Time to Ban Spanking and Encourage Unconditional Parenting

In April of 2016, an important meta-analysis was conducted by the University of Texas at Austin and the University of Michigan. Their study looked at 50 years worth of research encompassing 160,000 children on the effects of spanking. The results should at least place a grain of doubt into most people’s minds about the long-term efficacy of spanking.

Spanking, defined as an “open-ended hit on the behind or extremities,” was associated with 13 deleterious outcomes such as general mental health problems and anti-social behavior in adulthood. Not only is spanking ineffective at eliciting immediate compliance for the desired behavior, but it can also be potentially damaging to the child later in life. While these findings are general, they’re in tandem with more specific research on spanking. Simply put, spanking absolutely doesn’t work, and it’s time to make it illegal as France has recently done alongside 51 other countries.

Why We Shouldn’t Spank

Before getting into this, it’s important to note that I am not a parent. I am just looking at this issue from the standpoint of intellectual curiosity. This criticism of spanking shouldn’t be viewed as a diatribe towards parents who might employ that method of punishment. Rather, it’s just a sharing of the research done on this topic combined with my personal thoughts; nothing more, nothing less. This shouldn’t, however, disqualify what I have to say. While there is no rigid, scientific way to raise a child, academic research on parenting styles shouldn’t be smugly dismissed by parents, either.

Abstractly speaking, I can’t really fathom why anyone would want to spank a child. Spanking, as I observe it, is typically done when a child has done something the parent doesn’t like; they wander off at the zoo, yell loudly at a restaurant, mistreat other children at a family reunion, etc. All of these situations could easily justify the use of spanking along with a verbal lashing to a lot of parents. When I say “a lot,” I mean it: a 2012 survey revealed that about 70% of Americans agree that children sometimes need a “good, hard spanking.”

Why are children, who are completely defenseless and dependent, okay to hit when we’re displeased with their unruly behavior? Certainly, that wouldn’t be acceptable behavior on a fully functioning adult in any circumstance. If your significant other were doing something you didn’t like, you’d probably at least talk to them about it; resorting to “open-handed hits” would undoubtedly prompt legal trouble.

If it’s not okay to strike an adult with a fully developed brain cognizant of its surroundings, why, then, should it ever be okay to strike a child? These are the sorts of internal questions I can’t wrap my head around when thinking about this issue. Most children implicitly trust their parents; they provide their food, shelter, and a general sense of comfort and security. When they “misbehave,” perhaps they’re just communicating their displeasure in the best way they know how given their limited vocabulary and cognition. The outbursts might appear to be irrational and unseemly, yet they’re actually perfectly rational and appropriate in the mind of a child who doesn’t know how to otherwise communicate their displeasure. I’m generalizing on a hypothetical situation, but research also corroborates this.

Realizing Relationships

The formative years, which typically means from birth to around age 8, are vital for brain development. It’s been determined that about 90% of brain capacity develops before the age of 5 with the most critical time being between birth and 3. The role experience plays in the process of brain development is profound; our brains are very malleable and can be molded, so to speak, by environmental influences. As an article from Paediatrics and Child Health explained:

“The billions of neurons in the brain have the same genetic coding, but as the brain develops through experience in early life, neurons differentiate through specific gene activation. Experience also affects the formation of the connections (synapses) among neurons to establish pathways for the different hierarchies of brain function. These pathways govern or control our intellectual, emotional, psychological, physiological and physical responses to what we do every day.”

These are called epigenetic processes which means “above” or “on top of.” They alter the physical structure of DNA and can literally turn genes on and off depending on certain environmental factors. In fact, Dr. Jean-Pierre Issa, director of the Fels Institute for Cancer Research and Molecular Biology and a professor at Temple University, has claimed that epigenetic changes are more of a factor in cancers than genetic changes.

I’m only bringing this up because it helps lay the groundwork for how we understand correlations between early experiences and future behaviors. Yes, correlation doesn’t equal causation, but you’d be hard-pressed to find direct causation with anything in public health. Very few social issues have a singular, straightforward causation. Instead, they’re full of individual bricks, and it’s the job of sociologists, public health experts, and other individuals more qualified than I to apply mortar and erect a building.

A more helpful term for addressing this is preconditions which are mostly defined as “a condition that must be fulfilled before other things can happen or be done” (Joseph, p. 357). In sociology, this term is used in a public health context where population outcomes are considered. An example of this would be the link between unemployment and child maltreatment. The precondition, unemployment, is correlated to child maltreatment. Of course, unemployment can’t be said to literally cause child maltreatment, but there is a “statistical correlation between the condition of unemployment and chain reactions linked to it” (Joseph, p.7). I think most will get the gist of my little preamble, so let’s dive into the specific research regarding spanking (a type of precondition) and see if it correlates to anything positive.

Spanking and Behavior

As stated above, the first five years of life are arguably the most critical times in our lives. It’s not only a matter of “should” we spank, but it’s also a matter of “when” we spank. When we spank might have more of an impact during these years than in any other times as a study in the National Institutes of Health looked at.  The study looked at the associations of spanking with 3 outcomes — externalizing behavior problems, internalizing behavior problems, and cognitive skills — over the first five years of a child’s life.

They found that spanking was associated with higher levels of future externalizing and internalizing behavior problems. Spanking also potentially escalates behavioral issues instead of increasing the control of a child’s behavior; the exact opposite of what a parent is hoping to achieve. This is because spanking promotes what the researchers call a “cyclical pattern of negative parent-child interactions.” In other words, spanking doesn’t dissuade the child from their problematic behaviors.

The researchers decided, however, to give advice to parents who spank at such a young age:

“On the whole, then, our behavior problems results suggest that interventions that encourage parents who spank their children at young ages to discontinue this practice may help to diminish the likelihood that children will develop or continue to exhibit problem behaviors. By providing parents with alternative strategies for disciplining their children, practitioners may have the potential to better help parents control the problem behaviors that are likely to elicit spanking in the first place.”

Spanking and Overall Health

A study from the journal Pediatrics that looked at survey data from 35,000 adults found a correlation between physical punishment and worsening mental health in adult life. They also found that about 2-7% of the mental health disorders from the studies population was attributed to physical punishment. This study corroborates the meta-analysis study mentioned at the beginning of this post. Again, this doesn’t mean that spanking literally causes mental illness or that a child spanked will always be worse off psychologically; it’s merely pointing out an association.

On a more general level, spanking can have some adverse, external effects as well. Murray Straus, professor emeritus of sociology at the University of New Hampshire, elucidated this well during an interview discussing his co-authored book ‘The Primordial Violence’:

“Moreover, the research clearly shows that the gains from spanking come at a big cost. These include weakening the tie between children and parents and increasing the probability that the child will hit other children and their parents and, as adults, hit a dating or marital partner. Spanking also slows down mental development and lowers the probability of a child doing well in school.”

There are always unintended consequences from any social action performed; nothing is done in a vacuum. Going back to the concept of preconditions, we can see how spanking or physical abuse can rear its ugly head later on in life. Someone under the prospect of a costly divorce or possible jail time because they suddenly struck their wife/husband probably doesn’t understand why they did it. Rarely, though, would they make the connection to being spanked as a child. Again, to blame it solely on spanking would, of course, be ridiculous, but this link in the chain of causality shouldn’t be dismissed.

Conclusively, we just know too much about spankings possible detrimental effects. As another article in the National Institutes of Health made clear: spanking is ineffective, engenders more aggression, offers less long-term compliance, violates Article 19 of the Convention on the Rights of the Child, and is a form of violence. The author’s conclusion is worth quoting verbatim:

“We now have enough research to conclude that spanking is ineffective at best and harmful to children at worst. We also know that a range of professional and human rights organizations condemn the practice and urge parents to use alternative forms of discipline. We thus have research-based and human rights-based reasons for not spanking our children.

But there is a third reason not to spank our children, and that is a moral one. Although most Americans do not like to call it so, spanking is hitting and hitting is violence. By using the euphemistic term spanking, parents feel justified in hitting their children while not acknowledging that they are, in fact, hitting. We as a society have agreed that hitting is not an effective or acceptable way for adults to resolve their differences, so it should not be a surprise that hitting children, like hitting adults, causes more problems than it solves. It is time to stop hitting our children in the name of discipline.”

These research and morally-oriented findings are the main reasons why I think it’s time the US becomes the 53rd country to ban spanking. Concerns of this causing our kids to become more entitled or less respectful to authority are mostly baseless conjecture. We’ve been condemning youth for these same things for thousands of years (see Adam Conover’s comedic lecture for more on this), yet the human race lives on! Most of these accusations of entitlement and the like are either exaggerated or merely describing the normal process of growing up (Cornell University has a decent PowerPoint presentation about differentiating normal and abnormal aggression in kids/teens).

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Conditional vs. Unconditional

I’m only emphasizing spanking because it still seems to be the most contentious issue regarding punishments for children. This isn’t going to be my only focus, though. Instead, I want to broaden the subject to include all forms of aggressive, hostile parenting or, as it’s sometimes called, conditional parenting. I was introduced to this term in Alfie Kohn’s book ‘Unconditional Parenting: Moving from Rewards and Punishments to Love and Reason.’ Alfie is the author of 14 books that mostly center around social criticisms of competition, the education system, and how we view/treat children. He often lectures at a variety of universities and is well-respected in the academic community.

Conditional parenting is an approach that means “children must earn it [love] by acting in ways we deem appropriate, or by performing up to our standards.” This is contrasted with unconditional parenting which “doesn’t hinge on how they [children] act, whether they’re successful or well-behaved or anything else (Kohn, p.10-11).”

Another helpful way of comparing these two parenting styles is looking at their focus. Conditional parenting’s primary focus is behavioral: it has a pessimistic view of human nature, relies on rewards and punishments (or “doing to”), and thinks parental affection is something to be earned. Unconditional parenting, though, employs a more positive view: it has a favorable (neutral could work, too) perspective of human nature, uses problem-solving (or “working with”) techniques for dealing with behavior, and parental affection is a gift (Kohn, p. 19).

The Conditional Parents

Imagine a family has a 3-year-old daughter named Kaylee and every Sunday night they have a tradition of watching America’s Funniest Home Videos. The whole family enjoys this program, and it provides a temporary distraction from the reality of having to go to work/school the next morning. A few hours before its start time, however, Kaylee decided to throw a temper tantrum at the store. She kicked, wailed, and generally made the shopping trip unnecessarily stressful. This is obviously not socially acceptable behavior, so they enact punishment by banishing her to her room while everyone else continues to watch.

That would be the conditional parenting style of punishment. Kaylee wasn’t compliant with their expectations, so they took away something she likes. Another name for this is love withdrawal:  a tactic that mostly utilizes time-outs and confinement. While this may seem like a harmless, efficient way to “teach kids a lesson” so they behave better in the future, that claim has yet to be demonstrated by any evidence. Not only is this method ineffective at doing what it hopes to accomplish (foster acquiescence on a child), it communicates a very negative message to the child: “If you don’t do what I want, you’ll be forced to suffer as punishment.”

We don’t know all of the emotional complexities of Kaylee’s decision to throw a tantrum at the store. Why did she decide to throw a tantrum at the store even though she’s ordinarily well-behaved? The conditional parent views a child’s action in a vacuum and treats them as if they’re rational decision makers. The child isn’t complying with your expectations; therefore, punishment ensues. Easy. Simple. Straight to the point.

The Unconditional Parents

An alternative approach to Kaylee’s situation would be to continue the day as usual. Even after the tantrum at the store, the unconditional parents would still watch the TV program that night. This doesn’t mean they’d let her misbehave in public and act like nothing happened; that wouldn’t address the problem either. Instead, the parents realize the problem is inside, not outside. Something is going on internally that she cannot adequately express.

Perhaps Kaylee felt she wasn’t getting enough attention because her parents were too busy shopping. Mom and dad would understandably keep constant tabs on a 3-year-old at home or at a park, but with her secured in the cart, that need dissipates. As summed up by Alfie Kohn:

“Children are not pets to be trained, nor are they computers, programmed to respond predictably to an input. They act this way rather than that way for many different reasons, some of which may be hard to tease apart. But we can’t just ignore those reasons and respond only to the [behaviors] (p.15)”

The analogy of a computer is very helpful in understanding how the conditional parent thinks. If their child displays behavior they deem aberrant, then it becomes necessary to “re-program” that behavior, usually via spanking, isolation or some other form of aggressive punishment. I don’t think parents do this maliciously; most probably believe that enacting conditional parenting methods is the only way to teach their kids a proper lesson. However, as is pointed out by Unconditional Parenting, this isn’t the case.

