Public Health

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The Obama administration released its 2012 National Drug Control Strategy and accompanying 2013 drug budget Tuesday, and while the administration touted it as a "drug policy for the 21st Century," it is very much of a piece with anti-drug policies going back to the days of Richard Nixon.

"We will continue to pursue a balanced approach… in a national effort to improve public health and safety," wrote Office of National Drug Control Policy (ONDCP) head Gil Kerlikowske in the introduction to the strategy. "We will work to prevent illicit drug use and addiction before their onset and bring more Americans in need of treatment into contact with the appropriate level of care. We will continue to build on the administration’s progress in reforming the justice system, ensuring that laws are applied fairly and effectively -- protecting public safety while also ensuring that drug-involved offenders have the opportunity to end their drug use and rebuild their lives."

But that's only one half of the administration's approach. The other half, as Kerlikowske makes clear, it continued adherence to classic war on drugs strategies.

"We will continue to counter drug produc­tion and trafficking within the United States and will implement new strategies to secure our borders against illicit drug flows," the drug czar wrote. "And we will work with international partners to reduce drug production and trafficking and strengthen rule of law, democratic institutions, citizen security, and respect for human rights around the world."

The federal government will spend more than $25 billion on drug control under the proposed budget, nearly half a billion dollars more than this year. And despite the administration's talk about emphasizing prevention and treatment over war on drugs spending, it retains the same roughly 60:40 ratio of law enforcement and interdiction spending over treatment and prevention training that has obtained in federal drug budgets going back years. In fact, the 58.8% of the proposed budget that would go to drug war programs is exactly the same percentage as George Bush's 2008 budget and even higher than the 56.8% in Bush's 2005 budget.

In the 2013 drug budget, treatment and early intervention programs would be funded at $9.2 billion, an increase of more than $400 billion over this year, but most of that increase is for treatment covered under the Medicaid and Medicare programs. Grant programs under the Substance Abuse and Mental Health Services Administration (SAMHSA), including Access to Recovery, early screening and referral, and drug courts are all reduced under the 2013 budget, although drug courts would see an increase in funding under the Department of Justice's Problem Solving Justice Program.

One area where treatment funding is unequivocally increased is among the prison population. Federal Bureau of Prisons treatment spending would jump to $109 million, up 17% over this year, while the Residential Substance Abuse Treatment Program for state prisoners would be funded at $21 million, up nearly 50% over this year.

The drug strategy's rhetorical emphasis on prevention is not reflected in the 2013 budget, which calls for a 1% decrease in funding. SAMHSA prevention grants and Drug Free Communities funding would decrease slightly, while the administration seeks $20 million to restart the much maligned and congressionally zeroed-out Youth Drug Prevention Media Campaign.

On the drug war side of the ledger, domestic anti-drug law enforcement spending would increase by more than $61 million to $9.4 billion, with the DEA's Diversion Control Program (prescription drugs) and paying for federal drug war prisoners showing the biggest increases. The administration anticipates shelling out more than $4.5 billion to imprison drug offenders.

But domestic law enforcement is only part of the drug war picture. The budget also allocates $3.7 billion for interdiction, a 2.5% increase over the 2012 budget, and another $2 billion for international anti-drug program, including assistance to the governments of Central America, Colombia, Mexico, and Afghanistan.

Critics of the continued reliance on prohibition and repression were quick to attack the new drug strategy and budget as just more of the same.

"The president sure does talk a good game about treating drugs as a health issue but so far it's just that: talk," said Neill Franklin, executive director of Law Enforcement Against Prohibition (LEAP) and a former narcotics officer in Baltimore. "Instead of continuing to fund the same old 'drug war' approaches that are proven not to work, the president needs to put his money where his mouth is."

"This budget is appalling. The drug czar is trying to resurrect those stupid TV ads, like the one where a teenager gets his fist stuck in his mouth," said Rob Kampia, executive director of the Marijuana Policy Project. "The budget intentionally undercounts the federal government's expenditures on incarcerating drug offenders, who comprise more than half of the federal prison population. And the budget dangerously proposes a massive escalation in using the military to fight drugs domestically. Congress should just ignore this budget and start from scratch. Specifically, Congress should not provide the Obama administration with any money to go after nonviolent marijuana users, growers, or distributors."

In the 2013 drug strategy, the administration is highlighting a renewed emphasis on drugged driving and is encouraging states to pass "zero tolerance" drugged driving laws. It is also emphasizing attacking the massive increase in non-prescription use of opioid pain pills.

