Map of life expectancy at birth from Global Education Project.

Thursday, May 23, 2019

Harm Reduction

Kishore and colleagues in NEJM, including Josiah Rich from a university well known to me, discuss the harm reduction approach to injection drug use (IDU). Basically, this means using evidence to guide practice so as to minimize as much as possible the adverse public health consequences of addiction. In addition to the risk of overdose, which is getting most of the attention nowadays, IDU is a means of transmission of Hepatitis C and HIV, and contaminated needles transmit other common infectious organisms that can result in abscesses, and very serious consequences such as myocarditis.

So, assuring that users have access to sterile needles is an obvious way to reduce the damage caused by addiction. But the common reaction among citizens and politicians is that giving addicts injection equipment, or even allowing them to legally possess it, enables and encourages drug abuse and crime. Consequently, possession of hypodermic needles without a prescription is illegal in most states, and only 21 states have authorized any form of needle exchange. These are programs in which addicts can receive clean needles in exchange for used ones. Often they allow only one-to-one exchange, however, which does result in some re-use. According to the linked article, only 47 of 220 rural counties found by CDC to be most vulnerable to HIV and HCV outbreaks had needle exchange programs.

The truth is that there is no evidence that needle exchange programs increase the prevalence of injection drug use, or crime, and plenty of evidence that they reduce the transmission of disease and, by creating contact between users and service providers, they facilitate entry to treatment and can actually contribute to reducing IDU and controlling the epidemic.

The basic reason that these true facts fail to produce good public policy is that people still see addiction as a moral issue. Illicit drug use is stigmatized and many people seem to think that if addicts become infected or die that's their own fault. They seem to think that doing anything to help people who are sick and in desperate need signals approval of conduct that is morally wrong.

So get this straight. It is not a moral failure. In fact, in most cases these days, we are talking about iatrogenic disease -- a disease caused by physicians. Addicts cannot just stop. Their brains have been rewired and their behavior is compulsive. People need help and compassion, not condemnation and abandonment. We need to change both federal and state law. I'm not even going to safe injection sites, which are illegal thanks to congress. Maybe we'll discuss that later.

Monday, May 20, 2019

The Long Emergency: It isn't just climate change

I'm still sketching out the basic challenges facing humanity, in broad strokes. Last week I presented the history of human population in the past 2000 years and a very basic primer on climate. But there are much broader issues of resource depletion. Some people have expected bigger catastrophes sooner than they have actually happened, and it's perilous to make very specific predictions, but we're at the point now where we aren't just making predictions, we're observing what's already happening.

Here's the basic problem:



If 3 billion people are going to  achieve a standard of living comparable to that of a typical North American or European, we will have to triple our consumption of natural resources. Or maybe not. Perhaps we can ameliorate the problem by reducing the depredations of the few very rich people.



That could help, but it won't be enough. The surface area of the planet, in case you didn't know, is finite:



Of the earth's habitable land surface, 50% is already dedicated to agriculture. Of that, 3/4 is used to feed livestock. We can't cut down any more forest without accelerating the mass extinction that is already happening, and with it, climate change. Basically, we cannot expand the extent of agricultural land.



Agriculture requires water: