The Public Health System's Lead Role

in Fighting Drugs

by Kurt L. Schmoke

(Maryland/DC and Balliol '71)

THE AMERICAN OXONIAN

Winter 1990 Volume LXXVII Number 1

In 1984, Marcellus Ward, a Baltimore City police officer was killed - murdered - while taking part in an undercover drug sale. Officer Ward was wearing a wire and the entire deadly episode was captured on tape. As Baltimore City State's Attorney, and the person responsible for prosecuting Ward's killers, I had to listen to that tape many times.

However, I didn't need to hear the sounds of Marcellus Ward being shot to know that there was something terribly misguided about expecting law enforcement officers to stop drug abuse and drug trafficking. Rather than convince me of our need for a new national drug policy, Officer Ward's murder simply confirmed it.

The United States has been spending nearly ten billion dollars a year doing the kind of work that got Officer Ward killed: investigating, watching, arresting, prosecuting and jailing drug law violators.

And under the new National Drug Control Strategy recently proposed by President Bush and Secretary Bennett, still more money will be poured into the war on drugs in the years to come.

But more money won't buy more success. The war on drugs-as currently waged-is fruitless, in both senses of the word. It has not borne fruit; that is, it has not made the United States even close to drug free. Millions of Americans continute to violate our drug laws every year by using or selling illegal drugs. And, even more important, the war on drugs is fruitless in that it's doomed to failure. Doomed, not for lack of effort, money, or good intentions (the latter still paving the road to hell), but because of the internal - and inescapable - contradictions posed by the war on drugs. These I'll discuss shortly.

When I speak publicly about the war on drugs - civil war on drugs would be a more apt description - I usually begin by posing three questions.

1. Have we won the war on drugs?

2. Are our current strategies winning the war on drugs?

3. Will doing more of the same allow us to win in the future?

Given the contentiousness of the war on drugs, the unanimity with shich audiences respond "No" to each of those questions relfects a growing recongition that our current national drug policy is a failure.

If we haven't won, aren't winning, and won't win in the future by doing more of the same, it becomes legitimate, and perhaps even obligatory, to offer alternative strategies for stopping drug abuse and drug trafficking. That is what I've tried to do since April 1988 when I publicly called for a national debate on the merits of decriminalizing drugs. I have been arguing that law enforcement is incapable of ending drug abuse or drug-related crime, and that we should instead develop a public health strategy to the war on drugs. Making drugs illegal has not diminished the American appetite for these substances. That's because drug abuse is a disease. And like any other disease, it responds to medical treatment, not criminal sanctions.

What is decriminalization? It's not legalization of all drugs. Drugs would not simply be made available to anyone who wants them as is the case now with the drug nicotine. Decriminalization is in effect "medicalization", a broad public health strategy - led by the Surgeon General, not the Attorney General - designed to reduce the harm caused by drugs by pulling addicts into the public health system. Criminal penalties for drug use would be removed and health professionals would be allowed to use currently illegal drugs, or substitutes, as part of an overall treatment program for addicts. (Narcotics maintenance - giving drugs to addicts - is not a new idea. Heroin addicts have been maintained on methadone for many years.) Drugs would not be dispensed to non-users, and it would be up to a health professional to determine whether a person requesting maintenance is an addict.

For purposes of this article, I'm going to focus on three reasons why medicalization would be a better national drug policy than our current one. They are: 1) the unprecedented levels of crime- much of it violent- that has accompanied drug prohibition; 2) the increased rates of HIV infection caused by addicts sharing contaminated needles; and 3) the social inequities that have resulted from the war on drugs.

Crime: the War on Drugs as a Self-Inflicted Wound

It's pratically a truism that what frightens people most about drugs is not their use, but what results from the fact that they're illegal.

Random violence, unsafe streets, government corruption, young people working as lookouts and drug runners instead of being in school, money laundering, prison overcrowding, a crminal justice system near collapse: these are the problems that lead the publico to tell pollsters and pliticians that they want something done about drugs.

The irony is that something was done about nearly identical problems once already this century. Alcohol Prohibition was repealed in 1934 after it led to the same kind of chaos we're now experiencing with the war on drugs. (Actually we did more than repeal Prohibition; we unfortunately went to the other extreme and began promoting drinking as a social good. This promotion continues unabated with the alcohol beverage industry spending billions of advertising dollars each year to encourage people to drink.)

The views of decriminalization foes notwithstanding, there are lessons to be learned from alcohol Prohibition. The most important one being that easy profits from the sale of mind altering substances inevitably lead to the growth of criminal enterprises. And as we witness daily on television and in newspapers, these criminal enterprises will go to any length, sell to any person (children included), defy any law, murder any competition, bribe any official, and risk any punishment to protect their billions in ill-gotten gains.

