http://www.cedro-uva.org/lib/cohen.looking.html Peter Cohen (2006), Looking at the UN, smelling a rat. Amsterdam: CEDRO. © Copyright 2006 Peter Cohen. All rights reserved. Looking at the UN, smelling a rat A comment on ‘Sweden’s succesful drug policy: a review of the evidence’ UNODC september 2006 [1] Peter Cohen Introduction [i] The year 2009 will mark the centennial of the Shanghai Opium Conference, the first world-wide agreement on the reduction of opium use and production. China, then still an extremely poor feudal nation, was spending most of its foreign exchange on opium it imported through British traders. The British sold their cheap Indian Opium for pure silver to the Chinese, and had almost two centuries of opium fortune-making behind them. The fledgling United States of America tried to conquer a share of the profits in this lavish market, at a time when prohibitionist ideas about alcohol and opium control were expanding all over the globe. It was time for the American Disease to be born. [2] In later analyses of the history of drug and alcohol controls other names for the American Disease have been coined. The most appropriate one, not tied to any nationality per se, is the ‘Temperance Movement’. It was comprised of a collective of local movements prevalent in a group of nations. Later these nine nations would be identified as a special group, the nations where the temperance culture would endorse far reaching control policies in the attempt to regulate medical and recreational drugs. [3] The global impact of these temperance cultures has varied from almost nothing to considerable. It is this variance we will address in this comment because it is at the heart of the report that will be discussed. Sweden represents the most fundamentalist and extreme pole of this variance. Swedish policy makers and popular ideologues developed their own logic , policy language and version of Swedish drug history in order to convince themselves that no other policy could be possible. [4] The UNODC in 2006 After years of mismanagement, the UNODC not only has the difficult task of regaining some status for itself. It also has the task of reinstalling faith into its core business, the business of drug control. As its director aptly remarks in the opening phrases of the report on Sweden : “More people experiment with drugs and more people become regular users… There are thus suggestions, at the European level, that drug policies have failed to contain a widespread problem.” (page 5) The report we will be discussing here has to be seen against the background of diminishing support for present prohibitionist drug control policies world wide. It does not have, according to me, a purely empirical nor scientific ambition. It is too clumsy and too primitive for that to be the case. But as a helping hand for doubting drug control functionaries, struggling with the obvious increase in drug use and drug production all over the world and the astounding inadequacy of global policies, the report must be perceived as a genuine attempt to stand behind them. The report about Sweden is “a rapid assessment, based on open-source documents, supplemented by Government documents and information obtained from government officials” (page 7) Why did UNODC choose Sweden as an example? “….in the case of Sweden, the clear association between a restrictive drug policy and low levels of drug use, is striking.” “Swedish drug policy is highly effective in preventing drug use…” “….a review of fluctuations in abuse rates shows that periods of low drug abuse in the country are associated with times when the drug problem was regarded as a priority.” (page7) According to this report, then, if ever you had doubts that drug control has effects on levels of drug use, you should study the example of Sweden. Or, that if your drug control is not working, nor effective enough, you will have problems with drugs! UNODC director Costa said at the launch of World Drug Report 2006 that countries have the drug problems they deserve. He repeats this remark in the Sweden report, saying that “each government is responsible for the size of the drug problem in its country. Societies often have the drug problem they deserve” (page 5) So, we have to see the present work of UNODC to be tailor made to arrive at the conclusion that drug control works, and that a deficit in drug control will translate into an increased ‘drug problem’. Let us see how this precious work is done, and if it can stand the test of simple questions asked about it. I will proceed by selecting just a few examples of how this is done, because if the reader wants the full works, she had better read the full report. But since the method behind the work is the same throughout, it does not matter much which