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Taken from pages 119-136 of Alfie’s book, there are 12 general principles of unconditional parenting. Incorporating these will instill healthier attitudes in parents minds while ultimately improving society as a whole. In the spirit of trying to keep this post from becoming too verbose, I’ll condense it down to a few bullet points.

• Contemplate what causes certain emotional states like anger, impatience, or love when your child does something.
•  Ask yourself if your demands of a child are within reasonable expectations of their abilities.
• View your child’s misbehavior as a problem to be solved, not an act deserving punishment.
• Never forget respect: respecting children in nearly the same way you treat an adult is imperative.
• Do your best to not interrupt your child during a conversation, belittle their feelings, or trivialize their fears. I’m often surprised how frequently parents do these things as if it’s no big deal.

At the end of the day, the most important idea for unconditional parenting is to keep their child’s age in mind! This, in my view, is the most pertinent point made in the book about conceptualizing unconditional parenting. Conditional parents tend to hold unreasonably high expectations of their child. Kids, especially under 8, fidget, are loud, and tend to overreact to minuscule changes in their environment: to hold them responsible for this behavior is “fundamentally inappropriate” (Kohn, p.130).

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Concessions

Again, and I cannot say stress this enough, this shouldn’t be viewed as me perched on an ivory tower damning any parent who dares to do anything I deem wrong. I am not a parent, and I can fully empathize with their daily struggles. No one wants to come home after a long day of work to a screaming child or fight for their compliance while trying to enjoy a meal. I’ve been in the vicinity of screaming, unruly children before and I can feel my own blood pressure rise even though he/she has nothing to do with me.

I am also not saying spanking kids or administering conditional parenting methods will automatically induce all of the harmful effects listed above. Nevertheless, what they are is inauspicious reactions that have been researched to have no benefit. This is why the “I was spanked, and I’m fine” bromide is also unhelpful. Yes, you might be or feel fine according to your mental self-assessment, but that means very little when a systemic view is considered. Bottom line: something has to be done differently, and I think the principles laid forth in Alfie’s book could be a catalyst for positive change. 

 

The Anti-Narcan Mentality and Hungry Ghosts

I recently read a disheartening article about a sheriff in my home state (Ohio) defending his position to not allow his deputies to carry Narcan. Sheriff Richard Jones, in my view, gave a fairly myopic rationalization for this stating that, “he remains opposed for safety reasons because people can become hostile and violent after being revived with Narcan.” While this may be true, I imagine suddenly being revived from near-death while surrounded by police would be disorienting and cause some people to act a little mercurial. A brief episode of hostility hardly seems like justification to completely stop using a life-saving medicine.

An ostensibly more reasonable idea that is being promulgated throughout Ohio is the three-strike rule: this rule that would essentially stop emergency medical services after a second overdose. I’m guessing the thinking is that we’ll weed out the junkies who refuse to seek help, and in doing that, be left with only the addicts who are looking to better their lives.

This perverse application of “survival of the fittest” to eliminating any social problem whether it be crime, poverty, or drug addiction has typically failed in the past. This mentality also doesn’t address the root of the issue. The “root” I’m specifically referring to with addiction is the pain felt by the individual; most drug addiction is rooted in physical or emotional pain. The popping of oxycodone, the euphoric hit of a meth pipe, or the escapism from a heroin injection all serve as analgesics. This reality is talked about in greater detail in the book ‘In the Realm of Hungry Ghosts’ by Dr. Gabor Maté.

For example, a woman in the book under the pseudonym Julie was frequently abused by her foster family from the age of 7 until early adulthood, often by being locked in her room while being force-fed a liquid diet. As a result, she ended up attempting to slash her own throat at the age of 16 and has used a mixture of heroin, alcohol, and painkillers since then. She also routinely blamed herself for the abuse thinking that she deserved nothing.

This is an extreme case, of course, but as many as two-thirds of addicts seeking treatment report physical, sexual, or emotional abuse in childhood. More specifically, a survey of 1,400 women from the National Institute on Drug Abuse revealed a correlation between sexual abuse in childhood and drug dependence. Women who experienced any sexual abuse were 3.09 times more likely to become dependent on drugs compared to women who hadn’t been abused, 2.83 times for non-genital, and an astounding 5.70 times more likely for intercourse. More on the detrimental effects of Adverse Childhood Experiences can be found here.

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To put it a different way, a hardcore drug addict likely has little to no self-esteem, happiness, or socioeconomic power, so castigating them for their obviously destructive behavior at best does nothing and at worst exacerbates the problem. Whether the castigation is from someone’s parents, kids, or co-workers, the social rejection is still felt. Social rejection, a type of emotional pain for many people, has been shown to be analogous to physical pain.

Another angle to consider on this issue is the link between the economy and drug abuse. A study from the National Bureau of Economic Research showed that a 1% increase in unemployment raises the opioid-related deaths by 0.19/100,000 people and increases Emergency Department visits by 0.95/100,000 people. Using the U.S. population as an extrapolation, a 1% drop in unemployment could potentially save about 600 people from dying due to an opiate overdose and spare about 3,000 a hospital visit.

Another study that followed 28,000 current and formerly homeless people from 2003-2008 found that around 17% of total deaths were due to a drug overdose; 81% of those overdoses involve opioids. While it is true that drug abuse tends to transcend economic class, the poor/unemployed tend to use drugs more consistently and have fewer resources available to them for recovery.

I could drone on endlessly by linking study-after-study, but the important thing to realize is that the association between the economy and drug abuse is genuine. As long as poverty, unemployment, homelessness, and fluctuations in the economy still exist, so, too, will the problem of drug abuse and related overdoses. This is why merely not giving addicts Narcan in hopes that the issue will resolve itself is a non-solution.

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This isn’t to say that opponents of administering Narcan don’t have legitimate concerns such as the exponential increase in price for the drug: a 10-milliliter vial of generic Naxalone has skyrocketed to $150.  This concern pails in comparison, though, to the cost of imprisoning non-violent drug offenders which currently populate 20 percent of our federal prison population. A publication from the National Institute on Drug Abuse exemplifies this:

“Treatment is also much less expensive than its alternatives, such as incarcerating addicted persons. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $24,000 per person.”

So you could treat multiple addicts with a methadone prescription for the cost of imprisoning just one. Methadone maintenance has also been shown to have a 60-90% success rate, according to a study done by the California Society of Addiction Medicine. What about letting them die? This mentality isn’t as uncommon as one might think, though it’s usually masked under bromides such as “tough love” or “you can’t help someone who can’t help themselves.”

Going back to my state of Ohio, in Hamilton County, a single heroin overdose death was estimated to cost the taxpayers $2,124 with the bulk of the cost being the autopsy at $1,200. Comparatively, in the same area, Narcan comes to about $37.50/dose with additional costs for training. Treatment for drug abuse overall is also becoming a financial burden for Ohio taxpayers as an article in the Columbus Dispatch attempted to quantify:

“The Department of Mental Health & Addiction Services will spend $61.7 million over two years on drug treatment in prisons, $12.5 million over three years on housing for recovering addicts, and $1 million over two years for naloxone, a drug used to reverse potentially fatal overdoses from heroin and other opioids.”

So if the options are (1) let them die, (2) revive and imprison, or (3) revive and offer treatment programs, the cheapest option is 1. Of course, callously reducing human lives to mere numbers isn’t a practical or moral way to achieve progress on this issue. If it’s not, then what is?

A Quick Digression On Tough Love

As mentioned above, some people like to reduce this complex problem to pithy sayings like “tough love.” This is often done in a confrontational, intervention-type of environment where friends and family surround an addict and often threaten to shun him/her if they don’t seek treatment. I don’t think families do this maliciously, they probably often feel that it is a last-ditch effort to save their son or daughter from the grips of addiction. This method, however, can often have the opposite effect.

A 2007 article in The New York Times referenced a 1999 study that compared the aggressive type of intervention mentioned above to a less confrontational method that employs a nurturing attitude. The results were astonishing:

“More than twice as many families succeeded in getting their loved ones into treatment (64 percent) with the gentler approach than with standard intervention (30 percent). But no reality shows push the less dramatic method, and it is difficult to find clinicians who use it.”

Hungry Ghosts

It’s very easy to read a story about a drug addict who overdosed one or even 20 times (as was the case in Dayton, Ohio) and view their actions as some sort of personal, moral failing. Why couldn’t they just “choose” to behave otherwise? Don’t they understand the negative ramifications of their actions?

In social psychology, these types of questions are an example of Fundamental Attribution Error: a kind of fallacious thinking that tries to “explain someone’s behavior based on internal factors, such as personality or disposition, and to underestimate the influence that external factors, such as situational influences, have on another person’s behavior.”

It’s important to be cognizant of this term because it will allow you to pause, take a breath, and consider the possible concealed, external factors of an individual’s situation. Many fail to do this and will instead allow the negative, emotional impulses in their brain to amalgamate and cloud judgment. This isn’t to relieve culpability from a drug addict’s actions; a small number, of course, are beyond the point of rehabilitation or simply need to be institutionalized and taken away from society. However, this particular segment of the addicted population is infinitesimal; the reality is that most addicts actually loathe themselves to varying degrees and are very emotionally delicate in the advent of severe chastising (‘Hungry Ghosts,’ p. 316).

To conclude this little polemic, I want to briefly reference a chapter in ‘Hungry Ghosts’ titled ‘Toward an Enlightened Social Policy on Drugs.’ The chapter is from pages 313-329 of Dr. Maté’s book and, in my opinion, represents the most sensible and compassionate solutions for changing someone’s stance on drug users. I apologize in advance for the lengthy quotations, but the chapter deserves to be quoted verbatim.

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Basically, the system we have doesn’t work for the addict or for society and needs to be transformed. To rectify this, the first thing he suggests we must do is abolishing our (the non-addict) sense of moral superiority to the addict. A sanctimonious attitude doesn’t help the addict and serves as a distraction for the non-addict because they don’t have to look internally at their own flawed dispositions.

A second thing we must do is dispel the notion of “free choice.” The supposed autonomy granted to a hardcore addict assumes all that’s needed to rectify their habit is a simple act of will; this isn’t entirely true. Dr. Panksepp, in conversation with Dr. Maté, explicates this reality in the book when discussing what support is needed for addicts to overcome their painful experiences:

“The only way they can escape drug addictions is if their pain is alleviated, their emotions are brought back toward healthy balance, so they have a chance to think about it.  Free choice only comes from thinking; it doesn’t come from emotions. It emerges from the capacity to think about your own emotions. when you’re operating in the habit mode you are feeling, but those feelings are not being reflected upon. They are too powerful, they are too habitual. So, the treatment of addiction requires the island of relief where a need to soothe pain does not constantly drive a person’s motivation. It requires a complex and supportive social environment.”

In other words, if an addict’s day-to-day experience is pain and suffering, they will look for any and every avenue necessary to mollify that pain and suffering which tends to compound illicit drug use. This typically offers short-term relief followed by subsequent guilt and shame; it’s a perpetual cycle that’s understandably very hard to escape. Addicts also often have a very pessimistic outlook on their future; from p. 318 of the book:

“Addicts are locked into addiction not only by their painful past and distressing present but equally by their bleak view of the future as well. They cannot envision the real possibility of sobriety, of a life governed by values rather than by immediate survival needs and by desperation to escape physical and mental suffering. They are unable to develop compassion toward themselves and their bodies while they are regarded as outcasts, hunted as enemies, and treated like human refuse.”

Lastly, what is missing from even the most altruistic of individuals or rehabilitative programs is the concept of giving up a drug. As has been explained earlier, a drug like heroin is the bedrock for alleviating pain and suffering for a lot of addicts. Any attempt to immediately take that solution away from people is, in their view, a cruel act. This is why I quickly dismissed Sheriff Richard Jones’ view on Narcan; it fails to take a nuanced view of an addict’s perceived situation. As explained by Dr. Maté, you can’t simply take away someone’s method of pain-relief:

“To expect an addict to give up her drug is like asking the average person to imagine living without all his social skills, support networks, emotional stability, and sense of physical and psychological comfort. Those are the qualities that drugs, in their illusory and evanescent way, give the addict. People like Serena and Celia and the others whose portraits have appeared in this book perceive their drugs as their ‘rock and salvation.’ Thus, for all the valid reasons we have for wanting the addict to ‘just say no,’ we first need to offer her something to which she can say ‘yes.'”

