Public Health on Drugs

Michael Agar

Michael Agar

Rachelle Annechino invited me to write something about the concept of “public health” as I experienced it in my decades-long and checkered past in the drug field. That past is described in unbearable detail in a book called Dope Double Agent: The Naked Emperor on Drugs. The bottom line of my memory (if memories can have a bottom line) is that the phrase “public health” was a severe case of metaphor abuse. I only got clear on this slowly over the decades. This is the first time that I’ve tried to box it up in a summary, courtesy of ten years of hindsight after leaving the field.

The history of policy and practice around psychoactive substances in the 20th century U.S. has been a long slow-dance between docs and cops. Consider opioids as an example – opium and morphine and laudanum, and later heroin, and later methadone, and later buprenorphine, and now oxycontin — all opioid drugs that range from the organic to the synthetic. The docs first celebrated them for their medical use, then got upset when users broke the compliance rules and used them on their own, at which point the cops stepped in. In their different historical contexts they went through the same cycle, from legit (more or less) medication to popular use to crime. To those of us working in what the bureaucrats called the “demand” side of the drug field, attention to public health made a lot more sense than what the better funded “supply” side lusted after, namely, toss the addicted into jail.

The question was, how could anthropologists, among others, use and subvert the public health discourse in useful ways?

Like most U.S. presidential elections, “public health” was only the better of two bad choices. “Public health” has its uses. Boas studied with Virchow, a founder of social epidemiology, after all. It isn’t the right framework to describe and understand people in their social worlds and how chemicals they ingest do and don’t fit into the flow. But, if you want to join policy conversations about “substance abuse” in most countries I’ve worked in, you have to translate your arguments into a doc/cop creole to make sense to the other participants. It’s the old problem of naïve realism, as the social cognition types say, or doxa, if you’re a Bourdieu fan. Do you push from the outside or talk on the inside? I chose the latter. So the question was, how could anthropologists, among others, use and subvert the public health discourse in useful ways?

Here’s a pretty easy example of one way we did that. Historically, public health arose out of successes at finding and then controlling the biological mechanisms that caused a disease. Public health found those mechanisms using epidemiology and then attempted to control them with biology. Epidemiologists built a database of “case records.” A good case record consists of clinical criteria for diagnosis, severity, time and place of onset, and demographics. (See, for example, this introduction to epidemiology [pdf].)

With time, as the DSM molted during its travels along its Roman numeral marked trail, diagnostic criteria have become more subtle and more reasonable, but that official definition of “abuse” remains on NIDA’s web page today. By this definition, it’s hard to imagine anyone who hasn’t been, at least at one point in their life, a drug abuser.

In the drug field, “ diagnosis” and “severity” were corrupted by war on drugs ideology. The insanity reached a peak in the 1980s with the official definition of “drug abuse” as “any illicit use of a substance” — any at all — including “illicit use” of a legal substance as well. This madness occurred at about the same time as the famous “library purge” of 1984, in which the National Institute on Drug Abuse (NIDA) expunged a set of its own titles from its archives and encouraged librarians to remove them from card catalogs. With time, as the DSM molted during its travels along its Roman numeral marked trail, diagnostic criteria have become more subtle and more reasonable, but that official definition of “abuse” remains on NIDA’s web page today. By this definition, it’s hard to imagine anyone who hasn’t been, at least at one point in their life, a drug abuser. The “diagnostic” part of a case record lost any useful meaning for research or intervention.

This was a useful public health argument a sane person could make in Drugworld. Sometimes it even opened a window in the walls that policy was boxed in and changed the conversation.

By the way, notice another epidemiological problem here. “Drug ” is not a coherent and consistent category of “disease.” In fact it’s not a “disease” at all, but that’s very old news in medical anthropology that needs no elaboration here. One doesn’t “catch” drug dependence like one “catches” a cold, although there are “epidemics” of drug use in the sense of a rapidly rising curve. And, of course, in the US, other federal agencies handled prescription pharmaceuticals and alcohol. Things have blurred in recent times, as they should, but back in the day there were illegal drugs, legal drugs and prescribed drugs, and institutional boundaries kept them separate, though severe dependency happened — and didn’t — with all of them.

More on the drug case record — the basic data of illegal drug public health — is in order. But for now I want to move on to another distortion in the epidemiology. Say you’re at work, on the ground, as a new illegal drug flows into an area and takes off like an Apple product – or used to until Mavericks. Your best bet would be that any drug “epidemic” will produce a lot of experimentation and some controlled use. It will also produce some serious dependency that messes up the lives of the dependent and their family and friends. We saw this variation, for example, in the outbreak of heroin experimentation that happened in Baltimore County during my final drug study in the early 2000s. Say you plot what happens after the trend flattens out on a different curve with the number of people on the y-axis and the severity of dependency on the x-axis. It will probably look like the famous power law curve, with–generally speaking–a lot of experimenters on the left who try it a few times and that’s it and a smaller number who are really messed up out there on the right side of the curve.

