Does “Public Health” Really Want To Own Addiction?

Editor’s Note: Guest blogger and medical anthropologist Kim Sue returned from a recent conference entitled “From Punishment to Wellness: A Public Health Approach to Women and the War on Drugs” with some questions about the coherence of the public health paradigm.

To celebrate the release of a joint report published by the New York Academy of Medicine (NYAM) and the Drug Policy Alliance (DPA) entitled a Blueprint for a Public Health and Safety Approach to Drug Policy, WORTH (Women on The Rise Telling Herstory) organized a conference focusing on women and the War on Drugs. The conference brought together formerly incarcerated women, direct service providers, researchers, policy analysts, and advocates and activists to discuss how to move from a criminalization model of drug use to a public health model. “The war on drugs is more than a failure,” the organizers announced. “It has swollen the prison system, left millions of people with criminal records and damaged communities.” The one-day event was aimed at exploring “practical examples of public health alternatives,” through discussions around four main themes: prevention, treatment, harm reduction, and safety.

Thinking through public health at the New York Academy of Medicine.
Thinking through public health at the New York Academy of Medicine.

What was interesting to me during the panel sessions and the break-out groups was the relative absence of public health professionals and clinicians in these discussions (one notable exception was Professor Lynn Roberts of Hunter College’s Department of Community Health). While “public health” was one of the buzzwords of the day, it seemed to stand in for other things that the conference attendees were actually more interested in talking about: structural violence, poverty, racism, patriarchy—often referred to as the “structural determinants of health.” One possibility is that “public health” was being used rhetorically as a means to talk publicly and politically about race, class, gender and various axes of social inequality under “public health’s” cloak of respectability.

There was some discussion of specific legislation and public-health oriented programming by several of the speakers—for example, Good Samaritan Acts, needle exchange programs, the decriminalization of sex work, and bills against the criminalization of HIV status—but the conference neglected how the massive apparatus of the War on Drugs endeavor will be “public health-ified” on a large scale. What will be the unintended consequences of doing so?

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The Points Interview — Kathleen J. Frydl

Editor’s Note: Kathleen Frydl’s new book, The Drug Wars in America, 1940-1973, is just out from Cambridge University Press. Points welcomes her timely and enlightening interview.

Frydl-book-cover 1.  Describe your book in terms your bartender could understand.

I tell the story of how and why the US government became “addicted” to the modern drug war, choosing prohibition and punishment over treatment and regulation. I argue that the logic behind the particular shape and targets of the drug war (including that which was not targeted) had less to do with crime or addiction, and more to do with the management of state power.

2.  What do you think a bunch of drug and alcohol historians might find particularly interesting about your book?

To be honest, probably not that much. At several points, I rely on that scholarship, but I can’t say that I actually contribute to it. For readers of this blog, it might be interesting — maybe even troubling, but hopefully stimulating — to hear the story of the drug war narrated through a different voice.  I hope it is viewed as a complement to the literature.

That said, there are some parts of the book that may be of interest. In chapter 5, I argue that methadone clinics lost support for a variety of reasons. Proponents of punishment, recovery movements, and various groups on the left imposed standard medical — as opposed to public health — criteria on maintenance: built around “a crisis followed by a cure” paradigm. This is somewhat different from the goals of harm reduction. Under this more demanding paradigm, the fact that every recovery victory could be celebrated  compensated believers for so much failure. In the public health lens, on the other hand, successful maintenance meant only less to be dismayed about. The outcomes were not so heroic and the narrative not so redemptive. Whether it was the Black Panthers or traditional recovery movements, certain advocates criticized maintenance precisely because it staved off the “crisis” which they felt was needed in order to proceed to the “cure,” whether that cure was sobriety or revolution in the inner city.

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Reflections on Addicts Who Survived: How to Survive a Farce

Actually, he said: “Hegel remark somewhere that all facts and personages of great importance in world history occur, as it were, twice. He forgot to add: the first time as tragedy, the second as farce,” but as with Hegel, sometimes a paraphrase works better.
Actually, he said: “Hegel remarks somewhere that all facts and personages of great importance in world history occur, as it were, twice. He forgot to add: the first time as tragedy, the second as farce,” but as with Hegel, sometimes a paraphrase works better.