We must provide a secure environment for addicts as long as they need it. As was explained above, this includes a supervised use of their drugs. This is a thought that a lot of people will have trouble coming to terms with, but I feel it’s necessary if we are to really have an impact on this issue. Hopefully, I instilled at least a grain of doubt for the “anti-Narcan” crowds belief system and pushed everyone towards a more nuanced, compassionate understanding.

 

 

 

 

Drug Addiction: 4 Broad Solutions

A couple of weeks ago I wrote about what addictions entails and the importance of not labeling it as a disease. Now I want to push a train of thought towards possible solutions.

Train Of Thought?

I frequently use the phrase “train of thought” as opposed to the rigid, formulaic solutions that plague our political landscape because the world nowadays is too complicated for that mindset. I try my best not to align with any particular group or political party because they inherently limit themselves in terms of perspective. This cult-like thinking leads itself to naive notions of utopia; there is no final state of understanding. The “train of thought” mentality is wonderfully explicated by The Zeitgeist Movement (TZM) in their book. Here’s a small quote from page 10:

“Therefore, what is left can only be a train of thought with respect to the underlying causal scientific principles. TZM is hence loyal to this train of thought, not figures, institutions or temporal technological advancements.

Solution #1: End The Drug War

This may seem like an obvious solution (it is) to anyone who pays attention to the research, but I think the magnitude of this harmful, so-called ‘war’ needs to be regularly delineated.

In my view, without addressing the drug war, any other proposed solutions will have an infinitesimal impact. This is because the drug war has a litany of problems that encompass nearly every facet of daily life. I’ll list some of the focal points provided in a 2011 United Nations Office on Drugs and Crime report. Keep in mind, I’m only giving a bullet-point summary, so I encourage everyone to read the full report.

1) The drug war wastes billions:

• Globally, $100 billion/year is spent on drug law enforcement
• Specifically, regarding the United States, about $51 billion/year is spent on the war.

2) The drug war undermines security/health, fuels conflict:

• Illicit drug profits fund subversive, paramilitary and terrorist organizations
• This refocuses public spending from health to drug enforcement

3) The drug war actually creates more crime:

• Drugs are the world’s largest illegal trading commodity valued at $330 billion
• The increased financial power justifies more drug enforcement spending which leads to more arrests and violence; it’s a perpetual cycle

A more recent study from the John Hopkins Bloomberg School of Public Health had similar conclusions: not only has the war failed to reduce drug use, but it’s also having a negative impact on HIV rates and overall public health.

So if it doesn’t help with reducing drug use or crime, and actually worsens general public health, why would we continue with this costly method? I see no legitimate justification for continuing the drug war and its draconian punishments.

Solution #1.5: Abolish the Drug Enforcement Agency (DEA)

I put ‘1.5’ because the drug war and the DEA are, of course, inextricably linked. In my view, ending the drug war must be done in conjunction with abolishing the DEA.

Admittedly, I realize that whenever someone advocates for the outright removal of a government agency, they almost always sound hyperbolic. Take, for instance, Rick Perry’s intrepid proposal of wanting to eliminate 3 major government agencies during his 2012 primary campaign. One the agencies, which Mr. Perry momentarily forgot in a debate, was the Department of Energy. This is the agency that is responsible for maintaining our nuclear stockpile; a profoundly vital task, even if you think all nukes should be dismantled. As a result, the Department of Energy has at least one legitimate justification for its existence. I included this little side-tangent because I believe the DEA doesn’t fit this criterion of legitimate justification; their costs heavily outweigh their benefits.

In fact, their lack of legitimate justification can be proven from the onset of the war itself in the early 1970’s/1980’s. Drug-related crime was actually declining during this period; a disconcerting reality highlighted by Michelle Alexander in her book ‘The New Jim Crow.’

More specifically, the DEA have a laundry-list of issues. Stealing $16,000 from a traveler on an Amtrak train, meddling in medical records without probable cause to arrest alleged drug offenders, and paying 18,000 informants $237 million over five years with little oversight and no proof of reliable intelligence, as a result, are just a few examples.

To be fair, these are isolated instances, but they’re symptomatic of larger problems. These problems include being a burden on the taxpayers, committing racial discrimination, using failed supply-side methods (e.g. seizing large quantities of drugs; the efficacy of this approach has yet to be demonstrated) to reduce demand for illicit drugs, and committing many human rights cases of abuse. The Drug Policy Alliance has a short report that explains how and why these problems are perpetrated by the DEA.

Solution #2: Reducing Income Inequality 

At a glance, the link between income inequality and drug use might seem tenuous at best. However, Richard Wilkinson and Kate Pickett in their book The Spirit Level have provided the necessary research to fortify this link.

Wilkinson and Pickett use the 20:20 ratio measure of income inequality from the United Nations Human Development Index for the chart displayed below. The rates of drug use are from a 2007 United Nations World Drug Report. 

 Rates of drug use are lower in more equal countries, but why?

The authors posit that the emotional pain that comes from being in a low position in a social hierarchy as a possible reason. They support this claim by citing a study in Nature Neuroscience; a study which had an interesting conclusion:

“These data demonstrate that alterations in an organism’s environment can produce profound biological changes that have important behavioral associations, including vulnerability to cocaine addiction.”

Another study from Purdue University showed that social isolation or exclusion in this increasingly stratified society can lead to increased rates of depression and feelings of helplessness. This ostracization is also linked to increased intravenous drug use, homelessness, and irregular employment. Granted, the NIH study only looked at 1,879 people from 10 European cities, but the detrimental psychological effects of social exclusion in humans are stable.

These individuals who ruin their lives through drug use and general delinquency are also not entirely culpable for their “choices.” I’ll use the same quote I used in my prior post to reiterate this point of limited responsibility from Dr. Gabor Maté:

“Freedom of choice, understood from the perspective of brain development, is not a universal or fixed attribute but a statistical probability. In other words, given a certain set of life experiences, a human being will have either a lesser or a greater probability of having freedom in the realm of psyche. A warmly nurtured child is much more likely to develop emotional freedom than is an abused and neglected child. As we have seen, the in utero and early childhood experiences of hard-core addicts will likely diminish the possibility of freedom.”

Solution #3: Decriminalize All Drugs

A lot of countries have decriminalized drugs, but I’ll focus on Australia and Portugal because they’re both major, democratic countries analogous to the United States. The degree of decriminalization differs in these countries, but even a modicum of progressive reform yields positive results.

Australia

A report from the University of New South Wales found that a decriminalization program would reduce criminal justice system costs, improve employment outlooks, and have virtually no impact on drug use/crime. I think the fact that decriminalization has almost zero impact on drug use might provoke some cognitive dissonance in some people, so allow me to expand on that realization; from the report:

“Drug use rates don’t change or dramatically increase when the laws are changed to introduce decriminalisation. Research from across the globe has consistently found that decriminalisation is not associated with significant increases in drug use.”

The “research from across the globe” that they’re referring to is from the book Drug Policy and the Public Good. A book that was written by a combination of addiction, public health, and criminology scientists; a summary can be found here.

It’s important to note that in Australia, many people continue to be sent to court for possession of drugs, and they have yet to officially remove criminal penalties by law. However, in six of the countries eight states, De facto reform is provided. This means that citizens caught with illicit drugs are subject to a police referral for education, assessment, and treatment. Non-compliance with this may result in criminal penalties, though.

Portugal

Portugal decriminalized all drugs in 2001. Since then, the results have been overwhelmingly positive, despite some claims to the contrary.

A study published Law & Social Inquiry found that general, lifetime use among adults (15-64) did increase; this seemingly contradicts the above statements about  However, it’s worth pointing out that lifetime use is a very poor (UNODC, p.12) measurement for drug trends. Past-year and past-month, which are better indicators of drug use, have actually decreased.

According to a report from the Transform Drug Policy Foundation, decriminalization of drugs in Portugal led to extraordinary improvements in health, drug-related deaths, and crime:

• Newly diagnosed HIV cases via drug injection went from 1,016 in 2001 to 56 in 2012
• New AIDS cases via drug injection also decreased from 568 in 2001 to 38 in 2012
• Deaths due to drug use fell from 80 in 2001 to 16 in 2012
• Percentage of drug-related offenders in prison declined from 44% in 1999 to 21% in 2012

What the numbers don’t reflect on is the cultural change that stems from this sort of policy. Over time, drugs and drug addicts will be less stigmatized; stigma which is associated with poorer mental health and increased stress on an individual. I’ll let Dr. João Goulão conclude this section.

Solution #4: Legalize, Tax, and Regulate all Drugs

This is going to require lengthy explanation given the scope of the proposed solution. And yes, I am talking about all drugs: marijuana, alcohol, cocaine, heroin, LSD, mushrooms, methamphetamine, and opioids should all be legalized for purchase by any individual aged 21 or over. An important caveat to add, however, is that this shouldn’t be done on a whim by a government or society; incremental changes via education, treatment, regulation and decriminalization need to happen first. People need to be aware of the dangers and prior to having a plethora of powerful drugs immediately available to them.

Some people might be quick to think that this policy would instigate a dramatic spike in addiction rates. Yet, this hypothetical concern rests on the assumption that drugs directly cause addiction or, at the very least, lead to a higher likelihood of addiction. I think these fears are exaggerated because it ignores the majority of people who do not become addicted.

General Trends

I’ve already addressed the “drugs cause addiction” myth in my previous post, but here’s a piece from the section which addresses the big picture:

“According to Dr. Carl Hart in an interview with Democracy Now, 80-90% of people who use drugs don’t become addicted as I’ve defined it above–they handle their daily responsibilities. More specifically, it’s about 10-15 percent for alcohol and 15-20 percent for crack cocaine. This isn’t to say that 10-20% ruin their lives with drugs or spend every waking moment looking for their next hit like a desiccating vampire. They simply fit one or more of the criteria that indicates a potential problem. Even the ostensibly maniacal crack addicts that pervade our TV shows and news will display rationality and opt out of a free, immediate high when economic alternatives are presented.”

Dr. Carl Hart, in an interview with Radio Boston, also explains how most people are misinformed about the frequency of use. The number of individuals who have used heroin in the past 30 days in the United States is about 430,000; for marijuana, it’s about 22 million; for cocaine, it’s about 2 million; and for methamphetamine, it’s about 600,000. So it’s critical to maintain a proper perspective when reading newspapers, especially regarding heroin.

I think part of the reason we, as a society, think the number of people being addicted to harder drugs like heroin and methamphetamine are higher is that we typically only see the worst examples on the news. The users that are going to work, paying their rent or mortgage, and handling their daily responsibilities probably aren’t going to be very vocal about their drug habit, understandably.

Opioids

In my view, opioids should be on the same shelf as Tylenol and Ibuprofen (see the ‘Regulation’ section for more). Instead of jumping through hoops to get a prescription, the onus should be on the individual to make a responsible decision based on the amount of pain he/she is in. And most people, in fact, would make the responsible choice. Don’t believe me? Try pondering a thought experiment that includes alcohol:

• If you’re 21 or over, you can purchase enough alcohol from any gas station or store to kill yourself with relative ease. However, you, like most people, don’t do it; you handle the drug responsibly. Why do you think this is? And why, if alcohol can be managed responsibly, do you believe that this couldn’t apply to other drugs?

Coming back to opioids, their use in treating non-cancer patients with chronic pain, according to a study from the Journal of the Royal Society of Medicine, doesn’t carry a high risk of addiction. The authors of this study have a revealing conclusion:

“The published work on comorbid chronic pain and addiction is dominated by opinion rather than evidence. We suspect that, as happened previously with acute pain and palliative care, fears about addiction from opioid therapy in chronic non-cancer pain have been excessive. This is not to argue that opioids are always the drug of choice for chronic pain—just that excluding them a priori appears based more upon ignorance than on science.”

Education: Addressing Common Concerns

*This section is about challenging the biggest fears about opiates and heroin that our society currently holds. I’m not attempting to downplay the negative health impacts that these drugs can pose, nor am I saying they can’t be addictive. I’m strictly trying to downplay the delirium that is percolating throughout the media about these drugs. As is pointed out by beer commercials: use responsibly.*

When I eluded to education at the beginning of this solution, I wasn’t referring to the ineffective  tactics that masquerade as education by groups such as DARE. In fact, DARE (with their “just say no” slogans) has been linked to increased drug use, according to a report from the Journal of Research in Crime and Delinquency. 

Rather, I’m referring to educating people about what’s in the drugs specifically and how they interact within the human body. We mistakenly avoid talking about this to children with respects to heroin and other hard drugs. “Just saying no” campaigns combined with lugubrious stories about people ruining their lives with addiction isn’t education, it’s scaremongering.

