Abstract

Introduction

Journalist Juan Diego Quesada ¹1. Quesada JD. 72 horas na feroz guerra contra as drogas nas Filipinas. El País Internacional 2017; 5 Out. https://brasil.elpais.com/brasil/2017/10/05/internacional/1507198244_979504.html (acessado em 05/Out/2017).
https://brasil.elpais.com/brasil/2017/10... published a story in 2017 titled 72 Hours in the Fierce War on Drugs in the Philippines. The special envoy from El País to the Philippines began his report on the drug policy enforced in this Asian country with the following data: since June 2016, as soon as President Rodrigo Duterte came to power and launched a brutal campaign against drugs to clean the streets of dealers and consumers, more than 12,500 people have been assassinated, according figures by such organizations as Amnesty International ¹1. Quesada JD. 72 horas na feroz guerra contra as drogas nas Filipinas. El País Internacional 2017; 5 Out. https://brasil.elpais.com/brasil/2017/10/05/internacional/1507198244_979504.html (acessado em 05/Out/2017).
https://brasil.elpais.com/brasil/2017/10... .

In 2018, in his annual state of the nation speech, the president claimed to the country’s population that the war on drugs that started in 2016 was “far from over” and attacked the activists who were speaking out against the repressive measures ²2. Reuters. Presidente das Filipinas promete manter a sangrenta guerra às drogas. O Globo 2018; 23 Jul. https://oglobo.globo.com/mundo/presidente-das-filipinas-promete-manter-sangrenta-guerra-as-drogas-22911897.
https://oglobo.globo.com/mundo/president... . A few months after the president’s claim, the Philippines witnessed the assassination of the 34^th human rights attorney in the first two years of Duterte’s term ³3. Conde CH. Another rights lawyer murdered in the Philippines: killing highlights land conflict in Negros. Human Rights Watch 2018; 7 nov. https://www.hrw.org/news/2018/11/07/another-rights-lawyer-murdered-philippines.
https://www.hrw.org/news/2018/11/07/anot... . The case of the Philippines, the main example of a repressive-type drug policy today, summarizes various aspects of what the current essay intends to debate.

The topic this essay aims to explore in light of the best available evidence is the impact on the population’s health of drug policies focused on the criminalization of growing, selling, and consuming psychoactive substances. The article does not focus specifically on healthcare policies for persons engaged in problematic use (the more usual scope of the drug issue in the field of health) ⁴4. Room R, Babor T, Rehm J. Alcohol and public health. Lancet 2005; 365:519-30.^,55. Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet 2009; 373:2223-33.^,66. Kaner EF, Beyer FR, Muirhead C, Campbell F, Pienaar ED, Bertholet N, et al. Effectiveness of brief alcohol interventions in primary care populations. Cochrane Database Syst Rev 2018; (2):1465-858.^,77. Ritter APA, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2006; 25:611-24..

The term “problematic drug use” includes the consumption of psychoactive substances associated with social or health risk for the user or others ⁸8. Fernandes L, Carvalho MC. Por onde anda o que se oculta: o acesso a mundos sociais de consumidores problemáticos de drogas através do método do snowball. Revista Toxicodependências 2000; 6:17-28.. The definition extrapolates but includes more biomedical definitions such as addiction and also includes patterns of use that may be episodic but still generate social and health risks (like driving under the influence of substances, injecting drug use, etc.).

We thus aim to understand how the option for a specific approach to the drug issue by government, namely Drug Prohibition, plays a determinant role in establishing patterns of health access, risks, and needs. Having said this, we underline the pertinence of the social issue of drugs becoming the object of more studies in the Collective Health field. We define social “issue” or “problem” as “the angle by which societies can be described, read, and problematized in their history, their dilemmas, and their future prospects” ⁹9. Telles VS. Questão social: afinal, do que se trata? São Paulo Perspect 1996; 10:85-95. (p. 85), involving various stakeholders, institutions, and regulations that aim to find a solution to that issue ¹⁰10. Fiore M. Tensões entre o biológico e o social nas controvérsias médicas sobre uso de "drogas". https://neip.info/texto/tensoes-entre-o-biologico-e-o-social-nas-controversias-medicas-sobre-uso-de-drogas/ (acessado em 05/Out/2017).
https://neip.info/texto/tensoes-entre-o-... . Drug use is the object of public debate and a social issue that mobilizes multiple interests and diverse policies, although its recognition as a social problem has only been recent ¹⁰10. Fiore M. Tensões entre o biológico e o social nas controvérsias médicas sobre uso de "drogas". https://neip.info/texto/tensoes-entre-o-biologico-e-o-social-nas-controversias-medicas-sobre-uso-de-drogas/ (acessado em 05/Out/2017).
https://neip.info/texto/tensoes-entre-o-... .

Humankind and drugs: an age-old relationship

The consumption of psychoactive substances, generically grouped in everyday language under the term “drugs”, is an ancient and persistent phenomenon in human history. Except for populations living in areas completing lacking vegetation, there is not a single human group that has not engaged with different psychoactive substances, at different times and in different places ¹¹11. Escohotado A. Historia general de las drogas. Madrid: Espasa; 2002..

Various motivations have impelled humankind to relate to substances capable of altering their ordinary states of consciousness: the pursuit of pleasure, relief of worries and tensions, mood control, and expanded consciousness ¹²12. Filev R. Como você se comporta? Dilemas sobre as dependências de substâncias. In: Bokany V, organizadora. Drogas no Brasil: entre saúde e justiça: proximidades e opiniões. São Paulo: Fundação Perseu Ábramo/Fundação Rosa Luxemburgo; 2015. p. 103-18..

Among all the people that have used substances - in 2015, an estimated 250 million people made use of some drug -, around 11% develop a pattern of risky use to the point of dependence - that is, a biomedically defined condition that translates as repetitive use, generally associated with harmful use and difficulty controlling consumption (Organização Mundial da Saúde. Classificação Internacional e Estatística de Doenças e Problemas Relacionados à Saúde - CID-10. http://www.datasus.gov.br/cid10/V2008/cid10.htm, accessed on 01/Mar/2019) - and the need for clinical treatment ¹³13. United Nation Office on Drugs and Crime. World Drug Report 2017. Vienna: United Nation Office on Drugs and Crime; 2017..