Karl Marx is credited with observing that, “history repeats itself, first as tragedy, second as farce.” It is hard not to remember this insight when reading the brilliant Addicts Who Survived two decades after its initial publication. After all, the year the book was published, 1989, was the same year Bush Sr. announced that the $2400 bag of crack he had in his hand was purchased (gasp!) directly across from the White House. Of course, the dealer – a high school student – had been lured to that spot by DEA agents in order to produce the theatrical prop. In the years preceding this stunt, crack had entered the public consciousness as it burned through poor inner city communities. The government had responded by setting mandatory minimum sentences for drug offenses and creating a legal disparity between crack and cocaine that led to imprisonment of the most vulnerable and stigmatized drug users. Meanwhile, HIV/AIDS rates were ballooning exponentially, and injection drug use was increasingly the mode of transmission. The most popular response to the problems associated with drug use and addiction was Nancy Reagan’s 1984 campaign to “Just Say No.” Her husband remained silent on the subject of AIDS until 1985, when he expressed skepticism about allowing HIV-positive children to attend school. Although early forms of harm reduction were emerging in the UK and junkies were unionizing in the Netherlands, the movement did not take significant form in the US until the mid- to late-1980s.

bush crack cocaine-aacdfdc0955188a5f3889c1fc18791ffda8e7079-s6-c10
The War on Drugs: The Farcical Years. When asked to go to the White House to sell his crack, the dealer said, “Where the fuck is the White House?”
first-ladies-reagan
The War on Drugs; the farcical years. Just Say NO: right-O.

So when I bring Marx’s quote to mind, it is with the painful recognition that every farce is still a tragedy.Read More »

Setting the Record Straight, Part 5: A Disease They Didn’t Have

Editor’s note: Today marks the final installment of guest blogger Marcus Chatfield’s eye-opening exploration of the role that peer-reviewed research played in facilitating the survival of Straight Inc. into the 1990s, as well as its ongoing legacy in coercive youth drug abuse treatment.

In the 1989 Journal of Substance Abuse Treatment article “Outcome of a Unique Youth Drug Abuse Program: A Follow-up Study of Clients of Straight Inc.”, Alfred S. Friedman, Richard Schwartz, and Arlene Utada state that 99 percent of Straight’s clients were white and that 30 percent of clients attended church regularly prior to intake. It is relevant to consider the type of teens that were recruited for “treatment,” as well as how they were recruited for treatment and why their parents placed them in Straight. Notably, several authors have reported that many clients at Straight were treated for a disease they didn’t have. This was due in large part to Straight’s assertion that even the experimental use of alcohol or marijuana was the symptom of a disease. And because this disease was the cause of even initial drug use, treatment was required whether teens had experimented with drugs or not. Many clients in Straight were “dry druggies” who had never used an illegal substance but were displaying “druggie behavior.”

Spot the druggies.
Spot the druggies.

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The Points Interview — Edgar-André Montigny

Editor’s Note:  Edgar-André Montigny’s edited volume, The Real Dope: Social, Legal, and Historial Perspectives on the Regulation of Drugs in Canada (University of Toronto Press, 2011) takes the spotlight today.

The Real Dope1.  Describe your book in terms your bartender would understand.

The Real Dope is a collection of scholarly articles exploring how the government and society in general have dealt with various drugs, from alcohol and tobacco to ecstasy and LSD. The articles introduce us to 19th-century moral reformers, 1920s flappers, downtown Vancouver heroin addicts, psychology professors, hippies, glue-sniffing high school students, ravers, post-war government officials and senators, all interacting in some way with intoxicating substances through using, studying or regulating them.

2.  What do you think a bunch of alcohol historians might find particularly interesting about this book?

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Setting the Record Straight, Part 4

Editor’s note: Marcus Chatfield continues his series on Straight, Inc., the coercive treatment program for children and teens suspected of drug use that flourished with White House and NIDA support in the 1980s. In today’s entry, Marcus breaks down the flaws in the peer-reviewed research that helped cement this official legitimacy.

