A Global Village
Issue 9 » Narcotics

The War on Drugs

Moving Towards a Public Health Approach

Ian Perrin, Chatham House

The War on Drugs began in the early 1970s when President of the United States of America Richard Nixon proclaimed illicit drug abuse “public enemy number one.”1 Multiple United Nations conventions in 1961, 1971, and 1988 also tried to address the problem by criminalizing the possession, use and manufacture of illicit drugs.2 Policy makers argued that harsh law enforcement action against those involved in producing, distributing and using illegal drugs would decrease supply and demand of drugs such as cannabis, heroin and cocaine, and lead to a drug-free world.

However, an increasing number of politicians, heads of state and influential policy makers from around the world are now declaring that the existing approach, which focuses heavily on the use of law enforcement and sanctions, has failed to prevent illicit drug use and supply, or curtail the wider socio-economic and health issues associated with taking them. It is argued that a change to the current paradigm is therefore needed sooner rather than later. 

The 2011 report by the Global Commission on Drug Policy concluded that “vast expenditures on criminalization and repressive control measures directed at producers, traffickers and consumers of illegal drugs have clearly failed to effectively curtail supply or consumption”. On the demand side, UN estimates of annual drug consumption between 1998 and 2008 indicate that there was a 34.5% increase in the number of opiate users, a 27% increase in the number of cocaine users, and an 8.5% increase in the number of cannabis smokers.On the supply side, data from the United Nations Office on Drugs and Crime, indicate that the worldwide supply of illicit opiates such as heroin and opium has increased dramatically by more than 380% over the past three decades, from 1000 metric tons in 1980 to more than 4800 metric tons in 2010.5

Further evidence also suggests that despite the US budget for international supply reduction and counter-narcotics activities steadily increasing, the purity of cocaine has remained persistently high, while, during the same period, the purity- and inflation-adjusted price of cocaine in the US has concurrently dropped by more than 60%, suggesting that the overall supply of cocaine has overwhelmed law enforcement efforts.6

But the problem is more complicated than one of just supply and demand. There are a multitude of other indications that the War on Drugs has been a failure.

Counting the Cost of the War on Drugs

Enforcing the War on Drugs has been costly, with some estimates in the region of $100billion each year.7 Given the current economic climate and global uncertainty, it has been argued that this money could be more effectively spent elsewhere and is diverting funds from other law enforcement needs. 

Besides the economic cost, there has been a significant social cost. Stringent enforcement measures, especially those seen in recent years, have also led to a huge increase in violence and death. Upon coming to power in 2006, the former President of Mexico Felipe Calderón embarked on an ambitious heavy-handed crackdown on the drug gangs and cartels operating in the country. During his six-year term as leader, an estimated 50,000 to 55,000 people were killed as a result of drug-related violence in Mexico alone.8

The War on Drugs and the heavy-handed enforcement measures aimed at curtailing both supply and demand have also had a very negative impact on other aspects of public health. As a result, there is increasing recognition that any new approach needs to avoid the harm that the War on Drugs has done to drug users.

The adverse health effects of drugs are well documented. However, as the Transform Drug Policy Foundation outlines in its series of publications on the War on Drugs, “Count the Costs”, the health risks that have emerged directly as a consequence of the War on Drugs are great, and are threatening public health and spreading disease. These risks are separate to the adverse health effects of the drugs themselves, and are caused by the punitive approach that criminalizes many users. Often, these users are some of the most vulnerable members of society. Criminalizing use also puts organized crime gangs in control of the industry – gangs that give no consideration for the health impacts of their trade.

Evidence suggests that the enforcement-led approach maximizes harm to users and encourages risky behaviours and using environments,9 and that, as a direct result of enforcement against possession of drug-injecting paraphernalia, needle sharing can become more common, therefore increasing the risk of blood-borne virus transmission.10

Helping Users via Harm Reduction Policies
The enforcement-based approach also creates obstacles to effective harm-reduction policies. Harm-reduction policies, as opposed to policies to reduce drug use itself, emerged in the 1980s as a non-judgmental approach to tackling the health risks around drug-taking. Measures such as needle exchanges and opioid substitution therapy arose in response to the risk of HIV transmission from intravenous injecting. Countries that have successfully implemented comprehensive harm reduction strategies from the onset of the HIV epidemic in the 1980s, such as the UK, Switzerland, Germany and Australia, have much lower prevalence of HIV among those who inject drugs, compared with those nations that have only partially introduced, or introduced late, harm-reduction strategies, such as the US, Portugal and France. Nations that have never implemented any national harm reduction strategies have extraordinarily high HIV prevalence among injectable-drug users, such as Thailand, where prevalence is well over 40%.11

A soldier searches a vehicle at the Juarez Avenue border crossing into the USA in Juarez, Mexico. More than 1600 people were killed in Juarez in 2008, making Juarez the most violent city in Mexico. [Richard Ellis Photography]

Harm reduction is considered a highly cost-effective mechanism for reducing the risks associated with drug use. However, it seems that obstacles to expanded provision are primarily driven by failure of politics rather than of resources,12 and despite their becoming increasingly established, evidence suggests that the uptake of harm reduction strategies remains limited, especially in low- and middle-income countries.13