Although the idea of “addiction as a brain disease” has been widely disseminated in recent years by a certain group of authors ¹²12. Filev R. Como você se comporta? Dilemas sobre as dependências de substâncias. In: Bokany V, organizadora. Drogas no Brasil: entre saúde e justiça: proximidades e opiniões. São Paulo: Fundação Perseu Ábramo/Fundação Rosa Luxemburgo; 2015. p. 103-18., there are also specialists who emphatically claim the role of economic, social, psychological, and situational factors, in addition to genetic and biological determinations of the phenomenon of problematic drug use ¹⁴14. Kalant H. What neurobiology cannot tell us about addiction. Addiction 2010; 105:780-9.^,1515. Heim D. Addiction: not just brain malfunction. Nature 2014; 507:40..

The consumption of psychoactive substances is thus a historical and cultural phenomenon with medical, political, religious, and economic implications ¹⁶16. Minayo MCS, Deslandes SF. A complexidade das relações entre drogas, álcool e violência. Cad Saúde Pública 1998; 14:35-42.. Equally relevant is the need to distinguish between occasional/recreational use and drug addiction (avoiding labeling users as potential addicts) and the importance of establishing the differences between the various types of psychoactive substances and the harms they cause ¹⁶16. Minayo MCS, Deslandes SF. A complexidade das relações entre drogas, álcool e violência. Cad Saúde Pública 1998; 14:35-42..

The social issue of drugs and the prohibitionist paradigm

Although the consumption of psychoactive substances has been observed since remote times, it was not until the 20^th century that the use of some of these substances became a field of social and government attention, debate, and concern ¹⁷17. Fiore M. Prazer e risco: uma discussão a respeito dos saberes médicos sobre uso de "drogas". In: Labate BC, Goulart SL, Fiore M, MacRae E, Carneiro H, organizadores. Drogas e cultura: novas perspectivas. Salvador: EDUFBA; 2008. p. 141-55..

Having been raised to the level of a social issue, the drug problem was backed by three fundamental discourses: medicalization, criminalization, and moralization ¹⁷17. Fiore M. Prazer e risco: uma discussão a respeito dos saberes médicos sobre uso de "drogas". In: Labate BC, Goulart SL, Fiore M, MacRae E, Carneiro H, organizadores. Drogas e cultura: novas perspectivas. Salvador: EDUFBA; 2008. p. 141-55.^,1818. Rybka LN, Nascimento JL, Guzzo RSL. The dead and wounded in the "war on drugs". a criticism of the prohibitionist paradigm. Estud Psicol (Campinas) 2018; 35:99-109.. These three discourses established relations with each other, both approaching and moving away from the actual manifestations of the drug issue over the course of history.

The moralist pressure against drugs, dating to the late 19^th and early 20^th century, not only preceded the elaboration of laws on psychoactive substances, but also served as substrate for them ¹⁹19. Labate BC, Goulart SL, Fiore M, MacRae E, Carneiro H, organizadores. Drogas e cultura: novas perspectivas. Salvador: EDUFBA; 2008.. Henrique Carneiro calls attention to the precedence of the moral discourse in constructing the social issue of drugs, stating that the history of drug regulation initially shifted from the religious control of use to control, but maintaining the same ethnic and ideological prejudices ²⁰20. Carneiro H. Drogas: a história do proibicionismo. São Paulo: Autonomia Literária; 2019..

Analogously to the influence of moral aspects on drug legislation, there was an approach by the discourses of medicalization and criminalization. Both discourses converged to lend legitimacy to the illegality of certain drugs through the protection of what the field of Law refers to a legal good in public health ²¹21. Taffarello RF. Drogas: falência do proibicionismo e alternativas de política criminal [Dissertação de Mestrado]. São Paulo: Universidade de São Paulo; 2009..

There are also examples of avoiding the discourses of medicalization and criminalization. European drugs experts from various fields related to the drug issue have assessed the capacity of many drugs in producing harm to users and others, reaching a consensus that a psychoactive substance’s legal status is not directly related to its capacity to produce harm ²²22. Nutt DJ, King LA, Phillips LD. Drug harms in the UK: a multicriteria decision analysis. Lancet 2010; 376:1558-65.^,2323. van Amsterdam J, Nutt D, Phillips L, van den Brink W. European rating of drug harms. J Psychopharmacol 2015; 29:655-60..

Over the course of the 20^th century, a specific form of state action regarding the drug issue became hegemonic: namely Prohibition. The genesis and diffusion of this paradigm are the results of a combination of social, political, and economic factors. The construction of its hegemony drew on the political radicalization of American puritanism, the social elites’ fear of urban disorder, 20^th-century geopolitical conflicts, and the medical and pharmaceutical industry’s interest in their own monopoly of drug production ²⁴24. Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estudos Cebrap 2012; 92:9-21..

Among all the psychoactive substances, the principal targets of contemporary Prohibition have been cannabis (marijuana), coca (cocaine/crack), and poppy products (opium and heroin). An important international reference was the Single Convention on Narcotic Drugs in 1961, empowered by the United Nations and sponsored by the USA ²⁴24. Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estudos Cebrap 2012; 92:9-21..

Another important reference in Prohibition ²⁵25. Wood E, Werb D, Marshall BD, Montaner JS, Kerr T. The war on drugs: a devastating public-policy disaster. Lancet 2009; 373:989-90. was the declaration by U.S. President Richard Nixon, who in 1971 described illicit drugs as “public enemy number one”, declaring a “War on Drugs”. The declaration by the United Nations General Assembly in a special session in 1998 also affirmed the desire to free the world of the illegal production of opioids, cocaine, and cannabis, as well as of manufactured illegal drugs such as amphetamine stimulants ²⁶26. Fazey CSJ. The Commission on Narcotic Drugs and the United Nations International Drug Control Programme: politics, policies and prospect for change. Int J Drug Policy 2003; 14:155-69..

Although the advent of the drug problem as a state issue and the hegemony of Prohibition are a legacy with less than a century, in all societies there have always been forms of social regulation of drug consumption. The historical novelty of the 20^th century was the penal and international characteristic added to the problem ²⁷27. Carneiro H. As necessidades humanas e o proibicionismo das drogas no século XX. Revista Outubro 2002; 6:115-28..

