The front page of the Saturday Star 11 February 2017

Recently I was driving from Lanseria Airport to Pretoria on my way to meet with officials of South Africa’s National Department of Health and the South African Police Services to discuss the recent arrest of some of our healthcare workers providing HIV prevention services to people who inject drugs. The radio in the hired car was pre-tuned and the topic was drug use in Johannesburg. In the course of this discussion it was suggested by many callers that the solution to South Africa’s “drug problem” was to “bring back the death penalty” and “hang the bastards”. One caller went unchallenged as he suggest we “suspend the constitution” while we sort out the “addicts and dealers”.

At my meeting discussions went well and clear plans of action were decided. The discussions were reasoned and rational. I felt hope that a more evidence-based, compassionate, human rights based approach to people who use drugs will form part of the official policies in the near future. However, as we know, policies, developed with the input of expert advisors, are often vetoed, edited and rendered ineffectual or counter productive by political heads. And politicians are more-often-than-not the slaves of public opinion. And the public want blood.

While our meeting was happening, the new Mayor of Johannesburg was ignoring research in favour of rhetoric. As a result of his visits to the suburbs of Johannesburg, I was asked to answer a number of questions by a journalist for the Saturday Star, and on Saturday morning the sentiment of “the people” was made known in broad headlines “We’ll kill dealers”. Certainly people have a right to be angry. But, as I explained in my answers to the journalist, drugs are not the problem. Here are the questions I was asked, and my responses that explain why people have got it wrong:

Q: This week the Mayor of Joburg visited Rosettenville after fed-up residents there tried to burn down drug dens in the area. We spoke to residents, drug addicts and community workers who say they are considering the same as the people of Rosettenville if police and government do not intervene.

Are you finding that this is the case in drug-ridden communities throughout the country?

People are frustrated. They are frustrated with a lot of things, and they are looking for someone or something to blame. In the brilliant play Ulwembu[1], which is the result of 18 months of ethnographic study and interviews with people who use drugs, police, community members, social workers, rehab centres and religious groups, there is a line that says:

“You can go ahead and blame the police for not doing enough, but what can we do with all this blame? We can’t eat blame, we can’t smoke it, we can’t sell it…..We just move it around, like we do with the [drug] users. We just move them around from one area to the next, because we don’t want to deal with the real issues here. What happens to one of us, happens to all of us!”

Most marginalised and resource-poor communities are angry and frustrated, but the target of their blame shifts — foreigners, local government, education and drugs and people who use drugs. The frustrations and anger need a target, but not only a target, but a target that unifies them, that fulfills that very human need for connection and common cause. Some targets are therefore more attractive than others because they create a sense of common purpose, they link the community member with the businessman and the politician making them brothers in arms.

With this in mind, the focus on drugs and people who use drugs is becoming increasingly attractive. This is understandable given the information they have. International policy lays a solid foundation for this thinking. In the Single Convention of Narcotic Drugs, Drug “addiction” is described as a “serious evil” that we have a collective duty to “combat”. The 1988 UN Political Declaration on Drugs states: “Drugs are a grave threat to the health and well-being of all mankind, the independence of States, democracy, the stability of nations, the structure of all societies, and the dignity and hope of millions of people and their families.”

Politicians repeat this message: In 2013 Helen Zille said: “Our crisis of substance abuse is harming another generation of young people worse than even what apartheid did to their forefathers,”[2]

Communities see their youth standing idle on street corners or stealing copper cables and brass taps.

So it is understandable that people are angry. The problem is that the entire premise is false. This becomes immediately obvious when we realise that almost all “illicit drugs” have pharmaceutical equivalents that are used in mainstream medicine. [By example, see Prof Carl Hart here] Further, population studies have shown that for most people who take drugs, even street drugs, these do not become a problem. Drugs are not the problem in and of themselves, it is the mindset of the individual (often heavily informed by “drug education”), the individual vulnerabilities, and the setting (often influenced by the policy framework) that define the effect of the drug on a person[Zinberg’s seminal work “Drug, Set and Setting” explains this very persuasively]. We must remember that most people would not take a drug unless it provided something. Unless it met a need, carried meaning and filled a space that was worth the risk. In short, we do not have a drug problem, we have a drug solution.

Q: What, in your opinion, is the first step to rooting out drugs? From government? From communities? From parents?

The first step to rooting out drugs is to stop trying to root out drugs! It is impossible to ever reach the target of, as laid out by the UN and our own National Drug Master Plan, a drug free world. We don’t even have a consistent definition of what a drug is. Would we include alcohol, the drug that carries the most risk for the majority of people? Sugar? Chocolate? Coffee? These are all drugs. Some carry little risk, while some hold significantly more risk, but with all licit drugs, even alcohol, that risk is rendered “acceptable” by the legal regulation of the drug in question. Take any drug and prohibit it and remove legal regulation, and you immediately make it significantly more harmful. Criminalise the people who use the drug and you immediately marginalise and exclude the people who use that particular drug, and therefore increase the likelihood of the use becoming more habituated, dependent and salient.

The use of intoxicants is a biological imperative seen in all species. It is usually accompanied by a set of social sanctions or guidelines to protect from over-use. The use of hallucinogens by many cultures is almost never problematic. The use of traditional formulations of cocaine by Colombian nationals is almost never problematic. It is prohibition and the undue focus on “ridding the world of drugs” that increases the potential and realised harms of drugs.