A better example of education would be the fact that popular opioids (Vicodin/Percocet) contain large doses of acetaminophen, ranging from 300-600 milligrams. They also only carry about 5-10 milligrams of the actual opiate. For comparison, a regular dose of Extra Strength Tylenol has about 1,000 milligrams of acetaminophen; ingesting over 4,000 milligrams is considered an overdose. Consequently, acetaminophen poisoning is the number one cause of acute liver failure in the United States. The problem isn’t the opioid, it’s the acetaminophen.

This raises questions about how much, if any, acetaminophen needs to be in a painkiller. Dr. Carl Hart advocates for the complete removal of it in painkillers, as do I. There’s no reason for someone seeking a heroin-like pill to be needlessly exposed to acetaminophen.

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Heroin is another drug that the public desperately needs to educate themselves on to combat the endless hysteria such as the dreaded heroin overdose. Despite feelings to the contrary, it’s actually fairly difficult to overdose on heroin. Don’t take my unqualified word for it, Dr. Stanton Peele, a psychologist who has written numerous books on the subject of addiction, has an article on his website highlighting some of the research surrounding the issue:

“Research at the Jefferson Medical Center in Philadelphia in the 1920s showed that addicts could tolerate up to a ninefold increase in the concentration of their standard, already large, dose. These researchers estimated that a toxic dose of heroin would be at least 500 milligrams for nonusers and 1800 milligrams for addicts . . . the best guess as to what was killing these addicts (aside from general infection, illness, and malnutrition) were the impurities in the drug, such as quinine, which produced adverse reactions in some injectors. A related likelihood which is more evident today is the mixture of drugs, or of drugs and alcohol.”

Another report from the Schaffer Library of Drug Policy corroborates this thesis. They also point out that we often falsely attribute the deaths of well-known heroin users strictly to their use despite other factors. From the report:

“A conscientious search of the United States medical literature throughout recent decades has failed to turn up a single scientific paper reporting that heroin overdose, as established by these or any other reasonable methods of determining overdose, is in fact a cause of death among American heroin addicts. The evidence that addicts have been dying by the hundreds of heroin overdose is simply nonexistent.”

They go on to explain the peculiar history of diagnosing a death:

“At some point in the history of heroin addiction, probably in the early 1940s, the custom arose among coroners and medical examiners of labeling as “heroin overdose” all deaths among heroin addicts the true cause of which could not be determined. These ‘overdose’ determinations rested on only two findings: (1) that the victim was a heroin addict who ‘shot up’ prior to his death; and (2) that there was no evidence of suicide, violence, infection, or other natural cause. No evidence that the victim had taken a large dose was required to warrant a finding of death from overdose. This curious custom continues today. Thus, in common coroner and medical examiner parlance, ‘death from heroin overdose’ is synonymous with ‘death from unknown causes after injecting heroin.’ “

To be fair, this report was published in 1972 and referred specifically to New York City during the 1920’s-1970’s. I’m only including it for some historical background and the fact that most of its research has yet to be disproved.

Contemporary statistics also reveal high proportions of heroin deaths as a result from mixing. One 2013 count has deaths by heroin alone in the United States at around 33%, but this number omitted about 25% of death certificates. Taken state-by-state, the numbers vary greatly. At the high end of the spectrum is New Mexico with 98.9% of heroin deaths involving mixing and Oregon at the low end with 36.9%.

Given what was previously mentioned about the history of medical examination labeling, it’s important to take these numbers with a grain of salt.

Regulation

This is going to be a straightforward solution: treat all of the aforementioned drugs the same way we currently treat alcohol. We tried doing to alcohol what we’re doing to heroin, opiates (to a lesser degree), and psychedelics right now and it was an unmitigated failure. A book published by the National Research Council succinctly summed up 3 lessons from the prohibition era:

1. “Drinking customs in the United States are strongly held and resistant to frontal assault. It is well beyond the will or capacity of government ever to eradicate the customary demand for alcoholic beverages.”
2. “A criminal supply network emerges—if not instantly, then within a few years—if production and sale of alcoholic beverages are outlawed. The prices and extent of this criminal supply depend on the degree of public support for the law and the resources devoted to law enforcement.”
3. “The quantity of alcohol consumption and the rates of problems varying with consumption can, however, be markedly reduced by substantial increases in real price and reductions in the ease of availability.”

The third lesson might sound like a positive if you ignore the increased rates of alcohol poisoning due to bootlegged liquor. A problem which was later fixed with the ending of prohibition and the regulation of alcohol.

There’s no logical reason as to why this couldn’t work with other drugs. Instead of heroin being unknowingly laced with fentanyl or a mix of any other unknown sedatives by the user, the government could regulate the product to ensure purity. As I explained above, this would dramatically reduce heroin-related deaths.

Instead of opioids having copious amounts of acetaminophen, the government could dramatically reduce or outright remove it from the pills. This would lower rates of liver toxicity while giving autonomy back to ordinary citizens to make their own choices. There are more examples I could give, but the train of thought is easy to follow.

If we would adopt one or all of these solutions, I am very confident we could reduce rates of drug-related death, improve public health, and, most importantly, dramatically lower rates of addiction. This isn’t to say that things will be perfect, but continuing what we’re doing now will only intensify the problem.

Drugs and Addiction: A Different Train of Thought

The drug overdose issue seems to be on everyone’s mind nowadays and for a good reason. It has recently been revealed that heroin deaths surpassed gun homicides in 2015. Also, the CDC reported that 19 states saw a “statistically significant” increase in drug overdose deaths from 2014-2015. Not a day goes by where we don’t see a sad story about a fatal drug overdose or someone that has to be rescued from the brink with Naloxone. Innumerable stories can also be found about neglected children being stranded in vehicles during their parents’ overdose.

It’s very easy for someone to have a visceral reaction that’s full of contempt towards these individuals, but I think this comes from a misunderstanding of drugs and the biopsychosocial nature of addiction. Most addictions are attempts to soothe some sort of pain, suffering, or distress. This isn’t to say that we should absolve all culpability from parents who OD with their child present, the State should absolutely take their kids away until proven rehabilitation. However, if our society continues to ignore social roots of addiction, we will keep going down a continuous path of suffering for addicts and the general population as a whole.

From here on out, I’m going to make a lot of references to Dr. Gabor Maté, a Hungarian-born physician who specializes in addiction. More specifically, I’ll be referencing the works in his book ‘In the Realm of Hungry Ghosts’ along with the myriad of sources he provides. I highly recommend this impeccably sourced work which advocates for a compassionate view towards the victims of addiction; any information derived from it will be noted as “(Maté p.’x’)”. Let’s start with the definition of addiction itself.

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What Is Addiction?

An important caveat I’m throwing in before continuing (it’ll probably be fairly obvious) is that I have no scientific credentials in anything regarding neuroscience or addiction. I’m just sharing pieces of research I’ve collected to advocate for a train of thought in regards to drugs that incorporates biological, sociological and psychological factors.

I think many people’s intuition about what addiction entails aligns well with Merriam-Webster’s broad definition: a “persistent compulsive use of a substance known by the user to be harmful.” They also use the words ‘tolerance’ and ‘withdrawal’ in their specific definition about heroin, nicotine, and alcohol. This definition is correct in some ways, but it’s too narrow. Focusing solely on the drug itself and quantities of use distract from other arguably more important factors.

An example of this is Alcoholics Anonymous (AA) with its 12-step program. A cursory glance at this list will show that the primary focus is on the addicted person’s inability to escape the “power” of drugs which, for them, is mostly regarding alcohol. There’s a lot of poetic, religious language involved in the steps which of course can help certain people, but the overall efficacy of the program is pretty bleak with a 5-10% success rate. Although, other research suggests that it’s more beneficial in the long-term than no help at all.

AA aside, addiction, overall, has little to do with the severity of withdrawal, levels of tolerance, or even frequency, it’s actually a measure of social impact (Maté, p. 136). This still is not a complete definition because the social aspect of addiction is only one factor. Maté provides a more detailed list on the same page which includes the following:

1. Compulsive engagement with the behavior, a preoccupation with it.
2. Impaired control over the behavior.
3. Persistence or relapse despite evidence harm
4. Dissatisfaction, irritability, or intense craving when the object–be it a drug, activity, or other goal–is not immediately available.

In my opinion, number four is the most critical to understand. Addiction isn’t confined to drug use. Many social behaviors we regularly engage in such as compulsive shopping, overeating, and workaholism all have adverse effects on our personal health, so why do we continue in them? We continue in them because we are addicted; this is partially promoted by a toxic culture. I’ll quote Dr. Maté in an interview with Stefan Molyneux:

“I define addiction as any behavior that is characterized by craving, temporary relief, temporary pleasure and long-term, negative consequences; and we continue in them, despite the negative consequences. Now, I didn’t say anything about drugs, I said any behavior. So how many of us are familiar with having behaviors that give us temporary relief, but hurt us in the long-term and we continue it? So how different are we from the drug addict?”

Carl Hart, an associate professor of psychology and psychiatry at Columbia University, has similar views on defining addiction. On page 13 of his book ‘High Price,’ he uses the Diagnostic and Statistical Manual of Mental Disorders‘ (DSM) definition of the word which, again, involves the disruption of important life events such as parenting, work, and relationship responsibilities. The DSM also relies more on withdrawal and tolerance as factors in addiction, but I would say the key elements are craving and continuing the behavior despite a conscious awareness of the harmful effects. An individual suffering from Obsessive Compulsive Disorder might experience irritability or withdrawal symptoms if they cannot excessively wash their hands; this doesn’t mean they’re addicted to washing their hands. They don’t crave the behavior, nor are they aware of the harmful effects, they simply must do it. This is a crucial distinction.

Addiction as a Disease

The “addiction is a brain disease” narrative seems like a compassionate view to uphold. Unfortunately, it can actually do more harm than good in a sociological sense by exacerbating social injustice. If drugs themselves are to blame, we must rely on law enforcement to forcefully remove the drug (and drug user) from society. This type of thinking is what has lead to 20 percent of total federal prison inmates being non-violent drug offenders. This is all despite the fact, as Michelle Alexander explains in her book ‘The New Jim Crow,’ that drug-related crime was actually decreasing when the war on drugs was declared in 1971 and 1982; something worth thinking about.

There’s also not much biological evidence to support the claim. This doesn’t mean addiction is a choice per se, but more on choices later. The disease point-of-view places too much emphasis on the role of genes in determining behavior while subsequently giving validity to the theory of an addiction gene. Not only does an addiction gene not exist, it can’t exist (Maté, p. 213). We often view a genetic basis for a particular trait to be immutable and fatalistic, but this is not the case, as a study in the Yale Journal of Biology and Medicine suggests. This isn’t to say the genes don’t play a factor, they do. Yet, they can’t solely explain complex factors such as addiction.

Genes are contingent on the environment; without the proverbial on/off switch of social influences, it’s likely human life couldn’t exist (Maté, p.214). For example, the fundamental act of human contact or social attachment, especially in infancy, is critical for positive development later on in life. Skin-to-skin contact also helps alleviate a mother’s depression while being more receptive to their child’s needs, according to an article in Scientific American. This is called epigenetics, which studies the process of chemical reactions that activate and deactivate parts of the genome due to expression. Epigenetic effects are most influential during early childhood (Maté, p.214), they also place heavy emphasis on maternal care in mediating potentially harmful environmental effects on their child’s neural development.

Regarding the biology of the brain, as revealed by Carl Hart in a Nature article, this idea is also baseless. This is because we cannot currently differentiate between an addicted brain and a non-addicted brain. From the source:

“The notion that drug addiction is a brain disease is catchy but empty: there are virtually no data in humans indicating that addiction is a disease of the brain, in the way that, for instance, Huntington’s or Parkinson’s are diseases of the brain. With these illnesses, one can look at the brains of affected individuals and make accurate predictions about the disease involved and their symptoms.”

 It is true, though, that drugs, especially the powerful ones like methamphetamine and cocaine, profoundly alter brain chemistry when they’re ingested. This is especially noticeable with dopamine levels in the brain. Dopamine is the chemical that’s sometimes attributed to “making us human.” In the context of drug use, it can be described as a neurotransmitter that powers the Ventral Tegmental Area (VTA) and the other related brain circuits (Maté, p. 168). The VTA is basically responsible for holding dopamine and serotonin, these dopamine pathways are major sources of behavior motivation and incentive. So certain activities or brain-altering drugs can have a severe impact on dopamine levels.