However, before the prohibitionist paradigm became internationally hegemonic, there were initial experiments in banning psychoactive substances. These featured prohibition of the use of alcohol by the Volstead Act in the United States ²⁷27. Carneiro H. As necessidades humanas e o proibicionismo das drogas no século XX. Revista Outubro 2002; 6:115-28., whose results in terms of Collective Health already foretold the problems associated with this policy.

The groups comprising the prohibitionist movement in North America were quite heterogeneous ²⁴24. Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estudos Cebrap 2012; 92:9-21.. Carneiro notes that this raises some difficulty in analyzing this movement. It was puritanical and featured intense participation by women, with middle-class values, but with involvement of the working class and large industrialists, plus major Evangelical participation (especially Methodist), but also joined by Catholics ²⁰20. Carneiro H. Drogas: a história do proibicionismo. São Paulo: Autonomia Literária; 2019..

However, its effects were characterized by a series of unwanted consequences: corruption of agents in the state hierarchy, high incarceration rates, and the creation of an illegal circuit with the circulation of alcohol run by organized crime ¹¹11. Escohotado A. Historia general de las drogas. Madrid: Espasa; 2002.^,2828. Nutt D. Illegal drugs laws: clearing a 50-year-old obstacle to research. PLoS Biol 2015; 13:e1002047.. There was also an alarming explosion of unsafe alcohol use at the time, with deaths, poisonings, and physical sequelae caused by the ingestion of distilled alcohol unfit for consumption ¹¹11. Escohotado A. Historia general de las drogas. Madrid: Espasa; 2002..

Still, the setbacks from this prohibitionist experiment - which ended in 1933 - were not sufficient to prevent the successful attempt to expand and internationalize the ban on some substances, especially since 1961.

The success of contemporary Prohibition thus consolidated a veritable global crusade against drugs, legitimized by two fundamental premises, as defined by Fiore ²⁴24. Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estudos Cebrap 2012; 92:9-21.: (a) drug consumption is an avoidable and harmful practice, which justifies prohibition by the state; and (b) the ideal action by the state to fight drugs is to criminalize their circulation and consumption.

Faria ²⁹29. Faria ECC. Redução de danos em um contexto de "Guerra às Drogas": a formação sob a perspectiva de quem atua no SUS [Dissertação de Mestrado]. Campinas: Universidade Estadual de Campinas; 2017. (p. 45), in his Master’s thesis, expands on the definition of the prohibitionist paradigm by Fiore ²⁴24. Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estudos Cebrap 2012; 92:9-21., proposing a set of principles that would define the “Ideology of the War on Drugs”: (1) the perception of drugs, and by extension those who use and sell them, as enemies or essentially unwanted; (2) the use of military and police resources as the main means for dealing with the problem; (3) the idea that illicit drugs and their use can and should be eradicated; (4) the implicit concept that the solution to problematic drug use is abstinence; and (5) encouragement for the incarceration modalities - criminal or psychiatric - as the potential solution to the drug problem.

Thus, the hegemony of Prohibition decisively marked the contemporary drug issue and shaped the production of knowledge on psychoactive substances by arbitrarily defining which drugs would be considered legal and which would be made illegal ²⁴24. Fiore M. O lugar do Estado na questão das drogas: o paradigma proibicionista e as alternativas. Novos Estudos Cebrap 2012; 92:9-21.^,2828. Nutt D. Illegal drugs laws: clearing a 50-year-old obstacle to research. PLoS Biol 2015; 13:e1002047..

Prohibition and Collective Health: evidence of an unhealthy relationship

Having laid out the foundations of the prohibitionist paradigm and the War on Drugs resulting from it, we now discuss the consequences of this approach to the drugs phenomenon by the state. The consequences of Prohibition’s hegemony extrapolate the sphere of Public Security and care for problematic drug users - in which they are usually addressed - and directly interest Collective Health.

In Brazilian society, the most recent consensus on the drug issue led to the drafting of Law n. 11,343/2006³⁰30. Brasil. Lei nº 11.343, de 23 de agosto de 2006. Institui o Sistema Nacional de Políticas Públicas sobre Drogas - Sisnad; prescreve medidas para prevenção do uso indevido, atenção e reinserção social de usuários e dependentes de drogas; estabelece normas para repressão à produção não autorizada e ao tráfico ilícito de drogas; define crimes e dá outras providências. Diário Oficial da União 2006; 24 ago., the country’s prevailing Drug Law, and is based on two main elements: prevention of undue use, care, and social rehabilitation of drug users and addicts and repression of unauthorized drug production and illegal drug trade.

The law that summarizes the principal references in Brazil’s national drug policy thus linked two main discourses: a criminalizing discourse, aimed at drug dealers, and a medical and legal discourse, targeted to drug users. This link aimed to determine the punishments for drug dealing and to shift users from prisons to the healthcare system and social assistance ³¹31. Campos MS. Pela metade: as principais implicações da nova lei de drogas no sistema de justiça criminal em São Paulo [Tese de Doutorado]. São Paulo: Universidade de São Paulo; 2015..

Importantly, Law n. 11,343 does not refer to the decriminalization of any substance previously classified as illegal, but only to the fact that drug users would no longer be subject to prison sentences. Meanwhile, crimes related to drug dealing had their sentences increased, with a minimum punishment of five years’ confinement ³⁰30. Brasil. Lei nº 11.343, de 23 de agosto de 2006. Institui o Sistema Nacional de Políticas Públicas sobre Drogas - Sisnad; prescreve medidas para prevenção do uso indevido, atenção e reinserção social de usuários e dependentes de drogas; estabelece normas para repressão à produção não autorizada e ao tráfico ilícito de drogas; define crimes e dá outras providências. Diário Oficial da União 2006; 24 ago.. Note that this distinction appears not to apply in practice, especially when it comes to specific groups like black and the poor. There is evidence that a considerable share of persons incarcerated for drug trafficking in Brazil may actually be users or petty dealers, whose activity is not associated with violence ³¹31. Campos MS. Pela metade: as principais implicações da nova lei de drogas no sistema de justiça criminal em São Paulo [Tese de Doutorado]. São Paulo: Universidade de São Paulo; 2015..