examples are chosen. First, a clear definition of the ‘drug problem’ is not supplied. It can be anything UNODC deems it to be. Thus, the drug problem is defined as the level of drug use in the population, or in certain age cohorts. This material is supported by levels of ‘heavy use’ or drug abuse, a category that is not defined either. Drug use and drug abuse are freely interchanged in the language of the report, thereby repeating a source of confusion that has become standard in most writing about ‘the drug problem’. The first problem clearly is with the data that are chosen. I do not mean the reliability of the data, for that is a huge problem on its own (not discussed in the report). I mean that the choice of data that are presented for supporting the case of Sweden’s success, is left to the authors. Since there is no clear theory about what data are needed to create a standard description of the drug situation in a country, we can not blame UNODC for this. They simply use the lack of scientific or standardised clarity to legitimise their agenda. [5] So, by showing many tables of use of (cannabis) drugs, mostly with 15 year old school children or of 18 year old army conscripts, they define drug use levels in Sweden. In a few other places prevalence data are given for the Swedish population between 15 and 75 years old. All these data are then compared, sometimes to other individual countries, but most frequently to the European average, as reported by EMCDDA in Lisbon. The Sweden report then shows that on most of these variables Sweden shows scores below EU average. However, if one studies the tables that EMCDA provides for drug use, such as the last year use of cannabis for the drug use age cohort of 15-34 year olds, one can not escape the fact that 14 countries out of 19 produce prevalence figures below the EU average [6]. So in theory it would be possible to produce a UNODC report with the title “The successful drug policy of the Netherlands,” because on many indicators of drug and alcohol use and of the number of ‘heavy users’ seen in treatment, the Netherlands produces indicators that are (well) below the European average, and far below the USA or Australia. Just like Sweden. In the same vein UNODC could produce a series of reports called “The catastrophic drug policy of” France, the UK, or the Czech Republic, or the USA because these UN members show indicators of (some) drug use that are higher or far higher than the EU average. We invite UNODC to write such reports, as soon as possible! Sweden is also lauded because of the vast resources it spends on drug use prevention and drug policy in general. But Greece, (a culture profoundly different from those of the Netherlands or Sweden) spending almost nothing, the least of all EU countries on drug policies, has even LOWER drug use figures than Sweden (if one chooses to believe the Greek data). Looking at other figures from Sweden, ones that are not mentioned in the UNODC report, one sees that Sweden has relatively low levels of alcohol use, and low levels of tobacco use. (Liters of consumed pure alcohol per year in Sweden is 7, versus 10 in Holland and Greece, 14 in France. The percentage of daily smokers in Sweden is 16, versus 30 in the Netherlands and almost 40 in Greece) And the Swedes use relatively few pharmaceutical drugs as well, spending on them less than most countries in the EU (7% of health expenditures - the only country spending less than that is Norway, with 6%. The Dutch spend 12%!! The champion pharma client is Spain, with 23%) [7] So, in order not to fall into the trap of a detailed discussion of the hand picked data used in the UNODC report on Sweden, I would like to stress that the basic assumption of that report does not have any scientific legitimacy. The basic assumption is that the low figures that Sweden shows on a series of indicators on recreational drug use are due to Sweden’s drug policy. Maybe! And let us for the convenience of the argument ignore the quality of the data. But to propose this association, as the UNODC report clearly does, it should at least show some evidence the two are causally related, and why. This evidence is so completely lacking that one may ask if the report should not be seen as a religious document that is intended to prop up faith in drug control rather than an attempt at scientific rigour and clarification. The other thesis: drug control is irrelevant for levels of drug use. Maybe Sweden’s drug policy is just another phenomenon on its own, next to low levels of alcohol and drug use, that EXPRESSES a temperance culture, but does not cause it. In other words, even if Swedes were to choose a less extreme policy, their temperance culture would still produce low levels of intoxicant use, lower than