We will never be able to prosecute our way out of drug-related crime. That's true for two reasons. First, the volume of drug-related crime far exceeds the prosecuting capacity of the criminal justice system. In 1989, the Baltimore City police department expects to make over 19,000 arrests for controlled substances. That0s an average of 52 a day, and a 107% increase from 1984. At the same time Baltimore has been under a court order to reduce its jail population. Through the judicious use of alternatives to incarceration, we are now under the capacity level mandated by the cours. Nevertheless, Baltimore's jail and Maryland's penitentiary remain dangerously overcrowded because of the continued influx of drug law violators.

Nationwide the story is the same. According to statistics compiled by Professor Ethan Nadelmann of Princeton University, there are 750,000 people arrested every year for violating drug laws; three-quarters of those arrests are for possession. Meanwhile, prison overcrowding has become endemic. By the end of 1988, the inmate capacity of the federal prison system had already been exceeded by 30%. Moreover, if current trends continue, in 15 years half of all federal prisoners will be incarcerated for drug violations.

Those favoring a law enforcement approach to drugs argue that the answer to prison overcrowding, as well as excessive plea bargaining, court congestion and revolving door justice, is to build more prisons. Doubtless new prisons are needed, but we could never build enough of them to keep pace with the growing number of drug arrests. One explanation is taxpayer resistance. The average cost of a prison cess is $40,000 to $70,000. The average cost of incarcerating one prisoner is $10,000 to $20,000 per year. As others have pointed out, it's cheaper to send a young person to Penn State than to the State Pen.

The other reason that we will never prosecute our way out of drug crime is because a law enforcement strategy ends up creating the very problems it is intended to solve. I was a prosecutor for seven years. My office put thousands of drug offenders in jail. I atteinded anti-drug abuse conferences, sat on anti-drug abuse task forces, participated in anti-drug bause policy studies, controlled large anti-drug budgets, and supervised large anti-drug undercover operations. I worked with very committed law enforcement officers on the federal, state and local level. As State's Attorney I could certainly have used more money; but, it is not a lack of money or dedication that has kept law enforcement from putting an end to drug abuse and drug-related crime. Stepped-up prosecutions along with stepped-up interdiction efforts maintain or increase the black market price of drugs. These high prices- and profits- simply induce new traffickers to enter the trade. Thus, while the criminal law probably does deter some drug us

e, it does nothing to deter drug traffickers and drug-related violence. If traffickers willingly risk the violent internecine battles that are commonplace in the drug trade, it's not surprising that they continue to take relatively small risk of being caught by the police and the even smaller risk of being successfully prosecuted.

Deeper involvement by the military in drug interdiction will simply raise the price in the illegal market, increase dealer profits and expand the number of points of entry for drugs. A recent GAO report says, "department of Defense data show that in FY 1987, the Air Force designated 591 AWACS flying hours to drug interdiction, which resulted in six seizures and ten arrests. The incremental cost to DoD associated with this assistance was $2.6 million. In the first quarter of FY.1988 154 designated AWACS flying hours, which represents an incremental cost of $678.000 resulted in two seizures and three arrests".

This is a near perfect example of conventional wisdom at its worst. Using the military to fight drug smugglers sounds like a good idea, but it will be money and effort wasted. The nearly $3.3 million spent for the AWACS bought very meager results. The money would have been better spent on drug treatment and other substance abuse prevention efforts. The same can be said for the Navy and the Coast Guard who, together, spent $40 million in 1987 in order to seize 20 vessels and make 110 arrests, about a two-day average in Baltimore.

How will medicalization reduce drug-related crime? First it will remove most of the illegal profits from the durg trade that keep the traffickers in business. Second, it will reduce much of the crime that addicts commit to get money for drugs. Instead of buying drugs on the black market, addicts will be able to turn to the public health system for treatment - treatment that will be much more widely available than it is now. The money for this increased availability of treatment will come in part from the transfer of resources from law enforcement to public health. Under a policy of harm reduction, addicts could be maintained and eventually weaned from drugs. Such a policy would mean safer drugs for the addicts, and safer streets for everyone else.

One popular misconception about a public health strategy to the war on drugs is that it is a new, and even radical idea. Actually, decriminalizing drug use is not a new idea at all.

Prior to the passage of the Harrison Narcotics Axt in 1914, private physicians and clinics could dispense drugs to addicts. The authors of the Harrison Act never intended to change that policy. The law, on its face, was a licensing and revenue regulation. Nevertheless, it was interpreted by the Supreme Court to mean that private physicians could not prescribe narcotics for the sole purpose of keeping an addict comfortable. IN 1914 that was a radical idea.

