Drugs+don't+kill,+society+does

**// ARTEFACT //**
(Francisco, 1997)

This cartoon was created by Sean Francisco in 1997 during the American war on drugs. Francisco eludes to the fact that by ending harm minimisation strategies and implementing a zero tolerance prohibitionist approach, the war on drugs will be won essentially by killing off all drug users, eradicating the problem all together. The cartoon is satirical also suggesting that harm minimsation strategies that were previously in place (ie. education and needle exchange) were successful in preventing these major health issues by alluding to the fact that if removed “they all die’.

**// PUBLIC HEALTH ISSUE //**
The cartoon represents the major public health issue relating to the implementation of drug strategies. Both abstinence and harm minismation have benefits and disadvantages however as the artefact and current studies suggest, harm minimisation produces better health outcomes for the wider population (Lenngings, 2000, p59). To address the public health issue, it is necessary to examine the effects of prohibition, such as an increase in crime, incarceration, blood borne disease and eventually death and the impact that harm minismation strategies can positively address these concerns.

**// LITERATURE REVIEW //**
In an attempt to decrease the prevalence and health effects of drug use, Australia has previously implemented both abstinence based and harm minimisation policies. However, when comparing the Australian data recorded during these periods of differing strategies and investigating international statistics relating to the effects of implementation of policies, the disadvantages of prohibition and merits of harm minimisation become clear.

Whilst generally emphasizing a harm minimisation approach, the liberal government of the late 90’s began to strongly emulate the United States ‘war on drugs’ approach (Norman, 2001, p23). Howard (1999) argued that illicit drugs are highly dangerous with no safe level of use defining it as an immoral criminal behaviour (Medes, 2008, p56). However there were major social and health costs as a result of this policy. During Howard government in 1998-1999 the social cost of drugs was estimated to be $34.5 million, 53% of which were tangible costs associated with crime, loss of productivity and health care (Commonwealth Department of Human Services and Health, 2002).
 * __ Abstinence Policy __**

An interesting statement by Mugford in Lenton (1996) examines the connection between these social/health harms and availability of drugs. He suggests that harm is maximised at the extremes of availability, and that if a substance is prohibited, harm will result from the illicit market, crime, contaminated substances and expensive and intrusive law enforcement (Norman, 2001, p25). This statement is supported by epidemiological evidence and related health statistics during abstinence governed periods which will be discussed below.

Harsh prohibition laws began in the mid 1980’s and resulted in an incarceration boom with prisoner populations rising extremely from 1982 to 2000 (Jiggens, 2005, p5) as seen in figure 1.


 * Figure 1. Prison population rates per 100 000 population in Australia **
 * source: Jiggens, 2005, p5 **

Furthermore the cost of drug law enforcement during this time grew from $140million to $720million (Jiggens, 2005, p13) and had a massive impact on black market drug prices inflating the value of the cannabis market from $550million in 1982 to $3200million in 1998 (Jiggens, 2005, p13). This data emphasises the effect of supply side solutions (prohibition) on drug prices and how these rising prices increase criminal behaviour associated with drug use and as such, law enforcement and the overall social and health costs of drug use (Jiggens, 2005, p13). The health risks associated with cannabis use are less fatal than other illicit drugs and so most costs are associated with crime and incarceration, however, black market heroin can be incredibly impure and only a low dosage can produce a lethal overdose (Jiggens, 2005, p14). The Australian war on drugs primarily targeted cannabis, resulting in a national shortage. This created a heroin plague and as probation caused heavy reliance on black market drugs, fatal overdose from impure heroin use in Australia skyrocketed under this harsh policy as seen in figure 2.