Prohibition, violence, and mortality from external causes

The association between prohibitionist policies and the rise in violence and homicides is probably the most dramatic consequence of the War on Drugs.

The prohibition of drugs, products whose demand has remained stable and whose trade continues to generate fabulous profit margins ³²32. Souza TS. A economia das drogas em uma abordagem heterodoxa [Dissertação de Mestrado]. Campinas: Universidade Estadual de Campinas; 2015., is responsible for creating a parallel economy operated by criminal networks ³³33. United Nation Office on Drugs and Crime. World Drug Report 2018. Vienna: United Nation Office on Drugs and Crime; 2018..

Having said this, before we present data on the association between violence and repressive drug policies, we should highlight that despite the hegemony of Prohibition, the variety of drugs and their markets are expanding as never before in history ³³33. United Nation Office on Drugs and Crime. World Drug Report 2018. Vienna: United Nation Office on Drugs and Crime; 2018..

As an example, global cocaine production increased by 56% from 2013 to 2016. Likewise, the fact that the largest increase in cocaine seizures in 2016 occurred in Africa demonstrates the existence of an emerging market for the drug. There has also been an increase in the variety of illegally available psychoactive substances: from 2009 to 2017, 111 countries and territories reported seizing 803 new psychoactive substances ³²32. Souza TS. A economia das drogas em uma abordagem heterodoxa [Dissertação de Mestrado]. Campinas: Universidade Estadual de Campinas; 2015.^,3333. United Nation Office on Drugs and Crime. World Drug Report 2018. Vienna: United Nation Office on Drugs and Crime; 2018..

As for violence, a systematic review analyzed 15 studies that assessed the impacts of drug law enforcement on drug market violence. In this review, 93% of the studies evidenced adverse effects of drug laws on levels of violence, concluding that armed violence and high homicide rates are unavoidable consequences of drug prohibition ³⁴34. Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market violence: a systematic review. Int J Drug Policy 2011; 22:87-94..

Further on the relationship between Prohibition and rising homicide rates, the Mexican cases stands out in the world: the increase in the number of assassinations resulting from the use of military force against the drug traffic since 2006 has even reduced life expectancy in the country ³⁵35. Aburto JM, Beltrán-Sánchez H, García-Guerrero VM, Canudas-Romo V. Homicides in Mexico reversed life expectancy gains for men and slowed them for women, 2000-10. Health Aff (Millwood) 2016; 35:88-95.^,3636. Espinosa V, Rubin DB. Did the military interventions in the Mexican drug war increase violence? Am Stat 2015; 69:17-27.^,3737. Heinle K, Ferreira OR, Shirk DA. Drug violence in Mexico: data and analysis through 2014. San Diego: Justice in Mexico Project/Department of Political Science and International Relations/University of San Diego; 2015.

Brazil also displays high fatality rates from police action, although there are problems with the data’s reporting and composition. The excessive use of police force stands out. It is notoriously more intense in socially deprived areas such as Rio’s favelas, when compared to the rest of the city ³⁸38. Cano I, Sento-Sé JT, Ribeiro E, Souza FF. O impacto da violência no Rio de Janeiro. Rio de Janeiro: Laboratório de Análise Violência, Universidade do Estado do Rio de Janeiro; 2004., and more intense in Brazil than elsewhere in the world ³⁹39. Loche A. A letalidade da ação policial: parâmetros para análise. Revista TOMO 2010; 17:39-56.. From 2009 to 2016, more than twenty thousand people were killed in Brazil as the result of police action, mostly young black males ⁴⁰40. Lima RS, Bueno S. 11º Anuário Brasileiro de Segurança Pública 2017. São Paulo: Fórum Brasileiro de Segurança Pública; 2017..

In the USA, the War on Drugs is related to the erosion of legislation that curtail police action and to an increase in police brutality against the African-American minority, without a corresponding reduction in the use and sale of drugs on the streets ⁴¹41. Cooper HL. War on drugs policing and police brutality. Subst Use Misuse 2015; 50:1188-94.. In the Philippines, the declaration of the War on Drugs by President Rodrigo Duterte, elected in 2016, is implicated in escalating violence, incarceration, and avoidable mortality ⁴²42. McCall C. Philippines president continues his brutal war on drugs. Lancet 2017; 389:21-2., with thousands of deaths associated with this policy’s enforcement ⁴³43. Humans Right Watch. License to kill: Philippine police killings in Duterte's "War on Drugs". New York: Humans Right Watch; 2017.^,4444. Simangan D. Is the Philippine "War on Drugs" an act of genocide? J Genocide Res 2018; 20:68-89..

Violence associated with drugs is also mediated by other factors besides the substances’ legal status. These feature policing, the users’ socioeconomic context, their relationship with the drug, and the means used to access the substance.

Daudelin & Ratton ⁴⁵45. Daudelin J, Ratton JL. Mercados de drogas, guerra e paz no Recife. Tempo Social 2017; 29:115-33. analyzed the violence associated with the crack market, comparing it to the relatively peaceful drug trade for the middle classes, and observed that the levels of violence are associated not only with the product’s illegality, but result from “an explosive combination of compulsive and dependent consumption, a situation of poverty (…), extensive use of credit (…), and disruptive policing, with low dissuasion of violence” ⁴⁵45. Daudelin J, Ratton JL. Mercados de drogas, guerra e paz no Recife. Tempo Social 2017; 29:115-33. (p. 127).

The War on Drugs policy, as enforced in Brazil for purposes of controlling the territories where the supply is concentrated, can be considered a biopolitical strategy as defined by Foucault ⁴⁶46. Foucault M. Em defesa da sociedade: curso no College de France (1975-1976). São Paulo: Martins Fontes; 2005. and operated by the logic of exception as formulated by Agamben ⁴⁷47. Agambem G. Estado de exceção: Homo Sacer, II, I. São Paulo: Boitempo; 2004., dealing with the topic of exception by defining modern totalitarianism as the enforcement of legal mechanisms that allow the physical elimination of political adversaries and entire categories of citizens who for any reason do not appear amenable to integration into the political system.

This logic of exceptionality appears to apply appropriately to the case of police violence in Brazil’s peripheral communities, purportedly targeted to fighting drugs and dealers, where residents of poor communities (mostly black) have become disposable as victims of interventions perpetrated by recourse to sovereign exception ⁴⁸48. Alvarenga R, Silveira JI, Teixeira DSG. Política de drogas no Brasil no cenário de violações aos direitos humanos. Argumentum 2018; 10:123-36..