Food seeking increases brain dopamine levels by 50 percent; alcohol, nicotine and sexual arousal will yield a 100 percent increase; cocaine will triple them. Still, none of these compare to the effects of crystal meth, which increases dopamine levels by 1,200 percent (Maté, p.154). One of the addicted women in Maté’s book described crystal meth as an “orgasm without sex,” it’s easy to see why. However, with enough time and proper treatment, such as a temporary Methadone prescription, these damages to the brain can be reversed or nearly reversed depending on the severity and length of abuse.

Even taking into account the chemical alterations in the brain while using the drug, I still don’t think it’s grounds for labeling addiction a disease. All experiences, negative or positive, engender chemical changes within the brain. Nonetheless, most of these changes aren’t considered pathological; addiction could better be described as a learning disorder, as is argued in an article in Pacific Standard Magazine. This uses a broader perspective where we’re forced to look at environmental pressures that nudge us towards certain behaviors. Further research into the topic could result in addiction as a certain mental disease, this shouldn’t be ruled out definitively. I’m saying that we use the mental disorder term too ubiquitously considering the limited information we have.

As a final note on this topic, I’ll use a quote from the article:

“In order to use brain scans to prove addiction is a disease, you’d have to show changes that are only seen in addicted people, that occur in all cases of addiction, and that predict relapse and recovery. No one has yet done this.”

Drugs Cause Addiction?

When I listen to an everyday conversation about drug use, it seems like most agree that the best way to avoid drug addiction is to not dabble in them at all. In other words, drugs cause addiction. This perspective seems harmless even though it avoids talking about the overwhelming majority of people who use drugs (including cocaine, heroin and crystal meth) and have no problems. If drugs caused addiction, we should see a statistically significant correlation between use and rates of addiction; reality paints a different picture when a large-scale view is considered.

According to Dr. Carl Hart in an interview with Democracy Now, 80-90% of people who use drugs don’t become addicted as I’ve defined it above–they handle their daily responsibilities. More specifically, it’s about 10-15 percent for alcohol and 15-20 percent for crack cocaine. This isn’t to say that 10-20% ruin their lives with drugs or spend every waking moment looking for their next hit like a desiccating vampire. They simply fit one or more of the criteria that indicates a potential problem. Even the ostensibly maniacal crack addicts that pervade our TV shows and news will display rationality and opt out of a free, immediate high when economic alternatives are presented.

If drugs are inherently addictive, we probably shouldn’t be treating chronic pain, which affects 11.2% of the population, with opioids. However, research shows that when appropriately prescribed for cancer patients, the risk of addiction is very low while improving their quality of life. What about non-cancer treatment?

A 2006 study in the Canadian Medical Association Journal that treated severe, chronic pain with potent opioids (oxycodone and morphine) found that 8.7% self-reported “drug craving” in the morphine trials. Interestingly, however, 4.3% in the placebo group also reported having a “drug craving”; other factors are clearly at play beyond simple drug use. The authors make clear that addiction to opioids cannot be presumed to not exist, though this should certainly put a grain of skepticism into the “opioid crisis” hysteria. In fact, one group of researchers concluded that “doubts or concerns about opioid efficacy, toxicity, tolerance, and abuse or addiction should no longer be used to justify withholding opioids from patients with well-defined rheumatic disease pain.” To conclude this section, let’s talk about Vietnam.

It’s estimated that about half of enlisted men in the Vietnam War had tried some sort of opiate while overseas. Before shipping out, less than 1% had an addiction; after returning, 20% met the criteria for addiction. Once the soldiers returned, however, the remission rate for the afflicted individuals was nearly 95% (Maté, p.142). Overall, average relapse for drug addiction is between 40-60%, so the Vietnam finding was truly remarkable. The U.S. soldiers’ addiction clearly had nothing to do with the use of the substance itself, but the negative social conditions surrounding them. Once they were removed from that environment, need for the drug went away.

To hammer this point home, in 2005, 4.6% (that’s about 1.7 million people!) of Canadians tried crystal meth, yet only 0.5% (180,000) had used in the past year (Maté, p.144). This is more than a 900% reduction in a years time. Clearly, if mere drug use caused addiction, the numbers would be near identical. This also dispels the “try it once, and you’re hooked” scare tactic.

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Choices

This is where I’ll probably separate myself from the people who agree with me that addiction isn’t a mental disease. The debate, at least online, seems to be stuck in a false dichotomy between drug addiction as either a disease or a choice. It’s false because addiction is a biopsychosocial process, as noted above.

Viewing addiction exclusively as a choice is an ill-fated attempt to try and separate individual actions from the environment in which they’re oriented. Our actions aren’t isolated events, they follow a chain of causality. Regarding addiction, this chain of causality starts in childhood. Before getting into that, we have to think conceptually about what making a choice really means to establish a proper frame of reference.

The choice argument implies that we’re all autonomous individuals and any decision we make is of our own free will. As pointed out by Sam Harris in short book ‘Free Will’, this view of our will rests on two assumptions: (1) any behavior we exhibit, we could’ve chosen to behave differently in the past, and (2) that we are cognizant of all our actions and thoughts that motivate said actions. If you think about it, you’ll realize this isn’t true: thoughts spontaneously arise in consciousness.

I don’t want to waste too much time on the philosophical minutia of free will. Although, it’s worth spending a few minutes contemplating this question I’m stealing from one of Sam Harris’ lectures: “If you can’t control your next thought, and you don’t know what it’s going to be until it arises, where is your freedom of will?”

Free will doesn’t have a lot of scientific ground to stand on either. A study from the National Academy of Sciences showed–mainly through the use of Functional Magnetic Resonance Imaging–that human decision to take an immediate action precedes conscious awareness. The supposedly immediate action can be occurring in the brain for several seconds before a person believes that they’ve made a concerted decision to move.

This is an important point to elucidate because opinions on free will have real-world implications for how addicts are treated. If someone has an unwavering belief in free will, then any economic, familial, or moral failing by an individual is unambiguously the result of their bad choices. This is just untrue: trying to place human actions in a vacuum independent of the environment will always be futile.

This isn’t to make an argument for determinism; actions aren’t unconditionally determined by preexisting causes, the current moment is a factor. Rather, I’m saying that the spectrum of choice is much more limited than most hard-line free will proponents like to think. That spectrum is reliant on background causes of which the person isn’t aware.

Addiction and Childhood Trauma

I think it’s clear that the root of addiction starts in childhood. More specifically, events that are known as Adverse Childhood Experiences (ACE’s) are the main reason we’re aware of this. It’s not the sole cause, of course, but the strong association cannot be ignored. Broadly, ACE’s are linked to risky health behaviors, chronic health conditions, and early death. These risks increase as the number of individual ACE’s grow.

About two-thirds of all drug addicts seeking treatment report experiencing some kind of physical, sexual, or emotional abuse during childhood, according to the National Institute on Drug Abuse. Their survey of 1,400 women revealed a correlation with sexual abuse during childhood and drug dependence. Women who experienced any sexual abuse were 3.09 times more likely to become dependent on drugs compared to women who hadn’t been abused, 2.83 times for non-genital, and an astounding 5.70 times more likely for intercourse. Their solemn chart is worth looking at:

 A fact sheet from Boston University shows that about 25% of children under the age of 16 will experience at least one traumatic event which increases the risk of substance abuse in adulthood. Another study from the The National Child Traumatic Stress Network explained that traumatized kids were three times more likely to report current or past substance abuse. Regarding opiates specifically, users are 2.7 times more likely to have a history of childhood abuse than non-users. The link between trauma and an increased propensity for drug abuse is clear, but why?

One possible answer is the self-medication hypothesis. This posits that the abused/traumatized individual will seek particular types of drugs to placate various kinds suffering or unpleasant effects. Interestingly, a victim tends to gravitate towards specific types of drugs to relieve certain conditions. Alcohol, for example, is commonly used as an antidote for depression. Edward J. Khantzian in an article from the Harvard Review of Psychiatry describes it well:

“Although they are not good antidepressants, alcohol and related drugs create the illusion of relief because they temporarily soften rigid defenses and ameliorate states of isolation and emptiness that predispose to depression.”

The Big Picture

Even among large-scale population studies, the results are similar: trauma, neglect, abuse, pain, and suffering are all catalysts for substance abuse. If drug use or addiction is simply a choice, there should be much more variance in the studies and their outcomes. At the very least, there shouldn’t be distinct patterns where factors A, B, and C have a statistically high chance of leading to D. This isn’t to say that everyone who experiences abuse will end up developing a dependence on drugs. Some people escape and make it out okay, at least on the surface. I am saying, though, that the degree to which this professed freedom of choice influences our lives should be challenged.

Allow me to use yet another quote from Gabor Maté on page 308 of his book:

“Freedom of choice, understood from the perspective of brain development, is not a universal or fixed attribute but a statistical probability. In other words, given a certain set of life experiences, a human being will have either a lesser or a greater probability of having freedom in the realm of psyche. A warmly nurtured child is much more likely to develop emotional freedom than is an abused and neglected child. As we have seen, the in utero and early childhood experiences of hard-core addicts will likely diminish the possibility of freedom.”

 The main point in writing this was to try and change common perceptions of drug addicts using data-driven arguments. It’s easy to just state rhetorically that we should treat addicts with compassion and just leave it at that. This isn’t how most people think, though. Moralized language like this doesn’t produce any sort of long-term, tangible change. A more important point to focus on is the “why.”

Why would a parent overdose with their child in the car, don’t they care about their children? Using words like compassion and respect, while helpful in a limited sense, won’t properly answer these type of questions.

I’m not vain enough to expect to change anyone’s mind with a single, lengthy blog post. Although, if you made it this far, I hope to have at least placed a grain of curiosity to make any reader question their visceral reactions to a drug addict and look into the scientific literature of Adverse Childhood Experiences. At the very least, just try and have a conversation with a drug addict. You might be surprised about what you learn.

I’ll publish a post sometime around late May that lays out possible solutions to the addiction problem. I didn’t include them here for the purpose of limiting word count.

A Path Towards True Security

Whether it’s the police, military, TSA, ICE, or CBP, they all operate under the same banner of maintaining safety and security. This cultural meme has been propagated relentlessly with little regard for evidence. Take, for example, a concerning study done on the TSA which revealed that undercover agents were able to smuggle banned weapons and mock explosives through security 95 percent of the time. One could argue for stricter security measures as a solution, but the overall reality is that if someone is sufficiently determined enough to blow up or shoot up an airplane, they will find a way to do it.

These institutions listed above are predicated on aggression, intimidation, and fear to curb crime and maintain safety. However, these methods will never produce any long-term peace or stability because they fail to address the underlying roots of violence: socioeconomic inequality and its adverse effects. This isn’t the sole cause, but there’s an abundance of sociological research linking inequality to increases in violence, imprisonment, and drug use while decreasing mental health, educational performance, and social mobility.

I’m not claiming to have concrete solutions, nor am I suggesting that this would lead to a peaceful utopia. This is just an exercise to elucidate a general train of thought that incorporates a structuralist perspective to pursue a path towards a more peaceful society. First, it’s necessary to break down the process of violence which is the overarching issue when discussing safety or security.

Structural Violence

The word “act” that’s commonly used when describing a gruesome murder or mass shooting is actually a misnomer. The word ‘act’ in the phrase “an act of violence” implies that violence is a direct, behavioral action; this is simply untrue. Treating violence in this manner excludes any historical or socioeconomic factors. The truth is that violence is a multilayered process that can’t be nailed down to a singular cause. Any behavioral outcome, negative or positive, is a result of system assimilation, and trying to separate individual behavior from the environment is futile.

The realization of structural violence was first introduced to me by Dr. Paul Farmer who has done astounding work and provides a workable definition of the term:

“Structural violence is one way of describing social arrangements that put individuals and populations in harm’s way… The arrangements are structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people … neither culture nor pure individual will is at fault; rather, historically given (and often economically driven) processes and forces conspire to constrain individual agency. Structural violence is visited upon all those whose social status denies them access to the fruits of scientific and social progress.”

An important detail that I would personally add to this definition is that structural violence operates under a scientific reality where most basic human needs can be met. In other words, they’re almost entirely preventable if our social system were tweaked to promote better public health. A good illustration of preventable suffering is the absurd prevalence of food waste in the United States.

In 2015, 42.2 million Americans lived in food insecure households which are defined as households having inadequate physical, social or economic access to nutritious food.  Meanwhile, around 30-40% of the U.S. food supply is thrown away according to the USDA; this amounts to $160 billion worth of food. This problem is preventable partly because the arbitrary expiration dates, bulk packaging, and outright deliberate throwing away of food motivated by risible market logic is unnecessary. We already produce more than enough food for the entire population; the real issue here is poverty and degradation, not scarcity.

