The "War on Drugs" has never been a carefully planned public health protection initiative. Government officials did not enact current drug prohibition laws and enforcement policies because of any dispassionate, comprehensive review of drug hazards. Rather, hysterical fear-mongering has always been the real basis for the "War on Drugs."
Wars require propaganda to maintain them, and the drug war is no exception. The names of propaganda groups such as Partnership for a Drug-Free America and the U.S. Department of Education (DOE)'s Drug-Free Schools and Communities Program imply that nothing short of a utopian outcome will suffice. Efforts to achieve a drug-free society through war have had less than utopian consequences, however; and those consequences are exemplified by the war's casualties the victims of infection, violence and criminal injustice.
A History of Failed Prohibition Efforts
Federal drug prohibition began in the United States in 1914, when Congress passed a law to ensure the orderly marketing of narcotics: the Harrison Narcotic Act. The law responded to concerns about the cut-rate marketing of British opium in China and its effect on China's purchasing power for American products. The congressional debates on the act were concerned with international obligations, not with issues of public health.
To the surprise of many, law-enforcement officers and the courts interpreted the Harrison Act as highly restrictive. Physicians who prescribed opiates to addicts were arrested, convicted and imprisoned. Desperate for drugs, addicts found them available only through illegal channels. Thus, the association between drugs and crime was firmly established through acts of legislation and enforcement, not through the pharmacological actions of the drugs themselves.
The ratification of the 18th Amendment to the Constitution brought about the national prohibition of alcohol in 1920. Prohibition failed to live up to the widespread expectation of its producing an alcohol-free, slum-free, prison-emptied society. Instead, it encouraged the spread of organized crime and the corruption of public officials, overburdened the court and prison systems, made alcoholic beverages more dangerous to consume (black markets tend to lack appropriate manufacturing standards), removed a significant source of tax revenue and increased government spending.
The "noble experiment" of national alcohol prohibition ended with the ratification of the 21st Amendment in 1933. However, a new experiment was initiated a scant four years later. Largely due to Harry Anslinger, Commissioner of the Bureau of Narcotics, who had shamelessly been promoting distorted horror stories of marijuana use, Congress passed the Marijuana Tax Act. The law banned the nonmedicinal, untaxed sale or possession of marijuana. At the congressional hearings on the act, there was no medical testimony favoring its passage; the only physician to testify opposed the bill.
By 1988, in the spirit of "zero tolerance," federal law permitted, without even a semblance of due process, drug-enforcement agents to seize boats, cars and planes that contained even traces of marijuana.
Principles of Sound Public Health Policy
Only rarely can we (or should we) try to eliminate health threats the way we have eliminated smallpox. The American Council on Science and Health has documented the folly of numerous public health laws, most notably the Delaney Clause of the Food, Drug, and Cosmetic Act, which tolerates zero risk from food additives regardless of their benefits. ACSH has appropriately promoted the reduction of harm from significant, high-priority, public health hazards, not the elimination of all purported hazards regardless of their public health significance.
Public health activists should guard against promoting "cures" whose consequences are worse than the "diseases" they address. In developing rational policies toward nonmedicinal use of drugs, Charles Murray's "Law of Net Harm" should be considered: "The less likely it is that the unwanted behavior will change voluntarily, the more likely it is that a program to induce change will cause net harm."
In the interest of promoting the greatest good for the greatest number of people, public health interventions may on some occasions limit personal autonomy. In these cases, however, there should always be compelling reasons for the intrusive interventions; and the degree of intrusion should be kept to a minimum.
Sometimes it may be prudent to have public policies that attempt to protect people from making the sort of unwise decisions that can cause harm to themselves. Seat-belt laws are possible examples. It is more important, however, to protect people from the dangerous behavior of others. The gunfire and societal mayhem resulting from drug prohibition endangers people who would never consider taking the prohibited drugs.