In “Outcome of a Unique Youth Drug Abuse Program: A Follow-up Study of Clients of Straight Inc.” (1989), Alfred S. Friedman, Richard Schwartz, and Arlene Utada claim that their report will include: “(1) the description of the study sample, (2) the outcome of the improvement that occurred between intake and follow-up, (3) the comparison of the outcome between graduates and ‘dropouts,’ and (4) the relationship of the amount of time in treatment to treatment outcome.”

"This report is in fulfillment of NIDA Professional Services Contract #64986."
In their sights.

However, in each of these areas the study is flawed: (a) their description of the study sample reveals major problems, such as selective sampling; (b) the intake-to-follow-up comparisons show limited correlation and also, the authors state that they are meant to measure outcome of improvement rather than actual outcome; (c) they completely fail to discuss their promised comparisons between graduates and dropouts (they also claim to discuss a comparison between “respondents” and “nonrespondents” and then omit this comparison as well); and (d) perhaps most importantly, but left unexplained, they found that “time in treatment” had no effect on drug use reductions. Read More »

Setting the Record Straight, Part 3

Editor’s note: Today Marcus Chatfield continues his series on Straight Inc., the involuntary treatment program for adolescents suspected of drug use that operated in several states between the 1970s and 1990s. Parts 1 and 2 of the series can be found here and here.

In Help at Any Cost (2006), Maia Szalavitz reveals some of the troubling history of coercive programs. The sub-title of her book is, “How the Troubled Teen Industry Cons Parents and Hurts Kids,” and this is one of the hardest things for a survivor to describe – the deceit that protects abusive programs. Dr. Charles Huffine writes, “I cannot tell you how many youth I’ve been in contact with that do not tell their family about the painful aspects of their experiences for fear of making their family feel bad — though I can say they number in the majority. All too frequently, simply, they did not know they were abused, or worse, that the abuse was justified and necessary for them to ‘get better.’”

Straight-inspired TV movie Not My Kid (1985). Spoiler alert: they got their kid back.
Straight-inspired TV movie Not My Kid (1985). Spoiler alert: they got their kid back.

Tough-love programs often ritualize emotional testimonies and require testimony about conversion experiences as a prerequisite for release from treatment. Because there is no scientific evidence to validate the safety and efficacy of coercive methods, these anecdotes are the “hook” that this multi-billion dollar industry is built upon. Many victims of thought-reform treatments, like victims of domestic violence, will defend their captors as a self-protective survival response. Similar to abusive dynamics in families, when people are beaten down long enough they may believe it’s normal, deserved, and even good for them. As one former staff member of the program said to me recently, “at the time I graduated I was so duped into believing that I’d been helped, I couldn’t even begin to see the damage caused to me.”

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Failed Frontlash: How Liberals Furthered the Case for Mass Incarceration

The response to the Civil Rights Movement initiated one of the most punitive interventions in United States history. Beginning with the Law Enforcement Assistance Act of 1965 and onward, the state took on a new role in crime and drug control. State and federal governments revised their criminal codes, imposing mandatory minimums and effectively abolishing parole. Moreover, juveniles were now incarcerated in adult prisons, chain gangs returned—as did a malicious policy of felon disenfranchisement—all while prison rates soared, increasing six-fold between 1973 and the turn of the century.

ImageCompared to its advanced industrial counterparts, the United States imprisons at least five times more of its citizens per capita. Are we inherently more criminal than other nations? Or, do we manufacture criminality? For the most part, the United States and most other human societies across time and space have always had problems with drugs and crime. This is not unique. How the United States has chosen to combat said problem, as well as its unfortunate results, are unique. Legal scholar Jonathan Simon argues that in the United States, crime has become “a, if not the, defining problem of government.” How did we get here?

Vesla Mae Weaver’s work—particularly her use of “frontlash”—offers some important clues to understanding the punitive impulse.  Read More »

The American Disease: Still Learning?

Editor’s Note: This week’s symposium marking the 40th anniversary of David F. Musto’s The American Disease continues today with a reflection by Joe Spillane, managing editor emeritus of Points and Associate Professor of History at the University of Florida. Joe’s discussion illuminates the breadth of a scholar’s engagement with a major work in his field, ranging from deep immersion in the footnotes to meditations on the structure of Musto’s argument in relation to dominant historical ideas of its day.