As an aside, we can easily grow enough food to feed the 7.2 billion people in the world by utilizing vertical farms. It’d take about 144,000 thirty-story structures to accomplish while only using 0.006% of the Earth’s land (we currently use 11%) and 95% less water than conventional methods. Simply ending hunger and food insecurity will have a profound boost in public health, especially for children. This would lower hospitalizations, chronic health conditions, behavioral problems and pregnancy complications just to name a few.

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More personal, 1-on-1 violence has structuralist roots as well; Dr. James Gilligan, former director of the Center for the Study of Violence at Harvard Medical School, is an excellent source for this subject. His 1997 book ‘Violence: Reflections on a National Epidemic’ is a brilliant piece of writing where he describes his experiences as a prison psychiatrist.

Right from the onset, he seems to detest anyone using moralized language when describing the cause of violence. For example, using religious notions of “good and evil” when depicting a murderer is distracting and unhelpful. I think Dr. Gilligan summarized it well on p.92-93 of his book:

“I am suggesting that the only way to explain the causes of violence, so that we can learn how to prevent it, is to approach violence as a problem in public health and preventive medicine, and to think of violence as a symptom of life-threatening (and often lethal) pathology, which, like all forms of illness, has an etiology or cause, a pathogen. To think of violence as evil–if we confuse that value judgement about violence with an explanation of it– can only confuse us into thinking that we have an explanation when we do not.”

It is evident, at least in the context of the United States, that we are nowhere close to addressing the current problem of violence in a systemic way. Once someone is arrested for a violent act (and non-violent acts in regards to drug arrests) in the U.S., an inflexible “justice” system takes charge that’s incapable of minimizing recidivism when compared to other countries. This punitive mindset treats prisoners as a group incapable of rehabilitation. Meanwhile, in Norway, a study revealed that rehabilitation and job-training programs in the countries prison system was essential to reducing the pattern of criminal behavior in an individual. When you change the social environment from negative to positive, *most* will respond by improving their lives accordingly. Who would’ve guessed?!

Violence Is Natural?

As a final point of emphasis, I want briefly address the belief that violence is intrinsic to our species. Many people believe that humans have natural propensities for violent acts and cut-throat competition. If this is true, then there would be little point in trying to reduce violence since it’s ostensibly instinctive. Fortunately, the evidence suggests a different story. You shouldn’t separate an individual’s actions from the social environment in which they’re oriented. Dr. Gilligan highlights the dangers with this kind of thinking on p.212 of his book:

“If the assumption is that violence is an inextricable part of our inborn ‘human nature’, then clearly the only way to keep the problem under control is to emphasize just that: control, meaning the control of some people (whose violence is ‘bad’) by other people (whose violence is ‘good’).”

This dichotomy of “good vs. bad” with uses of violence is exactly how the police, military, TSA, ICE, and CBP vindicate their methods. Their perpetuation of violence is seen as a positive because they’re eradicating something they deem as dangerous: this could be called a cyclical circle of violence. Ideally, we should view every arrest by these institutions as a failure of the system; “the system” that I’m referring to here is the Prison Industrial Complex (PIC). The PIC is an overarching term used to describe confluence between government and private industry that use invasive, punitive techniques as solutions to social and economic problems. The reality is that our environment heavily shapes our behavior; thus we should all feel a sense of mutual responsibility.

Violence, for most of us, isn’t intertwined with our biology. We actually have a propensity for compassion (partially motivated by the lovely hormone oxytocin), and that reality is moderately exemplified by Rhesus monkeys. A 1964 study at Northwestern University led by psychiatrist Jules Masserman reported that Rhesus monkeys would literally starve themselves after they found out that pulling a chain that gave them food also gave a shock to a companion (The Compassionate Instinct, p.18).

Overall, most violent “acts” are multi-faceted and cannot be pinned down to any single cause. Ignoring negative social pressures (i.e. poverty, inequality) that push individuals towards certain destructive behaviors is a truncated point-of-view and will always lead to unhelpful individualized associations of violence which help sustain the cyclical circle of violence. 

Greater Equality Promotes Peace

Allow me to lay out the truth succinctly: socioeconomic equality produces a safer, healthier, stronger and more sustainable society. This assertion isn’t just a feel-good bromide, it’s supported by mountains of evidence which is unraveled by Richard Wilkinson and Kate Pickett in their book ‘The Spirit Level.’ Their research shows how unequal societies generally produce greater violence while also diminishing public health through various forms. The rest of this post will be showcasing the important charts in the book with subsequent explanations and corroborating evidence.

Poverty vs. Inequality

It’s important to explain the difference between poverty and inequality. Health and social problems cannot be wholly attributed to levels of income; the degree of inequality makes a profound difference.

All of the charts I will share that display international comparisons are using the 20:20 ratio measure of income inequality from the United Nations Human Development Index. All of the state comparisons are using the Gini Index. The statistics are all gathered from the World Bank, World Health Organization, the United Nations and the Organization for Economic Cooperation and Development–all of which are reputable sources.

Overall, public health is better in more equal countries. A statistical scatter like this cannot be explained away by chance or coincidence. Let’s see how this compares to overall income.

 The correlation here is tenuous and doesn’t exhibit a consistent trend like the previous chart on inequality. This is because wealth isn’t necessarily linked to improved living conditions. How do U.S. states compare?

While it’s a little less obvious than the country comparison, the trend within the states is still the same. Now let’s look at incomes per state.

A Brief Digression on Costa Rica

So why is poverty only weakly related (in rich countries) to health and social problems? It’s hard to pin down to a simple answer, but let’s take Costa Rica as an example. This is a deviation from the The Spirit Levels’ methods because Costa Rica doesn’t file under a “rich country” with a GDP of only $79 billion. However, I think the results when compared to the United States are worth taking into consideration.

It might come as a shock to many that the poorest Costa Ricans have a longer, healthier life than the poorest Americans. This conclusion is from Luis Rosero-Bixbya from the Universidad de Costa Rica and William H. Dow from the University of California, Berkeley. The findings were published in the Proceedings of the National Academy of Sciences of the United States of America.  Why is this?

It can’t be from income inequality seeing as Costa Rica has a Gini Index of 0.52 compared to the U.S. at 0.40. However, the inequality in health care within the U.S. is much higher. Costa Rica has lifetime universal health insurance and a strong social safety net for their residents under 65. Their healthcare system still struggles to help people with specialized care needs, and their inability to mitigate hypertension looks unfavorable when compared to the U.S. Regardless, the overall reality remains the same: poor Americans under 65 would be better off living in Costa Rica.

Structural Violence in Healthcare

I would argue that the first thing to consider when trying to reduce violence of all kind is healthcare. Without a stable, equitable system, the poorest individuals will become further saddled into debt which results in a downward spiral of desperation for the people. Desperation from this already debt-fueled economy leads to higher diastolic blood pressure, increases in depression and worse general health. This connection desperately needs to be acknowledged and contemplated by everyone, especially the representatives in Congress. America, for ideological reasons, chooses not to adopt a universal system that covers everyone even though it’d be more efficient. Our current system (assuming the AHCA is passed) will exacerbate income inequality and push a higher cost burden onto low-income citizens. The American healthcare system is a form of violence when taking this structural perspective.

Going back to The Spirit Level, the American system listed above that punishes the most desperate populations leads itself to a host of other adverse health effects. Let’s start with mental illness.

The countries here line up almost perfectly with the only outlier being Italy. The authors say that anxiety disorders, impulse-control disorders, and severe illness are all strongly correlated with inequality while mood disorders are weakly correlated (p.68). So why is mental illness higher in more unequal societies?

Some might attribute it to cultural affluenza where people’s only perception of social prestige is the amount of money one earns; this can lead to vulnerability to emotional distress. Economist Robert H. Frank coined the term ‘luxury fever’ which he describes as “luxury consumption in Western industrialized countries has been rising at an astronomical rate even though recent psychological research shows that there is a scant correlation between this consumption and levels of stated life satisfaction.” This behavior is more widely observed in unequal countries.

Drug Use

The use of drugs isn’t inherently a negative thing, but the higher use of more potent drugs like cocaine and amphetamines have profound impacts brain activity. These create severe imbalances in dopamine and serotonin; low dopamine and serotonin levels have been linked to depression and various other mental disorders (TSL, p.71).

We also have to look at this from a societal point-of-view as well. As mentioned prior, vast numbers of people are in federal prison for non-violent drug offenses. So not only does America have a high rate of drug use partially caused by inequality, but we also throw them in prison and, once released, deny them opportunities to get ahead mostly via discrimination. The cycle continues.

This post is becoming pretty verbose, and anyone making it this far can see the main idea that I’m delineating. There are many more categories: obesity, educational performance, teenage births, social mobility and social relations just to name a few. I encourage everyone to read the book for themselves, but overall, all of these are worse in more unequal countries. I wanted to start with health and social problems first because together they compound the problem of overall violence. Let’s look at one final category before I conclude and bring this all together: homicides.

These rates are from the United Nations Surveys on Crime Trends and the Operations of Criminal Justice Systems.  The trend is similar in U.S. states.

What are the reasons for this? Some propose that this may begin in childhood, to quote James Gilligan once again in talking about the violent men in prisons he worked with:

“They had been subjected to a degree of child abuse that was off the scale of anything I had previously thought of describing with that term. Many had been beaten nearly to death, raped repeatedly or prostituted, or neglected to a life-threatening degree by parents too disabled to care for their child. And of those who had not experienced these extremes of physical abuse or neglect, my colleagues and I found that they had experienced a degree of emotional abuse that had been just as damaging . . . in which they served as the scapegoat for whatever feelings of shame and humiliation their parents had suffered and then attempted to rid themselves of by transferring them onto their child, by subjecting him to systemic and chronic shaming and humiliation, taunting and ridicule.” (TSL, p.138)

One again, this violent behavior is structural through numerous factors over many years. But even this cannot explain fully why unequal societies have such high rates of homicides. All we know is that the overall trend is there and reversing inequality will certainly help.

Reducing Inequality

Now that a basic framework of the problems and a possible solution is established, what next? Pursuing a more egalitarian society is becoming increasingly necessary at this point in time. One small, obvious solution that mostly involves government intervention is ending low wages (which cost taxpayers about $152 billion/year) via raising the minimum wage to a living wage.

This isn’t a blanket $15/hr proposal that politicians incessantly rave about, but a calculated cost-of-living analysis that quantifies the number necessary on a county-by-county basis; MIT’s calculator is an excellent resource here. People who make the argument that you can’t quantify a living wage because you can’t account for the price of goods are partially correct. However, they drastically underestimate our ability to measure these sorts of factors nowadays.

For example, Purdue University has an online calculator where you punch in your businesses zip code and the proposed minimum wage hike, it will then give a report on what that particular number means for managers of fast-food restaurants. Overall, they found that a blanket $15/hr minimum wage increase would result in a 4.3% increase in the price of food at these ‘limited-service’ restaurants. As nice as this sounds, a living wage doesn’t address enough because meeting the bare minimum for living standards still produces anxiety among those populations. Other solutions involve incorporating a more progressive tax system while ending tax loopholes which would certainly help, but it’s a band-aid.

We need to focus less on the moral and ideological objections to policy and more on the mere fact of getting it done. For instance, a Universal Basic Income would be much more effective than trying to manipulate wages. I’ll quote a passage from one of my previous posts regarding a UBI.

A precursory step towards technical efficiency would be embracing and implementing the idea of a Universal Basic Income (UBI) which has a simple definition: a guaranteed income to every citizen with no work requirement or any other sort of test. I view UBI as more of a future inevitability rather than a pie-in-the-sky social or moral justice theory. This is because of the nearing technological unemployment phenomenon that will slowly engulf the menial, mechanical jobs. A 2013 study by Oxford researches concluded that around 45% of American jobs are under threat of automation in the next 20 years. Although data is sparse on UBI, we do have a few examples of it being implemented. Medicine Hat, a small city in Canada with a population of 60,000 (2011 census), decided to give the residents a UBI. They managed to house 885 of the cities 1,000 homeless people. This housing also saved an estimated $65,000/person in annual care costs according to Human Services in Alberta, Canada. This is because simply providing free housing/free money lessens the health impact these homeless people endure, thus alleviating some of the financial burden on the healthcare system. The simple reality is that just giving people money and a house with little questions asked is cheaper than leaving them on the streets.