The use of such sovereign exception in the form of lethal violence was the focus of an empirical study by Orlando Zaccone ⁴⁹49. Zaccone O. Indignos de vida: a forma jurídica da política de extermínio de inimigos na cidade do Rio de Janeiro. Rio de Janeiro: Revan; 2015., showing that the discourse of the Public Prosecutor’s Office on the presence of enemies in favelas presents “models” that are repeated as patterns in different petitions to terminate internal affairs proceedings, effectively authorizing police forces to claim self-defense and justifying the deaths of those labeled as “unworthy”.

The contemporary debate proposed by Achille Mbembe ⁵⁰50. Mbembe A. Necropolítica. São Paulo: N-1 Edições; 2018. on the conditions for exercising the power to kill, to let live, or to expose to death, as well as the subjects of this law, posits the insufficiency of the notion of biopower and defines the contemporary forms that subjugate life to the power of death - necropolitics and necropower - to address the ways by which firearms are distributed in the contemporary world.

Prohibition, mass incarceration, and health risk

The War on Drugs policies have been associated with high incarceration rates throughout the history of their enforcement. In the United States (the main underwriter of Prohibition and world leader in the number of prison inmates), the crackdown on the drug trade and drug use has led to a five-fold increase in the prison population since 1972, without a corresponding decrease in crime or drug use ⁵¹51. Moore LD, Elkavich A. Who's using and who's doing time: incarceration, the war on drugs, and public health. Am J Public Health 2008; 98 Suppl 1:S176-80..

The evidence is clear ⁵²52. Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, et al. Public health and international drug policy. Lancet 2016; 387:1427-80. that prohibitionist drug policies have been enforced with a racial bias. The United States is the case with the most complete documentation, and in 2014, blacks showed fivefold higher lifetime odds of incarceration when compared to whites.

The situation is analogous in Brazil, with the world’s third largest prison population (more than 700,000 inmates) and an incarceration rate of 352.6 inmates per 100 inhabitants in 2016, a rate that has shown an upward trend ⁵³53. Santos T, organizadora. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional, Ministério da Justiça e Segurança Pública; 2014..

The drug traffic is still not the most frequent cause of imprisonment in Brazil, but it has contributed the most to the increase in incarceration rates, currently accounting for 26% of the prison population in men and 62% in women ⁵³53. Santos T, organizadora. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional, Ministério da Justiça e Segurança Pública; 2014..

The Brazilian data also show that incarceration for drug-related crimes mostly involves small amounts of substances: up to 19% of imprisonments related to cocaine and 54% related to marijuana are for amounts of the drugs that would be classified as personal use under other legislations ⁵⁴54. Carlos JO. Política de drogas e encarceramento em São Paulo, Brasil. London: International Drug Policy Consortium; 2015..

In Brazil, as in the United States, blacks are also overrepresented in the prison population (64% versus 53% of blacks in the overall population), which is also mostly young (55%) and with low schooling (80% have not completed secondary school) ⁵³53. Santos T, organizadora. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional, Ministério da Justiça e Segurança Pública; 2014..

For this article’s purposes, we are now interested in assessing the consequences of indiscriminate incarceration for the field of health. The available data show that the prevalence of substance use disorders is higher in the prison population than in the general population ⁵⁵55. Fazel S, Bains P, Doll H. Substance abuse and dependence in prisoners: a systematic review. Addiction 2006; 101:181-91.. In addition, persons with a history of drug use (also overrepresented in the prison population) are at extremely high risk of overdose following release from state custody ⁵⁶56. World Health Organization. Community management of opioid overdose. Geneva: World Health Organization; 2014.^,5757. Farrell M, Marsden J. Acute risk of drug-related death among newly released prisoners in England and Wales. Addiction 2008; 103:251-5..

Repressive policing against drug use contributes heavily to the risk of HIV infection, associated with injecting drug use, when it constitutes a barrier to access to needle exchange services and therapies for replacement of injectable opioids with non-injectable ones ⁵⁸58. Voices of Community Activists and Leaders, Community Development Project of the Urban Justice Center. Beyond methadone: improving health and empowering patients in opioid treatment programs Hepatitis C, Overdose Prevention, Syringe Exchange, Buprenorphine & other opportunities to make programs work for patients. New York: Voices of Community Activists and Leaders; 2015.^,5959. Open Society Foundations. To protect and serve: how police, sex workers, and people who use drugs are joining forces to improve health and human rights. Protect and Serve: how police, sex workers, and people who use drugs are joining forces to improve health and human rights. 2014. https://www.opensocietyfoundations.org/sites/default/files/protect-serve-20140716.pdf (acessado em 05/Out/2017).
https://www.opensocietyfoundations.org/s... .

In addition, drug use, including injectable drugs, occurs inside penitentiaries, and HIV and hepatitis C transmission occurs among inmates, frequently complicated by coinfection with tuberculosis - in many places multi-resistant tuberculosis ⁵²52. Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, et al. Public health and international drug policy. Lancet 2016; 387:1427-80..

In Brazil, persons deprived of freedom have a 28 times higher chance of contracting tuberculosis when compared to the general population ⁵³53. Santos T, organizadora. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional, Ministério da Justiça e Segurança Pública; 2014.. Likewise, in the Brazilian prison population, the mortality rate from intentional violent means was six times that of the general population in 2013 ⁵³53. Santos T, organizadora. Levantamento nacional de informações penitenciárias. Brasília: Departamento Penitenciário Nacional, Ministério da Justiça e Segurança Pública; 2014.. The prevalence of substance use disorders was also higher in the country’s prison population than in the general population ⁶⁰60. Canazaro D, Argimon IIL. Características, sintomas depressivos e fatores associados em mulheres encarceradas no Estado do Rio Grande do Sul, Brasil. Cad Saúde Pública 2010; 26:1323-33..

