Issues Magazine

Addiction – The Failing War on Drugs

Issues 74: Addiction

Issues 74: Addiction

By Richard Di Natale

Public health policy is a science with very clear outcomes, but the current state of partisan politics makes weighing up the evidence harder than ever.

There can be few contenders for the most critical area of public policy that could compete with health. Managing the nation’s health is an important challenge for all governments, and this is for many good reasons. Access to health care is a fundamental expectation of the Australian people – I consider it a basic right. A healthy workforce is needed to keep the economy moving. Healthcare is expensive, and needs to be carefully managed to balance the budget.

Perhaps most importantly, health is a prerequisite to any enjoyment of life. Other reforms mean little to you if you are preoccupied with health problems (or, worse, no longer around to see them).

It would seem fortunate that good health is relatively easy to define and so the policy outcomes should be clear and not of a partisan nature. After all, politicians might fundamentally disagree on what the optimal industrial relations framework looks like, whether a better future will result from a closer alliance with China or whether Australia should invest in more combat aircraft. But when it comes to health, we all agree that longer lives, less time in hospital and greater productivity are the desirable outcomes.

Even better, health and medicine are fundamentally scientific pursuits in ways that many other portfolios are not. The public health community relies on carefully collected statistics to draw conclusions on the best interventions. Medicines undergo rigorous clinical trials that are controlled for any sources of bias. Health economics is a field of its own, where the costs and benefits of particular therapies are carefully weighed at a population level. Although science in the real world is an imperfect process, when done properly it should take ideological bias out of the equation.

Despite all this, pushing through needed health reforms remains an enormous political challenge. There are many important reforms that we have not tackled because they are too big, or there are vested interests, or the issue can be too easily exploited for political gain.

Even without rose-tinted glasses, the current climate appears hyper-partisan and nastier than “business as usual”. This is affecting health policy as much as many other areas.

The Platonic ideal of the policymaking process might look something like this:

identify desired outcome → gather evidence → implement reform

But a more contemporary representation of the process might look something like this:

identify potential reform → simplify for the media → sow fear, uncertainty, doubt → recoil in fear from campaign by vested interests → use issue to wedge opponents → weakened or no reform

One example of health reform that government has been reluctant to tackle is dental health. The historical accident that left the mouth separated from the rest of the body has resulted in some huge inequities in our health system. Research shows that even a $100 out-of-pocket cost is a huge barrier for many people and is preventing one-third of the country from getting health care they sorely need. Low income earners, older people, indigenous Australians and those in regional and remote areas are sorely disadvantaged.

It is estimated that up to one in ten GP visits are due to untreated dental problems and the Australian Institute of Health and Welfare reports that over 60,000 potentially preventable hospitalisations are due to oral health issues each year. If that wasn’t reason enough to act, here’s another one: bringing down the cost of dental treatment and giving Australians universal access to Medicare-funded dental treatment is overwhelmingly popular among the electorate.

The federal government have been dragged, reluctantly, to dental reform by the Greens. But the big picture push for universality is not happening. In a political climate that combines scaremongering about debt, competing claims for the mantle of fiscal responsibility and a debate in which “tax” is a dirty word, the great reforming spirit that gave us Medicare in the first place is moribund.

Another area of unanimity amongst public health experts is the need to act around non-communicable diseases such as obesity, and to limit the harms of alcohol abuse. These harms are calculated at about $30 billion per annum – surely sufficient incentive for any government to act.

It would cost the government little if anything to make some reforms in this area of preventative health: mandating warning labels on alcoholic beverages, for example, warning pregnant women of the harm alcohol can do to their baby; reforming the taxation of alcohol so that the system no longer provides perverse incentives to the manufacturers of cheap cask wine, which is in some cases cheaper than bottled water; better front-of-pack labelling for processed foods, or bans on the advertising of junk food to children. Each of these reforms is backed by evidence and championed by the medical community. But none of them are proceeding.

These modest public health measures are designed to change behaviour, and some of this behaviour change might affect the interests of large industries. Winemakers, distillers, the food and grocery industry and fast food restaurants are all represented by well-funded and vocal lobby groups. To make these reforms, a government would have to pick a fight. At the moment, the appetite for such a fight is simply not there.

Drug law reform provides a glaring example of politics trumping public health evidence. It is hard to imagine an area where the case for reform is clearer.

The arguments for change are pretty convincing. The decades-long war on drugs has millions jailed and billions spent, but drug production and consumption have soared. Narcotics are purer and cheaper than they’ve ever been. The policy has been a manifest failure.

When it comes to minimising the harm caused by drugs, Australia once had much to be proud of. With the rise of HIV and when the spread of infection by injecting drug users became known, Australia developed strategies to limit the harmful side-effects of drug use. A needle and syringe exchange program began in 1990.