This is the train of thought we need to pursue as a society if we’re ever going to lessen income inequality and mitigate violence. If these issues of inequality are addressed, the need for forceful institutions like the police will be drastically less needed and, ideally, eliminated. However, if we keep walking down the path we’re currently on, our public health problems will only get worse and may eventually lead to a major social collapse.

 

 

Regarding Healthcare

The most fundamental point that I can make regarding healthcare and healthcare systems is that they require significant state oversight to maintain their functions. One can talk about “red tape” and the costs of regulations, as the CATO institute has, but it misses the overall point: the push to rid the U.S. healthcare system of government involvement creates perverse incentives, makes it less efficient and pushes a higher cost burden onto the consumer. Some industries shouldn’t be utilized through the private sector, historically this references the Commons and natural monopolies.

For the next 4-8 years, the U.S. is going to be subject to an administration that seems to reduce healthcare policy discussion to rhetorical buzz phrases: “Government takeover of healthcare”, “sell across state lines” and “promoting competition” are a few that are chaotically thrown around.

To be fair, Trump does have actual policy proposals for reform, but it’s a very truncated view and has been estimated by the Commonwealth Fund to increase out-of-pocket spending by  $2,500 on average. Regardless, the political hoopla over keeping or reforming/replacing the Affordable Care Act (ACA) doesn’t take enough into consideration;  a pro vs. con list isn’t going to get the U.S. system very far.

Instead, a comparative policy analysis that factors in as many variables as possible is what seems to be missing in the political landscape. This is where T.R. Reid’s book ‘The Healing of America: A Global Quest for Better, Cheaper, and Fairer Healthcare’ comes in. Mr. Reid’s book combines statistical information with personal experience because he actually went and visited hospitals in Germany, Japan, England, Canada, France and India to inquiry about his shoulder which was so severely damaged that it required a total shoulder arthroplasty; a procedure with an average cost of around $10,000.

A Few Problems With U.S. Healthcare

It’s important to identify a few essential problems with the healthcare system that’s currently in place so the realization for a change is understood:

• Between 1995-2007, the uninsured rate (non-elderly) was around 16% (KFF)
• 45,000 people die every year from lack of access to health insurance (Harvard, 2009).
• Compared to 19 other industrialized nations, the U.S. comes in last when it comes to Preventable Mortality–deaths that might have been prevented with effective and timely care (Commonwealth Fund, 2008).
• Despite being less efficient, the U.S. still spends 17.1% of their GDP on healthcare, vastly higher compared with other nations like France (11.6%), Canada (10.7%), or the UK (8.8%) (Commonwealth Fund, 2015)
• Most for-profit insurance companies in the U.S. have administrative costs between 15-20%. Comparatively, it’s 3% for the Medicare system and 5% for Britain’s National Healthcare Service. (T.R. Reid, pg. 38)

Overall, there are 4 different models that encompass the countries with an established healthcare infrastructure, all of which I’ll garner from Mr. Reid’s book. For a more succinct online reference, look here.

The Bismarck Model

Named after Otto von Bismarck, a Prussian chancellor in the late 1800’s who was mainly focused on building a unified, powerful German state. He despised the spread of socialism in Europe and worked to introduce health insurance and pensions.

This model is currently used in Germany, Japan, Belgium and Switzerland. These countries are similar to the U.S. in the sense that they utilize the private sector for financing healthcare plans. However, unlike the U.S., the industry basically functions as a non-profit charity. Even though hospitals and insurance companies are private entities, there are tight medical regulations which serve as cost-control mechanisms.

The Beveridge Model

Named after William Beveridge, a British economist and social reformer in the early 1900’s who galvanized the National Health Service. The NHS launched in 1948 and provides free healthcare that’s funded purely from taxation to about 64 million residents in the UK.

This model is used in Britain, Spain, Italy and most of Scandinavia. There are no medical bills and healthcare is treated as a social utility analogous to a public library. Most hospitals and clinics are owned by the government where the staff are government employees. There are some private doctors and insurance plans, but polls have shown that only about 13% of (mostly upper-class) citizens in the UK belong to these plans. The exorbitant prices of these Private Medical Insurance plans are the main self-reported deterrent for individuals not subscribing to them.

The National Health Insurance Model

This is a blend of the Beveridge and Bismarck model: the payer is a government-run insurance program where every citizen contributes, but the providers are private. It’s mainly used in Canada with Australia, South Korea and Taiwan adopting some of the tenets.

With no need for marketing, profits, or offices of people who contribute to high administrative costs by denying claims, this system tends to be much cheaper than America’s for-profit system (T.R. Reid, pg. 19).

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By mentioning Canada, I feel obligated to write a quick rant about the waiting times argument because it’s often brought up as the holy grail of counterpoints.

First of all, it’s worth mentioning that the ostensible influx of Canadians migrating to the U.S. for healthcare is an exaggerated myth; from the source:

“This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross-border flow of care-seeking patients appears to be very small.”

Secondly, the dreaded wait times are mostly for non-elective procedures; anyone that requires urgent care can get it (T.R. Reid, pg. 130). The wait times are also partially attributed to choice; Canadians voluntarily choose not to spend more on their healthcare system which would result in decreased wait times. Canada spends about 10.4% (2012) of their GDP on healthcare, up from 8.9% in 2002 so there’s legitimate cause for concern.

Lastly,  Americans are more frequently observed as heading north for cheaper drugs or treatment compared to their Canadian counterparts (T.R. Reid, pg. 130).

The Out-Of-Pocket-Model 

To put it bluntly, this is a system where the wealthy receive medical care and everyone else stays sick or dies. This is mostly seen in rural regions of India, Africa, South America and China where millions will go their whole lives without ever seeing a doctor. As a result, these are regions where people are forced to rely on unsubstantiated alternative medicine for their main method of treatment.

Out-of-pocket spending accounts for 91% of health spending in Cambodia, 85% in India, 73% in Egypt, 17% in the United States and 3% in Britain (T.R. Reid, pg. 19-20).

So which system does the United States use? Well, it’s complicated. From page 20 of T.R. Reid’s book:

• For most working people under 65, they use the Bismarck Model.
• For Native Americans, military personnel, and veterans, they use the Beveridge Model.
• For individuals over 65, they use the National Health Insurance Model.
• For the 45 million uninsured Americans, they’re Cambodia.

With these 4 systems in mind, which one should the U.S. adopt? Should we keep the system we have now where a myriad of for-profit insurance companies contribute to an inefficient, bureaucratic system? Yes, that’s a loaded question fallacy, but it doesn’t make it untrue.

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My personal, opinionated solution is to adopt a “health care for all” single-payer system. Physicians for a National Healthcare Program have a detailed FAQ on their website that addresses a lot of the common objections to this model.

I think this country would benefit immensely from a healthcare system that has been proposed by Vermont Senator Bernie Sanders.

Although a 2015 Center for Medicare and Medicaid Services report highlighted that healthcare spending is about $3.2 trillion/year, Bernie’s plan posits that it can reduce this spending by $6 trillion over the next 10 years. Admittedly, it’s not very clear on his website on how these savings will be accomplished. However, his recently published book ‘Our Revolution: A Future to Believe In’ paints a more lucid picture.

From page 324-325 of the book:

“Private insurers’ overhead currently averages 12 percent, as compared with only 2.1 percent for fee-for-service Medicare. The complexity of reimbursement systems also forces physicians and hospitals to waste substantial resources on documentation, billing, and collections. As a result, U.S. healthcare administration costs are about double those in Canada, where the single-payer system pays hospitals global budgets and positions via simplified fee schedules. Reducing U.S. administrative costs to Canadian levels would save over $400 billion annually.”

 I think the $400 billion number by solely adopting Canada’s system is overestimated, the closest number I found was in a 2014 Commonwealth Fund study which concluded that reducing our administrative costs–costs that also have no link to higher quality of care– to Canadian levels (2011) would result in $158 billion annual savings. The PNHP FAQ sourced above corroborates this by stating the U.S. would save $150 billion a year.

Reducing administrative costs to the Medicare level of 2.1%, however, would certainly get the U.S. to the $400 billion number. The New England Journal of Medicine did a study that found replacing our for-profit, multi-payer system to a national health program would save $320 billion in administrative costs.

These savings are combined with the following revenue-raising taxes:

• 6.2% income-based health premium paid by employers ($630 billion/year).
• 2.2% income-based health premium paid by households ($210 billion/year). Also, any household making under $28,800/year wouldn’t pay this tax and households making $50,000/year would only pay $466/year under this plan.
• A progressive income tax ($110 billion/year) which includes the following:

1. 37% on incomes between $250,000-$500,000
2. 43% on incomes between $500,000-$2 million
3. 48% on incomes between $2-$10 million (this only affects 113,000 households, or 0.08% of the taxpaying population)
4. 52% on incomes above $10 million (this only affects 13,000 households, or 0.01% of the taxpaying population)

Also thrown into the mix is taxing capital gains, limiting tax deductions for the rich, and an estate tax which combines to $128 billion/year in revenue raised. Add all of this together combined with the savings listed above and you have a grand total of $1.398 trillion which pays for the $1.38 trillion cost of implementing this system.

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With all the dry economics out-of-the-way, I think the moral imperative of our system lacking healthcare equity is the heart of the issue . Alleviating the burden of healthcare costs for the poor, working class people who need it the most is an accomplishment that we should ultimately strive for. Currently, medical bills are the number one cause of bankruptcy in the United States. This unnecessary stress on our nations poorest people, which leads to higher vulnerability to diseases later in life, is something that our policy makers are exacerbating as a matter of choice.  That is simply immoral and a systemic failure.

Poor Americans live in areas with worse air quality which can lead to a litany of problems like  lower birth weights, kidney problems and even an increased propensity for heart attacks and strokes. All of this leads to an estimated 470,000 deaths per year and perhaps even millions when different factors are included, from the study:

“Using simulated concentrations for 2000 and 1850 and concentration–response functions (CRFs), we estimate that, at present, 470 000 (95% confidence interval, 140 000 to 900 000) premature respiratory deaths are associated globally and annually with anthropogenic ozone, and 2.1 (1.3 to 3.0) million deaths with anthropogenic PM_2.5-related cardiopulmonary diseases (93%) and lung cancer (7%).”

Until we get a strangle hold on man-made pollution, these problems will continue to persist and intensify.

A Change Of Culture

Americans today are seeming to become increasingly hostile towards the mere mention of any sort of tax increases regardless of context. We seem to view the government as a school yard bully who takes our lunch money; this is true in some areas. For example, The Army Corps of Engineers spending $74.5 million on an unused airport and $29 million on a harbor with no roads connecting to an Alaskan town of 75 full-time residents.

Healthcare isn’t one of these areas. As I’ve explained above, in the context of healthcare, the for-profit, private system is actually less efficient, less equitable, more bureaucratic and wasteful than the government. As a nation, we’ll simply have to do the hard work and look at the profound long-term benefits of a meager tax increase for a single-payer system. If we don’t, the U.S. will continue to fall further and further behind other developed nations in all categories of health.

Let’s talk efficiency

I’m starting to notice a lot of people use the word ‘efficiency’ in a very narrow reference. The word is most often used when trying to compare the idealized free market to the government. For example, the free market system is more efficient than government because it has built-in incentive structures such as appeasing stockholders, pressure from competing companies and the necessity to remain profitable. These are seen as intrinsically positive and more efficient than government because the public sector doesn’t have to worry about a bottom line  so they’re ostensibly careless with their funds. However, if I wanted to use that same logic I could argue that the government has a strong incentive to use taxes efficiently in order to avoid raising them considering  that 57% of Americans think that their federal income tax is already too high. Or I could highlight the Economic Policy Institute findings which show that millions more would be in poverty without government programs. Debating within these narrow parameters–parameters which dominate political discourse at the moment–is a false duality and will just lead down a rabbit hole that solves very little. We need to have a more tangible, scientific view of efficiency that addresses structural problems with respects to sustainability. Utilizing the scientific method in tandem with psychosocial  and environmental considerations is a good way to reference efficiency.

In Zeitgeist Movement circles, they like to differentiate between what they define as market efficiency vs. technical efficiency. I don’t want to use too much loaded language here, but establishing the foundations of this particular train of thought is important.

