Friday, July 26, 2013

Climate change and population health – lessons from the 19th century

Professor Emeritus Anthony McMichael AO

There are population health lessons from the mid-nineteenth century response to the rampant sickness, epidemic disease and increased death rates associated with the big, new and growing industrial cities. The subsequent great gains in human safety and health came from transformative legislation and social action. Today, we should be seeking to achieve similar transformative changes to deal with the population health challenges of climate change.

Among the several major and historically unprecedented global environmental changes that human pressures have caused, the climate system is the most likely source of acute shocks/emergencies within the coming decade.
Now, at last, as Australians and their policy-makers are beginning to perceive that the impacts of unabated climate change include impacts within the human system. Consideration of risks to the safety, health and survival of communities are entering the discourse. That crucial dimension has long been a paradoxical blind spot, a wavelength of relative ignorance. This recognition of risks to humans per se come about substantially, because of a growing understanding of the contributory, amplifying, role that underlying climate change plays in the increasing frequency and intensity of many categories of extreme weather events.
Climate change is no simple ‘risk factor’ for illness like smoking, alcohol abuse or not wearing one’s seat-belt. Nor are its health impacts restricted to the high-risk individuals. Its impacts impinge, via many paths, on whole communities. In that broader population health domain, there are appropriate lessons from the mid-nineteenth century response to the unintended negative consequences of population concentrations associated with rapid industrialisation.
The challenge was to deal with the rampant sickness, epidemic disease and increased death rates in the big new and growing industrial cities. The subsequent great gains in human safety and health came from transformative legislation and social action. Biomedical knowledge and intervention (really only available to the rich anyway) was limited and of dubious value. England provides the best documented examples: the installation of a huge sewer system in London (and elsewhere), legislation to curb factory smoke emissions, empirical knowledge (pre-germ theory) of the benefit of household and neighbourhood hygiene, filtration of reticulated water, and stricter food safety laws and monitoring. Quarantine in ports (though opposed by free traders) was introduced in response to the pandemics of cholera that swept through Europe in the 1830s and 1850s.
Today, motivated by recognition of the community-wide and long-term risks to the health and survival of populations, we should be seeking to achieve similar transformative changes in our (often carbon-intensive) technologies, economic priorities, and how we construe, measure and monitor human wellbeing and health, particularly at the collective levels of community or population.
Professor McMichael was a contributor to the Australia21 publication Placing global Change on the Australian election agenda released in June. Here is a link to his latest piece Why climate change should be a key health issue this election

Tuesday, July 23, 2013

Coffee Shops and Compromise: Separated Illicit Drug Markets in the Netherlands.

The second Australia21 report on drug policy in 2012, Alternatives to Prohibition. Illicit Drugs: How Can we Stop Killing and Criminalising Young Australians?, examined the drug policy of four European countries. The Netherlands, Switzerland and Portugal were contrasted with Sweden. The first group of countries, at different times, became dissatisfied with the results of conventional drug policies and adopted a more pragmatic approach. Sweden has for decades followed a similar harsh drug policy to the United States. In the early 1970s, the Netherlands became the first country in the world to break with the international drug control system by placing much more emphasis on pragmatic health and social interventions rather than relying heavily on drug law enforcement. Switzerland followed a similar path from the early 1990s. In 2001, Portugal also began re-defining illicit drugs as primarily a health and social problem. While the Australia21 report applauded some positive aspects of Sweden's drug policy, the emphasis on punishment has remained and some of the results of this policy have been concerning. Drug overdose deaths in Sweden have been higher than most other European countries and have also been rising.

The recent report from the Open Society Foundation Coffee Shops and Compromise. Separated Illicit Drug Markets in the Netherlands examines the results of decades of experience with the Dutch cannabis coffee shops. There is now considerable support in academic publications for this policy. The Open Society Foundation report is consistent with the conclusions of the Australia21 report.

In the Netherlands there are many fewer arrests for cannabis than in the United States. In 2005 there were 269 marijuana possession arrests for every 100,000 citizens in the United States, 206 in the United Kingdom, 225 in France, and 19 in the Netherlands. Consistent with several other studies (but perhaps counter-intuitively), less emphasis on drug law enforcement in the Netherlands did not lead to increased consumption. About 25.7% of Dutch citizens report having used cannabis at least once. This is about average for Europe. The United Kingdom and the United States have a much more punitive approach than the Netherlands but 30.2% (UK) and 41.9% (USA) report having used cannabis at least once. The cannabis coffee shops in the Netherlands were originally introduced to protect cannabis users from exposure to more dangerous drugs (such as heroin and cocaine). This notion is known as the “separation of markets.” The markets are much more separated in the Netherlands than in the United Kingdom and the United States. In Sweden, 52 % of people who use cannabis report that other drugs are available from their usual cannabis source. In the Netherlands, only 14 % of marijuana users can get other drugs from their cannabis source, according to European drug monitors. This is largely because the vast majority of cannabis users buy from coffee shops.

In addition, the Netherlands has virtually eliminated injecting drug use as a source of cases of new HIV infection. The Netherlands has the lowest rate of problem drug use in Europe.

However, as any other country, the Dutch approach is vulnerable to politics. In a policy area always at the mercy of populism, political squabbling can end up with regressive drug policy approaches. From time to time, as in other countries Dutch politicians have used drug policy as a wedge issue.

Supporters of the international drug control system claim that movement toward more conventional drug policy is an admission of failure regarding pragmatic approaches on the part of Dutch lawmakers. But Dutch drug policy has never failed. In some cases reforms were introduced as a means of dealing with local difficulties. In other cases, coffee shops represented an easy political target. Despite the variation in Dutch drug policy from time to time, the achievements of Dutch drug policy and their broad public support cannot be denied.
Do Australia and the international community have the political will to learn from the lessons of the Netherlands and carry them even further?

World opinion on drug policy is now changing. Two decades ago harm reduction, the notion that reducing harm should be the primary aim of drug policy rather than reducing consumption regardless of the consequences, was seen as radical. Harm reduction supporters were marginalised while supporters of drug prohibition were the mainstream. That situation has now reversed. Harm reduction and drug law reformers are increasingly regarded as the mainstream and supporters of drug prohibition are now increasingly marginalised.