The Drug War is very unhealthy. On March 24th, 2016, the John-Hopkins-Lancet Commission on Drug Policy and Health published its report on the negative health consequences of the War on Drugs: Public Health and International Drug Policy. In short, the Drug War, generally supported by claims that drugs are harmful and therefore draconian prohibition and criminalization laws are necessary to protect us, is far worse for global health than the drugs themselves. The John-Hopkins-Lancet Commission, cochaired by Professor Adeeba Kamarulzaman of the University of Malaya and Professor Michel Kazatchkine, the UN Special Envoy for HIV/AIDS in Eastern Europe and Central Asia, is composed of experts from throughout the world representing diverse disciplines, professions and nations. The Commission reviewed scientific evidence on the impact of prohibitionist drug policies on global health and human rights. It produced its 54 page report, densely supported by some 432 footnotes, in preparation of the upcoming April 2016 UN General Assembly Special Session (UNGASS) on drugs. The Report calls for a humane and reasonable drug policy based on sound scientific evidence of the most healthful practices:
We urge health professionals in all countries to inform themselves and join debates on drug policy at all levels. True to the stated goals of the international drug-control regime, it is possible to have drug policy that contributes to the health and wellbeing of humankind, but not without bringing to bear the evidence of the health sciences and the voices of health professionals. P.4.
Drug War Stories supports that call.
What follows are extensive excerpts from the Report, however, it deserves a full reading and we urge you to read it. Public policy should not be based on fear, but on principles of public good and doing what is in our best interest. The War on Drugs is unhealthy. The cure is ending the policy of prohibition and criminalization.
The Commission is concerned that drug policies are often coloured by ideas about drug use and dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug misuse. P.1.
The Report focused on a number of negative consequences of drug prohibition on health and well-being, including increased criminal and police/military violence; increases in HIV and Hepatitis C; racial and gender discrimination; increases in overdoses; the excessive use of incarceration; strains and health effects on families; and harm to rural farmers and growers.
Violence and enforcement of drug prohibition
The pursuit of drug prohibition has generated a parallel economy run by criminal networks. Both these networks, which resort to violence to protect their markets, and the police and sometimes military or paramilitary forces that pursue them contribute to violence and insecurity in communities affected by drug transit and sales. P.1.
A great deal of drug-related violence is associated with the efforts of armed criminal groups to protect their illicit markets, often against armed police or military or paramilitary forces. Some experts have suggested that heavy crackdowns by drug police can lead to major increases in violence when disruption of a criminal network leads rival groups to intensify their efforts to capture the territory of the weakened group. Mexico and Central and South America have borne an enormous burden of drug-related violence. P. 7.
HIV, hepatitis C virus infection, and harm reduction: neglect of proven solutions and law enforcement impact on infection
[R]epressive drug policing greatly contributes to the risk of HIV linked to injection. Policing could be a direct barrier to services such as needle and syringe programmes (NSP) and use of non-injected opioids to treat dependence among those who inject opioids, which is known as opioid substitution therapy (OST). Police seeking to boost arrest totals have targeted facilities that provide these services to find, harass, and detain large numbers of people who use drugs. Drug paraphernalia laws, which prohibit possession of injecting equipment, lead people who inject drugs to fear carrying syringes and force them to share equipment or dispose of it unsafely. Policing practices undertaken in the name of the public good have demonstrably worsened public health outcomes. One of the greatest impacts of pursuit of drug prohibition identified by the Commission with respect to infectious disease is the excessive use of incarceration as a drug-control measure. Many national laws impose lengthy custodial sentences for minor, non-violent drug offences, and people who use drugs are over-represented in prison and pretrial detention. P.1.
An extensive body of research has demonstrated that effective tools are available for prevention of HIV and HCV infection among people who use drugs by injection and other means …
WHO found that NSPs, particularly low-threshold (easy-access) exchange programmes, effectively reduced HIV transmission and were not associated with increased injection frequency or initiation of new injection in people not already injecting drugs. A meta-analysis suggested that NSPs were associated with a reduction in HIV transmission of about 58% …
A 2012 meta-analysis of studies from Europe, North America, and Asia concluded that oral OST, and methadone maintenance in particular, reduces risk of HIV transmission among people who inject opioids by about 54%. PP. 9-10.
Evidence from a number of countries indicates that drug law, policy, and law-enforcement practices can be barriers to provision and use of harm-reduction and other HIV prevention services … P. 15.
The performance of drug police in many countries is judged by the number of arrests that they make, and people who use drugs are likely to be easier to find than major drug traffickers, so they can help to bolster arrest totals. It is perhaps for this reason that police target facilities providing health and harm-reduction services to people who use drugs. A 2015 study of more than 500 methadone patients by non-governmental service providers in New York showed that 38% of the patients reported being stopped and searched by police outside the clinics where they received methadone, and 70% reported witnessing someone else being searched in these locations. In some countries, extortion of bribes from people who use drugs might be an important source of income for poorly paid police. Crackdowns and other intensive policing, often targeting low-income people, minorities, or marginalised people, can undermine harm reduction and add to drug-related risk. P.16.