Owing to the fact that drug users are classified as criminals, some find themselves in prison, often with their drug dealers or members of the crime networks that supply their dealers. Treating users as criminals has proven to be counterproductive, as drugs are prevalent in prisons and many lack harm reduction strategies, and so incarceration usually does not reduce the negative health effects associated with use. High levels of drug use continue among those who are incarcerated, and also bring with it additional risks including initiation into high-risk drug using behaviours.14 Prison-based harm reduction programmes are only available in very few countries, with prison-based opioid substitution therapy only being available in fewer than 40 countires, and prison-based needle exchanges only available in one in ten countries,15 despite clear guidance on harm reduction strategies available from the World Health Organization, United Nations Office on Drugs and Crime and UNAIDS.16

Other impacts associated with the War on Drugs are that in many countries enforcement often has consequences for human rights and subsequently health harms, through torture, corporal punishment and in some extreme cases capital punishment. Global enforcement efforts also have significant negative repercussions on the medical use of opiates for pain control and palliative care, as restrictive policies and regulations have been imposed in order to control illicit diversion of drugs. However, this means that a highly significant number of people around the world, especially in low- and middle-income countries, have limited, if any, access to opiate medicines, which are a cheap and very effective source of pain relief.17

There also exists a strange paradox where on the one hand authorities ban the use of certain kinds of drugs, but allow the use of what some would consider to be more dangerous products. This further exacerbates the risks to public health, as people infer from the legal status that these substances are less harmful than the ones that are banned – an assumption that some experts say is wrong. The former British government drugs adviser and Imperial College academic Professor David Nutt put the issues in context when he stated in 2009 that, statistically, alcohol and tobacco are more dangerous than LSD. So in short, the way in which we classify drugs also bears almost no relation to their relative degrees of harmfulness to health. 

Other so-called ‘legal highs’ further add to the confusion as their classification as legal is wholly misleading. Just because they are legal, it does not mean that they are safe.18  They are simply drugs that have not made it onto the list of illegal substances. The existing system has some fundamental conceptual challenges and seems unable to keep up as more and more drugs are continuously added to the list of banned substances. As soon as a new drug or legal high is added to the list to make it more difficult for users to obtain, it is not long before another legal substance – either already existing or new – replaces it on the drug-taking scene. This does not benefit public health as there is potentially a new health risk in the form of the danger associated with every new drug that emerges on the black market. Futhermore, it is often the case that little is known about its health effects initially, which poses a real challenge to emergency services and those developing treatment strategies.

Political Support for Change
Owing to the growing consensus that the existing approach has failed, there is increasing political will for a new approach, moving away from the costly enforcement-based model in order to address issues relating to gang-related violence, help reduce the huge amounts of money that are spent on law enforcement, and minimize the health risks for users.

However, national drugs policy and prevention strategies are contentious issues for politicians. The use of certain drugs has for many years been regarded as a criminal activity, and many politicians have been reluctant to change the existing approach because of endemic fears of potential backlash against altering the status quo. For politicians, being seen to be soft on drug users is often perceived as being soft on crime, something that could lose them votes. But Latin American States are leading the charge for a change to the current enforcement-based approach.19

Police investigator at the scene of a shoot out believed to be part of on-going drug war in a slum in Juarez, Mexico. [Richard Ellis Photography]

Newly elected Mexican President Enrique Peña Nieto has pledged to make violence reduction a priority after his predecessor Felipe Calderón’s heavy-handed crack-down. Similarly, Colombian President Juan Manuel Santos called for a reassessment of existing counter-narcotic strategies and an examination of possible alternatives at the 2012 Summit of the Americas. “I think the time has come to simply analyze if what we are doing is the best we could be doing, or if we can find an alternative that would be more effective and less costly to society … One extreme can be to put all users in prison. On the other extreme, legalization. In the middle there may be more practical policies, such as decriminalizing consumption but putting all the efforts into interdiction.”20

At the same summit, the President of the United States of America Barak Obama stated: “I think it is entirely legitimate to have a conversation about whether the laws in place are doing more harm than good in certain places.” However, he did clarify his remarks by stating that the United States will not be embarking on the path of legalization.21 The past 12 months has also seen a significant shift in the debate in the UK. Speaking to the Home Affairs Select Committee in July 2012, former Justice Secretary Ken Clarke said: “We have been engaged in the War on Drugs for the past 30 years. We are plainly losing it.”22

Thus, as momentum for a change in approach gathers pace, it appears that the political will is now also present for alternatives to be considered; something that would have been almost inconceivable not even five years ago.

The Difficulty in Finding an Alternative
Ultimately, the evidence suggests that the War on Drugs has failed to limit supply and demand, it has cost billions of dollars per year to enforce and resulted in many thousands of deaths. It has failed to combat the social ills associated with drug use, and it has only served to exacerbate the health toll of drugs on drug users. As the Global Commission on Drug Policy concluded, it is becoming clear that the global drug problem is not a war that needs to be waged or won. Rather, it is a set of interlinked health and social challenges that need to be managed.

