Pearls and Irritations

Alex Wodak

  • Alex Wodak. Reducing the demand for illicit drugs

    At his Congressional confirmation hearing in January 2001, the then Secretary of Defense-designate Donald Rumsfeld was asked whether US drug problems were best attacked by reducing demand or targeting drug supplies. Rumsfeld said that he believed that illicit drug use was “overwhelmingly a demand problem”. He added, “If demand persists, it’s going to find ways to get what it wants” and “if it isn’t from Colombia, it’s going to be from someplace else.” This might have been an unconventional view 14 years ago but it’s becoming a mainstream perspective these days.

    The conventional view is that young people make bad choices about illicit drugs because of an information deficit. Tell young people how bad illicit drugs are, so Conventional Wisdom asserts, and they won’t touch the stuff. Unfortunately, the experience of evaluating decades of educational mass and school-based campaigns is that, at best, modest and temporary benefits are achieved. But some studies have found that educational interventions often achieve no benefits or even increased drug use and problems. Community and therefore political expectations, are stubbornly unrealistic. In the various National Drug Strategy Household Surveys conducted for the Commonwealth Department of Health and Ageing every three years, the community always notionally allocates the lion’s share of government expenditure to drug education. Drug education is clearly the community panacea for drug problems.

    My personal journey thinking about these issues started after I spent an evening in a shooting gallery in Williamsburg, Brooklyn, New York City, in October 1987 while looking at HIV among people who inject drugs in Europe and North America. ‘Shooting galleries’, common in much of the USA, are derelict houses where people can bring drugs secreted on their person and hire (used) needles and syringes for a few hours to inject with. Shooting galleries helped to spread HIV extensively in the USA. The local police are usually paid to ignore shooting galleries.

    The Williamsburg area, now gentrified, was then clearly extremely dangerous. Abandoned cars rested propped on bricks on the side of the road. Many tenement buildings were derelict and lay empty after a fire. We gathered in a basement room carpeted with filth and broken glass. We had brought candles, as there was no electricity in the building. The front door of the house was missing. I watched aghast as four Hispanic people injected speedballs of heroin and cocaine for several hours.  I could not stop wondering why these two men and two women were so ridiculously indifferent to their health. I wondered why they made so little effort to avoid HIV? I established that they knew some people who had injected drugs and had AIDS, including some who had died of AIDS. But I was then instructed to stop asking further questions. I realized that these four people had lost all hope of decent housing, healthcare, education and employment. Not just for themselves but also for their children and grandchildren. Given the inevitability of a bleak future for them and their families and friends, enjoying a few hours of intense pleasure made some sense after all.

    In 2009, Richard Wilkinson and Kate Pickett published ‘The Spirit Level: Why Equality is Better for Everyone’. This influential book argued that many important public health and social outcomes were worse in countries with high levels of inequality, such as the USA and Australia, and better in countries with lower levels of inequality, such as Japan and Scandinavia. Illicit drug use was one of the issues that they included in their studies. This book has its critics but overall, the reception has been quite positive. My 1987 experience in Williamsburg, Brooklyn seemed to fit their theory like a glove.

    Last October I was invited to give some talks on harm reduction in Japan. I was struck by the fact that after a quarter century of economic stagnation, average unemployment was still only 3.1%  in Japan while after almost a quarter century of uninterrupted growth, average unemployment in Australia was more than double. Youth unemployment in both countries would have been several multiples of average unemployment. Heroin use is almost unknown in Japan but continues to be a significant problem in Australia. Amphetamine use in Japan is also tiny compared to Australia.

    In 2011, I was asked to give a presentation on demand reduction to the Global Commission on Drug Policy in Geneva. I argued that the results of conventional attempts to reduce drug use and problems through education were disappointing. The Chair of the Commission, Fernando Henrique Cardoso, who had been the President of Brazil from 1995- 2003, did not seem impressed by my negative assessment of demand reduction. Cardoso, a hero in Brazil for conquering hyperinflation in the 1990s, asked me what I would do to reduce the demand for drugs. I replied that his slaying of Brazilian hyperinflation had done more to reduce the demand for drugs than all the conventional drug education in the world. Although he did not seem to like that answer either, many clinicians and researchers around the world do accept that higher levels of illicit drugs use and problems are very likely if severe social and economic disadvantage is common.

    The conclusion seems inescapable to me: if we in Australia want lower levels of illicit drugs use and problems, we will have to reduce our high level of inequality. This may seem counter-intuitive to some but there are many examples of dangerous health conditions being conquered as much by improved social conditions as by powerful medical treatments. In the USA, with improved social conditions the prevalence of TB fell by more than two thirds in the early decades of the twentieth century before the advent of antibiotics.

    Dr Alex Wodak AM

    Emeritus Consultant, St Vincent’s Hospital, Darlinghurst, NSW 2010

     

     

     

     

     

     

     

  • Alex Wodak. The current imbalance between public and private interests. 