The first drug history book I owned was David Musto’s The American Disease.  I purchased the second edition (actually the first expanded edition) not long after it appeared in 1987. Musto’s footnotes were for me, as they had been for David Courtwright more than a decade earlier, loaded with clues as to how and where I might further mine the early history of drug control in the United States. I cannot express just how important those notes were–not only were they the only really comprehensive survey of historical source material, they offered comforting reassurance that I was not alone in my particular scholarly interest. Twenty-five years later, that expanded edition (paperback, of course) is still the one on my shelf to which I turn as a first reference; the majority of pages have at least some notation, and the folded corners, post-it notes, and margin comments serve as a record of my one-way conversation with David Musto over many years.

Scrutiny rewarded.
Scrutiny rewarded.

It took a long time for me to stop thinking about The American Disease solely as a reference volume, and come to grips instead with Musto’s argument. At the heart of the volume is a notion that American drug history is marked by series of cycles of tolerance and intolerance for drug use. Those cycles are partly learning cycles–or, more correctly, cycles of learning and forgetting. As I’ve noted before, I had always intended to ask David where his notion of cycles came from. To some extent, it seems drawn fairly directly from mid-century social learning theory. Here, the process of “learning” about the harms of particular drug use tend to fade away, which leads to a forgetting of what had been learned. This forgetting, in turn, produces a new round of consumption, the harms of which produce a new round of learning.

To this relatively straightforward (though highly disputable) social learning model, however, Musto added a layer focused on emotions and fear. In truth, this argument became clearer in the 1987 edition of the work–no doubt because of the remarkable social and political changes Musto observed in the years following the first edition’s appearance. In a 1991 Scientific American article, Musto concluded: “Americans seem to be the least likely of any people to accept the inevitability of historical cycles. Yet if we do not appreciate our history, we may again become captive to the powerful emotions [emphasis mine] that led to draconian penalties, exaggeration, or silence.” Emotions are the key. Musto was arguing that people respond to drug use with powerful emotions that come from equally powerful cultural dispositions, and that these emotions lead us from the objective response to the visceral, sometimes dangerously so, before the objective pulls us back again, and so on. As (again) I have written before, this argument sounds an awful lot like Richard Hofstadter’s mid-century emphasis on the non-rational aspects of populist and progressive movements, or perhaps John Higham’s portrait of the cycles of nativism in 1954’s Strangers in the Land, or even Andrew Sinclair’s 1962 account of Prohibition in America, Prohibition: The Era of Excess (to which Hofstadter contributed the Preface).

The cycles of emotional reaction argument.
The cycles of emotional reaction argument.

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Coca: The Survival of a Drug of the Dispossessed

In the beginning of this year, Bolivia gained the right to re-access the United Nations Single Convention on Narcotic Drugs with a reservation concerning the prohibition of the chewing of coca leaves. This is a small but perhaps not unimportant victory against the global War on Drugs. Especially it means some recognition of the right of indigenous people, the dispossessed of the earth, to their own drug use.

Bolivian woman protests against UN report on coca
Bolivian woman protests against UN report on coca

In my blog of 11 June 2012 I discussed how the knowledge of coca use among the Indians of Spanish America was disseminated by, among others, the buccaneers and pirates of the later seventeenth century. As a collateral result of their plunder voyages on the Spanish Main some of the Brethren of the Coast became key informants on American drugs for the botanists and trading companies of Western Europa. Some of these drugs became export products to the rest of the world, with varying commercial results. Coca, for some reason, didn’t. Was there in Europe in the early modern period no need for a drug that gave a slight stimulation throughout the day? Or did a drug used, not by wild and exotic Indian savages firing the imagination of European armchair adventurers, but used by poor Indian slaves adjusting themselves to Spanish tyranny, fail to have the necessary sexiness to be adopted in the lifestyles of Europeans? Was it just the case that Europeans weren’t used to and didn’t like the method of consumption of coca, chewing the leaves until their teeth turned green? Or was it a matter of too complicated logistics to export the leaves to Europe in a state of some potency?Read More »