Heroin-Asisted Treatment of Drug Addicts and the Political Pitfalls of Harm Reduction

By Jesse Singal, MPA 2013

In a piece published Monday in The Daily Beast, I covered a new study in the Canadian Medical Association Journal suggesting that the most cost-effective treatment for certain types of long-term heroin addicts might be... heroin. It's the latest in a rather long line of studies offering similar results.

It's a counterintuitive idea, and it highlights some of the political challenges of a favorite concept among public-health policy wonks: harm reduction. In short, harm reduction is the idea that rather than approach health issues with unrealistic, overly idealistic notions of the power of public policy, we need to understand that in many cases, the best we can hope to do is improve—not fix entirely—difficult, complicated situations. And as we seek to do so, evidence-based approaches should guide our efforts.*

Given how accustomed we are to big claims about quick fixes, it can be a hard concept to swallow. If one mayoral candidate promises to greatly drive down the "epidemic" of teen sex, and her opponent promises to improve sex education so as to reduce the number of teen pregnancies and the spread of STDs—well, it's easy to tell who will face more of an uphill battle come election day. A lot of people don't want to admit that teenagers always have had sex and always will.

Heroin-assisted treatment, or HAT, highlights this concept perfectly. No one wants to admit that a lot of addicts remain addicts for a long time, and the best we can hope to do (at a reasonable level of investment, at least) is to mitigate the damage they do to society. As I point out in the piece, even researchers sold on HAT's promise will admit that there’s something inherently crazy-sounding about the idea of giving heroin addicts heroin. “You sort of have to get over some pretty large hurdles of face implausibility,” Peter Reuter, a drug-policy expert at the University of Maryland, told me. “There’s something strange about the notion that on the one hand you prohibit this drug, but… if the user causes enough damage to society and to himself, well, we’ll give it to you free.”

But the idea starts to make sense the more one thinks about the neighborhoods that have been wrecked not because long-term heroin users use heroin (there is no more docile creature in the world than an addict who has just shot up), but because of the collateral damage done by their search for it—the petty crime, the violence, the black-market forces that shoot out of cracks in the social structure like thick tangled weeds. If heroin addicts didn't have to search for heroin, the damage wrought by the drug would be greatly ameliorated.

The notion of giving heroin to heroin addicts may make us uncomfortable; it just doesn't feel right in some deep, visceral way. But harm reduction is about being an adult, about realizing that sometimes you need to follow what the science tells you, even if it doesn't feel right.

* Thanks to fellow MPA1 and budding public-health expert Brett Keller for letting me run this language by him.

“Chasing Ice” Catches Up to Earth’s Changing Climate

By Elisabeth A. Cohen, MPA candidate 2012

It’s probably hard to imagine all of Manhattan tumbling into the Hudson River and washing away in less than five minutes, but that’s the equivalent of what you’ll see in the film “Chasing Ice,” as a city’s worth of towering icebergs collapse violently into the ocean — and that’s just one of countless spectacular images that flash across the screen in this astonishing documentary by director and cinematographer Jeff Orlowski, which premiered at Sundance in January and is opening at SXSW this week. 

The film is a documentary about a documentarian — a scientist-turned photographer named James Balog, whose obsession with images of ice has gotten him into the pages of The New Yorker and National Geographic. Despite his training as a geographer and geomorphologist, Balog was stunned to see how fast some of the glaciers that he shot were receding in the face of global warming. So he decided to create a long-term photography project he called the Extreme Ice Survey (EIS), which he hoped would merge art and science into a compelling story in pictures about what humans are doing to the climate.

A layer of cryoconite, dust which absorbs solar radiation, melting the snow, at the bottom of a Greenland Ice Sheet channel, July 2009. Credit: James Balog/Extreme Ice Survey. 

Originally, Balog planned to set up two time-lapse cameras to photograph glaciers, but within a few weeks his ambition had grown: he bought 23 more cameras, then assembled a team of 30 scientific experts, engineers, and photographers to help him carry out his vision.  Balog also asked Orlowski to film the project. “I wanted to work with James in some capacity,” said Orlowski, and the collaboration turned into “Chasing Ice.”

The movie is nothing short of spectacular. As you watch, you can see how Balog and his team set up all of those cameras on three continents, in places including Alaska, the Rockies, Greenland, Iceland, and Mt. Everest.  The team worked in below-freezing temperatures and high winds, rigged cameras to the sides of cliffs, and programmed them to take automatic photos every half-hour, powered by solar panels.  In total, they captured more than a million glacier portraits over five years.  “Without a doubt,” Orloski said, “this has been the most challenging project in my life.”