Use of incarceration in drug control
In 2014, the UNODC estimated that people convicted of drug crimes make up about 21% of incarcerated people worldwide. Possession of drugs for individual use was the most frequently reported crime globally. On the basis of data from 2011 annual country reports, the UNODC estimated that drug-possession offences constituted 83% of drug offences reported worldwide. Although not all of the crimes reported by the police result in incarceration, mandatory prison sentences are attached to possession of even a small amount of drugs in many countries. P.17.
The over-representation of people who use drugs in prison and the lack of essential care and support for them while they are in state custody are among the most devastating health legacies of pursuing drug prohibition. There is, moreover, no evidence that incarceration is an effective deterrent for drug use either in prison or afterwards. P.17.
Racial and gender discrimination in drug-related mass incarceration
The evidence also clearly demonstrates that enforcement of drug laws has been applied in a discriminatory way against racial and ethnic minorities in a number of countries. The USA is perhaps the best documented but not the only country with clear racial biases in policing, arrests, and sentencing. In the USA in 2014, African American men were more than five times more likely than white people to be incarcerated for drug offences in their lifetime, although there is no significant difference in rates of drug use among these populations. P.2.
The USA has the highest rate of incarceration in the world at about 707 people per 100 000 population, about 50% higher than that in Russia, and more than five times higher than that in China. Drug-related offences account for a substantial proportion of this incarceration. Aggressive prosecution of drug offences along with mandatory minimum sentences for some infractions helped to make drug-related mass incarceration a major engine for growth in US state and federal prison populations beginning in the 1980s. The racially disparate application of drug-related imprisonment in the USA is a prominent feature of mass incarceration. People of colour, particularly African Americans, have been disproportionately affected by drug-related mass incarceration. In 2011, among men aged 30–34 years, one in 13 African Americans were in prison compared with one in 36 Hispanic Americans and one in 90 white Americans, even though prevalence of drug use is similar in the three populations. The Sentencing Project, a non-governmental organization focused on criminal justice, calculated in 2014 that African American men had a 32% probability of being in prison or other state custody at some time in their lives, compared with 17% for Hispanic men and 6% for white men … This pattern reflects documented racial disparities at all stages of US law enforcement, from stop-and-search policies and arrest to sentencing and incarceration. PP. 18-19.
We also found substantial gender biases in current drug policies. Of women in prison and pretrial detention around the world, the proportion detained because of drug infractions is higher than that of men. Women involved in drug markets are often on the bottom rungs—eg, as couriers or drivers—and might not have information about major traffickers to trade as leverage with prosecutors. Gender and racial biases have pronounced overlap, resulting in an intersectional threat to women of colour and their children, families, and communities. P.2.
Impact on families and communities
The over-reliance on incarceration as a response to drug use could have a profound effect on the wellbeing of relatives and partners of people imprisoned for drug offences. Many studies document that incarceration of a family member imposes unique forms of financial strain, psychological distress, and logistic hardship on the family and is associated with deleterious health outcomes …
A 2014 survey of people visiting family members in Mexican prisons indicated similar kinds of challenges in that setting. Of the visitors, who were mostly women, more than 50% said that because of the imprisonment of a spouse or family member they had had to get a job or an additional job. By contrast 41% said that they had lost a job, more than 18% said that they had had to move house, and almost 40% said the imprisonment had impeded their ability to care for their children or grandchildren. Spouses of incarcerated people in this study were also disproportionately affected by a range of health problems, including high blood pressure and depression. PP. 20-21.
Drug policy and death from overdose
Lethal drug overdose is an important public health problem, particularly in light of rising consumption of heroin and prescription opioids in some parts of the world. Yet the Commission found that the pursuit of drug prohibition can contribute to overdose risks in numerous ways. Prohibition creates unregulated illegal markets in which it is impossible to control the presence of adulterants in street drugs, which add to overdose risk. Several studies also link aggressive policing to rushed injection and overdose risk. People with a history of drug use, who are over-represented in prison because of prohibitionist policies, are at extremely high risk of overdose when released from state custody. P.2.
Drug overdose should be an urgent priority in drug policy and harm-reduction efforts. Overdose can be immediately lethal and can also leave people with debilitating morbidity and injury, including from cerebral hypoxia. The authors of a 2013 systematic global review concluded that overdose was a leading cause of mortality in people who inject drugs in all regions. In 2014, WHO estimated that about 69 000 people worldwide died annually from opioid overdose,259 but that estimate might not have captured the substantial increase in opioid overdose deaths especially in North America since 2010…
According to the medical literature, there are numerous ways in which pursuit of drug prohibition can exacerbate overdose and the risk of death from overdose: barriers to access to OST and other treatment for opioid dependence; lack of control over strength, toxicity, and adulterants of street drugs; policing that increases overdose risk; overdose vulnerability linked to incarceration or abstinence-based detoxification, or both; bans on supervised injection sites; lack of use of anti-tampering packaging and other measures for controlled medicines; and barriers to access to availability and use of naloxone. PP. 26-27.
