DRUG TRIAL: DEFENDING THE PUBLIC HEALTH TRADEMARK

Public health is concerned with the well-being of populations and therefore
shares with medicine the goal of reducing suffering due to disease. But
its "patient" is the community and its measure of successful "treatment" is
the reduction of collective morbidity and mortality, usually measured in
terms of prevention. Indeed, clinical medicine exists as a function of
public health's failure: It treats the casualties of unhealthy social
policy and poor public health practice.

The problem with public health comes from its close historical association
with clinical medicine, i.e., an over-reliance on the disease model. While
a perfectly appropriate way of understanding the course and characteristics
of individual illness, the disease model is only a small part of what is
required to appreciate the complex biological and social circumstances that
contribute to morbidity and mortality. Many critics of the public health
perspective fail to distinguish its perspective from that of medicine.
Workplace injuries, highway accidents, and home poisonings are not
diseases, but they are well understood (and prevented) using a public
health model.

When it comes to drugs, public health data usually focus on the most
negative outcomes (disease and death) and the "hard realities" of drug use:
addiction, overdose, AIDS, crime, domestic violence. But this is only part
of the picture. In the vast majority of cases, the positive aspects of
drug use, such as psychological benefits and social involvements, outweigh
any harm. Because of the stigma attached to illegal drug use, these "soft
realities" are largely ignored in public discourse. But they can be
inferred from public health data.

While tens of millions of Americans have used illicit drugs - 70 to 80
million marijuana, 40 million cocaine, and 20 million heroin - the number
of heavy or problematic users is only 5 percent to 10 percent of those
figures, similar to the proportion seen with alcohol. Public health data
on moderate alcohol use (one or two drinks per day) suggest it is not only
harmless but actually beneficial. I suspect a similar case could be made
for other drugs, which are often used (successfully) to "self-medicate
anxiety, depression, and attentional difficulties.

Through public health data we can also see that, despite an overall
reduction in the number of drug users during the most vigorous prosecution
of the war on drugs, from 1972 on, the consequences of drug use have
generally gotten worse: There has been an absolute increase in drug-related
health problems such as AIDS and overdose deaths. Meanwhile, the huge
economic and social costs of massive incarceration and criminalization
associated with drug prohibition generate a cascade of adverse consequences
in the targeted communities. These are consequences not of drug use but of
drug policy. And it is public health methods that make them visible to the
naked eye.

So who could be against public health? Well, for a start, our gracious
editorial host, Jacob Sullum. His forthcoming book about America's current
"war on tobacco" bears the subtitle The Tyranny of Public Health. The
phrase is provocative, suggesting that public health could operate contrary
to the public interest, and possibly oxymoronic, since most of us who work
in the field are impressed by our relative powerlessness to affect
policies. But it does capture something of the battle for the right to use
the "trademark" of public health: One can cite many moralistic (and often
useless) restrictions imposed on victims of past epidemics in the name of
public health, or the contemporary use of imaginary or overblown health
risks to exert social control, as in bans on smoking in outdoor spaces.

On the face of it, any public which is fully and accurately informed of a
serious risk to its collective well-being may fairly decide that it wishes
to protect itself and restrict the freedom of some individuals to achieve
that goal. But if the advocates of drug prohibition want to justify their
position on public health grounds, why do they consistently overlook public
health data suggesting measures that might actually save lives? The
continued ban on the use of federal funds for needle-exchange programs, for
example, defies a large body of scientific literature demonstrating their
efficacy and ignores the recommendations of multiple expert commissions.
As a consequence of this failed policy, my colleague Peter Lurie and I
estimate, 10,000 to 20,000 preventable AIDS cases have occurred in the
United States.

The message of history is that most people are willing to forgo some
individual freedom for the larger good if the threat is real, the process
is fair, and the response is effective at saving lives - as with confining
or isolating carriers of easily infectious diseases such as typhoid or
bubonic plague. These examples seem to me the opposite of tyranny. But
current attempts to justify our demonstrably unhealthy drug policies in
public health or medical terms make a mockery of both professions, whose
best efforts are sorely needed to deal with our all-too-real drug problems.

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