The same is clearly true for Balog and the rest of the team, but the photos they brought back are incredibly valuable. It’s one thing to see an image of a single retreating glacier, but Balog’s cameras recorded dramatic changes in glaciers around the world.  The Columbia glacier in Alaska is just one striking example. Since 1984, the Columbia has deflated by a thickness equivalent to height of the Empire State Building. Over the life of the project, it retreated so quickly that to keep the edge of the glacier in the frame, the team had to keep returning to adjust the camera’s angle. “We never expected to see the glaciers change as much as we’ve seen,” Orlowski said. “That was the most shocking part for us.”

On one trip to Alaska, Orlowski recalled, “there are entire areas where we spent days and days climbing on ice, using our ice tools, and going up and down parts of the glacier. When we revisited them, all that ice was gone. The landscape looks so different that you almost don’t recognize it . . . that giant playground, that world of ice we were pretty much living on for a week, is completely gone.”

For the director, the experience was eye-opening.  “We think of glaciers as being part of geologic time,” he said, “something that happens over centuries and thousands of years.” What Balog has shown so vividly, he said, is that in a warming world, this conception is completely out of date.

On the other side of North America, in Greenland, Orlowski and project engineer Adam LeWinter stood watch in frigid conditions waiting for the end of a massive tidewater glacier to break off into the sea — a calving event, a glaciologist would call it. Finally, on the 17^th day, it happened. With nine cameras rolling, they recorded a chunk of ice some 400 feet deep and three miles wide calve off of the Ilulissat Glacier — and in a little more than an hour, the glacier continued disintegrating until it had retreated a total of about 1 mile. The block of ice that retreated and broke off into the ocean could have fit about 3,000 U.S. Capital buildings in it. Orlowski and his team condensed this event into a 3-minute clip that was, to put it simply, awesome.  For Orlowski, watching this live “was a life-changing event. Adam [the engineer] and I were the only two there and we felt we were watching history unfolding in front of us.”

James Balog hangs off a cliff near Columbia Glacier, Alaska to install a time-lapse camera. Credit: Tad Pfeffer/Extreme Ice Survey. 

“Chasing Ice” has lots of this natural drama, but there’s plenty of human drama as well. A couple of years into the project, for example, Balog had surgery on his knee. He opted for a procedure that had a quicker recovery time, so he could get back into the field faster, but it wasn’t as effective in the long run. His doctor ordered him to quit ice climbing — an order he promptly ignored. One night Balog even walked out onto the ice on crutches to capture one of Orlowski’s favorite photos of the entire project.  There are also lots of action scenes, with members of the team rappelling into gaping crevasses, making the movie a cross between a frozen “Planet Earth” and an action film.  In fact, “Chasing Ice” won the best adventure film award at the Boulder International Film Festival.

What is perhaps most surprising about the film is that Balog used to be a climate skeptic. He explains how he once thought that climate change theory was based solely on computer models, where in fact it’s based on scientific measurements of both modern and ancient climates. Once Balog learned that tree rings, sea floor sediments, and ice core data were showing that the climate is warming on average, he changed his mind. Orlowski’s film about Balog could, in turn, change the mind of other climate skeptics. One thing that struck me, however, was that although the evidence of climate change is overwhelming in “Chasing Ice,” there’s very little about slowing or stopping the planet from warming. 

It is hard to decide whether the jaw-dropping imagery or the climate-change messages in this film were more compelling. But it’s  no surprise that the film received the “Excellence in Cinematography Award: U.S. Documentary” during the 2012 Sundance film festival. In at least one screening at the Sundance Film Festival, the audience leapt to its feet cheering.

To do this film justice, go see it on the big screen.  The next opportunity to see the film is at the South by Southwest (SXSW) arts and music festival in Austin, TX the second week of March. The TV rights to “Chasing Ice” have been acquired by the National Geographic Channel and its website says a theatrical partner will follow shortly. To find out more see  National Geographic Channel Takes 'Chasing Ice' and visit the movie’s website. For “Chasing Ice” movie show times at SXSW click here.

* This article is reposted, with permission, from Climate Central. 

Removing Nigeria’s Oil Subsidy

Ayokunde Abogan, MPA

Nigeria is well known for its vast natural and human resources. It has the largest population in Africa (the 10^th largest population globally) and its crude oil resources gives it a respectable 6^th position in the world in terms of its export levels in the global oil market. Despite the country’s wealth, it has been difficult to leverage these resources to reduce the high levels of youth unemployment and poverty in country. While oil revenues represent only 14 percent of Nigeria’s GDP, it accounts for 98% of export earnings and close to 90% of the federal government’s revenue according to World Bank estimates in 2009. A significant proportion, about 31.4% of the country’s GDP is connected to exports and this is largely driven by its vast crude oil resources.

In essence, my country is primarily dependent on its oil resources for a lot of things. Although the economy is very much diversified with the burgeoning financial services, entertainment and telecommunications sectors moving up the ranks to take their respective places in the overall economy, the country’s vast agriculture and manufacturing sectors are crumbling. Government bias, mismanagement and inconceivable policies have all made it impossible to grow both sectors. This is further compounded by high electricity costs, dilapidated transportation networks, high business costs and political instability arising from religious and ethnic violence.




