ELI SHLEIFER
Matthew Rycroft CBE, Permanent Secretary Home Office, 2 Marsham Street, London, SW1P 4DF
April 2024
Dear Sir Matthew Rycroft KCMG CBE,
I write to you as a medical anthropology and medical student living in London, concerned about the troubling stigmatisation of people who use drugs (PWUD). Although the mobilisation of the government to tackle the issue of drugs in the UK is admirable, I write urging you to review the 10-year drug strategy you lead, From Harm to Hope, to make it more equitable, more evidence-based, and to better reduce the harms caused by drugs. As the lead of the six-department wide Strategy at the brink of another funding cycle, you occupy a critical role to think about where the funding for this program is directed, and the impacts of policies. There are significant inconsistencies between the Strategy and the call from the UN to promote public health approaches to drugs (UN 2018). These inconsistencies risk limiting the efficacy of the plan as it progresses, and increasing the socio-economic and ethnic inequalities prevalent in the UK (Collective Voice 2023). This letter aims to outline how the Strategy can take seriously the cultural change and real impact promised and move away from ideology-based policy.
Considering the Strategy’s commitment to evidence-based policy, it is important to first consider what kinds of evidence are being used. Reading transcripts from the Strategy review (Public Accounts Committee 2023), it is clear this plan falls prey to audit culture, characteristic of new public management approaches (Anderson 2017). The focus on metrics and measurement, though valuable, is limited in its ability to scope the issues at hand due to the limitations of quantitative data in capturing an adequate picture of complex societal issues. Proposed solutions lack understanding of how socioeconomic background creates vulnerability for substance use and fail to focus on improving community and mental health provisions. For example, despite recognizing that adverse childhood experiences, socioeconomic deprivation, and mental illness are highly related to drug use in young people (Shin et al. 2018), the Strategy focuses on education and punishment (HM Government 2022) and fails to emphasise prevention (National Audit Office 2023). I urge you to consider critical medical anthropology methods and frameworks to provide insights on “the social production of suffering, the use of drugs to self-medicate the emotional injuries of injustice and mistreatment and the political economy of the licit and illicit drug markets” (Singer 2012: 1750), all salient to the Strategy. By better understanding the social dynamics of these elements, they can more successfully be disrupted.
As Holland et al. (2022) point out, the Strategy simultaneously identifies the need to reduce stigma whilst suggesting that stigma is a good way to deter drug use. The Strategy not only over-determines the relationship between drugs and violent crime (Holland et al. 2022), it also uses stigmatizing language. Findings by the UK Drug Policy Commission (2010) indicate that stigma slows or prevents recovery, makes re-integration difficult, and makes it difficult to seek help. Angela Garcia, working with PWUD in New Mexico, outlines how “the addict cannot be disconnected from the broader ‘moral world’” (2010: 9). Two elements of this ‘moral world’ are salient to the UK. Firstly, Garcia describes how reliance on recovery models which emphasise personal will means that although “relapse is understandable and even expected (at least from the medical point of view), the relapsed addict is ultimately assigned blame for the relapse and is therefore seen as lacking the will to recover” (2010:18). Secondly, Garcia points to the ways that the model of chronicity in addiction ‘fixes’ individuals in suffering. Not only does the Strategy not clearly outline how it aims to tackle stigma, its criminalisation and stigmatisation reinforces a ‘moral world’ which can only further entrench drug users in narratives of personal failure and hopelessness, undermining the aims of the Strategy.
In a characteristic ‘tough on drugs’ approach, the White Paper SWIFT, CERTAIN, TOUGH proposes escalating consequences for drug possession, effectively ‘widening the net’ (Holland et al. 2022). This means more people facing questionably justified sanctions, more people being incarcerated and punished, and more people facing coerced drug treatment, “contravening human rights and medical ethics norms, with limited evidence that coerced treatment reduces future drug use” (Holland et al. 2022: 218). Adrienne Pine’s (2008) work in Honduras demonstrates the dangers of ‘zero-tolerance’ policies against vaguely-defined enemies, which are ultimately carried out against marginalised people rather than the abstract categories they name as the enemy. Along with Pine, Garcia argues that models such as Twelve Step and the criminalisation of drug use are justified by liberalism which “treats individuals as responsible for their freely chosen actions” (2010:18), disregarding the impact of their environment and socioeconomic status. Pine argues that these policies “unwittingly promote[s] the idea that those who have not become sober or who refuse to join AA are more deserving of violence” (2008:199). Pine demonstrates how reinforcing systemic imbalances of power with ever-increasing neoliberal institutions and policies create the conditions for gang violence and drug involvement (2008). Against UN human rights norms (Holland et al. 2022), the ‘zero-tolerance’ policy in the UK has translated to a refusal to implement evidence-based harm reduction policies for ‘recreational’ drug use such as an anonymous national drug testing service, in fear of ‘condoning’ drug use (Home Affairs Committee 2023). These refusals demonstrate the incompatibility of a ‘zero tolerance’ policy with aims of reducing harms.