While the strategy calls for lesser reliance on imprisonment for drug offenders, it also calls for increased "community corrections" surveillance of them, including calling for expanded drug testing with "swift and certain" sanctions for positive tests. But drug testing isn't just for parolees and probationers; the drug strategy calls for expanded drug testing in the workplace, as well.

The drug strategy acknowledges the calls for recognition of medical marijuana and marijuana legalization, but only to dismiss them.

"While the Administration supports ongoing research into determining what components of the marijuana plant can be used as medicine, to date, neither the FDA nor the Institute of Medicine has found the marijuana plant itself to meet the modern standard for safe or effective medicine for any condition," the strategy said. "The Administration also recognizes that legalizing marijuana would not provide the answer to any of the health, social, youth education, criminal justice, and community quality of life challenges associated with drug use."

For Bill Piper, director of national affairs for the Drug Policy Alliance, the 2012 drug strategy was all too familiar.

"This strategy is nearly identical to previous national drug strategies," he said. "While the rhetoric is new -- reflecting the fact that three-quarters of Americans consider the drug war a failure -- the substance of the actual policies is the same. In reality, the administration is prioritizing low-level drug arrests, trampling on state medical marijuana laws, and expanding supply-side interdiction approaches -- while not doing enough to actually reduce the harms of drug addiction and misuse, such as the escalating overdose epidemic."

The release of the drug budget comes just days after President Obama returned from the Summit of the Americas meeting, where he was pressed to open up a debate on legalizing and regulating drugs by sitting Latin American presidents like Juan Manuel Santos of Colombia and Otto Perez Molina of Guatemala. And it comes as marijuana legalization is at the cusp of majority support and trending upward.

It is past time to keep making minor adjustments -- a slight funding increase here, a decrease there, a shift of emphasis over there -- in what is fundamentally a flawed and failed policy, said LEAP's Franklin.

"The chorus of voices calling for a real debate on ending prohibition is growing louder all the time," said Franklin. "President Obama keeps saying he is open to a discussion but he never seems willing to actually have that discussion. The time for real change is now. This prohibition strategy hasn't worked in the past and it cannot work in the future. Latin American leaders know it, and President Obama must know it. Let's stop the charade and begin to bring drugs under control through legalization."

In just a couple of days, President Obama will fly to Cartagena, Colombia, to attend this weekend's Organization of American States (OAS) Sixth Summit of the Americas. He and the US delegation are going to get an earful of criticism of US drug policies from Latin American leaders, and that makes it an historic occasion. For the first time, alternatives to drug prohibition are going to be on the agenda at a gathering of hemispheric heads of state.

It's been building for some time now. More than a decade ago, Uruguayan President Jorge Batlle became the first Latin American sitting head of state to call for a discussion of drug legalization. Former Mexican President Vicente Fox joined the call, albeit only briefly while still in office through some media quotes, much more frequently after leaving office in 2006. Honduran President Manuel Zelaya issued a similar call in 2008, but didn't move on it before being overthrown in a coup the following year.

Meanwhile, drug prohibition-related violence in Mexico exploded in the years since President Felipe Calderon called out the army after taking office in December 2006. As the savagery of the multi-sided Mexican drug wars intensified and the death toll accelerated, surpassing 50,000 by the end of last year, the call for another path grew ever louder and more insistent.

In 2009, a group of very prominent Latin American political leaders and public intellectuals led by former Brazilian President Henrique Cardoso, former Colombian President Cesar Gaviria, and former Mexican President Ernesto Zedillo formed the Latin American Commission on Drugs and Democracy, calling for a fundamental reexamination of drug policy in the hemisphere and a discussion of alternatives, including decriminalization and regulation of black markets. That was followed last year by the Global Commission on Drug Policy, which includes the Latin American ex-presidents, as well as former Switzerland President Ruth Dreiffus and other prominent citizens such as Richard Branson and former UN Secretary General Kofi Annan, echoing the Latin American Commission's call for reform.

As the commissions issued their reports, the violence in Mexico not only worsened, it spread south into Central America, where governments were weaker, poverty more endemic, and violent street gangs already well-entrenched. Guatemala, Honduras, and El Salvador, in particular, saw homicide rates soar in recent years, well beyond Mexico's, as the Mexican cartels moved into the region, a key transit point on the cocaine trail from South America to the insatiable consumers of the north.

Colombian President Juan Manuel Santos, the secretary of defense under his predecessor, Alvaro Uribe, and a man who knows well just what a sustained war on drugs can and cannot achieve, has been among the latest to pick up the torch of drug reform. Santos has made repeated statements in favor of putting alternatives to prohibition on the table, although he has been careful to say Colombia doesn't want to go it alone, and now he has been joined by another unlikely reformer, Guatemalan President Otto Perez Molina, a rightist former general who campaigned on a tough on crime agenda.

