International Journal of Drug Policy 16 (2005) 5–7

Rejoinder

Public health or human rights?

Neil Hunt∗

Centre for Research on Drugs and Health Behaviour, Imperial College, The Reynolds Building, St Dunstan’s Road, London W6 8RP, UK

Accepted 11 October 2004

Readiness to acknowledge that your beliefs have changed canbe viewed as a sign of character but also involves making yourfallibility uncomfortably public. Consequently, it felt a littlerisky to expose my change of mind in what was a somewhatpersonal paper: ‘Public health or human rights: what comesfirst?’ (Hunt, 2004). I am therefore indebted to each of thosewRtoifr

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sympathetic toKushlik and Rolles’ (2004)argument that anemphasis other than uponrightsmay be necessary as far asstrategic and political questions are concerned.

During the production of The Angel Declaration(http://www.angeldeclaration.com/)—a set of proposals fora legal, regulated drug control system within the UK—it be-

moreboutctualwhatl tonistst behas,firstandcti-ht

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riting responses (Burris, 2004; Kushlik & Rolles, 2004;einarman, 2004) for their thoughtful reflections. I will limit

his rejoinder to elaborating three main points: (i) the purposef the paper as a prompt to introspection, (ii) the social justice

mperative and, (iii) the relevance of post-prohibition optionsor drug control within an evidence-based approach to drug-elated harm.

ntrospection—a provocation

The original paper (Hunt, 2004) was born out of recog-ition that mypersonalviews had changed and that I hadoved from ambivalence about a right to use drugs towardsfuller recognition that people should be entitled to deter-

came apparent to me that there was merit in urging arigorous examination of our underlying assumptions athe rights of drug users to use drugs, and the intelleand policy territory this takes us towards. Regardless ofmight be written in formal definitions, it seemed usefuwrite the paper as a provocation that asks harm reductioto interrogate their own beliefs and consider what mighimplied in order to be true to these. The paper can, andbeen read as a call to redefine harm reduction but itsintention was, instead, to act as a call for introspectionlogical consistency. Although ambiguity may be very pracal within definitions it was primarily ambiguity of thougthat was in my sights.

ine what they ingest, even if it does them harm. I foundhat this had a profound impact on how I thought about harmeduction, the issues and strategic questions that I was pre-ared to consider and what I was prepared to say and discuss

on-have

ad ad mehatopletirely

A parallel concern with social justice

Burris (2004)concedes that he dodges my question. Nev-ertheless he quite reasonably draws attention to a crucial pointt t tou thec elyd , no-t manR

ingp scenes rugsi theri nces

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n public forums. It did not mean that I stopped being cerned with the same practical public health issues thatominated my work for the past 15 years or so but it harked effect on the ideas and questions that intereste

n this sense, the paper was largely ethical. At root, wrinciples do we believe should determine the powers pean exercise over their bodies? Nevertheless, I am en

DOI of original article:10.1016/j.drugpo.2004.02.001∗ Tel.: +44 7780 665830.E-mail address:neil@dadden.demon.co.uk.

955-3959/$ – see front matter © 2004 Elsevier B.V. All rights reserveoi:10.1016/j.drugpo.2004.10.004

.

hat I did not address. It might well be argued that a righse drugs is a relatively trivial right when considered inontext of societies in which social conditions effectiveny people rights with far better established credentials

ably those enshrined in the Universal Declaration of Huights.Is it reasonable to expect that people living in grind

overty, who are oppressed, tyrannised or exposed to obocial inequalities would use an extended right to use dn ways that confer enjoyment yet avoid harm? No. Whet is with regard to alcohol and tobacco, volatile substa

6 N. Hunt / International Journal of Drug Policy 16 (2005) 5–7

or those substances that are currently illegal, drug-relatedharm is already clearly skewed towards the most vulnerable,impoverished and marginalised members of society.

The existing regime of drug prohibition does not pre-vent these groups from experiencing the biggest burden ofharm associated with their drug-taking. Indeed, in some in-stances such as the differential sentencing for cocaine pow-der and crack users in USA, prohibition is implemented in away that actively exacerbates it and contributes to the over-representation of the poor within the criminal justice system(Rhodes, Singer, & Bourgois, in press).

I find it impossible to conceive of a ‘harm reduction’ thatis not simultaneously concerned with these underlying socialconditions. However, this was not the main concern of thepaper. As critical as the social justice agenda is, I do not thinkthat reformers should pursue these objectives sequentiallybut, rather, that action calculated to produce reform shouldoccur in parallel.

Should harm reductionists be concerned with theimpact of post-prohibition policy options?

I largely agree withReinarman (2004)about the virtues ofambiguity within official definitions of harm reduction, whichI nu restst s ford gicald tiveso

cedm nallya s, inw thinw forh d yeta n thes r( rt ofe )r tismt ithint

-d om-m ) ofh rd toh oci-e con-t blyt ques-t guedt armay nities

for enhancing health and well-being that the removal ofdrug prohibition would provide? Of course, evidence thatwould assess how great or little these might be does not ex-ist. Self-evidently, policy options that are prohibited by in-ternational law cannot be evaluated. So I felt disappointedthat none of the commentators addressed the question ofwhether harm reduction—as an avowedly evidence-baseddiscipline—should be concerned to assess policy options thatare currently prohibited and to remove barriers that preventtheir careful evaluation.

