Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, Cepeda J, Comfort M, Goosby E, Goulão J, Hart C, Kerr T, Lajous AM, Lewis S, Martin N, Mejía D, Camacho A, Mathieson D, Obot I, Ogunrombi A, Sherman S, Stone J, Vallath N, Vickerman P,.
“Public health and international drug policy”.
Lancet. 2016 Mar 29.
In September, 2015, the member states of the UN
endorsed Sustainable Development Goals (SDGs) for
2030, which aspire to human-rights-centred approaches
to ensuring the health and wellbeing of all people. The
SDGs embody both the UN Charter values of rights and
justice for all and the responsibility of states to rely on
the best scientifi c evidence as they seek to better
humankind. In April, 2016, these same states will
consider control of illicit drugs, an area of social policy
that has been fraught with controversy and thought of as
inconsistent with human rights norms, and in which
scientific evidence and public health approaches have
arguably had too limited a role.
Conclusions and recommendations
Policies meant to prohibit or greatly suppress drugs
present a paradox. They are portrayed and defended
vigorously by many policy makers as necessary to
preserve public health and safety, and yet the evidence
suggests that they have contributed directly and indirectly
to lethal violence, communicable-disease transmission,
discrimination, forced displacement, unnecessary
physical pain, and the undermining of people’s right to
health. Some would argue that the threat of drugs to
society might justify some level of abrogation of human
rights for protection of collective security, as is provided
for in human rights law in case of emergencies.
International human rights standards dictate that, in
such cases, societies still should choose the least harmful
way to address the emergency and that emergency
measures should be proportionate and designed
specifi cally to meet transparently defi ned and realistic
goals. The pursuit of drug prohibition meets none of
Standard public health and scientific approaches that
should be part of policy making on drugs have been
rejected in the pursuit of prohibition. The idea of
reducing the harm of many kinds of human behaviour is
central to public policy in traffi c safety, tobacco and
alcohol regulation, food safety, safety in sports and
recreation, and many other areas of human life where
the behaviour in question is not prohibited. But explicitly
seeking to reduce drug-related harms through policy and
programmes and to balance prohibition with harm
reduction is regularly resisted in drug control. The
persistence of unsafe injection-linked transmission of
HIV and HCV that could be stopped with proven, costeff
ective measures remains one of the great failures of
the global responses to these diseases.
Drug policy that is dismissive of extensive evidence of
its own negative impact and of approaches that could
improve health outcomes is bad for all concerned.
Countries have failed to recognise and correct the
health and human rights harms that pursuit of
prohibition and drug suppression have caused, and, in
doing so, neglect their legal responsibilities. They
readily incarcerate people for minor off ences but then
neglect their duty to provide health services in custodial
settings. They recognise uncontrolled illegal markets as
the consequence of their policies, but do little to protect
people from toxic, adulterated drugs that are inevitable
in illegal markets or the violence of organised criminals,
which is often made worse by policing. They waste
public resources on policies that do not demonstrably
impede the functioning of drug markets, and miss
opportunities to invest public resources wisely in
proven health services for people often too frightened
to seek services.
To move towards the balanced policy that UN member
states have called for, we off er the following
• Decriminalise minor, non-violent drug off ences—
use, possession, and petty sale—and strengthen
health and social-sector alternatives to criminal
• Reduce the violence and other harms of drug
policing, including phasing out the use of military
forces in drug policing, better targeting of policing
on the most violent armed criminals, allowing
possession of syringes, not targeting harm-reduction
services to boost arrest totals, and eliminating racial
and ethnic discrimination in policing.
• Ensure easy access to harm-reduction services for all
who need them as a part of responding to drugs, in
doing so recognising the eff ectiveness and costeff
ectiveness of scaling up and sustaining these
services. OST, NSP, supervised injection sites, and
access to naloxone—brought to a scale adequate to
meet demand—should all fi gure in health services
and should include meaningful participation of
people who use drugs in planning and implementation.
Harm-reduction services are crucial in
prison and pretrial detention and should be scaled up
in these settings. The 2016 UNGASS should do better
than the UN Commission on Narcotic Drugs (CND)
in naming harm reduction explicitly and endorsing
its centrality to drug policy.
• Prioritise people who use drugs in treatment for HIV,
HCV infection, and tuberculosis, and ensure that
services are adequate to enable access for all who
need care. Ensure availability of humane and
scientifi cally sound treatment for drug dependence,
including scaled-up OST in the community and in
prisons. Reject compulsory detention and abuse in
the name of treatment.
• Ensure access to controlled drugs, establish
intersectoral national authorities to determine levels
of need, and give WHO the resources to assist the
International Narcotics Control Board in using the
best science to determine the level of need for
controlled drugs in all countries.
• Reduce the negative impact of drug policy and law on
women and their families, especially by minimising
custodial sentences for women who commit nonviolent
off ences and developing appropriate health
and social support, including gender-appropriate
treatment of drug dependence, for those who need it.
• Efforts to address drug-crop production need to take
health into account. Aerial spraying of toxic
herbicides should be stopped, and alternative
development programmes should be part of
integrated development strategies, developed and
implemented in meaningful consultation with the
people aff ected.
• A more diverse donor base is needed to fund the best
new science on drug-policy experiences in a nonideological
way that, among other things, interrogates
and moves beyond the excessive pathologising of
• UN governance of drug policy should be improved,
which should including respecting WHO’s authority
to determine the dangerousness of drugs. Countries
should be urged to include high-level health offi cials
in their delegations to CND. Improved representation
of health offi cials in national delegations to CND
would, in turn, be a likely result of giving health
authorities an important day-to-day role in
multisectoral national drug-policy-making bodies.
• Health, development, and human rights indicators
should be included in metrics to judge success of
drug policy, and WHO and the UNDP should help to
formulate them. The UNDP has already suggested
that indicators such as access to treatment, frequency
of overdose deaths, and access to social welfare
programmes for people who use drugs would be
useful indicators. All drug policies should also be
monitored and assessed as to their impact on racial
and ethnic minorities, women, children and young
people, and people living in poverty.
• Move gradually toward regulated drug markets and
apply the scientifi c method to their assessment.
Although regulated legal drug markets are not
politically possible in the short term in some places,
the harms of criminal markets and other consequences
of prohibition catalogued in this Commission will
probably lead more countries (and more US states) to
move gradually in that direction—a direction we
endorse. As those decisions are taken, we urge
governments and researchers to apply the scientifi c
method and ensure independent, multi disciplinary,
and rigorous assessment of regulated markets to draw
lessons and inform improvements in regulatory
practices, and to continue evaluating and improving.
We urge health professionals in all countries to inform
themselves and join debates on drug policy at all levels.
True to the stated goals of the international drug-control
regime, it is possible to have drug policy that contributes
to the health and wellbeing of humankind, but not
without bringing to bear the evidence of the health
sciences and the voices of health professionals.