Public Health on Drugs
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.
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].)
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.Read More… Public Health on Drugs
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