Assessing the incarceration issue from the legal point of view, Slokar et al. ⁶¹61. Slokar A, Zaffaroni ER, Batista N. Direito penal brasileiro: primeiro volume. 2ª Ed. Rio de Janeiro: Revan; 2003. made the distinction between primary criminalization - the act and effect of sanctioning a material penal law, which incriminates or allows the punishment of certain persons - generally exercised by policy agencies (legislatures, executive branches), from secondary criminalization, which is the punitive action exercised on actual persons, generally carried out by police forces. The enforcers of criminalization proceed selectively and simplistically, that is, performing the criminal selection of gross facts, which is easier, as well as the choice of persons that cause fewer problems, given their incapacity for positive access to political and economic power and to social communication ⁶¹61. Slokar A, Zaffaroni ER, Batista N. Direito penal brasileiro: primeiro volume. 2ª Ed. Rio de Janeiro: Revan; 2003..

Prohibition and health access

A Special Session of the United Nations General Assembly in 1998 endorsed the member countries’ commitment to strategies to eliminate or significantly reduce the illegal cultivation of coca, cannabis, and poppy, as well as manufactured psychoactive substances such as amphetamines, by the year 2008 ⁶²62. White T. The drug-free world. Subst Use Misuse 2012; 47:1637-9..

This intention to create what at the time was called “a drug-free world” spawned aggressive practices that were harmful to the health of workers involved in growing the plants used to make drugs, especially coca, poppy, and cannabis.

Such practices have featured spraying coca leaves with the defoliant glyphosate, which has been associated with respiratory and dermatological disorders and miscarriages. The forced displacement of landless rural families also aggravates food insecurity, and the growers’ geographic isolation deprives them of access to basic health services and prevents them from being reached by public health programs ⁶³63. Buxton J. Drugs and development: the great disconnect. Swansea: Global Drug Policy Observatory; 2015. (Policy Report, 2).^,6464. Fishstein P. Despair or hope: rural livelihoods and opium poppy dynamics in Afghanistan. Kabul: Afghanistan Research and Evaluation Unit; 2014.^,6565. United Nations Office on Drugs and Crime. Colombia: coca cultivation survey 2014. Bogota: United Nations Office on Drugs and Crime/Government of Colombia; 2015.^,6666. Salisbury DS, Fagan C. Coca and conservation: cultivation, eradication, and trafficking in the Amazon borderlands. Geography and the Environment Faculty Publications 2013; 78:41-60..

As for the relationship between Prohibition and access to legal recourse and health, it is essential to address the difficulties imposed on the study and clinical application of the therapeutic potential of currently banned psychoactive substances.

With varying degrees of available evidence, various illegal substances (cannabis, methylenedioxymethamphetamine - MDMA, psilocybin, and lysergic acid diethylamide - LSD) ²⁸28. Nutt D. Illegal drugs laws: clearing a 50-year-old obstacle to research. PLoS Biol 2015; 13:e1002047. or those with use restricted to ritual contexts (ayahuasca) have demonstrated potential for therapeutic use ⁶⁷67. Domínguez-Clavé E, Soler J, Elices M, Pascual JC, Álvarez E, de la Fuente Revenga M, et al. Ayahuasca: pharmacology, neuroscience and therapeutic potential. Brain Res Bull 2016; 126(Pt 1):89-101.^,6868. Osório FL, Sanches RF, Macedo LR, dos Santos RG, Maia-de-Oliveira JP, Wichert-Ana L, et al. Antidepressant effects of a single dose of ayahuasca in patients with recurrent depression: a preliminary report. Braz J Psychiatry 2015; 37:13-20..

Cannabis products show evidence of efficacy in the treatment of spasticity associated with multiple sclerosis ⁶⁹69. Zajicek J, Fox P, Sanders H, Wright D, Vickery J, Nunn A, et al. Cannabinoids for treatment of spasticity and other symptoms related to multiple sclerosis (CAMS study): multicentre randomised placebo-controlled trial. Lancet 2003; 362:1517-26. and HIV-related neuropathic pain ⁷⁰70. Abrams DI, Jay CA, Shade SB, Vizoso H, Reda H, Press S, et al. Cannabis in painful HIV-associated sensory neuropathy: a randomized placebo-controlled trial. Neurology 2007; 68:515-21.. There is also the possibility of use of cannabis as symptomatic treatment of post-traumatic stress disorder ⁷¹71. Passie T, Emrich HM, Karst M, Brandt SD, Halpern JH. Mitigation of post-traumatic stress symptoms by Cannabis resin: a review of the clinical and neurobiological evidence. Drug Test Anal 2012; 4:649-59.. The use of marijuana has also been discussed as harm reduction for crack use ⁷²72. Escobar JAC. A maconha como estratégia contra a fissura de crack em usuários de um programa de assistência social do estado de Pernambuco. Platô Drogas e Políticas 2018; 2:79-109..

There is also an important role for cannabidiol (CBD), a cannabinoid found in marijuana, as adjuvant treatment for patients with severe and resistant epileptic seizures in early childhood ⁷³73. Stockings E, Zagic D, Campbell G, Weier M, Hall WD, Nielsen S, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. J Neurol Neurosurg Psychiatry 2018; 89:741-53.. Importantly, via court action, Brazil has a path open for legalization of the therapeutic use of marijuana and sometimes even including its cultivation. Such strides have been made despite the lack of advances in the legislative field.

The use of MDMA had already been approved by the FDA a breakthrough therapy for patients with posttraumatic stress disorder, having demonstrated sustained symptomatic relief in patients resistant to traditional treatments ⁷³73. Stockings E, Zagic D, Campbell G, Weier M, Hall WD, Nielsen S, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. J Neurol Neurosurg Psychiatry 2018; 89:741-53.. There is also therapeutic potential to be explored in psychedelic substances, including psilocybin ⁷⁴74. Johnson MW, Garcia-Romeu A, Griffiths RR. Long-term follow-up of psilocybin-facilitated smoking cessation. Am J Drug Alcohol Abuse 2017; 43:55-60.^,7575. Ross S, Bossis A, Guss J, Agin-Liebes G, Malone T, Cohen B, et al. Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. J Psychopharmacol 2016; 30:1165-80.^,7676. Carhart-Harris RL, Bolstridge M, Rucker J, Day CM, Erritzoe D, Kaelen M, et al. Psilocybin with psychological support for treatment-resistant depression: an open-label feasibility study. Lancet Psychiatry 2016; 3:619-27., LSD ⁷⁷77. Krebs TS, Johansen PØ. Lysergic acid diethylamide (LSD) for alcoholism: meta-analysis of randomized controlled trials. J Psychopharmacol 2012; 26:994-1002.^,7878. Gasser P, Kirchner K, Passie T. LSD-assisted psychotherapy for anxiety associated with a life-threatening disease: a qualitative study of acute and sustained subjective effects. J Psychopharmacol 2015; 29:57-68., and ayahuasca ⁶⁷67. Domínguez-Clavé E, Soler J, Elices M, Pascual JC, Álvarez E, de la Fuente Revenga M, et al. Ayahuasca: pharmacology, neuroscience and therapeutic potential. Brain Res Bull 2016; 126(Pt 1):89-101.^,6868. Osório FL, Sanches RF, Macedo LR, dos Santos RG, Maia-de-Oliveira JP, Wichert-Ana L, et al. Antidepressant effects of a single dose of ayahuasca in patients with recurrent depression: a preliminary report. Braz J Psychiatry 2015; 37:13-20..

