Can we wage war with something that is not an actual enemy, not a sovereign power or an uprising within a nation? If indeed the metaphor of war is liberally applied, as it has been to campaigns against a variety of ills, can those wars be won?
As the United States convenes its political conventions, and September marks National Alcohol and Drug Addiction Recovery Month, we have an opportunity to consider what has been called the "war on drugs." We have also witnessed the "war on poverty" and the "war on cancer," among other ails. The history of these efforts bears attention so let's take a short look at each, starting with poverty, then cancer and finally drugs.
In 1964, President Lyndon Johnson, in his first State of the Union address, called for an "all-out war on human poverty." It was part of his vision for a "great society." President Ronald Reagan, also using the grand moment of a State of the Union address, pronounced that the war had failed, saying "My friends, some years ago, the federal government declared war on poverty, and poverty won." But it took President William Clinton to reframe the problem in 1996 when he claimed the legislation passed by his administration would "end ... welfare as we know it" -- principally through personal responsibility and work opportunities (more or less the name of the legislation he passed). In other words, if there was something that figuratively could be considered a war on poverty, we had lost, according to both political parties, and it was time to find not only another metaphor but also a better approach.
The "war on cancer" dates back to President Richard Nixon, who in 1971 signed the National Cancer Act that sought to find a cure for cancer. We have not won this "war" either, if indeed we can consider this effort a war. Certainly huge sums of money have funded research to end cancer. While some cancers now can be cured and others have more effective treatments that allow people to survive longer, the fact remains that after 40 years cancer remains a huge public health problem in this country and throughout the world. Sadly, we have not seen a significant decrease in the overall population death rate from cancer since the "war" began -- though there has been notable progress with greater survival rates in recent decades, especially for children's leukemia and cancers of the lung, prostate and colon (in men) and breast and colon (in women), in part due to earlier detection and more targeted treatments.
It was President Nixon who first used the metaphor "the war on drugs." A combination of prohibiting drug use in the United States and military intervention in other countries, he asserted, would destroy the illegal drug trade. But notable global leaders, including Kofi Annan, former presidents of Brazil and Columbia, the prime minister of Greece, Paul Volcker, and prominent writers and policy experts, issued a report in 2011 that pronounced that "the global war on drugs has failed."
The casualties of this "war" are great. Since President Nixon declared war, the incarceration rate in the United States has increased over 400 percent, resulting in this country having the highest incarceration rate in the world. By 1994, the "war" led to one million Americans arrested each year for drugs; about one in four arrests then were for marijuana possession; more recently marijuana was the charge in half of all drug-related arrests in this country. Many states implemented "Three Strike" laws in the 1990s that mandated very long sentences. By 2008, 1.5 million Americans were arrested annually for drugs, and one in three incarcerated. There is ample evidence that our prisons are filled with people of color; African-Americans are sentenced to state prisons 13 times more frequently than are Caucasians. Former prisoners are denied access to public housing (and other benefits) and stigmatized in hiring, thereby making the road back all the more steep.
President Barack Obama, however, in 2009, claimed that the term "war on drugs" was not useful and would not be used by his administration. The White House Office of National Drug Control Policy (ONDCP) declared, in 2011, that "drug addiction is a disease that can be successfully prevented and treated," and that "making drugs more available ... will make it harder to keep our communities healthy and safe."
The proposition underlying war is that there is an external enemy (or collection of enemies) outside our borders, or a civil uprising (such as the U.S. Civil War and countless examples abroad) threatening the future of a nation. This is where the war metaphor applied to drugs, poverty and cancer seems to fail us from the very start. War was declared on these human problems without the conditions to win; these "wars" seem to have met the fate that has been said of many wars, namely that they last until politicians and generals run out of money, or interest.
