The 'War on Drugs' has turned out to be a war between the State and America's ethnic minorities. Must the USA continue to suffer undeclared civil war, or can a public health model of drug policy bring about a truce?
The current US drug policy disserves all Americans - but particularly minorities. This paper attempts to provide an overview of the drug problem in America and the absence of attention paid to the health of urban, minority substance abusers. The drug problem in the USA is particularly serious in urban settings. It is well known that poverty and ill health are closely connected, that inner cities in the USA have the largest percentage of lowincome households, and that many of these are minority populations.
In the USA, the largest ethnic minorities are African Americans (12% of the population), Hispanic Americans (6%), Asian Americans 0.5%) (US Department of Commerce, 1983). These minorities are very unevenly distributed throughout the country. Some states' populations are virtually all white, whereas others have much larger than the overall average numbers of Blacks, Hispanics or Asian Americans. Minorities have increasingly concentrated in urban areas, particularly in eastern and some mid-western cities.
In Maryland, the state population is 75% White, 23% Black, and 2% other groups (US Department of Commerce, 1982). In Baltimore, a city of 750000 people, the population is 40% White and 60'.Yo Black (Baltimore City Health Department, 1987). In Baltimore, the ethnic minority is the majority.
How drug policy affects minorities in the USA must be viewed in the broader context of how public policy in general affects the minorities. In spite of large gains over the last 25 years in civil rights, economic status
I and political representation, Black Americans are still far from achieving equality with White Americans in terms of median income, health and longevity, employment and education. Consider the following points from a US Congressional Task Force Summary Report on the Future of African -Americans to the Year 2000: Black median household income in 1980 was US$16 000 as compared to the White median household income of US$27 500 (US Congressional Task Force Summary Report, 1988, p.3). Perhaps more significant is the fact that Black median income decreased from 1970 to 1980, whereas White median income increased during the decade (US Congressional Task Force Summary Report, 1988, p.3).Black median life expectancy was 67 years in 1980, whereas White median life expectancy was 74 years (US Congressional Task Force Summary report, 1988, p. 11). The incidence of cancer, although increasing for both races, has been rising faster for Blacks, who are now about 30 per cent more likely to have cancer than Whites (us Congressional Task Force Summary Report, 1988, p. 11). The median years of schooling of Blacks was 12.0 in 1980. The figure for whites was 12.5 (US Congressional Task Force Summary Report, 1988, p. 11). Although this difference is not significant, there is a significant difference in the quality of education available to Black and White students.
Although Blacks make up 12 per cent of the population, they hold less than 1.5 per cent of all elected offices (US Congressional Task Force Summary Report, 1988, p.21). We have been moving in the right direction; however, there is room for continued concern about the effect of public policies on the health and well-being of Black Americans. The US Drug Policy dates to the passage of 1914 Harrison Narcotics Act. A precursor of that law was a 1875 San Francisco ordinance banning the smoking of opium in Chinese opium (lens. This ordinance was designed by the city fathers to end interracial fraternisation between young Whites and Chinese.
Since the passage of the Harrison Narcotics Act, the USA has made enormous efforts to deny the reality that drug prohibition increases crime without eliminating addiction. This remains as true today as ever. We have spent 75 years and untold billions of dollars trying to square the circle, and, inevitably, we have failed.
Seventy-five years after the Harrison Narcotics Act, the following facts prevail:
US$10 billion is spent annually for the arrest and prosecution of a small fraction of the nation's drug users (Nadelmann, 1989, p.940).
Nine out of ten addicts are going untreated as a result of lack of treatment programmes (Stark, 1990).
Half of all new AIDS cases are the result of intravenous drug transmission (Baltimore City Health Department, 1990).
Children growing up in our inner cities are learning that joining the drug trade is one (J the few roads to easy riches.
Innocent people are gunned down in street battles waged by drug traffickers.
There is widespread corruption of our public officials - including police officers - due to the drug trade.
The volume of drugs pouring into our country has increased enormously. This fact has been documented by numerous scholars and historians. Clearly, America, with a small fraction of the world's population, has the means to purchase a disproportionate share of the world's drug supply.
This most insidious impact of our national drug policy is the disproportionately negative impact on Black Americans. Nationally, there are more Black men in prison than in college, due largely to narcotics convictions (Rangel, 1988). In 1986, 80 per cent of all Black State prison inmates had used an illegal drug at some time in the past, 62 per cent on a regular basis (Innes, 1988, p.3).
In Baltimore for 1988, 75 per cent of narcotics arrests were of Blacks, and 66 per cent were of Black males (Baltimore City Police Department, 1989). With respect to total arrests of Black adults, in Baltimore, the percentage for drug abuse violations has increased from 13 per cent in 1980 to 25 per cent in 1988 (Baltimore City Police Department, 1989). The phrase that has been coined to describe US drug policy: it is a mirage. Never having attained anything approaching zero tolerance in the history of our country, we are not likely to attain a drug-free America by 1995, or the year 2000.