Additionally, Garcia (2010) draws attention to the possible harmful effects of the ‘drug courts’ model adopted by the UK in initiatives such as Drug Rehabilitation Requirements (DRRs) and Intensive Supervision Courts pilots (HM Government 2023). Garcia highlights how “with the drug courts, the traditional boundaries between the therapeutic impetus of medical and social services and the state’s authority to control “criminal” individuals and populations are further blurred, even eradicated” (2010: 19). She highlights how ‘failure’ of recovery in instances of the ‘patient-prisoner’ can reinforce despair and fuel the problem of addiction and criminalisation. These policies not only go against evidence of limited effectiveness (Holland et al. 2022), but also disproportionately affect more marginalized individuals. A significant oversight in the Strategy is its inadequate mention of how it aims to tackle the effect of a ‘zero-tolerance’ of recreational drug use on already over-policed ethnic minority communities in the UK (Eastwood, Shiner and Bear 2013; Collective Voice 2023).
The current addiction recovery model inadequately addresses need and lacks recognition of ethnic disparities in treatment programs. Though the ACMD is currently undertaking work in this regard, lack of official focus on this issue is concerning. The move from ‘maintenance’ to ‘recovery’ cannot be separated from its emergence in 2010 in the context of economic downturn (Floodgate 2017). The current model focused on detoxification and ‘completion of treatment, with very little provision of post-detox aftercare, reinforces neoliberal subjectivity. This increases responsibility on individuals to “draw on their own “recovery capital” to become drug free and cease offending” (Duke 2013: 50), with significant social and penal repercussions in the case of ‘failure’. There is also great silence in the Strategy about plans to tackle ethnic disparities in the representation in research surrounding consequences of drug use (Collective Voice 2023). Overall, as Singer’s review demonstrates, “some addictions or aspects of addictions can be affirmative, creative and sustainable, at least at the individual level” (2012: 1747), and can fulfill certain needs. Ethnographic insights into addiction and recovery models highlight the importance of understanding the otherwise unfulfilled needs driving addiction, and to review recovery models in light of these understandings.
As illustrated by Brookfield et al. (2021), working with PWUD in Australia, there is a complex relationship between stigma, recovery, and drug use. This ethnography draws attention to the ways that ‘ambient paternalism’, “when individuals are guided towards a more palatable form of citizenship through policy” (2021:7), leads to metrics of ‘normality’ being pushed as ends in themselves. Notably, some participants in this study indicated how drug use and related crime was at times central to the performance of ‘normality’ required to lessen their experience of stigma and to navigate social services and employment. By prioritising the appearance of ‘normality’ defined by policies, there is limited scope in “the ability of services to support people to recover, or otherwise change their drug use… based around increasingly performative and perfunctory interactions” (2021:7). Brookfield et al. call for “a more flexible and responsive perspective on what can constitute ‘normal’, and a critical awareness of how this ideal is constructed and can impact service interactions” (2021:8), to reduce disengagement from services. This is critically relevant to the Strategy, where focus on ‘recovery’ intersects with modes of coercion which reify the ‘punitive turn’ in neoliberal governance (Floodgate 2017). This acts to reinforce the need to perform the appearance of a ‘normal life’, rather than focusing on minimising drug-related harms and creating real change.
Furthermore, the largely law-and-order approach to this issue has meant that there has been an oversight in public consultation. This goes against the UN’s call to promote public health approaches to drugs, putting “people, health and human rights at the centre” (UN 2018: 13). Along with in-depth reform of the strategy to introduce changes in line with human rights and best evidence, participatory action research (PAR) is a useful tool which could form a basis for addressing certain issues at a local level. One successful example is Toynbee Hall, part of the larger New Local network (New Local 2023). The foundational idea behind PAR is to combine research with action, while including those affected by the research as equal participants and focusing on shared ownership and responsibility (Anderson 2017). By facilitating PAR programs without co-opting them, these methods could effectively train those recovering or suffering from addiction in skills to carry out research, provide a voice to those in the community who are facing the effects of injustice and inequality, and provide communities with the support to find their own solutions (Anyon et al. 2018). These methods have the advantage of being able to reach out to those most marginalised, who would otherwise be excluded from the research, and can be one way that stigma can be tackled within communities. These methods would be in line with the report by the Advisory Council on the Misuse of Drugs (ACMD 2019) on how to reduce stigma and drug-related harms.