Drugs are what people with addictions use -- they are not armies at the gate. Addiction is "self-induced changes in neurotransmission that result in problem behavior." There is no external enemy but instead the powerful convergence of biology and social circumstance, the interplay of nature and nurture, which produces addictions (which span alcohol, drugs, and a variety of compulsive behaviors like gambling, video games and some sexual disorders).
Can we put an end to addictions, or at least greatly reduce their prevalence and burden? This seems the core question after we move beyond the metaphor of war. I believe we can incrementally achieve a society not consumed by addictions. Not by war, but by public health and community strengthening efforts.
There are public health approaches to controlling addictions. These are very different from criminal justice efforts that lock up drug users, or engage in interdiction at our borders, or crop destruction abroad. Instead, public health focuses on prevention, early intervention and effective treatment.
Drug courts are a growing alternative to incarceration for drug possession. They allow offenders to obtain treatment instead of doing prison time. Many states have drug courts, but not enough of them (the same can be said of mental health courts).
Prevention can be delivered through public education campaigns, and by fostering strong families and school programs that give youths alternatives to drugs. Prevention is also achieved by limiting access to drugs (and alcohol), but not by their prohibition (we tried that once in the United States and by the time it was ended the consumption of alcohol was greater than before it began). Limiting access is accomplished by regulation (not necessarily legalization) and what is called "price sensitivity" (the more a substance costs the less it is used, which is particularly effective with adolescents).
Science may add to our ability to limit drug (and alcohol) abuse by helping us to better understand the pleasure (reward) circuits in human brains (especially the neurotransmitter dopamine), and to develop compounds that enable those people with brains that seek substances to better achieve satisfaction in relationships, work and play; or by helping us discover and advance other interventions (including natural substances or altering the brain with yoga, meditation or other ways of producing calming brain patterns).
Early intervention means detecting addictive behaviors early and initiating help as soon as possible. Screening for alcohol and drugs is apt to become standard practice in primary care settings because that is where it is most apt to be discovered, insurance payment now possible for doing so, and where motivational techniques can help those who screen positive reduce their intake or seek treatment.
For those who already have developed the disease of addiction, we know that treatment can work -- and that there are many roads to recovery. These include 12-step programs (like AA and Narcotics Anonymous), medications that can reduce craving and assist with maintaining sobriety, recovery treatment programs, and a host of nutritional and non-Western approaches. The evidence is very strong that the longer a person stays in treatment the more likely he or she is to succeed. Greater emphasis (and funding) for treatment, rather than interdiction and prisons, is more likely to reduce the impact of addiction on our society.
Perhaps the greatest challenge, and one that does not comport with "war," may lie in the strengthening and revitalization of families and communities. Neighborhoods that have been scourged by poverty, crime and improbable exit from the "'hood" are breeding grounds for addiction. The prospect of a life with work, purpose and dignity, with the hope that has inspired centuries of classes of people to move beyond the limits of their current realities, may be the most difficult yet the most powerful anodyne to addiction that exists. When war can be put aside, real and metaphorical war, we stand to find better ways (and more money) to change communities, to give youth and adults opportunities to succeed, and to fashion a life where addiction will be seen as the enemy of success, rather than as a comforting friend.
Lloyd I. Sederer, MD
Dr. Sederer's book for families who have a member with a mental illness, The Family Guide to Mental Health Care, will be published by WW Norton in the spring of 2013.
The opinions expressed here are solely mine as a psychiatrist and public health advocate. I receive no support from any pharmaceutical or device company.
Visit Dr. Sederer's website (www.askdrlloyd.com) for questions you want answered, commentaries, movie and book reviews, and stories.
This post is part of the HuffPost Shadow Conventions 2012, a series spotlighting three issues that are not being discussed at the national GOP and Democratic conventions: The Drug War, Poverty in America, and Money in Politics.
HuffPost Live will be taking a comprehensive look at America's failed war on drugs August 28th and September 4th from 12-4 pm ET and 6-10 pm ET. Click here to check it out -- and join the conversation.
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