Q: Is the situation in Joburg, different to Cape Town? What is the situation in Durban?

Wherever you have lack of opportunity, marginalisation and inequity you will find habituated, dependent drug use. In the United Kingdom in the 80s when the mines were closed and Thatcher went on her free market rampage we saw dependent drug use skyrocket. Bruce Alexander, in his book “The Globalization of Addiction: A study in the Poverty of Spirit”[3] has persuasively demonstrated that the spread of free market economics is correlated with rates of “addictive” drug use.

As soon as we care more about the individual than the whole, as soon as we remove opportunity, hope and alternative meaning we see problematic drug use rise.

Traditionally our black populations have had lower levels of drug use than other populations. This is because they have a strong narrative history, a sense of belonging. Migrant workers, living in shocking conditions, had a family home to return to.

In the Western Cape, the population described under apartheid as “Coloured” did not have a strong narrative history or roots going back centuries. It is therefore logical, according to Alexander’s theory, that the levels of drug use in this community would be higher. Add to that the forced removal under apartheid that disrupted any consistent histories that were forming, and it is not surprising that the Cape Flats have had and still have the highest rates of drug related crime in the country.

But we are now seeing increased dislocation in black communities and rates are rising accordingly.

Q: Do we need more rehabilitation centres? Prisons?

No, we need less. Firstly, we cannot arrest our way out of drug use. It further marginalises people who use drugs and drives the continued need for drug use. It provides the fertile recruiting ground gangs, and it virtually guarantees that the person arrested for non-violent drug crime is exposed to violent crime and criminals.

As for rehab: The rehabilitation industry has relied on 28, day twelve step facilitation that relies on confronting denial, confronting the individual and their moral failings, admitting that one has a disease, tough love and other such concepts. It is important to note that there is not a single study ever done that shows that such treatment is any better than spontaneous rates of recovery. Further, 40 years of research has shown that confrontation has never improved outcomes, and is more likely to make them worse.

This does not mean some people don’t need a space to resolve issues which may or may not be related to drug use. Some do, particularly those with a psychiatric issue. But these are the absolute minority. For government to spend money on residential rehabs is a waste of money. As the traditional Native American saying goes: “We dig up a tree that bares no fruit, plant it in fertile soil and it bares fruit. Why would it still bare fruit if we took it back to the barren soil”

Most services for people who use drugs should be community based and focused more on skills development, problem solving and developing alternative meaning and purpose. You seldom break a habit by simply trying to stop. You grow out of it by learning something new, by finding something more attractive.

Q: What is your opinion on medical treatment for drug addicts?

Well, certainly where we have opioids like Nyaope [Let me clear any misconceptions Nyaope is essentially opioids, primarily heroin — it is not ARVs or Rat Poison as often reported. Some may contain these, but only since the press have ignored the tests that have been done on the street drugs in labs and went with the sensational] — we need opioid substitution therapy — Methadone and Buprenorphine. The evidence is by far the strongest we have for any form of resolving the problems related with dependent heroin use; reductions in mortality, illicit drug use, reduced rates of HIV, Hep C, better health, less crime. It is cost effective and saves lives. It is an absolute no brainer, yet it is not available in the public health sector. We need OST at community and primary care level delivered via low threshold flexible dosing time-unlimited services. This would make an immediate and massive difference. This is where we should be spending money above policing and any other interventions, considering the current levels of heroin/Nyaope use, particularly injecting use.

Second, we need to ensure that people who use drugs have access to basic health services. This includes ARV therapy, TB treatment, wound care and the rest. Often people are dying from totally curable or preventable diseases because they are stigmatised and excluded. This is wrong.

Having said that, we must be careful not to overly pathologize drug use, even dependent drug use. The “bad” or “sick” narrative is a binary approach that is simply two sides of the same coin, leading to “othering’ stigma and marginalisation, and the corresponding increases in the importance of continued drug use.

We need inclusive, compassionate services for all people based in the community.

What is currently the most notorious drug on the street? What is in it and what does it cost?

In Cape Town, possibly still methamphetamine or tik, but everywhere else people are talking about Unga, Whoonga or Nyaope — which is all heroin. But this is simply “notoriety” based on current public opinion. In reality it is the drug that is being targeted and blamed in that particular setting. That is because as soon as you label something as “the problem” and try and target it as “the problem” it is the problem.

In reality all drugs have risks and benefits, and people weigh the benefits against the risk when using. So one could argue that the most notorious drug at any one time is the one that is benefiting people who use it the most while also carrying the most risk in the eyes of others — we need to think critically about what in our communities makes the use of the drug so beneficial.

If we don’t get a handle on our drug problem soon, what, in your opinion, will be the consequences?

We need to get a handle on our drug policy problem. If we don’t get a handle on that, people will continue to die and we will have a self-perpetuating cycle. Our “drug problem” does not lie in drugs, but in the policies and rhetoric that surround drugs. If we don’t get a handle on our politicians, the press and leaders who perpetuate the rhetoric of the war on drugs, there will be blood.

[1] Ulwembu 2017 created by Neil Coppen, Dylan McGarry, Mpume Mtombeni, Vumani Khumalo, Phumlani Ngubane, Ngcebo Cele, SandileNxumalo & Zenzo Msomi

[2] http://www.iol.co.za/news/crime-courts/drug-scourge-worse-than-apartheid---zille-1564895

[3] Alexander BK. The globalization of addiction: A study in the poverty of spirit. Oxford: Oxford University Press; Aug 5;