Health impact of crop eradication
The pursuit of the elimination of drugs has led to aggressive and harmful practices targeting people who grow crops used in the manufacture of drugs, especially coca leaf, opium poppy, and cannabis. Aerial spraying of coca fields in the Andes with the defoliant glyphosate (N-(phosphonomethyl)glycine) has been associated with respiratory and dermatological disorders and miscarriages. Forced displacement of poor rural families who have no secure land tenure exacerbates their poverty and food insecurity and in some cases forces them to move their cultivation to more marginal land. PP.2-3.
Conclusions and recommendations
Research about drugs and drug policy has suffered from a lack of a diversified funding base and assumptions about drug use and drug pathologies on the part of the dominant funder, the US Government. At a time when drug-policy discussions are opening up around the world, there is an urgent need to bring the best of non-ideologically-driven health science, social science, and policy analysis to the study of drugs and the potential for policy reform. P.3.
Countries such as Portugal and the Czech Republic decriminalised minor drug offences years ago, with significant financial savings, less incarceration, significant public health benefits, and no significant increase in drug use. Decriminalisation of minor offences along with scaling up low-threshold HIV prevention services enabled Portugal to control an explosive, unsafe injection-linked HIV epidemic, and probably prevented one from happening in the Czech Republic. P.3.
Policies meant to prohibit or greatly suppress drugs present a paradox. They are portrayed and defended vigorously by many policy makers as necessary to preserve public health and safety, and yet the evidence suggests that they have contributed directly and indirectly to lethal violence, communicable-disease transmission, discrimination, forced displacement, unnecessary physical pain, and the undermining of people’s right to health. Some would argue that the threat of drugs to society might justify some level of abrogation of human rights for protection of collective security, as is provided for in human rights law in case of emergencies. International human rights standards dictate that, in such cases, societies still should choose the least harmful way to address the emergency and that emergency measures should be proportionate and designed specifically to meet transparently defined and realistic goals. The pursuit of drug prohibition meets none of these criteria.
Standard public health and scientific approaches that should be part of policy making on drugs have been rejected in the pursuit of prohibition … Drug policy that is dismissive of extensive evidence of its own negative impact and of approaches that could improve health outcomes is bad for all concerned. P.3.
To move towards the balanced policy that UN member states have called for, we offer the following recommendations:
Decriminalise minor, non-violent drug offences—use, possession, and petty sale—and strengthen health and social-sector alternatives to criminal sanctions. Reduce the violence and other harms of drug policing, including phasing out the use of military forces in drug policing, better targeting of policing on the most violent armed criminals, allowing possession of syringes, not targeting harm-reduction services to boost arrest totals, and eliminating racial and ethnic discrimination in policing.
Ensure easy access to harm-reduction services for all who need them…
Prioritise people who use drugs in treatment for HIV, HCV infection, and tuberculosis, and ensure that services are adequate to enable access for all who need care. Ensure availability of humane and scientifically sound treatment for drug dependence, including scaled-up OST in the community and in prisons. Reject compulsory detention and abuse in the name of treatment.
Ensure access to controlled drugs, establish intersectoral national authorities to determine levels of need, and give WHO the resources to assist the International Narcotics Control Board in using the best science to determine the level of need for controlled drugs in all countries.
Reduce the negative impact of drug policy and law on women and their families, especially by minimizing custodial sentences for women who commit nonviolent offences and developing appropriate health and social support, including gender-appropriate treatment of drug dependence, for those who need it.
Efforts to address drug-crop production need to take health into account. Aerial spraying of toxic herbicides should be stopped, and alternative development programmes should be part of integrated development strategies, developed and implemented in meaningful consultation with the people affected.
A more diverse donor base is needed to fund the best new science on drug-policy experiences in a nonideological way that, among other things, interrogates and moves beyond the excessive pathologising of drug use.
UN governance of drug policy should be improved, which should including respecting WHO’s authority to determine the dangerousness of drugs…
Health, development, and human rights indicators should be included in metrics to judge success of drug policy, and WHO and the UNDP should help to formulate them … All drug policies should also be monitored and assessed as to their impact on racial and ethnic minorities, women, children and young people, and people living in poverty.
Move gradually toward regulated drug markets and apply the scientific method to their assessment. Although regulated legal drug markets are not politically possible in the short term in some places, the harms of criminal markets and other consequences of prohibition catalogued in this Commission will probably lead more countries (and more US states) to move gradually in that direction—a direction we endorse. As those decisions are taken, we urge governments and researchers to apply the scientific method and ensure independent, multidisciplinary, and rigorous assessment of regulated markets to draw lessons and inform improvements in regulatory practices, and to continue evaluating and improving. PP.3-4.