The toll that this policy takes on minority Americans is, of course, not limited to crime and law enforcement. Drug abuse is a public health problem of epidemic proportions which is affecting minority Americans in increasing numbers.
First, consider AIDS: Blacks and other minorities are now contracting AIDS more frequently than Whites. This issue relates primarily to equipment sharing among intravenous drug users. In the USA, as of May 1989, there were 92 729 cases of AIDS reported to the Centers for Disease Control (Centers for Disease Control, 1989). Of this number, 42 per cent were among minority Americans (Centers for Disease Control, 1989).
To date, 20 per cent of AIDS cases are among persons whose only known risk factor is intravenous drug use (Centers for Disease Control, 1989). This percentage is rapidly increasing as the rate of transmission among homosexual males slows. Of the 18819 intravenous drug-related AIDS cases, 80 per cent are among Blacks and Hispanics (Centers for Disease Control, 1989). This is in stark contrast to the overall 42 per cent for minority AIDS cases (Centers for Disease Con, trol, 1989). In 1989, ethnic minority status in the USA was clearly an 4ndependent risk factor for HIV exposure among intravenous drug users. An increasing number of the victims of the drugs/AIDS connection are the babies born to an intravenous drug using mother or to the female partner of an intravenous drug user, and 25 of the 27 are Black (Baltimore City Health Department, 1990).
Statistics from the reporting system for all federally funded drug treatment programmes (acronym: CODAP) indicated that Blacks and Hispanics have consistently comprised a larger percentage of the population represented. In 1981, these groups comprised 38 per cent of CODAP clients - but constituted only 18 per cent of the national population (Gampel, 1988, No. 271-8313).
Data from the drug treatment programmes in Baltimore City reveal that although the 'Just Say No to Drugs' activities promoted for youth are having a positive impact among White uppermiddle class children, the drug problem is getting worse among poor Black children. Children are using harder drugs at earlier ages ~ in our inner city neighbourhoods. The drug problem is both the cause and the effect of other health problems, including infant mortality, personal injuries, hepatitis and other communicable diseases, and mental health problems. In fact, the drug 'problem' in minority communities goes far beyond drug abuse and AIDS. The lure of wealth from the drug tradeand the intense competition and stress involved in illegal drug activity have led to spiralling numbers of Black-on-Black homicides, primarily among drug dealers. The kind of selfhatred and lack of respect of human life reflected in these murders is ,a matter of serious concern. Previously, 'the enemy' of minority Americans was discrimination. Now, in addiction, the enemy is ourselves.
A little over a year ago, Baltimore Mayor, Kurt 'Schmoke, called for a national debate on drug policy including consideration of the decriminalisation of drugs. Thanks to the leadership of Kurt Schmoke and others, America's awareness of its drug problem has heightened, with forums being conducted at local, state and national levels. However, the direction that the federal drug policy has recently taken has been stricter drug law enforcement and interdiction. Pres&nt George Bush appointed a drug ezar, whose first proposal was stengthening the police force in the nation's capital and expanding out prison capacity to hold more drug criminals. There is little evidence of increased emphasis on public health interventions. We must continue to speak out to our leaders about the need for dramatic drug policy reform. Unfortunately, it is apparent that significant changes will be slow.
Meanwhile, there is much that can he done to promore a public health approach to the drug problem in our communities.
'Medicalisation' of addictions as opposed to the 'criminal isation' of addicts is needed. Drug abuse is a highly prevalent though often undetected condition. This chronic condition and its sequence are not always recognised and treated by medical practitioners, clinics and hospitals. We must put an end to the denial by the health care system in addressing this condition. The health care system should accept a mandate of taking on substance abuse and addiction as primarily a medical problem.
American society has a tertiary care system for addictions, which provides specialised outpatient chemotherapy and detoxification and rehabilitation. Primary care physicians are minimally involved in the treatment of addictions. In Baltimore, we are exploring the possibility of training a cadre of community physicians on the nature of substance abuse so that they can screen more extensively for substance abuse among their patients. We propose to have physicians treat certain types of substance abuse directly. Substance abuse counsellors may be deployed to the offices of private practitioners to support their efforts.
Physicians will be trained to use the tertiary resources in the community, i.e. methadone clinics, detoxification centres and inpatient/residential treatment sites. The way to mobilise the health care system fully in order to address the substance abuse problem is to develop a protocol for use by clinics and administrators at all levels, in all types of settings.
In conclusion, just as the drug trade disproportionately afflicts poor minority communities, the 'drug war' we are waging takes a heavy toll on these communities. All wars tend to scorch the earth. The war on drugs is no exception. In this war, what is being scorched is our inner city neighbourhoods and the people who live in them.
Maxie T. Collier
Commissioner for Health for Baltimore City
Anne E. Walker
Executive Assistant to Commissioner for Health
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