CRACK

Crack in America: Demon Drugs and Social Justice, edited by Craig Reinarman
and Harry G. Levine, 388 pp, with illus, $48, ISBN 0-520-20241-4, paper,
$17.95, ISBN 0-520-20242-2, Berkeley, Calif, University of California
Press, 1997.

The introduction and spread of smokable cocaine, or crack, has inflicted
tremendous harm to individuals and to society. Not the least, the authors
of this provocative book argue, is the inappropriate punitive reaction to a
largely mythical crack "epidemic." The much publicized war on drugs of the
1980s, which failed to stem the supply of crack or other illegal drugs, had
its origins in a misleading, medicalized view of drug abuse and in a
conservative ideology. As the editors assert, "Unemployment, poverty, urban
decay, school crises, crime, and all their attendant forms of human
troubles were spoken of and acted upon as if they were the result of
individual deviance, immorality, or weakness." In such a context, an
offensive was launched with the advent of crack in 1986 that did little to
help drug users and had numerous ill effects.

The authors of Crack in America may not convert any drug prohibitionists to
their view that "individual choices are influenced by social
circumstances." Nevertheless, they provide ample ammunition for those of us
who argue against drug wars and for new responses that focus foremost on
reduction of harm to society at large and to the marginalized populations
most at risk from drugs and the crossfire of drug wars.

We cannot radically reduce drug abuse until we begin to eliminate the
social conditions that foster it. An understanding of the complex social
factors involved is needed, not only to accurately describe the problem,
but also to formulate effective intervention strategies. To that end, this
book is very useful for policymakers, health care providers, and students
of medicine, social work, and public health. While it does not contain a
chapter on prevention or treatment for the minority of users who develop
serious addictions, its statements on the social and political contexts of
drugs in American society provide necessary background for all of us
working in the field.

Crack in America is a well-coordinated collection of 17 essays by an expert
panel of social scientists who believe that the dominant
psychopharmacological analysis of drug use has rationalized an approach
that deliberately ignores social factors. Two introductory essays by the
editors convincingly show how the media (including the televised appearance
of President Bush with a vial of the drug) exaggerated crack's dangers. The
media also created a public perception of illicit drugs as the nation's
preeminent problem at a time when the government was defunding social
programs addressing more prevalent issues. The editors argue that while
media attention, which included as many as 37 network news segments on
crack in July 1986 alone, may have had a perverse "advertising effect" on
use of the drug, still "lifetime prevalence of crack use began low and
declined thereafter." Citing figures from the National Institute of Drug
Abuse's National Household Survey, they show that by 1992 only about 3% of
18- to 34-year-olds had ever used crack, about 1% had used it in the year
preceding the survey, and less than 0.5% had used it in the prior month.

The book's central section assesses crack's "myths and realities" from a
variety of perspectives. One chapter reviews the scientific literature to
argue that powder cocaine and smoked crack do not have very different
effects on their users and that neither produces instant addiction as
claimed by numerous politicians, journalists, and even scientific
researchers. The more substantial differences are in the social profiles of
the users of cheap, mass-marketed crack vs the much more expensive powder
cocaine. Nevertheless, the demonizing of crack led to offensives against
its most vulnerable users, causing, through differential sentencing laws,
disproportionate incarceration of African Americans, who make up 15% of
American drug users but are half to two thirds of those imprisoned on drug
charges.

Three chapters are based on fieldwork. One stems from participant
observation in the underground economy of the crack business in New York
City. Another profiles the attempts of two cocaine users to free themselves
from dependence. Most useful, a chapter on "bingeing and addiction among
heavy cocaine smokers" provides insight drawn from interviews with the
users on the patterns of their use and implies that harm reduction
treatment approaches could extend the periods between binges among many
crack users. None of these empirically based studies, however, involves
large samples, nor do they include many women. More research needs to be
done using longitudinal and qualitative approaches that can penetrate more
deeply into the nature of crack use and other drugs. Qualitative research,
especially, will allow us to derive the meanings of the stories and
experiences of drug users. Such research, ultimately, will make it possible
to design better drug and other health and mental health treatment programs
that address sex and cultural issues and incorporate more fully
contextualized treatment approaches. Additionally, the differences in
psychology and social setting for female drug users make it critical that
treatment strategies for women be based on research that focuses on women
specifically, rather than extrapolating from existing data on male drug users.