Despite the promising results of the therapeutic use of currently banned substances, some of which have been known for decades, prohibition’s hegemony poses a persistent obstacle to clinical and pharmacological research involving the use of these substances, thus increasing the time for obtaining substances, the cost of studies, and the bureaucracy required to perform the studies ²⁸28. Nutt D. Illegal drugs laws: clearing a 50-year-old obstacle to research. PLoS Biol 2015; 13:e1002047..

The moral panic associated with Prohibition also interferes in maternal-child healthcare. The so-called “crack baby” phenomenon revealed how the fear of harm associated with prenatal exposure to cocaine led to punitive policies against user mothers ⁷⁹79. Paltrow LM. Governmental responses to pregnant women who use alcohol or other drugs. DePaul Journal of Health Care Law 2005; 8:461..

This type of approach, whose ethical, legal, and racially biased faults have been identified by academics, constituted a barrier to healthcare for the mothers and their children and were not backed by scientific evidence ⁸⁰80. Frank DA, Augustyn M, Knight WG, Pell T, Zuckerman B. Growth, development, and behavior in early childhood following prenatal cocaine exposure: a systematic review. JAMA 2001; 285:1613-25.. In Brazil, children of crack users classified as “in a high risk situation” - mostly poor and homeless - have been compulsorily separated from their mothers and referred to shelters ⁸¹81. Jansen M, Meyer DEE, Felix J. Mulheres usam substâncias psicoativas? atravessamentos de gênero na política de redução de danos no Brasil. Rev Psicol Polít 2017; 17:90-104..

Overcoming the prohibitionist paradigm: pathways to change in drug policies

The formulation of public health policies involves - both in their general aspects (structuring of a national health system) and in their specific themes (such as drug policy) - major budget resources and central political issues such as the option for a given type of state.

The macropolitical dimension has meant that since the Brazilian Unified National Health System (SUS) was created, it has been marked by multiple political voices, having been implemented in a scenario of heterogeneous interests ⁸²82. Campos GWS. Reforma política e sanitária: a sustentabilidade do SUS em questão? Ciênc Saúde Colet 2007; 12:301-6..

Brazil’s Health Reform, whose objectives were expressed in the understanding of health as a social right to be ensured by the state (Constituição da República Federativa do Brasil, 1988. http://www.planalto.gov.br/ccivil_03/constituicao/constituicao.htm) and in the creation of a Unified Health System with universal access and comprehensive healthcare ⁸³83. Brasil. Lei nº 8.080, de 19 de setembro de 1990. Dispõe sobre as condições para a promoção, proteção e recuperação da saúde, a organização e o funcionamento dos serviços correspondentes e dá outras providências. Diário Oficial da União 1990; 20 set., largely replaced the social security-based model focused on individual medical care (curative and specialized) that prioritized private health products and was linked to international capital ⁸⁴84. Oliveira JA, Teixeira SMF. (Im)previdência social: 60 anos de história da previdência no Brasil. 2ª Ed. Petrópolis: Editora Vozes/Rio de Janeiro: Associação Brasileira de Pós-graduação em Saúde Coletiva; 1989..

Despite the political victory of the vision of the Social State acting in health, ensured by the 1988 Brazilian National Constitution, the implementation of the SUS in the 1990s and 2000s has been marked by a permanent contradiction between the principle of universality on the one hand and that of containment of public expenditures on the other ⁸⁵85. Mendes A, Marques RM. O financiamento do SUS sob os "ventos" da financeirização. Ciênc Saúde Colet 2009; 14:841-50..

The same has been true for the political process of building the Mental Health Reform in Brazil, where the dispute between opposing interests resulted in contradictory policies by the Brazilian state in its institutional and economic positions ⁸⁶86. Paulin LF, Turato ER. The prelude to psychiatric reform in Brazil: the contradictions of the 1970s. Hist Ciênc Saúde Manguinhos 2004; 11:241-58..

In the period immediately prior to the organization of the Psychiatric Reform Movement in the 1970s, even while the official mental health policy incorporated elements from preventive psychiatry, government funding continued to favor private psychiatric institutions over community-based action ⁸⁶86. Paulin LF, Turato ER. The prelude to psychiatric reform in Brazil: the contradictions of the 1970s. Hist Ciênc Saúde Manguinhos 2004; 11:241-58.. Broad civil society involvement was necessary for the disputes over the psychiatric care model to be resolved in favor of the Reform’s proponents ⁸⁷87. Goulart MSB. A construção da mudança nas instituições sociais: a reforma psiquiátrica. Pesqui Prát Psicossociais 2006; 1:1-19., a complex process whose details are beyond the scope of this article.

The drug policies’ formulation is part of the contradictions in the actual implementation of the SUS and the realization of the Psychiatric Reform. This process is thus situated in the context of disputes between public and private interests in health.

In the case of mental health policies, the large void left by the state in policies for problematic users of alcohol and other drugs until the early 21^st century was occupied by Therapeutic Communities (TC) ⁸⁸88. Tófoli LF. Drugs policies and public health. Sur - International Journal on Human Rights 2015; 21:1-5., psychiatric hospitalizations, and mutual-help groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) ⁸⁹89. Machado AR. Uso prejudicial e dependência de álcool e outras drogas na agenda da saúde pública: um estudo sobre o processo de constituição da política pública de saúde do Brasil para usuários de álcool e outras drogas [Dissertação de Mestrado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2006.. The hegemonic medical and social approaches during this period, influenced by medical and moral values, all focused on the idea of abstinence as the only solution to problematic drug use.