It is Perez Molina who has been most active in recent weeks, calling for a Central American summit last month to discuss alternatives to drug prohibition ranging from decriminalization to regulated drug transit corridors to charging the US a "tax" on seized drugs. That summit saw two of his regional colleagues attend, Costa Rican President Laura Chinchilla and Panamian President Ricardo Martinelli, but no consensus was achieved, no declaration was issued, and three other regional leaders declined to show up. But that summit, too, was a first -- the first time Latin American leaders met specifically to discuss regional drug law reform.

All of this has not gone unnoticed by policymakers in Washington. Vice-President Biden, Homeland Security Secretary Napolitano, State Department functionaries and US military brass have all been flying south this year, reluctantly conceding that drug legalization may be a legitimate topic of debate, but that the US is having none of it.

"It's worth discussing," Biden told reporters in Mexico City last month. "But there's no possibility the Obama-Biden administration will change its policy on legalization. There are more problems with legalization than non-legalization."

But along with discussing an end to prohibition, the Latin Americans have also offered up proposals between the polar opposites of prohibition and legalization. Options discussed have included decriminalization of drug possession and marijuana legalization to different approaches to combating the drug trade to maintaining addicts with a regulated drug supply. In Colombia, Santos has sponsored legislation to decriminalize possession of "personal dose" quantities of drugs, restoring a policy mandated by the country's Constitutional Court but undone by a constitutional amendment under President Uribe.

And it's not just Latin American political leaders. The calls for change at the top are reflected in a civil society movement for drug reform that has been quietly percolating for years. In fact, an international, but mainly Latin American, group of non-governmental organizations this week issued an Open Letter to the Presidents of the Americas calling for decriminalizing drug use and possession, alternatives to incarceration for non-serious drug offenses, a regulated market for marijuana, a public health approach to problematic drug use, alternative development, respect for traditional uses, and a more focused war on organized crime that is less broadly repressive than current models. In Mexico, a social movement led by poet Javier Sicilia, whose son fell victim to cartel violence, has called for an end to the violence and pressed Preident Calderon on drug reform.

After decades of US-imposed drug war, from US military operations in Bolivia in the 1980s to the multi-billion dollar Plan Colombia, with its counterinsurgency and aerial herbicide spraying, to the blood-stained Mexican border towns and the drug gang-ridden slums of Rio de Janeiro, Latin America is growing increasingly ready to strike out on a different path.

That's what awaits President Obama and the US delegation in Cartagena. The most vibrant discussions may well take place in hallways or behind closed doors, but the US is now faced with yawning cracks in its decades-long drug war consensus.

"It's very clear that we may be reaching a point of critical mass where a sufficient number of people are raising the questions of why not dialog on this issue, why not discuss it, why peremptorily dismiss it, why does the president laugh when the subject of drugs is brought up, is he so archly political that it becomes a sort of diabolical act to seriously discuss it, why isn't some new direction being ventured forth?" said Larry Birns, executive director of the Council on Hemispheric Affairs.

"It seems the public is approaching the point where it has become credible to say quite frankly that the drug war hasn't worked. The real menace to society is not so much legalization but the failure to confront the hard fact that after decades of effort and hundreds of billions of dollars, a successful prohibition strategy has not been created, nor is there any likelihood of it being created," he said.

"This is the first major gathering of heads of state at which alternatives to prohibitionist drug control policies, including decriminalization and legal regulation of currently illegal drugs, will be on the agenda," said Ethan Nadelmann, head of the Drug Policy Alliance. "Arguments that were articulated just five years ago primarily by intellectuals and activists, and three years ago by former presidents, are now being advanced, with growing sophistication and nuance, by current presidents. There is now, for the first time, a critical mass of support in the Americas that ensures that this burgeoning debate will no longer be suppressed."

"A lot of countries don't want to do the US's dirty work anymore -- enforcing the prohibitionist policies that are unenforceable and hypocritical," said Laura Carlson, director for Latin America rights and security in the Americas program at the Center for International Policy. "Everybody knows that it's impossible to wipe out the illicit drug business without making it legal, and most people know that the efforts aimed at ostensibly doing that are not 100% honest and certainly not effective. Many Latin American countries don't want the degree of US intervention in their national security that the drug war entails either," she noted.

"Having said that, the US government is determined to put down any talk of alternatives and particularly alternatives that begin with regulation rather than prohibition. The recent visits of Napolitano, Biden, [US State Department Assistant Secretary for the Bureau of International Narcotics and Law Enforcement Affairs William] Brownfield and the military leaders all carried that message," the Mexico City-based analyst continued. "Small and dependent countries -- El Salvador is the example here, after reversing its position on legalization -- are afraid to stand up to the US on this, and progressive countries don't seem to want to get involved, both because they find the issue a political hot potato and because they are focusing efforts on strengthening alternative organizations to the OAS."

