excellent question. All policies have winners and losers. The losers from a law enforcement dominated drug policy are all too obvious: people who use drugs, their families and their communities. But the many winners from this approach are rarely identified. They include: politicians able to secure election or re-election by declaring they will support ‘tough’ drug policies, people working in customs, police, courts and prisons, their families, public servants working in law enforcement departments, drug traffickers, lawyers, those working in the financial services industry and real estate and of course the media.
Reducing individual or societal drug consumption by supply or demand measures does have a very important role in legal drugs as the correlation between quantity consumed and harm is very strong (though lagged). This relationship has now become more complicated for tobacco as vaping and other tobacco harm reduction options have largely decoupled harm from consumption. But the correlation between an individual or societal illicit drug consumption and harm is much more complex. Much of the harm is extrinsic to the illicit drugs and probably results from the very drug policy that is supposed to be protecting the community.
Harm reduction should be the front and centre of policy for legal and currently illegal drugs. In contrast to efforts to reduce supply or demand, drug harm reduction is generally very effective, rarely causes significant collateral damage, and is also usually cost-effective. The catch is that it’s always much harder to get accepted.