 * Figure 2. **
 * source: Jiggens, 2005, p14 **

It is also necessary to consider global patterns under abstinence-based strategies to fully understand the importance of drug policy for public health. For example, world leader in prohibition, Sweden, currently implements multiple abstinence-based strategies to achieve their goal of a ‘narcotics-free Sweden. These include criminalising use, possession and trafficking, which are all subject to the same penalites (Hugehes & Wodak, 2012, p2). However, this policy has not had the desired effect with problematic drug use, drug induced deaths and drug offences all increasing and the rate of HIV cases numbers remaining stable. Furthermore, a report written by the Global Commission on Drug Policy discusses the effect that prohibition has on HIV/AIDS. The Commission (2012) says that the global war on drugs is driving a disease pandemic as it “forces drug users away from public health services and into hidden environments where risk becomes markedly elevated” as well as the mass incarceration of drug offenders into prisons with little HIV prevention measures (Global Commission On Drug Policy, 2012, p2). For example, Thailand has maintained a consistent war-on-drugs approach to illicit drug use and whilst HIV prevalence across other risk associated behaviours has decreased over time, infections related to injecting drug uses has increased dramatically since 2007 (see figure 3) after the 2003 crackdown on drug dealers which resulted in 2500 deaths (Global Commission on Drug Policy, 2012, p9).

It is clearly evident that whilst abstinence-based strategies have the right idea of eliminating drug related health harms, both social and health costs are inflated.
 * Figure 3: Estimated HIV prevalence amoung different risk groups in Thaliand **
 * Source: Thailand Bureau of Epidemiology cited in Global Commission on Drug Policy, 2012, p9 **

Harm minimisation is the alternative policy to prohibition and Mendes has effectively summarised the major differences between the two stating that the former aims to save lives and reduce drug-related harm even if overall use increase whereas prohibition seeks to reduce drug use even if the number of deaths increase (Mendes, 2008, p59). Harm minimisation does embrace abstinence as the desired outcome but acknowledges that it is unrealistic in many cases due to the nature of drug use which will be discussed later, and acts under 3 pillars: demand, supply and harm reduction. These pillars combine preventative, educational and harm reducing strategies to combat drug use and its associated risks (Ministerial Council on Drug Strategy, 2010, p2). Notable evidence based strategies involved with harm minismation include methadone maintenance programs, needle/syringe programs (NSP), safe injecting rooms and education on safe drug practices. The major effect that this policy can have on a society is clearly seen through the related data available from areas where such strategies are implemented. For example, the current New South Wales NSP has effectively prevented over 32 000 new HIV and over 95 000 HVC infections since its trial began in 2009 (Department of Health and Ageing, 2009, p14). Merits of harm minimisation can also be seen internationally. British Columbia responded to an explosive injecting drug user HIV epidemic in the mid 1990s with antiretroviral therapy, opiod substitution (including heroin prescription), syringe programs and safe injecting facilities resulting in major declines in HIV incidence and death from AIDS as seen in figure 4 (Global Commission on Drug Policy, 2012, p10)
 * __ Harm Minimisation policy __**


 * Figure 4: Decline in new HIV cases attributable to drug injecting in British Columbia coinciding with public helath interventions. **
 * Source: BC centre for Disease Control/Excellence in HIV/AIDS cited in Global Commission on Drug Policy, 2012, p11 **

There are however some limitations to harm minimisation strategies, especially surrounding the methodologies involved in implementation of programs. For example, the Kings Cross Medically Supervised Injecting Centre (MSIC) has undergone continuous study on its effectiveness. Beek (2003) found that whilst the MSIC was appropriate in producing effective harm reducing results in Kings Cross and the area that it serviced, these results may not necessary translate in other areas and considerations of local socio-cultural and political circumstances must be applied when designing such models (Beek, 2003, p636). However, the national and international data clearly shows that harm minimisation is far more effective than abstinence-based policy at reducing the risks associated with drug use and minimising both social and health related harms. The success of harm minimisation policy on minimising drug related harms can be explained by understanding social theory and the forces behind drug use and behavior.