Market efficiency is mainly grounded in economic theories that are predicated around the assumption that anything promoting monetary growth & profit is efficient. Basically, anything that fosters GDP growth, lowers employment numbers, or shows optimistic PPI outlooks is interpreted as efficient because it yields positive results on the stock market. Other people may have different perceptions of market efficiency, but that’s how I see our most market-successful industries discussed in common conversation.  Unfortunately, these figures are erroneous and don’t address the real world; look here for a more sophisticated way of referencing societal well-being. These include time use, community vitality and good governance. Another exemplary example is the study comparing the low-income population in Costa Rica and the United states. The study highlights that poor Americans under 65 die at a rate 3.4 times higher than the rich while the rate is only 1.5 times higher for Costa Ricans. This is despite the fact that Costa Ricans are about as poor (referencing GDP/capita) than Iraqis. Universal healthcare probably plays the biggest role in mitigating the poor health of low-income individuals, or so I would assume.

Technical efficiency refers to using natural laws (which we are all bound by) in order to reduce waste, promote public health, and economically optimize our industries in the most logical way using scientific and technological applications. If we understand efficiency in this context we should realize that the contemporary free market system is in direct contradiction to one of the core principles that justify its own validity. Of course, not every conceivable technological advancement can be brought into fruition. This is where I separate myself from a lot of extreme futurist thinkers. They seem too focused on the theoretical–instead of scientific– capacity of existing technology. While this is fun and we should of course consider these, it’s easy to get carried away and completely ignore physical resource limitation. I will try to curtail this post around technical efficiency that’s tangible, but ignored by our current market efficiency logic that financially rewards obsolete products.

Negative Market Efficiency

A recent report sponsored by the UN found that virtually no industry would be profitable if environmental/natural capital costs were included; capital costs are defined as

 “those which are non-renewable and traded, such as fossil fuel and mineral ‘commodities’; and those which provide ecosystem services (renewable goods and services), and for which no price typically exists, such as groundwater, biodiversity and pristine forests.”

We are haphazardly destroying our ecological biodiversity for mere market gains. Some highlights of the report include un-priced natural capital costs such as

• Green house gas emissions
• Water and land use
• Air, land and water pollution
• General waste

The estimated total cost of these unaccounted externalities is $7.3 trillion, or 13% of global economic output in 2009. These natural capital costs that pervade our current economic model are a catalyst for the destabilization of the environment; this surely doesn’t seem efficient or optimal. The study recommends that companies and governments pursue internalizing these costs and focus on more on natural capital assets.  I would agree because this natural capital which factors environmental degradation is the only sustainable way to think about our economy. However, I admit this will be nearly impossible to pursue because of the underlying necessity to remain profitable in the sort of market-efficient logic that permeates our system at the moment. This example is one of economics, let’s look at a more human and psychosocial consequence of this market efficiency logic.

Most people are aware of the competitive ethos that is necessary in order to survive in Western society. This competition makes itself present in the market sense and in the human sense. The market manifestation of competition can create perverse incentives that plague critical fields such as mental health. Eric R. Maisel explained this in an article in Psychology Today. Eric made the observation that

“a mental health professional has a real incentive to support a system that helpfully creates mental disorders and clients or patients.”

This is because the workers in this field need a steady flow clients in order to sustain a living for themselves. I wouldn’t suggest a  conspiracy theory and claim that the mental health system is doing this intentionally; they’re simply playing by the market rules while still trying to perform a social service. From a technically efficient point-of-view, they would seek to provide a sort of stress relief that contextualize the patients specific behavior/lifestyle rather can doing a by-the-book checklist and diagnosis. These aren’t my words, they are the authors. I have no experience in the field so I’m not going to throw in my opinion on the solutions.

The story of Antony Breeze encapsulates another, albeit isolated example of the economic and social stress that is brought on by competition. Antony committed suicide after being bothered by loan sharks for a £1,600 debt. This is a relatively small amount considering the average British citizen was £8,431 in debt two years prior to the Antony story. Mr. Walsh, the deputy coroner, described Antony in a statement

“He was anxious to provide for his partner and his daughter, and he was a good man who provided for them. He was a man who had everything to live for and he was always looking forward to the future as a family unit.”

 Unsurprisingly, this was just an honest man who was socially pressured into making a couple of regrettable decisions. I’m cognizant of the fact that–in a limited sense–he is personally responsible for amounting that personal debt. No one literally forced his hand into signing *insert debt-bonding document here* that lead to Antony’s inevitable stress. Much could be said about how this particular point-of-view doesn’t address how our current debt-based system that revolves around fiat currency encourages this sort of behavior in order to keep the machine running. With our current system build upon these foundations, it’s no mystery why many feel the necessity to go into exorbitant amounts of debt.

A Quick Side Note

A precursory step towards technical efficiency would be embracing and implementing the idea of a Universal Basic Income (UBI) which has a simple definition: a guaranteed income to every citizen with no work requirement or any other sort of test. I view UBI as more of a future inevitability rather than a pie-in-the-sky social or moral justice theory. This is because of the nearing technological unemployment phenomenon that will slowly engulf the menial, mechanical jobs. A 2013 study by Oxford researches concluded that around 45% of American jobs are under threat of automation in the next 20 years. Although data is sparse on UBI, we do have a few examples of it being implemented. Medicine Hat, a small city in Canada with a population of 60,000 (2011 census), decided to give the residents a UBI. They managed to house 885 of the cities 1,000 homeless people. This housing also saved an estimated $65,000/person in annual care costs according to Human Services in Alberta, Canada. This is because simply providing free housing/free money lessens the health impact these homeless people endure, thus alleviating some of the financial burden on the healthcare system. This UBI idea will become necessary if we want society to keep functioning while still pursuing technical progress in separation from the market logic. Many more caveats need to be explored with this idea, but I want to stick to talking about efficiency in this post.

Technically Efficiency: A Few Examples

Electric vehicles have a messy and complicated history. With its conceptual origins at the beginning of the 19th century in the United States, the Netherlands, and Hungary; it was France and England who developed the first workable electric vehicle around 1890. The electric vehicles in those times were horseless carriages that topped out at 14 MPH and only lasted about 18 miles. Continued developments continued to progress up until about the 1920’s. What happened then? Well, the need to travel long distances brought upon by a more efficient system of roads that connected cities needed to be met. These aforementioned roads required long-distance vehicles which couldn’t be met by the electric vehicles at the time. They were outperformed by the gasoline-powered vehicles that were necessary for progress at the time.

Roughly 90 years later, we now know that the electric vehicles are once again able to be utilized in a beneficial way. A recent MIT analysis concluded that

“Roughly 90 percent of the personal vehicles on the road daily could be replaced by a low-cost electric vehicle available on the market today, even if the cars can only charge overnight.”

This will become necessary if we hope to make a reduction in carbon emissions. The standard criticisms are still being thrown around about electric cars: not enough range, unsafe batteries, electrical grid overload, too expensive, etc., but an array of academic research can abate those fears. Electric cars, like anything, aren’t perfect. However, not pursuing this technological progress because of general market concerns for dropping profits is illogical.

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According to the Food and Agricultural Organization (a branch of the UN), around 11% of global land surface is being used solely for crop production. Our agriculture is also responsible for using 80% of the United States consumptive water use, meaning water withdrawn from water sources such as a lake, river, or aquifer. This massive waste is unsustainable and inimical to our ecosystem. It’s unsustainable because the FAO estimates we need around 300 million more acres of arable land–land capable of growing crops–to keep up with food production demands by 2050. Most of this land is in developing countries which, if used for crop production, would cripple their other ecosystems and economies. This is why we need a more technological focus on farming that can localize (the FAO recommends moving toward a global trading system that is “fair” and “competitive”, but this seems like an ambiguous solution that doesn’t really address the long-term ecological problem) all types of foods and rely less on globalization. Fortunately, we have a solution that’s been around for longer than most people think: vertical farms. The term was coined in 1915 by Gilbert Ellis Bailey in his book Vertical Farming  which detailed the crude origins of the farming method. The modern definition of vertical farming is the use of hydroponics in multi-story greenhouses. These buildings would eliminate the massive land/water waste used by our current farming methods. Vertical farms have been shown to use 95% less water, according to David Rosenberg, co-founder of AeroFarms. They also have the ability to be unaffected by weather which can cripple land-farms during periods of droughts or floods.

I can sense alarm bells ringing in some people, greenhouses are electric-intensive and simply not feasible on a large-scale because of the cost, right? Probably not, according to Dr. Dickson Despommier. He argues that the higher costs (mostly LED lighting) are offset by the elimination of farm equipment, transportation costs of produce into cities–FAO estimates that by 2050, 80% of the population will reside in urban environments–, and the elimination of fossil fuels in fertilizer which runoff into coastal waters causing environmental havoc. This is all despite the fact that profound developments are being implemented which reduce these electrical costs. Even after all this, I must concede that no study to my knowledge has been done quantifying the potential cost comparisons of a vertical farm building with the elimination of conventional farming methods.

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Another thing that typically goes unquestioned or unchallenged in the market environment is the concept of ownership. In the TZM link listed above, they frame this as Property vs. Access. It’s essentially the concept that, from a technically efficient perspective, ownership of some utilities or goods is illogical. Most understand this concept in the view of libraries that give you access to resources such as books, magazines, etc., rather than owning these of part of your permanent property. Most don’t bother extending this logic into other commodities. For example, it’s more efficient in a market sense for 50 people to be driving 50 cars. This drives GDP, employment, and other technically non-contributing measurements I mentioned in the initial paragraphs to this post. Personally owned vehicles sit idle much longer than they are actually driven. Wouldn’t it make more sense to design a system that forgoes ownership and embraces utility based on measured time use? As an essay in TZM defined explains:

“If we analyze patterns of actual use of any given good on average, many types of products are found to be used intermittently. Transport vehicles, recreational equipment, project equipment and various other genres of goods are commonly accessed at relatively distant intervals, making the task of ownership not only somewhat of an inconvenience given the need to store these items, but also clearly inefficient in the context of true economic integrity, which seeks a reduction of waste at all times.”

From this they conclude:

“So, from the standpoint of technical efficiency, at the deep expense of market efficiency, a shared access rather than universal property oriented society would be exceptionally more sustainable and beneficial. Of course, such a practice would naturally challenge some deep value identifications common to the ‘propertied’ culture today”

I think the last sentence really poses the greatest challenge in adopting goods-sharing society. The cultural (I’m mainly talking about the U.S. and major Western European nations here) market system that value ownership and property regardless of context would be a hard thing to change. This value system relies mostly on flimsy, individualistic justifications such as personal freedom; having stuff for the sake of having it is a good enough reason for a lot of people. Personal freedom would not be sacrificed in a sharing system. In fact, about 500 cities (mostly in Europe) now have bike-sharing programs and it doesn’t seem that many people have a sense of lost freedom because of them. Most cities have actually seen reduced bicycle theft and vandalism while reducing the cost for the average consumer.

The Big Picture

I’ll try to wrap this up with some overall points of concession and clarification. I’m not saying that discussing the roles of governments and markets aren’t worth having, but they shouldn’t be at the forefront of how we look at the world in respects to efficiency and problem solving. I’m also not saying that these solutions would be perfect and bring about a utopia; the train of thought is the focus here: technical efficiency over market efficiency.

What I am saying is that government vs. market conversations don’t address the structural and technically focused view that is necessary if we ever hope to identify root causality with issues such as climate destabilization, income inequality, or any other bio-psycho-social problem I mentioned above. Also, the solutions that I referenced aren’t anything new or profound, it’s all being developed and discussed in the academic world but being ignored by most economically powerful institutions. This is why I went to great lengths to incorporate quotes, cite sources, and define terms because I’m not pretending to have some hidden knowledge that puts me on a pedestal above anyone else. All ideas and information originate from something else. No person is the sole arbiter of any idea or thought; there’s always some prior reference point for anything. This why the legal concept of intellectual property  is largely unhelpful because of the inherit market incentive to conceal new technological developments or ideas. Overall, most of our market institutions are unable to look past the very near future and completely disregard social and environmental factors in pursuit of monetary gain.

There are exceptions as Manoj Bhargava, founder and CEO of 5-hour Energy, showcases in the documentary Billions in Change. This is a massive company ($1.25 billion in annual sales) that is still involved with pursuing seemingly radical, technically efficient things such as free electric and limitless energy.  Manoj gave away about 99% of his fortune (which still leaves him with $40 million dollars, hardly roughing it) to charity by signing the Giving Pledge, a program started by the Gates family. If every CEO and corporation had this sort of ego-less social awareness, we could be miles ahead of where we are now in terms of technological capacity and ecological sustainability.

And that is the overall point: educating people on the ecological and technological benefits of escaping the market-centered way of thinking about the world. We need to think about and change our institutions in a vastly different way; a way that doesn’t involve corporate or government coercion. I just happen to believe that these trains of thought are a good starting point.