Drug Hazards in Perspective
You (yes, you!) have almost certainly self-administered drugs some time in your life. Strictly speaking, drugs are substances that, when administered, act chemically to produce behavioral or biological effects. Drugs are readily and legally available to Americans in over-the-counter products and by prescription.
Although legally sold to adults, one bundle of drugs, tobacco, kills more Americans (more than 400,000 annually) than do alcohol and all other drugs combined. Excluding tobacco, alcohol kills more Americans (more than 100,000 each year) than do these other drugs combined. American deaths from all other drugs are frequently estimated at about 10,000 per year, with over half of those deaths attributable to cocaine or heroin and none attributable to marijuana.
There may be no better example of distorted perspective than that of the parents who find out their children are drinkers and exclaim, "Thank God it isn't drugs!" It is unlikely that Partnership for a Drug-Free America which is funded in part by tobacco companies, distillers of alcoholic beverages, pharmaceutical companies and their advertising agencies would welcome a truly drug-free America.
Far more Americans die from the use of tobacco and the abuse of alcohol than die from abuse of other drugs largely because far more Americans abuse tobacco and alcohol than abuse other drugs. About 25 percent of American adults, college students and high school students are current smokers. The National Household Survey on Drug Abuse: Population Estimates 1992 showed, for the previous 30 days, 48 percent alcohol use, about four percent marijuana use and less than one percent use of cocaine, crack and heroin.
Defenders of drug prohibition may be tempted to argue that prohibition keeps the prevalence of drug use low and thereby limits drug-related morbidity and mortality. It is possible that the repeal of drug prohibition would lead to increased drug use, but I'm aware of no evidence that a large number of Americans are hoping that drugs will be legalized so that they can finally indulge in psychoactive recreations.
Prohibitionists' platitudes about "sending the wrong message" through legalization ignore, first, the dramatic decline in tobacco smoking since the 1960s without our having instituted tobacco prohibition; second, the very small increase in the use of marijuana, a drug feared far less than cocaine and heroin, following decriminalization in Oregon in 1973; and, third, the expansion of cocaine use during the 1980s, even with no change in cocaine's legal status.
Increases (or decreases) in drug use do not in and of themselves have public health significance because drug use in and of itself does not imply harmful consequences. The consequences of drug taking are determined by four factors: (1) the pharmacological actions at various doses, (2) the method of administration, (3) set and (4) setting.
1. Pharmacological actions. "The dose makes the poison" may be the most important concept in pharmacology. Protecting people from small amounts of drugs can have no more than a small impact on public health. Most use of small amounts of drugs with the notable exception of tobacco does not lead to disease or addiction.
2. Method of administration. Some methods of drug taking are more dangerous than others. Administration through injection, especially with shared needles, is potentially more dangerous than the drugs being injected.
3. Set and (4) Setting. "Set" refers to the psychological and physical characteristics of the drug user. "Setting" refers to the social and physical environment in which drugs are used. The rarity of addiction to prescribed narcotics for postoperative pain illustrates the importance of both set and setting. Focusing on the drugs themselves to the exclusion of all else ignores potential opportunities for reducing harm by addressing these "host" and "environmental" factors.
Unlike readily available legal pharmaceuticals, the illegal drugs sold on the street are typically adulterated. By introducing standards of identity, purity, sterility and dosage, legalization can reduce the harmful potential of heroin and the other drugs currently sold on the black market.
If the prohibition of drugs is as necessary as its defenders claim to protect public health, why do so few people promote the prohibition of tobacco and alcohol, the major causes of behaviorally induced mortality in the United States? Perhaps the prohibitionists secretly recognize that expanding the "War on Drugs" to include tobacco and alcohol would expand the number of war casualties
Casualties of the "Drug War"
The number of casualties resulting from the "war" on drugs exceeds the number of casualties resulting from drug use. Because of the legal restrictions placed on the distribution and possession of certain drugs, infection, violence and criminal injustice leave death and destruction in their wake.
