Drug policy campaigners often call for policy to be re-oriented towards public health, as a more progressive and constructive approach than the criminalising strategy of prohibition. The broad thrust of this type of call is that we should be more concerned about helping sick people, preventing the spread of disease and enhancing well-being, rather than punishing individuals for supposed moral transgressions. On the face of it, who could argue against that? Indeed, last month, I even found myself enlisted as a signatory to a letter enjoining the Government to ‘put public health first’ in its drug policy. But when I look at the genealogy of drug control policy over the last 150 years, I start to feel a little queasy about this apparently ‘obvious’ proposal. Here, I point to three key moments in this history that prompt my uncertainty.

1. The very first regulatory controls on opium in Britain were contained in the Pharmacy Act of 1868. This was a landmark piece of legislation within the genealogy of prohibition as it arguably paved the way for the first modern drug laws in the early twentieth century. Yet one of the key drivers for the 1868 legislation was the emerging public health movement which had identified the problem of poisonings as a major concern. In this sense, the foundation for our contemporary approach to drug control itself has deep roots in public health.

2. One period that reformers often hark back to as a high-point of a progressive public health approach is the so-called ‘British System’ ushered in by the famous Rolleston Report of 1926, in which doctors were empowered to treat heroin addiction as a manifestation of a disease rather than as a vice, which could be managed by the prescribing of opiates to addicts. But again, as I have argued elsewhere, things are not quite what they seem here either. The ‘British System’ was built on the base of a strategic liaison between penal and welfarist approaches, rather than a medical approach triumphing over a criminalizing one.

3. The British response to the threat of HIV in the mid to late 1980s has been seen as an exemplary public health approach to the drug problem which successfully averted a potential HIV epidemic. And I don’t question that success at all. Critics of the more recent obsession in drug policy with crime and criminal justice typically call for a return to the public health emphasis of the HIV era. But I am not convinced that the two strategies are in fact so different. Both are based on a shared view of the problem (drug users as threats to the community), a shared understanding of drug users (rational risk-takers and choice-makers) and a shared strategic response (urging and enabling responsible choice-making to reduce risk). (Incidentally, I see the current vogue for ‘recovery’ as essentially a variation on this same theme).

The idea then of a public health approach as a progressive alternative to a criminalizing penal one is problematic, as the two strategies have been closely intertwined over the last 150 years. It is difficult to sustain the idea that they are polar opposites or stark policy alternatives. I don’t mean by this that it is impossible, or undesirable, to emphasise or prioritise health concerns within drug policy. My point is rather that simple calls for a ‘public health drug policy’ ignore and gloss over this ambiguous and mixed lineage.

But I would also go further than this. Even if policy reformers eventually win the day and the entire existing prohibition regime is swept away, it is not clear to me that public health would or should necessarily emerge as the primary animating principle of any new approach. Other principles might stake an equal or greater claim to primacy, such as social justice, human rights, well-being or human security. Public health advocates would need very sharp elbows to emerge triumphant from that competition. 

[This post is a reworked version of pages 134-5 of this book]