From: Jim Rosenfield <[j n r] at [igc.apc.org]>
Newsgroups: talk.politics.drugs
Date: 11 Jun 94 11:47 PDT
Subject: Re: Collateral Casualties-JAMA 6/1/94

All rights belong to Journal of the American Medical Association
  (please see end-note regarding this posting)

`Collateral Casualties' Climb in Drug War

in JAMA June 1, 1994
by Andrew A. Skolnick

SINCE PRESIDENT Nixon declared war on drugs in 1972, the nation's
primary remedy for illicit drug use has been an escalation of
federal, state, and local law enforcement activities aimed at
discouraging use by punishing both dealers and users.  However,
an increasing number of health, law, and other experts say the
current policy is clearly failing and shows no sign of ever doing
more good than harm.

Advocates for reform are calling for an objective cost-benefit
analysis of current prohibition laws and of alternative
approaches that place more emphasis on harm reduction than on the
complete elimination of "recreational" illicit drug use.

Yet despite the nation's long, bitter and expensive war on drugs,
much vital data remain uncollected - such as the total number of
illegal-drug addicts killed by overdoses.  "There appears to be
an unwillingness among many national leaders to collect all the
data needed for an objective analysis of the nation's drug
policy,' says Baltimore (Md) Mayor Kurt Schmoke, a leading
proponent of the decriminalization or the "medicalization" of
illicit drugs. "So much of the nation's drug policy is driven by
politics and emotions rather than any objective analysis of the
most important data," he says.

While the total number of deaths in the United States from
overdose or toxic reactions to illegal drugs is unknown, a recent
study funded by the National Institute on Drug Abuse provides
some idea of the problem's magnitude.  The Drug Abuse Warning
Network Survey of a nonrepresentational sample of hospital
emergency department and medical examiner reports from 27
metropolitan areas found that 6001 people in 1991 suffered fatal
reactions to illicit drugs.  However, decriminalization advocates
point out that many if not most of such deaths result from the
use of contaminated drugs or drugs that have unexpectedly high
potency. The vast majority of these deaths, they say, could be
prevented by providing addicts with methadone or other
replacement drugs in a clinical setting where health care and
addiction therapy can be provided.  An often-cited argument
against de-criminalization is that it will increase the number of
infants exposed prenatally to illegal drugs. Indeed, some infants
born to heroin or cocaine addicts have a variety of physical and
cognitive problems that may be related to drug abuse. However,
the extent of this problem is not known.

Deanna S. Gomby, PhD, director of research and grants for child
development and Patricia H. Shiono, PhD, director of research and
grants for epidemiology, ar the Center for the Future of Children
Los Altos, Calif, estimate that 2% to 3% of newborns in the
United States each year may be exposed prenatally to cocaine,
compared with 73% exposed to alcohol and 38% exposed to the
effects of maternal smoking (in their report The Future of
Children. 1991;1:17-25). They say that 554,000 to 739,000 US
newborns are exposed each year to cocaine, heroin or other
illegal drugs.

 Their estimate is somewhat higher than the 350,000 to 625,000
newborns estimated by the Institute of Medicine to have been
exposed to illegal drugs, based on the National Institute on Drug
Abuse's 198 National Household Survey. However, these estimates
are not a measure of the harm caused by prenatal exposure to
these drugs. Prenatal exposure does not necessarily mean damage
to the fetus,   Gomby and Shiono write.

Media-generated hysteria over "crack babies" has led to the
imprisonment of women who use cocaine during pregnancy. Many
health care workers believe that the fear of prosecution and
imprisonment discourages many of the women who most need prenatal
care from seeking it (JAMA. 1990;261:30t 310). Ironically,
properly controlled scientific studies suggest maternal cocaine
use may pose less danger to a fetus than maternal cigarette
smoking (JAM, 1994;271:576577).

Legalization Spur to Crime?

Many addiction experts are not in favor of decriminalization.
Herbert D. Kleber, MD, executive vice-president and director of
the Center on Addiction and Substance Abuse, Columbia University,
New York, NY, argues that the current war on drugs has made
substantial progress toward reducing drug use as that the current
approach "is far preferable to proposals either to legalize drugs
or to refrain from enforcing the laws prohibiting their use" 
(N EngI Med. 1991;330:361-365).