"I think the US strategy of Brownfield and the State Department will be to say that legalization was brought up and rejected by the Latin American leaders," offered Sanho Tree, director of the Drug Policy Project at the Institute for Policy Studies. "They will use dichotomous rhetoric, they will try to maneuver the discussion into either prohibition or heroin in vending machines, but this is about the whole spectrum of regulatory possibilities. That's what we need to be talking about instead of that false dichotomy."

Still, to even deign to discuss policy alternatives to prohibition is a notable step forward for the US, even if it is only to dismiss them, Nadelmann argued.

"The shift in the public posture of the US government -- from rejecting any discussion of legalization to acknowledging that 'it is a legitimate subject of debate' -- is significant, notwithstanding the clear caveat by the Obama administration that it remains firmly opposed to the notion," he noted. "That said, it is safe to assume that the US government will do all it can to suppress, ignore, distort and otherwise derail the emerging dialog.  US officials are handicapped, however, by the remarkable failure of government agencies over the past thirty years to contemplate, much less evaluate, alternative drug control strategies. They also must contend with the fact that the United States has rapidly emerged -- at the level of civil society, public opinion and state government -- as a global leader in reform of marijuana policies."

The discussion on drug policy at Cartagena isn't taking place in a vacuum, and there is at least one other issue where the US finds itself at odds with its host and most of the region: Cuba. The US has once again insisted that Cuba not be allowed to attend the summit, and President Santos reluctantly acceded, but the whole affair leaves a sour taste in the mouth of Latin Americans. Ecuadorian President Correa is not coming because of the snub, and the issue only plays into hemispheric discontent with Washington's war on drugs.

"The US won the day in persuading Santos not to invite Cuba," said Birns, "but the political cost of that action is high, and the whole drug issue is twinned to it, not because Castro has an enlightened position on drugs, but because of anti-Americanism in the region. This means Cartagena is the city where a lethal blow against the status quo will be achieved."

"The United States is not going to listen," said Birns, "but this era of non-discussion of drug legalization and refusal to countenance the possibility of dialog on the issue may be coming to an end. More and more people who aren't known as drug reform crusaders are coming forth and saying it's not working, that we need another approach, and that's probably decriminalization and legalization. We're very much closer to liberation on this issue than we've ever been before."

"Liberation" may now be within sight, but diplomatic dissent is not yet close to being translated into paradigmatic policy shifts. Whatever discussion does take place in Cartagena this weekend, don't expect any official breakthroughs or even declarations, said Carlson.

"I am not optimistic about there being any formal commitment, or perhaps even mention, of legalization per se," she said. "The implementation group for the Sixth Summit is already working on the final declaration and it contains a section on 'Citizen Security and Transnational Organized Crime.' I think that as far as it will go is to state that transnational organized crime is a growing problem and that the nations of the Americas agree to work together, blah, blah, blah," she predicted.

"The United States will reiterate its 'shared responsibility' and commitment, but will not mention the need to change a failed model," Carlson said. "There will be more rhetorical emphasis on social programs for 'resilient communities' and especially on police and judicial reform, although the former will not be reflected in what are largely military and police budgets. I think the best we can hope would be a mandate for a policy review and a commitment to continue to discuss alternatives. The specific proposals to legalize transit, to create a regional court for organized crime cases and US payment for interdictions will not likely be resolved."

"This is a long process, not an immediate objective," said Tree. "In Central America, it's going to take a year or two of thoughtful -- not sensational -- media coverage. When people see anarchy, they want order. With a more thoughtful dialog, we can begin to get traction."

"It is too soon to predict that this Summit of the Americas represents any sort of tipping point in global or even regional drug control policy," Nadelmann summed up. "But the odds are good that this gathering will one day be viewed as a pivotal moment in the transformation from the failed global drug prohibition regime of the twentieth century to a new 21st century global drug control regime better grounded in science, health, fiscal prudence and human rights."

We'll see what happens this weekend, but at the very least, the taboo on serious discussion of reforming the drug prohibition regime at the highest levels has been shattered. Look for a report on the summit itself next week.

After 20 years of walking in the political wilderness, public health and harm reduction advocates for federal funding for needle exchange programs made it to the Promised Land in December 2009, when the Democratic-controlled Congress overturned the longstanding funding ban. But just two years later, led by the Republican-controlled House and with the acquiescence of the Democratic-controlled Senate, Congress reinstated the ban in its 2012 federal omnibus spending bill.

