Needle exchange, a famous example of harm reduction in drug policy, trades off prevalence of heroin/opiate use against prevalence of communicable diseases that are transmitted through dirty needles (most prominently, HIV). Tina Rosenberg has an excellent post on the surprisingly progressive drug policy in Iran of all places. Is it fear of dirty needles that is keeping you from shooting heroin? First, there is far stronger evidence that needle exchange reduces disease rates than there is for a resulting increase in heroin prevalence. Even if we admit that a non-negligible fraction of readers may answer "yes, but for dirty needles I'd be shooting up right now," is the deterrent value of maintaining the danger of heroin use really worth that added danger? Remember to factor in the high risk of exponential population-wide mortality increases.
(Source: http://whyy.org/cms/radiotimes/2010/01/22/needle-exchange/)
And yet, dirty needles endure. The issue is not the public health merits of such programs, for which there is sufficient evidence of benefit to convince most health policy scholars. Rather, as Rosenberg writes:
"The problem is the politics. It seems wrong for the government to be muddying a 'don’t-do-drugs' message by supplying the equipment for an illegal and dangerous activity. But to oppose harm reduction only provides the illusion of morality. Surely it is more moral to choose a strategy that does not increase drug use, but does save lives."
BIO:
Zachary Cahn has been in various places doing various things and now does public health policy at the Emory Rollins School of Public Health with a focus on substance control policy.
As a nurse I work with this topic weekly among homeless adults. I liked the brevity of your post, with links to additional references available. It reminded me of the Op-ed postings in the NYT. However, it was reading these other links that made your argument clear to me. There are a lot of data from great multi-city studies that could be drawn in to supplement your case. Given the power of this topic to turn heads and raise blood it might be helpful to lay out a few key arguments, studies or propositions more clearly from the pro and against sides. As public health professionals, it's important for us to help inform the opinions and support of lay people with science instead of bias.
ReplyDeleteAs a non-professional, I don't know what a "taboo trade-off" is. Providing a link to a horrifically academic article wasn't of any help either.
ReplyDelete"issues of incommensurability between these competing objectives" Those are "ten-dollar words" when something simpler could have served your message better.
This leads to a more basic issue: where do you want the real focus of your blog to be? Is it on the kinds and sources of trade-offs or is it on this surprising needle exchange program in Iran, given our assumptions about Iranian Islam?
Interesting post! I am not very familiar with the topic of needle exchange programs nor infectious disease in general. I would like to know more! What other information do you have on the history of needle exchange programs (ideally, from a more diverse reference section with varying viewpoints). I also might suggest starting the post with a question or thought provoking question - maybe even as simple as "are needle exchange programs worth it?" Starting off with a et al. might not interest some readers.
ReplyDeleteYou have "Iran of all places" I am curious by what you mean, maybe it might be helpful to give more information about why that is interesting to you. Overall - I really enjoyed the post and learned a great deal!
Gaya Myers, 2010 MPH (BSHE) grad - had Ariela as a teacher
The first time I was exposed to harm reduction in needle exchange was when I was a first year doctoral student. I had really mixed feelings about it and still do.
ReplyDeleteI still find this topic very interesting from both the perspective of behavior change and ethics, but I found your post to be REALLY academic and difficult to distill your main points.
Starting with a citation is not the way to go with a lay audience. What would be a more catchy way to get people's attention for this type of writing?
Last, I'm left hanging with the quote at the end. What's YOUR take home message?
Harm reduction is a really interesting topic, and I think it would have been great to be able to read a little more about the extent to which harm reduction strategies are accepted and used in different societies, as you began to mention when you included the sentence about Iran.
ReplyDeleteI found the post difficult to follow. I understand the use of rhetorical questions as a way to make the reader think, but it seemed a bit excessive when the text lacked clarity. More details and examples could really help to make the post easier to understand and catch the attention of a lay audience.
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ReplyDeleteThese are all good points. I regret that I did not do more to clarify the issue. Also, the topic of taboo-tradeoffs was probably too abstract to even bother with here. This was not a very good post. My initial point, however clumsily made, is that the intuitive benefit of forestalling an AIDS epidemic - one that effects not just users of dirty needles but also many non-users through other forms of transmission - would seem to far outweigh the costs. The key reason why heroin is more amenable to harm reduction than cocaine is that the method of delivery itself constitutes much of the harm of heroin when users are sharing needles. I apparently would have been better off sticking to effectiveness studies. For that, I would start here:
ReplyDeletehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC1307729/pdf/pubhealthrep00030-0079.pdf
Vlahov and Junge (no "et al" this time) analyze the relevant evidence for various possible positive and negative outcomes associated with exchange programs.
My comment about Iran was meant to convey surprise that a regime that I associate with conservatism is implementing a policy that I would associate with progressives. This was not a point about Islam.
The takeaway is that for public health policies, including but not only harm reduction policies, it often does not matter whether there is a strong public health case because the political obstacles are insurmountable for one reason or another.
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ReplyDeleteZach,
ReplyDeleteI think the other readers have raised some interesting questions and I appreciate your answers for clarification. Thanks for that.
Your post reminds me of an article that I am currently reading in the New Yorker. The article it about drug policy in Portugal and particularly addresses the 'problem with politics' you cite Rosenberg as discussing in your blog. In Portugal, drug issues have been moved out of the realm of crime management and into the realm of health policy.
You may find this article to be of interest: http://www.newyorker.com/reporting/2011/10/17/111017fa_fact_specter
Thanks for prompting the interesting discussion.
Bethany
Thanks for your comments Zach -- my point about engaging non public health folks is still that it's not the research that engages people -- it's something interesting, exciting, and catches attention. Your proposed new start: Vlahov and Junge (no "et al" this time) analyze the relevant evidence for various possible positive and negative outcomes associated with exchange programs." is still the same research focus.
ReplyDeleteCan you come up with something completely different that your average person would want to read? Think plain English. Think high school students. What's a way to start something like this that would make them say, "Wow, that's something I want to read!"
-- Ariela
@ Bethany: Thank you for pointing to that New Yorker article. Glenn Greenwald has analyzed the situation in Portugal and given recommendations as well: http://www.cato.org/pub_display.php?pub_id=10080. It is very interesting that you mention how in Portugal, health authorities rather than law enforcement are primarily in charge of drug policy. While I do not think that the Portugal model would work seamlessly here, I strongly believe that health authorities are better suited to device these policies than law enforcement.
ReplyDelete@ Ariela: As for a new hook, maybe something like "What if I told you we could trade off __ number of deaths due to dirty needles in exchange for a __ % increase in heroin addiction? Would it be worth it? Where would your breakeven point be?"
The notion of harm reduction as a difficult tradeoff can be an interesting way to engage people if it is done correctly. Actual questions may work better than rhetorical ones