    The public interest, meaning ‘the welfare or wellbeing of the general public’, has always competed with private interests. Furthermore, public and private interests will always be in competition. What is so unusual about the current tension is the extreme imbalance: these days, private interests almost always get what they want. The policy domination by huge companies and extremely wealthy individuals has severe adverse consequences for the community in areas such as health, social cohesion and the economy. The current extreme imbalance between private and public interests is now not merely an Australian phenomenon but is also international. Examples of this policy imbalance abound in Australia and include mining, alcohol, fast food, transport, taxation and gambling.

    The increasing dominance of private over public interests coincides with an increasing inequality of income and wealth. Inequality in Australia waxed and waned over the years with low levels reached in the 1970s. Inequality then began increasing in Australia, growing under Labor and Coalition governments. Inequality increased to even higher levels in the United States where the imbalance of private and public interests is even more evident and has had striking political repercussions.

    The health of Australians improved dramatically during the 20th century. For example, average life expectancy increased from about 45 years in 1900 to over 75 years in 2000. About 25 of the additional 30 years of life expectancy resulted from improvements in public health while advances in clinical medicine only added five additional years. Yet in Australia, 98 per cent of health expenditure funds clinical services with only 2 per cent allocated to prevention. In the first half of the 20th century, improved sewerage and drains substantially reduced deaths and disease. In the second half, the decline in smoking, improved diet and increased exercise were major factors improving health. Tobacco control has been a rare victory for a public interest David over a corporate Goliath. Yet in 2014, the federal government blocked the implementation of a national agreement to alert consumers to the potential health risks of some foods. Some powerful food producers were the only beneficiaries.

    The fate of the proposed Resource Super Profits Tax (RSPT) is another example of the recent dominance of private over public interests. In 2010, the federal government proposed the RSPT, modelled on the well-regarded Petroleum Resource Rent Tax levied on the off shore petroleum extraction industry, after accepting a recommendation from a review of Australia’s tax system. A distinguished committee chaired by a highly regarded Secretary of Treasury had carried out this review. Vociferous criticism from the mining industry including an effective advertising campaign followed, and after the deposition of the Prime Minister by the Deputy Prime Minister a heavily watered down and ineffective Minerals Resource Rent Tax (MRRT) replaced the RSPT. The then government contributed to its own problems through its political incompetence. Once again, powerful private interests got their way and the community lost.

    One of the common links in these examples is the development of monopoly, or near monopoly, arrangements used to generate vast wealth and thereby political power sufficient to extract huge economic rents.

    Taxation arrangements in Australia in recent decades including the abolition or reduction of inheritance taxes, capital gains taxes, private income and company tax, and generous concessions for superannuation and negative gearing, have benefited the wealthier members of the community and large companies.

    The coming to power of Thatcher in the UK and Reagan in the USA and the fall of communism in the USSR and its satellites increased support for the view that private economic interests are inherently more efficient than publicly owned enterprises.

    The replacement in China of a central command economy by a free market system which lifted hundreds of millions of people from poverty over the following decades seemed to exemplify the benefits of a free market economy with minimal restrictions for large companies and wealthy individuals. In the United States, major economists including Paul Krugman, Joseph Stiglitz and Jeffrey Sachs have warned that the currently high levels of inequality have corrupted the political system and there is increasing concern that with a radically extreme Republican Party often prepared to disregard the national interest the United States may have become ungovernable — surely a warning for Australia.

    What is to be done? The first step for those concerned by the increasing dominance of private and corporate interests over the public good is to articulate their views.

    Could a Public Interest Commission maintain a better balance in the future?  First some difficult questions would have to be answered. How will the public interest be defined and measured? Where will successful examples of a Public Interest Commission be drawn from? How will issues be selected and enquiries be conducted?

    And finally, what sort of Australia do its citizens want — an individualist Australia with marked inequalities, poor public services, choked roads and shrinking taxation on the American model, or a more collective and more equal Australia with less poverty, better public services but more taxation similar to the Scandinavian countries and Japan?

    A political correction to the current imbalance can only occur if Australians start to debate their values and visions. The political class can only do so much. Extensive polling shows that a majority of Australians want improved public services and are prepared to pay higher taxes to fund them. However, if large numbers of Australians want to see a different country emerge, they have to be prepared to work for these changes starting at the community level.

    Dr Alex Wodak AM, a physician, was Director of the Alcohol and Drug Service at St Vincent’s Hospital, Sydney from 1982 until he retired in 2012. His major retirement project is drug law reform.  Together with colleagues, Dr Wodak started Australia’s first needle syringe program and supervised injecting facility when both were pre-legal. He was also involved in establishing the National Drug and Alcohol Research Centre, the Australian Society of HIV Medicine and the NSW Users AIDS Association, an organisation for and by people who use drugs.  He is a Director of Australia21.

    This article is one of a series published by Australia 21 on the subject ‘Who speaks for and protects the public interest in Australia?’  For other articles published, see www.australia21.org.au.