The "Occupy Nigeria" Logo

 

A couple of my classmates have asked me about my thoughts regarding the removal of these fuel subsidies. Although I supported the government’s policy to remove it, I questioned the way this policy was hurriedly implemented. I supported it because this subsidy was costing the country about $7 billion every year. This is a lot of money that the government can spend on revamping our lagging educational system and improve our decaying infrastructural framework. Our health services systems are lacking needed funds to improve health interventions and delivery while the youths in the country are largely unemployed. Social welfare for the impoverished will go a long way to reduce the high levels of income inequality in my country.

However, I don’t support the way the entire fuel subsidy was removed without any recourse as to how the citizenry will mitigate the impact of any shocks to their incomes and overall well-being. Rather, this subsidy ought to have been removed gradually. Nevertheless, any promises by the federal government to devote the proceeds of this fuel subsidy to tangible investments is something all Nigerians would wish for due to the crass levels of patronage and corruption. Government subsidies for diesel fuel and kerosene that were removed in the past have yet to translate into any meaningful investments in the country apart from the small number of people who have lined their pockets with the country’s wealth.




Fuel prices before the oil subsidy was eliminated was N65 per litre. Prices rose to as much as N140 when the subsidy was removed.

 



Occupy Nigeria protestor in Lagos, Nigeria

 

To speak about this madness called “fuel subsidy” requires a walk down memory lane. However, let me start by saying a country like Nigeria, which is also the largest crude oil exporter in the African continent, imports fuel into the country. Aaaah, yes, I know this makes no sense. Unfortunately, it does. Nigeria has four national refineries that are barely functional because of the country’s poor planning and maintenance culture, and even more, our refining plants are ageing while the pipelines linking these plants have lacked adequate investments and they are terribly unreliable to support uninterrupted domestic production. Thus, Nigeria is forced to refine its crude oil resources outside its borders and then it imports the refined products, mostly from European suppliers, to satisfy the energy needs of its large population.

Estimates according to the Nigerian oil and gas industry reveal that the country imports about 85 percent of its fuel needs, while the country subsidizes these imported products to ensure that fuel prices at the pump is around half of the market rate to its citizens. In 2010, Nigeria spent 1.20 trillion naira (about $6.7 billion) to import fuel into the country. Sadly, a system ingrained in corruption makes it very difficult to know how these large amounts of money are accounted for in Nigeria’s budgetary processes. Worse, the bill all Nigerians have hoped will fix the country’s oil sector is yet to be passed.

Although things have calmed because the government had to reverse its stand, on the fuel subsidy, when the country was teetering on the brink of political and economic catastrophe, I still think that the fuel subsidy is nothing more than an opportunity for some people in the country to enrich themselves, while the country is continually lagging behind its peers both in the African continent and globally. Yes, Nigerians, including me, have benefitted from these subsidized fuel prices but the question should be: for how long are we going to keep on subsidizing fuel prices in Nigeria? Nigeria has a lot of potential and it has always frustrated me that a country which prides itself as the “Giant of Africa” cannot get its act together. The issue is Nigerians cannot trust its government to do anything meaningful while the government is finding it very difficult to address the challenges faced by average Nigerians.




Nigerians' view about the relationship between the Nigerian government and its citizens.

 

I have always wondered what it will take to fix my country and get it on a path to economic success. This is the reason why I decided to come to the Woodrow Wilson School to get a better sense of what to do to address development challenges and economic growth cases like Nigeria’s, that don’t create enough employment opportunities for their citizens but only makes the rich richer while the poor continue to suffer in order to meet their daily needs. I am happy to take suggestions from people who care about the success of my country however, as the adage goes, “heaven helps those who help themselves.” Nigeria needs all hands on deck to move it forward and I think this is a responsibility of all including my fellow compatriots.

Call me elitist or dumb, I will still support the removal of this government fuel subsidy if this issue rears its ugly head again. However, this time, it is important to use better tools that will ease the impact of subsidies particularly on wallets of poor and middle-income Nigerians. Still, I imagine it might be the right path to reduce the current challenges in Nigeria’s oil sector, and a significant step towards measurable progress on good governance and development. I don’t usually agree with Jeffrey Sachs on a lot of development issues but I am forced to concur that the “oil subsidy benefits the rich more than the poor and that the subsidy, when removed, [should] be used in targeted investments that serve the poor and more meaningful social investments.”




Occupy Nigeria in Lagos. The economy of the country was virtually at a standstill while the protests went on for eight days

 



Occupy Nigeria in London. Nigerians in diaspora also joined their family and friends in Nigeria to protest the actions of the Federal government.