some but not all countries. The Greeks, using little alcohol and drugs as well, will produce their own low figures from a series of completely different cultural or demographic characteristics and determinants, as do the Dutch. Nothing contradicts the thesis that drug policies, whatever they may be, have little to do with the production of the drug and alcohol situation that is found. For UNODC to even contemplate this ‘cultural construction’ notion would be disaster, because it opens the road to a scientific analysis of drug situations, separating it from the ideological analysis that suits UNODC. And this notion would completely invalidate Mr. Costa’s conviction that countries have the drug problem they ‘deserve’ if they fail in drug control orthodoxy. Another way of looking at the situation would be to correlate demographic and cultural variables to a local drug situation. For instance, in the Netherlands epidemiological research has shown that levels of cannabis use in the densely populated urban regions of the country is almost four times as high as in the open spaces of the rural regions. In other words, within a nation with a highly homogeneous drug policy, differences in use levels can be higher than between nations with markedly different drug policies. Also, in Amsterdam life time prevalence of cannabis use is about twice as high as in Rotterdam in spite of the identical drug policies reigning. [8] In the Netherlands the growth of the urban population has been high from 1975 until 2005, with levels varying from 0,5% to over 1% per year. In Sweden during this period urban growth has been less than 0,1 % per year (with the exception of the period 1990-1995, with 0,17% urban growth, exactly when drug use experienced an increase in Sweden) [9] It would be relevant to develop a line of reasoning in which proportions of urban/rural populations, and the change thereof, could be seen as a demographic variable that influences levels of drug use and the emergence of drug use fashions, irrespective of the drug ‘policies’ that are undertaken. Another demographic variable might be the proportion of the elderly in the population. In Greece — where cannabis use is lowest of all Europe — 44% of the population (compared to work force) are aged 65 or older. In Sweden, with 33% of the population older than 65, we observe slightly higher cannabis use. Slightly higher still cannabis use in the Netherlands corresponds with 24% of the population older than 65 (compared to work force)! But such simple eye catching associations will not create serious possibilities for understanding variation of drug use level in the populations of the world. Combinations with other variables will have to be developed. Important aspects of working life may be candidate variables. In Greece, with a relatively old population and a relatively high rate of unemployment (10% in 2004), people have to work a lot of hours for their income (1925 hours per year). Compare this with the Netherlands, with a relatively young population and low unemployment rate (4,6% in 2004): people work a far shorter time for their income (1357 hours). Couple this to continuous increases of urbanization and urban life styles in the Netherlands and we have a background for recreational behaviour that is different, perhaps far different, than other countries may exhibit. Countless local variations in these variables may exist as well, presenting nearly ideal conditions to test theories using these combinations of variables in relation to well measured (standardized!!) prevalence data and their development over time. The possibilities of examining reasonable hypotheses that relate drug use levels with combinations of economic, demographic or cultural variables has, however, not even begun. Rather, the dominance of ideological analysis is striking. But such studies would clearly help answer questions about why levels of drug use vary so vastly within Europe, and within countries. [10] Drug policy costs, are there any? The UNODC report on Sweden is not completely silent on the costs of Swedish drug control but gives them relatively little place. It mentions the funding it requires, and it mentions the high proportion of heavy (and severely marginalised) drug users who are subject to coerced and non-coerced treatment. It also shows that the proportion of high intensity/high frequency drug users is not markedly different in Sweden than in most other EU countries! The report also mentions the large number of drug deaths that is part of the Swedish drug situation but notes that it decreased “from 403 cases in 2001 to 385 cases in 2003” (page 33) to underscore the positive tone about the Swedish drug control. Unfortunately the topic of drug related deaths is not further