The treatment modality offered by TCs is heavily associated with Catholic, Evangelical, and Spiritist religious groups ⁸⁸88. Tófoli LF. Drugs policies and public health. Sur - International Journal on Human Rights 2015; 21:1-5.^,9090. Vieira FS, Benevides RPS. Os impactos do novo regime fiscal para o financiamento do Sistema Único de Saúde e para a efetivação do direito à saúde no Brasil. Brasília: Instituto de Pesquisa Econômica Aplicada; 2016.. Although according to Kurlander its foundations include elements that are similar to some of the principles of Psychiatric Reform ⁹¹91. Perrone PAK. A comunidade terapêutica para recuperação da dependência do álcool e outras drogas no Brasil: mão ou contramão da reforma psiquiátrica? Ciênc Saúde Colet 2014; 19:569-80., TCs presents highly heterogeneous therapeutic practices that frequently clash with the guidelines of Brazil’s national mental health policy ⁸⁸88. Tófoli LF. Drugs policies and public health. Sur - International Journal on Human Rights 2015; 21:1-5..

The case of TCs in drug policies clearly expresses what Campos ⁸²82. Campos GWS. Reforma política e sanitária: a sustentabilidade do SUS em questão? Ciênc Saúde Colet 2007; 12:301-6. had already outlined when analyzing the construction of the Brazilian health system: “in reality, the discourses and practices are mixed”.

From 2003 to 2018, Brazil practiced a national drug policy that considered harm reduction the principal therapeutic approach to the problematic use of psychoactive substances and at the same time included the TCs, focused on abstinence, in the country’s official Network of Psychosocial Care (RAPS in Portuguese) ⁹¹91. Perrone PAK. A comunidade terapêutica para recuperação da dependência do álcool e outras drogas no Brasil: mão ou contramão da reforma psiquiátrica? Ciênc Saúde Colet 2014; 19:569-80.. In practice, this shaped a health policy in which a lay state with a Psychiatric Reform-based mental health policy was financing (with loose regulation) TCs in which treatment was based on religious indoctrination and sometimes disrespect for human rights ⁸⁹89. Machado AR. Uso prejudicial e dependência de álcool e outras drogas na agenda da saúde pública: um estudo sobre o processo de constituição da política pública de saúde do Brasil para usuários de álcool e outras drogas [Dissertação de Mestrado]. Belo Horizonte: Universidade Federal de Minas Gerais; 2006.. Yet as in any process of formulation or modification of public policies, the Therapeutic Communities’ inclusion in the RAPS was not without political tension and resistance by the network’s health professionals, users, and their families ⁹²92. Conselho Regional de Psicologia do Rio Grande do Sul. Carta do I Encontro Nacional da RAPS, 2014. http://www.crprs.org.br/comunicacao/noticias/confira-a-carta-do-i-encontro-nacional-da-raps-2300 (acessado em 01/Mar/2019).
http://www.crprs.org.br/comunicacao/noti... .

The influence of prohibitionist policies in the field of drugs is associated with a specific form of action by the state in social issues, defined as the Penal State ⁹²92. Conselho Regional de Psicologia do Rio Grande do Sul. Carta do I Encontro Nacional da RAPS, 2014. http://www.crprs.org.br/comunicacao/noticias/confira-a-carta-do-i-encontro-nacional-da-raps-2300 (acessado em 01/Mar/2019).
http://www.crprs.org.br/comunicacao/noti... . This specific mode of state institutional action, as formulated by Loïc Wacquant ⁹³93. Wacquant L. Punir os pobres: a nova gestão da miséria nos Estados Unidos. Rio de Janeiro: Edição Revan; 2003. (p. 27), is processed by the combination of dismantling Social Society and “a state policy of criminalization of the consequences of the state’s misery”, through state action in police and penitentiary mode, within which the criminalization of poverty and confinement of disinherited categories take the turn of social policy for the helpless and according to a logic with the War on Drugs and the resulting mass incarceration.

Having described the risks associated with repressive policies, it is thus necessary to briefly indicate alternatives to Prohibition, with a view towards improving public health. The paths include: decriminalization of the use, possession, and small-scale sale of drugs; reduction of the violence and discrimination associated with law enforcement; focus on harm reduction policies; attention to gender specificities; inclusion of social variables as metrics for success in the treatment of problematic drug use; and increase in research for the production of scientific evidence. These proposals are part of the most comprehensive international review of drug policies and public health ⁵²52. Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, et al. Public health and international drug policy. Lancet 2016; 387:1427-80.. We could further add the need to consolidate the legal status of the therapeutic use of currently banned substances such as marijuana and some psychedelics.

Conclusions

The forms of regulation of the production, sale, and use of psychoactive substances, called drug policies, impact the field of Collective Health, including health access, mortality from avoidable causes, health conditions inside institutions, and maternal-child health.

Likewise, the way the state addresses the drug issue relates to the way health policies are conceived as a whole and to even broader issues such as human rights and the state’s role in guaranteeing social rights and their relationship to private interests.

Prohibition is associated with negative changes to health indicators that are not related directly to mental health or care for problematic users of psychoactive substances.

In the Brazilian case, it is crucial for the field of Collective Health to incorporate the critique of the health and social risks associated with Prohibition, since this is a policy whose conception and practical results run counter to the principles and guidelines of the SUS, necessary to guarantee the existence of a national health system.

Prohibition thus corresponds to a political paradigm that may respond to the moral wishes of a conservative society in relation to drugs, but which clashes with this same society’s values and rights. Particularly worrisome in this case is the limitation on health access.

Therefore, in addition to the discussion on models and policies of care for users of psychoactive substances, in the search to ensure the right to health, it essential for Collective Health as a field to expand the view of drug policies and to understand this view as interdisciplinary. In so doing, it is crucial to perceive how the ideals of the War on Drugs poison the policies and skew the debate. After so many years of harm to health in the name of its protection, it is necessary to understand and disarm the dangerous relations caused by the prohibitionist paradigm.

References

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