The curve looks something like this:

Power law curve (public domain)

Power law curve (public domain)

Most case records used by that war on drugs epidemiology were from the right side of the curve. Why? Because they were the people who showed up in the public institutions where most public health types — including me at first — gathered their data. What about all those cases on the left, experimenters and controlled users? According to drug war ideology, the experimenters on the left side couldn’t exist. Following the drug war equation of “any use = abuse,” they were doomed to slide rapidly into the right side in no time flat. Norm Zinberg did a famous study that looked at “controlled” use back in the early days, but he was the exception who proved the rule. Tell the truth, I don’t know how he got away with it. I like to think I helped as primary reviewer and site visitor on the funding panel. “Controlled” was bad enough in a drug policy that defined any use as abuse: if you really wanted to rattle the bars, try proposing research to understand positive effects an illegal drug might have.

Reading the most severe cases in the power law curve as the typical ones made no sense. If you wanted to understand the metaphorical “disease” and provide “prevention” and “treatment,” it would help if you understood why most people who were “exposed” to it didn’t “catch” it.

That power law curve was another argument you could make to subvert and open the policy conversation, though back in the day there wasn’t much experimenter/controlled use data and the curve hadn’t yet become well known in human social research. Still, reasonable people saw value in the argument, at least during a conversation. It usually had no consequences, though, because it undermined the key premise of the drug war definition of “abuse” — there can be NO control (let alone benefit) with respect to use of the illegal drug du jour. One time and you’re already represented by the far right side of the power law curve.

I’ll mention one more distortion, though it takes us from the 60s/early oughts into a longer timeline. Look at that right hand side of the curve again, the people who are seriously dependent. I’m staying with the heroin example. Most — far from all, but most — of the heavily dependent who were the epidemiological case records in the 60s and 70s were poor people of color. They were the majority of the “cases” at the far right side of the curve who showed up in public institutions. Claude Brown, in his autobiography set in Harlem, Manchild in the Promised Land, called that tipping point “the plague.”

Drug war epidemiology ignored its own core but politically inconvenient question, “Why these people in this place at this time?”

But then drug war epidemiology ignored its own core but politically inconvenient question, “Why these people in this place at this time?” It turned out — this was my last drug project — that poor people of color were in a particular historical position that made them particularly vulnerable to the use and possible abuse of heroin in the late 1960s and early 1970s. As David Musto showed in his drug law history, The American Disease, so were middle-class women in the early 20th century, and working class white men in the cities in the 1920s, and — we would learn during our project — white working class suburban kids in Baltimore County in the late 1990s. Same drug, different times, different demographics of those on the far right of the power law curve. Why?

Something other than pure demographics from the case records are required to explain it, something we called “open marginality,” a historical change made up of an unexpected and sudden rise in expectations that were denied, or normal expectations that were suddenly shattered by history like broken glass. That explanation is not in the demographics per se, though they can help look for social identity clusters. It is in the historical position of particular demographics at different points in time.

When I gave talks about our research, audiences would ask right away, “What about race, class and gender?” I’d answer, “They all can matter, but not necessarily, and in different combinations, at different points in time.” This was not an answer that drug war public health was fond of, but it was right, because a wave of severe heroin dependence emerged from a historical trajectory that impacted some people more than others, and the people who were impacted depended on which social identity had just been hit disproportionately by a surprising and negative historical change.

Traditional public health, for all its value in some contexts, wasn’t the right fit for the drug field. Its use was another example of the “medicalization” of complicated historical issues of humans in their sociocultural worlds. Even in a fairly straightforward metaphorical extension into the drug field, it led to distortions that suited the madness of the ideology. It was the language in terms of which we argued (by necessity), but the distortion of the phenomenon required by the language made it harder to make the argument. I suppose I should close with a Foucault-like summary of “drug discourse,” but back in the day I kept thinking of Roberta Flack singing “Killing me softly with his song.”

I hope it’s better now. There are signs it might be. I was invited to a gathering in 2009 that El Paso/Ciudad Juarez jointly sponsored to “celebrate” forty years of failure of the war on drugs. They rounded up all the old-timers they could find to talk about the damage it had done and alternatives. But media today are full of stories about a rise in opioid dependency all over the U.S., prescription pharmaceuticals like Oxycontin this time. On the same pages, print or web, I also see stories about increasing disparity of wealth, indebted college graduates looking for nonexistent jobs, and family-disrupting deportations. We live in times where a lot of people are openly marginal. But even though I’m getting too old to be optimistic, I see people in policy, research and programs who haven’t just subverted U.S. drug discourse. They’ve rejected it and created alternatives and taken action based on familiarity with what’s going on rather than hallucinated images to serve ideological ends. In that kind of saner context, public health could offer more effective help.


Killing Me Softly, Roberta Flack

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  1. Around the Web Digest: Week of June 1 | Savage Minds - June 8, 2014

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