Health Issues?
Diagnostics & D.C.’s Drug War
BY JULIEN SPURLING
PERSPECTIVES DIAGNOSTICS
The overdose crisis in D.C. was briefly an official “public emergency”, declared by Mayor Bowser in 2023 and then allowed to lapse in 2024 despite a sixth consecutive year of record-high overdose fatalities. The declaration fell short of demands from residents, community organizers and lawmakers to declare a public health emergency. Their demands track a shift in public opinion of drug use and overdose deaths “as a public health issue, rather than a criminal justice issue”. While the phrase “public health issue” is popular, the policy implications and background commitments it signals are under-described and often ambiguous between disparate approaches to drug use and overdose fatalities. Framing the issue in health terms doesn’t automatically pave a clear path to good policy. What does it mean to treat something as a “health issue” anyway?
We often think about “health issues” as medical conditions: pathological bodily differences that require diagnosis, treatment, cure or management by medical professionals. Much public discussion about the overdose crisis evidences this kind of thinking about health, as does D.C’s Opioid Abatement Advisory Commission (OAAC), which is charged with overseeing how the settlement funds are spent. Commission members are mostly physicians, health service providers, medical administrators and government officials. The composition of the commission indicates the kind of expertise the Mayor and Councilmembers take to be relevant for addressing the crisis. The expertise of commission members is mostly on providing treatment and recovery interventions on individual behavior and mental health. Despite all the research demonstrating how drug user health and overdose fatality is negatively impacted by housing instability, income inequality, and policing and drug busts, no commission members have expertise in these areas and adjustments to housing, fiscal and “public safety” policy do not appear to be serious considerations as abatement measures for the commission.
Instead, our policymakers appear to be centrally focused on Substance Use Disorders; the term appears on nearly every page of D.C.’s current Strategic Plan for addressing opioid overdoses. At the peak of the crisis in 2023, D.C. policymakers listed fostering a “culture of awareness of opioid and substance use disorder as a disease” as a “key achievement”, without any explanation of what material gain this awareness has brought to community members who have overdosed or lost loved ones to overdose fatalities. The Department of Behavioral Health (which houses the OAAC) describes its role as providing “screening, diagnosis and treatment for both mental and substance use disorders”. The problem to be solved, on this view, is that too many people are sick with a condition that first and foremost requires medical intervention and treatment.
The emphasis on the disease view of substance use reflects the language and theoretical framework of agencies like the National Institute of Drug Abuse (NIDA). Substance Use Disorder (or, colloquially, “addiction”) is defined by NIDA as a “chronic, relapsing brain disease… characterized by compulsive use despite adverse consequences”. This is the “medical model” of addiction; people keep using drugs despite negative consequences because they have a brain disease that makes it very difficult, or literally impossible, to stop using them. The surge in fatal overdoses is understood as the natural outcome of the spread of a brain disease among the population. On this view, we ought to manage it as we do other epidemics: provide treatment for those with the disease to either cure or manage the condition and prevent others from developing the disease. (“Prevention” appears often in drug policy, and is another ambiguous term that can refer to anything from harm reduction programs to increased policing of “at risk” populations. In D.C., the prevention programming is a set of public awareness campaigns to educate on the dangers of drug use). The medical model lends itself to a simple argument: we ought to help, treat, and care for people who are sick, not punish them for displaying symptoms of their disease. Helping sick people involves ensuring they have access to proper medical care, and conducting research to better understand and treat the condition.
This approach seems clearly preferable to what philosophers call the “moral failing” view, on which drug users are imagined as irresponsible self-indulgent hedonists or law breakers who bring their suffering upon themselves by not having the good sense to avoid drugs in the first place, or to stop before endangering themselves. The moral failing view is typically associated with punitive or “criminal justice” approaches to drug use: seizure, arrest, incarceration. On the moral failing view, we might provide care or support to drug users out of benevolence, but it is not considered a requirement as a matter of justice. This is why arguments for the disease view are so common among advocates for more compassionate drug policy; it provides justification for using collective resources on drug users. Public opinion research indicates that people are generally opposed to government spending to address “self-inflicted” harms. The medical model works to counteract the view of the harms as self-inflicted; no one chooses to get sick or have a disease
But the medical model and disease-centric approach to the overdose crisis comes with dangers. While it can secure some protections and access to healthcare by casting drug users as sick, the disease condition is one in which people are thought to be arational and non-agential. The disorder involves acting against one’s own interests, pathologically harming oneself, and doing so because one is unable to do otherwise. Sometimes we talk about this as the brain being “hijacked” by repeated drug use. People diagnosed with Substance Use Disorders are often framed as unable to determine their own best interests, unable to be held responsible or accountable for their actions, and unable to act freely as a result of their disease, and that framing is the basis on which we justify care and treatment programs, as well as insurance coverage and healthcare access. It can be strategic in some cases to cede one’s own credibility and political agency for the social capital that doctors and neuroscientists can wield while advocating for better treatment for drug users, decreased stigma, etc. However, these are steep costs that can interfere with better policy development and instead further entrench already prevalent technocratic decision-making. This approach also tends to rely on a shallow notion of health justice; accessing medical treatment is important, but it isn’t everything when it comes to health. It isn’t even most of what accounts for the disparities in health or life expectancy; social determinants like the quality of working conditions, education, housing and income are.
The trade-off of using this strategy to secure protections and medical care or justify social spending is that it prevents policymakers from taking drug user expertise seriously. Arational non-agents that don’t act in their own best interests or act autonomously can only be seen as a population to be cared for and managed, not as partners in collaborative policy development. It’s rare for drug users to be meaningfully involved in determining drug policy or budgetary deliberation concerning overdose response measures. Current and former drug users often have important insights on practical ways to keep one another safe and the policies that pose obstacles to community safety. Historically, the most effective overdose prevention measures have been ones developed by drug users in community with one another to keep their loved ones safe. Fortunately, the most recent Strategic Plan issued by the District lists “stronger integration of peers with lived experience within organizations” and “increasing harm reduction activities” among its primary aims. These are laudable goals, backed by empirical research demonstrating the value of peer knowledge in harm reduction programs, and by ethical imperatives to ensure that people most impacted by harm-reduction services have meaningful involvement and influence over how those services operate.
When “health issue” advocates call on D.C. politicians to expand medical services for drug users or remove barriers to accessing those services, the ask isn’t for charity, but for health justice. Health justice worth fighting for involves redress for the harms wrought by the War on Drugs on marginalized communities, especially older Black men in D.C. and the District’s homeless population. This might involve individual payouts to victims to help provide means to a dignified life, decriminalization of drug possession and redirection of policing funds toward D.C. 's harm reduction programs to train and employ peer workers. Narrow medical frameworks for understanding drug use and the overdose crisis obscure vital non-medical components to truly compassionate drug policy. The settlement funds are an important resource that we ought to make the most of. So is the knowledge and political vision of D.C. residents that have been fighting the War on Drugs for decades.