Although the latest data shows there is still much work to be done, since then we have managed to prevent tens of thousands of cases of HIV and hepatitis C in the community by pioneering needle and syringe exchange programs. Politics did not get in the way of spending hundreds of millions of dollars on these programs, which ultimately saved billions in health costs.

We have been similarly successful in leading the way on methadone programs, which have been available here since 1970. The safe injecting facility in Sydney’s King’s Cross opened in 2001 and has dramatically reduced overdoses in that area. But unfortunately the bipartisanship that allowed all these successful programs to begin appears to be a thing of the past.

We saw an unfortunate change when John Howard used his powers as Prime Minister to shut down a scientific trial of prescribed heroin in the ACT and renew the war on drugs. More recently we’ve seen safe injecting facilities in Victoria scuppered by governments of both persuasions. Politicians who will stand up for science over sensationalism are an endangered species.

The fact that former politicians seem so ready to engage is further evidence that the political culture of the day is the problem. A recent Australia21 report included a former premier, a chief minister, a federal health minister, police prosecutors, Australian Federal Police commissioner and others amongst its authors, and was scathing of the current policy of prohibition and criminal sanctions for drug users. It called for a reopening of the national debate on the regulation and control of illicit drugs.

The report resulted in strong bipartisan agreement to do nothing, with both leaders dropping it like a hot potato. Now, among sitting members, only the Greens and one or two rogues are willing to speak up on the issue. When even broadcaster Alan Jones admits that the war on drugs is a failure, you know the worm is turning.

In private, politicians of all stripes happily express the commonsense view that things need to change. The time is ripe for leadership.

Public opinions on this issue are more nuanced than before. It is probably fair to say that the majority of Australians have used drugs or know somebody who has. Drug users are not just criminals in the abstract; they are relatives and friends. But people still worry that softening drug laws could lead to more drug use and greater harm, and they need to be shown that this is not the case.

Reform in this area could end a lot of suffering. It could prevent waste of resources in hospitals, prisons and police forces and it could prevent the erosion of respect for the law. But in political terms, we may be as far from reform as we’ve been since US President Richard Nixon declared the War on Drugs in 1971, and Australia followed.

The politics confound what seems like an obvious reform. It is easy to imagine a golden age of bipartisanship and evidence-based policy that never existed. But things have changed. There was a time when, for instance, the issue of the influx of refugees from South-East Asia was handled calmly and without alarmism by both sides of politics. It is scarcely possible to imagine this happening today – indeed, the opposite can be seen on the front pages of newspapers on a daily basis. What’s changed?

There are several factors. The rise and misuse of polling is one. What used to be a gauge of public understanding of a reform is now used to determine what policies to pursue in the first place. Career politicians with a managerial bent have come to replace activists and crusaders who became parliamentarians to champion a cause come hell, high water or bad polls.

The media landscape has changed dramatically. The platforms competing for our attention are as diverse as ever, while diversity of ownership is at an historic low. Politicians now have less time to make an argument to the public, even as their ability to do so appears to have waned. In the context of today’s atmosphere of winner-takes-all wedge politics, this makes reform much harder than it needs to be.

There has also been a shift of power. When powerful lobby groups and individuals can quickly mount a national advertising campaign to defend their interests against those of the general public, just the threat of such a mobilisation can give politicians pause. That’s if it doesn’t torpedo reform altogether.

Lives might be at stake in a debate such as that around drugs, but unless the electoral dividends are great and obvious, the political drive is not there. It’s easier these days to sell a tax rebate to a target demographic than a vision for a healthier and happier society that benefits all.

Ideology does play a role in some of these health debates. Parts of the public health and preventative health agenda conflict with notions of “personal responsibility” and are dismissed as paternalistic. Public health reforms are often social reforms, and social policy can become contentious. But where evidence is clear and the health outcomes are not disputed, the sailing should be much smoother than it currently is.

As all politicians eventually must learn, it’s not evidence that changes people’s minds on contentious issues. People vote with their hearts as much as their minds, and it takes more than just the dry facts to bring the general public around. But evidence should certainly change the minds of politicians and leaders – that is the essence of good governance. Bringing the public along is what leadership is all about.

A return to this strong leadership on issues may be too much to hope for at present. But public health reforms usually pay for themselves over time; they are backed by a coterie of scientists, doctors and public health professionals; and they lead to social outcomes such as lower crime and less crowded emergency rooms, which are easy to sell to the public. Even when they are not bipartisan issues they present battles worth fighting and winning. Either way, health policy is the right place to start turning the political ship around.