Addiction often exists as part of a syndemic, the “synergistic interaction of two or more coexistent diseases and resultant excess burden of disease” (Singer and Clair 2003: 423) in the context of particular social conditions. It is surprising that this avenue of analysis has not been extensively explored (Coid et al. 2021). As evidenced by Dame Black’s Review, “homelessness and substance use are mutually reinforcing problems, often co-occurring with and exacerbated by mental ill health and physical health needs” (Black 2020: 92). High quality epidemiological, qualitative and biomedical research is needed to examine the forces that tie substance use with comorbid diseases and social conditions together, at the population level and at the biological and social level, to drive the development of targeted solutions (Singer and Clair 2003). As pointed out by Milstein, using a syndemics framework can “advance a specific course of social change, one focused on the connection between health and social justice” (2001:9), in line with the ‘cultural change’ proposed by the Strategy.
The Strategy cannot hope to be effective in reducing harms caused by drugs if it fails to address and even reinforces stigma, overlooks the impacts of over-policing, and fails to include a diverse range of voices in policy-making and treatment planning. A ‘tough on drugs’ policy ultimately reinforces neoliberal governance and structural violence on the most marginalised and fails to reduce supply or demand. The Strategy as it stands risks deepening structural violence, and examples internationally should give pause. A proactive, anti-stigma, evidence-based approach should be taken to rectify an otherwise impressive government mobilisation.
Kindest regards,
A concerned student
Reference List
Anderson, Gary. 2017. “Participatory Action Research (PAR) as Democratic Disruption: New Public Management and Educational Research in Schools and Universities.” International Journal of Qualitative Studies in Education 30 (5): 432–49. https://doi.org/10.1080/09518398.2017.1303211.
Anyon, Yolanda, Kimberly Bender, Heather Kennedy, and Jonah Dechants. 2018. “A Systematic Review of Youth Participatory Action Research (YPAR) in the United States: Methodologies, Youth Outcomes, and Future Directions.” Health Education & Behavior 45 (6): 865–78. https://doi.org/10.1177/1090198118769357.
Black, Dame Carol. 2020. “Review of Drugs – Evidence Relating to Drug Use, Supply and Effects, Including Current Trends and Future Risks.” https://assets.publishing.service.gov.uk/media/5eafffedd3bf7f65363e4fda/Review_of_Drugs_Evidence_Pack.pdf.
———. 2021. “Review of Drugs Part Two: Prevention, Treatment, and Recovery.” GOV.UK. Department of Health and Social Care. https://www.gov.uk/government/publications/review-of-drugs-phase-two-report/review-of-drugs-part-two-prevention-treatment-and-recovery#contents.
Bowden-Jones, Owen, Robert Wolstenholme, and Zahi Sulaiman. 2019. “Drug-Related Harms in Homeless Populations.” London: Advisory Council on the Misuse of Drugs. https://assets.publishing.service.gov.uk/media/5d0a566eed915d0936ba5fb6/Drug-related_harms_in_homeless_populations.pdf.
Brookfield, Samuel, Lisa Fitzgerald, Linda Selvey, and Lisa Maher. 2021. “‘We’re Supposed to Be a Family Here’: An Ethnography of Preserving, Achieving, and Performing Normality within Methamphetamine Recovery.” SSM – Population Health 16 (December): 100969. https://doi.org/10.1016/j.ssmph.2021.100969.
Coid, Jeremy, Yingzhe Zhang, Paul Bebbington, Simone Ullrich, Bianca de Stavola, Kamaldeep Bhui, and Alexander C. Tsai. 2021. “A Syndemic of Psychiatric Morbidity, Substance Misuse, Violence, and Poor Physical Health among Young Scottish Men with Reduced Life Expectancy.” SSM – Population Health 15 (September): 100858. https://doi.org/10.1016/j.ssmph.2021.100858.
Duke, K. 2013. “From Crime to Recovery: The Reframing of British Drugs Policy?” Journal of Drug Issues, 43(1): 39–55. https://doi.org/10.1177/0022042612466614.
Eastwood, Niamh, Michael Shiner, and Daniel Bear. 2013. “The Numbers in Black and White: Ethnic Disparities in the Policing and Prosecution of Drug Offences in England and Wales.” London: Release. https://www.release.org.uk/sites/default/files/pdf/publications/Release%20-%20Race%20Disparity%20Report%20final%20version.pdf.