I think the following questions might all merit studyby a movement concerned to reduce drug-related harm: (i)Would people with heroin dependence receive treatmentmore rapidly and readily if their source of supply was from,say, licensed distributors where there was some degree ofmedical supervision of sales? (ii) Could regulated supplysystems be structured so as promote transitions away fromdrug formulations that work more intensively—heroin andcocaine—towards those with more moderated actions—cocaand opium? (iii) In what ways could fiscal measures be usedto moderate use asEdwards et al. (1994)discuss for alcoholand might a hypothecated sales tax provide a bounty for pre-vention and treatment that we can only dream of at present?(iv) Could legal distribution systems help reverse or mod-erate inner-city problems such as escalating gun-crime andt soci-a v)I armsa em?S ventt nd,g es,c ft theb n de-vB

eachs d inp andt thisi ated.S ctions wec ns?

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acknowledge (Hunt, 2004, p. 236). This ambiguity is andoubted strength that allows effective coalitions of inte

o take immediate action that confers vital, direct benefitrug users in a way that, often, usefully sidesteps ideoloisputes between authoritarian and libertarian perspecn societies and the body.

Nevertheless, for me, the logic of my new position fore to re-evaluate the questions that concern me persos a harm reductionist. If I recognise a right to use drughat contexts would I want to see that right exerted, wihat regulatory framework? It seems legitimate territoryarm reduction to debate and explore these questions anlthough harm reduction theorists have not been mute oubject, they have not been especially audible (Haden’s pape2004)is nevertheless an interesting example of the soxploration that is required, as isRolles and Kushlik’s (2004eport). Perhaps it is harm reduction’s tradition of pragmahat leads us to focus so much on what can be done whe immediate conditions that prevail: drug prohibition?

As I noted,Newcombe’s (1992)conception of harm reuction draws attention to a range of levels (individual, cunity, societal) and types (health, social, economicarm. These are conventionally considered with regaarms directly associated with drug use; but within the stal/economic realm, questions concerning the harms

ingent on drug prohibition seem equally salient, notahe direct cost of its maintenance and the associatedions of its cost-effectiveness. Equally, it has been arhat drug prohibition damages justice—a societal/social hs well as a societal/economic cost (Husak, 2002). And be-ond these costs/harms might there also be opportu

,

he powerful allure of drug-related career pathways asted with lucrative, criminally controlled illicit markets? (

n what ways might a legal, regulated market reduce ht the bottom end of the production and distribution systpecifically to what extent could alternative systems pre

he exploitation and imprisonment of drug ‘mules’? Aiven the abject failure of crop substitution programmould trading systems such as ‘Fairtrade’ be used to shialance of wealth back towards subsistence farmers ieloping economies and increase trade justice asBailie andrett (2001)have suggested?The answer to none of these questions is clear, yet

eems to merit investigation within a movement groundeublic health. However, at present, drug prohibition—

he denial of a corresponding right to use drugs thatmplies—means that these questions cannot be evaluurely an evidence-based project such as harm reduhould be concerned to create the conditions in whichan generate evidence that would answer such questio

eferences

ailie, R., & Brett, A. (2001).The Government’s drugs policy: Isworking? Home Affairs Select Committee, Memoranda of evideVolume 2I, Memorandum 8. Retrieved October 28 2004 fromhttp://www.parliament.the-stationery-office.co.uk/pa/cm200102/cmselecmhaff/318/318m12.htm.

urris, S. (2004). Harm reduction’ first principle: “the opposite of hatrInternational Journal of Drug Policy, 15, 243–244.

dwards, G., Anderson, P., Babor, T., Ferrence, R., Giesbrecht, N.,frey, C., et al. (1994).Alcohol policy and the public good. Oxford:Oxford University Press.

N. Hunt / International Journal of Drug Policy 16 (2005) 5–7 7

Haden, M. (2004). Regulation of illegal drugs: An exploration of publichealth tools.International Journal of Drug Policy, 15, 225–230.

Hunt, N. (2004). Public health or human right: What comes first?Inter-national Journal of Drug Policy, 15, 231–237.

Husak, D. (2002).Legalize this! The case for decriminalizing drugs. Lon-don: Verso.

Kushlik, D., & Rolles, S. (2004). Human rights versus political capital.International Journal of Drug Policy, 15, 245.

Newcombe, R. (1992). The reduction of drug related harm: A conceptualframework for theory, practice and research. In O’Hare, R. New-

combe, A. Matthews, E. C. Buning, & E. Drucker (Eds.),The reduc-tion of drug related harm. London: Routledge.

Reinarman, C. (2004). Public health and human rights: The virtues ofambiguity. International Journal of Drug Policy, 15, 239–241.

Rhodes, T., Singer, M., Bourgois, P., Friedman S., & Strathdee, S. (inpress). The social structural production of HIV risk among injectingdrug users.Social Science and Medicine.

Rolles, S., & Kushlik, D. (2004).After the war on drugs: Options forcontrol. Bristol: Transform Drug Policy Foundation.