Journalist Sam Quinones’s book The Least of Us was published in 2021. The book has been commended, even by critics, for its vivid storytelling. The book shares “true tales of America and hope in the time of fentanyl and meth.” But the story is also about chemistry: Drugs have changed, becoming more powerful and destructive and contributing to the pervasive encampments and street crime in larger cities in the United States. Local governments have often been confronted with what appears to be a binary choice: focus on interdiction of and prosecution for the possession of drugs or build more subsidized housing. The answer is more complex.
Quinones writes that there is “a larger narrative—a shift in drug supply from plant-based drugs such as marijuana, cocaine, and heroin to synthetic drugs, which can be made anywhere, quickly, cheaply, and year-round.” The drugs are cheap and easy to get, with new and more deadly varieties being engineered all the time. When one variety stops working for the addict or can’t be found, another variety is available. “The use of mind-altering substances by humans is age-old,” writes Quinones, “but we have entered a new era.”
Battle-lines have been drawn by advocates of a strategy called Housing First, “an approach to quickly and successfully connect individuals and families experiencing homelessness to permanent housing without preconditions and barriers to entry, such as sobriety, treatment or service participation requirements.” Supporters of this approach argue that high-barrier programs requiring sobriety force addicts to choose between living on the street and total abstinence. This approach is associated with the concept of harm reduction.
On the other side are groups like the Discovery Institute, which holds that harm reduction is a failure because it is based on “the premise that human beings are subordinated to biological determinism, with almost no room for agency, hope, or grace.” They’ve supported legislation offered by Kentucky Republican Andy Barr that would, he says, “fix Housing First” by mandating 30 percent of federal funds allocated to the program be used for service providers who offer abstinence-based “wrap around services,” including faith-based organizations. Entry to these programs could require sobriety.
First, all public health is about harm reduction—in other words, it is about persuading people, gradually, to make beneficial behavioral changes. When I worked in the tobacco-use-prevention field, we knew a strategy of higher taxes on cigarettes, regulatory restrictions on public smoking, and cheap and easy pharmaceutical nicotine replacement therapy would reduce the prevalence of tobacco use. And over the years it has, falling from 42 percent around the time of the first Surgeon General’s report in 1964 to less than 12 percent today.
The historical bedrock of public health practice has been and should be the story of Doctor John Snow and the pump handle. During a cholera outbreak in London, Snow hypothesized that a particular well was the source; when he had the handle removed, people began getting their water elsewhere and the epidemic abated. It would be decades, though, before the idea that germs were responsible for disease would take hold. But the idea of removing a choice—taking away the handle—while also educating the public about why you were doing so, has formed the basis of epidemiology and health education since.
Tuberculosis was a scourge for centuries, claiming the lives of rich and poor, famous and obscure. Today, it hardly registers as a threat for the average person. Most would guess that it was the invention of antibiotics that ended the disease. René Dubos, in his brilliant epidemiological history of the disease, The White Plague: Tuberculosis, Man, and Society, points out that it wasn’t pharmacological interventions that ended the disease, but changes in policies, practices, and procedures, many pioneered by one New York doctor, Herman Biggs, at the turn of the 20th century. Biggs was a controversial figure who put quarantines into effect to prevent the spread of the disease. Even at the turn of the last century, some medical professionals doubted that germs caused tuberculosis.
Dubos, in his Herman Biggs lecture in 1951, says that the strategies implemented by Biggs—identifying carriers of the disease, keeping them from infecting others, and educating the population on sanitary measures—seems “commonplace today, but it was then a revolutionary departure in medical and social philosophy.” Dubos goes on to say that Biggs’s approach “shifted the emphasis from treatment of the individual patient to the control of disease in society,” today known as population-based health.
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In the 19th century, there was what has been called “consumption chic,” a bizarre trend of fetishizing the outward symptoms of tuberculosis. To die of the disease, as John Keats did, was seen as kind of sexy. He wrote in an Ode to a Nightingale,
I have been half in love with easeful Death,
Call'd him soft names in many a mused rhyme,
To take into the air my quiet breath;
Now more than ever seems it rich to die,
To cease upon the midnight with no pain
Perhaps the most toxic poison today in America isn’t even the jacked-up drugs described by Quinones, but the deep mistrust in our institutions and each other in which we seem to indulge without regard for the consequences. I’m as puzzled by how in love we seem to be with this drug as I am by the devastating and destructive effect of the chemicals on the street. It’s unclear what will beguile us back to the basics of a true continuum of care based on a mix of engagement, will, and self-identified and sustainable goals toward recovery. Our cities, and our homeless populations, depend on it.