Kleber, who as deputy director of the Office of National Drug
Control Policy was a general in President Rush's escalated war on
drugs, which promoted the policy of "zero tolerance," says
legalizing illicit drugs would lead inevitably to a sharp rise in
use. Cocaine use would increase from the current 2 million users
to between 18 million (the estimated number of problem drinkers)
and 50 million (the estimated number of smokers), he says.
Moreover, in the New England Journal article cited above, Kleber
writes, "Crime would not decrease if drugs were legalized. If the
cost of drugs were low, addicts would tend to spend more time
using them and less time working, so they would continue to need
to commit crimes in order to acquire money. If the total number
of addicts rose sharply as availability increased, crime would
also increase."

While acknowledging that marijuana does not induce violent or
criminal behavior, as cocaine and alcohol are said to do,
legalizing that drug, he says, will do nothing to reduce crime in
the streets.

KIeber concedes that mandatory minimum sentencing laws may
require revision in order "to deter or control the true `drug
kingpins' and to make better use of limited prison facilities."
He also calls for increased funding for drug addiction prevention
and treatment programs.

Disease Follows War

Although the morbidity and mortality that directly result from
illicit drug use in the United States have not been adequately
measured, there are a good deal of data on the morbidity and
mortality that result from prohibition. Epidemics of disease
always follow in the footsteps of wars. The war on drugs is no
exception. The difficulty users of intravenously administered
illegal drugs have in obtaining clean needles has stymied efforts
to control the spread of drug abuse associated hepatitis, AIDS,
and tuberculosis (TB). Other infections are mounting as well, as
is the number of children and adults who have been killed in
battles over drug-dealing turfs, in crimes committed by addicts
to pay for the next fix, and in shootouts between drug dealers
and law enforcement officials. In addition to rising body counts,
the war's toll includes the rending of the social fabric of the
nation's inner cities, especially in black and Hispanic
communities that have become the main focus of law enforcement
activities.

Despite the severe punishment users of illicit drugs face if
caught, illicit drug use is widespread in the United States.
According to the National Institute on Drug Abuse's 1992 National
Household Survey, more than one in three Americans (36.2%) have
used illegal drugs at least once in their lifetime, nearly 28
million Americans (11.1%) used them in the previous year, and
almost 14 million Americans (5.5%) used them during the past
month.

While choice of drugs may vary, illicit drug use is comparable
among blacks, whites, and Hispanics. Nevertheless, although
blacks and Hispanics make up approximately 20% of the US
population, they make up nearly 75% of the men and women in jails
and prisons for drug violations, says Jerome Miller, PhD, founder
and director of the National Center on Institutions and
Alternatives, a group in Alexandria, Va, that does research and
consultant work in criminal and juvenile justice.

With nearly five in every 1000 Americans behind bars on any given
day, the United States has the dubious distinction of
incarcerating a higher percentage of its citizens than any
country in the world. Thanks in large part to the country's war
on drugs, US prison and jail populations are 2-1/2 times larger
than they were in 1980. That growth has outpaced all attempts to
house and care for the inmates. Each week the United States must
add nearly 1000 prison beds for its rapidly growing inmate
population.

According to US Bureau of Justice statistics, on December 31,
1993, there were 883,656 inmates (50,493 women) in state and
federal prisons. An additions 441,781 adults, including 39,834
women were in local jails on June 30, 1992. In 1980, federal and
state prisons held only 329,821 inmates.

More than 20% of men in prisons are there for drug violations.
One in three women in prison were sentenced for drug crimes, up
from one in eight in 1983. The incarceration of these women, in
particular, has had an enormous impact or their families.
According to a 1939 survey of inmates of 424 local jails across
the nation, two thirds of incarcerate women were mothers of
children younger than 18 years, and two thirds of the mothers
said their children were in their custody at the time of their
arrest.

According to the Drug Policy Foundation, Washington, DC, from
1980 to 1992 federal and state government spent approximately
$150 billion on law enforcement efforts in the war against
illegal drugs. An additional $150 billion is likely to be spent
between 1992 and 1997. In 1980, the federal government spent $1
billion on the war. The proposed federal drug control budget for
1995 is $13.2 billion. State and local governments will spend
$16.5 billion more says press officer David Fratello.

The foundation and other critics see similarities between the
drug war and the Vietnam war, in which costs escalated and the
body counts mounted while the nation's other problems became
increasingly underfunded and defenders of the war periodically
claimed to see the `light at the end of the tunnel."