**// CULTURAL AND SOCIAL ANALYSIS //**
Before discussing the importance that social theory plays in regards to the choice of drug use policy, the anthropological data available must be addressed. The National Drug report of 2011 found that two out of five people in Australia currently use drugs (Australian Institute of Health and Welfare, 2011, p27). Furthermore, four social/cultural groups were found to have the highest rates of partaking in drug related behaviour. These are those who identify as homosexual/bisexual, Indigenous Australians, the Unemployed and those of lower social economic status, as seen in figure 5. Social theory can help to explain why identifying as a part of these groups can increase risk of drug use and as such, understanding these theories play a major role in policy implementation


 * Figure 5: Prevalence of drug use in relation to social groups in Australia **
 * Source: Australian Institute of Health and Welfare, 2011, p27 **

To understand the theories, the paradigms underpinning them should be acknowledged. Structural Functionalism, shaped by Comte, Durkheim and Talcott-Parsons, which focuses on macro forces, suggests that societal agreement on moral values and conformity create a smooth functioning society and that too much conflict or deviation can take away from this stability (Anderson, 2007, p5). Structural-functionalists believe that anomie and alienation are the result of this breakdown or dysfunction of society (Anomie, 2010). The high risk groups identified previously challenge the stability of a conformist society by deviating from the norms, for example – being unemployed or straying from heteronormativity and as a result, are alienated from society.

Another important paradigm is social-conflict, whose theories discuss the conflict that arises due to material and immaterial inequities. This model believes that society is structured by those with the most power, wealth and social/economic/cultural assets (Anderson, 2007, p7). It also suggests alienation as a result of these inequities and theorizes that deviance is a common response to deal with negative social labeling and feelings of rejection. This alienation is an important concept to help explain the large prevalence of drug use in social minorities within Australia’s population, however social theories, including labeling theory and strain theory are able to examine this at a deeper lever and will be discussed below.

A critical social theory in the debate of abstinence vs harm minimisation is the Labelling Theory. This theory, derived from social interactionists such as Hughes, Becker, Lemert, Goffman, Matza, Brown and Denzin, speculates that negative social reactions (such as stigma and labeling) derived from the anomie explained earlier in regards to structural functionism facilitates drug use rather than hindering it (Anderson, 2007, p10). It also looks at this deviant behaviour as a type of career and suggests that stigmatisation increases the likelihood that individuals will adopt deviant identities or roles and will become “greatly enmeshed in deviant careers” (Anderson, 2007, p10). This theory argues that the degree of otherness placed upon those social groups at highest risk and the drug users themselves only increases the prevalence of drug abuse. Abstinence based policy stems from the idea that drug use is an individual choice, “suggests a degree of helplessness on the part of the drug user in the face of the drug” and implies a strong moral disapproval of drug users (Lennings, 2000, p58). This policy does not acknowledge those groups who are at higher risk due to this alienation and therefore the harms of drug use under prohibition are also disproportionately borne by those groups of lower status (MacCoun & Reuter, 2011, p64).
 * __ Social Theories __**

Another important theory relating to the anthropological data is the Strain theory. Merton (1958) discussed the phenomena of unequal opportunity: that some educational and economic opportunities were not equally available to all and that access to these opportunities relied on status, including; occupation, neighborhood, age, sex, race, education and religion (Anderson, 2007, p29). Therefore, social groups with lower degrees of status experienced more Anomie, or strain, and as such, responded in different ways, one of which being deviance and social retreat involving behaviours such as drug use. Harm minimisation policy, unlike abstinence policy discussed above, seeks to reduce anoime (Anderson, 2007, p13) by taking a morally neutral approach to drug use recognising the importance of treating drug users as normal citizens with the same rights as other community members (Mendes, 2008, p57). Lennings (2000) states that harm minimisation acknowledges the impact of societal forces such as poverty, cultural and sexuality on drug use and as such, reduces strain by implementing strategies targeted at those social groups with highest risk. This focus decreases drug related health and societal harms.