A separate section examines why crack did not reach epidemic levels in
three comparable societies: Canada, Australia, and the Netherlands. The
Canadian experience may be most relevant, as Canada's proximity made supply
easiest and the heavy influence of the US media led the Canadian public to
expect a similar "plague." The authors suggest that the relative lack of
ghettoes in Canadian cities may be the determining factor in crack's
inability to find a market there. The negligible use of crack in the other
two societies makes them less enlightening models for understanding the
situation in the United States. However, the Netherlands has long had a
less punitive response to drug use, based on earlier alcohol use policies.
Decriminalization and an emphasis on harm reduction have had positive
results in the Netherlands in addressing problems related to other drugs.
For example, use of marijuana in the Netherlands is less prevalent than in
the United States, and needle exchange programs have largely prevented the
spread of the human immunodeficiency virus (HIV) among Dutch heroin users.
Furthermore, Canada, Australia, and the Netherlands have national health
programs and more extensive social services than the United States, which
makes it possible to treat people with drug problems in a context of health
care rather than law enforcement.

A third section of the book discusses the harmful impact of the American
drug war on civil liberties, and in the final section, the editors discuss
alternatives to the prohibition model for drug policy. They do not endorse
calls for a blanket legalization of drugs or expect changes of policy or
public opinion overnight. Instead, they seek to influence debate on drug
policy over the long run so that society can move toward gradual,
controlled decriminalization. In their view, there are now "signs of
significant undercurrents of opposition to U.S. drug policy at major
institutions of influence and power," including the media and the medical,
law enforcement, and public health professions. They note several African
American mayors, including Kurt Schmoke of Baltimore, Md, who espouse the
value of harm-reduction strategies, such as needle exchange programs, in
addressing problems caused by illegal drugs.

In 1995, $8.2 billion was spent on the federal drug war, yet resources for
treatment and prevention remain extremely limited. The authors describe a
mother who was prosecuted after giving birth for distributing cocaine to
her baby in the moments just after birth, but who was denied entry into
several day treatment programs while she was pregnant. In my own research
on drug use among poor, primarily African American and Latina women in New
York City, I interviewed a woman who was upset over testing negative for
HIV because, while drug treatment is often accessible for HIV-positive
individuals, none would be available for her.

Some recent figures indicate a waning in use of crack cocaine. While drug
prohibitionists may claim credit, the decline is far more likely the result
of a normal, cyclical pattern and the attendant buildups of publicity and
law enforcement. One author in this book argues that "preliminary evidence
suggests that initiation into crack use began to decline at precisely the
time—late 1989—when crack was cheapest and most abundant."

No one can deny the extensive damage to society caused by the effects of
drug abuse. My recent research, for instance, has found that 60% to 70% of
drug-using women are victims of spousal abuse, vs 21% to 34% in the general
population. What is clear is that the long-standing approach in the United
States of responding to illicit drugs by increasing law enforcement has
been wasteful of resources, ineffective, and even cruel. Creative,
innovative approaches are needed in applying harm reduction to the
recurrent problem of drugs in our society. What we need are drug treatment
programs in which the cornerstone is realistic education about drugs and
their outcomes. These programs must focus on the full context of drug use,
including economic, social, and sex-specific factors, and not just on use
of drugs per se. The public has supported the use of methadone in treatment
of heroin addiction and can be persuaded of the value of other
harm-reduction approaches. Schools, churches, and the media all need to
enlist in spreading knowledge-based information and awareness of the value
of socially constructed knowledge in understanding drugs in our society.

A shortcoming of Crack in America is its lack of reference to how the
movement toward managed care and cutbacks in social programs through
welfare reform will affect those in need of drug treatment. Current
research has shown that large proportions of drug users are found in the
criminal justice, primary health, and welfare systems. With more people
being dropped from welfare rolls and losing associated health insurance
benefits, we need to devise means of intervention before they are
encountered in the criminal justice system. Additionally, research is
needed into the particular difficulties current and former drug users may
face finding the jobs required by new welfare policies.

Access to treatment and the maintenance of an array of services is
critical. Family, medical, economic, and social problems all need to be
addressed together if inroads are to be made into the damage caused to
individuals and to society by illegal drugs. To have more such effective
programs, we need extensive changes in our public policy and our politics.
For those changes to begin to seem possible, we need research and social
and political analysis like that presented in this book.

Nabila El-Bassel, DSW Columbia University School of Social Work New York, NY

© 1995-1998 American Medical Association.