Perhaps the side effect of the drug war that has caused the
greatest public concern is the nation's climbing murder rate,
attributable in large part to drug-related crime in inner-city
areas. Like many critics of current policy, Mayor Schmoke blames
much of the violence in Baltimore and other American cities on
the "failed national drug strategy," which he and others say has
made the illicit drug trade enormously profitable. "Drug
traffickers kill to protect or seize drug turf, and addicts
commit crimes to get money for drugs," he says. "Almost half the
murders in Baltimore in 1992 were drug related."

According to the Federal Bureau of Investigation, 5.7% of the
22,510 homicides that occurred in the United States in 1992
involved motives related to an illegal drug transaction. However,
this number does not include victims of crimes committed to
obtain money for illegal drugs or those killed in battles over
drug-dealing turf. Local studies show that a much higher
percentage of murders may be drug related. A study of all
homicides involving victim' younger than 18 years in Fulton
County Georgia, between 1988 and 1992 (for which a motive was
determined), showed that 121 (21%) were connected to illegal drug
activity (MMWR MorS MoM Wkly Rep. 1994;43:251-261). Another study
showed that 434 (20%) of all homicides in Los Angeles, Calif,
between January 1986 and August 1988 involved illegal drugs
(AJDC. 1992;146:683887)

The decriminalization of illegal drug could greatly reduce the
forces that drive both violent crimes and crimes against
property, Schmoke says.

Baltimore, he says, is a perfect example of how and why the
national drug strategy is failing. With 48,000 heroin and cocaine
users and only 5,300 treatment slots, the only therapy most
addicts receive is arrest and incarceration. "We made 18000
drug-related arrests last year. Fifty-five percent of the cases
handled by the Baltimore state's attorney's office are drug
offenses."  The national situation is not much better. According
to federal figures, there are more than 2.77 million Americans in
need of treatment for addiction to illicit drugs, but only
600,000 slots in the nation's treatment facilities. 

Breading Ground for HIV and TB

Although the public's fears seem to be centered on drug-related
violence, the number of deaths caused by diseases spread by
shared hypodermic needles is many times greater and growing every
year. The news media continue to focus on the hundreds killed in
drug wars but give little attention to the tens of thousands
dying of diseases spread by IV drug use each year.

According to the Centers for Disease Control and Prevention's
October 1993 Hw/MDS Surveillance Report, from October 1992
through September 1993, 26,033 people (19,142 men and 6,391
women) developed AIDS attributable to needles shared during IV
drug use. Another 3,576 (1102 men and 2474 women) developed AIDS
through heterosexual contact with IV drug users. In addition, 397
children of IV drug-using mothers or fathers were diagnosed as
having AIDS. All totaled, 30,006 cases of AIDS, or 30.3% of all
new AIDS cases in 1992, were caused by contaminated hypodermic
needles.

Despite this great toll in death and the enormous strain on
public health services, many political leaders still strongly
oppose needle exchange programs, even though studies show that
the programs are effective in reducing the spread of human
immunodeficiency virus (HIV) infection. Nine states still have
laws that prevent addicts from obtaining sterile hypodermic
needles.

Opponents of needle exchange programs argue that providing
addicts with sterile needles condones their illegal behavior.
However, advocates for these programs say that at least some of
this resistance reflects an underlying belief that illicit drug
users should pay for their crime with their lives and that their
deaths will deter others from using such drugs.

More than one champion of the "zero- tolerance" policy has
publicly described drug users as deserving the worst of fates. In
1938, former First Lady Nancy Reagan told the press that "if
you're a casual drug user, you are an accomplice to murder."
Former Los Angeles police a chief Daryl Gates went further by
advising the US Senate Judiciary Committee that "casual drug
users" should be "taken out and shot." 

Reuse of hypodermic needles by addicts also results in an unknown
number of cases of hepatitis B, bacteremia, and other infections.
Some of these diseases are also transmitted to sexual partners,
children, and others in the community.  Disease spread by
contamInated needles is clearly a major public health problem
that is not adequately addressed by the current national drug
control policy.

By incarcerating large numbers of drug users, the nation has been
housing men and women at high risk of HIV infection and TB in
greatly overcrowded facilities, in an environment that encourages
the spread of these diseases. Inmates infected with HIV and TB
are at high risk for developing active TB and spreading it in
prison and when they are released, in the community. Overtaxed
medical staffs at correctional facilities are not able to detect
and treat many of the infectious cases (JAMA.1992;2G8:3177-3178).