Therefore, with this understanding of social theory and the forces behind drug use and prevalence in Australia, it is clear to see that harm minimisation policy is far more appropriate to address the public health issues associated with drugs and society.

**// ANALYSIS OF THE ARTEFACT AND LEARNING REFLECTIONS //**
The cultural artefact chosen gives a clear and somewhat frank representation of the health implications relating to the two main policies that can be implemented to address the public health issue of drug use. Whilst created to address the American ‘War on Drugs’ at the time, the message clearly transmits to Australian society and its debate on drug policy. The satire of the comic, which suggests that a prohibitionist or abstinence approach will win the war on drugs simply by killing off all those associated, was found to have an underlying honesty. Drug related harm, as insinuated in the comic, was found to greatly increase under this policy, whereas harm minimisation strategies are able to acknowledge social theory and help to significantly reduce societal and health issues.

To me, the comic represents that ‘quick fix’ ideal of many modern governments wanting to be able to show they are producing results no matter who suffers as a result. Harm minimisation is both socially and politically a more controversial and tougher policy to implement due to the moral panic associated with ‘drug condoning’ strategies, however, the society as a whole benefits far greater. Understanding the inequities that predispose drug related behaviour has influenced my thinking in relation to all criminal behaviour, the harsh labels that these social groups endure and the harmful results of this otherness upon their communities. These inequalities possibly generate many other major public health issues and I believe that looking to decrease these disparities should be a vital focus of public policy.

**// REFERENCES //**
Anderson, T. (2007). //Chapter 6. Sociological Theories of Drug Abuse// (unpublished thesis). University of Delware, Newark, DE. Anomie (2010). In // Encyclopedia of Identity. // Retrieved October 27, 2013 From [] Australian Institute of Health and Welfare. (2011). // 2010 National Drug Strategy Household Survey Report. // Retrieved from [] Beek, I. (2003). The Sydney Medically Supervised Injecting Centre: A clinical model. // Jounral of Drug Issues, 33 // (3). 625-638, retrieved from [] Collins, D., Lapsley, H, Commonwealth Department of Health and Ageing. (2002). //Counting the cost: estimates of the social costs of drug abuse in Australia in 1998-9.// Retrieved from The Australian Government Department of Health website [] Collins, D., Lapsley, H. Commonwealth Department of Human Services and Health (1996). //The social costs of drug abuse in Australia in 1988 and 1992.// Retrieved from The Australian Government Department of Health website [] Francisco, S. (1997). //Methadone Today, January 1998// [Image]. Retrieved October 21, 2013, from [] Global Commission on Drug Policy. (2012). //The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic.// Retrieved from the Global Commission on Drugs Organisation webstie [] Hughes, C., Wodak, A., Australia21. (2012). //A Background Paper for an Australia21 Roundtable: What can Australia learn from different approaches to drugs in Europe including especially Portugal, Switzerland, the Netherlands and Sweden?.// Retrieved from [] Jiggens, J. (2005, October). //The Cost of Drug Prohibition in Australia//. Paper presented at the Social Change in the 21st Century Conference. Retrieved from [] Lennings, C. (2000). Harm minimization or abstinence: an evaluation of current policies and practices in the treatment and control of intravenous drug using groups in Australia. //Journal of Disability and Rehabilitation, 22//(1), 57-64. Retrieved from [] MacCoun, R., Reuter, P. (2011). Assessing Dru Prohibition and Its Alternatives: A Guide for Agnostics. //Annual Review of Law and Social Science, 21//(52), 61-78. Doi: 10.1146/annurev-lawsocsci-1025105442 Medes, P. (2008). Fighting the Drugs War: The role of prohibitionist groups in Australian illicit drugs policy. //Dissent, 1//(26), 56-68. Retrieved from [] Ministerial Council on Drug Strategy. (2010). //National Drug Strategy 2010-2015: A framework for action on alcohol, tobacco and other drugs.// Retrieved from the National Drug Strategy website []