elaborated, which led Ted Goldberg to note the following: “The figures UNODC uses for drug related deaths are misleading. Peter Krantz, a postmortem examiner, has been studying statistics for drug related deaths as revealed in autopsies. He found 296 in 2000 and 425 in 2002. To give you an idea how high 425 is in a country the size of Sweden, it means 1.2 per day in a country where 1.5 per day die in traffic accidents. And of course it’s not recreational consumers who are dying. Contemporary drug policy is in fact an important reason why so many problematic consumers die. Drug policy accomplishes this by driving users further out of society, by coercing them into meaningless and repressive treatment, by making them afraid to contact the authorities when, for instance someone has overdosed, by not providing injection facilities where people don’t have to be in a hurry and can take a part of an injection and wait and see what happens so they don’t overdose, and where there is qualified help on the premises, etc. Drug policy as it is today is actually killing people — not saving lives.” [11] The topic of drug related deaths is treated in the UNODC report without comparing the Swedish rate to DRD rates in other countries (in dark contrast to the overdose of such comparisons of drug use in 15 year olds). We know that the variable ‘drug related death’ is not the gold standard of precision and that in spite of feeble EMCDDA efforts serious unsolved registration, definition and calculation issues are at stake here, as much as with all other non-standardised variables in the epidemiology of the drug arena. But if we trust the bookkeeping talents of EMCDDA we have at least some insight into the drug deaths data each government supplies to the international shareholders of the drug problem industry. EMCDDA reports a lower number of drug related deaths (DRD) than UNODC for the year in which comparisons are calculated, 2002 or thereabout. It reports that Sweden has 160 DRD in 2002 and the same proportion of DRD as Greece, 18 per million inhabitants (versus 7 for the Netherlands or 55 for the UK). UNODC, Goldberg, but also Lenke and Olson mention a much higher number than EMCDDA because they include other types of DRD than overdose only. UNODC mentions 391 for 2002, Goldberg mentions 425 for 2002 , Lenke and Olson [12] mention 350 for 1999. Accepting these numbers would considerably raise the present computations by EMCDDA of the DRD rate per million inhabitants in Sweden. It would topple that country from a relatively middle position versus other countries to a high position. A dramatic issue that is not dealt with at all in the report is the far reaching power of the special drug police. In Stockholm, police will chase drug users all through the night and collect them in their vans from the streets, and from the cafés. Trained special police can go into a bar, merely look one in the eye and arrest him or her, then drag them into police headquarters where blood is extracted from them against their will. Police violence on the drug using population is carefully nurtured in Sweden as a necessary element in the witch hunt against this alien evil, drugs. In an emotional appeal to the audience , the chairperson of the newly created Swedish Drug users Association asked in 2003 in Lisbon for a reform of Swedish drug policy because of the hardships it creates for all users, especially so called ‘heavy’ users. He asked for the creation of needle exchange and expansion of the availability of methadone for which there are far too few treatment opportunities. [13] Stahlenkrantz also mentions that heavy users “sometimes avoid calling for an ambulance because they are too scared of attracting the attention of social workers or the police.” (see ref 9). Discussion Harry Levine writes that Sweden uses far less alcohol than other countries “but they worry about it far more than almost anybody except other nordics and some English speaking countries” (personal communication), thereby illustrating his well known observation about the special character of the Protestant temperance cultures in relation to the use of alcohol and drugs. The same scholar writes in a personal communication: It is important to understand that shock waves have recently rolled over the Nordic alcohol model, forcing the Nordic societies to radically reconsider a hundred years of temperance-oriented alcohol policies. A group of Finnish and other drug researchers have written a smart, interesting book about this with the telling title: Broken Spirits. Power and Ideas in Nordic Alcohol Control. Stanton Peele writes about the temperance countries in his review of Broken Spirits: ”Broken Spirits describes the post-World War I creation of state alcohol monopolies in the Nordic