1. Infection. Inflated drug prices resulting from the lack of a free market provide an incentive to buyers to use the efficient, yet dangerous, injection method to administer drugs. Through many years of syringe and needle prohibition, a culture of sharing the "works" has developed. But the sharing of needles and syringes speeds the spread of infectious diseases such as tetanus, hepatitis and AIDS. According to the CDC, through December 1994 in the United States, there were 109,393 AIDS cases traceable to injecting drug use; 28,521 cases among men who have sex with men and inject drugs; 15,758 cases traceable to heterosexual contact with injecting drug users; and 3,376 pediatric AIDS cases for which the mother was at risk of infection through either injecting drug use or sex with an injecting drug user.
2. Violence. Major drug dealers have more to lose than anyone from the legalization of drugs. Operating as they do outside free markets and without the burden of the taxes that legitimate businesspeople pay, black-market drug traffickers have opportunities for extraordinary profits.
A common business problem among dealers is the processing of enormous amounts of cash. As a consequence, dealers are usually well armed, both to protect themselves from those law enforcement officers who are not on their payrolls and to blow away anyone else who crosses them. In countries such as Brazil, Peru, Mexico, Panama and Colombia, drug cartels, gangs and death-and-torture squads have murdered countless opponents of the illegal drug trade including judges, journalists, political candidates and other citizens.
In any forceful response to drug terrorists, additional people including innocent bystanders inevitably die. For example, the American military's pursuit and capture of the former drug-trafficking tyrant of Panama, Manuel Noriega, killed over 200 civilians and over 300 soldiers. Hundreds of millions of U.S. dollars were spent on the invasion of Panama and Noriega's trial.
The ties between the drug trade and gangs are close ones. A significant number of the 809 juveniles who were victims of gang slayings in the United States in 1992 were undoubtedly child casualties of the drug war. The U.S. Department of Justice conservatively estimated that 1,284 drug-related homicides occurred in the United States in 1992. Many of those victims were and continue to be people who never used drugs or associated with the drug trade but who happened to wind up in the line of fire, some of it from police.
In 1988, drug scams or disputes over drugs accounted for 18 percent of the defendants in murder cases in the nation's 75 most populous counties. It is unrealistic to expect armed drug dealers to handle their most difficult conflicts through legal channels.
3. Criminal Injustice. Nevertheless, drug dealers and users of illegal drugs often do wind up in the criminal justice system. According to the U.S. Department of Justice, in 1992 there were about 980,700 adult arrests for drug offenses, up from 471,200 in 1980. That 1992 figure was larger than the same year's combined total of arrests for murder, rape, robbery, aggravated assault and burglary. In 1992 there were about 102,000 new court commitments for drug offenses, representing an estimated 30.5 percent of all new court commitments. That figure was up from 6.8 percent in 1980.
Clogged courts mean plea bargaining and reduced sentences for violent offenders who are the real menaces to society. Overcrowded prisons expose nonviolent offenders convicted on drug charges to prison violence, epidemics of drug-resistant tuberculosis and other infectious diseases and the socialization influences of hardened criminals.
Prematurely releasing violent criminals to make room for nonviolent drug offenders sentenced to draconian mandatory minimum sentences is an outrageous assault on public health. Those who advocate imprisoning drug users (at a cost of about $20,000 per year per offender) are often strongly pro-family, but few events disrupt the functioning of a family and thereby increase the risk for juvenile drug abuse as much as a family member going to prison.
The term "War on Drugs" is a misnomer. It is not a war on inanimate objects, but a war on people. Its casualties of epidemic infection, corruption, torture, murder and incarceration far exceed the speculated casualties from drug abuse under any plausible, pessimistic, post-legalization scenario. The failure to heed the Hippocratic dictum "first do no harm" in formulating drug policy gave us the longest, most destructive war in American history. It's time for peace.
William M. London, Ed.D. is an associate professor of health education at Kent State University and an M.P.H. student in health administration at Loma Linda University. For the past four years he has directed drug-abuse-prevention training projects funded by the U.S. Department of Education.
(From Priorities Vol. 7, No. 2, 1995)