The rates of TB in some jails and prisons have skyrocketed. In
19%, the case rate in the general population was 13.7 per 1% 000.
Case rates in correctional facilities have been as high as 400 to
500 per 100000.

`Decimating' Black Communities

"The drug war takes most of its collateral casualties from the
inner cities," says Ethan Nadelmann, PhD, assistant professor at
Princeton (NJ) University's Woodrow Wilson School of Public and
International Affairs. "Drug prohibition has created a permanent
under-class of unemployable inner-city youths whose lives have
become hopelessly interwoven with drug crime and who in turn are
becoming parents to another generation of dysfunctional
children."

The war on drugs has virtually decimated many black communities
and has led to increasing poverty, alienation, and violent
antisocial behavior, says Miller of the National Center on
Institutions and Alternatives. Miller, who is author of Search
and Destroy: African-American Males and the Criminal Justice
System (New York, NY: Cambridge University Press. In press), says
his center's figures show that 75% to 30%-of black men will be
arrested at least once by the time they reach 35 years of age

"Those who spend time in correctional facilities are compelled to
adopt the values and violent tactics necessary to survive in
these facilities," Miller says- "They then bring these antisocial
survival tactics back out to the streets.

"The war on drugs is causing far more destruction than the use of
illicit drugs ever could." Miller blames much of the inner-city
violence on some of the drug control strategies used by police.
"The widespread use of stiff sentences to force drug users and
minor dealers to inform on others has helped escalate the
violence," he says. "Gang-related murders have become the way
young men are expected to establish membership in the group and
convince fellow gang members that they're not snitches who will
ever rat on them."

According to a General Accounting Office (GAO) report, only 1% of
the estimated 27,000 federal inmates who have moderate-to-severe
substance abuse problems receive adequate treatment. In state
prisons, the GAO found that less than 20% of inmates with drug
problems received any type of treatment (GAO. Drug Treatment:
State Prisons Face ChalLenges in Providing Services. Washington,
DC: GAO; 1991).

According to a 1999 and 1990 American Jail Association survey,
less than 20% of jails reported having drug treatment programs
involving paid staff and 75% provided no group therapy, drug
education, transition planning, or referral to community drug
treatment agencies.

In 1992, the American Bar Association Ad Hoc Committee on Drugs
concluded that mandatory minimum sentences require expenditures
"disproportionate to any deterrent or rehabilitative effect they
might have." The committee found that there is no proof that
incarcerating large numbers of drug offenders with stiffer prison
sentences is reducing criminal behavior. Indeed, it concluded,
the burden of "warehousing" more and more prisoners is preventing
correctional facilities from providing drug offenders with drug
treatment, education, and job-training programs that might
benefit them.

A joint position paper by the American College of Physicians, the
National Commission on Correctional Health Care, and the American
Correctional Health Services Association (Ann Intern Med. 1992;
117:71-77) concludes: "Clearly, Mandatory sentencing practices
and the National Drug Control Strategy have overwhelmed
correctional facilities to the point of crisis, without
substantially alleviating the national problem of drug abuse or
drug-related crime.... As health professionals, we are seeing the
human costs of putting more and more people behind bars.

"Given its enormous human and financial cost, the National Drug
Control Strategy, with its emphasis on incarceration, must be
reconsidered. Its effectiveness in managing and preventing drug
abuse must be evaluated, and alternative approaches that put less
emphasis on criminal sanctions and more on prevention and
treatment must be considered."

================================================================
This posting is not made with any permission whatsoever.  This
'email' version was OCRed and retyped by Jim Rosenfield from the
original personal copy and is shared in this form strictly for
the purpose of furthering this informal public discourse.  It is
intended for no commercial purpose whatsoever and all readers are
advised to contact JAMA regarding any issue of copyright.  

I am presently seeking formal permission to post this and other
articles in this way for strictly non-commercial purposes and
trusting that JAMA will not be offended.  I commend the journal
to you and urge you to buy your own copy if this material is of
interest to you.

One thing this posting needs is a thorough proof-reading and
comparison to the original to make sure all the biliographical
refs and so on were retyped correctly.  If anyone can take this
on, please send me an ascii or WP5 file with the corrected
version. Angels will smile upon your efforts.

[j n r] at [igc.org]