countries, including Iceland, as ‘a spectacular historical experiment in social control.’” [14] The word ‘spectacular’ is fully applicable to the type of drug prohibition in these countries as well, being subordinated to the same control fundamentalism as has been shown toward alcohol, but in a higher gear, and of meaner disposition. These remarks by Levine and Peele invite us to think that the perceived decay of alcohol control policies in Sweden, as well as in other Nordic countries may be behind some of the brute tenacity that is shown in relation to conserving drug policies [15]. It is such tenacity that UNODC wants to see applauded, and we fear that UNODC will use the year 2009 to promote China to the status of hero of drug control, in spite of the disasters drug control is creating in relation to Chinese human rights (even more than in Sweden or the USA). We may not be surprised when UNODC presents us with a report that drug control in China is excellent, successful and that the number of public executions of drug sellers is actually declining from 1909 a year to 1896! Time for a good merry go round in Shanghai. Amsterdam october 2006 Notes [1] “Sweden’s succesful drug policy” UNODC June 2006 [2] David Musto The American disease. Origins of Narcotic Control 1973 Yale University Press [3] Harry Gene Levine "Temperance Cultures: Alcohol as a Problem in Nordic and English-Speaking Cultures" in Malcom Lader, Griffith Edwards, and D. Colin Drummon (ed) The Nature of Alcohol and Drug-Related Problems. New York: Oxford University Press, 1993, pp.16-36 [4] Boekhout van Solinge, Tim (1997), The Swedish drug control policy. An in-depth review and analysis. Amsterdam, Uitgeverij Jan Mets/CEDRO. [5] Until now we do not have for drugs what we do have for the economy, a standardised profile of economic indicators as provided by the World Bank or by OECD. Also the economic indicators themselves have been standardised. For instance, OECD provides comparison between ‘standardised’ calculations of a nation’s unemployment in order to circumvent the large variety of data that individual governments supply of ‘unemployment’. By dedicating institutions to the production of methodologically homogenised indicators , comparisons become possible. EMCDDA in Lisbon was assumed to supply this for drugs but has not the funding nor the management to do this. Maybe drug situation profiles should be produced by OECD, steeped into the difficulty of indicator driven profile production as they are. For pharmaceutical products and production OECD does a great job already. [6] http://annualreport.emcdda.europa.eu/en/elements/fig23-en.html [7] All these figures come from OECD Health Data 2006. [8] Abraham, Manja D. (1998), Drug use and lifestyle: Behind the superficiality of drug use prevalence rates. CEDRO Univ of Amsterdam. Abraham, Manja D., Hendrien L. Kaal, & Peter D.A. Cohen (2002), Licit and illicit drug use in the Netherlands 2001. Amsterdam: CEDRO/Mets en Schilt. [9] United Nations Urbanization Prospects:the 2005 revision population database http://esa.un.org/unup/p2k0data.asp [10] Political resistance against such notions can be understood as resistance to loosing a wonderful tool for political fire works.Drug policy is a tool that, lacking in definition or clarity, maybe used for all sorts of rallying the troops behind moral entrepreneurs who ‘will defend youth against drugs’ while sending them into wars or imprisoning them in their urban getto’s. [11] Ted Goldberg Ph.D,University of Stockholm, personal communication. See also Goldberg:”The evolution of Swedish Drug Policy” Jrnl of Drug Issues 2004 pages 551-576. [12] Leif Lenke and Borje Olsson,University of Stockhom: “The drug policy relevance of drug related deaths” in Henrik Thamm,ed: “Review of Swedish drug policy” Senlis Council 2003 [13] Berne Stahlenkranz,Stockholm: “ The tragic outcome of Sweden’s dream of a good drug free Society” Lisbon 2003 Senlis Council. Stahlenkranz speaks of the ‘extreme measures’ in Sweden from a point of view that is never mentioned in reviews of Swedens policy, the perspective of the drug user. I recommend organisers of conferences to invite him and ask for some of his descriptions of the police activity in Stockholm. [14] Whose Spirits Have Been Broken Anyway? Review of Broken Spirits: Power and Ideas in Nordic Alcohol Control. http://www.peele.net/lib/brokenspirits.html [15] Goldberg sees signs that the drug policies may show some relaxation, as the alcohol policies, and that voices pleading for expansion of needle exchange and methadone prescription are now gaining influence in Sweden (personal commincation). [i] Thanking Peter Webster for his editing, and clarifying where badly needed. Last update: October 20, 2006 Webmaster: Arjan Sas