Milstein, Bobby 2001 Introduction to the Syndemics Prevention Network. Atlanta: Centers for Disease Control and Prevention.
Public Accounts Committee. 2023. Oral evidence: Reducing the harm from illegal drugs. House of Commons. London: House of Commons. https://committees.parliament.uk/oralevidence/14127/pdf/.
Pine, Adrienne. 2008. “Conclusion.” In Working Hard, Drinking Hard: On Violence and Survival in Honduras, 192–204. California: University of California Press. https://www.jstor.org/stable/10.1525/j.ctt1pppbx.9.
Shin, Sunny H., Shelby Elaine McDonald, and David Conley. 2018. “Patterns of Adverse Childhood Experiences and Substance Use among Young Adults: A Latent Class Analysis.” Addictive Behaviors 78 (March): 187–92. https://doi.org/10.1016/j.addbeh.2017.11.020.
Singer, Merrill. 2012. “Anthropology and Addiction: An Historical Review.” Addiction 107 (10): 1747–55. https://doi.org/10.1111/j.1360-0443.2012.03879.x.
Singer, Merrill, and Scott Clair. 2003. “Syndemics and Public Health: Reconceptualizing Disease in Bio-Social Context.” Medical Anthropology Quarterly 17 (4): 423–41. https://www.jstor.org/stable/3655345.
Floodgate, William. 2017. “From Maintenance to Recovery: Exploring the Reorientation towards Recovery in British Drug Policy during a Time of Reform and Economic Austerity.” https://pure.manchester.ac.uk/ws/portalfiles/portal/66046259/FULL_TEXT.PDF.
Garcia, Angela. 2010. The Pastoral Clinic: Addiction and Dispossession along the Rio Grande. 1st ed. University Presses of California. http://www.jstor.org/stable/10.1525/j.ctt1pppms..
Holland, A. D., A. Stevens, M. Harris, D. Lewer, H. Sumnall, D. Stewart, E. Gilvarry, et al. 2022. “Analysis of the UK Government’s 10-Year Drugs Strategy—a Resource for Practitioners and Policymakers.” Journal of Public Health 45 (2). https://doi.org/10.1093/pubmed/fdac114.
Home Affairs Committee. 2023. “Drugs: Government Response to the Committee’s Third Report of Session 2022–23.” London: UK Parliament. https://publications.parliament.uk/pa/cm5804/cmselect/cmhaff/127/report.html#.
HM Government. 2022. From Harm to Hope: A 10-Year Drugs Plan to Cut Crime and Save Lives. London: Home Office.
HM Government. 2023. From harm to hope: a 10-year drugs plan to cut crime and save lives First Annual Report 2022-23. London: Home Office.
National Audit Office. 2023. “Reducing the Harm from Illegal Drugs.” NAO. https://www.nao.org.uk/press-releases/reducing-the-harm-from-illegal-drugs/.
New Local. 2023. “How We Did It: Participatory Action Research.” New Local. September 6, 2023. https://www.newlocal.org.uk/articles/how-we-did-it-participatory-action-research-2/#:~:text=Participatory%20action%20research%20(PAR)%20is.
Pine, Adrienne. 2008. “Conclusion.” In Working Hard, Drinking Hard: On Violence and Survival in Honduras, 192–204. California: University of California Press. https://www.jstor.org/stable/10.1525/j.ctt1pppbx.9.
Singer, Merrill. 2012. “Anthropology and Addiction: An Historical Review.” Addiction 107 (10): 1747–55. https://doi.org/10.1111/j.1360-0443.2012.03879.x.
Collective Voice. 2023. “Drug Use in Ethnic Minority Groups Collective Voice Submission to the Advisory Council on the Misuse of Drugs Call for Evidence.” London: The National Alliance of Drug and Alcohol Treatment and Recovery Charities. https://www.collectivevoice.org.uk/wp-content/uploads/2023/10/Drug-Use-in-Ethnic-Minority-Groups.pdf.
UK Drug Policy Commission. 2010. “Getting Serious about Stigma: The Problem with Stigmatising Drug Users.” https://www.ukdpc.org.uk/wp-content/uploads/Policy%20report%20-%20Getting%20serious%20about%20stigma_%20the%20problem%20with%20stigmatising%20drug%20users.pdf.
United Nations Chief Executives Board for Coordination. 2018. United Nations system common position supporting the implementation of the international drug control policy through effective inter-agency collaboration. https://unsceb.org/sites/default/files/2021-01/2018%20Nov%20-%20UN%20system%20common%20position%20on%20drug%20policy.pdf
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