Advocates were outraged and dismayed by the congressional action, but are determined to fight back to restore funding for a harm reduction practice repeatedly proven to save lives and reduce the spread of infectious blood-borne diseases, such as HIV/AIDS and hepatitis C. This week, they came out swinging with a national day of action Wednesday that saw organized call-ins to members of Congress and civil disobedience actions leading to dozens of arrests at the offices of four of them, as well as actions in a dozen others cities across the county.

Although the funding ban's main proponents are Republicans, repealing the ban is actually the states' rights, deregulation position. Each year the federal government authorizes funding for grants to states to be used for AIDS prevention and treatment. When the ban was temporarily lifted, it neither increased nor decreased the amount of AIDS funding, but it meant that states could choose for themselves whether or not to use some of those funds to support needle exchange programs.

The activists have science and the evidence on their side. The Centers for Disease Control and Prevention (CDC), American Medical Association, National Academy of Sciences, American Public Health Association, and numerous other scientific bodies have found that syringe exchange programs are highly effective at preventing the spread of HIV/AIDS and other infectious diseases. Eight federal reports have found that increasing access to sterile syringes saves lives without increasing drug use.

More than 200 needle exchange programs operate across the country in cooperation with local law enforcement officials and health departments, but many are in danger of closing their doors or cutting back services without access to federal funds. That puts lives and the public health at risk.

Needle exchange supporters said the restored the ban will result in thousands of Americans contracting HIV/AIDS, hepatitis C or other infectious diseases next year alone. According to the Harm Reduction Coalition (HRC), needle sharing by injection drug users accounts for 8,000 new cases of HIV and 15,000 new cases of hepatitis C each year. In New York City, there has been a 75% reduction in new HIV cases as a result of instituting such programs, according to a 2005 study cited by HRC.

"We need Congress to stand behind public health and science, and declare a cease-fire on syringe exchange," said HRC executive director Allan Clear. "All of the research tells the same story: Syringe exchange prevents infections, promotes drug treatment, and reduces drug use. Congress must stop treating syringe exchange as an ideological pawn in partisan politics."

"The federal syringe funding ban was costly in both human and fiscal terms -- it is outrageous that Congress has restored it given how overwhelming and clear the science is in support of making sterile syringes widely available," said Bill Piper, director of national affairs for the Drug Policy Alliance. "Make no mistake about it -- members of Congress who supported this ban have put the lives of their constituents in jeopardy."

The renewed ban on federal funding for needle exchanges couldn't come at a more inopportune time. With a wave of drug users who began their careers with opioid pain pills finding succor in the needle, making access to clean needles more difficult is likely to make matters worse.

"We need to support syringe exchange programs now more than ever," said HRC policy director Daniel Raymond. "Health officials in many states report a disturbing new trend of hepatitis C outbreaks in young people, driven by a new wave of injection drug use linked to the prescription painkiller epidemic. We're in danger of starving programs of federal funds, just when the demand for syringe exchange is increasing."

In Washington, while a coordinated campaign of phone calling kept the congressional switchboard humming, dozens of AIDS and harm reduction activists went to Capitol Hill and held sit-ins at the offices of four House Republicans, including Speaker John Boehner (R-OH), Rep. Denny Rehberg (R-MT), Mike Rogers (R-MI) and Eric Cantor (R-VA) for their role in reinstating the ban on federal funding for syringe exchange programs last December.

Carrying signs reading "Syringe Exchange: A Fix for AIDS," the activists chanted and blocked doorways before being arrested by Capitol Police. They were expected to be booked and released later Wednesday.

At least 32 people were arrested at Congress, according to Housing Works, a New York City-based group that provides services for AIDS sufferers. Housing Works participated in the action as part of the We Can End AIDS Coalition, an umbrella group coordinating a July 24 mass protest in Washington around economic justice and human rights for AIDS patients.

"Our government should be embarrassed as this year's host of the International AIDS Conference to have sneaked this into an unrelated bill under the cloak of night last December," said Housing Works CEO Charles King. "The US cannot be any shining example to the rest of the world on how to end the AIDS epidemic when we’re still fighting foolish policies that reject what we know works."

Wednesday's action was only an opening skirmish in what will be a determined battle to restore the federal funds. The AIDS, public health, and harm reduction communities are not going to just roll over and play dead while Congress makes decisions that will result in real people becoming really dead.

"We refuse to let the close-mindedness of anti-science conservatives dictate public health policy," said Clear. "We can't afford these political games, and we can't afford any more new infections. Our communities are struggling; Congress needs to listen and show leadership by rescinding the funding ban."