Politicians around the world are increasingly accepting that the time has come for a change. But finding a suitable alternative may be a tall order. Shifting away from the prohibition approach would no doubt reduce the burden for law enforcement agencies, and a move towards a new strategy focused around public health will no doubt reduce some health concerns associated with illicit drug use.

However, although the rhetoric of shifting towards a public health approach is straightforward, in reality it is much harder to implement, and whatever change takes place needs to do so without promoting the normalization of drug use. Should we move towards decriminalization of drug use while continuing to pursue drug-related organized crime, violence and intimidation, or should we lean towards a system of legalization and regulation of drugs? This decision will create a huge challenge for policy makers in the coming years, but at least this conversation is now underway at the highest levels and it appears that progress is being made toward a public health approach to managing drug use.

Ian Perrin is the Manager of the Centre on Global Health Security at Chatham House, home of the Royal Institute for International Affairs.


  • Posted by Job Joris Arnold on Feb 21, 2013 2:40 AM

    I think the author makes a useful analysis of both the complete failure of the costly prohibitionist approach towards drugs, as well as the shifting political debate finally acknowledging this obvious truth.

    However, although the rhetoric of shifting towards a public health approach is straightforward, in reality it will be much harder to implement, at least as long as those promoting it are convinced that 'whatever change takes place needs to do so without promoting the normalization of drug use.'

    Criminalization of drug use is a disaster, it's now official. Medicalization will be the next, unless normalization is embraced for what it is: the only way forward.

    Normalization has stood at the core of Dutch drugs policy since the 1970s, as it was considered the best way to serve the public health agenda.

    Unfortunately, in recent years consecutive governments have been slowly but surely replacing this ideal with their public order agenda, giving in to international pressure of foreign powers (read: the US) unhappy with the evident successes of the Dutch approach in the past.

  • Posted by Darryl Bickler on Feb 21, 2013 10:31 AM

    Oh dear, this piece written from the reverse paradigm. The whole thing is wrong conceptually, the author hasn't realised the deceit at the heart of the whole problem at all. None of these ideas actually make any sense linguistically, the whole problem of using transfered epithets such as 'war on drugs', 'illegal drugs' etc has been missed. The fact that the writer thinks that the schedule of 'controlled drugs' is a list of illegal substances is completely hopeless.

  • Posted by Andria E-Mordaunt on Mar 8, 2013 1:06 PM

    Great article. More please

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[1] Wood, E., Werb, D., Marshall, B. et al (2009) The War On Drugs: A Devastating Public-Policy Disaster. The Lancet, 373(9668): 989-990.
[2] Bewley-Taylor, D., 2003. Challenging the UN Drug Control Conventions: Problems and Possibilities. International Journal of Drug Policy, 14:159.
[3] Report of the Global Commission on Drug Policy (June 2011) Count The Costs.
[4] Ibid.
[5] World Drug Report (2010) United Nations Office on Drugs and Crime. 
[6] The War on Drugs and HIV/AIDS How the Criminalization of Drug Use Fuels the Global Pandemic (June 2012) Report of the Global Commission on Drug Policy. 
[7] Rolles, S., Murkin, G., Powell, M. et al (June 2012) The Alternative World Drug Report: Counting The Costs of the War On Drugs. Count the Costs.
[8] Archibold, R. & Cave, D. (2012) Candidates in Mexico Signal a New Tack in the Drug War. The New York Times, 10 June.
[9] The War on Drugs: Threatening Public health, Spreading Disease and Death (2011) Count The Costs
[10] Rhodes, T., Singer, M., Bourgois, P., Friedman S. & Strathdee, S. (2005) The Social Structural Production of HIV Risk Among Injecting Drug Users.Social Science and Medicine, 61 (5): 1026-1044. [11] Report of the Global Commission on Drug Policy (June 2011) Count The Costs.
[12] Stimson, G., Cook, C., Bridge, J., et al (2010) Three Cents is Not Enough. International Harm Reduction Association
[13] Cook, C. (2010) The Global State of Harm Reduction: Key Issues for Broadening the Response. International Harm Reduction Association
[14] The War on Drugs: Threatening Public Health, Spreading Disease and Death (2011) Count The Costs
[15] Cook, C. (2010) The Global State of Harm Reduction: Key Issues for Broadening the Response. International Harm Reduction Association.
[16] HIV/AIDS Prevention, Care, Treatment and Support in Prison Settings: A Framework for an Effective National Response (2006) United Nations Office on Drugs and Crime, World Health Organization, UNAIDS. 
[17] The War on Drugs: Threatening Public Health, Spreading Disease and Death (2011) Count The Costs. 
[18] Legal Highs (2012) NHS Choices.
[19] ‘War on Drugs’ Has Failed, Say Latin American Leaders (2012) The Guardian. 7 April. 
[20] U.S.-Colombia Trade Deal to Take Effect in May (2012) CNN online. 14 April.
[21] Ibid.
[22] Ken Clarke: Britain Plainly Losing War on Drugs (2012) The Telegraph. 3 July.