To serve and protect? Toward a better relationship between drug control policy and public health

Abstract

117–118Keywords: HIV, police, drug policy, enforcementThe USA has the highest rate of incarceration in theworld; over 2 million people are behind bars and another4.5 million are on probation or parole. The number ofincarcerated people in the USA has almost doubled overthe last decade [1,2], due at least in part to penally-oriented US drug policies. In their paper [3], Friedmanet al. examine the extent to which legal repressiveness –measured through drug-related arrests, police per capitaand corrections expenditures percapita – influences HIVinfectionin89majorUSmetropolitanareas.Inanelegantanalysis, the authors show that their three indices of legalrepressiveness had no effect on drug use measures, but allthree were associated with higher HIV prevalence.The growing body of literature surrounding policing andHIV risk [3–9] has important implications for bothresearchandpolicy.Intermsofresearch,thereisaneedtodetermine the extent to which the relationship betweenpolicing practices and HIV infection is causal, and if so,whether the effectis direct or indirect. Literature exists tosupport both direct and indirect pathways. Police canhaveadirecteffectonwhere,withwhom,whenandhowinjection drug users (IDUs) administer theirdose. Studiesfrom the USA and elsewhere show that police pressure isassociatedwithuseofshootinggallerieswhereneedlesarerented or sold and needle sharing is commonplace [5–7].Police can also have an indirect effect on HIV risk, forexamplebydiscouragingIDUsfromutilizationofsyringeexchange programs (SEPs) [8] ordisplacing IDUs to areaswith limited or no access to SEPs ordrug treatment [8,9].Friedman and colleagues [3] provide yet another piece ofevidencethattheUSwarondrugsishavingserious,oftendevastating health effects that can be reduced throughpublic health interventions.The war on drugs, which the USA has prosecuted withsingle-minded vigor at home and abroad, is a losingproposition.Yetonecanhardlyconcludethatabandoningcollective efforts to reduce harmful drug consumptionwould produce a net benefit to society: drugs, both legaland illegal, can carry significant health hazards. In legalandillegalmarkets,theprofitmotivedrivesproducersandsellerstomarketaseffectivelyaspossible.Thus,theissueisnot whether to continue drug control efforts, but whichsorts of efforts, and in what combination, will have thegreatest positive impact on drug abuse and the type,severity and distribution of harms. Experiences withnicotine, alcohol and heroin all have something to teachus about regulatory models and their health effects.The prescription for policy is not obvious. Reducingdemand, incarcerating fewer drug users, improving andexpanding harm reduction services and drug treatmentoptionsareallsensiblepiecesof anewdrugpolicy,butwehave no more consensus about what policies work thanwe do on the question of which ones do not. Moreover,we do not have one global drug problem but many,varying with place, culture, economic conditions and