In the invervening years since 1914, the original role of the medical profession in fighting drug addiction has been all but forgotten . In its place has come a policy of trying to end drug abuse through the force of law. It's a policy accompanied by martial rhetoric. It's a policy filled with righteous indignation. It's a policy that promises a civilization without drugs. But it is also a policy bereft of reality and as non-existent as the Emperor's new clothes.

The question is, how much longer can we afford to keep our eyes closed to both the danger and the mythology of the war on drugs? With the AIDS epidemic the time has already passed.

AIDS is now the world's most dangerous communicable disease. IN the United States, there are over 117,000 known cases of AIDS, and as of November 1989 there were 68,441 deaths. The Centers for Disease Control estimate that as many as 1.5million Americans are knowingly or unknowingly carrying the HIV virus. Furthermore, the number of AIDS cases is expected to soar to 365,000 by 1992, with 80,000 new cases in that year alone. Also by 1992, the CDC is projecting 263,000 deaths from AIDS in the United States. There is no known cure and no vaccine for AIDS.

On the other hand, this is known: intravenous drug use is now the single largest source of the new HIV infections. Taking Baltimore as an example, there were 908 cases of AIDS in Baltimore City as of November 21, 1989. Of those, 45% were related to I.V. drug use, an increase of 4% just since May.

These statistics should have a sobering effect on those responsible for our national drug policy, but so far they haven't. Thus, instead of coming to grips with the frightening reality that thousands of people are contracting AIDS directly or indirectly through I.V. drug use (many of whom are infants born to infected mothers), our national leaders continue to condemn needle exhcange programs or any other decriminalization policy that is designed to slow the spread of AIDS. A needle exchange program is a form of Decriminalization because it requires the removal of criminal sanctions for the opssession and distribution of syringes.

Einstein once said in reference to war that the atomic bomb changed everything except the way people think. We can now say the same about drug abuse: AIDS has changed everything except the way policymakers think.

The Social Inequities of Drug Abuse: The Price of Being Poor

There's always been something slightly Orwellian about the war on drugs. On the one hand the war is often carried out in the name of children. On theother hand, children especially those at-risk of failure are some of its most frequent victims.

We used to think of ?at-risk" children as poor children or children of teenage parents. That's still true. But now the definition must include teenagers who have found drug dealing to be a better road to prosperity than school; teenage bustanders caught in the middle of drug turf battles: children born to I.V. drug users infected with AIDS; crack-addicted children with no place to go for medical treatment; teenagers arrested on durg possession charges spending time in jail instead of school. All of these children are losers in the war against drugs.

And what about poor people generally? They fare no better. The fact of the matter is the urban poor - those among us with the least money, the least education and the least change of achieving economic opportunity-year in and year out bear a disproportionate share of drug addiction, incarceration, drug-related crimes and now AIDS. This is a fundamental injustice, and it's been lost sight of in our effort to stop drug abuse throught use of the criminal law.

But we can do something about this injustice. We can step back from the brink of losing millions of young people to illiteracy, crime and finally to jail. We can put an end to the corrupting influence on poor children of drug traffickers and their profits. And we can restore a measure of fairness to the victims of the war on drugs and even a measure of peace.

But to do that we need to recognize that drug abuse is a disease, impervious to coercion, but not to treatment. We also have to recognize that changing to a public health strategy with an emphasis on harm reduction is only part of the answer- the short-term part. In the long term, if we really want to turn people. especially young people, away from mind-altering substances, we need to turn them toward education, literacy, and economic opportunity. More of all three won't come cheaply. But they will save lives. They will promote justice. And they will reduce the number of people abusing drugs: claims that our law enforcement approach to drugs cannot make, even after 75 years.

Medicalization: The First Step

There's no clear path, no risk-free way, of changing from a drug policy that relies on law enforcement to one that relies on the public health system. That is why I have called for the establishment of a national commission to recommend how all drugs, legal and illegal, should be regulated. The Commission would be made up of medical and legal experts and would be guided by the principle of harm reduction: The availability of any particular drug being based on the dangerousness of that drug. Under this scheme, marijuana could probably be sold in government stores to adults. On the other hand, cigarettes which contain the drug nicotine and kill 350,000 people every year, would likely be more closely regulated than they are now. In no case could narcotics legally be sold to children.

As much as I believe we need a national commission, I have to admit that there's been little public support for the idea. It, like so many others ideas tied to medicalization, is dismissed as surrender to the drug lords. Better, the conventional wisdom goes, to escalate the war on drugs by hiring more police, building more prisons and placing our civil liberties more at risk.

But the conventional wisdom is wrong. The way to win the war on drugs is o build more schools, not more prisons. To hire and train more treatment specialists, not more police and prosecutors. To be consistent in our approach to drugs, not to be hypocritical. Nicotine and alcohol kill hundreds of thousands of people every year but few, if any, advocate making them illegal. The drug traffickers know all this already. Their great fear is that those who write our drug laws might one day know it too.